LPN Notes: Nurse's Clinical Pocket Guide, 2nd Edition

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Contacts • Phone/E-Mail Name: Ph:

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2nd Edition

Ehren Myers, RN Tracey Hopkins, BSN, RN Purchase additional copies of this book at your health science bookstore or directly from F. A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2008 by F. A. Davis Company All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Robert G. Martone Developmental Editor: William Welsh Director of Content Development: Darlene D. Pedersen Senior Project Editor: Danielle J. Barsky Art and Design Manager: Carolyn O’Brien Consultants: Kim Cooper, MSN, RN; Faith Darilek, MSN, RN; Loretta H. Diehl, MSN, RN As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 80361767/08
$.10.

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Sticky Notes ✓ HIPAA Compliant ✓ OSHA Compliant

Waterproof and Reusable Wipe-Free Pages Write directly onto any page of LPN Notes, 2e with a ballpoint pen. Wipe old entries off with an alcohol pad and reuse.

BASICS

ASSESS

LIFE SPAN MED-SURG

MEDS LABS ECG PATIENT IV FLUIDS EDUCATION

TOOLS

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1 Communication Lifespan Considerations ■ Be considerate of generational and gender differences. ■ When dealing with elderly Pts, be aware of cognitive impairment, but never assume that a Pt is cognitively impaired simply because of advanced age. ■ Approach children at their eye level. Address them by name and use language appropriate to their developmental level.

Cultural Considerations ■ Be aware that culture has a strong influence on an individual’s interpretation of and responses to health care. ■ An interpreter may help ease anxieties of a language barrier. ■ Be sensitive to cultural influence on nonverbal communication, i.e., touching or eye contact may be perceived as disrespectful.

Communication Techniques ■ Using Open-Ended Questions: Avoids placing limits on a Pt’s response, e.g., “How do you feel today?” ■ Offering General Leads: Encourages Pt to continue and elaborate on a topic, e.g., “Can you tell me more?” ■ Providing Broad Openings: Encourages Pt to take the initiative, e.g., “What would you like to talk about?” ■ Clarifying: Increases the accuracy of the Pt’s understanding, e.g., “You seem concerned about your procedure.” ■ Reflecting: Clarifies meaning and encourages Pt to elaborate. Repeat Pt’s statement back in a questioning tone, e.g., “You’re not sleeping well since you were admitted?” ■ Exploration: Prompts Pt to elaborate on specific areas of interest so that you can assess a pertinent topic in more detail, e.g., “Tell me more about that.” ■ Focusing: Keeps conversation goal-directed, specific, and concrete. Demonstrates to Pt that you are attending to what is being discussed, e.g., “What does that mean to you?” ■ Using Hypothetical Questions: Helps to determine a Pt’s cognitive abilities and accuracy of information. Assesses readiness to be discharged, e.g., “What will you do if you become short of breath?” ■ Silence: Conveys acceptance of Pt whether or not Pt is talking, e.g., remain silent and allow Pt to collect thoughts and express emotions. ■ Evaluation: Encourages Pt to evaluate quality of care you are providing so that you can better accommodate an individual’s needs, i.e., “How does that seem to you?”

BASICS

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BASICS

Oxygen Delivery Equipment Nasal Cannula ■ ■ ■ ■ ■

Indicated for low flow, low percentage supplemental O2. Flow rate of 1–6 L/min. Delivers 22%–44% O2. Pt can eat, drink, and talk. Extended use can be very drying; use with a humidifier.

Simple Face Mask ■ ■ ■ ■ ■

Indicated for higher percentage supplemental O2. Flow rate of 6–10 L/min. Delivers 35%–60% O2. Lateral perforations permit exhaled CO2 to escape. Permits humidification. Exhalation ports

Elastic strap

To oxygen source

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3 Nonrebreather Mask ■ Indicated for high percentage supplemental O2. ■ Flow rate of up to 15 L/min. ■ Delivers up to 100% O2. ■ One-way flaps open and close with respiration and result in a high concentration of delivered O2 and minimal to no CO2 rebreathed by Pt.

(one-way valves)

Exhalation port

Inhalation port

Venturi Mask (Ventimask) ■ Indicated for precise titration of percentage of O2. ■ Flow rate of 4–8 L/min. ■ Delivers 24%–40% O2. ■ Accurate delivery of O2 is accomplished with a graduated dial that is set to desired percentage of O2 to be delivered.

BASICS

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BASICS

Bag-Valve Mask (BVM) ■ Indicated for manual ventilation of a Pt who has no or ineffective respirations. ■ Can deliver up to 100% O2 when it is connected to O2 source. ■ Appropriate mask size and fit are essential to create a good seal. ■ To create seal, hold mask with thumb and index finger and grasp underneath the ridge of the jaw with remaining three fingers.

One way valve

Reservoir

Mask Bag O2 supply

Humidified Systems ■ Indicated for Pts requiring longterm O2 therapy to prevent drying of mucous membranes. ■ Setup may vary among brands. Fill canister with sterile water to recommended level, attach to O2 source, and attach mask or cannula to humidifier. Adjust flow rate.

To oxygen source

To patient

Maximum fill line

Sterile water in reservoir

Transtracheal Oxygenation ■ Indicated for Pts with tracheostomy who require long-term O2 therapy and/or intermittent, transtracheal aerosol treatment. ■ Ensure proper placement (over stoma, tracheal tube). ■ Assess for and clear secretions as needed. ■ Assess skin for irritation.

Chain necklace Tract Transtracheal catheter (connect to oxygen) Trachea

4

Minimum water level line

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5 Artificial Airways Oropharyngeal Airway (OPA) OROPHARYNGEAL AIRWAY ■ Indicated for unconscious Pts TRACHEA who have no gag reflex. TONGUE ESOPHAGUS ■ Measure from corner of Pt’s OROPHARYNGEAL AIRWAY mouth to the earlobe. PHARYNX ■ Insertion method # 1 (do not use for small child): Insert upside down and rotate 180 degrees as it passes crest of tongue. Be careful not to injure hard or soft palate, to minimize risk of bleeding. ■ Insertion method # 2 (all ages): Displace tongue with tongue depressor and insert airway (right side up) posteriorly, following normal curve of oral cavity.

Nasopharyngeal Airway (NPA) ■ Indicated for Pts with a gag reflex or for comatose Pts with spontaneous respirations. ■ Measure from tip of Pt’s nose to earlobe. ■ Diameter should match Pt’s smallest finger. ■ NEVER insert in presence of facial trauma!

Endotracheal Tube (ETT) ■ Indicated for apnea, airway obstruction, respiratory failure, risk of aspiration, or therapeutic hyperventilation. ■ Can be inserted through mouth or nose. ■ Inflated cuff protects Pt from aspiration.

BASICS

NASOPHARYNGEAL AIRWAY PHARYNX TRACHEA

ESOPHAGUS

NASOPHARYNGEAL AIRWAY

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BASICS

Laryngeal Mask Airway (LMA) ■ Often used in noncomplicated surgical procedures and by EMS. ■ Direct visualization not needed for proper placement. ■ When cuff is inflated, mask conforms to hypopharynx, occludes esophagus, and protects glottic opening.

Pulse Oximeters Finding SpO2
95% SpO2 91%–94%

SpO2 85%–90%

SpO2 85%

Intervention ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Considered normal and requires no intervention. Continue routine monitoring of Pt. Considered acceptable. Assess probe placement and adjust if necessary. Continue to monitor Pt. Raise HOB and stimulate Pt to breathe deeply. Assess airway and encourage coughing Suction airway if needed. Administer oxygen and titrate to SpO2
90%. Notify physician and RT if SpO2 fails to improve after a few minutes. ■ Administer 100% oxygen, position Pt to facilitate breathing, suction airway if needed, and notify physician and RT immediately. ■ Check medication record and consider naloxone or flumazenil for medication-induced respiratory depression. ■ Be prepared to manually ventilate or aid in intubation if condition worsens or fails to improve.

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7 Caution: Consider readings within overall context of Pt’s medical history and physical exam. Reliability of pulse oximeters is sometimes questionable, and many conditions can produce false readings. Assess Pt’s skin signs, RR, and HR. Ask how Pt is feeling. Repositioning probe to a different location (ears, toes, or different finger) may help correct suspected false reading. Note: readings
90% may be considered normal to acceptable in Pts who normally live at higher altitudes.

Conditions That May Produce False Readings Alkalosis . . . . . . . . . . . . . . . . . . . . . . . . . . Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . Carbon monoxide (CO) poisoning . . . . . . Hypovolemia . . . . . . . . . . . . . . . . . . . . . . Pt movement . . . . . . . . . . . . . . . . . . . . . . Cool extremities . . . . . . . . . . . . . . . . . . . . Dark pigment . . . . . . . . . . . . . . . . . . . . . . Nail polish or nail infections . . . . . . . . . . Medication (peripheral vasoconstrictors) Poor peripheral circulation . . . . . . . . . . . Raynaud’s disease . . . . . . . . . . . . . . . . . .

. . . . false high . . . . false high . . . . false high . . . . false high . . . . erratic readings . . . . false low . . . . false low . . . . false low . . . . false low . . . . false low . . . . false low

Suctioning a Patient on a Ventilator Preparation ■ Prepare Pt: Explain procedure and offer reassurance. ■ Gather supplies: Sterile gloves, sterile suction catheter and tubing, sterile normal saline, sterile basin, bag-valve mask connected to a supplemental oxygen source, suction source. ■ Equipment: Ensure that wall or portable suction is turned on (no higher than 120 mm Hg), and position supplies and suction tubing so that they are easily accessible. ■ Wash hands: Follow standard precautions.

Preprocedure ■ Setup: Using sterile technique, open and position supplies so that they are within easy reach. Fill sterile basin with sterile normal saline, and open sterile gloves close by so that they are easy to reach. ■ Position yourself: Stand at Pt’s bedside so that your nondominant hand is toward Pt’s head. ■ Preoxygenate: Manually ventilate Pt with 100% O2 for several deep breaths.

BASICS

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BASICS

Technique ■ Don sterile gloves. ■ Wrap sterile suction catheter around your dominant hand and connect it to the suction tubing. Wrapping catheter around your hand prevents it from dangling and minimizes risk of contamination. Be careful not to touch your dominant hand with the end of suction tubing. ■ Note: Your nondominant hand is no longer sterile and must not touch any part of the catheter or your dominant hand. ■ Insert suction catheter just far enough to stimulate cough reflex. ■ Apply intermittent suction while withdrawing catheter and rotating 360 degrees for no longer than 10–15 seconds to prevent hypoxia. ■ Ventilate with 100% O2 for several deep breaths. ■ Repeat until Pt’s airway is clear. ■ Suction oropharynx after suctioning of airway is complete. ■ Rinse catheter in basin with sterile saline in between suction attempts (apply suction while holding tip in the saline). ■ Rinse suction tubing when done and discard soiled supplies.

Troubleshooting Tracheostomies Neuro: Anxiety, restlessness Resp: Respiratory distress, gasping, airway obstruction CV: Tachycardia, hypertension Skin: Cool, pale, cyanotic, diaphoretic Note: Pt may be asymptomatic (with established stomas)

Tracheostomy Dislodgement ■ If tracheostomy is less than 4 days old, STAT intervention is required because tract can collapse suddenly. ■ Notify physician and RT STAT. Only trained personnel should replace new tracheostomy tube. ■ Open tracheostomy with a sterile hemostat, suction catheter, or sterile gloved finger to maintain airway and to keep the edges of the tracheostomy from collapsing. ■ If Pt cannot breathe, ventilate using BVM. ■ If you cannot be sure that someone clinically prepared to reinsert tracheostomy tube will arrive within 1 minute, call Code. ■ If tracheostomy is more than 4 days old, tract will be well formed and will not close quickly. ■ Notify physician and RT that tube needs to be replaced. ■ Obtain replacement tube, if not already at Pt’s bedside. ■ Stay with Pt and prepare for insertion of new tube.

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9 NG (Nasogastric) Tube: Insertion ■ Explain procedure to Pt and offer reassurance. ■ Auscultate abdomen for positive bowel sounds if NG tube is to be used for administration of feedings or medication. ■ Position Pt upright in high-Fowler’s position. Instruct Pt to keep chin-tochest posture during insertion. This helps to prevent accidental insertion into trachea. ■ Measure tube from tip of nose to earlobe, then down to the xiphoid. Mark this point on tube with tape. ■ Lubricate tube by applying water-soluble lubricant to tube. Never use petroleum-based jelly, which degrades PVC tubing. ■ Insert tube through nostril until you reach previously marked point on tube. Instruct Pt to take small sips of water during insertion to help facilitate passing of tube. ■ Secure tube to Pt’s nose using tape. Be careful not to block nostril. Tape tube 12–18 inches below insertion line and then pin tape to Pt’s gown. Allow slack for movement. ■ Position HOB at 30–45 degrees to minimize risk of aspiration. ■ Confirm proper location of NG tube: ■ Pull back on plunger* of a 20-mL syringe to aspirate stomach contents. Typically, gastric aspirates are cloudy and green, or tan, off-white, bloody, or brown. Gastric aspirate can look like respiratory secretions, so it is best also to check pH. ■ Dip litmus paper into gastric aspirate. A reading of a pH of 1–3 suggests placement in stomach. ■ An alternative, but less reliable, method is to inject 20 mL of air into tube while auscultating the abdomen. Hearing loud gurgle of air suggests placement in stomach. If no bubbling is heard, remove tube and reattempt. Withdraw tube immediately if Pt becomes cyanotic or develops breathing problems. ■ An inability to speak also suggests intubation of trachea instead of stomach. ■ *Note: small-bore NI (nasointestinal) tubes (i.e., Dobhoff) may collapse under pressure, and initial confirmation of placement is obtained by xray. ■ Assemble equipment (wall suction, feeding pump, etc.) per manufacturer guidelines. ■ Document type and size of NG tube, which nostril, and how Pt tolerated procedure. Document how tube placement was confirmed and whether tubing was left clamped or attached to feeding pump or suction.

BASICS

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BASICS

NG Tube: Care and Removal Patient Care ■ Reassess placement of tube before administering bolus feedings, fluids, or meds and at every shift for continuous feedings. ■ Flush tube with 30 mL of water after each feeding and after each administration of medication. ■ Assess for skin irritation or breakdown. Retape daily and at alternate sites to avoid constant pressure on one area of the nose. Gently wash around nose with soap and water and dry before replacing tape. Provide nasal hygiene daily and p.r.n. ■ Provide good oral hygiene every 2 hours and p.r.n. (mouth wash, water, toothettes → clean tongue, teeth, gums, cheeks, and mucous membranes). If Pt is performing oral hygiene, remind him or her not to swallow any water.

Removal ■ Explain procedure to Pt. Observe standard precautions. ■ Remove tape from nose and face. ■ Clamp or plug tube (prevents aspiration), instruct Pt to hold breath, and remove tube in one gentle, but swift motion. ■ Assess for signs of aspiration.

NG Tube Feedings ■ Confirm placement before using: (1) Using 20-mL syringe, inject 20-mL bolus of air into feeding tube while auscultating abdomen. Loud gurgling indicates proper placement. DO NOT attempt this with water! (2) Use 20-mL syringe and gently aspirate gastric content. Dip litmus paper into gastric aspirate; pH of 1–3 suggests proper placement. ■ Maintenance: Flush with 30 mL of water every 4–6 hours and before and after administering tube feedings, checking for residuals, and administering medications. ■ Medication: Dilute liquid medications with 20–30 mL of water. Obtain all medications in liquid form. If liquid form is not available, check with pharmacy to see if medication can be crushed. Administer each medication separately and flush with 5–10 mL of water between each medication. Do not mix medications with feeding formula! ■ Residuals: Check before bolus feeding, administration of medication, or every 4 hours for continuous feeding. Hold feeding if
100 mL and recheck in 1 hour. If residuals are still high after 1 hour, notify physician.

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11 Types of Tube Feedings ■ Initial tube feedings: Advance as tolerated by 10–25 mL/hour every 8–12 hours until goal rate is reached. ■ Intermittent feedings: Infusions of 200–400 mL of enteral formulas several times per day infused over a 30-minute period. ■ Continuous feedings: Feedings initiated over 24 hours with the use of an infusion pump.

Checking Residuals ■ Using 60-mL syringe, withdraw from gastric feeding tube any residual formula that may remain in stomach. ■ Volume of this formula is noted, and if it is greater than predetermined amount, stomach is not emptying properly, and next feeding dose is withheld. ■ This process can indicate gastroparesis and intolerance to advancement to higher volume of formula.

Tube Feeding Complications Nausea, Vomiting, and Bloating

■ Large residuals: Withhold or decrease feedings. ■ Medication: Review meds and consult physician. ■ Rapid infusion rate: Decrease rate.

Diarrhea

■ Too rapid administration: Reduce rate. ■ Refrigerated TF (too cold): Administer at room temp. ■ Tube migration into duodenum: Retract tube to reposition in stomach and reconfirm placement.

Constipation

■ Decreased fluid intake: Provide adequate hydration. ■ Decreased dietary fiber: Use formula with fiber.

Aspiration and gastric reflux

■ Improper tube placement: Verify placement. ■ Delayed gastric emptying: Check residuals. ■ Position of patient: Keep HOB elevated 30–45 degrees.

BASICS

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BASICS

Occluded tube

■ Inadequate flushing: Flush more routinely. ■ Use of crushed meds: Switch to liquid meds.

Displaced tube

■ Improperly secured tube: Retape the tube. ■ Confused patient: Follow hospital protocol.

Ostomy Care Types of Ostomies ■ Colostomy: May be permanent or temporary. Used when only part of large intestine is removed. Commonly placed in sigmoid colon, stoma is made from large intestine and is larger in appearance than an ileostomy. Contents range from firm to fully formed, depending on amount of remaining colon. ■ Ileostomy: May be permanent or temporary. Used when entire large intestine must be removed. Stoma is made from small intestine and is therefore smaller than that of a colostomy. Contents range from paste-like to watery. ■ Urostomy: Used when urinary bladder is either bypassed or must be removed altogether.

Procedure for Changing an Ostomy Bag ■ ■ ■ ■ ■ ■ ■ ■

■ ■ ■

Explain procedure to Pt. Gather supplies. Place Pt in supine position. Wash hands and observe standard precautions (don gloves). Remove old pouch by gently pulling away from skin. Discard gloves, wash hands, and don new pair of gloves. Gently wash area around stoma with warm, soapy water, and then dry skin thoroughly. Inspect appearance of the stoma and condition of skin, and note amount, color, consistency of contents, and presence of unusual odor (note: normal-looking stoma should be pink-red, and peristomal skin should be free from any redness or ulceration). Cover exposed stoma with gauze pad to absorb any drainage during ostomy care. Apply skin prep in circular motion and allow to air dry for approximately 30 seconds. Apply skin barrier in circular motion.

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13 ■ Measure stoma using stoma guide and cut ring to size. ■ Remove paper backing from adhesive-backed ring, and, using gentle pressure, center ring over stoma and press it to skin. ■ Smooth out any wrinkles to prevent seepage of effluent. ■ Center faceplate of bag over stoma and gently press down until completely closed. ■ Document appearance of the stoma, condition of skin, amount, color, and consistency of contents, and presence of any unusual odor. ■ Discard soiled items per hospital policy using standard precautions.

Urinary Catheters Straight Catheter ■ Also called a red rubber catheter or “straight cath.” Straight catheters have only single lumen and do not have balloon near tip. Straight catheters are inserted for only as much time as it takes to drain bladder or obtain urine specimen.

Indwelling Catheter ■ Also called a Foley or retention catheter. Indwelling catheters have two lumens, one for urine drainage and the other for inflation of balloon near tip. Three-Way Foley catheters are used for continuous or intermittent bladder irrigation. They have a third lumen for irrigation.

Procedure for Insertion ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Prepare Pt: Explain procedure and provide privacy. Assess Pt for allergies to latex, iodine, or tape. Collect appropriate equipment. Place Pt in supine position (Female: knees up, legs apart; Male: legs flat, slightly apart). Open and set up catheter kit using sterile technique. Don sterile gloves and set up sterile field. If placing indwelling catheter, check for leaks and proper inflation of balloon by filling with 5 mL of sterile water. Remove water. Lubricate end of catheter. Saturate cotton balls with cleansing solution. With nondominant hand (now contaminated): Female: hold labia apart; use dominant (sterile) hand to hold swabs with sterile forceps and swab from front to back, in following order: (1) labia farthest from you, (2) labia

BASICS

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BASICS

■ ■ ■ ■ ■ ■ ■

nearest to you, (3) center of meatus between each labia. Use one swab per swipe. Male: retract foreskin (replace foreskin back down over penis after catheter has been successfully inserted); use dominant (sterile) hand to hold swabs with sterile forceps and swab in circular motion from meatus outward. Repeat three times, using different swab each time. Gently insert catheter (about 2–3 inches for female Pts and 6–9 inches for male Pts) until return of urine is noted. Caution: Never force catheter if resistance is encountered! For straight catheters: Obtain specimen or drain bladder and then remove and discard catheter. For indwelling catheters: Insert additional inch and then inflate balloon with recommended volume. Attach catheter to drainage bag using sterile technique. Secure catheter to Pt’s leg according to hospital policy. Hang drainage bag on bed frame below level of bladder. Document type and size of catheter, amount and appearance of urine, and how Pt tolerated procedure.

Urinary Catheter Care and Removal Routine Catheter Care ■ Use standard precautions. ■ Keep bag below level of Pt’s bladder at all times. ■ Check frequently to be sure there are no kinks or loops in tubing and that Pt is not lying on tubing. ■ Do not pull or tug on catheter. ■ Wash around catheter entry site with soap and water twice each day and after each bowel movement. ■ Do not use powder around catheter entry site. ■ Periodically check skin around catheter entry site for signs of irritation, redness, tenderness, swelling, or drainage. ■ Offer fluids frequently (if not contraindicated by health status), especially water or cranberry juice. ■ Record urine output every shift or per physician orders. ■ Empty collection bag each shift; note quantity, color, clarity, odor, and presence of sediment. ■ Notify physician of any of the following: ■ Blood, cloudiness, or foul odor. ■ Decreased urine output (30 mL/hour): order bladder scan. ■ Irritation, redness, tenderness, swelling, or drainage or leaking around catheter entry site. ■ Fever or abdominal or flank pain.

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15 Procedure for Removal ■ Don gloves and observe standard precautions. ■ Use 10-mL syringe to withdraw all water from balloon. Some catheter balloons are overinflated or have up to 30-mL balloon; withdraw and discard water until no more water can be removed. ■ Hold a clean 44 at meatus in nondominant hand. With dominant hand, gently pull catheter. If you meet resistance, stop and reassess if balloon is completely deflated. If balloon appears to be deflated and catheter cannot be removed easily, notify physician. ■ Wrap tip in clean 44 as it is withdrawn to prevent leakage of urine. If culture of catheter tip is desired, wrap tip in sterile 44 as it is withdrawn. ■ Note time that catheter was discontinued. ■ Provide bedpan, urinal, or assistance to bathroom as needed. ■ Document time of removal and how Pt tolerated procedure. ■ Document amount and time of spontaneous void. ■ If Pt does not void within 8 hours, palpate bladder and notify physician. Catheter may need to be reinserted.

Specimen Collection: Blood General Guidelines ■ ■ ■ ■ ■

Verify if Pt has allergies to latex, iodine, adhesives, etc. Tourniquet should not be left in place longer than 1 minute. Previous puncture site areas should be avoided for 24–48 hours. Specimens should never be collected above IV site. Order of draw: If multiple tubes are required, they are collected in following order: blood cultures, red or red marble-top with gel, light blue, green, lavender, and then gray.

Procedure ■ Prepare Pt: Explain procedure to Pt, offer reassurance, and assess for allergies to latex, iodine, or tape. ■ Supplies: Tourniquet, skin cleanser, sterile 22 gauze, evacuated collection tubes or syringes, needle and needle holder, and tape. ■ Position patient: Sitting or lying with arm extended and supported. ■ Tourniquet: 3–4 inches above intended venipuncture site. ■ Choose vein: Most common and easily accessed are median cubital, cephalic, and basilic veins located in antecubital (AC) fossa anterior to elbow. Veins of forearm, wrist, and hand may also be used but are smaller and often more painful.

BASICS

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BASICS

■ Cleanse site: Briefly remove tourniquet. With alcohol swab, cleanse site from center outward, using a circular motion. Allow site to air dry for 30–60 seconds. For blood alcohol level and blood culture specimens, use iodine in place of alcohol. ■ Perform venipuncture: Reapply the tourniquet. If necessary, cleanse end of gloved finger for additional vein palpation. Insert needle, bevel up, at 15–30 degrees using dominant hand. With nondominant hand, push evacuated collection tube completely into needle holder or pull back on syringe plunger with slow, consistent tension. ■ Remove tourniquet: If procedure will last longer than 1 minute, remove tourniquet after blood begins to flow. ■ Remove needle: Remove tourniquet if still in place. Place sterile gauze over puncture site, remove needle, and apply pressure. ■ Equipment disposal: Per facility policy/standard precautions. ■ Prepare specimen: If using syringes, transfer specimen into proper tubes. Mix additives with gentle rolling motion. Label specimen tubes with Pt’s name, ID number, date, time, and your initials. ■ Document: Record specimen collection in medical record.

Examples of Common Labs Red: (blood bank, type and cross, discard tube) Red marble-top or gold: (chemistry, Ca, BUN, creatinine) Light blue: (coagulation studies, PT, PTT, INR, fibrinogen)

Lavender: (hematology, CBC, ABC, H&H, platelet counts,) Gray: (chemistry, glucose determinations)

Green: (chemistry, ionized Ca, plasma determinations)

Specimen Collection: Urine Random ■ Indicated for routine screening and may be collected at any time. ■ Instruct Pt to void into specimen container.

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17 Clean Catch (Midstream) ■ Indicated for microbiologic and cytologic studies. ■ Male patients: Wash hands thoroughly, cleanse the meatus, pull back foreskin, void small amount into toilet, then void into specimen collection container. Secure lid tightly. ■ Female patients: Wash hands thoroughly, and cleanse labia and meatus from front to back. While holding labia apart, void small amount into toilet, and then, without interrupting flow of urine, void into specimen collection container. Secure lid tightly.

Catheterized Random/Clean Catch ■ Ensure that tubing is empty, and then clamp tube distal to collection port for 15 minutes. ■ Cleanse collection port with antiseptic swab and allow to air dry. ■ Using needle and syringe, withdraw required amount of specimen and then unclamp tubing. ■ Follow lab guidelines for handling.

First Morning ■ Yields very concentrated specimen for screening substances less detectible in more dilute sample. ■ Instruct Pt to void into specimen container on awakening.

Second Void ■ Instruct Pt to void, drink a glass of water, wait 30 minutes, and then void into specimen collection container.

Timed (24-Hour Urine) ■ Used to quantify substances in urine and to measure substances whose level of excretion varies over time. ■ Ideally, collection should begin between 6:00 a.m. and 8:00 a.m. ■ Specimen container should be refrigerated or kept on ice for entire collection period. ■ Start time of 24-hour collection begins with collection and discard of first void. ■ Instruct Pt to discard first void of day and record date and time on collection container.

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■ Add each subsequent void to collection container, and instruct Pt to void at same time on following morning and add it to collection container. ■ This is the end of 24-hour collection period. ■ Record date and time, and send specimen to lab.

Timed (24-Hour Urine): Catheterized Patients ■ Follows the same guidelines as regular timed urine collection, but started after bag and tubing have been replaced. This is start time and should be recorded on collection container. ■ Either collection bag is kept on ice or specimen is emptied every 2 hours into a collection container, which is refrigerated or kept on ice. ■ At end of 24 hours, remaining urine is emptied into collection container. ■ This is the end of 24-hour collection period. ■ Record date and time, and send specimen to lab.

Specimen Collection: Sputum/Throat Culture General Guidelines ■ Use standard precautions when obtaining or handling specimen. ■ Cultures should be obtained before administration of antimicrobial therapy. ■ Document all specimen collections in medical record.

Expectorated Specimens ■ Instruct Pt to brush teeth or rinse mouth before specimen collection, to avoid contamination with normal oral flora. ■ Assist Pt to an upright position and provide over-bed table. ■ Instruct Pt to take two to three deep breaths and then cough deeply. ■ Sputum should be expectorated directly into sterile container. ■ Label specimen container, and send at room temperature to lab.

Throat Culture ■ ■ ■ ■ ■

Contraindicated in patients with acute epiglottitis. Instruct Pt to tilt the head back and open mouth. Use tongue depressor to prevent contact with tongue/uvula. Using sterile culturette, swab both tonsillar pillars and oropharynx. Place culturette swab into culturette tube and squeeze bottom to release liquid transport medium. ■ Ensure that swab is immersed in liquid transport medium. ■ Label specimen container and send at room temperature to lab.

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19 Specimen Collection: Stool General Guidelines ■ Use standard precautions when obtaining/handling specimen. ■ Freshest sample possible will yield optimal results. ■ Specimens should not contact urine or toilet water. Provide clean specimen hat, and instruct Pt to urinate into toilet first and discard (flush) urine before collecting stool sample. ■ Preservatives are poisonous; avoid contact with skin.

Occult Blood (Hemoccult, Guaiac) ■ Open collection card. ■ Obtain a small amount of stool with wooden collection stick and apply onto area labeled box A. ■ Use other end of wooden collection stick to obtain second sample from different area of stool and apply it onto area labeled box B. ■ Close card, turn over, and apply one drop of control solution to each box as indicated. ■ Color change is positive, indicating blood in stool. ■ Note: If Pt will be collecting specimens at home, instruct Pt to collect specified number of specimens, keep them at room temperature, and drop them off within designated time frame. ■ Document results on Pt’s record and notify physician if indicated.

Cysts and Spores: Ova and Parasites ■ Open collection containers. ■ Using spoon attached to cap, place bloody or slimy/whitish (mucous) areas of stool into each container. ■ Do not overfill containers. ■ Place specimen in empty container (clean vial) up to fill line, and replace cap and tighten securely. ■ Place enough specimen in container with liquid preservative (fixative) until liquid reaches fill line, and replace cap and tighten securely. ■ Shake container with preservative until specimen is mixed. ■ Write Pt’s identification information and date and time of collection on each of containers, keep at room temperature, and send specimens to lab immediately after collection. ■ Note: If Pt will be collecting specimens at home, instruct Pt to collect specified number of specimens, keep them at room temperature, and drop them off within designated time frame. ■ Document: Record specimen collection in medical record.

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Sterile Dressing Change ■ ■ ■ ■ ■ ■ ■ ■ ■

■ ■

■ ■ ■

Wash hands, explain procedure, and position and drape Pt. Open sterile gloves on nearby surface. Using sterile technique, open supplies and set up sterile field. Instruct Pt not to touch incision/wound or sterile supplies. Don clean (nonsterile) gloves and remove old dressing: ■ Pull tape toward incision, parallel to skin. ■ Be careful not to dislodge any drainage tubes or sutures. Assess condition and appearance of wound including size, color, and presence of exudate, odor, ecchymosis, or induration. Discard gloves and old dressing per standard precautions. Wash hands and don sterile gloves. Cleanse wound with prescribed solution: ■ Start from area of least contamination, and cleanse toward the area of most contamination (use a separate swab for each stroke). ■ Cleanse around drains using a circular motion working outward. Apply medicated/antiseptic ointments as prescribed. Apply prescribed sterile dressing to incision or wound: ■ Cut dressings to fit around drain if present (use sterile scissors). ■ Dry dressing: Cover wound with sterile gauze (22, 44, etc.). ■ Wet-to-dry: Cover or pack wound with saline-moist, sterile gauze, and then cover with dry, sterile gauze (22, 44, etc.), thick ABD, or SurgiPad. ■ Wound packing: Soak sterile gauze in prescribed sterile solution and wring out any excess. Using sterile forceps, gently pack wound until all wound edges are in contact with moist gauze, including any undermined areas. Do not overpack wound (stop at skin level). Reinforce with thick cover dressing (ABD or Surgi-Pad). Secure dressing with tape, rolled gauze, or Montgomery ties. Document: Record dressing change and assessment findings.

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21 Complete Health History ■ Biographic Data: Record Pt’s name, age and date of birth, gender, race, ethnicity, nationality, religion, marital status, children, level of education, job, and advance directives. ■ Chief Complaint (subjective): Symptom analysis for chief complaint. This is what the Pt tells you. Chief complaint should not be confused with medical diagnosis (e.g., Pt is complaining of nausea and vomiting and is later diagnosed to be having an MI; chief complaint is nausea and vomiting and is documented as such even though the medical diagnosis may be evolving MI). ■ Past Health History: Record childhood illnesses, surgical procedures, hospitalizations, serious injuries, medical problems, immunization, and recent travel or military service. ■ Medications: Ask about prescription medications taken on a regular basis as well as those medications taken only when needed (p.r.n). Note: p.r.n. medications may not be used very often and are likely to have an outdated expiration date. Remind Pts to replace outdated medications. Inquire about OTC drugs, vitamins, herbs, alternative regimens, and use of recreational drugs or alcohol. ■ Allergies: Do not limit to drug allergies. Include allergies to food, insects, animals, seasonal changes, chemicals, latex, adhesives, etc. Try to differentiate between allergy and sensitivity, but always err on the side of safety if unsure. Determine type of allergic reaction (itching, hives, dyspnea, etc.). ■ Family History: Includes health status of spouse/significant other, children, siblings, parents, aunts, uncles, and grandparents. If deceased, obtain age and cause of death. ■ Social History: Assess health practices and beliefs, typical day, nutritional patterns, activity/exercise patterns, recreation, pets, hobbies, sleep/rest patterns, personal habits, occupational health patterns, socioeconomic status, roles/relationships, sexuality patterns, social support, and stress coping mechanisms. ■ Physical Assessment (objective): There are three methods for performing a complete physical assessment. ■ Head-to-toe: More complete, it assesses each region of the body (i.e., head and neck) before moving on to the next. ■ Systems assessment: More focused, it assesses each body system (i.e., cardiovascular) before moving on to the next. ■ Focused assessment: Priority of assessment is dictated by Pt’s chief complaint.

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Physical Assessment Systematic Approach ■ ■ ■ ■ ■ ■ ■ ■

Always observe standard precautions. Listen to your Pt. Provide a comfortable environment and ensure privacy. If there is an obvious problem, start at that point. Work from head to toe and compare right to left. Let your Pt know your findings and use this time to teach. Leave sensitive or painful areas until the end of the exam. Techniques used for physical assessment include (1) inspection, (2) palpation, (3) percussion, and (4) auscultation and, except for the abdomen, are carried out in this order. ■ Document assessments, interventions, and outcomes.

Assessing Vital Signs ■ Heart Rate: Using two to three fingers, palpate pulse over pulse point for 30 seconds and multiply by two. If pulse is irregular, count for an entire minute. Compare pulses right to left. Document: Rate, rhythm, strength, and any right-left differences. ■ Respirations: Ensure that Pt is resting comfortably and is unaware that respirations are being monitored. Count respirations for 30 seconds and multiply by two (count irregular or labored respirations for a full minute). Document: Rate, depth, effort, rhythm, and any sounds, noting whether heard on inspiration, expiration, or both. ■ Blood Pressure: Place Pt in comfortable position with arm slightly flexed and palm facing up, with forearm supported at heart level (Pt’s legs should not be crossed). Apply cuff snugly around upper arm and ensure proper size and fit. Place stethoscope over brachial artery and inflate cuff ~30 mm Hg over expected systolic pressure. Slowly release cuff pressure. NEVER measure BP on arm with dialysis shunt, injury, intra-arterial line, or same side mastectomy or axilla surgery! Avoid arms with IV/VAD if possible. Document: Point at which sound is first heard (systolic) over point at which sound completely ceases (diastolic). ■ Temperature: Oral—electronic: Reading obtained in ~1 minute; Oral— glass: Reading obtained in ~2–3 minutes; Oral—chemical (Temp-a-dot): Reading obtained in ~45 seconds; Tympanic—electronic: Reading obtained in ~2 seconds. Document: Temperature reading and route.

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23 Focused Symptom Analysis (PQRST) Below are three examples (pain, respiratory, and nausea) of how the PQRST mnemonic can be universally applied when assessing any number of symptoms or various Pt complaints. P

Provocative, precipitating, and palliative factors ■ Pain: Activity at or before onset. Does anything make pain better or worse? ■ Respiratory: Activity at or before onset. Factors that lessen or worsen level of distress. ■ Nausea: Last oral intake before onset. Factors that make nausea better or worse.

Q

Ask Pt to describe quality of the symptom. ■ Pain: Dull, stabbing, achy, pressure, or squeezing. ■ Respiratory: Productive/nonproductive cough, chest heaviness, bronchial tickle/cough reflex. ■ Nausea: Emesis, gagging/dry heaving, nausea only.

R

Ask Pt to describe location and/or whether symptom radiates to another region of body or if there are any related symptoms. ■ Pain: Location and radiation to another region of body. ■ Respiratory: Related symptoms (e.g., CP, nausea, fever, cough reflex, etc.). ■ Nausea: Related symptoms (e.g., diarrhea, constipation, indigestion, fever, headache, etc.).

S

Assess severity of the symptom. ■ Pain: Rate pain using 0/10 pain scale (see pages 42–43). ■ Respiratory: Can Pt speak in full sentences or must he or she take another breath after only one–two words? ■ Nausea: Nausea only, emesis, dehydration.

T

Determine timing factors related to symptom. ■ Determine duration of symptom. ■ Determine if symptom is constant or intermittent. ■ Determine if onset of symptom is sudden or gradual (over minutes, hours, days, or weeks).

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Adult Vital Signs: Normal Ranges HR

RR

SBP

DBP

60–100 12–20
120
80 Tympanic temperature 37.0–38.1C (98.6–100.6F) Oral temperature 36.4–37.6C (97.6–99.6F) Rectal temperature 37.0–38C (98.6–100.4F) Axillary temperature 35.9–37.0C (96.6–98.6F)

Temp *See below

Factors Affecting Vital Signs Factor

HR

Fever ↑ Anxiety ↑ Pain, acute ↑ Pain, chronic ↓ Acute MI ↓ Spinal injury ↓ Tamponade ↑ CHF ↑ Pulm. embolism ↑ Exercise ↑ ↓ H&H ↑ ↓ Blood glucose Normal/↑ ↑ Blood glucose ↑ ↑ WBC ↑ ↑ K ↓ ↓ K ↑ ↑ Ca ↓ ↓ Ca ↓ ↑ Na ↑ ↓ Na ↑ Narcotics ↓ Beta blockers ↓ Ca channel blockers ↓

RR

SBP

Temp

↑ ↑ ↑ Normal ↑ ↓ ↑ ↑ ↑ ↑ ↑ Normal ↑/Deep ↑ Shallow Shallow Normal Varies Normal/↑ Normal/↑ ↓ ↓ ↓

Normal ↑ ↑ Normal ↓ (Late) ↓ ↓ ↑ (Early) ↓ ↑ ↓ Normal/↑ ↓ ↓ (Sepsis) Normal/↑ ↓ ↓ ↓ ↑ ↓ ↓ ↓ ↓

↑ Normal Normal Normal Normal Normal/↑ Normal ↑ ↑ ↑ ↓ ↓ ↑ ↑ Normal Normal Normal Normal ↑ Normal ↓ Normal Normal

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25 Head and Neck Appearance: Inspect Pt’s overall appearance. ■ Hygiene, state of well-being, nutrition status. ■ Level of consciousness, emotional status, speech patterns, affect, posture, gait, coordination, and balance. ■ Any gross deformities. Skin: Inspect and palpate exposed skin. ■ Warmth, moisture, color, texture, lesions. ■ Scars, body piercings, tattoos. Hair and Nails: Inspect hair, hands, and nails. ■ Hair color, fullness, and distribution, noting any signs of malnutrition (thinning). ■ Infestation or disease. ■ Clubbing of nails, deformity, abnormalities of hands. Head: Inspect and palpate face and scalp. ■ Facial symmetry. ■ Scalp tenderness, lesions, or masses. Eyes: Inspect sclera, conjunctiva, and pupils. ■ Color and hydration of conjunctiva and sclera. ■ PERRLA: Pupils equal, round, reactive to light and accommodation. Ears: Inspect. ■ Hearing impairment. ■ Use of hearing aids. ■ Pain, inflammation, and drainage. Nose: Inspect. ■ Congestion, drainage, and sense of smell. ■ Patency/equality of nostrils, nasal flaring. ■ Septal deviation. Throat and Mouth: Inspect teeth, gums, tongue, mucous membranes, and oropharynx. ■ Color and hydration of mucous membranes. ■ Gingival bleeding or inflammation. ■ Condition of teeth (any missing, severe decay), dentures. ■ Difficult or painful swallowing. ■ Presence or absence of tonsils. ■ Oral hygiene and the presence of odor.

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Neck: Inspect and palpate neck. Test ROM. ■ Jugular vein distention (JVD), tracheal alignment (deviation), and retractions. ■ Swollen lymph nodes or enlarged thyroid......... ■ Decreased ROM, stiffness, or pain.

Cardiovascular System ■ Inspect: Overall condition and appearance. Inspect skin, nail beds, and extremities for flushing, pallor, cyanosis, bruising, and edema. Observe chest for scars, symmetry, movement, and deformity. Inspect neck for JVD and inspect PMI for any remarkable pulsations. Analyze ECG recording if available. ■ Palpate: Skin temperature and moisture. Palpate PMI for any lifts, heaves, thrills, or vibrations. Palpate and grade radial, dorsalis pedis, and posterior tibial pulses; note rate and rhythm. Palpate and grade edema if present. ■ Percuss: Starting at the midaxillary line, percuss toward the left cardiac border along the fifth ICS. Sound should change from resonance to dullness at midclavicular line. ■ Auscultate: Using stethoscope, auscultate apical pulse and compare it with radial pulse. Auscultate heart valves for normal S1 (lub) and S2 (dub) heart sounds. Abnormal sounds include extra beats (S3 and S4), bruits, valvular murmurs, pericarditic rubs, and artificial valve clicks.

Respiratory System ■ Inspect: Respirations for rate, depth, effort, pattern, and presence of cough (productive or nonproductive); note signs of distress such as nasal flaring or sternal retractions. Inspect size and shape of chest, symmetry of chest wall movement, and use of accessory muscles. Inspect extremities for cyanosis and fingers for clubbing indicating chronic hypoxia. Inspect trachea for scars, stomas, or deviation from midline. ■ Palpate: Anterior and posterior thorax for subcutaneous emphysema, crepitus, and tenderness. Assess tactile fremitus by palpating the chest as the Pt says “99.” ■ Percuss: Anterior and posterior thorax for tympany (hollow organs), resonance (air-filled organs), dullness (solid organs), or flatness (muscle or bone). ■ Auscultate: Using stethoscope, auscultate all anterior and posterior lung fields, noting normal, abnormal, or absence of lung sounds.

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27 Respiratory Patterns Normal (eupnea) Tachypnea Bradypnea Hyperventilation Apneustic Cheyne-Stokes Kussmaul Air trapping

Regular and comfortable at 12–20 breaths/minute. 20 breaths/minute.
12 breaths/minute. Rapid, deep respiration 20 breaths/minute. Neurologic: sustained inspiratory effort. Neurologic: alternating patterns of depth separated by brief periods of apnea. Rapid, deep, and labored: common in DKA. Difficulty during expiration: emphysema.

Lung Sounds: Differential Diagnosis Rales (Crackles) ■ ■ ■ ■

Simulated by rolling hair near ear between two fingers. Best heard on inspiration in lower bases. Unrelieved by coughing. Associated with bronchitis, CHF, and pneumonia.

Wheezes ■ ■ ■ ■

High-pitched, squeaky sound. Best heard on expiration over all lung fields. Unrelieved by coughing. Associated with asthma, bronchitis, CHF, and emphysema.

Rhonchi ■ ■ ■ ■

Coarse, harsh, loud gurgling. Best heard on expiration over bronchi and trachea. Often relieved by coughing. Associated with bronchitis and pneumonia.

Stridor ■ Harsh, high-pitched, audible sound. ■ Easily heard without stethoscope during inspiration and expiration.

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■ Indicates progressive narrowing of upper airway and can be lifethreatening, requiring immediate attention. ■ Associated with partial airway obstruction, croup (inspiratory), and epiglottitis (severe, audible).

Unilaterally Absent or Diminished ■ Inability to hear equal, bilateral breath sounds. ■ Associated with pneumothorax, tension pneumothorax, hemothorax, or history of pneumectomy.

Documentation of Lung Sounds ■ Rate, rhythm, depth, effort, sounds (indicate if sound is inspiratory and/or expiratory phase), and fields of auscultation. ■ Interventions (if any implemented) and outcomes.

Cardiac Auscultation Sites Aortic valve Pulmonic valve Right base

Left base

1

Mitral valve

Erb's point

2 3

Tricuspid valve

4

Left lateral sternal border

5 6

Apex Xiphoid

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29 Order of Auscultating Lung Sounds

Anterior view

Posterior view

Circulation and Pulses Assess

Document: Assessment, interventions, outcomes.

Pulses

Equality and character of pulses, comparing right and left.

6 Ps

Pain, pallor, pulselessness, polar, paresthesia, paralysis.

S/S

Swelling, limb pain, change in sensation, fatigue.

Skin

Color, temperature, moisture, hair growth.

Edema

Extremities and dependent areas for edema, varicosities.

Nails

Capillary refill, cyanosis, angle of attachment, clubbing.

History

PVD, DM, HTN, CHF, DVT, surgical procedures, lymphedema, meds.

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Capillary Refill Normal . . . . . . . . . . . . . . .
3 seconds Delayed . . . . . . . . . . . . . . . 3 seconds

Pulse Strength 0 1 2 3 4

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

. Absent . Weak . Normal . Full . Bounding

Right arm:

Left arm:

Right leg:

Left leg:

Edema Scale 1 . . . Slight pitting with 2 mm of depression that disappears rapidly. No visible distortion of extremity. 2 . . . Deeper pitting with 4 mm of depression that disappears in ~10–15 seconds. No visible distortion of extremity. 3 . . . Depression of 6 mm that lasts 1 minute. Dependent extremity appears swollen. 4 . . . Very deep pitting with 8 mm of depression that lasts 2–3 minutes. Dependent extremity is grossly edematous.

Common Pulse Points Temporal . . . . Carotid . . . . . Apical . . . . . . Brachial . . . . . Radial . . . . . . Femoral . . . . . Popliteal . . . . Dorsal pedis . . Posterior tibial

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

Just anterior to upper third of ear Below angle of jaw on either side of trachea Left side of chest at the 5th ICS, midclavicular line Medial antecubital fossa Medial-ventral wrist below base of thumb Crease of groin between pubis and hip bone Popliteal fossa behind knee Medial dorsum of foot Slightly below the posterior malleolus of the foot

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31 Abdomen Skill

Document: Assessment, Interventions, Outcomes

Inspect

Skin, distention, scars, obesity, herniations, bruising, pulsations.

Auscultate (before palpate)

Bowel tones: Hypoactive, every minute; normal, every 15–20 seconds; hyperactive, every 3 seconds.

Percussion

Dullness: Solid organ such as the liver. Tympany: Hollow organs such as bowels. Resonance: Air-filled organs such as lungs. Flatness: Dense tissue such as muscle and bone.

Palpate (last)

Pulsations, masses, tenderness, rigidity.

■ Work from area of least pain toward area of most pain. ■ Assess each abdominal quadrant (RUQ, LUQ, RLQ, LLQ). ■ When documenting assessment findings, always refer to specific abdominal quadrant related to finding.

Extremities Grips

Equality and strength: Have Pt squeeze your fingers with his or her hands and assess push-pull strength of feet.

CSM

Distal pulses, capillary refill, sensation, and motor movement.

Nails

Cyanosis, angle of attachment, clubbing.

ROM

Limitations and pain during movement.

Edema

Localized vs. diffuse, dependent vs. nondependent.

DVT

Homans’ sign (calf pain on dorsiflexion of foot) especially with postsurgical and debilitated Pts (NEVER massage affected extremities!). Signs/symptoms include pain, venous distention, localized tenderness.

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Skin: Integumentary Assess

Document: Assessment, Interventions, Outcomes

Color Temp Moisture Turgor

Cyanosis, redness, pallor, or jaundice. Coolness or warmth. Diaphoresis or excessive dryness. The time it takes the skin to flatten out after pinching section over forehead or sternum (do not use hand or arm; these are unreliable areas); poor skin turgor may indicate dehydration (may be normal in elderly). Extremities, sacrum, dependent side (if debilitated, bedfast, or chairfast), facial/sclera, bilateral vs. unilateral. Presence and type of skin lesions.

Edema Lesions

Genitourinary—Reproductive Assessment ■ Pain: Female Pts: Assess for dysmenorrhea (abnormally severe cramping or pain in lower abdomen during menstruation); Male Pts: Assess for pain in penis, testes, scrotum, and groin area. Is there any history of painful or burning urination? ■ Lesions: Inspect perineum for blisters, ulcers, sores, warts, or rashes. ■ Breast: Inspect for asymmetry. Inspect skin for dimpling or edema. Inspect nipples for color, discharge, or inversion. Palpate in concentric circles, outward from nipple, including axillae, for lumps or tenderness and presence of implants. Does Pt perform regular breast self-examinations? ■ Testicles: Palpate scrotum and groin area for lumps, masses, or swelling. Does Pt perform testicular self-examinations? ■ Discharge: Female Pts: Assess for vaginal discharge and note color, odor, amount, and any associated symptoms; Male Pts: Inspect meatus for discharge and note color, amount, and any associated symptoms. ■ Menstruation: Describe last menstrual period including date. Do periods occur regularly? Have Pt describe her “normal flow.” Bleeding other than normal menstrual period should be further assessed including frequency, quantity, and associated symptoms. ■ Genitourinary Symptoms: Kidney stones, blood in urine, dysuria, change in voiding pattern (frequency), itching, or erectile dysfunction in males. ■ Sexual History: Is Pt sexually active? Does he or she use protection against infection? Method of birth control? Multiple or same-sex partners? Any concern with or history of STD? ■ Document: Assessment, interventions, and outcomes.

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33 Brief Neurologic Exam Mental Status ■ Impression: Observe affect, mood, appearance, behavior, cognition, and grooming. ■ Speech: Assess for clarity and coherence. ■ LOC: Is Pt alert, lethargic, stuporous, or obtunded? ■ Orientation: Person, place, time, and/or situation.

Motor ■ Inspect: Involuntary movements, muscle symmetry, atrophy. ■ Muscle Tone: Flex and extend wrists, elbows, ankles, and knees; slight, continuous resistance to passive movement is normal. Note any decreased (flaccid) or increased (rigid or spastic) muscle tone. ■ Motor Strength: Have Pt move against your resistance and score accordingly (see Muscle Strength Grading Scale, page 35).

Reflexes ■ Tendon Reflexes: (see Deep Tendon Reflex Grading Scale, page 35). ■ Babinski (Plantar Reflex): Stroke lateral aspect of sole of each foot with reflex hammer. Normal response is flexion (withdrawal) of toes. Positive Babinski is characterized by extension of big toe with fanning of other toes (abnormal). ■ Clonus: With knee supported in partially flexed position, quickly dorsiflex foot. Rhythmic oscillations: positive clonus.

Gait/Balance ■ ■ ■ ■

Observe gait while Pt walks across room and comes back. Have Pt walk heel-to-toe or on heels in a straight line. Have Pt hop in place on each foot. Have Pt stand from sitting position or do shallow knee bend.

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Coordination ■ Rapid Alternating Movements: Instruct Pt to tap tip of thumb with tip of index finger as fast as possible. ■ Point-to Point Movements: Instruct Pt to touch his or her nose and your index finger alternately several times. Continually change the position of your finger during test. ■ Romberg Test: Be prepared to catch Pt! Request that Pt stand with feet together, eyes closed for 10 seconds. If Pt becomes unstable, test is positive, indicating proprioceptive or vestibular problem. ■ Proprioception: While standing, instruct Pt to close eyes and alternate touching his or her index fingers to nose.

Sensory ■ Using your finger and a toothpick, instruct Pt to distinguish between sharp and dull sensations. Compare left to right, with Pt’s eyes closed.

Pupil Scale (mm)

Glasgow Coma Score Eyes Open

Best Verbal Response

■ ■ ■ ■ ■ ■ ■ ■ ■

Spontaneously . . . To command . . . . To pain . . . . . . . . . Unresponsive . . . . Oriented . . . . . . . . Confused . . . . . . . Inappropriate . . . . Incomprehensible Unresponsive . . . .

. . . . . . . . .

. . . . . . . . .

. . . . . . . . .

4 3 2 1 5 4 3 2 1

Findings

Findings

(Continued on following page)

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35 Glasgow Coma Score (continued) ■ ■ ■ ■ ■ ■

Obeys commands . . . . . . . . 6 Findings Localizes pain . . . . . . . . . . . . 5 Withdraws from pain . . . . . . 4 Abnormal flexion . . . . . . . . . 3 Abnormal extension . . . . . . 2 Unresponsive . . . . . . . . . . . . 1 Total.................... Note: The total GCS score should be broken down into its relative components (e.g., a GCS of 11 could be stated as E3V3M5). A GCS of 13–14 may indicate a mild brain injury; 9–12, moderate brain injury; 3–8, severe brain injury. Best Motor Response

Muscle Strength Grading Scale 0 1 2 3 4 5

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. . . . . .

. No muscle movement . Visible muscle movement, but no joint movement . Joint movement, but not against gravity . Movement against gravity, but not against added resistance . Movement against resistance, but less than normal . Normal strength

Deep Tendon Reflex Grading Scale 0.. 1 2 3 4

. . . . .

. . . . .

. . . . .

. . . . .

. Absent . Diminished . Normal . Hyperactive without clonus . Hyperactive with clonus

Levels of Consciousness ■ Alert: Awake, alert, and oriented and responds appropriately. ■ Lethargic: Oriented to person, time, and place; sluggish speech; sleepy; awakens and remains awake with sufficient stimulation. ■ Confused: Disoriented to person, time, and place. Memory deficits, difficulty following commands, restless, agitated.

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■ Obtunded: Extreme drowsiness, responds with one–two words, follows simple commands, but requires vigorous stimulation. ■ Stuporous: Minimal movement, responds unintelligibly, and awakens briefly only to repeated vigorous stimulation. ■ Coma: Unresponsive to verbal stimuli. May have appropriate motor response (withdraws from pain) or nonpurposeful or no response.

AVPU Scale A V P U

Alert Verbal Painful Unresponsive

Pt Pt Pt Pt

is alert and requires no stimulation. responds only to verbal stimulation. responds only to painful stimulation. is unresponsive to any stimulation.

Possible Causes of Altered LOC Cause A E

Alcohol Epilepsy

I

Electrolyte Insulin

O

Overdose

U

Uremia

T

Trauma Temp

I

Infection

P S

Psychiatric Stroke (neuro) Shock

Remarks Protect airway, anticipate emesis. Protect Pt from injury, do not insert object into Pt’s mouth, assess seizure med levels. Monitor and treat serial serum electrolytes. Protect airway, obtain stat blood glucose level and treat accordingly (dextrose for hypoglycemia or insulin for hyperglycemia). Protect airway, take precautions to protect self if Pt is aggressive, give reversal agents. Assess for overuse of NSAIDs, especially with elderly; Pts will require dialysis. Protect airway, immobilize cervical spine, assess pupils, assess for neurologic deficits. Obtain core (preferred) body temperature, administer prescribed antipyretics, use cooling blanket, lukewarm sponge bath as ordered. Protect airway, obtain blood cultures, and administer antibiotics as ordered. Protect self, do not confront Pt, get help. Protect airway, position Pt onto affected side, assess pupils, assess for neurologic deficits. Establish ABCs; immobilize c-spine as indicated.

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37 Dermatomes Each dermatome represents an area supplied with afferent or sensory nerve fibers from an individual nerve root from the spinal cord; cervical, C1–8; thoracic, T1–12; lumbar, L1–5; sacral, S1–5. Dermatomes are used to assess sensation when trying to locate source of lesion or spinal cord injury.

Assessment ■ Test sensation to pinprick in all dermatomes. ■ If Pt is found to have no sensation below level of nipples, then lesion or injury is likely to be at level of T4.

Document ■ Record most caudal (lowest) dermatome that feels pinprick (e.g., “No sensation at or below level T4”). C2 C3 C4 C5 C6 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12

V1 V2 V3

L1

C6

L2

C7

C8

L1 L2 L3 L4 C8

S4

L3 L4

S5

S1

L1 L2

S2

L3 L5 L4 S1

L4

ASSESS

C6

L5

S3

C8 S2 S3

C7

L5

C7

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Psychiatric/Mental Health Assessment General Safety Guidelines ■ Safety: Your safety ALWAYS comes first! ■ Awareness: Watch for nonverbal indicators of aggression or violence: clenched fists, pacing, raised tone of voice, increased respirations, profanity, verbal threats, weapons, wide-eyed stare. ■ Exit: Always position yourself between Pt and an exit. Never allow Pt to block your means of escape. ■ Be Assertive: Make your boundaries known, set limits, and stick to them. Avoid arguing or bargaining with Pts.

Psychiatric—Mental Status Assessment

Appearance

■ Grooming, hygiene, posture, eye contact, correlation between appearance and developmental stage and age.

Motor Activity

■ Tremors, tics, mannerisms, gestures, gait, hyperactivity, restlessness, agitation, echopraxia, rigidity, aggressiveness.

Speech Pattern

■ Aphasia, volume, impairments, stutter.

General Attitude

■ Cooperative, uncooperative, friendly, hostile, defensive, guarded, apathetic.

Mood

■ Depressed, sad, anxious, fearful, labile, irritable, elated, euphoric, guilty, despairing.

Affect

■ Congruent with mood, flat, inappropriate.

Thought Process

■ Form of Thought: Tangentiality, word salads, neologisms, echolalia, attention span ■ Content of Thought: Delusional, suicidal, homicidal, obsession, paranoid, suspicious, religiosity-based, phobic, magical.

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39 Sensory/Perceptual Disturbances

■ Hallucinations (auditory, visual, tactile, olfactory, gustatory), illusions (depersonalization, derealization).

Cognitive

■ Alertness, orientation, memory, abstract thinking.

Impulse Control

■ Aggression, fear, guilt, affection, sexual.

Judgment/Insight

■ Decision making, problem solving, coping.

Common Psychiatric Disorders Psychotic (Schizophrenia) ■ Characteristics: Delusions, hallucinations, impaired reality, disordered thinking, ambivalence, autistic thinking, disorganized verbalizations, flat or blunted affect. ■ Subdivided into: Paranoid, catatonic, undifferentiated, and disorganized. ■ Common Treatments and Medications: Chlorpromazine (Thorazine), haloperidol (Haldol), risperidone (Risperdal).

Mood (Mania/Depression) ■ Characteristics: Manic Phase: Hyperactivity, euphoria, flamboyance, flight of ideas, sexual acting out, dehydration, delusions of grandeur, hostility and aggression; Depressive Phase: Loss of ambition, lack of interest, low self-esteem, boredom, sadness, high suicide risk. ■ Common Treatments: Mania: Lithium (Lithotabs; toxic: 1.5 mEq/L); Depression: Amitriptyline (Elavil, doxepin (Sinequan), sertraline (Zoloft), imipramine (Tofranil), fluoxetine (Prozac), phenelzine (Nardil).

Anxiety: Obsessive-Compulsive Disorder (OCD) ■ Characteristics: Uncontrolled, recurrent thoughts; ritualistic behavior that serves to reduce tension from obsessive thoughts. ■ Common Treatments: Clomipramine (Anafranil).

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Personality (Borderline Personality) ■ Characteristics: Impulsivity, unpredictability, behavior problems, difficulty interacting, marked mood shifts, predisposition to self-harm, uncertainty about self-image, gender identity, values, splitting. ■ Common Treatments: Protect from self-mutilation and suicidal gestures, set limits, use calm approach, teach relaxation techniques and cognitivebehavioral therapy.

Somatoform (Hypochondriasis) ■ Characteristics: Unrealistic belief of having a serious illness regardless of medical reassurance; preoccupation with bodily functions that are misinterpreted; history of seeing many doctors with numerous diagnostic tests; dependent behavior; focus is anxiety, not perceived symptom. ■ Common Treatments: Use diversionary activities, limit interactions, provide correct information about etiology of perceived symptoms and cognitive-behavioral therapy.

Suicide: Assessment and Interventions General Guidelines ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

If, at any time, Pt is threatening suicide, get help, call 911. Provide safe environment. Always take overt or covert suicide threats or attempts seriously. Observe Pt closely. Encourage expression of feelings. Assign tasks to increase feelings of usefulness. Provide full schedule of activities. Show acceptance, respect, and appreciation. Do not argue with Pt. Remind Pt that there are alternatives to suicide.

■ ■ ■ ■ ■ ■

Adolescent and young adult Pts (ages 15–24). Elderly Pts. Terminally ill Pts. Patients who have experienced stress or loss. Survivors of persons who have committed suicide. Individuals with bipolar disorder or schizophrenia.

Groups at Increased Risk for Suicide

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41 ■ ■ ■ ■

Pts coming out of depression. People who abuse alcohol or other drugs. Patients who have previously attempted suicide. More women attempt suicide; however, more men actually complete suicide.

Lethality Assessment ■ Intention: Ask Pt if he or she thinks about and/or intends to harm self. ■ Plan: Ask Pt if he or she has formulated a plan. What are the details; where, when, and how will the plan be carried out? ■ Means: Check availability of method to commit suicide. Does Pt have access to gun, knife, pills, etc? ■ Lethality of Means: Pills vs. gun; jumping vs. slitting wrist. ■ Rescue: Possibility of rescue. ■ Support or lack of support. ■ Availability of alcohol or drugs. ■ Anxiety level. ■ Hostility. ■ Disorganized thinking. ■ Preoccupation with thought of suicide plan. ■ Prior suicide attempts.

Alcohol and Drug Abuse Assessment CAGE-AID Questionnaire Cut down: Have you ever felt that you should cut down on your drinking or use of drugs? Annoyed: Have you ever felt annoyed by being criticized about your drinking or use of drugs? Guilty: Have you ever felt guilty about drinking or using drugs? Eye opener: Have you ever needed an eye opener (alcohol or drugs) after waking up to get rid of a hangover or calm your nerves? Note: A total score of 2 or greater is considered clinically significant and indicates a high likelihood for alcoholism. From http://www.niaaa.nih.gov/publications/inscage.html

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Yes

No

1

0

1

0

1

0

1

0 Total

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Alcohol and Drug Abuse Assessment RAFFT Questionnaire Relaxation: Do you ever use drugs or drink alcohol in order to relax or improve your self-esteem? Alone: Do you ever use drugs or drink alcohol while you are alone? Friends: Do you have any friends who use drugs or have a problem with alcohol? Family: Does any of your close family use drugs or have a problem with alcohol? Trouble: Have you ever gotten into trouble because of alcohol or drugs? Note: Any positive answer warrants further investigation

Yes 1

No 0

1

0

1

0

1

0

1

0 Total

From http://p2001.health.org/Rs01/MRAPPL8.htm

Pain Assessment ■ Whatever the Pt says it is, existing whenever the Pt says it exists. ■ Pain is the “fifth vital sign.” Always include it with every assessment! ■ Beliefs about pain and how to respond to it differ between cultures. ■ Must be considered to manage pain effectively.

Definition of Pain

Cultural Factors

Numerical Pain Scale 0

1

2

3

4

5

6

42

7

8

9

10

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43 Wong-Baker FACES Pain Rating Scale*

0

2

4

NO HURT

HURTS LITTLE BIT

HURTS LITTLE MORE

6 HURTS EVEN MORE

8 HURTS WHOLE LOT

10 HURTS WORST

*For pediatric and non-English speaking Pts From Hockenberry, MJ: Wong’s Essentials of Pediatric Nursing, ed 7. Mosby, St. Louis, Missouri, 2005, p 1301. Copyrighted by Mosby, Inc. Reprinted by permission.

PQRST Provokes Palliation Precipitation

What provokes the pain (exertion, spontaneous onset, stress, postprandial, etc.)? What makes it better (position, being still)? What makes it worse (inspiration, movement)?

Quality

Is it dull, achy, sharp, stabbing, pressing, deep, surface, etc.? Similar to pain you’ve had before?

Radiation

Does it travel anywhere (jaw, back, arms, etc.)?

Severity or Signs and Symptoms

Explain the pain scale (0 being no pain and 10 being the worst pain imaginable) and have Pt rate pain. Are there any associated signs or symptoms (nausea, vomiting, ↑ HR, ↑ RR, diaphoresis, etc.)?

Time (onset and duration)

When did it start? Is it constant or intermittent? How long does it last? Sudden or gradual onset? Does it start after you’ve eaten? Frequency?

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COLDERRA Characteristics.................. Dull, achy, sharp, stabbing, pressure? Onset................................. When did it start? Location ............................ Where does it hurt? Duration............................ How long does it last? Frequency? Exacerbation..................... What makes it worse? Radiation........................... Does it travel to another part of the body? Relief ................................. What provides relief? Associated s/s .................. Nausea, anxiety, autonomic responses?

Nursing Interventions for Pain Management Provide comfort . . . . . . . . . . . . . . . . . . . Positioning, rest and relaxation Validate Pt’s response to pain . . . . . . . . Offer reassurance Relieve anxiety and fears . . . . . . . . . . . Set aside time with Pt Relaxation techniques . . . . . . . . . . . . . . Rhythmic breathing, guided imagery Cutaneous stimulation . . . . . . . . . . . . . Massage, heat and cold therapy Decrease irritating stimulus . . . . . . . . . Bright lights, noise, temp

Referred Pain

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45 Characteristics of Different Types of Pain Acute Pain Onset

Current

Duration ANS response


6 months ↑ HR, RR, BP, diaphoresis, pupillary dilation, muscle tension Diminishes as healing occurs

Relevance to healing Analgesics

Responsive

Chronic Pain Continuous or intermittent 6 months Rarely present

Continues long after healing Rarely responsive

Cancer Pain ■ ■ ■ ■

May be acute or chronic. Pain may be associated with cancer itself or with treatment. Second biggest fear among these Pts. Refer to your facility’s cancer pain algorithms.

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Nutritional Assessment Normal Findings Demeanor Weight Hair Eyes

Suggests Malnutrition

Alert and responsive with positive outlook Reasonable for build

Lethargic, negative attitude

Glossy, full, firmly rooted, and uniform in color Bright, clear, and shiny

Lips Tongue

Smooth Deep red and slightly rough with one longitudinal furrow

Teeth

Bright and painless

Gums Skin

Pink and firm Clear, smooth, firm, and not excessively dry

Nails

Pink and firm

Mobility

Erect posture, good muscle tone, walks without difficulty

Underweight, overweight, or obese Dull, sparse, easily and painlessly plucked Pale conjunctiva, redness, dryness Chapped, red, and swollen Bright red or purple, swollen or shrunken, with several longitudinal furrows Cavities, painful, mottled, or missing Spongy, bleeding, receding Rashes, swelling, light or dark spots, excessive dryness, poorly healing wounds Spoon shaped, ridged, spongy bases Muscle wasting, skeletal deformities, loss of balance

Physical Findings of Dehydration Mild Mentation Capillary refill Mucous membranes Heart rate

Moderate

Alert 2 seconds

Lethargic 2–4 seconds

Normal

Dry

Slightly increased

Increased

Severe Obtunded 4 seconds, cool skin Parched, cracks Very increased

(Continued on following page)

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47 Physical Findings of Dehydration (continued) Mild Pulse (character) Respiratory rate Blood pressure Skin turgor Urine output

Moderate

Severe

Normal, full

Thready

Faint, impalpable

Normal

Increased

Fast; hyperpnea

Normal

Orthostatic

Decreased

Normal Decreased

Slow Oliguria

Tenting Oliguria, anuria

Fluid and Electrolytes Normal Intake and Output ■ Intake: 1500–2500 mL over a 24-hour period. ■ Remember! A kilogram gained is a liter retained! ■ Output: 1500–2500 mL over a 24-hour period (40–80 mL/hour), which includes insensible losses. ■ Minimum urine output is 30 mL/hour. ■ Insensible loss (respiration, sweating, BM) is 500–1000 mL/day.

Fluid Volume Overload ■ General: Weight gain and edema. ■ Skin and mucous membranes: Skin stretched and shiny. ■ CV: Decreased hematocrit, widened pulse pressure, emptying of hand veins 5 seconds, pulmonary edema, congestive heart failure. ■ Urinary: Polyuria, dilute urine (decreased output in renal failure). ■ GI: Nausea and anorexia (edema of bowel). ■ CNS: Deteriorating confusion.

Fluid Volume Deficit ■ General: Weight loss. ■ Skin and mucous membranes: Decreased skin turgor, dry mucous membranes. ■ CV: Increased hematocrit, narrowing pulse pressure, filling of hand veins 5 seconds, postural hypotension, tachycardia on standing.

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■ Urinary: Oliguria, concentrated urine. ■ GI: Thirst, anorexia (decreased blood flow to intestine), longitudinal furrows on tongue. ■ CNS: Confusion and disorientation.

Electrolyte Imbalances Imbalance

Signs and Symptoms

Weakness, fatigue, anoHypercalcemia rexia, nausea, vomiting, Serum calcium constipation, polyuria, level 10.5 mg/dL tingling lips, muscle cramps, confusion, hypoactive bowel tones. Anxiety, irritability, Hypocalcemia twitching around the Serum calcium mouth, convulsions, level
8.5 mg/dL tingling/numbness of fingers, diarrhea, abdominal/muscle cramps, arrhythmias. Weakness, nausea, Hyperkalemia diarrhea, hyperactive GI, Serum potassium muscle weakness and level 5.0 mEq/L paralysis, arrhythmias, dizziness, postural hypotension, oliguria. Anorexia, nausea, vomitHypokalemia ing, fatigue, ↓ LOC, leg Serum potassium cramps, muscle weaklevel
3.5 mEq/L ness, anxiety, irritability, arrhythmias, postural hypotension, coma. Hypermagnesemia Muscle weakness and fatigue are most comSerum magnesium mon, nausea, vomiting, level 2.7 mg/dL flushed skin, diaphoresis, thirst, arrhythmias, palpitations, dizziness.

Common Causes Hyperparathyroidism or malignancies, thiazide diuretics, lithium, renal failure, immobilization, metabolic acidosis. Low albumin level is most common, renal failure, hyperthyroid, ↑ magnesium, acute pancreatitis, Crohn’s disease.

Potassium-sparing diuretics, NSAIDs, renal failure, multiple transfusions, ↓ renal steroids, OD of potassium supplements. Anorexia, fad diets, prolonged NPO status, alkalosis, transfusion of frozen RBCs, prolonged NGT suctioning. ↑ Magnesium intake, chronic renal disease, pregnant women on parenteral magnesium for pre-eclampsia, Addison’s disease. (Continued on following page)

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49 Electrolyte Imbalances (continued) Imbalance

Signs and Symptoms

Common Causes

Hypomagnesemia Diarrhea, anorexia, arrhythProlonged NGT suctionSerum magnesium mias, lethargy, muscle ing, diarrhea, laxative level
1.7 mg/dL weakness, tremors, nausea, abuse, malnutrition, dizziness, seizures, alcoholism, prolonged irritability, confusion, diuretic use, DKA, psychosis, ↓ BP, ↑ HR. digoxin. Hypernatremia Confusion if severe, fever, Fever, vomiting, Serum sodium tachycardia, low BP, posdiarrhea, ventilated level 145 mEq/L tural hypotension, dehyPts, severe burns, dration, poor skin turgor, profuse sweating, dry mucous membranes/ diabetes insipidus, tongue, flushed. diuresis. Hyponatremia Nausea, vomiting, abdominal Diuretic use, vomiting, Serum sodium cramps, diarrhea, headache, diarrhea, burns, level
135 mEq/L dizziness, confusion, flat hemorrhage, fever, affect, ↓ DBP, ↑ HR, postural diaphoresis, CHF, hypotension, ↓ deep tendon renal failure, hyperreflex. glycemia, ↑ ADH.

ASSESS

Treatments/Current Status

Height:

Reusable Assessment Form (make photocopies for multiple Pts) Vital Signs Q:

Diet NPO Clear Full ADA AHA

Weight:

Pt Initials

T ()

1st Assess____:____

CBG

Sex HR

Activity

p.r.n.

Room

Diagnosis RR

Age

Code Status

Dressing Foley

BP on

IV/Fluids

SpO2

Admit Date History

Lungs

Teaching Labs/Diagnostics

Pain

Intake

Allergies

Primary

Output

Tx/Result

Attending

50

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on

↓

Med/Treatment →

Times

Scheduled Medications/Treatments

Reusable Assessment Form (make photocopies for multiple Pts) 2nd Assess ___:___ T () HR RR BP SpO2 Lungs Pain Tx/Result Intake Output

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General Report (make copies for multiple Pts) Name

Age

Sex

Diagnosis Code Status Admit Date

Dr.

Surgery Procedure Neurologic Respiratory CV GI-GU MS Pain Skin Incision-Dressing I&O IVs

LTC

Diet-NPO Activity Labs-Procedures Miscellaneous D/C Planning-Teaching Needs

52

Rm #

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53 Erikson’s Developmental Stages Developed by psychiatrist Erik Erikson in 1956.

Stage

Age

Trust vs. Mistrust

Birth–18 months

Autonomy vs. Shame or Doubt Initiative vs. Guilt Industry vs. Inferiority

3–6 years 6–12 years

12–20 years Identity vs. Role Confusion 20–30 years Intimacy vs. Isolation 30–65 years Generativity vs. Stagnation Ego Integrity vs. Despair

(
) Outcome

(—) Outcome

Strong bonds, trust Inability to bond, in mothering insecure, distrustfigure ful 18 months–3 Independence, Doubtful of own years some self-esteem ability, dependent

65–death

Sense of purpose and ability Self-confidence by doing and achieving Secure sense of self, positive ideals Lasting relationship or commitment Creates a family, considers future welfare of others Positive sense of self-worth, accepts and prepares for death

Immobilized by guilt, dependent Sense of inferiority, inability to achieve Confusion, inability to make decisions Isolation and fear of commitment Stagnation, selfcentered, unfulfilled life and career Feeling of hopelessness, fears and denies death

Maslow’s Hierarchy of Needs Developed by psychologist Abraham Maslow in 1943. Throughout the life span, individuals seek self-actualization. Lower-level needs must be fulfilled before higher-level needs can be fulfilled. People fluctuate between levels depending on life circumstances.

LIFE SPAN

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LIFE SPAN

Physiological Needs Safety Love Esteem Self-Actualization

Food, water, shelter, warmth, sexual expression Security, freedom from fear, physical safety Satisfying interpersonal relationships Achievement, mastery, self-respect Self-fulfillment, reach highest potential

Pregnancy Terms Associated with Pregnancy Abortion . . . . . . . . the spontaneous or induced termination of pregnancy before the fetus reaches viability Chloasma . . . . . . . mask of pregnancy Crowning . . . . . . . presentation of the fetal head at the vaginal introitus CST . . . . . . . . . . . . contraction stress test Deceleration . . . . . decrease in fetal heart rate Dilatation . . . . . . . widening of cervical os and canal Eclampsia . . . . . . . seizures secondary to hypertension EDD or EDC . . . . . estimated date of delivery or confinement Effacement . . . . . . shortening and thinning of cervix Embryo phase . . . weeks 3–8 Fetus phase . . . . . from week 9 until delivery FHR . . . . . . . . . . . . . fetal heart rate FHT . . . . . . . . . . . . . fetal heart tone Gravida . . . . . . . . . number of ALL pregnancies, regardless of outcome, including current pregnancy HCG . . . . . . . . . . . . human chorionic gonadotropin HELLP . . . . . . . . . . hemolysis, elevated liver enzymes, lowered platelets (a bleeding disorder similar to DIC) Homans’ sign . . . . pain elicited by dorsiflexion of foot Hyperemesis . . . . excessive nausea and vomiting in early gravidarum pregnancy IDM . . . . . . . . . . . . infant of diabetic mother Involution . . . . . . . return of uterus to nonpregnant size Lanugo . . . . . . . . . soft downy body hair of newborn infant LGA . . . . . . . . . . . . large for gestational age LNMP (LMP) . . . . . last normal menstrual period L:S ratio . . . . . . . . lecithin/sphingomyelin ratio: determines fetal lung maturity (2:1 ratio is desirable) MAb . . . . . . . . . . . . miscarriage abortion Macrosomia . . . . . birth weight 4000 g

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55 Meconium . . . . . . . . . . . fetal defecation while in utero at time of labor that occurs with fetal distress Miscarriage . . . . . . . . . . spontaneous abortion Multigravida . . . . . . . . . has been pregnant more than once Multipara . . . . . . . . . . . . two or more pregnancies beyond 20 weeks Nidation . . . . . . . . . . . . . implantation: occurs between day 7 and 10 after conception NST . . . . . . . . . . . . . . . . . nonstress test Nullipara . . . . . . . . . . . . . never produced a viable offspring OCT . . . . . . . . . . . . . . . . . oxytocin challenge test Operculum . . . . . . . . . . . mucous plug Organogenesis . . . . . . . weeks 3–8 Para . . . . . . . . . . . . . . . . . number of viable births 20 weeks Pica . . . . . . . . . . . . . . . . . ingestion of non-nutritive substances PIH . . . . . . . . . . . . . . . . . . pregnancy-induced hypertension (see preeclampsia this section) Post-term . . . . . . . . . . . . gestation lasting longer than 42 weeks POC . . . . . . . . . . . . . . . . . product of conception Preeclampsia . . . . . . . . . mild preeclampsia, ≥140/90 mm Hg; severe, ≥160/110 mm Hg Pre-term . . . . . . . . . . . . . born before beginning of 38th week Primigravida . . . . . . . . . first pregnancy ever Primipara . . . . . . . . . . . . only one pregnancy carried past 20 weeks PTL . . . . . . . . . . . . . . . . . . preterm labor Puerperal period . . . . . . ≤21–42 days postpartum ROM . . . . . . . . . . . . . . . . . rupture of membranes (1000 mL at term) SGA . . . . . . . . . . . . . . . . . small for gestational age Station, fetal . . . . . . . . . relation of presenting part to maternal pelvic ischial spines Striae . . . . . . . . . . . . . . . . stretch marks Supine hypotension . . . caused by compression of vena cava ■ Relieved by lying in a lateral recumbent position TAb . . . . . . . . . . . . . . . . . therapeutic abortion Teratogenic . . . . . . . . . . harmful to developing embryo TPAL . . . . . . . . . . . . . . . . term, premature births, abortions or miscarriages, living children Trimester . . . . . . . . . . . . one of three phases of pregnancy, each consisting of 13 weeks Variability . . . . . . . . . . . . refers to irregularities in fetal heart rate Vernix . . . . . . . . . . . . . . . cheese-like coating on newborn’s skin Viability . . . . . . . . . . . . . pregnancy lasting beyond 20 weeks of gestation Viable fetus . . . . . . . . . . uncompromised fetus beyond 20 weeks

LIFE SPAN

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LIFE SPAN

Predicting the Due Date (Nägele’s Rule) ■ Add 7 days to the first day of the LNMP. ■ Subtract 3 months. ■ Add 1 year. ■ See example to right. →

1st day of LNMP 7/14/07 ■ Add 7 days 7/21/07 ■ Subtract 3 months 4/21/07 ■ Add 1 year (EDD) 4/21/08

Fetal Development Timetable (Length and Weight) 4 weeks . 8 weeks . 12 weeks 16 weeks 20 weeks

. . . . .

. . . . .

. . . . .

. . . . .

. . . . .

0.4 cm, 0.4 g 2.5 cm, 2 g 7 cm, 19 g 12.5 cm, 100 g 17–18 cm, 300 g

24 28 32 36 40

weeks: weeks: weeks: weeks: weeks:

23 27 31 35 40

cm, cm, cm, cm, cm,

600 g 1100 g 1800–2100 g 2200–2900 g 3200 g

Normal Changes Throughout Pregnancy Cardiovascular ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Heart rate . . . . Blood pressure Blood volume . Hct . . . . . . . . . . RBC . . . . . . . . . WBC . . . . . . . . Vasodilatation . Stroke volume . CO . . . . . . . . . . SVR . . . . . . . . . Supine position

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

. . . . . . . . . . .

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increases lower first half, no change last half as much as a 50% increase slight decrease as much as a 30% increase increases caused by increased progesterone levels increases increases decreases decreases perfusion to baby

Respiratory ■ ■ ■ ■ ■

Respiratory rate . . . . . . . . . . Oxygen consumption . . . . . Tidal volume . . . . . . . . . . . . Functional residual capacity Dyspnea . . . . . . . . . . . . . . .

. . . . .

. . . . .

. . . . .

. . . . .

increases increases by 15% increases decreases normal at end of third trimester

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57 ■ ■ ■ ■

pH . . . PaO2 . . PaCO2 HCO3 .

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. . . .

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. . . .

increases increases decreases decreases

Renal ■ Proteinuria . . . . . . . may indicate possible PIH ■ GFR . . . . . . . . . . . . . increases by as much as 50%

Metabolic ■ Temperature . . . . . . slight increase ■ Blood glucose . . . . . increase may indicate gestational diabetes

Hormones Associated with Pregnancy ■ ■ ■ ■

Follicle-stimulating hormone (FSH) Luteinizing hormone (LH) . . . . . . . . Progesterone . . . . . . . . . . . . . . . . . . Prolactin . . . . . . . . . . . . . . . . . . . . .

. . . .

. . . .

. . . .

. . . .

. . . .

follicle growth and maturation egg development and ovulation maintains pregnancy initiation and continuation of milk production (lactation) ■ Oxytocin . . . . . . . . . . . . . . . . . . . . . . . . . . stimulates uterine contractions and milk let-down

Weight Gain and Nutritional Requirements Optimal Weight Gain ■ Total weight gain during pregnancy . . . . . . . . . . 20–24 lb ■ First trimester . . . . . . . . . . . . . . . . . . . . . . . . . . . . about 2–3 lb ■ Second–third trimester . . . . . . . . . . . . . . . . . . . . 3/4 lb every week

Nutritional Requirements ■ ■ ■ ■ ■

Additional caloric needs .................. Protein ............................................... Carbohydrate .................................... Fiber................................................... Fats ....................................................

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300 cal/day (2500 total) 75 g/day 175 g/day (mostly complex) 28 g/day 20–35 g/day

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■ Sodium ..................................... should not be restricted unless under MD guidance ■ Iron ............................................ 27 mg/day ■ Calcium ..................................... 1000 mg/day ■ Folic acid................................... 600 g/day (500 g/day while lactating) ■ Daily fluid intake ...................... ~3 L/day unless preeclampsia exists

Immunization During Pregnancy (United States, 2005) Recommended During Pregnancy ■ Tetanus-Diphtheria (Td) ■ Influenza. Note: Given during second or third trimester if a chronic disease exists; otherwise, given anytime during flu season.

Recommended Only If Medical/Exposure Indication Exists ■ Hepatitis A and B ■ Pneumococcal (polysaccharide) Contraindicated During Pregnancy ■ MMR and Varicella

Fundal Height Assessment ■ Measured to assess fetal growth and development. ■ Using a cm ruler, measure from the top of the symphysis pubis to the top of the fundus (subtract 1 cm if very obese). ■ Measurements greater than 4 cm from estimated gestational age require further evaluation. Gestation 12 16 20 24 28 32 36 40 (weeks) Ht (cm) 11–13 15–17 19–21 23–24 27–29 31–33 35–37 33–35

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59 Comparison of True and False Labor True Labor Contractions ■ Frequency ■ Duration ■ Intensity Cervix Discomfort

Consistent pattern Progressively increasing Progressively increasing Progressively increasing; increases with walking Progressive effacement and dilation Mostly low back and abdominal

False Labor Inconsistent pattern Inconsistent Inconsistent Inconsistent; subsides or does not increase with walking No significant change Mostly abdominal and groin

Progression of Labor Factors Affecting Progression of Labor (5 Ps) ■ Passenger: Size of the baby and its head, fetal presentation, lie, attitude, and position in relation to the birth canal. ■ Passageway: Size of the birth canal in relation to the baby. ■ Power: Force, regularity, and duration of contractions. ■ Position: Birthing position and comfort/discomfort of mother. ■ Psychological: Pain and anxiety experienced by the mother including preparation for the delivery and support system.

Stages of Labor Stage I

Stage II Stage III Stage IV

From onset of contractions through full effacement and dilatation of cervix (latent phase, 0–3 cm; active phase, 4–7 cm; transition phase, 8–10 cm). Duration: 8–18 hours. From full dilatation of cervix until delivery of baby. Duration: 15–90 minutes. From birth of baby until expulsion of placenta. Duration: ≤20 minutes. First 1–2 hours after expulsion of placenta.

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Newborn Initial Newborn Care and Assessment

ABCs and Temperature

■ Baby should be pink (for dark-skinned Pts, assess oral mucosa, conjunctivae, palms, soles of feet, etc.) and have a loud, vigorous cry. ■ Suction nose and mouth to clear excess secretions, mucus. ■ Stimulate breathing with vigorous rubbing and drying. ■ Dry baby and maintain warmth (wrap in blankets, warmer, etc.).

APGAR and Vital Signs (see Apgar Score, page 61)

■ Assess and document APGAR at 1 and 5 minutes after delivery. Note: Some hospitals also require a 10-minute APGAR score. ■ Assess and record vital signs (see normal ranges below). Age Preterm Newborn

RR

HR

SBP

Temp

50–70 30–60

140–180 120–160

40–60 60–90

36.8–37.5C 36.8–37.5C

Identification

■ Place ID bands on baby and mother. ■ Record baby’s footprints in chart.

Measurements ■ ■ ■ ■

Weight: Normal is 6–10 lb. Length: Normal is 18–22 in. Head circumference: Normal is 13–14 in (33–35 cm). Chest circumference: Normal is 12–13 in (30–33 cm).

Physical Assessment Note: Perform regular, head-to-toe assessment, similar to an adult, but note the following areas specific to newborn assessment: ■ Appearance: Baby should be pink, have a loud, vigorous cry, and be well flexed with full ROM and spontaneous movements. ■ Fontanels: Anterior is diamond-shaped, ~4 cm at widest point (closes at 7–19 months); posterior is triangular, ≤1 cm at widest point (closes at 1–2 months). ■ Molding: Skull may be oddly shaped with overlapping cranial bones. ■ Mouth: Inspect mouth for cleft lip and/or cleft palate. ■ Heart murmur: Soft murmur considered normal in first few days. ■ Breathing: Abdominal breathing normal in newborns. ■ Umbilical cord: Should have one vein and two arteries. Should be clamped, may or may not be pulsating, and no sign of bleeding. ■ Extremities: Legs and arms equal length to each other and all fingers and toes accounted for.

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61 ■ Male genitalia: Testes palpable in scrotum or inguinal canal. ■ Female genitalia: Large labia minora and vaginal discharge of blood or mucus considered normal.

Routine Newborn Medication and Labs ■ Eyes: Eyes medicated with antibiotic ointment according to hospital policy. ■ Vitamin K injection: Given to prevent hemorrhage. ■ PKU (phenylketonuria): Should be obtained 24 hours after feeding begins. Normal serum blood level is 4 mg/dL. Sample is obtained from heel stick using lancet. ■ Coombs’ test: Done if mother’s blood is Rh negative. Determines if mother has formed harmful antibodies against her fetus’ RBCs and transferred them to her baby via placenta. Heel stick sample. ■ Immunizations: Physician may order first hepatitis B vaccine (Hep-B) to be given soon after birth, before discharge (see Childhood Immunization Schedule, page 70).

Apgar Score Appearance (color)

1 min

5 min

1 min

5 min

1 min

5 min

1 min

5 min

■ Pink torso and extremities . . . . . . . . . . 2 ■ Pink torso, blue extremities . . . . . . . . . 1 ■ Blue all over . . . . . . . . . . . . . . . . . . . . . 0

Pulse (heart rate) ■ 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 ■ 100 . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 ■ Absent . . . . . . . . . . . . . . . . . . . . . . . . . . 0

Grimace (irritability/reflexes) ■ Vigorous cry . . . . . . . . . . . . . . . . . . . . . 2 ■ Limited cry . . . . . . . . . . . . . . . . . . . . . . 1 ■ No response to stimulus . . . . . . . . . . . 0

Activity (muscle tone) ■ Actively moving . . . . . . . . . . . . . . . . . . 2 ■ Limited movement . . . . . . . . . . . . . . . . 1 ■ Flaccid . . . . . . . . . . . . . . . . . . . . . . . . . . 0

(Continued on following page)

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Apgar Score (continued) Respiratory Effort

1 min

5 min

■ Strong loud cry . . . . . . . . . . . . . . . . . . . 2 ■ Hypoventilation, irregular . . . . . . . . . . 1 ■ Absent . . . . . . . . . . . . . . . . . . . . . . . . . . 0 Totals* *8–10, normal 4–6, moderate depression 0–3, aggressive resuscitation

Postpartum Care and Assessment: Mother General Assessment Pearls ■ Monitor for signs of postpartum hemorrhage and shock. ■ If preeclamptic, assess blood pressure every hour. ■ It is considered normal to have slight fever (100.4F) for first 24 hours postpartum; temp 101.4F indicates infection. ■ Urinary retention is likely to occur postpartum; encourage fluids and monitor I & O for first 12 hours. ■ Encourage early ambulation; instruct Pt to change position slowly, because postural hypotension is common postpartum.

Breasts and Breast-feeding ■ Colostrum appears within 12 hours, and milk appears in ~72 hours postpartum. Breasts become engorged by postpartum day 3 or 4 and should subside spontaneously within 24–36 hours. ■ Assess breasts for infection and assess nipples for irritation. ■ Encourage use of bra between feedings.

Complications:

■ Pain: Assess for mastitis, abscess, milk plug, thrush, etc. Proper positioning of infant (football carry) will minimize soreness. Breast shields are used to prevent clothing from rubbing on nipples. ■ Engorgement: Apply moist heat for 5 minutes before breast-feeding. Use ice compress after each feeding to reduce swelling and discomfort. Avoid bottles and pacifiers while breasts engorged, because may cause nipple confusion or preference.

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63 ■ Mastitis: Encourage rest and continuation of feeding or pumping. Administer prescribed antibiotics. Note: Breast milk is not infected and will not harm infant.

Abdomen and Uterus ■ Uterus should be firm, about size of grapefruit, central, and at level of umbilicus immediately postpartum. Deviation to the right may indicate distended bladder. ■ Assess for bladder fullness (full bladder may inhibit uterine contractions and cause uterine bleeding). Have mother void if bladder is full. ■ If postvoid uterus is still boggy, massage top of fundus with fingers held together and reassess every 15 minutes. ■ Mother and/or partner may be instructed to massage fundus. ■ Auscultate bowel sounds and inquire daily about BMs. ■ Constipation is common from anesthesia and analgesics as well as fear of perineal pain. ■ Increased fiber and fluid intake, along with early and routine ambulation, will help to reduce occurrence of constipation.

Perineum ■ Episiotomy: Assess for swelling, bleeding, and infection. ■ Hemorrhoids: Encourage sitz baths to help reduce discomfort. ■ Lochia: Amount, character, and color. Explain stages and duration of lochial discharge and instruct Pt to report any odor. ■ Lochia rubra: 1–3 days postpartum, mostly blood and clots. ■ Lochia serosa: 4–10 days postpartum, serosanguineous. ■ Lochia alba: 11–21 days postpartum, creamy white, scant flow.

Lower Extremities ■ Thrombophlebitis: Unilateral swelling, decreased pulses, redness, heat, tenderness, and positive Homans’ sign (calf pain or tenderness on dorsiflexion of foot). Leg exercises and early ambulation help minimize occurrence of venous stasis and clot formation.

Emotional Status ■ Explain to mother and to her family that her emotions may shift from high to low and that these changes are considered a normal result of the tremendous hormonal changes occurring postpartum. ■ Assess parent-infant bonding and family support system.

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Involution of the Uterus After delivery

Umbilicus

Postpartum day 1 2nd day (U-1) 3rd day (U-2) 4th day (U-3) 5th day (U-4) 6th day (U-5) 7th day (U-6) 8th day (U-7) 9th day (U-8) Note: The uterus is about the size of a large grapefruit immediately after delivery, and within a few hours, should rise to the level of the umbilicus and remain there for the first 24 hours. After this, it will descend ~1 cm/day. By day 10, it should have descended into the pelvic cavity and no longer be palpable in the abdominal cavity.

The Pediatric Patient Normal Pediatric Vital Signs Age

RR

HR

SBP

Preterm Newborn 6 months 1 year

50–70 30–60 25–35 20–30

140–180 110–120 110–180 80–160

40–60 60–90 85–105 95–105

Temp (C) 36.8–37.5 36.8–37.5 37.5 37.5

(Continued on following page)

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65 Normal Pediatric Vital Signs (continued) Age

RR

HR

SBP

Temp (C)

2 years 4 years 6 years 8 years 10 years 12 years Teenager

20–30 20–30 18–24 18–22 16–20 16–20 12–20

80–130 80–120 75–115 70–110 70–110 60–110 60–100

95–105 95–110 95–110 95–115 95–120 95–125 95–135

37.5 37.5 37 37 37 37 37

Average Height and Weight (50th percentile) Age

Height (in)

Newborn 6 months 1 year 2 years 4 years 6 years 8 years 10 years 12 years Teenager

18 26 30 34 40 45 50 55 60 65

Weight (cm)

(lb)

45.7 66 76.2 86.4 101.6 114.3 127 139.7 152.4 165.1

8 16 21 27 35 45 56 73 92 110

Pediatric Health History Chief Complaint ■ What prompted parents to bring child to hospital? ■ What is child complaining of (pain, nausea, dyspnea)?

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(kg) 3.6 7.2 9.5 12.2 16 20.5 25.5 33.2 41.8 50

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Focused Symptom Analysis ■ ■ ■ ■ ■

P: Precipitating or palliative factors. Q: Quality/quantity; describe symptom(s). Are ADLs affected? R: Radiation/region/related symptoms. S: Severity; is symptom mild, moderate, or severe? T: Timing; time of onset, frequency, and duration.

Immunization History ■ Are child’s immunizations up to date? (see Childhood Immunization Schedule, page 70) ■ Has child ever been diagnosed with a communicable disease? ■ Has there been any recent exposure to a communicable disease?

Allergies ■ Has child ever had allergic reaction to food, meds, etc.? ■ What types of reactions occur with known allergies?

Medications ■ Is child currently taking any medications? (Include OTC and prescription medications and herbal remedies.) ■ What was time and dose of last medication taken?

Past Medical History ■ Prior illnesses and injuries. ■ Past or recent hospitalizations and surgical procedures. ■ Overall health status since birth.

Events Surrounding Illness or Injury ■ History and onset of current illness. ■ History and mechanism of injury.

Current Intake and Output ■ ■ ■ ■

Document last oral intake. Has child been drinking and eating normally? Assess for malnutrition and dehydration. Does urine and stool output seem normal?

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67 Pediatric Assessment by Developmental Milestone Age

Developmental Milestones

1 mo

Cries to communicate, reflex activity, eye contact

2 mo

Coos, smiles, frowns, tracks objects, lifts head

3 mo

Turns from back to side, sits with support

4 mo

Turns from back to abdomen, lifts head, bears weight on forearms, can hold head erect, places everything in mouth, grasps with both hands, laughs

5–6 mo

Turns onto back, uses hands independently, plays with toes, puts feet into mouth, sits alone leaning forward on hands, holds bottle, extends arms to be picked up, stranger anxiety

7–8 mo

Begins to crawl, bears weight on feet when supported, pulls to a standing position, sits alone without any support, increased fear of strangers, walks alongside furniture, well-developed crawl

9–10 mo

May begin to walk and climb, one–two word vocabulary, understands “No!,” shakes head to indicate “No!,” follows simple directions

12 mo

Walks alone or with assistance, falls frequently while walking, points with one finger

15–18 mo

Walks independently, throws overhanded, pulls/pushes toys, builds with blocks, runs clumsily, jumps in place on both feet, 8—10 word vocabulary

2 yr

Runs well, climbs stairs, bladder and bowel (potty) trained, names objects, two–three word phrases

3–4 yr

Rides tricycle, turns doorknobs, dresses self, uses short sentences, hops on one foot, can catch a ball

6–12 yr

Physically coordinated, uses complete sentences, has extensive vocabulary, swims, skates, rides bicycle, uses complex sentences, reads, forms social groups

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Pediatric Assessment Pearls ■ Begin by obtaining the history from child’s parent(s) and work toward physical assessment. Use this time to establish trust. ■ Have parent hold child as much as possible during assessment. ■ Approach child at his or her eye level and use first name frequently. ■ Use simple language appropriate for child’s developmental level. ■ Begin assessment with diversion such as toy or game. ■ Demonstrate procedures on doll whenever possible. ■ Always tell the truth, especially when it comes to painful procedures. ■ Hold off on any invasive assessment that may cause pain or discomfort until end of assessment. ■ Be friendly, but assertive. Do not give child choice when there is none (e.g., “May I look in your mouth?”).

Pain Assessment and Intervention Signs and Symptoms by Developmental Stage ■ Infant: Grimacing, frowning, startled expression, flinching, high-pitched, harsh cry, generalized, total-body response, extremities may thrash about, tremors, increased HR and BP, ↓ oxygen saturation. ■ Toddler: Guarding, may touch or rub area, generalized restlessness, loud cry, increased HR and BP, may verbalize with words such as “owie” or “boo-boo.” ■ Preschooler: May perceive pain as punishment, may deny pain to avoid treatment, may be able to describe location and intensity, may exhibit crying and kicking, or may be withdrawn. ■ School-aged: Fear of bodily harm and mutilation, awareness of death, able to describe pain, may exhibit stiff body posture, may withdraw, and may attempt to delay procedures. ■ Adolescent: Perceives pain at physical, emotional, and mental levels, is able to describe pain, may exhibit increased muscle tension, may be withdrawn, and may show decreased motor activity.

Interventions for Pain

Nonopioid Analgesics

■ Acetaminophen (Tylenol): 10–15 mg/kg PO q.4h., max five doses/day. ■ Ibuprofen (Advil): (2 yr) 7.5 mg/kg PO q.i.d., max 30 mg/kg/day. ■ Naproxen (Naprosyn): (2 yr) 5 mg/kg PO b.i.d., max two doses.

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69 Opioid Analgesics

■ Codeine: (1 yr) 0.5 mg/kg (15 mg/m2) PO, IM, SC q.4–6h., max four doses/day. Note: Not recommended for IV use. Infants may receive SC or IM codeine at same dose. ■ Meperidine (Demerol): 1.1–1.8 mg/kg PO, IM, SC q.3–4h. p.r.n., max 50–100 mg/dose. ■ Morphine: 0.1–0.2 mg/kg IV, IM, or SC p.r.n., max 15 mg/dose. ■ Sublimaze (Fentanyl): (2 yrs) 2–3 g/kg IV.

Nonpharmacologic Interventions

■ ■ ■ ■ ■

Distraction: Music, TV, games, dolls, stuffed animals, art, etc. Minimize environmental stimuli: Noises, bright lights, etc. Provide comfort: Positioning, rest, and relaxation Cutaneous stimulation: Massage or heat or cold therapy. Guided imagery: Guide the child to either a make-believe place or someplace he or she has visited in the past (i.e., Disneyland). Encourage the child to describe this place.

Pediatric IM Injection Sites Muscle* Infant Toddler Older child

Ventrogluteal or vastus lateralis Ventrogluteal or vastus lateralis Ventrogluteal or deltoid

Needle

1 mL

5/8–1′′

1 mL

5/8–1′′

1 mL

*The dorsogluteal site is contraindicated in infants and children.

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Max Volume

5/8–7/8′′

HepB

Department of Health and Human Services • Centers for Disease Control and Prevention

HepB

Hib

DTaP DTaP DTaP

Hib

IPV

HepB DTaP Tdap

IPV

Hib

IPV

DTaP

MCV4

MCV4

MMR

Tdap

HepB Series

Recommended Childhood / Adolescent Immunization Schedule USA • 2006 1 2 4 6 12 15 18 24 Birth mo mo mo mo mo mo mo mo 4–6 yr 11–12 yr 13–14 yr 15 yr 16–18 yr HepB (hepatitis B)

Hib

IPV

MMR

Varicella MCV4

PPV

11–12-year-old assessment

Influenza (Yearly) HepA Series

MMR

Influenza (Yearly)

DTaP (diphtheria, tetanus, pertussis) Hib (Haemophilus influenzae type b) IPV (inactivated poliovirus) MMR (measles, mumps, rubella) Varicella Meningococcal

Catch-up immunizations

MPSV4 PCV

Pneumococcal Influenza HepA (hepatitis A)

Varicella Vaccines within broken lines are for selected populations PCV PCV PCV PCV

Range of recommended ages

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71 The Geriatric Patient General Guidelines ■ Be mindful that the elderly may be hard of hearing, but never assume that being elderly automatically makes it hard to hear. ■ Approach and speak to elderly Pts as you would any other adult Pt. It is insulting to speak to the elderly like a child. Speaking slowly is sometimes necessary but does not indicate decreased intelligence. ■ Eye contact helps instill confidence and, in the presence of impaired hearing, will help the Pt to understand you better. ■ Be aware that decreased tactile sensation and ROM are both normal changes with aging. Care should be taken to avoid unnecessary discomfort or even injury during assessment. ■ Be aware of generational differences, especially gender differences (e.g., modesty for women, independence for men). ■ Assess for altered mental states. Use your ′′3-D vision.′′ ■ Dementia: Cognitive deficits. ■ Delirium: Confusion/excitement marked by disorientation to time and place, usually accompanied by delusions and/or hallucinations. ■ Depression: Diminished interest or pleasure in most or all activities.

Age-related Changes and Implications

Decreased Skin Thickness

■ Elderly Pts are more prone to skin breakdown and should be assessed more frequently for pressure ulcers.

Decreased Skin Vascularity

■ Altered thermoregulation response can put elderly at risk for heat stroke.

Loss of Subcutaneous Tissue

■ Decreased insulation can put elderly at risk for hypothermia.

Decreased Aortic Elasticity

■ Increased diastolic blood pressure.

Calcification of Thoracic Wall

■ Obscured heart and lung sounds and displacement of apical pulse.

Loss of Nerve Fibers/Neurons

■ Allow for extra time to comprehend, to learn, and to perform certain tasks.

Decreased Nerve Conduction ■ Response to pain is altered.

Reduced Tactile Sensation

■ Puts Pt at risk for injury to self.

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Social Issues and Their Implications Issue

Implication

■ Pts who are living alone are less likely to access health care and are more likely to suffer from health problems, social isolation, and/or depression. Living arrangements ■ Ease of access to shopping and services. ■ Available support from family and friends. ■ Income level directly influences Pt’s ability to Financial status access health care, especially prescription drugs. ■ Education level influences Pt’s ability to Education understand and carry out instructions. ■ Pts with caregiving roles may be reluctant to Caregiver report their own symptoms. responsibilities ■ Availability (or unavailability) of caregivers Caregiver influences Pt’s access to health care. availability ■ Pts of advanced age have more difficult time ADLs completing common, everyday ADLs. ■ Lack of hobbies or interests may lead to social Hobbies and isolation and depression. interests Marital or companion status

Eating Problems in the Elderly Possible Causes GI Disturbances ■ Difficulty swallowing ■ Constipation ■ Nausea and vomiting ■ Gastric reflux (GERD)

Nursing Interventions Observe Pt for signs of swallowing difficulty (coughing while eating, holding food in the mouth, frequent attempts to clear throat); suggest consult with speech therapy for evaluation. Monitor bowel patterns; determine if Pt has trouble passing stool; assess for impaction. Investigate cause of nausea and vomiting and assess for signs and symptoms of GERD. Document and report assessments, interventions, and outcomes. (Continued on following page)

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73 Eating Problems in the Elderly (continued) Possible Causes

Nursing Interventions

Inspect dentures for proper fit, use dental adhesive, suggest dental consult if necessary. Provide mouth care before and after meals as needed. Offer fluids frequently while eating, to provide sufficient moisture to foods. Document and report assessments, interventions, and outcomes. Suggest consult with occupational therapist for Functional Deficits assistive devices. ■ Weakness; inability to If Pt needs to be fed, offer small spoonfuls feed self; tremors slowly and allow ample time for chewing and ■ Difficulty sitting upright, swallowing. confined to bed Ensure Pt is in upright, comfortable position for ■ Poor vision, less eating. discriminating taste Use all assistive devices including glasses, buds, and other hearing aids, and special, handled utensils. sensory deficits Document and report assessments, interventions, and outcomes. Work with health-care team to help manage Neurologic Issues pain, anxiety, and/or depression effectively. ■ Depression Provide consistent staff members to feed Pt; ■ Anxiety have family member present at mealtimes, if ■ Pain possible. ■ Dementia Document and report assessments, interventions, and outcomes. Medication Side Effects Evaluate medications for possible source of eating difficulties. ■ Anorexia (e.g., Work with health-care team to change or psychotropic drugs discontinue drugs, if possible. and digoxin) Treat side effects if medications cannot be ■ Nausea, vomiting, changed (stool softeners, antiemetics, etc.). taste changes (e.g., Evaluate effects of interventions. chemotherapy) Document and report assessments, ■ Constipation (e.g., interventions, and outcomes. opioid analgesics) ■ Drowsiness (e.g., sleeping meds, antianxiety agents) Oral Problems ■ Missing or poorly fitting dentures ■ Missing teeth, dental cavities, gum disease ■ Dry mouth

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Dehydration in the Elderly Dehydration is more common in older adults and can lead to confusion, urinary and respiratory tract infections, constipation, hospitalization, stroke, and death.

Risk Factors ■ Diminished feelings of thirst ■ Decreased total body water (TBW). In older adults, TBW represents 60% of weight; in younger adults, TBW is 70%. ■ Factors that contribute to high risk for dehydration include ■ Age 85 years ■ Nursing home resident ■ Recent weight loss 5% of body weight ■ Difficulties with feeding and eating, difficulty swallowing ■ Dementia ■ Fever ■ Multiple chronic conditions ■ Confined to bed ■ Multiple medications (four or more) ■ Limited opportunity to drink ■ Vomiting, diarrhea ■ Diuretic or laxative use ■ Self-restriction of fluids related to incontinence or increased frequency of nighttime voiding

Signs and Symptoms ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Confusion, change in level of consciousness Tachycardia, orthostatic hypotension, elevated temperature Low urine output, dark yellow to brownish urine Dry skin, poor skin turgor, dry mucous membranes Constipation, fecal impaction Dizziness Infection Weakness, fatigue Signs of electrolyte imbalance Muscle weakness, poor skin turgor over forehead or sternum (do not use hand or arm; it is unreliable) ■ Increased urine specific gravity ■ Increased hematocrit

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75 Nursing Interventions ■ Evaluate hydration status by assessing ■ Vital signs ■ Urine specific gravity ■ BUN/creatinine/electrolytes ■ Complete blood count ■ Urine color ■ 24-hour fluid intake and urine output ■ NPO status, enteral/tube feedings ■ Usual pattern of fluid intake ■ To calculate the desired fluid intake per day ■ Start with the patient’s weight (kg)  70 ■ Subtract 20  50 ■ Multiply by 15  750 ■ Add 1500  2250 ■ Multiply by 0.75  1688 is the fluid goal for a patient weighing 70 kg. ■ Provide 80% of desired fluid goal at meals (1350 mL for 70-kg patient). ■ Provide remaining 20% between meals (338 mL for 70-kg patient). ■ Offer a variety of fluids and have patient take sips throughout the day if he or she has trouble taking more at a time. ■ Document intake and output, difficulties drinking. ■ Assess weight daily and record. ■ Note urine specific gravity and urine color. ■ Post the volume of each container (cups, bowls, tea cup, etc.) in the patient’s room. ■ If patient requires test preparation (NPO or bowel cleansing), arrange timing so that test occurs as soon as possible. Offer fluids immediately after test is completed unless contraindicated. Consider IV hydration if NPO status is prolonged. ■ Notify physician or nurse practitioner immediately if signs or symptoms of dehydration are present. Dehydration can progress quickly and become severe, associated with a high mortality rate in elderly Pts.

Depression and Suicide in the Elderly Depression is quite common in older adults, is often unreported and unrecognized, diminishes quality of life, and can lead to suicide.

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Depression Facts ■ Depression often occurs with other serious illnesses such as heart disease, stroke, diabetes, cancer, and Parkinson’s disease. ■ Older adults are subject to various social and economic difficulties. ■ Health-care professionals should not assume that depression is a normal response to illness and loss. ■ Depression should be treated when it occurs alone or with other illnesses; untreated depression can delay recovery from or worsen the outcome of other illnesses. ■ Up to 25% of nursing home residents are depressed. ■ Cognitive-behavioral therapy and interpersonal therapy with antidepressant medication are effective in 80% of older adults with depression. ■ Older adults are more likely to die as a result of suicide than younger persons. ■ Older adults often use highly lethal methods and are less able to recover. ■ Events associated with suicide in older adults include death of a loved one, physical illness, chronic pain, fear of dying a prolonged death; fear of becoming a financial or physical burden to their families, social isolation, loneliness, and feeling useless.

Signs and Symptoms of Depression

Physical ■ ■ ■ ■

Aches, pains, stomach problems Changes in appetite Insomnia or excessive sleeping Feeling tired all the time

Emotional ■ ■ ■ ■ ■ ■

Unrelenting feeling of sadness Apathy and diminished pleasure Crying for no apparent reason Indifference to others Feelings of hopelessness and helplessness Feelings of worthlessness

Cognitive ■ ■ ■ ■

Impaired concentration Problems with memory Indecisiveness Recurrent thoughts of death and suicide

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77 Behavioral ■ ■ ■ ■

Neglecting personal appearance Withdrawing from others Increased alcohol consumption or use Agitation/anxiety

■ ■ ■ ■

Talking about death as a relief Giving away possessions Failing to take prescribed medicines Obtaining a weapon

Signs of Suicidal Intent

Nursing Interventions ■ Assess patients for signs and symptoms of depression. ■ If patient is depressed, ask if he or she has thought about committing suicide. ■ Show interest and offer support; elders may want to talk about their lives. Called life review, these talks can help the older adult identify the main themes of their lives, express regret, and talk about their legacy. ■ Avoid giving pat answers or advice such as “you have a lot to live for” or avoiding the conversation altogether. ■ Identify the patient’s support among friends, family, clergy. ■ Remove implements or medications that can be used for suicide. ■ Notify other staff, document your findings, and participate in the plan of care.

Geriatric Depression Scale (GDS) Instruct the Pt to choose the answer that best describes how they felt over the past week ■ Are you basically satisfied with your life? ■ Have you dropped any of your activities or interests? ■ Do you feel that your life is empty? ■ Do you often get bored? ■ Are you in good spirits most of the time? ■ Are you afraid that something bad is going to happen to you?

Yes

No

(Continued on following page)

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Geriatric Depression Scale (GDS) (continued) ■ Do you feel happy most of the time? ■ Do you often feel helpless? ■ Do you prefer to stay at home rather than going out and doing new things? ■ Do you feel that you have more problems with memory than most people? ■ Do you think that it is wonderful to be alive? ■ Do you feel pretty worthless the way you are now? ■ Do you feel full of energy? ■ Do you feel that your situation is worthless? ■ Do you feel that most people are better off than you are? Note: A total of five–six inappropriate answers is suggestive of depression; a total of seven or more inappropriate answers is significant and indicates that Pt needs further evaluation.

Causes of Delirium (ICM) ■ Infection (urinary tract, sepsis, pneumonia) ■ Injury (subdural bleed) ■ Intoxication (alcohol) ■ Cerebrovascular accident ■ Congestive heart failure ■ Cerebral anoxia

■ Medication (individual or polypharmacy) ■ Metabolic (dehydration, electrolyte imbalance, hypoglycemia) ■ Myocardial infarction

Causes of Dementia (DEMENTIA) D E

■ ■ ■ ■

Dehydration Depression Endocrine (thyroid disease) Environment (change or new environment, hyperthermia, hypothermia) ■ Electrolyte disturbances (Continued on following page)

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79 Causes of Dementia (DEMENTIA) (continued) M E N

T I

A

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Medication Metabolic (diabetes, hypokalemia, dehydration, uremia) Eye and ear problems Nutritional deficiencies Normal pressure hydrocephalus Neurosyphilis Tumor (primary or secondary) Trauma Infection (respiratory, urinary, sepsis) Impaction (fecal) Ischemia (MI, stroke, embolism) Insomnia Anemia deficient in vitamin B12 or folate) Anoxia (CHF, respiratory failure) Alcoholism Anesthetic

Differentiating Delirium and Dementia Factor Onset Duration LOC Motor Speech Language

Memory Attention Perception

Delirium Sudden Brief (hours–days) Fluctuates throughout day Tremor, myoclonus, ataxia, hyperactivity Incoherent Vocabulary usual for Pt, but frequent use of wrong words Impaired Impaired, fluctuates Hallucinations common

Dementia Gradual Long (months–years) Unaffected None until late Normal to aphasic in later stages Impoverished, worsens as disorder progresses Impaired Normal to easily distracted Hallucinations uncommon (Continued on following page)

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Differentiating Delirium and Dementia (continued) Factor

Delirium

Dementia

Mood

Fearful, suspicious, irritable

Sleep General condition Clinical course

Disturbances common Pts look sick

Fearful, suspicious, irritable, normal affect, depressed early in disorder Disturbances common Pts look healthy

Fluctuates over short term

Stable over short term

Pharmacokinetics in the Elderly Definition: Pharmacokinetics is the way the body absorbs, distributes, metabolizes, and excretes medication. Age-related physiological changes affect body systems, alter pharmacokinetics, and increase or alter a drug’s effect.

Physiological Change Absorption ■ Decreased intestinal motility ■ Diminished blood flow to the gut Distribution ■ Decreased fluid volume ■ ■ ■ Metabolism ■ ■ Excretionº

■ ■

Effect on Pharmacokinetics ■ Delayed peak effect ■ Delayed signs and symptoms of toxicity

■ Increased serum concentration of water-soluble drugs Increased body fat ■ Increased half-life of fatpercentage soluble drugs Decreased plasma proteins ■ Increased amount of active drug Decreased lean body mass ■ Increased drug concentration Decreased blood flow to ■ Decreased rate of drug liver clearance by the liver Decreased liver function ■ Increased accumulation of some drugs Decreased kidney function ■ Increased accumulation of Decreased creatinine drugs that are normally clearance excreted by the kidneys

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81 Polypharmacy Definition: Polypharmacy is the concurrent use of several drugs. Taking two drugs increases the risk of an adverse drug event by 6%; taking eight drugs increases the risk by 100%.

How Polypharmacy Develops ■ ■ ■ ■ ■ ■ ■

Medications taken for no apparent reason Duplication; different medications taken for same reason Concurrent use of interacting medications Contraindicated medications taken Medications used to treat the side effects of other medications Medications not discontinued after resolution of problem Use of OTC or herbals in conjunction with prescription medications

Assessment and Prevention ■ Have pharmacy and physician regularly review medications. ■ Take complete medication history, including OTC, herbal, and natural supplements. ■ Evaluate all medications for correct dose, duplication, and potential for drug-drug interactions. ■ Look up contraindications and drug-drug interactions of medications. ■ Coordinate care if multiple physicians are caring for Pt. ■ Educate Pt and family about medication use. ■ Encourage Pts to use one pharmacy for all their prescriptions. ■ Help Pts develop a simple medication regimen. ■ Ensure that all pill bottles are easy to read and labeled correctly. ■ Encourage nonpharmacologic treatments whenever possible.

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Inappropriate Medications for the Elderly Note: Based on 1997 Beers Criteria & Classification by Expert Panel

Always Avoid

Rarely Appropriate

Barbiturates Belladonna alkaloids Chlorpropamide Dicyclomine Flurazepam Hyoscyamine Meperidine Meprobamate Pentazocine Propantheline Trimethobenzamide

Carisoprodol Chlordiazepoxide Chlorzoxazone Cyclobenzaprine Diazepam Metaxalone Methocarbamol Propoxyphene

Often Misused Amitriptyline Chlorpheniramine Cyproheptadine Diphenhydramine Dipyridamole Disopyramide Doxepin Hydroxyzine Indomethacin Methyldopa Oxybutynin Promethazine Reserpine Ticlopidine

From Beers, MH: Explicit criteria for determining potentially inappropriate medication use by the elderly: An update. Arch Intern Med 157:1531–1536, 1997.

Potential Problems with Medications Commonly Prescribed for the Elderly Benzodiazepines (e.g., lorazepam [Ativan], diazepam [Valium], alprazolam [Xanax]) ■ Can be addictive. ■ Can accumulate in elderly and cause daytime sleepiness, confusion, and increased risk of falls. Shorter-acting benzodiazepines have less tendency to accumulate. ■ Daily long-term use and long-acting products should be avoided whenever possible.

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83 Beta-Blockers (e.g., timolol [Blocadren], esmolol [Brevibloc], propranolol [Inderal]) ■ Can worsen heart failure, asthma, and emphysema. ■ Lipid-soluble beta-blockers (propranolol and metoprolol) cross the bloodbrain barrier more easily than water-soluble beta-blockers (atenolol and nadolol) and have a greater potential to produce adverse CNS reactions such as vivid dreams, fatigue, and depression.

Calcium Channel Blockers (e.g., nifedipine [Adalat], verapamil [Calan], diltiazem [Cardizem]) ■ Can worsen heart failure.

Digoxin (e.g., Lanoxin, Lanoxicaps) ■ Digitalis toxicity occurs more frequently in the elderly. ■ Cardiac arrhythmias and conduction disturbances are first sign of toxicity more often than nausea, anorexia, and visual disturbances. ■ The risk for digitalis toxicity is greater when given concurrently with diuretics, verapamil, amiodarone, and/or quinidine.

H2 Histamine Antagonists (e.g., famotidine [Pepcid], cimetidine [Tagamet], ranitidine [Zantac]) ■ Cimetidine interferes with the metabolism of phenytoin, carbamazepine, theophylline, warfarin, and quinidine and increases their half-life. Ranitidine has a similar but lesser effect. ■ Cimetidine has been associated with confusion, psychosis, and hallucinations, most commonly in elderly and/or severely ill Pts. These CNS effects resolve within a few days after discontinuation of the drug.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) (e.g., ibuprofen [Motrin], celecoxib [Celebrex]) ■ Chronic use of NSAIDs contributes to gastric ulceration and bleeding, acute tubular necrosis, and renal failure. ■ There are often no warning signs, such as abdominal pain or nausea, of NSAID-induced gastric ulcers or bleeding. ■ Upper GI bleeding is first sign of GI toxicity in elderly Pts.

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Thiazides (e.g., benzthiazide [Exna], hydrochlorothiazide [HydroDIURIL], metolazone [Zaroxolyn]) ■ Can cause greater potassium loss (hypokalemia) in elderly Pts, often requiring potassium supplementation. ■ Can cause low serum sodium (hyponatremia), which can manifest as delirium.

Tricyclic Antidepressants (e.g., amitriptyline [Elavil], imipramine [Tofranil PM]) ■ Can aggravate glaucoma and cause urinary retention. ■ Amitriptyline can cause severe hypotension in elderly Pts.

Fall Risk Assessment and Prevention Risk Factor

Intervention

Assessment Data ■ Age 65 years ■ History of falls Medications ■ Polypharmacy ■ CNS depressants ■ BP/HR lowering ■ Diuretics and meds that affect GI motility Mental Status ■ Altered LOC or orientation

■ ■ ■ ■ ■

Cardiovascular ■ Postural hypotension Neurosensory ■ Visual impairment ■ Peripheral neuropathy ■ Difficulty with balance or gait

■ ■ ■ ■

■ ■ ■ ■ ■

■ ■

Monitor frequently. Pt should be close to nurses’ station. Implement fall prevention interventions. Review medications with physician. Assess for medications that may affect blood pressure, heart rate, balance, or LOC. Educate about use of sedatives, narcotics, and vasoactive medications. Encourage nonopioid pain management. Routinely reorient Pt to situation. Maintain safe and structured environment. Utilize pressure-sensitive alarms in bed and chairs. Change positions slowly. Review med record for possible changes. Provide illumination at night. Minimize clutter and remove unnecessary or infrequently used equipment from room. Provide protective footwear. Provide appropriate assistive devices and instruct on proper use. (Continued on following page)

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85 Fall Risk Assessment and Prevention (continued) Risk Factor

Intervention

GI/GU ■ Incontinence ■ Urinary frequency ■ Diarrhea Musculoskeletal ■ Decreased ROM ■ Amputee Assistive Devices ■ Use of cane, walker, C or W Environment ■ Cluttered room ■ Tubes and lines

■ ■ ■ ■ ■ ■ ■ ■

Ensure call light is within easy reach. Create toileting schedule. Provide bedside commode or urinal. Unobstructed, well-lit path to the bathroom. Provide ROM exercises and stretching. PT or OT consult. Provide appropriate assistive devices. Ensure that assistive devices are not damaged and are appropriately sized. ■ Instruct Pt on proper and safe use. ■ Minimize clutter. Remove unnecessary or infrequently used equipment. ■ Ensure call light is within easy reach.

Preventing Falls Skilled Nursing Facility ■ Identify and report unsafe conditions in facility. ■ Advise residents to avoid alcohol and sedatives. ■ Refer unsteady residents to PT/OT for evaluation. ■ Teach residents on use of correct assistive devices. ■ Review medication record. ■ Emphasize need to change body position gradually. ■ Encourage strength and ROM exercises. ■ Teach about appropriate attire (e.g., sturdy shoes with thin, nonslip soles). ■ Inform provider about recent changes in hearing, vision, or physical abilities. ■ Notify provider of untoward effects of meds.

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At Home ■ Arrange furniture to ensure unobstructed pathway. ■ Keep all pathways well lit. ■ Avoid using throw rugs. ■ Excess cords should be coiled and next to wall. ■ Install overhead lights and light switches at top and bottom of stairs. ■ Fix uneven or damaged steps and install handrails on both sides of entire length of stairs. ■ Use steady step stool with a grip bar and keep often-used items at waist level. ■ Install grab bars in tub and in bathroom next to toilet. ■ Ensure bathroom floor and tub have nonslip surfaces.

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Wound Assessment ■ Appearance: Color (pink, healing; yellow, infection; black, necrosis), sloughing, eschar, longitudinal streaking, etc. ■ Size: Measure length, width, and depth in cm. ■ Incisions: Approximated edges, dehiscence, or evisceration. ■ Undermining: Use a sterile, cotton-tipped applicator to probe gently underneath the edges until resistance is met. With a felt-tipped pen, mark where the applicator can be felt under the skin. ■ Induration: Abnormal firmness of tissues with margins. Assess by gently pinching tissue distal to wound edge; if indurated you will be unable to pinch fold of skin. ■ Tissue edema: Note if edema is pitting or nonpitting. Note: If wound is crepitant, notify physician immediately. ■ Granulation: Bright red, shiny, and granular. Indicates that the wound is healing. Note: poorly vascularized tissue appears pale pink, dull, or dusky red. ■ Drainage: Type, (sanguineous, serosanguineous, purulent) amount, color, and consistency. ■ Odor: Foul odor indicates infection. ■ Staging: See Staging Pressure Ulcers, below.

Staging Pressure Ulcers Intact, nonblanching erythematous area; indicates potential for ulceration. Interruption of epidermis, dermis, or both; presents as Stage II abrasion, blister, or very shallow crater. Full-thickness crater involving damage and/or necrosis Stage III down to, but not penetrating, fascia. Full thickness, similar to stage III, but penetrating the Stage IV fascia with involvement of muscle, bone, and supporting structures; may involve undermining. Note: Ulcers that are covered with eschar and cannot be staged without débridement are sometimes called stage V. Stage I

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87 Risk Factors for Developing Pressure Ulcers ■ Alterations in sensation or response to discomfort: Degenerative neurologic/neuromuscular disease, cerebrovascular disease, brain or spinal cord injury, depression, or drugs that adversely affect alertness. ■ Alterations in mobility: Neurologic disease/injury, fractures, contractures, pain, or restraints. ■ Significant changes in weight: Protein-energy malnutrition (PEM), severe edema, obesity. ■ Medical conditions: Malnutrition and dehydration, diabetes mellitus, peripheral vascular disease, end-stage renal disease, congestive heart failure, malignant diseases, chronic obstructive pulmonary disease, obesity, or bowel and bladder incontinence.

Pressure Ulcer Prevention Strategies ■ Inspect skin at the beginning of each shift and document findings. More frequent (every 2 hours) assessments are required for debilitated Pts. ■ Effectively manage urine and fecal incontinence. ■ Clean skin promptly, using mild, nonirritating, nondrying cleaning solution, and avoid friction during cleaning. ■ Use topical moisture barriers and moisture-absorbing pads for incontinent Pts. ■ Position Pts to alleviate pressure and shearing forces. ■ Reposition Pts every 2 hours while in bed and every hour while in chair. ■ Teach Pt to shift weight every 15 minutes while in chair. ■ Use appropriate positioning devices and foam padding. ■ Do not use donut-shaped devices. ■ Avoid positioning Pts directly on trochanters or directly on wound. ■ Maintain lowest head elevation position possible to minimize sacral pressure. ■ Utilize extra staff and appropriate lifting devices. ■ Prevent contractures. ■ Provide adequate hydration and nutrition. ■ Do not massage reddened areas over bony prominences.

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Pressure Ulcer Management Stage I Pressure Ulcer ■ No dressing required. ■ Prevent continued injury from pressure or shearing forces. ■ Assess frequently.

Stage II Pressure Ulcer ■ Use dressing that will keep ulcer bed continuously moist. ■ Keep surrounding intact skin dry. ■ Fill wound dead space with loosely packed dressing material to absorb excess drainage and maintain moist environment.

Stage III Pressure Ulcer ■ Same as stage II treatment plus débride eschar, necrotic tissue. ■ Note: Heel ulcers with dry eschar and no edema, erythema, or drainage may not need to be débrided. ■ Débridement may be done surgically, with enzymatic agents, or mechanically with wet-to-dry dressings, water jets, or whirlpool. ■ Do not use topical antiseptics.

Stage IV Pressure Ulcer ■ Same as stages II and III plus remove all dead tissue, explore undermined areas, and remove skin “roof.” ■ Use clean, dry dressings for 8–24 hours after sharp débridement to control bleeding, and then resume moist dressings.

Common Dressings for Pressure Ulcers Transparent Dressings (Stage I and II Pressure Ulcers) ■ Waterproof; maintains moisture and prevents bacterial contamination. ■ For superficial wounds, blisters, and skin tears.

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89 Hydrogel Dressings (Stage II, III, and IV Pressure Ulcers) ■ Provides moist wound environment. Reduces pain and soothes. ■ For dry, sloughy wound beds; cleanses and débrides.

Hydrocolloid Dressings (Stage II and III Pressure Ulcers) ■ For autolytic débridement of dry, sloughy, or necrotic wounds. ■ For wounds with low to moderate amounts of exudate.

Alginate Dressings (Stage III and IV Pressure Ulcers) ■ Available in pads, ropes, or ribbons. ■ For wounds with moderate to heavy amounts of exudate.

Foam Dressings (Stage III and IV Pressure Ulcers) ■ Highly absorbent; may be left on for 3–4 days before changing. ■ For wounds with heavy exudate, deep cavities, weeping ulcers. ■ Used after débridement or desloughing of pressure ulcers.

Compression Bandages for Venous Ulcers Type Single-layer

Three-layer

Four-layer

Impregnated wrap

Description and Examples Simple tubular woven bandages imprinted with rectangles that stretch to squares when appropriate wrapping tension (30–40 mm Hg) is applied (e.g., ACE bandage, Comperm, Setopress). Layers include padding absorption layer, compression bandage layer, and cohesive compression bandage. Bandages may be left in place for 1 week depending on wound exudate volume (e.g., Dyna-Flex). Layers include nonwoven wound contact layer permeable to wound exudate and four overlying bandages. Bandages may be left in place for 1 week depending on exudate volume (e.g., Profore). Porous flexible occlusive dressing comprising stretchable gauze and nonhardening zinc oxide paste (e.g., Unna boot).

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Areas Susceptible to Pressure Ulcers

Front

Back

Side

90

Sitting

Department of Health and Human Services • Centers for Disease Control and Prevention

Substitute 1 dose of TdaP for Td Three doses (females) One or two doses

65 years

Recommended if some other indication is present (e.g., occupation, lifestyle, etc.)

Two doses 6–12 months apart Three doses, each dose 1–4 months apart One or more doses

Two doses 4–8 weeks Two doses 4–8 weeks apart apart One dose annually One dose annually One–two doses One dose

One dose

One dose Td booster every 10 years

Adult Immunization Schedule USA • Oct. 2006 through Sept. 2007 19–49 years 50–64 years Td/TdaP (tetanus, diphtheria, pertussis) HPV (human papillomavirus) MMR (measles, mumps, rubella) Varicella Influenza Pneumococcal (polysaccharide) Hepatitis A Hepatitis B Meningococcal

Recommended immunization schedule by age group or lack of documentation

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Resuscitation Maneuvers Head-Tilt, Chin-Lift: Adult/Child

Jaw-Thrust: Adult/Child For known or suspected trauma

Pulse Check: Adult/Child (Carotid)

Pulse Check: Infant (Brachial)

Hand Placement: Adult/Child Lower half of sternum

Finger Placement: Infant One finger width below nipples

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93 Resuscitation Maneuvers Abdominal Thrusts Conscious Adult/Child Use chest thrusts for pregnant or obese Pts.

Relief of Foreign Body: Unresponsive Adult/Child Chest compressions (CPR)

Shoulders directly over sternum Elbows locked and arms kept stiff

Back Blows and Chest Thrusts: Infant—Always support head/neck.

Head-Tilt, Chin-Lift: Infant Do not hyperextend the neck.

Recovery Position Reassess ABCs frequently.

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Responding in a Code Situation Advance directives/DNR (do not resuscitate) orders: Under normal circumstances, all Pts should have advance directives in their medical record that indicate whether or not they wish to be resuscitated (and to what extent resuscitative efforts should be carried out) in the event of respiratory or cardiac arrest. Note: If there is any doubt as to the interpretation (or whereabouts) of a Pt’s advance directives, then a code must be called and resuscitative efforts initiated.

Clinical Presentation ■ Unresponsive Pt with no detectiable respirations or pulse. ■ Pt in respiratory arrest with no obvious cause and is not immediately reversible (e.g., opioid intoxication, which can be reversed with an opioid antagonist such as naloxone). ■ Pt who has become critically unstable hemodynamically (e.g., HR
20, BP
70 mm Hg, unresponsive, etc.)

Immediate Interventions (Before Arrival of Code Team) ■ Stay calm! If clinical situation cannot be immediately corrected (e.g., reconnecting Pt to the ventilator, suctioning thick secretions, administering an opioid antagonist, etc.), prepare to call an overhead code (e.g., “I need STAT help in room 4; someone call an overhead code!”). Note: Always include floor, unit, and room number when calling a code. ■ Stay with the Pt and begin resuscitation measures (see CPR Quick Reference, page 96) while waiting for the code team to arrive. ■ Position the Pt flat in the supine position (do not attempt this if you are by yourself). ■ Clear the immediate Pt area of any obstacles (e.g., bedside tables, chairs) and instruct visitors to wait outside the room. ■ Administer 100% oxygen using a bag-valve mask (BVM) device. ■ Insert an oral or nasal airway if available at bedside. ■ Assess pulse and begin chest compressions if undetectable.

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95 Ongoing Interventions (After the Code Team Has Arrived) Depending on the hospital and the location of the code, the number of code team members will vary from five to seven or more staff members. A code team consists of one–two nurses from critical care (ICU/CCU), respiratory therapy (RT), IV therapy, a pharmacist, resident/intern physicians (at teaching facilities), attendings/hospitalists (physicians on duty), and a chaplain. ■ Inform the code team of the minimum pertinent information: ■ Pt’s admitting diagnosis and current treatments. ■ Events before calling the code. ■ Pertinent medical/surgical history. ■ Medications and allergies. ■ Status of advance directives if known. ■ Obtain the Pt’s chart and notify: ■ Surgeon on-call if a surgical Pt. ■ Attending on-call (service who admitted Pt) if a medical Pt. ■ Notify physician of type of event (e.g., cardiac arrest, unresponsive, etc.), interventions (e.g., code called, CPR in progress, intubated, defibrillated, etc.), and if Pt is responding to the resuscitative efforts being implemented. ■ Assist the code team in the resuscitation effort as requested: ■ Notify Pt’s family and/or other medical personnel. ■ Perform chest compressions. ■ Administer ventilations and assist with intubation. ■ Operate code cart and administer defibrillations. ■ Administer resuscitation drugs. ■ Record all interventions and times on the code record. ■ Record ECG strips with each rhythm change, defibrillation attempt, and medication administration. Clinical tip: Record time and other pertinent information (e.g., drugs and dosages) directly onto the ECG strips for easier recall when you are documenting after the code. ■ Carry out code team requests (e.g., order labs, 12-lead ECG, portable chest x-ray, arrange transfer to critical care, etc.). ■ Request chaplain or appropriate staff to notify and/or communicate with Pt’s family.

Documentation ■ All code team members who participated in the code must sign code record including RNs, physicians, and support staff. ■ Ensure that all times and interventions are recorded. ■ Attach ECG strips to code record in chronologic order. ■ Document a brief summary with outcome in Pt’s chart. ■ Attach code record to Pt’s chart after completed.

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CPR Quick Reference Determine unresponsiveness. ■ Adult: Call 911; get help; AED if available. ■ Child or infant: Call 911 after 2 min (five cycles) of CPR. Airway: Open airway. ■ All ages: Head-tilt, chin-lift. ■ If trauma suspected, use jaw-thrust method. Breathing: Assess for breathing. ■ Look, listen, and feel for no longer than 10 sec. ■ If not breathing, give two slow breaths at 1 second/breath. ■ If unsuccessful, reposition airway and reattempt to ventilate. If still unsuccessful, refer to Choking Quick Reference, page 97. Circulation: Check for a pulse for 10 seconds. ■ If pulse is present, but Pt is not breathing, begin rescue breathing (see table below). ■ If no definite pulse after 10 sec, or if
60 bpm in child or infant with poor perfusion, start chest compressions. Defibrillation/AED: Power on and follow voice prompts. ■ Perform 2 min of CPR between each shock. ■ Adults: Do not use pediatric pads. ■ Child: Use after 2 min (five cycles) of CPR (may use adult pads if pediatric pads are unavailable). Note: Recheck pulse every 2 min and after each shock without interrupting chest compressions.

Adult

Child and Infant

Newborn

Ventilations Pulse check

10–12/min Carotid

Events/min Ratio

100/min 30:2 (1 or 2 rescuers) 1 1/2–2 inches

12–20/min Child: Carotid Infant: Brachial 100/min 30:2 (15:2 if rescuers) 1/2–1/3 depth of chest

40–60/min Brachial or umbilicus 120/min 3:1 (1 or 2 rescuers) 1/3 depth of chest

Compression depth

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97 Choking Quick Reference Conscious Victim 1. Assess for airway obstruction. ■ Adult or child: Ask victim if he or she is choking; can he or she speak or make any sounds? ■ Infant: Cannot cry or ineffective cough 2. Attempt to relieve obstruction. ■ Adult or child: Abdominal thrusts until obstruction is relieved or victim becomes unresponsive (see step 3 below) ■ Pregnant or obese Pts: Chest thrusts until the obstruction is relieved or Pt becomes unresponsive (see step 3 below) ■ Infant: Five back blows and five chest thrusts until obstruction is relieved or victim becomes unresponsive (see step 3 below)

Unresponsive Victim 1. Determine unresponsiveness. ■ Adult: Get help or call 911 before any intervention. ■ Child or infant: Get help or call 911 after 1 min. 2. Open airway: Head-tilt, chin-lift. If trauma suspected, use jaw-thrust method. 3. Assess breathing and attempt to ventilate. If unsuccessful, reposition airway and reattempt ventilation. If still unsuccessful, begin CPR (for all ages). 4. Inspect mouth and remove obstruction. ■ Adult, child, and infant: Use tongue-jaw lift while opening the airway during CPR and perform finger sweep only to remove visible foreign body. 5. Repeat the following steps: Inspect, sweep, ventilate, and CPR until obstruction relieved. Note: If Pt resumes breathing, place into recovery position and reassess ABCs every min.

Pulseless Arrest ■ BLS algorithm, call for help, begin CPR if indicated. ■ Administer oxygen and attach monitor/defibrillator. ■ Search for and manage reversible causes (see below).

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V-Fib/Pulseless VT Shock: Biphasic, 200 J; or monophasic, 360 J. CPR: Immediately resume 5 cycles of CPR (2 min). Vasopressor (given without interrupting CPR): ■ Epinephrine 1 mg IV or IO (2–2.5 mg ET) every 3–5 min. or ■ Vasopressin 40 units IV or IO, one time only. May use to replace 1st or 2nd dose of epinephrine. Shock: Biphasic, 200 J; or monophasic, 360 J. Consider antiarrhythmics (given without interrupting CPR): ■ Amiodarone 300 mg IV or IO, repeat 150 mg in 3–5 min. ■ Lidocaine 1.0–1.5 mg/kg IV or IO, repeat 0.5–0.75 mg/kg every 5–10 min, max 3 mg/kg. ■ Magnesium 1–2 g IV or IO for torsade de pointes.

Asystole/PEA CPR: Resume CPR for five cycles (~2 min). Vasopressor (given without interrupting CPR): ■ Epinephrine 1 mg IV or IO (2–2.5 mg ET) every 3–5 min. or ■ Vasopressin 40 units IV or IO, one time only. May use to replace 1st or 2nd dose of epinephrine. CPR: Immediately resume 5 cycles of CPR (2 min) ■ Atropine 1 mg IV (2–3 ET) every 3–5 min (max 3 mg) for asystole or PEA
60.

Search for Reversible Causes ■ Hypovolemia ■ Hypoxia ■ Hydrogen ion (acidosis) ■ Hypokalemia ■ Hyperkalemia ■ Hypoglycemia ■ Hypothermia ■ Toxins ■ Tamponade (cardiac) ■ Tension pneumothorax ■ Thrombosis (coronary, PE) ■ Trauma

Perfusing Arrhythmias ■ BLS algorithm, call for help, begin CPR if indicated. ■ Administer oxygen and attach monitor/defibrillator. ■ Search for and manage reversible causes (see above).

Bradycardia

All Unstable* Tachycardia

Stable (adequate perfusion): ■ Monitor and supportive care as needed.

*(CP, ↓BP, SOB, or ALOC) Cardiovert: Immediate synchronized cardioversion.

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99 Bradycardia

All Unstable* Tachycardia

Unstable, with poor perfusion (CP, ↓BP, SOB, or ALOC) ■ Pace: Prepare for transcutaneous pacing (TCP). Do not delay for second-degree type 2 or thirddegree AV block. ■ Atropine 0.5 mg IV every 3–5 min to a max of 3 mg. ■ Epinephrine 2–10 g/min or Dopamine 2–20 g/kg/min if TCP is ineffective or unavailable. ■ Prepare for transvenous pacing, treat reversible causes.

■ Monomorphic VT/A-fib: 100 J, 200 J, 300 J, 360 J. ■ Atrial flutter and SVT: May start with 50 J ■ Polymorphic VT: Unsynchronized with 360 J. Premedicate: Administer sedatives and analgesia whenever possible. Caution: If delays occur with synchronization and clinical situation is critical, go immediately to unsynchronized cardioversion at 360 J.

Automatic External Defibrillators (AEDs) ■ Assessment: Follow BLS protocol (CPR) until AED arrives. ■ Power: Turn on AED and follow voice prompts. ■ Attach pads: Stop CPR, attach appropriate size* pads to Pt, and plug pad cable into AED unit if needed. ■ Analyze: Press the “Analyze” button and wait for instructions (do not contact Pt while AED is analyzing). ■ Shock: Announce “shock indicated, stand clear,” ensure no one is in contact with Pt, and depress shock button. ■ If AED does not advise 2nd shock, check for pulse and begin CPR if indicated (AED will reanalyze every min). *Do not use child pads on adults (adult pads are OK on child).

Abdominal Pain: Distention Clinical Picture Neuro: Anxiety, restlessness. Resp: Increased respiratory rate and/or distress. CV: Increased heart rate and/or hypotension. Skin: Fever and/or cool, pale, and diaphoretic. GI/GU: Anorexia, hyperactive, hypoactive, or absent bowel sounds, nausea, vomiting, diarrhea, constipation, GI bleeding. MS: Abdominal tenderness, distention, rigidity, guarding, flank pain, palpable pulsatile mass, fatigue, malaise.

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Nursing Interventions ■ ■ ■ ■ ■

■

■ ■ ■ ■ ■ ■ ■ ■ ■

Place Pt in position of comfort and offer reassurance. Obtain and document baseline VS (HR, RR, BP, temp, SpO2). Administer supplemental oxygen titrated to SpO2 90%. Obtain focused symptom analysis (see PQRST, page 43). Obtain focused history including recent events. ■ Nutritional and hydration status including last PO intake and urine output. ■ Recent bowel habits including laxatives or enemas. Complete focused examination of Pt’s abdomen: ■ Inspect abdomen for symmetry and distention. ■ Auscultate bowel sounds (hyper/hypoactive or absent). ■ Palpate abdomen for masses, pulsations, tenderness, and rigidity. Note: When palpating the abdomen, do so from the area of least tenderness to the area of most tenderness. Assess NG tube placement and output if applicable and initiate nasogastric suctioning if ordered. If Pt does not have NG tube in place, prepare to insert one if ordered. Assess indwelling urinary catheter if applicable to ensure drainage, and record amount, color, and clarity of urine. If Pt does not have urinary catheter in place, prepare to insert one if ordered. Obtain STAT bedside blood glucose level if Pt is diabetic. Test emesis/NG drainage and/or stool for occult blood. Obtain IV access if ordered and titrate to SBP 90 mm Hg. Administer antiemetic and pain medication if ordered. Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. Consult physician about continued treatment, including insertion of NG tube or urinary catheter, labs (Hct and Hgb, CBC, WBC, guaiac stools, LFTs), possible return to OR (postop Pts), and/or transfer to ICU. Document assessments, any interventions, and outcome.

Allergic Reaction: Anaphylaxis Clinical Findings Neuro: Anxiety, restlessness. Resp: Dyspnea, bronchospasm, wheezing, stridor, swelling of tongue or throat, respiratory arrest. CV: Hypotension, localized or systemic edema, CV collapse. Skin: Rash, itching, hives, cool, pale, cyanosis, diaphoresis.

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101 Nursing Interventions ■ If Pt is in respiratory distress or exhibiting signs of inadequate perfusion (e.g., decreased LOC; hypotension; cool, moist skin), call code/ notify physician and RT STAT. Note: Follow hospital protocol when calling code. ■ Remove source of allergy (e.g., discontinue suspect medication, blood transfusion, latex gloves, etc.). ■ Administer supplemental oxygen titrated to SpO2 90% and be prepared to ventilate Pt manually using BVM if needed. ■ Obtain IV access if ordered and titrate to SBP 90 mm Hg. ■ If Pt is receiving blood transfusion, assess Pt for possible blood transfusion reaction. If transfusion reaction evident or suspected, discontinue blood, hang normal saline, and (after crisis) return unused blood product to blood bank for analysis. ■ Administer STAT medication if ordered: epinephrine 1:1,000 0.3–0.5 mg SC; diphenhydramine 25–50 mg IV or IM. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering a STAT 12-lead ECG, labs (CBC, electrolytes, and coagulation studies) chest x-ray, additional pharmacologic therapy (e.g., bronchodilators, corticosteroids, vasopressors), and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.

Altered Level of Consciousness (ALOC) Clinical Findings Neuro: Confused, lethargic, obtunded, stuporous, or comatose. Resp: Depressed (likely opioid OD), Cheyne-Stokes (likely CVA), Kussmaul’s respirations or fruity odor on breath (likely DKA), apneustic (likely brainstem injury), odor of alcohol (likely intoxicated), sweet almond odor (likely cyanide exposure). CV: Increased BP and decreased HR (likely ↑ ICP), hypotension (likely sepsis, MI, OD, internal bleeding), dysrhythmias. Skin: Cool and moist (likely hypoglycemia, vasovagal response, MI, shock), warm and flushed (likely spinal injury, hyperglycemia, sepsis). GI/GU: Nausea and vomiting, incontinence. MS: Weakness, fatigue, abnormal flexion or extension, trauma.

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Nursing Interventions ■ Place Pt in position of comfort and offer reassurance. If Pt is unable to maintain airway or clear secretions, place Pt into lateral-lying position and suction airway as needed. Consider inserting oropharyngeal airway, or, if Pt has gag reflex and there is no evidence of facial trauma, use nasopharyngeal airway. ■ Administer supplemental oxygen titrated to SpO2 90% and be prepared to ventilate Pt manually if RR
8 breaths/minute. ■ Assess pupils and establish baseline GCS score. ■ Assess for neuro deficits such as slurred speech, facial droop, or weakness or numbness on one side of the body. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Obtain STAT bedside blood glucose level. ■ Review medication administration record and recent labs for possible causes of ALOC (see AEIOU-TIPS, page 36). ■ Administer STAT medication if ordered: Glucose 25 g IV for hypoglycemia; naloxone 0.4–2 mg IV for narcotic OD; flumazenil 0.2 mg for benzodiazepine OD. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering STAT 12-lead ECG, labs (CBC, electrolytes, coagulation studies, medication levels) additional pharmacologic therapy (e.g., insulin drip, reversal agents, restoring electrolyte imbalances), and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.

Bradycardia Clinical Findings Neuro: Dizziness, lightheadedness, ALOC, syncope. Resp: Shortness of breath. CV: HR
60 beats/minute, hypotension, pulmonary congestion. Skin: Cyanosis, coolness, pallor, diaphoresis. GI/GU: Nausea and vomiting. MS: Weakness, lethargy, fatigue, exhaustion.

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103 Nursing Interventions ■ Note: if Pt is exhibiting signs of unstable bradycardia (CP, shortness of breath, ALOC, hypotension, cyanosis), call code/notify physician STAT and refer immediately to Unstable Bradycardia in ACLS (page 99). ■ Assess LOC and orientation. ■ Lay Pt flat and elevate foot of bed 10–15 degrees. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Assess for associated symptoms (chest pain, respiratory distress, and/or hypotension). ■ Administer supplemental oxygen titrated to SpO2 90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering STAT 12-lead ECG, labs (cardiac-specific markers, CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to CCU. ■ Document assessments, any interventions, and outcome.

Chest Pain Clinical Findings Neuro: Anxiety, restlessness, dizziness, lightheadedness, syncope; Pt may have sense of impending doom. Resp: Shortness of breath, tachypnea, abnormal lung sounds. CV: Tachycardia or bradycardia, signs of congestive heart failure. Skin: Coolness, pallor, cyanosis, diaphoresis. MS: Substernal pain, weakness, fatigue, sensation of chest heaviness or chest tightness. GI/GU: Nausea and vomiting.

Nursing Interventions ■ Place Pt in position of comfort and offer reassurance. ■ Administer supplemental oxygen titrated to SpO2 90%. ■ Assess apical pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain focused symptom analysis (PQRST).

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■ Administer STAT medication if ordered: nitroglycerin 0.4 mg SL every 5 minutes until CP relieved (hold for BP
90 mm Hg); chewable aspirin 325 mg (non–enteric coated); morphine 2–4 mg IV (hold for SBP
90). ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering a STAT 12-lead ECG, labs (cardiac-specific markers, CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to a CCU. ■ Document assessments, any interventions, and outcome.

Dizziness—Vasovagal Response—Syncope Clinical Findings Neuro: Dizziness, lightheadedness, faintness, anxiety, syncope. Resp: Shortness of breath, hyperventilation. CV: Hypotension, tachycardia, bradycardia, chest pain, chest tightness or pressure, palpitations, dysrhythmias. Skin: Cool, pale, and diaphoretic. GI/GU: Nausea and vomiting. MS: Weakness, fatigue.

Nursing Interventions ■ Stay with Pt until you can assist him or her to chair or back to bed (if, during assist, Pt experiences syncopal episode, gently assist Pt to floor, call for help, and then assess ABCs). ■ Lay Pt flat and elevate foot of bed 10–15 degrees. ■ If Pt is hyperventilating, encourage slow, deep breathing. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Assess for neuro deficits such as slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of the body and other associated findings such as chest pain; respiratory distress; rapid, thready pulse; or hypotension. ■ Administer supplemental oxygen titrated to SpO2 90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Review medical record (medication, recent labs, and treatments) for possible causes of dizziness or syncope. ■ Obtain STAT bedside blood glucose level if Pt is diabetic. ■ Obtain and document orthostatic vital signs (each set, 1 minute apart) from supine, sitting, and standing positions. Note: An increase in HR

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105 ■ ■ ■ ■

or decrease in SBP by 20 points from baseline is positive for orthostatic hypotension. Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. Consult physician about continued treatment, including 12-lead ECG, labs (CBC, electrolytes) pharmacologic therapy, diagnostic studies, and/or transfer to ICU. Document assessments, any interventions, and outcome. Note: If vasovagal/syncopal episode is reasonably anticipated in relation to Pt’s clinical status (e.g., anxiety related to an overt fear of needles), it is not immediately necessary to notify physician, unless there exists a need to order (or clarify an order for) medication or additional treatment, or, if you suspect underlying cause such as dysrhythmia.

Fever Clinical Findings Neuro: Headache, dizziness, lightheadedness, confusion. Resp: Hyperpnea, tachypnea, abnormal lung sounds. CV: Tachycardia or bradycardia, signs of congestive heart failure. Skin: Warm to hot or cool, flushed or pale, dry or diaphoretic. MS: Body aches or cramps, stiff neck, stiff joints, weakness, fatigue, chills, shivering. GI/GU: Nausea and vomiting, constipation, diarrhea, UTI. Metabolic: Temperature 100.4F (38C).

Nursing Interventions ■ Place Pt in position of comfort and offer reassurance. ■ Offer Pt cool compress to forehead or nape of neck and encourage fluids as ordered. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Assess for associated symptoms: Fluid-volume status (dehydration, decreased urine output), surgical site complications (redness, tenderness, swelling, and warmth), lung sounds (crackles, rhonchi, diminished or absent), deep vein thrombosis (pain, redness, and warmth), GI/GU (diarrhea, constipation, UTI, odoriferous discharge). ■ Review medical record for medication, recent labs (WBC, blood and sputum cultures, and urinalysis), treatments, and temperature trends, for possible causes of fever.

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■ Encourage Pt to cough and deep breathe (if incentive spirometer ordered, encourage Pt to use regularly). ■ Administer p.r.n. antipyretic medication per order. ■ Notify physician of change in Pt status, including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including antipyretic medication, alternative cooling measures, ordering labs (WBC, blood and sputum cultures, or urinalysis) or chest x-ray. ■ Document assessments, any interventions, and outcome. ■ Note: If fever is reasonably anticipated in relation to Pt’s clinical status (e.g., admitted to hospital for pneumonia), it is not immediately necessary to notify physician, unless there exists a need to order (or clarify an order for) antipyretic medication.

Hypertension Clinical Findings Neuro: Dizziness, lightheadedness, vertigo, faintness, headache, anxiety, ALOC, restlessness, visual disturbances, seizures. Resp: Shortness of breath, hyperventilation. CV: Tachycardia, bradycardia, chest pain, palpitations, dysrhythmias, dependent edema, symptoms of CHF. Skin: Cool and moist, warm and flushed, tingling sensation. GI/GU: Nausea and vomiting. MS: Weakness, fatigue.

Nursing Interventions ■ ■ ■ ■ ■

■ ■ ■

Note: if SPB 220 or DPB 140 mm Hg, notify physician STAT. Elevate Pt’s HOB to 30–45 degrees and offer reassurance. Assess LOC and orientation. Assess apical pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. Assess for neuro deficits such as slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of body and other associated findings such as chest pain; respiratory distress; rapid, thready pulse; or ALOC. Administer supplemental oxygen titrated to SpO2 90%. Obtain and document baseline VS (HR, RR, BP, temp, SpO2), and obtain and record blood pressure readings in both arms. Administer antihypertensive medication if ordered.

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107 ■ Review medical record (medication, recent labs, and treatments) for possible causes of rise in BP. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering STAT 12-lead ECG, labs (BUN, creatinine, CBC, electrolytes, UA, and coagulation studies), chest x-ray, additional pharmacologic therapy (e.g., betablockers, ACE inhibitors, calcium channel blockers), or transfer to ICU. ■ Document assessments, any interventions, and outcome. ■ Note: If elevated BP is reasonably anticipated in relation to Pt’s clinical status, it is not immediately necessary to notify the physician, unless there exists a need to order (or clarify an order for) antihypertensive medications.

Hypotension Clinical Findings Neuro: Anxiety, restlessness, dizziness, lightheadedness, decreased LOC, faintness, syncope. Resp: Shortness of breath, respiratory distress. CV: SBP
90 mm Hg, or SBP 40 mm Hg below Pt’s normal baseline BP, tachycardia, bradycardia, chest pain, dysrhythmia. Skin: Cool, pale, diaphoretic. GI/GU: Nausea and vomiting, UO
30 mL/hour. MS: Weakness, fatigue.

Nursing Interventions ■ Lay Pt flat, unless contraindicated by respiratory or airway compromise, and elevate foot of bed 10–15 degrees. ■ Assess LOC and orientation. ■ Assess for and control any bleeding with direct pressure. ■ Anticipate and prepare for return to surgery if Pt is postop. ■ Assess for associated symptoms (chest pain, respiratory distress, cyanosis, decreased LOC). ■ Assess apical pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Administer supplemental oxygen titrated to SpO2 90% and be prepared to ventilate Pt manually if RR
8 breaths/minute. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2).

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■ Obtain IV access, if not already in place, and titrate to SBP 90 mm Hg. Caution: Keep IV at TKO if hypotension is secondary to heart failure or cardiogenic shock. ■ Review medical record (medication, recent labs, and treatments) for possible causes of drop in BP. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including 12-lead ECG, labs (CBC, Hgb and Hct, electrolytes, BUN and creatinine, urine specific gravity), additional pharmacologic therapy (fluids, blood products, vasopressors), chest x-ray, and/or transfer to ICU. ■ Document assessments, any interventions, and outcome.

Nausea Clinical Findings Neuro: Dizziness, lightheadedness, anxiety. Resp: Hyperventilation. CV: Hypotension, hypertension, tachycardia, bradycardia. Skin: Cool, pale, diaphoretic, warm and flushed. GI/GU: Nausea, vomiting, diarrhea, constipation. MS: Weakness, fatigue, abdominal pain.

Nursing Interventions ■ Place Pt in position of comfort and provide Pt with an emesis basin. If Pt is unable to protect airway (e.g., clear emesis), place Pt into lateral-lying position to prevent aspiration and be prepared to suction oropharynx to clear emesis if needed. ■ Offer Pt cool compress to forehead or nape of neck. ■ Assess for associated symptoms (chest pain, respiratory distress, cyanosis, decreased LOC, anxiety). ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Keep Pt NPO until nausea passes or as orders dictate. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Review medical record (medication, recent labs, and treatments) for possible causes of nausea. ■ Administer p.r.n. antiemetic/antinausea medication if ordered. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented.

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109 ■ Consult physician about continued treatment, including antiemetic/ antinausea medication, withholding PO medications or changing them to an alternate route, NPO status, ordering labs, reviewing and changing treatments. ■ Document assessments, any interventions, and outcome. ■ Note: If nausea is reasonably anticipated in relation to Pt’s clinical status, it is not immediately necessary to notify physician, unless there exists a need to order (or clarify an order for) antinausea/antiemetic medication.

PostOp Hemorrhage Clinical Findings Neuro: Early signs: anxiety, agitation, restlessness, lightheadedness; late signs: decreased LOC, confusion. Resp: Shortness of breath, respiratory distress. CV: Hypotension (late sign), tachycardia, capillary refill 3 seconds, diminished peripheral pulses. Skin: Cool, pale, diaphoretic, cyanosis, mottled, ecchymosis. GI/GU: Rigid, distended abdomen; periumbilical and/or retroperitoneal bruising; nausea, hematemesis; decreased UO, thirst. MS: Weakness, fatigue. Incision: Excessive swelling and ecchymosis. Other: Excessive wound drainage, saturated dressing, melena, excessive blood loss via chest tube or NGT.

Nursing Interventions ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Assess for and control external bleeding with direct pressure. Get help and notify surgeon STAT. Discontinue any thrombolytics or anticoagulants. Reinforce saturated dressing with additional dressing and pressure (do not remove saturated dressing). Lay Pt flat, unless contraindicated by respiratory or airway compromise, and elevate the foot of the bed 10–15 degrees. Anticipate and prepare for Pt to return to surgery. Assess LOC and orientation. Administer supplemental oxygen titrated to SpO2 90%. Obtain and document baseline VS (HR, RR, BP, temp, SpO2). Obtain and record outputs (surgical drains, urinary catheter). Obtain type and crossmatch status from blood bank. Administer IV fluids and assist with administration of blood products if ordered.

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■ Consult surgeon about continued treatment, including STAT labs (Hgb and Hct, type and crossmatch, ABGs, electrolytes, coagulation studies), volume expansion, portable chest or abdominal x-ray, and return to surgery. ■ Document assessments, any interventions, and outcome.

Respiratory Distress Clinical Picture Neuro: Anxiety, restlessness, confusion, ALOC. Resp: Dyspnea, tachypnea, bradypnea, use of accessory muscles, sternal retractions, wheezing, rales, stridor, coughing. CV: Tachycardia, dysrhythmias, HTN, pulmonary edema (CHF). Skin: Cyanosis, coolness, pallor, diaphoresis. MS: Weakness, lethargy, fatigue, exhaustion, bolt upright or tripod position to facilitate breathing.

Nursing Interventions ■ Place Pt in position of comfort and offer reassurance. ■ Assess Pt for signs associated with allergic reaction (see Allergic Reaction: Anaphylaxis, page 100, for signs and symptoms). ■ Administer supplemental oxygen titrated to SpO2 90%. Note: SpO2
90% is considered abnormal and may require immediate intervention, but some Pts (e.g., Pts with COPD) can maintain a baseline SpO2 of 88%–89% and are considered stable. These Pts depend on increased levels of CO2 in order to maintain their respiratory drive. Use oxygen judiciously when administering supplemental oxygen in presence of COPD, because excessive amounts may actually decrease Pt’s respiratory drive and inevitably cause clinical situation to progress to full respiratory arrest. ■ If Pt is exhibiting signs of inadequate oxygenation (e.g., ALOC, cyanosis) or RR
8 breaths/minute, consider inserting nasopharyngeal airway and provide manual ventilations. ■ Suction oropharynx and clear secretions as needed. ■ If Pt is hyperventilating, encourage slow, deep breathing. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Obtain focused symptom analysis (see PQRST, page 43). ■ Obtain focused history including recent events: ■ History of asthma, COPD, pneumonia, aspiration.

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111 ■

■ ■ ■ ■

■ Recent surgical procedures, especially ones involving bone. ■ History of recent pelvic or lower extremity fracture. Complete a focused respiratory assessment: ■ Inspect for symmetry and equal expansion of chest. ■ Inspect tracheal alignment and for jugular vein distention. ■ Auscultate lungs bilaterally. Note equality, depth, rate, effort, and presence (or absence) of lung sounds. Obtain STAT labs including arterial blood gases if ordered. Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. Consult physician about continued treatment, including STAT 12-lead ECG, labs (arterial blood gases, CBC, electrolytes), pharmacologic therapy (bronchodilators, diuretics), chest x-ray, or transfer to ICU. Document assessments, interventions, and outcomes.

Seizure Clinical Findings Neuro: Loss of consciousness (blank stare if petit mal seizure). Resp: Inability to breathe adequately, apnea. Skin: Cyanosis, cool and moist, or warm and flushed. MS: Repetitive jerking movements of upper and lower extremities, blinking, deviation of eyes and/or tongue. GI/GU: Urinary or fecal incontinence.

Progression of a Seizure ■ Aura (before the seizure starts): An auditory or sensory warning or recognition by Pt that seizure is imminent. ■ Ictal Phase (active seizing): Tonic posturing or clonic jerking. ■ Postictal Phase (after the seizure has subsided): ALOC, extreme confusion, fatigue, fear, and disorientation.

Nursing Interventions ■ Protect Pt from injury by clearing immediate area of potential hazards (e.g., tables, chairs) and call for help. ■ If Pt is in bed, raise side rails and protect from injury by placing pillows between Pt and rails and call for help. ■ If Pt is out of bed, assist Pt to floor and call for help.

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■ If Pt is found on the floor, anticipate possible head and spinal injury, and take cervical spine precautions, but do not attempt to restrain Pt forcefully during seizure. ■ Assess Pt’s airway and effectiveness of respiratory effort. ■ Position Pt (if able) in lateral recumbent position to help minimize risk of aspiration, and suction oropharynx to clear secretions if Pt’s airway becomes compromised. ■ Administer supplemental oxygen (if able) and be prepared to ventilate Pt manually using BVM if needed. ■ Stay with Pt, and do not insert any objects into Pt’s mouth. ■ Administer STAT anticonvulsant medication as ordered. ■ Assess ABCs and LOC once seizure has subsided. ■ Obtain STAT bedside blood glucose level. ■ If seizures are likely to recur, install seizure pads on all side rails to minimize risk of injury. ■ Reorient Pt, provide reassurance, and allow Pt to sleep. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including labs (serum blood levels of anticonvulsant medication, blood glucose level, and electrolytes), pharmacologic therapy (anticonvulsants), or transfer to ICU. ■ Document assessments, type of seizure and duration, any interventions implemented, and outcome.

Tachycardia Clinical Findings Neuro: Dizziness, lightheadedness, anxiety, ALOC, restlessness. Resp: Shortness of breath, hyperventilation. CV: HR 100 beats/minute, chest discomfort, palpitations, dysrhythmias. Skin: Cool and moist, warm and flushed, tingling sensation. GI/GU: Nausea and vomiting. MS: Weakness, fatigue.

Nursing Interventions ■ Note: if Pt is exhibiting signs of unstable tachycardia (CP, shortness of breath, ALOC, hypotension, cyanosis), call code/notify physician STAT and refer immediately to Unstable Tachycardia in ACLS. ■ Place Pt in position of comfort and offer reassurance. If tachycardia results from anxiety or agitation, attempt to reduce external stressors (e.g.,

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■ ■ ■

reduce noise and bright lights, adequate pain management, adjust room temperature). Lay Pt flat; elevate foot of bed 10–15 degrees if Pt is feeling dizzy, lightheaded, or faint. Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. Assess for associated symptoms (chest pain, respiratory distress, cyanosis, decreased LOC). Administer supplemental oxygen titrated to SpO2 90%. Obtain and document baseline VS (HR, RR, BP, temp, SpO2). Obtain and document orthostatic VS (each set, 1 minute apart) from supine, sitting, and standing positions. Note: An increase in HR or decrease in SBP by 20 points from baseline is positive for orthostatic hypotension. Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. Consult physician about continued treatment, including ordering STAT 12lead ECG, labs (cardiac-specific markers, CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to a CCU. Document assessments, any interventions, and outcome.

Transfusion Reaction Clinical Findings Neuro: Anxiety, restlessness. Resp: Shortness of breath, dyspnea, tachypnea, bronchospasm. CV: Chest pain, tachycardia, hypotension. Skin: Urticaria, pruritus, erythema, burning at infusion site. GI/GU: Nausea, vomiting, diarrhea, hematuria, oliguria, anuria. MS: Flank, back, or joint pain. Metabolic: Fever, chills.

Nursing Interventions ■ Stop transfusion and run normal saline to maintain IV access. Note: LR contains calcium and will clot blood in the tubing. ■ Palpate radial pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Administer supplemental oxygen titrated to SpO2 90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2). ■ Assess and document LOC.

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■ ■ ■ ■ ■ ■ ■ ■ ■

Notify physician and blood bank of reaction STAT. Recheck Pt ID and blood labels for possible errors. Return unused blood product to blood bank for analysis. Administer ordered medications (see specific reaction). Assess indwelling urinary catheter and record amount, color, and clarity of urine. If Pt does not have urinary catheter in place, prepare to insert one for monitoring UO. Continue IV fluids to maintain minimum UO of 30 mL/hour. Monitor for early detection of any hemodynamic instability (e.g., dysrhythmias, abnormal lab values, CHF). Consult physician about continued treatment, including ordering 12-lead ECG, labs (CBC, electrolytes, and coagulation studies), chest x-ray, and/or transfer to ICU. Document assessments, any interventions, and outcome.

Reaction-Specific Treatments

Anaphylactic Reaction

■ Support airway, breathing, and circulation as indicated. ■ Administer epinephrine, antihistamines, and corticosteroids. ■ Maintain intravascular volume.

Hemolytic Reaction ■ ■ ■ ■

Maintain renal perfusion with aggressive fluid resuscitation. Consider furosemide to increase renal blood flow. Consider low-dose dopamine to improve renal blood flow. Maintain urine output at 30–100 mL/hour.

Febrile, Nonhemolytic Reaction

■ Treat fever with acetaminophen. ■ If Pt develops chills, cover with blanket unless temp is 102F.

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115 Medication Administration Medication Rights

Triple Check

■ ■ ■ ■ ■

■ When obtaining medication from where it is stored. ■ Side-by-side comparison of medication and written order and MAR. ■ One last time after preparation, just before administration.

Right Right Right Right Right

Pt medication dose time route

Approximate Onset

Assessment and Documentation

IV

3–5 minutes

IM

3–20 minutes

SC

3–20 minutes

PO

30–45 minutes

■ Assessment needs vary and depend on route and medication. ■ Always assess Pt after giving drugs that may adversely affect RR, HR, BP, LOC, and blood glucose. ■ Assess meds for their efficacy and adverse drug reaction (ADR). ■ Document: Drug, dose, route, time given, and time discontinued if applicable. Include Pt’s response and any ADR.

These onset times are only approximate, but will help guide you in your assessment.

Aspirate (IM and SC Injections) ■ The reason for aspirating before actually injecting medication is to ensure that the needle is not in a blood vessel. ■ If blood appears in syringe, withdraw needle, discard syringe, and prepare new injection.

When Not to Aspirate ■ When administering SC anticoagulants (e.g., heparin) or insulin, it is recommended that you do not aspirate. ■ Entering a blood vessel is unlikely with SC injection, and manipulating the syringe is more likely to cause bruising. ■ Aspiration while administering anticoagulants increases risk of bleeding and bruising.

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Points to Remember ■ Confirm MAR is up to date. Question unclear medication orders. ■ Always confirm compatibility. ■ Always check for allergies and assess for reactions to new drugs not previously taken by Pt. ■ Do not crush sustained-release or enteric-coated capsules or pills. ■ Take VS before and 5 minutes after applying NTG paste and administration of IV vasoactive meds. ■ Always use filter needle when withdrawing medication from glass ampule (discard and replace filter needle before injection). ■ Use straw for PO iron to prevent staining of Pt’s teeth.

Medication Error: Intervention Immediate Interventions ■ Discontinue the medication. ■ Treat symptoms of ADR per protocol.

Focused Assessment ■ Assess for any ADR to the medication including changes in LOC, VS, N&V, allergic reaction, etc. ■ Ascertain whether Pt has any known allergy to medication given in error.

Ongoing Assessment and Intervention ■ Notify physician of medication error, along with any adverse reactions to medication.

Documentation ■ Complete appropriate documentation per hospital policy. ■ Document on MAR and progress notes if indicated. ■ Avoid using such phrases as “given in error.” State facts; document medication, dose, time, and route on MAR. ■ In progress notes, document physician notified. ■ If there was any ADR, include intervention and outcome. ■ Do not indicate within progress notes that an incident report was filled out (e.g., “see incident report”).

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117 Preventing a Medication Error ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Always observe the five medication rights. Triple check all medications given. Always read product packaging to note strength and route. Always double check with pharmacist about dosage range. When mixing insulin, have second nurse witness. Always have colleague confirm dosage calculations and infusion pump programming. Suspect missed decimal point and clarify any order if dose requires more than three dosing units. Clarify any order that is unclear or contains abbreviations. If taking verbal order, ask prescriber to spell out drug name and dosage to avoid sound-alike confusion (e.g., hearing Cerebyx for Celebrex, or 50 for 15). Read back the order to prescriber after you have written it in chart. Label all syringes and discard syringe immediately after use. Do not borrow medications from other Pts. Do not begin new medications before order has been received in pharmacy, because this circumvents built-in checks that can detect potential error. Document immediately after administering any medication. Do not document medication until after it has been administered. Never administer medication drawn up by another person. Review each Pt’s medications for: ■ Medication use without an indication. ■ Contraindications. ■ Improper drug selection. ■ Overdose/subtherapeutic dose (consider age, renal/hepatic impairment). ■ Medication duplication. ■ Efficacy. ■ ADRs/toxicity. ■ Potential drug or food interactions. ■ Weight changes requiring dosage adjustments. ■ Appropriate duration of therapy. ■ Adherence with prescribed medication therapy.

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Error-Prone Abbreviations and Symbols Abbreviations ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■


g AD, AS, AU OD, OS, OU BT cc D/C IJ IN HS, hs IU o.d., OD OJ Per os q.d., QD q1d q6PM, etc. SC, SQ, sub q ss SSRI, SSI 1/d TIW, tiw U, u

Symbols ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

3 (dram)
(minim) @ (at) & (and)  (hour) / (slash)  (plus)  (minus)  (greater than)  (less than) Apothecary symbols

MTX Nitro drip Norflox PCA PTU T3 TAC TNK ZnSO4

General Tips ■ Avoid using a zero after a decimal point. ■ Use a zero before a decimal point. ■ Use commas for dosing units at or above 1,000. ■ Place adequate space between a drug name, dose, and the unit of measure.

Drug Names ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

■ ■ ■ ■ ■ ■ ■ ■ ■

ARA A AZT CPZ DPT DTO HCl HCT HCTZ IV Vanc MgSO4

Copyright The Institute for Safe Medication Practices.

Specific High-Alert Meds ■ ■ ■ ■ ■ ■ ■

Insulin (IV and SC) IV amiodarone IV calcium IV colchicine IV digoxin IV heparin IV lidocaine

■ ■ ■ ■ ■ ■ ■

IV magnesium IV nitroprusside IV potassium Methotrexate Nesiritide Saline solutions 0.9% Warfarin

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119 High-Alert Medication Classes ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Adrenergic agonists/antagonists Anesthetic agents Cardioplegic solutions Chemotherapeutic agents Dextrose solutions 20% Dialysis solutions Epidural/intrathecal meds Glycoprotein IIb and IIIa inhibitors Hypoglycemic agents (oral) Inotropic meds Liposomal forms of drugs Moderate sedatives Narcotics and opiates Neuromuscular blocking agents Radiocontrast agents Thrombolytics and fibrinolytics TPN solutions

Common Medication Formulas Injections: Amount to be drawn up into a syringe

(Desired amount of drug  total volume) Total amount of drug on hand

Volume/hour (mL/hr; e.g., 150 mL/hr)

(Volume  drip set factor)

mg/min (e.g., 4 mg/min) mg/hr (i.e., 20 mg/hr)

(Desired amount  volume  drip set factor)

To figure the rate of an existing IV

Time in minutes

Amount of drug on hand Total infusion time in minutes 1. Count drops/minute and multiply by 60. 2. Divide result by the drip factor being used.

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IV Fluid Drip Rate Table (drops/minute) Rate (mL/hr) → 10 gtt/mL set 12 gtt/mL set 15 gtt/mL set 20 gtt/mL set 60 gtt/mL set

TKO

50

75

100

125

150

175

200

250

5

8

13

17

21

25

29

33

42

6

10

15

20

25

30

35

40

50

8

13

19

25

31

37

44

50

62

10

17

25

33

42

50

58

67

83

30

50

75

100

125

150

175

200

250

Note: TKO is 30 mL/hr

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Universal Formula: Figure Out Drip Rates and Drug Amounts

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IV Solutions IV solutions can be divided into two basic categories: ■ Crystalloids contain water, dextrose, and/or electrolytes and are commonly used to treat different fluid and electrolyte imbalances. ■ Volume expanders (often referred to as colloids or plasma expanders) have an increased osmotic pressure in comparison with crystalloids; they remain in the intravascular space longer and are used for volume expansion.

Crystalloids Type of Solution

Components

Indications

Saline solutions NS, 0.9% NaCl, sodium chloride, saline, 3% and 5% saline Dextrose solutions D5W, D10W

Na and Cl

■ Alkalosis ■ Fluid loss ■ Sodium depletion

Dextrose in water

Dextrose and saline mixtures D5NS, D51/2NS, D10NS

Dextrose in saline

Multielectrolyte solutions LR, Lactated Ringer’s, Ringer’s lactate, RL

Combination of Na, Cl, K, Ca, and lactate

■ Replace calories as carbohydrates ■ Prevent dehydration ■ Maintain water balance ■ Promote sodium diuresis ■ Promote diuresis ■ Correct moderate fluid loss ■ Prevent alkalosis ■ Provide calories and sodium chloride ■ Replace fluid lost from vomiting or GI suctioning ■ Treat dehydration ■ Restore normal fluid balance

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123 Blood Transfusion Reactions Type

Cause

Manifestation

Allergic

Sensitivity to foreign proteins

■ Hives, urticaria, flushing ■ Fever

Febrile, nonhemolytic

Sensitization to donor’s WBC, platelets, and/or plasma proteins

■ ■ ■ ■

Fever, chills, flushing Headache and muscle aches Respiratory distress Cardiac dysrhythmias

Acute hemolytic

ABO incompatibility reaction to RBC antigens

■ ■ ■ ■ ■

Fever, chills, flushing Low back pain Tachycardia and hypotension Vascular collapse Cardiac arrest

Anaphylactic

Administration of donor IgA proteins to recipient with anti-IgA antibodies

■ ■ ■ ■

Urticaria Restlessness Wheezing Shock and cardiac arrest

Circulatory overload

Infusion of blood at a rapid rate that leads to fluid volume excess

■ ■ ■ ■ ■

Pulmonary congestion Restlessness Cough, shortness of breath HTN Distended neck veins

Bacteremia

Infusion of blood infected with bacteria

■ ■ ■ ■

Fever and chills Vomiting and diarrhea Hypotension Septic shock

See the Med-Surg tab for assessment and management of blood transfusion reactions.

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Intramuscular (IM) Injection Sites Deltoid Site

Ventrogluteal Site

Vastus Lateralis Site

Dorsogluteal Site

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125 Z-Track Method for Giving IM Injections

Injections: Intradermal (ID), Subcutaneous (SC), and Intramuscular (IM) ID Site

Inner forearm, chest, and back

Gauge Length Angle

27–30 g 1/4–3/8 inch 10–15 degrees

Volume

0.1–0.2 mL

SC Upper posterior arm, upper back, low back, anterior lateral thigh, and abdomen 25–28 g 3/8–5/8 inch 90 degrees or 45 degrees for very thin Pts 0.5–1 mL

MEDS IV FLUIDS

IM Gluteus, thigh, and deltoid muscles

23 g 1–1 1/2 inch 90 degrees

≤3 mL; small muscles (deltoid) no more than 1 mL

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Angle of Injection

SC Injection Sites

Two inches away from the umbilicus

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127 ID Sites Anterior aspect of the forearm

SC Injection Technique ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Always observe Pt’s rights and standard precautions. Select and cleanse appropriate site with alcohol swab. Don gloves and hold syringe in dominant hand. With nondominant hand, either pinch or spread skin. Note: If 1 inch can be pinched between fingers, pinch skin and insert needle at 45-degree angle. If 1 inch can be pinched, spread the skin and insert needle at 90-degree angle. Insert needle to hub with one steady motion. Do not aspirate when administering heparin or insulin; otherwise, aspirate to ensure that needle is not in blood vessel. Inject medication and withdraw needle. Apply gentle pressure to site using sterile gauze (avoid massaging site, which can injure underlying tissues); if injecting heparin, hold gentle pressure for 30–60 seconds. Discard equipment per facility guidelines. Document medication, dose, site of injection, and Pt’s response to medication.

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Flushing Peripheral and Central Lines Catheter Type

Solution

Strength

Frequency

Peripheral Vascular Access Devices (VAD) ■ Peripheral IV line ■ Midline catheter

NS Heparin

N/A 10 U/mL

3 mL daily and p.r.n. 5 mL daily and p.r.n.

Peripherally Inserted Central Catheters (PICC) ■ Groshong PICC

NS

N/A

■ Per-Q-Cath (Pediatric VAD)

Heparin

10 U/mL

5 mL/lumen every 7 days and after each use 2.5 mL (child) or 0.5 mL (infant) q8h and after each use

Central Venous Catheters (CVC) ■ Valved-tip (no clamps) ■ Open-ended (clamps)

NS

N/A

Heparin

10 U/mL

5 mL/lumen weekly and p.r.n. 5 mL daily and p.r.n.

100 U/mL

5 mL daily and p.r.n..

Implanted Port Catheters ■ Groshong Port-A-Cath

Heparin

Routine Care of Peripheral and Central Lines ■ Clamps: Open-ended catheters will always have clamps to prevent the backflow of blood and air embolisms; all open-ended catheters must be flushed with heparin to minimize fibrin collection and clot formation. ■ No clamps: Valved-tip catheters do not have any clamps and require saline flushes; use positive-pressure flush technique. ■ End caps: Change the end cap(s) every 7 days or sooner if any blood, cracks, or leaks are seen. ■ Syringe size: The smaller the syringe size, the greater the pressure in pounds per square inch (PSI); greater PSI increases the potential for catheter damage. Therefore, a syringe size of 10 mL is recommended for all central line flushes. ■ Positive-pressure flush: To reduce the potential for blood backflow into the catheter tip, which promotes clot formation and catheter occlusion, always remove needles or needleless caps slowly while injecting the last 0.5 mL of NS.

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129 Pregnancy Risk Categories (FDA Definitions) ■ Category A: Adequate, well-controlled studies in pregnant women have not shown an increased risk of fetal abnormalities. ■ Category B: (1) Animal studies show no adverse fetal effects, but there are no controlled human studies; or (2) animal studies show adverse fetal effects, but well-controlled human studies do not. ■ Category C: (1) Animal studies show adverse fetal affect, but there are no controlled human studies; or (2) no animal or well-controlled human studies have been conducted. ■ Category D: Well-controlled or observational human studies show positive evidence of human fetal risk; maternal benefit may outweigh fetal risk in serious or life-threatening situations. ■ Category X: Contraindicated. Well-controlled or observational human and/or animal studies show positive evidence of serious fetal abnormalities; fetal risks far outweigh maternal benefit.

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MEDS IV FLUIDS

Mixing Insulin

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131 General Chemistry Note: Reference ranges vary according to brand of laboratory assay materials used. Always check normal reference ranges from your facility’s laboratory. Note: normal or expected ranges are normally included with reported lab results.

Lab

Conventional

SI Units

Albumin 3.5–5.0 g/100 mL Aldolase 1.3–8.2 U/L Alkaline phosphatase 13–39 U/L, infants and adolescents up to 104 U/L Ammonia 12–55 mol/L Amylase 4–25 U/mL Anion gap 8–16 mEq/L AST (formerly SGOT) Male: 8–46 U/L Female: 7–34 U/L Bilirubin, direct ≤0.4 mg/100 mL Bilirubin, total ≤1.0 mg/100 mL BUN 8–25 mg/100 mL Ca
(calcium) 8.5–10.5 mg/100 mL Calcitonin Male: 0–14 pg/mL Female: 0–28 pg/mL Carbon dioxide (CO2) 24–30 mEq/L Chloride (Cl) 100–106 mEq/L Cholesterol 200 mg/dL Cortisol (AM) 5–25 g/100 mL (PM) 10 g/100 mL Creatine Male: 0.2–0.5 mg/dL Female: 0.3–0.9 mg/dL Creatine kinase (CK) Male: 17–148 U/L Female: 10–79 U/L Creatinine 0.6–1.5 mg/100 mL Ferritin 10–410 ng/dL

35–50 g/L 22–137 nmol·sec1/L 217–650 nmol·sec1/L, up to 1.26 mol/L 12–55 mol/L 4–25 arb. unit 8–16 mmol/L 0.14–0.78 kat/L 0.12–0.58 kat/L ≤7 mol/L ≤17 mol/L 2.9–8.9 mmol/L 2.1–2.6 mmol/L 0–4.1 pmol/L 0–8.2 pmol/L 24–30 mmol/L 100–106 mmol/L 5.18 mmol/L 0.14–0.69 mol/L 0–0.28 mol/L 15–40 mol/L 25–70 mol/L 283–2467 nmol·sec1/L 167–1317 nmol·sec1/L 53–133 mol/L 10–410 g/dL

(Continued on following page)

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LABS ECG

General Chemistry (continued) Lab Folate Glucose Ionized calcium Iron (Fe) Iron binding capacity (IBC) K
(potassium) Lactic acid LDH (lactate dehydrogenase) Lipase Magnesium Mg

(magnesium) Na
(sodium) Osmolality Phosphorus Potassium (K
) Prealbumin Protein, total PSA Pyruvate Sodium (Na
) T3 T4, free T4, total Thyroglobulin Triglycerides TSH Urea nitrogen Uric acid

Conventional

SI Units

2.0–9.0 ng/mL 70–110 mg/100 mL 4.25–5.25 mg/dL 50–150 g/100 mL 250–410 g/100 mL

4.5–20.4 nmol/L 3.9–5.6 mmol/L 1.1–1.3 mmol/L 9.0–26.9 mol/L 44.8–73.4 mol/L

3.5–5.0 mEq/L 0.6–1.8 mEq/L 45–90 U/L

3.5–5.0 mmol/L 0.6–1.8 mmol/L 750–1500 nmol·sec1/L

≤2 U/mL 1.5–2.0 mEq/L 1.5–2.0 mEq/L 135–145 mEq/L 280–296 mOsm/kg water 3.0–4.5 mg/100 mL 3.5–5.0 mEq/L 18–32 mg/dL 6.0–8.4 g/100 mL 4.0 ng/mL 0–0.11 mEq/L 135–145 mEq/L 75–195 ng/100 mL Male: 0.8–1.8 ng/dL Female: 0.8–1.8 ng/dL 4–12 g/100 mL 3–42 g/mL 40–150 mg/100 mL 0.5–5.0 U/mL 8–25 mg/100 mL 3.0–7.0 mg/100 mL

≤2 arb. unit 0.8–1.3 mmol/L 0.8–1.3 mmol/L 135–145 mmol/L 280–296 mmol/kg 1.0–1.5 mmol/L 3.5–5.0 mmol/L 180–320 mg/L 60–84 g/L 4 g/L 0–0.11 mmol/L 135–145 mmol/L 1.16–3.00 nmol/L 10–23 pmol/L 10–23 pmol/L 52–154 nmol/L 3–42 g/L 0.4–1.5 g/L 0.5–5.0 arb. unit 2.9–8.9 mmol/L 0.18–0.42 mmol/L

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133 Hematology (ABC, CBC, Blood Counts) Lab

Conventional

SI Units

8.5%–9.0% of body weight in kg Red blood cell (RBC) Male: 4.6–6.2 million/mm3 Female: 4.2–5.9 million/mm3 Male: 13–18 g/100 mL Hemoglobin (Hgb) Female: 12–16 g/100 mL Male: 45%–52% Hematocrit (Hct) Female: 37%–48% 4300–10,800/mm3 Leukocytes (WBC) 0%–5% ■ Bands 0%–1% ■ Basophils 1%–4% ■ Eosinophils 25%–40% ■ Lymphocytes 10%–20% ■ B Lymphocytes 60%–80% ■ T Lymphocytes 2%–8% ■ Monocytes 54%–75% ■ Neutrophils 150,000–350,000/mm3 Platelets Erythrocyte sedimen- Male: 1–13 mm/hr tation rate (ESR) Female: 1–20 mm/hr Blood volume

80–85 mL/kg 4.6–6.2  1012/L 4.2–5.9  1012/L Male: 8.1–11.2 mmol/L Female: 7.4–9.9 mmol/L Male: 0.45–0.52 Female: 0.37–0.48 4.3–10.8  109/L 0.03–0.08 0–0.01 0.01–0.04 0.25–0.40 0.10–0.20 0.60–0.80 0.02–0.08 0.54–0.075 150–350  109/L Male: 1–13 mm/hr Female: 1–20 mm/hr

Lipids (Cholesterol) Total HDL LDL Triglycerides

200 mg/dL 30–75 mg/dL 130 mg/dL 40–150 mg/100 mL

5.20 mmol/L 0.80–2.05 mmol/L 1.55–4.65 mmol/L 0.4–1.5 g/L

LABS ECG

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LABS ECG

Cardiac Markers Lab Troponin-I Troponin-T CPK CPK-MB AST (formerly SGOT) LDH Myoglobin

Progression→ Troponin-I Troponin-T CPK CPK-MB AST (formerly SGOT) LDH Myoglobin

Conventional

SI Units

0–0.1 ng/mL 0.18 ng/mL 150 U/L 0–5 ng/mL 1–36 U/L 70–180 Male: 10–95 ng/mL Female: 10–65 ng/mL

0–0.1 g/L 0.18 g/L 150 U/L 0–5 g/L 1–36 U/L 70–180 10–95 g/L 10–65 g/L

Onset

Peak

3–6 hr 3–5 hr 4–6 hr 4–6 hr 12–18 hr 3–6 days 2–4 hr

12–24 hr 24 hr 10–24 hr 14–20 hr 12–48 hr 3–6 days 6–10 hr

Duration 4–6 days 10–15 days 3–4 days 2–3 days 3–4 days 7–10 days 12–36 hr

Coagulation Lab

Conventional

ACT PTT (activated) Bleeding time Fibrinogen INR Plasminogen Platelets PT (prothrombin time) PTT (partial thromboplastin time) Thrombin time

90–130 sec 21–35 sec 3–7 min 160–450 mg/dL Target therapeutic: 2–3 62%–130% 150,000–300,000/mm3 10–12 sec 30–45 sec

90–130 sec 21–35 sec 3–7 min 1.6–4.5 g/L Target therapeutic: 2–3 0.62–1.30  106/L 10–12 sec 30–45 sec

11–15 sec

11–15 sec

134

SI Units

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135 DIC Panel: Disseminated Intravascular Coagulopathy Lab PT PTT Fibrinogen Thrombin time D-Dimer

Conventional

SI Units

10–12 sec 30–45 sec 160–450 mg/dL 11–15 sec 20

10–12 sec 30–45 sec 1.6–4.5 g/L 11–15 sec 2000 g/L

Cerebrospinal Fluid (CSF) Color Pressure Cell count and diff. Protein A/G ratio IgG Glucose Lactate Urea Glutamine

Clear Clear 75–200 mm H2O 0–5 cells (zero RBCs or granulocytes) 0.15–0.45 g/L 15–45 mg/dL 8:1 3%–12% of total protein 2.22–4.44 mmol/L 40–80 mg/dL 1.1–2.2 mmol/L 10–20 mg/dL 3.6–5.3 mmol/L 10–15 mg/dL 1370 mol/L 20 mg/dL

Thyroid Panel Lab

Conventional

SI Units

T3, total T3 uptake (RT3U) T3 uptake ratio T4, total T4, free TSH

75–195 ng/100 mL 25%–35% 0.1–1.35 4–12 g/100 mL 0.9–2.3 ng/dL 0.5–5.0 U/mL

1.16–3.00 nmol/L 0.25–0.35 0.1–0.35 52–154 nmol/L 10–30 nm/L 0.5–5.0 arb. unit

LABS ECG

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LABS ECG

Medication Levels (Therapeutic) Medication

Therapeutic

Toxic

Acetaminophen Amiodarone Carbamazepine Digoxin Lidocaine Lithium Nitroprusside Phenobarbital Phenytoin (Dilantin) Procainamide Propranolol Quinidine Salicylate Theophylline

5–20 mg/L 0.5–2.0 mg/L 4.0–12.0 g/mL 0.5–2.0 g/L 1.5–5.0 mg/L 0.6–1.2 mEq/L 10 mg/dL 15–50 g/mL 10–20 g/mL 4–10 mg/mL 50–100 ng/mL 1.2–4.0 mg/mL 20–25 mg/100 mL 10–20 mg/L

25 2.0 15 2.4 7.0 2.0 10 45 20 15 100 5.0 30 20

SI Units

17–51 mol/L

0.6–1.2 nmol/L 65–215 mol/L 20–80 mol/L 17–42 mol/L 3.7–12.3 mol/L 1.4–1.8 mmol/L

Antibiotic Levels Antibiotic Gentamicin Tobramycin Vancomycin

Peak

Trough

5–12 g/mL 5–12 g/mL 20–40 g/mL

2 g/mL 2 g/mL 5–10 g/mL

Renal/Kidney Lab BUN Creatinine Uric acid

Conventional 6–23 mg/dL 15–25 mg/kg of body weight/day Male: 4.0–9.0 mg/dL Female: 3.0–6.5 mg/dL

136

SI Units 2.5–7.5 mmol/L 0.13–0.22 mmol · kg–1/day 238–535 mol/L 178–387 mol/L

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137 Urinalysis (UA) Lab Color Specific Gravity pH Glucose Sodium Potassium Chloride Protein Osmolality

Conventional

SI Units

Yellow-straw 1.005–1.030 5.0-8.0 Negative 10–40 mEq/L 8 mEq/L 8 mEq/L Negative–trace 500–800 mOsm/L

24-Hour Urine Lab Acetone Amylase Calcium Chloride Creatine Creatinine clearance Magnesium Osmolality Phosphorus Potassium Protein Sodium Urea nitrogen Uric acid

Conventional

SI Units

Negative 24–76 U/mL 300 mg/day 110–250 mEq/24 hr 100 mg/day 70–130 mL/min

Negative 24–76 arb. unit 7.5 mmol/day 110–250 mmol/day 0.75 mmol/day 70–130 mL/min/1.73 m2

5–10 mEq/24 hr 450–900 mOsm/kg 900–1300 mg/24 hr 40–80 mEq/24 hr 150 mg/24 hr 80–180 mEq/24 hr 7–20 g/24 hr 250–750 mg/24 hr

2.5–5.0 mmol/d 450–900 mOsm/kg 900–1300 mmol/day 40–80 mmol/day 150 mg/day 80–180 mmol/day 1.5–4.5 mmol/day

LABS ECG

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LABS ECG

Normal Arterial Blood Gases Lab

Conventional

pH PaO2 PaCO2 HCO3 Base excess CO2 SaO2

7.35–7.45 75–100 mm Hg 35–45 mm Hg 22–26 mmol/L (2)–(
2) mEq/L 19–24 mEq/L 96%–100%

SI Units 36–45 mol/L 10.0–13.3 kPa 4.7–6.0 kPa 22–26 mmol/L (2) –(
2) mmol/L 19–24 mmol/L 0.96–1.00

Venous Blood Gas pH PaO2 PaCO2 HCO3

7.31–7.41 30–40 mm Hg 41–51 mm Hg 22–29 mEq/L

(0) –(
4) mmol/L

Base excess CO2 SaO2

60%–85%

Acid-Base Imbalance pH

HCO3

PCO2

↑ or normal

↑

Slightly ↓ With or normal compensation ↑ Respiratory alkalosis

↑

↑

↓ or normal

↓

Slightly ↓ With or normal compensation ↓ Metabolic acidosis

↓

↓

↓

↓ or normal

Respiratory acidosis

↓

Compensation Kidneys conserve HCO3 and eliminate H
to ↑ pH

Kidneys eliminate HCO3 and conserve H
to ↓ pH

Hyperventilation to blow off excess CO2 and conserve HCO3

(Continued on following page)

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139 Acid-Base Imbalance (Continued) PCO2

Compensation

Slightly ↓ With or normal compensation ↑ Metabolic alkalosis

pH

HCO3 ↓

↓

↑

↑ or normal

Hypoventilation to ↑ CO2 Kidneys keep H
and excrete HCO3

Slightly ↓ With or normal compensation

↑

↑

Common Causes of Acid-Base Imbalance Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Asphyxia, respiratory and CNS depression Hyperventilation, anxiety, DKA Diarrhea, renal failure, salicylate (aspirin) OD Hypercalcemia, OD on an alkalines (antacid)

Basic ECG Interpretation Standard Lead Placement: Three- and Five-Wire Cable Systems

RA

LA

RA

LA V1

LL

RL

LABS ECG

LL

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LABS ECG

Normal Cardiac Rhythm Parameters Normal sinus rhythm (NSR) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60–100 bpm Sinus bradycardia (SB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 bpm Sinus tachycardia (ST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 bpm PR interval (PRI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.12–0.20 second QRS interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.06–0.10 second QT interval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.30–0.52 second Atrial rate (inherent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60–100 bpm Junctional rate (inherent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40–60 bpm Ventricular rate (inherent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20–40 bpm

Systematic Approach to ECG Assessment Rate Rhythm P waves PR interval QRS Extra

Is it normal (60–100), fast (100) or slow (60)? Is it regular or irregular? Are they present and 1:1 with the QRS? Is it normal (0.12–0.20 sec)? Does it remain consistent? Is it normal (0.06–0.10 sec) or wide (0.10 sec)? Are there any extra or abnormal complexes?

Components of the PQRST

QT Interval R

T

P

PR Interval

QS

ST Segment

QRS Interval

140

U

Isoelectric line

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141 Normal Sinus Rhythm

Sinus Tachycardia

Sinus Bradycardia

LABS ECG

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LABS ECG

Sinus Arrhythmia

Atrial Fibrillation

Atrial Flutter

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143 Junctional Rhythm

Ventricular Tachycardia

Torsade de Pointes

LABS ECG

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LABS ECG

Fine Ventricular Fibrillation

Coarse Ventricular Fibrillation

Asystole

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145 First-Degree AV Block

Second-Degree AV Block (Mobitz Type I, Wenckebach)

Second-Degree AV Block (Mobitz Type—II)

LABS ECG

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LABS ECG

Third-Degree AV Block (Complete Heart Block)

Premature Ventricular Complex (PVC)

Premature Atrial and Junctional Complex

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147 Pacemaker (Single Chamber—Ventricular)

AV Sequential (Dual Chamber) Pacemaker

LABS ECG

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PATIENT EDUCATION

Ways to Enhance Patient Learning Patient Education: Health information and instruction to help Pt learn about specific or general medical topics, such as the need for preventive services, the adoption of healthy lifestyles, or the care of diseases or injuries at home. ■ Be supportive, positive, and reassuring toward the Pt. ■ Respect the Pt’s values, attitudes, and beliefs. ■ Communicate using culturally appropriate context and terms. ■ Allow Pt to express and consider their own values. ■ Involve Pt (family when appropriate) in the learning process. ■ Identify Pt’s interests and concerns with their health. ■ Assess Pt’s ability to learn and tailor an individual teaching plan accordingly. ■ Develop a learning strategy based on Pt’s own life experiences. ■ Provide information and educational material appropriate to Pt’s educational level and cognitive abilities. ■ Reinforce Pt education by providing simple-to-read, written material in addition to oral instructions. ■ Allow Pt to learn at a comfortable pace, and allow time for new information to be assimilated by Pt. ■ Allow enough time for Pt to ask questions. Answer any questions completely and thoroughly. ■ Assess efficacy of education, and identify strengths and weaknesses of Pt’s ability and willingness to learn.

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Visual area

Visual association area

Occipital lobe

Parietal lobe

Sensory association area

General sensory area

Functional Areas of the Brain Motor area

Auditory area

Premotor area Frontal lobe

Orbitofrontal cortex

Motor speech area Auditory association area

Temporal lobe

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Respiratory System Arteriole Pulmonary capillaries

Frontal sinuses

Alveolar duct Sphenoidal sinuses Nasal cavity Nasopharynx Soft palate Epiglottis

Alveolus

Larynx and vocal folds Trachea Superior lobe Right lung

B

Right primary bronchus

Left primary bronchus

Venule Left lung

Superior lobe

Middle lobe

Bronchioles Inferior lobe Mediastinum Inferior lobe

Diaphragm

Cardiac notch

A

150

Pleural membranes Pleural space

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151 Cardiovascular System (Arteries)

Maxillary Occipital Internal carotid Vertebral Brachiocephalic Aortic arch

Facial External carotid Common carotid Subclavian Axillary Pulmonary

Celiac Left gastric Hepatic Splenic Superior mesenteric Abdominal aorta Right common iliac Internal iliac External iliac

Intercostal Brachial Renal Gonadal Inferior mesenteric Radial Ulnar Deep palmar arch Superficial palmar arch

Deep femoral Femoral

Popliteal Anterior tibial Posterior tibial

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Cardiovascular System (Veins) Superior sagittal sinus Inferior sagittal sinus Straight sinus Transverse sinus Vertebral External jugular Internal jugular Subclavian

Anterior facial Superior vena cava Axillary Cephalic

Brachiocephalic Pulmonary Hepatic Hepatic portal Left gastric Renal Splenic Inferior mesenteric

Hemiazygos Intercostal Inferior vena cava Brachial Basilic Gonadal Superior mesenteric

Internal iliac External iliac

Common iliac Dorsal arch Volar digital Femoral Great saphenous Popliteal Small saphenous

Anterior tibial

Dorsal arch

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153 Heart Left subclavian artery Brachiocephalic (trunk) artery

Left internal jugular vein Left common carotid artery Aortic arch Left pulmonary artery (to lungs)

Superior vena cava Right pulmonary artery

Left atrium Left pulmonary veins (from lungs) Circumflex artery Left coronary artery Left coronary vein Left anterior descending artery Left ventricle

Right pulmonary veins Right atrium Right coronary artery Inferior vena cava Right ventricle

A

Brachiocephalic artery Superior vena cava Right pulmonary artery Right pulmonary veins Pulmonary semilunar valve Right atrium Tricuspid valve

Aorta Left common carotid artery Left subclavian artery Aortic arch Left pulmonary artery Left atrium Left pulmonary veins Mitral valve Left ventricle Aortic semilunar valve Interventricular septum

Inferior vena cava

B

Chordae tendineae Right ventricle

Apex Papillary muscles

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Lymphatic System

Submaxillary nodes Cervical nodes Left subclavian vein Thoracic duct

Mammary plexus

Axillary nodes Right lymphatic duct

Spleen Cisterna chyli Mesenteric nodes

Cubital nodes

Iliac nodes Inguinal nodes

Popliteal nodes

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155 Digestive System Tongue

Teeth Parotid gland Pharynx Sublingual gland

Esophagus

Submandibular gland

Liver

Left lobe

Stomach (cut)

Spleen Right lobe Gallbladder Bile duct Transverse colon(cut) Ascending colon Cecum

Duodenum Pancreas Descending colon Small intestine

Rectum Anal canal

Vermiform appendix

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PATIENT EDUCATION

Urinary System

Ribs Aorta Inferior vena cava Left adrenal gland Superior mesenteric artery

Diaphragm

Left renal artery and vein Left kidney Left ureter Right kidney Left common iliac artery and vein Psoas major muscle

Lumbar vertebra Pelvis

lliacus muscle

Sacrum

Right ureter Opening of ureter Trigone of bladder Symphysis pubis

Urinary bladder Urethra

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157 Skeletal System SKULL CLAVICLE SCAPULA

CERVICAL VERTEBRAE (1-7)

STERNUM

HUMERUS

THORACIC VERTEBRAE (1-12)

RIBS

LUMBAR VERTEBRAE (1-5) RADIUS ULNA

HIP BONE: ILIUM, PUBIS, ISCHIUM SACRUM

CARPALS

COCCYX METACARPALS

FEMUR PATELLA

PHALANGES TIBIA FIBULA

TARSALS METATARSALS PHALANGES

PATIENT EDUCATION

Sebaceous gland

Receptor for touch (encapsulated) Hair follicle

Receptor for pressure (encapsulated)

Nerve Venule

Free nerve ending

Eccrine sweat gland

Pore

Integumentary System

Arteriole

Stratum germinativum

Fascia of muscle

Subcutaneous tissue

Dermis Pilomotor muscle

Papillary layer with capillaries

Epidermis

Stratum corneum

Adipose tissue

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Symphysis pubis

Ductus deferens Urinary bladder

Corpus cavernosum Corpus spongiosum Cavernous urethra Glans penis Prepuce Scrotum

Membranous urethra

Epididymis

Male Reproductive System

Testis

Sacrum

Opening of ureter

Rectum

Seminal vesicle

Ejaculatory duct

Prostate gland

Bulbourethral gland

Anus

PATIENT EDUCATION

Symphysis pubis

Urinary bladder Opening of ureter

Urethra

Clitoris

Bartholin's gland

Fimbriae

Female Reproductive System

Vagina

Fallopian tube

Labium major

Labium minor

Ovary

Rectum

Cervix

Sacrum

Uterus

Anus

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161 Exercise and Nutrition Education General Principles and Guidelines ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

BMI of 25–30 kg/m2
overweight; BMI 30 kg/m2
obese. 1 lb of body fat
3500 cal. The recommended rate of weight loss is 1–2 lb/week. Most effective way to manage weight is through combination of diet, exercise, and behavior modification. Too many calories from any source of carbohydrates, fat, and/or protein promote weight gain. Serving sizes of all foods should be managed. Food pyramid can be used as guide to healthy eating. Exercise burns calories and assists in weight management. Attempt to complete 30–60 minutes of exercise each day. Watch less TV and play fewer video games. Fat is most concentrated source of calories, and an excessive amount is a contributing factor of weight gain. Limit fat (9 cal/g) intake to 25%–30% of total calories/day. Keeping a food diary enhances successful weight management, and keeping a weekly graph of weight change is recommended. Limit fast food to only those establishments that offer low-calorie menu options. Keep food safe to eat (store foods at proper temperature and check expiration dates often). Choose a diet low in saturated fat and cholesterol. Choose and prepare foods with less salt. Choose a variety of grains daily, especially whole grains. Choose a variety of fruits and vegetables daily. Consume 6–8 cups (48–64 oz) of water daily. Choose beverages and foods that limit your intake of sugar and caffeine. If you drink alcoholic beverages, do so in moderation.

Sources: Heska, S, et al: Weight loss with self-help compared with a structured commercial program: a randomized trial. JAMA 289: 14, 2003; and Lutz, C, and Przytulski, K: Nutri Notes: Nutrition and Diet Therapy Pocket Guide. FA Davis, Philadelphia, 2004.

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Food Sources for Specific Nutrients Calcium-Rich Foods ■ ■ ■ ■

■ ■ ■ ■

Bokchoy Broccoli Canned fish Creamed soups

Clams Dairy Molasses Oysters

■ ■ ■ ■

Refried beans Spinach Tofu Turnip greens

Iron-Rich Foods ■ Dried fruit ■ Leafy green vegetables

■ Cereals ■ Clams ■ Dried beans/peas

■ Lean red meat ■ Molasses ■ Organ meats

Potassium-Rich Foods ■ ■ ■ ■ ■ ■ ■

■ ■ ■ ■ ■ ■ ■ ■

Apricots Avocados Bananas Broccoli Cantaloupe Dried fruit Grapefruit Honey dew

■ ■ ■ ■ ■

Salt Fast food Canned foods Mac and cheese Canned sauces

■ ■ ■ ■ ■

■ ■ ■ ■ ■ ■

Baked poultry Canned pumpkin Cooked turnips Egg yolk Fresh vegetables Fruit

■ ■ ■ ■ ■ ■

■ ■ ■ ■ ■ ■ ■

Kiwi Lima beans Meats Dried beans and peas Nuts Oranges Peaches

Plantains Potatoes Rhubarb Spinach Sunflower seeds Tomatoes Winter squash

Sodium-Rich Foods Butter Margarine Buttermilk Baking mixes BBQ sauce

■ ■ ■ ■ ■

Salad dressing Cured meats Chips Potato salad Ketchup

■ ■ ■ ■ ■ ■

Potatoes Puffed wheat Puffed rice Lima beans Sherbet Unsalted nuts

Low-Sodium Foods Grits Honey Jams, jellies Lean meats Low-cal mayo Macaroons

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163 Food Sources for Specific Nutrients (cont.) Vitamin D–Rich Foods ■ Fish ■ Fish liver oils ■ Cereals

■ Canned salmon ■ Canned sardines ■ Canned tuna

■ Fortified milk ■ Nonfat dry milk

Vitamin K–Rich Foods ■ ■ ■ ■ ■

■ ■ ■ ■ ■

Asparagus Beans Broccoli Brussels sprouts Mustard greens

Cauliflower Collards Green tea Kale Milk

■ ■ ■ ■ ■

Cabbage Spinach Swiss chard Turnips Yogurt

Foods Containing Tyramine ■ Aged, processed cheeses ■ Avocado ■ Bananas ■ Bean curd ■ Beer and ale ■ Caffeinated beverages ■ Caviar ■ Chocolate

■ ■ ■ ■ ■ ■ ■ ■ ■

■ ■ ■ ■ ■ ■ ■ ■ ■

Distilled spirits Sausage Liver Tenderized meat Miso soup Overripe fruit Peanuts Raisins Raspberries

Red wine Sauerkraut Sherry Shrimp paste Smoked or pickled fish Soy sauce Vermouth Yeasts Yogurts

Foods that Acidify Urine ■ ■ ■ ■ ■

Cheese Corn Cranberries Eggs Fish

■ ■ ■ ■

Grains Lentils Meats Nuts (walnuts, Brazil, filberts)

■ ■ ■ ■ ■

Pasta Plums Poultry Prunes Rice

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PATIENT EDUCATION Foods that Alkalize Urine ■ All fruits except cranberries, prunes, plums

■ All vegetables except corn ■ Milk

■ Almonds ■ Chestnuts

Food Pyramid

Physical Activity: Do 30 minutes for most days of the week. Eat 6 oz Eat 2 1/2 Eat 2 cups Oils: Limit Get 3 cups Eat 5 1/2 daily cups daily daily intake daily oz daily

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165 Food Pyramid Modifications

Vegetarians

■ Subtract meats, poultry, eggs, and fish. ■ Add legumes, nuts, and seeds: Two–three servings every day.

Pts 70 Years ■ ■ ■ ■ ■ ■ ■ ■

Fats, oils, and sweets: Use sparingly Dairy: Three servings every day Meat, legumes, and nuts: Two servings every day Vegetables: At least three servings every day Fruit: Two servings every day Bread, cereal, rice, and pasta: Six servings every day Water: Eight servings every day Supplements: Calcium, vitamin D, and vitamin B12

Medication Administration Educating Pts about their medications is a critical nursing function that promotes proper medication use and improved outcomes. It also can prevent adverse drug reactions or early or improper discontinuation of a medication. Many issues related to medication errors, such as ambiguous directions, unfamiliarity with a drug, and confusing packaging, affect Pts as well as healthcare providers, thus underscoring need for careful education. Pt education also enhances compliance, which is a factor in proper medication use. ■ All Pts need clear written and verbal instruction for all medications. ■ Present information in a format Pt can understand. ■ Use an interpreter if provider and Pt speak different languages. ■ Do not rush. ■ Include family members. ■ Have Pt repeat information you provide. ■ Make sure to tell Pt: ■ Brand and generic names of medication. ■ Purpose of medication. ■ Strength and dose and when to take medication. ■ Possible side effects and what to do if they occur. ■ How long to take medication. ■ What medications or foods to avoid and why they should be avoided. ■ How to store medication. ■ What to do if a dose is missed. ■ What activities, if any, should be avoided while taking medication. ■ Signs and symptoms of adverse drug reaction. ■ To inform physician if they are pregnant or are likely to become pregnant while taking this medication.

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Medication Safety General Safety Guidelines for the Home ■ Instruct Pts to keep a list of all medications that they take, including prescription medications, nonprescription medications, herbal supplements, and natural remedies. ■ Instruct Pts to keep a list of medication allergies, including type of reaction that the medication caused. ■ Instruct Pts to take medications exactly as prescribed by health-care provider (e.g., right dose, right time). ■ Instruct Pts to ask health-care provider or pharmacist if they should limit or avoid certain foods, beverages, other medications, or activities while taking their medication. ■ Emphasize importance of asking health-care provider or pharmacist to explain anything Pts do not understand regarding medications, including all nonprescription medications, and herbal supplements. ■ Instruct Pts not to take medication that has been prescribed to another person (including family members). ■ Instruct Pt to discard medications properly on expiration date. ■ Instruct Pt on proper storage of medications and that they should be kept in original containers. ■ Instruct Pts to take full prescription dose and not to stop abruptly without first informing physician. ■ Emphasize that all medication, regardless if it is in a childproof container, should be kept out of reach of children.

Foods to Avoid with Certain Drugs/Herbs Drug/Herb

Avoid or Moderate

ACE inhibitors

Potassium-containing salt substitute

Ampicillin

Carbonated beverages, acidic juices

Aspirin

Feverfew, ginkgo, green tea

Barbiturates

Valerian

Calcium-channel blockers

Grapefruit juice

Cloxacillin

Carbonated beverages, acidic juices (Continued on following page)

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167 Foods to Avoid with Certain Drugs/Herbs (continued) Drug/Herb

Avoid or Moderate

Cyclosporine

Grapefruit juice, potassium-containing salt substitute

Digoxin

High-fiber foods and meals

Enteric-coated pills

Excess milk, hot beverages, alcohol

Fluoroquinolones

Foods high in calcium, iron, or zinc (dairy and red meat)

Hemorrhoid medications

Saw palmetto

Indomethacin

Potassium-containing salt substitute

Isoniazid

High-carbohydrate foods

Levodopa

Excess protein

Lithium

Significant increase or decrease in sodium intake

MAO inhibitors

Foods containing tyramine

Methyldopa

Excess protein

NSAIDs

Asian ginseng, ginkgo

Penicillin G

Carbonated beverages, acidic juices

Phenytoin

Excess protein

Potassium-sparing diuretics

Potassium-containing salt substitute

“Statin” drugs

Grapefruit and grapefruit juice

Tetracycline

Iron-rich food or supplements, calcium

Theophylline

Excess protein

Warfarin (Coumadin)

Vitamin K–rich foods and supplements, Asian ginseng, feverfew, garlic, ginger, ginkgo, St. John’s wort, green tea

Zidovudine

Excess fat

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Common Herb–Rx Drug Interactions Herb Aloe Anise Brewer’s yeast Echinacea Eucalyptus Feverfew Garlic Ginger Ginkgo Ginseng

Goldenseal Hawthorne Kava-kava Ma-huang Oak bark Peppermint Psyllium St. John’s wort Saw palmetto Valerian Notes

Known Drug Interaction Increases risks associated with cardiac glycosides. May interfere with anticoagulants, MAO inhibitors (MAOIs), and hormone therapy. MAOIs can cause an increase in BP. May possibly interfere with immunosuppressant agents. Induction of liver enzymes, which may increase the metabolism of other drugs. May inhibit platelet activity (avoid use with warfarin or other anticoagulants). May potentiate effects of MAOIs (ginkgo).

May potentiate effects of caffeine. May interfere with phenelzine. May inhibit platelet activity (avoid use with warfarin or other anticoagulants). May interfere with antacids, sucralfate, H2 antagonists, antihypertensive agents, and anticoagulants. May inhibit metabolism of ACE inhibitors and potentiate effect of cardiac glycosides. May potentiate or have additive effects of CNS depressants, antiplatelets, and MAOIs. Potentiates sympathomimetic effects of antihypertensives, antidepressants, MAOIs. Inhibits absorption of alkaloids and other alkaline drugs. May interfere with gastric acid–blocking drugs. Interferes with absorption of other drugs. May increase risk of adverse reactions of antidepressants. May significantly reduce blood concentrations of indinavir. May interfere with oral contraceptives and hormone therapy. May potentiate sedative effects.

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169 Suggested Diet Modification Related to Diseases Disease Process Celiac sprue Cholelithiasis Cirrhosis Congestive heart failure Coronary artery disease Diabetes mellitus Diverticulosis Dysphagia Esophagitis Gastroesophageal reflux Gout Hyperhomocysteinemia Hyperlipidemias

Iron-deficiency anemia Irritable bowel syndrome Kidney stone formers Nephrotic syndrome Obesity Osteoporosis Pernicious anemia Renal failure Women and men, 25 years of age

Suggested Dietary Modification Avoid gluten-containing foods. Avoid fatty foods. Limit sodium; limit protein intake; avoid alcohol. Limit sodium. American Heart Association diets. American Diabetic Association diet; limit calories; exercise. Low-residue diet. Special consistency diets as indicated by testing/tolerance. Avoid alcohol, nonsteroidal drugs, tobacco; consume thick liquids. Avoid caffeine, chocolates, mints, or late meals. Limit alcohol, purine, and citric acid intake. Increase consumption of folates, vitamin B12. National Cholesterol Education Program diet with limited fat and cholesterol and increased fiber. Iron supplements with vitamin C. Increase fiber content of meals; limit dairy products. Liberal fluid intake. Limit sodium intake. Restrict calories, increase exercise. Supplement calcium and vitamin D; limit alcohol and tobacco. Supplement cyanocobalamin (vitamin B12). Limit sodium, potassium, protein, and fluids. Supplement calcium: 1000 mg/day (1200 mg/day if 50 years old).

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Diseases and Disorders Alzheimer’s Disease (AD) Definition: A disabling degenerative disease of the nervous system characterized by dementia and failure of memory for recent events, followed by total incapacitation and eventually death. Incidence: Most common cause of elderly dementia, accounting for about half of all dementias. Onset: The disease process starts long before symptoms start to develop. The early-onset form of AD may begin as early as 40 years of age and the late-onset form typically begins after age 60. Life expectancy after development of symptoms ranges from 8–10 years. Etiology: Unknown.

Clinical Findings Stage I: Loss of recent memory, irritability, loss of interest in life, and decline of abstract thinking and problem-solving ability. Stage II: (Most common stage when disease is diagnosed): Profound memory deficits, inability to concentrate or manage business or personal affairs. Stage III: Aphasia, inability to recognize or use objects, involuntary emotional outbursts, and incontinence. Stage IV: Pts become nonverbal and completely withdrawn. Loss of appetite leads to a state of emaciation. All body functions cease, and death quickly ensues.

Nursing Focus

■ Monitor vital signs and LOC, and implement collaborative care as ordered. ■ Keep requests simple and avoid confrontation. ■ Maintain a consistent environment and frequently reorient Pt.

Patient Teaching

■ Provide Pt and family with literature on AD. ■ Advise family that, as AD progresses, so does need for supervision of ADLs such as cooking and bathing. ■ Advise family to lock windows and doors to prevent wandering. ■ Explain that Pt should wear an ID bracelet in case he or she becomes lost. ■ Explain actions, dosages, side effects, and adverse reactions of meds.

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171 Asthma Definition: Often referred to as reactive airway disease (RAD), asthma is an intermittent, reversible, obstructive lung disease characterized by bronchospasm and hyperreactivity to a multitude of triggering agents (allergens/ antigens/irritants). Incidence: Asthma can occur at any age and is estimated to affect ~5% of the population. Men are twice as likely as women to have asthma. Onset: Onset is usually sudden. Etiology: Triggers include allergens, infections, exercise, abrupt changes in the weather, or exposure to airway irritants, such as tobacco smoke, perfume, or cold air. Clinical Findings: Difficulty breathing, wheezing, cough (either dry or productive of thick, white sputum), chest tightness, anxiety, and prolonged expiratory phase.

Nursing Focus

■ During an attack, assess and maintain ABCs, notify RT/MD, and implement collaborative care such as meds and IV fluid as ordered. ■ Stay with Pt and offer emotional support. ■ Monitor vital signs and document response to prescribed therapies.

Patient Teaching

■ Provide Pt and family with literature on asthma. ■ Explain actions, dosages, side effects, and adverse reactions of asthma meds. ■ Provide instructions on proper use of metered dose inhalers. ■ Provide instructions on proper use of peak flow meter and answer any questions about Pt’s asthma management plan. ■ Teach Pt and family about kinds of triggering agents that can precipitate an attack and how to minimize risk of exposure. ■ Instruct Pt to seek immediate medical attention if symptoms are not relieved with prescribed meds.

Cancer: General Overview Definition: Malignant neoplasia marked by the uncontrolled growth of cells, often with invasion of healthy tissues locally or throughout the body (metastasis). Incidence: Second leading cause of death in the U.S., after CV disease. Onset: Varies with different types of cancer. Etiology: Varies with different types of cancer. Risk factors include tobacco use, sun exposure, environmental/occupational exposure to carcinogens, poor nutrition, decreased level of physical activity, and infectious diseases.

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PATIENT EDUCATION Clinical Findings: Vary with different types of cancer. For a general overview of symptoms suggestive of cancer, see CAUTION: Seven Warning Signs of Cancer later in this section.

Types of Treatments

■ Surgery: Removing cancerous tissue surgically or by means of cryosurgery (technique for freezing and destroying abnormal cells). ■ Chemotherapy: Treatment of cancer with drugs (“anticancer” drugs) that destroy cancer cells or stop them from growing or multiplying. Because some drugs work better together than alone, two or more drugs are often given concurrently (combination therapy). ■ Radiation Therapy: Ionizing radiation (x-rays, gamma rays, or radioactive implants) deposits energy that injures or destroys cells in target tissue by damaging their genetic material and making it impossible for them to continue to grow. ■ Palliative and Hospice Care: Care focused solely on minimizing pain and suffering when cure is not an option.

Nursing Focus

■ Nausea/Vomiting: Administer antiemetics as needed and before chemotherapy is initiated. Withhold foods and fluids 4–6 hours before chemotherapy. Provide small portions of bland foods after each treatment. ■ Diarrhea: Administer antidiarrheals. Monitor electrolytes. Give clear liquids as tolerated. Maintain good perineal care. ■ Stomatitis: Avoid commercial mouth wash containing alcohol. Encourage good oral hygiene. Help Pt rinse with viscous lidocaine before eating to reduce discomfort and again after meals. Apply water-soluble lubricant to cracked lips. Popsicles provide a good source of moisture. ■ Itching: Keep Pt’s skin free of foreign substances. Avoid soap: wash with plain water and pat dry. Use cornstarch or olive oil to relieve itching, and avoid talcum powder and powder with zinc oxide.

Patient Teaching

■ Provide literature for specific type of cancer to Pt and family. ■ Prepare Pt and family for what to expect with chemo and radiation therapy. ■ If surgery is to be performed, provide preoperative teaching to prepare Pt and family for procedure and postoperative care. Provide discharge instructions. ■ Explain actions, dosages, side effects, and adverse reactions of meds.

Tumor Facts

■ Benign Tumors: Noncancerous. They can often be removed, and, in most cases, they do not come back. Cells from benign tumors do not spread to other parts of the body. Most importantly, benign tumors are rarely a threat to life.

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173 ■ Malignant Tumors: Cancerous. Cells in these tumors are abnormal and divide without control or order. They can invade and damage nearby tissues and organs. ■ Metastasis: Process by which cancer cells break away from a malignant tumor and enter bloodstream or lymphatic system, thereby spreading from original cancer site to form new tumors in other organs.

TNM Staging of Cancer T: Tumor Size

N: Nodes Involved

T1 . . . . . . Small T2 or T3 . . Medium T4 . . . . . . Large

M: Metastasis

N0 . . . . . . . No involvement N1 –N3 . . . Moderate N4 . . . . . . . Extensive

M0 . . . None M1 . . . Metastasis

CAUTION: Seven Warning Signs of Cancer C A U T I O N

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. Change in bowel or bladder habits . Any sore that does not heal . Unusual bleeding or discharge . Thickening or lump in breast or elsewhere . Indigestion or dysphagia . Obvious change in wart or mole . Nagging cough or hoarseness

ABCDs of Melanoma Asymmetry: One side of lesion looks different from the other Border: Edges irregular, ragged, notched, or blurred Color: Color not uniform throughout lesion Diameter: 6 mm or an increase in size

Asymmetry

Border

Color

Diameter

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PATIENT EDUCATION Breast Self-Examination

4

GENTLY SQUEEZE NIPPLE AND OBSERVE FOR SECRETION, AND NIPPLE ERECTION AFTER EACH NIPPLE IS GENTLY STIMULATED

OBSERVE FOR SYMMETRY, LUMPS, DIMPLING, NIPPLE RETRACTION, OR FAILURE OF NIPPLE ERECTION 1

2 5

WHILE LEANING FORWARD, OBSERVE BREASTS AS THEY ARE REFLECTED IN MIRROR TO DETECT IRREGULARITY, RETRACTED AREAS, NIPPLE RETRACTION ESPECIALLY ON ONE SIDE ONLY 3 6

FEEL FOR NODES, IRREGULARITY, AND TENDERNESS BOTH IN BREASTS AND AXILLARY AREAS

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175 Testicular Self-Examination The Testicular Cancer Research Center (TCRC) recommends following these steps every month. ■ The self-exam for testicular cancer is best performed after a warm bath or shower (heat relaxes the scrotum and makes it easier to spot anything abnormal). ■ Stand in front of a mirror and check for any swelling on the scrotal skin. ■ Examine each testicle with both hands. Place the index and middle fingers under the testicle with the thumbs placed on top. ■ Roll the testicle gently between the thumbs and fingers. You shouldn’t feel any pain when doing the exam. ■ It is normal for one testicle to be slightly larger than the other. ■ Find the epididymis, the soft, tube-like structure behind the testicle that collects and carries sperm. If you are familiar with this structure, you won’t mistake it for a suspicious lump. ■ Cancerous lumps usually are found on the sides of the testicle but can also show up on the front. ■ Lumps on the epididymis are not cancerous.

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PATIENT EDUCATION Common Types of Cancers

Basal Cell Carcinoma (BCC) (See Skin Cancer [Basal Cell and Squamous Cell], page 178 Breast Cancer Incidence: Most common cancer in women in the U.S. and second only to lung cancer in causes of cancer deaths in women. Predominantly affects women; only 1% of breast cancer affects men. Onset: Can develop at any age, but most likely to occur in women 40 years old and in men 60 years. Etiology: Breast cancer begins in epithelial tissues of ducts and lobules. Risk factors include family history, nulliparity or age 30 years for first-time pregnancy, menarche 12 years, menopause 55 years, and long-term hormone replacement therapy. Clinical Findings: Presence of palpable breast lump, inflammation of breast, dimpling, orange-peel appearance, distended vessels, and/or nipple changes or ulcerations.

Colorectal Cancer Incidence: Accounts for ~15% of all malignant cancers and ~11% of all cancer deaths for both men and women in the U.S. Onset: Can develop at any age. In general, chances of developing colorectal cancer are greatest after age 40 years and then begin to decline after age 75. Development of colorectal cancer in younger Pts (20–30 years old) usually results in a poor prognosis. Etiology: Diets high in saturated fats and refined carbohydrates may contribute to development of colorectal cancer. Risk factors include family or personal history of past colorectal cancer, ulcerative colitis, Crohn’s disease, or colon polyps. Clinical Findings: Changes in bowel patterns such as constipation or diarrhea, bloody stools (may be bright red or tarry in appearance), abdominal cramping, nausea and vomiting, anorexia, feeling of fullness, and palpable abdominal masses.

Hodgkin’s Disease Incidence: Uncommon overall, but more common in men than women. With treatment, Hodgkin’s is significantly less lethal than non-Hodgkin’s lymphoma. Onset: Usually young adults age 15–38 years and older adults 55 years. Etiology: Unknown. Clinical Findings: Painless swelling of lymph nodes of neck, axillae, and inguinal areas. Other symptoms include fatigue, fever and chills, night sweats, unexplained weight loss, anorexia, and pruritus.

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177 Leukemia Incidence: Accounts for ~8% of all cancers. Onset: Acute leukemia presents with rapid onset and, if left untreated, leads to 100% mortality within days to months. Chronic leukemia presents with gradual onset and may not be detected for several years. Etiology: Unknown. Risk factors include previous overexposure to radiation, chemicals such as benzene, and viruses. Clinical Findings: Fever, chills, persistent fatigue or weakness, frequent infections, anorexia, unexplained weight loss, swollen lymph nodes, enlarged liver or spleen, petechiae rash, night sweats, bone tenderness, abnormal bruising, and increased bleeding time.

Lung Cancer Incidence: Leading cause of cancer death among both men and women. Men have higher incidence of lung cancer than women. Onset: Average age to develop lung cancer is ~60 years, and diagnosis is rare 40 years. Etiology: Cigarette smoking accounts for ~80% of lung cancers and increases a smoker’s risk to 10 times that of a nonsmoker. Other risk factors include exposure to second-hand smoke, carcinogenic industrial and air pollutants (asbestos, radon, arsenic, etc.), and family history. Clinical Findings: Early-stage lung cancer is usually asymptomatic and is discovered from abnormal findings on routine chest x-ray. Advanced-stage lung cancer often manifests with persistent cough, chest pain, dyspnea, fatigue, weight loss, hemoptysis, and hoarseness.

Lymphoma (See Hodgkin’s Disease, page 176 and Non-Hodgkin’s Lymphoma, page 177) Melanoma (See Skin Cancer [Melanoma], page 178) Non-Hodgkin’s Lymphoma (NHL) Incidence: Fifth most common cause of cancer in the U.S. Non-Hodgkin’s lymphoma has higher mortality rate than Hodgkin’s disease. Onset: Can occur at any age, but is most common 60 years. Etiology: Unknown. Clinical Findings: Fatigue, unexplained weight loss, pruritus, fever, and night sweats.

Ovarian Cancer Incidence: Leading cause of death from reproductive system malignancies in women; occurs most often between the ages of 20 and 54 years. Onset: Typically develops slowly, without symptoms, and is typically diagnosed after tumor metastasis has already occurred. Etiology: Unknown. Risk factors include family history, diet high in saturated fat, exposure to carcinogens, nulliparity, infertility, and celibacy.

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PATIENT EDUCATION Clinical Findings: Abdominal distention and palpable masses, unexplained weight loss, pelvic pain and discomfort, urinary urgency, and constipation.

Prostate Cancer Incidence: Most common cause of cancer among men in the U.S. Onset: Most commonly diagnosed between the ages of 60 and 70 years. Etiology: Unknown. Clinical Findings: Urinary frequency, nocturia, dysuria, and hematuria may be present. In advanced stages, Pts may complain of back pain and weight loss. Digital rectal exam reveals prostatic lesions, and laboratory tests show prostate-specific antigen (PSA) level 10 ng/mL (normal is 4 ng/mL).

Skin Cancer (Basal Cell and Squamous Cell) Incidence: Most common form of cancer, accounting for 40% of all cancers in the U.S., and affecting ~1,000,000 people annually. Basal cell carcinoma (BCC) accounts for 90% of all skin cancers in the U.S. Onset: Most skin cancer cases are diagnosed ~50 years of age, but damage that causes skin cancers starts much earlier in life. Etiology: UV radiation (sun exposure, tanning beds) is the main cause. Clinical Findings: A classic indication of skin cancer is a skin change, especially a new lesion with nonuniform shape and color or a sore that will not heal.

Skin Cancer (Melanoma) Incidence: Melanoma is seventh most common type of cancer; it accounts for ~4% of all skin cancers but ~80% of all skin cancer deaths in the U.S. Melanoma is one of the most common cancers in younger adults. Onset: May occur at any age. Etiology: Exact cause is unknown, but melanoma frequently originates from a nevus or mole. Risk factors include fair skin, development of freckles, red or blonde hair, and presence of a large number of nevi. Clinical Findings: A classic sign of melanoma is a change in color, shape, or size of an existing mole or nevus. Melanomas are usually dark blue to black.

Squamous Cell Carcinoma (SCC) (See Skin Cancer [Basal Cell and Squamous Cell], see above) Testicular Cancer Incidence: Most common solid-tumor malignancy in men ages 15–45 years but causes 1% of all cancer deaths. Onset: Usually rapid and most common between ages 25 and 29 years. Etiology: Unknown, but may be linked to cryptorchidism (failure of affected testicle to descend).

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179 Clinical Findings: Earliest sign is small, hard, painless lump on testicle. Other symptoms include low back pain, feeling of heaviness in scrotum, gynecomastia, and breast tenderness. Depending on stage of cancer, there may be enlarged lymph nodes in surrounding areas.

Uterine Cancer Incidence: Most common in endometrium of uterus; endometrial cancer is fourth leading cause of cancer in women. Onset: Occurs most commonly in postmenopausal women between the ages of 58 and 60 years. Occurrence is rare 30 years. Etiology: Unknown. Risk factors include age, familial and genetic influence, early menarche, delayed menopause (52 years), nulliparity, HRT, obesity, HTN, DM, polycystic ovarian disease, and pelvic irradiation. Clinical Findings: The most common symptom is abnormal, painless vaginal bleeding. Late symptoms include pain, fever, and bowel or bladder dysfunction. Palpation may reveal enlarged uterus and uterine masses. A mucosanguineous, odorous discharge may indicate vaginal metastasis.

Chronic Obstructive Pulmonary Disease (COPD) Definition: A group of diseases that cause airflow blockage and breathingrelated problems. COPD includes asthma, chronic bronchitis, and emphysema. COPD is a slowly progressive disease of airways that is characterized by gradual loss of lung function. Incidence: COPD occurs most often in Pts ≥25 years and represents fourth leading cause of death in the U.S. Onset: COPD develops slowly, and it may be many years before symptoms start to develop. Etiology: COPD is caused by repeated exposure to inhaled fumes and other irritants that damage lung and airways. Cigarette smoking is most common cause of COPD. Clinical Findings: Cough productive of sputum, shortness of breath, wheezing, and chest tightness.

Three Types of COPD

■ Asthma: See Asthma, page 171. ■ Chronic Bronchitis: Characterized by productive cough lasting 3 months during 2 consecutive years and airflow obstruction caused by excessive tracheobronchial mucus production. ■ Emphysema: Characterized by abnormal, permanent enlargement of the distal air spaces past the terminal bronchioles, loss of elasticity, distal air space distention, and alveolar septal destruction.

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PATIENT EDUCATION Nursing Focus ■ ■ ■ ■

Position Pt to maximize ease of breathing (HOB 30–45 degrees). Teach “pursed-lipped” breathing to decrease air trapping. Stage activities to conserve energy and decrease oxygen demand. Encourage frequent small feedings of high-calorie foods/liquids to maximize calorie intake. ■ During an exacerbation, assess and maintain ABCs, notify RT/MD, and implement collaborative care such as meds and IV fluid as ordered. ■ Monitor vital signs and document response to prescribed therapies.

Patient Teaching ■ ■ ■ ■

Provide Pt and family with literature on specific type of COPD. Explain actions, dosages, side effects, and adverse reactions of meds. Provide instructions on proper use of metered dose inhalers. Instruct Pt to seek immediate medical attention if symptoms are not relieved with prescribed meds.

Congestive Heart Failure (CHF) Definition: Condition in which heart is unable to pump sufficient blood to meet metabolic needs of the body. Result of inadequate cardiac output (CO) is poor organ perfusion and vascular congestion in pulmonary (left-sided failure) and systemic (right-sided failure) circulation. Incidence: Increases with age; ~1% of people 50 years old and ~10% of people 80 years old have CHF. Onset: With exception of acute and severe damage to myocardium, as in an AMI, CHF develops slowly, over a long period of time. Etiology: Most common cause is CAD. Other causes include MI, HTN, diabetes, congenital heart disease, cardiomyopathy, and valvular disease. Clinical Findings: Most common symptoms include fatigue, shortness of breath, and edema (vascular congestion in either the pulmonary or systemic circulation) in ankles or feet, in sacral area, or throughout body. Ascites may cause Pt to feel bloated and may compromise respiratory effort. Onset of symptoms may be rapid or gradual, depending on underlying etiology. Leftsided heart failure: Orthopnea, pulmonary edema, crackles or wheezes, dysrhythmias, tachycardia, tachypnea, dyspnea, anxiety, cyanosis, HTN (early CHF), low BP (late CHF), and decreased CO. Right-sided heart failure: Dependent edema, JVD, bounding pulses, oliguria, dysrhythmias, enlargement of the liver and/or spleen, increased CVP, and altered liver function tests.

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181 Nursing Focus

■ Encourage rest and help alleviate dyspnea by administering supplemental oxygen as ordered and elevating HOB 30–45 degrees. ■ In end-stage CHF, slightest activity can cause fatigue and shortness of breath; therefore, assist Pt with ADLs and eating as needed. Stage activities to conserve energy and decrease oxygen demand. ■ Restrict fluid intake (typically 2 L/day) and sodium intake as ordered (typically 1500–2300 mg/day depending on severity of heart failure). ■ Assess vital signs before and after any level of increased activity. ■ Monitoring for signs and symptoms of fluid overload, impaired gas exchange, activity intolerance, daily intake and output, and weight gain will help in early detection of exacerbation.

Patient Teaching

■ Provide Pt with literature on CHF. ■ Teach Pt and family to monitor for increased shortness of breath or edema. ■ Teach Pt to limit fluids to 2 L/day and restrict sodium as ordered. ■ Teach Pt to weigh self at same time every day using same scale and report any weight gain 4 lb in 2 days. ■ Instruct Pt to call for emergency assistance with acute shortness of breath or chest discomfort that is not relieved with rest. ■ Review fluid and dietary restrictions, and stress importance of reducing sodium intake. ■ Explain dosages, route, actions, and adverse reactions of meds.

Coronary Artery Disease (CAD) Definition: Narrowing and hardening of arterial lumen resulting in decreased coronary blood flow and decreased delivery of oxygen and nutrients to the myocardium. Incidence: Most common type of heart disease and leading cause of death for both men and women in U.S. Onset: Can start in childhood and progress with age. Etiology: Buildup of fatty fibrous plaque or calcium plaque deposits on inner walls of coronary arteries causes atherosclerosis (thickening and hardening of inner walls of coronary arteries). Clinical Findings: Most common symptom is angina, although some individuals remain asymptomatic.

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PATIENT EDUCATION Nursing Focus

■ Monitor vital signs and document response to prescribed therapies. ■ Monitor and maintain cardiopulmonary function and enhance myocardial perfusion by implementing prescribed therapies. ■ Document nursing and medical interventions and their outcomes.

Patient Teaching

■ Provide Pt and family with literature about CAD. ■ Explain lifestyle modifications necessary to control CAD. ■ Review dietary restrictions and stress importance of reading food labels to avoid foods high in sodium, saturated fats, trans fats, and cholesterol. ■ Explain actions, dosages, side effects, and adverse reactions of prescribed meds. ■ Provide information about resumption of sexual activity acceptable for Pt’s medical condition. ■ If surgery is to be performed, provide preoperative teaching to prepare Pt and family for procedure, ICU, postoperative care, and cardiac rehabilitation.

Crohn’s Disease Definition: Type of inflammatory bowel disease (IBD). Crohn’s disease usually occurs in the ileum, but it can affect any part of the digestive tract from mouth to anus. Diagnosis is sometimes difficult because Crohn’s disease often resembles other disorders including irritable bowel syndrome and ulcerative colitis. Incidence: Men and women equally affected. Onset: Most likely to occur between 15 and 30 years old and 60 years. Etiology: Unknown (theorized autoimmune disorder). Clinical Findings: Most common symptoms are abdominal pain, often in lower right quadrant, and diarrhea. Rectal bleeding, weight loss, and fever may also occur. Anemia may occur if bleeding is persistent.

Nursing Focus ■ ■ ■ ■ ■

Monitor intake and output and maintain fluid and electrolyte balance. Assess for skin breakdown and provide routine skin care. Unless contraindicated, fluid intake should be 3000 mL/day. Use calorie counts to ensure adequate nutrition. Monitor lab results.

Patient Teaching

■ Provide Pt and family with literature on Crohn’s disease. ■ Instruct Pt that fluid intake should be 3 L/day, and meals should be small and frequent to maintain adequate nutrition.

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183 ■ Teach Pt to minimize frequency and severity of future exacerbations by getting adequate rest and relaxation, reducing or avoiding stress, and maintaining adequate nutrition. ■ Explain dosages, route, actions, and adverse reactions of meds.

Diabetes Mellitus (DM) Definition: A chronic metabolic disorder marked by hyperglycemia. DM results either from a primary failure of pancreatic beta cells to produce insulin (type 1 DM) or from development of insulin resistance in body cells, with initial increased insulin secretion to maintain metabolism followed by eventual inability of pancreas to secrete enough insulin to sustain normal metabolism (type 2 DM).

Type 1 Diabetes (Previously Called InsulinDependent Diabetes Mellitus [IDDM]) Incidence: Accounts for ~5%–10% of diagnosed diabetes. Onset: Develops most often in children and young adults, but can appear at any age. Etiology: Develops when immune cells attack and destroy insulin-producing beta cells in pancreas, with resulting loss of insulin production. Clinical Findings: Weight loss, muscle wasting, loss of subcutaneous fat, polyuria, polydipsia, polyphagia, ketoacidosis.

Type 2 Diabetes (Previously Called Adult-Onset Diabetes) Incidence: Most common form of diabetes, accounting for 90%–95% of diagnosed diabetes. Onset: Gradual. Early on, pancreas is usually producing enough insulin, but for unknown reasons, body cells lose their ability to respond to insulin effectively. Eventually, insulin production decreases or ceases altogether. Etiology: Associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and ethnicity. About 80% of Pts with type 2 diabetes are overweight. Type 2 DM is increasingly being seen in children, adolescents, and young adults. Clinical Findings: Polyuria, polydipsia, pruritus, peripheral neuropathy, frequent infections, and delayed healing of wounds or sores.

Nursing Focus

■ Routine assessment for hyperglycemia and hypoglycemia and their associated signs and symptoms. ■ Monitor blood glucose level as ordered, and document response to prescribed therapies. ■ Assess body systems for complications associated with effects of diabetes.

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PATIENT EDUCATION Patient Teaching

■ Provide Pt with literature on managing diabetes. ■ Encourage necessary lifestyle changes including weight reduction if overweight, dietary modifications, and exercise. ■ Explain purpose, dosage, route, and side effects of insulin and/or oral hypoglycemic agents. ■ If self-administered insulin is prescribed, ensure Pt’s ability to demonstrate appropriate preparation and administration. ■ Educate Pt on proper foot care to minimize risk of injury. ■ Advise Pt about importance of never going barefoot, either outside or around the house, and emphasize that soft slippers or socks do not provide any protection from injury. ■ Instruct Pt to inspect feet every day, to use a mirror or ask someone to help if he or she has difficulty performing this task alone, and to notify health-care professional of any untoward findings (e.g., cuts, scratches, skin cracks, calluses, ulcers, punctures, wounds, or ingrown toenails). ■ Instruct Pt to wash feet daily, thoroughly dry, and apply moisturizing lotion to entire foot (not between toes). ■ Emphasize that Pts who have been diagnosed with diabetic neuropathy should have routine nail care performed by health-care professional or diabetic foot care specialist.

Diabetes Facts

■ Glucagon: Hormone secreted by alpha cells of pancreas in response to low blood sugar that increases blood glucose levels by stimulating liver to convert stored glycogen into glucose. ■ Glycogen: Excess carbohydrates stored in liver and muscles. ■ Glycosuria: Glucose present in urine. A diagnostic sign of diabetes. ■ Insulin: Hormone secreted by beta cells of pancreas in response to high blood glucose. Insulin is required for transport of glucose across cell membrane. Inadequate insulin level or cellular resistance to insulin results in elevated blood glucose levels (hyperglycemia). ■ Ketones: Byproduct of metabolism of fat and protein. Body responds to excess ketones (ketoacidosis) by increasing respiratory rate. ■ Polydipsia: Excessive thirst; diuresis causes cellular dehydration and fluid and electrolyte depletion, resulting in excessive thirst. ■ Polyphagia: Hunger; caused by cellular starvation, secondary to decreased amount of glucose available to cells. ■ Polyuria: Excessive urination; as excess glucose flows or “spills over” from kidneys, it pulls water with it by osmosis, resulting in diuresis, which leads to dehydration.

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185 Hypertension (HTN) Definition: Persistent or intermittent elevation of systolic BP (SBP) 140 mm Hg or diastolic BP (DBP) 90 mm Hg.

Primary (Essential) HTN Incidence: Most common type. Onset: Gradual (over many years). Etiology: Underlying cause is unknown. Clinical Findings: Typically asymptomatic, primary HTN is usually not recognized until secondary complications develop, including atherosclerosis, TIAs, strokes, MI, left ventricular hypertrophy, CHF, and renal failure.

Secondary HTN Incidence: Less common. Onset: Varies according to etiology. Etiology: Can result from any condition that impairs normal regulation of blood pressure, such as renal, endocrine, vascular, or neurologic disorders. Clinical Findings: Variable, but most common symptoms are CV and neurologic (malaise, weakness, fatigue, flushing of the face, headache, dizziness, lightheadedness, nose bleeds, ringing in the ears, or blurred vision) as well as symptoms associated with underlying etiology.

Four Stages of HTN ■ ■ ■ ■

Normal BP: SBP 120 mm Hg and DBP 80 mm Hg. Prehypertension: SBP 120–139 mm Hg or DBP 80–89 mm Hg. HTN Stage I: SBP 140–159 mm Hg or DBP 90–99 mm Hg. HTN Stage II: SBP 160 mm Hg or DBP 100 mm Hg.

Nursing Focus

■ Monitor vital signs and document response to prescribed therapies for reducing blood pressure. ■ Assess for signs of end-organ dysfunction (angina, low serum potassium levels, elevated serum creatinine and BUN, proteinuria, and uremia). ■ Implement collaborative care such as administering antihypertensive meds. ■ Caution: It is critical that BP be reduced gradually; excessive and rapid reduction in BP can precipitate cerebral, myocardial, and renal ischemia.

Patient Teaching

■ Provide Pt with literature on reducing high blood pressure. ■ Encourage necessary lifestyle modifications including weight reduction (for Pts who are overweight), limiting alcohol intake to one drink per day, increased physical activity (30–45 minutes/day), and smoking cessation.

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PATIENT EDUCATION ■ Review dietary guidelines and stress importance of reading food labels to avoid processed foods high in sodium, saturated fats, trans fats, and cholesterol. ■ Provide information to help Pt reduce intake of sodium, saturated fats, and cholesterol, and keep consumption of trans fats to an absolute minimum. ■ Explain importance of maintaining adequate intake of potassium, calcium, and magnesium. ■ Explain actions, dosages, side effects, and adverse reactions of HTN meds.

Irritable Bowel Syndrome (IBS) Definition: Condition marked by abdominal pain (often relieved by passage of stool or gas), disturbances of evacuation (constipation, diarrhea, or alternating episodes of both), bloating and abdominal distention, and passage of mucus in stools. Incidence: IBS is most common digestive disorder in U.S. and is more common in women than men by 3:1. Onset: Usually vague and gradual, IBS most often begins to develop in Pts between 20 and 35 years of age. Etiology: Unknown. Clinical Findings: Classic IBS symptoms include abdominal pain, flatus, constipation, and diarrhea.

Nursing Focus ■ ■ ■ ■

Monitor hydration, intake, and output. Encourage Pt to eat small meals at regular intervals. Encourage fluids; goal is eight glasses of water per day. Encourage frequent ambulation.

Patient Teaching ■ ■ ■ ■ ■

Provide Pt and family with literature on IBS. Encourage necessary lifestyle changes to promote stress reduction. Encourage regular exercise, such as walking 30 minutes/day. Suggest Pt get adequate sleep and avoid becoming fatigued. Suggest Pt eat frequent, small meals throughout the day and avoid foods and beverages identified as triggers, such as wheat, barley, rye, chocolate, dairy, caffeine, or alcohol. ■ Explain actions, dosages, side effects, and adverse reactions of meds.

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187 Multiple Sclerosis (MS) Definition: Chronic and progressive disorder of brain and spinal cord (CNS) caused by damage to myelin sheath (white matter). Destruction of myelin sheath leads to scarring (sclerosis), which decreases and eventually blocks nerve conduction. Incidence: Affects 1 out of 1000 people and occurs more often in women. Onset: Most commonly between 20 and 40 years of age. Etiology: Unknown; possibly autoimmune disorder or exposure to virus. Clinical Findings: Weakness, paresis, or paralysis of one or more limbs, myoclonus (involuntary muscle jerks), impaired or double vision, eye and facial pain, fatigue, dizziness, decreased coordination, and loss of balance.

Nursing Focus

■ Goal of therapy is to control symptoms and preserve function to maximize quality of life. ■ Perform or arrange for ROM exercises to be done twice a day. ■ Assess skin for breakdown and perform routine skin care.

Patient Teaching

■ Provide Pt and family with literature on MS. ■ Encourage healthful and active lifestyle that includes exercise to maintain good muscle tone, good nutrition, and plenty of rest and relaxation. ■ Stress importance of avoiding stress and fatigue. ■ Depending on progression of MS, arrange for occupational, physical, and speech therapy. ■ Explain actions, dosages, side effects, and adverse reactions of all meds, which may include steroids and immunosuppressant therapy, antiviral agents, muscle relaxants, and/or antidepressants.

Pancreatitis Definition: Inflammation of pancreas caused by activation of pancreatic enzymes within pancreas that digest pancreas itself. Incidence: Affects ~80,000 people annually in the U.S. Onset: Acute pancreatitis comes on suddenly and without warning. Chronic pancreatitis develops gradually, usually over many years, with initial symptoms that are vague and difficult to diagnose. Etiology: Most common causes are gallstones and excessive alcohol intake. Acute pancreatitis becomes chronic once pancreatic tissue is destroyed and scarring develops. Other, less common causes include hyperlipidemia, hypercalcemia, abdominal trauma, and bacterial or viral infection.

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PATIENT EDUCATION Clinical Findings: Classic symptom of pancreatitis is abdominal pain that radiates toward the back and increases when supine. Other symptoms include swollen and tender abdomen that may worsen after eating, nausea, vomiting, fever, and tachycardia.

Nursing Focus

■ Goals of treatment are pain management, supportive care, and prevention of secondary complications. ■ Assess lab results for elevated levels of serum amylase and serum lipase. ■ Monitor glucose, Ca, Mg, Na, K, and bicarbonate levels.

Patient Teaching

■ Provide Pt and family with literature on pancreatitis. ■ Teach Pt to avoid alcoholic beverages and decrease consumption of foods high in fat. ■ Provide teaching before diagnostic procedures, which include abdominal ultrasound to look for gallstones and CT scan to look for inflammation and destruction of pancreas. ■ Explain dosages, route, actions, and adverse reactions of meds.

Peripheral Artery Disease (PAD) Definition: Disease of peripheral blood vessels characterized by narrowing and hardening of arteries that supply legs and feet. Decreased blood flow results in nerve and tissue damage to extremities. Incidence: PAD is a very common disorder and is most common in men 50 years old. Onset: Similar to CAD, PAD has gradual onset and is asymptomatic until secondary complications develop. Etiology: Atherosclerosis is primary cause of PAD. Risk factors include smoking, diabetes, hyperlipidemia, CAD, atrial fibrillation, CVA, and renal disease. Clinical Findings: Intermittent claudication (leg pain on activity that is relieved with rest), weak or absent peripheral pulses, pallor or cyanosis, numbness, cool extremities, and minimal to no hair growth on extremities.

Nursing Focus

■ Assess and monitor distal circulation and sensory and motor function. ■ Prevent pressure sores with frequent position changes and assessment. ■ Encourage and assist with frequent ambulation.

Patient Teaching

■ Provide Pt and family with literature on PAD. ■ Encourage light to moderate activity alternated with periods of rest. ■ Explain options available for smoking cessation.

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189 ■ Teach Pt to reduce intake of saturated fats, trans fats, and cholesterol. ■ Explain proper foot care such as wearing shoes that fit properly (avoid open-toed/heeled shoes), keeping feet clean and dry, and minimizing risk of injury by never going barefoot. Inspect bottom of feet daily for injuries. ■ Encourage leg exercises (ankle rotations) and/or a walking regimen. ■ Explain dosages, route, actions, and adverse reactions of meds.

Pneumonia Definition: Infection and/or inflammation of interstitial lung tissues in which fluid, white blood cells, and cellular debris from phagocytosis of infectious agent accumulate in alveoli. Incidence: Approximately 50% of all pneumonia cases are bacterial; pneumococcal pneumonia accounts for 25%–35% of all community-acquired pneumonia cases and ~40,000 deaths annually. Mycoplasma accounts for 20% of all cases of pneumonia. Onset: Varies according to type of pneumonia. Etiology: Causes include viruses, bacteria, fungi, and inhalation of vomitus, food, liquid, or gases. TB and other respiratory diseases can also secondarily cause pneumonia. Clinical Findings: Fever, productive cough, substernal pain and discomfort, shortness of breath, crackles on auscultation, increased fremitus, and dullness on percussion over affected lobe(s).

Three Types of Pneumonia

■ Primary Pneumonia: Caused by inhalation or aspiration of bacterial or viral pathogen into lower respiratory tract. ■ Secondary Pneumonia: Results from lung injury caused by spread of bacteria from infection elsewhere in body or by inhalation of noxious chemical, which can precipitate ARDS. ■ Aspiration Pneumonia: Caused by aspiration of foreign matter such as food, vomitus, or secretions into bronchial tree. Risk factors include old age, decreased gag reflex, anesthesia and sedation, debilitation, and ALOC.

Nursing Focus

■ Position Pt to facilitate an open airway and ease breathing (HOB 30–45 degrees). ■ Encourage coughing and deep breathing every 2 hours. ■ Suction airway to clear secretions as needed. ■ Encourage fluids as ordered. ■ If antibiotic therapy is started, closely monitor routine peak and trough levels.

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PATIENT EDUCATION Patient Teaching

■ Provide Pt and family with literature on pneumonia. ■ Explain dosages, route, actions, and adverse reactions of meds. ■ Stress the importance of limiting activity and of resting frequently to avoid fatigue. ■ Explain that combined fluid intake (liquid, soup, Jell-O, etc.) should be at least 3 L/day. ■ Teach Pt to eat small, frequent meals to maintain adequate nutrition. ■ Explain that prescribed coughing, deep breathing, and incentive spirometry promote healing and help prevent recurrence. ■ Provide literature on smoking cessation to Pts who smoke. ■ Advise Pts 65 years old and those in high-risk groups to receive the pneumonia vaccine.

Renal Failure: Chronic (CRF) Definition: Gradual and progressive loss of ability of kidneys to excrete wastes, concentrate urine, and conserve electrolytes. In contrast, acute renal failure occurs suddenly. Incidence: Affects 2 out of 1000 people in the U.S. annually. Onset: Gradual, over many years. Etiology: Diabetes and HTN are primary causes of CRF, accounting for 40% and 25%, respectively, of all cases. Other causes include trauma, autoimmune disorders, birth defects, drug OD, and genetic diseases. Clinical Findings: Edema throughout the body, shortness of breath, fatigue, flank pain, oliguria (progressing to anuria), elevated BP, and pale skin.

Nursing Focus

■ Never measure BP or perform venipuncture on an arm with a dialysis shunt. ■ Help minimize discomfort from frustrations with fluid restrictions by offering ice chips, frozen lemon swabs, diversional activities, and hard candies. ■ Provide routine skin care; uremia causes itching and dryness of skin. ■ Monitor BUN and serum creatinine levels. ■ Monitor strict fluid intake and output; fluids are typically restricted to an amount equal to previous day’s urine output plus 500–600 mL. ■ Perform frequent turning and ROM exercises to minimize skin breakdown.

Patient Teaching

■ Provide Pt and family with literature on CRF and/or dialysis. ■ Restrict sodium, water, potassium, phosphate, and protein intake as ordered. ■ Encourage compliance with secondary preventive measures. ■ Explain actions, dosages, side effects, and adverse reactions of meds.

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191 Urinary Incontinence Definition: Intermittent or complete absence of ability to control excretion of urine. Incidence: Affects 13 million people in the U.S. and twice as many women as men. Onset: Depending on cause, may occur at any age. Etiology: In women, pregnancy, childbirth, and menopause are responsible for most cases. In both men and women, various underlying medical conditions include spinal cord injury, birth defects, strokes, MS, and physical problems associated with aging. Clinical Findings: Involuntary leakage of urine.

Types of Incontinence

■ Stress: Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising). ■ Urge: Involuntary passage of urine occurring soon after a strong sense of urgency to void. ■ Mixed: Usually the occurrence of stress and urge incontinence together. ■ Overflow: Unexpected leakage of urine because of a full bladder. ■ Functional (environmental): Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet. ■ Transient: Leakage that occurs temporarily because of a condition that will pass (infection, med).

Nursing Focus ■ ■ ■ ■

Provide routine skin care and assessment including fluid intake and output. Encourage Pt to practice Kegel exercises and monitor effectiveness. Offer reassurance and encouragement. Ensure a barrier-free pathway to bathroom (functional incontinence).

Patient Teaching

■ Provide Pt and family with literature on incontinence. ■ Teach Kegel exercises: Contract the pelvic floor muscles (same muscles that stop flow of urine) for 10 seconds, and then relax for 10 seconds. Perform 3 sets of 10 contractions every day. ■ Encourage Pt to quit smoking to reduce coughing and bladder irritation. Smoking also increases risk of bladder cancer. ■ Explain that alcohol and caffeine can overstimulate bladder and should be avoided. ■ Advise Pt to avoid foods and drinks that may irritate bladder such as spicy foods, carbonated beverages, and citrus fruits and juices. ■ Explain actions, dosages, side effects, and adverse reactions of meds. ■ If surgery is to be performed, provide preoperative teaching to prepare Pt and family about procedure and postoperative care and recovery.

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Metric Conversions Weight lb 300 275 250 225 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 10 5 2.2 2 1

Temperature kg

136.4 125.0 113.6 102.3 95.5 90.9 86.4 81.8 77.3 72.7 68.2 63.6 59.1 54.5 50.0 45.5 40.9 36.4 31.8 27.3 22.7 18.2 13.6 9.1 4.5 2.3 1 0.9 0.45


F 212 107 106 105 104 103 102 101 100 99 98.6 98 97 96 95 94 93 92 91 90 32


C 100 Boil 42.2 41.6 40.6 40.0 39.4 38.9 38.3 37.8 37.2 37.0 36.7 36.1 35.6 35.0 34.4 34.0 33.3 32.8 32.1 0 Freeze

192

Height cm

in

ft/in

142 145 147 150 152 155 157 160 163 165 168 170 173 175 178 180 183 185 188 191 193 196

56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77

4′ 8′′ 4′ 9′′ 4′ 10′′ 4′ 11′′ 5′ 0′′ 5′ 1′′ 5′ 2′′ 5′ 3′′ 5′ 4′′ 5′ 5′′ 5′ 6′′ 5′ 7′′ 5′ 8′′ 5′ 9′′ 5′10′′ 5′11′′ 6′ 0′′ 6′ 1′′ 6′ 2′′ 6′ 3′′ 6′ 4′′ 6′ 5′′

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193 lb  kg  2.2 or kg  lb  0.45
F  (
C  1.8)  32 or
C  (
F32)  0.556 Inches  cm  0.394 or cm  inches  2.54

Volume

Weight

1 teaspoon (tsp) . . . . . . . . . . . 0.5 milliliters (mL) 1 tablespoon (tbsp) . . . . . . . 15 mL 1 ounce (oz) . . . . . . . . . . . . 30 mL 1 cup (c) . . . . . . . . . . . . . . 240 mL 1 pint (pt) . . . . . . . . . . . . . 473 mL 1 quart (qt) . . . . . . . . . . . . 946 mL

1 milligram (mg) . . . . . . . . . . . . 1000 micrograms (g) 1 gram (g) . . . . . . . . . . . . . . . . 1000 mg 1 grain (gr) . . . . . . . . . . . . . . . . . 60 mg 1 kilogram (kg) . . . . . . . 2.2 pounds (lb) 1 liter (L) of water . . . . . . . . . . . . . . 1 kg 1 ounce (oz) . . . . . . . . . . . . . . . . . . 28 g

Common Equivalents and Formulas ■ Convert oz to cc or mL: Multiply number of ounces by 30 ■ Convert cc or mL to oz: Divide number of mL by 30 1 cc equals . . . . . . . . . . . . . . . . . . . . . . 1 mL Large soda (22 oz) 660 mL 1 oz equals . . . . . . . . . . . . . . . . . . . . . 30 mL Coffee mug (8 oz) 240 mL 8-oz juice glass . . . . . . . . . . . . . . . . . 240 mL Milk carton (4 oz) 120 mL Small (12-oz) soda . . . . . . . . . . . . . . 360 mL Popsicle (3 oz) 90 mL Medium (16-oz) soda . . . . . . . . . . . . 480 mL Jell-O cup (4 oz) 120 mL

Equivalents Specific to Your Institution

Body Surface Area (BSA) Using cm and kg: Ht (cm)  Wt (kg) 
 3600 Using in and lb: Ht (in)  Wt (lb) 
 3131

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Waist-to-Hip Ratio ■ Measure the circumference of the waist at its narrowest point with the stomach relaxed. ■ Measure the circumference of the hips at their fullest point where the buttocks protrude the most. ■ Divide the circumference of the waist by the circumference of the hips. ■ Women should have a waist-to-hip ratio ≤0.8. ■ Men should have a waist-to-hip ratio ≤0.95.

Frequently Used Phone Numbers Overhead Code: Security: Admitting: Blood Bank: Burn Unit: CICU (CCU): Chaplain-Pastor: Computer Help (IS, IT): CT (Computed Tomography): Dietary-Dietitian: ECG: 12-Lead: Emergency (ED): ICU: Interpreter Services: Laboratory: Maintenance-Engineering: Med-Surg: MRI (Magnetic Resonance Imaging): Nutrition: Food Services: OT (Occupational Therapy): PACU (Recovery): Pediatrics: Pharmacy (Rx): Poison Control:

99/Blue: Emergency ext:

USA—1-800-222-1222 (Continued on following page)

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195 Frequently Used Phone Numbers (continued) PT (Physical Therapy): Respiratory (RT): Social Services: Speech-Language Pathology (SLP): Supervisor-Manager: Surgery: Inpatient (OR): Surgery: Day/Outpatient: Telemetry Unit: X-Ray:

Cultural Diversity in Health Care Note: Within the United States there are 400 ethnocultural groups, so it is impossible to include cultural characteristics for all of them. The cultural groups selected for inclusion in this book met at least one of the following criteria: (a) the group has a large population in the United States, (b) the group is relatively new in its migration status, (c) the group is widely dispersed throughout the United States, (d) little is written about the group in the health-care literature, or (e) the group holds a significant minority or disenfranchised status.

Selected Reference Purnell, L, and Paulanka, B: Guide to Culturally Competent Health Care. Philadelphia, FA Davis, 2005.

Guidelines for a Positive Cultural Interaction ■ Be aware that culture has a strong influence on an individual’s interpretation of and responses to health care. ■ Assess patient’s depth of understanding of English, and use an interpreter whenever needed. ■ Ask patients how they like to be greeted and what name they prefer. ■ Identify who makes decisions: patient, spouse, children, etc. If unsure, ask patients specific questions regarding their culture. ■ Be open-minded, accepting, and willing to learn.

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American Indian Communication: Primary language varies from tribe to tribe, but most younger generations are bilingual (English and their native language). Greetings should be formal. Long periods of silence are normal. Talking loudly is rude. Physical contact from strangers is unacceptable; however, shaking hands is okay. Respect personal space, because it is generally greater than that of European Americans. Health-Care Practices: A lot of questioning during an assessment may foster mistrust. Illness is unacceptable; older patients, even when seriously ill, must be encouraged to rest. Diet and Nutrition: Food has major significance beyond nourishment, but is not generally associated with promoting health or illness. Corn is a staple. Diet may be deficient in vitamin D owing to high incidence of lactose intolerance. Pain Management: Most individuals are stoic and will not ask for pain meds; it is believed that pain should be endured. Death and Dying: Autopsy and organ donation are unacceptable to traditional American Indians. Some Native American tribes may wish the window to be opened to allow the spirit to leave at death. Taboos and Disrespect: Direct eye contact and/or finger pointing may be disrespectful.

Arab Heritage Communication: Primary language is Arabic. Speech may be loud, expressive, and involve gesturing, with an emphasis placed on nonverbal communication; avoid misinterpreting as anger or confrontation. Title is important; ask how patient or family prefers to be addressed. Shaking hands (right hand only) is okay, but men should not initiate a handshake with girls and women. Health-Care Practices: Same-gender health-care provider is strongly preferred. Reluctant to share sensitive medical information with someone other than family and friends. Diet and Nutrition: Pork, pork products, and alcohol are prohibited by Muslims; medications should not contain alcohol. Bread should accompany all meals. Pass food to patients only with your right hand. During Ramadan, fasting is required from sunup until sundown. Pain Management: Most individuals are stoic around strangers; take cues from family members regarding patient discomfort. Pain medication is acceptable.

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197 Death and Dying: Patients should face Mecca (northeast from the U.S.) when death is imminent. Autopsy (if needed), organ donation, and transplant are acceptable. “Shahadah” or the statement of faith prayer is whispered into the ear of the dying patient. Menstruating women may be considered unclean and may not be allowed in the room of a dying person. The room may also be ritually perfumed by family members. Taboos and Disrespect: The left hand is used for toileting and is considered dirty. Direct eye contact between members of the opposite sex is considered disrespectful.

Asian Heritage Note: C, J, K, and V refer to Chinese, Japanese, Korean, and Vietnamese, respectively. Communication: Primary language varies with country. Greetings should be formal (C, J, K, V). Direct eye contact (C, J, K) or invasion of personal space (C, J) may cause uneasiness. Touch only when necessary (C, J, V). Shaking hands is okay (J, K), but men should not initiate a handshake with girls or women (V). Health-Care Practices: Same-gender health-care provider is strongly preferred by women (C, K, V). Assumption of the sick role is highly tolerated, and long recuperation is encouraged (J). May seek traditional, alternative treatment first, before accepting Western medicine (C, J, K, V). Likely to refuse blood transfusions (V). Diet and Nutrition: Rice is a staple (J, K, V) and is included in every meal throughout the day, including snacks (J). Tofu is a staple (C). High intake of sweets may account for high incidence of tooth decay (J). High incidence of lactose intolerance (J, K, V) and iron-deficiency anemia (V). Prefer beverages without ice (C). Pain Management: May be reluctant to accept or request pain medication (J, K). Death and Dying: Responsibility for any special arrangements falls to the eldest son (J, K). Mourning can be elaborate by Western standards (J) and can include offerings of food and money (C, J). The concept of advance directives may be confusing (J). Strong desire to die at home (V). Unlikely to consent to an autopsy (V), and organ donation or transplantation may be unacceptable (J, K, V). Practicing Buddhists may prefer cremation of the remains. Taboos and Disrespect: Open discussion about serious illness and death (J), addiction (J), mental illness (J), direct eye contact (C, J, V), pointing (V), chopsticks stuck upright in food (C), touching the head (V), placing feet on desk or table (V).

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Bosnian Heritage Communication: Primary language is Serbo-Croatian. Older and traditional patients expect formal greetings. Women maintain eye contact with other women but not with men. Physical contact between genders is not exhibited in public. Shaking hands (right hand only) is okay, but men should not initiate a handshake with girls or women. Asking too many questions may cause apprehension. Health-Care Practices: High value placed on cleanliness. Same-gender health-care provider is strongly preferred. Most consider it shameful to accept Medicaid. Diet and Nutrition: Pork, pork products, and alcohol are prohibited by Muslims; medications should not contain alcohol. Pass food to patients only with your right hand. During Ramadan, fasting is required from sunup until sundown. Pain Management: Most individuals are stoic; take cues from family members regarding patient discomfort. Pain medication is acceptable. Death and Dying: Patients should face Mecca (northeast from the U.S.) when death is imminent. “Shahadah” or the statement of faith prayer is whispered into the ear of the dying patient. Menstruating women are considered unclean and should not be allowed in the room of a dying person. The room may also be ritually perfumed by family members. Taboos and Disrespect: The left hand is used for toileting and is considered dirty.

Cuban Heritage Communication: Primary language is Spanish. Speech tends to be loud and fast by Western standards, and direct eye contact is acceptable during conversation. Greetings should be formal. Shaking hands and casual contact are okay, but necessity to touch private areas during an assessment may need to be explained. Health-Care Practices: Language is the biggest barrier to health care, and many may seek traditional folk healers or alternative treatment first; otherwise, Western medicine openly accepted. Blood transfusion is generally acceptable. Diet and Nutrition: Yams, yucca, plantains, and grains are staples. High incidence of lactose intolerance. Being overweight is seen as positive, healthy, and sexually attractive.

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199 Pain Management: Pain is expressed openly as verbal complaints, moaning, and crying. Emotional or psychic “pain” may be expressed through somatic complaints of bodily ailments. Explaining that pain medication promotes healing will help patients to accept pain medication more easily. Death and Dying: Bereavement is expressed openly, and mourning may be elaborate by Western standards. Organ donation is generally acceptable. Taboos and Disrespect: Cutting an infant’s hair or nails before the age of 3 months is believed to cause blindness and deafness.

Filipino Heritage Communication: Primary language is Filipino, but starting in the third grade, all education is taught in English. Adults should be greeted formally. Prolonged eye contact is avoided with a figure of authority or a person who is older. Meanings are embedded in nonverbal communication. Male healthcare workers should avoid prolonged eye contact with younger women because it may be interpreted as flirting. Close personal space should be respected. Health-Care Practices: High value placed on personal cleanliness. May seek traditional folk healers or alternative treatment first; otherwise, Western medicine openly accepted. Assumption of the sick role is highly tolerated, and family members readily care for the patient. Diet and Nutrition: High incidence of lactose intolerance. Cold drinks, fruit juice, and tomatoes are avoided in the morning to prevent stomach upset. Pain Management: More stoic than Western standards. Pain medication may need to be encouraged. Death and Dying: Many are resistant to discussing advance directives or living wills. Cremation is acceptable, but organ donation is not. Taboos and Disrespect: Planning one’s death is viewed as tempting fate.

Haitian Heritage Communication: Primary languages are French and Creole. Greetings should be formal, and shaking hands is okay. Haitians are very expressive with their emotions, including loud animated speech. Do not misinterpret loud speech as anger. Eye contact with authority figures is avoided, but otherwise acceptable. Casual touching is a common gesture and is not considered inappropriate. Health-Care Practices: It is common for Haitians to use traditional folk healers and Western practitioners simultaneously. Privacy is highly regarded; therefore, family should not be used for interpretation. Expect a large number of visitors for Haitian patients. Nursing homes for the elderly are not acceptable to the family.

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Diet and Nutrition: Yogurt, cottage cheese, and runny egg yolks are not eaten, and patients may refuse non-Haitian hospital food. Being overweight is normal compared with Western standards. Pain Management: Pain manifests outwardly with moaning and facial expressions. Many Haitians have a very low pain threshold. Death and Dying: Haitians prefer to die at home. Mourning is highly emotional and expressive by Western standards. Organ donation and transplantation are generally not acceptable. Taboos and Disrespect: Homosexuality is taboo.

Mexican Heritage Communication: Primary language is Spanish. Emphasis is placed on verbal communication. Greetings should be formal. Older generations may regard direct eye contact as disrespectful, but most younger generations do not. Shaking hands is okay, but physical contact during an assessment may need to be explained. Health-Care Practices: May seek traditional folk healers or alternative treatment first; otherwise, Western medicine openly accepted. Assumption of the sick role is highly tolerated and family members readily take on the patient’s responsibilities. Blood transfusion is acceptable. Diet and Nutrition: Rice, beans, tortillas, chilies, and citrus fruits are staples. Being overweight is seen as positive. Pain Management: May have fear of becoming addicted to pain medications. Explaining that pain medication promotes healing will help patients to accept pain medication more easily. Death and Dying: Expect to have many visitors when death is imminent. Electric candles may be used when family wants lighted candles near the patient. Organ donation and transplantation, cremation, and autopsy are generally not acceptable. If practicing Roman Catholics, family may desire anointing of the sick or last rites be performed by a priest. Taboos and Disrespect: Direct eye contact with older generation.

Puerto Rican Heritage Communication: Primary languages are Spanish and English. Speech is fast by Western standards. Greetings should be formal. Older generations may regard direct eye contact as disrespectful, but most younger generations encourage it. Shaking hands is encouraged. Women of older generations may require larger personal space when interacting with men. Many enjoy sharing personal information and expect the same in return from health-care workers while developing a professional relationship.

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201 Health-Care Practices: Women may need to consult their husbands before signing a consent form. Many are reluctant to receive or donate blood. Samegender health-care provider may be requested. Many combine traditional, folk, and Western medicine. Diet and Nutrition: Rice and beans and citrus fruits are staples. Being overweight is a sign of health and wealth. Pain Management: Many tend to be loud and outspoken when expressing pain. Emotional or psychic “pain” may be expressed through somatic complaints of bodily ailments. Pain medication is openly accepted. Older generations may not understand the concept of a pain scale. Death and Dying: Seek out the head of the family (usually the eldest son or daughter) for notification of a deceased patient. Grieving may be loud and expressive by Western standards. Cremation is rarely practiced, and autopsy is considered a violation of the body. Organ donation is regarded as highly positive. Taboos and Disrespect: Open communication about physical ailments and sexuality is taboo. Addressing patient or family with terms such as “honey” or “sweetheart” may be considered disrespectful. Refusing food from family members may be regarded as personal rejection.

Russian Heritage Communication: Primary language is Russian. Greetings should be formal. Direct eye contact and touching are acceptable, independent of age and gender. Until trust is established, patients may be standoffish toward healthcare workers. Health-Care Practices: News of a critical or terminal illness is believed to make the condition worse. Cupping is a form of suction cup–like therapy used to treat a multitude of respiratory illnesses. It produces bruising on the back, which may be misinterpreted as a sign of abuse. Many have an elevated fear of contracting HIV/AIDS from blood donation and transfusion. Diet and Nutrition: Bread is a staple in every meal. Diets are high in fat and sodium. Patients generally do not prefer cold drinks. Pain Management: More stoic than Western standards, and patients are not likely to ask for pain medication. Health-care workers may need to encourage pain medication and explain that it will enhance healing. Death and Dying: Expression of grief is variable. Families prefer to be told of impending death before telling the patient. It is appropriate to discuss do-not-resuscitate (DNR) orders with the family and patient. Most prefer hospice care. Taboos and Disrespect: No significant cultural taboos noted.

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Basic English-to-Spanish Translation English Phrase

Pronunciation

Spanish Phrase

oh-lah bweh-nohs dee-ahs bweh-nahs tahr-dehs bweh-nahs noh-chehs meh yah- moh soy en-fehr-meh-ra koh-moh seh yah-mah oo-stehd? koh-moh eh-stah oo-stehd? mwee b’ yehn grah-s’yahs see, noh pohr fah-vohr deh nah-dah

Hola Buenos días Buenas tardes Buenas noches Me llamo Soy enfermera ¿ Cómo se llama usted?

Introductions: Greetings Hello Good morning Good afternoon Good evening My name is I am a nurse What is your name? How are you? Very well Thank you Yes, no Please You’re welcome

¿Cómo está usted? Muy bien Gracias Sí, no Por favor De nada

Assessment: Areas of the Body English Phrase Head Eye Ear, hearing Nose Throat Neck Chest, heart Back Abdomen Stomach Rectum Penis

Pronunciation kah-beh-sah oh-hoh oh-ee-doh nah-reez gahr-gahn-tah kweh-yoh peh-choh, kah-rah-sohn eh-spahl-dah ahb-doh-mehn eh-stoh-mah-goh rehk-toh peh-neh

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Spanish Phrase Cabeza Ojo Oído Nariz Garganta Cuello Pecho, corazón Espalda Abdomen Estómago Recto Pene

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203 English Phrase Vagina Arm, hand Leg, foot

Pronunciation vah-hee-nah brah-soh, mah-noh p’yehr-nah, p’yeh

Spanish Phrase Vagina Brazo, mano Pierna, pie

Assessment: History Do you have… ■ Difficulty breathing? ■ Chest pain? ■ Abdominal pain? ■ Diabetes? Are you… ■ Dizzy? ■ Nauseated? ■ Pregnant? Are you allergic to any medications?

T’yeh-neh oo-stehd… di-fi-kul-thad doh-lorh hen lh peh-chow doh-lorh ab-do-min-al dee-ah-beh-tehs ehs-tah ma:r-eh-a-dho(dha) ka:n now-she-as ¿ehm-bah-rah-sah-dah? ¿ehs ah-lehr-hee-koh ah ahl-goo-nah meh-deesee-nah?

¿Tiene usted… Dificultad para respirar? Dolor en el pecho? Dolor abdominal? Diabetes? ¿Está… Mareado(a)? Con nauseas? Embarazada? ¿Es alergico a alguna medicina?

Assessment: Pain English Phrase Do you have pain? Where does it hurt? Is the pain… ■ Dull? ■ Aching? ■ Crushing? ■ Sharp? ■ Stabbing? ■ Burning? Does it hurt when I press here? Does it hurt to breathe deeply?

Pronunciation T’yeh-neh oo-stehd dohlorh? dohn-deh leh dweh-leh? es oon doh-lor… leh-veh? kons-tan-teh? ah-plahs-tahn-teh? ah-goo-doh? ah-poo-neo-lawn-the? ahr-d’yen-teh? Leh dweh-leh kwahn-doh ah-pree-eh-toh ah-kee? S’yen-teh oo-stehd doh-lor kwahn-doh reh-spee-rah pro-foon-dah-men-teh?

Spanish Phrase ¿Tiene usted dolor? ¿Donde le duele? ¿Es un dolor… Leve? Constante? Aplastante? Agudo? Apuñalante? Ardiente? ¿Le duele cuando le aprieto aqui? ¿Siente usted dolor cuando respira profundamente?

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English Phrase Does it move to another area? Is the pain better now?

Pronunciation Lh doh-lor zeh moo-eh-veh a oh-trah ah-ri-ah? c-n-the al-goo-nah me-horree-ah?

Spanish Phrase ¿El dolor se mueve a otra area? ¿Siente alguna mejoría?

Symbols and Abbreviations a- ............................................. before ............................................... alpha

................................................. beta @ ..................................................... at # ............................. pound, quantity ′′ .................................................. inch ® ................................................ right L ................................................... left B .......................................... bilateral ↑........................................... increase ↓.......................................... decrease ....................................... psychiatric Ø ......................................... none, no ∆............................................. change /............................. per or divided by ......................................... less than  ................................... greater than
............................................ degrees Rx ............... treatment, prescription ............................................... micro AAA ..................... abdominal aortic aneurysm ABC........... automated blood count ABD .............. abdominal (dressing) ABG..................... arterial blood gas AC .................... before meals (A.M.), antecubital

ACE............ angiotensin-converting enzyme ACS ......................... acute coronary syndrome AD ................. right ear, Alzheimer’s disease ADA .................. American Diabetes Association ADH .............. antidiuretic hormone ADL ........... activities of daily living ADR ............. adverse drug reaction AED ................. automated external defibrillator AFB....................... acid-fast bacillus AHA........................ American Heart Association AKA............................... above-knee amputation ALOC....................... altered level of consciousness AMI ...................... acute myocardial infarction AP ................... anterior to posterior APAP...................... acetaminophen aPTT ......... activated partial thromboplastin time AS.......................................... left ear ASA ....................................... aspirin (Continued on following page)

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205 Symbols and Abbreviations (continued) AU ..................................... both ears AV............................ atrioventricular BBB........................... bundle branch block BCC, BCCa ...................... basal cell carcinoma BE ............................ barium enema, base excess b.i.d. .............................. twice a day BKA ............................... below-knee amputation BM ....................... bowel movement BMI ...................... body mass index BP ............................ blood pressure BPM ..................... beats per minute BS ..................... blood sugar, bowel sounds BSA ............................ body or burn surface area BUN ................................ blood urea nitrogen BVM ....................... bag-valve mask c- .................................................. with
C ........................... degrees Celsius, centigrade C & S or CS ................ culture and sensitivity Ca .................................... calcium CA .......................................... cancer CAD ........................ coronary artery disease CBC ........................ complete blood count CBG......................... chemical blood glucose

CHB ............... complete heart block CHF ........... congestive heart failure CI ................................ cardiac index Cl- ........................................ chloride CNS........... central nervous system CO ...................... carbon monoxide, cardiac output CO2 .......................... carbon dioxide COBS...................... chronic organic brain syndrome COPD ............... chronic obstructive pulmonary disease CP .................... chest pain, cerebral palsy CPAP............... continuous positive airway pressure CSF ................... cerebrospinal fluid CSM.................. circulation sensory and motor CT............... computed tomography CV............................. cardiovascular CVA ........ cerebrovascular accident CVC........... central venous catheter CVP.......... central venous pressure CX ........ circumflex coronary artery D5W .............. 5% dextrose in water DBP ............................... diastolic BP DC...................... discontinue, direct current DIC ............. disseminated intravascular coagulopathy DKA............... diabetic ketoacidosis dL......................................... deciliter DM ....................... diabetes mellitus (Continued on following page)

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Symbols and Abbreviations (continued) DO2 ........................ oxygen delivery DVT.............. deep vein thrombosis ECG.................... electrocardiogram (formerly EKG) ED.............. emergency department (also ER) EFM.......................... electronic fetal monitoring EMS ................. emergency medical services ESR....................... erythrocyte sedimentation rate ET ................................ endotracheal ETOH .................................... alcohol ETT ..................... endotracheal tube
F....................... degrees Fahrenheit Fe................................................ iron FFP .................. fresh frozen plasma FHR .......................... fetal heart rate Fr, fr ...................................... French GCS ........................ Glasgow Coma Scale GI ............................ gastrointestinal gtt ............................................. drop GU .............................. genitourinary H&H ...................... hemoglobin and hematocrit h, hr .......................................... hour H ............................... hydrogen ion HA ..................................... headache HCl ..................... hydrogen chloride HCO3 .......................... carbonic acid Hct................................ hemoglobin

HELLP ............. hemolysis, elevated liver enzymes, low platelets Hgb ................................. hematocrit HOB .............................. head of bed HS ........... hour of sleep (nighttime) HTN............................. hypertension IBC ................ iron binding capacity IBD.............. irritable bowel disease IBS.......... irritable bowel syndrome IBW ..................... ideal body weight ICP ................. intracranial pressure ICS........................ intercostal space ID ................................... intradermal IDDM ................. insulin-dependent diabetes mellitus IM............................... intramuscular INR...................... international ratio IO ................................. intraosseous I/O, I&O .............. intake and output IV................................... intravenous IVC...................... inferior vena cava IVF ........................ intravenous fluid IVP....................... intravenous push IVPB ........... intravenous piggyback J ............................................... joule JVD............. jugular vein distention K .................................... potassium KB.................... knife blade (scalpel) KCl.................... potassium chloride kg ....................................... kilogram LAD .......... left anterior descending LAT ......................................... lateral (Continued on following page)

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207 Symbols and Abbreviations (continued) LBBB ........ left bundle branch block LLQ ................... left lower quadrant LMA............ laryngeal mask airway LNMP .......... last normal menstrual period LOC............. level of consciousness LPM ...................... liters per minute LR......... lactated Ringer’s (solution) LTC ............................... left to count LUQ .................. left upper quadrant mA ................................ milliampere MAP ........... mean arterial pressure MAR .......... medication administration record
g ................ (also mcg) microgram mEq ......................... milliequivalent mg..................................... milligram Mg ............................ magnesium MgSO4 ............. magnesium sulfate MH ........... malignant hyperthermia MI .................. myocardial infarction min ..................... minute, minimum mL ....................................... milliliter mm .................................. millimeter mm Hg ........ millimeter of mercury MRI ................. magnetic resonance imaging MRSA.............. methicillin-resistant Staphylococcus aureus MS.......... morphine, musculoskeletal, multiple sclerosis MSO4 ................... morphine sulfate MVA ........... motor vehicle accident

Na ....................................... sodium NAD ................... no apparent/acute distress NaHCO3 ......... sodium bicarbonate NG ................................. nasogastric NGT ...................... nasogastric tube NI ............................... nasointestinal NIDDM ...... non–insulin-dependent diabetes mellitus NPA ........... nasopharyngeal airway NPO.................... nothing by mouth (per os) NRB .......................... nonrebreather NS .............................. normal saline NSAID ................ nonsteroidal antiinflammatory drug NSR ............... normal sinus rhythm NTG ............................. nitroglycerin NTP ................... nitroglycerin paste n/v ................. nausea and vomiting O2 .......................................... oxygen OD .................... overdose, right eye OPA ............. oropharyngeal airway OPP..................... organophosphate OS ......................................... left eye OT.................. occupational therapy OTC....................... over the counter OU .................................... both eyes oz ............................................ ounce - ................................................ after p PAC ........ premature atrial complex PaO2 ..... partial pressure of oxygen in arterial blood (Continued on following page)

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Symbols and Abbreviations (continued) PAP...................... pulmonary artery pressure PCW ................ pulmonary capillary wedge pressure PE ................ pulmonary embolism, edema PEA ..... pulseless electrical activity PEEP ......... positive end-expiratory pressure PET ..................... positron emission tomography pH................. potential of hydrogen PICC .............. peripherally inserted central catheter PIH.................... pregnancy-induced hypertension PJC................ premature junctional complex PMI........ point of maximal impulse PO ........... per os (by mouth, orally) PPD ...... purified protein derivative (tuberculin skin test) PPF............ plasma protein fraction PRBC .......... packed red blood cells PRI .................................. PR interval PRN ................................. as needed PSA ......... prostate-specific antigen PSI ............ pounds per square inch PSVT........... paroxysmal supraventricular tachycardia PT........ prothrombin time, physical therapy, or patient (also Pt) PTT ..... partial thromboplastin time PVC.............. premature ventricular complex

PVD .................. peripheral vascular disease q, Q.......................................... every q.i.d. .................. four times per day q.o.d. ..................... every other day R ............................ regular (insulin) RBBB ..... right bundle branch block RCA ............... right coronary artery RL........... Ringer’s lactate (solution) RLQ ................ right lower quadrant ROM ....... range of motion, rupture of membranes RSI ........ rapid-sequence intubation RT ........... respiratory therapy, right RUQ............... right upper quadrant s- .......................................... without SaO2 ................... oxygen saturation SBP............ systolic blood pressure SC or SQ.................. subcutaneous SCC ....... squamous cell carcinoma SI .................................. stroke index SLP .... speech-language pathology SOB.................. shortness of breath SpO2 ........................ pulse oximeter (measurement of blood oxygen saturation) ss ................... signs and symptoms STD ................ sexually transmitted disease SV ............................. stroke volume SVC................... superior vena cava SVO2..................... systemic venous oxygen saturation (Continued on following page)

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209 Symbols and Abbreviations (continued) SVR....................... systemic venous resistance T .................................. temperature TB ................................. tuberculosis TCP ............ transcutaneous pacing TF ................................. tube feeding TIA........... transient ischemic attack t.i.d. ................. three times per day TPN ......... total parenteral nutrition TPR .................. temperature, pulse, respirations TVP.................. transvenous pacing U ................................................. unit

UA..................................... urinalysis UO ................................ urine output URI....... upper respiratory infection UTI................ urinary tract infection VAD ............ vascular access device VO2................ oxygen consumption VRE............... vancomycin-resistant enterococcus VRSA............ vancomycin-resistant Staphylococcus aureus WBC ................... white blood count WC .................................. wheelchair WPW ........... Wolff-Parkinson-White (syndrome)

NANDA Nursing Diagnoses A Activity Intolerance [specify level] Activity Intolerance, risk for Airway Clearance, ineffective Allergy Response, latex Allergy Response, latex, risk for Anxiety [specify level] Anxiety, death Aspiration, risk for Attachment, risk for impaired parent/infant/child Autonomic Dysreflexia Autonomic Dysreflexia, risk for B Blood Sugar, risk for unstable Body Image, disturbed

Body Temperature, risk for imbalanced Bowel Incontinence Breastfeeding, effective Breastfeeding, ineffective Breastfeeding, interrupted Breathing pattern, ineffective C Cardiac Output, decreased Caregiver Role Strain Caregiver Role Strain, risk for Comfort, readiness for enhanced Communication, impaired verbal Communication, readiness for enhanced Conflict, parental role Confusion, acute (Continued on following page)

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NANDA Nursing Diagnoses (continued) Confusion, risk for acute Confusion, chronic Constipation, perceived Constipation, risk for Contamination Contamination, risk for Coping, defensive Coping, ineffective Coping, readiness for enhanced Coping, ineffective community Coping, readiness for enhanced community Coping, compromised family Coping, disabled family Coping, readiness for enhanced family D Death Syndrome, risk for Sudden Infant Decisional Conflict [specify] Denial, ineffective Dentition, impaired Decision-Making, readiness for enhanced Development, risk for delayed Diarrhea Disuse Syndrome, risk for Diversional Activity, deficient E Energy Field, disturbed (revised) Environmental Interpretation Syndrome, impaired F Failure to Thrive, adult Falls, risk for

Family Processes, dysfunctional: alcoholism Family Processes, interrupted Family Processes, readiness for enhanced Fatigue Fear (specify focus) Fluid Balance, readiness for enhanced [Fluid Volume, deficient hyper/hypotonic] Fluid Volume, deficient [isotonic] Fluid Volume, excess Fluid Volume, risk for deficient Fluid Volume, risk for imbalanced G Gas Exchange, impaired Glucose, risk for unstable level Grieving Grieving, complicated Grieving, risk for complicated Growth, risk for disproportionate Growth and Development, delayed H Health Behavior, risk prone Health Maintenance, ineffective Health-Seeking Behaviors (specify) Home Maintenance, impaired Hope, readiness for enhanced Hopelessness Human Dignity, risk for compromised Hyperthermia Hypothermia I Identity, disturbed personal (Continued on following page)

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211 NANDA Nursing Diagnoses (continued) Immunization Status, readiness for enhanced Infant Behavior, disorganized Infant Behavior, organized, readiness for enhanced Infant Behavior, risk for disorganized Infant Feeding Pattern, ineffective Infection, risk for Injury, risk for Injury, risk for perioperative positioning Insomnia Intracranial Adaptive Capacity, decreased K Knowledge, deficient [Learning Need] [specify] Knowledge [specify], readiness for enhanced L Lifestyle, sedentary Liver Function, risk for impaired Loneliness, risk for M Memory, impaired Mobility, impaired bed Mobility, impaired physical Mobility, impaired wheelchair Moral distress N Nausea Noncompliance [Adherence, ineffective] [specify] Nutrition, less than body requirements, imbalanced

Nutrition, more than body requirements, imbalanced Nutrition, readiness for enhanced Nutrition, more than body requirements, risk for imbalanced O Oral Mucous Membrane, impaired P Pain, acute Pain, chronic Parenting, impaired Parenting, readiness for enhanced Parenting, risk for impaired Perioperative Positioning, risk for Peripheral Neurovascular Dysfunction, risk for Poisoning, risk for Post-Trauma Syndrome [specify stage] Post-Trauma Syndrome, risk for Power, readiness for enhanced Powerlessness [specify level] Powerlessness, risk for Protection, ineffective R Rape-Trauma Syndrome Rape-Trauma Syndrome: compound reaction Rape-Trauma Syndrome: silent reaction Religiosity, impaired Religiosity, risk for impaired Religiosity, readiness for enhanced Relocation Stress Syndrome Relocation Stress Syndrome, risk for Role Performance, ineffective (Continued on following page)

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NANDA Nursing Diagnoses (continued) S Self-Care Deficit: bathing/hygiene Self-Care Deficit: dressing/grooming Self-Care Deficit: feeding Self-Care Deficit: toileting Self-Care Deficit, readiness for enhanced Self-Care, readiness for enhanced Self-Concept, readiness for enhanced Self-Esteem, chronic low Self-Esteem, situational low Self-Esteem, risk for situational low Self-Mutilation Self-Mutilation, risk for Sensory Perception, disturbed (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Sexual Dysfunction Sexuality Pattern, ineffective Skin Integrity, impaired Skin Integrity, risk for impaired Sleep, readiness for enhanced Sleep Deprivation Social Interaction, impaired Social Isolation Sorrow, chronic Spiritual Distress, risk for Spiritual Well-Being, readiness for enhanced Stress Overload Suffocation, risk for Suicide, risk for

Surgical Recovery, delayed Swallowing, impaired T Therapeutic Regimen Management, effective Therapeutic Regimen Management, ineffective Therapeutic Regimen Management, ineffective community Therapeutic Regimen Management, ineffective family Therapeutic Regimen Management, readiness for enhanced Thermoregulation, ineffective Thought Processes, disturbed Tissue Integrity, impaired Tissue Perfusion, ineffective (specify type: cerebral, cardiopulmonary, renal, gastrointestinal, peripheral) Transfer Ability, impaired Trauma, risk for U Unilateral Neglect Syndrome Urinary Elimination, impaired Urinary Elimination, readiness for enhanced Urinary Incontinence, functional Urinary Incontinence, overflow Urinary Incontinence, reflex Urinary Incontinence, stress Urinary Incontinence, total Urinary Incontinence, urge Urinary Incontinence, risk for urge Urinary Retention [acute/chronic] (Continued on following page)

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213 NANDA Nursing Diagnoses (continued) V Ventilation, impaired spontaneous Ventilatory Weaning Response, dysfunctional Violence, [actual/] risk for otherdirected Violence, [actual/] risk for self-directed

W Walking, impaired Wandering [specify sporadic or continual

[Author recommendations]

From NANDA International: Definitions and Classifications, 2007–2008. NANDA, Philadelphia, 2007.

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Index Note: Page numbers followed by “f” and “t” indicate figures and tables, respectively. Consciousness A altered levels of, 101–102 Abbreviations, 118–119, 204–209 levels of, 35–36 Abdomen/abdominal organs Coronary artery disease (CAD), 181–182 pain, 99–100 CPR, quick reference, 96 physical assessment, 31 Crohn’s disease, 182–183 postpartum assessment, 63 Cultural information, 195–204 Acid-base imbalance, 138t–139t Airways, artificial, 5f–6f Alcohol abuse assessment, 41–42 D Allergic reactions, 100–101 Dehydration, 46t–47t, 74 Alzheimer’s disease, 170 Dermatomes, 37f Anaphylaxis, 100–101, 114 Development/developmental stages Apgar score, 61t–62t Erikson’s, 53t Arrhythmias, 102–103, 112–113 milestones, pediatric assessment by, 67 ECG patterns, 141f–147f Diabetes mellitus (DM), 183–184 perfusing, 98–99 Digestive system, 155f Assessment form, 50–52 Dizziness/syncope, 104–105 Asthma, 171 Dressing(s) changes, sterile, 20 pressure ulcer, 88–89 B Drug abuse assessment, 41–42 Blood Drugs. See Medications normal values, 131t–135t, 138t specimen collection, 15–16 Blood pressure, 24, 106–108, 185–186 E Body surface area (BSA), 193 Edema scale, 30 Brain, 149f Education, patient, 148 Breast, self examination, 174f disease-related diet modification, 169t exercise/nutrition, 161–165 C medication, 165–168 Cancer, 171–173 Elderly common types of, 176–179 dehydration in, 74–75 staging of, 173t depression/suicide in, 75–78 Cardiac arrest, pulseless, 97–98 eating problems in, 72t–73t Cardiovascular system, 29–30, 151f, 152f, 153f. medications in, 82–84 See also Arrhythmias social issues in, 72t auscultation sites, 28f Electrocardiograms normal rhythm parameters, 140 lead placement, 139f physical assessment, 26 patterns, 141f–147f Catheters PQRST components, 140f urinary, 13–15 Electrolyte(s), 47 venous, 128 imbalances, 48t–49t Cerebrospinal fluid (CSF), 135t Extremities, 31 Chest pain, 103–104 Choking, quick reference, 97 Chronic obstructive pulmonary disease (COPD), F 179–180 Fever, 105–106 Communication, 1 Fluids/electrolytes, 47–48 Congestive heart failure (CHF), 180–181 Focused system analysis (PQRST), 23

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215 G Genitourinary system, 32 Geriatrics, 71–85 Glasgow coma scale, 34–35

Newborns, care and assessment of, 60–62 Nutrition assessment, 46t patient education in, 161–165

H Head/neck, physical assessment, 23–26 Heart, 153f. See also Cardiovascular system Hemorrhage, post-op, 109–110 History complete health, 21 pediatric, 65–66 Hypertension, 106–107, 185–186 Hypotension, 107–108

O Ostomy care, 12–13 Oxygen delivery systems, 2f–4f

IJK Immunizations adult, 91t pediatric, 70t during pregnancy, 58 Injection sites, 124f, 125f, 125t, 126f, 127f pediatric, 69t Insulin, 130f Irritable bowel syndrome (IBS), 186 IV(s) care of, 128 solutions, 122 L Labor, 59 Lung sounds, 27–28 order of auscultating, 29t Lymphatic system, 154 M Maslow’s Hierarchy of Needs, 53–54 Medications administration of, 115–116, 165 common formulas, 119–121f in elderly, 82–84 therapeutic levels, 136t Melanoma, 173f Mental health assessment, 38–42 Metric conversions, 192t–193t Multiple sclerosis, 187 N Nägele’s Rule, 56 NANDA nursing diagnoses, 209–213 Nasogastric (NG) tubes, 9–12 Nausea, 108–109 Neurologic exam, 33–36

PQ Pain abdominal, 99–100 assessment of, 42–45, 44f, 68 interventions for, 68–69 Pancreatitis, 187–188 Pediatrics assessment, 67t, 68 health history, 65–66 immunization schedule, 70t injection sites, 69t Peripheral artery disease (PAD), 188–189 Physical assessment, 22 Pneumonia, 189–190 Polypharmacy, 81 Postpartum care/assessment, 62–64 Pregnancy, 54–59 risk categories, 129 Pressure ulcers, 86–89, 90f Psychiatric/mental health assessment, 38–42 Pulse oximeters, 6–7 Pulse points, 30 Pupil scale, 34 R Renal failure, chronic, 190 Reproductive system, 32, 159f, 160f Respiratory arrest, 110–111 Respiratory system, 150f physical assessment, 26–28, 29f Resuscitation maneuvers, 92f, 93f, 94–99 S Seizure, 111–112 Skeletal system, 157f Skin/integumentary system, 32, 158f Specimen collection, 15–19 Symbols, 118–119, 204–209 T Testicles, self examination, 175f Thyroid panel, 135t

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Tracheostomy, troubleshooting, 8 Transfusion reaction, 113–114, 123t U Urinary systemu incontinence, 191 normal values, 136t–137t Urine, specimen collection, 16–18 Uterus, involution of, 64f

V Ventilated patient, 7–8 Vital signs, 24 pediatric, 64–65 WXYZ Waist-to-hip ratio, 194 Wounds, assessment of, 86

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