ATI Topic Descriptors

Basic Care and Comfort (13)

Plan A

Hygiene Care: Evaluating Appropriate Use of Assistive Devices

Cane instructions:
Maintain two points of support on the ground at all times
Keep the cane on the stronger side of the body
Support body wt on both legs, move cane forward 6-10 inches, then move the weaker
leg forward toward the cane.
Next, advance the stronger leg

Dentures:
Clients who have fragile oral mucosa require gentle brushing and flossing.

Perform denture care for the client who is unable to do it himself

Remove dentures with a gloved hand, pulling down and out at the front of the upper
denture, and lifting up and out at the front of the lower denture.

Place dentures in a denture cup or emesis basin

Brush them with a soft brush and denture cleaner

Rinse them with water

Store the dentures, or assist the client with reinserting the dentures

Complimentary and Alternative Therapies: Appropriate Use of Music Therapy for

Pain Management

Music
decreases physiological pain, stress and anxiety by diverting the persons
attention away from the pain and creating a relaxation response.

let client select the type of music

music produces an altered state of consciousness through sound, silence, space
and time
must be listened to for 15-30 minutes to be therapeutic
earphones help client concentrate on music while avoiding other clients or staff
highly effective in reducing postop pain
if pain acute, increase volume of music
Prostate Surgeries: Calculating a Clients Output When Receiving Continuous
Bladder Irrigations

purpose: to maintain the patency of indwelling urinary catheters (bec blood, pus, or
sediment can collect within tubing resulting in bladder sistention and buildup of stagnant
urine)

Med-Surg p. 1443
after prostate surgery, irrigation is typically done to remove clotted blood from the
bladder and ensure drainage of urine.
if bladder manually irrigated, 50ml of irrigating soln should be instilled and then
withdrawn with a syringe to remove clots that may be in bladder and catheter.

with CBI, irrigating soln is continuously infused and drained from the bladder. The rate
of infusion is based on the color of drainage. Ideally the urine drainage should be light
pink without clots. The inflow and outflow of irrigant must be continuously monitored. If
outflow is less than inflow, the catheter patency should be assessed for clots or kinks. If
the outflow is blocked and patency cannot be reestablished by manual irrigation, the
CBI is stopped and the physician notified.

Record amount of urine output and

character of urine every eight (8) hours
or as per physicians orders.
(To obtain urine output, subtract amount
of fluid instilled into bladder from total
output.)

intermittent irrigation
dorsal recumbent or supine position
avoid cold solution bec may result in bladder spasm
clamp cath just below soft injection port
cleanse injection port with antiseptic swab (same port as specimen collection)
insert needle through port at 30degree angle
slowly inject fluid into cath and bladder
withdraw syringe remove clamp and allow solution to drain into drainage bag
if ordered by MD, keep clamped to allow solution to remain in bladder for short time
(20-30min)

Closed continuous irrigation

Recording and Reporting

Record type and amt of irrigation soln used, amt returned as drainage and the character
of drainage
Record and report any findings such as complaints of bladder spasms, inability to instill
fluid into bladder and/or presence of blood clots.

Urinary Elimination: Kegel Exercises for Urinary Incontinence

sits on toilet with knees far apart and tightens muscle to stop the flow of urine ( to
learn the muscle)

then practiced at nonvoiding times

instruct client to contract muscle for a count of 3, hold and release for a count of 3, and
repeat this 10x.

Client should repeat these cycles for 25-30x 3x/day for 6 months.

Client should do this 5x.day

Bowel Elimination Needs: Client Education Regarding Colostomy Care

Stoma s/b pink.

Dusky blue stoma---ischemia

Brown-black stoma---necrosis

mild to moderate swelling for 1st 2-3 weeks after surgery

intact skin barriers with no evidence of leakage do not need to be changed daily and
can remain in place for 3-5 days.

skin should be washed with mild soap, warm water and dried thoroughly before
barrier applied

pouch must fit snugly to prevent leakage around stoma. The opening around the
appliance should be no more than 1/16 inch larger than the stoma. Stoma shrinks and
does not reach usual size for 6-8 weeks

empty pouch before it is 1/3 full to prevent leakage

cleanse skin and use skin barriers and deodorizers to prevent skin breakdown and
malodor
apply skin barrier and pouch. if creases next to stoma occur, use barrier paste to fill in;
let dry 1-2 min

apply non-allergic paper tape around the pectin skin barrier in a picture frame method.

Burns: Non-pharmacologic Comfort Interventions for Dressing Changes

Med/Surg p. 534-535

Distractions

Relaxation tapes
visualization
guided imagery
biofeedback
meditation

used as adjuncts to traditional pharmacologic txs of pain

Visualization and guided imagery can be helpful to the nurse as well as the pt

nurse ask the pt about a favorite hobby or recent vacation

nurse can explore these areas further by asking questions that make the pt visualize
and describe a favorite hobby or recent vacation

by using this method, both the nurse and the pt must focus on things besides the task at
hand. (ie dressing change) to keep the conversation flowing

Relaxation tapes can be helpful when played at night to help the pt fall asleep.

Application of Heat and Cold: Assess Need for Heat/Cold Applications

Application of Cold: Ensure Safe Use of Cold Applications

Potter/Perry p. 1253-1254

Cold and heat applications relieve pain and promote healing.

selection varies with clients conditions.

moist heat can help relieve the pain from a tension HA

cold heat can reduce the acute pain from inflamed joints

avoid injury to skin by checking the temp and avoiding direct application of the cold or
hot surface to the skin

esp at risk: spinal cord or other neuro injury, older adults, confused clients
Ice massage or cold therapy are particularly effective for pain relief.

Ice massage: apply the ice with firm pressure followed by slow steady, circular massage

Cold may be applied to pain site on the opposite side of the body corresponding to the
pain site or on a site located between the brain and the pain site.

takes 5-10 minutes to apply cold

each client responds differently to the site of the application that is the most effective

application near the actual site of pain tends to work best

a client feels cold, burning and aching sensations and numbness. When numbness
occurs, the ice should be removed.

cold is particularly effective for tooth or mouth pain when ice is place on the web of the
hand between the thumb and index finger

cold applications are also effective before invasive needle punctures

Heat application
dont lay on heating element bec burning could occur

Assessment for Temperature Tolerance (P/P p. 1549)

before applying either, the nurse should assess the clients physical condition for signs
of potential intolerance to heat and cold

first observe the area to be txd

alterations in skin integrity, such as abrasions, open wounds, edema, bruising, bleeding
or localized areas of inflammation increase the clients risk of injury.

baseline skin assessment provides a guide for evaluating skin changes that might occur
during therapy

assessment includes id of conditions that contraindicate heat or cold therapy:

an active area of bleeding should not be covered by a warm application bec bleeding
will continue

warm applications are contraindicated when client has an acute, localized inflammation
such as appendicitis bec the heat could cause the appendix to rupture.
if client has CV problems, it is unwise to apply heat to large portions of the body bec the
resulting massive vasodilation may disrupt blood supply to vital organs.

cold is contraindicated if the site of injury is already edematous

cold furth retards circulation to the area and prevents absorption of the interstitial fluid.

if client has impaired circulation (arteriosclerosis), cold further reduces blood supply to
affected area

cold contraindicated in presence of neuropathy (client unable to perceive temp

changes)

cold contraindicated in shivering (intensifies shivering and dangerously increase body

temp)

If MD orders cold therapy to lower extremity, assess for cap refill, observing skin color
and palpating skin temp, distal pulses and edematous areas

if signs of circulatory inadequacy, question order

if confused or unresponsive, make freq observations of skin integrity after therapy

begins

assess condition of equip used

before applying heat and cold, understand normal body responses to local temp
variations, assess the integrity of the body part, determine the clients ability to sense
temp variations and ensure proper operation of equipment.

Crohns Disease: Selecting a Low-Fiber, Low-Residue Diet

No raw vegetables, vegs not strained, dried beans, peas, and legumes
No raw fruits, fruits with skins, seeds
No nuts, raisins, rich desserts
no whole grain breads or cereals
no fried, smoked, pickled or cured meats,
no alcohol, fruit juices with pulp

Dumping Syndrome: Client Education Regarding Dietary Interventions

meal size must be reduced accordingly (6 small feedings)

no drinking fluids with meals (30-45 min before or after meals)
helps prevent distention or a feeling of fullness
dry foods with low-carb content and moderate protein and fat content
proteins and fats are increased
promotes rebuilding of body tissues and to meet energy needs
specifically meat, cheese, eggs and mild products

no concentrated sweets (honey, sugar, jelly, jam)

cause dizziness, diarrhea, a sense of fullness

short rest period after each meal

Cholecystitis: Dietary Restrictions

Low in fat, and sometimes a wt reduction diet is also recommended (4-6 weeks

take fat soluble vit supplements

Palliative Care: Client/ Family Teaching

caring interventions rather than curing interventions

for any age, diagnosis, any time, and not just during the last few months of life

preservation of dignity becomes the goal of palliative care

allows clients to make more informed choices, achieve better alleviation of sx and have
more opportunity to work on issues of life closure

establish a caring relationship with both client and family

management of sx of disease and therapies

Preparing the Dying Clients Family (P/P 588)

Objectives:
family will be able to provide appropriate physical care for the dying client in home
family will be able to provide appropriate psychological support to the dying client.

Describe and demonstrate feeding techniques and selection of foods to facilitate ease
of chewing and swallowing
Demonstrate bathing, mouth care, and other hygiene measures and allow family to
perform return demo
show video on simple transfer techniques to prevent injury to themselves and client,
help family to practice
instruct family on need to enforce rest periods
teach family to recognize s/s to expect as the clients condition worsens and provide info
on who to call in an emergency
discuss ways to support the dying person and listen to needs and fears
solicit questions from family and provide info as needed.

Evaluation:
Have the family members demo physical care techniques
ask family members to describe how they vary approaches to care when the client has
sx such as pain or fatigue
ask the family to discuss how they feel about their ability to support the client .

Cognitive Disorders: Promoting Independence in Hygiene for A Client with

Alzheimers Disease
Stage S/S

Stage 1, Forgetfulness Short term memory loss

Decreased Attn Span
Subtle Personality Changes
Mild cognitive deficits
Difficulty with depth perception

Stage 2, Confusion Obvious memory loss

Confusion, impaired judgement,
confabulation
Wandering behavior
Sundowning (more confusion in late
afternoon/early evening)
Irritability and agitation
Poor spatial orientation, impaired motor
skills
Intensification of sx when the client is
stressed, fatigued, or in an unfamiliar
environment
Depression r/t awareness of reduced
capacities

Stage 3, Ambulatory dementia loss of reasoning ability

Increasing loss of expressive language
Loss of ability to perform ADLs
More Withdrawn
 Stage S/S

Stage 4, End Stage Impaired or absent cognitive,

communication and/or motor skills
Bowel and bladder incontinence
Inability to recognize family members or
self in mirror

Assess teaching needs for the client and especially for the family members when the
clients cognitive ability is progressively declining.

Review the resources avail to the family as the clients health declines. A wide variety of
home care and community resources may be avail to the family in many areas of the
country, and these resources may allow the client to remain at home rather than in an
institution

Perform self assessment regarding possible feelings of frustration, anger, or fear when
performing daily care for clients with progressive dementia

NCP Med/Surg 1592

Monitor pts ability for independent self-care to plan appropriate interventions specific to
pt unique problems
Use consistent repetition of daily health routines as a means of establishing them bec
memory loss impairs pts ability to plan and complete specific sequential activities
assist pt in accepting dependency to ensure that all needs are met.
teach family to encourage independence and to intervene only when the pt is
unable to perform to promote independence

Bathing/Hygiene

provide desired personal articles, such as bath soap and hairbrush, to enhance memory
and provide care
facilitate pts bathing self as appropriate to facilitate independence and provide
appropriate help in hygiene

Dressing/Grooming

provide pts clothes in accessible area to facilitate dressing

Be available for assistance in dressing as necessary to facilitate independence and
provide appropriate help in dressing
Toileting

Assist pt to toilet as specified intervals to promote regularity

facilitate toilet hygiene after completion of elimination to prevent discomfort and skin
breakdown.

Rest and Sleep: Recognizing and Reporting Sleep Disorders (P/P 1203)

If untreated lead to three problems

insomnia
abnormal movements or sensation during sleep or when awakening at night, or
excessive daytime sleepiness.

Four categories

Dyssomnias (origins in body systems )

Intrinsic (initiating and maintaining sleep)

psychophysiological insomnia
narcolepsy
periodic limb movement disorders
sleep apnea syndromes

Extrinsic (outside the body)

inadequate sleep hygiene
insufficient sleep syndrome
hypnotic dependent sleep disorders
alcohol dependent sleep disorders

Circadian Rhythm Sleep Disorders (misalignment of timing and what is desired)

Time Zone Change
Shift work sleep disorder
Delayed sleep phase syndrome

Parasomnias (undesirable behaviors that occur during sleep)

Arousal Disorders
Sleepwalking
Sleep terrors

Sleep-Wake Transition Disorders

Sleeptalking
Sleep starts
 Nocturnal leg cramps

REM Sleep disturbances

nightmares
REM Sleep behavior disorder
sleep paralysis

Other Parasomnias
sleep bruxism (teeth grinding)
sleep enuresis (bed-wetting)
SIDS

Sleep Disorders associated with Med-Psych Disorders

Psych Disorders
Mood disorders
Anxiety disorders
Psychoses
Alcoholism

Neurologic Disorders
Dementia
Parkinsonism
Central degenerative disorders

Other Med Disorders

Nocturnal cardiac ischemia
COPD
PUD

Proposed sleep Disorders

Menstruation-associated sleep disorders

Sleep choking syndrome
Pregnancy associated sleep disorders

Questions to Ask to Assess for Sleep Disorders

Insomnia

How easily do you fall asleep

Do you fall asleep and have difficulty staying asleep? How many times do you awaken
Do you awaken early from sleep
What time do awaken for good? What causes you to awaken early?
What do you do to prepare for sleep? To improve you sleep?
What do you think about as you try to fall asleep
How often do you have trouble sleeping

Sleep Apnea

Do you snore loudly?

Has anyone ever told you that you often stop breathing for short periods during sleep?
(Spouse or bed partner/roommate report this)
Do you experience HAs after awakening
Do you have difficulty staying awake during the day
Does anyone else in your family snore loudly or stop breathing during sleep?

Narcolepsy

Are you tired during the day

Do you fall asleep at inopportune times?
Do you have episodes of losing muscle control or falling to the floor
have you ever had the feeling of being unable to move or talk just before falling asleep
Do you have vivid lifelike dreams when going to sleep or waking up?

Basic Care and Comfort (13)

Plan B

Mobility and Immobility: Recognizing Proper Use of Crutches

Crutch instructions

Do not alter crutches after proper fit has been determined

Follow crutch gait prescribed by physical therapy
support body wt at hand grips with elbows flexed 30 degrees
position crutches on unaffected side when sitting or rising from chair.

Elkin---pg 135

Use of crutches may be a temporary aid for persons with strains, in a cast or following
surgical treatments
crutches may be routinely and continuously used for those with congenital or acquired
MS abnormalities, neuromuscular weakness, or paralysis or they may be used after
amputations.

Crutch measurement includes three areas:

 clients height
distance between crutch pad and axilla
angle of elbow flexion
[make sure shoes are on before measuring]
Standing
crutches 4-6 in in front of feet and side of feet
Crutch pads
two to three fingers between top of crutch and axilla
Elbow
should be flexed (30 degrees ATI)

***any tingling in torso means crutches are used incorrectly or wrong size

if crutch too long---pressure on axilla causing paralysis of elbow and wrist (crutch palsy)
if crutch too short---bent over and uncomfortable

low handgrips cause radial nerve damage

high handgrips cause clients elbow to be sharply flexed and strength and stability are
decreased

4-point gait
requires wt bearing on both legs
often used when client has paralysis, as in spastic children with CP
may also be used for arthritic clients
improves balance by providing wider base of support

R crutch, L foot, L crutch, R foot

3 point gait
requires wt bearing on 1 foot
affected leg does not touch ground
may be useful for client with broken leg or sprained ankle

R/L crutches, unaffected foot, R/L crutches, unaffected foot

2-point gait
requires partial wt bearing on each foot
faster than 4-point gait
requires more balance
crutch movements are similar to arm movements while walking

L crutch and R foot together, R crutch and L foot together.

Swing to gait
freq used by clients whose lower extremities are paralyzed or who wear
wt-supporting braces on their legs
 easier of the two swing gaits
requires ability to bear body wt partially on both legs
Swing through gait
requires client have ability to sustain partial wt bearing on both feet

Stairs

( up) unaffected leg on step, both crutches come to step, repeat

(down) move crutches to stair below, move affected leg forward, then unaffected
leg

Pain Management: Nonpharmacological Pain Management

P/P---ch 42
P/P---pg 1250

Nonpharmacological interventions include cognitive-behavioral and physical

approaches

best if taught when not experiencing pain

Goals of cognitive-behavioral interventions

change clients perceptions of pain
alter pain behavior
provide clients with greater sense of control
Goals of physical approaches
providing comfort
correcting physical dysfunction
altering physiological responses
reducing fears associated with pain-related immobility

Relaxation and Guided Imagery

Relaxation
mental and physical freedom from tension or stress
provide self control when discomfort or pain occurs
reverse physical and emotional stress of pain
can be used at any phase of health or illness
not taught when client is in acute discomfort bec inability to concentrate
describe common sensations client may feel
decrease in temp
numbness of a body part
use as feedback

free of noise
light sheet or blanket

use with guided imagery or separate

 progressive takes about 15 min

pay attn to body noting areas of tension, tense areas replaced with
warmth and relation
some times better if eyes closed
background music can help

combination of controlled breathing exercises and a series of contractions

and relaxation of muscle groups.

Guided Imagery
client creates an image in the mind, concentrate on that image and
gradually becomes less aware of pain

Distraction
RAS (reticular activating system) inhibits painful stimuli if a person
receives sufficient or excessive sensory input

directs attention to something else and reduces awareness of pain even

increases tolerance

1 disadvantage
if works, may question the existence of pain

works best for short, intense pain lasting a few minutes

ex: invasive procedure or while waiting for analgesic to work

RN assesses activities enjoyed by client that may act as distractions

singing
praying
describing photos or pictures aloud
listening to music
playing games

may include ambulation, deep breathing, visitors, television, and music

Music
decreases physiological pain, stress and anxiety by diverting the persons
attention away from the pain and creating a relaxation response.

let client select the type of music

music produces an altered state of consciousness through sound, silence, space
and time
must be listened to for 15 minutes to be therapeutic
earphones help client concentrate on music while avoiding other clients or staff
 highly effective in reducing postop pain
if pain acute, increase volume of music

Biofeedback
behavioral therapy that involves giving individuals information about physiological
responses (BP and tension) and ways to exercise voluntary control over those
responses

used to produce deep relaxation and is effective for muscle tension and migraine
HA

Cutaneous stimulation
stimulation of the skin to relieve pain
massage
warm bath
ice bag
for inflammation
transcutaneous electrical nerve stimulation (TENS) (also called counter
stimulation)

causes release of endorphins thus blocking transmission of painful stimulation

advantage: measures can be used in the home

reduce pain perception and help reduce muscle tension

RN eliminates sources of environmental noise, helps client to assume a

comfortable position, explains purpose of therapy

Acupressure/Acupuncture
vibration or electrical stimulation via tiny needles inserted into the skin and
subcutaneous tissues at specific points

elevation of edematous extremities to promote venous return and decrease

swelling

Urinary Elimination Needs: Preventing Incontinence

Use timed voidings to increase intervals between voidings/decrease voiding frequency

perform pelvic floor (Kegel) exercises
perform relaxation techniques
offer undergarments while client is retraining
teach client not to ignore urge to void
provide positive reinforcement as client maintains continence
Urinary Elimination: Providing Catheter Care

Prevent infection
Maintain unobstructed flow of urine through the cath drainage system

Perineal Hygiene

perineal hygiene 2x/day or prn for client with retention cath

soap and water are effective

can be delegated to AP

Catheter care

assess urethral meatus and surrounding tissue for inflammation, swelling and
discharge. Note amt, color, odor, and consistency of discharge. Ask client if any burning
or discharge is felt

with towel, soap and water, wipe in a circular motion along length of catheter for 4
inches

apply an abx ointment at urethral meatus and along 1 inch of cath if ordered by MD

Mobility and Immobility: Evaluating for Complications of Immobility

Complications of Immobility

Integumentary--Maintain intact skin turn the client q 1-2 hr

decrease pressure
limit sitting in chair to less than 2 hr

Respiratory--maintain patent airway, teach the client to turn, cough and deep
achieve optimal lung expansion and gas breath q 1-2 hr
exchange and mobilize airway secretions yawn every hour
use incentive spirometer
CPT
2000ml fluid
 Integumentary--Maintain intact skin turn the client q 1-2 hr
decrease pressure
limit sitting in chair to less than 2 hr

Cardiovascular---maintain CV fx, increase increase activity

activity tolerance and prevent thrombus
formation
avoid valsalva maneuver
stool softener
ROM
avoid pillows under knees
use elastic stockings
SCD
give low dose heparin

Metabolic---decrease injuries to skin and provide high calorie high protein diet with
maintain metabolism within normal fxing additional vits B and C
monitor oral intake

Elimination--maintain or achieve normal maintain hydration (at least 2000 mL

urinary and bowel elimination patterns stool softener
bladder and bowel training
insert cath if bladder distended

Musculoskeletal--maintain or regain body change position in bed q 2 hrs

alignment and stability decrease skin and ROM
MS system changes, achieve full or nutritional intake
optimal ROM and prevent contractures CPM

Psychosocial--maintain normal sleep/wake coping skills

patter, achieve socialization and achieve maintain orientation
independent completion of self care develop schedule

Gastroenteral Feedings: Monitoring Tube Feedings

Monitoring for tube placement

initial placement is confirmed with xray

monitor gastric contents for pH. A good indication of appropriate placement is obtaining
gastric contents with a pH between 0-4

Injecting air into the tube and listening over the abdomen is not an acceptable practice
Aspirate for residual volume---note: intestinal residual < 10 mL, gastric residual <
100mL

return aspirated contents or follow protocol

Flush tubing with 30-60 mL of H20

Acute Glomerulonephritis: Dietary Choice

Acute Glomerulonephritis: insoluble immune complexes develop and become trapped in

the glomerular tissue producing swelling and capillary cell death

Maintain prescribed dietary restrictions

Fluid restriction (24 hr output + 500 mL)

Sodium restriction
Protein restriction (if azotemia is present)
Edema is treated by restricting sodium and fluid intake

Dietary protein intake may be restricted if there is evidence of nitrogenous wastes.

Varies with degree of proteinuria.

Low protein, low sodium, fluid restricted diet

Rest and Sleep: Interventions to Promote Sleep for Hospitalized Clients

Assist the client in establishing and following a bedtime routine

Attempt to minimize the number of times the client is awakened during the night while
hospitalized

Offer to assist the client with personal hygiene needs and/or a back rub prior to sleep to
increase comfort

Instruct the client to:

Exercise regularly at least 2 hr before bed time

Arrange the sleep environment to what is comfortable

Limit alcohol, caffeine, and nicotine in the late afternoon and evening

Engage in muscle relaxation before bedtime

Apply CPAP devices as ordered by PCP for clients with sleep apnea
As a last resort, provide a pharmacological agent as prescribed.

ATI Topic Descriptors

Plan A

Health Promotion and Maintenance (13)

Uterine Atony: Performing Appropriate Assessment (Murray/Mckinney p. 734-736)

Atony: lack of muscle tone that results in failure of the uterine muscle fibers to contract
firmly around the blood vessels when the placenta separates

relaxed muscles allow rapid bleeding from the endometrial arterieries at the placental
site

bleeding continues until uterine muscle fibers contact to stop the flow of blood.

retention of a large segment of the placenta does not allow the uterus to contract firmly
and therefore can cause uterine atony

Major signs of uterine atony include:

fundus that is difficult to locate

a soft or boggy feel when the fundus is located
a uterus that becomes firm as it is massaged byt loses its tone when massage is
stopped
a fundus that is located above the expected levels which is at or near the umbilicus
excessive lochia especially if it is bright red
excessive clots expelled

if a peripad is saturated in an hour, a lg amt of blood is considered to have been lost

saturation in 15 min represents an excessive loss of blood in the early PP period

a constant steady trickle is just as dangeiours

if uterus is not firmly contracted, the first intervention is to massage the fundus until it is
firm and to express clots that may have accumulated in the uterus

one hand is placed just above the symphysis pubis o support the lower uterine segment
while the other hand getnly but firmly massages the fundus in a cirucular motion

clots are expressed by applying firm but gently pressure on the fundus in the direction of
the vagina
critical that uterus is contracted firmly before clots are expressed
pushing on an uncontracted uterus could invert the uterus and cause massive
hemorrhage and rapid shock.

ATI book p.304

uterine atony is hypotonic uterus that is not firm described as boggy.

if untreated will result in postpartum hemorrhage and may result in uterine inversion

Nursing assessments

monitor for s/s of uterine atony which include

a uterus that is larger than normal and boggy with possible lateral displacement on
pelvic exam
prolonged lochia discharge
irregulaor or excessive bleeding

Assessments for uterine atony include:

fundal height, consistency and location
lochia quantity, color, and consistency

Normal Physiological Changes of Pregnancy: Calculating the clients delivery

date

ATI p. 34

Nageles rule:

take the first day of the last menstrual period, subtract 3 months and add 7 days and 1
year.

McDonalds method

measure uterine fundal height in centimeteres from the symphysis pubis to the top of
the uterine fundus (between 18 to 30 weeks gestation age). The calculation is as follows

the gestational age is estimated to be equal to fundal height.

Cesarean Birth: Appropriate Client Positioning ATI p. 218

Positioning the client in a supine position with a wedge under one hip to laterally tilt her
and keep her off her vena cava and descending aorta. This will help maintain optimal
perfusion of oxygenated blood to the fetus during the procedure.

Antepartum Diagnostic Interventions: Monitoring during a Nonstress Test ATI p.

85

Nonstress Test

monitor the response of the FHR to fetal movement

client pushes a button attached to the monitor whenever she feels a fetal movement
that is noted on the paper tracing.

NST Reactive : FHR accelerates to 15 beats/min for at least 15 sec and occurs 2 or
more times during a 20 min period

placenta is adequately perfused and the fetus is well-oxygenated

NST Nonreactive: FHR does not accelerate adequately with fetal movement or no fetal
movements occur in 40 min.

if so, further assessment such as a contraction stress test or biophysical profile is
indicated

Disadvantages: high rate of false nonreactive results with the fetal movement response
blunted by fetal sleep cycles, chronic tobacco smoking, meds, and fetal immaturity

client should be in a reclining chair or in a semi-fowlers or left lateral position

if there are no fetal movements (fetal sleeping), vibroacoustic stimulation (sound source,
usually laryngeal stimulator) may be activated for 3 sec on the maternal abdomen over
the fetal head to awaken a sleeping fetus

If still nonreactive, anticipate a CST or a BPP

Newborn Hypoglycemia: Identify Appropriate Interventions ATI p. 424

Hypoglycemia : serum glucose level of less than 40mg/dL

differs from preterm and term newborn

Hypoglycemia occurring in the 1st 3 days of life in the term newborn is defined as a
blood glucose level of <40 mg/dL. In the preterm newborn, hypoglycemia is defined as a
blood glucose level of < 25 mg/dL

Untreated hypoglycemia can result in mental retardation

S/S

poor feeding
jitteriness. tremors
hypothermia
diaphoresis
weak shrill cry
lethargy
flaccid muscle tone
seizures/coma

assessments:

monitoring BG level closely

monitoring IV if unable to orally feed
monitoring for signs of hypoglycemia
monitoring VS and temp

Nursing interventions

obtaining blood per heel stick for glucose monitoring

freq oral and/or gavage feeding or continuous parenteral nutrition is provided early after
birth to treat hypoglycemia (untreated can lead to seizures, brain damage, and death)

Labor and Birth Processes: Assess for True Labor vs. False Labor ATI p. 136

True Labor

Contractions
regular frequency
stronger, last longer and are more freq
felt in lower back, radiating to abdomen
walking can increase contraction intensity
continue despite comfort measures

Cervix
progressive change in dilation and effacement
moves to anterior portion
bloody show
Fetus
presenting part engages in pelvis

False Labor

Contractions
painless, irregular freq, and intermittent
decrease in freq, duration, and intensity with walking or position changes
felt in lower back or abdomen above umbilicus
often stop with comfort measures such as oral hydration

Cervix (assessed by vaginal exam)

no significant change in dilation or effacement
often remains in posterior position
no significant bloody show

Fetus
presenting part is not engaged in fetus

Bonding: Promoting Maternal Psychosocial Adaptation During the Taking-In

Phase ATI p. 290

Taking In Phase--begins immediately following birth lasting a few hours to a couple of

days. Characteristics include passive-dependent behavior and relying on others to meet
needs for comfort, rest, closeness, and nourishment. the client focuses on her own
needs and is concerned about the overall health of her newborn. She is excited and
talkative, repeatedly reviewing the labor and birth experience.

Facilitate the bonding process by placing the infant skin-to-skin wiht the mother soon
after birth in an en face position

Encourage the parents to bond with the infant through cuddling, feeding, diapering and
inspecting the infant

provide a quiet and private environment that enhances the family bonding process.

provide frequent praise, support and reassurance to the mother during the taking-hold
phase as she moves toward independence in care of the newborn and adjusts to the
maternal role

encourage the mother/parents to discuss their feelings, fears, and anxieties about
caring for their newborn
Toddler: Recognizing Expected Body-Image Changes

ATI
the toddler appreciates the usefulness of various body parts

toddlers develop gender identity by age 3

Wongs Nursing Care of Children (p. 608)

Growth slows considerably during toddlerhood.

avg wt @ 2 years is 12 kg.

head circumference slows and is usually equal to chest circumference by 1-2 years.

Chest circumference continues to increase and exceeds head circumference during the
toddler years.

After the 2nd year the the chest circumference exceeds the abdominal measurement
which in addition to the growth of the lower extremities, gives the child, a taller leaner
appearance.

However, the toddler retains a squat, pot-bellied appearance bec of less well-
developed abdominal musculature and short legs.

Legs retain a slightly bowed or curved appearance during the second year form the
weight of the relatively large trunk.

Adolescent (12-20 years): Planning Age-Appropriate Health Promotion Education

Substance abuse:

Drug Abuse Resistance Education (DARE) and other similar programs provide
assistance in preventing experimentation

Sexual Experimentation:
Abstinence is highly recommended. if sexually activity is occurring the use of birth
control is recommended

Sexually Transmitted Diseases:

Adolescents should undergo external genitalia exams, PAP smears, and cervical and
urethral cultures (specific to gender).

Rectal and oral cultures may also need to be taken

The adolescent should be counseled about risk taking behaviors and their exposure to
STDs as well as AIDS, hepatitis. The use of condoms will decrease the risk of STDs

Pregnancy

identification of pregnant adolescents should be done to ensure that nutrition and

support is offered to promote the health of the adolescent and the fetus. Following infant
delivery, education should be given to prevent future pregnancies.

Injury prevention

encourage attendance at drivers ed courses. Emphasize the need for compliance with
seat belt use

teach the dangers of combining substance abuse with driving (MADD)

Insist on helmet use with bicycles, motorcycles, skateboards, roller blades and
snowboards

screen for substance abuse

teach the adolescent not to swim alone

teach proper use of sporting equipment

Age-appropriate activities:

nonviolent video games

nonviolent music

sports

caring for a pet

career training programs

reading

social events

Contraception: Recognizing Correct Use of Condoms ATI p. 6

Condoms: a thin flexible sheath worn on the penis during intercourse to prevent semen
from entering the uterus

Client Instruction

man places condom on his erect penis, leaving an empty space at the tip for a sperm
reservoir

following ejaculation, the man withdraws his penis from the womans vagina while
holding condom rim to prevent any semen spillage to vulva or vaginal area
may be used in conjunction with spermicidal gel or cream to increase effectiveness.

only water soluble lubricants should be used with latex condoms to avoid condom
breakage.

Immunizations: Recognizing Complications to Report ATI p. 279

anaphylaxis
review sx with parents
prodromal sx--uneasiness, impending doom, restlessness, irritability,
severe anxiety, HA, dizziness, parethesia, disorientation
cutaneous signs are the most common initial sign,child may complain of
feeling warm. angioedema is most noticeable in the eyelids, lips, tongue,
hands, feet and genitalia
cutaneous manifestations are often followed by bronchiolar
constriction-- narrowing of the airway, dilated pulmonary circulation
causes pulmonary edema and hemorrhages and there is often life-
threatening laryngeal edema

instruct parents to call 991 or other emergency number and to keep the child
quiet until help arrives
Encephalitis, seizures, and.or neuritis
review sx with parents. instruct parents when to seek medical care
teach parents to prevent injury during a seizure

Thrombocytopenia
usually associated with measles vaccination
teach parents to observe for bleeding
 instruct the parents to call the primary care provider if bleeding, bruising, or re
dot-like rash occurs.

Older Adult (0ver 65 years): Assessing Risk for Social Isolation

Two forms of isolation

may be a choice, the result of a desire not to interact with others
may be a response to conditions that inhibit the ability or the opportunity to interact wiht
others.
vulnerable to its consequences

vulnerability increased in the absence of the support of other adults as may occur with
loss of the work role or relocation to unfamiliar surroundings.
impaired hearing, diminished vision, and reduced mobility all contribute to reduced
interaction with others and isolation
the loss of the ability to drive may limit older adults ability to live independently as well
as contributing to isolation
some withdraw bec of feelings of rejection
older adults see themselves as unattractive and rejected bec of changes in their
personal appearance due to normal aging

nurse can assist lonely older adults to rebuild social networks and reverse patterns of
isolation
outreach programs
meals on wheels
socialization needs
daily telephone call by volunteers
need for activities such as outings

Spinal Cord Injury: Promoting Independence In Self-Care

Spinal cord injuries involve losses of motor fx, sensory, fx, reflexes, and control of
elimination

The level of cord involved dictates the consequences of spinal cord injury. For example,
injury at C3 to C5 poses a great risk for impaired spontaneous ventilation bec of
proximity of the phrenic nerve.

Tetraplegia/paresis = 4 extremities. Paraplegia/paresis= 2 lower extremities

Tetraplegia
C1-C8

Paraplegia
T1-L4
 Level of Injury
C1-C3
Often fatal injury, vagus
nerve domination of heart,
respiration, blood vessels,
and all organs below injury
C4
vagus nerve domination of
heart, respirations and all
vessels and organs below
injury
C5
vagus nerve domination of
heart, respirations, and all
vessels and organs below
the injury
C6
vagus nerve domination of
heart, respirations, and all
vessels and organs below
the injury
Movement Remaining
movement in neck and
above, loss of innervation to
diaphragm, absence of
independent respiratory fx
sensation and movement in Same as C1-C3
neck and above; may be
able to breathe without a
ventilator
full neck, partial shoulder,
back, biceps; gross elbow,
inability to roll over or use
hands; decreased
respiratory reserve
shoulder and upper back
abduction and rotation at
shoulder, full biceps to
elbow flexion, wrist
extension, weak grasp of
thumb, decreased
respiratory reserve
Rehab Potential
ability to drive electric
wheelchair equipped with
portable ventilator by using
chin control or mouth stick,
headrest to stabilize head;
computer use with mouth
stick, head wand, or noise
control; 24 hr attendant
care, able to instruct others
Ability to drive electric
wheelchair with mobile hand
supports; indoor mobility in
manual wheelchair; able to
feed self with setup and
adaptive equipment;
attendant care 10 hrs per
day
ability to assist with transfer
and perform some self-care;
feed self with hand devices;
push wheelchair on smooth,
flat surface; drive adapted
van from wheelchair;
independent computer use
with adaptive equipment;
attendant care 6 hrs per day
 Level of Injury Movement Remaining
C7-C8 All triceps to elbow
vagus nerve domination of extension, finger extensors
heart, respirations, and all and flexors, good grasp with
vessels and organs below some decreased strength,
the injury decreased respiratory
reserve
T1-T6 full innervation of upper
Sympathetic innervation to extremities, back essential
heart, vagus nerve intrinsic muscles of hand;
domination of all vessels full strength and dexterity of
and organs below injury grasp; decreased trunk
stability, decreased
respiratory reserve
T6-T12 Full stable thoracic muscle
Vagus nerve domination and upper back; functional
only of leg vessels, GI and intercostals, resulting in
genitourinary organs increased respiratory
reserve
L1- L2 Varying control of legs and
Vagus nerve domination of pelvis, instability of lower
leg vessels back
Level of Injury Movement Remaining
L3-L4 Quadriceps and hip flexors,
Partial vagus nerve absence of hamstring
domination of leg vessels, function, flail ankles
GI and genitourinary organs
The success of rehabilitation depends on many variables, including the following:
Rehab Potential
ability to transfer self to
wheelchair; roll over and sit
up in bed; push self on most
surfaces; perform most self-
care; independent use of
wheelchair; ability to drive
care with powered hand
controls (in some pts);
attendant care 0-6 hrs per
day
full independence in self-
care and in wheelchair
ability to drive car with hand
controls (in most patients);
independent standing in
standing frame
Full independent us of
wheelchair; ability to stand
erect with full leg brace,
ambulate on crutches with
swing (although gait
difficult); inability to climb
stairs
Good sitting balance; full
use of wheelchair;
ambulation with long leg
braces
Rehabilitation Potential
Completely independent
ambulation with short leg
braces and canes; inability
to stand for long periods


level and severity of the SCI


type and degree of resulting impairments and disabilities


overall health of the patient


family support
It is important to focus on maximizing the patient's capabilities at home and in the
community. Positive reinforcement helps recovery by improving self-esteem and
promoting independence.

The goal of SCI rehabilitation is to help the patient return to the highest level of function
and independence possible, while improving the overall quality of life - physically,
emotionally, and socially.

Health Promotion and Maintenance

Plan B

Antepartum Diagnostic Interventions: Prenatal Fetal Heart Rate Monitoring

Nonstress Test (see below)

Contraction Stress test (CST) an assessment performed to stimulate contractions

(which decrease placental blood flow) and analyze the FHR in conjunction with the
contractions to determine how the fetus will tolerate the stress of labor.

A pattern of at least 3 contractions within a 10 min time period with duratio of 40-60 sec
each must be obtained to use for assessment data

Nipple stimulated CST consists of the woman lightly brushing her palm across the
nipple for 2 or 3 min, which causes the pituitary gland to release endogenous oxytocin,
and then stopping the nipple stimulation when a contraction begins The same process
is repeated after a 5 min rest period

Hyperstimulation of the uterus (uterine contraction longer than 90 sec or more

freq than q 2 min) should be avoided by stimulating the nipple intermittently with rest
periods in between and avoiding bimanual stimulation of both nipples unless stimulation
of one nipple is uncuccessful

Oxytocin admin CST is used if nipple stimulation fails and consists of IV admin of
oxytocin to induce uterine contractions

Contractions started with oxytocin may be difficult to stop and can lead to
preterm labor
A negative CST (normal finding) is indicated if within a 10 min period, with 3 uterine
contractions, there are no late decels of the FHR

A positive CST (abnormal finding) is indicated with persistent and consistent late decels
on more than half of the contractions. This is suggestive of uteroplacental insufficiency.
Variable decels may indicate cord compression and early decls may indicate fetal head
compression.

Nursing Management

For a CST, the nurse should

Obtain a baseline of the FHR, fetal movement and contractions for 10-20 min
and document

Complete an assessment without artificial stimulation if contractions are

occurring spontaneously

Initiate nipple stimulation if there are no contractions. Instruct the client to roll a
nipple between her thumb and fingers or brush her palm across her nipple. the
client should stop when a uterine contraction occurs.

Monitor and provide adequate rest periods for the client to avoid hyperstimulation
of the uterus.

Initiate IV oxytocin admin if nipple stimulation fails to elicit a sufficient uterine

contraction pattern

Complications

Hyperstimulation of the uterus

Preterm labor

Monitor for contractions lasting longer than 90 sec and/or occurring more
freq than q 2 min

Biophysical Profile (BPP)

uses a real time ultrasound to visualize physical and physiological characteristics of the
fetus and observe for fetal biophysical responses to stimuli.

Five variables

Reactive FHR: reactive nonstress test = 2, nonreactive = 0

Fetal breathing movements: at least 1 episode of 30 sec in 30 min = 2, absent or less
than 30 sec duration = 0

Gross body movements: at least 3 body or limb extensions with return to flexion in 30
min = 2, less than 3 episodes = 0

Fetal tone: at least 1 episode of extension with return to flexion = 2; slow extension and
flexion, lack of flexion, or absent of movement = 0

Amniotic fluid volume: at least 1 pocket of fluid that measures at least 1 cm in 2

perpendicular planes = 2; pockets absent or less than 1 cm = 0

For BPP the nurse should

follow the same management as ultrasound

Complications of Pregnancy: Recognizing Abnormal Findings

Bleeding during Pregnancy

vaginal bleeding during pregnancy is always abnormal and must be carefully

investigated in order to determine the cause

Spontaneous Abortion

when a pregnancy is terminated before 20 weeks gestation (the point of fetal

viability) or fetal wt less than 500 g.

Assessments

vaginal spotting or moderate to heavy bleeding with or without pain in early

pregnancy

passage of tissue (products of conception)

mild to severe uterine atony
backache
rupture of membranes
dilation of the cervix
fever
abdominal tenderness
s/s of hemorrhage such as hypotension

Ectopic Pregnancy
 abnormal implantation of the fertilized ovum outside of the uterine cavity. The
implantation is usually in the fallopian tube, which can result in a tubal rupture
causing a fatal hemorrhage.

Assessments

one or two missed menses

unilateral stabbing pain and tenderness in the lower abdominal quadrant

scant, dark red or brown vaginal spotting if tube ruptures (bleeding may be into
intraperitoneal area).

referred shoulder pain from blood irritation of the diaphragm or phrenic nerve
(common sx)

N/V freq after tube rupture

sx of hemorrhage and shock

Gestational Trophoblastic Disease

proliferation and degeneration of trophoblastic villi in the placenta which becomes

swollen, fluid-filled and takes on the appearance of grape-like clusters. the
embryo fails to develop beyond a primitive start and these structures are
associated with choriocarcinoma which is a rapidly metastasizing malignancy.
Two types of molar growths are identifies by chromosomal analysis

Assessments

rapid uterine growth larger than expected for the duration of the pregnancy due
to the overproliferation of trophoblastic cells

vaginal bleeding at approximately 16 wks gestation. Bleeding is often dark brown

resembling prune juice, or bright red that is either scant or profuse and continues
for a few days or intermittently for a few weeks

bleeding accompanied by discharge from the clear fluid-filled vesciles

excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels

sx of pregnancy-induced HTN (PIH), including HTN, edema, and proteinuria that

occur prior to 20 weeks gestation (PIH usually does not occur until after 20 wks
gestation)

Incompetent Cervix

painless, passive dilation of the cervix in the absence of uterine contractions. The
cervix is incapable of supporting the wt and pressure of the growing fetus and
results in expulsion of the products of conception during the second trimester of
pregnancy. This usually occurs around week 20 of gestation.

Assessments

pink stained vaginal discharge or bleeding

increase in pelvic pressure

possible gush of fluid (rupture of membranes)

uterine contractions with the expulsion of the fetus

postop (cerclage) monitoring for uterine contractions, rupture of membranes and

signs of infection

Placenta Previa

when the placenta abnormally implants in the lower segment of the uterus near
or over the cervical os instead of attaching to the fundus. The abnormal implantation
results in bleeding during the third trimester of pregnancy as the cervix begins to dilate
and efface

Assessments

painless, bright red vaginal bleeding that increases as the cervix dilates

a soft relaxed, nontender uterus with normal tone

a fundal ht greater than usually expected for gestational age

a fetus in a breech, oblique or transverse position

a palpable placenta

VS that are usual and within normal limits

Abruptio Placenta
 the premature separation of the placenta from the uterus, which can be a partial
or complete detachment. This separation occurs after 20 wks gestation, which is
usually in the third trimester. It has significant maternal and fetal morbidity and
mortality and is a leading cause of maternal death

Assessments

sudden onset of intense localized uterine pain

vaginal bleeding that is bright red or dark

A board like abdomen that is tender

a firm rigid uterus with contractions (uterine hypertonicity)

fetal distress

sx of hypovolemic shock

Hyperemesis Gravidarum

excess N/V (r/t elevated HcG levels) that is prolonged past 12 weeks gestation
and results in a 5% wt loss form prepregnancy wt, dehydration, electrolyte
imbalance, ketosis, and acetonuria.

Assessments

excessive vomiting for prolonged periods

dehydration with possible electrolyte imbalance

wt loss

decreased blood pressure

increased pulse rate

poor skin turgor

Gestational Hypertension/Pregnancy Induced Hypertension

begins after the 20th wk of pregnancy,

 woman has an elevated BP at 140/90 mmHg or greater, or a systolic increase of
30 mmHg or diastolic increase of 15 mmHg from the prepregnancy state

Mild preeclampsia is GH with the addition of proteinuria of 1 - 2+ and a wt gain of

more than 2 kg per wk in the 2nd and 3rd trimesters.

Severe preeclampsia consists of BP that is 160-100 mmHg or greater, proteinuria

3-4+, oliguria, elevated serum creatinine greater than 1.2 mg/dL, cerebral or
visual disturbances (HA and blurred vision), hyperreflexia with possible ankle
clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic
dysfunction, epigastric and RUQ pain.

Eclampsia is severe preeclampsia sx along with the onset of seizure activity or

coma.

Assessments

progression of hypertensive disease with indications of worsening liver

involvement, renal failure, worsening HtN, cerebral involvement, and developing
coagulopathies

rapid wt gain 2 kg per wk in the second and third trimester

fetal distress
Gestational Diabetes

an impaired toleratnce to glucose with the first onset or recognition during

pregnancy. The ideal blood glucose level should fall between 60-120 mg/dL

Assessments

hunger and thirst

freq urination

blurred vision

excess wt gain during pregnancy

TORCH infections

group of infections that can negatively affect a woman who is pregnant. These
infections can cross the placenta and have teratogenic affects on the fetus. TORCH
does not include all the major infections that present risks to the mother and fetus
 infection sign/symptom

T-toxoplasmosis influenza sx or lymphadenopathy

O-other infection dependent on infection

R-rubella (german measles) rash, muscle aches, joint pain, mild

lymphedema, fetal consequences including
miscarriage, congenital anomalies and
death

C-cytomegalovirus (member of Herpes asymptomatic or mononucleosis-like sx

virus family)

H-Herpes simples virus (HSV) lesions initial outbreak

Circumcision: Evaluating Effectiveness of Discharge Teaching

Postop parent teaching:

Teach the parents to keep the area clean. Change the infants diaper at least every 4 hr
and clean the penis with warm water with each diaper change.

With clamp procedures, apply petroleum jelly with each diaper change for at least 24 hr
after the circumcision to keep the diaper from adhering to the penis. The diaper should
be fan folded to prevent pressure on the circumcised area

Avoid wrapping the penis in tight gauze, which can impair circulation to the glans.

A tub bath should not be given until the circumcision is completely healed. Until then,
warm water should be gently trickled over the penis

Notify the PCP if there is any redness, discharge, swelling, strong odor, tenderness,
decrease in urination, or excessive crying from the infant.

Tell the parents a film of yellowish mucus may form over the glans by day 2 and it is
important not to wash this off

Teach the parents to avoid using premoistened towelettes to clean the penis bec they
contain alcohol.

Inform the parents that the newborn may be fussy or may sleep for several hrs after the
circumcision
Inform the parents that the circumcision will heal completely within a couple of weeks.

Discharge Teaching: Evaluating Clients Understanding of Bulb Syringe Use

Oral and Nasal Suctioning

teach the parents to use a bulb syringe to suction any excess mucus from the nose and
mouth

parents should suction the mouth first and then the nose, one nostril at a time

the bulb should be compressed before inserting it into the infants mouth or nose

when suctioning the infants mouth, always insert the bulb on the sides of the infants
mouth not in the middle and do not touch the back of the throat to avoid the gag reflex

Postpartum Physiological Changes and Nursing Care: Performing Fundal

Assessment

Document the fundal height, location and uterine consistency

Determine the fundal ht by placing fingers on the abdomen and measuring how many
fingerbreadths (cm) fit between the fundus and the umbilicus above, below, or at the
umbilical level

Determine if the fundus is midline in the pelvis or displaced laterally (caused by a full
bladder)

Determine if the fundus is firm or boggy. If the fundus is boggy (not firm), lightly
massage the fundus in a circular motion.

Toddler: Provide Education on Age-Specific Growth and Development

Stages of Development

Theorist Type of Development Stage

Erickson Psychosocial Autonomy vs Shame

Freud Psychosocial Anal

 Theorist Type of Development Stage

Piaget Cognitive Sensorimotor Transitions to

preoperational

Physical Development

anterior fontanel close by 18 months of age

Wt: At 30 months the toddler should weigh 4x his birth wt.

Ht: the toddler grows by 7.5 cm (3 in) per year

Developmental Skills

development of steady gait

climbing stairs

jumping and standing on one foot for short periods

stacking blocks in increasingly higher numbers

drawing stick figures

undressing and feeding self

toilet training

Cognitive Development

concept of object permanence is fully developed

Toddlers demonstrate memory of events that relate to them

language increase to about 400 words with the toddler speaking in 2-3 word phrases

pre-operational thought does not allow for the toddler to understand other viewpoints,
but it does allow toddlers to symbolize objects and people in order to imitate activities
they have seen previously

Psychosocial Development
independence is paramount for the toddler who is attempting to do everything for
himself

separation anxiety continues to occur when a parent leaves the child

Moral Development

Moral development is closely associated with cognitive development

Egocentric--toddlers are unable to see anothers perspective; they can only view thing
from their point of view.

the toddlers punishment and obedience orientation begins with a sense of good
behavior is rewarded and bad behavior is punished.

Self Concept Development

toddlers progressively see themselves as separate from their parents and increase their
explorations away from them

Age Appropriate Activities

Solitary play evolves into parallel play where the toddler observes other children and
then may engage in activities nearby

filling and emptying containers

playing with blocks

reading books

playing with toys that can be pushed and pulled

tossing a ball

Infant (Birth to 1 yr): Identifying Normal Physical Assessment Findings

Physical Development

The infants posterior fontanel closes at 2-3 months of age

The infants size is tracked by wt, ht, and head circumference

Wt: the infant gains 0.7 kg (1.5 lb) per month the first 6 months and 0.3 kg (0.75 lb) per
month the last 6 months. The infant triples birth wt by the end of the first year

Ht: The infant grows 2.5 cm (1 in) per month the first 6 month and then 1.25 cm (0.5 in)
per month the last 6 months.

Head Circumference: The circumference of the infants head increases 1.25 cm (0.5 in)
per month the first 6 months

Following size, the infant develops gross motor skills

Holds head up at 3 months

Rolls over at 5-6 months

Holds head steady when sitting at 6 months

Gets to sitting position alone and can pull up to a standing position at 9 months

Stand hold on at 12 months

Stands alone at 12 months

Fine motor development follows next in the sequence

Brings hans together

grasps rattle

looks for items that are dropped from view

transfers an object from one hand to the other (6 months)

rakes finger food with hand ( 6 months)

uses thumb-finger to grasp items (9 months)

Bangs two toys together (9 months)

Can nest one object inside another (12 months)

Scoliosis: Recognizing Signs During Routine Screening

School age children should be screened for scoliosis by examining for a lateral
curvature of the spine before and during growth spurts.
Marked curvatures in posture are abnormal.

A slight limp, a crooked hemline, or a sore back are other s/s of scoliosis

inspect the back for any tufts of hair, dimples, or discoloration. Mobility of vertebral
column is easily assessed in children bec of their propensity for constant motion durin
exam

ATI Topic Descriptors

Management of Care (24)

Plan A

Advance Directives: Recognize Purpose

(ATI)

Advance directive are written instructions that allow a client to convey his wishes
regarding medical tx for situations when those wishes can no longer be personally
communicated.

All clients admitted to a health care facility be asked if they have an advance directive.

The client without an advance directive must be given written information that outlines
his rights r/t health care decisions and how to formulate an advance directive.

A health care representative should be available to help with this process

Living wills

allows the client to specify end of life decisions she does or does not sanction
when unable to speak for herself. For example, the client can specify use or refusal of:

CPR, if cardiac or respiratory arrest occurs

Artificial nutrition through IV or tube feedings

Prolonged maintenance on a respirator if unable to breathe adequately alone

Living wills must be specific and be signed by two witnesses.

They can minimize conflict and confusion regarding health care decisions that need to
be made

vary from state to state

A durable power of attorney for health care (health proxy) is an indiv designated to
make health care decisions for a client who is unable based upon the clients living will

Based upon the clients advance directives, the physician writes orders for life-
sustaining tx. Examples include:

DNR
Medical interventions (eg comfort measures only, IV fluids but no intubation, full tx)

Use of ABX

Artificially administered nutrition through a tube.

Nursing responsibilities regarding advance directives include:

provide written information regarding advance directives

document the clients advance directive status

ensure that the advance directive is current and reflective of the clients current
decisions.

inform all members of the health care team of the clients advance directive.

(P/P)

Two basic advance directives

living will
written documents that direct tx in accordance with a clients wishes in the event
of a terminal illness or condition.

may be difficult to interpret

two witnesses, neither of whom can be a relative or physician, are needed when
the client signs the document

if health care workers follow the directions of the living will, they are immune from
liability

durable power of attorney for health care

 designates an agent, surrogate, or proxy to make health care decisions if and
when the client is no longer able to make decisions on his or her own behalf.

In order for living wills or durable powers of attorney for health care to be enforceable,
the client must be legally incompetent or lack decisional capacity to make decisions
regarding health care treatment

The determination of legal competency is made by a judge, and the determination of

decisional capacity is usually made by the physician and family.

The implementation of the advance directive is done within the context of the health
care team and the health care institution.

When clients are legally incompetent and are unable to make health care decisions, the
courts balance the states interest with what the client would have wanted.

Client Advocacy: Intervening on behalf of the Client

As an advocate, nurses must ensure that clients are informed of their rights and have
adequate information on which to base health care decisions

Nurses must be careful to assist clients with health care decisions and not direct or
control their decisions

Situations in which the nurse may advocate for the client or assist the client to advocate
for herself include:

End of life decisions

Access to health care

Protection of client privacy

Informed consent

Substandard practice

Essential Components of Advocacy

Skills
risk taking
vision
self-confidence
Articulate communication
assertiveness

Values
caring
autonomy
respect
empowerment

The nurse protects the clients human and legal rights and provides assistance in
asserting those rights if the need arises

keep in mind the clients religion and culture

Discharge Planning: Interventions to Promote Timely Client Discharges

The process begins at time of admission

Plans are developed with client and family input, focusing on active participation by the
client to facilitate a timely discharge

Serves as a starting point for continuity of care for the client by the caregiver, home
health nurse, or receiving facility.

The need for additional client or family support is included with recommendations for
support services such as home health, outpatient therapy and respite care.

Discharge Summary includes:

Step by step instructions for procedures to be done at home

Precautions to take when performing procedures or administering meds

S/s of complications that should be reported

Names and numbers of health care providers and community services the client/family
can contact.

Plans for follow up care and therapies

Time of discharge, mode of transportation, and who accompanied the client.

This should begin when the client is admitted to the facility unless the facility is to be the
clients permanent residence

assess whether or not the client will be able to return to his previous residence

determine whether or not the client will nee and/or have someone to assist him at home

assess the residence to see if adaptations are required to accommodate the client prior
to discharge
make a referral to the social worker to arrange for community services required by the
client at discharge

communicate client health status and needs to community service providers.

Clients Rights: Recognizing Client Rights Regarding Review of Records

Only health care team members directly responsible for the clients care should be
allowed access to the clients records. The client has the right to review his medical
record and request information as necessary for understanding.

Clients rights

To inspect and copy PHI

To ask the health care agency to amend the PHI that is contained in a record if the PHI
is inaccurate
To request a list of disclosures made regarding the PHI as specified by HIPAA
To request to restrict the way the health care agency uses or discloses PHI regarding tx,
payment or health care operations unless info is needed to provide emergency tx
To request that the healthcare agency communicates with the client in a certain way or
at a certain location ; the request must specify how or where the clients wishes to be
contacted.

Collaboration with Interdisciplinary Team: Methods for Collaboration

An interdisciplinary team is a group of health care professionals from different

disciplines

Collaboration is used by interdisciplinary teams to make health care decisions about

clients with multiple problems. Collaboration, which may take place at team meetings,
allows the achievement of results that the participants would be incapable of
accomplishing if working alone.

Key elements of collaboration include:

 Effective communication skills

Mutual respect and trust

Shared decision making

The nurse contributes

Knowledge of nursing care and its management

A holistic understanding of the client, her health care needs,and health care
systems

Nurse-primary care provider collaboration should be fostered to create a climate of

mutual respect and collaborative practice

Collaboration can occur among different levels of nurses and nurses with different areas
of expertise.

Nursing Interventions:

Use effective communication skills

Participate in client rounds and interdisciplinary team meetings

Present info relevant to the clients health status and tx regimen

Attend interdisciplinary clinical conferences/case presentations.

COPD: Planning Strategies for Fatigue

ATI---determine the clients physical limitations and structure activity to include

periods of rest

promote adequate nutrition

increased work of breathing increases caloric demands

Med-Surg

Energy Conservation Techniques

pacing and pursing (pacing activity and using pursed lip breathing with activities
assuming the tripod position and a mirror placed on the table during use of an electric
razor or hair dryer conserves more energy than when the pt stands in front of a mirror to
shave or blow dry hair.

use 02 during activities of hygiene bec these are energy consuming

pt should be encouraged to make a schedule and plan daily and weekly activities so as
to leave plenty of time for rest periods

pt should also try to sit as much as possible when performing activities

exhale when pushing, pulling or exerting effort during and activity and inhale during rest.

walking is the best exercise for COPD

coordinated walking with slow, pursed-lip breathing without breath holding.

breathe in and out through now while taking one step then to breathe out through
pursed lips while taking 2-4 steps

walk 15-20 minutes a day with gradual increases

use MDI 10 minutes before exercises

Conflict Resolution: Identify Strategies

Conflict is the result of opposing thoughts, ideas, feeling, perceptions, behaviors,

values, opinions, or actions between individuals.

Conflict is an inevitable part of professional, social, and personal life and can result in
constructive or destructive consequences

Constructive Consequences Destructive Consequences

stimulates growth and open and honest can produce divisiveness

communication may foster rivalry and compeitition
increases group cohesion and commitment misperceptions, distrust, and frustration
to common goals can be created
facilitates understanding and problem group dissatisfaction with the outcome may
solving occur
motivates group to change

Lack of conflict can create organizational stasis, while too much conflict can be
demoralizing, produce anxiety, and contribute to burnout
The desired goal in resolving conflict in both parties is to reach a satisfactory resolution.
This is a win-win situation

Conflict Resolution Strategies

Strategy Characteristics

Compromising Each party gives up something

To consider this a win-win solution, both
parties must give up something equally
valuable. If one party gives up more than
the other it can become a win-lose
situation

Competing One party pursues a desired solution at the

expense of others
This is a win-lose solution
Managers may use this when a quick or
unpopular decision must be made
The party who loses something may
experience anger, frustration, and a desire
for retribution

Cooperating/Accommodating One party sacrifices something, allowing

the other party to get what it wants. This is
the opposite of competing.
this is a lose-win solution.
The original problem may not actually be
resolved.
The solution may contribute to future
conflict
 Strategy Characteristics

Smoothing One party attempts to smooth other party,

decreasing the emotional component of
the conflict
Often used to preserve or maintain a
peaceful work environment
The focus may be on what is agreed upon,
leaving conflict largely unresolved
This is usually a lose-lose solution

Avoiding Both parties know there is a conflict, but

they refuse to face it or attempt to resolve
it.
May be appropriate for minor conflicts or
when one party holds more power than the
other party or if the issue may work itself
out over time
Since the conflict remains, it may surface
again at a later date and escalate over
time
this is usually a lose-lose solution

Conflict Resolution Advantages Disadvantages

Technique

Avoiding--ignoring the does not make a big deal conflict can become bigger
conflict out of nothing; conflict may than anticipated
be minor in comparison to
other priorities

Accommodating--- one side is more concerned one side holds more power
smoothing or cooperating. with the issue than the other and can force the other side
One side gives in to the side to give in
other side

Competing---forcing; the two produces a winner; good Produces a loser; leaves

or three sides are forced to when time is short and anger and resentment on
compete for the goal stakes are high losing sides
 Conflict Resolution Advantages Disadvantages
Technique

Compromising---each side no one should win or lose
gives up something and but both should gain
gains something something; good for
disagreements between
indiv
may cause a return to the
conflict if what is given up
becomes more important
than the original goal

Negotiating---high level stakes are high and solution agreements are permanent,
discussion that seeks is rather permanent; often even though each side has
agreement but not involves powerful groups gains and losses
necessarily consensus

Collaborating--both sides best solution for the conflict takes a lot of time; requires
work together to develop and encompasses all the commitment to success
optimal outcome goals to each side

Confronting--immediate and does not allow conflict o may leave impression that
obvious movement to stop take root; very powerful conflict is not tolerated
conflict at the very start

Genitalia and Rectum: Providing Privacy

Preparation of the client (for Female pelvic exam)

Client is asked to empty her bladder so that urine is not accidently expelled during the
exam.

Client is assisted in assuming the lithotomy position in bed or on an exam table for an
external genitalia assessment and is assisted in stirrups if a speculum exam is to be
performed.

The nurse places a hand to the edge of the table and then instructs the client to move
until touching the hand. The clients arms should be at her side or folded across the
chest to prevent tightening of abdominal muscles

A square drape or sheet is given to the client. She holds one corner over the sternum,
the adjacent corners fall over each knee, and the fourth corner covers the perineum.
Close the door, or pull room curtains around the bathing area. While bathing the client,
expose only the areas being bathed.

During bowel elimination, the nurse should maintain the clients privacy.
this is especially important for a client using a bedpan. The call light and a supply of
toilet paper should be within easy reach. Respond immediately.

Consultation: Referral in Response to a Client Concern

A consultant is a professional who provides expert advice in a particular area. A

consultation is requested to determine what tx/services the client requires.

Consultations provide expertise to clients who require a particular type of knowledge or

service (eg, a cardiologist for a client who had a myocardial infarction, a psychiatrist for
a client whose risk for suicide needs to be assessed)
Coordination of the consultants recommendations with other health care providers
recommendations is necessary to protect the client form conflicting and potentially
dangerous orders.

Consultation is a process in which a specialist is sought to identify methods of care or tx

plans to meet the needs of a client.

Consultation is needed when the nurse encounters a problem that cannot be solved
using nursing knowledge, skills, and available resources

Consultation also is needed when the exact problem remains unclear; a consultant can
objectively and more clearly assess and identify the exact nature of the problem

Referrals are made so that the client can access the care identified by the PCP or
consultant

The care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg,
hospice care, home health aide)

Discharge referrals are based on client needs in r/t actual and potential problems and
may enlist the aid of:

social services
specialized therapists (eg PT,OT, speech)
care providers (home health nurses, hospice nurse)

Knowledge of community resources i necessary to appropriately link the client with

needed services

Consultation (interventions)

Initiate the necessary consults or notify the PCP of the clients needs so the consult can
be initiated.

Provide the consultant with all pertinent info about the problem
Incorporate the consultants recommendations into the clients plan of care

Facilitate coordination of the consultants recommendations with other health care

providers; recommendations to protect the client from conflicting and potentially
dangerous orders.

Referrals (Interventions)

To ensure continuity of care by the use of referrals, the nurse should:

Initiate the discharge plan upon the clients admission.

Evaluate client/family competencies in r/t home care prior to discharge.

Involve the client and family in care planning

Collaborate with other health care professionals to ensure all health care needs are met

Complete referral forms to ensure proper reimbursement for services ordered.

Client Education: Document Client Teaching

Client teaching documentation

Information presented, method of instruction (eg discussion, demonstration, videotape,

booklet), client response, including questions and evidence of understanding such as
return demo or change in behavior.

Nursing documentation must be accurate to correctly record information regarding the

clients care.

The purpose of reporting is to provide continuity of care for client when several nurses
provide care. Reporting should be conducted in a confidential manner.

Evaluation of Client Teaching

Observe the client demonstrating the learned activity (best for eval of psychomotor
learning)

Ask questions.

Listen to the client explain the info learned

use written tools to measure accuracy of information

Request the clients self-eval of progress

Observe verbal and nonverbal communication

Revise the care plan as needed.

Delegation: Use of the Five Rights of Delegation

Right Task

The right task is one that is delegable for a specific client, such as tasks that are
repetitive, require little supervision and are relatively noninvasive.

Identify what tasks are appropriate to delegate for each specific client.

Delegate activities to appropriate levels of team members (eg LPN, AP) based on
professional standards of practice, legal and facility guidelines, and available resources.

Ex:

Right Task Wrong Task

Delegate LPN to perform a dressing Delegate LPN to develop the care plan for
change on a client with cellulitis. a client with cellulitis.

Delegate AP to assist a client with Delegate AP to administer a neb tx to a

pneumonia to use a bedpan client with pneumonia.

Right Circumstances

The appropriate client, available resources, and other relevant factors are considered.
In an acute care setting, clients conditions can change quickly. good clinical decision
making is needed to determine what to delegate. If the circumstances have been
assessed or are deemed too complicated, the nurse takes the responsibility and does
not delegate to the AP.

Ex:
 Right Circumstance Wrong Circumstance

Delegate AP to take and record check-in Delegate AP to take VS on a client

VS of office clients.
Delegate AP to assist in obtaining VS from
a stable postop client.
receiving IV therapy for hypovolemic
shock.
Delegate AP to assist in obtain VS from a
postop client who required naloxone
(Narcan) for depressed respirations.

Right person

the right person is delegating the right tasks to the right person to be performed on the
right person.

Assess and verify the competency of the health care team member.

the task must be within the team members scope of practice

the team member must have the necessary competence/training

Continually review the performance of the team member and determine care
competency.

Assess team member performance based on standards, and when necessary, take
steps to remediate failure to meet standards.

Ex:

Right person Wrong Person

Delegate an LPN to administer enteral Delegate an AP to administer enteral

feedings to a client with a head injury. feedings to a client with a head injury.

Delegate LPN to perform trach care on a Delegate an AP to perform trach care on a

client client.

Right Direction/ Communication

A clear, concise, description of the task, including its objective, limits, and expectations
is given. Communication must be ongoing between RN and AP during a shift of care.

Communicate either in writing or orally:

Data that need to be collected

Method and timeline for reporting, including when to report concerns/assessment
findings
Specific task(s) to be performed; client specific instructions
Expected results, timelines, and expectations for follow-up communication.

Ex:

Right direction/communication Wrong direction/communication

Delegate AP the task of assisting the client Delegate AP the task of assisting the client
in room 312 with a shower, to be in room 312 with morning hygiene.
completed by 0900.
Delegate AP the task of obtaining a urine
Delegate AP the task of obtaining a clean- specimen on a client in room 423, but not
catch urine specimen from the client in informing her of what type of urine
room 423, bed 2 specimen, or which specific client in the
room needs the specimen.

Right Supervision

Appropriate monitoring, evaluation, intervention as needed and feedback are provided.

AP should feel comfortable to ask questions and seek assistance.

Ex:
 Right Supervision Wrong Supervision

An RN delegates to an LPN the task of An RN delegates to an LPN the task of

administering enteral feedings to a client
(after the RN performs a physical
assessment to evaluate the clients
tolerance to feedings thus far).
An RN delegates to an AP the task of
ambulating a client after completing the
admission assessment
providing client teaching to a client without
a written care plan in place.
An RN delegates an AP to ambulate a
client prior to performing an admission
assessment.

Care that cannot be delegated:

Nursing process.
Assessment
Diagnosis
Planning
Evaluation
Nursing judgment.

Delegation: Monitoring Outcomes of Delegated Tasks

Another important step in delegation is evaluation of clients outcomes. The RN must

give constructive and appropriate feedback. The RN should always give specific
feedback in regard to any mistakes that were made, explaining how the mistakes could
have been avoiding. Giving feedback in private is the professional way and preserves
the APs dignity. The RN may discover the need to review a procedure with staff and
offer demonstration or even recommend that additional training by scheduled with the
education dept.

Delegation: Assigning Tasks To AP Based On Role parameters and Skill Required

Assess the knowledge and skills of the delegate

open ended questions

Match tasks to the delegates skills

know what skills are included in the training program of the facility

Communicate clearly
 alway provide unambiguous and clear directions by describing a task, the desired
outcome, time period within which the task should be completed.

never give task through another staff member

Listen attentively

Provide feedback.

Roles/Tasks for AP/LPN

Task AP LPN RN

Developing a teaching plan for a client newly dxd with diabetes x

mellitus

Assessing a client admitted for surgery x

Collecting VS q 30 min for a client who is 1 hr post cardiac cath x x x

Calculating a clients I/O x x x

Administering blood to a client x

Monitoring a clients condition during blood transfusions and IV admin x x

Providing oral and bathing hygiene to an immobilized client x x x

Initiating client referrals x

Dressing change of an uncomplicated wound x x

Routine nasotracheal suctioning x x

Receiving report from surgery nurse regarding a client to be admitted x

to a unit from the PACU

Initiating a continuous IV infusion of dopamine with dosage titration x

based on hemodynamic measurements

Administering subcutaneous insulin x x

Assessing and documenting a clients decubitus ulcer x x

Evaluating a clients advance directive status x

 Task AP LPN RN

Providing written information regarding advance directives x x

Initial feeding of a client who had a stroke and is at risk for aspiration x

Assisting a client with toileting x x x

Developing a plan of care for a client x

Administering an oral med x x

Assisting a client with ambulation x x x

Administering an IM pain med x x

Checking a clients feeding tube placement and patency x x

Turning a client q 2 hr x x x

Calculating and monitoring TPN flow rate x

Disaster Planning and Emergency Management: Prioritizing Delivery of Client

Care

Triage is the process of separating casualties and allocating tx on the basis of the
victims potentials for survival.

Highest priority is always given to victims who have life-threatening injuries but who
have a high probability of survival once stabilized.

Second priority is given to victims with injuries that have systemic complications that are
not yet life threatening and could wait 45-60 min for tx

Last priority is given to those victims with local injuries without immediate complications
and who can wait several hours for medical attention, or those who have minimal
probability of surviving.

Ethics and Values: Appropriate Response to Experiencing Negative Feelings

about a Client
Countertransference refers to the feelings and thoughts that service providers have
toward the client. The provider may harbor certain images of the client that result in
blind spots which can be destructive or disruptive to the therapeutic process.

This nontherapeutic event can be resolved with consultation, supervision, or both.

Nurses must be aware of possible countertransference responses.

Beneficence---the care give is in the best interest of the client.

Client Education: Assisting Clients to Access current Health Information Using

Information Technology

Client education assists individuals, families, and communities in achieving optimal

health.

Teaching in interactive, promotes learning, and leads to a change in a behavior.

Information technology can be used to enhance access to and delivery of knowledge

Client Education: Selecting Appropriate Information Technology for Adolescent

Client Education

Adolescents are in transition between childhood and adulthood.

Transition between concrete operations to formal operations in reasoning.

Use logic and reasoning to grasp simultaneous influence of several variables to invent a
systematic procedure for keeping track of results of experiments.

Peer teaching is very effective. Teens benefit from visiting others who are coping
successfully with similar problems.

Group instruction/discussion is a very powerful way to help teens belong to a group

Informed Consent: Ensure Informed Consent

Informed Consent

Once surgery has been discussed with the client or surrogate as tx, it is the
responsibility of the PcP to obtain consent after discussing the risks and benefits of the
procedure. The nurse is not to obtain consent for the PcP in any circumstance

the nurse can clarify any information that remains unclear after the PCPs
explanation of the procedure

The nurses role is to witness the clients signing of the consent forma after the client
acknowledges understanding of the procedure.

Informed Consent

Consent is required for all tx that is given to the client in a healthcare facility

State laws prescribe who is able to give informed consent. Laws will vary
regarding age limitations and emergencies. the nurse is responsible for knowing the
laws in the state of practice

People authorized to grant consent for another person include:

parent of a minor

legal guardian

court specified representative by a court order

spouse or closest avail relative who has durable power of attorney for health care

The Provider: obtains informed consent

The Client: gives informed consent
The Nurse: witnesses informed consent
ensuring that the provide gave the client the necessary information
ensuring that the client understood the information and is competent to
give informed consent

Legal Responsibilities: Reporting Client Abuse

Abuse and Neglect of Vulnerable Older Adults

Description
older adults may be the victims of emotional, physical and sexual abuse
 the nurse must be alert to the signs of abuse and neglect possible from
caregivers

Signs of abuse include unexplained bruises or welts, multiple bruises; unexplained

fractures, abrasions, and lacerations; multiple injuries; withdrawal or passivity or fear;
depression and hopelessness

Signs of neglect include dehydration; malnourishment; overmedication or

undermedication; desertion or abandonment; inappropriate or soiled clothes; lack of
glasses; dentures, or other aids if usually worn; and being left unattended

Exploitation of the vulnerable older adult includes disappearance of possessions, forced

to sell possessions or change a will, overcharged for home repairs, inadequate living
environment, inability to afford social activities, being forced to sign over control of
finances and no money for food or clothes

The nurse must report abuse, neglect and exploitation to the proper authorities

Intentional Torts

Assault: any intentional threat to bring about harmful or offensive contact

no contact is made
the law protects clients who are afraid of harmful contact
It is an assault for a nurse to threaten to give a client an injection or to threaten to
restrain a client for an xray procedure when the client has refused consent

Battery is any intentional touching without consent. Contact can be harmful

Performance Improvement: Utilize References to Improve Performance and

Maintain Safe Practice

Performance Improvement:

includes measuring performance against a set of predetermined standards. In health

care these standards may be set by the specific facility and take into consideration
accrediting and professional standards.

The Joint Commission (formerly JCAHO):

sets standards in relation to policies, procedures, and the competency of health care
team members

Annually publishes the National Patient Safety Goals which specify the standard of care
that clients should receive.
Requirements include:

policies, procedures, and standards describe and guide how the nursing staff provides
nursing care, tx, and services

All nursing policies, procedures, and standards are defined, documented, and
accessible in written or electronic format.

Step 1

Standard is developed and approved by facility committee

Step 2

Provide and document care according to the developed standard.

An audit is performed to determine if the standard is being met.

Retrospective audit: happens after the client receives care

Concurrent audit: occurs while the client is receiving care

Prospective audit: predicts how future client care will be affected by current level of
services.

Step 3

Educational or corrective action is provided when results indicate that a standard is not
being met.

The Nurses Role in Performance Improvement:

Step 1

Serve as unit representative on committees developing policies and procedures

Use reliable resources for information (CDC, professional journals, evidenced based
research)

Step 2

Enhance knowledge and understanding of the facilitys policies and procedures.

Provide client care consistent with these policies and procedures
Document client care thoroughly and according to facility guidelines
Participate in the collection of info/data r/t staffs adherence to selected policy or
procedure
Assist with analysis of the info/data
Compare results with the established standard
Make a judgment about performance in regard tot eh findings

Step 3

Assist with the provision of education of training necessary to improve the performance
of staff

Act as a role model by practicing in accordance with the established standard

Assist with re-evaluation of staff performance by collection of info/data at a specified

time.

Referrals: Assessing Need to Refer Clients for Assistance

A referral is made so that the client can access the care identified by the primary care
provider or the consultant

The care may be provided in the inpatient setting (eg PT, OT) or outside the facility (eg
hospice care, home health aide)

Clients being released from health care facilities and discharged to their home still
require nursing care.

Discharge referrals are based on client needs in relation to actual and potential
problems and may enlist the aid of :
social services
specialized therapists (eg: PT, OT, speech)
care providers (eg home health nurses, hospice nurse

Knowledge of community resources is necessary to appropriately link the client with

needed services

To ensure continuity of care by the use of referrals, the nurse should:

Initiate the discharge upon the clients admission

Evaluate client/family competencies in relation to home care prior to

discharge

Involve the client and family in care planning

Collaborate with other health care professionals to ensure all health care needs
are met
 Complete referral forms to ensure proper reimbursement for services
offered.

Staff Development: Selecting Staff Education Activities Based on Staff Learning

Styles

Domains of Learning

Cognitive learning, which includes all intellectual activities.

Ex: person is taught and then can list what is learned.

Affective learning, which includes feelings, opinions, and values.

Ex: person is attentive and willing to listen to instructor

Psychomotor learning, which is learning to complete a physical activity.

Ex: client practices a skill.

Auditory learners---learn by listening

Visual learners---learn by seeing

Kinesthetic learners---learn by doing

Staff Development and Performance Improvement: Selecting Educational

Activities to Ensure Staff Competencies

Competence

the ability to meet the requirement of a particular role

Strategies to maintain competence include

 use of checklists to provide a record of opportunities and the level of
proficiency in relation to skills

peer observation/evaluation, planned or incidental, to assess

competence

complete of electronic learning modules

attendance at in-services to update skills

attendance at training sessions to learn specialized skills (ACLS,

PLS

Supervising Client Care: Information Sources for Making Client Assignments

Assignment Factors

Client Factors

complexity of care needed

specific care needs (eg cardiac monitoring, mechanical ventilation)

need for special precautions (eg private room with negative air pressure
and anteroom, fall precautions, seizure precautions)

Health care team factors

Skills

Experience

Nurse to client ratio

Management of Care (24)

Plan B

Culturally Competent Care: Recognize Need for Use of Translator for Non-English
Speaking Client

Communication

Improve the nurse/client relationship when the communication barrier is great

enough to impact the exchange of info between the nurse and client
 use interpreters when the communication barrier is great enough to impact
the exchange of info between the nurse and the client

cautiously use nonverbal communication as it may have very different

meanings for the client and the nurse

Peripheral Venous Disease: Modification of Care Plan in Response to DVT

Development

Interventions

Deep Vein Thrombosis and Thrombophlebitis

Encourage REST

facilitate bedrest and elevation of extremity above the level of the heart (avoid
using a knee gatch or pillow under knees)

admin intermittent or continuous warm moist compresses (to prevent thrombus

from dislodging and becoming an embolus, DO NOT massage the affected limb)

provide thigh-high compression or antiembolism stockings to reduce venous

stasis and to assist in venous return of blood to the heart.

Admin meds as prescribed

anticoags

unfractionated heparin IV based on body wt is given to prevent formation of

other clots and to prevent enlargement of existing clot, followed by oral anticoag with
warfarin.

hospital admin is required for lab value monitoring and dose adjustment

monitor aPTT to allow for adjustments of heparin dosage

monitor platelet counts for heparin-induced thrombocytopenia

ensure that protamine sulfate, the antidote for heparin is available if needed for
excessive bleeding

monitor the hazards and SE associated with anticoag therapy

Low molecular wt Heparin (LMWH) is given subq.

 Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) have
consistent action and are approved for the prevent and tx of DVT

may be managed at home by home care nurse

must have stable DVT or PE, low risk for bleedign, adequate renal function
and normal VS

client must be willing to learn self injection

the aPTT is not checked on an ongoing basis bec the doses of LMWH are
not adjusted

Warfarin works in the liver to inhibit synthesis of the four vit K dependent clotting
factors

takes 3-4 days before it has therapeutic anticoagulation

heparin is continued until the warfarin effect is achieved then IV heparin

may be d/cd

if client is on LMWH, warfarin is added after the first dose of LMWH.

Therapeutic levels are measured by INR

monitor for bleeding

ensure that Vit K (the antidote for warfarin) is available in case of

excessive bleeding

Thrombolytic Therapy

effective in dissolving thrombi quickly and completely

must be initiated within 5 days after onset of sx to be most effective

advantage is the prevention of valvular damage and consequential venous

insufficiency or postphlebitis syndrome

contraindicated during pregnancy and following surgery, childbirth, trauma, a

CVA, or spinal injury

tissue plasminogen activator (t-PA), a thrombolytic agent, and platelet inhibitors

such as abciximab (REoPRo), tirofiban (Aggrastat) and sptifibatide (Integrilin) may be
effective in dissolving a clot or preventing new clots during the first 24 hr.
 primary complication of therapy is serious bleeding

Analgesics: Admin as ordered to reduce pain

Venous Insufficiency

Instruct client to

elevate legs for at least 20 min four to five times/day above the level of the
heart

avoid prolonged sitting or standing, constrictive clothing or crossing legs

when seated

wear elastic or compression stockings during the day and evening

put elastic stockings on before getting out of bed after sleep

clean the elastic stockings each day, keep the seams to the
outside, and do not wear bunched up or rolled down

replace worn out compression stockings as needed

on using an intermittent sequential pneumatic compression system

instruct the client to apply the system twice daily for 1 hour in am
and evening

advise the client with an open ulcer that the compression system is
applied over a dressing

Varicose Veins

emphasize the importance of antiembolism stockings as prescribed

instruct the client to elevate the legs as much as possible

instruct the client to avoid constrictive clothing and pressure on the legs.

Consultation: Contacting Wound Care Consultant when Outcomes are Not Being
Met

A consultant is a professional who provides expert advice in a particular area. A

consultation is requested to help determine what tx/services the client requires.
Consultants provide expertise to clients who require a particular type of knowledge or
service (eg. a cardiologist for a client who had a myocardial infarction, a psychiatrist for
a client whose risk for suicide needs to be assessed.

Coordination of the consultants recommendations with other health care providers

recommendations is necessary to protect the client form conflicting and potentially
dangerous orders.

Interventions:

Initiate the necessary consults or notify the PCP of the clients needs so the consult can
be initiated.

Provide the consultant with all pertinent info about the problem (eg,, info from the client/
family, the clients medical records).

Incorporate the consultants recommendations into the clients plan of care.

Facilitate coordination of the consultants recommendations with other health care

providers recommendations to protect the client from conflicting and potentially
dangerous orders.

Question:
A nurse is assigned to care for an older adult client who has been in the health care
facility for 3 weeks due to a total hip replacement and subsequent pulmonary
complications. During morning assessment, the nurse notes that the client is beginning
to develop a decubitus ulcer on his coccyx. Which of the following actions by the nurse
would be most appropriate in an effort to obtain a plan of care for this problem?
a. Notify the unit manager that staff may not be consistently or effectively carrying out
the skin care protocol for high-risk clients.
b. Call for a consult with the wound care nurse.
c. Bring the problem to the attention of the surgeon during rounds
d. Develop a nursing care plan for impaired skin integrity: decubitus ulcer.

The nurse should call the wound care nurse for a consult with this client. since the
wound care nurse is an expert in this area, she would be the most knowledgeable
person to enlist in the development of a plan of care. While the surgeon should be
notified of the decubitus ulcer, she may not be as knowledgeable about tx options. It is
appropriate to notify the unit manager that a client on the unit has developed a
decubitus ulcer and that this may indicate a staff education need. However, this action
would not facilitate the development of a plan of care for this client. Development of a
nursing care plan for impaired skin integrity: decubitus ulcer: is indicated but should be
done with the wound care nurse to enhance the quality of care prescribed.
Delegation: Making Appropriate Client Assignment for a Float Nurse

Assignment Factors:

Complexity of care needed

Specific care needs (eg cardiac monitoring, mechanical ventilation)

Need for special precautions (eg private room with negative air pressure and anteroom,
fall precautions, seizure precautions)

Health care team factors:

Skills
Experience
Nurse-to-Client ratio

Floating is an acceptable, legal practice used by hospitals to solve their understaffing

problems

Legally a nurse cannot refuse to float unless a union contract guarantess that nurses
can work only in a specified area or the nurse can prove lack of knowledge for the
performance of assigned tasks.

Nurses in a floating situation must not assume responsibility beyond their level of
experience or qualification

Nurses who float should inform the supervisor of any lack of experience in caring for the
type of clients on the new nursing unit

The nurse should request and be given orientation to the new unit

Delegation: Identification of Client Concerns to be Reported to Nurse by AP for

Delegated Tasks

Question:

Toward the end of the shift, an LPN reports to an RN that a recently hired AP has not
totaled clients I&O for the past 8 hr. Which of the following should the RN take?

A. Confront the AP and instruct him to complete the I&O measurements

B. Delegate this task to the LPN since the AP may not have been educated on this task
C. Ask the AP if he needs assistance completing the I&O records.
D. Notify the nurse manager to include this on the APs evaluation.
I&O measurements are routine AP tasks; however the AP is new and my need some
assistance. Making assumptions and negative evaluation without direct evidence should
be avoided.

Prioritizing Client Care: Recognizing Assessment Priorities Among Multiple

Clients

Prioritizing is deciding which needs or problems require immediate action and which
ones could be delayed until a later time bec they are not urgent.

Guidelines for Prioritizing

The nurse and client mutually rank the clients needs in order of importance based on
the clients physical and psychological needs, safety, and the clients own needs and
expectations; what the client sees as his or her priority needs may be different from
what the nurse sees as the priority

Priorities are classified as high, intermediate, or low.

Client needs that are life threatening or that could result in harm to the client if they are
left untreated are high priorities

Nonemergency and non-life-threatening client needs are intermediate priorities

Client needs that are not related directly to the clients illness or prognosis are low
priorities

When providing care, the nurse needs to decide which ones could be delayed until a
later time bec they are not urgent

The nurse considers client problems that involve actual or life-threatening concerns
before potential health-threatening concerns

When prioritizing care, the nurse must consider time constraints and availbalbe
resources

Problems identified as important by the client must be given high priority

The nurse can use the ABCs---as a guide when determining priorities; client needs r/t
maintaining a patent airway are always the priority
The nurse can use Maslows hierarchy of needs theory as a guide to determine
priorities and identify the levels of physiological needs; safety, love and belonging, self-
esteem; and self-actualization (basic needs are met before moving to other needs in the
hierarchy)

The nurse can use the steps of the nursing process as a guide to determine priorities;
remember that assessment is the first step of the nursing process

Ethical Practice: Recognizing Clients Rights

The clients rights document also called the patients bill of rights reflects
acknowledgement of clients right to participate in their health care with an emphasis on
client autonomy

The document provides a list of rights of the client and responsibilities that the hospital
cannot violate.

Right to considerate and respectful care

Right to be informed about illness, possible txs, likely outcome, and to discuss this info
with the MD

Right to know the names and roles of the persons who are involved in care

Right to consent or refuse a tx

Right to have an advance directive

Right to privacy

Right to expect that medical records are confidential

Right to review the medical record and to have info explained

Right to expect that the hospital will provide necessary health services

Right to know if the hospital has relationships with outside parties that may influence tx
or care

Right to consent or refuse to take part in research

Right to be told or realistic car alternatives when hospital care is no longer appropriate

Right to know about hospital rules that affect tx and about charges and payment
methods
Legal Responsibilities: Reporting Suspected Staff Substance Abuse

Nurses are required to report certain communicable diseases or criminal activities such
as abuse, gunshot or stab wounds, assaults, homicides and suicides to the appropriate
authorities

The impaired nurse

If a nurse suspects that a co-worker is abusing chemicals, the nurse must report
the individual to nursing admin in a confidential manner.

Nursing admin then notifies the board of nursing regarding the nurses
behavior

Resource Management: Identifying and Reporting Client Care Needs

Resources (eg., supplies, equipment, personnel) are critical to accomplishing the goals
and objectives in a health care facility

Resource management includes budgeting and resource allocation

Budgeting is usually the responsibility of the unit manager, but the staff nurse may be
asked to provide input.

Resource allocation is responsibility of the the unit manager as well as every practicing
nurse. Providing cost-effective client care should be balanced with quality of care.

Cost-effective resource allocation includes:

providing necessary equipment and properly charging client.

Returning uncontaminated unused equipment to the appropriate dept for credit.

Using equipment properly to prevent wastage.

Providing training to staff unfamiliar with equipment.

Returning equipment (eg., IV, kangaroo pumps) to the proper dept (eg central service,
central distribution) as soon as it is no longer needed. This action will prevent further
cost to the client.

Performance Improvement: Recognizing Priority Data Needed to Plan Staffing

Referrals: Recognizing Client Need for Rehabilitation Services

Resource Management: Safe Cost-Effectiveness Nursing Interventions

Cost-Effective resource allocation includes:

Providing necessary equipment and properly charging the client

Returning uncontaminated, unused equipment to the appropriate dept for credit.

using equipment properly to prevent wastage

Providing training to staff unfamiliar with equipment

Returning equipment (eg IV, kangaroo pumps) to the proper dept (eg central service,
central distribution) as soon as it is no longer needed. This action will prevent further
cost to the client.

Staff Development: Evaluate Outcomes of Staff Education Activities

Staff Development: Orientation to the Workplace

Orientation

helps new graduates translate knowledge, principles, skills, and theories learned
in nursing school into practice
 is necessary for nurses new to health care facility or unit to learn the procedures
and protocols

Topic Descriptors

PHARMACOLOGICAL AND PARENTERAL THERAPIES (24)

Form A

Medications to Treat Depression: Recognizing Side Effects of Tricyclic

Antidepressants

Mohr---

predominant SE of tricyclic antidepressants are:

sedation
dry mouth
blurred vision
urinary retention
delayed micturition
dizziness
fainting

Other SE

confusion
disturbed concentration
weight gain
constipation

ATI----

Select Prototype Med: amytriptyline (Elavil)

 Side/Adverse Effect Nursing Intervention/Client Education

Orthostatic Hypotension Instruct clients about the signs of postural

hypotension (lightheadedness, dizziness).
If these occur, advise the client to sit or lie
down. Orthostatic hypotension can be
minimized by getting up slowly

Anticholinergic effects (eg., dry mouth, Instruct the client on ways to minimize
blurred vision, photophobia, acute urinary anticholinergic effects.
retention, constipation, tachycardia) Advise the client to chew sugarless gum,
eat foods high in fiber, and increase water
intake to at lease 8-10 glasses/day
Teach the client to monitor HR and report
noteworthy increases.
Advise the client to notify the primary care
provider if sx are intolerable.

Cardiac toxicity usually only at excessive Obtain the clients baseline ECG and
dosing monitor during tx

Sedation Usually diminishes over time

Advise clients to avoid hazardous activities
such as driving if sedation is excessive.
Advise the client to take med at bedtime to
minimize daytime sleepiness and to
promote sleep

Toxicity evidenced by dysrhythmias, Give Clients who are acutely ill only a 1-
mental confusion, and agitation, followed week supply of med
by seizures, and coma Monitor the client for signs of toxicity
Notify the PCP if signs of toxicity occur.

Immunosuppressants: Recognizing Risk Factors for Infection

Calcineurin inhibitors: cyclosporine

(Sandimmune, Gengraf, Neoral)
Glucocorticoids: Prednisone
Cytotoxics: azathioprine (Imuran)

tacrolimus (Prograf), methotrexate (Rheumatrex, trexall)

increases risk of infection such as fever an/or sore through

advise the client if sx occur to notify the primary care provider immediately

Glucocorticoids are contraindicated in recurring live virus vaccines (increases risk of

infection) and systemic fungal infections.

Cyclosporine is contraindicated in recent contact or active infection of chicken pox or

herpes zoster

Estrogens: Recognizing Side Effects

endometrial and ovarian CA--occur when prolonged estrogen is the only

postmenopausal therapy
give client progestins along with estrogen
instruct client to report persistent vaginal bleeding
advise client to have endometrial biopsy q 2 years

potential risk for estrogen-dependent breast CA--

rule out prior to starting therapy

encourage regular self-breast exams and mammograms

embolic events (ie: MI, pulmonary embolism, DVT, CVA)

discourage client from smoking

monitor the client for pain, swelling, warmth or erythema in lower legs

feminization (gynecomastia, testicular and penile atrophy),, impotence, and decreased

libido in males

avoid use of estrogen vaginal creams prior to sexual intercourse
sx disappear when med is discontinued

Magnesium Sulfate Therapy: Appropriate Interventions to Counteract Toxicity for

a client with Gestational Hypertension

Gestational Hypertension begins after the 20th week of pregnancy

BP at 140/90 or greater

systolic increase of 30 mmHg

diastolic increase of 15 mmHg

there is no proteinuria or edema

clients BP returns to baseline by 6 weeks postpartum

Magnesium Sulfate Toxicity include

absence of patellar DTRs

UOP < 30 cc/hr
Resp < 12/min
decreased LOC

If Mag toxicity is suspected

immediately discontinue infusion

administer calcium gluconate, (IV admin of 1 g (10ml of 10% soln) at 1 ml/min)

Discontinue mag if RR < 12, a low pulse ox (<95%) persists or DTRs are absent
Notify MD
If UOP falls below 20ml/hr the MD is notified so that the drugs admin can be adjusted to
maintain a therapeutic range

Calcium opposes the effects of mag at the neuromuscular junction

Always have an injectable form of calcium gluconate avail when administering

magnesium sulfate by IV

Succinylcholine: Recognizing and Responding to Malignant Hyperthermia

Malignant hyperthermia is a rare metabolic disease characterized by hyperthermia with

rigidity of skeletal muscles that can result in death

occurs in affected people exposed to certain anesthetic agents

Succinylcholine (Anectine) especially in conjunction with volatile inhalation agents,

appears to be the primary trigger of the disorder

usually during general anesthesia but it may manifest in the recovery period as well.
fundamental defect: hypermetabolism resulting in altered control of intracellular calcium
leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis and
hemodynamic and cardiac alterations.

hyperthermia not an early sign

definitive treatment is Dantrolene (Dantrium) which slows metabolism along with

symptomatic support to correct hemodynamic instability

Blood and Blood Products: Evaluating Client Response to Blood Transfusions

NS ok

No dexrose solns or lactated ringers.

no other additives s/b given via the same tubing

During 1st 15 min or 50ml the nurse should remain with the pt

rate s/b no more than 2ml per min

usual rate after the 1st 15 min...1 unit over 2 hrs

should not take more than 4 hrs to administer.

Steps if acute blood reaction occurs.

e. Stop the transfusion

f. Maintain a patent IV line with saline soln
g. notify the blood bank and HCP immediately
h. recheck ID tags and numbers
i. monitor VS and UOP
j. tx sx per MD order
k. save the blood bag and tubing and send them to blood bank for exam
l. complete tranfusion reaction reports
m.collect required blood and urine specimens at intervals stipulated by hospital policy to
evaluate for hemolysis
n. document on transfusion reaction.

Acute reactions: 15 min

Delayed reactions: 2-14 days after administration
Acute hemolytic

treat shock if present

draw blood samples
maintain BP with IV colloid soln
give diuretics to maintain urine flow
insert indwelling cath or measure amts of hourly UOP
do not transfuse additional RBC

Febrile

give antipyretics as prescribed

do not restart transfusion

Mild allergic

give antihistamine as directed

if sx are mild and transient, transfusion may be restarted

Anaphylactic and severe allergic

initiate CPR if indicated

have epi ready for injection 0.4 ml of 1:1000 soln SQ or 0.1 ml 1:1000 soln diluted to
10ml with saline for IV use
Do not restart transfusion

Circulatory overload

place pt upright with feet in dependent position

admin prescribed diuretics, 02, morphine
phlebotomy may be indicated

Sepsis

obtain culture of pts blood and send bag with remaining blood and tubing to blood bank
for further study

treat septicemia as directed---abx, IV, fluids

Vascular Access: Recognizing and Documenting Expected Finding for a Client

with a central venous access device.

PICC line
Insertion: basilic or cephalic vein at least 1 fingers breadth below or above the
anticubital fossa. tip is positioned in the lower 1/3 of the superior vena cava

Indications:
admin of blood
long term admin of chemo
abx
tpn

care:
assess q 8 hr. note redness, swelling, drainage, tenderness and condition of dressing
change tube and positive pressure cap per protocol (usually q 3 days)
us 10ML or larger syringe to flush the line
clean insertion port with alcohol for 3 sec, let dry
perform flush for intermittent med admin usually 10 Ml of NS before, between and after
meds.
use transparent dressing usually change q 7 days and when indicated
advise client to avoid excessive physical exercise on affected extremity

Tunneled Caths (Hickman)

Insertion: subq tunnel separating point where the cath enters the vein from where it
enters the skin with a cuff

indication:
need for vascular access is long term (1 year or more)
commonly for chemo

care:
to access:
apply local anesthetic, palpate to locate the port
clean with alcohol for 3 sec
access with noncoring needle
flush after q use and at least once a month

Basic Pharmacological Principles: Expected Dosage Adjustments Based on Age

of Client

Pediatric dosages are based on body wt, body surface area and maturation of body
organs.

meds are based on age bec of greater risk for decreased skeletal growth, acute CV
failure or hepatic toxicity.
Hematopoietic Growth Factors: Evaluating Client Outcomes

Hematopoietic growth factors act on the bone marrow to increase production of red
blood cells

Epoetin

used for
anemia of CRF
HIV infected clients taking Retrovir
anemia induced by chemo
anemia in clients scheduled for elective surgery

SE: hypertension secondary to elevations in HCT

increased risk for CV event

Nursing Interventions:

Monitor clients iron levels

RBC growth dependent on adequate quantities of iron, folic acid, and vit B12

monitor the clients Hgb and Hct twice a week until target range is reached

obtain baseline BP

in CRF, control HTN before tx

do not combine with other med

Evaluation of med effectiveness : Hgb level of 10-12 and HCT of 40%

increased reticulocyte count

filgrastin (Neupogen), pegfilgrastin (Neulasta)

stimulate the bone marrow to increase production of neutrophils

decreases the risk of infection in clients with neutropenia

SE: bone pain

leukocytosis---decrease dose or stop tx if WBC > 50000 or platelets > 500000

contraindicated in clients sensitive to E. Coli

should not be combined with other med

Evaluation of Medication Effectiveness

absence of infection
in chemo for CA tx, an absolute neutrophil count increase to greater than 10,000 after
chemo induced nadir.

sargramostim (leukine)

acts on the bone marrow to increase production of WBC (neutrophils, monocytes,

macrophages, eosinophils

facilitates recovery of bone marrow after bone marrow transplant

used in the tx of failed bone marrow transplant

SE: diarrhea, weakness, rash, bone pain

leukocytosis, thrombocytosis

reduce tx if WBC> 50000, neutrophil > 20000 or platelets > 500000

contraindicated in clients allergic to yeast products

use cautiously in clients with heart disease, hypoxia, peripheral edema, pleural and
pericardial effusion

Evaluation of Medication Effectiveness

absence of infection

WBC and differential within normal ranges

Proton Pump Inhibitors: Client Education

omeprazole (Prilosec)

reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric
acid

prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions
(Zollinger-Ellison syndrome)

Allow at least a 2 hr interval between this med and:

Ampicillin
Digoxin
Iron
ketoconazole

delayed absorption of these meds may occur if taken concurrently with omeprazole.

Therapeutic Interventions and Client Education

Do not crush, chew, or break sustained release capsules

may sprinkle contents of the capsule over food to facilitate swallowing

take once a day prior to eating

avoid irritating meds (ibuprofen, ETOH)

active ulcers should be txd for 4-6 weeks

Protonix (pantoprazole) can be admin to client IV. Monitor IV site. may be low incidence
of HA and diarrheat

notify PCP for any sign of obvious or occult GI bleeding

Migraine Medications: Evaluating Appropriate Use of Sumatriptan (Imitrex)

sumatriptan (Imitrex)

serotonin receptor agonist

prevent the inflammation and dilation of the incranial blood vessels thereby relieving
migraine pain

therapeutic uses

to abort acute migraine attack

prevent migraine attack

Contraindicated in clients with ischemic heart disease, hx of MI, uncontrolled HTN and
other heart diseases

do not give with ergotamine (ergostat)---leads to spastic reaction of blood vessels.

don not give triptans within 2 weeks of stopping MAOIs---can lead to MAO toxicity.
Cephalosporins: Evaluating Tx Effectiveness

beta-lactam abx similar to PCNs that destroy bacterial cell walls causing destruction of
microorganisms

effective against gram neg organisms and anaerobes

more able to reach CSF

broad spectrum bactericidal meds with a high therapeutic index that treat UTIs, post op
infections, pelvic infections, and meningitis.

Evaluation of Medication Effectiveness

improvement of infection sx: reduction of fever, pain, and inflammation, clear breath
sounds, reduced UTI sx, negative urine CX

Basic Principles of Med Admin: Client Education Regarding Age Related

interventions

Promoting Compliance in the older adults

give clear and concise instructions, verbally and in writing

ensure dosage form is appropriate. liquids should be admin to clients who have difficulty
swallowing

provide clearly marked containers that are easy to open

assist the client to set up a daily calendar with the use of pill containers

suggest that the client obtain assistance from a friend, neighbor, or relative.

Medication Admin and Error Prevention: Disposing of Unused Controlled

Schedule Medications

If only one part of a premeasured dose of a controlled substance is given, a second

nurse witnesses disposal of the unused portion and documents such on the record form

Dosage Calculation: Calculating Hourly Infusion Rate for a Large Volume of Fluid

A RN is to admin 500 mL of D5W over 4 hr. The IV pump should be set to deliver how
many mL per hour

125 mL/ hr
An IV med is to run over 20 min on the pump. The med is mixed in 50 ML of NS. The IV
pump should be set to deliver how many mL/hr.

150mL/hr

An IV med is to run over 45 min on the pump. The med is mixed in 100mL of NS. The IV
pump should be set to deliver how many mL/ hr?

133 mL/hr.

Intravenous Therapy: Priority Interventions with Initiation of Therapy

Unexpected Outcomes and Related Interventions

Fluid volume deficit AMB decreased UOP, dry mucous membranes, hypotension,
tachycardia
notify MD, may require adjustment of infusion rate

Fluid Volume excess AMB crackles in lungs, shortness of breath, edema

reduce IV flow rate if sx appear and notify MD

Electrolyte imbalances AMB abnormal serum electrolyte levels, changes in mental

status and alterations in neuromuscular function, changes in VS and other
manifestations
notify MD. additives in IV or type of IV fluid may be adjusted.

Infiltration as indicated by swelling and possible pitting edema, pallor, coolness, pain at
insertion site and possible decrease in flow rate
stop infusion and d/c IV. elevate affected extremity. restart new IV if continued
therapy is necessary

phlebitis as indicated by pain, increased skin temp, erythema along path of vein.
stop infusion and d/c IV. restart new IV if continued therapy is necessary.
place moist warm compress over area of phlebitis

Bleeding occurs at venipuncture site

bleeding from vein is usually slow, continuous seepage. common in clients who
have received heparin or have a bleeding disorder or if the IV site is over bend in arm/
hand
if bleeding occurs around venipuncture site and catheter is within vein, gauze dressing
may be applied over site. eventually IV may need to be discontinued
blood on the dressing can result when the administration set becomes disconnected
from the catheters hub. When blood appears on the dressing, verify that the system is
intact and change the dressing
Intravenous Therapy: Documenting Discontinuation of IV Following Signs of
Phlebitis

Signs of Phlebitis

Edema
Throbbing, burning or pain at the site
Warmth
Erythema
May be a red line up the arm with a palpable band at the vein site
Slowed infusion

Prevention:
rotation of sites
avoiding the lower extremities
proper handwashing and surgical aseptic technique.

Promptly d/c infusion.

Notify PCP
elevation
warm/moist compresses
restarting with new tubing and fluid
TED hose and/or anticoagulants
culturing the site if drainage is present

(P/P)

Unexpected Outcomes and Related Interventions

Phlebitis is present, as evidenced by erythema and tenderness along vein pathway.

Stop IV infusion and d/c IV. Restart new IV in other extremity if continued therapy
is necessary.

Record appearance of IV site, type of dressing, and status of IV fluid infusion.

A special parenteral fluid flow sheet may be used for recording.

Medications Affecting the Respiratory System: Recognizing Ineffectiveness of

Beta2-Adrenergic Agonists.

albuterol (Proventil, ventolin)

act by selectively activating the beta2 receptors in the bronchial smooth muscle
resulting in bronchodilation. As a result:
bronchodilation is relieved
histamine release is inhibited
ciliary motility is increased

prevention of asthma
tx for ongoing asthma attack
long term control of asthma

Effectiveness may be evidenced by

long term control of asthma attacks

prevention of exercise induced asthma attack
resolution of asthma attack as evidenced by absence of SOB, clear breath sounds,
absence of wheezing, return of RR to baseline.

Oral Hypoglycemics: Client Teaching Regarding Use in Pregnancy

Avoid use in pregnancy and lactation (risk for fetal/infant hypoglycemia)

Oral hypoglycemic medication contraindicated (causes birth defects).

Medications Used to Treat TB: Recognizing Risk for Phenytoin Toxicity due to
Med interactions.

INH (isoniazid)

highly specific for mycobacteria. Isoniazid inhibits growth of mycobacteria by preventing

synthesis of mycolic acid in the cell wall

indicated for active and latent TB

Latent INH only ---daily for 6 months
Active: multiple med therapy including INH, rifampin, pyrazinamide, and/or
pyridoxine daily for 6 months

Med reaction:

Phenytoin--INH interferes with the metabolism of phenytoin with accumulation of

phenytoin, resulting in ataxia, and incoordination

monitor levels of phenytoin. dosage of phenytoin may need to be adjusted based on

phenytoin levels.

Opioids: Monitoring Client for Interactions with Anesthesia

Opioids are used preoperatively for sedation and analgesia, intraoperatively for
induction and maintenance of anesthesia and postop for pain management. Opioids
alter the perception of pain and the response to painful stimuli. When admin before the
end of a surgical procedure the residual analgesia often carries over into the PACU
allowing the pt to awaken relatively pain free.
All opioids produce dose-related respiratory depression. Respiratory depression may
be difficult to detect in the OR and therefore requires close observation and pulse
oximetry monitoring. Respiratory depression is reversed with naloxone (Narcan).
However its use is often associated with a reversal of the analgesic effects of the
narcotics as well.

Pain Management: Evaluating Effectiveness of Treatment

Pain Management:

The goals of teaching r/t pain management include that the pt and family member
understand the following

need to maintain a record of pain level and effectiveness of tx

no need to wait until becomes severe to take drugs or use nondrug therapies for pain
relief
med will stop working after it is taken for a period of time, and dosages may need to be
adjusted
potential SE and complications associated with therapy. SE: N/V, constipation, itching,
sedation and drowsiness, urinary retention, sweating
need to report when pain is not relieved to tolerable levels.

client attained her pain relief goal most of the time

client is performing ADLs, walking and ability to sleep

if nurse assess that a client continues to have discomfort after an intervention, it may be
necessary to try a different approach. If an analgesic provides only partial relief, the
nurse may add relaxation exercises or guided imagery exercises. The nurse may also
consult with the physician about increasing the dosage, decreasing the interval between
doses, or trying different analgesics.

nurse evaluates the clients perceptions of the effectiveness of the interventions. The
client may help decide the best times to attempt a tx. in essence, the client is the best
judge of whether an intervention works. The nurse also evaluates tolerance to therapy
and the overall relief obtained. a nurse admin an analgesic, SE from the med and the
clients reported pain relief must be assessed.

client is the best resource for evaluating the effectiveness of pain relief measures.

TPN: Recognizing Appropriate TPN Interventions

TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrients
and electrolytes given through an indwelling or central IV catheter which may be
inserted peripherally or percutaneously, implanted or tunneled.

PN: is a form of specialized nutrition support in which nutrients are provided

intravenously. Safe admin of the form of nutrition depends on appropriate assessment
of nutrition needs, meticulous management of the CVC and careful monitoring to
prevent or tx metabolic complications. Parenteral nutrition is admin in a variety of setting
including the clients home. Regardless of the setting, the nurse adheres to the same
principle of asepsis and infusion management to ensure safe nutrition support.

clients who are unable to digest or absorb enteral nutrition benefit from PN.

goal to move toward the use of the GI tract is constant.

lipid emulsions provide supplemental kilocalories and prevent essential fatty acid
deficiencies. These emulsions can be admin through a separate peripheral line, through
the central line by Y-connector tubing or as an admixture to the PN soln.

The addition of lipid emulsion to the PN solution is called a 3-in-1 mixture and is given
over a 24 hr period. The mixture should not be used if oil droplets are observed or i an
oil or creamy layer is observed on the surface of mixture. indicates that the emulsion
has broken into large lipid droplets that can cause fat emboli if admin.

Initiating PN:

Clients with short-term nutritional needs often receive IV solns of less than 10%
dextrose via a peripheral vein in combination with amino acids and lipids. Peripheral
solns are not as caloricly dense as TPN solutions and therefore are usually temporary.
Parenteral nutrition with greater than 10% dextrose requires a CVC that is placed into a
high-flow central vein such as the superior vena cava by a MD under sterile conditions.
After placement, the cath is flushed with saline or heparin until the position is
radiographically confirmed

Before beginning any parenteral nutrition infusion, verify MDs order and inspect the
soln for particulate matter or a break in the lipid emulsion. An infusion pump is always
used. An initial rate of 40-60 ml/hr is recommended. The rate is gradually increased until
the clients complete nutrition needs are supplied.

Preventing Complications

include:
mechanical complication from insertion of the CVC
infection
metabolic alterations
pneumothorax results from a puncture insult to the pulmonary system and results in the
accumulation of air in the pleural cavity with subsequent collapse of the lung and
impaired breathing.

sudden sharp chest pain

dyspnea
coughing

air embolus can occur during insertion of the catheter or when changing the tubing or
cap
have pt perform valsalva maneuver (hold breath and bear down) while assuming
a left lateral decubitus position can prevent air embolus

the increased venous pressure created by the maneuver prevents air from
entering the bloodstream during cath insertion

infection

tubing should be changed q 24 hrs with lipids and q 48 hrs with no lipids.

during dressing changes, sterile mask and gloves are always used and insertion
sites should be assessed for s/s of infection

Vit K must be given as ordered throughout therapy. Vit K can be synthesized by

microflora found in the jejunum and ileum with normal use of the GI tract however bec
PN circumvents GI use, exogenous vit K must be administered.

Admin of concentrated glucose is accompanied by increases in endogenous insulin

production, which causes cations (K+, Mg+ and Ph+) to move intracellularly.

In malnourished or cachetic clients, the resulting low serum extracellular levels of

electrolytes and edema may cause cardiac dysrhythmias, CHF, respiratory distress,
convulsions, coma, death. (Refeeding syndrome)

Too rapid admin of hypertonic dextrose can result in an osmotic diuresis and
dehydration. If an infusion falls behind scheule, the nurse should not increase the rate in
an attempt to catch up.

Sudden discontinuation of the soln can cause hypoglycemia.

usually 5-10% dextrose is infused when PN soln is suddenly d/cd.

catheter occlusion
 temporarily stop infusion and flush with NS or heparin. if effort to flush is
unsuccessful, attempt to aspirate a clot, is still unsuccessful, follow protocol for use of
thrombolytic agent (urokinase)

hypoglycemia

to prevent: do not abruptly discontinue TPN but taper rate down to within 10% of
infusion rate 1-2 hours before stopping.

hyperglycemia

monitor BG level daily until stable then as ordered or prn. TPN is initiated slowly
and tapered up to maximal infusion rate. additional insulin may be required during
therapy if problem persists.

Form B

Aminoglycosides: Assessing for Nephrotoxicity

Nephrotoxicity r/t high total cumulative dose resulting in acute tubular necrosis
(proteinuria, casts in the urine, dilute urine, elevated BUN, creatinine levels

Monitor I/O, BUN, creatinine levels

Normal values:
BUN 5-20 mg/dL
Creatinine 0.5-1.3 mg/dL

Instruct pt to report a significant decrease in UOP

Glucocorticoids: Recognizing SE of Long Term Therapy

Hypokalemia may develop

Predisposition to peptic ulcer disease
skeletal muscle atrophy and weakness
mood and behavior changes
fat from extremities is redistributed to trunk and face
hypocalcemia r/t anti-vit D effect
healing is delayed. at increased risk for wound dehiscence
susceptibility to infection is increased. Infection develops more rapidly and spreads
more widely
suppression of pituitary ACTH synthesis occurs
increased BP occurs
Protein depletion decreases bone formation, density and strength

Ceftriaxone (Rocephin): Clostridium Difficile Complication During Antimicrobial

Therapy

antibiotic associated pseudomembranous colitis

observe the pt for diarrhea and notify the PCP
d/c abx

Abx can cause diarrhea by altering the normal bowel flora. Pts receiving abx are
susceptible to Clostridium difficile infection. Health care workers who do not adhere to
infection control precautions can transmit C. difficile from pt to pt.

Some strains of C. difficile release a toxin that causes mucosal damage resulting in
cramping, pain and diarrhea that may be bloody. C. Difficile infection can also result in
pseudomembranous enterocolitis and intestinal perforation.

Sx: watery diarrhea to severe abdominal pain; fever; leukocytosis; leukocytes in the
stool

Medications Affecting Blood: Appropriate Procedure for Transfusing Packed

RBCs

Admin of packed red blood cells increases the number of RBC

Before starting a packed RBC transfusion, verify the PCPs order, clients blood typing,
obtain consent for transfusion, and check clients transfusion hx

A second person is necessary to check id of donor blood and recipient, blood

compatibility, and expiration order

assess the client before, during and after admin

Upon initiation of the transfusion, obtain baseline VS and assessment of UOP,

document on clients MR, record start and completion times of transfusion, total volume
of transfusion and clients response to transfusion,

Assess infusion site for infection or infiltration

assess patency of IV line

do not admin blood along with any IV solution other than NS. IV solutions containing
dextrose cause hemolysis of RBC
Admin blood using a gauge 19 or larger IV needle (to avoid breakage of cells and
blockage of needle lumen), a blood filter (to remove particles and possible contaminants
within old blood), and use a Y tubing connection (so that NS can be infused by
piggyback)

Observe universal precautions during handling and admin of blood products

Do no admin blood products with any other meds

Complete transfusion within 2-4 hr

In the event of a blood transfusion reaction

Stop transfusion immediately and notify the PcP

do not turn on IV fluids that are connected to the Y tubing bec the remaining
blood in the Y tubing will be infused and aggravate the clients reaction. Admin a new IV
soln of NS

Stay with the client and monitor VS and UOP

Notify the blood bank, recheck ID tag and numbers on the blood tag and send blood
bag and IV tubing to blood bank for analysis

Obtain urine specimen and send to lab to determine for RBC hemolysis

Complete transfusion log sheet, which includes complete record of baseline VS,
ongoing monitoring, and clients response to transfusion.

Basic Dosage Calculation: Monitoring IV Heparin Infusion

Monitor VS.
In the case of heparin overdose, stop heparin, admin protamine sulfate and avoid ASA
Monitor activated partial thromboplastin time (aPTT). Keep value at , 2 times the
baseline.

Dosages must be checked by another nurse before admin.

For continuous IV admin, use an infusion pump. Rate of infusion must be monitored q
30-60 min.

Monitor aPPT q 4-6 hr until appropriate dose is determined and then monitor daily

Medication effectiveness:
aPTT levels of 60-80 sec

No development or no further development of venous thrombi

Glucocorticoids for Rheumatoid Arthritis: Evaluating Client Education Regarding

Long Term Effects

Client Teaching for Corticosteroid Therapy

E. Plan a diet high in protein, calcium (at least 1500 mg per day) and potassium but low
in fat and concentrated simple carbs such as sugar, honey, syrups and candy.
F. Identify measures to ensure adequate rest and sleep such as daily naps and
avoidance of caffeine lat in the day
G.develop and maintain an exercise program to help maintain bone integrity
H.recognize edema and ways to restrict sodium intake to less than 2000mg per day if
edema occurs
I. monitor glucose levels and recognize sx and signs of hyperglycemia (eg polydipsia,
polyuria, blurred vision) and glycosuria (glucose in the urine). The pt should be
instructed to report hyperglycemic sx or capillary glucose levels greater than 180 mg/
dL or urine positive for glucose
J. notify HCP if experiencing postprandial heartburn or epigastric pain that is not
relieved by antacids.
K. See an eye specialist yearly to assess development of possible cataracts
L. use safety measures such as getting up slowly from bed or a chair and use good
lighting to avoid accidental injury
M.maintain good hygiene practices and avoid contact with persons with colds or other
contagious illnesses to avoid infection.
Osteoporosis
Advise the client to take Ca supplements, vit D, and/or biphosphonate

Adrenal suppression
advise client to observe for sx

Insulin: Monitoring Adequate Blood Glucose Control

Medication effectiveness:

Glucose levels of 90-130 mg/dL preprandial and < 180 mg/dL postprandial

HgA1c < 7 %

Normotensive (< 130/80 mmHg)

Cholesterol levels within normal range

Insulin Duration For meal time Onset Peak

dose, admin

Lispro insulin Short, rapid 15 min ac Rapid 15-30 min 1/2 - 2 1/2 hr
(Humalog) acting (3-6.5 hr)

Aspart insulin Short, rapid 5-10 min ac Rapid 10-20 min 1-3 hr
(Novolog) acting (3-5 hr)

Reg Insulin Short, slower 30 min ac 30 -60 min 1-5 hr

(Humulin R, acting (6-10 hr) Bolus 30 min ac
Novolin R)

NPH insulin Intermediate Admin 2x/day 1-2 hr 6-14 hr

(Humulin-N, (16-24 hr) (same time)
Novolin-N)

Glargine insulin Long (24 hr) Admin 1x/day 70 min None

(Lantus) (same time)

Cardiac Glycosides: Client Education to Reduce Risk

Therapeutic Nursing Interventions and Client Education

Advise clients to take med as prescribed and not to double the dose when a dose is not
taken at the prescribed time

Check pulse rate and rhythm before admin of digoxin and record, notify the PcP if HR is
< 60 beats/min in an adult, <70 beats/min in children and < 90 beats/min in infants.

Admin dig at same time daily.

Monitor dig levels periodically while on tx and maintain therapeutic levels between
0.5-2.0 ng/mL to prevent dig toxicity

Avoid taking OTC meds to prevent adverse SE and med interactions

Instruct clients to observe symptoms of hypokalemia such as muscle weakness, and to

notify the PCP if sx occur.
Instruct clients to observe sx of dig toxicity (eg anorexia, fatigue, weakness) and to
notify PcP if sx occur

Management of dig toxicity

Dig and potassium sparing med should be stopped immediately

Monitor K levels. For levels, < 3.5 mEq/L, potassium should be administered IV or by
mouth. Do not give any further K+ level > 5.0 mEq/L

Treat dysrhythmias with phenytoin or lidocaine

treat bradycardia with atropine

For excessive overdose, activated charcoal, cholestyramine, or Digibind can be used to

bind Digoxin and prevent absorption

Pharmacological Pain Management: Knowledge of Pudendal Blocks

Pudendal blocks anesthetizes the lower vagina and part of the perineum to provide
anesthesia for an episiotomy and vaginal birth using low forceps if needed

A pudendal block does not block pain from uterine contractions and the mother feels
pressure.

The pudendal block is a highly localized type of regional block similar to a dental
anesthetic that provides numbness for dental procedures

The MD injects the pudendal nerves near each ischial spine with a local anesthetic.
Perineum is infiltrated with local anesthetic bec the pudendal block does not fully
anesthetize this area.

As in local infiltration, a delay occurs between injection and onset of numbness.

Possible maternal complications include a toxic reaction to the anesthetic, rectal

puncture, hematoma, and sciatic nerve block.

If maternal toxicity is avoided, the fetus is usually not affected

Medications to Treat Psychoses: Recognizing Adverse Effects

Antipsychotics: Conventional
Thorazine, Haldol

Extrapyramidal Symptoms
Early
dystonia (severe spasms of tongue, neck, face and back)
Parkinsonism (bradykinesia, rigidity, shuffling gait, drooling) tremors
Akathisia (inability to stand or sit , pacing)

Late
tardive dyskinesia (twisting or worm-like movement of the tongue and face, lip
smacking)

Neuroleptic Malignant Syndrome

sudden high grade fever, BP flucuations, dysrhythmias, muscle rigidity, change in
LOC developing into coma
Anticholinergic Effects
dry mouth, visual disturbance, acute urinary retention, constipation, tachycardia

Orthostatic Hypotension

Sedation

Neuroendocrine effects
gynecomastia, galactorrhea, menstrual irregularities

Sexual dysfunction

Skin effects
photosensitivity resulting in severe sunburn, contact dermatitis from handling
meds

Agranulocytosis

Severe dysrhythmias

Antipsychotics-Atypical
Clozapine
Risperidone
olanzapine
quetiapine
aripiprazole

Adverse Effects
Agranulocytosis
Seizures
New onset of DM or loss of glucose control in clients with DM
Wt gain
Inflammation of hear muscle AEB dyspnea, increased RR, CP, palpitations.
ACE Inhibitors: Intervening for Client Response

ACE inhibitors produce their effects by blocking the production of angiotensin II This
results in:
vasodilation (mostly arteriole)
excretion of Na and H20, and retention of K+ (through effects on kidney)
possible prevention of angiotensin II and aldosterone-induced pathological
changes in blood vessels and heart.

Side/Adverse Effects Interventions/Client Education

First dose orthostatic hypotension if pt taking diuretic, stop med

temporarily for 2-3 days prior to the
start of an ACE inhibitor
Start tx with a low dosage
monitor the BP for 2 hr after
initiation of tx
instruct the client to change
positions slowly and to lie down if
feeling dizzy, lightheaded, or faint

Cough inform client of dry cough

notify PCP as med will most likely
be d/cd

HYPERKALEMIA monitor K+ levels to maintain

normal range of 3.0-5.0 mEq/L
Only take K+ substitutes if
instructed by PCP

Rash and dysgeusia (altered taste) client should inform PCP

Angioedema (manifested as treat severe effects with

swelling of the tongue and oral subcutaneous injection of
pharynx epinephrine

Neutropenia--rare complication of monitor the clients WBC counts

Captopril every 2 wks for 3 months, then
periodically.
inform the client to notify PCP at
first signs of infection
Furosemide: Recognizing Interactions with Other Medications

Furosemide (Lasix), a high ceiling loop diuretics work in the ascending limb of Loop of
Henle to
Block reabsorption of Na+ and Cl-, and prevent the reabsorption of H20

Cause extensive diuresis

SE:
dehydration
hypotension
ototoxicity
hypokalemia

Interactions with other Meds

Medication Nursing Intervention

Digoxin toxicity (can occur in the
presence of hypokalemia
monitor pts cardiac status and K+ and
dig levels
K+ sparing diuretics are often used in
conjunction with loop diuretics to reduce
the risk of hypokalemia

Antihypertensives--concurrent use can monitor BP

have additive hypotensive effect

Lithium--levels can rise due to diuresis monitor Lithium levels

NSAIDS blunt diuretic effect Watch for a decrease in effectiveness of

diuretic such as a decrease in UOP

Medications to Treat Pain: Identifying Need for Additional Analgesia

Pain is whatever the person experiencing it says it is, and existing whenever the person
says it does. The clients report of pain is the most reliable diagnostic measure of pain.
Self report using standardized pain scales are useful in clients over the age of &

Pain assessment should be done and recorded freq, and may be considered the fifth
VS

Subjective:
Location
Quality
Intensity
Timing
Setting
Associated sx

Behaviors complement self-report and assist in pain assessment of nonverbal clients

facial expressions
body movements
moaning, crying
decreased attention span

Physiological measures of BP, pulse, RR will be temporarily increased by acute pain.

Follow a clinical approach ABCDE to pain assessment and management

A---ask about pain regularly, ASSESS pain systematically

B---believe the client and family
C---choose appropriate pain control options
D---deliver interventions in a timely fashion
E--empower the client and family

Raking a proactive approach by giving analgesics before pain is severe (for PRN orders
of pain med)

Educating the client regarding misconceptions about pain

Assisting the client to reduce fear and anxiety

Creating a tx plan that includes both nonpharmacological and pharmacological pain
relief measures.

Total Parenteral Nutrition: Recognizing Desired Client Outcomes Based on

Pathophysiology
TPN: a nutritionally adequate hypertonic soln consisting of glucose and other nutrients
and electrolytes given through an indwelling or central IV catheter which may be
inserted peripherally or percutaneously, implanted or tunneled.

PN: is a form of specialized nutrition support in which nutrients are provided

intravenously. Safe admin of the form of nutrition depends on appropriate assessment
of nutrition needs, meticulous management of the CVC and careful monitoring to
prevent or tx metabolic complications. Parenteral nutrition is admin in a variety of setting
including the clients home. Regardless of the setting, the nurse adheres to the same
principle of asepsis and infusion management to ensure safe nutrition support.

clients who are unable to digest or absorb enteral nutrition benefit from PN.

goal to move toward the use of the GI tract is constant.

lipid emulsions provide supplemental kilocalories and prevent essential fatty acid
deficiencies. These emulsions can be admin through a separate peripheral line, through
the central line by Y-connector tubing or as an admixture to the PN soln.

The addition of lipid emulsion to the PN solution is called a 3-in-1 mixture and is given
over a 24 hr period. The mixture should not be used if oil droplets are observed or i an
oil or creamy layer is observed on the surface of mixture. indicates that the emulsion
has broken into large lipid droplets that can cause fat emboli if admin.

Initiating PN:

Clients with short-term nutritional needs often receive IV solns of less than 10%
dextrose via a peripheral vein in combination with amino acids and lipids. Peripheral
solns are not as caloricly dense as TPN solutions and therefore are usually temporary.
Parenteral nutrition with greater than 10% dextrose requires a CVC that is placed into a
high-flow central vein such as the superior vena cava by a MD under sterile conditions.
After placement, the cath is flushed with saline or heparin until the position is
radiographically confirmed

Before beginning any parenteral nutrition infusion, verify MDs order and inspect the
soln for particulate matter or a break in the lipid emulsion. An infusion pump is always
used. An initial rate of 40-60 ml/hr is recommended. The rate is gradually increased until
the clients complete nutrition needs are supplied.

Preventing Complications

include:
mechanical complication from insertion of the CVC
infection
metabolic alterations
pneumothorax results from a puncture insult to the pulmonary system and results in the
accumulation of air in the pleural cavity with subsequent collapse of the lung and
impaired breathing.

sudden sharp chest pain

dyspnea
coughing

air embolus can occur during insertion of the catheter or when changing the tubing or
cap
have pt perform valsalva maneuver (hold breath and bear down) while assuming
a left lateral decubitus position can prevent air embolus

the increased venous pressure created by the maneuver prevents air from
entering the bloodstream during cath insertion

infection

tubing should be changed q 24 hrs with lipids and q 48 hrs with no lipids.

during dressing changes, sterile mask and gloves are always used and insertion
sites should be assessed for s/s of infection

Vit K must be given as ordered throughout therapy. Vit K can be synthesized by

microflora found in the jejunum and ileum with normal use of the GI tract however bec
PN circumvents GI use, exogenous vit K must be administered.

Admin of concentrated glucose is accompanied by increases in endogenous insulin

production, which causes cations (K+, Mg+ and Ph+) to move intracellularly.

In malnourished or cachetic clients, the resulting low serum extracellular levels of

electrolytes and edema may cause cardiac dysrhythmias, CHF, respiratory distress,
convulsions, coma, death. (Refeeding syndrome)

Too rapid admin of hypertonic dextrose can result in an osmotic diuresis and
dehydration. If an infusion falls behind schedule, the nurse should not increase the rate
in an attempt to catch up.

Sudden discontinuation of the soln can cause hypoglycemia.

usually 5-10% dextrose is infused when PN soln is suddenly d/cd.

catheter occlusion
 temporarily stop infusion and flush with NS or heparin. if effort to flush is
unsuccessful, attempt to aspirate a clot, is still unsuccessful, follow protocol for use of
thrombolytic agent (urokinase)

hypoglycemia

to prevent: do not abruptly discontinue TPN but taper rate down to within 10% of
infusion rate 1-2 hours before stopping.

hyperglycemia

monitor BG level daily until stable then as ordered or prn. TPN is initiated slowly
and tapered up to maximal infusion rate. additional insulin may be required during
therapy if problem persists.

Topic Descriptors

Physiological Adaption (21)

Form A

Prolapsed Umbilical Cord: Emergency Nursing Response

Prolapsed Umbilical Cord occurs when the umbilical cord is displaced preceding the
presenting part of the fetus or protruding through the cervix

results in cord compression and compromised fetal circulation

Assessment:
client states she can feel something coming through the vagina
visualization or palpation of the umbilical cord protruding from the introitus
assessment that show FHR to have variable decelerations
extreme increase in fetal activity that occurs and then ceases. This may be suggestive
of severe fetal hypoxia.

Nursing interventions

include relieving the cord compression immediately and increasing fetal oxygenation

call for assistance immediately

notify the primary care provider of the prolapsed cord

position the clients hips higher than her head

reposition the client in a knee chest position. Trendelenberg or a side-lying position with
a rolled towel under the clients right or left hip to relieve pressure on the cord

using a sterile gloved hand, insert two fingers into the vagina and apply finger pressure
on either side of the cord to the fetal presenting part to elevate it off the cord

apply a sterile saline soaked towel to the cord to prevent drying and to maintain blood
flow if it is protruding from the vaginal introitus.

closely monitor the FHR with an electronic fetal monitor for variable decelerations
indicative of fetal asphyxia and hypoxia from cord compression

administer oxygen at 8-10 L via a face mask. This will improve fetal oxygenation

Amnioinfusion of NS or LR solution as prescribed should be instilled into the amniotic

cavity through a transcervical catheter introduced into the uterus to alleviate cord
compression if it is caused by oligohydramnios

prepare the client for a C-section if other measures fail.

Myocardial Infarction: Evaluating Effectiveness of Medication Interventions

Nursing Interventions

Administer 02 4-6 L as prescribed

Obtain and maintain IV access

Administer meds as prescribed

Vasodilators oppose coronary artery vasospasm and reduce preload and afterload,
decreasing myocardial oxygen demand
NITROGlYCERIN

Analgesics reduce pain, which decrease sympathetic stress leading to preload

reduction
MORPHINE

Beta blockers have antidysrhythmic and antihypertensive properties and decrease the
imbalance between myocardial oxygen supply and demand by reducing afterload
in an acute MI, beta-blockers decrease infarct size and improve short and long term
survival rates

Thrombolytic agents can be effective in dissolving thrombi if admin within the first 6 hrs
following an MI. Contraindications include recent surgery, recent head trauma, and any
other situation that poses an additive risk for bleeding internally.
Antiplatelet agents inhibit cyclooxygenase, which produces thromboxane A2, a potent
platelet activator
ASPIRIN

Anticoags (heparin, low molecular wt heparins) are used to prevent the recurrence of a
clot after fibrinolysis

Client education regarding response to chest pain

stop activity and rest

place nitro under tongue to dissolve (quick absorption)

repeat every 5 min if the pain is not relieved.

call 911 if pain is not relieved in 15 min.

Fractures: Discharge Teaching Regarding Cast Care

Patient and Family Teaching Guide

Do Not

Get plaster cast wet

Remove any padding
Insert any foreign object inside cast
Bear wt on new cast for 48 hr (not all casts are made for wt bearing; check with HCP
when unsure
Cover cast with plastic for prolonged periods

Do

Apply ice directly over fracture site for first 24 hr (avoid getting cast wet by keeping ice
in plastic bag and protecting cast with cloth
Check with HcP before getting fiberglass cast wet
Dry cast thoroughly after exposure to water
blot dry with towel
use hair dryer on low setting until cast is thoroughly dry
Elevate extremity above level of heart for 1st 48 hr
Move joints above and below cast regularly
Report signs of possible problems to HCP
increasing pain
 swelling associated with pain and discoloration of toes or fingers
pain during movement
burning or tingling under the cast
sores or foul odor under the cast
Keep appointment to have fracture and cast checked.

Electrolyte Imbalances: Evaluating Effectiveness of Hypokalemia Interventions

Potassium normal levels (3.5-5.0 mEq/L)

most common causes: abnormal losses via the kidneys or GI tract, metabolic alkalosis,
sometimes associated with tx of diabetic ketoacidosis bec of increased urinary K loss
and shift of K into cells with admin of Insulin and correction of acidosis

S/S

Expected Findings

serum K+ < 3.5 mEq/L

metabolic alkalosis: pH> 7.45

EKG: PVCs, bradycardia, blocks, VTach, inverted T waves, ST depression

alters resting membrane potential

potentially lethal ventricular arrhythmias

flattening of T wave and eventual emergence of a U wave, increased P wave

skeletal muscle weakness and paralysis (most observed in legs)

respiratory muscles and those innervated by cranial nerves not involved

muscle cramps and muscle cell breakdown (rhabdomyolysis)

leads to myoglobin in the plasma and urine which can in tern, lead to renal failure.

Nursing Implementation

txd by giving potassium chloride supplements (PO or IV) and increasing dietary intake
of potassium
Except in severe deficiencies, KCl is never given unless there is UOP of at lease 0.5 ml/
kg of body wt per hour.

KCl supplements added to IV should never exceed 60mEq/L. Preferred level is 40 mEq/
L

Rate should not exceed 10 to 20 mEq per hour to prevent hyperkalemia and cardiac
arrest.

ATI

Encourage foods high in potassium (avocados, broccoli, dairy products, dried fruit,
cantaloupe, bananas

IV potassium
never IV push (risk of cardiac arrest
maximum recommended rate is 5-10 mEq/hr
monitor for phlebitis
monitor and maintain UOP

monitor for shallow ineffective respirations and diminished breath sounds

monitor the clients cardiac rhythm and intervene promptly as needed
monitor LOC and maintain client safety
monitor bowel sounds and abdominal distention and intervene as needed.

Fluid Imbalances: Appropriate Intervention in Response to Signs of Fluid Volume

Excess

hypervolemia: both water and sodium are retained abnormally high proportions

overhydration: more water is gained than electrolytes

Expected Findings

HGB and HCT:

Overhydration: decreased (hemodilution)

Serum Osmolarity:
Overhydration: decreased (hemodilution) osmolarity (<270mOsm/L)
decreased protein and electrolytes

Serum Sodium
Overhydration: decreased (hemodilution)

Electrolytes, BUN, creatinine

 Hypervolemia: Increased electrolytes, BUN, and creatinine

Nursing Interventions:
Report abnormal findings to PCP

Client Findings:

VS: tachycardia, bounding pule, HTN, tachypnea, increased ICP

Neuro: confusion
MS: muscle weakness
GI: wt gain, ascites
Resp: dyspnea, orthopnea, crackles
Other: edema, distended neck veins

Nursing Interventions:

Assess breath sounds

Monitor ABGs for hypoxemia and respiratory alkalosis
position the client in semi-Fowlers position
administer 02 as needed
reduce IV flow rates
Administer diuretics (osmotic, loop) as ordered.
monitor daily I/O and Wt
Limit fluid and sodium as ordered

Monitor and document presence of edema (pretibial, sacral, periorbital)

monitor and document circulation to the extremities

Turn and position the client at least q 2 hr
support arms and legs to decrease dependent edema as appropriate
monitor for/treat skin breakdown

Complications:

Pulmonary Edema

s/s include ascending crackles, dyspnea at rest, and confusion

position in high Fowlers
admin IV morphine
Admin IV diuretic
prepare for possible intubation and mechanical ventilation

Electrolyte Imbalances: Recognizing Priority Interventions in Response to

Hyponatremia
Na+ serum level 135-145 mEq/L

hyponatremia is a net gain of water or loss of sodium rich fluids

delays and slow the depolarization of membranes

Expected Findings

Serum sodium
decreased <135 mEq/L

Serum osmolarity
decreased < 270 mOsm/L

Expected Client findings

depends on whether it is associated with a normal decreased or increased ECF volume

VS: hypothermia, tachycardia, thready pulse, hypotension, orthostatic hypotension

Neur: HA, confusion, lethargy

MS: muscle weakness to the point of possible respiratory compromise, fatigue,

decreased DTRs

GI: Increased motility, hyperactive bowel sounds, abdominal cramping

Nursing interventions

Report abnormal findings to PCP

Fluid Overload: restrict water intake as ordered
acute hyponatremia
admin hypertonic oral and IV fluids as ordered
encourage foods and fluids high in sodium (cheese, milk, condiments)
restoration of normal ECF: administer isotonic IV therapy (0.9% NS, LR)
monitor I/O and daily wt
monitor VS and LOC--report abnormal findings.

Complications: Seizures

Congenital Heart Disease: Interventions for Decreased Cardiac Output

Cardiac output (CO) depends on preload, afterload, and myocardial contractility, HR,
and metabolic state of the individ.
overloaded heart resorts to compensatory mechanisms to try to maintain adequate CO.
The main compensatory mechanisms include ventricular dilation, ventricular
hypertrophy, increased SNS stimulation and neurohormonal responses.

As CO falls, blood flow to kidneys decreases,

Low CO causes a decrease in cerebral perfusion pressure.

Interventions for CHF:

If client is experiencing respiratory distress, place the client in high Fowlers position and
admin 02 as prescribed

encourage bedrest until the client is stable

encourage energy conservation by assisting with care and ADLs

maintain dietary restrictions as prescribed (restricted fluid intake, restricted sodium

intake)

administer meds as prescribed

diuretics: todecrease preload
loop diuretics (furosemide (Lasix), bumetanine (Bumex) )
thiazide diuretics: HCTZ
tech client taking loop or or thiazide diuretics to ingest foods and drinks that are
high in K+ to counter hypokalemia effect. Potassium supplement may be required.

Administer IV furosemide no fast than 20mg/min

Afterload reducing agents

ACE inhibitors (enalapril, captopril, monitor for initial dose hypotension

beta blockers (Coreg, metoprolol)

Angiotensin II blockers such as losartan

Inotropic agents
digoxin
dopamine
dobutamine
milrinone
to increase contractility and thereby improve CO

Vasodilators
nitrates

to decrease preload and afterload

 hBNP
nesiritide (Natrecor)

to tx acute HF by causing natriuresis (loss of sodium and

vasodilation)

Anticoagulants
warfarin (Coumadin), heparin, clopidrogrel
to prevent thrombus formation associated with
congestion/stasis and associated afib.

Shock: Recognizing S/S of Hypovolemia

Hypovolemic shock occurs when there is a loss of intravascular fluid volume

One of the first clinical signs of shock may be a fall in BP

Decreased LOC
Restlessness
Anxiety
Weakness
Rapid, weak, thready pulses
Arrhythmias
Hypotension
Narrowed pulse pressure
cool clammy skin
tachypnea, dyspnea, shallow irregular respirations
decreased 02 saturation
extreme thirst
N/V
chills
feeling of impending doom
pallor
cyanosis
obvious hemorrhage or injury
temp dysregulation

Acute GI Disorders: Recognizing S/S to report

Appendicitis

mild or cramping, epigastric or periumbilical pain (initial)

constant, intense RLQ pain (later)
N/V
anorexia
Rebound tenderness (pain after deep pressure is applied and released over
McBurneys point (located halfway between the umbilicus and anterior iliac spine)
Pain that decrease with a decrease in right hip flexion or increases with coughing and
movement may indicate perforation with peritonitis
muscle rigidity, tense positioning, guarding may indicate perforation with peritonitis
normal to low grade temp (higher suggests peritonitis)

Acute Abdominal/GI Findings (Med-Surg)

Diffuse, localized, dull, burning or sharp abdominal pain or tenderness

rebound tenderness
abdominal distention
abdominal rigidity
N/V/D
hematemesis
melena

Abdominal Trauma

Surface Findings

abrasions or ecchymosis on abdominal wall, flank, or peritoneum

open wounds, lacerations,eviscerations
puncture wounds, gunshot wounds
impaled object
healed incisions or old scars

Abdominal/GI Findings

N/V
Bloody urine
abdominal distention
abdominal rigidity
abdominal pain with palpation
rebound tenderness
pain radiation to shoulder and back

Herpes Zoster: Evaluating Client Teaching

Interventions

Use an air mattress or bed cradle for pain prevention/control

isolate the client until the vesicles are crusted

maintain strict wound care precautions

Herpes zoster is potentially transmissible and caution should be exercised around

infants, pregnant women who have not had chickenpox, and immunocompromised
clients.

Administer meds as prescribed

Analgesics (NSAIDS, narcotics)

Antiviral agens such as acyclovir, valacyclovir, favicilovir (shorten the clinical

course)

moisten dressings with cool tap water or 5% aluminum acetate (Burows solution) and
apply to the affected skin for 30-60 min 4-6x/day as prescribed

Lotions (for example, Calamine) may help relieve discomfort.

Cystic Fibrosis: Managing Illness at Home

Care in the Home (ATI)

Ensure parents/caregivers have information regarding access to medical equipment

Provide teaching about equipment prior to discharge

Instruct parents/caregivers in ways to provide CPT and breathing exercises. For

example, a child can stand on her head by using a large cushioned chair place against
a wall.

administer abx through a venous access port. Parents/caregivers need instruction in

admin techniques, SE to observe for, and how to manage difficulties with the venous
access port

Promote regular PCP visits

Ensure up-to-date immunizations with the addition of initial influenza vaccine at 6

months of age and then a yearly booster.

Encourage regular physical activity

Encourage participation in a support group and involvement in community resources.

Question:
A child with cystic fibrosis and his parent are receiving discharge teaching by a nurse.
Which of the following statements made by the parent indicates a need for further
instruction
o. My child should not get an annual influenza vaccine bec of increased risk
p. I will have my child stand on his head for chest physiotherapy
q. We will encourage our child to use the Flutter mucus clearance device
r. Our child will use a metered dose inhaler to administer a bronchodilator

Cystic fibrosis is hereditary and is transmitted as an autosomal recessive trait, both

parents must be carriers.

Cystic fibrosis is a dysfunction of the exocrine glands, causing the glands to produce
thick, tenacious mucus.

Major organs affected are the lungs, pancreas and liver

Initial sx may occur at varying ages during infancy, childhood, or adolescence

Thick mucus obstructs the respiratory passages causing trapped air and overinflation of
the lungs.

Abnormally thick mucus leads to obstruction of the secretory ducts of the pancreas, liver
and reproductive organs which alters the fx of those organs

Sweat and salivary glands excrete excessive electrolytes specifically sodium and
chloride

The multisystem disease results in increased viscosity of secretions, causing

obstruction of small pathways in various organs (eg bronchioles, pancreas, small
intestine, bile ducts

Chronic, recurrent respiratory infections are a classic sign of the disease process.
Atelectasis and small lung abscess are common early complications. Bronchiectasis
and emphysema may develop with pulmonary fibrosis

Interventions

Resp interventions

Promptly tx resp infx with abx therapy

provide pulmonary hygiene with CPT (eg breathing exercises to strengthen thoracic
muscles) a minimum of twice a day (in the am and at bedtime)

Have the child use the Flutter mucus clearing device to assist with mucus removal
Administer bronchodilators through MDIs or hand held neb to promote expectoration of
excretions

Administer dornase alfa (Pulmozyme) through a nebulizer to decrease viscosity of

mucus.

Promote physical activity that the child enjoys to improve mental well being, self-
esteem, and mucus secretion.

GI interventions

Administer pancreatic enzymes with meals and snacks

The amt of enzyme replacement will vary between children based on each childs
deficiency and response to the replacement

instruct the child/family that the capsules can be swallowed whole or opened to
sprinkle the contents on a small amt of food

encourage the child to select meals and snacks if appropriate

facilitate high caloric, high protein intake through meals and snacks

multiple vits and water soluble forms of A, D, E, K are often prescribed.

HIV/AIDS: Interventions to Prevent Spread of HIV

HIV is transmitted through blood and body fluids (semen, vaginal secretions)

HIV is found in breast milk, amniotic fluid, urine, feces, saliva, tears, CSF, lymph nodes,
cervical cells, corneal tissue and brain tissue, but epidemiologic studies indicate that
these are unlikely sources of infections.

Risk Factors

unprotected sex (vaginal, anal, oral)

multiple sex partners

occupational exposure (healthcare worker)

perinatal exposure

blood transfusions (not a significant source of infection in the U.S.)

IV drug use with contaminated needle

Med/Surg---

Prevention techniques divided into safe activities (those that eliminate risk) and risk-
reducing activities (those that decrease risk but do not eliminate it).

Decreasing risks r/t sexual intercourse

safe sex eliminates the risk of exposure to HIV in semen and vaginal secretions

abstaining is the most effective way to accomplish this but there are safe options for
those who cannot or do not wish to abstain

outercourse (limiting sexual behavior to activities in which the mouth, penis, vagina or
rectum does not come into contact with a partners mouth, penis, vagina, or rectum) is
safe bec there is not contact

includes massage, masturbation, mutual masturbation, telephone sex

insertive sex between partners who are not infected with HIV or not at risk of becoming
infected with HIV is considered to be safe

Risk reducing sexual activities decrease the risk of contact through the use of barriers.

should be used when engaging in insertive sexual activity with a partner who is
known to be HIV infected or with a partner whose HIV status is not known

most common barrier device is male condom

female condoms

squares of latex

plastic food wrap

Decreasing risks r/t drug use

major risk for HIV infection is r/t sharing injecting equipment and/or having unsafe sex
experiences while under the influence of drugs.

basic rules

do not use drugs

if you do, dont share equipment

do not have sex when under the influence of any drug (including alcohol) that impairs
decision making ability

use alternatives to injecting such as smoking, snorting, or ingesting the durg

injecting equipment includes needles, syringes, cookers (spoons or bottle caps used to
mix the drug) cotton, and rinse water

another safe tactic is for the user to have access to sterile equipment (needle exchange
programs)

cleaning equipment before use is a risk-reducing activity

Decreasing risks for perinatal transmission

best way to prevent HIV in infants is to prevent HIV infection in women

If HIV-infected pregnant women are txd with AZT, REtrovir, the rate of perinatal
transmission is decreased.

tx has minimal SE for the baby

Combination ART as appropriate for the mothers HIV infection can further decrease the
risk of perinatal transmission to less than 2%

Decreasing risks at work

employers must protect workers from exposure to blood and other potentially infectious
materials.

precautions and safety devices decrease the risk of direct contact with blood and body
fluids.

should exposure to HIV infected fluids occur, postexposure prophylaxis with

combination ART based on the type of exposure the volume of exposure and the status
of the source pt decreases the risk of infections.

Glomerular Disease: Recognizing Risk factors

Risk Factors (ATI)

Immunological Reactions
Primary infection with group A beta-hemolytic streptococcal infection (most
common)

Systemic Lupus Erythematosus

Vascular injury (HTN)

Metabolic disease (DM)

Nephrotoxic drugs

Excessively high protein and high sodium diets

Burns: Priority Interventions

Chemical Burns

Emergency Interventions

Ensure patent airway

assess airway, breathing, circulation before decontamination procedures
Brush dry chemical from skin before irrigation
flush chemical from wound and surrounding area with saline or water
remove clothing, including shoes, watches, jewelry and contact lenses if face exposed
establish IV access with large-bore catheter needle if greater than 15% TBSA burn
begin fluid replacement
blot skin dry with clean towels. Do not rub dry
cover burned areas with dry, sterile dressing or clean, dry sheet
anticipate intubation if significant inhalation injury present
contact poison control center for assistance
caregiver should protect self from potential exposure

Ongoing monitoring

monitor airway if airway exposed to chemicals

Inhalation injury

Emergency Management

Ensure patent airway

administer high flow 02 by non rebreather mask
remove pts clothing
establish IV access with large bore catheter needle
begin fluid replacement
place in high fowlers position unless spinal cord injury suspected
assess for facial/neck burns or other trauma
obtain arterial blood gas carboxyhemoglobin levels and chest xray
anticipate need for fiberoptic bronchoscopy or intubation
Ongoing Monitoring

Monitor VS, LOC, 02 sat, respiratory status, cardiac rhythm

Electrical Burns

Emergency Management

Removal of current source must be done by trained personnel with special equipment to
prevent injury to rescuer

Assess and tx pt after removal from source of current

ensure patent airway
stabilize cervical spine
administer hi flow 02 by non rebreather mask
establish IV access with large-bore catheter needle
begin fluid replacement
remove pts clothing
check pulses distal to burns
cover burn sites with dry dressing assess for any other injuries (fractures, head injury)

Ongoing Monitoring

monitor cardiac rhythm, VS, LOC, 02 sat, neurovascular status in injured limbs
monitor UOP to ensure adequate volume replacement
monitor urine for development of myoglobinuria secondary to muscle breakdown
anticipate admin of mannitol and NaHCO3 for myoglobinuria and hemoglobinuria.

Thermal Burns

Emergency Management

Ensure patent airway

Stop the burning process
inspect face and neck for singed nasal hair, hoarseness of voice, stridor, soot in the
sputum
administer high flow 02 by non rebreather mask
anticipate intubation with significant inhalation injury
establish IV access with large bore catheter
begin fluid replacement
remove clothing and jewelry
identify and tx associated injuries (fractured ribs, pneumothorax)
determine depth, extent, and severity of burn
administer IV analgesia
cover large burns with dry dressing
apply cool compresses or immerse in cool water for minor injuries only (less than 10%
TBSA burn)
insert urinary catheter for severe burns
prevent loss of body heat
transport asap to burn center
do not debride burns or apply topical agents before transfer to a burn center
administer tetanus prophylaxis as appropriate

Ongoing monitoring

monitor VS, LOC, 02 sat, cardiac rhythm, UOP

monitor temp
monitor pain and medicate as needed based on pt response.

Mechanical Ventilation: Response to Ventilator Alarms and Respiratory Distress

ATI

Ventilators have alarms to signal that the client is not receiving correct ventilation

If the nurse cannot determine the cause of a ventilator dysfx, the client is
disconnected from the ventilator and manually ventilated with an Ambu bag

Ventilator alarms should never be turned off

There are three types of ventilator alarms: volume, pressure, and apnea alarms

volume(low pressure) alarms indicate low exhaled volume due to disconnection, cuff
leak and tube displacement

pressure (high pressure) alarms indicate excess secretions, client biting the tubing,
kinks in the tubing, client coughing, pulmonary edema, bronchospasm, and
pneumothrorax.

apnea alarms indicate that the ventilator does not detect spontaneous respiration in a
present time period.

Questions

The high pressure alarm sounds on the ventilator. What should the nurse assess for?

client biting of the tube

breath sounds---indicating the need for suctioning
kinks in the tube

The low pressure alarm sounds on the ventilator. What should the nurse assess for?

Tubing disconnections
air leak around the cuff.

Pulmonary Embolism: Evaluation of Tx Effectiveness

Objectives:
prevent further growth or multiplication of thrombi in the lower extremities
prevent embolization from the upper or lower extremities to the pulmonary vascular
system
provide cardiopulmonary support if indicated

Evaluation

The expected outcomes are that the pt who has pulmonary embolism will have

adequate tissue perfusion and respiratory fx

adequate CO
increased level of comfort
no recurrence of PE

Treatment includes

Conservative Therapy

02 by mask or cannula may be adequate

02 is given in a concentration determined ABG analysis

endotrach intubation and mechanical vent may be needed to maintain adequate 02

turning, coughing and deep breathing to prevent or tx atelectasis

for shock, vasopressor agents to support systemic circulation

for heart failure, digitalis, diuretics

pain with narcotics, usually morphine

Drug Therapy

anticoags

Heparin and warfarin drugs of choice

heparin should be started immediately and is continued while oral anticoags are
initiated.
dosage adjusted according to PTT and warfarin dose is determined by INR

may be indicated if the pt has blood dyscrasias, hepatic dysfunction, overt bleeding, a
hx of hemorrhagic stroke or neurologic conditions

Thrombolytic agents, such as tPA dissolve PE and the source of the thrombus in the
pelvis or deep leg veins thereby decreasing the likelihood of recurrent pulmonary emboli

Surgical Therapy

if degree of pulmonary arterial obstruction is severe (greater than 50%) and the pt does
not respond to conservative therapy, an immediate embolectomy may be indicated.

COPD: Evaluating ABGs

ABGs

serial ABGs are monitored to evaluate respiratory status

Increased paCO2 and decreased PaO2

Respiratory acidosis, metabolic alkalosis (compensation)

Med-Surg

ABGs

Emphysema

near normal ABGs, decreased PaO2, normal or decreased PaCO2

Chronic Bronchitis

decreased Pa02, increased Pa02

Cancer: Preventing Complications of Radiation Treatments

Stomatitis:

Encourage pt to use artificial saliva

teach pt to assess oral mucosa daily
discourage use of irritant such as tobacco and alcohol
apply topical anesthetics such as viscous Lidocaine

N/V
teach to eat and drink when not nauseated
admin antiemetics as needed
use diversional activities

Anorexia

monitor wt
provide small freq meals of high protein, high calorie foods
gently encourage pt to eat but avoid nagging
serve food in pleasant environment

Diarrhea

give antidiarrheal agents as needed

Constipation

provide stool softener as needed

encourage to eat high fiber foods

Hepatotoxicity

monitor liver function tests

Anemia

Monitor Hgb and Hct levels

Encourage intake of foods that promote RBC production

Leukopenia

monitor WBC count, especially neutrophils

teach to report temp elevation and any other manifestations of infection
teach to avoid large crowds and people with infections
teach to use good hand washing techniques

Thrombocytopenia

observe for signs of bleeding

monitor hgb and hct and platelet counts
teach to use soft bristle toothbrush and use electric razor

Alopecia

discuss impact of hair loss on self image

suggest way t to cope with hair loss (hair pieces, wigs, scarves)
cut long hair before therapy
avoid excessive shampooing, brushing, and combing of hair
avoid use of electric hair dryers curler and curling irons

Skin reactions

protect skin from trauma

lubricate dry skin with nonirritating creams
avoid the use of harsh soaps

Cystitis

monitor manifestations such as urgency, freq, and hematuria

Reproductive dysfunction

discuss these changes with patients

Nephrotoxicity

monitor BUN and serum creatinine levels

Increased ICP

may be controlled with steroids and pain meds

Peripheral neuropathy

monitor for these manifestations in pts on these drugs

Pneumonitis

monitor for dry, hacking cough, fever and exertional dyspnea

Pericarditis and myocarditis

monitor for clinical manifestations of these disorders

cardiotoxicity

monitor heart with ECG and cardiac ejection factions
drug therapy may need to be modified

Hyperuricemia
 monitor uric acid levels
allopurinol (zyloprim) may be given as a prophylactic measure
encourage high fluid intake

Fatigue

tell pt that fatigue is an expected SE of therapy

encourage pt to rest when fatigued to maintain usual lifestyle patterns as closely
as possible and to pace activities in accordance with energy level

Pain

use an analgesic ladder to provide basis for pain med admin

teach use of imagery, relaxation therapy

Pain Management: Recognizing and Responding to Complications of Opioid Use

ATI

Overdosing of opioid analgesics can lead to respiratory depression and even death

sedation always precedes respiratory depression

Oversedation and respiratory depression can be prevented by

Identifying risks, titrating doses carefully and monitoring the client

stopping the opioid and giving the antagonist naloxone if the clients respirations are
less than 8/min and shallow and the client is difficult to arouse. Naloxone must be
diluted in NS (0.4mg/10mL) and given by IV slowly. After admin of naloxone, the client
should be reassessed.

Assessing the cause of sedation and monitoring the clients level of arousal and
respiratory rate and depth for one full minute

using a sedation scale in addition to a pain rating scale to assess a clients pain
especially when administering opioids.

Blood Transfusions: Interventions for Complications

Transfusion Reactions

Acute Hemolytic
Onset: Immediate

chills, fever, low back pain, tachycardia, flushing, hypotension, chest tightening or pain,
tachypnea, nausea, anxiety, and hemoglobinuria

Febrile

Onset: 30min to 6 hr

chills, fever, flushing, HA, anxiety

admin: antipyretics

Mild allergic

Onset: During or up to 24 hr after transfusion

itching, urticaria, flushing

Admin antihistamines such as Benadryl

Anaphylactic

Immediate

wheezing, dyspnea, chest tightness, cyanosis, hypotension

Maintain airway, administer 02, IV fluids, antihistamines, corticosteroids, vasopressors

Stop the transfusion immediately if a reaction is suspected

Initiate a saline infusion. The saline infusion should be initiated with a separate line so
as not to give more blood from the transfusion tubing

Save the blood ag with the remaining blood and the blood tubing for testing

Circulatory overload

Sx include: dyspnea, chest tightness, tachycardia, tachypnea, HA, HTN, JVD,

peripheral edema, orthopnea, sudden anxiety and crackles in the base of the lungs

Admin 02, monitor VS, slow the infusion rate and admin diuretics as ordered

Notify PCP immediately

Sepsis and Septic Shock

sx include: fever, N/V, abdominal pain, chills, hypotension

maintain patent airway and admin 02

admin abx therapy as ordered

obtain samples for blood cultures

admin vasopressors such as dopamine, to combat vasodilation in the late phase

elevate the clients feet

If DIC occurs

admin anticoags such as heparin in early phase

admin clotting factors and blood products during the late phase (clotting factors are
used up in the early stage

administer activated protein C (xigris) to control inflammatory response.

Oxygen Therapy: Assessing for S/S of Toxicity

S/S include

nonproductive cough
substernal pain
nasal stiffness
N/V
fatigue
HA
ST
hypoventilation

use the lowest level of 02 to maintain adequate Sa02

Monitor ABGs and notify PCP if Sa02 levels rise above expected parameters

use of 02 mask with CPAP continuous positive airway pressure, bilevel positive airway
pressure, or positive end-expiratory pressure while a client is on a mechanical ventilator
may decrease the amt of need 02

the oxygen amt should be decreased as soon as the client conditions permits.
Form B

Burns: Sequencing of Wound Care Interventions

Wound care should be delayed until a patent airway, adequate circulation and adequate
fluid replacement have been established.

Full thickness wounds will be dry and waxy white to dark brown/black and will have little
to no sensation bec nerve endings have been destroyed.

Partial thickness burns are pink to cherry red and wet and shiny with serous exudate.
These wounds may or may not have intact blisters and are painful when touched or
exposed air.

Cleansing and debridement can be done in a hydrotherapy tub, cart shower, shower, or
bed.

Debridement may need to be done in the operating room.

During these procedures, loose, necrotic skin is removed. Care should be taken to
accomplish this procedure as quickly and effectively as possible.

Immersion in a tank for longer than 20-30 min can cause electrolyte loss from open
burned areas

Prolonged immersion can lead to chilling after the bath and cross-contamination of
wounds from one area of the body to another

Bec of these factors, some institutions do not submerge the pt.

Instead the pt can be showered

The water does not need to be sterile and tap water not exceeding 104 degrees is
acceptable.

Bec pathogenic organisms are present on the burn wound, a surgical detergent,
disinfectant, or cleansing agent may be used.

The pt may be bathed two time daily to limit the amt of bacterial growth. Degree of freq
may be too painful for pt.

A once daily bath or shower followed by a dressing change in the pts room is a popular
alternative
Infection is the most serious threat to further tissue injury and further sepsis. Survival is
directly r/t prevention of wound contamination. The source of infection in burn wounds
is the pts own flora, predominantly form the skin, respiratory tract and TI tract.

Prevention of cross-contamination from one pt to another is a priority

Two type of wound tx are used to control infection

open method
use of multiple dressing changes

Open method

burn is covered with a topical abx and has no dressing over the wound

Multiple dressing changes

sterile gauze dressings are impregnated with or laid over a topical abx. These dressings
may be changed two to three times q 24 hr to once q 3 days.

When pts wounds are exposed, the staff must wear disposable hats, masks, gowns
and gloves.

When removing dressing and washing the wound, the nurse should use nonsterile
disposable gloves. Sterile gloves are used when applying ointments and strile
dressings.

Room must be kept warm (85%)

All attire is changed before nurse treats another pt.

Careful hand washing is also required to prevent cross-contamination.

After the pt has bee txd in the tub, car shower, or shower, the equipment is disinfected
with a chemical prep.

Coverage is the primary goal for burn wounds. Bec there is rarely enough unburned
skin in the major burn pt for immediate skin grafting, other temp wound closure methods
are used. Allograft or homograft skin (usually from cadavers) is commonly used.

rejection eventually occurs bec the pts immune system reacts against foreign
substance.

Monitoring Intracranial Pressure: Preventing Complications

Caring for a Client undergoing ICP monitoring

Before the insertion procedure, medication may be given to help the client relax. The
head is shaved around the insertion site. The site is then scrubbed with an antibacterial
soln. Local anesthetic is applied to numb the area.

After the insertion procedure, the nurse observes ICP waveforms, noting the pattern of
waveforms and monitoring for increased ICP (a sustained elevation of pressure above
15 mmHg). Normal ICP is 10-15 mmHg.

Assess the clients clinical status and monitor routine and neurologic VS q hour as
needed.

Calculate cerebral perfusion pressure (CPP) hourly. To calculate CPP, subtract ICP from
mean arterial pressure (MAP)

Keep the system closed at all times. There is a serious risk of infection.

Inspect the insertion site at least q 24 hours for redness, swelling and drainage. Change
the sterile dressing covering the access site per facility protocol.

ICP monitoring equipment must be balanced and recalibrated as per facility protocols.

Caring for clients with or at risk for increased ICP

Monitoring and maintaining airway patency is the PRIORITY intervention for clients with
increased IcP and deteriorating neurological status.

When suctioning a client with increased ICP, hyperoxygenate with 100% prior to each
suctioning attempt.

Keep the PaCO2 around 35 mmHg and maintain a normal oxygen level by adjusting the
rate of mechanical ventilation (for ex, hyperventilating to blow off CO2). Hypercarbia
leads to cerebral vasodilation which increases ICP

Maintain head at midline neutral position and keep the HOB at greater than 30 degrees
to promote venous drainage. Prevent neck flexion or extension. Log roll client when
turning.

Avoid clustering nursing activities

Avoid overstimulation of the client

keep the clients room dark and quiet

discuss visiting limitations

speak softly and limit conversations to light and pleasant discussions.

Complications

Infection and Bleeding

Follow strict surgical aseptic technique
Perform sterile dressing changes
Keep drainage systems closed
Limit monitoring to 3-5 days
Irrigate the system only as needed to maintain patency

Occlusion of the Catheter--brain herniation

Overdrainage and Collapse of the Ventricles

Electrolyte Imbalances: Priority Interventions for Hyperkalemia

Expected Client Findings

VS: Slow, irregular pulse, hypotension

Neuro: Restless, irritability, parethesias

MS: weakness to the point of ascending flaccid paralysis

GI: N/V/D, increased motility, hyperactive bowel sounds

Other signs: oliguria

Nursing Interventions

Decrease potassium intake

Stop infusion of IV potassium

Withhold oral potassium

Provide potassium restricted diet (avoid foods high in potassium such as

avocados, broccoli, dairy products, dried fruits, cantaloupe, bananas).

Increase potassium excretion

Administer loop diuretics, such as furosemide (Lasix), if renal fx is adequate

Administer cation exchange resins such as sodium polystyrene sulfonate

(Kayexalate)
Promote movement of potassium from ECF to ICF

Admin IV fluids with dextrose (glucose) and Reg Insulin

Administer sodium bicarbonate (reverse acidosis)

Monitor the clients cardiac rhythm and intervene promptly as needed.

Tonsillitis/Tonsillectomy: Assessing for Postoperative Complications

Hemorrhage

use a good light source and possibly a tongue depressor to directly observe the
childs throat

assess the child for signs of bleeding (eg tachycardia, repeated swallowing, and
clearing of throat, hemoptysis). Hypotension is a late sign of shock

contact PCP immediately if there is any indication of bleeding

Bleeding can occur either immediately or several days after the procedure. Discharge
instructions must be carefully followed.

Chronically infected tonsils may pose a potential threat to other parts of the body.

some children who have freq bouts with severe tonsillitis may develop other diseases
such as rheumatic fever and kidney disease

Cleft Lip and Palate: Client Eduction Regarding Feeding Techniques

Support mothers decision to continue breastfeeding her infant. Assist her to be open to
alternatives such as using breast milk placed in special feeding devices if necessary

provide instruction to promote feeding. Teach the parents to use an enlarged nipple,
which will stimulate the infants suck reflex and ensure that the infant swallow
appropriately. After feeding, infant should be allowed to rest.

Identify alternate feeding devices such as special nipple for a bottle

Teach parents to feed the infant in an upright position

Teach parent to burp the infant more freq due to the amt of air swallowed. This will help
prevent aspiration and abdominal distention.
Glaucoma: Planning Appropriate Postoperative Interventions

IOP is checked 1-2 hr postoperatively by the surgeon

postop eye is covered with a patch or protective shield

client is instructed not to lie on the operative side and to report severe pain or nausea
(possible hemorrhage)

GERD: Recognizing Signs and Symptoms

The chief sx of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) and
regurgitation (acid reflux) in relationship to eating or activities.

Other sx include chronic cough, dysphagia, belching (eructation), flatulence (gas),

atypical chest pain and asthma exacerbations

Infection Control: Preventing Transmission

Communicable Diseases: Interventions to Prevent Transmission

Transmission Precautions (Tier Two)

Airborne precautions are to protect against droplet infections smaller than 5

micrometers (eg measles, varicella, pulmonary or laryngeal tuberculosis). Airborne
precautions require a:

private room

mask/respiratory protection device for caregivers and visitors

negative pressure airflow exchange in the room of at least six exchanges an hour.

Droplet precautions protect against droplets larger than 5 micrometers (streptococcal

pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma
pneumonia, meningococcal pneumonia/sepsis or pneumonic plague) Droplet
precautions require a:

Private room or a room with other clients with the same infectious disease

Mask for providers and visitors

Contact precautions protect the visitors and caregivers against direct client/
environmental contact infections (eg respiratory synctial virus, shigella, enteric diseases
caused by micor-organisms, wound infections, herpes simplex, scabies, varicella zoster,
and multidrug-resistant organisms). Contact precautions require

private room or a room with other clients with the same infection

gloves and gowns worn by the caregivers and visitors

disposal of infectious dressing material in to a single nonporous bag without

touching the outside of bag

Emergency Nursing Principles: Establish Patent Airway

This is the most important step in performing the primary survey.

If a patent airway is not established, subsequent steps of the primary survey are futile

If the client is awake and responsive, the airway is open

If the clients ability to maintain an airway is lost, it is important to inspect for blood,
broken teeth, vomitus, or other foreign materials in the airway that may cause an
obstruction

Unresponsive without suspicion of trauma

the airway should be opened with a head tilt chin lift maneuver

this is the most effective manual technique for opening a clients airway

It must NOT be performed on clients who have a potential cervical spine injury

Technique: The nurse should assume a position at the head of the client, place one
hand on the forehead, and the other on the chin. The head should be tilted while the
chin is lifted superiorly. This lifts the tongue out of the laryngopharynx and provides for a
patent airway.
Unresponsive with suspicion of trauma

The airway should be opened with modified jaw thrust maneuver

Technique: The nurse should assume a position at the head of the client and place both
hands on the side of the clients head. Locate the connection between the maxilla and
the mandible. Lift the jaw superiorly while maintaining alignment of the cervical spine.
Once the airway is opened, it should be inspected for blood, broken teeth, vomitus and
secretions. If present obstruction should be cleared with suction or a finger sweep
method.

The open airway can be maintained with airway adjustments, such as an oropharygeal
or nasopharyngeal airway.

Bag-Valve-mask with a 100% 02 source is indicated for clients who need additional
support during resuscitation

Esophageal Varices: Response to Hemorrhage

Hemorrhage and hypovolemic shock are serious complications of esophageal varices.

observe the client carefully for sings of hemorrhage and shock

Monitor VS, Hgb, and hematocrit

Replace losses and employ therapeutic procedures such as gastric lavage, shunts and
sclerotherapy to stop/control bleeding

HIV/AIDS: Evaluating Antiretroviral Treatment

The use of potent combination ART to suppress HIV replication limits the potential for
selection of antiretroviral resistant HIV variants, the major factor limiting the ability of
antiretroviral drugs to inhibit virus replication and delay disease progression. Maximum
achievable suppression of HIV replication should be the goal of therapy

the most effective means to accomplish durable suppression of HIV replication is the
simultaneous initiation of combinations of effective anti HIV drugs with which the pt has
not been previously treated and that are not cross resistant with antiretroviral agents
with which the pt has been previously treated.

Antiretroviral drugs used in combo therapy regimens should always be used according
to optimum schedules dosages.

The available effective antiretroviral drugs are limited to number and mechanism of
action and cross resistance between specific drugs has been documented. Therefore
any change in ART can decrease future therapeutic options

Women should receive optimal ART regardless of pregnancy status

Acute primary HIV infections should be txd with combination ART to suppress virus
replication to levels below the limit of detection
HIV infected persons even those with viral loads below detectable limits and those on
effective ART should be considered infectious and should be counseled to avoid sexual
and drug use behavior that are associated with transmission or acquisition of HIV and
other infections pathogens

Oncological Emergencies: Recognizing Sx of Radiation Therapy Complications

Metabolic Emergencies are caused by the production of ectopic hormones directly from
the tumor secondary to cancer tx. They include:

Syndrome of inappropriate antidiuretic hormone (SIADH)

from vincristine and cyclophosphamide (Cytoxan) which stimulate the release of ADH
from the pituitary or tumor cells.

Sx include:
wt gain
weakness
anorexia
N/V
personality changes
seizures
coma

Tx:
fluid restriction
in severe cases: IV admin of 3% sodium chloride solution

Tumor Lysis syndrome (TLS)

freq triggered by chemotherapy

Results from rapid destruction of a large number of tumor cells which can cause fatal
biochemical changes.

often associated with tumors that have a high growth rates and are sensitive to the
effects of chemo.

TLS can result in acute renal failure

The four hallmark signs of TLS are:

hyperuricemia
hyperphosphatemia
hyperkalemia
hypocalcemia
Usually occurs within the first 24-48 hrs after the initiation of chemo and may persist for
approx 5-7 days.

Primary goal of management is preventing renal failure and severe electrolyte

imbalances

Primary tx includes increasing urine production using hydration therapy and decreasing
uric acid concentrations using allopurinol

Spinal Cord Compression

r/t metastases. Assess the clients neurological status, including motor and/or sensory
deficits. Administer corticosteroids as prescribed. Support the client during radiation
therapy.

Hypercalcemia

A common complication of leukemia; breast lung, head and neck CA; lymphomas,
multiple myelomas; and bony metastases of any cancer. Sx include:
Anorexia
N/V
Shortened QT interval
Kidney stones
Bone pain
Changes in mental status

Administer isotonic saline, fusosemide (Lasix), pamidronate, and phosphates as

prescribed

Super vena cava syndrome

Results from obstruction (for example, metastases from breast or lung CA) of venous
return and engorgement of the vessels from the head and upper body. Sx include
periorbital and facial edema, erythema of the upper body, dyspnea, and epistaxis. Initial
lung expansion. High dose radiation therapy may be used for emergency temporary
relief.

Disseminated intravascular coagulation (DIC)

A coagulation complication secondary to leukemia or adenocarcinomas. Observe the

client for bleeding and apply pressure as needed. Avoid ASA and NSAIDS.

Pneumonia: Recognizing and Responding to Hypoxia

Hypoxia occurs when the PaO2 has fallen sufficiently to cause s/s of inadequate
oxygenation

Hypoxia is adequate tissue oxygenation at the cellular level

S/S:
apprehension
restlessness
inability to concentrate
declining LOC
dizziness
behavioral changes

Client is unable to lie down and appears fatigued and agitated.

VS changes include an increased pulse rate and increased rate and depth of respiration

During early stages, BP is elevated unless the condition is caused by shock

As hypoxia worsens, the RR may decline as a result of respiratory muscle fatigue

Hypoxemia can lead to hypoxia if not corrected.

If hypoxia or hypoxemia is severe, the cells shift from aerobic to anaerobic

metabolism . Anaerobic metabolism uses more fuel adn produces less energy and is
less efficient.

Waste produce is lactic acid.

monitor oxygenation levels and acid-base balance

prepare for intubation and mechanical ventilation as indicated

maintain adequate oxygenation and ventilation

done by collaboration among the nursing, medical and respiratory care teams

primary goal: correct hypoxemia

Ineffective Breathing Pattern r/t inflammation and pain (amb rapid respirations, dyspnea,
tachypnea, nasal flaring, altered chest excursion.

Interventions
monitor respiratory and oxygenation status to provide baseline assessment

auscultate breath sounds, noting areas of decreased or absent ventilation, and

presence of adventitious sounds

Position to minimize respiratory efforts to reduce oxygen needs

monitor effects of position change on oxygenation (SpO2) to assess appropriate

position

initiate and maintain supplemental oxygen as prescribed to improve respiratory status

admin drugs (eg bronchodilators) that promote airway patency and gas exchange

Topic Descriptors

Psychosocial Integrity (14)

Form A

Family and Community Violence: Evaluating Client Outcomes for the Client Who
Has been Abused

Non-substance Related Dependencies: Providing Care and Support for Client

with Gambling Dependency

ATI

provide emotional support and reassurance to the client and family

Begin to educate the client about addition and the initial treatment goal of abstinence
Begin to develop motivation and commitment for abstinence and recovery
(abstinence plus working a program of personal growth and self-discovery)

Encourage self-responsibility

help the client develop an emergency plan---a list of things the client would do and
people he would contact if he felt like using or actually used.

Individual psychotherapies
CBT
psychodynamic therapies

relapse prevention therapy teaches the client to recognize s/s of relapse and
factors that contribute to relapse and helps the client develop strategies such as
meditating, exercising to create feelings of pleasure form activities other than using
substances or from process addictions

Group Therapy

groups of clients with similar dx may meet in an outpt setting and within mental
health residential facilities

Family Therapy

teaches families about abuse of substances

educates the family regarding such issues as family coping, problem solving,
relapse signs, and availability of support groups

Self-help groups

12-step programs including AA, NA, Gamblers anonymous teach that abstinence
is necessary for recovery and use the belief in a higher power to assist in recovery.

Crisis Management: Identifying Interventions

Provide for client safety

ensure that external controls such as hospitalization are applied for protection of
the person in crisis if the indiv has suicidal or homicidal thoughts

organize interventions so tangible threats are addressed first

Use strategies to decrease anxiety

develop a therapeutic nurse-client relationship

 listen, observe and ask questions
make eye contact
ask questions r/t the clients feelings
ask questions r/t the event

demonstrate genuineness and caring

communicate clearly and, if needed, with clear directives

avoid false reassurance and other nontherapeutic responses

teach relaxation techniques such as medication

use problem solving to anticipate the clients needs (anticipatory guidance)

identify and teach coping skills (eg assertiveness training, parenting skills, occupational
training)

assist the client with the development of an action plan

short term no longer than 24-72 hrs

focused on the crisis

realistic and manageable

identify and coordinate with support agencies and other resources

plan and provide for follow up care

Care of Those Who Are Dying: Providing Support to the Family Regarding
Decision making

End of life issues include decision making in a highly stressful time during which the
nurse must consider the desires of the client and the family. Any decisions must be
shared with other HCP for smooth transition during this time of stress, grief, and
bereavement.

Advance directives are legal documents for medical treatment per the clients wishes

Durable power of attorney for health care---an agent appointed by the client or the
courts to make medical decisions when the client is no longer able to do so.

Mood disorders: Recognizing S/S of Relapse for Bipolar Disorder

Use of substances (eg alcohol, drugs of abuse, caffeine) can lead to an episode of
mania.
sleep disturbances may come before, be associated with, or brought on by an episode
of mania.

Cognitive Disorders: Recognizing S/S of Impaired Cognition

Impairments in memory, judgment, ability to focus, and ability to calculate; impairments

may fluctuate throughout the day (delirium) or not change throughout the day
(dementia). LOC can be altered (delirium) or unchanged (dementia). Restless, agitation
are common, sundowning (confusion during the night) may occur, behaviors may
increase or decrease daily (delirium) or remain stable (dementia).

Amnestic disorder

decreased awareness of surroundings

inability to learn new info despite normal attention
inability to recall previously learned info
possible disorientation to place and time
typically there is no personality change or impairment in abstract thinking.

Psychopharmacological Therapies: Evaluating Client Teaching Regarding

Lithium, Methlyphenidate, Disulfiram, and Fluoxetine

Lithium

Clients must maintain adequate sodium and fluid intake while taking lithium
lithium takes the place of sodium in body

advise the clients that effects of lithium begin within 5-7 days and that it may take 2-3
weeks to achieve full benefits

advise the client to report signs of toxicity and to take the med as prescribed

encourage the client to comply with lab appts needed to monitor lithium effectiveness
and adverse effects

encourage the client to comply with follow up appts to monitor thyroid and renal function

Methylphenidate (Ritalin)

Advising the client to swallow sustained release tablets whole and to avoid chewing or
crushing tablets
Teaching the client the importance of administering the med on a regular schedule and
taking the med exactly as prescribed

Instructing the client to be alert for signs of mild overdose such as restlessness,
insomnia and nervousness. Signs of severe overdose include panic, hallucinations,
circulatory collapse and seizures.

Suggesting to parents to initiate a periodic pill count if they doubt the clients med
compliance

advising the client to avoid other CNS stimulants such as coffee, cola, tea, and
chocolate

instructing the client to avoid alcohol or OTC meds unless approved by the PcP. Many
OTC meds contain CNS stimulant properties

Educating the client about the SE of abruptly stopping the med (potential for abstinence
syndrome)

Instructing the client to take the morning (or daily) dose after breakfast and the last dose
in the early afternoon to minimize wt loss and insomnia. the med should be taken at
least 6 hr before bedtime

advising the client that sucking hard candy, chewing gum and taking sips of water may
help minimize dry mouth.

Disulfiram (Antabuse)

Inform the client of the potentials dangers of drinking any alcohol

advise the client to avoid any products that contain alcohol (eg cough syrups,
aftershave lotion)

encourage the client to wear medic alert bracelet

Fluoxetine (Prozac)

Advise the client to take med with meals/food and to take the med on a daily basis to
establish therapeutic plasma levels

assist the client with med regimen compliance by informing hte client that therapeutic
effects may not be experienced for 1-3 weeks and that it might take 2-3 months for full
benefits to be achieved.

instruct the client tot continue therapy after improvement in sx. sudden d/c of med can
result in relapse
advise the client that therapy usually continues for 6 months after resolution of sx and
may continue for 1 yr or longer

older adults clients taking diuretics should be monitored for sodium levels. Obtain
baseline sodium levels and monitor periodically.

Spiritual Care: Evaluating If Needs Have Been Met

Interventions

Identify the clients perceptions for the existence of a higher power

facilitate growth in the clients abilities to connect with a higher power

assist the client to feel connected or reconnected to a higher power by
allowing time and/or resources fro the practice of religious rituals
providing privacy for prayer, meditation, or the reading of religious materials

facilitate development of a positive outcome in a particular situation

provide stability for the person experiencing a dysfunctional spiritual mood.

establish a caring presence in being with the client and family rather than merely
performing tasks for them

support all healing relationships

holistic approach to care--seeing the large picture for the client
using client-identified spiritual resources and needs

identify and provide for the clients support system

family
community
pastoral
religious artifacts and rituals

be aware of diet therapies included in spiritual beliefs

support religious rituals

icons
statues
prayer rugs
devotional reads
music

support restorative care

 prayer
meditation
grief work

Evaluation of care is ongoing and continuous with a need for flexibility as the client and
family process the current crisis through their spiritual identity.

Potter/Perry

Evaluation

Review the clients self-perceptions regarding spiritual health

Review the clients view of his or her purpose in life
Discuss with family and close associates the clients connectedness
ask if the clients needs are being met

Example: if the nurses assessment finds the client losing hope, the follow-up evaluation
will involve a discussion with the client to determine if the client has regained an attitude
of something to live for
family and friends with whom the client seeks to have fellowship can be a useful source
of evaluative information
successful outcomes should reveal the client developing an increased or restored sense
of connectedness with family; maintaining, renewing, or reforming a sense of purpose in
life and for some, a confidence and trust in a supreme being or power

use established expected outcomes to evaluate the clients response to care

The nurse evaluates whether the client expectations were met.

evaluating if the clients spiritual practices were respected and if the nurse-client
relationship was one of caring and support

both client and family should be able to relate if opportunities were offered for religious
rituals

Sensoriperceptual Alterations: Planning Interventions for the Hearing Impaired

Client

Communication
get the clients attention before speaking
Stand/sit facing the client in a well-lit, quiet room without distractions
speak clearly and slowly to the client without shouting and without hands or other
objects covering the mouth
arrange for communication assistance (sign language interpreter, closed caption,
phone amplifiers, TTY capabilities) as needed
Planning (P/P)

select strategies to assist the client in remaining functional in the home

adapt therapies depending on whether sensory deficit is hort or long term
involve the family in helping the client adjust to limitations
refer to appropriate HCP and/or community agency

Clients who enter the health care setting and who have sensory alterations at the time
are usually more informed about how to adapt interventions to their lifestyle.

Stress Management: Evaluate Effectiveness of Teaching Regarding Stress

Management Techniques

Interventions
Relaxation Techniques

meditation includes formal meditation techniques as well as prayer for those who
believe in a higher power

guided imagery---a leader guides the client through a series of images to

promote relaxation. Images vary depending on the indiv. for example, one client might
imagine walking on a beach, while another might imagine himself in a position of
success

breathing exercises are used to slow rapid breathing and promote relaxation

progressive muscle relation (PMR)--a person trained in this method can help a
client attain complete relaxation within a few minutes of time

physical exercise (eg yoga, walking, biking) causes release of endorphins that
lower anxiety, promote relaxation, and have antidepressant effects

Journal Writing

journaling has been shown to allow for therapeutic release of stress

this activity can help the client identify stressors and plan for the future with more
hope

Cognitive reframing

the client is helped to look at irrational cognitions (thoughts) in a more realistic

light and to restructure the thoughts in a more positive way
Priority restructuring

the client learns to prioritize differently to reduce the number of stressors

impacting her

Biofeedback

a nurse or other HCP trained in this method can assist the client to gain voluntary
control of such autonomic functions a heart rate and blood pressure

Assertiveness training

the client learns to communicate in a more assertive manner in order to decrease

psychological stressors

(P/P) Goals and Outcomes

Desirable outcomes for persons experiencing stress

s. effective coping
t. family coping
u. caregiver emotional health
v. psychosocial adjustment: life change

By evaluating goals expected outcomes, the nurse knows if the nursing interentions
were effective and if the client is coping with stress.

Family Dynamics: Interventions Involving Client Support Systems

ATI Fundamentals

Interventions

Identify and adapt family strengths to perceived stressors

Communication
Adaptability
Nurturing
Crisis as a growth element
parenting skills
resiliency

Set goals with the family that are realistic

Provide information on support networks

Child and adult day care
caregiver support groups

Promote family unity
Encourage conflict resolution when it exists
minimize family process disruption effects
remove barriers to health promotion
increase family members abilities to participate
perform interventions that the family cannot perform
evaluate goals within the context of the family by checking back to ensure that the goals
were realistic and achievable

Effective Communication in Mental Health Nursing: Giving Broad Openings

(Mohr)

Giving broad openings

Purpose:
communicates a desire to begin a meaningful interaction
Ex: What would like to discuss today?
allows the client to define the problem or issue
Ex: Tell me about how you have been doing?

Creating and Maintaining a Therapeutic and Safe Environment: Promote a

Therapeutic Milieu for Group of Clients

Management of the milieu means manipulating the total environment of the mental
health unit in order to provide the least amount of stress while promoting the greatest
benefit for all the clients

Within this therapeutic milieu of the mental health facility the client is expected to learn
adaptive coping, interaction, and relationship skills that can be generalized to other
aspects of life

The nurse, as manager of care, is responsible for structuring and/or implementing many
aspects of the therapeutic milieu within the unit

The structure of the therapeutic milieu often includes regular community meetings,
which include both nursing staff and clients.

Characteristics

clean and orderly unit

color scheme should be appropriate for the clients age
setting should include comfortable furniture for lounging and interacting with others
solitary spaces for reading and thinking alone, comfortable places conducive to meals,
and quiet areas for sleeping
floors should be attractive, easy to clean, safe for walking
traffic flow considerations should be conducive to client and staff

promote independence for self care and individual growth in clients

allow choices for clients within the daily routine and within indiv tx plans
tx client as indiv
apply rules of fair tx for all clients
model good social behavior for clients, such as respect for the rights of others
work cooperatively as a team to provide care
maintain boundaries with clients
maintain professional appearance and demeanor
promote safe and satisfying peer interactions among clients
practice open communication techniques with HCP and clients

promote feelings of self-worth and hope for the future

clients should feel safe from harm (self-harm, as well as harm from disruptive behaviors
of other clients)
clients should feel cared about and accepted by the staff and others

The therapeutic milieu includes safety for both the clients and the staff within the
environment

Physical Safety
the nurses station and other areas should be set up for easy observation of
clients by staff and access to staff by clients

Set up the following provisions to prevent client self-harm or harm by others:

no access to sharp or otherwise harmful objects

restriction of client access to out of bounds or locked areas

monitoring of visitors

restriction of alcohol and illegal drug access or use

restriction of sexual activity among clients

deterrence for elopement from facility

rapid de-escalation of disruptive and potentially violent behaviors through

planned interventions by trained staff

Seclusion rooms and restraints should be set up for safety and used only after all less
restrictive measures have been tried. When used, there should be procedures and
policies to prevent any client harm

Plan for safe access to recreational areas, occupational therapy and meeting rooms
Teach fire, evacuation, and other safety rules to all staff

Have clear plans for keeping clients and staff safe in emergencies

Maintain staff skills, such as CPR with in service training

Considerations of room assignments on a 24 hr inpatient unit should include

personalities of each roommate

the likelihood of nighttime disruptions for a roommate if one client has difficulty
sleeping

medical diagnoses, such as how two clients with severe paranoia might interact
with each other

Nurses within a mental health unit must allow time for both structured and unstructured
activity for clients and staff

Structured activity may include time for

Community meetings
Group activities and indiv therapy sessions
recreational activities
psychoeducational classes such as learning about medication side effects

Unstructured flexible time in which the nurse and other staff are able to observe
clients and interact spontaneously within the milieu

Body Image: Interventions to Assist Client Adaptation

ATI Fundamentals

Interventions

Establish a therapeutic relationship with the client. A caring and nonjudgmental manner
puts the client at ease and fosters meaningful communication

ensure privacy and confidentiality. many sensitive issues may be discussed, and hte
client needs to know that these issues are safe to discuss.

identify indiv who may be at risk for body image disturbances

acknowledge anger, depression, and denial as normal feelings when adjusting to body
changes
encourage the client to participate in the plan of care

arrange for a visit form a volunteer who has experienced a similar body image change.

Form B

Cognitive Disorders: Identifying Appropriate Interventions

Environment

Assign the client to a room close to the nurses station for close observation
provide a room with a low level of visual and auditory stimuli
provide compensatory memory aids such as clocks, calendars, photos, memorabilia,
seasonal decorations and familiar objects

windows may help time orientation and help decrease the sundowning effect

Pharm Tx

Admin meds as prescribed

Meds that have been approved by the FDA that demonstrate positive effects on
cognitive, behavioral and daily activity function include

Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)
Memantine (Namenda)

Communication

Reinforce orientation to time, place and person

Establish eye contact and use short, simple sentences when speaking to the client
Encourage reminiscence about happy times, talk about familiar things
Break instructions and activities into short timeframes when instructing the client

Safety

Have the client wear an id bracelet; use monitors and bed alarm devices as needed
Ensure safety in the physical environment, such as lowered bed and removal of scatter
rugs to prevent falls. Many aspects of the physical environment may need to be
changed for the home bound client with dementia
Provide eyeglasses and hearing assistive devices as needed

Nursing care and Caregiver Education

Monitor food and fluid intake, bowel and bladder fx, and sleep patterns
Educate family/caregivers about illness, methods of care, and adaptation of the home
environment
provide support for caregivers; recommend local support groups for caregivers as well
as respite care
Establish a routine. Make sure all caregivers know/apply the routine. Attempt to have
consistency in all caregivers.

Group Therapy: Appropriate Group Leader Communication Techniques

Leadership Styles

Democratic: this style supports group interaction and decision making to solve problems

Laissez-faire: the group process progresses without any attempt by the leader to control
the direction of the group

Autocratic: The leader completely controls the direction and structure of the group
without allowing group interaction or decision making to solve problems

All therapy sessions should provide open and clear communication, guidelines for the
therapy session and cohesiveness

Be goal directed

Coping: Assessing Support Systems

Identify the strengths and abilities of the client and family

Discuss the client and familys ability to deal with the current situation

Identify available community resources and refer for counseling if needed

Culturally Competent Care: Incorporate Religious Beliefs

Respect the religious/spiritual practices of the client

Death rituals vary among cultures and the nurse must be prepared to facilitate such
practices whenever possible

End of Life: Assessing Client Coping

Symptoms of Normal Grief

feelings range from sadness to anxiety to yearning

thoughts may be confused, hopeless and preoccupied with the decreased person

difficulties sleeping, eating and crying are common behaviors

fatigue, muscle tension or weakness and oversensitivity to stimuli are common

physical sx

Determine the state of grief the client and family are experiencing

Understand the factors influencing the grieving process

type of loss
significance of loss
past coping mechanisms that have been effective
availability of support systems
prior experiences with loss

Understand the desires and expectations of the family for end of life care

Family Dynamics: Interventions to promote Integration of Older Adults into family

Structure

Death and Dying: Recognizing Preschool Responses to Death

Egocentric thinking

think magically, which causes them to feel guiltily, shameful and to sense punishment
interpret separation from parents as punishment for bad behavior
view dying as temporary, since they have no concept of time and the dead person may
still have attribute of the living (sleeping, eating and breathing)

Schizophrenia: Identifying Signs and Symptoms

characteristics symptoms

positive sx hallucinations
delusions
disorganized speech
bizarre behavior, such as
walking backward constantly

negative sx blunted affect

alogia (poverty of though or
speech)
avolition (lack of motivation
in activities and hygiene)
anhedonia
anergia

cognitive sx disordered thinking

inability to make decisions
poor problem solving ablilty
difficulty concentrating to
perform task
memory deficits (long term)

depressive sx hopelessness
suicidal ideation

type symptoms

paranoid hallucinations and delusions

 type symptoms

disorganized loose associations

bizarre mannerisms
incoherent speech
hallucinations and delusions

catatonic withdrawn stage

(psychomotor retardation,
waxy flexibility, self care
needs)
excited stage (constant
movement, unusual
posturing, incoherent
speech, elf care needs,
danger to self or others

residual anergia, anhedonia, avolition

withdrawal from social
activities
impaired role fx
speech probs

undifferentiated any positive or negative sx

may be present

Developing and Maintaining a Therapeutic Nurse-Client Relationship: Intervene to

Promote Trust

In the orientation phase of relationship, build trust by establishing expectations and

boundaries

Topic Descriptors

Reduction of Risk Potential (24)

Form A

Seizures: Client Education Regarding EEG

EEG records electrical activity and identifies the origin of seizure activity. Client
instruction includes:
No caffeine
Wash hair before the procedure (no oils, sprays) and after the procedure (remove
electrode glue)

May be asked to take deep breaths and/or be exposed to flashes of a strobe light during
the test

Sleep may be withheld prior to test and possible induced during test

Rheumatic Fever: Recognizing Expected Lab Findings

Antistreptolysin O titer > 250 IU/ml

Erythrocyte sedimentation rate > 15 mm/hr in men, > 20 mm/hr in women
C-reactive protein Positive
Throat culture Positive for streptococci (usually negative)
WBC count Elevated
Red blood cell parameters Mild to mod degress of normocytic, normo-
(HCT, Hgb, RBC) chromic anemia

Diabetes Mellitus: Client Teaching Regarding Purpose of Self-Blood Glucose

Monitoring

Attempt to maintain normal blood glucose levels to prevent development of

complications

Hypoglycemia

Hyperglycemia

Diabetic Ketoacidosis

Acid-Base Imbalances: Identify Expected lab Data

pH PaCO2 HCO3 Diagnosis

7.35-7.45 35-45 22-26 homeostasis

< 7.35 > 45 22-26 respiratory acidosis

 pH PaCO2 HCO3 Diagnosis

< 7.35 35-45 < 22 metabolic acidosis

> 7.45 < 35 22-26 respiratory alkalosis

> 7.45 35-45 > 26 metabolic alkalosis

Uncompensated: The pH will be abnormal and either the HCO3 or the PaCO2 will be
abnormal

Partially compensated: The pH, HCO3, and PaCO2 will be abnormal

Fully Compensated: The pH will be normal, but the PaCO2 and HCO3 will both be
abnormal

Diabetic Ketoacidosis: Recognize Clinical Manifestations

DKA is an acute, life-threatening condition characterized by hyperglycemia (> 300mg/

dL) resulting in breakdown of body fat for energy and an accumulation of ketones int eh
blood and urine. The onset is rapid.

Results in severe hyperglycemia from

lack of sufficient insulin
increased need for insulin

DKA is more common in indiv with type 1 DM

Signs/Symptoms

polyuria, polydipsia, polyphagia (early signs)

change in mental status

signs of dehydration (dry mucous membranes, wt loss, sunken eyeballs, resulting from
fluid loss such as polyuria

Kussmaul respiration pattern, rapid and deep respirations, fruity breath

N/V, abdominal pain

Fluid Imbalances: Interpret Lab Values for Dehydration

Expected Findings

Hgb and HCT = increased

Normal Hgb = 13.5-18 g/dL (males)
12-16 g/dL (females)

Normal HCT = 40-54% (males)

38-47% (females

Serum osmolarity = increased (hemoconcentration) osmolarity (> 300mOsm/L) -

increased protein, BUN, electrolytes and glucose
Normal BUN = 10-30 mg/dL
Potassium = 3.5-5.5 mEq/L

Urine Specific Gravity and osmolarity = increased (concentration)

Normal Specific Gravity = 1.005-1.030

Serum Sodium = Increased (hemoconcentration)

Normal 135-145 mEq/L

Diabetes Insipidus: Recognizing Expected Lab Findings

Urine chemistry: think DILUTE

decreased urine specific gravity ( < 1.005)

decreased urine osmolality (50-200 mOsm/kg)

decreased urine pH

decreased urine Na

decreased urine K

As urine volume increases, urine osmolality decreases

Serum chemistry
increased serum osmolality ( > 295 mOsm/kg

increased serum Na

increased serum K+

As serum volume decreases, the serum osmolality increases

Heart Failure: Recognizing Expected Lab Findings

BNP (Human B type Natriuretic Peptide)

used to differentiate dyspnea r/t CHF vs respiratory problem and to monitor the
need for and effectiveness of aggressive CHF intervention

BNP levels < 100 pg/mL = no CHF

BNP levels 100-300 pg/mL suggest CHF is present
BNP levels >300 pg/mL = mild CHF
BNP levels > 600 pg.mL = moderate CHF
BNP levels > 900 pg/mL = severe CHF

Hemodynamic Monitoring

increased CVP (central venous pressure)

increased right arterial pressure
increased PCWP (pulmonary capillary wedge pressure)
increased pulmonary artery pressure (PAP)
decreased CO

Conscious Sedation: Monitoring Client Physiologic Response Following

Conscious Sedation

Conscious Sedation is the admin of sedatives and/or hypnotics to the point where the
client is relaxed enough that minor procedures can be performed without comfort, yet
the client can respond to verbal stimuli, retains protective reflexes (gag reflex), is easily
arousable and (most important) independently maintains a patent airway.

Nursing Responsibilities After the Procedure

The monitoring nurse continues to record VS and LOC until the client is fully awake and
all assessment criteria return to pre-sedation levels.

Typical discharge criteria:

LOC as on admission
VS stable for 30-90 min
 Ability to cough and deep breathe
ability to take oral fluids
No N/V, SOB, or dizziness

Peripheral Venous Disease: Prevent Complications

Complications

Ulcer Formation: typically over malleolus, more often medially than laterally . May lead
to amputation and/or death

Pulmonary Embolism: occurs when thrombus is dislodge, becomes emboli and lodges
in the pulmonary vessels

Interventions

Deep Vein Thrombosis and Thrombophlebitis

Encourage REST

facilitate bedrest and elevation of extremity above the level of the heart (avoid
using a knee gatch or pillow under knees)

admin intermittent or continuous warm moist compresses (to prevent thrombus

from dislodging and becoming an embolus, DO NOT massage the affected limb)

provide thigh-high compression or antiembolism stockings to reduce venous

stasis and to assist in venous return of blood to the heart.

Admin meds as prescribed

anticoags

unfractionated heparin IV based on body wt is given to prevent formation of

other clots and to prevent enlargement of existing clot, followed by oral anticoag with
warfarin.

hospital admin is required for lab value monitoring and dose adjustment

monitor aPTT to allow for adjustments of heparin dosage

monitor platelet counts for heparin-induced thrombocytopenia

 ensure that protamine sulfate, the antidote for heparin is available if needed for
excessive bleeding

monitor the hazards and SE associated with anticoag therapy

Low molecular wt Heparin (LMWH) is given subq.

Enoxaparin (Lovenox), dalteparin (Fragmin) and ardeparin (Normiflo) have

consistent action and are approved for the prevent and tx of DVT

may be managed at home by home care nurse

must have stable DVT or PE, low risk for bleedign, adequate renal function
and normal VS

client must be willing to learn self injection

the aPTT is not checked on an ongoing basis bec the doses of LMWH are
not adjusted

Warfarin works in the liver to inhibit synthesis of the four vit K dependent clotting
factors

takes 3-4 days before it has therapeutic anticoagulation

heparin is continued until the warfarin effect is achieved then IV heparin

may be d/cd

if client is on LMWH, warfarin is added after the first dose of LMWH.

Therapeutic levels are measured by INR

monitor for bleeding

ensure that Vit K (the antidote for warfarin) is available in case of

excessive bleeding

Thrombolytic Therapy

effective in dissolving thrombi quickly and completely

must be initiated within 5 days after onset of sx to be most effective

advantage is the prevention of valvular damage and consequential venous

insufficiency or postphlebitis syndrome
 contraindicated during pregnancy and following surgery, childbirth, trauma, a
CVA, or spinal injury

tissue plasminogen activator (t-PA), a thrombolytic agent, and platelet inhibitors

such as abciximab (REoPRo), tirofiban (Aggrastat) and sptifibatide (Integrilin) may be
effective in dissolving a clot or preventing new clots during the first 24 hr.

primary complication of therapy is serious bleeding

Analgesics: Admin as ordered to reduce pain

Venous Insufficiency

Instruct client to

elevate legs for at least 20 min four to five times/day above the level of the
heart

avoid prolonged sitting or standing, constrictive clothing or crossing legs

when seated

wear elastic or compression stockings during the day and evening

put elastic stockings on before getting out of bed after sleep

clean the elastic stockings each day, keep the seams to the
outside, and do not wear bunched up or rolled down

replace worn out compression stockings as needed

on using an intermittent sequential pneumatic compression system

instruct the client to apply the system twice daily for 1 hour in am
and evening

advise the client with an open ulcer that the compression system is
applied over a dressing

Varicose Veins

emphasize the importance of antiembolism stockings as prescribed

instruct the client to elevate the legs as much as possible

instruct the client to avoid constrictive clothing and pressure on the legs.
Sickle Cell Anemia: Preventing Sickle Cell Crisis

Manifestations

Vaso-occlusive (painful episode) usually lasting 4-6 days

Acute
severe pain, usually in bones, joints, and abdomen
swollen joints, hands and feet
anorexia, vomiting and fever
hematuria
obstructive jaundice
visual disturbances

Chronic
increased risk of respiratory infections and/or osteomyelitis
retinal detachment and blindness
systolic murmurs
renal failure and enuresis
liver failure
seizures
deformities of the skeleton

Sequestration

excessive pooling of blood in the liver (hepatomegaly) and spleen

(splenomegaly)

tachycardia, dyspnea, weakness, pallor, and shock

Aplastic

extreme anemia as a result of decreased RBC production

Hyperhemolytic

increased rate of RBC destruction leading to anemia, jaundice, and/or

reticulocytosis

Avoiding Complications

avoid high altitudes

maintain adequate fluid intake

treat infections promptly

pneumovax, influenza, and hepatitis immunizations should be admin

treat chronic leg ulcers with bed rest, abx, warm saline soaks.

take freq rest breaks during physical activities (minimize tissue deoxygenation)

avoid contact sports if spleen is enlarged

adequate nutrition, freq medical supervision, proper hand washing and isolation from
known sources of infection

Thyroidectomy: Assess for Complications

Complications

Hemorrhage

the surgical dressing and incision need to be assessed for excessive drainage or
bleeding during the postop period.

inspect the surgical dressing for bleeding especially at the back of the neck and
change the dressing as directed

avoid pressure on the suture line, encourage the client to avoid neck flexion or
extension

support the head and neck with pillows or sandbags. If client needs to be
transferred from stretcher to bed, support the head and neck in good body
alignment

Thyroid Storm

monitor for signs of thyrotoxicosis (tachycardia, diaphoresis, increased BPs,

anxiety)

Airway Obstruction

a trach tray should be kept near the client at all times during the immediate
recovery period

maintain the bed in high-fowlers position to decrease edema and swelling of the
neck
 if the client reports the dressing feels tight, the surgeon needs to be alerted
immediately

Hypocalcemia and Tetany (due to damage to the parathyroid glands)

monitor for s/s of hypocalcemia (tingling of the fingers and toes, carpopedal
spasms and convulsions)

have calcium gluconate available

maintain seizure precautions

Nerve damage

nerve damage can lead to vocal cord paralysis and vocal disturbances

teach the client that he/she will be able to speak only rarely and will need to rest
the voice for several days and should expect to be hoarse

after the procedure, monitor the clients ability to speak with each measurement
of VS

assess the clients voice tone and quality and compare it to the preop voice.

CVA: Interventions to Prevent Aspiration

Nursing Interventions

Maintain a patent airway

monitor for changes in clients LOC (increased ICP sign)

Elevate clients head to reduce ICP and to promote venous drainage. Avoid extreme
flexion or extension, maintain head in midline neutral position and elevate to 30 degrees

institute seizure precautions

maintain a non-stimulating environment

assist with communication skills if clients speech is impaired.

assist with safe feeding

assess swallowing reflexes: swallowing, gag, and cough before feeding

 the clients liquids may need to be thickened to avoid aspiration

have client eat in an upright position and swallow with the head and neck flexed
slightly forward

place food in the back of the mouth on the unaffected side

suction on standby

maintain a distraction free environment during meals

Aspiration Complication---suction as needed. preassess the clients swallowing abilities.

Postoperative Nursing: Preventing Circulatory Complications

Prevent and Monitor for thromboembolism (esp following abdominal and pelvic
surgeries)
apply pneumatic compression stockings and/or elastic stockings

reposition the client every 2 hr and ambulate early and regularly

administer low-level anticoag as prescribed

monitor extremities for calf pain, warmth, erythema, and edema

Client positioning

position the client supine with head flat (prevent hypotension)

do not elevate the legs higher than placement on a pillow if the client has
received spinal anesthesia

do not put pillows under knees or use a knee gatch (decreases venous return)

Angiography: Recognizing Complications

Complications

Cardiac Tamponade
results from fluid accumulation in the pericardial sac

signs include
hypotension
JVD
muffled heart sound
 paradoxical pulse (variation of 10 mmHg or more in systolic blood
pressure between expiration and inspiration)

hemodynamic monitoring will reveal intracardiac and pulmonary artery pressures

similar and elevated (plateau pressures)

notify the PCP immediately

admin IV fluids to combat hypotension as ordered

obtain a chest xray or echocardiogram to confirm dx

prepare the client for pericardiocentesis (informed consent, gather materials,

admin meds as appropriate)

monitor hemodynamic pressures as they normalize

monitor heart rhythm; changes indicate improper positioning of the needle

monitor for reoccurrence of signs after the procedure

Hematoma Formation

assess the groin at prescribed intervals and as needed

hold pressure for uncontrolled oozing/bleeding

monitor peripheral circulation

notify PCP

Restenosis (of treated vessel)

assess ECG patterns and for occurrence of CP

notify PCP immediately

prepare the client for return to the cardiac cath lab

Retroperitoneal Bleeding

assess for flank pain and hypotension

notify the PCP

admin IV fluids and blood products as ordered.

Gastroenteral Feedings: Measures to prevent Aspiration

Assess for gag reflex. Place tongue blade in clients mouth, touching uvula to induce a
gag response.

identifies ability to swallow and determines if there is a risk for aspiration.

Clients with impaired LOC may also have impaired gag reflex and their risk of
aspiration is increased.

Assist client to High Fowlers position unless contraindicated

reduces risk of aspiration and promotes effective swallowing

Complication

Aspiration of stomach contents into the respiratory tract (immediate response)

evidenced by coughing, dyspnea, cyanosis, auscultation of crackles and wheezes

position client on side

suction nasotracheally and oral tracheally
consult PCP to order chest x-ray exam

Aspiration of stomach contents into respiratory tract (delayed response) evidenced by

dyspnea, fever, auscultation of crackles and wheezes

consult PCP to obtain order for chest xray

prepare for possible initiation of abx

Head Injury: Assessing Neurological Status

Assess/Monitor

Respiratory Status---the priority assessment

Changes in LOC--the EARLIEST indication of neurological deterioration

LOC and length

Cushing reflex (severe HTN with a widened pulse pressure and bradycardia)--late sign
of ICP

Posturing (decorticate, decerebrate, flaccid)

Cranial Nerve function

Pupillary changes (PERRLA, pinpoint, fixed/nonresponsive, dilated)

Signs of infection (nuchal rigidity with meningitis)

CSF leakage from nose and ears (halo sign yellow stain surrounded by by blood, test
positive for glucose)

GCS rating (15 normal; 3=deep coma)

Eye opening Verbal Response Motor Response

Response (E) (V) (M)

4 = spontaneous 5 = normal 6 = normal

conversation

3 = to voice 4 = disoriented 5 = localizes to pain

conversation

2 = to pain 3 = words; but not 4 = withdraws to pain

coherent

1 = none 2 = no words, only 3 = decorticate

sounds posture

1 = none 2 = decerebrate
posture

1 = none

E Score V Score M Score E+ V+ M = total

score

Urinary Tract Infection: Recognizing Risk Factors

Risk Factors/Causes of UTI

Female Gender
short urethra
close proximity of the urethra to the rectum
decreased estrogen in aging women promotes atrophy of the urethral opening
toward the rectum.
sexual intercourse
freq use of feminine hygiene sprays, tampons, sanitary napkins, spermicidal
jellies
pregnancy
women who are fitted poorly for diaphragms
hormonal influences within the vaginal flora
synthetic underwear and pantyhose
wet bathing suits
freq submersion into baths or hottubs

Indwelling urinary catheters

stool incontinence
bladder distention
urinary conditions (anomalies, stasis, calculi, and residual urine
possible genetic links
disease (DM)

Joint Replacement: Client Teaching Regarding Postop Activity Limits

Hip Replacement Surgery

Early Ambulation

Transfer out of bed from unaffected side

Wt bearing status is determined by the orthopedic surgeon and by the choice of

cemented (partial/full wt bearing as tolerated) vs non cemented prostheses (only partial
wt bearing until after a few weeks of bone growth)

use of assistive devices (for example, walker)

Do Dont

use elevated seating/raised avoid flexion of hip > 90

toilet seat degrees

use straight chairs with arms avoid low chairs

 Do Dont

use and abduction between do not cross legs

legs while in bed (and with
turning)

externally rotate toes don not internally rotate toes

Client position: supine with head slightly elevated with affected leg n neutral position
and a pillow or abduction device between legs to prevent abduction (movement toward
midline) which could cause hip dislocation

arrange for raised toilet seats, extended handle items (shoehorn, dressing sticks)

Knee Replacement Surgery

Positions of flexion of the knee are limited to avoid flexion contractures

Avoid knee gatch and pillows placed behind the knee

knee immobilizer may be used while in bed

goal is to be able to straight leg raise

kneeling and deep knee bends are limited indefinitely

CPM is used to promote motion in the knee and prevent scar tissue formation .

Preoperative Nursing: Recognizing Client Finding Indicative of Readiness for

Surgical Intervention

Preoperative Assessment

Detailed hx (including med problems, allergies, med use, substance abuse,

psychosocial probs, cultural considerations)

anxiety level regarding the procedure

lab results

H-T assessment

VS
Informed Consent

Once surgery has been discussed with the client or surrogate as tx, it is the
responsibility of the PcP to obtain consent after discussing the risks and benefits of the
procedure. The nurse is not to obtain consent for the PcP in any circumstance

the nurse can clarify any information that remains unclear after the PCPs
explanation of the procedure

The nurses role is to witness the clients signing of the consent forma after the client
acknowledges understanding of the procedure.

Postoperative Nursing: Maintain Function of Jackson-Pratt Drain

Monitor incisions and drain sites for bleeding and/or infection

monitor drainage (should progress from sanguineous to serosanguineous to

serous)

monitor the incision site (expected findings include pink wound edges, slight
swelling, under sutures/staples, slight crusting of drainage). Report signs of infection,
including redness, excessive tenderness and purulent drainage.

monitor wound drains (with each VS assessment). Empty as often as needed to

maintain compression. Report increases in drainage (possible hemorrhage)

Change wound dressing as required using surgical aseptic technique

use an abdominal binder for obese or debilitated clients

encourage splinting with position changes

administer prophylactic abx as prescribed

The nurse looks for drainage flow through the tubing as well as around the tubing. A
sudden decrease in drainage may indicate a blocked drain, and the PcP should be
notified. When a drain is connected to suction, the nurse asses the system to be sure
the pressure ordered is being exerted. Evacuator units such as Hemovac or Jackson-
Pratt exert a constant low pressure as long as the suction device (bladder or bag) is
fully compressed. These types of drainage devices are referred to as self-suction.

When the evacuator device is unable to maintain a vacuum on its own, the nurse
notifies the surgeon who can then order a secondary vacuum system (such as a wall
suction) If fluid is allowed to accumulate in the tissues, wound healing will not progress
at an optimum rate, and the risk of infection is increased.
Pain Management: Management of an Epidural Catheter

Epidural analgesia is the infusion of pain-relieving medication through a catheter placed

into the epidural space surrounding the spinal cord. the goal is delivery of med directly
to opiate receptors in the spinal cord. The admin may be intermittent or constant and is
monitored by the nurse. The overall effectiveness and the technique of admin result in
constant circulating level and a total reduced dose of med.

Intrathecal morphine can produce the same SE of nausea, mental clouding, and
sedation bec it is absorbed via the CSF into the circulation of the epidural vascular
plexus

Nursing Implications

catheter is connected to an epidural infusion pump, a port or reservoir or is capped off

for bolus injections.

to reduce the risk of accidental epidural injections of drugs intended for IV use, the
catheter should be clearly labeled epidural catheter

continuous infusions must be administered through electronic infusion devices for

proper control.

bec of catheter location, strict surgical asepsis is needed to prevent a serious and
potentially fatal infection

PcP notified immediately of any s/s of infections or pain at the insertion site

thorough nursing care is needed during hygiene procedures to keep the catheter
system clean and dray

Prevent catheter displacement

secure catheter (if not connected to implanted reservoir) carefully to outside skin

Maintain catheter function

check external dressing around catheter site for dampness or discharge (leak of
CSF may develop)

use transparent dressing to secure catheter and to aid inspection

inspect catheter for breaks

Prevent infection
 use strict aseptic technique when caring for catheter
do not routing change dressing over site
change infusion tubing q 24 hrs

Monitor for respiratory depression

monitor VS esp respirations, per policy

pulse oximetry and apnea monitoring may be used

Prevent undesirable complications

assess for pruritus (itching) and N/V

administer antiemetics as ordered

Maintain urinary and bowel function

monitor I/O
assess for bladder and bowel distention
assess for discomfort, freq, and urgency

Intraoperative Nursing: Circulating Nurse Role Priorities

Circulating nurse must be an RN

Responsibilities include:

review of the preop assessment

establishing and implementing the intraoperative plan of care
evaluating the care
providing for continuity of care postoperatively

assists with procedures as needed such as endotrach intubation and blood admin

monitors sterile technique and a safe operating room environment

assists the surgeon and surgical team by operating nonsterile equipment, provides
additional supplies verifies sponge and instrument counts and maintains accurate and
complete written records.

Blood Pressure: Recognizing and Responding to Factors Affecting Blood

Pressure

Key Factors

Pulse pressure
 the difference between the systolic and the diastolic pressure reading s

Postural (orthostatic) hypotension

a BP that falls when a client changes position from lying to sitting or standing and
it may result from various causes (eg peripheral vasodilation, med SE, fluid depletion)

Orthostatic changes are assessed by taking the clients BP and HR in the supine
position. next, have the client change to the sitting or standing position, wait 1-5 min,
and reassess the BP and HR. the client is experiencing orthostatic hypotension if the
SBP decreases more than 20 mmHg and/or the DBP decreases more than 10 mmHg
with a 10-20% increase in the HR.

Age

infants have a low BP that gradually increases with age

older children and adolescents will have varying BP based on body size. Large
children will have higher BP

older adult clients may have a slightly elevated SBP due to decreased elasticity
of blood vessels

Circadian Rhythms
affect BP with BP usually being the lowest in the early morning hours and
peaking during the later part of the afternoon or evening

Stress
associated with fear, emotional strain, and acute pain can increase BP

Ethnicity
African Americans have a higher incidence of HTN in general and at earlier ages

Gender
Adolescent to middle-age men have higher BPs than their female counterparts.
Postmenopausal women have higher BPs than their male counterparts

Medications
opiates, antihypertensives, and cardiac meds can lower BP. Some illicit drugs
(cocaine), cold meds, oral contraceptives and antidepressants can increase BP

Exercise
can decrease BP for several hours afterwards.
Form B

Angina: Recognize Appropriate Diagnostic Test Based on Client Findings

Electrocardiograms (ECG): check for changes on serial ECGs

Angina: ST depression and/or T wave inversion (ischemia)

MI: T-wave inversion (ischemia), ST segment elevation (injury) and an

abnormal Q wave (necrosis)

Clients with non-ST elevation MIs have other indicators

ST segment depression that resolves with relief of chest pain

New Development of left BBB

T-wave inversion in all chest lead

Serial Cardiac Enzymes: Typical pattern of elevation and decrease back to baseline
occurs with MI

Cardiac Enzyme Normal Levels Elevated Levels 1st Expected Duration

Detectable of Elevated Levels
Following
Myocardial Injury

Creatinine kinase MB 0% of total CK 4-6 hr 3 days

isoenzyme (CK-MB)- (30-170 units/L)
more sensitive to
myocardium

Troponin T < 0.2 ng/L 3-5 hr 14-21 days

Troponin I < 0.03 ng/L 3 hr 7-10 days

Myoglobin < 90 mcg/L 2 hr 24 hr

Myocardial Infarction: Recognizing Diagnostic findings and Planning Care in

Response

See above
Cervical CA: Recognizing Indications for Colposcopy and Biopsies

Early cervical CA is generally asymptomatic. Sx do not develop until the cA has become
invasive

Pap tests are an effective screening tool for detecting the earliest changes associated
with cervical CA.

Cervical biopsy (definitive) is performed for cytologic studies when a cervical lesion is
identified. Biopsy is usually performed during colposcopy as a follow up to an abnormal
Pap smear.

Unsatisfactory colposcopy findings or a positive biopsy necessitates removal of the

lesion by conization, cryotherapy, laser ablation or loop electrosurgical excision
procedure (LEEP)

Clients with more extensive CA may require a total abdominal hysterectomy or a more
extensive pelvic surgery called exenteration

S/S

painless vaginal bleeding

watery blood tinged vaginal discharge
leg pain (sciatic) or leg swelling
Flank pain (hydronephrosis)
unexplained wt loss
pelvic pain

Iron Deficiency Anemia: Identifying Expected lab Findings

Hb/Hct---decreased
McV---decreased
MCH---decreased
MCHC----decreased
Reticulocytes------normal or decreased
Serum iron-----decreased
TIBC------increased
Bilirubin------normal or decreased
Platelets------normal or increased

Conscious Sedation: Intervene for Complications

Complications that may arise
airway obstruction: insert airway, suction

 respiratory depression: admin 02 and reversal agents, such as naloxone
(Narcan) and flumazenil (Romazicon)

cardiac arrhythmias: set up 12 lead ECG, provide antidysrhythmics and fluids

hypotension: provide fluids, vasopressors

Anaphylaxis: Administer epinephrine

Osteoporosis: Measures to Prevent Injury

Assess the home environment for safety (remove throw rugs, adequate lighting, clear
walkways)

Reinforce the use of safety equipment and assistive devices

Instruct the client to avoid inclement weather (ice or slippery surfaces)

Clearly mark thresholds, doorways and steps

Prevention

Teach the importance of regular, wt bearing exercise

Leukemia: Interventions to Reduce Infection Risks of Chemotherapy

Prevent Infections

freq thorough handwashing is a priority intervention

place the client in a private room

screen visitors carefully

encourage good nutrition (low-bacteria diet, avoid salads, raw fruits, and vegs)
and fluid intake

Monitor WBC counts

Encourage good personal hygiene

Avoid crowds if possible
Immobilizing Interventions: Assessing for Altered Tissue Perfusion

Neurovascular assessment is essential throughout immobilization. Assessments are

done frequently following initial trauma to prevent neurovascular compromise r/t edema
and/or immobilization device. Neurovascular assessment includes assessment of the
following
Pain
Paresthesia
Pallor
Polar
Paralysis
Pulses
Neurovascular Early or Late Sign Assessment Client Teaching/Sx
Components Parameters to Report

Pain Early Assess area involved increasign pain not

using 0-10 rating relieved with
scale; 0= no pain, 10 elevation or pain
= worst pain med

Paresthesia Early assess for numbness or tingling,

numbness/tingling; pins or needles
pins or needles sensation
sensation: should be
absent

Pallor Early assess cap refill increased cap refill

Brisk is < 3 sec time > 3 sec , blue
fingers or toes

Polar Late assess skin temp by cool/cold fingers or

touch: warm or cool toes

Paralysis Late assess mobility; unable to move

moves fingers or fingers or toes
toes
able to plantar
dorsiflex the ankle
area not involved or
restricted by cast
 Neurovascular Early or Late Sign Assessment Client Teaching/Sx
Components Parameters to Report

Pulses Late assess pulses distal weak palpable

to injury; pulse is pulses, unable to
palpable and strong palpate pulses, pulse
detected only with
Doppler

Angina: Assessing Risk Factors

Risk factors:

male gender
hypertension
smoking hx
increased age
hyperlipidemia
metabolic disorders: DM, hyperthyroidism
Methamphetamine or cocaine use
Stress: Occupational, physical exercise, sexual activity

Postoperative Nursing: Evaluating Postop Interventions to Prevent Complications

Complications

Airway Obstruction

Monitor for choking, noisy irregular respirations, decreased 02 sat scores, and cyanosis
and intervene accordingly. Keep emergency equipment at the bedside in the PACU

Hypoxia

Monitor oxygenation status and admin 02 as prescribed. Encourage the client to cough
and deep breathe. Position the client to facilitate respiratory expansion

Hypovolemic Shock

Monitor for decreased BP and UOP, increased HR and slow cap refill. Admin fluids and
vasopressors as indicated

Paralytic ileus: Monitor bowel sounds, encourage ambulation, advance the diet as
tolerated, and admin prokinetic agents, such as metoclopramide (Reglan) as prescribed

Wound Dehiscence or Evisceration:

Monitor risk factors (obesity, coughing, moving without splinting, DM, day 5-10). If
wound dehiscence or evisceration occurs, call for help, stay with the client, cover with
sterile towel or dressing moistened with sterile saline, do not attempt to reinsert organs,
monitor the client for shock and notify PCP immediately.

Retinal Detachment: Evaluating Client Education Regarding Postop Care

Restrict activity to prevent additional detachment

cover the affected eye with an eye patch

monitor for drainage

Admin meds as prescribed

mydriatics (dilating)--prevent pupil constriction and reduce accommodation

antiemetics

analgesics

Instruct client to avoid activities that increase IOP

bending over at the waist
sneezing
coughing
straining
vomiting
head hyperflexion
wearing restrictive clothing (for example tight shirt collars)

DM: S/S of Hypoglycemia

BS: < 50 mg/dL

cool, clammy skin

diaphoresis

anxiety, irritability, confusion, blurred vision

hunger

general weakness, seizures, (severe hypoglycemia)

Suctioning: Evaluation of Endotrach Suctioning Effectiveness

Endotrach Suctioning (ETS) is performed through a trach or endotrach tube

Sterility must be maintained during endotracheal suctioning

The outer diameter of the suction catheter should be less than 1/2 the internal diameter
of the endotrach tube

Hyperoxygenate the client utilizing a bag-valve-mask (BVM) or specialized ventilator

function with 100% Fi02

immediately after the BVM ventilator is removed from the trach or endotrach tube, insert
the catheter into the lumen of the airway. Advance until resistance is met. The catheter
should reach the level of the carina (location of bifurcation into the main stem bronchi).

Intermittent suction is only applied during catheter withdrawal, lasting no longer than
10-15 sec at a time. Suction is performed by covering and releasing the suction port
with the thumb while concurrently withdrawing the catheter, rotating it between the
thumb and forefinger.

Reattach the BVM or ventilator and supply the client with 100% inspired 02.

Clear the catheter and tubing

Allow time for client recovery between sessions.

Repeat as necessary

Many mechanical ventilators have in-line suction devices. This may eliminate the need
for an assistant. Follow institution protocols for these systems. Always maintain surgical
aseptic technique

COPD: Interventions for Abnormal 02 Saturation Findings

Pulse Oximetry

monitor oxygen saturation levels

Less than normal (normal = 94-98%) oxygen saturation levels

Position the client to maximize ventilation (high Fowlers)

Encourage effective coughing, or suction to remove secretions

Encourage deep breathing and use of incentive spirometer

Administer breathing txs and meds as prescribed

 Bronchodilators

Short acting beta agonists, such as albuterol (Proventil, Ventolin) provide

rapid relief

Cholinergic antagonists (anticholinergic drugs, such as ipratropium

(Atrovent), block the parasympathetic nervous system. This allows for the
sympathetic nervous system effects of increased bronchodilation and
decreased pulmonary secretions

Methylxanthines, such as theophylline (Theo-Dur), require close

monitoring of serum med levels due to narrow therapeutic range.

Anti-inflammatories decrease inflammation

Corticosteroids such as fluticasone (Flovent) and prednisone. If given

systemically, monitor for serious SE (immunosuppression, fluid retention,
hyperglycemia, hypokalemia, poor wound healing)

Leukotriene antagonists, such as montelukast (Singulair)

Mast cell stabilizers, such as cromolyn sodium (Intal)

Combination agents (bronchodilator and anti-inflammatory)

Ipratropium and albuterol (Combivent)

Fluticasone and salmeterol (Advair)

If prescribed separately for inhalation admin at the same time, administer

the bronchodilator first in order to increase the absorption of the
anti-inflammatory agent.

Admin heated and humidified oxygen therapy as prescribed. Monitor for skin breakdown
from the 02 device.

Instruct clients to practice breathing techniques to control dyspneic episodes

Diaphragmatic or abdominal breathing

Pursed lip breathing

Provide oxygen therapy as prescribed to relieve hypoxemia

 client with COPD may need 2-4 L/min per nasal cannula or up to 40% Venturi
mask

Clients with chronic hypercarbia usually require 1-2 L/min via nasal cannula. It is
important to recognize that low arterial levels of oxygen serve as their primary
drive for breathing

Determine the clients physical limitations and structure activity to include periods of rest

Promote adequate nutrition

increased work of breathing increases caloric demands

proper nutrition aids in the prevention of secondary respiratory infections

Provide support to the client and family

Encourage verbalization of feelings

Encourage smoking cessation if applicable. Smoking and other flame sources must be
avoided by clients on supplemental oxygen (enhances (combustion) in the home

Topic Descriptors

Safety and Infection Control (17)

Form A

Newborn Discharge Teaching: Infant Safety Priorities

Provide community resources to clients who may need additional and ongoing
assessment and instruction on infant care (eg adolescent parents)

Never leave the infant unattended with pets or other small children

Keep small objects (coins) out of reach of infants (choking hazard)

Never leave the infant alone on a bed, couch, or table. Infants move enough to reach
the edge and fall off

Never provide an infant a soft surface to sleep (eg pillows and waterbed). The infants
mattress should be firm. Never put pillows, large floppy toys or loose plastic sheeting in
a crib. The infant can suffocate.
Never place the infant on its stomach to sleep during the first few months of life. The
back lying position is the position of choice

when using an infant carrier, always be within arms reach when the carrier is on a high
place such as a table. If possible, place the carrier on the floor near you.

Do not tie anything around the infants neck. Check the infants crib for safety. Slats
should be no more than 2.5 inches apart. The space between the mattress and sides
should be less than 2 finger widths

Keep a crib or playpen away form window blinds and drapery cords. Infants can
become strangled in them.

The bassinet or crib should be placed on an inner wall, not next to a window to prevent
cold stress by radiation.

Eliminate potential fire hazards. Keep a crib and playpen away from heaters, radiators,
and heat vents. Linens could catch fire if in contact with heat sources

Smoke detectors should be on every floor of a home and should be checked monthly to
assure they are working. Batteries should be changed yearly. (Change batteries when
daylight saving occurs)

Provide adequate ventilation. Control the temp and humidity of the infants environment.

Avoid exposure to cigarette or cigar smoke in a home or elsewhere. Passive exposure

increases the infants risk of developing respiratory sx and illnesses.

Be gentle with the infant. Do not swing the infant by his arms or throw the infant up in
the air

All visitors should wash their hands before touching the newborn

Any individual with an infection should be kept away from the newborn.

Always use an approved car seat when traveling. Parent should be instructed about the
proper installation of an approved car safety seat.

The infant should always be in a rear-facing car seat from birth to 9.1 kg (20 lb) or 1
year of age, after which, a toddler seat should be used.

The infant car seat should be secured in the rear seat of the car.

The shoulder straps should be snug enough so they do not fall off the infants
shoulders.
Disaster Planning: Identify Disaster Preparedness Activities

Develop a disaster response plan based on the most probable disaster threats

identifying community disaster warning system and communication center and learning
how to use it

identify the first responders in the community disaster plan

making a list of agencies that are available for the varying levels of disaster both locally
and nationally

defining the nursing roles in first priority, second priority and third priority triage

identifying specific roles of personnel involved in disaster response and the chain of
command.

locating all equipment and supplies needed for disaster management, including Level
III suits, infectious control items, medical supplies, food, and potable water. Replenish
these regularly.

Checking equipment (including evacuation vehicles) regularly to ensure proper

operation.

evaluating the efficiency, response time, and safety of disaster drills, mass casualty
drills and disaster plans.

Emergency Management: Decontamination Following Exposure to Bioterrorism

Anthrax: instruct clients to remove contaminated clothing and store in labeled plastic
bags. Handle clothing minimally to avoid agitation. Instruct clients to shower throroughly
with soap and water. Use standard precautions and wear appropriate protective barriers
when handling contaminated clothing or other items. Recommended postexposure
prophylaxis includes the admin of oral fluorquinolones (cipro, levofloxacin, and
ofloxacin)

Botulism: decontamination is not required

Plague: Risk for reaerosolization form contaminated clothing of exposed persons is low.
In the case of gross exposure, instruct clients to remove contaminated clothing and
store in labeled plastic bags. Handle clothing minimally to avoid agitation. Instruct
clients to shower thoroughly with soap and water. Use standard precautions and wear
appropriate protective barriers when handling contaminated clothing or other items.
Postexposure prophylaxis is recommended for clients and HCP. The antimicrobial agent
of choice is doxycycline or cipro.
Smallpox: Client decontamination after exposure is not indicated.

Ergonomic Principles: Prevention of Carpal Tunnel Syndrome

Avoid repetitive movements of the hands, wrists, and shoulders. Take a break q 15-20
min to flex and stretch joints and muscles.

Adaptive devices such as wrist splints may be worn to hold the wrist in slight
dorsiflexion to relieve pressure on the median nerve.

Special keyboard pads that help prevent repetitive pressure on the median nerve

Safe Medication Administration and Error Prevention: Selecting Appropriate

Resources for Checking Prescription Accuracy

Nursing drug handbooks

Pharmacology textbooks

Professional journals

PDR

Professional Websites.

Error Prevention: Ensuring Client Safety When Transcribing Orders

Components of a medication order

Name of client

Date and time of order

Name of med

Dosage

Route of Admin

Time and Freq --exact times or number of times per day (dictated by facility/agency
policy or specific qualities of the med)

Signature of prescribing doctor

When the nurse receives a verbal or telephone order, he or she writes the complete
order or enters it into a computer and then reads it back and receives confirmation from
the prescriber to confirm accuracy. The nurse indicates the time and the name of the
prescriber who gave the order and then signs the order.

Common abbreviations may be used when writing orders. However, JCAHO now
requires healthcare organizations to develop a dangerous abbreviation acronyms and
symbols list.

Handling Infectious Materials: Appropriate Disposal

The CDC recommends a single bag for discarding items if the bag is impervious and
sturdy and if the article can be placed in the bag without contaminating the outside of
the bag. Soiled linen should be place in an impervious laundry bag in the clients room

the CDC recommends double bagging if it is impossible to prevent contamination of the

bags outer surface. Double bagging is not otherwise recommended.

Client Safety: Removing Fire Hazards

Faulty equipment (eg frayed cords, disrepair) can start a fire or cause a shock and
should be removed and reported immediately per the health care agencys policy.

Seizures: Appropriate Use of Seizure Precautions to Maintain Client Safety

To develop a plan of care, assess the client with a hx of seizures for:

freq
type and date of last seizure
meds
triggers or trends of the seizures

Ensure rescue equipment is at the bedside to include oxygen, an oral airway, and
suction equipment. A saline lock may be put in for IV access if the client is at high risk
for experiencing a generalized seizure

Inspect the clients environment for items that may cause injury in the event of a seizure
and remove items that are not necessary for current tx

Assist the client at risk for a seizure in ambulation and transfer to reduce the risk of
injury

Advise all caregivers and family not top put anything in the clients mouth (except in
status epilepticus, where an airway is needed) in the event of a seizure

Advise all caregivers and family not to restrain the client in the event of a seizure,
ensure the clients safety by lowering him to the floor or bed, protect his head, remove
nearby furniture, provide privacy, put the client on his side, if possible and loosen
clothing to prevent injury and promote dignity of the client

After a seizure, explain what happened to the client, provide comfort and understanding
and a quiet environment for the client to recover.

Document the seizure in the clients record with any precipitating behaviors and a
description of the event (eg movements, any injuries, length of seizure, aura, postictal
state) and report it to the PCP.

Surgical Asepsis: Performing Aseptic Technique

Procedure:

Wash hands

Open plastic covering of package per manufacturers directions, slipping the package
onto the center of the workspace with the top flap of wrapper opening away from the
body.

Reach around the package to open the top flap of the package, grasp the outside flap
between the thumb and index finger and unfold the top flap away from body.

Next open the side flaps, using the right hand for the right flap and the left hand for the
left flap

The last flap should be grasped and turned down toward body

Additional sterile packages

Open next to the sterile field by holding the bottom edge with one hand and
pulling back on the top flap with the other hand. Place the packages that are to be used
last furthest from the sterile field, and open these first.

Add them directly to the sterile field. Lift the package from the dry surface holding
it 15 cm (6 in) above the sterile field, pulling the two surfaces apart, and dropping it onto
the sterile field.

Pour sterile solutions by

Removing the bottle cap

Placing the bottle cap face up on the surface

Holding the bottle with the label in the palm of the hand so that the solution does
not run down the label
 First pouring a small amt (1 -2 ml) of the solution into an available receptacle.

pouring the solution onto the dressing or site without touching the bottle to the
site.

Once the sterile field is set up, it is necessary to don sterile gloves.

Sterile gloving includes opening the wrapper and handling only the outside of the
wrapper. Don gloves by using the following steps.

With the cuff side pointing toward the body, use the left hand and pick up the righ
hand glove by grasping the folded bottom edge of the cuff and lifting it up and
away from the wrapper.

While picking up the edge of the cuff, pull the right glove on the hand.

With the sterile right gloved hand, place the fingers of the right hand inside the
cuff of the left glove, lifting it off the wrapper and put the left hand into it.

When both hands are gloved, adjustments of the fingers in the gloves may be
made if necessary.

During that time, only the sterile gloved hand can touch the other sterile glvoed
hand.

At the close of the sterile procedure, or if the gloves tear, the gloves must be
removed. Take off the gloves by grasping the outer part at the wrist, pulling the
glove down over the fingers and into the hand that is still gloved. Then, place the
ungloved hand inside the soiled glove and pull the glove off so that it is inside out
and only the clean inside part is exposed. Discard into an appropriate receptacle.

Infection Control: Identifying and Reporting Errors in Surgical Skin Preparation

Surgical handwashing

Turn on water using knee or foot controls and adjust to comfortable temp

Wet hands and arms under running lukewarm water and lather with detergent to 5 cm (2
in) above the elbows. (Hands need to be above the elbows at all times

Rinse hands and arms thoroughly under running water. Remember to keep hands
above elbows.

Under running water, clean under nails of both hands with nail pick. Discard after use
Wet clean sponge and apply antimicrobial detergent. Scrub nails of one hand with 15
strokes. Holding sponge perpendicular, scrub palm, each side of thumb and fingers and
posterior side of hand with 10 strokes each. The arm is mentally divided into thirds and
each third is scrubbed 10 times. Entire scrub should last 5-10 min. Rinse sponge and
repeat sequence for other arm. A two-sponge method may be substituted.

Discard sponge and rinse hands and arm thoroughly. Turn water off with foot and knee
control and back into room entrance with hands elevated in front of and away from the
body.

Artificial Airway: Instructing Family on Safe Use of Equipment

Provide trach care q 8 hrs to decrease the risk of infection and skin breakdown

suction the trach tube, if necessary using sterile suctioning supplies

remove old dressing and excess secretions

apply the oxygen source loosely if the client desaturates during the procedure

use cotton-tipped applicators and gauze pads to clean exposed outer cannula
surfaces. Begin with H202 followed by normal saline. Clean in circular motion from
stoma site outward.

using surgical aseptic technique, remove and clean the inner cannula (use H202
to clean the cannula and sterile saline to rinse it. Use new inner cannula if it is
disposable)

Clean the stoma site and the trach plate with H202 followed by sterile saline.

Place split 4x4 dressing around trach.

Change trach ties if they are soiled. Secure new ties in place before removing soiled
ones to prevent accidental decannulation.

If a know is needed, tie a square know that is visible on the side of the neck. One or two
finger should be able to be placed between the tie tape and the neck.

document the type and amt of secretions, the general condition of the stoma and
surrounding skin, the clients response to the procedure, and any teaching that
occurred.

Provide adequate humidification and hydration to thin secretions and decrease risk of
mucus plugging
Do not suction routinely as this causes mucosal damage, bleeding and bronchospasm.

Suction PRN when assessment findings indicate (eg audible/noisy secretions, crackles,
restlessness, tachypnea, tachycardia, presence of mucus in the airway.

Emergency Management: Order of Client Evacuation in Response to a Fire

Clients who are close to the fire, regardless of its size, are at risk of injury and should be
moved to another area.

If a client is receiving oxygen but not life support, the nurse discontinues the oxygen,
which is combustible and can fuel an existing fire.

If the client is on life support, the nurse may need to maintain the clients respiratory
status manually with an Ambu-bag until the client is moved away from the fire. Abulatory
clients can be directed to walk by themselves to a safe area and in some cases may be
able to assist in moving clients in wheelchairs.

Bedridden clients are generally moved form the scene of a fire by a stretcher, their bed
or a wheelchair.

If none of these methods, the client must be carried from the area.

HIV/AIDS: Appropriate Environmental Precautions

Direct contact (skin to skin or contact with mucous membrane discharges)

HIV is transmitted through blood and body fluids (semen, vaginal secretions)

HIV is found in breast milk, amniotic fluid, urine, feces, saliva, tears, CSF, lymph nodes,
cervical cells, corneal tissue and brain tissue, but epidemiologic studies indicate that
these are unlikely sources of infections.

Decreasing risks r/t sexual intercourse

safe sex eliminates the risk of exposure to HIV in semen and vaginal secretions

abstaining is the most effective way to accomplish this but there are safe options for
those who cannot or do not wish to abstain

outercourse (limiting sexual behavior to activities in which the mouth, penis, vagina or
rectum does not come into contact with a partners mouth, penis, vagina, or rectum) is
safe bec there is not contact
 includes massage, masturbation, mutual masturbation, telephone sex

insertive sex between partners who are not infected with HIV or not at risk of becoming
infected with HIV is considered to be safe

Risk reducing sexual activities decrease the risk of contact through the use of barriers.

should be used when engaging in insertive sexual activity with a partner who is
known to be HIV infected or with a partner whose HIV status is not known

most common barrier device is male condom

female condoms

squares of latex

plastic food wrap

Decreasing risks r/t drug use

major risk for HIV infection is r/t sharing injecting equipment and/or having unsafe sex
experiences while under the influence of drugs.

basic rules

do not use drugs

if you do, dont share equipment

do not have sex when under the influence of any drug (including alcohol) that impairs
decision making ability

use alternatives to injecting such as smoking, snorting, or ingesting the drug

injecting equipment includes needles, syringes, cookers (spoons or bottle caps used to
mix the drug) cotton, and rinse water

another safe tactic is for the user to have access to sterile equipment (needle exchange
programs)

cleaning equipment before use is a risk-reducing activity

Decreasing risks for perinatal transmission

best way to prevent HIV in infants is to prevent HIV infection in women

If HIV-infected pregnant women are txd with AZT, REtrovir, the rate of perinatal
transmission is decreased.

tx has minimal SE for the baby

Combination ART as appropriate for the mothers HIV infection can further decrease the
risk of perinatal transmission to less than 2%

Decreasing risks at work

employers must protect workers from exposure to blood and other potentially infectious
materials.

precautions and safety devices decrease the risk of direct contact with blood and body
fluids.

should exposure to HIV infected fluids occur, postexposure prophylaxis with

combination ART based on the type of exposure the volume of exposure and the status
of the source pt decreases the risk of infections.

Meningitis: Client Education Regarding Prophylactic Precautions

Risk Factors

Bacterial Infections (Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus

influenzae) such as upper respiratory infections (otitis media, pneumonia, sinusitis)

Immunosuppression

Invasive Procedures, skull fracture, or penetrating head wound (direct access to CSF)

Overcrowded Living conditions

prevention of respiratory infection through vaccination program for pneumococcal

pneumonia and influenza should be supported

In addition, early and vigorous tx of respiratory and ear infections is important.

persons who have close contact with anyone who has bacterial meningitis should be
given prophylactic antibiotics.

Client Safety: Evaluating Appropriate Selection of Restraints Based on Client

Situation
Client Safety: Appropriate Use of Restraints

Reasons for use of a physical restraint are to be clearly stated

the use of restraints must be part of clients medical tx all less restrictive interventions
must be tried first, other disciplines must be consulted, and supporting documentation
must be provided.

if a nurse uses restraints in an emergent situation, such as when a client is a danger to

self or others, a face-to-face assessment is to be done within 1 hr by a PCP

a physicians order is required based on a face-to-face assessment of the client.

the order must state the type of restraint, location, and specific client behaviors for
which restraints are to be used and must have a limited time frame.

these orders should be renewed within a specific time frame according to the agencys
policy.

Assessment must ongoing.

Proper documentation including behaviors that necessitated the application of

restraints, the procedure used in restraining and the condition of the body part
restrained and the evaluation of the client response is essential.

Use of restraints must meet the following objectives:

reduce the risk of client injury from falls

prevent interruption of therapy such as traction, IV infusions, NG tube feeding or Foley

cath

prevent the confuse or combative client from removing life support equipment

reduce the risk of injury to others by the client

Client Safety: Maintain Prescribed Restraints

Remove or replace restraints frequently to ensure good ciruclation to the area and allow
for full ROM to the limb that has been restricted.

Pad bony prominences and do neurosensory checks (to include loosening or removing
the restraint and testing temperature, mobility, and capillary refill) q 2 hr to identify any
neurological or circulatory deficits.
Always tie the restraint to the bed frame (loose knots that are easily removed) where it
will not tighten when the bed is raised or lowered.

Leave the restraint loose enough for ROM and with enough room to fit two fingers
between the device and the client to prevent injury.

always explain the need for the restraint to the client and family so as to help them
understand that these actions are for the safety of the client.

Regularly assess the need for continued use of the restraints to allow for discontinuation
of the restraint or limiting the restraint at the earliest possible time while ensuring the
clients safety.

Never leave the client unattended without the restraint.

Restraints should:

Never interfere with tx

Restrict movement as little as is necessary to ensure safety

Fit properly

Be easily changed to decrease the chance of injury and to provide for the greatest level
of dignity

Documentation for the use of restraints is very specific and must include:

the behavior that makes the restraint necessary

nursing interventions used prior to the placement of restraints.

clients LOC

type of restraint used and location

education/explanations to the client and family

exact time of application of removal

clients behavior while restrained.

Form B

Emergency Management: Appropriate Response to Fire

The RACE mnemonic is a basic guideline for reacting to a fire within the health care
facility.

Rescue Rescue everyone from the area

Alarm Pull the fire alarm which will activate the

EMS response
Systems that could increase fire spread
are automatically shut down with activation
of alarm

Contain Once the room or area has been cleared,

the fire doors should be kept closed in
order to contain the fire.
Keep fire doors closed as much as
possible when moving from section to
section within the facility
 Rescue Rescue everyone from the area

Extinguish Make an attempt to extinguish small fires

using a single fire extinguisher,
smothering, or water (except with an
electrical or grease fire).
Evacuation should occur if the nurse
cannot put the fire out with these methods.
Attempts at extinguishing the fire should
only be made when the employee has
been properly trained in the safe and
proper use of a fire extinguisher and when
only one extinguisher is needed.

Clients who are close to the fire, regardless of its size, are at risk of injury and should be
moved to another area.

If a client is receiving oxygen but not life support, the nurse discontinues the oxygen,
which is combustible and can fuel an existing fire.

If the client is on life support, the nurse may need to maintain the clients respiratory
status manually with an Ambu-bag until the client is moved away from the fire. Abulatory
clients can be directed to walk by themselves to a safe area and in some cases may be
able to assist in moving clients in wheelchairs.

Bedridden clients are generally moved form the scene of a fire by a stretcher, their bed
or a wheelchair.

If none of these methods, the client must be carried from the area.

Ergonomic Principles: using Body Mechanics to Prevent Injuries to the Nurse

The center of gravity is the center of a mass. In the body, the center of gravity is the
pelvis. When an individual moves, the center of gravity also shifts. The closer the line of
gravity is to the center of the base of support, the more stable the individual is. To lower
the center of gravity, bend the hips and knees. Avoid twisting the spine or bending at the
waist (flexion) to minimize the risk for injury

When lifting, use the major muscle groups to prevent back strain and tighten the
abdominal muscles to increase support to the back muscles. Distribute the wt between
the large muscles of the arms and legs to decrease the strain on any one muscle group
and avoid strain to smaller muscles. When lifting from the floor, flex the hips, knees and
back. Get the object to thigh level keeping the knees bent and straightening the back.
Hold the object as close as possible, bringing the load to the center of gravity to
increase stability and decrease strain. Use assistive devices whenever possible, and
find assistance whenever it is needed.

When pushing or pulling a load, widen the base of support. if pushing, move the front
foot forward and if pulling, move the rear leg back and promote stability. Face the
direction of movement if moving a client. It is easier and safer to pull toward than to
push away from the center of gravity. use body wt when pushing or pulling to decrease
the strain on muscles which makes the movement easier. Sliding, rolling and pushing
require less energy than lifting and have less risk for injury

Guidelines to Prevent Injury

Plan ahead for activities that require lifting, transfer or ambulation of a cliet and ask
others to be ready to assist at the time planned.

Rest between these heavy activities to decrease muscle fatigue

Maintain good posture and exercise regularly to increase the strength of arm, leg, back
and abdominal muscles so these activities require less energy

Get help from others, use assistive devices and offer to help others in lifting clients to
reduce the load for any one indiv.

Use smooth movements when lifting and moving clients to prevent injury through
sudden or jerky muscle movements

When standing for long periods of time, flex the hip and knee through use of a foot rest.
When sitting for long periods of time, keep the knees slightly higher than the hips

The client who is debilitated does not move easily and has difficulty changing positions
freq. it is the responsibility of the caregiver to reposition the client regularly while
maintaining good body alignment for the client, and using good body mechanics for the
providers safety.

Avoid repetitive movements of the hand, wrists and shoulders. Take a break every
15-20 min to flex and stretch joints and muscles.

Maintain good posture (head and neck in straight line with the pelvic) to avoid neck
flexion and hunched shoulders which can cause impingement of nerves in the neck.

Error prevention: Questioning Prescriptions

A nurse is obligated to carry out a physicians order except when the nurse believes an
order to be inappropriate or inaccurate

A nurse carrying out an inaccurate order may be legally responsible for any harm
suffered by the client

The nurse should clarify with the physician an unclear or inappropriate order or an order
in question

If no resolution occurs regarding he order in questions, the nurse should contact the
nurse manager or supervisor

Hazardous Materials: Appropriate Handling of Chemotherapy

Disposal of Cytoxic Drug

1. All material contaminated with cytotoxic drugs must be placed in yellow
plastic sharps/chemotherapy disposal containers.

2. All needles and syringes must be placed as a single unit into the
yellow sharps/chemotherapy disposal containers.

Client Safety: Interventions to Prevent Falls

Assess the clients risk for falling

Assign the client at risk for falling to a room near the nurses station
Alert all personnel to the clients risk for falling
Orient the client to physical surrounding s
Instruct the client to seek assistance when getting up
Explain use of the call bell system
Keep the bed in the low position with side rails up if required
Lock all beds, wheelchairs, and stretcher
Keep personal items within reach
Eliminate clutter and obstacles in the clients room
Provide adequate lighting
Reduce bathroom hazards
maintain the clients toileting schedule throughout the day

Incidents: Priority Responses

Incident reports are used as a means of identifying risk situations and improving client
care.

Follow specific documentation guidelines

fill out the report completely, accurately and factually

The report form should not be copied or placed in the clients record

Make no reference to the incident report form in the clients record.

The report is not a substitute for a complete entry in the clients record regarding the
incident.

Examples of incidents:

Accidental omission of ordered therapies

Circumstances that led to injury or a risk for client injury

Client falls

Medication admin error

Needlestick injuries

Procedure related or equipment related accidents

A visitor having symptoms of an illness

Security Plans: Appropriate Interventions to Maintain Security on Obstetrical Unit

Teach parents how to recognize picture identification badges worn by birth facility
personnel

Parents should also be aware of other identifying measures such as color coded
badges or uniforms for maternity staff

Written and verbal information, including a picture of special identification badges worn
by staff should be given to parents

Parents must be cautioned never to give their infant to anyone who does not have
proper identification

Question anyone carrying a newborn near an exit or in an unusual part of the facility
Be suspicious of anyone who does not seem to be visiting a specific mother, asks
detailed questions about the nursery or discharge routines, asks to hold infants or
behaves in an unusual manner

Be suspicious of unknown people carrying large bags or packages that could contain an
infant

respond immediately when an alarm signals that a remote exit has been opened or an
infant has been taken into an unauthorized area

Never leave infants unattended. Teach parents that infant must be observed at all times.
Suggest that mothers have the nursing staff take over care of the infant if the mother
feels unwell or is napping and no family members are available to watch the infant

Take infants to mothers one at at time. never leave an infant in a crib in the hall while
the nurse is in a room with another mother. Never leave an infant unsupervised.

When infants are left in mothers room, position the crib away from the doorways,
preferably on the side of the mothers bed opposite the door

If entrances to the maternity unit or nurseries are equipped with locks that open to
codes or card keys, protect them from others

When a parent or family member comes to the nursery to take an infant, always match
the infant and adult identification bracelet numbers. never give an infant to anyone who
does not have the correct identification bracelet or other proper id

Alert hospital security immediately when any suspicious activity occurs

Suggest that parents do no place announcements in the paper or signs in their yard that
might alert an abductor that a new baby is in the home