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• Post-test of 7 5 questions simulating the NCLEX Client Needs percentages helps you evaluate your progress.

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Instructor of Nursing Salve Regin a Un iversity, Newport, Rh ode Islan d

President Nu rsin g Reviews, In c., Hen derso n , Nevad a Nu rsin g Reviews, In c., Ch arlesto wn , Rh od e Islan d an d Profession al Nursin g Sem in ars, In c., Ch arlestown , Rh ode Islan d

Elsevier Consultant HESI NCLEX-RN ® an d NCLEX-PN® Live Review Courses

Assistant Professor To uro Un iversity Nevad a—Sch o ol of Nu rsin g Hen d erson , Nevad a

3251 Riverport Lan e St. Louis, Missouri 63043

SAUNDERS CO MPREHENSIVE REVIEW FO R THE NCLEX-RN® EXAMINATIO N, SEVENTH EDITIO N

ISBN: 978-0-323-35851-4

Co p yrigh t © 2017 b y Elsevier, In c. All righ ts reserved .

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Previo us edition s copyrigh ted 2014, 2012, an d 2009.

NCLEX®, NCLEX-RN®, an d NCLEX-PN® are registered tradem arks of th e Nation al Coun cil of State Boards of Nursin g, In c.

Lib rary o f Co n gress Catalo gin g-in -Pu b licatio n Data Nam es: Silvestri, Lin da An n e, auth or. Title: Saun ders com preh en sive review for th e NCLEX-RN exam in ation / Lin da An n e Silvestri. O th er titles: Com preh en sive review for th e NCLEX-RN exam in ation Description : Seven th ed ition . j St. Lo uis, Misso uri : Elsevier, [2017] j In cludes b ibliograph ical referen ces an d in d ex. Iden tifiers: LCCN 2016011692 j ISBN 9780323358514 (p bk. : alk. p aper) Subjects: j MESH: Nu rsin g, Practical j Nursin g Care j Nu rsin g Process j Exam in ation Q u estion s Classification : LCC RT62 j NLM WY 18.2 j DDC 610.73076–dc23 LC record available at h ttp:/ / lccn .loc.gov/ 2016011692

Content Strategist: Jam ie Blum Content Development Manager: Laurie Gower Content Development Specialist: Laura Go odrich Publishing Services Manager: Jeff Patterson Book Production Specialist: Bill Dro n e Designer: Ren ee Duen ow

Prin ted in th e Un ited States of Am erica

Last digit is th e p rin t n u m ber: 9 8 7 6 5 4 3 2 1

Contents

UNIT I NCLEX-RN® Exam Preparation, 1 1 Th e NCLEX-RN® Exam in atio n , 2 2 Path ways to Su ccess, 14 3 Th e NCLEX-RN® Exam in atio n fro m

a Grad u ate’s Persp ective, 18 4 Test-Takin g Strategies, 20

UNIT II Professional Standards in Nursing, 30 5 Cu ltu ral Awaren ess an d Health Practices, 32 6 Eth ical an d Legal Issu es, 44 7 Prio ritizin g Clien t Care: Lead ersh ip ,

Delegatio n , an d Em ergen cy Resp o n se Plan n in g, 59

UNIT III Nursing Sciences, 76 8 Flu id s an d Electro lytes, 78 9 Acid -Base Balan ce, 97

10 Vital Sign s an d Lab o rato ry Referen ce In tervals, 108

11 Nu tritio n , 124 12 Paren teral Nu tritio n , 134 13 In traven o u s Th erap y, 144 14 Ad m in istratio n o f Blo o d Pro d u cts, 158

UNIT IV Fundamentals of Care, 169 15 Health an d Ph ysical Assessm en t o f th e Ad u lt

Clien t, 171 16 Pro visio n o f a Safe En viro n m en t, 192 17 Calcu latio n o f Med icatio n an d In traven o u s

Prescrip tio n s, 204 18 Perio p erative Nu rsin g Care, 215 19 Po sitio n in g Clien ts, 230 20 Care o f a Clien t with a Tu b e, 239

UNIT V Growth and Development Across the Life Span, 255 21 Th eo ries o f Gro wth an d Develo p m en t, 257 22 Develo p m en tal Stages, 265 23 Care o f th e O ld er Clien t, 281

UNIT VI Maternity Nursing, 289 24 Rep ro d u ctive System , 291 25 Pren atal Perio d , 299 26 Risk Co n d itio n s Related to Pregn an cy, 314 27 Lab o r an d Birth , 332 28 Pro b lem s with Lab o r an d Birth , 346 29 Po stp artu m Perio d , 356 30 Po stp artu m Co m p licatio n s, 364 31 Care o f th e Newb o rn , 372 32 Matern ity an d Newb o rn Med icatio n s, 393

UNIT VII Pediatric Nursing, 403 33 In tegu m en tary Diso rd ers, 404 34 Hem ato lo gical Diso rd ers, 411 35 O n co lo gical Diso rd ers, 419 36 Metab o lic an d En d o crin e Diso rd ers, 430 37 Gastro in testin al Diso rd ers, 439 38 Eye, Ear, an d Th ro at Diso rd ers, 457 39 Resp irato ry Diso rd ers, 463 40 Card io vascu lar Diso rd ers, 479 41 Ren al an d Urin ary Diso rd ers, 491 42 Neu ro lo gical an d Co gn itive

Diso rd ers, 499 43 Mu scu lo skeletal Diso rd ers, 511 44 In fectio u s an d Co m m u n icab le

Diseases, 520 45 Ped iatric Med icatio n Ad m in istratio n an d

Calcu latio n s, 536

iii

UNIT VIII Integumentary Disorders of the Adult Client, 543 46 In tegu m en tary System , 544 47 In tegu m en tary Med icatio n s, 569

UNIT IX Hematological and Oncological Disorders of the Adult Client, 578 48 Hem ato lo gical an d O n co lo gical Diso rd ers, 580 49 Hem ato lo gical an d O n co lo gical

Med icatio n s, 614

UNIT X Endocrine Disorders of the Adult Client, 625 50 En d o crin e System , 626 51 En d o crin e Med icatio n s, 653

UNIT XI Gastrointestinal Disorders of the Adult Client, 669 52 Gastro in testin al System , 671 53 Gastro in testin al Med icatio n s, 698

UNIT XII Respiratory Disorders of the Adult Client, 706 54 Resp irato ry System , 708 55 Resp irato ry Med icatio n s, 737

UNIT XIII Cardiovascular Disorders of the Adult Client, 754 56 Card io vascu lar System , 755 57 Card io vascu lar Med icatio n s, 797

UNIT XIV Renal and Urinary Disorders of the Adult Client, 815 58 Ren al an d Urin ary System , 817 59 Ren al an d Urin ary Med icatio n s, 850

UNIT XV Eye and Ear Disorders of the Adult Client, 860 60 Th e Eye an d th e Ear, 861 61 Eye an d Ear Med icatio n s, 882

UNIT XVI Neurological Disorders of the Adult Client, 892 62 Neu ro lo gical System , 893 63 Neu ro lo gical Med icatio n s, 923

UNIT XVII Musculoskeletal Disorders of the Adult Client, 936 64 Mu scu lo skeletal System , 937 65 Mu scu lo skeletal Med icatio n s, 958

UNIT XVIII Immune Disorders of the Adult Client, 965 66 Im m u n e Diso rd ers, 966 67 Im m u n o lo gical Med icatio n s, 980

UNIT XIX Mental Health Disorders of the Adult Client, 987 68 Fo u n d atio n s o f Psych iatric Men tal Health

Nu rsin g, 988 69 Men tal Health Diso rd ers, 1000 70 Ad d ictio n s, 1019 71 Crisis Th eo ry an d In terven tio n , 1030 72 Psych iatric Med icatio n s, 1043

UNIT XX Comprehensive Test, 1056

References, 1079

Glossary, 1081

Index, 1090

Priority Nursing Action List, Back of Inside Cover

iv Contents

To my parents—

To my mother, Frances Mary,

and in loving memory of my father, Arnold La wrence,

who taught me to always love, care,

and be the best that I could be.

To All Fu tu re Registered Nu rses,

Con gratulation s to you!

You sh ould be very proud an d pleased with yourself on your m ost recen t well- deserved acco m plish m en t of com pletin g your n ursin g program to becom e a regis- tered n urse. I kn ow th at you h ave worked very h ard to beco m e successful an d th at yo u h ave proven to yourself th at in deed you can ach ieve your go als.

In m y opin io n , you are ab out to en ter th e m ost won derful an d rewardin g profession th at exists. Your willin gn ess, desire, an d ability to assist th o se wh o n eed n ursin g care will brin g great satisfaction to your life. In th e profession of n ursin g, yo ur learn in g will be a lifelon g process. Th is aspect of th e profession m akes it stim - ulatin g an d dyn am ic. Your learn in g process will con tin ue to exp an d an d grow as th e profession con tin ues to evolve. Your n ext very im portan t en deavor will be th e learn in g process in volved to ach ieve success in your exam in ation to beco m e a registered n urse.

I am excited an d pleased to be able to provid e yo u with th e Sau n ders Pyramid to Success produ cts, wh ich will h elp you prepare for yo ur n ext im portan t profession al go al, beco m in g a registered n urse. I wan t to th an k all of m y form er n ursin g studen ts wh om I h ave assisted in th eir studies for th e NCLEX-RN® exam in ation for th eir willin gn ess to offer ideas regardin g th eir n eeds in preparin g for licen su re. Studen t id eas h ave certain ly added a special un iquen ess to all of th e products available in th e Sau n ders Pyramid to Success.

Saun ders Pyramid to Success products provide yo u with everyth in g th at you n eed to ready yourself for th e NCLEX-RN exam in ation . Th ese produ cts in clude m aterial th at is required for th e NCLEX-RN exam in ation for all n ursin g studen ts regardless of edu cation al backgroun d, specific stren gth s, areas in n eed of im provem en t, or clin ical experien ce durin g th e n ursin g program .

So let’s get started an d begin our journ ey th rough th e Saun ders Pyramid to Success, an d welcom e to th e won derful profession of n ursin g!

Sin cerely,

vi

About the Author

Linda Anne Silvestri, PhD, RN ( Photo by Laurent W. Valliere.)

As a ch ild, I always dream edof beco m in g eith er a n urse or a teach er. In itially I ch ose to beco m e a n urse because I really wan ted to h elp oth ers, esp e-

cially th ose wh o were ill. Th en I realized th at both of m y dream s could com e true; I could be both a n urse an d a teach er. So I pursued m y dream s.

I received m y diplom a in n ursin g at Cooley Dickin - son Hospital Sch o ol of Nursin g in North am pton , Mas- sach usetts. Afterward, I worked at Baystate Med ical Cen ter in Sprin gfield, Massach usetts, wh ere I cared for clien ts in acute m edical-surgical un its, th e in ten sive care un it, th e em ergen cy dep artm en t, pediatric un its, an d oth er acu te care un its. Later I received an associate degree from Holyo ke Com m un ity College in Ho lyoke, Massa- ch usetts; m y BSN from Am erican In tern ation al College in Sprin gfield, Massach usetts; an d m y MSN from An n a Maria College in Paxton , Massach usetts, with a dual m ajo r in Nursin g Man agem en t an d Patien t Education . I received m y Ph D in Nu rsin g from th e Un iversity of Nevad a, Las Vegas, an d con d ucted research on self- efficacy an d th e predictors of NCLEX® success. I am also a m em ber of th e Hon o r Society of Nu rsin g, Sigm a Th eta Tau In tern ation al, Ph i Kappa Ph i, th e Am erican Nu rses Asso ciation , th e Nation al League for Nursin g, th e West- ern In stitute of Nursin g, th e Eastern Nu rsin g Research Society, an d th e Golden Key In tern ation al Ho n our Soci- ety. In ad dition , I received th e 2012 Alum n a of th e Year/ Nurse of th e Year Award from th e Un iversity of Nevada, Las Vegas, Sch ool of Nursin g.

As a n ative of Sprin gfield, Massach usetts, I began m y teach in g career as an in structo r of m edical-surgical n urs- in g an d leadersh ip-m an agem en t n ursin g in 1981 at Baystate Med ical Cen ter Sch ool of Nu rsin g. In 1989,

I relocated to Rh od e Islan d an d began teach in g ad- van ced m edical-surgical n ursin g an d psych iatric n ursin g to RN an d LPN studen ts at th e Com m un ity College of Rh ode Islan d. Wh ile teach in g th ere, a group of studen ts approach ed m e for assistan ce in preparin g for th e NCLEX exam in ation . I h ave always h ad a very special in terest in test success for n ursin g studen ts because of m y own person al experien ces with testin g. Takin g tests was n ever easy for m e, an d as a studen t I n eeded to fin d m eth od s an d strategies th at would brin g success. My own difficult experien ces, desire, an d dedication to assist n ursin g studen ts to overcom e th e obstacles associated with testin g in spired m e to develop an d write th e m an y produ cts th at would foster success with testin g. My exp e- rien ces as a studen t, n ursin g edu cator, an d item writer for th e NCLEX exam in ation s aided m e as I developed a com preh en sive review course to prepare n ursin g graduates for th e NCLEX exam in ation .

Later, in 1994, I began teach in g m edical-su rgical n ursin g at Salve Regin a Un iversity in Newport, Rh ode Islan d, an d I rem ain th ere as an ad jun ct faculty m em ber. I also prepare n ursin g studen ts at Salve Regin a Un iversity for th e NCLEX-RN exam in ation .

I establish ed Profession al Nursin g Sem in ars, In c. in 1991 and Nursin g Reviews, In c. in 2000. Th ese com pan ies are located in Ch arlestown , Rh ode Islan d. In 2012, I estab- lish ed an addition al com pan y, Nursin g Reviews, In c. in Hen derson , Nevada. Both com panies are dedicated to h elpin g n ursin g graduates ach ieve th eir goals of becom in g registered n urses, licen sed practical/ vocation al n urses, or both .

Today, I am th e successful auth o r of n um erou s review produ cts. Also, I serve as an Elsevier con sultan t for HESI Live Reviews, th e review courses for th e NCLEX exam in ation s con ducted th rough ou t th e coun try. I am so pleased th at you h ave decided to join m e on your journ ey to success in testin g for n ursin g exam in ation s an d for th e NCLEX-RN exam in ation !

vii

Contributors

Consultants Dia nne E. Fiorent ino Research Co o rd in ato r Nu rsin g Reviews, In c. Hen d erson , Nevad a

Ja mes Guiba ult, Jr., BS, Pha rmD Clin ical Ph arm acist Wilbrah am , Massach usetts

Nichola s L. Silvest ri, BA Ed itorial an d Co m m u n icatio n s An alyst Nu rsin g Reviews, In c. Ch arlesto wn , Rh o de Islan d

Ja ne Tyerma n, RN, MScN, PhD Facu lty Tren t/ Flem in g Sch oo l o f Nu rsin g Peterb oro ugh , O n tario, Can ada

Contributors Ma rilee Aufdenkamp, BSN, MS Assistan t Pro fesso r Sch oo l o f Nu rsin g Creigh to n Un iversity O m ah a, Nebraska

Ja skaranjeet Bhulla r, RN Graduate Sch oo l o f Nu rsin g To uro Un iversity Nevad a Hen d erson , Nevad a

Jea n Burt , BS, BSN, MSN In structor, Nu rsin g City Co lleges o f Ch icago Ch icago , Illin o is

Reit ha Ca ba niss, EdD, MSN Nu rsin g Directo r Bevill State Co m m u n ity College Jasp er, Alab am a

Ba rbara Ca llaha n, MEd, RN, NCC, CHSE Retired Len oir Com m un ity College Kin ston , No rth Carolin a

Na ncy Curry, BSN, MSN Assistan t Pro fessor, Nu rsin g No rth western State Un iversity Co llege o f Nu rsin g an d Sch o ol

o f Allied Health Sh revepo rt, Lou isian a

Ma tt ie Da vis, DNP, MSN, RN Nu rsin g In stru cto r, Health Scien ces J.F. Drake State Tech n ical Co llege Hun tsville, Alabam a

Ma rgie Fra ncisco, EdD, MSN, RN Nu rsin g Professo r Health Division Illin ois Valley Com m un ity College O glesby, Illin o is

Ma rilyn Greer, MS, RN Asso ciate Professo r o f Nu rsin g Ro ckfo rd Co llege Ro ckfo rd , Illin o is

Joyce Ha mmer, RN, MSN Ad ju n ct Facu lty, Nursin g Mon ro e Co un ty Com m un ity College Mon ro e, Mich igan

Donna Russo, MSN, CCRN, CNE Nu rsin g In stru cto r ARIA Health Sch oo l o f Nu rsin g Ph ilad elp h ia, Pen n sylvan ia

Ma ry Scheid, RN, MSN NCMC Breast Cen ter No rth Colo rad o Medical Cen ter Greeley, Colorado

Laurent W. Va lliere, BS, DD Vice Presiden t o f Nu rsin g Reviews, In c. Pro fessio n al Nu rsin g Sem in ars, In c. Ch arlesto wn , Rh o de Islan d

Donna Wilsker, MSN, BSN Assistan t Pro fessor Dish m an Dep artm en t of Nursin g Lam ar Un iversity Beau m on t, Texas

viii

Item Writer and Section Editor Donna Russo, MSN, CCRN, CNE Nursin g In structor ARIA Health Sch o ol of Nursin g Ph iladelph ia, Pen n sylvan ia

Item Writers Amber Ba llard, MSN, RN Registered Nurse Em ergen cy Dep artm en t Sp arrow Health System Lan sin g, Mich igan

Bett y Cheng, MSN Assistan t Professor Sch o ol o f Nursin g MCPHS Un iversity Bosto n , Massach u setts

Christ ina Keller, MSN, RN In stru cto r Sch o ol o f Nursin g Radfo rd Un iversity Radfo rd , Virgin ia

Heidi Monroe, MSN, RN-BC, CAPA Assistan t Professor o f Nu rsin g NCLEX-RN® Co ordin ator Bellin Co llege Green Bay, Wiscon sin

Betha ny Hawes Sykes, EdD, RN, CEN, CCRN Em ergen cy Dep artm en t RN St Lu ke’s Hosp ital New Bed ford, Massach usetts Adju n ct Faculty Departm en t o f Nu rsin g Salve Regin a Un iversity Newp ort, Rh o de Islan d

Linda Turchin, RN, MSN, CNE Assistan t Professo r, Nu rsin g Fairm o n t State Un iversity Fairm o n t, West Virgin ia

Donna Wilsker, MSN, BSN Assistan t Professo r Dish m an Departm en t o f Nu rsin g Lam ar Un iversity Beaum o n t, Texas

Olga Va n Dyke, PhD (c), CAGS, MSN Assistan t Professo r Sch o ol o f Nu rsin g MCPHS Un iversity Bosto n , Massach u setts

The author and publisher would also like to acknowledge the following individuals for contributions to the previous edition of this book:

Marilee Au fd en kam p , RN, MS Hastin gs, Neb raska

Margaret Barn es, MSN, RN Marion , In dian a

Reith a Cab an iss, MSN, RN, CNE Jasp er, Alabam a

Jo an n a E. Cain , BSN, BA, RN Austin , Texas

Barb ara Callah an , MEd , RN, NCC, CHSE

Kin sto n , North Caro lin a

Mary C. Carrico , MS, RN Pad ucah , Ken tu cky

Mary L. Do well, Ph D, RN, BC San An to n io, Texas

Beth B. Gau l, Ph D, RN Des Moin es, Io wa

Su san Go ld en , MSN, RN Ro swell, New Mexico

Marilyn L. Jo h n essee Greer, MS, RN Ro ckfo rd , Illin ois

Jam ie Lyn n Jo n es, MSN, RN, CNE Little Rock, Arkan sas

Lyn n Ko rvick, Ph D, RN, CNE Jop lin , Misso u ri

Tara McMillan -Q u een , RN, MSN, ANP, GNP

Ch arlo tte, North Carolin a

Heid i Mo n ro e, MSN, RN-BC, CPAN, CAPA

Green Bay, Wisco n sin

David Mo rro w, BSN, RN Las Vegas, Nevad a

Deb ra L. Price, RN, MSN, CPNP Fort Worth , Texas

Do n n a Ru sso , RN, MSN, CCRN Ph ilad elp h ia, Pen n sylvan ia

An gela Silvestri, Ph D, RN, CNE Hen d erson , Nevad a

Ch ristin e Su m p , MSN, RN No rfo lk, Virgin ia

Beth an y Hawes Sykes, Ed D, RN, CEN, CCRN

Newpo rt, Rh od e Islan d

Lin d a Tu rch in , RN, MSN, CNE Fairm o n t, West Virgin ia

Lau ren t W. Valliere, BS, DD Ch arlesto wn , Rh o de Islan d

ixContributors

Reviewers

Da nese M. Boob, RN-BC, BSN, MSN/ ED Certification in Perin atal Nu rsin g an d Med ical-Surgical

Nu rsin g Dep artm en t of Nursin g Pen n sylvan ia State Un iversity Hersh ey, Pen n sylvan ia

Jea n Eliza bet h Burt , MS, RN Nu rsin g In stru cto r Wilbu r Wrigh t Co llege Ch icago , Illin o is

Bet ty Cheng, MSN, RN, FNP In structor of Nursin g Sch oo l o f Nu rsin g Q uin cy College Q uin cy, Massach usetts

Ma rguerite C. DeBello, RN, MSN, ACNS-BC, CNE, NP

Assistan t Pro fesso r Sch oo l o f Nu rsin g Eastern Mich igan Un iversity Ypsilan ti, Mich igan

Ma rgie L. Fra ncisco, EdD, MSN, RN Nu rsin g Professo r Nu rsin g/ Health Pro fessio n s Dep artm en t Illin o is Valley Co m m u n ity Co llege O glesb y, Illin o is

Shari Gould, MSN, RN Asso ciate Professor o f Nu rsin g Career, Health an d Tech n ical Profession s Departm en t Victoria Co llege Victoria, Texas

Sheila Grossman, PhD, APRN, FNP-BC, FAAN Pro fessor & Coo rdin ato r, Fam ily Nu rse Practitio n er Track Nu rsin g Departm en t Fairfield Un iversity Sch oo l o f Nu rsin g Fairfield, Co n n ecticut

Joyce Ha mmer, RN, MSN Ad ju n ct Clin ical Facu lty Nu rsin g Departm en t Mon ro e Co u n ty Com m un ity College Mon ro e, Mich igan

Lila h M. Ha rper, RN, CA Presid en t, Harper Con sultin g Services Valley Cen ter, Califo rn ia Lead Nu rse Plan n er, An derso n Con tin u in g Edu catio n Sacram en to, Califo rn ia

Laura Hope, MSN, RN Nu rsin g Faculty Nu rsin g Program Floren ce-Darlin gto n Tech n ical Co llege Floren ce, Sou th Caro lin a

Donna Wa lker Hubba rd, RN, MSN, CNNe Assistan t Pro fessor, Retired Nu rsin g Departm en t Un iversity of Mary Hardin -Baylo r Belton , Texas

Pa ula Celest e Hughes, MSN, RN Nu rsin g Faculty Nu rsin g an d Allied Health Dep artm en t Georgia North western Tech n ical College Ro m e, Geo rgia

Georgina Julious, RN, BSN, MSN BLS In stru cto r; Facility Ad m in istrato r Nu rsin g Departm en t O ut-Patien t Dialysis Hartsville, So uth Caro lin a

Eliza bet h B. McGrat h, MS, APRN, AGACNP-BC, AOCNP, ACHPN

Nu rse Practitio n er Dartm o uth Hitch cock Medical Cen ter—Geisel Sch oo l o f Medicin e at Dartm ou th Leb an o n , New Ham psh ire

Pa t A. Perryma n, MSN, RN, PhD Presid en t Ad m in istration Dallas Nursin g In stitu te Dallas, Texas

Ka ren Robert son, RN, MSN, MBA, PhD(c) Asso ciate Professo r Nu rsin g Departm en t Ro ck Valley Co llege Ro ckfo rd , Illin o isx

Charlot t e D. St ra hm, DNSc, RN, CNS Assistan t Professor Departm en t o f Nu rsin g Pu rd ue Un iversity No rth Cen tral Westville, In d ian a

Christ ine Sump, MSN, RN Nursin g Lectu rer Nursin g Dep artm en t O ld Do m in io n Un iversity Norfolk, Virgin ia

Daryle Wane, PhD, ARNP, FNP-BC RN to BSN Coo rd in ato r Departm en t o f Health O ccu patio n s Pasco-Hern an d o State College New Po rt Rich ey, Florid a

Donna Wilsker, MSN, RN Assistan t Professo r Dish m an Departm en t o f Nu rsin g Lam ar Un iversity Beaum o n t, Texas

Ka ren Winsor, MSN, RN, ACNS-BC APRN for O rth op edic Trau m a Austin , Texas

xiReviewers

Preface

“To laugh often and much, to appreciate beauty, to find the best in others, to leave the world a bit better,

to know that even one life has breathed easier because you have lived, this is to have succeeded.”

—Ralph Waldo Emerson

Welcome to Saunders Pyra mid t o Success! An Essential Resource for Test Success Saunders Comprehensive Review for the NCLEX-RN ® Exam- ination is on e in a series of produ cts design ed to assist you in ach ievin g your go al of beco m in g a registered n urse. Th is text will provide you with a com preh en sive review of all n ursin g con ten t areas specifically related to th e n ew 2016 test plan for th e NCLEX-RN exam in a- tion , wh ich is im plem en ted by th e Nation al Coun cil of State Boards of Nu rsin g. Th is resource will h elp you ach ieve success on your n ursin g exam in ation s dur- in g n ursin g sch o ol an d on th e NCLEX-RN exam in ation .

Organization

Th is book con tain s 20 un its an d 72 ch apters. Th e ch ap- ters are design ed to iden tify specific com pon en ts of n urs- in g con ten t. Th ey con tain practice question s, in cludin g a critical th in kin g question , an d both m ultiple-ch oice an d altern ate item form ats th at reflect th e ch apter con ten t an d th e 2016 test plan for th e NCLEX-RN exam in ation . Th e fin al un it con tain s a 75-question Com p reh en sive Test. All question s in th e book an d on th e Evo lve site are presen ted in NCLEX-style form at.

Th e n ew test plan iden tifies a fram ework based on Client Needs. Th ese Clien t Needs categories in clude Safe an d Effective Care En viron m en t, Health Prom otion and Main ten ance, Psych osocial In tegrity, an d Physiological In tegrity. Integrated Processes are also iden tified as a com - pon en t of th e test plan . Th ese in clude Carin g, Com m un i- cation an d Docum en tation , Culture an d Spirituality, Nursin g Process, an d Teach in g an d Learn in g. All ch apters address th e com pon en ts of th e test plan fram ework.

Special Features of the Book Pyramid Terms Pyramid Terms are im portan t to th e discussion of th e con - ten t in th e ch apters in each un it. Th erefore, th ey are in

bold green type th rou gh out th e con ten t section of each ch apter. Th e defin ition s can be foun d in th e Glossary at th e en d of th e book.

Pyramid to Success Th e Pyramid to Success, a featured part of each un it in - troduction , provides you with an overview, guidan ce, an d direction regardin g th e focus of review in the particular con ten t area, as well as th e con ten t area’s relative im por- tan ce to the 2016 test plan for th e NCLEX-RN exam in a- tion . Th e Pyramid to Success reviews th e Clien t Needs an d provides learn in g objectives as th ey pertain to the con ten t in th at un it. Th ese learn in g objectives iden tify the specific com pon en ts to keep in m in d as you review each ch apter.

Priority Concepts Each ch apter iden tifies two Priority Concepts reflective of its con ten t. Th ese Priority Concepts will assist you to focus on th e im portan t aspects of th e con ten t an d associated n ursin g in terven tion s.

Pyramid Points Pyramid Points ( ) are placed next to specific content through out th e ch apters. Th e Pyramid Points h ighlight con- tent th at is im portan t for preparin g for the NCLEX-RN exam ination and iden tify con ten t that is likely to appear on the NCLEX-RN exam ination .

Pyramid Alerts Pyramid Alerts are th e red text fo u n d th ro u gh o u t th e ch ap ters th at alert yo u to im p o rtan t in fo rm atio n ab o u t n u rsin g co n cep ts. Th ese alerts id en tify co n ten t th at typ ically ap p ears o n th e N CLEX-RN exam in atio n .

Priority Nursing Actions Num erous Priority Nursing Actions boxes h ave been placed th rough out th e ch apters. Th ese boxes presen t a clin ical n ursin g situation an d th e priority action s to take in th e even t of its occurrence. Arationale is provided th at explain s th e correct order of action, alon g with a referen ce for addi- tion al research . A list of th ese boxes can be foun d in th e backm atter of the book for easier location.xii

Critical Thinking: What Should You Do? Questions Each chapter con tain s a Critical Thinking: What Should You Do? question . Th ese question s provide a brief clin ical sce- n ario related to th e con ten t of the ch apter an d ask you what you sh ould do about th e clien t situation presen ted. A n arrative an swer is provided alon g with a referen ce source for research in g furth er in form ation .

Special Features Found on Evolve Pretest and Study Calendar Th e accom panyin g Evolve site con tain s a 75-question pre- test th at provides you with feedback on your stren gth s an d weakn esses. Th e results of your pretest will gen erate an individualized study calen dar to guide you in your prepa- ration for th e NCLEX-RN exam in ation .

Heart, Lung, and Bowel Sound Questions Th e acco m p an yin g Evo lve site co n tain s Audio Q uestions rep resen tative o f co n ten t ad d ressed in th e 2016 test p lan fo r th e N CLEX-RN exam in atio n . Each q u estio n p resen ts an au d io clip as a co m p o n en t o f th e q u estio n .

Video Questions Th e accom pan yin g Evo lve site con tain s Video Questions represen tative of con ten t addressed in th e 2016 test plan for th e NCLEX-RN exam in ation . Each question presen ts a video clip as a com po n en t of th e question .

Testlet Questions Th e acco m pan yin g Evo lve site con tain s testlet question s. Th ese question typ es in clude a clien t scen ario an d sev- eral acco m pan yin g practice question s th at relate to th e con ten t of th e scen ario.

Audio Review Summaries and Animations Th e com pan ion Evolve site in cludes th ree Audio Review Summaries th at cover ch allen gin g subject areas addressed in th e 2016 test plan for th e NCLEX-RN exam in ation , in cludin g Pharmacology, Acid-Base Balance, an d Fluids and Electrolytes. An im ation s th at presen t various con ten t areas are also available for viewin g.

Practice Questions

While preparin g for th e NCLEX-RN exam in ation , it is crucial for studen ts to practice takin g test question s. Th is book con tain s 996 NCLEX-style m ultiple-ch oice an d altern ate item form at questions. Th e accom pan yin g soft- ware in cludes all questions from th e book plus addition al Evolve question s for a total of m ore th an 5200 question s.

Multiple-Choice and Alternate Item Format Questions Startin g with Un it II, each ch apter is followed by a prac- tice test. Each practice test con tain s several question s reflective of th o se presen ted on th e NCLEX-RN exam in a- tion . Th ese question s provide you with practice in

prioritizin g, decision -m akin g, an d critical th in kin g skills. Ch apter 1 of th is book provides a description of each question type an d th e an swer section . Th e an swer section in cludes th e correct an swer, ration ale, test-takin g strategy, question categories, an d referen ce.

In each practice question , th e specific test-takin g strat- egy th at will assist you in an swerin g the question correctly is h igh ligh ted in bold b lu e type. Specific suggestion s for review are iden tified in th e test-takin g strategy and are h igh ligh ted in bold m agen ta type to provide you with direction for locatin g th e specific con ten t in th is book. Th is h igh ligh tin g of th e specific test-takin g strategies an d spe- cific con ten t areas in th e practice question s will provide you with guidan ce on wh at topics to review for furth er rem ediation in both Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam and Saunders Comprehensive Review for the NCLEX-RN® Examination.

Th e categories iden tified in each practice question in clude Level of Cogn itive Ability, Clien t Needs, In tegrat- ed Process, Priority Con cepts, an d th e specific n ursin g Con ten t Area. Every question on th e accom pan yin g Evolve site is organ ized by th ese question codes, so you can cus- tom ize your study session to be as specific or as gen eric as you n eed. Addition ally, n orm al laboratory referen ce in tervals are provided with each laboratory question .

Pharmacology and Medication Calculations Review

Studen ts con sisten tly state th at ph arm acology is an area with wh ich th ey n eed assistan ce. The 2016 NCLEX-RN test plan con tinues to in corporate ph arm acology in th e exam - in ation , but on ly th e gen eric drug n am es will be in cluded. Th erefore, ph arm acology ch apters h ave been in cluded for your review an d practice. Th is book includes 13 ph arm a- cology ch apters, a m edication and in travenous calculation ch apter, an d a pediatric m edication calculation ch apter. Each of th ese ch apters is followed by a practice test th at uses the sam e question form at described earlier. This book con - tain s n um erous ph arm acology questions. Addition ally, m ore th an 900 ph arm acology question s can be foun d on the accom pan yin g Evolve site.

How to Use This Book

SaundersComprehensive Reviewfor theNCLEX-RN® Examina- tion is especially design ed to help you with your successful journ ey to th e peak of th e Saun ders Pyramid to Success: becom in g a registered n urse! As you begin your journey th rough th is book, you will be in troduced to all ofthe im por- tan t points regardin g th e 2016 NCLEX-RN exam in ation, th e process oftestin g, an d un ique an d special tips regardingh ow to prepare yourself for this very im portan t exam ination .

You should begin your process th rough th e Saun ders Pyramid to Success by readin g all of Un it I in this book

xiiiPreface

an d becom in g fam iliar with th e cen tral poin ts regardin g th e NCLEX-RN exam in ation . Read Ch apter 3, written by a n ursing graduate wh o recen tly passed th e exam in ation , an d n ote wh at sh e h as to say about the testin g experien ce. Ch apter 4 will provide you with th e critical testin g strate- gies th at will guide you in selectin g the correct option or assist you in selectin g an answer to a question if you m ust guess. Keep th ese strategies in m in d as you proceed th rough th is book. Con tinue by studyin g th e specific con - ten t areas addressed in Un its II th rough XIX. Review th e defin ition s of th e Pyramid Terms located in th e Glossary an d th e Pyramid to Success n otes, an d iden tify the Clien t Needs an d Learn in g O bjectives specific to the test plan in each area. Read th rough th e ch apters an d focus on th e Pyramid Points and Pyramid Alerts th at identify th e areas m ost likely to be tested on th e NCLEX-RN exam in ation . Pay particular atten tion to th e PriorityNursing Actionsboxes because th ey provide inform ation about th e steps you will take in clin ical situation s requirin g prioritization .

As yo u read each ch apter, iden tify your areas of stren gth an d th ose in n eed of furth er review. High ligh t th ese areas an d test your abilities by an swerin g th e Crit- ical Thinking: What Should You Do? question an d takin g all practice tests provided at th e en d of th e ch apters. Be sure to review all ration ales an d test-takin g strategies.

After reviewin g all ch apters in th e book, turn to Un it XX, th e Com p reh en sive Test. Take th is exam in ation an d th en review each question , an swer, an d ration ale. Iden tify an y areas requirin g furth er review; th en take th e tim e to review those areas in both th e book and th e com pan ion Evolve site. In preparation for th e NCLEX-RN exam in ation , be sure to take th e pretest an d gen erate your study calen dar. Follow the calen dar for your review because th e calen dar represen ts your pretest results an d th e best study path to follow based on your stron g an d weak con ten t areas. Also, be sure to access th e Testlets and th e Audio Review Summaries as part of your preparation for th e NCLEX-RN exam in ation .

Climbing the Pyra mid t o Success

Th e purpose of th is book is to provide a co m p reh en - sive review of the n ursin g con ten t you will be tested on durin g th e NCLEX-RN exam in ation . However, Saunders Comprehensive Review for the NCLEX-RN® Examination is in ten ded to do m ore th an sim ply prepare you for th e rigors of th e NCLEX-RN exam in ation ; th is book is also m ean t to serve as a valuable study tool th at you can refer to th rough - out your n ursin g program , with custom izable Evolve site selections to h elp iden tify an d rein force key con ten t areas.

After using th is book for com preh en sive con ten t review, your n ext step on th e Pyramid to Success is to get addition al practice with a Q &A review product. Saunders Q&A Review for the NCLEX-RN® Examination offers m ore th an 6000 un ique practice question s in th e book an d on th e com pan ion Evolve site. Th e question s are focused on th e Clien t Needs an d Integrated Processes of the NCLEX- RN test plan , m akin g it easy to access your study area of ch oice. For on -th e-go Q &A review, you can pick up Saun- ders Q&A Review Cards for the NCLEX-RN® Examination.

Your fin al step on th e Pyramid to Success is to m aster th e o n lin e review. Saunders Online Review for the NCLEX- RN® Examination provides an in teractive an d in dividual- ized platform to get yo u ready for your fin al licen su re exam . Th is on lin e course provid es 10 h igh -level con ten t m odules, supplem en ted with in struction al videos, an i- m ation s, audio, illustration s, testlets, an d several subject m atter exam s. En d-of-m o dule practice tests are provid ed alon g with several Crossing the Finish Line practice tests. In addition , you can assess your progress with a pretest, Test Yourself quizzes, an d a com preh en sive exam in a com puterized en viron m en t th at prepares you for th e actual NCLEX-RN exam in ation .

At th e base of th e Pyramid to Success are m y test- takin g strategies, which provide a foun dation for under- stan din g an d unpackin g the com plexities of NCLEX-RN exam in ation question s, in cludin g altern ate item form ats. Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam takes a detailed look at all of th e test-takin g strategies you will n eed to kn ow in order to pass an y n ursin g exam in ation , in cludin g th e NCLEX-RN. Spe- cial tips are integrated for n ursing studen ts, an d th ere are m ore th an 1200 practice question s included so you can apply th e testing strategies.

Good luck with your journ ey th rou gh th e Sau n ders Pyramid to Success. I wish you con tin ued success th rough - out your n ew career as a registered n urse!

Linda Anne Silvestri

xiv Preface

Acknowledgments

Sin cere appreciation an d warm est th an ks are exten ded to th e m an y in dividuals wh o in th eir own ways h ave con tributed to th e publication of th is book.

First, I wan t to th an k all of m y n ursin g studen ts at th e Com m un ity College of Rh od e Islan d in Warwick wh o approach ed m e in 1991 an d persu aded m e to h elp th em prepare to take th e NCLEX-RN ® exam in ation . Th eir en th u siasm an d in spiration led to th e com m en cem en t of m y profession al en deavors in con d uctin g review courses for th e NCLEX-RN exam in ation for n ursin g stu- den ts. I also th an k th e n um erou s n ursin g studen ts wh o h ave atten ded m y review courses for th eir willin gn ess to sh are th eir n eeds an d ideas. Th eir in put h as certain ly added a special un iquen ess to th is publication .

I wish to ackn owledge all of th e n ursin g facu lty wh o taugh t in m y review courses for th e NCLEX-RN exam in a- tion . Th eir com m itm en t, ded ication , an d expertise h ave certain ly h elped n ursin g studen ts to ach ieve success with th e exam .

I wan t to exten d a very special th an k you to m y n iece Dr. An gela Silvestri-Elm o re, wh o fun ctio n ed as m y “super-ed itor” for th is book. In m y eyes sh e is defin itely “super,” an d h er trem en d ous th eoretical an d clin ical kn owledge an d exp ertise an d h er con sisten t ideas an d in pu t certain ly added to th e excellen t quality of th is produ ct. Th an k you An gela!

I also wish to offer a very special ackn o wledgm en t an d th an k you to Jan e Tyerm an for reviewin g th is en tire book to en sure th at it in cluded Can adian n ursin g prac- tice an d stan dards. Th an k yo u, Jan e!

I wan t to ackn o wledge an d sin cerely th an k m y h us- ban d , Lauren t W. Valliere, or Larry, for h is con tribu tion to th is publication , for teach in g in m y review co urses for th e NCLEX-RN exam in ation , an d for h is com m itm en t an d ded ication in h elpin g m y n ursin g studen ts prepare for th e NCLEX-RN exam in ation from a n on academ ic poin t of view. Larry h as supp orted m y m an y profes- sion al en deavors an d was so loyal an d lo vin g to m e each an d every m om en t as I worked to ach ieve m y profes- sion al goals. Larry, th an k you so m uch !

An d, a special th an k you also goes to Jaskaran jeet Bh ullar, RN, BSN, for writin g a ch apter for th is book about h er experien ces preparin g for an d takin g th e NCLEX-RN exam in ation .

I sin cerely ackn owledge an d th an k m an y very im por- tan t in dividuals fro m Elsevier wh o are so dedicated to m y work in creatin g NCLEX products for n ursin g stu- den ts. I th an k Yvon n e Alexo poulo s, Sen ior Con ten t Strategist, for h er con tin uous assistan ce, en th usiasm , support, an d expert profession al guidan ce as I prepared th is publication , an d Laurie Gower, Con ten t Develop- m en t Man ager, for h er expert ideas as we plan n ed th e project an d for h er con tin uo us supp ort th rough ou t th e produ ction process.

An d, a special an d sin cere th an k you to Laura Goodrich , Con ten t Developm en t Specialist, for h er trem en d ous am oun t of support an d assistan ce, for prior- itizin g for m e to keep m e on track, for h er id eas for th e produ ct, an d for h er profession al an d exp ert skills in organ izin g an d m ain tain in g an en orm ous am oun t of m an uscript for produ ction . I could n ot h ave com pleted th is project with ou t Laura—th an k you, Laura! I also wan t to ackn owledge Jam ie Ran dall, Con ten t Strategist for all of h er assistan ce in com pletin g th is project— th an k you, Jam ie!

I th an k Elo dia Dian n e Fioren tin o for research in g con ten t an d preparin g referen ces for each practice ques- tion ; Nich olas Silvestri for editin g, form attin g, an d orga- n izin g m an uscript files for m e; Jam es Guilbault for research in g an d updatin g m ed ication s; an d m y perso n al team wh o participated in reviewin g th e Evo lve site th at accom pan ies th is produ ct. A special th an k you to all of yo u for provid in g con tin uo us supp ort an d ded ication to m y work in preparin g th is publication an d m ain tain - in g its excellen t quality.

I wan t to ackn owledge all of th e staff at Elsevier for th eir trem en dous assistan ce th rou gh out th e preparation an d production of th is publication an d all of th e Elsevier staff in volved in th e publication of previous edition s of th is outstan din g NCLEX review product. A special th an k you to all of th em . I th an k all of th e im portan t peo ple in th e produ ction an d m arketin g dep artm en t, in cludin g Bill Dron e, Boo k Produ ction Specialist; Dan ielle LeCom p te, Marketin g Man ager; Jeff Patterso n , Publish in g Services Man ager; Am y Sim pson , Multim edia Produ cer; an d Ren ee Duen ow, Design er.

An d a special th an k you to Loren Wilson , form er Sen ior Vice Presiden t, for h er years of expert guidan ce xv

an d con tin uous supp ort for all of th e products in th e Pyramid to Success.

I would also like to ackn owledge Patricia Mieg, for- m er education al sales represen tative, wh o en couraged m e to subm it m y ideas an d in itial work for th e first edi- tion of th is book to th e W.B. Saun d ers Com pan y.

A very special an d h eartfelt th an k you goes to m y paren ts, wh o open ed th e door of oppo rtun ity in edu ca- tion for m e. I th an k m y m oth er, Fran ces Mary, for all of h er lo ve, supp ort, an d assistan ce as I con tin uo usly worked to ach ieve m y profession al goals. I th an k m y fath er, Arn old Lawren ce, wh o always provid ed in sigh tful words of en couragem en t. My m em ories of h is love an d support will always rem ain in m y h eart. I am certain th at h e would be very proud of m y profession al accom plish m en ts.

I also th an k m y en tire fam ily for bein g con tin uo usly supportive, givin g, an d h elpful durin g m y research an d preparation of th is publication .

I wan t to especially ackn owledge each an d every in dividual wh o con tribu ted to th is publication —th e reviewers, con tributors, item writers, an d updaters— for th eir expert in pu t an d ideas. I also th an k th e m an y faculty an d studen t reviewers of th e m an u script for

th eir th o ugh ts an d id eas. A very special th an k yo u to all of you!

I also n eed to th an k Salve Regin a Un iversity for th e opportun ity to edu cate n ursin g studen ts in th e baccalau- reate n ursin g program an d for its support durin g m y research an d writin g of th is publication . I would like to especially ackn o wledge m y colleagues Dr. Eileen Gray, Dr. Ellen McCarty, an d Dr. Beth an y Sykes for all of th eir en couragem en t an d supp ort.

I wish to ackn owledge th e Com m un ity College of Rh ode Islan d, wh ich provided m e with th e oppo rtun ity to edu cate n ursin g studen ts in th e Associate Degree of Nursin g Program . A special th an k yo u goes to Patricia Miller, MSN, RN, an d Mich elin a McClellan , MS, RN, from Baystate Med ical Cen ter, Sch ool of Nursin g, in Sprin gfield, Massach usetts, wh o were m y first m en tors in n ursin g education .

Fin ally, a very special th an k yo u to all of m y n ursin g studen ts—past, presen t, an d future. All of you ligh t up m y life! Your love an d ded ication to th e profession of n ursin g an d yo ur co m m itm en t to provid in g h ealth care will brin g n ever-en din g rewards!

Linda Anne Silvestri

xvi Acknowledgments

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UNIT I

NCLEX-RN® Exam Preparation

C H A P T E R 1 The NCLEX-RN® Examination

The Pyramid to Success

Welcome to the Pyramid to Success Sa unders Comprehensive Review for t he NCLEX-RN® Exa mina t ion Saunders Comprehensive Review for the NCLEX-RN ® Exam- ination is specially design ed to h elp you begin your suc- cessful journ ey to th e peak of th e pyram id, beco m in g a registered n urse. As you begin your jou rn ey, yo u will be in trodu ced to all of th e im portan t poin ts regardin g th e NCLEX-RN exam in ation an d th e process of testin g, an d to th e un ique an d special tip s regardin g h ow to pre- pare yourself for th is im portan t exam in ation . You will read wh at a n ursin g graduate wh o recen tly passed th e NCLEX-RN exam in ation h as to say about th e test. Im portan t test-takin g strategies are detailed. Th ese details will guid e you in selectin g th e correct option or assist yo u in selectin g an an swer to a question at wh ich you m ust guess.

Each un it in th is book begin s with th e Pyram id to Success. Th e Pyram id to Success ad dresses specific poin ts related to th e NCLEX-RN exam in ation . Clien t Needs as iden tified in th e test plan fram ework for th e exam in ation are listed as well as learn in g objectives for th e un it. Pyr- am id Term s are key words th at are defin ed in th e glossary at th e en d of th e book an d set in color th rough ou t each ch apter to direct your atten tion to sign ifican t poin ts for th e exam in ation .

Th rough out each ch apter, you will fin d Pyram id Poin t bullets th at iden tify areas m ost likely to be tested on th e NCLEX-RN exam in ation . Read each ch apter, an d iden tify your stren gth s an d areas th at are in n eed of fur- th er review. Test your stren gth s an d abilities by takin g all practice tests provided in th is book an d on th e accom pa- n yin g Evolve site. Be sure to read all of th e ration ales an d test-takin g strategies. Th e ration ale provides yo u with sign ifican t in form ation regardin g th e co rrect an d in cor- rect option s. Th e test-takin g strategy provides you with th e logical path to selectin g th e correct option . Th e test-takin g strategy also iden tifies th e co n ten t area to review, if required. Th e referen ce source an d page n um - ber are provided so th at yo u can easily fin d th e in form a- tion th at you n eed to review. Each question is coded on th e basis of th e Level of Cogn itive Ability, th e Clien t

Needs category, th e In tegrated Process, Priority Con - cepts, an d th e n ursin g con ten t area.

Sa unders Q&A Review for the NCLEX-RN® Exa mina t ion Followin g th e com pletion of yo ur com preh en sive review in th is book, con tin ue on yo ur journ ey th rou gh th e Pyr- am id to Success with th e com pan ion book, Saunders Q&A Review for the NCLEX-RN® Examination. Th is book provides you with m ore th an 6000 practice question s in th e m ultiple-ch oice an d altern ate item form ats, in clud- in g audio an d video question s. Th e book is design ed based on th e NCLEX-RN exam in ation test plan fram e- work, with a specific focus on Clien t Needs an d In te- grated Processes. In ad dition , each practice question in th is book in cludes a Priority Nu rsin g Tip, wh ich pro- vides you with an im portan t piece of in form ation th at will be h elpful to an swer question s. Th en , you will be ready for HESI/Saunders Online Review for the NCLEX- RN® Examination. Addition al produ cts in Saun ders Pyr- am id to Success in clude Saunders Strategies for Test Suc- cess: Passing Nursing School and the NCLEX® Exam an d Saunders Q&A Review Cards for the NCLEX-RN ® Exam. Th ese products are described n ext.

HESI/ Sa unders Online Review for t he NCLEX-RN® Exa mina t ion Th is product addresses all areas of th e test plan id en tified by th e Nation al Coun cil of State Boards of Nu rsin g (NCSBN). Th e course con tain s a pretest th at provides feedback regardin g your stren gth s an d weakn esses an d gen erates an in dividualized study sch edule in a calen dar form at. Con ten t review is in an outlin e form at an d in cludes self-ch eck practice question s an d testlets (case studies) , figures an d illustration s, a glossary, an d an im a- tion s an d videos. Num erou s on lin e exam s are in cluded. Th ere are 2500 practice question s; th e types of question s in th is course in clude m ultiple-ch oice an d altern ate item form ats.

Sa unders St ra tegies for Test Success: Pa ssing Nursing School a nd t he NCLEX® Exa m Th is produ ct focuses on th e test-takin g strategies th at will h elp you to pass your n ursin g exam in ation s wh ile in n ursin g sch ool an d will prepare yo u for th e NCLEX-RN

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exam in ation . Th e ch apters describe various test-takin g strategies an d in clude sam ple question s th at illustrate h ow to use th e strategies. Also in cluded in th is book is in form ation on cultural ch aracteristics an d practices, ph arm acology strategies, m edication an d in traven o us calculation s, laborato ry values, position in g guidelin es, an d th erap eutic diets. Th is book h as m ore th an 1200 practice question s, an d each question provid es a tip for th e begin n in g n ursin g studen t. Th e practice question s reflect th e fram ework an d th e con ten t iden tified in th e NCLEX-RN test plan an d in clude m ultiple-ch oice an d altern ate item form at question s, in cludin g audio an d video question s.

Sa unders Q&A Review Ca rds for t he NCLEX-RN® Exa m Th is product is organ ized by con ten t area an d the fram e- work of th e NCLEX-RN test plan . It provides you with 1200 un ique practice test question s on portable and easy-to-use cards. Th e cards h ave th e question on th e fron t of the card, and th e an swer, ration ale, an d test-takin g strategy are on th e back of the card. Th is product includes m ultiple-ch oice question s an d altern ate item form at question s, in cludin g fill-in -th e-blan k, m ultiple-respon se, ordered-respon se, figure, an d ch art/ exh ibit question s.

Sa unders RNt ert a inment for t he NCLEX-RN® Exa m RNtertain m en t: Th e NCLEX® Review Gam e, 2n d Edition is a revolution ary board gam e th at offers n ursin g stu- den ts a fun an d ch allen gin g ch an ge of pace from stan - dard review option s. 800 clin ical question s an d scen arios cover all th e m ajo r n ursin g categories on th e NCLEX® test plan —in cludin g Health Prom o tion an d Main ten an ce, Ph ysiological In tegrity, Psych osocial In tegrity, an d Safe an d Effective Care En viron m en t. Th is com pletely redesign ed secon d edition also features n ew altern ate item form ats, test-takin g tips an d test-takin g traps coverin g h elpful test takin g strategies an d tech - n iqu es, an d a ration ales booklet th at provides justifica- tion for correct an swers.

All produ cts in th e Sau n ders Pyram id to Success can be obtain ed on lin e by visitin g h ttp :/ / elsevierh ealth .com or by callin g 800-545-2522.

Let’s begin our journ ey th rou gh th e Pyram id to Success.

Examination Process

An im portan t step in th e Pyram id to Success is to beco m e as fam iliar as possib le with th e exam in ation process. Can did ates facin g th e ch allen ge of th is exam i- n ation can experien ce sign ifican t an xiety. Kn o win g wh at th e exam in ation is all about an d kn owin g wh at you will en coun ter durin g th e process of testin g will assist in alle- viatin g fear an d an xiety. Th e in form ation con tain ed in th is ch apter was obtain ed from th e NCSBN Web site

(h ttp :/ / www.n csbn .org) an d from th e NCSBN 2016 test plan for th e NCLEX-RN an d in cludes som e procedures related to registerin g for th e exam , testin g procedures, an d th e an swers to th e question s m ost com m on ly asked by n ursin g studen ts an d graduates preparin g to take th e NCLEX. You can obtain ad dition al in form ation regard- in g th e test an d its develo pm en t by accessin g th e NCSBN Web site an d clickin g on th e NCLEX Exam tab or by writ- in g to th e Nation al Coun cil of State Boards of Nursin g, 111 East Wacker Drive, Suite 2900, Ch icago, IL 60601. You are en couraged to access th e NCSBN Web site because th is site provides yo u with valuable in form ation about th e NCLEX an d oth er resou rces available to an NCLEX can didate.

Computer Adaptive Testing

Th e acron ym CAT stan d s for com pu ter adaptive test, wh ich m ean s th at th e exam in ation is created as th e test-taker an swers each question . All th e test question s are categorized on th e basis of th e test plan structure an d th e level of difficu lty of th e question . As you an swer a question , th e com pu ter determ in es your com peten cy based on th e an swer you selected. If you selected a cor- rect an swer, th e com puter scan s th e question ban k an d selects a m ore difficult question . If you selected an in cor- rect an swer, th e com puter scan s th e question ban k an d selects an easier question . Th is process con tin ues un til all test plan requirem en ts are m et an d a reliable pass- or-fail decision is m ade.

Wh en takin g a CAT, on ce an an swer is recorded, all subsequ en t question s adm in istered depen d, to an exten t, on th e an swer selected for th at question . Skip- pin g an d return in g to earlier question s are n ot com pat- ible with th e logical m eth od ology of a CAT. Th e in ability to skip question s or go back to ch an ge previous an swers will n ot be a disadvan tage to you; you will n ot fall in to th at “trap” of ch an gin g a correct an swer to an in correct on e with th e CAT system .

If you are faced with a question th at con tain s un fa- m iliar co n ten t, yo u m ay n eed to guess at th e an swer. Th ere is n o pen alty for gu essin g but you n eed to m ake an educated gu ess. With m ost of th e question s, th e an swer will be righ t th ere in fron t of you. If you n eed to gu ess, use your n ursin g kn owledge an d clin ical exp e- rien ces to th eir fullest exten t an d all of th e test-takin g strategies you h ave practiced in th is review program .

You do n ot n eed an y com pu ter experien ce to take th is exam in ation . A keyb oard tutorial is provided an d adm in istered to all test-takers at th e start of th e exam in a- tion . Th e tutorial will in struct you on th e use of th e on - screen option al calculator, th e use of th e m ouse, an d h ow to record an an swer. Th e tutorial provid es in struc- tion s on h ow to respo n d to all question types on th is exam in ation . Th is tutorial is provided on th e NCSBN Web site, an d you are en couraged to view th e tutorial

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wh en you are preparin g for th e NCLEX exam in ation . In addition , at th e testin g site, a test adm in istrator is presen t to assist in explain in g th e use of th e com pu ter to en sure your full un d erstan din g of h ow to proceed.

Development of the Test Plan

Th e test plan for th e NCLEX-RN exam in ation is devel- oped by th e NCSBN. Th e exam in ation is a n ation al exam in ation ; th e NCSBN con siders th e legal scope of n ursin g practice as go vern ed by state laws an d regula- tion s, in cludin g th e Nurse Practice Act, an d uses th ese laws to defin e th e areas on th e exam in ation th at will assess th e com peten ce of th e test-taker for licen sure.

Th e NCSBN also co n ducts an im portan t study every 3 years, kn own as a practice an alysis study, to determ in e th e fram ework for th e test plan for th e exam in ation . Th e participan ts in th is study in clude n ewly licen sed regis- tered n urses from all types of basic n ursin g edu cation program s. From a list of n ursin g care activities provided, th e participan ts are asked ab out th e frequen cy an d im portan ce of perform in g th em in relation to clien t safety an d th e settin g in wh ich th ey are perform ed. A pan el of con ten t experts at th e NCSBN an alyzes th e results of th e study an d m akes decision s regardin g th e test plan fram ework. Th e results of th is recen tly con - ducted study provid ed th e structure for th e test plan im plem en ted in April 2016.

Test Plan

Th e con ten t of th e NCLEX-RN exam in ation reflects th e activities iden tified in th e practice an alysis study con - ducted by th e NCSBN. Th e question s are written to address Level of Cogn itive Ability, Clien t Needs, an d In tegrated Processes as iden tified in th e test plan devel- oped by th e NCSBN.

Level of Cognitive Ability Levels of cogn itive ability in clude kn owledge, under- stan din g, applyin g, analyzin g, syn th esizin g, evaluatin g, an d creatin g. Th e practice of n ursing requires com plex th ought processin g an d critical th in kin g in decision m ak- in g. Th erefore, you will n ot en coun ter an y kn owledge or un derstan din g question s on th e NCLEX. Q uestion s on th is exam in ation are written at th e applyin g level or at h igh er Levels of Cogn itive Ability. Box 1-1 presents an exam ple of a question th at requires you to apply data.

Client Needs Th e NCSBN iden tifies a test plan fram ework based on Clien t Needs, wh ich in cludes 4 m ajor categories. Som e of th ese categories are divided furth er in to subcategories. Th e Clien t Needs categories are Safe an d Effective Care En viron m en t, Health Prom o tion an d Main ten an ce,

Psych osocial In tegrity, an d Ph ysiological In tegrity (Table 1-1).

Sa fe a nd Effective Ca re Environment Th e Safe an d Effective Care En viron m en t category in cludes 2 subcategories: Man agem en t of Care, an d Safety an d In fection Con trol. Accordin g to th e NCSBN, Man agem en t of Care (17% to 23% of question s) addresses prioritizin g con ten t an d con ten t th at will en sure a safe care delivery settin g to protect clien ts, fam - ilies, sign ifican t oth ers, visitors, an d h ealth care perso n - n el. Th e NCSBN in dicates th at Safety an d In fection Con trol (9% to 15% of question s) addresses con ten t th at will protect clien ts, fam ilies, sign ifican t oth ers, vis- itors, an d h ealth care perso n n el from h ealth an d en vi- ron m en tal h azards with in h ealth care facilities an d in com m un ity settin gs. Box 1-2 presen ts exam ples of ques- tion s th at address th ese 2 subcategories.

BOX 1-1 Level of Cognitive Ability: Applying The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these find- ings, the nurse should implement which action? 1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration.

Answer: 1 This question requires that you focus on the data in the ques- tion and determine that the client is experiencing an infiltra- tion. Next, you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the appropriate action is to remove the IV to prevent any further damage.

TABLE 1-1 Client Needs Categories and Percentage of Questions on the NCLEX-RN Examination

Client Needs Category Percentage of Questions

Safe and Effective Care Environment Management of Care 17-23

Safety and Infection Control 9-15

Health Promotion and Maintenance 6-12

Psychosocial Integrity 6-12

Physiological Integrity Basic Care and Comfort 6-12

Pharmacological and Parenteral Therapies 12-18

Reduction of Risk Potential 9-15

Physiological Adaptation 11-17

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Hea lt h Promot ion a nd Ma intena nce Th e Health Prom o tion an d Main ten an ce category (6% to 12% of question s) addresses th e prin ciples related to growth an d developm en t. Accordin g to th e NCSBN, th is Clien t Needs category also addresses con ten t required to assist th e clien t, fam ily m em bers, an d sign if- ican t oth ers to preven t h ealth problem s; to recogn ize alteration s in h ealth ; an d to develop h ealth practices th at prom o te an d support welln ess. See Box 1-3 for an exam ple of a question in th is Clien t Needs category.

Psychosocia l Int egrit y Th e Psych o social In tegrity category (6% to 12% of ques- tion s) ad dresses co n ten t required to prom o te an d sup- port th e ab ility of th e clien t, clien t’s fam ily, an d clien t’s sign ifican t oth er to cope, adap t, an d problem - solve durin g stressful even ts. Th e NCSBN also in dicates th at th is Clien t Needs category addresses th e em o tion al, m en tal, an d social well-bein g of th e clien t, fam ily, or sig- n ifican t oth er, an d care for th e clien t with an acute or ch ron ic m en tal illn ess. See Box 1-4 for an exam ple of a question in th is Clien t Needs category.

Physiologica l Integrity Th e Ph ysio lo gical In tegrity catego ry in clu d es 4 su b cat- ego ries: Basic Care an d Co m fo rt, Ph arm aco lo gical an d Paren teral Th erap ies, Red u ctio n o f Risk Po ten tial, an d

BOX 1-2 Safe and Effective Care Environment

Management of Care The nurse has received the client assignment for the day. Which client should the nurse assess first? 1. The client who needs to receive subcutaneous insulin

before breakfast 2. The client who has a nasogastric tube attached to intermit-

tent suction 3. The client who is 2 days postoperative and is complaining

of incisional pain 4. The client who has a blood glucose level of 50 mg/ dL

(2.8 mmol/ L) and complaints of blurred vision

Answer: 4 This question addresses the subcategory Management of Care in the Client Needs category Safe and Effective Care Envi- ronment. Note the strategic word, first, so you need to estab- lish priorities by comparing the needs of each client and deciding which need is urgent. The client described in the cor- rect option has a low blood glucose level and symptoms reflec- tive of hypoglycemia. This client should be assessed first so that treatment can be implemented. Although the clients in options 1, 2, and 3 have needs that require assessment, their assessments can wait until the client in the correct option is stabilized.

Safety and Infection Control The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin- resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheos- tomy attached to a mechanical ventilator, which requires fre- quent suctioning. The nurse should assemble which necessary protective items before entering the client’s room? 1. Gloves and gown 2. Gloves and face shield 3. Gloves, gown, and face shield 4. Gloves, gown, and shoe protectors

Answer: 3 This question addresses the subcategory Safety and Infection Control in the Client Needs category Safe and Effective Care Environment. It addresses content related to protecting one- self from contracting an infection and requires that you con- sider the methods of possible transmission of infection, based on the client’s condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct.

BOX 1-3 Health Promotion and Maintenance The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. Puzzle 2. Toy soldiers 3. Large stacking blocks 4. A card game with large pictures

Answer: 3 This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principles of growth and development of a toddler. Note the strategic word, best. Toddlers like to master activities indepen- dently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy sol- diers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.

BOX 1-4 Psychosocial Integrity A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. “This will help only if I play music at the same time.” 2. “This will work for me only if I am alone in a quiet area.” 3. “I need to do this only when I lie down in case I fall asleep.” 4. “The best thing about this is that I can use it anywhere,

anytime.”

Answer: 4 This question addresses the Client Needs category Psychoso- cial Integrity and the content addresses coping mechanisms. Guided imagery involves the client creating an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation tech- niques or play music with it.

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Ph ysio lo gical Ad ap tatio n . Th e NCSBN d escrib es th ese su b catego ries as fo llo ws. Basic Care an d Co m fo rt ( 6% to 12% o f q u estio n s) ad d resses co n ten t fo r p ro vid in g co m fo rt an d assistan ce to th e clien t in th e p erfo rm an ce o f activities o f d aily livin g. Ph arm aco lo gical an d Par- en teral Th erapies (12% to 18% of question s) addresses con ten t for adm in istering m edication s an d paren teral th erapies such as intraven ous th erapies an d paren teral n utrition , an d adm in isterin g blood an d blood products. Reduction of Risk Poten tial (9% to 15% of questions) addresses con ten t for preven tin g com plication s or h ealth problem s related to the clien t’s con dition or

an y prescribed treatm en ts or procedures. Ph ysiological Adaptation (11% to 17% of question s) addresses con ten t for providin g care to clien ts with acute, ch ron ic, or life-th reaten in g con dition s. See Box 1-5 for exam ples of question s in th is Clien t Needs category.

Integrated Processes Th e NCSBN iden tifies 5 processes in th e test plan th at are fun dam en tal to th e practice of n ursin g. Th ese processes are in corpo rated th rough ou t th e m ajor categories of Cli- en t Needs. Th e In tegrated Process subcategories are Car- in g, Com m un ication an d Docum en tation , Nu rsin g

BOX 1-5 Physiological Integrity Basic Care and Comfort Aclient with Parkinson’s disease develops akinesia while ambu- lating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a

walker. 4. Consciously think about walking over imaginary lines on the

floor.

Answer: 4 This question addresses the subcategory Basic Care and Com- fort in the Client Needs category Physiological Integrity, and addresses client mobility and promoting assistance in an activ- ity of daily living to maintain safety. Clients with Parkinson’s dis- ease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe.

Pharmacological and Parenteral Therapies The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception

Answer: 1 This question addresses the subcategory Pharmacological and Parenteral Therapies in the Client Needs category Physiological Integrity. Note the strategic word, early. Digoxin is a cardiac gly- coside that is used to manage and treat heart failure and to con- trol ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointesti- nal disturbances such as anorexia, nausea, and vomiting. Neu- rological abnormalities can also occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular distur- bances (photophobia, diplopia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs.

Reduction of Risk Potential A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should imple- ment which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter. 2. Remove all metal-containing objects from the client. 3. Keep the client NPO (nil per os; nothing by mouth) for 6 hours

before the test. 4. Instruct the client in inhalation techniques for the adminis-

tration of the radioisotope.

Answer: 2 This question addresses the subcategory Reduction of Risk Potential in the Client Needs category Physiological Integrity, and the nurse’s responsibilities in preparing the client for the diagnostic test. In an MRI study, radiofrequency pulses in a mag- netic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. NPO status is not necessary for an MRI study of the head. The groin may be shaved for an angio- gram, and inhalation of the radioisotope may be prescribed with other types of scans but is not a part of the procedures for an MRI.

Physiological Adaptation A client with renal insufficiency has a magnesium level of 3.5 mEq/ L (1.75 mmol/ L). On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity

Answer: 2 This question addresses the subcategory Physiological Adap- tation in the Client Needs category Physiological Integrity. It addresses an alteration in body systems. The normal magnesium level is 1.5 to 2.5 mEq/ L(0.75 to 1.25 mmol/ L). A magnesium level of 3.5 mEq/ L (1.75 mmol/ L) indicates hyper- magnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, leth- argy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur.

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Process (Assessm ent, Analysis, Plan n in g, Im plem en tation , and Evaluation ), Culture an d Spirituality, an d Teachin g and Learn in g. See Box 1-6 for an exam ple of a question that in corporates th e In tegrated Process of Carin g.

Types of Questions on the Examination

Th e types of question s that m ay be adm in istered on the exam in ation in clude m ultiple-ch oice; fill-in -the-blan k; m ultiple-respon se; ordered-respon se (also kn own as drag and drop); question s th at con tain a figure, ch art/ exh ibit, or graph ic option item ; an d audio or video item form ats. Som e question s m ay require you to use the m ouse an d cursor on th e com puter. For exam ple, you m ay be pre- sen ted with a picture that displays th e arterial vessels of an adult clien t. In th is picture, you m ay be asked to “poin t and click” (usin g the m ouse) on th e area (h ot spot) where the dorsalis pedis pulse could be felt. In all types of ques- tion s, th e an swer is scored as eith er righ t or wron g. Credit is n ot given for a partially correct an swer. In addition , all question types m ay in clude pictures, graph ics, tables, ch arts, soun d, or video. Th e NCSBN provides specific directions for you to follow with all question types to guide you in your process of testing. Be sure to read th ese directions as they appear on th e com puter screen. Exam - ples of som e of th ese types of question s are n oted in this ch apter. All question types are provided in th is book an d on th e accom pan yin g Evolve site.

Multiple-Choice Questions Man y of th e question s th at you will be asked to an swer will be in th e m ultiple-ch oice form at. Th ese question s

provide you with data about a clien t situation an d 4 an swers, or option s.

Fill-in-the-Blank Questions Fill-in -th e-blan k question s m ay ask you to perform a m edication calculation , determ in e an in traven o us flow rate, or calculate an in take or outp ut record on a clien t. You will n eed to type on ly a n um ber (you r an swer) in th e an swer box. If th e question requires roun din g th e an swer, th is n eeds to be perform ed at th e en d of th e cal- culation . Th e rules for roun din g an an swer are described in th e tutorial provided by th e NCSBN, an d are also pro- vided in th e specific question on th e com puter screen . In addition , you m ust type in a decim al poin t if n ecessary. See Box 1-7 for an exam ple.

Multiple-Response Questions For a m ultiple-respon se question , you will be asked to select or ch eck all of th e options, such as n ursing in terven - tion s, that relate to the in form ation in th e question . In these question types, th ere m ay be 2 or m ore correct an swers. No partial credit is given for correct selection s. You n eed to do exactly as th e question asks, which will be to select all of th e option s th at apply. See Box 1-8 for an exam ple.

Ordered-Response Questions In th is type of question , you will be asked to use th e com - puter m ouse to drag an d drop your n ursin g action s in order of priority. In form ation will be presen ted in a question an d, based on th e data, you n eed to determ in e wh at yo u will do first, secon d, th ird, an d so forth . Th e un ordered option s will be located in boxes on th e left side of th e screen , an d you n eed to m ove all option s in order of prio rity to ordered-respon se boxes on th e

BOX 1-6 Integrated Processes A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic? 1. “Can you tell me what you understand about the

procedure?” 2. “Your fears are a sign that you really should have this

procedure.” 3. “Those are very normal fears, but please be assured that

everything will be okay.” 4. “Try not to worry. This is a well-known and easy procedure

for the health care provider.”

Answer: 1 This question addresses the subcategory Caring in the cate- gory Integrated Processes. The correct option is a therapeutic communication technique that explores the client’s feelings, determines the level of client understanding about the proce- dure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 does not address the client’s fears, provides false reassurance, and puts the client’s feelings on hold. Option 4 diminishes the client’s feelings by directing attention away from the client and toward the health care provider’s importance.

BOX 1-7 Fill-in-the-Blank Question A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500 mg/ 15 mL. The nurse prepares how many milliliters to administer 1 dose? Fill in the blank. Record your answer using one decimal place.

Answer: 19.5 mL Formula:

Desired Available

 volume¼ mL

650 mg 500 mg

 15 mL¼ 19:5 mL

In this question, you need to use the formula for calculat- ing a medication dose. When the dose is determined, you will need to type your numeric answer in the answer box. Always follow the specific directions noted on the computer screen. Also, remember that there will be an on-screen calculator on the computer for your use.

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righ t side of th e screen . Specific direction s for m ovin g th e option s are provid ed with th e question . See Figure 1-1 for an exam ple. Exam ples of th is question type are located on th e accom pan yin g Evo lve site.

Figure Questions A question with a picture or graph ic will ask you to an swer th e question based on th e picture or graph ic. Th e ques- tion could con tain a ch art, a table, or a figure or illustra- tion . You also m ay be asked to use the com puter m ouse to poin t an d click on a specific area in th e visual. A figure or illustration m ay appear in an y type of question , in cludin g a m ultiple-ch oice question . See Box 1-9 for an exam ple.

Chart/Exhibit Questions In this type of question, you will be presen ted with a problem an d a ch art or exh ibit. You will be provided with 3 tabs or buttons th at you n eed to click to obtain th e in form ation n eeded to an swer th e question . A prom pt or m essage will appear th at will indicate th e n eed to click on a tab or button . See Box 1-10 for an exam ple.

Graphic Option Questions In th is typ e of question , th e option selection s will be pic- tures rath er th an text. Each option will be preceded by a circle, an d you will n eed to use th e co m puter m ou se to click in th e circle th at represen ts your an swer ch oice. See Box 1-11 for an exam ple.

Audio Questions Audio question s will require listenin g to a sound to answer th e question . Th ese question s will prom pt you to use th e h eadset provided an d to click on the soun d icon . You will be able to click on th e volum e button to adjust the volum e to your com fort level, an d you will be able to listen to th e

BOX 1-8 Multiple-Response Question The emergency department nurse is caring for a child sus- pected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply.

1. Obtain a throat culture. 2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 4. Maintain the child in a supine position. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor.

In a multiple-response question, you will be asked to select or check all of the options, such as interventions, that relate to the information in the question. To answer this question, recall that acute epiglottitis is a serious obstructive inflamma- tory process that requires immediate intervention and that air- way patency is a priority. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate fur- ther obstruction. A lateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on an oxygen saturation monitor to monitor oxygena- tion status. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen.

FIGURE 1-1 Example of an ordered-response question.

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soun d as m an y tim es as n ecessary. Con ten t exam ples include, but are n ot lim ited to, various lun g sounds, h eart soun ds, or bowel soun ds. Exam ples of th is question type are located on th e accom pan yin g Evolve site (Fig. 1-2).

Video Questions Video question s will require viewin g of an an im ation or video clip to an swer th e question . Th ese question s will prom p t you to click on th e video icon . Th ere m ay be soun d associated with th e an im ation an d video, in wh ich case yo u will be prom p ted to use th e h ead set.

BOX 1-9 Figure Question A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action?

1. Takes the client’s blood pressure 2. Initiates cardiopulmonary resuscitation (CPR) 3. Places a nitroglycerin tablet under the client’s tongue 4. Continues to monitor the client and then contacts the health care provider (HCP)

Answer: 2 This question requires you to identify the cardiac rhythm, and then determine the priority nursing action. Note the strategic word, immediately. This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The HCP or an Advanced Cardiac Life Support (ACLS)–qualified nurse must immediately defibrillate the client. If a defibrillator is not readily available, CPR is initiated until the defibrillator arrives. Options 1, 3, and 4 are incorrect actions and delay life-saving treatment.

BOX 1-10 Chart/ Exhibit Question Client’s Chart

History and physical Medications

Diagnostic results

Item 1: Has renal calculi Item 2: Had throm- bophlebitis 1 year ago

Item 3: Multivita- min orally daily

Item 4: Electrocar- diogram normal

The nurse reviews the history and physical examination documented in the medical record of a client requesting a pre- scription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented item? Refer to chart.

Answer: 2 This chart/ exhibit question provides you with data from the cli- ent’s medical record and asks you to identify the item that is a contraindication to the use of oral contraceptives. Oral contra- ceptives are contraindicated in women with a history of any of the following: thrombophlebitis and thromboembolic disor- ders, cardiovascular or cerebrovascular diseases (including stroke), any estrogen-dependent cancer or breast cancer, benign or malignant liver tumors, impaired liver function, hypertension, and diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep venous thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarc- tion, and accelerations of preexisting breast tumors.

BOX 1-11 Graphic Options Question The nurse should place the client in which position to admin- ister an enema? (Refer to the figures in 1 to 4.)

1.

2.

3.

4.

Answer: 2 This question requires you to select the picture that represents your answer choice. To administer an enema, the nurse assists the client into the left side-lying (Sims’) position with the right knee flexed. This position allows the enema solution to flow downward by gravity along the natural curve of the sig- moid colon and rectum, improving the retention of solution. Option 1 is a prone position. Option 3 is a dorsal recumbent position. Option 4 is a supine position.

9CHAPTER 1 The NCLEX-RN® Examination

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Con ten t exam ples in clude, but are n ot lim ited to, assess- m en t tech n iques, n ursin g procedures, or com m un ica- tion skills. Exam ples of th is question type are located on th e acco m pan yin g Evolve site (Fig. 1-3).

Registering to Take the Examination

It is im portan t to obtain an NCLEX Exam in ation Can di- date Bulletin from th e NCSBN Web site at www.n csbn . org because th is bulletin provides all of th e in form ation you n eed to register for and sch edule your exam in ation . It also provides you with Web site an d telephon e in form a- tion for NCLEX exam in ation con tacts. Th e in itial step in th e registration process is to subm it an application to th e state board of n ursin g in th e state in wh ich you in ten d to obtain licen sure. You n eed to obtain in form ation from th e board of n ursin g regardin g the specific registration process because th e process m ay vary from state to state. Th en , use th e NCLEX Exam in ation Can didate Bulletin as your guide to com plete th e registration process.

Followin g th e registration in structions an d com plet- in g the registration form s precisely an d accurately are im portan t. Registration form s n ot properly com plet- ed or n ot accom pan ied by the proper fees in the required m eth od of paym en t will be returned to you and will delay testin g. You m ust pay a fee for takin g the exam in ation; you also m ay h ave to pay additional fees to the board of n ursin g in the state in which you are applyin g.

Authorization to Test Form and Scheduling an Appointment

O n ce you are eligible to test, yo u will receive an Auth o- rization to Test (ATT) form . You can n ot m ake an appoin tm en t un til yo u receive an ATT form . Note th e validity dates on th e ATT form , an d sch edule a testin g date an d tim e before th e expiration date on th e ATT form . Th e NCLEX Exam in ation Can did ate Bulletin pro- vides yo u with th e direction s for sch edulin g an appoin t- m en t an d you do n ot h ave to take th e exam in ation in th e sam e state in wh ich you are seekin g licen su re.

Th e ATT form con tain s im portan t in form ation , in cludin g yo ur test auth o rization n um ber, can didate iden tification n um ber, an d validity date. You n eed to take your ATT form to th e testin g cen ter on th e day of your exam in ation . You will n ot be adm itted to th e exam - in ation if yo u do n ot h ave it.

Changing Your Appointment

If for an y reason you n eed to ch an ge your appointm en t to test, you can m ake th e ch an ge on the can didate Web site or by callin g can didate services. Refer to th e NCLEXExam in a- tion Candidate Bulletin for this contact in form ation an d oth er im portan t procedures for can celing an d chan gin g an appoin tm en t. If you fail to arrive for the exam in ation

FIGURE 1-2 Example of an audio question.

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or fail to can cel your appoin tm en t to test without provid- in g appropriate n otice, you will forfeit your exam in ation fee and your ATT form will be in validated. Th is in form a- tion will be reported to th e board of n ursin g in th e state in which you h ave applied for licensure, an d you will be required to register and pay th e testin g fees again .

Day of the Examination

It is im portan t th at you arrive at the testin g cen ter at least 30 m in utes before th e test is sch eduled. If you arrive late for th e sch eduled testin g appoin tm en t, you m ay be required to forfeit your exam in ation appoin tm en t. If it is necessary to forfeit your appoin tm en t, you will n eed to reregister for th e exam in ation an d pay an addition al fee. Th e board of n ursin g will be n otified th at you did n ot take th e test. A few days before your sch eduled date of testin g, take th e tim e to drive to th e testin g cen ter to determ in e its exact location, th e len gth of tim e required to arrive at th at des- tin ation , an d an y potential obstacles th at m igh t delay you, such as road con struction , traffic, or parkin g sites.

In ad dition to th e ATT form , you m ust h ave proper iden tification (ID) such as a U.S. driver’s licen se, pass- port, U.S. state ID, or U.S. m ilitary ID to be adm itted to take th e exam in ation . All acceptable iden tification m ust be valid an d n ot expired an d con tain a ph otograph an d sign ature (in En glish ). In addition , th e first an d last n am es on th e ID m ust m atch th e ATT form . Accordin g to th e NCSBN guidelin es, an y n am e discrepan cies require

legal docum en tation , such as a m arriage licen se, divorce decree, or court action legal n am e ch an ge.

Testing Accommodations

If you require testin g accom m odation s, you should con - tact the board of n ursin g before subm ittin g a registration form . Th e board of n ursin g will provide th e procedures for the request. The board of n ursin g m ust auth orize testin g accom m odation s. Followin g board of n ursing approval, the NCSBN reviews th e requested accom m odation s and m ust approve th e request. If th e request is approved, th e can didate will be n otified an d provided th e procedure for registerin g for and sch edulin g the exam in ation .

Testing Center

Th e testin g cen ter is design ed to en sure com plete security of the testin g process. Strict can didate iden tification requirem en ts h ave been establish ed. You will be asked to read the rules related to testin g. A digital fin gerprin t an d palm vein prin t will be taken . A digital signature an d ph o- tograph will also be taken at the testin g cen ter. These iden - tity con firm ation s will accom pan y th e NCLEX exam results. In addition, if you leave th e testin g room for an y rea- son , you m ay be required to perform th ese iden tity confir- m ation procedures again to be readm itted to th e room .

Person al belon gin gs are n ot allowed in th e testin g room ; all electron ic devices m ust be placed in a sealable

FIGURE 1-3 Example of a video question.

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bag provided by th e test ad m in istrator an d kept in a locker. An y eviden ce of tam perin g with th e bag could result in an in ciden t an d a result can cellation . A locker an d lo cker key will be provid ed for you; h owever, storage space is lim ited, so you m ust plan acco rdin gly. In addi- tion , th e testin g cen ter will n ot assum e respo n sibility for your perso n al belon gin gs. Th e testin g waitin g areas are gen erally sm all; frien ds or fam ily m em bers wh o accom - pan y you are n ot perm itted to wait in th e testin g cen ter wh ile you are takin g th e exam in ation .

O n ce you h ave com pleted th e adm ission process, th e test adm in istrator will escort you to th e assign ed com - puter. You will be seated at an in dividual workspace area th at includes com puter equipm en t, appropriate ligh tin g, an erasable n ote board, an d a m arker. No item s, in cludin g un auth orized scratch paper, are allowed in to th e testin g room . Eatin g, drin kin g, or th e use of tobacco is n ot allowed in th e testin g room . You will be observed at all tim es by th e test adm in istrator wh ile takin g th e exam in a- tion . In addition , video an d audio recordin gs of all test ses- sions are m ade. Th e testin g cen ter h as n o con trol over th e soun ds m ade by typin g on th e com puter by oth ers. If these soun ds are distractin g, raise your h an d to sum m on th e test adm in istrator. Earplugs are available on request.

You m ust follow th e direction s given by th e testin g cen - ter staff an d m ust rem ain seated durin g th e test except wh en auth orized to leave. If you th in k th at you h ave a problem with the com puter, n eed a clean n ote board, n eed to take a break, or n eed the test adm in istrator for an y rea- son , you m ust raise your h an d. You are also en couraged to access th e NCSBN can didate Web site to obtain addition al in form ation about th e physical en vironm en t of th e testin g cen ter an d to view a virtual tour of th e testin g cen ter.

Testing Time

Th e m axim u m testin g tim e is 6 h ours; th is period in cludes th e tutorial, th e sam ple item s, all breaks, an d th e exam in ation . All breaks are option al. Th e first option al break will be offered after 2 h ours of testin g. Th e secon d option al break is offered after 3.5 h ours of testin g. Rem em b er th at all breaks coun t again st testin g tim e. If you take a break, you m ust leave th e testin g ro om an d, wh en you return , you m ay be required to perform iden tity con firm ation proced ures to be readm itted.

Length of the Examination

Th e m in im um n um ber of question s th at you will n eed to an swer is 75. O f these 75 question s, 60 will be operation al (scored) question s an d 15 will be pretest (un scored) question s. Th e m axim um n um ber of question s in th e test is 265. Fifteen of the total n um ber of question s th at you n eed to an swer will be pretest (un scored) question s.

Th e pretest question s are question s th at m ay be pre- sen ted as scored question s on future exam in ation s.

Th ese pretest question s are n ot iden tified as such . In oth er words, you do n ot kn ow wh ich question s are th e pretest (un sco red) question s; h owever, th ese pretest (un scored) question s will be adm in istered am on g th e first 75 question s in th e test.

Pass-or-Fail Decisions

All exam in ation question s are categorized by test plan area an d level of difficulty. Th is is an im portan t poin t to keep in m in d wh en you con sider h ow th e com puter m akes a pass-or-fail decision because a pass-or-fail decision is n ot based on a percen tage of correctly an swered question s.

Th e NCSBN in dicates th at a pass-or-fail decision is govern ed by 3 differen t scen arios. Th e first scen ario is th e 95% Con fid en ce In terval Rule, in wh ich th e com - puter stops ad m in isterin g test question s wh en it is 95% certain th at th e test-taker’s ability is clearly above th e passin g stan dard or clearly below th e passin g stan - dard. Th e secon d scen ario is kn own as th e Maxim u m - Len gth Exam , in wh ich th e fin al ability estim ate of th e test-taker is con sidered. If th e fin al ability estim ate is above th e passin g stan dard, th e test-taker passes; if it is below th e passin g stan dard, th e test-taker fails.

Th e th ird scen ario is th e Run -O ut-O f-Tim e (R.O.O .T) Rule. If th e exam in ation en ds because the test-taker ran out of tim e, th e com puter m ay n ot h ave en ough in form a- tion with 95% certain ty to m ake a clear pass-or-fail deci- sion . If this is the case, the com puter will review th e test-taker’s perform an ce durin g testin g. If th e test-taker h as n ot an swered th e m in im um n um ber of required ques- tion s, th e test-taker fails. If th e test-taker’s ability estim ate was con sisten tly above the passing stan dard on th e last 60 question s, th e test-taker passes. If th e test-taker’s ability estim ate falls below the passin g stan dard, even on ce, th e test-taker fails. Addition al inform ation about pass- or-fail decision s can be foun d in th e NCLEX Exam in ation Can didate Bulletin located at www.n csbn .org.

Completing the Examination

Wh en th e exam in ation h as en ded, you will co m plete a brief com puter-delivered question n aire about your testin g experien ce. After you com plete th is question - n aire, you n eed to raise your h an d to sum m on th e test adm in istrator. Th e test adm in istrator will collect an d in ven tory all n ote boards an d th en perm it yo u to leave.

Processing Results

Every com puterized exam in ation is scored twice, on ce by th e com puter at th e testin g cen ter an d again after th e exam in ation is tran sm itted to th e test scorin g cen ter. No results are released at th e testin g cen ter; testin g cen ter staff do n ot h ave access to exam in ation results. Th e board of n ursin g receives your result an d yo ur result will

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be m ailed to you approxim ately 1 m on th after you take th e exam in ation . In som e states, an un o fficial result can be obtain ed via th e Q uick Resu lts Service 2 busin ess days after takin g th e exam in ation . Th ere is a fee for th is service an d in form ation about obtain in g your NCLEX result by th is m eth od can be obtain ed on th e NCSBN Web site un der can didate services.

Candidate Performance Report

A can didate perform an ce report is provided to a test-taker who failed th e exam in ation . This report provides th e test- taker with in form ation about h er or h is stren gth s and weakn esses in relation to th e test plan fram ework an d pro- vides a guide for studyin g an d retakin g th e exam in ation . If a retake is n ecessary, th e can didate m ust wait 45 to 90 days between exam in ation adm in istration , depen din g on state procedures. Test-takers sh ould refer to th e state board of n ursin g in th e state in wh ich licen sure is sough t for proce- dures regardin g when th e exam in ation can be taken again .

Interstate Endorsement

Becau se th e NCLEX-RN exam in ation is a n ation al exam - in ation , you can apply to take th e exam in ation in an y state. Wh en licen su re is received, you can apply for in ter- state en dorsem en t, wh ich is obtain in g an oth er licen se in an oth er state to practice n ursin g in th at state. Th e pro- cedu res an d requirem en ts for in terstate en dorsem en t m ay vary from state to state, an d th ese procedures can be obtain ed from th e state board of n ursin g in th e state in wh ich en dorsem en t is sough t.

Nurse Licensure Compact

It m ay be possible to practice n ursin g in an oth er state un der th e m utual recogn ition m odel of n ursin g licen sure if th e state h as en acted a Nurse Licen sure Com pact. To obtain inform ation about th e Nurse Licen sure Com pact and th e states th at are part of th is in terstate com pact, access the NCSBN Web site at h ttp:/ / www.ncsbn .org.

The Foreign-Educated Nurse

An im portan t first step in th e process of obtain in g infor- m ation about becom in g a registered n urse in the Un ited States is to access the NCSBN Web site at h ttp:/ / www. n csbn .org an d obtain in form ation provided for in tern a- tion al n urses in th e NCLEX Web site lin k. Th e NCSBN provides inform ation about som e of th e docum en ts you n eed to obtain as an intern ational n urse seekin g licen sure in th e Un ited States an d about creden tialin g agen cies. Refer to Box 1-12 for a listin g of som e of th ese

docum ents. Th e NCSBN also provides in form ation regardin g the requirem en ts for education and En glish proficien cy, an d im m igration requirem en ts such as visas an d VisaScreen . You are en couraged to access th e NCSBN Web site to obtain th e m ost curren t in form ation about seekin g licen sure as a registered n urse in th e Un ited States.

An im portan t factor to con sider as you pursue th is process is th at som e requirem en ts m ay vary from state to state. You n eed to con tact th e board of n ursin g in th e state in wh ich yo u are plan n in g to obtain licen su re to determ in e th e specific requirem en ts an d docum en ts th at yo u n eed to subm it.

Boards of n ursin g can decide eith er to use a creden tial- in g agency to evaluate your docum en ts or to review your docum ents at th e specific state board, kn own as in-house evaluation . When you contact the board of n ursin g in th e state in wh ich you in ten d to work as a n urse, in form them that you were educated outside of the United States an d ask that th ey sen d you an application to apply for licen sure by exam in ation. Be sure to specify that you are applyin g for registered n urse (RN) licensure. You sh ould also ask about the specific docum en ts n eeded to becom e eligible to take th e NCLEX exam . You can obtain contact in form a- tion for each state board of n ursin g through the NCSBN Web site at h ttp:/ / www.ncsbn .org. In addition , you can write to th e NCSBN regardin g the NCLEX exam . Th e address is 111 East Wacker Drive, Suite 2900, Ch icago, IL 60601. Th e telephon e n um ber for the NCSBN is 1-866-293-9600; in tern ational teleph on e is 011 1 312 525 3600; the fax n um ber is 1-312-279-1032.

BOX 1-12 Foreign-Educated Nurse: Some Documents Needed to Obtain Licensure

1. Proof of citizenship or lawful alien status 2. Work visa 3. VisaScreen certificate 4. Commission on Graduates of Foreign Nursing Schools

(CGFNS) certificate 5. Criminal background check documents 6. Official transcripts of educational credentials sent directly

to credentialing agency or board of nursing from home country school of nursing

7. Validation of a comparable nursing education as that pro- vided in U.S. nursing programs; this may include theoretical instruction and clinical practice in a variety of nursing areas, including, but not limited to, medical nursing, surgical nurs- ing, pediatric nursing, maternityand newborn nursing, com- munityand public health nursing, and mentalhealth nursing

8. Validation of safe professional nursing practice in home country

9. Copy of nursing license or diploma or both 10. Proof of proficiency in the English language 11. Photograph(s) 12. Social Security number 13. Application and fees

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C H A P T E R 2 Pathways to Success Laurent W. Valliere, BS, DD

The Pyramid to Success

Preparin g to take th e NCLEX-RN® exam in ation can pro- duce a great deal of an xiety. You m ay be th in kin g th at th is exam is th e m ost im portan t on e you will ever h ave to take an d th at it reflects th e culm in ation of everyth in g you h ave worked so h ard for. Th is is an im portan t exam - in ation because receivin g your n ursin g licen se m ean s th at you can begin your career as a registered n urse. Your success on th is exam in volves gettin g rid of all th o ugh ts th at allow th is exam in ation to appear overwh elm in g an d in tim idatin g. Such th ough ts can take com plete con tro l over your destin y. A stron g positive attitu de, a structured plan for preparatio n , an d m ain tain in g con - trol in your path way to success en sure reach in g th e peak of th e Pyram id to Success ( Fig. 2-1).

Pathways to Success ( Box 2-1) Foundation Th e foun dation of path ways to success begin s with a stron g positive attitude, the belief th at you will ach ieve success, and developin g con trol. It also in cludes develop- in g a list of your person al short-term an d lon g-term goals an d a plan for preparation . With out th ese com pon en ts, your path way to success leads to n owh ere an d h as n o en dpoin t. You will expen d en ergy an d valuable tim e in your journ ey, lack con trol over wh ere you are h eadin g, an d experien ce exh austion with out an y accom plish m en t.

Wh ere do yo u start? To begin , fin d a lo cation th at offers solitude. Sit or lie in a com fo rtable position , clo se your eyes, relax, in h ale deeply, h old yo ur breath to a coun t of 4, exh ale slowly, an d, again , relax. Repeat th is breath in g exercise several tim es un til you feel relaxed, free from an xiety, an d in con trol of your destin y. Allow your m in d to beco m e vo id of all m in d ch atter; n ow you are in con trol an d your m in d’s eye can see for m iles. Next, reflect on all th at you h ave acco m plish ed an d th e path th at brough t yo u to wh ere you are today. Keep a journ al of your reflection s as you plan th e order of your journ ey th rough th e Pyram id to Success.

List It is tim e to create th e “List.” Th e List is your set of sh o rt- term an d lon g-term go als. Begin by develo pin g th e go als th at you wish to acco m plish today, tom o rrow, over th e n ext m on th , an d in th e future. Allow yourself th e oppo r- tun ity to list all th at is flo win g from your m in d . Write your goals in your person al jou rn al. Wh en th e List is com plete, put it away for 2 or 3 days. After th at tim e, retrieve an d review th e List an d begin th e process of plan n in g to prepare for th e NCLEX-RN exam .

Plan for Preparation Now th at you h ave th e List in order, lo ok at th e go als th at relate to studyin g for th e licen sin g exam . Th e first task is to decide wh at study pattern works best for you. Th in k about wh at h as worked m ost successfully for you in th e past. Q uestion s th at m ust be addressed to develop your plan for study are listed in Box 2-2.

Th e plan m ust in clude a sch edule. Use a calen dar to plan an d docum en t th e daily tim es an d n ursin g con ten t areas for your study session s. Establish a realistic sch ed- ule th at in cludes yo ur daily, weekly, an d future goals, an d stick to your plan of study. Th is con sisten cy will provide advan tages to you an d th e people supportin g you. You will develo p a rh yth m th at can en h an ce yo ur reten tion an d positive m om en tum . Th e people wh o are supportin g you will sh are th is rh yth m an d be able to sch edule th eir activities an d lives better wh en you are con sisten t with yo ur study sch edule.

Th e len gth of th e study session depen ds on your abil- ity to focus an d con cen trate. You n eed to th in k about quality rath er th an quan tity wh en you are decidin g on a realistic am oun t of tim e for each session . Plan to sch ed- ule at least 2 h ours of quality study tim e daily. If you can spen d m ore th an 2 h ours, by all m ean s do so.

You m ay ask, “Wh at do yo u m ean by quality study tim e?” Q uality study tim e m ean s spen d in g un in ter- rupted quiet tim e at your study session . Th is m ay m ean th at you h ave to isolate yo urself for th ese study session s. Th in k again about wh at h as worked for yo u durin g n urs- in g sch ool wh en yo u studied for exam in ation s; select a study place th at h as worked for yo u in th e past. If you

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h ave a special study room at h om e th at you h ave always used, plan your study session s in th at special room . If you h ave always studied at a library, plan yo ur study ses- sion s at th e library. Som etim es it is difficu lt to balan ce your study tim e with your fam ily obligation s an d possi- bly a work sch edule, but, if yo u can , plan your study tim e wh en you kn ow th at you will be at h om e alon e. Try to elim in ate an yth in g th at m ay be distractin g durin g your study tim e. Silen ce your cellph on e appropriately so th at you will n ot be disturbed. If yo u h ave sm all ch ildren , plan yo ur study tim e durin g th eir n ap tim e or durin g th eir sch ool h ours.

Your plan m ust in clude h ow you will m an age your study n eeds with your oth er obligation s. Your fam ily an d frien d s are key players in your life an d are goin g to becom e part of your Pyram id to Success. After you h ave establish ed your study n eeds, com m un icate your n eeds an d th e im portan ce of yo ur study plan to your fam ily an d frien ds.

A difficult part of th e plan m ay be h ow to deal with fam ily m em bers an d frien ds wh o ch oo se n ot to partici- pate in your plan for success. For exam ple, wh at do you do if a frien d asks you to go to a m ovie an d it is yo ur sch eduled study tim e? Your frien d m ay say, “Take som e tim e off. You h ave plen ty of tim e to study. Study later wh en we get back!” You are faced with a decision . You m ust weigh all facto rs carefully. You m ust keep your goals in m in d an d rem em ber th at yo ur n eed for positive m om en tum is critical. Your decision m ay n ot be an easy on e, but it m ust be on e th at will en sure th at your goal of becom in g a registered n urse is ach ieved.

Positive Pampering

Positive pampering m ean s th at yo u m ust con tin ue to care for yourself h olistically. Positive m om en tum can be m ain tain ed on ly if you are properly balan ced. Proper exercise, diet, an d positive m en tal stim ulation are crucial to ach ievin g your goal of beco m in g a registered n urse. Just as yo u h ave developed a sch edule for study, you sh ould h ave a sch edule th at in cludes fun an d ph ysical

Control

S tructure d s tudy pla n

S trong pos itive a ttitude

Re g is te re d Nurs e !

FIGURE 2-1 Pyramid to Success.

BOX 2-1 Pathways to Success

Foundation Maintaining a strong positive attitude Thinking about short-term and long-term realistic goals Developing a plan for preparation Maintaining control

List Writing short-term and long-term realistic goals in a journal

Plan for Preparation Developing a study plan and schedule Deciding on the place to study Balancing personal and work obligations with the study

schedule Sharing the study schedule and personal needs with others Implementing the study plan

Positive Pampering Planning time for exercise and fun activities Establishing healthy eating habits Including activities in the schedule that provide positive men-

tal stimulation

Final Preparation Reviewing and identifying goals achieved Remaining focused to complete the plan of study Writing down the date and time of the examination and post-

ing it next to your name with the letters “RN” following, and the word “YES!”

Planning a test drive to the testing center Engaging in relaxing activities on the day before the

examination

Day of the Examination Grooming yourself for success Eating a nutritious breakfast Maintaining a confident and positive attitude Maintaining control—breathe and focus Meeting the challenges of the day Reaching the peak of the Pyramid to Success

BOX 2-2 Developing a Plan for Study Do I work better alone or in a study group? If I work best in a group, how many study partners should I

have? Who are these study partners? How long should my study sessions last? Does the time of day that I study make a difference? Do I retain more if I study in the morning? How does my work schedule affect my study pattern? How do I balance my family obligations with my need to

study? Do I have a comfortable study area at home or should I find

another environment that is conducive to my study needs?

15CHAPTER 2 Pathways to Success

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activity. It is yo ur ch oice—aero bics, walkin g, weigh t lift- in g, bowlin g, or wh atever m akes you feel good about yourself. Tim e spen t away from th e h ard study sch edule an d devoted to som e fun an d ph ysical exercise pays you back a h un dredfold. You will be m ore en ergetic with a sch edule th at in cludes th ese activities.

Establish h ealth y eatin g h abits. Be sure to drin k plen ty of water, wh ich will flush an d clean your body cells. Stay away from fatty foods because th ey slow you down . Eat ligh ter m eals an d eat m ore frequen tly. In clude com plex carbo h ydrates such as oatm eal or wh ole grain food s in your diet for en ergy, an d be careful n ot to in clude too m uch caffein e in your daily diet.

Take th e tim e to pam per yourself with activities th at m ake you feel even better about wh o you are. Make din - n er reservation s at yo ur favorite restauran t with som e- on e wh o is special an d is supportin g your goal. Take walks in a place th at h as a particular tran quility th at en ables yo u to reflect on th e positive m om en tum th at you h ave ach ieved an d m ain tain ed. Wh atever it is, wh er- ever it takes you, allow yo urself th e tim e to do som e pos- itive pam perin g.

Final Preparation

You h ave establish ed th e foun dation of your Pyram id to Success. You h ave developed yo ur list of goals an d your study plan , an d you h ave m ain tain ed yo ur positive m om en tum . You are m ovin g forward, an d in con trol. Wh en you receive yo ur date an d tim e for th e NCLEX- RN exam in ation , yo u m ay im m ediately th in k, “I am n ot ready!” Stop! Reflect on all you h ave ach ieved. Th in k about your goal ach ievem en t an d th e organ ization of th e positive life m om en tum with wh ich yo u h ave sur- roun ded yourself. Th in k about all of th e people wh o love an d support yo ur effort to beco m e a registered n urse. Believe th at th e ch allen ge th at awaits yo u is on e th at you h ave successfully prepared for an d will lead you to your go al of becom in g a registered n urse.

Take a deep breath an d organ ize th e rem ain in g days so th at th ey supp ort your education al an d perso n al n eeds. Supp ort your positive m om en tum with a visu al tech n iqu e. Write your n am e in large letters, an d write th e letters “RN” after it. Post 1 or m ore of th ese visual rein fo rcem en ts in areas th at you frequen t. Th is is a visu al m otivation al tech n iqu e th at works for m an y n ursin g graduates preparin g for th is exam in ation .

It is im perative th at you n ot fall in to th e trap of expectin g too m uch of yourself. Th e idea of perfectio n m ust n ot drive you to a poin t th at cau ses your positive m om en tum to falter. You m ust believe an d stay focused on your goal. Th e date an d tim e are at h an d. Write th e date an d tim e, an d un dern eath write th e word “YES!” Post th is n ext to your n am e plus “RN.”

En sure th at yo u h ave com m an d over h ow to get to th e testin g cen ter. A test run is a m ust. Tim e th e drive,

an d allow for road con struction or wh atever m igh t occur to slow traffic down . O n th e test ru n , wh en you arrive at th e test facility, walk in to it an d beco m e fam iliar with th e lobby an d th e surroun din gs. Th is m ay h elp to alleviate som e of th e periph eral n ervousn ess associated with en terin g an un kn own buildin g. Rem em ber th at you m ust do wh atever it takes to keep yourself in con trol. If fam iliarizin g yo urself with th e facility will h elp you to m ain tain positive m om en tum , by all m ean s be sure to do so.

It is tim e to ch eck your study plan an d m ake th e n ec- essary ad justm en ts n ow th at a firm date an d tim e are set. Adjust your review so th at your study plan en ds 2 days before th e exam in ation . Th e m in d is like a m uscle. If it is overworked, it h as n o stren gth or stam in a. Your strat- egy is to rest th e body an d m in d on th e day befo re th e exam in ation . Your strategy is to stay in con tro l an d allow yourself th e opportun ity to be ab solutely fresh an d atten tive on th e day of th e exam in ation . Th is will h elp you to con trol th e n ervousn ess th at is n atural, ach ieve th e clear th ough t processes required , an d feel con fiden t th at you h ave don e all th at is n ecessary to prepare for an d con quer th is ch allen ge. Th e day befo re th e exam in a- tion is to be on e of pleasure. Treat yourself to wh at you en joy th e m ost.

Relax! Take a deep breath , h old to a coun t of 4, an d exh ale slowly. You h ave prepared yourself well for th e ch allen ge of tom o rrow. Allow yourself a restful n igh t’s sleep, an d wake up on th e day of th e exam in ation kn ow- in g th at you are absolutely prepared to succeed. Loo k at your n am e with “RN” after it an d th e word “YES!”

Day of the Examination (Bo x 2-3)

Wake up believin g in yourself an d th at all you h ave accom plish ed is about to propel you to th e profession al level of registered n urse. Allow yourself plen ty of tim e, eat a n utritious breakfast, an d groo m yo urself for suc- cess. You are ready to m eet th e ch allen ges of th e day an d overcom e an y obstacle th at m ay face you. Today will soon be h isto ry, an d tom o rrow will brin g you th e en ve- lope on wh ich you read your n am e with th e words “Reg- istered Nu rse” after it.

Be proud an d con fiden t of your ach ievem en ts. You h ave worked h ard to ach ieve your goal of beco m in g a

BOX 2-3 Day of the Examination Breathe: Inhale deeply, hold your breath to a count of 4, exhale

slowly Believe: Have positive thoughts today and keep those

thoughts focused on your achievements Control: You are in command Believe: This is your day Visualize: “RN” with your name

16 UNIT I NCLEX-RN® Exam Preparation

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registered n urse. If you believe in yo urself an d your goals, n o on e person or obstacle can m ove you off th e path way th at leads to success! Con gratulation s, an d I wish you th e very best in your career as a registered n urse!

This Is Not a Test

1. Wh at are th e facto rs n eeded to en sure a produ ctive study en viron m en t? Select all th at ap p ly. 1. Secure a location th at offers solitude. 2. Plan breaks durin g yo ur study session . 3. Establish a realistic study sch edule th at in cludes

your goals. 4. Con tin ue with th e study pattern th at h as worked

best for you. Answers: 1, 2, 3, 4 Ra tiona le: A lo cation of solitude h elps to en sure con cen - tration . Takin g breaks durin g your study session h elps to clear your m in d an d in crease your ab ility to con cen trate an d focus. Establish in g a realistic study pattern will keep you in con trol. Do n ot vary yo ur study pattern . It h as been successful for you, so wh y ch an ge n ow? 2. Wh at are key factors in your fin al preparation ? Select

all th at ap p ly. 1. Rem ain focused on th e study plan . 2. Visualize th e “RN” after your n am e. 3. Avoid studyin g on th e day before th e exam

an d relax. 4. Kn ow wh ere th e testin g cen ter is an d h ow lon g it

takes to get th ere. Answers: 1, 2, 3, 4

Ra tiona le: Focus on your plan of study an d success will follow. Positive rein forcem en t: Write your n am e in large letters on a piece of paper with “RN” after your n am e an d post it wh ere you will see it often . Allow yo urself a day of pam perin g befo re th e test. Wake up on th e day of th e test refresh ed an d ready to succeed. En sure th at you kn ow wh ere th e testin g cen ter is; m ap out your route an d th e average tim e it takes to arrive. 3. Wh at key poin ts do th e “Path ways to Success” em ph a-

size to h elp en sure your success? Select all th at app ly. 1. A stron g positive attitu de 2. Believin g in yo ur ability to succeed 3. Bein g proud an d con fiden t in your ach ievem en ts 4. Main tain in g co n trol of yo ur m in d, surroun din g

en viron m en t, an d ph ysical bein g Answers: 1, 2, 3, 4 Ra tiona le: A stron g positive attitude leads to success. Believe in wh o yo u are an d th e goals you h ave set for yourself. Be “proud and confident.” If you believe in your- self, you will ach ieve success. Maintain control an d all of your goals are attain ab le.

Your grade: A+ Continue to “Believe” and you will succeed. RN belongs to you!

17CHAPTER 2 Pathways to Success

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C H A P T E R 3 The NCLEX-RN® Examination from a Graduate’s Perspective Jaskaranjeet “Jessica” Bhullar, BSN, RN

Graduatin g from n ursin g sch ool is a h uge accom plish - m en t. After earn in g m y Bach elor of Scien ce in Nu rsin g (BSN), I reflected on all of th e work th at h ad led to th at m om en t. Th e past 16 m on th s h ad been a wh irlwin d. Mem ories of preparin g for sim ulation s an d late n igh ts studyin g for exam s an d com pletin g detailed care plan s flooded m y m in d . Th ou gh I was don e with sch o ol, I kn ew th ere was on e m ore test I would h ave to pass before I could call m yself a registered n urse. Th e NCLEX® is a n ation al licen sin g exam th at is adm in is- tered to every n ursin g sch ool graduate. Passin g th is exam gives graduates a licen se to practice. I kn ew it would be th e m ost im portan t exam of m y life an d I was deter- m in ed to pass it.

In addition to studyin g, a few th in gs m ust be don e in preparation for th e NCLEX. Approxim ately 1 m on th before I graduated, I subm itted th e required paperwo rk an d fees to m y State Board of Nursin g. It is im portan t to do th is well in advan ce, as it can poten tially take m on th s for your state board to process th e paperwo rk. Your sch ool will n otify th e board on ce your degree is con - firm ed. Th en it is a m atter of waitin g for your Auth oriza- tion to Test (ATT). An ATT en ab les you to sch edule your test date. Sin ce I h ad don e everyth in g on m y part to en sure th at th ere would be n o delays, I expected to receive m y ATT with in a few weeks after graduation . Wh ile I waited, I packed up m y apartm en t an d m oved from Nevad a to m y h om e state of Californ ia. I also spen t som e tim e catch in g up with frien d s I h ad n ot seen in m on th s. With in a few days of arrivin g h om e, I received m y ATT. I wan ted to take the exam as soon as possible, so I expan ded m y search for testin g cen ters to n eigh borin g cit- ies. I did n ot m in d drivin g a bit farth er if it m ean t that I could take th e exam soon er. I foun d that th e earliest avail- able test date was 3 weeks later in a city about 45 m in utes away. Th e on ly available tim e was 2:00 p.m ., wh ich I gladly accepted as it m ean t I could get a good n igh t’s rest an d avoid early m orn in g traffic. I felt th at I h ad a solid kn owledge base fro m sch ool, an d 3 weeks would be m ore th an en ough tim e to review co n cepts an d

practice m ore question s. You will n eed to assess your person al kn owledge level an d con fiden ce to gauge h ow m uch tim e yo u require to study. It is recom m en ded to take th e exam with in a m axim u m of 3 m on th s to en sure th at yo u are n ot losin g th e kn owledge you learn ed wh ile in sch ool.

Now th at I h ad a date m arked in m y calen dar, I felt em powered to create a study plan . I ch ose to use 1 or 2 resources at th e m ost in order to stay focused an d m as- ter con ten t realistically. Based on m y research , I ch ose Saunders Comprehensive Review for the NCLEX-RN ® Exam- ination. I used th is text in n ursin g sch o ol an d kn ew it would ben efit m e durin g m y NCLEX preparation . Be th ough tful an d selective wh en ch oosin g study tools an d fin d wh at works best for yo u. Wh at works for som e people m ay n ot work for oth ers. I set a go al to practice 150 to 200 question s a day. Th e NCLEX can ask as few as 75 question s an d as m an y as 265. I wan ted to build up m y test-takin g en duran ce, wh ich is wh y I ch ose to practice so m an y question s. Wh en I an swered question s, I would read th e en tire ration ales regardless of wh eth er I an swered correctly or n ot. A wealth of in form ation is in cluded in each ration ale. You will gain a better un der- stan din g of n ot on ly con ten t, but also why you selected an in correct or correct an swer. It is also im portan t to read th e Test-Takin g Strategy, because th is will provide you with a logical way of an swerin g th e question if you were n ot as con fid en t in your m astery of th e m aterial as you would h ave liked. I prefer to study alon e, an d I spen t m ost days practicin g question s at h om e or in a n earby cafe. I m ade sure to take a break every h ou r to stretch an d refresh m y m in d. Kn owin g th at I h ad on ly a few weeks to study m ade m e use m y tim e m ore wisely. I kn ew it was on ly a m atter of tim e before I would be don e with th e NCLEX, an d I wan ted to feel as if I h ad don e everyth in g I could to pass th e exam .

If th ere is an yth in g yo u can do to alleviate test an xi- ety, do it! Two days before th e exam , I drove to th e test- in g cen ter. I left m y h ou se arou n d th e sam e tim e I plan n ed to leave on th e actu al test day, so I could see

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wh at traffic would be like an d th e parkin g availability. I foun d a m arket n earby wh ere I plan n ed to h ave lun ch before takin g th e exam . Sim ply doin g th is dry ru n h elped to calm m y n erves. I could visualize wh at m y test day would look like. Th e day before th e NCLEX, I ch ose to relax m y m in d , so I didn ’t practice an y question s. I m ade sure to put m y ATT an d id en tification (ID) aside because th ey are required at ch eck-in an d I didn ’t wan t to forget th em . I spen t th e day with m y fam ily an d wen t to bed early. Keep in m in d th at th e exam can take as lon g as 6 h ours, so ad equate sleep is a m ust!

O n th e day of th e NCLEX, I left m y h ou se a few h ours early so I would h ave a ch an ce to eat lun ch an d practice a few question s, just to get in to test-takin g m od e. I believe th at a positive m en tal attitu de is im portan t in life an d especially in poten tially stressful situation s. I kn ew th at in a m atter of h ours, th e exam would be over. It does n ot m atter at wh at question n um ber yo ur com pu ter turn s off, but rath er th at you an swered each question th o ugh t- fully an d to th e best of your ability. I arrived at th e testin g cen ter 30 m in u tes early. I was aware th at lockers are pro- vided, but I brough t as little as possible with m e. Th e ch eck-in process in volves sh owin g your ATT an d ID, h avin g your fin gers an d palm s scan n ed, an d h avin g your ph oto taken . You will also be given a form with in struc- tion s about th e exam , wh ich yo u will be required to sign . It is all very straigh tforward. I was directed to a com puter

in th e testin g room . I took a deep breath an d began th e exam . I treated each question as if it was th e last on e I h ad to an swer. Before I kn ew it, I was on question n um ber 75 an d I clicked subm it. Th e com pu ter sh ut down an d I felt a wave of relief. I was don e with th e NCLEX!

I left th e testin g cen ter feelin g con fiden t. Th e ques- tion s h ad beco m e difficu lt very quickly, an d I took th at as an in dication th at I was doin g well. I replayed th e question s in m y m in d on th e drive h om e, an d began to dwell on a couple I h ad been un sure ab out. I didn ’t allow m yself to becom e con sum ed by self-do ubt because th e exam was over an d th ere was n oth in g I could do but wait! A couple of days later, I foun d out I was officially a registered n urse! My lifelon g dream was n ow a reality. I h ad worked so h ard for th is, an d felt th at n ow I could celebrate with m y frien ds an d fam ily.

Th e NCLEX is th e last h urdle you will h ave to jum p over before you begin your profession al career. It m ay be tem p tin g to put off takin g th e test un til you feel 100% prepared, but th e lo n ger yo u wait th e m ore likely it is th at yo u will forget con ten t you learn ed durin g sch ool. Believe in yo urself an d your edu cation ! Use your tim e wisely an d reduce an xiety h owever you can . I h op e th ese suggestion s will ben efit you. Co n gratu latio n s fo r all yo u h ave an d will acco m p lish , an d th e b est o f lu ck in yo u r n ew career!

19CHAPTER 3 The NCLEX-RN® Examination from a Graduate’s Perspective

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C H A P T E R 4 Test-Taking Strategies

If you would like to read m ore about test-takin g strate- gies after com pletin g th is ch apter, Saunders Strategies for Test Success: Passing Nursing School and the NCLEX®

Exam focuses on th e test-takin g strategies th at will h elp you to pass your n ursin g exam in ation s wh ile in n ursin g sch ool an d will prepare you for th e NCLEX-RN®

exam in ation .

I. Key Test-Taking Strategies (Box 4-1)

II. How to Avoid Reading into the Question (Box 4-2) A. Pyram id Poin ts

1. Avoid askin g yourself th e forbidden words, “Well, what if …?” because th is will lead you to the “for- bidden ” area: readin g in to the question.

2. Focus on ly on th e data in th e question , read every word, an d m ake a decision ab out wh at th e ques- tion is askin g. Reread th e question m ore th an 1 tim e; ask yourself, “Wh at is th is question ask- in g?” an d “Wh at con ten t is th is question test- in g?” (see Box 4-2).

3. Loo k for th e strategic words in th e question , such as immediate, initial, first, priority, initial, best, need for follow-up, or need for further teaching; strategic words m ake a differen ce regardin g wh at th e question is askin g.

4. In m ultiple-ch oice question s, m ultiple-respon se question s, or question s th at require you to arran ge n ursin g in terven tion s or oth er data in order of priority, read every ch oice or option pre- sen ted before an swerin g.

5. Always use th e process of elim in ation wh en ch oices or option s are presen ted; after you h ave elim in ated option s, reread th e question before selectin g your fin al ch oice or ch oices. Focus on th e data in both th e question an d th e option s to assist in th e process of elim in ation an d direct- in g you to th e correct an swer (see Box 4-2).

6. With question s th at require you to fill in th e blan k, focus on th e data in th e question an d determ in e wh at th e question is askin g; if th e question requires you to calculate a m edication dose, an in traven ous flow rate, or in take an d out- put am oun ts, rech eck your work in calculatin g

an d always use th e on -screen calculator to verify th e an swer.

B. In gredien ts of a question ( Box 4-3) 1. Th e in gredien ts of a question in clude th e even t,

wh ich is a clien t or clin ical situation ; th e even t query; an d th e option s or an swers.

2. Th e even t provid es yo u with th e con ten t about th e clien t or clin ical situation th at you n eed to th in k about wh en an swerin g th e question .

3. Th e even t query asks som eth in g specific about th e con ten t of th e even t.

4. Th e option s are all of th e an swers provided with th e question .

5. In a m ultiple-ch oice question , th ere will be 4 option s an d you m ust select one; read every option carefully an d thin k about th e even t an d th e even t query as you use th e process of elim in ation.

6. In a m ultiple-respon se question , th ere will be several option s an d you m ust select all option s th at ap ply to th e even t in th e question . Each option provided is a true or false statem en t; ch oose th e true statem en ts. Also, visu alize th e even t an d use your n ursin g kn owledge an d clin - ical experien ces to an swer th e question .

7. In an ordered-respon se (prioritizin g)/ drag-an d- drop question , you will be required to arran ge in order of priority n ursin g in terven tion s or oth er data; visu alize th e even t an d use your n ursin g kn owledge an d clin ical experien ces to an swer th e question .

8. A fill-in-the-blan k question will n ot con tain option s, an d som e figure/ illustration questions an d audio or video item form ats m ay or m ay n ot con tain option s. A graph ic option item will con tain option s in the form of a picture or graph ic.

9. A ch art/ exh ibit question will m ost likely con tain option s; read th e question carefully an d all of th e in form ation in th e ch art or exh ibit befo re select- in g an an swer. In th is question type, th ere will be in form ation th at is pertin en t to h ow th e question is an swered, an d th ere m ay also be in form ation th at is n ot pertin en t. It is n ecessary to discern wh at in form ation is im portan t an d wh at th e “distractors” are.20

10. A Testlet is also kn own as a Case Study. In form a- tio n about a clien t or even t is presen ted in th e testlet follo wed by several question s th at relate to th e in form ation . Th ese question s can be in a m ultiple ch oice form at or an altern ate item for- m at. It is im portan t to read all of th e data in th e question an d lo ok for abn orm alities in th e in form ation presen ted befo re an swerin g th e acco m pan yin g question s.

III. Strategic Words (Boxes 4-4 and 4-5) A. Strategic words focus your atten tion on a critical

poin t to con sider wh en an swerin g th e question an d will assist you in elim in atin g th e in correct option s. Th ese words can be located in eith er th e even t or th e query of th e question .

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BOX 4-1 Key Test-Taking Strategies ▪ The Question ▪ Focus on the data, read every word, and make a deci-

sion about what the question is asking. ▪ Note the subject and determine what content is being

tested. ▪ Visualize the event; note if an abnormality exists in the

data provided. ▪ Look for the strategic words; strategic words make a dif-

ference regarding what the question is asking about. ▪ Determine if the question presents a positive or nega-

tive event query. ▪ Avoid asking yourself, “Well, what if…?” because this

will lead you to reading into the question. ▪ The Options ▪ Always use the process of elimination when choices or

options are presented and always read each option care- fully; once you have eliminated options, reread the ques- tion before selecting your final choice or choices.

▪ Look for comparable or alike options and eliminate these.

▪ Determine if there is an umbrella option; if so, this could be the correct option.

▪ Identify any closed-ended words; if present, the option is likely incorrect.

▪ Use the ABCs, airway, breathing, and circulation, Maslow’s Hierarchy of Needs, and the steps of the Nursing Process to answer questions that require prioritizing.

▪ Use therapeutic communication techniques to answer communication questions and remember to focus on the client’s thoughts, feelings, concerns, anxieties, and fears.

▪ Use delegating and assignment-making guidelines to match the client’s needs with the scope of practice of the health care provider.

▪ Use pharmacology guidelines to select the correct option if the question addresses a medication.

▪ Determine whether the question is a positive or nega- tive event query.

BOX 4-2 Practice Question: Avoiding the “What if …?” Syndrome and Reading into the Question

The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea. The nurse should take which immediate action?

1. Administer oxygen to the client 2. Prepare to administer furosemide 3. Elevate the head of the client’s bed 4. Call the health care provider (HCP)

Answer: 3 Test-Ta king St ra t egy: You mayimmediatelythink that the client has developed pulmonary edema, a complication of heart fail- ure, and needs a diuretic. Although pulmonary edema is a com- plication of heart failure, the question does not specifically state that pulmonary edema has developed, and the client could be experiencing shortness of breath or dyspnea as a symptom of heart failure exacerbation. This is why it is important to base your answer only on the information presented, without assum- ing something else could be occurring. Read the question care- fully. Note the strategic word, immediate, and focus on the data in the question, the client’s complaints. An HCP’s prescription is needed to administer oxygen. Although the HCP may need to be notified, this is not the immediate action. Furosemide is a diuretic and may or may not be prescribed for the client; further data would be needed in order to make this determination. Because there are no data in the question that indicate the pres- ence of pulmonary edema, option 3 is correct. Additionally, focus on what the question is asking. The question is asking you for a nursing action, so that is what you need to look for as you eliminate the incorrect options. Use nursing knowledge and test-taking strategies to assist in answering the question. Remember to focus on the data in the question, focus on what the question is asking, and avoid the “What if …?” syndrome and reading into the question.

BOX 4-3 Ingredients of a Question: Event, Event Query, and Options

Event: The nurse is caring for a client with terminal cancer. Event Query: The nurse should consider which factor when planning opioid pain relief? Opt ions:

1. Not all pain is real. 2. Opioid analgesics are highly addictive. 3. Opioid analgesics can cause tachycardia. 4. Around-the-clock dosing gives better pain relief than as-

needed dosing.

Answer: 4 Test-Ta king St ra tegy: Focus on what the question is asking and consider the client’s diagnosis of terminal cancer. Around-the- clock dosing provides increased pain relief and decreases stressors associated with pain, such as anxiety and fear. Pain is what the client describes it as, and any indication of pain should be perceived as real for the client. Opioid analgesics may be addictive, but this is not a concern for a client with ter- minal cancer. Not all opioid analgesics cause tachycardia. Remember to focus on what the question is asking.

21CHAPTER 4 Test-Taking Strategies

B. Som e strategic words m ay in dicate th at all option s are correct an d th at it will be n ecessary to prio ritize to select th e correct option ; words th at reflect th e process of assessm en t are also im portan t to n ote (see Box 4-4). Words th at reflect assessm en t usually in dicate th e n eed to look for an option th at is a first step, sin ce assessm en t is th e first step in th e n ursin g process.

C. As you read th e question , look for th e strategic words; strategic words m ake a differen ce regardin g th e focus of th e question . Th rough out th is book,

strategic words presen ted in th e question , such as th ose th at in dicate th e n eed to prioritize, are bolded. If th e test-takin g strategy is to focus on strategic words, th en strategic words is h igh ligh ted in b lu e wh ere it appears in th e test-takin g strategy.

IV. Subject of the Question (Box 4-6) A. Th e subject of th e question is th e specific topic th at

th e question is askin g ab out. B. Iden tifyin g th e subject of th e question will assist in

elim in atin g th e in correct option s an d direct you in selectin g th e correct option . Th rough out th is book, if th e subject of th e question is a specific strategy to use in an swerin g th e question correctly, it is h igh ligh ted in b lu e in th e test-takin g strategy. Also, th e specific con ten t area to review, such as heart fail- ure, is bold in m agen ta wh ere it appears in th e test- takin g strategy.

C. Th e h igh ligh tin g of th e strategy an d specific con ten t areas will provide yo u with guid an ce on wh at strat- egies to review in Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam an d th e con ten t areas in n eed of furth er rem ediation in Saunders Comprehensive Review for the NCLEX-RN ®

Examination.

V. Positive and Negative Event Queries (Boxes 4-7 and 4-8)

A. A positive even t query uses strategic words th at ask you to select an option th at is correct; for exam ple, th e even t query m ay read, “Wh ich statem en t by a cli- en t indicates an understanding of th e side effects of th e prescribed m edication ?”

B. A n egative even t query uses strategic words th at ask you to select an option th at is an in correct item or statem en t; for exam ple, th e even t query m ay read,

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BOX 4-4 Common Strategic Words: Words That Indicate the Need to Prioritize and Words That Reflect Assessment

Words That Indicate the Need to Prioritize Best Early or late Essential First Highest priority Immediate Initial Most Most appropriate Most important Most likely Next Primary Vital

Words That Reflect Assessment Ascertain Assess Check Collect Determine Find out Gather Identify Monitor Observe Obtain information Recognize

BOX 4-5 Practice Question: Strategic Words The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse should monitor for which early sign of hypovolemic shock?

1. Sleepiness 2. Increased pulse rate 3. Increased depth of respiration 4. Increased orientation to surroundings

Answer: 2 Test-Ta king Stra tegy: Note the strategic word, early, in the query and the word just in the event. Think about the patho- physiology that occurs in hypovolemic shock to direct you to the correct option. Restlessness is one of the earliest signs followed by cardiovascular changes (increased heart rate and a decrease in blood pressure). Sleepiness is expected in a cli- ent who has just returned from surgery. Although increased depth of respirations occurs in hypovolemic shock, it is not an early sign. Rather, it occurs as the shock progresses. This is why it is important to recognize the strategic word, early, when you read the question. It requires the ability to discern between early and late signs of impending shock. Increased orientation to surroundings is expected and will occur as the effects of anesthesia resolve. Remember to look for stra- tegic words, in both the event and the query of the question.

BOX 4-6 Practice Question: Subject of the Question

The nurse is teaching a client in skeletal leg traction about measures to increase bed mobility. Which item would be most helpful for this client?

1. Television 2. Fracture bedpan 3. Overhead trapeze 4. Reading materials

Answer: 3 Test -Ta king Stra tegy: Focus on the subject, increasing bed mobility. Also note the strategic word, most. The use of an overhead trapeze is extremely helpful in assisting a client to move about in bed and to get on and off the bedpan. Televi- sion and reading materials are helpful in reducing boredom and providing distraction and a fracture bedpan is useful in reducing discomfort with elimination; these items are helpful for a client in traction, but they are not directly related to the subject of the question. Remember to focus on the subject.

22 UNIT I NCLEX-RN® Exam Preparation

“Wh ich statem en t by a clien t indicates a need for fur- ther teaching about th e side effects of th e prescribed m edication ?”

VI. Questions That Require Prioritizing A. Man y question s in th e exam in ation will require you

to use th e skill of prioritizin g n ursin g action s. B. Look for th e strategic words in th e question th at in di-

cate th e n eed to prio ritize (see Box 4-4). C. Rem em b er th at wh en a question requires prioritiza-

tion , all option s m ay be correct an d yo u n eed to determ in e th e correct order of action .

D. Strategies to use to prioritize in clude th e ABCs (air- way–breath in g–circulation ), Maslow’s Hierarch y of Needs th eory, an d th e step s of th e n ursin g process.

E. Th e ABCs (Box 4-9) 1. Use th e ABCs—airway–breath in g–circulation —

wh en selectin g an an swer or determ in in g th e order of priority.

2. Rem em ber the order of priority: airway–breath ing– circulation .

3. Airway is always the first priority. Note that an exception occurs wh en cardiopulm on ary resusci- tation is perform ed; in th is situation, the n urse fol- lows th e CAB (com pressions–airway–breath in g) guidelin es.

F. Maslow’s Hierarch y of Needs th eory ( Box 4-10; Fig. 4-1) 1. Accordin g to Maslow’s Hierarch y of Needs th e-

ory, ph ysiological n eeds are th e priority, fol- lowed by safety an d security n eeds, love an d belon gin g n eeds, self-esteem n eeds, an d, fin ally, self-actualization n eeds; select th e option or determ in e th e order of priority by addressin g ph ysiological n eeds first.

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BOX 4-7 Practice Question: Positive Event Query The nurse provides medication instructions to a client about digoxin. Which statement by the client indicates an under- standing of its adverse effects?

1. “Blurred vision is expected.” 2. “If I am nauseated or vomiting, I should stay on liquids

and take some liquid antacids.” 3. “This medication may cause headache and weakness

but that is nothing to worry about.” 4. “If my pulse rate drops below 60 beats per minute I

should let my health care provider know.”

Answer: 4 Test -Ta king Stra tegy: This question is an example of a positive event queryquestion. Note the words indicates an understanding, and focus on the subject, adverse effects. Additionally, focus on the data provided in the options. Digoxin is a cardiac glycoside and works by increasing contractility of the heart. This medica- tion has a narrow therapeutic range and a major concern is tox- icity. Currently, it is considered second-line treatment for heart failure because of its narrow therapeutic range and potential for adverse effects. Adverse effects that indicate toxicity include gastrointestinal disturbances, neurological abnormalities, bra- dycardia or other cardiac irregularities, and ocular disturbances. If any of these occur, the health care provider (HCP) is notified. Additionally, the client should notify the HCP if the pulse rate drops below 60 beats per minute because serious dysrhythmias are another potential adverse effect of digoxin therapy. Remem- ber to focus on the data provided and note positive event queries.

BOX 4-8 Practice Question: Negative Event Query

The nurse has reinforced discharge instructions to a client who has undergone a right mastectomy with axillary lymph node dissection. Which statement by the client indicates a need for further teaching regarding home care measures?

1. “I should use a straight razor to shave under my arms.” 2. “I need to be sure that I do not have blood pressures or

blood drawn from my right arm.” 3. “I should inform all of my other health care providers

that I have had this surgical procedure.” 4. “I need to be sure to wear thick mitt hand covers or use

thick pot holders when I am cooking and touching hot pans.”

Answer: 1 Test -Ta king Stra tegy: This question is an example of a negative event query. Note the strategic words, need for further teaching. These strategic words indicate that you need to select an option that identifies an incorrect client statement. Recall that edema and infection are concerns with this client due to the removal of lymph nodes in the surgical area. Lymphadenopathy can result and the client needs to be instructed in the measures that will avoid trauma to the affected arm. Recalling that trauma to the affected arm could potentially result in edema and/ or infection will direct you to the correct option. Remember to watch for negative event queries.

BOX 4-9 Practice Question: Use of the ABCs A client with a diagnosis of cancer is receiving morphine sul- fate for pain. The nurse should employ which priority action in the care of the client?

1. Monitor stools. 2. Encourage fluid intake. 3. Monitor urine output. 4. Encourage the client to cough and deep breathe.

Answer: 4 Test-Ta king Stra tegy: Use the ABCs—airway–breathing– circulation—as a guide to direct you to the correct option and note the strategic word, priority. Recall that morphine sul- fate suppresses the cough reflex and the respiratory reflex, and a common adverse effect is respiratory depression. Coughing and deep breathing can assist with ensuring adequate oxygen- ation since the number of respirations per minute can poten- tially be decreased in a client receiving this medication. Although options 1, 2, and 3 are components of the plan of care, the correct option addresses airway. Remember to use the ABCs—airway–breathing–circulation—to prioritize.

23CHAPTER 4 Test-Taking Strategies

2. Wh en a ph ysiological n eed is n ot addressed in th e question or n oted in on e of th e option s, con - tin ue to use Maslow’s Hierarch y of Needs th eory seq uen tially as a guid e an d look for th e option th at addresses safety.

G. Steps of th e n ursin g process 1. Use th e step s of th e n ursin g process to prioritize. 2. Th e steps in clude assessm en t, an alysis, plan n in g,

im plem en tation , an d evaluatio n (AAPIE) an d are follo wed in th is order.

3. Assessm en t a . Assessm en t question s address th e process of

gath erin g subjective an d objective data rela- tive to th e clien t, con firm in g th e data, an d com m un icatin g an d docum en tin g th e data.

b . Rem em b er th at assessm en t is th e first step in th e n ursin g process.

c. Wh en you are asked to select your first, im m e- diate, or in itial n ursin g action , follow th e steps of th e n ursin g process to prioritize wh en selectin g th e correct option .

d . Look for words in th e option s th at reflect assessm en t (see Box 4-4).

e. If an option con tain s th e con cept of assess- m en t or th e collectio n of clien t data, th e best ch oice is to select th at option (Box 4-11).

f. If an assessm en t action is n ot on e of th e option s, follow th e steps of th e n ursin g process as your guide to select your n ext best action .

g. Possib le exception to th e guidelin e—if th e question presen ts an em ergen cy situation , read carefully; in an em ergen cy situation , an in terven tion m ay be th e priority rath er th an takin g th e tim e to assess furth er.

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BOX4-10 Practice Question: Maslow’s Hierarchy of Needs Theory

The nurse caring for a client experiencing dystocia determines that the priority is which action?

1. Position changes and providing comfort measures 2. Explanations to family members about what is happen-

ing to the client 3. Monitoring for changes in the physical condition of the

mother and fetus 4. Reinforcement of breathing techniques learned in child-

birth preparatory classes

Answer: 3 Test-Ta king Stra tegy: All the options are correct and would be implemented during the care of this client. Note the strategic word, priority, and use Maslow’s Hierarchy of Needs theory to prioritize, remembering that physiological needs come first. Also, the correct option is the only one that addresses both the mother and the fetus. Remember to use Maslow’s Hierar- chy of Needs theory to prioritize.

Nurs ing Prio ritie s fro m

Mas lo w's Hie rarc hy o f Ne e ds The o ry

S e lf- Ac tualizatio n

Hope S piritua l we ll-be ing Enha nce d growth

S e lf-Es te e m Control

Compe te nce Pos itive re ga rd

Acce pta nce /worthine s s

Lo ve and Be lo ng ing Ma inta in s upport s ys te ms

P rote ct from is ola tion

S afe ty and S e c urity P rote ction from injury

P romote fe e ling of s e curity Trus t in nurs e -clie nt re la tions hip

Bas ic Phys io lo g ic al Ne e ds Airwa y

Re s pira tory e ffort He a rt ra te , rhythm, a nd s tre ngth of contra ction

Nutrition Elimina tion

FIGURE 4-1 Use Maslow’s Hierarchyof Needs theoryto establish priorities.

BOX 4-11 Practice Question: The Nursing Process—Assessment

A client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action should the nurse take first?

1. Elevate the arm. 2. Document the findings. 3. Medicate with an additional dose of an opioid. 4. Check for paresthesias and paralysis of the right arm.

Answer: 4 Test -Ta king Stra tegy: Note the strategic word, first. Based on the data in the question, determine if an abnormality exists. The question event indicates that the client complains of pain at the wrist when the arm is passively moved. This could indi- cate an abnormality; therefore, further assessment or inter- vention is required. Use the steps of the nursing process, remembering that assessment is the first step. The only option that addresses assessment is the correct option. Options 1, 2, and 3 address the implementation step of the nursing process. Also, these options are inaccurate first actions. The arm in a cast should have already been elevated. The client may be experiencing compartment syndrome, a complication following trauma to the extremities and applica- tion of a cast. Additional data need to be collected to deter- mine whether this complication is present. Remember that assessment is the first step in the nursing process.

24 UNIT I NCLEX-RN® Exam Preparation

4. An alysis (Box 4-12) a. An alysis question s are th e m ost difficult ques-

tio n s because th ey require un derstan din g of th e prin ciples of ph ysiological respon ses an d require in terp retatio n of th e assessm en t data.

b . An alysis question s require critical th in kin g an d determ in in g th e ration ale for th erapeutic prescription s or in terven tion s th at m ay be ad dressed in th e question .

c. Analysis questions m ay address the form ulation of a statem ent that iden tifies a clien t n eed or problem . Analysis question s m ay also in clude the com m un ication an d docum entation of th e results from the process of the an alysis.

d . O ften , th ese typ es of question s require assim - ilation of m ore th an on e piece of in form ation an d application to a clien t scen ario.

5. Plan n in g (Box 4-13) a. Plan n in g question s require prioritizin g clien t

problem s, determ in in g goals an d outcom e criteria for go als of care, developin g th e plan of care, an d co m m un icatin g an d docum en t- in g th e plan of care.

b . Rem em ber th at actual clien t problem s rath er th an poten tial clien t problem s will m ost likely be th e prio rity.

6. Im p lem en tation (Box 4-14) a. Im p lem en tation question s address th e pro-

cess of organ izin g an d m an agin g care, coun selin g an d teach in g, provid in g care to

ach ieve establish ed goals, supervisin g an d coordin atin g care, an d co m m un icatin g an d docum en tin g n ursin g in terven tion s.

b . Focus on a n ursin g action rath er th an on a m ed ical action wh en you are an swerin g a question , un less th e question is askin g you wh at prescribed m ed ical action is an ticipated.

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BOX 4-12 Practice Question: The Nursing Process—Analysis

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2 30 mm Hg, and HCO3 22 mEq/ L (22 mmol/ L). The nurse analyzes these results as indicating which condition?

1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

Answer: 2 Test -Ta king Stra t egy: Use the steps of the nursing process and analyze the values. The question does not require further assessment; therefore, it is appropriate to move to the next step in the nursing process, analysis. The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. So, you can eliminate options 1 and 3. In an alkalytic condition, the pH is elevated. The values identified indicate a respiratory alkalosis. Compensation occurs when the pH returns to a nor- mal value. Because the pH is in the normal range at the high end, compensation has occurred. Remember that analysis is the second step in the nursing process.

BOX 4-13 Practice Question: The Nursing Process—Planning

The nurse developing a plan of care for a client with a cataract understands that which problem is the priority?

1. Concern about the loss of eyesight 2. Altered vision due to opacity of the ocular lens 3. Difficulty moving around because of the need for glasses 4. Becoming lonely because of decreased community

immersion

Answer: 2 Test-Ta king St ra tegy: Note the strategic word, priority, and use the steps of the nursing process. This question relates to plan- ning nursing care and asks you to identify the priority problem. Use Maslow’s Hierarchy of Needs theory to answer the ques- tion, remembering that physiological needs are the priority. Concern and becoming lonely are psychosocial needs and would be the last priorities. Note that the correct option directly addresses the client’s problem. Remember that plan- ning is the third step of the nursing process.

BOX 4-14 Practice Question: The Nursing Process—Implementation

The nurse is caring for a hospitalized client with angina pec- toris who begins to experience chest pain. The nurse admin- isters a nitroglycerin tablet sublingually as prescribed, but the pain is unrelieved. The nurse should take which action next?

1. Reposition the client. 2. Call the client’s family. 3. Contact the health care provider. 4. Administer another nitroglycerin tablet.

Answer: 4 Test-Ta king St ra t egy: Note the strategic word, next, and use the steps of the nursing process. Implementation questions address the process of organizing and managing care. This question also requires that you prioritize nursing actions. Additionally, focus on the data in the question to assist in avoiding reading into the question. You may think it is neces- sary to check the blood pressure before administering another tablet, which is correct. However, there are no data in the question indicating that the blood pressure is abnormal and could not sustain normality if another tablet were given. In addition, checking the blood pressure is not one of the options. Recalling that the nurse would administer 3 nitroglyc- erin tablets 5 minutes apart from each other to relieve chest pain in a hospitalized client will assist in directing you to the correct option. Remember that implementation is the fourth step of the nursing process.

25CHAPTER 4 Test-Taking Strategies

c. O n th e NCLEX-RN exam , th e on ly clien t th at you n eed to be con cern ed ab out is th e clien t in th e question th at you are an swerin g; avoid th e “Wh at if …?” syn drom e an d rem em ber th at th e clien t in th e question on th e com - puter screen is your only assign ed clien t.

d . An swer th e question from a textbook an d ideal poin t of view; rem em ber th at th e n urse h as all of th e tim e an d all of th e equ ipm en t n eeded to care for th e clien t readily available at th e bedside; rem em ber th at you do n ot n eed to run to th e supp ly room to obtain , for exam ple, sterile gloves because th e sterile gloves will be at th e clien t’s bedside.

7. Evaluation ( Box 4-15) a . Evaluation question s focus on com parin g th e

actu al outcom es of care with th e exp ected outcom es an d on com m un icatin g an d docu- m en tin g fin din gs.

b . Th ese question s focus on assistin g in deter- m in in g th e clien t’s respon se to care an d iden - tifyin g facto rs th at m ay in terfere with ach ievin g expected outcom es.

c. In an evaluation question , watch for n egative even t queries because th ey are frequen tly used in evaluatio n -type question s.

H. Determ in e if an Abn orm ality Exists (Box 4-16) 1. In th e even t, th e clien t scen ario will be described.

Use yo ur n ursin g kn owledge to determ in e if an y of th e in form ation presen ted is in dicatin g an abn o rm ality.

2. If an abn o rm ality exists, eith er furth er assess- m en t or furth er in terven tion will be required . Th erefore, con tin uin g to m on itor or docum en t- in g will n ot be a correct an swer; don ’t select th ese option s if th ey are presen ted!

VII. Client Needs A. Safe an d Effective Care En viron m en t

1. Accordin g to th e Nation al Coun cil of State Boards of Nu rsin g (NCSBN), th ese question s test th e con cepts of providin g safe n ursin g care an d collabo ratin g with oth er h ealth care team m em - bers to facilitate effective clien t care; th ese ques- tion s also focus on th e protectio n of clien ts, sign ifican t oth ers, an d h ealth care perso n n el from en viron m en tal h azards.

2. Focus on safety with th ese types of question s, and rem em ber th e im portan ce of h an d wash in g, call ligh ts or bells, bed position in g, appropriate use of side rails, asepsis, use of stan dard an d oth er precaution s, triage, an d em ergen cy respon se plan n in g.

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BOX 4-15 Practice Question: The Nursing Process—Evaluation

The nurse is evaluating the client’s response to treatment of a pleural effusion with a chest tube. The nurse notes a respira- tory rate of 20 breaths per minute, fluctuation of the fluid level in the water seal chamber, and a decrease in the amount of drainage by 30 mL since the previous shift. Based on this information, which interpretation should the nurse make?

1. The client is responding well to treatment. 2. Suction should be decreased to the system. 3. The system should be assessed for an air leak. 4. Water should be added to the water seal chamber.

Answer: 1 Test-Ta king St ra tegy: Use the steps of the nursing process and note that the nurse needs to evaluate the client’s response to treatment. Focus on the subject and the data in the ques- tion. Also, determine if an abnormality exists based on these data. Remember that fluctuation in the water seal chamber is a normal and expected finding with a chest tube. Since the client is being treated for a pleural effusion, it can be determined that he or she is responding well to treatment if the amount of drainage is gradually decreasing because the fluid from the pleural effusion is being effectively removed. If the drain- age were to stop suddenly, the chest tube should be assessed for a kink or blockage. There is no indication based on the data in the question to decrease suction to the system; in fact, it is unclear as to whether the client is on suction at all. There are also no data in the question indicating an air leak. Lastly, there are no data in the question indicating the need to add water to the water seal chamber; again, it is unclear as to whether the client has this type of chest tube versus a dry suction chest tube. Remember that evaluation is the fifth step of the nursing process.

BOX 4-16 Practice Question: Determine If an Abnormality Exists

The nurse is caring for a client being admitted to the emer- gency department with a chief complaint of anorexia, nausea, and vomiting. The nurse asks the client about the home med- ications being taking. The nurse would be most concerned if the client stated that which medication was being taken at home?

1. Digoxin 2. Captopril 3. Losartan 4. Furosemide

Answer: 1 Test -Ta king Stra tegy: Note the strategic word, most. The first step in approaching the answer to this question is to deter- mine if an abnormality exists. The client is complaining of anorexia, nausea, and vomiting; therefore, an abnormality does exist. This tells you that this could be an adverse or toxic effect of one of the medications listed. Although gastrointes- tinal distress can occur as an expected side effect of many medications, anorexia, nausea, and vomiting are hallmark signs of digoxin toxicity. Therefore, the nurse would be most concerned with this medication if taken at home by the client. Remember to first determine if an abnormality exists in the event before choosing the correct option.

26 UNIT I NCLEX-RN® Exam Preparation

B. Ph ysiological In tegrity 1. Th e NCSBN in dicates th at th ese question s test

th e con cepts th at th e n urse provides care as it relates to com fort an d assistan ce in th e perfor- m an ce of activities of daily livin g as well as care related to th e adm in istration of m edication s an d paren teral th erapies.

2. Th ese question s also address th e n urse’s ability to reduce th e clien t’s poten tial for developin g co m - plication s or h ealth problem s related to treat- m en ts, procedures, or existin g con d ition s an d to provide care to clien ts with acute, ch ron ic, or life-th reaten in g ph ysical h ealth con dition s.

3. Focus on Maslow’s Hierarch y of Needs th eory in th ese types of question s an d rem em ber th at ph ysiological n eeds are a prio rity an d are ad dressed first.

4. Use th e ABCs—airway–breath in g–circulation — an d th e step s of th e n ursin g process wh en select- in g an option addressin g Ph ysiological In tegrity.

C. Psych o social In tegrity 1. Th e NCSBN n otes th at th ese question s test th e

con cepts of n ursin g care th at prom o te an d sup- port th e em otion al, m en tal, an d social well- bein g of th e clien t an d sign ifican t oth ers.

2. Con tent addressed in th ese question s relates to supportin g an d prom otin g the client’s or sign ifi- can t oth ers’ability to cope, adapt, or problem -solve in situation s such as illn esses; disabilities; or stress- ful even ts in cludin g abuse, n eglect, or violen ce.

3. In th is Clien t Needs category, you m ay be asked com m un ication -typ e question s th at relate to h ow you would respo n d to a clien t, a clien t’s fam ily m em ber or sign ifican t oth er, or oth er h ealth care team m em bers.

4. Use th erapeutic com m un ication tech n iques to an swer com m un ication question s because of th eir effectiven ess in th e com m un ication process.

5. Rem em ber to select th e option th at focuses on th e th ough ts, feelin gs, con cern s, an xieties, or fears of th e clien t, clien t’s fam ily m em ber, or sig- n ifican t oth er (Box 4-17).

D. Health Prom o tion an d Main ten an ce 1. Accordin g to th e NCSBN, th ese question s test th e

con cepts th at th e n urse provides an d assists in directin g n ursin g care to prom o te an d m ain tain h ealth .

2. Con ten t ad dressed in th ese question s relates to assistin g th e clien t an d sign ifican t oth ers durin g th e n orm al expected stages of growth an d devel- opm en t, an d providin g clien t care related to th e preven tion an d early detection of h ealth problem s.

3. Use th e Teach in g an d Learn in g th eory if th e ques- tio n addresses clien t teach in g, rem em berin g th at th e clien t’s willin gn ess, desire, an d readin ess to learn is th e first priority.

4. Watch for n egative even t queries because th ey are frequen tly used in question s th at ad dress Health Prom o tion an d Main ten an ce an d clien t edu cation .

VIII. Eliminate Comparable or Alike Options (Box 4-18) A. Wh en readin g th e option s in m ultiple-ch oice or

m ultiple-respon se question s, lo ok for option s th at are com parable or alike.

B. Com p arable or alike option s can be elim in ated as possib le an swers because it is n ot likely for both option s to be correct.

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BOX 4-17 Practice Question: Communication A client scheduled for bowel surgery states to the nurse, “I’m not sure if I should have this surgery.” Which response by the nurse is appropriate?

1. “It’s your decision.” 2. “Don’t worry. Everything will be fine.” 3. “Why don’t you want to have this surgery?” 4. “Tell me what concerns you have about the surgery.”

Answer: 4 Test-Ta king Stra tegy: Use therapeutic communication tech- niques to answer communication questions and remember to focus on the client’s thoughts, feelings, concerns, anxieties, and fears. The correct option is the only one that addresses the client’s concern. Additionally, asking the client about what specific concerns he or she has about the surgery will allow for further decisions in the treatment process to be made. Option 1 is a blunt response and does not address the client’s concern. Option 2 provides false reassurance. Option 3 can make the client feel defensive and uses the nontherapeutic communication technique of asking “why.” Remember to use therapeutic communication techniques and focus on the client.

BOX 4-18 Practice Question: Eliminate Comparable or Alike Options

The nurse is caring for a group of clients. On review of the cli- ents’ medical records, the nurse determines that which client is at risk for excess fluid volume?

1. The client taking diuretics 2. The client with an ileostomy 3. The client with kidney disease 4. The client undergoing gastrointestinal suctioning

Answer: 3 Test-Ta king Stra t egy: Focus on the subject, the client at risk for excess fluid volume. Think about the pathophysiology associated with each condition identified in the options. The only client who retains fluid is the client with kidney dis- ease. The client taking diuretics, the client with an ileostomy, and the client undergoing gastrointestinal suctioning all lose fluid; these are comparable or alike options. Remember to eliminate comparable or alike options.

27CHAPTER 4 Test-Taking Strategies

IX. Eliminate Options Containing Closed-Ended Words (Box 4-19)

A. Som e clo sed-en ded words are all, always, every, must, none, never, an d only.

B. Elim in ate option s th at con tain clo sed-en ded words because th ese words im ply a fixed or extrem e m ean - in g; th ese typ es of option s are usually in correct.

C. O ption s th at con tain open -en ded words, such as may, usually, normally, commonly, or generally, sh ould be con sidered as possible correct option s.

X. Look for the Umbrella Option (Box 4-20) A. Wh en an swerin g a question , look for th e um b rella

option .

B. Th e um b rella option is on e th at is a broad or un iver- sal statem en t an d th at usually con tain s th e con cepts of th e oth er option s with in it.

C. Th e um b rella option will be th e correct an swer.

XI. Use the Guidelines for Delegating and Assignment Making (Box 4-21)

A. You m ay be asked a question th at will require you to decide h ow you will delegate a task or assign clien ts to oth er h ealth care providers (HCPs).

B. Focus on th e in form ation in th e question an d wh at task or assign m en t is to be delegated.

C. Wh en yo u h ave determ in ed wh at task or assign m en t is to be delegated, con sider th e clien t’s n eeds an d m atch th e clien t’s n eeds with th e scope of practice of th e HCPs iden tified in th e question .

D. Th e Nu rse Practice Act an d an y practice lim itation s defin e wh ich aspects of care can be delegated an d wh ich m ust be perform ed by a registered n urse. Use n ursin g scope of practice as a guide to assist in an swerin g question s. Rem em b er th at th e NCLEX is a n ation al exam an d n ation al stan d ards rath er th an agen cy-sp ecific stan dard s m ust be followed wh en delegatin g.

E. In gen eral, n on in vasive in terven tion s, such as skin care, ran ge-of-m otion exercises, am bulation , groom - in g, an d h ygien e m easu res, can be assign ed to an un licen sed assistive perso n n el (UAP).

F. A licen sed practical n urse (LPN) can perform th e tasks th at a UAP can perform an d can usually per- form certain in vasive tasks, such as dressin gs, suc- tion in g, urin ary cath eterization , an d adm in isterin g m edication s orally or by th e subcutan eous or

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BOX 4-19 Practice Question: Eliminate Options That Contain Closed-Ended Words

A client is to undergo a computed tomography (CT) scan of the abdomen with oral contrast, and the nurse provides pre- procedure instructions. The nurse instructs the client to take which action in the preprocedure period?

1. Avoid eating or drinking after midnight before the test. 2. Limit self to only 2 cigarettes on the morning of the test. 3. Have a clear liquid breakfast only on the morning of the

test. 4. Take all routine medications with a glass of water on the

morning of the test.

Answer: 1 Test-Ta king Stra t egy: Note the closed-ended words only in options 2 and 3 and all in option 4. Eliminate options that con- tain closed-ended words because these options are usually incorrect. Also, note that options 2, 3, and 4 are comparable or alike options in that they all involve taking in something on the morning of the test. Remember to eliminate options that contain closed-ended words.

BOX 4-20 Practice Question: Look for the Umbrella Option

A client admitted to the hospital is diagnosed with urethritis caused by chlamydial infection. The nurse should implement which precaution to prevent contraction of the infection dur- ing care?

1. Enteric precautions 2. Contact precautions 3. Standard precautions 4. Wearing gloves and a mask

Answer: 3 Test-Ta king St ra tegy: Focus on the client’s diagnosis and recall that this infection is sexually transmitted. Also, note that the correct option is the umbrella option. Remember to look for the umbrella option, a broad or universal option that includes the concepts of the other options in it.

BOX 4-21 Practice Question: Use Guidelines for Delegating and Assignment Making

The nurse in charge of a long-term care facility is planning the client assignments for the day. Which client should be assigned to the unlicensed assistive personnel (UAP)?

1. A client on strict bed rest 2. A client with dyspnea who is receiving oxygen therapy 3. Aclient scheduled for transfer to the hospital for surgery 4. Aclient with a gastrostomy tube who requires tube feed-

ings every 4 hours

Answer: 1 Test -Ta king St ra t egy: Note the subject of the question, the assignment to be delegated to the UAP. When asked ques- tions about delegation, think about the role description and scope of practice of the employee and the needs of the client. A client with dyspnea who is receiving oxygen therapy, a client scheduled for transfer to the hospital for surgery, or a client with a gastrostomy tube who requires tube feedings every 4 hours has both physiological and psychosocial needs that require care by a licensed nurse. The UAP has been trained to care for a client on bed rest. Remember to match the client’s needs with the scope of practice of the health care provider.

28 UNIT I NCLEX-RN® Exam Preparation

in tram uscular route; som e selected piggyback in tra- ven o us m ed ication s m ay also be adm in istered.

G. A registered n urse can perform th e tasks th at an LPN can perform an d is respo n sible for assessm en t an d plan n in g care, an alyzin g clien t data, im plem en t- in g an d evaluatin g clien t care, supervisin g care, in iti- atin g teach in g, an d adm in isterin g m ed ication s in traven ously.

XII. Answering Pharmacology Questions (Box 4-22) A. If you are fam iliar with th e m ed ication , use n ursin g

kn owledge to an swer th e question . B. Rem em ber th at th e question will iden tify th e gen eric

n am e of th e m edication on m ost occasion s. C. If th e question iden tifies a m ed ical diagn osis, try to

form a relation sh ip between th e m edication an d th e diagn osis; for exam ple, you can determ in e th at cyclop h osph am ide is an an tin eoplastic m ed ication if th e question refers to a clien t with breast can cer wh o is takin g th is m edication .

D. Try to determ in e th e classification of th e m ed ication bein g addressed to assist in an swerin g th e question . Iden tifyin g th e classification will assist in determ in - in g a m ed ication ’s action or side effects or both .

E. Recogn ize th e com m on side effects an d adverse effects associated with each m ed ication classification an d relate th e appropriate n ursin g in terven tion s to each effect; for exam ple, if a side effect is h yperten - sion , th e associated n ursin g in terven tion would be to m on itor th e blood pressure.

F. Focus on wh at th e question is askin g or th e subject of th e question ; for exam ple: in ten ded effect, side effect, ad verse effect, or toxic effect.

G. Learn m edication s th at belon g to a classification by com m on alities in th eir m edication n am es; for exam ple, m ed ication s th at act as beta blockers en d with “-lol” (e.g., aten o lol).

H. If th e question requires a m edication calculation , rem em ber th at a calculator is available on th e co m - puter; talk yourself th rough each step to be sure th e an swer m akes sen se, an d rech eck th e calculation befo re an swerin g th e question , particularly if th e an swer seem s like an un usual dosage.

I. Ph arm acology: Pyram id Poin ts to rem em ber 1. In gen eral, th e clien t sh ould n ot take an an tacid

with m ed ication because th e an tacid will affect th e absorption of th e m edication .

2. En teric-coated an d sustain ed-release tablets sh ould n ot be crush ed; also, cap sules sh ould n ot be open ed.

3. Th e clien t sh ould n ever ad just or ch an ge a m ed- ication dose or abruptly stop takin g a m ed ication .

4. Th e n urse n ever adjusts or ch an ges th e clien t’s m ed ication dosage an d n ever discon tin ues a m ed ication .

5. Th e clien t n eeds to avoid takin g an y over-th e- coun ter m ed ication s or an y oth er m ed ication s, such as h erbal preparation s, un less th ey are approved for use by th e HCP.

6. Th e clien t n eeds to avoid con sum in g alcoh ol. 7. Med ication s are n ever adm in istered if th e

prescription is difficult to read, is un clear, or iden tifies a m edication dose th at is n ot a n orm al on e.

8. Addition al strategies for an swerin g ph arm acol- ogy question s are presen ted in Saunders Strategies for Test Success: Passing Nursing School and the NCLEX® Exam.

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BOX 4-22 Practice Question: Answering Pharmacology Questions

Quinapril hydrochloride is prescribed as adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse should monitor which item as the priority?

1. Weight 2. Urine output 3. Lung sounds 4. Blood pressure

Answer: 4 Test-Ta king Stra t egy: Focus on the name of the medication and note the strategic word, priority. Recall that the medica- tion names of most angiotensin-converting enzyme (ACE) inhibitors end with “-pril” and one of the indications for use of these medications is hypertension. Excessive hypotension (“first-dose syncope”) can occur in clients with heart failure or in clients who are severely sodium-depleted or volume- depleted. Although weight, urine output, and lung sounds would be monitored, monitoring the blood pressure is the pri- ority. Remember to use pharmacology guidelines to assist in answering questions about medications and note the strate- gic words.

29CHAPTER 4 Test-Taking Strategies

UNIT II

Professional Standards in Nursing

Pyramid to Success

Nurses often care for clien ts wh o com e from eth n ic, cul- tural, or religious backgroun ds th at are differen t from th eir own . In th e past 10 years, th e Hispan ic popu lation in th e Un ited States h as in creased by 43%, th e African Am erican population by 12.3%, an d th e Asian popula- tion by 43% (U.S. Cen sus Bureau , 2010). It is projected th at m in o rity groups will m ake up a m ajo rity of th e U.S. population by 2042 (U.S. Departm en t of State, 2008). Awaren ess of an d sen sitivity to th e un iq ue h ealth an d illn ess beliefs an d practices of peo ple of differen t backgroun ds are essen tial for th e delivery of safe an d effective care. Ackn owledgm en t an d acceptan ce of cul- tural differen ces with a n on judgm en tal attitude are essen tial to providin g culturally sen sitive care. Th e NCLEX-RN® exam test plan is un iq ue an d in dividual- ized to th e clien t’s culture an d beliefs. Th e n urse n eeds to avoid stereotypin g an d n eeds to be aware th at th ere are several subcultures with in cultures an d th ere are sev- eral dialects with in lan guages. In n ursin g practice, th e n urse sh ould assess th e clien t’s perceived n eeds before plan n in g an d im plem en tin g a plan of care.

Across all settin gs in th e practice of n ursin g, n urses fre- quen tly are con fron ted with eth ical an d legal issues related to clien t care. Th e profession al n urse h as th e respon sibility to be aware of th e eth ical prin ciples, laws, an d guidelin es related to providing safe an d quality care to clien ts. In the Pyram id to Success, focus on eth ical prac- tices; the Nurse Practice Act an d clien ts’righ ts, particularly con fiden tiality, in form ation security an d con fiden tiality, an d in form ed con sen t; advocacy, docum en tation , and advan ce directives; an d cultural, religious, an d spiritual issues. Kn owledgeable use of inform ation techn ology, such as an electron ic h ealth record, is also an im portan t role of th e n urse.

Th e Nation al Coun cil of State Boards of Nu rsin g (NCSBN) defin es m an agem en t of care as th e n urse

directin g n ursin g care to en h an ce th e care delivery set- tin g to protect th e clien t an d h ealth care person n el. As described in th e NCLEX-RN exam test plan , a profes- sion al n urse n eeds to provid e in tegrated , cost-effective care to clien ts by coordin atin g, supervisin g, an d collab- oratin g or con sultin g with m em bers of th e in terp rofes- sion al h ealth care team . A prim ary Pyram id Poin t focuses on th e skills required to prio ritize clien t care activities. Pyram id Poin ts also focus on con cepts of lead- ersh ip an d m an agem en t, th e process of delegation , em ergen cy respo n se plan n in g, an d triagin g clien ts.

Client Needs: Learning Objectives Safe and Effective Care Environment Actin g as a clien t advocate In tegratin g advan ce directives in to th e plan of care Becom in g fam iliar with th e em ergen cy respo n se plan Delegatin g clien t care activities an d providin g con tin uity

of care En surin g th at eth ical practices are im plem en ted En surin g th at in form ed con sen t h as been obtain ed En surin g th at legal righ ts an d respo n sibilities are

m ain tain ed Collaboratin g with in terp rofessio n al team s Establish in g priorities related to clien t care activities In stitutin g quality im provem en t proced ures In tegratin g case m an agem en t con cepts Main tain in g con fid en tiality an d in form ation security

issues related to th e clien t’s h ealth care Supervisin g th e delivery of clien t care Triagin g clien ts Uph oldin g clien t righ ts Usin g in form ation tech n ology in a con fiden tial m an n er Usin g lead ersh ip an d m an agem en t skills effectively

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Health Promotion and Maintenance Con siderin g cultural an d spiritual issues related to fam -

ily system s an d fam ily plan n in g Iden tifyin g ch an ges related to th e agin g process Iden tifyin g h igh -risk beh aviors of th e clien t Perform in g ph ysical assessm en t tech n iqu es Prom o tin g h ealth an d preven tin g disease Prom o tin g th e clien t’s ability to perform self-care Provid in g h ealth screen in g an d h ealth prom otio n

program s Resp ectin g cu ltural preferen ces an d lifestyle ch oices

Psychosocial Integrity Addressin g en d-of-life care based on th e clien t’s prefer-

en ces an d beliefs Assessin g th e use of effective copin g m ech an ism s Becom in g aware of cultural an d spiritu al preferen ces an d

in corpo ratin g th ese preferen ces wh en plan n in g an d im plem en tin g care

Iden tifyin g ab use an d n eglect issues Iden tifyin g clien ts wh o do n ot speak or un d erstan d

En glish an d determ in in g h ow lan guage n eeds will be m et by th e use of agen cy-appro ved in terp reters

Iden tifyin g en d-of-life care issues Iden tifyin g fam ily dyn am ics as th ey relate to th e clien t’s

culture

Iden tifyin g supp ort system s for th e clien t Providin g a th erap eutic en viron m en t an d buildin g a

relation sh ip based on trust Respectin g religious an d spiritual in fluen ces on h ealth

(see Box 5-1)

Physiological Integrity En surin g th at em ergen cies are h an dled usin g a prioriti-

zation procedure Iden tifyin g cultural an d spiritual differen ces for provid-

in g h olistic clien t care Iden tifyin g cultural issues related to altern ative an d com -

plem en tary th erap ies Iden tifyin g cultural issues related to receivin g blood an d

blood products Im plem en tin g th erapeutic procedures con sid erin g cul-

tural preferen ces Providin g n on ph arm aco logical co m fort in terven tion s Providin g n utrition an d oral h ydration , con siderin g cul-

tural preferen ces (see Box 5-1) En surin g th at palliative an d com fo rt care is provided to

th e clien t Mon itorin g for alteration s in body system s or un ex-

pected respo n ses to th erap y

31UNIT II Professional Standards in Nursing

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C H A P T E R 5 Cultural Awareness and Health Practices

PRIORITY CONCEPTS Culture; Health Promotion

CRITICAL THINKING What Should You Do? The nurse is preparing a client for an echocardiogram and notes that the client is wearing a religious medal on a chain around the neck. What should the nurse do with regard to removing this personal item from the client? Answer located on p. 40.

For referen ce th rou gh out th e ch apter, see Figure 5-1 an d Box 5-1.

Cultural awareness includes learning about the cultures of clients with whom you will be working; also, ask clients about their health care practices and preferences.

I. African Americans A. Description : Citizen s or residen ts of th e Un ited

States wh o m ay h ave origin s in an y of th e black population s in Africa.

B. Com m un ication 1. Mem bers are com peten t in stan dard En glish . 2. Head n oddin g does n ot always m ean agreem en t. 3. Prolon ged eye con tact m ay be in terp reted as

ruden ess or aggressive beh avio r. 4. No n verbal com m un ication m ay be im portan t. 5. Perso n al question s asked on in itial con tact with

a perso n m ay be viewed as in trusive. C. Tim e orien tation an d perso n al space preferen ces

1. Tim e orien tation varies accordin g to age, socio- econ om ics, an d subcultures an d m ay in clude past, presen t, or future orien tation .

2. Mem bers m ay be late for an appoin tm en t because relation sh ips an d even ts th at are occur- rin g m ay be deem ed m ore im portan t th an bein g on tim e.

3. Mem bers are com fo rtable with clo se perso n al space wh en in teractin g with fam ily an d frien ds.

D. Social roles 1. Large exten ded-fam ily n etworks are im portan t;

older adults are respected.

2. Man y h ouseh olds m ay be h eaded by a sin gle- paren t wom an .

3. Religiou s beliefs an d ch urch affiliation are sources of stren gth .

E. Health an d illn ess 1. Religiou s beliefs profou n dly affect ideas about

h ealth an d illn ess. 2. Food preferen ces in clude such item s as fried

food s, ch icken , pork, green s such as collard green s, an d rice; som e pregn an t African Am erican wom en en gage in pica.

F. Health risks 1. Sickle cell an em ia 2. Hyperten sion 3. Heart disease 4. Can cer 5. Lactose in toleran ce 6. Diabetes m ellitus 7. O besity

G. In terven tion s 1. Assess th e m ean in g of th e clien t’s verbal an d

n on verbal beh avio r. 2. Be flexible an d avoid rigidity in sch edulin g care. 3. En cou rage fam ily in volvem en t. 4. Altern ative m odes of h ealin g in clude h erbs,

prayer, an d layin g on of h an ds practices.

Assess each individual for cultural preferences because there are many individual and subculture variations.

II. Amish A. Descrip tion

1. Th e Am ish are kn own for sim ple livin g, plain dress, an d reluctan ce to adopt m odern con ve- n ien ce an d can be con sidered a distin ct ethnic group ; th e various Am ish ch urch fellowsh ips are Ch ristian religious den om in ation s th at form a very tradition al subgrou pin g of Men n on ite ch urch es.

2. Cultural beliefs an d preferen ces vary dep en din g on specific Am ish com m un ity m em bersh ip.32

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• S umma rize da ta obta ine d

Nurs ing as s e s s me nt

• Clie nt's cultura l a nd ra cia l ide ntifica tion

• P la ce of birth • Time in country

Culturally unique individual • La ngua ge s poke n • Voice qua lity • P ronuncia tion • Us e of s ile nce • Us e of nonve rba ls

Co mmunic atio n

• De gre e of comfort obs e rve d (conve rs a tion)

• P roximity to othe rs • Body move me nt • P e rce ption of s pa ce

S pac e

• Culture • Ra ce • Ethnicity • Fa mily Role Function

S o c ial o rie ntatio n

• Work • Le is ure • Church • Frie nds

• Us e of • Me a s ure s • De finition • S ocia l time • Work time • Time orie nta tion Future P re s e nt P a s t

Time

• Cultura l he a lth pra ctice s Effica cious Ne utra l Dys functiona l Unce rta in • Va lue s • De finition of he a lth a nd illne s s

Enviro nme ntal c o ntro l

• Body s tructure • S kin color • Ha ir color • Othe r phys ica l dime ns ions • Enzyma tic a nd ge ne tic e xis te nce of dis e a s e s s pe cific to popula tions • S us ce ptibility to illne s s a nd dis e a s e • Nutritiona l pre fe re nce s a nd de ficie ncie s • P s ychologica l cha ra cte ris tics , coping, a nd s ocia l s upport

Bio lo g ic al variatio ns

FIGURE 5-1 Giger and Davidhizar’s Transcultural Assessment Model.

BOX 5-1 Religions and Dietary Preferences

Buddhism Alcohol is usually prohibited. Many are lacto-ovo vegetarians. Some eat fish, and some avoid only beef.

Church of Jesus Christ of Latter-day Saints (Mormon) Alcohol, coffee, and tea are usually prohibited. Consumption of meat is limited. The first Sunday of the month is optional for fasting.

Eastern Orthodox During Lent, all animal products, including dairy products, are

forbidden. Fasting occurs during Advent. Exceptions from fasting include illness and pregnancy; children

may also be exempt.

Hinduism Manyare vegetarians; those who eat meat do not eat beef or pork. Fasting rituals vary. Children are not allowed to participate in fasting.

Islam Pork, birds of prey, alcohol, and any meat product not ritually

slaughtered are prohibited. During the month of Ramadan, fasting occurs during the day-

time; some individuals, such as pregnant women, may be exempt from fasting.

Jehovah’s Witnesses Any foods to which blood has been added are prohibited. They can eat animal flesh that has been drained.

Judaism Orthodox believers need to adhere to dietary kosher laws: ▪ Meats allowed include animals that are vegetable eaters,

cloven-hoofed animals (deer, cattle, goats, sheep), and animals that are ritually slaughtered.

▪ Fish that have scales and fins are allowed. ▪ Any combination of meat and milk is prohibited; fish and

milk are not eaten together. During Yom Kippur, 24-hour fasting is observed. Pregnant women, children, and ill individuals are exempt from

fasting. During Passover, only unleavened bread is eaten.

Pentecostal (Assembly of God) Alcohol is usually prohibited. Members avoid consumption of anything to which blood has

been added. Some individuals avoid pork.

Roman Catholicism They avoid meat on Ash Wednesday and Fridays of Lent. They practice optional fasting during Lent season. Children, pregnant women, and ill individuals are exempt from

fasting.

Seventh-Day Adventist (Church of God) Alcohol and caffeinated beverages are usually prohibited. Many are lacto-ovo vegetarians; those who eat meat avoid pork. Overeating is prohibited; 5 to 6 hours between meals without

snacking is practiced.

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3. In gen eral, th ey h ave fewer risk factors for disease th an th e gen eral population because of th eir practice of m an u al labor, diet, an d rare use of tobacco an d alcoh ol; risk of certain gen etic dis- orders is in creased because of in term arriage (sexu al abuse of wom en is a problem in som e com m un ities).

4. Diabetes m ellitus can beco m e a h ealth issue later in life an d is related to th e obesity th at can occur.

B. Com m un ication : Usually speak a Germ an dialect called Pen n sylvan ia Dutch ; Germ an lan guage is usu- ally used durin g worsh ip an d En glish is usually learn ed in sch o ol.

C. Tim e orien tation an d perso n al space preferen ces 1. Mem bers gen erally rem ain separate from oth er

com m un ities, ph ysically an d socially. 2. Th ey often work as farm ers, builders, quilters,

an d h om em akers. D. Social roles

1. Wom en are n ot allowed to h old position s of power in th e co n gregation al organ ization .

2. Roles of wom en are con sidered equally im por- tan t to th ose of m en but are very un equ al in term s of au th ority.

3. Fam ily life h as a patriarch al structure. 4. Marriage outsid e th e faith is n ot usually allowed;

un m arried wom en rem ain un der th e auth o rity of th eir fath ers.

E. Health an d illn ess 1. Most Am ish n eed to h ave ch urch (bish op an d

com m un ity) perm ission to be h ospitalized because th e com m un ity will com e togeth er to h elp pay th e costs.

2. Usually, Am ish do n ot h ave h ealth in suran ce because it is a “worldly produ ct” an d m ay sh ow a lack of faith in God.

3. Som e of th e barriers to m odern h ealth care in clude distan ce, lack of tran sportation , cost, an d lan guage (m ost do n ot un derstan d scien tific jargon ).

F. Health risks 1. Gen etic disorders because of in term arriage

(in breedin g) 2. No n im m un ization 3. Sexual abuse of wom en

G. In terven tion s 1. Speak to both th e h usban d an d th e wife or th e

un m arried wom an an d h er fath er regardin g h ealth care decision s.

2. Health in struction s m ust be given in sim ple, clear lan guage.

3. Teach in g sh ould be focused on h ealth im plica- tion s associated with n on im m un ization , in ter- m arriage, an d sexual abuse issues.

Be alert to cues regarding eye contact, personal space, time concepts, and understanding of the recom- mended plan of care.

III. Asian Americans A. Descrip tion : Am erican s of Asian descen t; can in clude

ethnic groups such as Ch in ese Am erican s, Filipin o Am erican s, In dian Am erican s, Vietn am ese Am eri- can s, Korean Am erican s, Japan ese Am erican s, an d oth ers wh o se n ation al origin is th e Asian co n tin en t.

B. Com m un ication 1. Lan gu ages in clude Ch in ese, Japan ese, Korean ,

Filipin o, Vietn am ese, an d En glish . 2. Silen ce is valued. 3. Eye con tact m ay be con sid ered in approp riate or

disresp ectful (som e Asian cultures in terp ret direct eye con tact as a sexual in vitation ).

4. Criticism or disagreem en t is n ot exp ressed verbally.

5. Head n od din g does n ot always m ean agreem en t. 6. Th e word “n o” m ay be in terp reted as disrespect

for oth ers. C. Tim e orien tation an d perso n al space preferen ces

1. Tim e orien tation reflects respect for th e past, but in cludes em p h asis on th e presen t an d future.

2. Form al perso n al space is preferred, except with fam ily an d close frien ds.

3. Mem bers usually do n ot touch oth ers durin g con versation .

4. For som e cultures , touch in g is un acceptable between m em bers of th e oppo site sex.

5. Th e h ead is con sid ered to be sacred in som e cultures; touch in g som eon e on th e h ead m ay be disrespectful.

D. Social roles 1. Mem bers are devoted to tradition . 2. Large exten ded-fam ily n etworks are com m on . 3. Loyalty to im m ediate an d exten ded fam ily an d

h on or are valued. 4. Th e fam ily un it is structured an d h ierarch ical. 5. Men h ave th e power an d auth o rity, an d wom en

are expected to be obedien t. 6. Education is viewed as im portan t. 7. Religion s in clude Taoism , Bud dh ism , Con fu-

cian ism , Sh in toism , Hin duism , Islam , an d Ch ristian ity.

8. Social organ ization s are stron g with in th e com m un ity.

E. Health an d illn ess 1. Health is a state of ph ysical an d spiritu al h ar-

m on y with n ature an d a balan ce between posi- tive an d n egative en ergy forces (yin an d yan g).

2. A h ealth y body m ay be viewed as a gift from th e an cestors.

3. Illn ess m ay be viewed as an im balan ce between yin an d yan g.

4. Illn ess m ay also be attributed to prolon ged sit- tin g or lyin g or to overexertion .

5. Food preferen ces in clude raw fish , rice, an d vegetables.

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Yin foods are cold and yang foods are hot; one eats cold foods when one has a hot illness, and one eats hot foods when one has a cold illness.

F. Health risks 1. Hyperten sion 2. Heart disease 3. Can cer 4. Lactose in toleran ce 5. Th alassem ia

G. In terven tion s 1. Be aware of an d respect ph ysical boun daries;

request perm ission to touch th e clien t before doin g so.

2. Lim it eye con tact. 3. Avo id gesturin g with h an ds. 4. A fem ale clien t usually prefers a fem ale h ealth

care provider (HCP). 5. Clarify respo n ses to question s an d expectation s

of th e HCP. 6. Be flexible an d avoid rigidity in sch edulin g care. 7. En cou rage fam ily in volvem en t. 8. Altern ative m od es of h ealin g in clude h erbs, acu-

pun cture, restoration of balan ce with food s, m as- sage, an d offerin g of prayers an d in cen se.

If health care recommendations, interventions, or treatments do not fit within the client’s cultural values, they will not be followed.

IV. Hispanic and Latino Americans A. Description : Am erican s of origin s in Latin coun tries;

Mexican Am erican s, Cuban Am erican s, Colom bian Am erican s, Dom in ican Am erican s, Puerto Rican Am er- ican s, Span ish Am erican s, an d Salvadoran Am erican s are som e Hispan ic an d Latin o Am erican subgroups.

B. Com m un ication 1. Lan gu ages in clude prim arily En glish an d

Span ish . 2. Mem bers ten d to be verbally expressive, yet con-

fidentiality is im portan t. 3. Avo idin g eye con tact with a person in au th ority

m ay in dicate respect an d atten tiven ess. 4. Direct con fron tation is usually disresp ectful an d

th e expression of n egative feelin gs m ay be im polite.

5. Dram atic body lan guage, such as gestures or facial exp ression s, m ay be used to express em o- tio n or pain .

C. Tim e orien tation an d perso n al space preferen ces 1. Mem bers are usually orien ted m ore to th e

presen t. 2. Mem bers m ay be late for an ap poin tm en t

because relation sh ips an d even ts th at are occur- rin g are valued m ore th an bein g on tim e.

3. Mem bers are co m fortable in clo se proxim ity with fam ily, frien d s, an d acquain tan ces.

4. Mem bers are very tactile an d use em b races an d h an dsh akes.

5. Mem bers value th e ph ysical presen ce of oth ers. 6. Politen ess an d m od esty are im portan t.

D. Social roles 1. Th e n uclear fam ily is th e basic un it; also , large

exten ded-fam ily n etworks are co m m on . 2. Th e exten ded fam ily is h igh ly regarded. 3. Needs of th e fam ily take preced en ce over th e

n eeds of an in dividual fam ily m em ber. 4. Depen din g on age an d acculturation facto rs, m en

are usually th e decision m akers an d wage earn ers, an d wom en are th e caretakers an d h om em akers.

5. Religion is usually Cath olicism , but m ay vary dep en din g on origin .

6. Mem bers usually h ave stron g ch urch affiliation s. 7. Social organ ization s are stron g with in th e

com m un ity. E. Health an d illn ess

1. Health m ay be viewed as a reward fro m God or a result of good lu ck.

2. Som e m em bers believe th at h ealth results from a state of ph ysical an d em otion al balan ce.

3. Illn ess m ay be viewed by som e m em bers to be a result of God’s pun ish m en t for sin s.

4. Som e m em bers m ay ad h ere to n on tradition al h ealth m easu res such as folk m ed icin e.

5. Food preferen ces in clude bean s, fried food s, an d spicy food s.

F. Health risks 1. Hyperten sion 2. Heart disease 3. Diabetes m ellitus 4. O besity 5. Lactose in toleran ce 6. Parasites

G. In terven tion s 1. Allow tim e for th e clien t to discuss treatm en t

option s with fam ily m em bers. 2. Protect privacy. 3. O ffer to call clergy because of th e sign ifican ce of

religious preferen ces related to illn esses. 4. Ask perm issio n before touch in g a ch ild wh en

plan n in g to exam in e or care for h im or h er; som e believe th at touch in g th e ch ild is im portan t wh en speakin g to th e ch ild to preven t “evil-eye.”

5. Be flexible regardin g tim e of arrival for ap poin t- m en ts an d avoid rigidity in sch edulin g care.

6. Altern ative m odes of h ealin g in clude h erbs, con sul- tation with lay h ealers, restoration of balan ce with h ot or cold foods, prayer, an d religious m edals.

Treat each client and individuals accompanying the client with respect and be aware of the differences and diversity of beliefs about health, illness, and treatment modalities.

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V. Native Americans A. Description : Term th at th e U.S. govern m en t uses to

describe in digen ous peoples from th e region s of North Am erica en com p assed by th e con tin en tal Un ited States, in cludin g parts of Alaska, an d th e islan d state of Hawaii; com prises a large n um ber of distin ct tribes, states, an d ethnic groups, m an y of wh ich survive as in tact political com m un ities.

B. Com m un ication 1. Th ere is m uch lin guistic diversity, depen din g on

origin . 2. Use of a profession al in terp reter is im portan t

because of privacy con cern s an d because accu- racy of com m un ication is m ade clearer.

3. Silen ce in dicates respect for th e speaker for som e grou ps.

4. Som e m em bers m ay speak in a lo w ton e of voice an d expect oth ers to be atten tive.

5. Eye con tact m ay be viewed as a sign of disresp ect. 6. Body lan guage is im portan t.

C. Tim e orien tation an d perso n al space preferen ces 1. Mem bers are orien ted prim arily to th e presen t. 2. Perso n al space is im portan t. 3. Mem bers m ay ligh tly touch an oth er person ’s

h an d durin g greetin gs. 4. Massage m ay be used for th e n ewborn to pro-

m ote bon din g between th e in fan t an d m oth er. 5. Som e grou ps m ay proh ibit touch in g of a

dead body. D. Social roles

1. Mem bers are fam ily orien ted. 2. Th e basic fam ily un it is th e exten ded fam ily,

wh ich often in cludes person s fro m several h ouseh old s.

3. In som e groups, gran dparen ts are viewed as fam - ily leaders.

4. Eld ers are h on ored. 5. Ch ildren are taugh t to respect tradition s. 6. Th e fath er usually does all work outside th e

h om e, an d th e m oth er assum es respon sibility for dom estic duties.

7. Sacred m yth s an d legen ds provide spiritu al guid- an ce for som e groups.

8. Most m em bers adh ere to som e form of Ch ris- tian ity, an d religion an d h ealin g practices are usually in tegrated.

9. Com m un ity social organ ization s are im portan t. E. Health an d illn ess

1. Health is usually con sid ered a state of h arm on y between th e in dividual, fam ily, an d en viron m en t.

2. Som e groups believe th at illn ess is cau sed by supern atural forces an d disequilibrium between th e perso n an d en viron m en t.

3. Tradition al h ealth an d illn ess beliefs m ay con - tin ue to be observed by som e grou ps, in cludin g n atural an d religious folk m edicin e tradition .

4. For som e groups, food preferen ces in clude corn - m eal, fish , gam e, fruits, an d berries.

F. Health risks 1. Alcoh o l abuse 2. O besity 3. Heart disease 4. Diabetes m ellitus 5. Tuberculosis 6. Arth ritis 7. Lactose in toleran ce 8. Gallbladder disease

G. In terven tion s 1. Clarify com m un ication . 2. Un derstan d th at th e clien t m ay be atten tive, even

wh en eye con tact is absen t. 3. Be atten tive to your own use of body lan gu age

wh en carin g for th e clien t or fam ily. 4. O btain in pu t fro m m em bers of th e exten ded

fam ily. 5. En cou rage th e clien t to perso n alize space in

wh ich h ealth care is delivered; for exam ple, en courage th e clien t to brin g perso n al item s or objects to th e h ospital.

6. In th e h om e, assess for th e availability of run n in g water, an d m od ify in fectio n co n trol an d h ygien e practices as n ecessary.

7. Altern ative m od es of h ealin g in clude h erbs, resto- ration of balan ce between th e perso n an d th e un i- verse, an d co n sultatio n with tradition al h ealers.

If language barriers pose a problem, seek a qualified medical interpreter; avoid using ancillary staff or family members as interpreters.

VI. White Americans A. Descrip tion : Term used to in clude U.S. citizen s or

residen ts h avin g origin s in an y of th e origin al people of Eu rope, th e Middle East, or North Africa; th e term is in terch an geab le with Cau casian Am erican .

B. Com m un ication 1. Lan gu ages in clude lan gu age of origin (e.g., Ital-

ian , Polish , Fren ch , Russian ) an d En glish . 2. Silen ce can be used to sh ow respect or disrespect

for an oth er, depen din g on th e situation . 3. Eye con tact is usually viewed as in dicatin g

trustworth in ess in m ost origin s. C. Tim e orien tation an d perso n al space preferen ces

1. Mem bers are usually future orien ted. 2. Tim e is valued; m em bers ten d to be on tim e an d

to be im patien t with people wh o are n ot on tim e. 3. Som e m em bers m ay ten d to avoid clo se ph ysical

con tact. 4. Han dsh akes are usually used for form al

greetin gs. D. Social roles

1. Th e n uclear fam ily is th e basic un it; th e exten ded fam ily is also im portan t.

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2. Th e m an is usually th e dom in an t figure, but a variation of gen d er roles exists with in fam ilies an d relation sh ips.

3. Religion s are varied, dep en din g on origin . 4. Com m un ity social organ ization s are im portan t.

E. Health an d illn ess 1. Health is usually viewed as an absen ce of disease

or illn ess. 2. Man y m em bers usually h ave a ten den cy to be

stoic wh en expressin g ph ysical con cern s. 3. Mem bers usually rely prim arily on th e m od ern

Western h ealth care delivery system . 4. Food preferen ces are based on origin ; m an y

m em bers prefer food s con tain in g carboh ydrates an d m eat item s.

F. Health risks 1. Can cer 2. Heart disease 3. Diabetes m ellitus 4. O besity 5. Hyperten sion 6. Th alassem ia

G. In terven tion s 1. Assess th e m ean in g of th e clien t’s verbal an d

n on verbal beh avior. 2. Resp ect th e clien t’s person al space an d tim e. 3. Be flexible an d avoid rigidity in sch edulin g care. 4. En cou rage fam ily in volvem en t.

Some cultures believe that eye contact gives the other person an opening to see into, or to take, the soul.

VII. End-of-Life Care (Box 5-2) A. People in th e Jewish faith gen erally oppose prolon g-

in g life after irreversib le brain dam age. B. Som e m em bers of Eastern O rth odox religion s,

Muslim s, an d O rth odox Jews m ay proh ibit, oppo se, or discourage au topsy.

C. Muslim s perm it organ tran splan t for th e purpo se of savin g h um an life.

D. Th e Am ish perm it organ don atio n with th e exception of h eart tran splan ts (th e h eart is th e soul of th e body).

E. Buddh ists in th e Un ited States en courage organ don ation an d con sider it an act of m ercy.

BOX 5-2 Religion and End-of-Life Care Christianity Amish Funerals are conducted in the home without a eulogy, flower

decorations, or any other display; caskets are plain and simple, without adornment.

At death, a woman is usually buried in her bridal dress. One is believed to live on after death, with either eternal reward

in heaven or punishment in hell.

Ca t holic and Ort hodox A priest anoints the sick. Other sacraments before death include reconciliation and Holy

Communion.

Church of Jesus Christ of Lat ter-da y Sa int s (Mormons) A sacrament may be administered if the client requests it.

Prot esta nt No last rites are provided (anointing of the sick is accepted by

some groups). Prayers are given to offer comfort and support.

Jehova h’s Wit nesses Members are not allowed to receive a blood transfusion. Members believe that the soul cannot live after the body has

died.

Islam Second-degree male relatives such as cousins or uncles should

be the contact people and determine whether the client or family should be given information about the client.

The client may choose to face Mecca (west or southwest in the United States).

The head should be elevated above the body. Discussions about death usually are not welcomed. Stopping medical treatment is against the will of Allah (Arabic

word for God). Grief may be expressed through slapping or hitting the body. If possible, only a same-sex Muslim should handle the body

after death; if not possible, non-Muslims should wear gloves so as not to touch the body.

Judaism A client placed on life support should remain so until death. A dying person should not be left alone (a rabbi’s presence is

desired). Autopsy and cremation are usually not allowed.

Hinduism Rituals include tying a thread around the neck or wrist of the

dying person, sprinkling the person with special water, and placing a leaf of basil on the person’s tongue.

After death, the sacred threads are not removed, and the body is not washed.

Buddhism A shrine to Buddha may be placed in the client’s room. Time for meditation at the shrine is important and should be

respected. Clients may refuse medications that may alter their awareness

(e.g., opioids). After death, a monk may recite prayers for 1 hour (need not be

done in the presence of the body).

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F. Som e m em bers of Morm on , Eastern O rth o dox, Islam ic, an d Jewish (Con servative an d O rth odox) faith s discourage, oppo se, or proh ib it crem ation .

G. Hin dus usually prefer crem ation an d desire to cast th e ash es in a h oly river.

H. African Am erican s 1. Mem bers discuss issues with th e spouse or older

fam ily m em ber (elders are h eld in h igh respect). 2. Fam ily is h igh ly valued an d is cen tral to th e care

of term in ally ill m em bers. 3. O pen displays of em otion are com m on an d

accepted. 4. Mem bers prefer to die at h om e.

I. Asian Am erican s 1. Fam ily m em bers m ay m ake decision s about care

an d often do n ot tell th e clien t th e diagn osis or progn osis.

2. Dyin g at h om e m ay be co n sidered bad lu ck. 3. O rgan don ation m ay n ot be allowed in som e

eth n ic grou ps. J. Hispan ic an d Latin o groups

1. Th e fam ily gen erally m akes decision s an d m ay request to with h old th e diagn osis or progn osis from th e clien t.

2. Exten ded-fam ily m em bers often are in volved in en d-of-life care (pregn an t wom en m ay be pro- h ibited from carin g for dyin g clien ts or atten din g fun erals).

3. Several fam ily m em bers m ay be at th e dyin g clien t’s bed side.

4. Vocal exp ression of grief an d m ou rn in g is accept- able an d expected.

5. Mem bers m ay refuse proced ures th at alter th e body, such as autopsy.

6. Dyin g at h om e m ay be co n sidered bad lu ck. K. Native Am erican s

1. Fam ily m eetin gs m ay be h eld to m ake decision s about en d-of-life care an d th e type of treatm en ts th at sh ould be pursued.

2. Som e groups avoid con tact with th e dyin g (m ay prefer to die in th e h ospital).

Provide individualized end-of-life care to the client and families.

VIII. Complementary and Alternative Medicine (CAM) A. Description

1. Th erapies are used in addition to con ven tion al treatm en t to provid e h ealin g resources an d focus on th e m in d -bod y con n ection .

2. High -risk th erap ies (th erapies th at are in vasive) an d low-risk th erap ies (th ose th at are n on in va- sive) are in cluded in CAM.

3. Th e Nation al Cen ter for Com plem en tary an d Altern ative Medicin e (NCCAM) h as propo sed a classification system th at in cludes 5 categories of co m plem en tary an d altern ative types of th er- apy ( Box 5-3).

B. Wh ole m ed ical system s 1. Tradition al Ch in ese m ed icin e (TCM): Focuses

on restorin g an d m ain tain in g a balan ced flo w of vital en ergy; in terven tion s in clude acupres- sure, acupun cture, h erbal th erap ies, diet, m edita- tion , tai ch i, an d qigon g (exercise th at focuses on breath in g, visualization , an d m ovem en t).

2. Ayurveda: Focuses on th e balan ce of m in d, body, an d spirit; in terven tion s in clude diet, m ed icin al h erbs, deto xification , m assage, breath in g exer- cises, m ed itation , an d yoga.

3. Hom eopath y: Focuses on h ealin g an d in terven - tion s con sistin g of sm all doses of specially pre- pared plan t an d m in eral extracts th at assist in th e in n ate h ealin g process of th e body.

4. Naturop ath y: Focuses on en h an cin g th e n atural h ealin g respon ses of th e body; in terven tion s in clude n utrition , h erbology, h ydroth erapy, acu- pun cture, ph ysical th erapies, an d coun selin g.

C. Min d-bod y m ed icin e 1. Min d -body m ed icin e focuses on th e in teraction s

am on g th e brain , m in d , body, an d beh avior an d on th e powerfu l ways in wh ich em otion al, m en - tal, social, spiritual, an d beh avioral factors can directly affect h ealth .

2. In terven tion s in clude biofeedb ack, h ypn osis, relaxation th erap y, m editation , visu al im agery, yoga, tai ch i, qigon g, cogn itive-beh avioral th era- pies, group supp orts, autogen ic train in g, an d spiritu ality.

D. Biologically based practices (Box 5-4) 1. Biologically based th erap ies in CAM use sub-

stan ces foun d in n ature, such as h erb s, foods, an d vitam in s.

2. Th erapies in clude botan icals, prebiotics an d pro- biotics, wh o le-food diets, fun ction al foods, an im al-derived extracts, vitam in s, m in erals, fatty acids, am in o acids, an d protein s.

E. Man ipu lative an d body-b ased practices 1. In terven tion s in volve m an ipulation an d m ove-

m en t of th e body by a th erap ist. 2. In terven tion s in clude practices such as ch iro-

practic an d osteopath ic m an ipulation , m assage th erap y, an d reflexology.

F. En ergy m ed icin e 1. En ergy th erap ies focus on en ergy origin atin g

with in th e body or on en ergy fro m oth er sources.

BOX 5-3 Categories of Complementary and Alternative Medicine

▪ Whole medical systems ▪ Mind-body medicine ▪ Biologically based practices ▪ Manipulative and body-based practices ▪ Energy medicine

38 UNIT II Professional Standards in Nursing

2. In terven tion s in clude soun d en ergy th erapy, ligh t th erapy, acu pun cture, qigon g, Reiki an d Joh re, th erap eutic touch , in tercessory prayer, wh ole m edical system s, an d m agn etic th erap y.

IX. Herbal Therapies (Box 5-5) A. Herbal th erapy is th e use of h erbs (plan t or a plan t

part) for th eir th erap eutic value in prom o tin g h ealth . B. Som e h erb s h ave been determ in ed to be safe, but

som e h erb s, even in sm all am oun ts, can be toxic. C. If th e clien t is takin g prescription m ed ication s, th e

clien t sh ould con sult with th e HCP regardin g th e use of h erbs because serious h erb-m edication in ter- action s can occur.

D. Clien t teach in g poin ts 1. Discuss h erb al th erap ies with th e HCP

befo re use. 2. Con tact th e HCP if an y side effects of th e h erb al

substan ce occur.

3. Con tact th e HCP before stoppin g th e use of a prescription m ed ication .

4. Avoid usin g h erbs to treat a serious m edical con - ditio n , such as h eart disease.

5. Avoid takin g h erbs if pregn an t or attem p tin g to get pregn an t or if n ursin g.

6. Do n ot give h erbs to in fan ts or youn g ch ildren . 7. Purch ase h erbal supp lem en ts on ly from a repu-

table m an ufacturer; th e label sh ould con tain th e scien tific n am e of th e h erb, n am e an d address of th e m an u facturer, batch or lot n um - ber, date of m an u facture, an d expiration date.

8. Adh ere to th e recom m en ded dose; if h erbal preparation s are taken in h igh doses, th ey can be toxic.

9. Moistu re, sun ligh t, an d h eat m ay alter th e com - pon en ts of h erbal preparation s.

10. If surgery is plan n ed, th e h erbal th erap y m ay n eed to be discon tin ued 2 to 3 weeks before surgery.

Some herbs have been determined to be safe, but some herbs, even in small amounts, can be toxic. Ask the client to discuss herbal therapies with the HCP before use.

X. Low-Risk Therapies A. Low-risk th erapies are th erap ies th at h ave n o adverse

effects an d, wh en im plem en tin g care, can be used by th e n urse wh o h as train in g an d experien ce in th eir use.

B. Com m on low-risk th erapies 1. Med itation 2. Relaxation tech n iques 3. Im agery 4. Music th erap y 5. Massage 6. Touch 7. Laugh ter an d h um or 8. Spiritu al m easu res, such as prayer

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BOX 5-4 Biologically Based Practices

Aromatherapy The use of topical or inhaled oils (plant extracts) that promote

and maintain health

Herbal Therapies The use of herbs derived mostly from plant sources that main-

tain and restore balance and health

Macrobiotic Diet Diet high in whole-grain cereals, vegetables, beans, sea vege-

tables, and vegetarian soups Elimination of meat, animal fat, eggs, poultry, dairy products,

sugars, and artificially produced food from the diet

Orthomolecular Therapy Focus on nutritional balance, including use of vitamins,

essential amino acids, essential fats, and minerals

BOX 5-5 Commonly Used Herbs and Health Products Aloe: Antiinflammatory and antimicrobial effect; accelerates

wound healing Black cohosh: Produces estrogen-like effects Chamomile: Antispasmodic and antiinflammatory; produces

mild sedative effect Dehydroepiandrosterone (DHEA): Converts to androgens and estro-

gen; slows the effects of aging; used for erectile dysfunction Echinacea: Stimulates the immune system Garlic: Antioxidant; used to lower cholesterol levels Ginger: Antiemetic; used for nausea and vomiting Ginkgo biloba: Antioxidant; used to improve memory Ginseng: Increases physical endurance and stamina; used for

stress and fatigue

Glucosamine: Amino acid that assists in the synthesis of cartilage

Melatonin: A hormone that regulates sleep; used for insomnia Milk thistle: Antioxidant; stimulates the production of new liver

cells, reduces liver inflammation; used for liver and gallblad- der disease

Peppermint oil: Antispasmodic; used for irritable bowel syndrome

Saw palmetto: Antiestrogen activity; used for urinary tract infec- tions and benign prostatic hypertrophy

St. John’s wort: Antibacterial, antiviral, antidepressant Valerian: Used to treat nervous disorders such as anxiety,

restlessness, and insomnia

39CHAPTER 5 Cultural Awareness and Health Practices

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CRITICAL THINKING What Should You Do? Answer: Before certain diagnostic procedures, it is typical to have a client remove personal objects that are worn on the body. The nurse should ask the client about the significance of such an item and its removal because it may have cultural or spiritual significance. The nurse should also determine whether the item will compromise client safety or the test results. If so, the nurse should ask the client if the item can be either removed temporarily or placed on another part of the body during the procedure.

Reference: Lewis et al. (2014), p. 25.

P R A C T I C E Q U E S T I O N S 1. The am bulatory care nurse is discussing preoperative

procedures with a Japanese Am erican client who is sched- uled for surgery the following week. During the discus- sion, the client con tinually sm iles an d nods th e h ead. How should th e nurse interpret this non verbal behavior? 1. Reflectin g a cultural value 2. An acceptan ce of th e treatm en t 3. Clien t agreem en t to th e required proced ures 4. Clien t un derstan din g of th e preoperative procedures

2. Wh en com m un icatin g with a clien t wh o speaks a dif- feren t lan guage, wh ich b est practice sh ould th e n urse im plem en t? 1. Speak lo udly an d slowly. 2. Arran ge for an in terp reter to tran slate. 3. Speak to th e clien t an d fam ily togeth er. 4. Stan d clo se to th e clien t an d speak loudly.

3. Th e n urse educator is providin g in -service education to th e n ursin g staff regarding tran scultural n ursin g care; a staff m em ber asks th e n urse educator to provide an exam ple of th e con cept of acculturation . Th e n urse edu- cator should m ake wh ich m o st app ro p riate respon se? 1. “A grou p of in dividuals id en tifyin g as a part of th e

Iroqu ois tribe am on g Native Am erican s.” 2. “A perso n wh o m oves from Ch in a to th e Un ited

States (U.S.) an d learn s ab out an d adapts to th e culture in th e U.S.”

3. “A group of in dividuals livin g in th e Azores th at id en tify auton om o usly but are a part of th e larger popu lation of Portugal.”

4. “A perso n wh o h as grown up in th e Ph ilippin es an d ch ooses to stay th ere because of th e sen se of belon gin g to h is or h er cultural group.”

4. Th e n urse is providin g disch arge in struction s to a Ch i- n ese Am erican clien t regardin g prescribed dietary m od ification s. Durin g th e teach in g session , th e clien t con tin uously turn s away from th e n urse. Th e n urse sh ould im plem en t wh ich b est action ?

1. Con tin ue with th e in struction s, verifyin g clien t un derstan din g.

2. Walk aroun d th e clien t so th at th e n urse con stan tly faces th e clien t.

3. Give th e clien t a dietary booklet an d return later to con tin ue with th e in struction s.

4. Tell th e clien t about th e im portan ce of th e in struc- tion s for th e m ain ten an ce of h ealth care.

5. A critically ill Hisp an ic clien t tells th e n urse th rough an in terp reter th at sh e is Rom an Cath olic an d firm ly believes in th e rituals an d tradition s of th e Cath olic faith . Based on th e clien t’s statem en ts, wh ich action s by th e n urse dem on strate cu ltural sen sitivity an d spir- itual supp ort? Select all th at ap p ly.

1. En sures th at a clo se kin stays with th e clien t. 2. Makes a referral for a Cath olic priest to visit th e

clien t. 3. Rem o ves th e cru cifix from th e wall in th e

clien t’s room . 4. Adm in isters th e sacram en t of th e sick to th e cli-

en t if death is im m in en t. 5. O ffers to provide a m ean s for prayin g th e rosary

if th e clien t wish es. 6. Rem in ds th e dietary departm en t th at m eals

served on Fridays durin g Len t do n ot con tain m eat.

6. Wh ich clien ts h ave a h igh risk of obesity an d diabetes m ellitus? Select all th at ap p ly.

1. Latin o Am erican m an 2. Native Am erican m an 3. Asian Am erican wom an 4. Hisp an ic Am erican m an 5. African Am erican wom an

7. Th e n urse is preparin g a plan of care for a clien t, an d is askin g th e clien t ab out religious preferen ces. Th e n urse con siders th e clien t’s religious preferen ces as bein g ch aracteristic of a Jeh ovah ’s Witn ess if wh ich clien t statem en t is m ade? 1. “I can n ot h ave surgery.” 2. “I can n ot h ave an y m ed icin e.” 3. “I believe th e soul lives on after death .” 4. “I can n ot h ave an y food con tain in g or prepared

with blood.”

8. Wh ich m eal tray sh o uld th e n urse deliver to a clien t of O rth odox Judaism faith wh o follows a kosh er diet? 1. Pork ro ast, rice, vegetables, m ixed fruit, m ilk 2. Crab salad on a cro issan t, vegetables with dip,

potato salad, m ilk 3. Sweet an d sour ch icken with rice an d vegetables,

m ixed fru it, juice 4. Noodles an d cream sauce with sh rim p an d vegeta-

bles, salad, m ixed fruit, iced tea

40 UNIT II Professional Standards in Nursing

9. An Asian Am erican clien t is experien cin g a fever. Th e n urse plan s care so th at th e clien t can self-treat th e disorder usin g wh ich m eth od ? 1. Prayer 2. Magn etic th erap y 3. Foods con sid ered to be yin 4. Food s con sidered to be yan g

10. Wh ich is th e b est n ursin g in terven tion regardin g com plem en tary an d altern ative m edicin e? 1. Advisin g th e clien t about “good ” versus “bad”

th erapies 2. Discouragin g th e clien t from usin g an y altern a-

tive th erap ies 3. Educatin g th e clien t about th erap ies th at h e or

sh e is usin g or is in terested in usin g 4. Iden tifyin g h erbal rem edies th at th e clien t sh ould

request from th e h ealth care provider

11. An an tih yp erten sive m edication h as been prescribed for a clien t with h yperten sio n . Th e clien t tells th e clin ic n urse th at h e would like to take an h erb al sub- stan ce to h elp lower h is blood pressure. Th e n urse sh o uld take wh ich action ?

1. Advise th e clien t to read th e labels of h erbal th er- apies closely.

2. Tell th e clien t th at h erbal substan ces are n ot safe an d sh ould n ever be used.

3. En cou rage th e clien t to discuss th e use of an h erb al substan ce with th e h ealth care provid er (HCP).

4. Tell th e clien t th at if h e takes th e h erbal substan ce h e will n eed to h ave h is blood pressure ch ecked frequen tly.

12. Th e n urse edu cator asks a studen t to list th e 5 m ain categories of com plem en tary an d altern ative m ed i- cin e (CAM), develo ped by th e Nation al Cen ter for Com p lem en tary an d Altern ative Med icin e. Wh ich statem en t, if m ade by th e n ursin g studen t, in dicates a n eed fo r fu rth er teach in g regardin g CAM categories? 1. “CAM in cludes biologically based practices.” 2. “Wh ole m ed ical system s are a com pon en t

of CAM.” 3. “Min d-bod y m ed icin e is part of th e CAM

ap proach .” 4. “Magn etic th erap y an d m assage th erapy are a

focus of CAM.”

A N S W E R S 1. 1 Ra t ion a le: Nod din g o r sm ilin g b y a Jap an ese Am erican clien t m ay reflect o n ly th e cultural value of in terp erso n al h arm o n y. Th is n on verb al b eh avio r m ay n o t be an in d icatio n of accep - tan ce of th e treatm en t, agreem en t with th e sp eaker, o r u n d er- stan din g o f th e proced ure. Test -Ta kin g St r a tegy: Elim in ate op tion s 2 an d 3 first b ecau se th ey are co m p a r a b le o r a lik e an d are in co rrect. From th e rem ain in g option s, n ote th at th e clien t is Japan ese Am erican an d th in k abo ut th e ch aracteristics of th is grou p . Th is will direct yo u to op tion 1. In add itio n , o p tion 4 is an in correct in terpretation o f th e clien t’s n o n verb al b eh avio r. Review: Th e cultu ral ch aracteristics o f Asia n Am er ica n s Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Psych o social In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Fun dam en tals of Care—Cu ltural Awaren ess Pr ior ity Con cepts: Com m un icatio n ; Cu lture Refer en ces: Giger (2013), p. 317; Jarvis (2016), p . 35.

2. 2 Ra t ion a le: Arran gin g for an in terpreter wo u ld be th e b est prac- tice wh en co m m u n icatin g with a clien t wh o sp eaks a d ifferen t lan guage. O ptio n s 1 an d 4 are in ap p ro priate an d in effective ways to com m un icate. O ption 3 is in ap prop riate b ecause it vio - lates privacy an d d o es n o t en su re co rrect tran slatio n . Test -Ta kin g St r a t egy: No te th e st r a t egic wo r d , best, in th e qu estio n an d n ote th e su b ject , co m m u n icatin g with a clien t of a d ifferen t cu lture. Elim in ate op tio n 3 first because th is actio n can con stitute a vio lation o f th e clien t’s righ t to p rivacy, an d d oes n ot rep resen t b est practice. Next, elim in ate o p tion s 1

an d 4, n o tin g th e wo rd loudly in th ese op tio n s an d becau se th ey are n o n th erap eutic action s an d also are n o t best practices. Review: Co m m u n ica t io n t ech n iq u es for a clien t wh o speaks a differen t lan gu age Level of Cogn it ive Abilit y: App lyin g Clien t Need s: Psych oso cial In tegrity In t egr a ted Pr ocess: Co m m u n ication an d Do cu m en tatio n Con t en t Ar ea : Fun d am en tals of Care—Cu ltural Awaren ess Pr ior ity Con cepts: Com m un icatio n ; Cu lture Refer en ce: Jarvis (2016), p p. 45–46.

3. 2 Ra t ion a le: Acculturation is a p rocess o f learn in g a d ifferen t cul- tu re to adap t to a n ew or ch an gin g en viron m en t. O p tion s 1 an d 3 describe a subculture. O ption 4 describes eth n ic iden tity. Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d s, most appropri- ate. Fo cus o n th e su b ject , accu lturation . No te th e wo rd s a per- son who moves an d adapts in th e correct o ptio n an d relate th is to th e defin itio n of acculturation . Review: Th e defin itio n o f a ccu lt u r a t io n Level of Cogn it ive Ability: App lyin g Clien t Need s: Psych oso cial In tegrity In t egr a ted Pr ocess: Teach in g an d Learn in g Con t en t Ar ea : Fun d am en tals of Care—Cu ltural Awaren ess Pr ior ity Con cepts: Cultu re; Pro fession alism Refer en ce: Jarvis (2016), p p. 14–15.

4. 1 Ra t ion a le: Most Ch in ese Am erican s m ain tain a fo rm al dis- tan ce with oth ers, wh ich is a fo rm o f resp ect. Man y Ch in ese Am erican s are un co m fo rtab le with face-to-face co m m u n ica- tion s, especially wh en eye co n tact is direct. If th e clien t turn s away fro m th e n u rse d u rin g a con versatio n , th e b est action is

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41CHAPTER 5 Cultural Awareness and Health Practices

to con tin u e with th e con versatio n . Walkin g aro un d th e clien t so th at th e n u rse faces th e clien t is in direct co n flict with th is cultu ral practice. Th e clien t m ay con sid er it a ru de gestu re if th e n u rse return s later to co n tin ue with th e explan ation . Tellin g th e clien t abo ut th e im p ortan ce of th e in stru ctio n s fo r th e m ain ten an ce o f h ealth care m ay be viewed as d egrad in g. Test-Ta kin g St r a t egy: No te th e st r a t egic wo r d , best. Fo cus on th e su b ject , th e b eh avio r o f a Ch in ese Am erican clien t. Elim - in ate op tio n s 3 an d 4 first becau se th ese actio n s are n o n th era- p eutic. To select fro m th e rem ain in g o ption s, th in k ab ou t th e cultu ral p ractices o f Ch in ese Am erican s an d recall th at d irect eye con tact m ay be u n co m fortable for th e clien t. Review: Th e co m m u n ication p ractices of Asia n Am er ica n s Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Psych o so cial In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n d am en tals o f Care—Cultu ral Awaren ess Pr ior it y Con cept s: Clien t Ed ucation ; Culture Refer en ce: Jarvis (2016), p. 36.

5. 1, 2, 5 Ra tion a le: In tim es of illn ess, a Rom an Catho lic clien t m ay turn to prayer for spiritual sup port. Th is m ay in clu de ro sary prayers o r visits fro m a p riest, who is th e spiritual leader in the Rom an Cath o lic faith . Close fam ily m em b ers usually wan t to stay with a d yin g fam ily m em b er in o rd er to h ear th e wishes of th e clien t, allowin g th e sou l to leave in p eace. A p riest, n ot a n urse, wou ld adm in ister th e sacram en t o f th e sick. Rom an Catho lics would n ot ask for th e cru cifix to b e rem oved . Mem b ers o f oth er reli- gio us gro ups such as Islam or Jud aism m ay req uest th e rem oval o f the cru cifix. Dietary rituals are n ot a con cern at th is tim e. Test-Ta kin g St r a t egy: Fo cus o n th e su b ject , th e Ro m an Cath - o lic religion . Co n sid er th e role o f th e sp iritual leader an d fam - ily in th e Cath olic faith . Th is will assist in selectin g o p tion s 2 an d 5. Fo r th e rem ain in g op tion s, recall th at th e presen ce of fam ily is a sou rce of sup po rt. Review: Sp iritual an d religiou s Hisp a n ic clien t s Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Psych o so cial In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n d am en tals o f Care—Cultu ral Awaren ess Pr ior it y Con cept s: Care Co o rd in atio n ; Cu lture Refer en ce: Po tter et al. (2015), p p . 111–112, 702–703.

6. 1, 2, 4, 5 Ra tion a le: Because of th eir h ealth an d d ietary p ractices, Latin o Am erican s, Native Am erican s, Hisp an ic Am erican s, an d Afri- can Am erican s h ave a h igh risk o f o besity an d diab etes m elli- tu s. O win g to d ietary practices, Asian Am erican s h ave a lo wer risk for o besity an d diabetes m ellitu s. Test-Ta king Stra tegy: Focus on the su b ject, those with a high risk for diabetes m ellitus and obesity. Think about the health and dietary practices of each cultural group in the options to answer correctly. Review: Th e h ea lt h r isk s for vario us eth n ic grou ps Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Health Pro m otio n an d Main ten an ce In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n d am en tals o f Care—Cultu ral Awaren ess Pr ior it y Con cept s: Cu lture; Health Pro m o tio n Refer en ce: Lewis et al. (2014), p p . 908, 1170.

7. 4 Ra tion a le: Am o n g Jeh o vah ’s Witn esses, surgery is n ot p ro h ib - ited , bu t th e ad m in istration o f bloo d an d b loo d prod ucts is fo r- b idd en . For a Jeh o vah ’s Witn ess, ad m in istratio n of m edicatio n is an acceptab le practice excep t if th e m edication is derived fro m b loo d prod ucts. Th is religio u s gro up believes th at th e so ul can n ot live after d eath . Jeh o vah ’s Witn esses avo id fo od s p rep ared with o r co n tain in g b loo d. Test-Ta kin g Str a tegy: Focus o n th e su b ject , beliefs of Jeh o- vah ’s Witn esses. Rem em b er th at th e ad m in istration of blo od an d an y associated b loo d p ro du cts is forbid d en am o n g Jeh o - vah ’s Witn esses. Even fo od s prepared with b lo od o r con tain in g b loo d are avo id ed. Review: Th e cu ltural preferen ces o f Jeh o va h ’s Wit n esses Level of Cogn itive Ability: An alyzin g Clien t Need s: Psych o so cial In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Cultu ral Awaren ess Pr ior it y Con cept s: Care Co ord in atio n ; Cu lture Refer en ce: Lewis et al. (2014), p . 677.

8. 3 Ra tion a le: Mem bers of O rth od o x Ju d aism ad h ere to d ietary ko sh er laws. In th is religio n , th e dairy-m eat com bin atio n is u n accep tab le. O n ly fish th at h ave scales an d fin s are allo wed ; m eats th at are allowed in clu de an im als th at are vegetable eaters, clo ven h o ofed , an d ritually slau gh tered. Test-Ta kin g St r a t egy: Focus on th e su b ject , dietary kosh er laws, an d recall th at th e d airy-m eat co m b in ation is u n accep t- able in th e O rth o do x Ju d aism grou p. Elim in ate o ption 1 b ecau se th is op tio n co n tain s p ork roast an d m ilk. Next, elim - in ate o p tion s 2 an d 4 b ecau se b o th o ptio n s con tain sh ellfish . Review: Th e d ietary ru les o f m em bers o f th e Or t h o d o x Ju d a - ism religio u s gro up Level of Cogn itive Ability: Ap plyin g Clien t Need s: Psych o so cial In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n dam en tals o f Care—Cultu ral Awaren ess Pr ior it y Con cept : Cu lture; Nu trition Refer en ces: Giger (2013), pp. 516–517; Nix (2013), p p. 266–267.

9. 3 Ra tion a le: In th e Asian Am erican cu ltu re, h ealth is believed to b e a state o f ph ysical an d spiritu al h arm on y with n atu re an d a b alan ce b etween po sitive an d n egative en ergy forces (yin an d yan g). Yin fo o ds are co ld an d yan g foo ds are h o t. Co ld fo od s are eaten wh en o n e h as a h ot illn ess (fever), an d h o t fo o ds are eaten wh en o n e h as a co ld illn ess. O p tion s 1 an d 2 are n o t h ealth practices sp ecifically asso ciated with th e Asian Am erican cultu re or th e yin an d yan g th eo ry. Test-Ta kin g Str a tegy: Focus on th e su b ject , an Asian Am eri- can , an d th e clien t’s diagn o sis, fever. Rem em b er th at co ld fo od s (yin fo od s) are eaten wh en o n e h as a h o t illn ess, an d h o t fo od s ( yan g fo od s) are eaten wh en on e h as a cold illn ess. Review: Th e h ealth practices o f th e Asia n Am er ica n cu ltu re Level of Cogn itive Ability: Ap plyin g Clien t Need s: Psych o so cial In tegrity In tegr a t ed Pr ocess: Nu rsin g Pro cess—Plan n in g Con ten t Ar ea : Fun dam en tals o f Care—Cultu ral Awaren ess

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42 UNIT II Professional Standards in Nursing

Pr ior ity Con cept: Cultu re; Th erm oregulation Refer en ce: Jarvis (2016), p p. 18, 20.

10. 3 Ra t ion a le: Co m plem en tary an d altern ative th erap ies in clud e a wid e variety of treatm en t m od alities th at are used in add itio n to co n ven tion al th erap y to treat a d isease or illn ess. Ed u catin g th e clien t abo u t th erap ies th at h e o r sh e uses o r is in terested in usin g is th e n urse’s ro le. O ptio n s 1, 2, an d 4 are in ap p ro priate actio n s fo r th e n u rse to take becau se th ey provid e ad vice to th e clien t. Test -Ta kin g Str a tegy: Note th e st r a t egic wo r d , best. Use t h er - a p eu t ic co m m u n ica t io n t ech n iq u es. Elim in ate op tio n s 1, 2, an d 4 because th ey are n o n th erapeu tic. Also n o te th at th ey are co m p a r a b le o r a lik e in th at th ey provid e advice to th e clien t. Reco m m en din g an h erb al rem ed y or disco uragin g a clien t fro m do in g so m eth in g is n o t with in th e role p ractices of th e n urse. In ad d itio n , it is n o n th erapeu tic to advise a clien t to do so m eth in g. Review: Th er a p eu t ic co m m u n ica t io n t ech n iq u es an d th e n urse’s role in ed ucatin g clien ts ab ou t co m p lem en t a r y a n d a lt er n a t ive m ed icin e Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Fun dam en tals of Care—Cu ltural Awaren ess Pr ior ity Con cepts: Clien t Edu catio n ; Cu ltu re Refer en ces: Lewis et al. (2014), pp . 85–86; Perry, Potter, O sten - do rf (2014), p . 31.

11. 3 Ra t ion a le: Alth ou gh h erb al sub stan ces m ay h ave so m e b en e- ficial effects, n o t all h erb s are safe to use. Clien ts wh o are b ein g treated with co n ven tion al m edicatio n th erap y sh o uld b e en cou raged to avoid h erb al su b stan ces b ecau se th e co m b in a- tion m ay lead to an excessive reactio n or to u n kn own

in teractio n effects. Th e n u rse sh ou ld advise th e clien t to d iscu ss th e u se of th e h erb al sub stan ce with th e HCP. Th erefore, o p tion s 1, 2, an d 4 are in ap prop riate n u rsin g actio n s. Test -Ta kin g St r a t egy: Elim in ate o ption 2 first b ecause o f th e clo sed -en d ed wo r d never. Next, elim in ate op tion s 1 an d 4 b ecause th ey are co m p a r a b le o r a lik e an d in d icate accep tan ce o f u sin g an h erb al sub stan ce. Review: Th e lim itatio n s asso ciated with th e u se of h er b a l su b st a n ces Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Fun d am en tals of Care—Cu ltural Awaren ess Pr ior ity Con cepts: Clien t Ed u catio n ; Safety Refer en ce: Lewis et al. (2014), pp . 81, 85–86.

12. 4 Ra t ion a le: Th e 5 m ain catego ries o f CAM in clu d e wh o le m ed- ical system s, m in d-b od y m ed icin e, b io logically b ased p rac- tices, m an ip ulative an d b od y-based practices, an d en ergy m ed icin e. Magn etic th erapy an d m assage th erap y are th erap ies with in specific categories of CAM. Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d s, need for fur- ther teaching. Th ese wo rd s in dicate a n ega t ive even t q u er y an d th e n eed to select th e in correct o ption . Also , focus o n th e su b ject of th e qu estio n , th e 5 m ain categories of CAM. No t- in g th at th e q uestion asks ab ou t m ain categories, n o t specific th erap ies, will assist in d irectin g you to th e co rrect op tion . Review: Th e categories of co m p lem en t a r y a n d a lt er n a t ive m ed icin e Level of Cogn it ive Ability: Evaluatin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Teach in g an d Learn in g Con t en t Ar ea : Fun d am en tals of Care—Cu ltural Awaren ess Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ce: Lewis et al. (2014), p. 80.

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43CHAPTER 5 Cultural Awareness and Health Practices

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C H A P T E R 6 Ethical and Legal Issues

PRIORITY CONCEPTS Ethics; Health Care Law

CRITICAL THINKING What Should You Do? While preparing a client for surgery scheduled in 1 hour, the client states to the nurse: “I have changed my mind. I don’t want this surgery.” What should the nurse do? Answer located on p. 54.

I. Ethics A. Description : Th e bran ch of ph ilosoph y con cern ed

with th e distin ction between righ t an d wro n g on th e basis of a body of kn owledge, n ot on ly on th e basis of opin ion s

B. Morals: Beh avior in acco rdan ce with custom s or tra- dition , usually reflectin g perso n al or religious beliefs

C. Ethical principles: Codes th at direct or govern n ursin g action s (Box 6-1)

D. Values: Beliefs an d attitu des th at m ay in fluen ce beh avior an d th e process of decision m akin g

E. Values clarification : Process of an alyzin g on e’s own values to un derstan d on eself m ore com pletely regardin g wh at is truly im portan t

F. Eth ical codes 1. Eth ical codes provide broad prin ciples for deter-

m in in g an d evaluatin g clien t care. 2. Th ese codes are n ot legally bin d in g, but th e

board of n ursin g h as auth o rity in m ost states to reprim an d n urses for un profession al con duct th at results from violation of th e eth ical codes.

3. Specific eth ical codes are as follo ws: a . Th e Code of Eth ics for Nurses developed by

th e In tern ation al Coun cil of Nurses; Web site: h ttp :/ / www.icn .ch / abo ut-icn / co de-of-eth ics- for-n u rses/ .

b . Th e Am erican Nu rses Asso ciation Code of Eth ics can be viewed on th e Am erican Nu rses Asso ciation Web site: h ttp :/ / www. n ursin gworld.org/ codeofeth ics.

G. Eth ical dilem m a 1. An eth ical dilem m a occurs wh en th ere is a co n -

flict between 2 or m ore ethical principles.

2. No correct decision exists, an d th e n urse m ust m ake a ch oice between 2 altern atives th at are equally un satisfactory.

3. Such dilem m as m ay occur as a result of differ- en ces in cultural or religious beliefs.

4. Eth ical reason ing is th e process of th in king th rough what on e should do in an orderly and system atic m an n er to provide justification for action s based on prin ciples; th e n urse sh ould gath er all in form a- tion to determ in e wheth er an eth ical dilem m a exists, exam in e his or h er own values, verbalize th e prob- lem , con sider possible courses of action , n egotiate th e outcom e, an d evaluate th e action taken .

H. Advocate 1. An ad vocate is a person wh o speaks up for or acts

on th e beh alf of th e clien t, protects th e clien t’s righ t to m ake h is or h er own decision s, an d uph olds th e prin ciple of fidelity.

2. An advocate represen ts th e clien t’s viewpoin t to oth ers.

3. An advo cate avoids lettin g perso n al values in flu- en ce advocacy for th e clien t an d supports th e cli- en t’s decision , even wh en it con flicts with th e advocate’s own preferen ces or ch oices.

I. Eth ics com m ittees 1. Eth ics com m ittees take an in terp rofession al

approach to facilitate dialogu e regardin g eth ical dilem m as.

2. Th ese com m ittees develop an d establish policies an d proced ures to facilitate th e preven tion an d resolutio n of dilem m as.

An important nursing responsibility is to act as a client advocate and protect the client’s rights.

II. Regulation of Nursing Practice A. Nurse Practice Act

1. A n urse practice act is a series of statutes th at h ave been en acted by each state legislature to regulate th e practice of n ursin g in th at state.

2. Nurse practice acts set education al requirem en ts for th e n urse, distin guish between n ursin g44

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practice an d m ed ical practice, an d defin e th e scope of n ursin g practice.

3. Addition al issues covered by n urse practice acts in clude licen su re requirem en ts for protection of th e public, groun ds for disciplin ary action , righ ts of th e n urse licen see if a disciplin ary action is taken , an d related topics.

4. All n urses are respo n sible for kn owin g th e provi- sion s of th e act of th e state or provin ce in wh ich th ey work.

B. Stan dards of care 1. Stan dards of care are guidelin es th at iden tify

wh at th e clien t can exp ect to receive in term s of n ursin g care.

2. Th e gu idelin es determ in e wh eth er n urses h ave perform ed duties in an ap propriate m an n er.

3. If th e n urse does n ot perform duties with in accepted stan d ards of care, th e n urse places h im - self or h erself in jeopardy of legal action .

4. If th e n urse is n am ed as a defen dant in a malprac- tice lawsuit an d proceedin gs sh ow th at th e n urse followed n either th e accepted stan dards of care outlin ed by th e state or provin ce n urse practice act n or th e policies of th e em ployin g institution, th e n urse’s legal liability is clear; h e or she is liable.

C. Em ployee guidelin es 1. Resp on deat superior: Th e em plo yer is h eld liable

for an y n egligen t acts of an em plo yee if th e alleged n egligen t act occurred durin g th e em p loym en t relation sh ip an d was with in th e scope of th e em p loyee’s respon sibilities.

2. Con tracts a. Nu rses are respo n sible for carryin g out th e

term s of a con tractual agreem en t with th e em p loyin g agen cy an d th e clien t.

b . Th e n urse-em ployee relation sh ip is govern ed by establish ed em p loyee h an dbo oks an d cli- en t care policies an d proced ures th at create obligation s, righ ts, an d duties between th o se parties.

3. In stitution al policies a. Written policies an d proced ures of th e

em p loyin g in stitutio n detail h ow n urses are to perform th eir duties.

b . Policies an d proced ures are usually specific an d describe th e expected beh avior on th e part of th e n urse.

c. Alth ou gh policies are n ot laws, courts gen er- ally ru le again st n urses wh o violate policies.

d . If th e n urse practices n ursin g accord in g to cli- en t care policies an d procedures establish ed by th e em plo yer, fun ction s with in th e job respo n sibility, an d provides care con sisten tly in a n on n egligen t m an n er, th e n urse m in i- m izes th e poten tial for liability.

The nurse must follow the guidelines identified in the Nurse Practice Act and agency policies and proce- dures when delivering client care.

D. Hospital staffin g 1. Ch arges of ab an don m en t m ay be m ade again st

n urses wh o “walk out” wh en staffin g is in adeq uate.

2. Nu rses in sh o rt staffin g situation s are obligated to m ake a report to th e n ursin g ad m in istration .

E. Floatin g 1. Floatin g is an acceptable practice used by h ealth

care facilities to alleviate un derstaffin g an d overstaffin g.

2. Legally, th e n urse can n ot refuse to float un less a un io n co n tract guaran tees th at n urses can work on ly in a specified area or th e n urse can prove lack of kn owledge for th e perform an ce of assign ed tasks.

3. Nu rses in a floatin g situation m ust n ot assum e respo n sibility beyon d th eir level of exp erien ce or qualification .

4. Nu rses wh o float sh o uld in form th e supervisor of an y lack of experien ce in carin g for th e type of clien ts on th e n ew n ursin g un it.

5. A resou rce n urse wh o is skilled in th e care of clien ts on th e un it sh ould also be assign ed to th e float n urse; in addition , th e float n urse sh ould be given an orien tation of th e un it an d th e stan d ards of care for th e un it sh o uld be reviewed (th e float n urse can care for “overflow” clien ts wh o se acu ity level m ore clo sely m atch th e n urses’ experien ce).

F. Disciplin ary action 1. Boards of n ursin g m ay den y, revoke, or suspen d

an y licen se to practice as a registered n urse, acco rdin g to th eir statutory auth ority.

2. Som e causes for disciplin ary action are as follo ws: a. Un profession al con d uct b . Con duct th at could affect th e h ealth an d wel-

fare of th e public adversely

BOX 6-1 Ethical Principles Autonomy: Respect for an individual’s right to self-determi-

nation Nonmaleficence: The obligation to do or cause no harm to

another Beneficence: The duty to do good to others and to maintain a

balance between benefits and harms; paternalism is an undesirable outcome of beneficence, in which the health care provider decides what is best for the client and encourages the client to act against his or her own choices

Justice: The equitable distribution of potential benefits and tasks determining the order in which clients should be cared for

Veracity: The obligation to tell the truth Fidelity: The duty to do what one has promised

45CHAPTER 6 Ethical and Legal Issues

c. Breach of clien t confidentiality d . Failure to use sufficien t kn owled ge, skills, or

n ursin g judgm en t e. Ph ysically or verbally abusin g a clien t f. Assum in g duties with out sufficien t preparation g. Kn o win gly delegatin g to un licen sed perso n -

n el n ursin g care th at places th e clien t at risk for in jury

h . Failure to m ain tain an accu rate record for each clien t

i. Falsifyin g a clien t’s record j. Leavin g a n ursin g assign m en t with out prop-

erly n otifyin g appropriate person n el

III. Legal Liability A. Laws

1. Nu rses are govern ed by civil an d crim in al law in roles as providers of services, em plo yees of in sti- tution s, an d private citizen s.

2. Th e n urse h as a perso n al an d legal obligation to provide a stan dard of clien t care expected of a reason ably com peten t profession al n urse.

3. Profession al n urses are h eld respon sible (liab le) for h arm resultin g from th eir n egligen t acts or th eir failure to act.

B. Types of laws (Box 6-2; Fig. 6-1) C. Negligence an d malpractice (Box 6-3)

1. Negligen ce is con d uct th at falls below th e stan - dard of care.

2. Negligen ce can in clude acts of com m ission an d acts of om ission .

3. Th e n urse wh o does n ot m eet appropriate stan - dard s of care m ay be h eld liable.

4. Malpractice is n egligen ce on th e part of th e n urse.

5. Malpractice is determ in ed if th e n urse owed a duty to th e clien t an d did n ot carry out th e duty an d th e clien t was in jured because th e n urse failed to perform th e duty.

6. Proof of liability a . Duty: At th e tim e of in jury, a duty existed

between th e plain tiff an d th e defen dan t. b . Breach of duty: Th e defen dan t breach ed duty

of care to th e plain tiff. c. Proxim ate cau se: Th e breach of th e duty was

th e legal cause of in jury to th e clien t.

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BOX 6-2 Types of Law

Contract Law Contract law is concerned with enforcement of agreements among private individuals.

Civil Law Civil law is concerned with relationships among persons and the protection of a person’s rights. Violation may cause harm to an individual or property, but no grave threat to society exists.

Criminal Law Criminal law is concerned with relationships between individ- uals and governments, and with acts that threaten society and its order; a crime is an offense against society that violates a law and is defined as a misdemeanor (less serious nature) or felony (serious nature).

Tort Law A tort is a civil wrong, other than a breach in contract, in which the law allows an injured person to seek damages from a per- son who caused the injury.

The Co ns titutio n

Type s o f law applic able to nurs e s

S ta tutory la w Common la w P riva te la w

Adminis tra tive la w

Le gis la tive bra nch

Inte ntiona l (a ction is s ubs ta ntia lly

ce rta in to ca us e a n e ffe ct) • Fra ud • De fa ma tion • As s a ult a nd ba tte ry • Fa ls e impris onme nt • Inva s ion of priva cy

• Ne glige nce • Ma lpra ctice

Uninte ntiona l (viola tion of

s ta nda rd of ca re )

J udicia l bra nch

S ta nda rd of proof is pre ponde ra nce of the e vide nce

S ta nda rd of proof is guilt be yond a re a s ona ble doubt

Civil

• Nurs e -pa tie nt re la tions hip

Contra cts

Torts

• Ma ns la ughte r • As s a ult a nd ba tte ry • Fra ud

Fe lony

Mis de me a nor

Crimina l

Exe cutive bra nch

S o urc e s o f Law (the balanc e o f po we r)

• P roce dura l la w • P ublic la w • S ubs ta ntive la w

FIGURE 6-1 Sources of law for nursing practice.

46 UNIT II Professional Standards in Nursing

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d . Dam age or in ju ry: Th e plain tiff experien ced in ju ry or dam ages or both an d can be com - pen sated by law.

The nurse must meet appropriate standards of care when delivering care to the client; otherwise the nurse would be held liable if the client is harmed.

D. Profession al liability in suran ce 1. Nu rses n eed th eir own liability in suran ce for pro-

tection again st m alpractice lawsuits. 2. Havin g th eir own in suran ce provides n urses pro-

tection as in dividuals; th is allows th e n urse to h ave an attorn ey, wh o h as on ly th e n urse’s in ter- ests in m in d , presen t if n ecessary.

E. Good Sam aritan laws 1. State legislatures pass Good Sam aritan laws,

wh ich m ay vary fro m state to state. 2. Th ese laws en courage h ealth care profession als

to assist in em ergen cy situation s an d lim it liabil- ity an d offer legal im m un ity for person s h elpin g in an em ergen cy, provided th at th ey give reason able care.

3. Im m un ity from suit applies on ly wh en all con di- tio n s of th e state law are m et, such as th at th e h ealth care provid er (HCP) receives n o com pen - sation for th e care provid ed an d th e care given is n ot in ten tion ally n egligen t.

F. Con trolled substan ces 1. Th e n urse sh ould adh ere to facility policies an d

procedures con cern in g ad m in istration of con - tro lled substan ces, wh ich are go vern ed by federal an d state laws.

2. Con trolled substan ces m ust be kep t locked securely, an d on ly au th orized person n el sh ould h ave access to th em .

3. Con trolled substan ces m ust be properly sign ed out for adm in istration an d a correct in ven tory m ust be m ain tain ed.

IV. Collective Bargaining A. Collective bargain in g is a form alized decision -

m akin g process between represen tatives of m an age- m en t an d represen tatives of labor to n egotiate wages an d co n dition s of em p loym en t.

B. Wh en collective bargain in g breaks down because th e parties can n ot reach an agreem en t, th e em ployees m ay call a strike or take oth er work action s.

C. Strikin g presen ts a moral dilem m a to m an y n urses because n ursin g practice is a service to peo ple.

V. Legal Risk Areas A. Assault

1. Assault occurs wh en a person puts an oth er per- son in fear of a h arm fu l or offen sive con tact.

2. Th e victim fears an d believes th at h arm will result because of th e th reat.

B. Battery is an in ten tion al touch in g of an oth er’s body with ou t th e oth er’s consent.

C. In vasion of privacy in cludes violating confidentiality, intrudin g on private clien t or fam ily m atters, an d shar- ing clien t in form ation with un auth orized person s.

D. False im prison m en t 1. False im prison m en t occurs wh en a clien t is n ot

allowed to leave a h ealth care facility wh en th ere is n o legal justification to detain th e clien t.

2. False im prison m en t also occurs wh en restrain in g devices are used with ou t an appropriate clin ical n eed.

3. A clien t can sign an Again st Medical Advice form wh en th e clien t refuses care an d is co m peten t to m ake decision s.

4. Th e n urse sh o uld docum en t circum stan ces in th e m ed ical record to avoid allegation s by th e clien t th at can n ot be defen ded.

E. Defam ation is a false com m un ication th at cau ses dam age to som eon e’s reputation , eith er in writin g (libel) or verbally (slan der) .

F. Frau d results from a deliberate deception in ten ded to produ ce un lawful gain s.

G. Th ere m ay be exception s to certain legal risks areas, such as assault, battery, an d false im prison m en t, wh en carin g for a clien t with a m en tal h ealth disor- der experien cin g acute distress wh o poses a risk to h im self or h erself or oth ers. In th is situation , th e n urse m ust assess th e clien t to determ in e loss of con - trol an d in terven e accordin gly; th e n urse sh ould use th e least restrictive m eth od s in itially, but th en use in terven tion s such as restrain t if th e clien t’s beh avior in dicates th e n eed for th is in terven tion .

VI. Client’s Rights A. Description

1. Th e clien t’s righ ts docum en t, also called the Cli- ent’s (Patient’s) Bill of Rights, reflects ackn owledg- m en t of a client’s righ t to participate in h er or h is h ealth care with an em ph asis on clien t auton om y.

BOX 6-3 Examples of Negligent Acts ▪ Medication errors that result in injury to the client ▪ Intravenous administration errors, such as incorrect flow

rates or failure to monitor a flow rate, that result in injury to the client

▪ Falls that occur as a result of failure to provide safety to the client

▪ Failure to use sterile technique when indicated ▪ Failure to check equipment for proper functioning ▪ Burns sustained by the client as a result of failure to mon-

itor bath temperature or equipment ▪ Failure to monitor a client’s condition ▪ Failure to report changes in the client’s condition to the

health care provider ▪ Failure to provide a complete report to the oncoming nurs-

ing staff

Adapted from Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 20 13, Mosby.

47CHAPTER 6 Ethical and Legal Issues

2. Th e docum en t provid es a list of th e righ ts of th e clien t an d respo n sibilities th at th e h ospital can - n ot violate ( Box 6-4).

3. Th e clien t’s righ ts protect th e clien t’s ability to determ in e th e level an d typ e of care received; all h ealth care agen cies are required to h ave a Client’s Bill of Rights posted in a visible area.

4. Several laws an d stan dard s pertain to clien t’s righ ts ( Box 6-5).

B. Righ ts for th e m en tally ill ( Box 6-6) 1. Th e Men tal Health System s Act created righ ts for

m en tally ill peo ple. 2. Th e Join t Com m ission h as developed policy

statem en ts on th e righ ts of m en tally ill people.

3. Psych iatric facilities are required to h ave a Cli- en t’s Bill of Righ ts posted in a visible area.

C. O rgan don ation an d tran splan tation 1. A clien t h as th e righ t to decide to becom e an

organ don or an d a righ t to refuse organ tran s- plan tation as a treatm en t option .

2. An in dividual wh o is at least 18 years old m ay in dicate a wish to beco m e a don or on h is or h er driver’s licen se (state-specific) or in an advance directive.

3. Th e Un ifo rm An atom ical Gift Act provid es a list of in dividuals wh o can provide informed consent for th e don ation of a deceased in dividual’s organ s.

4. Th e Un ited Network for O rgan Sh arin g sets th e criteria for organ don ation s.

5. Som e organ s, such as th e h eart, lu n gs, an d liver, can be obtain ed on ly fro m a perso n wh o is on m ech an ical ven tilation an d h as suffered brain death , wh ereas oth er organ s or tissues can be rem oved several h ours after death .

6. A don or m ust be free of in fectio us disease an d can cer.

7. Requ ests to th e deceased ’s fam ily for organ don a- tion usually are don e by th e HCP or n urse spe- cially train ed for m akin g such requests.

8. Don ation of organ s does n ot delay fun eral arran gem en ts; n o obvious eviden ce th at th e organ s were rem oved from th e body sh ows wh en

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BOX 6-4 Client’s Rights When Hospitalized ▪ Right to considerate and respectful care ▪ Right to be informed about diagnosis, possible treatments,

and likely outcome, and to discuss this information with the health care provider

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

▪ Right to consent or refuse a treatment ▪ 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 information

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 treatment or care ▪ Right to consent or refuse to take part in research ▪ Right to be told of realistic care alternatives when hospital

care is no longer appropriate ▪ Right to know about hospital rules that affect treatment,

and about charges and payment methods

From Christensen B, Kockrow E: Foundations of nursing, ed 6, St. Louis, 20 10, Mosby; and adapted from American Hospital Association: The patient care partnership: understanding expectations, rights and responsibilities. Available at www.aha.org/ content/ 0 0 -10/ pcp_english_0 30 730 .pdf.

BOX 6-5 Laws and Standards

American Hospital Association Issued Patient’s Bill of Rights

American Nurses Association Developed the Code of Ethics for Nurses, which defines the nurse’s responsibility for upholding client’s rights

Mental Health Systems Act Developed rights for mentally ill clients

The Joint Commission Developed policy statements on the rights of mentally ill individuals

BOX 6-6 Rights for the Mentally Ill ▪ Right to be treated with dignity and respect ▪ Right to communicate with persons outside the hospital ▪ Right to keep clothing and personal effects with them ▪ Right to religious freedom ▪ Right to be employed ▪ Right to manage property ▪ Right to execute wills ▪ Right to enter into contractual agreements ▪ Right to make purchases ▪ Right to education ▪ Right to habeas corpus (written request for release from

the hospital) ▪ Right to an independent psychiatric examination ▪ Right to civil service status, including the right to vote ▪ Right to retain licenses, privileges, or permits ▪ Right to sue or be sued ▪ Right to marry or divorce ▪ Right to treatment in the least restrictive setting ▪ Right not to be subject to unnecessary restraints ▪ Right to privacy and confidentiality ▪ Right to informed consent ▪ Right to treatment and to refuse treatment ▪ Right to refuse participation in experimental treatments or

research

Adapted from Stuart G: Principles and practice of psychiatric nursing, ed 10 , St. Louis, 20 13, Mosby.

48 UNIT II Professional Standards in Nursing

th e body is dressed; an d th e fam ily in curs n o cost for rem oval of th e organ s don ated.

D. Religiou s beliefs: O rgan don ation an d tran splan - tatio n 1. Cath olic Ch u rch : O rgan don ation an d tran s-

plan ts are acceptable. 2. O rth odox Ch u rch : Ch u rch discourages organ

don ation . 3. Islam (Muslim ) beliefs: Body parts m ay n ot be

rem oved or don ated for tran splan tatio n . 4. Jeh ovah ’s Witn ess: An organ tran splan t m ay be

accepted, but th e organ m ust be clean sed with a n on blood solution befo re tran splan tatio n .

5. O rth odox Judaism a. All body parts rem oved durin g au topsy m ust

be buried with th e body because it is believed th at th e en tire body m ust be return ed to th e earth ; organ don ation m ay n ot be con sidered by fam ily m em bers.

b . O rgan tran splan tation m ay be allowed with th e rabb i’s approval.

6. Refer to Ch apter 5 for addition al in form ation regardin g en d-of-life care.

VII. Informed Consent A. Description

1. In form ed con sen t is th e clien t’s approval (or th at of th e clien t’s legal represen tative) to h ave h is or h er body touch ed by a specific in dividual.

2. Consents, or releases, are legal docum en ts th at in dicate th e clien t’s perm ission to perform sur- gery, perform a treatm en t or proced ure, or give in form ation to a th ird party.

3. Th ere are differen t types of con sen ts (Box 6-7). 4. In form ed con sen t in dicates th e clien t’s participa-

tio n in th e decision regardin g h ealth care. 5. Th e clien t m ust be in form ed, in un derstan dable

term s, of th e risks an d ben efits of th e surgery or treatm en t, wh at th e con sequ en ces are for n ot h avin g th e surgery or procedure perform ed, treat- m en t option s, an d th e n am e of th e h ealth care provider perform in g th e surgery or procedure.

6. A clien t’s question s about th e surgery or proce- dure m ust be an swered befo re sign in g th e con sen t.

7. A con sen t m ust be sign ed freely by th e clien t with out th reat or pressure an d m ust be witn essed (th e witn ess m ust be an ad ult).

8. A clien t wh o h as been m ed icated with sed atin g m ed ication s or an y oth er m ed ication s th at can affect th e clien t’s cogn itive abilities m ust n ot be asked to sign a con sen t.

9. Legally, th e clien t m ust be m en tally an d em o- tio n ally com peten t to give con sen t.

10. If a clien t is declared m en tally or em otion ally in com peten t, th e n ext of kin , appoin ted guard- ian (appoin ted by th e court), or durable power

of atto rn ey for h ealth care h as legal au th ority to give con sen t (Box 6-8).

11. A com peten t clien t 18 years of age or older m ust sign th e con sen t.

12. In m ost states, wh en th e n urse is in volved in th e in form ed con sen t process, th e n urse is witn es- sin g on ly th e sign ature of th e clien t on th e in form ed co n sen t form .

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BOX 6-7 Types of Consents

Admission Agreement Admission agreements are obtained at the time of admission and identify the health care agency’s responsibility to the client.

Immunization Consent An immunization consent may be required before the admin- istration of certain immunizations; the consent indicates that the client was informed of the benefits and risks of the immunization.

Blood Transfusion Consent A blood transfusion consent indicates that the client was informed of the benefits and risks of the transfusion. Some cli- ents hold religious beliefs that would prohibit them from receiving a blood transfusion, even in a life-threatening situation.

Surgical Consent Surgical consent is obtained for all surgical or invasive proce- dures or diagnostic tests that are invasive. The health care pro- vider, surgeon, or anesthesiologist who performs the operative or other procedure is responsible for explaining the procedure, its risks and benefits, and possible alternative options.

Research Consent The research consent obtains permission from the client regarding participation in a research study. The consent informs the client about the possible risks, consequences, and benefits of the research.

Special Consents Special consents are required for the use of restraints, photo- graphing the client, disposal of body parts during surgery, donating organs after death, or performing an autopsy.

BOX 6-8 Mentally or Emotionally Incompetent Clients

▪ Declared incompetent ▪ Unconscious ▪ Under the influence of chemical agents such as alcohol or

drugs ▪ Chronic dementia or other mental deficiency that impairs

thought processes and ability to make decisions

49CHAPTER 6 Ethical and Legal Issues

13. An in form ed con sen t can be waived for urgen t m ed ical or surgical in terven tion as lon g as in sti- tution al policy so in dicates.

14. A clien t h as th e righ t to refuse in form ation an d waive th e in form ed con sen t an d un dergo treat- m en t, but th is decision m ust be docum en ted in th e m ed ical record.

15. A clien t m ay with draw con sen t at an y tim e.

An informed consent is a legal document, and the client must be informed by the HCP (i.e., physician, sur- geon), in understandable terms, of the risks and benefits of surgery, treatments, procedures, and plan of care. The client needs to be a participant in decisions regarding health care.

B. Min o rs 1. A m in or is a clien t un der legal age as defin ed by

state statute (usually youn ger th an 18 years). 2. A m in o r m ay n ot give legal co n sen t, an d con sen t

m ust be obtain ed fro m a paren t or th e legal guardian ; assen t by th e m in o r is im portan t because it allows for com m un ication of th e m in o r’s th o ugh ts an d feelin gs.

3. Paren tal or gu ardian con sen t sh o uld be obtain ed befo re treatm en t is in itiated for a m in or except in th e followin g cases: in an em ergen cy; in situation s in wh ich th e con sen t of th e m in o r is sufficien t, in cludin g treatm en t related to sub- stan ce abuse, treatm en t of a sexually tran sm itted in fectio n , h um an im m un od eficien cy virus (HIV) testin g an d acq uired im m un od eficien cy syn - drom e (AIDS) treatm en t, birth con trol services, pregn an cy, or psych iatric services; th e m in o r is an em an cipated m in o r; or a court order or oth er legal auth o rization h as been obtain ed. Refer to th e Guttm ach er Report on Public Policy for addi- tion al in form ation : h ttp:/ / www.guttm ach er.org/ pubs/ tgr/ 03/ 4/ gr030404.h tm l.

C. Em an cipated m in o r 1. An em an cipated m in o r h as establish ed in depen -

den ce from h is or h er paren ts th rough m arriage, pregn an cy, or service in th e arm ed forces, or by a court order.

2. An em an cipated m in or is con sidered legally cap able of sign in g an in form ed con sen t.

VIII. Health Insurance Portability and Accountability Act A. Description

1. Th e Health In suran ce Portability an d Accoun t- ability Act (HIPAA) describes h ow perso n al h ealth in form ation (PHI) m ay be used an d h ow th e clien t can obtain access to th e in form ation .

2. PHI in cludes in dividually iden tifiable in form a- tion th at relates to th e clien t’s past, presen t, or future h ealth ; treatm en t; an d paym en t for h ealth care services.

3. Th e act requires h ealth care agen cies to keep PHI private, provid es in form ation to th e clien t about th e legal respo n sibilities regardin g privacy, an d explain s th e clien t’s righ ts with respect to PHI.

4. Th e clien t h as various righ ts as a con sum er of h ealth care un d er HIPAA, an d an y clien t requests m ay n eed to be placed in writin g; a fee m ay be attach ed to certain clien t requests.

5. Th e clien t m ay file a com plain t if th e clien t believes th at privacy righ ts h ave been violated.

B. Clien t’s righ ts in clude th e righ t to do th e followin g: 1. In spect a copy of PH I. 2. Ask th e h ealth care agen cy to am en d th e PHI

th at is con tain ed in a record if th e PHI is in accurate.

3. Requ est a list of disclosures m ade regardin g th e PHI as specified by HIPAA.

4. Req u est to restrict h o w th e h ealth care agen cy u ses o r d isclo ses PH I regard in g treatm en t, p aym en t, o r h ealth care services, u n less in fo r- m atio n is n eed ed to p ro vid e em ergen cy treatm en t.

5. Requ est th at th e h ealth care agen cy com m un i- cate with th e clien t in a certain way or at a certain location ; th e request m ust specify h ow or wh ere th e clien t wish es to be con tacted.

6. Requ est a paper copy of th e HIPAA n otice. C. Health care agen cy use an d disclosure of PHI

1. Th e h ealth care agen cy obtain s PH I in th e course of providin g or adm in isterin g h ealth in suran ce ben efits.

2. Use or disclosure of PHI m ay be don e for th e followin g: a . Health care paym en t purpo ses b . Health care operation s purpo ses c. Treatm en t purpo ses d . Provid in g in form ation about h ealth care

services e. Data aggregation purpo ses to m ake h ealth

care ben efit decision s f. Adm in isterin g h ealth care ben efits

3. Th ere are ad dition al uses or disclosures of PHI (Box 6-9).

IX. Confidentiality/ Information Security A. Descrip tion

1. In th e h ealth care system , confidentiality/ informa- tion security refers to th e protectio n of privacy of th e clien t’s PHI.

2. Clien ts h ave a righ t to privacy in th e h ealth care system .

3. A special relation sh ip exists between th e clien t an d n urse, in wh ich in form ation discussed is n ot sh ared with a th ird party wh o is n ot directly in volved in th e clien t’s care.

4. Violation s of privacy occur in various ways (Box 6-10).

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50 UNIT II Professional Standards in Nursing

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B. Nurse’s respo n sibility 1. Nu rses are boun d to protect clien t confidentiality

by m ost n urse practice acts, by ethical principles an d stan d ards, an d by in stitutio n al an d agen cy policies an d proced ures.

2. Disclosure of con fiden tial in form ation exposes th e n urse to liability for in vasion of th e clien t’s privacy.

3. Th e n urse n eeds to protect th e clien t fro m in dis- crim in ate disclosure of h ealth care in form ation th at m ay cau se h arm (Box 6-11).

C. Social n etworks an d h ealth care ( Box 6-12) D. Medical records

1. Med ical records are con fid en tial. 2. Th e clien t h as th e righ t to read th e m ed ical record

an d h ave copies of th e record. 3. O n ly staff m em bers directly in volved in care

h ave legitim ate access to a clien t’s record; th ese m ay in clude HCPs an d n urses carin g for th e cli- en t, tech n ician s, th erap ists, social workers, un it secretaries, clien t advo cates, an d adm in istrators (e.g., for statistical an alysis, staffin g, quality care review). O th ers m ust ask perm ission fro m th e clien t to review a record.

BOX 6-9 Uses or Disclosures of Personal Health Information

▪ Compliance with legal proceedings or for limited law enforcement purposes

▪ To a family member or significant other in a medical emergency

▪ To a personal representative appointed by the client or des- ignated by law

▪ For research purposes in limited circumstances ▪ To a coroner, medical examiner, or funeral director about a

deceased person ▪ To an organ procurement organization in limited

circumstances ▪ To avert a serious threat to the client’s health or safety or

the health or safety of others ▪ To a governmental agency authorized to oversee the health

care system or government programs ▪ To the Department of Health and Human Services for the

investigation of compliance with the Health Insurance Por- tability and Accountability Act or to fulfill another lawful request

▪ To federal officials for lawful intelligence or national secu- rity purposes

▪ To protect health authorities for public health purposes ▪ To appropriate military authorities if a client is a member

of the armed forces ▪ In accordance with a valid authorization signed by the

client

Adapted from U.S. Department of Health and Human Services Office for Civil Rights: Health information privacy. Available at http:/ / www.hhs.gov/ ocr/ privacy/ .

BOX 6-10 Violations and Invasion of Client Privacy

▪ Taking photographs of the client ▪ Release of medical information to an unauthorized person,

such as a member of the press, family, friend, or neighbor of the client, without the client’s permission

▪ Use of the client’s name or picture for the health care agency’s sole advantage

▪ Intrusion by the health care agency regarding the client’s affairs

▪ Publication of information about the client or photographs of the client, including on a social networking site

▪ Publication of embarrassing facts ▪ Public disclosure of private information ▪ Leaving the curtains or room door open while a treatment

or procedure is being performed ▪ Allowing individuals to observe a treatment or procedure

without the client’s consent ▪ Leaving a confused or agitated client sitting in the nursing

unit hallway ▪ Interviewing a client in a room with only a curtain between

clients or where conversation can be overheard ▪ Accessing medical records when unauthorized to do so

BOX 6-11 Maintenance of Confidentiality ▪ Not discussing client issues with other clients or staff unin-

volved in the client’s care ▪ Not sharing health care information with others without

the client’s consent (includes family members or friends of the client and social networking sites)

▪ Keeping all information about a client private, and not revealing it to someone not directly involved in care

▪ Discussing client information only in private and secluded areas

▪ Protecting the medical record from all unauthorized readers

BOX 6-12 Social Networking and Health Care ▪ Specific social networking sites can be beneficial to health

care providers (HCPs) and clients; misuse of social net- working sites by the HCP can lead to Health Insurance Por- tability and Accountability Act (HIPAA) violations and subsequent termination of the employee.

▪ Nurses need to adhere to the code of ethics, confidentiality rules, and social media rules. Additional information about these codes and rules can be located at the American Nurses Association Web site at http:/ / www.nursingworld. org/ FunctionalMenuCategories/ AboutANA/ Social-Media/ Social-Networking-Principles-Toolkit.

▪ Standards of professionalism need to be maintained and any information obtained through any nurse-client rela- tionship cannot be shared in any way.

▪ The nurse is responsible for reporting any identified breach of privacy or confidentiality.

51CHAPTER 6 Ethical and Legal Issues

4. Th e m ed ical record is stored in th e records or th e h ealth in form ation dep artm en t after disch arge of th e clien t from th e h ealth care facility.

E. In form ation tech n ology/ co m pu terized m ed ical records 1. Health care em ployees sh ould h ave access on ly

to th e clien t’s records in th e n ursin g un it or work area.

2. Con fiden tiality/ in form ation security can be pro- tected by th e use of special com puter access codes to lim it wh at em plo yees h ave access to in com - puter system s.

3. Th e use of a password or iden tification code is n eeded to en ter an d sign off a com pu ter system .

4. A passwo rd or iden tification co de sh ould n ever be sh ared with an oth er person .

5. Perso n al passwo rds sh o uld be ch an ged periodi- cally to preven t un au th orized com pu ter access.

F. Wh en con ductin g research , an y in form ation pro- vided by th e clien t is n ot to be reported in an y m an - n er th at iden tifies th e clien t an d is n ot to be m ade accessible to an yon e outsid e th e research team .

The nurse must always protect client confidentiality.

X. Legal Safeguards A. Risk m an agem en t

1. Risk m an agem en t is a plan n ed m eth od to iden - tify, an alyze, an d evaluate risks, followed by a plan for reducin g th e frequen cy of acciden ts an d in juries.

2. Program s are based on a system atic reportin g sys- tem for in ciden ts or un usual occurren ces.

B. In cid en t reports ( Box 6-13) 1. Th e in ciden t report is used as a m ean s of id en ti-

fyin g risk situation s an d im provin g clien t care. 2. Follo w specific docum en tation guidelin es. 3. Fill out th e report com pletely, accu rately, an d

factu ally. 4. Th e report form sh o uld n ot be copied or placed

in th e clien t’s record. 5. Make n o referen ce to th e in ciden t report form in

th e clien t’s record.

6. Th e report is n ot a substitute for a com plete en try in th e clien t’s record regardin g th e in ciden t.

7. If a clien t in jury or error in care occurred, assess th e clien t frequen tly.

8. Th e h ealth care provider m ust be n otified of in ci- den t an d th e clien t’s con ditio n .

C. Safeguardin g valuables 1. Clien t’s valuables sh ould be given to a fam ily

m em ber or secured for safekeep in g in a stored an d locked design ated location , such as th e agen cy’s safe; th e location of th e clien t’s valu- ables sh ould be docum en ted per agen cy policy.

2. Man y h ealth care agen cies require a clien t to sign a release to free th e agen cy of th e respo n sibility for lost valuables.

3. A clien t’s weddin g ban d can be taped in place un less a risk exists for swellin g of th e h an ds or fin gers.

4. Religiou s item s, such as m edals, m ay be pin n ed to th e clien t’s gown if allowed by agen cy policy.

D. HCP’s prescription s 1. Th e n urse is obligated to carry out an HCP’s pre-

scrip tion except wh en th e n urse believes a pre- scrip tion to be in approp riate or in accurate.

2. Th e n urse carryin g out an in accurate prescription m ay be legally respo n sible for an y h arm suffered by th e clien t.

3. If n o resolutio n occurs regardin g th e prescription in question , th e n urse sh ould con tact th e n urse m an ager or supervisor.

4. Th e n urse sh ould follow specific gu idelin es for telep h on e prescription s ( Box 6-14).

5. Th e n urse sh ould en sure th at all com po n en ts of a m edication prescription are docum en ted (Box 6-15).

The nurse should never carry out a prescription if it is unclear or inappropriate. The HCP should be con- tacted immediately.

E. Docum en tation 1. Docum en tation is legally required by accreditin g

agen cies, state licen sin g laws, an d state n urse an d m edical practice acts.

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BOX 6-13 Examples of Incidents That Need to Be Reported

▪ Accidental omission of prescribed therapies ▪ Circumstances that led to injury or a risk for client injury ▪ Client falls ▪ Medication administration errors ▪ Needle-stick injuries ▪ Procedure-related or equipment-related accidents ▪ A visitor injury that occurred on the health care agency

premises ▪ Avisitor who exhibits symptoms of a communicable disease

BOX 6-14 Telephone Prescription Guidelines ▪ Date and time the entry. ▪ Repeat the prescription to the health care provider (HCP),

and record the prescription. ▪ Sign the prescription; begin with “t.o.” (telephone order),

write the HCP’s name, and sign the prescription. ▪ If another nurse witnessed the prescription, that nurse’s

signature follows. ▪ The HCP needs to countersign the prescription within a

timeframe according to agency policy.

52 UNIT II Professional Standards in Nursing

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2. Th e n urse sh ould follow agen cy guidelin es an d procedures ( Box 6-16).

3. Refer to Th e Join t Com m ission Web site for acceptable abbreviation s an d docum en tation gu idelin es: h ttp:/ / www.join tcom m ission .org/ stan dards_in form ation / n psgs.aspx.

F. Clien t an d fam ily teach in g 1. Provide com plete in struction s in a lan guage th at

th e clien t or fam ily can un derstan d. 2. Do cum en t clien t an d fam ily teach in g, wh at was

tau gh t, evalu ation of un derstan din g, an d wh o was presen t durin g th e teach in g.

3. In form th e clien t of wh at could h appen if in for- m ation sh ared durin g teach in g is n ot followed.

XI. Advance Directives A. Clien t (Patien t) Self-Determ in ation Act

1. Th e Clien t (Patien t) Self-Determ in ation Act is a law th at in dicates clien ts m ust be provided with in form ation ab out th eir righ ts to iden tify written direction s about th e care th at th ey wish to receive in th e even t th at th ey beco m e in capacitated an d are un ab le to m ake h ealth care decision s.

2. O n adm ission to a h ealth care facility, th e clien t is asked about th e existen ce of an advan ce direc- tive, an d if on e exists, it m ust be docum en ted an d in cluded as part of th e m ed ical record; if th e cli- en t sign s an ad van ce directive at th e tim e of adm ission , it m ust be docum en ted in th e clien t’s m ed ical record.

3. Th e 2 basic typ es of advan ce directives in clude in struction al directives an d durable power of attorn ey for h ealth care. a. In struction al directives: Lists th e m ed ical

treatm en t th at a clien t ch oo ses to om it or refuse if th e clien t becom es un ab le to m ake decision s an d is term in ally ill.

b . Du rable power of attorn ey for h ealth care: Appo in ts a person (h ealth care proxy) ch osen by th e clien t to m ake h ealth care decision s on th e clien t’s beh alf wh en th e clien t can n o lon - ger m ake decision s.

B. Do n ot resuscitate (DNR) orders 1. A DNR order sh ould be written if th e clien t an d

h ealth care provider h ave m ade th e decision th at th e clien t’s h ealth is deterioratin g an d th e clien t ch oo ses n ot to un dergo cardiop ulm on ary resus- citation if n eeded.

2. Th e clien t or h is or h er legal represen tative m ust provide informed consent for th e DNR status.

3. Th e DNR order m ust be defin ed clearly so th at oth er treatm en t, n ot refused by th e clien t, will be con tin ued.

4. Som e states offer DNR Com fo rt Care an d DNR Com fo rt Care Arrest protoco ls; th ese protoco ls list specific action s th at HCPs will take wh en pro- vidin g cardiop ulm on ary resuscitation (CPR).

5. All h ealth care person n el m ust kn ow wh eth er a clien t h as a DNR order; if a clien t does n ot h ave a DNR order, HCPs n eed to m ake every effort to revive th e clien t.

6. A DNR order n eeds to be reviewed regularly acco rdin g to agen cy policy an d m ay n eed to be ch an ged if th e clien t’s status ch an ges.

7. DNR protoco ls m ay vary from state to state, an d it is im portan t for th e n urse to kn ow h is or h er state’s protoco ls.

C. Th e n urse’s role 1. Discussin g advan ce directives with th e clien t opens

th e com m un ication ch an n el to establish what is im portan t to the clien t an d what the clien t m ay view as prom otin g life versus prolon gin g dyin g.

BOX 6-15 Components of a Medication Prescription

▪ Date and time prescription was written ▪ Medication name ▪ Medication dosage ▪ Route of administration ▪ Frequency of administration ▪ Health care provider’s signature

BOX 6-16 Do’s and Don’ts Documentation Guidelines: Narrative and Information Technology

▪ Use a black-colored ink pen for narrative documentation. ▪ Date and time entries. ▪ Provide objective, factual, and complete documentation. ▪ Document care, medications, treatments, and procedures

as soon as possible after completion. ▪ Document client responses to interventions. ▪ Document consent for or refusal of treatments. ▪ Document calls made to other health care providers. ▪ Use quotes as appropriate for subjective data. ▪ Use correct spelling, grammar, and punctuation. ▪ Sign and title each entry. ▪ Follow agency policies when an error is made (i.e., draw 1

line through the error, initial, and date). ▪ Follow agency guidelines regarding late entries. ▪ Use only the user identification code, name, or password

for computerized documentation. ▪ Maintain privacy and confidentiality of documented infor-

mation printed from the computer. ▪ Do not document for others or change documentation for

other individuals. ▪ Do not use unacceptable abbreviations. ▪ Do not use judgmental or evaluative statements, such as

“uncooperative client.” ▪ Do not leave blank spaces on documentation forms. ▪ Do not lend access identification computer codes to

another person; change password at regular intervals.

53CHAPTER 6 Ethical and Legal Issues

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2. Th e n urse n eeds to en sure th at th e clien t h as been provided with in form ation about th e righ t to iden tify written direction s about th e care th at th e clien t wish es to receive.

3. O n ad m ission to a h ealth care facility, th e n urse determ in es wh eth er an advan ce directive exists an d en sures th at it is part of th e m ed ical record; th e n urse also offers in form ation about advan ce directives if th e clien t in dicates h e or sh e wan ts m ore in form ation .

4. Th e n urse en sures th at th e HCP is aware of th e presen ce of an advan ce directive.

5. All h ealth care workers n eed to follow th e direc- tion s of an advan ce directive to be safe from liability.

6. Som e agen cies h ave specific policies th at pro- h ibit th e n urse from sign in g as a witn ess to a legal docum en t, such as an in struction al directive.

7. If allowed by th e agen cy, when th e n urse acts as a witness to a legal docum en t, th e n urse m ust docu- m en t th e even t an d th e factual circum stan ces sur- roun din g th e sign in g in th e m edical record; docum en tation as a witn ess sh ould in clude wh o was presen t, an y sign ifican t com m en ts by th e cli- en t, an d th e n urse’s observation s of the clien t’s con duct durin g this process.

XII. Reporting Responsibilities A. Nurses are required to report certain com m un icable

diseases or crim in al activities such as ch ild or elder abuse or dom estic violen ce; dog bite or oth er an im al bite, gun sh ot or stab woun ds, assaults, an d h om icides; an d suicides to th e appropriate auth o rities.

B. Im paired n urse 1. If th e n urse susp ects th at a co-worker is abusin g

ch em icals an d poten tially jeopardizin g a clien t’s safety, th e n urse m ust report th e in dividual to th e n ursin g supervisor/ n ursin g ad m in istration in a con fiden tial m an n er. (Clien t safety is always th e first priority.)

2. Nu rsin g adm in istration n otifies th e board of n ursin g regardin g th e n urse’s beh avior.

3. Man y in stitution s h ave policies th at allow for drug testin g if im pairm en t is suspected.

C. O ccupation al Safety an d Health Act (O SHA) 1. O SHA requires th at an em ployer provide a safe

workplace for em ployees accordin g to regulation s. 2. Em ployees can con fiden tially report workin g

con d ition s th at violate regulatio n s. 3. An em ployee wh o reports un safe workin g con di-

tion s can n ot be retaliated again st by the em ployer. D. Sexual h arassm en t

1. Sexual h arassm en t is proh ib ited by state an d federal laws.

2. Sexual h arassm en t in cludes un welcom e con duct of a sexual n ature.

3. Follow agen cy policies an d proced ures to h an dle reportin g a con cern or com plain t.

CRITICAL THINKING What Should You Do? Answer: If the client indicates that he or she does not want a prescribed therapy, treatment, or procedure such as surgery, the nurse should further investigate the client’s request. If the client indicates that he or she has changed his or her mind about surgery, the nurse should assess the client and explore with the client his or her concerns about not wanting the surgery. The nurse would then withhold further surgical preparation and contact the surgeon to report the client’s request so that the surgeon can discuss the conse- quences of not having the surgery with the client. Under no circumstances would the nurse continue with surgical preparation if the client has indicated that he or she does not want the surgery. Further assessment and follow-up related to the client’s request need to be done. In addition, it is the client’s right to refuse treatment.

References: Lewis et al. (20 14), p. 326. Perry, Potter, Ostendorf (2014), p. 882.

P R A C T I C E Q U E S T I O N S 13. Th e n urse h ears a clien t callin g out for h elp, h urries

down th e h allway to th e clien t’s room , an d fin ds th e clien t lyin g on th e flo or. Th e n urse perform s an assessm en t, assists th e clien t back to bed, n otifies th e h ealth care provid er of th e in ciden t, an d com - pletes an in ciden t report. Wh ich statem en t sh ould th e n urse docum en t on th e in ciden t report? 1. Th e clien t fell out of bed . 2. Th e clien t clim bed over th e side rails. 3. Th e clien t was foun d lyin g on th e flo or. 4. Th e clien t becam e restless an d tried to get out

of bed .

14. A clien t is brough t to th e em ergen cy departm en t by em ergen cy m edical services (EMS) after bein g h it by a car. Th e n am e of th e clien t is un kn own , an d th e clien t h as sustain ed a severe h ead in jury an d m ulti- ple fractures an d is un con scious. An em ergen cy cra- n ioto m y is required. Regard in g in form ed con sen t for th e surgical proced ure, wh ich is th e b est action ? 1. O btain a court order for th e surgical procedure. 2. Ask th e EMS team to sign th e in form ed con sen t. 3. Tran sport th e victim to th e operatin g ro om for

surgery. 4. Call th e police to iden tify th e clien t an d locate th e

fam ily.

15. Th e n urse h as just assisted a clien t back to bed after a fall. Th e n urse an d h ealth care provider h ave assessed the clien t an d h ave determ in ed th at th e clien t is n ot

54 UNIT II Professional Standards in Nursing

in jured. After com pletin g th e in ciden t report, the n urse should im plem ent wh ich action n ext? 1. Reassess th e clien t. 2. Con duct a staff m eetin g to describe th e fall. 3. Docum en t in th e n urse’s n otes th at an in ciden t

report was com pleted. 4. Con tact th e n ursin g supervisor to update in for-

m ation regardin g th e fall.

16. Th e n urse arrives at work an d is told to report (float) to th e in ten sive care un it (ICU) for th e day because th e ICU is un d erstaffed an d n eeds addition al n urses to care for th e clien ts. Th e n urse h as n ever worked in th e ICU. Th e n urse sh ould take wh ich b est action ? 1. Refuse to float to th e ICU based on lack of un it

orien tation . 2. Clarify with th e team leader to m ake a safe ICU

clien t assign m en t. 3. Ask th e n ursin g supervisor to review th e h ospital

policy on floatin g. 4. Subm it a written protest to n ursin g adm in istra-

tion , an d th en call th e h ospital lawyer.

17. Th e n urse wh o works on the n igh t sh ift en ters the m edication room an d fin ds a co-worker with a tourn i- quet wrapped aroun d the upper arm . Th e co-worker is about to in sert a n eedle, attach ed to a syrin ge con tain - in g a clear liquid, in to th e an tecubital area. Which is the m o st ap p ro p riate action by th e n urse? 1. Call security. 2. Call th e police. 3. Call th e n ursin g supervisor. 4. Lock th e co-worker in th e m ed ication room un til

h elp is obtain ed.

18. A h ospitalized clien t tells th e n urse th at an in struc- tio n al directive is bein g prepared an d th at th e lawyer will be brin gin g th e docum en t to th e h os- pital today for witn ess sign atures. Th e clien t asks th e n urse for assistan ce in obtain in g a witn ess to th e will. Wh ich is th e m o st ap p ro p riate respon se to th e clien t? 1. “I will sign as a witn ess to yo ur sign ature.” 2. “You will n eed to fin d a witn ess on your own .” 3. “Wh oever is available at th e tim e will sign as a

witn ess for you.” 4. “I will call th e n ursin g supervisor to seek assis-

tan ce regardin g your request.”

19. Th e n urse h as m ade an error in a n arrative docu- m en tation of an assessm en t fin din g on a clien t an d obtain s th e clien t’s record to co rrect th e error. Th e n urse sh ould take wh ich action s to correct th e error? Select all th at ap p ly.

1. Do cum en t a late en try in th e clien t’s record. 2. Draw 1 lin e th rou gh th e error, in itialin g an d

datin g it.

3. Try to erase th e error for space to write in th e correct data.

4. Use wh iteout to delete th e erro r to write in th e correct data.

5. Write a con cise statem en t to explain wh y th e correction was n eeded.

6. Do cum en t th e correct in form ation an d en d with th e n urse’s sign ature an d title.

20. Wh ich iden tifies accurate n ursin g docum en tatio n n otatio n s? Select all th at ap p ly.

1. Th e clien t slept th rough th e n igh t. 2. Abdo m in al woun d dressin g is dry an d in tact

with ou t drain age. 3. Th e clien t seem ed an gry wh en awaken ed for

vital sign m easu rem en t. 4. Th e clien t ap pears to becom e an xiou s wh en it

is tim e for respiratory treatm en ts. 5. Th e clien t’s left lower m edial leg woun d is 3 cm

in len gth with out redn ess, drain age, or edem a.

21. A n ursin g in structor delivers a lecture to n ursin g stu- den ts regardin g th e issue of clien t’s righ ts an d asks a n ursin g studen t to iden tify a situation th at repre- sen ts an exam ple of invasion of client privacy. Wh ich situation , if id en tified by th e studen t, in dicates an un derstan din g of a violation of th is clien t righ t? 1. Perform in g a procedure with ou t con sen t 2. Th reaten in g to give a clien t a m ed ication 3. Tellin g th e clien t th at h e or sh e can n ot leave th e

h ospital 4. O bservin g care provid ed to th e clien t with ou t th e

clien t’s perm ission

22. Nursin g staff m em bers are sitting in th e loun ge takin g th eir m orn in g break. An un licen sed assistive person - n el (UAP) tells th e group th at sh e th inks th at the un it secretary h as acquired im m un odeficien cy syn drom e (AIDS) and proceeds to tell th e n ursin g staff th at th e secretary probably con tracted th e disease from h er h usban d, who is supposedly a drug addict. The registered n urse sh ould in form th e UAP that m akin g th is accusation h as violated wh ich legal tort? 1. Libel 2. Slan der 3. Assault 4. Negligen ce

23. An 87-year-o ld wom an is brough t to th e em ergen cy dep artm en t for treatm en t of a fractured arm . O n ph ysical assessm en t, th e n urse n otes old an d n ew ecch ym otic areas on th e clien t’s ch est an d legs an d asks th e clien t h ow th e bruises were sustain ed. Th e clien t, alth ough relu ctan t, tells th e n urse in con fi- den ce th at h er son frequen tly h its h er if supp er is n ot prepared on tim e wh en h e arrives h om e from

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work. Wh ich is th e m o st ap p ro p riate n ursin g respo n se? 1. “O h , really? I will discuss th is situation with

your son .” 2. “Let’s talk ab out th e ways you can m an age your

tim e to preven t th is from h app en in g.” 3. “Do you h ave an y frien d s wh o can h elp yo u out

un til you resolve th ese im portan t issues with yo ur son ?”

4. “As a n urse, I am legally boun d to report abuse. I will stay with you wh ile you give th e report an d h elp fin d a safe place for you to stay.”

24. Th e n urse calls th e h eath care provider (HCP) regardin g a n ew m ed ication prescription because th e dosage prescribed is h igh er th an th e recom - m en ded dosage. Th e n urse is un able to lo cate th e HCP, an d th e m edication is due to be adm in istered. Wh ich action sh ould th e n urse take?

1. Con tact th e n ursin g supervisor. 2. Adm in ister th e dose prescribed. 3. Ho ld th e m ed ication un til th e HCP can be

con tacted. 4. Adm in ister th e recom m en ded dose un til th e

HCP can be located.

25. Th e n urse em p loyed in a h ospital is waitin g to receive a report fro m th e labo ratory via th e facsim ile (fax) m ach in e. Th e fax m ach in e activates an d th e n urse expects th e report, but in stead receives a sexu- ally orien ted ph otograph . Wh ich is th e m o st ap p ro - p riate in itial n ursin g action ? 1. Call th e police. 2. Cut up th e ph o tograp h an d th row it away. 3. Call th e n ursin g supervisor an d report the in ciden t. 4. Call th e labo ratory an d ask for th e n am e of th e

in dividual wh o sen t th e ph otograph .

A N S W E R S 13. 3 Ra tion a le: Th e in cid en t repo rt sh o uld con tain a factual d escrip tion o f th e in cid en t, an y in juries exp erien ced b y th ose in vo lved , an d th e o u tco m e of th e situatio n . Th e correct op tio n is th e on ly o n e th at d escribes th e facts as o b served b y th e n u rse. O ptio n s 1, 2, an d 4 are in terp retatio n s of th e situatio n an d are n o t factu al in fo rm atio n as o bserved b y th e n u rse. Test-Ta kin g St r a t egy: Fo cu s on th e su b ject , d ocum en tatio n of even ts, an d n ote t h e d a t a in t h e q u est io n to select th e correct o ptio n . Rem em ber to focus o n factual in fo rm atio n wh en d o c- u m en tin g, an d avoid in clud in g in terp retation s. Th is will d irect yo u to th e correct o ptio n . Review: Do cum en tatio n prin ciples related to in cid en t r ep o r t s Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Com m un icatio n an d Docum en tation Con ten t Ar ea : Leadersh ip/ Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Co m m u n ication ; Health Care Law Refer en ce: Hub er (2014), p p. 318–319.

14. 3 Ra tion a le: In gen eral, th ere are two situ ation s in wh ich in form ed co n sen t o f an ad ult clien t is n o t n eed ed . O n e is wh en an em ergen cy is presen t an d delayin g treatm en t for th e pu rp ose o f o btain in g in form ed con sen t wou ld resu lt in in ju ry o r d eath to th e clien t. Th e secon d is wh en th e clien t waives th e righ t to give in fo rm ed con sen t. O p tio n 1 will d elay em ergen cy treat- m en t, an d o p tion 2 is in app ro priate. Alth o ugh op tion 4 m ay b e p ursued , it is n o t th e best actio n because it delays n ecessary em ergen cy treatm en t. Test-Ta kin g Str a tegy: No te th e st r a t egic wo r d , best. Recallin g th at wh en an em ergen cy is presen t an d a d elay in treatm en t fo r th e pu rp ose o f ob tain in g in fo rm ed con sen t co uld resu lt in in ju ry or death will direct yo u to th e co rrect o ptio n .

Review: Th e issues su rrou n d in g in fo r m ed co n sen t Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip / Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Eth ics; Health Care Law Refer en ces: Po tter et al. (2013), p p. 302–303; Zerwekh , Zer- wekh Garn eau (2015), pp. 475–476.

15. 1 Ra tion a le: After a clien t’s fall, th e n u rse m ust freq u en tly reas- sess th e clien t b ecau se po ten tial com p lication s d o n o t always app ear im m ediately after th e fall. Th e clien t’s fall sh o u ld b e treated as p rivate in form atio n an d sh ared o n a “n eed to kn o w” b asis. Co m m u n icatio n regardin g th e even t sh o u ld in volve o n ly th e in d ivid uals p articipatin g in th e clien t’s care. An in ciden t report is a problem -solvin g d ocum en t; h o wever, its co m ple- tio n is n o t do cum en ted in th e n urse’s n o tes. If th e n u rsin g su pervisor h as been m ad e aware o f th e in ciden t, th e sup ervisor will con tact th e n urse if status update is n ecessary. Test-Ta kin g Str a tegy: Note th e st r a t egic wo r d , next. Usin g th e st ep s o f t h e n u r sin g p r o cess will direct you to th e co rrect o ptio n . Rem em ber th at assessm en t is th e first step. Add itio n - ally, use Ma slo w’s Hier a r ch y o f Need s t h eo r y, recallin g th at p h ysio logical n eeds are th e priority. Th e co rrect op tio n is th e o n ly op tio n th at ad dresses a p oten tial p h ysio lo gical n eed of th e clien t. Review: Gu idelin es related to in cid en t r ep o r t s an d care to th e clien t after su stain in g a fa ll Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n dam en tals o f Care—Safety Pr ior it y Con cept s: Co m m u n ication ; Safety Refer en ces: Lewis et al. (2014), p. 1682; Zerwekh , Zerwekh Garn eau (2015), pp. 479–480.

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16. 2 Ra t ion a le: Floatin g is an acceptab le practice used b y h o spitals to so lve u n d erstaffin g prob lem s. Legally, th e n u rse can n o t refuse to flo at un less a un ion co n tract guaran tees th at n urses can work on ly in a specified area or th e n urse can p ro ve th e lack of kn o wledge fo r th e p erform an ce of assign ed tasks. Wh en en cou n terin g th is situ atio n , th e n u rse sh ou ld set prio rities an d id en tify po ten tial areas o f h arm to th e clien t. Th at is wh y clarifyin g th e clien t assign m en t with th e team lead er to en su re th at it is a safe o n e is th e best op tion . Th e n ursin g sup er- visor is called if th e n urse is exp ected to p erform tasks th at h e o r sh e can n o t safely perform . Su bm ittin g a written p ro test an d callin g th e h osp ital lawyer is a prem atu re action . Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d , best. Elim in ate op tion 1 first becau se o f th e word refuse. Next, elim in ate op tion s 3 an d 4 b ecau se th ey are p rem atu re actio n s. Review: Nu rsin g resp on sibilities related to flo a t in g Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Lead ersh ip / Man agem en t—Eth ical/ Legal Pr ior ity Con cepts: Care Co ordin ation ; Pro fessio n alism Refer en ce: Zerwekh , Zerwekh Garn eau (2015), pp . 589–591.

17. 3 Ra t ion a le: Nu rse p ractice acts req uire repo rtin g im p aired n urses. Th e b oard of n ursin g h as ju risd iction o ver th e practice of n u rsin g an d m ay develop plan s fo r treatm en t an d sup ervi- sion o f th e im paired n urse. Th is in ciden t n eeds to b e rep orted to th e n ursin g sup ervisor, wh o will th en rep ort to th e b oard o f n ursin g an d o th er au th o rities, su ch as th e p o lice, as req uired . Th e n urse m ay call security if a d isturban ce o ccu rs, b ut n o in fo rm ation in th e qu estio n su p po rts th is n eed , an d so th is is n o t th e app ro p riate action . O p tion 4 is an in ap pro priate an d un safe action . Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d s, most appro- priate. Elim in ate op tio n 4 first b ecau se th is is an in ap p ro priate an d un safe actio n . Recall th e lin es of organ izatio n al stru ctu re to assist in d irectin g you to th e co rrect op tio n . Review: Th e n urse’s respo n sib ilities wh en d ealin g with an im p a ir ed n u r se Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Lead ersh ip / Man agem en t—Eth ical/ Legal Pr ior ity Con cepts: Eth ics; Profession alism Refer en ce: Zerwekh , Zerwekh Garn eau (2015), pp . 452–453.

18. 4 Ra tion a le: In struction al directives (livin g wills) are req uired to be in writin g and sign ed by th e clien t. Th e clien t’s sign atu re m ust be witn essed b y specified in divid uals o r n otarized . Laws an d guidelin es regard in g in struction al d irectives vary from state to state, an d it is th e respo n sib ility of th e n urse to kn ow th e laws. Man y states p roh ibit any em p lo yee, in clu din g th e n urse o f a facility wh ere th e clien t is receivin g care, fro m b ein g a witn ess. O ption 2 is n on th erapeu tic an d n ot a h elpfu l respon se. Th e n urse sh o uld seek th e assistance o f the n ursin g sup ervisor. Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d s, most appropri- ate. O p tion s 1 an d 3 are co m p a r a b le o r a lik e an d sh o uld b e

elim in ated first. O p tion 2 is elim in ated becau se it is a n o n th er- ap eu tic resp o n se. Review: Legal im p licatio n s associated with in st r u ct io n a l d ir ect ives Level of Cogn it ive Ability: App lyin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Lead ersh ip/ Man agem en t—Eth ical/ Legal Pr ior ity Con cepts: Health Care Law; Profession alism Refer en ce: Zerwekh , Zerwekh Garn eau (2015), pp. 420, 476–477.

19. 2, 6 Ra t ion a le: If th e n u rse m akes an error in n arrative do cum en - tatio n in th e clien t’s reco rd , th e n urse sh o uld fo llo w agen cy p o licies to correct th e erro r. Th is in clud es d rawin g o n e lin e th ro ugh th e erro r, in itialin g an d d atin g th e lin e, an d th en do c- u m en tin g th e correct in form atio n . A late en try is used to d o cu m en t ad dition al in fo rm atio n n o t rem em b ered at th e in i- tial tim e of d ocum en tation , n o t to m ake a co rrection of an error. Do cu m en tin g th e co rrect in fo rm atio n with th e n u rse’s sign ature an d title is co rrect. Erasin g data from th e clien t’s record an d th e u se of wh iteou t are proh ibited. Th ere is n o n eed to write a statem en t to explain wh y th e correction was n ecessary. Test -Ta kin g St r a t egy: Fo cu s on th e su b ject , co rrectin g a d oc- u m en tatio n error, an d u se prin cip les related to d ocum en ta- tion . Recallin g th at alteration s to a clien t’s record are to b e avo id ed will assist in elim in atin g op tio n s 3 an d 4. From th e rem ain in g o p tion s, fo cu sin g on th e su b ject of th e q u estion an d usin g kn owled ge regard in g th e prin cip les related to do cu- m en tation will direct you to th e correct op tio n . Review: Th e p rin cip les an d gu idelin es related to d o cu m en - t a t io n Level of Cogn it ive Ability: App lyin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Co m m u n ication an d Do cu m en tatio n Con t en t Ar ea : Lead ersh ip/ Man agem en t—Eth ical/ Legal Pr ior ity Con cepts: Com m un icatio n ; Pro fession alism Refer en ces: Perry, Potter, O sten d orf (2014), p. 51; Zerwekh , Zerwekh Garn eau (2015), p . 466.

20. 1, 2, 5 Ra t ion a le: Factu al d ocum en tatio n co n tain s descriptive, o bjec- tive in form ation abo ut wh at th e n urse sees, h ears, feels, o r sm ells. Th e use of in feren ces with o u t su pp o rtin g factu al data is n o t accep table b ecau se it can be m isu n d erstoo d. Th e u se o f vagu e term s, su ch as seemed o r appears, is n o t acceptab le b ecau se th ese word s su ggest th at th e n u rse is statin g an op in io n . Test -Ta kin g St r a t egy: Fo cu s o n th e su b ject , accurate do cu- m en tation n o tation s. Elim in ate o ptio n s 3 an d 4 b ecause th ey are co m p a r a b le o r a lik e an d in clu d e vague term s (seem ed, ap pears). Review: Do cu m en t a t io n gu idelin es Level of Cogn it ive Abilit y: App lyin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Co m m u n ication an d Do cu m en tatio n Con t en t Ar ea : Lead ersh ip/ Man agem en t—Eth ical/ Legal Pr ior ity Con cepts: Com m un icatio n ; Pro fession alism Refer en ce: Perry, Po tter, O sten do rf (2014), p p. 50–51.

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21. 4 Ra tion a le: In vasion of privacy o ccurs with un reaso n able in tru- sio n in to an in d ivid ual’s p rivate affairs. Perfo rm in g a p ro ce- d ure with o u t con sen t is an exam p le of b attery. Th reaten in g to give a clien t a m ed icatio n co n stitu tes assault. Tellin g th e cli- en t th at th e clien t can n o t leave th e h o sp ital con stitutes false im p riso n m en t. Test-Ta kin g St r a t egy: Fo cu s on th e su b ject , in vasion of p rivacy. No tin g th e wo rd s without the client’s permission will d irect yo u to th is o ptio n . Review: Situ ation s th at in clud e in va sio n o f p r iva cy Level of Cogn it ive Abilit y: Evalu atin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Leadersh ip/ Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Eth ics; Pro fessio n alism Refer en ce: Zerwekh, Zerwekh Garneau (2015), p p. 447, 473– 474.

22. 2 Ra tion a le: Defam ation is a false com m un ication o r a careless d isregard fo r th e tru th th at cau ses d am age to som eo n e’s rep u- tatio n , eith er in writin g (lib el) o r verb ally (slan der). An assault o ccurs wh en a perso n p uts an o th er person in fear of a h arm fu l o r offen sive co n tact. Negligen ce in vo lves th e actio n s of profes- sio n als th at fall belo w th e stan d ard of care fo r a sp ecific p ro fessio n al gro u p. Test-Ta kin g Str a tegy: Note th e su b ject , th e legal tort violated. Focus on th e d a t a in t h e q u est io n and elim in ate o ptio ns 3 and 4 first b ecau se th eir d efin ition s are un related to th e data. Recallin g th at slander con stitutes verb al defam atio n will d irect you to th e correct o ption fro m th e rem ain in g o ption s. Review: Th e defin ition s of lib el, sla n d er , a ssa u lt , an d n egligen ce Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip/ Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Health Care Law; Pro fessio n alism Refer en ce: Zerwekh , Zerwekh Garn eau (2015), p p. 448, 473.

23. 4 Ra tion a le: Th e n u rse m u st repo rt situatio n s related to ch ild or eld er ab u se, gu n sh ot wou n d s an d o th er crim in al acts, an d cer- tain in fectiou s d iseases. Co n fid en tial issues are n o t to be d is- cussed with n o n m ed ical perso n n el or th e clien t’s fam ily or frien d s with ou t th e clien t’s p erm ission . Clien ts sh o uld be assu red th at in fo rm ation is kep t con fid en tial, un less it p laces th e n u rse u n der a legal o b ligation . O ption s 1, 2, an d 3 d o n o t ad d ress th e legal im p licatio n s o f th e situ ation an d d o n o t en su re a safe en viro n m en t for th e clien t. Test-Ta kin g St r a t egy: Note th e st r a t egic wo r d s, most appropri- ate. Fo cus on th e d a t a in t h e q u est io n an d n ote th at an 87- year-o ld wo m an is receivin g p h ysical ab u se b y h er so n . Recall th e n u rsin g resp on sibilities related to clien t safety an d rep ort- in g ob ligatio n s. O p tio n s 1, 2, an d 3 sh o uld be elim in ated b ecau se th ey are co m p a r a b le o r a lik e in th at th ey do n o t p ro - tect th e clien t from in ju ry.

Review: Th e n u rsin g respo n sib ilities related to r ep o r t in g r esp o n sib ilit ies Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip / Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Health Care Law; In terperson al Violen ce Refer en ces: Lewis et al. ( 2014), p p. 68–69; Zerwekh , Zerwekh Garn eau (2015), p. 472.

24. 1 Ra tion a le: If th e HCP writes a prescrip tion th at requ ires clari- fication , th e n urse’s resp on sibility is to con tact th e HCP. If th ere is n o resolutio n regardin g th e p rescriptio n because th e HCP can n o t b e lo cated o r b ecau se th e p rescriptio n rem ain s as it was written after talkin g with th e HCP, th e n u rse sh o u ld con tact th e n urse m an ager o r n u rsin g sup erviso r for furth er clarificatio n as to wh at th e n ext step sh ou ld be. Un der n o cir- cum stan ces sh o u ld th e n u rse pro ceed to carry ou t th e p rescrip- tio n un til ob tain in g clarification . Test-Ta kin g Str a tegy: Elim in ate o ptio n s 2 an d 4 first b ecause th ey are co m p a r a b le o r a lik e an d are u n safe action s. Ho ld in g th e m ed ication can resu lt in clien t in jury. Th e n u rse n eed s to take actio n . Th e co rrect o p tion clearly iden tifies th e req uired action in th is situ ation . Review: Nursin g resp on sib ilities related to th e HCP’s p r escr ip t io n s Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip / Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Perry, Po tter, O sten d orf (2014), p. 489.

25. 3 Ra tion a le: En surin g a safe workp lace is a respo n sibility of an em ployin g in stitu tion . Sexual h arassm en t in th e wo rkplace is p ro h ib ited b y state an d fed eral laws. Sexu ally suggestive jo kes, to uch in g, p ressu rin g a co -wo rker fo r a d ate, an d o p en d isplays o f o r tran sm ittin g sexually o rien ted ph oto grap h s or p osters are exam ples of con du ct th at co uld be co n sidered sexual h arass- m en t b y an o th er worker. If th e n u rse b elieves th at h e o r sh e is bein g sub jected to un welco m e sexu al co n du ct, th ese con - cern s sh ou ld be rep o rted to th e n u rsin g su perviso r im m edi- ately. O p tio n 1 is u n n ecessary at th is tim e. O p tion s 2 an d 4 are in ap prop riate in itial actio n s. Test-Ta kin g St r a t egy: Note th e st r a t egic wo r d s, most appropri- ate initial. Rem em ber th at usin g th e o rgan ization al ch an n els of com m un icatio n is best. Th is will assist in d irectin g yo u to th e correct op tio n . Review: Nu rsin g respo n sibilities wh en sexu a l h a r a ssm en t o ccurs in th e wo rkp lace Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip / Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Health Care Law; Pro fessio n alism Refer en ce: Zerwekh , Zerwekh Garn eau (2015), p p. 474–475.

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58 UNIT II Professional Standards in Nursing

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C H A P T E R 7 Prioritizing Client Care: Leadership,

Delegation, and Emergency Response Planning

PRIORITY CONCEPTS Leadership; Health Care Organizations

CRITICAL THINKING What Should You Do? The nurse notes that there has been an increase in the number of intravenous (IV) site infections that developed in the clients being cared for on the nursing unit. How should the nurse proceed to implement a quality improvement program? Answer located on p. 71.

I. Health Care Delivery Systems A. Man aged care

1. Managed care is a broad term used to describe strategies used in th e h ealth care delivery system th at reduce th e costs of h ealth care.

2. Clien t care is outcom e driven an d is m an aged by a case management process.

3. Man aged care em p h asizes th e prom o tion of h ealth , clien t education an d respon sible self- care, early iden tification of disease, an d th e use of h ealth care resources.

B. Case m an agem en t 1. Case m an agem en t is a h ealth care delivery strat-

egy th at supports m an aged care; it uses an in ter- profession al h ealth care delivery approach th at provides com preh en sive clien t care th rou gh out th e clien t’s illn ess, usin g available resources to prom ote h igh -quality an d cost-effective care.

2. Case m an agem en t in cludes assessm en t an d developm en t of a plan of care, co ordin ation of all services, referral, an d follow-up.

3. Critical path ways are used, an d variatio n an alysis is con d ucted.

Case management involves consultation and collab- oration with an interprofessional health care team.

C. Case m an ager 1. A case m an ager is a profession al n urse wh o

assum es respo n sibility for coordin atin g th e cli- en t’s care at adm ission an d after disch arge.

2. Th e case m an ager establish es a plan of care with th e clien t, coordin ates an y in terp rofession al con sultation s an d referrals, an d facilitates disch arge.

D. Critical path way 1. A critical path way is a clin ical m an agem en t

care plan for providin g clien t-cen tered care an d for plan n in g an d m on itorin g th e clien t’s progress with in an establish ed tim e fram e; interprofes- sional collaboration an d team wo rk en sure sh ared decision m akin g an d quality clien t care.

2. Variation an alysis is a con tin uous process th at th e case m an ager an d oth er caregivers con duct by com parin g th e specific clien t outcom es with th e expected outcom es described on th e critical path way.

3. Th e goal of a critical path way is to an ticipate an d recogn ize n egative varian ce (i.e., clien t prob- lem s) early so th at appropriate action can be taken an d positive clien t outcom es can result.

E. Nursin g care plan 1. A n ursin g care plan is a written guidelin e an d

com m un ication tool th at iden tifies th e clien t’s pertin en t assessm en t data, problem s an d n ursin g diagn oses, go als, in terven tion s, an d exp ected outcom es.

2. Th e plan en h an ces in terpro fession al con tin uity of care by id en tifyin g specific n ursin g action s n ecessary to ach ieve th e go als of care.

3. Th e clien t an d fam ily are in volved in developin g th e plan of care, an d th e plan id en tifies sh o rt- term an d lo n g-term goals.

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4. Clien t problem s, goals, in terven tion s, an d expected outcom es are docum en ted in th e care plan , wh ich provides a fram ework for evaluation of th e clien t’s respo n se to n ursin g action s.

II. Nursing Delivery Systems A. Fun ction al n ursin g

1. Fun ction al n ursin g in volves a task approach to clien t care, with tasks bein g delegated by th e ch arge n urse to in dividual m em bers of th e team .

2. Th is type of system is task-o rien ted, an d th e team m em ber focuses on th e delegated task rath er th an th e total clien t; th is results in fragm en tation of care an d lack of accountability by th e team m em ber.

B. Team n ursin g 1. Th e team gen erally is led by a registered n urse

(team leader) wh o is respo n sible for assessin g cli- en ts, an alyzin g clien t data, plan n in g, an d evalu- atin g each clien t’s plan of care.

2. Th e team leader determ in es th e work assign - m en t; each staff m em ber works fully with in th e realm of h is or h er edu cation al an d clin ical expertise an d job description .

3. Each staff m em ber is acco un table for clien t care an d outcom es of care delivered in accordan ce with th e licen sin g an d practice scope as deter- m in ed by h ealth care agen cy policy an d state law.

4. Mod ular n ursin g is sim ilar to team n ursin g, but takes in to accoun t th e structure of th e un it; th e un it is divided in to m od ules, allowin g n urses to care for a group of clien ts wh o are geograph i- cally clo se by.

C. Relation sh ip-b ased practice (prim ary n ursin g) 1. Relation sh ip-b ased practice (prim ary n ursin g) is

con cern ed with keepin g th e n urse at th e bed side, actively in volved in clien t care, wh ile plan n in g goal-d irected, in dividualized care.

2. O n e (prim ary) n urse is respon sible for m an agin g an d co ordin atin g th e clien t’s care wh ile in th e h ospital an d for disch arge, an d an associate n urse cares for th e clien t wh en th e prim ary n urse is off-du ty.

D. Clien t-focused care 1. Th is is also kn own as th e total care or case

m eth od ; th e registered n urse assum es total respo n sibility for plan n in g an d deliverin g care to a clien t.

2. Th e clien t m ay h ave differen t n urses assign ed dur- in g a 24-h our period; th e n urse provides all n eces- sary care n eeded for th e assign ed tim e period.

III. Professional Responsibilities A. Accountability

1. Th e process in wh ich in dividuals h ave an obliga- tion (or duty) to act an d are an swerable for th eir action s.

2. In volves assum in g on ly th e respo n sibilities th at are with in on e’s scope of practice an d n ot assum - in g respo n sibility for activities in wh ich co m pe- ten ce h as n ot been ach ieved.

3. In volves adm ittin g m istakes rath er th an blam in g oth ers an d evalu atin g th e outcom es of on e’s own action s.

4. In clu des a respon sibility to th e clien t to be com - peten t, providin g n ursin g care in acco rdan ce with stan d ards of n ursin g practice an d adh erin g to th e profession al eth ics codes.

Accountability is the acceptance of responsibility for one’s actions. The nurse is always responsible for his or her actions when providing care to a client.

B. Leadership an d management 1. Lead ersh ip is th e in terp erson al process th at

in volves in fluen cin g oth ers (followers) to ach ieve goals.

2. Man agem en t is th e accom plish m en t of tasks or goals by on eself or by directin g oth ers.

C. Th eories of leadersh ip an d m an agem en t ( Box 7-1) D. Leader an d m an ager approach es

1. Autocratic a . Th e leader or m an ager is focused an d m ain -

tain s stron g con trol, m akes decision s, an d addresses all problem s.

b . Th e leader or m an ager dom in ates th e group an d com m an ds rath er th an seeks suggestion s or in pu t.

2. Dem ocratic a . Th is is also called participative management. b . It is based on th e belief th at every grou p m em -

ber sh o uld h ave in put in to problem solvin g an d th e developm en t of goals; lead er obtain s participation from grou p an d th em m akes best decision for th e organ ization , based upon th e in put from grou p.

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BOX 7-1 Theories of Leadership and Management

Cha risma tic: Based on personal beliefs and characteristics Qua ntum: Based on the concepts of chaos theory; maintain-

ing a balance between tension and order prevents an unstable environment and promotes creativity

Rela tiona l: Based on collaboration and teamwork Serva nt : Based on a desire to serve others; the leader emerges

when another’s needs assume priority Sha red: Based on the belief that several individuals share the

responsibility for achieving the health care agency’s goals Tra nsa ctiona l: Based on the principles of social exchange

theory Tra nsforma t iona l: Based on the individual’s commitment to

the health care agency’s vision; focuses on promoting change

60 UNIT II Professional Standards in Nursing

c. Th e dem ocratic style is a m ore “talk with th e m em bers” style an d m uch less auth o ritarian th an th e au tocratic style.

3. Laissez-faire a. A laissez-faire leader or m an ager assum es a

passive, n on directive, an d in active approach an d relin qu ish es part or all of th e respon sibil- ities to th e m em bers of th e grou p.

b . Decision m akin g is left to th e group, with th e laissez-faire leader or m an ager providin g lit- tle, if an y, guidan ce, support, or feedback.

4. Situ ation al a. Situ ation al style uses a com bin ation of styles

based on th e curren t circum stan ces an d even ts.

b . Situ ation al styles are assum ed acco rdin g to th e n eeds of th e grou p an d th e tasks to be ach ieved.

5. Bureaucratic a. Th e leader or m an ager believes th at in divid-

uals are m otivated by extern al forces. b . Th e leader or m an ager relies on organ iza-

tio n al policies an d procedures for decision m akin g.

E. Effective leader an d m an ager beh aviors an d qualities ( Box 7-2)

F. Fun ction s of m an agem en t (Box 7-3) G. Problem -solvin g process an d decision m akin g

1. Problem solvin g in volves obtain in g in form ation an d usin g it to reach an acceptable solution to a problem .

2. Decision m akin g in volves iden tifyin g a problem an d decidin g wh ich altern atives can best ach ieve objectives.

3. Steps of th e problem -solvin g process are sim ilar to th e steps of th e n ursin g process ( Table 7-1).

H. Types of m an agers 1. Fron tlin e m an ager

a. Fron tlin e m an agers fun ctio n in supervisory roles of th o se in volved with delivery of clien t care.

b . Fron tlin e ro les usually in clude ch arge n urse, team leader, an d clien t care co ordin ato r.

c. Fron tlin e m an agers coordin ate th e activity of all staff wh o provide clien t care an d supervise team m em bers durin g th e m an ager’s period of accoun tability.

2. Middle m an ager a. Middle m an ager roles usually in clude un it

m an ager an d supervisor. b . A m iddle m an ager’s respo n sibilities m ay

in clude supervisin g staff, preparin g budgets, preparin g work sch edules, writin g an d im ple- m en tin g policies th at guide clien t care an d un it operation s, an d m ain tain in g th e quality of clien t services.

3. Nu rse executive a. Th e n urse executive is a top-level n urse m an -

ager an d m ay be th e director of n ursin g ser- vices or th e vice presiden t for clien t care services.

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BOX 7-2 Effective Leader and Manager Behaviors and Qualities

Behaviors Treats employees as unique individuals Inspires employees and stimulates critical thinking Shows employees how to think about old problems in new

ways and assists with adapting to change Is visible to employees; is flexible; and provides guidance,

assistance, and feedback Communicates a vision, establishes trust, and empowers

employees Motivates employees to achieve goals

Qualities Effective communicator; promotes interprofessional collabo-

ration Credible Critical thinker Initiator of action Risk taker Is persuasive and influences employees

Adapted from Huber D: Leadership and nursing care management, ed 5, Philadelphia, 20 14, Saunders.

BOX 7-3 Functions of Management Pla nning: Determining objectives and identifying methods

that lead to achievement of objectives Orga nizing: Using resources (human and material) to achieve

predetermined outcomes Direct ing: Guiding and motivating others to meet expected

outcomes Controlling: Using performance standards as criteria for mea-

suring success and taking corrective action

TABLE 7-1 Similarities of the Problem-Solving Process and the Nursing Process

Problem-Solving Process Nursing Process

Identifying a problem and collecting data about the problem

Assessment

Determining the exact nature of the problem Analysis

Deciding on a plan of action Planning

Carrying out the plan Implementation

Evaluating the plan Evaluation

61CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

b . Th e n urse executive supervises n um erous dep artm en ts an d works clo sely with th e adm in istrative team of th e organ ization .

c. Th e n urse executive en sures th at all clien t care provided by n urses is con sisten t with th e objectives of th e h ealth care organ ization .

IV. Power A. Power is th e ability to do or act to ach ieve desired

results. B. Powerful people are ab le to m od ify beh avior an d

in fluen ce oth ers to ch an ge, even wh en oth ers are resistan t to ch an ge.

C. Effective n urse lead ers use power to im prove th e delivery of care an d to en h an ce th e profession .

D. Th ere are differen t types of power (Box 7-4).

V. Empowerment A. Em po werm en t is an in terperson al process of

en ablin g oth ers to do for th em selves. B. Em po werm en t occurs wh en in dividuals are able to

in fluen ce wh at h appen s to th em m ore effectively. C. Em po werm en t in volves open co m m un ication ,

m utu al goal settin g, an d decision m akin g. D. Nurses can em power clien ts th rou gh teach in g an d

advocacy.

VI. Formal Organizations A. An organ ization ’s m ission statem en t com m un icates

in broad term s its reason for existen ce; th e geograph - ical area th at th e organ ization serves; an d attitu des, beliefs, an d values from wh ich th e organ ization fun ction s.

B. Goals an d objectives are m easu rable activities spe- cific to th e develo pm en t of design ated services an d program s of an organ ization .

C. Th e organ ization al ch art dep icts an d com m un icates h ow activities are arran ged, h ow au th ority relation - sh ips are defin ed , an d h ow com m un ication ch an - n els are establish ed.

D. Policies, proced ures, an d protoco ls 1. Policies are guid elin es th at defin e th e organ iza-

tion ’s stan d poin t on courses of action .

2. Proced ures are based on policy an d defin e m eth od s for tasks.

3. Protoco ls prescribe a specific course of action for a specific typ e of clien t or problem . a . Cen tralization is th e m akin g of decision s by a

few in dividuals at th e top of th e organ ization or by m an agers of a dep artm en t or un it, an d decision s are com m un icated th ereafter to th e em plo yees.

b . Decen tralization is th e distribution of auth o r- ity th rou gh ou t th e organ ization to allow for in creased respon sibility an d delegation in decision m akin g; decen tralization tries to m ove th e decision -m akin g as clo se to th e clien t as possible.

The nurse must follow policies, procedures, and protocols of the health care agency in which he or she is employed.

VII. Evidence-Based Practice A. Research is an im portan t ro le of th e profession al

n urse. Research provides a foun dation for im prove- m en t in n ursin g practice.

B. Eviden ce-based practice is an ap proach to clien t care in wh ich th e n urse in tegrates th e clien t’s preferen ces, clin ical exp ertise, an d th e best research eviden ce to deliver quality care.

C. Determ in in g th e clien t’s perso n al, social, cultural, an d religious preferen ces en sures in dividualization an d is a com po n en t of im plem en tin g eviden ce- based practice.

D. Th e n urse n eeds to be an observer an d iden tify an d question situation s th at require ch an ge or result in a less th an desirable outcom e.

E. Use of in form ation tech n ology such as on lin e resources, in cludin g research publication s, provid es curren t research fin din gs related to areas of practice.

F. Th e n urse n eeds to follo w eviden ce-based practice protoco ls developed by th e in stitution an d question th e ration ale for n ursin g approach es id en tified in th e protoco ls as n ecessary. Th e n urse sh o uld use appro- priate evaluation criteria wh en determ in in g areas in n eed of research ( Table 7-2).

Evidence-based practice requires that the nurse base nursing practice on the best and most applicable evidence from clinical research studies. The nurse should also be alert to clinical issues that warrant inves- tigation and develop a researchable problem about the issue.

VIII. Quality Improvement A. Also kn own as perform an ce im provem en t, quality

im provem en t focuses on processes or system s th at sign ifican tly con tribu te to clien t safety an d effective clien t care outcom es; criteria are used to m on itor

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BOX 7-4 Types of Power Rewa rd: Ability to provide incentives Coercive: Ability to punish Referent : Based on attraction Expert: Based on having an expert knowledge foundation and

skill level Legit ima t e: Based on a position in society Persona l: Derived from a high degree of self-confidence Informa tiona l: When one person provides explanations why

another should behave in a certain way

62 UNIT II Professional Standards in Nursing

outcom es of care an d to determ in e th e n eed for ch an ge to im prove th e quality of care.

B. Q uality im provem en t processes or system s m ay be n am ed quality assuran ce, con tin uous quality management, or con tin uo us quality im provem en t.

C. When quality im provem en t is part of th e ph ilosoph y of a h ealth care agen cy, every staff m em ber becom es in volved in ways to im prove clien t care an d outcom es.

D. A retrospective (“lookin g back”) audit is an evalua- tion m eth od used to in spect th e m edical record after th e clien t’s disch arge for docum en tation of com pli- an ce with th e stan dards.

E. A con curren t (“at th e sam e tim e”) audit is an evalu- ation m eth od used to in spect com plian ce of n urses with predeterm in ed stan d ards an d criteria wh ile th e n urses are providin g care durin g th e clien t’s stay.

F. Peer review is a process in wh ich n urses em ployed in an organ ization evalu ate th e quality of n ursin g care delivered to th e clien t.

G. Th e quality im provem en t process is sim ilar to th e n ursin g process an d in volves an in terp rofession al approach .

H. An outcom e describes th e m ost positive respon se to care; com parison of clien t respon ses with the expected outcom es in dicates wh eth er th e in terven tion s are effective, wh eth er th e clien t h as progressed, h ow well stan dards are m et, an d wheth er ch an ges are n ecessary.

I. Th e n urse is respon sible for recogn izin g tren ds in n urs- in g practice, iden tifyin g recurren t problem s, an d in iti- atin g opportunities to im prove the quality of care.

Quality improvement processes improve the quality of care delivery to clients and the safety of health care agencies.

IX. Change Process A. Ch an ge is a dyn am ic process th at leads to an alter-

ation in beh avior. 1. Lewin ’s basic con cept of th e ch an ge process

in cludes 3 elem en ts for successful ch an ge: un freezin g, m ovin g an d ch an gin g, an d refreezin g (Fig. 7-1). a. Un freezin g is th e first ph ase of th e process,

durin g wh ich th e problem is iden tified an d in dividuals in volved gath er facts an d evi- den ce supportin g a basis for ch an ge.

b . Du rin g th e m ovin g an d ch an gin g ph ase, ch an ge is plan n ed an d im plem en ted.

c. Refreezin g is th e last ph ase of th e process, durin g wh ich th e ch an ge beco m es stabilized.

2. Leadership style in fluen ces th e approach to in iti- atin g th e ch an ge process.

B. Types of ch an ge 1. Plan n ed ch an ge: A deliberate effort to im prove a

situation 2. Un plan n ed ch an ge: Ch an ge th at is un predictable

but is ben eficial an d m ay go un n oticed C. Resistan ce to ch an ge ( Box 7-5)

1. Resistan ce to ch an ge occurs wh en an in dividual rejects propo sed n ew ideas with ou t critically th in kin g about th e propo sal.

2. Ch an ge requires en ergy. 3. Th e ch an ge process does n ot guaran tee positive

outcom es. D. O vercom in g barriers

1. Create a flexible an d ad aptable en viron m en t. 2. En cou rage th e peo ple in volved to plan an d set

goals for ch an ge. 3. In clude all in volved in th e plan for ch an ge. 4. Focus on th e ben efits of th e ch an ge in relation to

im provem en t of clien t care. 5. Delin eate th e drawb acks from failin g to m ake th e

ch an ge in relation to clien t care. 6. Evaluate th e ch an ge process on an on go in g basis,

an d keep everyon e in form ed of progress. 7. Provide positive feed back to all in volved. 8. Com m it to th e tim e it takes to ch an ge.

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TABLE 7-2 Evaluation Criteria for Evidence for Clinical Questions

Level Definition

Level I Evidence comes from a review of a number of randomized controlled trials (RCTs) or from clinical practice guidelines that are based on such a review.

Level II Evidence comes from at least one well-designed RCT.

Level III Evidence comes from well-designed controlled studies that are not randomized.

Level IV Evidence comes from well-designed case-controlled and cohort studies.

Level V Evidence comes from a number of descriptive or qualitative studies.

Level VI Evidence comes from a single descriptive or qualitative study.

Level VII Evidence comes from the opinion of authorities and/ or reports of expert committees.

From Zerwekh J, Zerwekh Garneau A: Nursing today: transition and trends, ed 8, Philadelphia, 20 15, Saunders. Data from Sackett D et al.: Evidence-based medicine: how to practice and teach EBM, London, 200 0 , Churchill Livingstone.

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FIGURE 7-1 Elements of a successful change.

63CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

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X. Conflict A. Con flict arises from a percep tion of in com patibility

or differen ce in beliefs, attitu des, values, goals, prior- ities, or decision s.

B. Types of co n flict 1. In trap erson al: O ccurs with in a person 2. In terperson al: O ccurs between an d am on g cli-

en ts, n urses, or oth er staff m em bers 3. O rgan ization al: O ccurs wh en an em ployee con -

fron ts th e policies an d proced ures of th e organ ization

C. Mod es of co n flict resolutio n 1. Avoidan ce

a . Avoiders are un assertive an d un cooperative. b . Avoiders do n ot pursue th eir own n eeds,

goals, or con cern s, an d th ey do n ot assist oth ers to pursue th eirs.

c. Avoiders postp on e dealin g with th e issue. 2. Accom m odation

a . Accom m odators n eglect th eir own n eeds, goals, or con cern s (un assertive) wh ile tryin g to satisfy th o se of oth ers.

b . Accom m odators obey an d serve oth ers an d often feel resen tm en t an d disappo in tm en t because th ey “get n oth in g in return .”

3. Com p etition a . Com p etitors pursue th eir own n eeds an d

goals at th e expen se of oth ers. b . Com p etitors also m ay stan d up for righ ts an d

defen d im portan t prin ciples. 4. Com p rom ise

a . Com p rom isers are assertive an d cooperative. b . Com p rom isers work creatively an d open ly to

fin d th e solution th at m ost fully satisfies all im portan t goals an d con cern s to be ach ieved.

XI. Roles of Health Care Team Members A. Nurse roles are as follows:

1. Prom o te h ealth an d preven t disease 2. Provid e com fo rt an d care to clien ts 3. Make decision s 4. Act as clien t advocate 5. Lead an d m an age th e n ursin g team 6. Serve as case m an ager 7. Fun ction as a reh abilitator 8. Com m un icate effectively 9. Educate clien ts, fam ilies, an d co m m un ities an d

h ealth care team m em bers 10. Act as a resou rce person 11. Allocate resources in a cost-effective m an n er

B. Health care provider (HCP): An HCP diagn oses an d treats disease.

C. HCP assistan t 1. An HCP assistan t (also kn own as ph ysician assis-

tan t) acts to a lim ited exten t in th e ro le of th e HCP durin g th e HCP’s ab sen ce.

2. Th e HCP assistan t con ducts ph ysical exam in a- tion s, perform s diagn ostic proced ures, assists in th e operatin g room an d em ergen cy departm en t, an d perform s treatm en ts.

3. Certified an d licen sed HCP assistan ts in som e states h ave prescriptive powers.

D. Nurse practition er: an advan ced practice registered n urse (APRN) wh o is edu cated to diagn ose an d treat acute illn ess an d ch ron ic con dition s; h ealth prom o - tion an d m ain ten an ce is a focus.

E. Ph ysical th erapist: A ph ysical th erapist assists in exam in in g, testin g, an d treatin g ph ysically disabled clien ts.

F. O ccupation al th erap ist: An occupation al th erap ist develo ps ad aptive devices th at h elp ch ron ically ill or h an dicap ped clien ts to perform activities of daily livin g.

G. Respiratory th erapist: A respiratory th erapist delivers treatm en ts design ed to im prove th e clien t’s ven tila- tion an d oxygen ation status.

H. Speech th erapist: A speech th erapist evaluates a cli- en t’s ability to swallow safely an d effectively an d com m un icates a plan to im prove a clien t’s swallow- in g ability.

I. Nutrition ist: A n utrition ist or dietitian assists in plan n in g dietary m easures to im prove or m ain tain a clien t’s n utrition al status.

J. Con tin uin g care n urse: Th is n urse coordin ates dis- ch arge plan s for th e clien t.

K. Assistive perso n n el, in cludin g un licen sed assistive person n el an d clien t care tech n ician s, h elp th e regis- tered n urse with specified tasks an d fun ctio n s.

L. Ph arm acist: A ph arm acist form ulates an d dispen ses m edication s.

M. Social worker: A social worker coun sels clien ts an d fam ilies ab out h om e care services an d assists th e con - tin uin g care n urse with plan n in g disch arge.

BOX 7-5 Reasons for Resisting Change

Conformity One goes along with others to avoid conflict.

Dissimilar Beliefs and Values Differences can impede positive change.

Habit Routine, set behaviors are often hard to change.

Secondary Gains Benefits or payoff are present, so there is no incentive to change.

Threats to Satisfying Basic Needs Change may be perceived as a threat to self-esteem, security, or survival.

Fear One fears failure or has fear of the unknown.

64 UNIT II Professional Standards in Nursing

N. Ch aplain : A ch aplain (or train ed layperson ) offers spiritual support an d guid an ce to clien ts an d fam ilies.

O. Adm in istrative staff: Adm in istrative or support staff m em bers organ ize an d sch edule diagn ostic tests an d procedures an d arran ge for services n eeded by th e clien t an d fam ily.

XII. Interprofessional Collaboration A. Clien t care plan n in g can be accom plish ed th rough

referrals to or con sultatio n s or interprofessional col- laborations with oth er h ealth care specialists an d th rou gh clien t care con feren ces, wh ich in volve m em - bers from all h ealth care disciplin es. Th is approach h elp s to en sure con tin uity of care.

B. Repo rts 1. Repo rts sh ould be factu al, accurate, curren t,

com plete, an d organ ized. 2. Repo rts sh ould in clude essen tial backgroun d

in form ation , subjective data, objective data, an y ch an ges in th e clien t’s status, clien t problem s or n ursin g diagn oses as appropriate, treatm en ts an d procedures, m edication adm in istration , cli- en t teach in g, disch arge plan n in g, fam ily in for- m ation , th e clien t’s respon se to treatm en ts an d procedures, an d th e clien t’s prio rity n eeds.

3. Ch an ge of sh ift report a. Th e report facilitates co n tin uity of care

am on g n urses wh o are respon sible for a clien t.

b . Th e report m ay be written , oral, au diotaped, or provid ed durin g walkin g roun ds at th e cli- en t’s bedside.

c. Th e report describes th e clien t’s h ealth status an d in form s th e n urse on th e n ext sh ift ab out th e clien t’s n eeds an d priorities for care.

4. Teleph on e reports a. Purpo ses in clude in form in g an HCP of a cli-

en t’s ch an ge in status, com m un icatin g in for- m ation about a clien t’s tran sfer to or from an oth er un it or facility, an d obtain in g results of laborato ry or diagn ostic tests.

b . Th e teleph o n e report sh ould be docum en ted an d sh ould in clude wh en th e call was m ade, wh o m ade th e call, wh o was called, to wh o m in form ation was given , wh at in form ation was given , an d wh at in form ation was received.

5. Tran sfer reports a. Tran sferrin g n urse reports provide con tin uity

of care an d m ay be given by telep h on e or in perso n ( Box 7-6).

b . Receivin g n urse sh o uld repeat tran sfer in for- m ation to en sure clien t safety an d ask ques- tio n s to clarify in form ation about th e clien t’s status.

6. Situ ation , Backgrou n d, Assessm en t, Recom m en - dation (SBAR)

a. SBAR is a structured an d stan dard ized com - m un ication tech n iqu e th at im proves com - m un ication am on g team m em bers wh en sh arin g in form ation on a clien t.

b . SBAR in cludes up-to -date in form ation ab out th e clien t’s situation , associated backgroun d in form ation , assessm en t data, an d recom - m en dation s for care, such as treatm en ts, m ed- ication s, or services n eeded.

XIII. Interprofessional Consultation A. Con sultation is a process in wh ich a specialist is

sough t to iden tify m eth od s of care or treatm en t plan s to m eet th e n eeds of a clien t.

B. Con sultation is n eeded wh en th e n urse en coun ters a problem th at can n ot be solved usin g n ursin g kn owl- edge, skills, an d available resources.

C. Con sultation also is n eeded wh en th e exact problem rem ain s un clear; a con sultan t can objectively an d m ore clearly assess an d iden tify th e exact n ature of th e problem .

D. Rapid respo n se team s are bein g developed with in h ospitals to provide n ursin g staff with in tern al con - sultative services provided by expert clin ician s.

E. Rapid respon se team s are used to assist n ursin g staff with early detection an d resolution of clien t problem s.

F. Medication recon ciliation in cludes collabo ration am on g th e clien t, HCPs, n urses, an d ph arm acists to en sure m ed ication accuracy wh en clien ts experi- en ce ch an ges in h ealth care settin gs or levels of care or are tran sferred fro m on e care un it to an oth er, an d upon disch arge ( Box 7-7).

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BOX 7-6 Transfer Reports ▪ Client’s name, age, health care provider, and diagnoses ▪ Current health status and plan of care ▪ Client’s needs and priorities for care ▪ Any assessments or interventions that need to be per-

formed after transfer, such as laboratory tests, medication administration, or dressing changes

▪ Need for any special equipment ▪ Additional considerations such as allergies, resuscitation

status, precautionary considerations, cultural or religious issues, or family issues

BOX 7-7 Process for Medication Reconciliation 1. Obtain a list of current medications from the client. 2. Develop an accurate list of newly prescribed medications. 3. Compare new medications to the list of current medications. 4. Identify and investigate any discrepancies and collaborate

with the health care provider as necessary. 5. Communicate the finalized list with the client, caregivers,

health care provider, and other team members.

From Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby.

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XIV. Discharge Planning A. Disch arge plan n in g begin s wh en th e clien t is adm it-

ted to th e h ospital or h ealth care facility. B. Disch arge plan n in g is an in terprofession al process that

en sures that th e clien t h as a plan for con tin uin g care after leavin g the h ealth care facility an d assists in th e clien t’s tran sition from on e en viron m en t to an oth er.

C. All caregivers n eed to be in volved in disch arge plan - n in g, an d referrals to oth er HCPs or agen cies m ay be n eeded. An HCP’s prescription m ay be n eeded for th e referral, an d th e referral n eeds to be approved by th e clien t’s h ealth care in surer.

D. Th e n urse sh o uld an ticipate th e clien t’s disch arge n eeds an d m ake th e referral as soon as possible (in vo lvin g th e clien t an d fam ily in th e referral process).

E. Th e n urse n eeds to educate th e clien t an d fam ily regardin g care at h om e ( Box 7-8).

XV. Delegation and Assignments A. Delegation

1. Delegation is a process of tran sferrin g perfor- m an ce of a selected n ursin g task in a situation to an in dividual wh o is com peten t to perform th at specific task.

2. Delegation in volves ach ievin g outcom es an d sh arin g activities with oth er in dividuals wh o h ave th e auth ority to acco m plish th e task.

3. Th e n urse practice act an d an y practice lim ita- tion s (in stitution al policies an d procedures, an d job description s of person n el provided by th e in stitutio n ) defin e wh ich aspects of care can be delegated an d wh ich m ust be perform ed by a registered n urse.

4. Even th o ugh a task m ay be delegated to som e- on e, th e n urse wh o delegates m ain tain s account- ability for th e task.

5. O n ly th e task, n ot th e ultim ate accoun tability, m ay be delegated to an oth er.

6. Th e 5 righ ts of delegation in clude th e righ t task, righ t circum stan ces, righ t perso n , righ t direction / com m un ication , an d righ t supervision / evaluation .

The nurse delegates only tasks for which he or she is responsible. The nurse who delegates is accountable for the task; the person who assumes responsibility for the task is also accountable.

B. Prin ciples an d gu idelin es of delegatin g ( Box 7-9) C. Assign m en ts

1. Assign m en t is th e tran sfer of perform an ce of cli- en t care activities to specific staff m em bers.

2. Guidelin es for clien t care assign m en ts a . Always en sure clien t safety. b . Be aware of in dividual variatio n s in work

abilities. c. Determ in e wh ich tasks can be delegated an d

to wh om . d . Match th e task to th e delegatee on th e basis of

th e n urse practice act an d an y practice lim ita- tion s (in stitution al policies an d procedures, an d job description s of perso n n el provided by th e in stitutio n ).

e. Provid e direction s th at are clear, con cise, accu rate, an d com plete.

f. Validate th e delegatee’s un derstan din g of th e direction s.

g. Com m un icate a feelin g of con fiden ce to th e delegatee, an d provide feedback prom ptly after th e task is perform ed.

BOX 7-8 Discharge Teaching ▪ How to administer prescribed medications ▪ Side and adverse effects of medications that need to be

reported to the health care provider (HCP) ▪ Prescribed dietary and activity measures ▪ Complications of the medical condition that need to be

reported to the HCP ▪ How to perform prescribed treatments ▪ How to use special equipment prescribed for the client ▪ Schedule for home care services that are planned ▪ How to access available community resources ▪ When to obtain follow-up care

BOX 7-9 Principles and Guidelines of Delegating

▪ Delegate the right task to the right delegatee. Be familiar with the experience of the delegatees, their scopes of prac- tice, their job descriptions, agency policy and procedures, and the state nurse practice act.

▪ Provide clear directions about the task and ensure that the delegatee understands the expectations.

▪ Determine the degree of supervision that may be required. ▪ Provide the delegatee with the authority to complete the

task; provide a deadline for completion of the task. ▪ Evaluate the outcome of care that has been delegated. ▪ Provide feedback to the delegatee regarding his or her

performance. ▪ In general, noninvasive interventions, such as skin care,

range-of-motion exercises, ambulation, grooming, and hygiene measures, can be assigned to the unlicensed assistive personnel (UAP).

▪ In general, a licensed practical nurse (LPN) or licensed vocational nurse (LVN) can perform not only the tasks that a UAP can perform, but also certain invasive tasks, such as dressing changes, suctioning, urinary catheterization, and medication administration (oral, subcutaneous, intramus- cular, and selected piggyback medications), according to the education and job description of the LPN or LVN. The LPN or LVN can also review with the client teaching plans that were initiated by the registered nurse.

▪ A registered nurse can perform the tasks that an LPN or LVN can perform and is responsible for assessment and planning care, initiating teaching, and administering med- ications intravenously.

66 UNIT II Professional Standards in Nursing

h . Main tain con tin uity of care as m uch as possi- ble wh en assign in g clien t care.

XVI. Time Management A. Description

1. Tim e m an agem en t is a tech n iqu e design ed to assist in co m pletin g tasks with in a defin ite tim e period.

2. Learn in g h ow, wh en , an d wh ere to use on e’s tim e an d establish in g person al go als an d tim e fram es are part of tim e m an agem en t.

3. Tim e m an agem en t requires an ability to an tici- pate th e day’s activities, to com bin e activities wh en possible, an d to n ot be in terrup ted by n on - essen tial activities.

4. Tim e m an agem en t in volves efficien cy in com - pletin g tasks as quickly as possible an d effective- n ess in decidin g on th e m ost im portan t task to do (i.e., prioritizing) an d doin g it correctly.

B. Prin ciples an d guidelin es 1. Iden tify tasks, obligation s, an d activities an d

write th em down . 2. O rgan ize th e workday; iden tify wh ich tasks m ust

be com pleted in specified tim e fram es. 3. Prioritize clien t n eeds acco rdin g to im portan ce. 4. An ticipate th e n eeds of th e day an d provide tim e

for un exp ected an d un plan n ed tasks th at m ay arise.

5. Focus on begin n in g th e daily tasks, workin g on th e m ost im portan t first wh ile keepin g goals in m in d; look at th e fin al goal for th e day, wh ich h elps in th e breakd own of tasks in to m an ageable parts.

6. Begin clien t roun ds at th e begin n in g of th e sh ift, collectin g data on each assign ed clien t.

7. Delegate tasks wh en appropriate. 8. Keep a daily h our-by-h our lo g to assist in provid-

in g structure to th e tasks th at m ust be accom - plish ed, an d cross tasks off th e list as th ey are acco m plish ed.

9. Use h ealth care agen cy resources wisely, an tici- patin g resource n eeds, an d gath er th e n ecessary supp lies before begin n in g th e task.

10. O rgan ize paperwo rk an d co n tin uou sly docu- m en t task com pletion an d n ecessary clien t data th rou gh ou t th e day (i.e., docum en tation sh ould be con cu rren t with com pletion of a task or obser- vation of pertin en t clien t data).

11. At th e en d of th e day, evaluate th e effectiven ess of tim e m an agem en t.

XVII. Prioritizing Care A. Prio ritizin g is decidin g wh ich n eeds or problem s

require im m ediate action an d wh ich on es could tol- erate a delay in respon se un til a later tim e because th ey are n ot urgen t.

B. Guidelin es for prioritizin g (Box 7-10)

C. Settin g priorities for clien t teach in g 1. Determ in e th e clien t’s im m ediate learn in g n eeds. 2. Review th e learn in g objectives establish ed for th e

clien t. 3. Determ in e wh at th e clien t perceives as

im portan t. 4. Assess th e clien t’s an xiety level an d th e tim e avail-

able to teach . D. Prioritizin g wh en carin g for a group of clien ts

1. Iden tify th e problem s of each clien t. 2. Review th e problem s an d an y n ursin g diagn oses. 3. Determ in e wh ich clien t problem s are m ost

urgen t based on basic n eeds, th e clien t’s ch an g- in g or un stable status, an d com plexity of th e cli- en t’s problem s.

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BOX 7-10 Guidelines for Prioritizing ▪ The nurse and the client mutually rank the client’s needs in

order of importance based on the client’s preferences and expectations, safety, and physical and psychological needs; what the client sees as his or her priority needs may be dif- ferent from what the nurse sees as the priority needs.

▪ 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 client’s ill- ness or prognosis are low priorities.

▪ When providing care, the nurse needs to decide which needs or problems require immediate action and which ones could be delayed until a later time because 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 con- straints and available resources.

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

▪ The nurse can use the ABCs—airway–breathing–circula- tion—as a guide when determining priorities; client needs related to maintaining a patent airway are always the priority.

▪ If cardiopulmonary resuscitation (CPR) is necessary, the order of priority is CAB—compressions–airway–breath- ing—this is the exception to using the ABCs when determin- ing priorities.

▪ The nurse can use Maslow’s Hierarchy of Needs theory as a guide to determine priorities and to 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, remembering that assess- ment is the first step of the nursing process.

67CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

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4. An ticipate th e tim e th at it m ay take to care for th e prio rity n eeds of th e clien ts.

5. Com b in e activities, if possib le, to resolve m ore th an 1 problem at a tim e.

6. In vo lve th e clien t in h is or h er care as m uch as possible (see Prio rity Nu rsin g Actio n s).

Use the ABCs (airway–breathing–circulation), Maslow’s Hierarchy of Needs theory, and the steps of the nursing process (assessment is first) to prioritize. Also consider the acuity level of clients when applying these guidelines. If cardiopulmonary resuscitation (CPR) needs to be initiated, use CAB (compressions– airway–breathing) as the priority guideline.

XVIII. Disasters and Emergency Response Planning A. Description

1. A disaster is an y h um an -m ade or n atural even t th at cau ses destructio n an d devastation th at can - n ot be alleviated with ou t assistan ce ( Box 7-11).

2. In tern al disasters are disasters th at occur with in a h ealth care agen cy (e.g., h ealth care agen cy fire, structural collapse, radiation spill), wh ereas

extern al disasters are disasters th at occur outside th e h ealth care agen cy (e.g., m ass tran sit acciden t th at could sen d h un dreds of victim s to em er- gen cy departm en ts) .

3. A multi-casualty even t in volves a lim ited n um ber of victim s or casualties an d can be m an aged by a h ospital with available resou rces; a mass casualty event in volves a n um ber of casualties th at exceed s th e resou rce capab ilities of th e h ospital, an d is also kn own as a disaster.

4. An em ergen cy respon se plan is a form al plan of action for coordin atin g th e respon se of the h ealth care agen cy staff in th e event of a disaster in th e h ealth care agen cy or surroun din g com m un ity.

B. Am erican Red Cross (ARC) 1. Th e ARC h as been given auth o rity by th e federal

govern m en t to provide disaster relief. 2. All ARC disaster relief assistan ce is free, an d local

offices are located across th e Un ited States. 3. Th e ARC participates with th e govern m en t in

developin g an d testin g com m un ity disaster plan s.

4. Th e ARC iden tifies an d train s person n el for em ergen cy respon se.

5. Th e ARC works with busin esses an d labor orga- n ization s to iden tify resou rces an d in dividuals for disaster work.

6. Th e ARC edu cates th e public about ways to pre- pare for a disaster.

PRIORITY NURSING ACTIONS Assessing a Group of Clients in Order of Priority The nurse is assigned to the following clients. The order of priority in assessing the clients is as follows:

1. A client with heart failure who has a 4-lb weight gain since yesterday and is experiencing shortness of breath

2. A24-hour postoperative client who had a wedge resection of the lung and has a closed chest tube drainage system

3. A client admitted to the hospital for observation who has absent bowel sounds

4. A client who is undergoing surgery for a hysterectomy on the following day

The nurse determines the order of priority by considering the needs of the client. The nurse also uses guidelines for pri- oritizing, such as the ABCs—airway–breathing–circulation— Maslow’s Hierarchy of Needs theory, and the steps of the nursing process. Clients 1 and 2 have conditions that relate to the cardiac system or respiratory system. These clients are the high priorities. Client 1 is the first priority because this cli- ent is experiencing shortness of breath (life-threatening). There is no indication that client 2 is experiencing any diffi- culty. Because client 4 is scheduled for surgery on the follow- ing day, this client would be the last priority (low priority), and the nurse would assess this client and prepare this client for surgery after other clients are assessed. Because absent bowel sounds could be an indication of a bowel obstruction (intermediate priority), client 3 would be the nurse’s third priority.

References Potter et al. (20 13), pp. 237–238; Zerwekh, Zerwekh Garneau (2015),

pp. 35–36.

BOX 7-11 Types of Disasters

Human-Made Disasters Dam failures resulting in flooding Hazardous substance accidents such as pollution, chemical

spills, or toxic gas leaks Accidents involving release of radioactive material Resource shortages such as food, water, and electricity Structural collapse, fire, or explosions Terrorist attacks such as bombing, riots, and bioterrorism Mass transportation accidents

Natural Disasters Avalanches Blizzards Communicable disease epidemics Cyclones Droughts Earthquakes Floods Forest fires Hailstorms Hurricanes Landslides Mudslides Tidal waves Tornadoes Volcanic eruptions

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7. Th e ARC operates sh elters, provides assistan ce to m eet im m ediate em ergen cy n eeds, an d provides disaster h ealth services, in cludin g crisis coun selin g.

8. Th e ARC h an dles in qu iries fro m fam ily m em bers.

9. Th e ARC coordin ates relief activities with oth er agen cies.

10. Nu rses are in volved directly with th e ARC an d assum e fun ction s such as m an agers, supervisors, an d edu cators of first aid; th ey also participate in em ergen cy respo n se plan s an d disaster relief pro- gram s an d provide services, such as blood collec- tio n drives an d im m un ization program s.

C. HAZMAT (Hazardous Materials) Team 1. HAZMAT team s are typically com po sed of em er-

gen cy departm en t h ealth care providers an d n ursin g staff because th ey will be th e first in di- vidu als to en coun ter th e poten tial exposu re.

2. Mem bers of HAZMAT team s h ave been educated on h ow to recogn ize pattern s of illn ess th at m ay be in dicative of n uclear, biological, an d ch em ical exp osure; protocols for ph arm acological treat- m en t of in fectio us disease agen ts; availability of deco n tam in ation facilities an d perso n al pro- tective gear; safety m easu res; an d th e m eth ods of respo n din g to an exposu re.

D. Ph ases of disaster management 1. Th e Federal Em ergen cy Man agem en t Agen cy

(FEMA) iden tifies 4 disaster m an agem en t ph ases: m itigation , preparedn ess, respon se, an d recovery.

2. Mitigation en com passes th e followin g: a. Action s or m easu res th at can preven t th e

occurren ce of a disaster or reduce th e dam ag- in g effects of a disaster

b . Determ in atio n of th e com m un ity h azards an d com m un ity risks (actual an d poten tial th reats) befo re a disaster occurs

c. Awaren ess of available co m m un ity resources an d com m un ity h ealth perso n n el to facilitate m ob ilization of activities an d m in im ize ch aos an d con fusion if a disaster occurs

d . Determ in atio n of th e resources available for care to in fan ts, older adults, disabled in divid- uals, an d in dividuals with ch ron ic h ealth problem s

3. Preparedn ess en com passes th e followin g: a. Plan s for rescue, evacuation , an d carin g for

disaster victim s b . Plan s for train in g disaster person n el an d

gath erin g resources, equip m en t, an d oth er m aterials n eeded for dealin g with th e disaster

c. Iden tificatio n of specific respo n sibilities for various em ergen cy respon se perso n n el

d . Establish m en t of a com m un ity em ergen cy respo n se plan an d an effective public com - m un ication system

e. Developm en t of an em ergen cy m edical sys- tem an d a plan for activation

f. Verification of proper fun ction in g of em er- gen cy equip m en t

g. Collection of an ticipatory provision s an d cre- ation of a location for providin g food , water, clo th in g, sh elter, oth er supp lies, an d n eeded m ed icin e

h . In ven tory of supplies on a regular basis an d replen ish m en t of outd ated supp lies

i. Practice of com m un ity em ergen cy respo n se plan s (m ock disaster drills)

4. Resp on se en com passes th e followin g: a. Puttin g disaster plan n in g services in to action

an d th e action s taken to save lives an d preven t furth er dam age

b . Prim ary con cern s in clude safety, ph ysical h ealth , an d m en tal h ealth of victim s an d m em bers of th e disaster respon se team

5. Recovery en com p asses th e followin g: a. Actio n s taken to return to a n orm al situation

after th e disaster b . Preven tin g debilitatin g effects an d restorin g

perso n al, econ om ic, an d en viron m en tal h ealth an d stability to th e com m un ity

E. Levels of disaster 1. FEMA iden tifies 3 levels of disaster with FEMA

respo n se (Box 7-12). 2. Wh en a federal em ergen cy h as been declared, th e

federal respo n se plan m ay take effect an d activate em ergen cy support fun ction s.

3. Th e em ergen cy support fun ction s of th e ARC in clude perform in g em ergen cy first aid, sh elter- in g, feed in g, providin g a disaster welfare in for- m ation system , an d coordin atin g bulk distribution of em ergen cy relief supplies.

4. Disaster m edical assistan t team s (team s of spe- cially train ed personn el) can be activated an d sen t to a disaster site to provide triage an d m edical care to victim s un til th ey can be evacuated to a h ospital.

BOX 7-12 Federal Emergency Management Agency (FEMA) Levels of Disaster

Level I Disaster Massive disaster that involves significant damage and results in a presidential disaster declaration, with major federal involvement and full engagement of federal, regional, and national resources

Level II Disaster Moderate disaster that is likely to result in a presidential dec- laration of an emergency, with moderate federal assistance

Level III Disaster Minor disaster that involves a minimal level of damage, but could result in a presidential declaration of an emergency

69CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

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F. Nurse’s ro le in disaster plan n in g 1. Perso n al an d profession al preparedn ess

a . Make person al an d fam ily preparation s ( Box 7-13).

b . Be aware of th e disaster plan at th e place of em p loym en t an d in th e com m un ity.

c. Main tain certification in disaster train in g an d in CPR.

d . Participate in m ock disaster drills, in cludin g a bom b th reat drill.

e. Prepare profession al em ergency response item s, such as a copy of n ursing licen se, personal h ealth care equipm en t such as a steth oscope, cash , warm cloth in g, record-keepin g m aterials, an d other n ursin g care supplies.

2. Disaster respon se a . In th e h ealth care agen cy settin g, if a disaster

occurs, th e agen cy disaster prepared n ess plan (em ergen cy respon se plan ) is activated im m e- diately, an d th e n urse respo n ds by follo win g th e direction s iden tified in th e plan .

b . In th e com m un ity settin g, if th e n urse is th e first respo n der to a disaster, th e n urse cares for th e victim s by atten din g to th e victim s with life-th reaten in g problem s first; wh en res- cue workers arrive at th e scen e, im m ediate plan s for triage sh ould begin .

In the event of a disaster, activate the emergency response plan immediately.

G. Triage 1. In a disaster or war, triage con sists of a brief

assessm en t of victim s th at allows th e n urse to classify victim s acco rdin g to th e severity of th e in jury, urgen cy of treatm en t, an d place for treat- m en t (see Priority Nursin g Actio n s).

BOX 7-13 Emergency Plans and Supplies Plan a meeting place for family members. Identify where to go if an evacuation is necessary. Determine when and how to turn off water, gas, and electricity

at main switches. Locate the safe spots in the home for each type of disaster. Replace stored water supply every 3 months and stored food

supply every 6 months. Include the following supplies:

▪ Backpack, clean clothing, sturdy footwear ▪ Pocket-knife or multi-tool ▪ A 3-day supply of water (1 gallon per person per day) ▪ A 3-day supply of nonperishable food ▪ Blankets/ sleeping bags/ pillows ▪ First-aid kit with over-the-counter medications and

vitamins ▪ Adequate supply of prescription medication ▪ Battery-operated radio ▪ Flashlight and batteries ▪ Credit card, cash, or traveler’s checks ▪ Personal ID card, list of emergency contacts, allergies,

medical information, list of credit card numbers and bank accounts (all sealed in water-tight package)

▪ Extra set of car keys and a full tank of gas in the car ▪ Sanitation supplies for washing, toileting, and dispos-

ing of trash; hand sanitizer ▪ Extra pair of eyeglasses/ sunglasses ▪ Special items for infants, older adults, or disabled

individuals ▪ Items needed for a pet such as food, water, and leash ▪ Paper, pens, pencils, maps ▪ Cell phone ▪ Work gloves ▪ Rain gear ▪ Roll of duct tape and plastic sheeting ▪ Radio and extra batteries ▪ Toiletries (basic daily needs, sunscreen, insect repel-

lent, toilet paper) ▪ Plastic garbage bags and resealable bags ▪ Household bleach for disinfection ▪ Whistle ▪ Matches in a waterproof container

From Ignatavicius D, Workman M: Medical surgical nursing: patient-centered collab- orative care, ed 7, Philadelphia, 2013, Saunders.

PRIORITY NURSING ACTIONS Triaging Victims at the Site of an Accident The nurse is the first responder at the scene of a school bus accident. The nurse triages the victims from highest to low- est priority as follows:

1. Confused child with bright red blood pulsating from a leg wound

2. Child with a closed head wound and multiple compound fractures of the arms and legs

3. Child with a simple fracture of the arm complaining of arm pain

4. Sobbing child with several minor lacerations on the face, arms, and legs

Triage systems identify which victims are the priority and should be treated first. Rankings are based on immediacy of needs, including victims with immediate threat to life requiring immediate treatment (emergent), victims whose injuries are not life-threatening provided that they are treated within 30 minutes to 2 hours (urgent), and victims with sustained local injuries who do not have immediate complications and can wait at least 2 hours for medical treatment (nonurgent). Victim 1 has a wound that is pulsating bright red blood; this indicates arterial puncture. The child is also confused, which indicates the presence of hypoxia and shock (emergent). Victim 2 has sustained multiple traumas, so this victim is also classi- fied as emergent and would require immediate treatment; how- ever, victim 1 is the higher priority because of the arterial puncture. Victim 3 has sustained injuries that are not life- threatening provided that the injuries can be treated in 30 minutes to 2 hours (urgent). Victim 4 has sustained minor injuries that can wait at least 2 hours for treatment (nonurgent).

Reference Perry, Potter, Ostendorf (2014), pp. 327–328.

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2. In an em ergen cy departm en t, triage co n sists of a brief assessm en t of clien ts th at allows th e n urse to classify clien ts accord in g to th eir n eed for care an d establish prio rities of care; th e typ e of illn ess or in jury, th e severity of th e problem , an d th e resou rces available govern th e process.

H. Em ergen cy dep artm en t triage system 1. A com m on ly used ratin g system in an em ergen cy

dep artm en t is a 3-tier system th at uses th e catego- ries of em ergen t, urgen t, an d n on urgen t; th ese categories m ay be id en tified by color codin g or n um bers ( Box 7-14).

2. Th e n urse n eeds to be fam iliar with th e triage sys- tem of th e h ealth care agen cy.

3. Wh en carin g for a clien t wh o h as died, th e n urse n eeds to recogn ize th e im portan ce of fam ily an d cultural an d religious rituals an d provide support to loved on es.

4. O rgan don ation procedures of th e h ealth care agen cy n eed to be addressed if appropriate.

Think survivability. If you are the first responder to a scene of a disaster, such as a train crash, a priority victim is one whose life can be saved.

I. Clien t assessm en t in th e em ergen cy dep artm en t 1. Prim ary assessm en t

a. Th e purpo se of prim ary assessm en t is to iden - tify an y clien t problem th at poses an im m edi- ate or poten tial th reat to life.

b . Th e n urse gath ers in form ation prim arily th rou gh objective data an d, on fin din g an y abn o rm alities, im m ediately in itiates in terven tion s.

c. Th e n urse uses th e ABCs—airway–breath in g– circulation —as a gu ide in assessin g a clien t’s n eeds an d assesses a clien t wh o h as sustain ed a traum atic in ju ry for sign s of a h ead in jury or cervical spin e in jury. If CPR n eeds to be in itiated, use CAB (com pressio n s–airway– breath in g) as th e priority guidelin e.

2. Secon dary assessm en t a. Th e n urse perform s secon dary assessm en t

after th e prim ary assessm en t an d after treat- m en t for an y prim ary problem s iden tified.

b . Secon dary assessm en t iden tifies an y oth er life-th reaten in g problem s th at a clien t m igh t be exp erien cin g.

c. Th e n urse obtain s subjective an d objective data, in cludin g a h isto ry, gen eral overview, vital sign m easu rem en ts, n eurological assess- m en t, pain assessm en t, an d com plete or focused ph ysical assessm en t.

CRITICAL THINKING What Should You Do? Answer: Quality improvement, also known as performance improvement, focuses on processes or systems that signifi- cantly contribute to client safety and effective client care out- comes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the number of intravenous (IV) site infections, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed by evaluation of results based on the evidence-based practice protocols used.

Reference: Zerwekh, Zerwekh Garneau (20 15), pp. 511, 514.

BOX 7-14 Emergency Department Triage

Emergent (Red): Priority 1 (Highest) This classification is assigned to clients who have life- threatening injuries and need immediate attention and con- tinuous evaluation, but have a high probability for survival when stabilized.

Such clients include trauma victims, clients with chest pain, clients with severe respiratory distress or cardiac arrest, clients with limb amputation, clients with acute neurological deficits, and clients who have sustained chemical splashes to the eyes.

Urgent (Yellow): Priority 2 This classification is assigned to clients who require treatment and whose injuries have complications that are not life- threatening, provided that they are treated within 30 minutes to 2 hours; these clients require continuous evaluation every 30 to 60 minutes thereafter.

Such clients include clients with an open fracture with a distal pulse and large wounds.

Nonurgent (Green): Priority 3 This classification is assigned to clients with local injuries who do not have immediate complications and who can wait at least 2 hours for medical treatment; these clients require eval- uation every 1 to 2 hours thereafter. Such clients include cli- ents with conditions such as a closed fracture, minor lacerations, sprains, strains, or contusions.

Note: Some triage systems include tagging a client “Black” if the victim is dead or who soon will be deceased because of severe injuries; these are victims that would not benefit from any care because of the severity of injuries.

From Ignatavicius D, Workm an M: Medical surgical nursing: patient-centered collab- orative care, ed 7, Philadelphia, 20 13, Saunders.

71CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

P R A C T I C E Q U E S T I O N S 26. Th e n urse is assign ed to care for four clien ts. In plan -

n in g clien t roun ds, wh ich clien t sh o uld th e n urse assess first? 1. A postoperative clien t preparin g for disch arge

with a n ew m ed ication 2. A clien t requirin g daily dressin g ch an ges of a

recen t surgical in cision 3. A clien t sch eduled for a ch est x-ray after in sertio n

of a n aso gastric tube 4. A clien t with asth m a wh o requested a breath in g

treatm en t durin g th e previous sh ift

27. Th e n urse em ployed in an em ergen cy departm en t is assign ed to triage clien ts com in g to the em ergen cy departm en t for treatm en t on the even in g shift. Th e n urse sh ould assign p rio rity to wh ich clien t? 1. A clien t co m plain in g of m uscle ach es, a h ead-

ach e, an d h isto ry of seizures 2. A clien t wh o twisted h er an kle wh en rollerblad-

in g an d is requestin g m ed ication for pain 3. A clien t with a m in or laceration on th e in dex fin -

ger sustain ed wh ile cuttin g an eggplan t 4. A clien t with ch est pain wh o states th at h e just ate

pizza th at was m ade with a very spicy sauce

28. A n ursin g graduate is atten din g an agen cy orien tation regardin g the n ursin g m odel of practice im plem en ted in th e h ealth care facility. The n urse is told th at th e n ursin g m odel is a team n ursin g approach . Th e n urse determ in es that which scen ario is ch aracteristic of th e team -based m odel of n ursin g practice? 1. Each staff m em ber is assign ed a specific task for a

grou p of clien ts. 2. A staff m em ber is assign ed to determ in e th e cli-

en t’s n eeds at h om e an d begin disch arge plan n in g.

3. A sin gle registered n urse (RN) is respo n sible for providin g care to a group of 6 clien ts with th e aid of an un licen sed assistive perso n n el (UAP) .

4. An RN leads 2 licen sed practical n urses (LPNs) and 3 UAPs in providin g care to a group of 12 clien ts.

29. Th e n urse h as received th e assign m en t for th e day sh ift. After m akin g in itial ro un ds an d ch eckin g all of th e assign ed clien ts, wh ich clien t sh ould th e n urse plan to care for first? 1. A clien t wh o is am bulatory dem on stratin g

steady gait 2. A postoperative clien t wh o h as just received an

opioid pain m ed ication 3. A clien t sch eduled for ph ysical th erapy for th e

first crutch -walkin g session 4. A clien t with a wh ite blood cell coun t of

14,000 m m 3 (14Â109/ L) an d a tem perature of 38.4 °C

30. Th e n urse is givin g a bed bath to an assign ed clien t wh en an un licen sed assistive perso n n el (UAP) en ters th e clien t’s room an d tells th e n urse th at an oth er assign ed clien t is in pain an d n eeds pain m ed ication . Wh ich is th e m o st ap p ro p riate n ursin g action ? 1. Fin ish th e bed bath an d th en adm in ister th e pain

m edication to th e oth er clien t. 2. Ask th e UAP to fin d out wh en th e last pain m ed-

ication was given to th e clien t. 3. Ask th e UAP to tell th e clien t in pain th at m edica-

tio n will be adm in istered as soon as th e bed bath is com plete.

4. Cover th e clien t, raise th e side rails, tell th e clien t th at you will return sh ortly, an d adm in ister th e pain m edication to th e oth er clien t.

31. Th e n urse m an ager h as im plem en ted a ch an ge in th e m eth od of th e n ursin g delivery system from fun c- tion al to team n ursin g. An un licen sed assistive per- son n el (UAP) is resistan t to th e ch an ge an d is n ot takin g an active part in facilitatin g th e process of ch an ge. Wh ich is th e b est approach in dealin g with th e UAP? 1. Ign ore th e resistan ce. 2. Exert coercion on th e UAP. 3. Provide a positive reward system for th e UAP. 4. Con fron t th e UAP to en courage verbalization of

feelin gs regardin g th e ch an ge.

32. Th e registered n urse is plan n in g th e clien t assign - m en ts for th e day. Wh ich is th e m o st ap p ro p riate assign m en t for an un licen sed assistive perso n n el (UAP)? 1. A clien t requirin g a colostom y irrigation 2. A clien t receivin g con tin uo us tube feedin gs 3. A clien t wh o requires urin e specim en collectio n s 4. A clien t with difficu lty swallowin g food an d

fluids

33. Th e n urse m an ager is discussin g th e facility protoco l in th e even t of a torn ado with th e staff. Wh ich in struction s sh ould th e n urse m an ager in clude in th e discussion ? Select all th at ap p ly.

1. O pen doors to clien t room s. 2. Move beds away from win do ws. 3. Clo se win do w sh ades an d curtain s. 4. Place blan kets over clien ts wh o are con fin ed

to bed . 5. Relocate am bulatory clien ts from th e h all-

ways back in to th eir room s.

34. Th e n urse em p loyed in a lon g-term care facility is plan n in g assign m en ts for th e clien ts on a n ursin g un it. Th e n urse n eeds to assign four clien ts an d h as a licen sed practical (vocation al) n urse an d 3 un licen sed assistive perso n n el (UAPs) on a n ursin g

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team . Wh ich clien t would th e n urse m o st ap p ro p ri- ately assign to th e licen sed practical (vocation al) n urse? 1. A clien t wh o requires a bed bath 2. An older clien t requirin g frequen t am bulation 3. A clien t wh o requires h ou rly vital sign

m easu rem en ts 4. A clien t requirin g ab dom in al woun d irrigation s

an d dressin g ch an ges every 3 h ou rs

35. Th e ch arge n urse is plan n in g th e assign m en t for th e day. Wh ich facto rs sh ould th e n urse rem ain m in dful of wh en plan n in g th e assign m en t? Select all th at ap p ly.

1. Th e acu ity level of th e clien ts 2. Specific requests from th e staff 3. Th e clusterin g of th e room s on th e un it 4. Th e n um ber of an ticip ated clien t disch arges 5. Clien t n eeds an d workers’ n eeds an d abilities

A N S W E R S 26. 4 Ra t ion a le: Airway is always th e h igh est prio rity, an d th e n u rse wo uld atten d to th e clien t with asth m a wh o req u ested a breath - in g treatm en t du rin g th e p revio us sh ift. Th is cou ld in d icate th at th e clien t was experien cin g d ifficulty b reath in g. Th e clien ts described in o ption s 1, 2, an d 3 h ave n eed s th at wou ld be id en - tified as in term ed iate p riorities. Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d , first. Use th e ABCs—a ir wa y, b r ea t h in g, a n d cir cu la t io n —to an swer th e qu estio n . Rem em b er th at airway is always th e h igh est p rio rity. Th is will direct yo u to th e correct o ptio n . Review: Pr io r it izin g gu id elin es Level of Cogn it ive Ability: An alyzin g Clien t Needs: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Process—Plan n in g Con t en t Ar ea : Lead ersh ip / Man agem en t—Prio ritizin g Pr ior ity Con cepts: Care Co ordin ation ; Clin ical Jud gm en t Refer en ces: Jarvis (2016), p p. 4–5; Po tter et al. (2013), pp . 838–840.

27. 4 Ra t ion a le: In an em ergen cy d ep artm en t, triage in volves brief clien t assessm en t to classify clien ts accordin g to th eir n eed for care an d in cludes establish in g p riorities o f care. Th e type o f ill- n ess o r in jury, th e severity o f th e problem , an d th e resou rces availab le govern th e p ro cess. Clien ts with traum a, ch est p ain , severe respirato ry d istress or card iac arrest, lim b am putation , an d acu te n eu ro lo gical deficits, or wh o h ave sustain ed ch em ical splash es to th e eyes, are classified as em ergen t and are th e n um ber-1 p riority. Clien ts with con dition s such as a sim p le frac- ture, asth m a with out respiratory distress, fever, h yp erten sion , abd om in al p ain , o r a ren al ston e h ave urgen t n eeds and are clas- sified as a n um b er-2 priority. Clien ts with con dition s such as a m in o r laceration , sprain , o r cold sym p tom s are classified as n on - urgen t an d are a n um ber-3 priority. Test -Ta kin g St r a t egy: No te th e st r a t egic wo r d , priority. Use th e ABCs—a ir wa y, b r ea t h in g, a n d cir cu la t io n —to direct yo u to th e co rrect op tion . A clien t experien cin g ch est p ain is always classified as Prio rity 1 u n til a m yo cardial in farctio n h as been ruled o ut. Review: Th e t r ia ge classificatio n system Level of Cogn it ive Ability: An alyzin g Clien t Needs: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Lead ersh ip / Man agem en t—Triage Pr ior ity Con cepts: Care Co ordin ation ; Clin ical Jud gm en t Refer en ce: Jarvis (2016), p p. 4–5.

28. 4 Ra t ion a le: In team n u rsin g, n ursin g p erso n n el are led b y a reg- istered n urse lead er in p ro vidin g care to a grou p o f clien ts. O p tion 1 id en tifies fu n ctio n al n ursin g. O p tion 2 id en tifies a co m p on en t o f case m an agem en t. O ption 3 iden tifies prim ary n ursin g (relation sh ip -based practice). Test -Ta kin g St r a t egy: Focus o n th e su b ject , team n ursin g. Keep th is su b ject in m in d an d select th e op tio n th at b est d escrib es a team app ro ach . Th e co rrect op tion is th e on ly o n e th at iden tifies th e con cep t of a team app ro ach . Review: Th e vario u s types of n u r sin g d eliver y syst em s Level of Cogn it ive Ability: App lyin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Pro cess—Plan n in g Con t en t Ar ea : Lead ersh ip/ Man agem en t—Delegatin g Pr ior ity Con cepts: Care Coo rd in ation ; Co llab oration Refer en ce: Hu ber (2014), pp . 263, 265–266.

29. 4 Ra tion a le: Th e n urse sh ould p lan to care for th e clien t wh o h as an elevated white b lood cell coun t an d a fever first b ecau se this cli- ent’s n eeds are the p riority. Th e clien t wh o is am bulatory with stead y gait an d the clien t sch ed uled for ph ysical th erapy for a cru tch -walkin g session do n ot h ave priority n eeds. Waitin g for p ain m edication to take effect b efore providin g care to th e p ost- o perative clien t is b est. Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d , first, an d use p rin ciples related to prioritizin g. Recallin g th e n o rm al wh ite b lo od cell co un t is 5000–10,000 m m 3 (5–10 Â 109/ L) an d th e n orm al tem p eratu re ran ge 97.5 °F to 99.5 °F ( 36.4 °C to 37.5 °C) will direct yo u to th e correct o ptio n . Review: Th e prin cip les related to p r io r it izin g gu id elin es Level of Cogn it ive Ability: An alyzin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Pro cess—Plan n in g Con t en t Ar ea : Lead ersh ip/ Man agem en t—Prio ritizin g Pr ior ity Con cepts: Care Coo rd in ation ; Clin ical Ju d gm en t Refer en ces: Po tter et al. (2013), pp . 838–840; Zerwekh , Zer- wekh Garn eau (2015), pp. 35–36.

30. 4 Ra t ion a le: Th e n urse is resp on sible for th e care p ro vided to assign ed clien ts. Th e ap pro priate actio n in th is situatio n is to p ro vid e safety to th e clien t wh o is receivin g th e bed b ath an d p repare to adm in ister th e pain m edicatio n . O ption s 1 an d 3 d elay th e ad m in istration o f m ed ication to th e clien t in p ain . O p tion 2 is n ot a resp on sibility of th e UAP. Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d s, most appropri- ate, an d u se prin cip les related to prio rities of care. O ption s 1

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73CHAPTER 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning

an d 3 are co m p a r a b le o r a lik e an d d elay th e adm in istratio n o f p ain m edication , an d o p tion 2 is n ot a respo n sib ility o f th e UAP. Th e m ost app rop riate actio n is to p lan to ad m in ister th e m edicatio n . Review: Prin ciples related to p r io r it izin g ca r e Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip/ Man agem en t—Prioritizin g Pr ior it y Con cept s: Care Co o rd in atio n ; Clin ical Ju dgm en t Refer en ce: Po tter et al. (2013), p . 784.

31. 4 Ra tion a le: Con fron tatio n is an im portan t strategy to m eet resis- tan ce h ead-on . Face-to -face m eetin gs to con fron t th e issue at h an d will allow verbalizatio n of feelin gs, iden tificatio n of pro b- lem s and issu es, an d developm en t o f strategies to solve the pro b- lem . O ption 1 will n ot add ress th e p ro blem . O ption 2 m ay p ro du ce add itio n al resistan ce. O ptio n 3 m ay p ro vide a tem po - rary solu tion to th e resistan ce, b ut will n ot address th e con cern specifically. Test-Ta kin g Str a tegy: No te th e st r a t egic wo r d , best. O ptio n s 1 an d 2 can be elim in ated first b ecau se of th e words ignore in o ptio n 1 an d coercion in o ption 2. From th e rem ain in g o ptio n s, select th e correct o ption o ver o ptio n 3 b ecause th e correct o ptio n sp ecifically ad dresses p ro blem -so lvin g m easures. Review: Resist a n ce t o ch a n ge Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip/ Man agem en t—Eth ical/ Legal Pr ior it y Con cept s: Lead ersh ip ; Pro fessio n alism Refer en ce: Hub er (2014), p p. 38, 46–47.

32. 3 Ra tion a le: Th e n u rse m ust determ in e th e m o st ap prop riate assign m en t b ased o n th e skills of th e staff m em b er an d th e n eeds o f th e clien t. In th is case, th e m o st ap prop riate assign - m en t fo r th e UAP wo uld b e to care for th e clien t wh o req uires u rin e specim en co llection s. Th e UAP is skilled in th is p ro ce- d ure. Co losto m y irrigation s an d tub e feed in gs are n ot per- fo rm ed b y UAPs b ecau se th ese are in vasive proced ures. Th e clien t with d ifficulty swallowin g foo d an d flu id s is at risk fo r asp iratio n . Test-Ta kin g St r a t egy: Note th e st r a t egic wo r d s, most appropri- ate, an d n o te th e su b ject , an assign m en t to th e UAP. Elim in ate o ptio n 4 first because o f th e wo rd s difficulty swallowing. Next, elim in ate o ption s 1 an d 2 b ecause th ey are co m p a r a b le o r a lik e an d are b oth in vasive p rocedu res an d as su ch a UAP can - n o t perform th ese p ro cedu res. Review: Delega t io n gu id elin es Level of Cogn it ive Abilit y: Creatin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Plan n in g Con ten t Ar ea : Leadersh ip/ Man agem en t—Delegatin g Pr ior it y Con cept s: Care Co o rd in atio n ; Clin ical Ju dgm en t Refer en ces: Hu ber ( 2014) , p p . 147–148; Zerwekh , Zerwekh Garn eau (2015), p. 305.

33. 2, 3, 4 Ra tion a le: In th is weath er even t, th e appropriate n ursin g action s focu s o n p ro tectin g clien ts from flyin g d eb ris o r glass. Th e n u rse sh o uld clo se do ors to each clien t’s roo m an d m o ve b eds away fro m win d o ws, an d close win do w sh ades an d cur- tain s to p ro tect clien ts, visitors, an d staff fro m sh atterin g glass an d flyin g d eb ris. Blan kets sh o u ld be placed over clien ts con - fin ed to b ed. Am b ulato ry clien ts sh o uld be m oved in to th e h allways from th eir ro om s, away fro m win do ws. Test-Ta kin g Str a tegy: Focus on th e su b ject , p ro tectin g th e cli- en t in th e even t o f a torn ad o. Visu alize each of th e action s in th e op tion s to determ in e if th ese action s wo uld assist in pro - tectin g th e clien t an d p reven tin g an accid en t o r in ju ry. Review: Th e vario us typ es of safety m easures in th e even t of a d isa st er Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Leadersh ip / Man agem en t—Prioritizin g Pr ior it y Con cept s: Lead ersh ip ; Pro fessio n alism Refer en ce: Po tter et al. (2013), p p. 366–367, 387.

34. 4 Ra tion a le: Wh en d elegatin g n u rsin g assign m en ts, th e n urse n eeds to co n sid er th e skills an d ed u catio n al level of th e n u rsin g staff. Givin g a b ed b ath , assistin g with freq uen t am b u- latio n , an d takin g vital sign s can b e provid ed m o st app ro p ri- ately b y UAP. Th e licen sed p ractical (vo cation al) n u rse is skilled in wo un d irrigatio n s an d d ressin g ch an ges an d m o st app rop riately wou ld b e assign ed to th e clien t wh o n eeds th is care. Test-Ta kin g Str a t egy: Fo cu s o n th e su b ject , assign m en t to a licen sed practical (vo catio n al) n u rse, an d n o te th e st r a t egic wo r d s, most appropriately. Recall th at education an d job posi- tio n as described by th e n u rse p ractice act an d em p lo yee gu id e- lin es n eed to be co n sid ered wh en d elegatin g activities an d m akin g assign m en ts. O ption s 1, 2, an d 3 can b e elim in ated b ecau se th ey are n on in vasive tasks th at th e UAP can perform . Review: Th e prin cip les an d gu id elin es o f d elega t io n a n d a ssign m en t s Level of Cogn itive Ability: Creatin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Plan n in g Con ten t Ar ea : Leadersh ip / Man agem en t—Delegatin g Pr ior it y Con cept s: Care Co ord in atio n ; Clin ical Ju dgm en t Refer en ce: Zerwekh , Zerwekh Garn eau (2015), p p. 305, 308.

35. 1, 5 Ra tion a le: Th ere are gu id elin es th at th e n urse sh o uld use wh en d elegatin g an d plan n in g assign m en ts. Th ese in clud e th e follow- in g: en su re clien t safety; b e aware of in dividu al variatio n s in work abilities; determ in e wh ich tasks can be delegated an d to wh om ; m atch th e task to th e delegatee on th e basis of th e n urse p ractice act an d ap p ro priate po sitio n descriptio n s; p rovid e d irectio n s th at are clear, con cise, accu rate, an d co m p lete; vali- d ate th e d elegatee’s u n d erstan din g of th e direction s; com m un i- cate a feelin g of con fiden ce to th e delegatee an d provid e feed back prom p tly after th e task is p erfo rm ed ; an d m ain tain

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74 UNIT II Professional Standards in Nursing

co n tin u ity o f care as m u ch as p ossible wh en assign in g clien t care. Staff requ ests, con ven ien ce as in clusterin g clien t ro om s, an d an ticipated ch an ges in u n it cen su s are n o t specific guide- lin es to use wh en delegatin g an d plan n in g assign m en ts. Test -Ta kin g St r a t egy: Fo cu s o n th e su b ject , gu id elin es to u se wh en d elegatin g an d plan n in g assign m en ts. Read each o ptio n carefully an d u se Ma slo w’s Hier a r ch y o f Need s t h eo r y. No te th at th e correct op tio n s d irectly relate to th e clien t’s n eed s an d clien t safety.

Review: Th e p rin ciples an d guidelin es o f d elega t io n a n d a ssign m en t s. Level of Cogn it ive Abilit y: App lyin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Pro cess—Plan n in g Con t en t Ar ea : Lead ersh ip/ Man agem en t—Delegatin g Pr ior ity Con cepts: Clin ical Jud gm en t; Pro fessio n alism Refer en ces: Hub er (2014) , pp . 150–151; Zerwekh , Zerwekh Garn eau (2015), p. 510. F

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UNIT III

Nursing Sciences Pyramid to Success

Pyram id Poin ts focus on fluids an d electrolytes, acid- base balan ce, laborato ry referen ce in tervals, n utrition , in traven ous (IV) th erapy, an d blood adm in istration . Fluids an d electrolytes an d acid-base balan ce con stitute a con ten t area th at is som etim es com plex an d difficult to un derstan d. For a clien t wh o is exp erien cin g th ese im bal- an ces, it is im portan t to rem em ber th at m ain ten an ce of a paten t airway is a priority an d th e n urse n eeds to m on - itor vital sign s, ph ysio logical status, in take an d output, laborato ry referen ce in tervals, an d arterial blood gas values. It is also im portan t to rem em ber th at n orm al lab- oratory referen ce levels m ay vary sligh tly, depen din g on th e laborato ry settin g an d equipm en t used in testin g. If you are fam iliar with th e n orm al referen ce in tervals, you will be able to determ in e wh eth er an ab n orm ality exists wh en a laborato ry value is presen ted in a question . Th e specific labo ratory referen ce levels iden tified in th e NCLEX® test plan th at yo u n eed to kn ow in clude arterial blood gases kn own as ABGs (pH, PO 2, PCO 2, SaO 2, HCO 3), blood urea n itrogen (BUN), ch olestero l (total), glucose, h em atocrit, h em oglobin , glycosylated h em o- globin (HgbA1C) , platelets, potassium , sodium , wh ite blood cell (WBC) coun t, creatin in e, proth rom bin tim e (PT), activated partial th rom boplastin tim e (aPTT), an d in tern ation al n orm alized ratio (INR). Th e question s on th e NCLEX-RN exam in ation related to labo ratory referen ce in tervals will require you to iden tify wh eth er th e labo ratory value is n orm al or abn orm al, an d th en you will be required to th in k critically ab out th e effects of th e labo ratory value in term s of th e clien t. Note th e disorder presen ted in th e question an d th e associated body organ affected as a result of th e disorder. Th is pro- cess will assist you in determ in in g th e correct an swer.

Nutrition is a basic n eed th at m ust be m et for all cli- en ts. Th e NCLEX-RN exam in ation addresses th e dietary m easures required for basic n eeds an d for particular body system alteration s an d addresses paren teral n utri- tion (PN) , both partial paren teral n utrition (PPN) an d total paren teral n utrition (TPN) . Wh en presen ted with

a question related to n utrition , con sider th e clien t’s diag- n osis an d th e particular requirem en t or restrictio n n eces- sary for treatm en t of th e disorder. With regard to IV th erapy, assessm en t of th e clien t for allergies, in cludin g latex sen sitivity, before in itiation of an IV lin e an d m on - itorin g for com plication s are critical n ursin g respo n sibil- ities. Likewise, th e proced ure for adm in isterin g blood com pon en ts, th e sign s an d sym ptom s of tran sfusio n reaction , an d th e im m ediate in terven tion s if a tran sfu- sion reaction occurs are a focus.

Client Needs: Learning Objectives Safe and Effective Care Environment Applyin g prin ciples of in fectio n con trol Collaboratin g with in terp rofessio n al team s En surin g th at in form ed con sen t h as been obtain ed for

in vasive proced ures an d for th e adm in istration of blood produ cts

Establish in g priorities for care Han dlin g h azardo us an d in fectio us m aterials to preven t

in jury to h ealth care person n el an d oth ers Iden tifyin g th e clien t with at least 2 form s of iden tifiers

(e.g., n am e an d iden tification n um ber) prior to th e adm in istration of a blood product

In itiatin g h om e h ealth care referrals Main tain in g con tin uity of care an d providin g close

supervisio n durin g a blood tran sfusion Main tain in g asepsis an d preven tin g in fectio n in th e cli-

en t wh en sam ples for labo ratory studies are obtain ed or wh en IV solution s are ad m in istered

Main tain in g stan dard , tran sm ission -b ased, an d oth er precaution s to preven t tran sm issio n of in fectio n to self an d oth ers

Preven tin g acciden ts an d en surin g safety of th e clien t wh en a fluid or electrolyte im balan ce exists, particu- larly wh en ch an ges in cardiovascular, respiratory, gastroin testin al, n eurom u scular, ren al, or cen tral n er- vous system s occur, or wh en th e clien t is at risk for com plication s such as seizu res, respiratory depres- sion , or dysrh yth m ias

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Provid in g in form ation to th e clien t about com m un ity classes for n utrition edu cation

Provid in g safety for th e clien t durin g im plem en tatio n of treatm en ts

Usin g equipm en t such as electron ic IV in fusion devices safely

Uph oldin g clien t righ ts

Health Promotion and Maintenance Assessin g th e clien t’s ab ility to perform self-care Con siderin g lifestyle ch oices related to h om e care of th e

IV lin e Evaluatin g th e clien t’s h om e en viron m en t for self-care

m od ification s Iden tifyin g clien ts at risk for an acid-b ase im balan ce Iden tifyin g com m un ity resou rces available for follow-up Iden tifyin g lifestyle ch oices related to receivin g a blood

tran sfusion Im plem en tin g h ealth screen in g an d m on itorin g for th e

poten tial risk for a fluid an d electrolyte im balan ce Perform in g ph ysical assessm en t tech n iqu es Provid in g clien t an d fam ily education regardin g th e

adm in istration of PN at h om e Provid in g edu cation related to m edication an d diet

m an agem en t Provid in g education related to th e poten tial risk for a

fluid an d electrolyte im balan ce, m easu res to preven t an im balan ce, sign s an d sym pto m s of an im balan ce, an d action s to take if sign s an d sym pto m s develop

Teach in g th e clien t an d fam ily about preven tion , early detection , an d treatm en t m easures for h ealth disorders

Teach in g th e clien t to m on itor for sign s an d sym pto m s th at in dicate th e n eed to n otify th e h ealth care provid er

Teach in g th e clien t an d fam ily ab out care of th e IV lin e

Psychosocial Integrity Assessin g th e clien t’s em o tion al respo n se to treatm en t Con siderin g cultural an d spiritual preferen ces related to

n utrition al pattern s an d lifestyle ch oices Discussin g role ch an ges an d alteration s in lifestyle

related to th e clien t’s n eed to receive PN En surin g th erap eutic in teraction s with th e clien t regard-

in g th e proced ure for blood adm in istration Iden tifyin g co pin g m ech an ism s

Iden tifyin g religious, spiritu al, an d cultural con sider- ation s related to blood adm in istration

Iden tifyin g support system s in th e h om e to assist with carin g for an IV an d th e ad m in istration of PN

Providin g em o tion al supp ort to th e clien t durin g testin g Providin g reassuran ce to th e clien t wh o is experien cin g a

fluid or electrolyte im balan ce Providin g supp ort an d con tin uo usly in form in g th e cli-

en t of th e purpo ses for prescribed in terven tion s

Physiological Integrity Adm in isterin g an d m on itorin g m ed ication s, IV fluid s,

an d oth er th erapeutic in terven tion s Adm in isterin g blood products safely Assessin g an d carin g for cen tral ven ous access devices Assessin g for exp ected an d un exp ected respo n ses to th er-

apeutic in terven tion s an d docum en tin g fin din gs Assessin g ven ous access devices for blood adm in istration Assistin g with obtain in g an ABG specim en an d an alyz-

in g th e results Iden tifyin g clien ts wh o are at risk for a fluid or electrolyte

im balan ce Main tain in g IV th erap y Man agin g m ed ical em ergen cies if a tran sfusio n reaction

or oth er com plication occurs Mon itorin g for com plication s related to blood

adm in istration Mon itorin g for com plication s related to a body system

alteration Mon itorin g for ch an ges in status an d for com plication s;

takin g action s if a com plication arises Mon itorin g for clin ical m an ifestation s associated with

an ab n orm al laborato ry value Mon itorin g of en teral feedin gs an d th e clien t’s ability to

tolerate feedin gs Mon itorin g for expected effects of ph arm aco logical an d

paren teral th erap ies Mon itorin g labo ratory referen ce in tervals; determ in in g

th e sign ifican ce of an abn o rm al labo ratory value an d th e n eed to im plem en t specific action s based on th e laborato ry results

Mon itorin g of n utrition al in take an d oral h ydration Providin g woun d care wh en blood is obtain ed for an

ABG study Reducin g th e likelih oo d th at an acid-b ase im balan ce

will occur

77UNIT III Nursing Sciences

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C H A P T E R 8 Fluids and Electrolytes

PRIORITY CONCEPTS Cellular Regulation; Fluid and Electrolytes

CRITICAL THINKING What Should You Do? The nurse notes the presence of U waves on a client’s cardiac monitor screen. What actions should the nurse take? Answer located on p. 91.

I. Concepts of Fluid and Electrolyte Balance A. Electro lytes

1. Description : An electrolyte is a substan ce th at, on dissolvin g in solution , ion izes; th at is, som e of its m olecu les split or dissociate in to electrically ch arged ato m s or ion s ( Box 8-1).

2. Measu rem en t a . Th e m etric system is used to m easu re vo lum es

of fluids—liters (L) or m illiliters (m L). b . Th e un it of m easu re th at expresses th e com -

bin in g activity of an electrolyte is th e m illieq uivalen t (m Eq).

c. O n e m illieq uivalen t (1 m Eq) of an y cation always reacts ch em ically with 1 m Eq of an an ion .

d . Millieq uivalen ts provide in form ation about th e n um ber of an ion s or cation s available to com bin e with oth er an ion s or cation s.

B. Body flu id com partm en ts (Fig. 8-1) 1. Description

a . Fluid in each of th e body co m partm en ts con - tain s electrolytes.

b . Each co m partm en t h as a particular com po si- tion of electrolytes, wh ich differs from th at of oth er com partm en ts.

c. To fun ction n orm ally, body cells m ust h ave fluid s an d electrolytes in th e righ t com part- m en ts an d in th e righ t am oun ts.

d . Wh en ever an electrolyte m oves out of a cell, an oth er electrolyte m oves in to take its place.

e. Th e n um bers of cation s an d an ion s m ust be th e sam e for homeostasis to exist.

f. Com p artm en ts are separated by sem iperm e- able m em bran es.

2. In travascular com partm en t: Refers to fluid in side a blood vessel

3. In tracellular com partm en t a . Th e in tracellular com partm en t refers to all

fluid in side th e cells. b . Most bodily fluids are in side th e cells.

4. Extracellular com partm en t a . Refers to fluid outsid e th e cells. b . Th e extracellular com partm en t in cludes th e

in terstitial fluid , wh ich is flu id between cells (som etim es called th e third space), blood, lym ph , bon e, con n ective tissue, water, an d tran scellular flu id.

C. Th ird-spacin g 1. Th ird-spacin g is th e accu m ulation an d sequestra-

tion of trapp ed extracellular fluid in an actu al or poten tial body space as a result of disease or in jury.

2. Th e trapped fluid represen ts a vo lum e lo ss an d is un available for n orm al ph ysiological processes.

3. Fluid m ay be trapped in body spaces such as th e pericardial, pleural, periton eal, or join t cavities; th e bowel; or th e abdom en , or with in soft tissues after traum a or burn s.

4. Assessin g th e in travascular fluid loss caused by th ird-sp acin g is difficu lt. Th e loss m ay n ot be reflected in weigh t ch an ges or in take an d output records, an d m ay n ot beco m e apparen t un til after organ m alfun ction occurs.

D. Edem a 1. Edem a is an excess accu m ulation of fluid in

th e in terstitial space; it occurs as a result of alteration s in on cotic pressure, h ydrostatic pres- sure, cap illary perm eability, an d lym p h atic obstru ction .

2. Localized edem a occurs as a result of traum atic in jury from acciden ts or surgery, local in flam m a- tory processes, or burn s.

3. Gen eralized edem a, also called anasarca, is an excessive accu m ulation of fluid in th e in terstitial78

space th rough ou t th e body an d occurs as a result of con dition s such as cardiac, ren al, or liver failure.

E. Body fluid 1. Description

a. Bod y fluid s tran spo rt nutrients to th e cells an d carry waste products from th e cells.

b . To tal body fluid (in tracellular an d extracellu- lar) am oun ts to about 60% of body weigh t in th e adult, 55% in th e older ad ult, an d 80% in th e in fan t.

c. Th us in fan ts an d older adults are at a h igh er risk for fluid-related problem s th an yo un ger ad ults; ch ildren h ave a greater propo rtion of body water th an adults an d th e older adult h as th e least propo rtion of body water.

2. Con stituen ts of body fluids a. Body fluids con sist of water an d dissolved

substan ces. b . Th e largest sin gle fluid co n stituen t of th e

body is water. c. Som e substan ces, such as gluco se, urea, an d

creatin in e, do n ot dissociate in solution ; th at is, th ey do n ot separate from th eir com plex form s in to sim pler substan ces wh en th ey are in solution .

d . O th er substan ces do dissociate; for exam ple, wh en sodium ch loride is in a solution , it dis- sociates, or separates, in to 2 parts or elem en ts.

Infants and older adults need to be monitored closely for fluid imbalances.

F. Body flu id tran sport 1. Diffusion

a. Diffusion is th e process wh ereby a solute (substan ce th at is dissolved ) m ay spread th rou gh a solution or solven t (solution in wh ich th e solute is dissolved).

b . Diffusion of a solute spreads th e m olecules from an area of h igh er con cen tration to an area of lower co n cen tration .

c. A perm eable m em bran e allows substan ces to pass th rough it with ou t restriction .

d . A selectively perm eable m em bran e allows som e solutes to pass th rou gh with out restric- tion but preven ts oth er solutes from passin g freely.

e. Diffusion occurs with in flu id com partm en ts an d from on e com partm en t to an oth er if th e barrier between th e com partm en ts is per- m eable to th e diffusin g substan ces.

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BOX 8-1 Properties of Electrolytes and Their Components Atom An atom is the smallest part of an element that still has the

properties of the element. The atom is composed of particles known as the proton (posi-

tive charge), neutron (neutral), and electron (negative charge).

Protons and neutrons are in the nucleus of the atom; therefore, the nucleus is positively charged.

Electrons carry a negative charge and revolve around the nucleus.

As long as the number of electrons is the same as the number of protons, the atom has no net charge; that is, it is neither pos- itive nor negative.

Atoms that gain, lose, or share electrons are no longer neutral.

Molecule A molecule is 2 or more atoms that combine to form a

substance.

Ion An ion is an atom that carries an electrical charge because it has

gained or lost electrons. Some ions carry a negative electrical charge and some carry a

positive charge.

Cation A cation is an ion that has given away or lost electrons and

therefore carries a positive charge. The result is fewer electrons than protons, and the result is a

positive charge.

Anion An anion is an ion that has gained electrons and therefore

carries a negative charge. When an ion has gained or taken on electrons, it assumes a neg-

ative charge and the result is a negatively charged ion.

Intrac e llular fluid

Extrac e llular fluid

Inte rs titia l

Intra va s cula r

Tra ns ce llula r (ce re bros pina l ca na ls , lympha tic tis s ue s , s ynovia l joints , a nd the e ye )

(70%)

(30%)

(22%)

(6%)

(2%)

FIGURE 8-1 Distribution of fluid by compartments in the average adult.

79CHAPTER 8 Fluids and Electrolytes

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2. O sm o sis a . O sm o tic pressure is th e force th at draws th e

solven t fro m a less con cen trated solute th rou gh a selectively perm eable m em bran e in to a m ore con cen trated solute, th us ten din g to equalize th e con cen tration of th e solven t.

b . If a m em bran e is perm eable to water but n ot to all solutes presen t, th e m em bran e is a selec- tive or sem iperm eable m em bran e.

c. O sm osis is the m ovem en t of solvent m ole- cules across a m em bran e in respon se to a con - cen tration gradien t, usually from a solution of lower to on e of h igh er solute con cen tration .

d . Wh en a m ore con cen trated solution is on on e side of a selectively perm eable m em bran e an d a less con cen trated solution is on th e oth er side, a pull called osmotic pressure draws th e water th rough th e m em bran e to th e m ore con cen trated side, or th e side with m ore solute.

3. Filtration a . Filtration is th e m ovem en t of solutes an d sol-

ven ts by h ydrostatic pressure. b . Th e m ovem en t is from an area of h igh er pres-

sure to an area of lower pressure. 4. Hydro static pressure

a . Hydro static pressure is th e force exerted by th e weigh t of a solution .

b . Wh en a differen ce exists in th e h ydrostatic pressure on two sides of a m em bran e, water an d diffusible solutes m ove out of th e solu- tion th at h as th e h igh er h ydrostatic pressure by th e process of filtration .

c. At th e arterial en d of th e cap illary, th e h ydro- static pressure is h igh er th an th e osm o tic pres- sure; th erefore, fluids an d diffusible solutes m ove out of th e capillary.

d . At th e ven ous en d, th e osm o tic pressure, or pull, is h igh er th an th e h ydrostatic pressure, an d fluid s an d som e solutes m ove in to th e cap illary.

e. Th e excess fluid an d solutes rem ain in g in th e in terstitial spaces are return ed to th e in travas- cular com partm en t by th e lym p h ch an n els.

5. O sm o lality a . O sm o lality refers to th e n um ber of osm o ti-

cally active particles per kilogram of water; it is th e con cen tration of a solution .

b . In th e body, osm o tic pressure is m easu red in m illiosm oles (m O sm ).

c. Th e n orm al osm o lality of plasma is 275- 295 m O sm / kg (275-295 m m o l/ kg).

G. Movem en t of body fluid 1. Description

a . Cell m em bran es separate th e in terstitial fluid from th e in travascular fluid .

b . Cell m em bran es are selectively perm eable; th at is, th e cell m em bran e an d th e cap illary

wall allow water an d som e solutes free pas- sage th rou gh th em .

c. Several forces affect th e m ovem en t of water an d solutes th rough th e walls of cells an d cap- illaries; for exam ple, th e greater th e n um ber of particles with in th e cell, th e m ore pressure exists to force th e water th rou gh th e cell m em - bran e out of th e cell.

d . If th e body loses m ore electrolytes th an fluids, as can h app en in diarrh ea, th en th e extracel- lular fluid con tain s fewer electrolytes or less solute th an th e in tracellu lar flu id.

e. Fluids an d electrolytes m ust be kept in bal- an ce for h ealth ; wh en th ey rem ain out of bal- an ce, death can occur.

2. Isoton ic solution s a . Wh en th e solution s on both sides of a selec-

tively perm eable m em bran e h ave establish ed equilibrium or are equ al in con cen tration , th ey are isoton ic.

b . Isoton ic solution s are isoton ic to h um an cells, an d th us very little osm o sis occurs; iso- ton ic solution s h ave th e sam e osm olality as body fluids.

c. Refer to Ch apter 13, Table 13-1, for a list of isoton ic solution s.

3. Hypoton ic solution s a . Wh en a solution con tain s a lower co n -

cen tration of salt or solute th an an oth er, m ore con cen trated solution , it is con sidered h ypo ton ic.

b . A h ypoton ic solution h as less salt or m ore water th an an isoton ic solution ; th ese solu- tion s h ave lower osm o lality th an body fluids.

c. Hypoton ic solution s are h ypo ton ic to th e cells; th erefore, osm osis would co n tin ue in an attem p t to brin g about balan ce or equ ality.

d . Refer to Ch apter 13, Table 13-1, for a list of h ypo ton ic solution s.

4. Hyperton ic solution s a . A solution th at h as a h igh er con cen tration of

solutes th an an oth er, less con cen trated solu- tion is h yperton ic; th ese solution s h ave a h igh er osm olality th an body flu ids.

b . Refer to Ch apter 13, Table 13-1, for a list of h yperton ic solution s.

5. O sm o tic pressure a . Th e am oun t of osm o tic pressure is determ in ed

by th e con cen tration of solutes in solution . b . Wh en th e solution s on each side of a selec-

tively perm eable m em bran e are equal in con - cen tration , th ey are isoton ic.

c. A h ypo ton ic solution h as less solute th an an isoton ic solution , wh ereas a h yperton ic solu- tion co n tain s m ore solute.

d . A solven t m oves from th e less con cen trated solute side to th e m ore con cen trated solute side to equ alize con cen tration .

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6. Active tran spo rt a. If an ion is to m ove th rough a m em bran e

fro m an area of lower con cen tration to an area of h igh er con cen tration , an active tran s- port system is n ecessary.

b . An active tran sport system m oves m olecules or ion s again st con cen tration an d osm o tic pressure.

c. Metab olic processes in th e cell supply th e en ergy for active tran spo rt.

d . Substan ces th at are tran spo rted actively th rou gh th e cell m em bran e in clude ion s of sodium, potassium, calcium, iron , an d h ydro- gen ; som e of th e sugars; an d th e am in o acids.

H. Body fluid in take an d output (Fig. 8-2) 1. Bod y fluid in take

a. Water en ters th e body th rou gh 3 sources— orally in gested liquid s, water in food s, an d water form ed by oxidation of food s.

b . Abou t 10 m L of water is released by th e metabolism of each 100 calories of fat, carbo- h ydrates, or protein s.

2. Bod y fluid output a. Water lost th rou gh th e skin is called insensible

loss (th e in dividual is un aware of losin g th at water).

b . Th e am oun t of water lost by perspiration varies accordin g to th e tem perature of th e en viron - m en t an d of th e body, but th e average am ount of loss by perspiration alon e is 100 m L/ day.

c. Water lost from th e lu n gs is called insensible loss an d is lost th rough exp ired air th at is sat- urated with water vapo r.

d . Th e am oun t of water lost from th e lun gs var- ies with th e rate an d th e depth of respiration .

e. Large quan tities of water are secreted in to th e gastro in testin al tract, but alm o st all of th is flu id is reabsorbed.

f. Alarge volum e of electrolyte-con tain in g liquids m oves in to th e gastroin testin al tract an d th en returns again to th e extracellular fluid.

g. Severe diarrh ea results in th e lo ss of large quan tities of flu ids an d electrolytes.

h . Th e kidn eys play a m ajor role in regulatin g fluid an d electrolyte balan ce an d excrete th e largest quan tity of fluid.

i. No rm al kidn eys can ad just th e am oun t of water an d electrolytes leavin g th e body.

j. Th e quan tity of fluid excreted by the kidn eys is determ in ed by th e am oun t of water ingested an d th e am oun t of waste and solutes excreted.

k . As lon g as all organ s are fun ctio n in g n or- m ally, th e body is able to m ain tain balan ce in its fluid con ten t.

The client with diarrhea is at high risk for a fluid and electrolyte imbalance.

I. Main tain in g flu id an d electrolyte balan ce 1. Description

a. Homeostasis is a term th at in dicates th e rela- tive stability of th e in tern al en viron m en t.

b . Con cen tration an d com po sition of body fluid s m ust be n early con stan t.

c. Wh en on e of th e substan ces in a clien t is defi- cien t—eith er fluids or electrolytes—th e sub- stan ce m ust be replaced n orm ally by th e in take of food an d water or by th erapy such as in traven ous (IV) solution s an d m edication s.

d . Wh en th e clien t h as an excess of fluid or elec- trolytes, th erapy is directed toward assistin g th e body to elim in ate th e excess.

2. Th e kidn eys play a m ajor ro le in con trollin g bal- an ce in fluid an d electrolytes.

3. Th e ad ren al glan ds, th rou gh th e secretio n of aldo steron e, also aid in con tro llin g extracellular fluid vo lum e by regulatin g th e am oun t of sodium reabsorb ed by th e kidn eys.

4. An tidiu retic h orm on e from th e pituitary glan d regulates th e osm otic pressure of extracellular fluid by regulatin g th e am oun t of water reab- sorbed by th e kidn eys.

II. Fluid Volume Deficit A. Description

1. Deh ydration occurs wh en th e fluid in take of th e body is n ot sufficien t to m eet th e fluid n eeds of th e body.

2. Th e goal of treatm en t is to restore fluid vo lum e, replace electrolytes as n eeded, an d elim in ate th e cau se of th e flu id volum e deficit.

B. Types of flu id volum e deficits 1. Iso ton ic deh ydratio n

a. Water an d dissolved electrolytes are lost in equ al propo rtion s.

b . Kn o wn as hypovolemia, isoton ic deh ydratio n is th e m ost com m on typ e of deh ydration .

c. Iso ton ic deh ydration results in decreased cir- culatin g blood volu m e an d in adeq uate tissue perfusion .

Fluid intake

Inge s te d wa te r Inge s te d food Me ta bolic oxida tion

TOTAL

1200-1500 mL

800-1100 mL

300 mL

2300-2900 mL

Fluid o utput

Kidne ys Ins e ns ible los s through s kin Ins e ns ible los s through lungs Ga s trointe s tina l tra ct

TOTAL

1500 mL

600-800 mL

400-600 mL 100 mL

2600-3000 mL

FIGURE 8-2 Sources of fluid intake and fluid output.

81CHAPTER 8 Fluids and Electrolytes

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2. Hyperton ic deh ydration a . Water loss exceeds electrolyte loss. b . Th e clin ical problem s th at occur result from

alteration s in th e con cen tration s of specific plasm a electrolytes.

c. Fluid m oves fro m th e in tracellular com part- m en t in to th e plasma an d in terstitial fluid spaces, causin g cellular deh ydration an d sh rin kage.

3. Hypo ton ic deh ydratio n a . Electrolyte loss exceed s water loss. b . Th e clin ical problem s th at occur result from

fluid sh ifts between com partm en ts, causin g a decrease in plasm a volum e.

c. Fluid m oves from th e plasm a an d in terstitial fluid spaces in to th e cells, causin g a plasm a volu m e deficit an d causin g th e cells to swell.

C. Causes of fluid volum e deficits 1. Isoton ic deh ydration

a . In adequ ate in take of fluids an d solutes b . Fluid sh ifts between com partm en ts c. Excessive losses of isoton ic body fluids

2. Hyperton ic deh ydration —con dition s th at in crease fluid loss, such as excessive perspiration , h yperventilation , ketoacidosis, prolon ged fevers, diarrh ea, early-stage kidn ey disease, an d diabetes in sipidus

3. Hypoton ic deh ydration a . Ch ron ic illn ess b . Excessive fluid replacem en t (h ypoton ic) c. Kidn ey disease d . Ch ron ic malnutrition

D. Assessm en t (Table 8-1) E. In terven tion s

TABLE 8-1 Assessment Findings: Fluid Volume Deficit and Fluid Volume Excess Fluid Volume Deficit Fluid Volume Excess

Cardiovascular ▪ Thready, increased pulse rate ▪ Bounding, increased pulse rate ▪ Decreased blood pressure and orthostatic (postural)

hypotension ▪ Elevated blood pressure

▪ Flat neck and hand veins in dependent positions ▪ Distended neck and hand veins ▪ Diminished peripheral pulses ▪ Elevated central venous pressure ▪ Decreased central venous pressure ▪ Dysrhythmias ▪ Dysrhythmias Respiratory ▪ Increased rate and depth of respirations ▪ Increased respiratory rate (shallow respirations) ▪ Dyspnea ▪ Dyspnea

▪ Moist crackles on auscultation Neuromuscular ▪ Decreased central nervous system activity, from

lethargy to coma ▪ Altered level of consciousness

▪ Fever, depending on the amount of fluid loss ▪ Headache ▪ Skeletal muscle weakness ▪ Visual disturbances

▪ Skeletal muscle weakness ▪ Paresthesias

Renal ▪ Decreased urine output ▪ Increased urine output if kidneys can compensate; decreased urine output if kidney

damage is the cause

Integumentary ▪ Dry skin ▪ Pitting edema in dependent areas ▪ Poor turgor, tenting ▪ Pale, cool skin ▪ Dry mouth Gastrointestinal ▪ Decreased motility and diminished bowel sounds ▪ Increased motility in the gastrointestinal tract ▪ Constipation ▪ Diarrhea ▪ Thirst ▪ Increased body weight ▪ Decreased body weight ▪ Liver enlargement

▪ Ascites Laboratory Findings ▪ Increased serum osmolality ▪ Decreased serum osmolality ▪ Increased hematocrit ▪ Decreased hematocrit ▪ Increased blood urea nitrogen (BUN) level ▪ Decreased BUN level ▪ Increased serum sodium level ▪ Decreased serum sodium level ▪ Increased urinary specific gravity ▪ Decreased urine specific gravity

82 UNIT III Nursing Sciences

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1. Mon itor cardiovascu lar, respiratory, n eurom us- cular, ren al, in tegu m en tary, an d gastroin testin al status.

2. Preven t furth er fluid losses an d in crease fluid com partm en t volum es to n orm al ran ges.

3. Provide oral reh ydration th erap y if possible an d IV fluid replacem en t if th e deh ydration is severe; m on itor in take an d output.

4. In gen eral, isoton ic deh ydration is treated with isoton ic flu id solution s, h yperton ic deh ydration with h ypo ton ic flu id solution s, an d h ypoton ic deh ydratio n with h yperton ic flu id solution s.

5. Adm in ister m edication s, such as an tidiarrh eal, an tim icrobial, an tiem etic, an d an tipyretic m edi- cation s, as prescribed to correct th e cau se an d treat an y sym ptom s.

6. Mon itor electrolyte values an d prepare to ad m in - ister m ed ication to treat an im balan ce, if presen t.

III. Fluid Volume Excess A. Description

1. Flu id in take or fluid reten tion exceeds th e fluid n eeds of th e body.

2. Flu id volum e excess is also called overhydration or fluid overload.

3. Th e goal of treatm en t is to restore fluid balan ce, correct electrolyte im balan ces if presen t, an d elim in ate or con trol th e un d erlyin g cau se of th e overload.

B. Types 1. Iso ton ic overh ydration

a. Kn o wn as hypervolemia, isoton ic overh yd ra- tio n results from excessive fluid in th e extra- cellular fluid com partm en t.

b . On ly th e extracellular fluid com partm en t is expan ded, an d fluid does n ot sh ift between th e extracellular an d in tracellular com partm en ts.

c. Iso ton ic overh ydration causes circulatory overload an d in terstitial edem a; wh en severe or wh en it occurs in a clien t with poor cardiac fun ction , h eart failure an d pulm on ary edem a can result.

2. Hyperton ic overh yd ration a. Th e occurren ce of h yperton ic overh yd ration

is rare an d is caused by an excessive sodium in take.

b . Flu id is drawn fro m th e in tracellular fluid com partm en t; th e extracellular flu id vo lum e exp an ds, an d th e in tracellular fluid vo lum e con tracts.

3. Hypo ton ic overh ydration a. Hypo ton ic overh yd ration is kn own as water

intoxication. b . Th e excessive fluid m oves in to th e in tracellu-

lar space, an d all body fluid com partm en ts exp an d.

c. Electrolyte im balan ces occur as a result of dilution .

C. Causes 1. Iso ton ic overh ydration

a. In ad equately con trolled IV th erap y b . Kidn ey disease c. Lon g-term corticosteroid th erap y

2. Hyperton ic overh ydration a. Excessive sodium in gestion b . Rap id in fusion of h yperton ic salin e c. Excessive sodium bicarbon ate th erapy

3. Hypo ton ic overh ydration a. Early kidn ey disease b . Heart failure c. Syn drom e of in approp riate an tidiuretic h or-

m on e secretio n d . In ad equately con trolled IV th erap y e. Replacem en t of isoton ic fluid lo ss with h ypo-

ton ic fluids f. Irrigation of woun ds an d body cavities with

h ypo ton ic flu ids D. Assessm en t (see Table 8-1) E. In terven tion s

1. Mon itor cardiovascular, respiratory, n eurom us- cular, ren al, in tegu m en tary, an d gastro in testin al status.

2. Preven t furth er fluid overload an d restore n or- m al flu id balan ce.

3. Adm in ister diuretics; osm o tic diuretics m ay be prescribed in itially to preven t severe electrolyte im balan ces.

4. Restrict fluid an d sodium in take as prescribed. 5. Mon itor in take an d output; m on itor weigh t. 6. Mon itor electrolyte values, an d prepare to adm in is-

ter m edication to treat an im balan ce if presen t.

A client with acute kidney injury or chronic kidney disease is at high risk for fluid volume excess.

IV. Hypokalemia A. Description

1. Hypo kalem ia is a serum potassium level lower th an 3.5 m Eq/ L (3.5 m m ol/ L) ( Box 8-2).

2. Potassium deficit is poten tially life-th reaten in g because every body system is affected .

BOX 8-2 Potassium

Normal Value 3.5 to 5.0 mEq/ L (3.5 to 5.0 mmol/ L)

Common Food Sources Avocado, bananas, cantaloupe, oranges, strawberries,

tomatoes Carrots, mushrooms, spinach Fish, pork, beef, veal Potatoes Raisins

83CHAPTER 8 Fluids and Electrolytes

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B. Causes 1. Actual total body potassium lo ss

a . Excessive use of m ed ication s such as diuretics or corticosteroid s

b . In creased secretio n of aldostero n e, such as in Cush in g’s syn dro m e

c. Vom itin g, diarrh ea d . Woun d drain age, particularly gastro in testin al e. Prolon ged n asogastric suction f. Excessive diaph o resis g. Kidn ey disease im pairin g reabsorp tio n of

potassium 2. In ad equate potassium in take: Fastin g; n oth in g

by m ou th status 3. Movem en t of potassium from th e extracellular

fluid to th e in tracellular fluid a . Alkalosis b . Hyperin sulin ism

4. Dilution of serum potassium a . Water in toxication b . IV th erapy with potassiu m -deficien t solution s

C. Assessm en t (Tables 8-2 an d 8-3) D. In terven tion s

1. Mon itor cardiovascular, respiratory, n eurom us- cular, gastro in testin al, an d ren al status, an d place th e clien t on a cardiac m on itor.

2. Mon itor electrolyte values. 3. Adm in ister potassiu m supplem en ts orally or

in traven ously, as prescribed. 4. O ral potassium supplem en ts

a . O ral potassium supplem en ts m ay cause n ausea an d vom itin g an d th ey sh ould n ot be taken on an em pty stom ach ; if th e clien t com plain s of abdom in al pain, disten tion , n ausea, vom itin g, diarrh ea, or gastroin testin al bleedin g, the sup- plem en t m ay n eed to be discon tin ued.

b . Liquid potassium ch loride h as an un pleasan t taste an d sh ould be taken with juice or an oth er liqu id.

5. In traven ously adm in istered potassium (Box 8-3) 6. In stitute safety m easures for th e clien t experien c-

in g m uscle weakn ess. 7. If th e clien t is takin g a potassium -losin g diuretic,

it m ay be discon tin ued; a potassiu m -retain in g diuretic m ay be prescribed.

8. In struct th e clien t about food s th at are h igh in potassium con ten t (see Box 8-2).

Potassium is never administered by IV push, intra- muscular, or subcutaneous routes. IV potassium is always diluted and administered using an infusion device!

V. Hyperkalemia A. Description

1. Hyperkalem ia is a serum potassium level th at exceed s 5.0 m Eq/ L (5.0 m m o l/ L) (see Box 8-2).

2. Pseudo h yperkalem ia: a con d ition th at can occur due to m eth od s of blood specim en collection an d cell lysis; if an in creased serum value is obtain ed in th e absen ce of clin ical sym pto m s, th e speci- m en sh ould be redrawn an d evaluated.

B. Causes 1. Excessive potassiu m in take

a . O verin gestion of potassium -con tain in g foods or m edication s, such as potassium ch loride or salt substitutes

b . Rapid in fusio n of potassium -con tain in g IV solution s

2. Decreased potassium excretio n

TABLE 8-2 Assessment Findings: Hypokalemia and Hyperkalemia

Hypokalemia Hyperkalemia

Cardiovascular ▪ Thready, weak, irregular pulse ▪ Slow, weak, irregular heart rate ▪ Weak peripheral pulses ▪ Decreased blood pressure ▪ Orthostatic hypotension Respiratory ▪ Shallow, ineffective

respirations that result from profound weakness of the skeletal muscles of respiration

▪ Profound weakness of the skeletal muscles leading to respiratory failure

▪ Diminished breath sounds Neuromuscular ▪ Anxiety, lethargy, confusion,

coma ▪ Early: Muscle twitches,

cramps, paresthesias (tingling and burning followed by numbness in the hands and feet and around the mouth)

▪ Skeletal muscle weakness, leg cramps

▪ Late: Profound weakness, ascending flaccid paralysis in the arms and legs (trunk, head, and respiratory muscles become affected when the serum potassium level reaches a lethal level)

▪ Loss of tactile discrimination ▪ Paresthesias ▪ Deep tendon hyporeflexia Gastrointestinal ▪ Decreased motility, hypoactive

to absent bowel sounds ▪ Increased motility,

hyperactive bowel sounds ▪ Nausea, vomiting,

constipation, abdominal distention

▪ Diarrhea

▪ Paralytic ileus Laboratory Findings ▪ Serum potassium level lower

than 3.5 mEq/ L (3.5 mmol/ L) ▪ Serum potassium level that

exceeds 5.0 mEq/ L (5.0 mmol/ L)

▪ Electrocardiogram changes: ST depression; shallow, flat, or inverted T wave; and prominent U wave

▪ Electrocardiographic changes: Tall peaked T waves, flat P waves, widened QRS complexes, and prolonged PR intervals

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a. Potassium -retain in g diuretics b . Kid n ey disease c. Adren al in sufficien cy, such as in Addison ’s

disease 3. Movem en t of potassium from th e in tracellular

flu id to th e extracellular fluid a. Tissue dam age b . Acidosis c. Hyperuricem ia d . Hypercatabo lism

C. Assessm en t (see Tables 8-2 an d 8-3)

Monitor the client closely for signs of a potassium imbalance. A potassium imbalance can cause cardiac dysrhythmias that can be life-threatening!

D. In terven tion s 1. Mon itor cardiovascular, respiratory, n eurom us-

cular, ren al, an d gastroin testin al status; place th e clien t on a cardiac m on itor.

2. Discon tin ue IVpotassium (keep th e IVcath eter pat- en t), and with h old oral potassium supplem en ts.

3. In itiate a potassium -restricted diet. 4. Prepare to adm in ister potassium -excretin g

diuretics if ren al fun ction is n ot im paired. 5. If ren al fun ction is im paired, prepare to adm in ister

sodium polystyren e sulfon ate (oral or rectal route), a cation -exch ange resin th at prom otes gastroin testi- nal sodium absorption an d potassium excretion .

6. Prepare th e clien t for dialysis if potassiu m levels are critically h igh .

7. Prepare for th e adm in istration of IV calcium if h yperkalem ia is severe, to avert m yocardial excitability.

8. Prepare for th e IV ad m in istration of h yperton ic gluco se with regular in sulin to m ove excess potassium in to th e cells.

9. Wh en blood tran sfusion s are prescribed for a cli- en t with a potassiu m im balan ce, th e clien t sh ould receive fresh blood , if possible; tran sfu- sion s of stored blood m ay elevate th e potassium level because th e breakd own of older blood cells releases potassium .

10. Teach th e clien t to avoid foods h igh in potassium (see Box 8-2).

11. In struct th e clien t to avoid th e use of salt substi- tutes or oth er potassium -con tain in g substan ces.

Monitor the serum potassium level closely when a client is receiving a potassium-retaining diuretic!

VI. Hyponatremia A. Description

1. Hypo n atrem ia is a serum sodium level lower th an 135 m Eq/ L (135 m m o l/ L) ( Box 8-4).

TABLE 8-3 Electrocardiographic Changes in Electrolyte Imbalances

Electrolyte Imbalance Electrocardiographic Changes

Hypocalcemia Prolonged ST segment Prolonged QT interval

Hypercalcemia Shortened ST segment Widened T wave

Hypokalemia ST depression Shallow, flat, or inverted T wave Prominent U wave

Hyperkalemia Tall peaked T waves Flat P waves Widened QRS complexes Prolonged PR interval

Hypomagnesemia Tall T waves Depressed ST segment

Hypermagnesemia Prolonged PR interval Widened QRS complexes

BOX 8-3 Precautions with Intravenously Administered Potassium

▪ Potassium is never given by intravenous (IV) push or by the intramuscular or subcutaneous route.

▪ A dilution of no more than 1 mEq/ 10 mL (1 mmol/ 10 mL) of solution is recommended.

▪ Many health care agencies supply prepared IVsolutions con- taining potassium; before administering and frequently dur- ing infusion of the IV solution, rotate and invert the bag to ensure that the potassium is distributed evenly throughout the IV solution.

▪ Ensure that the IV bag containing potassium is properly labeled.

▪ The maximum recommended infusion rate is 5 to 10 mEq/ hour (5 to 10 mmol/ hour), never to exceed 20 mEq/ hour (20 mmol/ hour) under any circumstances.

▪ A client receiving more than 10 mEq/ hour (10 mmol/ hour) should be placed on a cardiac monitor and monitored for cardiac changes, and the infusion should be controlled by an infusion device.

▪ Potassium infusion can cause phlebitis; therefore, the nurse should assess the IV site frequently for signs of phlebitis or infiltration. If either occurs, the infusion should be stopped immediately.

▪ The nurse should assess renal function before administering potassium, and monitor intake and output during administration.

85CHAPTER 8 Fluids and Electrolytes

2. Sodium im balan ces usually are associated with fluid vo lum e im balan ces.

B. Causes 1. In creased sodium excretion

a . Excessive diaph o resis b . Diuretics c. Vom itin g d . Diarrh ea e. Woun d drain age, especially gastroin testin al f. Kidn ey disease g. Decreased secretio n of aldo steron e

2. In ad equate sodium in take a . Fastin g; n oth in g by m ou th status b . Low-salt diet

3. Dilution of serum sodium a . Excessive in gestion of h ypoton ic flu ids or irri-

gation with h ypo ton ic fluids b . Kidn ey disease c. Fresh water drown in g d . Syn drom e of in approp riate an tidiuretic h or-

m on e secretio n e. Hyperglycem ia f. Heart failure

C. Assessm en t (Table 8-4) D. In terven tion s

1. Mon itor cardiovascular, respiratory, n eurom us- cular, cerebral, ren al, an d gastro in testin al status.

2. If h ypo n atrem ia is acco m pan ied by a fluid vol- ume deficit (h ypovolem ia), IV sodium ch loride in fusion s are ad m in istered to restore sodium con ten t an d fluid vo lum e.

3. If h ypon atrem ia is acco m pan ied by fluid volume excess (h ypervolem ia), osm o tic diuretics m ay be prescribed to prom ote th e excretion of water rath er th an sodium .

4. If caused by in approp riate or excessive secretio n of an tidiuretic h orm on e, m ed ication s th at an tagon ize an tidiuretic h orm on e m ay be adm in istered.

5. In struct th e clien t to in crease oral sodium in take as prescribed an d in form th e clien t about th e food s to in clude in th e diet (see Box 8-4).

6. If th e clien t is takin g lith ium , m on itor th e lith ium level, because h ypon atrem ia can cause dim in - ish ed lithium excretion , resultin g in toxicity.

Hyponatremia precipitates lithium toxicity in a client taking lithium.

VII. Hypernatremia A. Description : Hypern atrem ia is a serum sodium level

that exceeds 145 m Eq/ L (145 m m ol/ L) (see Box 8-4). B. Causes

1. Decreased sodium excretion a . Corticostero ids b . Cush in g’s syn dro m e c. Kidn ey disease d . Hyperaldostero n ism

2. In creased sodium in take: Excessive oral sodium in gestion or excessive adm in istration of sodium -con tain in g IV fluid s

3. Decreased water in take: Fastin g; n oth in g by m ou th status

4. In creased water loss: In creased rate of metabo- lism, fever, h yperven tilatio n , in fectio n , excessive diaph o resis, watery diarrh ea, diabetes in sipidus

C. Assessm en t (see Table 8-4) D. In terven tion s

1. Mo n ito r card io vascu lar, resp irato ry, n eu ro - m u scu lar, cereb ral, ren al, an d in tegu m en tary statu s.

2. If th e cau se is fluid lo ss, prepare to adm in ister IV in fusion s.

3. If th e cause is in adequate ren al excretion of sodium , prepare to ad m in ister diuretics th at pro- m ote sodium loss.

4. Restrict sodium an d fluid in take as prescribed (see Box 8-4).

VIII. Hypocalcemia A. Descrip tion : Hypo calcem ia is a serum calcium level

lower th an 9.0 m g/ dL (2.25 m m o l/ L) (Box 8-5). B. Causes

1. In h ibition of calcium absorption from th e gas- troin testin al tract a . In adequ ate oral in take of calcium b . Lactose in toleran ce c. Malab sorption syn dro m es such as celiac

sprue or Cro h n ’s disease d . In adequ ate in take of vitam in D e. En d-stage kidn ey disease

2. In creased calcium excretion a . Kidn ey disease, polyuric ph ase b . Diarrh ea c. Steatorrh ea d . Woun d drain age, especially gastro in testin al

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BOX 8-4 Sodium

Normal Value 135 to 145 mEq/ L (135 to 145 mmol/ L)

Common Food Sources Bacon, frankfurters, lunch meat Butter, cheese Canned food Ketchup, mustard Milk Processed food Snack foods Soy sauce Table salt

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3. Con dition s th at decrease th e ion ized fraction of calcium a. Hyperprotein em ia b . Alkalosis c. Med ication s such as calcium ch elato rs or

bin d ers d . Acute pan creatitis e. Hyperph osph atem ia f. Im m obility g. Rem o val or destruction of th e parath yroid

glan d s C. Assessm en t (Table 8-5 an d Fig. 8-3; also see

Table 8-3) D. In terven tion s

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TABLE 8-4 Assessment Findings: Hyponatremia and Hypernatremia Hyponatremia Hypernatremia

Cardiovascular ▪ Symptoms vary with changes in vascular volume ▪ Heart rate and blood pressure respond to vascular

volume status ▪ Normovolemic: Rapid pulse rate, normal blood pressure ▪ Hypovolemic: Thready, weak, rapid pulse rate; hypotension; flat neck veins; normal or

low central venous pressure ▪ Hypervolemic: Rapid, bounding pulse; blood pressure normal or elevated; normal or

elevated central venous pressure

Respiratory ▪ Shallow, ineffective respiratory movement is a late manifestation related to skeletal

muscle weakness ▪ Pulmonary edema if hypervolemia is present

Neuromuscular ▪ Generalized skeletal muscle weakness that is worse in the extremities ▪ Early: Spontaneous muscle twitches; irregular muscle

contractions ▪ Diminished deep tendon reflexes ▪ Late: Skeletal muscle weakness; deep tendon reflexes

diminished or absent

Central Nervous System ▪ Headache ▪ Altered cerebral function is the most common

manifestation of hypernatremia ▪ Personality changes ▪ Normovolemia or hypovolemia: Agitation, confusion,

seizures ▪ Confusion ▪ Hypervolemia: Lethargy, stupor, coma ▪ Seizures ▪ Coma Gastrointestinal ▪ Increased motility and hyperactive bowel sounds ▪ Extreme thirst ▪ Nausea ▪ Abdominal cramping and diarrhea Renal ▪ Increased urinary output ▪ Decreased urinary output Integumentary ▪ Dry mucous membranes ▪ Dry and flushed skin

▪ Dry and sticky tongue and mucous membranes ▪ Presence or absence of edema, depending on fluid

volume changes

Laboratory Findings ▪ Serum sodium level less than 135 mEq/ L (135 mmol/ L) ▪ Serum sodium level that exceeds 145 mEq/ L (145 mmol/ L) ▪ Decreased urinary specific gravity ▪ Increased urinary specific gravity

BOX 8-5 Calcium

Normal Value 9.0 to 10 .5 mg/ dL (2.25 to 2.75 mmol/ L)

Common Food Sources Cheese Collard greens Kale Milk and soy milk Rhubarb Sardines Tofu Yogurt

87CHAPTER 8 Fluids and Electrolytes

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1. Mon itor cardiovascular, respiratory, n eurom us- cular, an d gastro in testin al status; place th e clien t on a cardiac m on itor.

2. Adm in ister calcium supplem en ts orally or cal- ciu m in traven ously.

3. Wh en adm in isterin g calcium in traven ously, warm th e in jection solution to body tem perature before adm in istration an d adm in ister slowly; m on itor for electrocardiograph ic ch an ges, observe for infiltra- tion, an d m on itor for h ypercalcem ia.

4. Adm in ister m edication s th at in crease calcium absorption .

a . Alum in um h ydroxide reduces phosphorus levels, causin g th e coun tereffect of in creasin g calcium levels.

b . Vitam in D aids in th e absorption of calcium from th e in testin al tract.

5. Provid e a quiet en viron m en t to reduce en viron - m en tal stim uli.

6. In itiate seizure precaution s. 7. Move th e clien t carefully, an d m on itor for sign s

of a path olo gical fracture. 8. Keep 10% calcium gluco n ate available for treat-

m en t of acu te calcium deficit.

TABLE 8-5 Assessment Findings: Hypocalcemia and Hypercalcemia Hypocalcemia Hypercalcemia

Cardiovascular ▪ Decreased heart rate ▪ Increased heart rate in the early phase; bradycardia that

can lead to cardiac arrest in late phases ▪ Hypotension ▪ Increased blood pressure ▪ Diminished peripheral pulses ▪ Bounding, full peripheral pulses Respiratory ▪ Not directly affected; however, respiratory failure or arrest can result from decreased

respiratory movement because of muscle tetany or seizures ▪ Ineffective respiratory movement as a result of profound

skeletal muscle weakness

Neuromuscular ▪ Irritable skeletal muscles: Twitches, cramps, tetany, seizures ▪ Profound muscle weakness ▪ Painful muscle spasms in the calf or foot during periods of inactivity ▪ Diminished or absent deep tendon reflexes ▪ Paresthesias followed by numbness that may affect the lips, nose, and ears in

addition to the limbs ▪ Disorientation, lethargy, coma

▪ Positive Trousseau’s and Chvostek’s signs ▪ Hyperactive deep tendon reflexes ▪ Anxiety, irritability Renal ▪ Urinary output varies depending on the cause ▪ Urinary output varies depending on the cause Gastrointestinal ▪ Increased gastric motility; hyperactive bowel sounds ▪ Decreased motility and hypoactive bowel sounds ▪ Cramping, diarrhea ▪ Anorexia, nausea, abdominal distention, constipation Laboratory Findings ▪ Serum calcium level less than 9.0 mg/ dL (2.25 mmol/ L) ▪ Serum calcium level that exceeds 10.5 mg/ dL

(2.75 mmol/ L) ▪ Electrocardiographic changes: Prolonged ST interval, prolonged QT interval ▪ Electrocardiographic changes: Shortened ST segment,

widened T wave

A B C FIGURE 8-3 Tests for hypocalcemia. A, Chvostek’s sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. B, Trousseau’s sign is a carpal spasm induced by inflating a blood pressure cuff (C) above the systolic pressure for a few minutes.

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9. In struct th e clien t to con sum e foods h igh in cal- ciu m (see Box 8-5).

IX. Hypercalcemia A. Description : Hypercalcem ia is a serum calcium level

th at exceeds 10.5 m g/ dL (2.75 m m ol/ L) (see Box 8-5). B. Causes

1. In creased calcium absorption a. Excessive oral in take of calcium b . Excessive oral in take of vitam in D

2. Decreased calcium excretion a. Kid n ey disease b . Use of th iazide diuretics

3. In creased bon e resorptio n of calcium a. Hyperparath yroidism b . Hyperth yroidism c. Malign an cy (bo n e destruction from m eta-

static tum ors) d . Im m obility e. Use of gluco cortico ids

4. Hem o con cen tration a. Deh ydration b . Use of lith iu m c. Adren al in sufficien cy

C. Assessm en t (see Tables 8-3 an d 8-5) D. In terven tion s

1. Mon itor cardiovascu lar, respiratory, n eurom us- cular, ren al, an d gastro in testin al status; place th e clien t on a cardiac m on itor.

2. Discon tin ue IV in fusio n s of solution s con tain in g calcium an d oral m ed ication s con tain in g cal- ciu m or vitam in D.

3. Th iazide diuretics m ay be discon tin ued an d replaced with diuretics th at en h an ce th e excre- tio n of calcium .

4. Adm in ister m ed ication s as prescribed th at in h ibit calcium resorption from th e bon e, such as ph osph orus, calciton in , bisph osp h on ates, an d prostaglan din syn th esis in h ibitors (acetylsa- licylic acid, n on steroidal an tiin flam m ato ry m ed ication s) .

5. Prepare th e clien t with severe h ypercalcem ia for dialysis if m edication s fail to reduce th e serum calcium level.

6. Move th e clien t carefully an d m on itor for sign s of a path ological fracture.

7. Mon itor for flan k or abdom in al pain , an d strain th e urin e to ch eck for th e presen ce of urin ary ston es.

8. In struct th e clien t to avoid food s h igh in calcium (see Box 8-5).

A client with a calcium imbalance is at risk for a pathological fracture. Move the client carefully and slowly; assist the client with ambulation.

X. Hypomagnesemia A. Description : Hypom agnesem ia is a serum magnesium

level lower th an 1.3 m Eq/L (0.65 m m ol/ L) (Box 8-6).

B. Causes 1. In sufficien t m agn esium in take

a. Maln utrition an d starvation b . Vom itin g or diarrh ea c. Malab sorption syn drom e d . Celiac disease e. Croh n ’s disease

2. In creased m agn esium excretio n a. Med ication s such as diuretics b . Ch ron ic alcoh olism

3. In tracellular m ovem en t of m agn esium a. Hyperglycem ia b . In sulin adm in istration c. Sepsis

C. Assessm en t ( Table 8-6; also see Table 8-3) D. In terven tion s

1. Mon itor cardiovascular, respiratory, gastro in tes- tin al, n eurom uscular, an d cen tral n ervou s sys- tem status; place th e clien t on a cardiac m on itor.

2. Because h ypo calcem ia frequen tly acco m pan ies h ypo m agn esem ia, in terven tion s also aim to restore n orm al serum calcium levels.

3. O ral preparatio n s of m agn esium m ay cau se diar- rh ea an d in crease m agn esium loss.

4. Magn esium sulfate by th e IV route m ay be pre- scribed in ill clien ts wh en the m agn esium level is low (in tram uscular injection s cause pain an d tis- sue dam age); in itiate seizure precaution s, m on itor serum m agn esium levels frequen tly, an d m on itor for dim in ish ed deep ten don reflexes, suggestin g hyperm agn esem ia, durin g th e adm in istration of m agn esium .

5. In struct th e clien t to in crease th e in take of foods th at con tain m agn esium (see Box 8-6).

XI. Hypermagnesemia A. Description : Hyperm agn esem ia is a serum magne-

sium level th at exceeds 2.1 m Eq/ L (1.05 m m ol/ L) (see Box 8-6).

BOX 8-6 Magnesium

Normal Value 1.3 to 2.1 mEq/ L (0.65 to 1.0 5 mmol/ L)

Common Food Sources Avocado Canned white tuna Cauliflower Green leafy vegetables, such as spinach and broccoli Milk Oatmeal, wheat bran Peanut butter, almonds Peas Pork, beef, chicken, soybeans Potatoes Raisins Yogurt

89CHAPTER 8 Fluids and Electrolytes

B. Causes 1. In creased m agn esium in take

a . Magn esium -co n tain in g an tacids an d laxatives b . Excessive adm in istration of m agn esium

in traven ously 2. Decreased ren al excretion of m agn esium as a

result of ren al in sufficien cy C. Assessm en t (see Tables 8-3 an d 8-6) D. In terven tion s

1. Mon itor cardiovascular, respiratory, n eurom us- cular, an d cen tral n ervou s system status; place th e clien t on a cardiac m on itor.

2. Diuretics are prescribed to in crease ren al excre- tion of m agn esium .

3. In traven o u sly ad m in istered calciu m ch lo rid e o r calciu m glu co n ate m ay b e p rescrib ed to reverse th e effects o f m agn esiu m o n card iac m u scle.

4. In struct th e clien t to restrict dietary in take of m agn esium -co n tain in g food s (see Box 8-6).

5. In struct th e clien t to avoid th e use of laxatives an d an tacids con tain in g m agn esium .

Calcium gluconate is the antidote for magnesium overdose.

XII. Hypophosphatemia A. Descrip tion

1. Hypoph osph atem ia is a serum phosphorus (ph osph ate) level lower th an 3.0 m g/ dL (0.97 m m o l/ L) (Box 8-7).

2. A decrease in th e serum ph osph orus level is acco m pan ied by an in crease in th e serum calcium level.

B. Causes 1. In sufficien t ph o sph orus in take: Malnutrition an d

starvation 2. In creased ph osph orus excretion

a . Hyperparath yroidism b . Malign an cy c. Use of magnesium-based or alum in um

h ydroxide–based an tacids 3. In tracellular sh ift

a . Hyperglycem ia b . Respiratory alkalosis

C. Assessm en t 1. Card iovascular

a . Decreased con tractility an d cardiac output b . Slowed periph eral pulses

2. Resp iratory: Sh allow respiration s 3. Neurom u scular

a . Weakn ess b . Decreased deep ten don reflexes c. Decreased bon e den sity th at can cause frac-

tures an d alteration s in bon e sh ape d . Rh abd om yolysis

4. Cen tral n ervou s system a . Irritability b . Con fusion c. Seizu res

5. Hem atological a . Decreased platelet aggregation an d in creased

bleedin g b . Im m un osuppression

D. In terven tion s 1. Mon itor cardiovascular, respiratory, n eurom u s-

cular, cen tral n ervous system , an d h em atological status.

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TABLE 8-6 Assessment Findings: Hypomagnesemia and Hypermagnesemia

Hypomagnesemia Hypermagnesemia

Cardiovascular ▪ Tachycardia ▪ Bradycardia, dysrhythmias ▪ Hypertension ▪ Hypotension Respiratory ▪ Shallow respirations ▪ Respiratory insufficiency

when the skeletal muscles of respiration are involved

Neuromuscular ▪ Twitches, paresthesias ▪ Diminished or absent deep

tendon reflexes ▪ Positive Trousseau’s and

Chvostek’s signs ▪ Skeletal muscle weakness

▪ Hyperreflexia ▪ Tetany, seizures Central Nervous System ▪ Irritability ▪ Drowsiness and lethargy that

progresses to coma ▪ Confusion Laboratory Findings ▪ Serum magnesium level

less than 1.3 mEq/ L (0.65 mmol/ L)

▪ Serum magnesium level that exceeds 2.1 mEq/ L (1.05 mmol/ L)

▪ Electrocardiographic changes: Tall T waves, depressed ST segments

▪ Electrocardiographic changes: Prolonged PR interval, widened QRS complexes

BOX 8-7 Phosphorus (Phosphate)

Normal Value 3.0 to 4.5 mg/ dL (0 .97 to 1.45 mmol/ L)

Common Food Sources Dairy products Fish Nuts Pork, beef, chicken, organ meats Pumpkin, squash Whole-grain breads and cereals

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2. Discon tin ue m edication s th at con tribu te to h ypo ph osph atem ia.

3. Adm in ister ph o sph orus orally alon g with a vita- m in D supp lem en t.

4. Prepare to adm in ister ph osph orus in traven ously wh en serum ph o sph orus levels fall below 1 m g/ dL an d wh en th e clien t exp erien ces critical clin i- cal m an ifestation s.

5. Adm in ister IV ph osph orus slowly because of th e risks associated with h yperph osph atem ia.

6. Assess th e ren al system before adm in isterin g ph o sph orus.

7. Move th e clien t carefully, an d m on itor for sign s of a path o logical fracture.

8. In struct th e clien t to in crease th e intake of the ph osph orus-con tain in g foods while decreasin g th e in take of any calcium -con tain in g foods (see Boxes 8-5 an d 8-7).

A decrease in the serum phosphorus level is accom- panied by an increase in the serum calcium level, and an increase in the serum phosphorus level is accompanied by a decrease in the serum calcium level. This is called a reciprocal relationship.

XIII. Hyperphosphatemia A. Description

1. Hyperph osph atem ia is a serum phosphorus level th at exceed s 4.5 m g/ dL (1.45 m m o l/ L) (see Box 8-7).

2. Most body system s tolerate elevated serum ph o s- ph o rus levels well.

3. An in crease in th e serum ph o sph orus level is acco m pan ied by a decrease in th e serum calcium level.

4. Th e problem s th at occur in h yperph osph atem ia cen ter on th e h ypo calcem ia th at results wh en serum ph osph orus levels in crease.

B. Causes 1. Decreased ren al excretion resultin g from ren al

in sufficien cy 2. Tu m or lysis syn d rom e 3. In creased in take of ph osph orus, in cludin g die-

tary in take or overuse of ph o sph ate-con tain in g laxatives or en em as

4. Hypo parath yroidism C. Assessm en t: Refer to assessm en t of h ypo calcem ia. D. In terven tion s

1. In terven tion s en tail th e m an agem en t of h ypo calcem ia.

2. Adm in ister ph osph ate-bin din g m edication s th at in crease fecal excretion of ph osph orus by bin din g ph osph orus from food in th e gastroin testin al tract.

3. In struct the clien t to avoid ph osph ate-con tainin g- m edication s, in cludin g laxatives an d en em as.

4. In struct th e clien t to decrease th e in take of food th at is h igh in ph osph orus (see Box 8-7).

5. In struct th e clien t in m ed ication adm in istration : Take ph osph ate-bin din g m ed ication s, em ph asiz- in g th at th ey sh ould be taken with m eals or im m ediately after m eals.

CRITICAL THINKING What Should You Do? Answer: Cardiac changes in hypokalemia include impaired repolarization, resulting in a flattening of the T wave and eventually the emergence of a U wave. Therefore, the nurse should suspect hypokalemia. The incidence of potentially lethal ventricular dysrhythmias is increased in hypokalemia. The nurse should immediately assess the client’s vital signs and cardiac status for signs of hypokalemia. The nurse should also check the client’s most recent serum potassium level and then contact the health care provider to report the findings and obtain prescriptions to treat the hypokalemic state.

Reference: Lewis et al. (20 14), pp. 297–298.

P R A C T I C E Q U E S T I O N S

36. Th e n urse is carin g for a clien t with h eart failure. O n assessm en t, th e n urse n otes th at the clien t is dys- pn eic, an d crackles are audible on auscultation . Wh at additional m an ifestation s would th e n urse expect to n ote in th is clien t if excess fluid volum e is presen t? 1. Weigh t loss an d dry skin 2. Flat n eck an d h an d vein s an d decreased urin ary

outp ut 3. An in crease in blood pressure an d in creased

respiratio n s 4. Weakn ess an d decreased cen tral ven o us

pressure (CVP)

37. Th e n urse is preparin g to care for a clien t with a potassium deficit. Th e n urse reviews th e clien t’s record an d determ in es th at th e clien t is at risk for developin g th e potassium deficit because of wh ich situation ? 1. Sustain ed tissue dam age 2. Requ ires n aso gastric suction 3. Has a h isto ry of Addison ’s disease 4. Uric acid level of 9.4 m g/ dL (559 µm ol/ L)

38. Th e n urse reviews a clien t’s electrolyte laboratory report an d n otes th at the potassium level is 2.5 m Eq/ L (2.5 m m ol/ L). Wh ich patterns sh ould th e nurse watch for on th e electrocardiogram (ECG) as a result of th e laboratory value? Select all th at ap p ly.

1. U waves 2. Absen t P waves 3. In verted T waves 4. Depressed ST segm en t 5. Widen ed Q RS com plex

91CHAPTER 8 Fluids and Electrolytes

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39. Potassium ch loride in traven o usly is prescribed for a clien t with h ypo kalem ia. Wh ich action s sh ould th e n urse take to plan for preparatio n an d ad m in istra- tion of th e potassium ? Select all th at ap p ly.

1. O btain an in traven o us (IV) in fusio n pum p. 2. Mon itor urin e output durin g adm in istration . 3. Prepare th e m edication for bolus

ad m in istration . 4. Mon itor th e IV site for sign s of in filtration or

ph lebitis. 5. En sure th at th e m edication is diluted in th e

appropriate vo lum e of fluid. 6. En su re th at th e bag is labeled so th at it reads

th e vo lum e of potassium in th e solution .

40. Th e n urse provides in struction s to a clien t with a low potassium level about th e foods th at are h igh in potassium an d tells th e clien t to con sum e wh ich food s? Select all th at ap p ly.

1. Peas 2. Raisin s 3. Potatoes 4. Can taloup e 5. Cauliflower 6. Strawberries

41. Th e n u rse is reviewin g lab o rato ry resu lts an d n o tes th at a clien t’s seru m so d iu m level is 150 m Eq / L ( 150 m m o l/ L) . Th e n u rse rep o rts th e seru m so d iu m level to th e h ealth care p ro vid er ( H CP) an d th e H CP p rescrib es d ietary in stru ctio n s b ased o n th e so d iu m level. Wh ich accep tab le fo o d item s d o es th e n u rse in stru ct th e clien t to co n su m e? Select all th at ap p ly.

1. Peas 2. Nu ts 3. Ch eese 4. Cauliflower 5. Processed oat cereals

42. Th e n urse is assessin g a clien t with a suspected diag- n osis of h ypocalcem ia. Wh ich clin ical m an ifestation would th e n urse expect to n ote in th e clien t? 1. Twitch in g 2. Hypo active bowel soun ds 3. Negative Trousseau’s sign 4. Hypoactive deep ten don reflexes

43. Th e n urse is carin g for a clien t with h ypo calcem ia. Wh ich pattern s would th e n urse watch for on th e electrocardiogram as a result of th e labo ratory value? Select all th at ap p ly.

1. U waves 2. Widen ed T wave 3. Prom in en t U wave 4. Prolon ged Q T in terval 5. Prolon ged ST segm en t

44. Th e n urse reviews th e electrolyte results of an assign ed clien t an d n otes th at th e potassium level is 5.7 m Eq/ L (5.7 m m o l/ L). Wh ich pattern s would th e n urse watch for on th e cardiac m on itor as a result of th e labo ratory value? Select all th at ap p ly.

1. ST depression 2. Prom in en t U wave 3. Tall peaked T waves 4. Prolon ged ST segm en t 5. Widen ed Q RS co m plexes

45. Wh ich clien t is at risk for th e developm en t of a sodium level at 130 m Eq/ L (130 m m ol/ L)? 1. Th e clien t wh o is takin g diuretics 2. Th e clien t with h yperaldosteron ism 3. Th e clien t with Cush in g’s syn d rom e 4. Th e clien t wh o is takin g corticosteroid s

46. Th e n urse is carin g for a clien t with h eart failure wh o is receivin g h igh doses of a diuretic. O n assessm en t, th e n urse n otes th at th e clien t h as flat n eck vein s, gen eralized m uscle weakn ess, an d dim in ish ed deep ten don reflexes. Th e n urse suspects h ypon atrem ia. Wh at ad dition al sign s would th e n urse expect to n ote in a clien t with h ypo n atrem ia? 1. Muscle twitch es 2. Decreased urin ary outp ut 3. Hyperactive bowel soun ds 4. In creased specific gravity of th e urin e

47. Th e n urse reviews a clien t’s labo ratory report an d n otes th at th e clien t’s serum ph osph orus (ph os- ph ate) level is 1.8 m g/ dL (0.45 m m o l/ L). Wh ich con d ition m o st likely caused th is serum ph osph o- rus level? 1. Maln utrition 2. Ren al in sufficien cy 3. Hypo parath yroidism 4. Tum or lysis syn drom e

48. Th e n urse is readin g a h ealth care provider’s (HCP’s) progress n otes in th e clien t’s record an d reads th at th e HCP h as docum en ted “in sen sible flu id loss of approxim ately 800 m L daily.” Th e n urse m akes a n otatio n th at in sen sible fluid loss occurs th rough wh ich type of excretion ? 1. Urin ary outp ut 2. Woun d drain age 3. In tegum en tary outp ut 4. Th e gastro in testin al tract

49. Th e n urse is assign ed to care for a grou p of clien ts. O n review of th e clien ts’ m edical records, th e n urse determ in es th at wh ich clien t is m o st likely at risk for a fluid vo lum e deficit? 1. A clien t with an ileostom y 2. A clien t with h eart failure

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3. A clien t on lo n g-term corticosteroid th erap y 4. A clien t receivin g frequen t woun d irrigation s

50. Th e n urse carin g for a clien t wh o h as been receivin g in traven ous (IV) diuretics susp ects th at th e clien t is exp erien cin g a flu id volum e deficit. Wh ich assess- m en t fin din g would th e n urse n ote in a clien t with th is con dition ? 1. Weigh t loss an d poor skin turgor 2. Lun g con gestion an d in creased h eart rate 3. Decreased h em atocrit an d in creased urin e outp ut 4. In creased respiration s an d in creased blood

pressure

51. O n review of th e clien ts’ m ed ical records, th e n urse determ in es th at wh ich clien t is at risk for flu id vol- um e excess?

1. Th e clien t takin g diuretics an d h as ten tin g of th e skin

2. Th e clien t with an ileostom y fro m a recen t ab dom in al surgery

3. Th e clien t wh o requires in term itten t gastro in tes- tin al suction in g

4. Th e clien t with kidn ey disease an d a 12-year h is- tory of diabetes m ellitus

52. Wh ich clien t is at risk for th e developm en t of a potassium level of 5.5 m Eq/ L (5.5 m m o l/ L)? 1. Th e clien t with colitis 2. Th e clien t with Cush in g’s syn d rom e 3. Th e clien t wh o h as been overusin g laxatives 4. Th e clien t wh o h as sustain ed a traum atic burn

A N S W E R S 36. 3 Ra t ion a le: A flu id volu m e excess is also kn o wn as overhydration or fluid overload an d o ccurs wh en fluid in take o r fluid reten tion exceeds th e fluid n eeds of th e bo dy. Assessm en t fin d in gs asso- ciated with flu id vo lu m e excess in clud e co ugh , d ysp n ea, crackles, tach ypn ea, tach ycard ia, elevated blo od p ressure, bo un din g p ulse, elevated CVP, weigh t gain , edem a, n eck an d h an d vein d isten tio n , altered level o f co n scio usn ess, an d decreased h em atocrit. Dry skin , flat n eck an d h an d vein s, decreased urin ary o utp ut, an d decreased CVP are n oted in fluid vo lu m e d eficit. Weakn ess can be p resen t in eith er flu id volum e excess o r d eficit. Test -Ta kin g St r a t egy: Focu s on th e su b ject , flu id vo lum e excess. Rem em b er th at wh en th ere is m ore th an on e part to an op tion , all p arts n eed to be correct in o rd er fo r th e o ptio n to be co rrect. Th in k ab ou t th e path o ph ysiology asso ciated with a flu id vo lum e excess to assist in directin g you to th e co rrect op tion . Also, n o te th at th e in correct o p tion s are co m p a r a b le o r a lik e in th at each in clud es m an ifestatio n s th at reflect a decrease. Review: Th e assessm en t fin din gs n o ted in flu id vo lu m e excess Level of Cogn it ive Ability: Syn th esizin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Fun dam en tals of Care—Fluids & Electro lytes Pr ior ity Con cepts: Flu id an d Electrolytes; Perfusion Refer en ces: Ign ataviciu s, Wo rkm an (2016), p p. 158–159; Lewis et al. (2014), p p. 292–293.

37. 2 Ra t ion a le: Th e n o rm al serum p otassium level is 3.5 to 5.0 m Eq / L ( 3.5 to 5.0 m m ol/ L) . A p otassiu m d eficit is kn own as hypokalemia. Po tassium -rich gastroin testin al fluids are lost th ro ugh gastroin testin al su ctio n , placin g th e clien t at risk for h ypo kalem ia. Th e clien t with tissue dam age o r Ad dison ’s dis- ease an d th e clien t with h yp eru ricem ia are at risk for h yperkale- m ia. Th e n o rm al uric acid level for a fem ale is 2.7 to 7.3 m g/ dL (0.16 to 0.43 m m o l/ L) an d fo r a m ale is 4.0 to 8.5 m g/ dL ( 0.24 to 0.51 m m ol/ L) . Hyp eru ricem ia is a cau se o f h yp erkalem ia.

Test -Ta kin g Str a tegy: No te th at th e su b ject o f th e qu estio n is p o tassium deficit. First recall th e n orm al uric acid levels an d th e causes of h yp okalem ia to assist in elim in atin g o p tion 4. Fo r th e rem ain in g op tio n s, n o te th at th e correct o p tion is th e on ly o n e th at iden tifies a loss o f bo dy fluid . Review: Th e cau ses of h yp o k a lem ia Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Fluid s & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), pp . 296, 1211.

38. 1, 3, 4 Ra t ion a le: Th e n orm al serum potassium level is 3.5 to 5.0 m Eq/ L (3.5 to 5.0 m m ol/ L). Aserum potassium level lower th an 3.5 m Eq/ L (3.5 m m ol/ L) in dicates h ypokalem ia. Potassium deficit is an electrolyte im balan ce th at can be poten tially life-th reaten in g. Elec- trocardiograph ic ch an ges in clude sh allow, flat, or in verted Twaves; STsegm ent depression ;and prom inent U waves.Absent P wavesare n ot a characteristicofh ypokalem ia but m aybe n oted in a client with atrial fibrillation , jun ction al rh yth m s, or ven tricular rh yth m s. A widen ed Q RS com plex m ay be n oted in h yperkalem ia an d in h yperm agnesem ia. Test -Ta kin g Str a tegy: Fo cu s o n th e su b ject , th e ECG pattern s th at m ay be n oted with a clien t with a p o tassium level o f 2.5 m Eq / L ( 2.5 m m ol/ L) . From th e in fo rm atio n in th e q ues- tion , you n eed to d eterm in e th at th e clien t is exp erien cin g severe h ypo kalem ia. Fro m th is po in t, you m u st kn ow th e elec- trocard io grap h ic ch an ges th at are exp ected wh en severe h yp o - kalem ia exists. Review: Th e electrocard io graph ic ch an ges th at o ccu r in h yp o k a lem ia Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Fluid s & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ces: Ign ataviciu s, Wo rkm an (2016), p p. 163–164; Lewis et al. ( 2014) , p . 298.

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39. 1, 2, 4, 5, 6 Ra tion a le: Potassium ch lo rid e ad m in istered in traven ou sly m ust always b e diluted in IV flu id an d in fu sed via an in fusio n p um p . Po tassium ch loride is n ever given b y bo lus (IV p u sh ). Givin g po tassiu m ch lo ride by IV push can result in cardiac arrest. Th e n u rse sh ou ld en su re th at th e p o tassium is d ilu ted in th e ap pro priate am ou n t of diluen t or fluid. Th e IV b ag con - tain in g th e po tassium ch lo rid e sh ou ld always b e lab eled with th e volum e o f p otassiu m it co n tain s. Th e IV site is m on itored closely becau se p otassium ch lo rid e is irritatin g to th e vein s an d th ere is risk o f p h lebitis. In ad d itio n , th e n u rse sh o uld m o n ito r fo r in filtration . Th e n u rse m on itors urin ary o utp ut du rin g ad m in istratio n an d co n tacts th e h ealth care pro vider if th e u ri- n ary ou tpu t is less th an 30 m L/ h o u r. Test-Ta kin g St r a tegy: Fo cu s on th e su b ject , th e prep aratio n an d adm in istratio n o f po tassiu m ch lo ride in traven o usly. Th in k ab ou t th is proced ure an d th e effects o f p otassiu m . No te th e wo rd bolus in op tion 3 to assist in elim in atin g th is o ption . Review: Th e precaution s with in traven ously adm in istered p o t a ssiu m Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Ph arm aco logy—Card iovascular Medicatio n s Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ces: Gah art, Nazaren o ( 2015) , p p. 1009–1011; Lewis et al. ( 2014), p. 298.

40. 2, 3, 4, 6 Ra tion a le: Th e n o rm al p otassiu m level is 3.5 to 5.0 m Eq/ L (3.5 to 5.0 m m ol/ L). Com m on fo od sou rces of p otassiu m in clu d e avo cad o , ban an as, can talo up e, carrots, fish , m ush - roo m s, oran ges, p otato es, p ork, beef, veal, raisin s, sp in ach , strawb erries, an d tom atoes. Peas an d cauliflo wer are h igh in m agn esiu m . Test-Ta kin g Str a tegy: Focus on th e su b ject , foo d s h igh in p otassiu m . Read each fo od item an d use kn o wled ge ab ou t n u trition an d co m p o n en ts o f fo od . Recall th at peas an d cauli- flo wer are h igh in m agn esium . Review: Th e fo o d item s h igh in p o t a ssiu m co n ten t Level of Cogn it ive Abilit y: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Fu n d am en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clien t Ed ucation ; Nutritio n Refer en ces: Lewis et al. (2014), pp . 296, 1115; Nix (2013), p . 138.

41. 1, 2, 4 Ra tion a le: Th e n orm al serum sod iu m level is 135 to 145 m Eq/ L (135 to 145 m m ol/ L). A serum sod ium level of 150 m Eq/ L (150 m m o l/ L) in d icates h yp ern atrem ia. O n th e b asis o f th is fin din g, th e n u rse wou ld in stru ct th e clien t to avoid fo od s h igh in so diu m . Peas, n u ts, an d cau liflo wer are goo d foo d sou rces of p h o sph orus an d are n o t h igh in sod iu m (u n less th ey are can n ed o r salted ) . Peas are also a go od sou rce of m agn esium . Pro cessed foo d s su ch as ch eese an d p ro cessed o at cereals are h igh in sod iu m co n ten t. Test-Ta kin g St r a t egy: Fo cu s o n th e su b ject , fo o ds accep tab le to be con sum ed b y a clien t with a so dium level o f 150 m Eq/ L (150 m m o l/ L). First, yo u m u st d eterm in e th at th e clien t h as

h yp ern atrem ia. Select peas an d cauliflower first b ecau se th ese are vegetables. From th e rem ain in g o ptio n s, n o te th e word pro- cessed in o ptio n 5 an d recall th at ch eese is h igh in so d ium . Rem em ber th at processed fo od s ten d to b e h igh er in sod iu m con ten t. Review: Fo od s h igh in so d iu m con ten t Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Fun dam en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clien t Ed ucation ; Nu trition Refer en ces: Lewis et al. (2014), p . 295; Nix (2013), p. 141.

42. 1 Ra tion a le: Th e n o rm al serum calcium level is 9 to 10.5 m g/ d L (2.25 to 2.75 m m ol/ L). A seru m calciu m level lower th an 9 m g/ dL (2.25 m m o l/ L) in dicates h yp ocalcem ia. Sign s of h yp ocalcem ia in clu de p aresth esias fo llo wed by n u m b n ess, h yp eractive d eep ten d o n reflexes, an d a po sitive Trou sseau’s o r Ch vo stek’s sign . Ad ditio n al sign s o f h ypo calcem ia in clud e in creased n eu ro m uscular excitab ility, m u scle cram ps, twitch - in g, tetan y, seizu res, irritability, an d an xiety. Gastro in testin al sym pto m s in clu d e in creased gastric m otility, h yperactive b owel so un ds, ab do m in al cram p in g, an d d iarrh ea. Test-Ta kin g St r a t egy: No te th at th e th ree in correct op tion s are co m p a r a b le o r a lik e in th at th ey reflect a h ypo activity. Th e o ptio n th at is d ifferen t is th e co rrect op tio n . Review: Th e m an ifestation s o f h yp o ca lcem ia Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clin ical Ju dgm en t; Flu id an d Electrolytes Refer en ce: Lewis et al. (2014), p p. 299–300.

43. 4, 5 Ra tion a le: Th e n o rm al serum calcium level is 9 to 10.5 m g/ d L (2.25 to 2.75 m m ol/ L). A seru m calciu m level lower th an 9 m g/ dL (2.25 m m o l/ L) in dicates h yp o calcem ia. Electrocar- d iograph ic ch an ges th at o ccu r in a clien t with h ypo calcem ia in clu de a p ro lo n ged Q T in terval an d p ro lo n ged ST segm en t. A sh orten ed ST segm en t an d a widen ed T wave occur with h yp ercalcem ia. ST d epressio n an d p ro m in en t U waves occu r with h ypokalem ia. Test-Ta kin g Str a tegy: Focu s o n th e su b ject , th e electro card io- grap h ic pattern s th at o ccur in a calciu m im b alan ce. It is n eces- sary to kn ow th e electrocard io graph ic ch an ges th at o ccu r in h yp ocalcem ia. Rem em b er th at h ypo calcem ia cau ses a pro - lo n ged ST segm en t an d prolo n ged Q T in terval. Review: Th e electrocardiograph ic ch an ges th at occur in h yp o ca lcem ia Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clin ical Ju dgm en t; Flu id an d Electrolytes Refer en ce: Lewis et al. (2014), p . 299.

44. 3, 5 Ra tion a le: Th e n o rm al po tassiu m level is 3.5 to 5.0 m Eq / L (3.5 to 5.0 m m ol/ L). A seru m p otassium level greater th an

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5.0 m Eq / L ( 5.0 m m o l/ L) in dicates h yp erkalem ia. Electro car- dio grap h ic ch an ges asso ciated with h yperkalem ia in clu de flat P waves, p ro lo n ged PR in tervals, widen ed Q RS com plexes, an d tall peaked T waves. ST d ep ressio n an d a p ro m in en t U wave occurs in h yp o kalem ia. A p ro lo n ged ST segm en t occurs in h ypo calcem ia. Test -Ta kin g Str a tegy: Fo cu s on th e su b ject , th e electro card io - graph ic ch an ges th at occur in a p otassiu m im b alan ce. Fro m th e in fo rm ation in th e qu estio n , you n eed to d eterm in e th at th is co n d ition is a h yp erkalem ic on e. Fro m th is p oin t, yo u m u st kn o w th e electrocard io grap h ic ch an ges th at are exp ected wh en h yperkalem ia exists. Rem em b er th at tall peaked T waves, flat P waves, widen ed Q RS co m p lexes, an d p ro lon ged PR in terval are asso ciated with h yperkalem ia. Review: Th e electrocard io grap h ic ch an ges th at o ccu r in h yp er k a lem ia Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Fun dam en tals of Care—Fluids & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p . 296.

45. 1 Ra t ion a le: Th e n o rm al seru m so dium level is 135 to 145 m Eq / L (135 to 145 m m ol/ L) . A serum sodium level of 130 m Eq/ L (130 m m ol/ L) in dicates h yp on atrem ia. Hyp on atrem ia can occu r in th e clien t takin g diu retics. Th e clien t takin g corticoste- ro ids an d th e clien t with h yperaldosteron ism or Cush in g’s syn - drom e are at risk fo r h ypern atrem ia. Test -Ta kin g Str a tegy: Focus o n th e su b ject , th e cau ses of a sod ium level o f 130 m Eq / L (130 m m o l/ L). First, d eterm in e th at th e clien t is exp erien cin g h yp o n atrem ia. Next, yo u m ust kn o w th e cau ses of h ypo n atrem ia to direct yo u to th e co rrect op tion . Also , recall th at wh en a clien t takes a d iu retic, th e clien t loses flu id an d electro lytes. Review: Th e n o rm al seru m so diu m level an d th e cau ses o f h yp o n a t r em ia Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Fun dam en tals of Care—Fluids & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p p. 295–296.

46. 3 Ra t ion a le: Th e n orm al seru m sod iu m level is 135 to 145 m Eq / L (135 to 145 m m o l/ L) . Hyp on atrem ia is evid en ced by a seru m sod ium level lower th an 135 m Eq/ L (135 m m o l/ L). Hyperac- tive bo wel sou n d s in d icate h yp on atrem ia. Th e rem ain in g op tion s are sign s of h ypern atrem ia. In h ypo n atrem ia, m uscle weakn ess, in creased urin ary o utp ut, an d decreased sp ecific gravity of th e urin e wou ld be n o ted. Test -Ta kin g Str a tegy: Fo cu s o n th e d a t a in t h e q u es t io n an d th e s u b ject o f th e q u estio n , sign s o f h yp o n atrem ia. It is n ecessary to kn o w th e sign s o f h yp o n atrem ia to an swer co rrectly. Also , th in k ab o u t th e actio n an d effects o f so d iu m o n th e b o d y to an swer co rrectly. Rem em b er th at in creased b o wel m o tility an d h yp eractive b o wel so u n d s in d icate h yp o n atrem ia.

Review: Th e sign s associated with h yp o n a t r em ia an d h yp er n a t r em ia Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Fluid s & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p. 295.

47. 1 Ra t ion a le: Th e n o rm al seru m p h o sph orus (p h o sph ate) level is 3.0 to 4.5 m g/ d L ( 0.97 to 1.45 m m o l/ L). Th e clien t is experien cin g h ypo ph osp h atem ia. Causative factors relate to m aln utrition o r starvatio n an d th e u se o f alu m in u m h yd ro x- ide–b ased o r m agn esiu m -b ased an tacid s. Ren al in sufficien cy, h ypo parath yro id ism , an d tu m or lysis syn dro m e are cau sative factors o f h yp erp h o sp h atem ia. Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d s , most likely. Fo cu s on th e su b ject , a serum ph osp h o ru s level of 1.8 m g/ d L (0.45 m m ol/ L). First, you m u st d eterm in e th at th e clien t is experien cin g h ypo ph osp h atem ia. Fro m th is p oin t, th in k ab ou t th e effects o f ph osp h o ru s on th e b o dy an d recall th e causes o f h yp o ph o sp h atem ia in order to an swer correctly. Review: Th e causative facto rs asso ciated with h yp o p h o - sp h a t em ia Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Fluid s & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p. 301.

48. 3 Ra t ion a le: In sen sible lo sses m ay o ccur with ou t th e perso n ’s awaren ess. In sen sib le lo sses o ccur daily th rou gh th e skin an d th e lu n gs. Sen sible lo sses are th ose o f wh ich th e person is aware, such as th ro u gh urin atio n , wo un d drain age, an d gastro- in testin al tract lo sses. Test -Ta kin g Str a tegy: No te th at th e su b ject o f th e qu estio n is in sen sible flu id loss. No te th at u rin ation , wo u n d drain age, an d gastroin testin al tract lo sses are co m p a r a b le o r a lik e in th at th ey can be m easured fo r accu rate o utp ut. Fluid lo ss th rou gh th e skin can n o t be m easured accurately; it can on ly b e ap pro xim ated. Review: Th e d ifferen ce b etween sen sib le a n d in sen sib le flu id lo ss Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Co m m u n ication an d Do cu m en tatio n Con t en t Ar ea : Fun d am en tals of Care—Fluid s & Electro lytes Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ces: Lewis et al. (2014) , pp . 290, 293; Perry, Po tter, O sten do rf (2014), p . 810.

49. 1 Ra t ion a le: A fluid volu m e d eficit o ccurs wh en th e flu id in take is n o t sufficien t to m eet th e flu id n eed s o f th e b od y. Causes of a fluid volu m e deficit in clud e vo m itin g, diarrh ea, con dition s th at cause in creased resp iration s or in creased u rin ary ou tpu t, in su fficien t in traven o u s flu id rep lacem en t, d rain in g fistu las,

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95CHAPTER 8 Fluids and Electrolytes

an d th e presen ce o f an ileo stom y o r co losto m y. A clien t with h eart failu re o r on lo n g-term co rtico stero id th erap y o r a clien t receivin g frequ en t wo un d irrigatio n s is m ost at risk fo r flu id vo lum e excess. Test-Ta kin g St r a t egy: No te th e st r a t egic wo r d s, most likely. Read th e qu estio n carefully, n otin g th e su b ject , th e clien t at risk for a d eficit. Read each o ption an d th in k ab o ut th e flu id im b alan ce th at can o ccur in each . Th e clien ts with h eart failu re, on lo n g-term cortico steroid th erap y, an d receivin g frequ en t wou n d irrigatio n s retain flu id . Th e on ly co n d itio n th at can cause a d eficit is th e co n dition n o ted in th e co rrect o ptio n . Review: Th e cau ses o f a flu id vo lu m e d eficit Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n d am en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clin ical Ju dgm en t; Fluid an d Electrolytes Refer en ce: Lewis et al. (2014), p . 292.

50. 1 Ra tion a le: A flu id vo lu m e deficit occu rs wh en th e fluid in take is n ot sufficien t to m eet th e flu id n eeds o f th e b od y. Assessm en t fin din gs in a clien t with a flu id volu m e d eficit in clud e in creased resp iratio n s an d h eart rate, d ecreased cen tral ven o us p ressu re (CVP) (n orm al CVP is between 4 an d 11 cm H 2O ), weigh t lo ss, poor skin turgor, dry m ucous m em bran es, d ecreased u rin e vo lum e, in creased specific gravity o f th e urin e, in creased h em atocrit, an d altered level o f co n sciou sn ess. Lun g con gestion , in creased u rin ary o utp ut, an d in creased bloo d p ressu re are all associated with flu id vo lu m e excess. Test-Ta kin g St r a t egy: Fo cu s on th e su b ject , flu id vo lu m e def- icit. Th in k ab ou t th e path op h ysio logy fo r flu id vo lum e d eficit an d flu id vo lu m e excess to an swer co rrectly. No te th at op tion s 2, 3, an d 4 are co m p a r a b le o r a lik e an d are m an ifestation s asso ciated with flu id vo lu m e excess. Review: Th e assessm en t fin d in gs n o ted in flu id vo lu m e d eficit Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n d am en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clin ical Ju dgm en t; Fluid an d Electrolytes Refer en ce: Lewis et al. (2014), p . 292.

51. 4 Ra tion a le: A fluid vo lum e excess is also kn o wn as overhydration o r fluid overload an d occu rs wh en flu id in take o r flu id reten tio n

exceed s th e flu id n eed s of th e bo dy. Th e causes o f fluid vo lu m e excess in clud e decreased kidn ey fu n ction , h eart failure, u se of h yp oto n ic fluid s to rep lace iso ton ic fluid lo sses, excessive irri- gation of wou n d s an d bo dy cavities, an d excessive in gestio n of so diu m . Th e clien t takin g d iu retics, th e clien t with an ileos- to m y, an d th e clien t wh o requ ires gastro in testin al suctio n in g are at risk for fluid vo lum e d eficit. Test-Ta kin g Str a tegy: Focus on th e su b ject , fluid volum e excess. Th in k abo ut th e path o p h ysio logy associated with flu id volum e excess. Read each o ptio n an d th in k abo ut th e flu id im balan ce th at can o ccur in each . Clien ts takin g d iu retics or h avin g ileo sto m ies o r gastro in testin al suctio n in g all lo se fluid . Th e o n ly co n dition th at can cau se an excess is th e co n d itio n n o ted in th e co rrect op tion . Review: Th e causes o f flu id vo lu m e excess Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clin ical Ju dgm en t; Flu id an d Electrolytes Refer en ce: Lewis et al. (2014), p p. 292, 299–300.

52. 4 Ra tion a le: Th e n o rm al po tassiu m level is 3.5 to 5.0 m Eq / L (3.5 to 5.0 m m ol/ L). A serum p otassiu m level h igh er th an 5.0 m Eq/ L (5.0 m m ol/ L) in d icates h yperkalem ia. Clien ts wh o experien ce cellular sh iftin g of potassium in th e early stages o f m assive cell destru ctio n , su ch as with traum a, b urn s, sepsis, o r m etabo lic or respiratory acid osis, are at risk for h yperkale- m ia. Th e clien t with Cush in g’s syn drom e or colitis an d th e clien t wh o h as been o veru sin g laxatives are at risk fo r h yp okalem ia. Test-Ta kin g St r a t egy: Elim in ate th e clien t with colitis an d th e clien t overu sin g laxatives first b ecause th ey are co m p a r a b le o r a lik e, with bo th reflectin g a gastroin testin al loss. Fro m th e rem ain in g option s, recallin g th at cell destructio n causes p otas- siu m sh ifts will assist in directin g you to th e co rrect o ptio n . Also , rem em ber th at Cush in g’s syn d ro m e p resen ts a risk fo r h yp okalem ia an d th at Add iso n ’s disease presen ts a risk fo r h yp erkalem ia. Review: Th e risk facto rs asso ciated with h yp er k a lem ia Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Flu id s & Electrolytes Pr ior it y Con cept s: Clin ical Ju dgm en t; Flu id an d Electrolytes Refer en ce: Lewis et al. (2014), p . 296.

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96 UNIT III Nursing Sciences

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C H A P T E R 9 Acid-Base Balance

PRIORITY CONCEPTS Acid-Base Balance; Oxygenation

CRITICAL THINKING What Should You Do? The nurse performs an Allen’s test on a client scheduled for an arterial blood gas draw from the radial artery. On release of pressure from the ulnar artery, color in the hand returns after 20 seconds. The nurse should take which actions? Answer located on p. 103.

I. Hydrogen Ions, Acids, and Bases A. Hydro gen io n s

1. Vital to life an d expressed as pH. 2. Circulate in th e body in 2 form s:

a. Volatile h ydrogen of carbo n ic acid b . Non volatile form of h ydrogen an d organ ic acids

B. Acid s 1. Acids are produ ced as en d produ cts of

metabolism. 2. Acids con tain h ydrogen ion s an d are h ydrogen

io n don ors, wh ich m ean s th at acids give up h ydrogen ion s to n eutralize or decrease th e stren gth of an acid or to form a weaker base.

3. Th e stren gth of an acid is determ in ed by th e n um ber of h ydrogen ion s it con tain s.

4. Th e n um ber of h ydrogen ion s in body fluid determ in es its acidity, alkalin ity, or n eutrality.

5. Th e lun gs excrete 13,000 to 30,000 m Eq/ d ay of vo latile h ydrogen in th e form of carbo n ic acid as carbo n dioxide (CO 2).

6. Th e kidn eys excrete 50 m Eq/ d ay of n on volatile acids.

C. Bases 1. Con tain n o h ydrogen ion s. 2. Are h ydrogen io n acceptors; th ey accept h ydro-

gen ion s from acids to n eutralize or decrease th e stren gth of a base or to form a weaker acid.

II. Regulatory Systems for Hydrogen Ion Concentration in the Blood

A. Buffers 1. Buffers are th e fastest actin g regulato ry system .

2. Buffers provide im m ediate protection again st ch an ges in h ydrogen ion con cen tration in th e extracellular fluid.

3. Buffers are reactors th at fun ction on ly to keep th e pH with in th e n arrow lim its of stability wh en too m uch acid or base is released in to th e system , an d buffers absorb or release h ydrogen ion s as n eeded.

4. Buffers serve as a tran spo rt m ech an ism th at carries excess h ydrogen ion s to th e lun gs.

5. O n ce th e prim ary buffer system s react, th ey are co n sum ed, leavin g th e body less able to with stan d furth er stress un til th e buffers are replaced.

B. Prim ary buffer system s in extracellular fluid 1. Hem o globin system

a. System m ain tain s acid-base balan ce by a pro- cess called chloride shift.

b . Ch loride sh ifts in an d out of th e cells in respo n se to th e level of oxygen (O 2) in th e blood .

c. For each ch loride ion th at leaves a red blood cell, a bicarbon ate ion en ters.

d . For each ch loride ion th at en ters a red blood cell, a bicarbon ate ion leaves.

2. Plasma protein system a. Th e system fun ction s alon g with th e liver to

vary th e am oun t of h ydrogen ion s in th e ch em ical structure of plasm a protein s.

b . Plasm a protein s h ave th e ability to attract or release h ydrogen ion s.

3. Carb on ic acid –bicarbon ate system a. Prim ary buffer system in th e body. b . Th e system m ain tain s a pH of 7.4 with a ratio

of 20 parts bicarbon ate (HCO 3 À ) to 1 part carbo n ic acid (H 2CO 3) (Fig. 9-1).

c. Th is ratio (20:1) determ in es th e h ydrogen ion con cen tration of body fluid.

d . Carb on ic acid con cen tration is con trolled by th e excretio n of CO 2 by th e lun gs; th e rate an d dep th of respiration ch an ge in respon se to ch an ges in th e CO 2. 97

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e. Th e kidn eys con trol th e bicarbo n ate con cen - tration an d selectively retain or excrete bicar- bon ate in respo n se to bodily n eeds.

4. Ph osph ate buffer system a . System is presen t in th e cells an d body fluids

an d is especially active in th e kidn eys. b . System acts like bicarbon ate an d n eutralizes

excess h ydrogen ion s. C. Lun gs

1. Th e lun gs are th e secon d defen se of th e body an d in teract with th e buffer system to m ain tain acid- base balan ce.

2. In acido sis, th e pH decreases an d th e respiratory rate an d dep th in crease in an attem p t to exh ale acids. Th e carbon ic acid created by th e n eutraliz- in g action of bicarbo n ate can be carried to th e lun gs, wh ere it is reduced to CO 2 an d water an d is exh aled; th u s h ydrogen ion s are in acti- vated an d exh aled.

3. In alkalosis, th e pH in creases an d th e respiratory rate an d dep th decrease; CO 2 is retain ed an d car- bon ic acid in creases to n eutralize an d decrease th e stren gth of excess bicarbon ate.

4. Th e action of th e lu n gs is reversible in co n trollin g an excess or deficit.

5. Th e lun gs can h old h ydrogen ion s un til th e deficit is corrected or can in activate h ydrogen ion s, chan g- in g the ion s to water m olecules to be exh aled alon g with CO 2, th us correctin g th e excess.

6. Th e process of correctin g a deficit or excess takes 10 to 30 secon ds to com plete.

7. Th e lun gs are capable of in activatin g on ly h ydro- gen ion s carried by carbon ic acid; excess h ydro- gen ion s created by oth er m ech an ism s m ust be excreted by th e kidn eys.

Monitor the client’s respiratory status closely. In acidosis, the respiratory rate and depth increase in an attempt to exhale acids. In alkalosis, the respiratory rate and depth decrease; CO2 is retained to neutralize and decrease the strength of excess bicarbonate.

D. Kidn eys 1. Th e kidn eys provide a m ore in clusive corrective

respo n se to acid-b ase disturban ces th an oth er corrective m ech an ism s, even th ough th e ren al excretion of acids an d alkalis occurs m ore slowly.

2. Compensation requires a few h ours to several days; h owever, th e com pen sation is m ore th o r- ough an d selective th an th at of oth er regulators, such as th e buffer system s an d lu n gs.

3. In acido sis, th e pH decreases an d excess h ydro- gen ion s are secreted in to th e tubules an d com - bin e with buffers for excretion in th e urin e.

4. In alkalo sis, th e p H in creases an d excess b icarb o n ate io n s m o ve in to th e tu b u les, co m b in e with s odium , an d are excreted in th e u rin e.

5. Selective regulation of bicarbon ate occurs in th e kidn eys. a . Th e kidn eys restore bicarbo n ate by excre-

tin g h ydrogen ion s an d retain in g bicarbo - n ate io n s.

b . Excess h ydrogen io n s are excreted in th e urin e in th e form of ph osph oric acid.

c. Th e alteration of certain am in o acids in th e ren al tubules results in a diffusion of am m o- n ia in to th e kidn eys; th e am m on ia com bin es with excess h ydrogen io n s an d is excreted in th e urin e.

E. Potassium (K+) 1. Potassium plays an exch an ge role in m ain tain in g

acid-b ase balan ce. 2. Th e b o d y ch an ges th e p o tassiu m level b y d raw-

in g h yd ro gen io n s in to th e cells o r b y p u sh in g th em o u t o f th e cells ( p o tassiu m m o vem en t acro ss cell m em b ran es is facilitated b y tran s- cellu lar sh iftin g in resp o n se to acid -b ase p attern s) .

3. Th e potassium level ch an ges to com pen sate for h ydrogen io n level ch an ges ( Fig. 9-2). a . In acido sis, th e body protects itself from th e

acidic state by m ovin g h ydrogen ion s in to th e cells. Th erefore, potassium m oves out to m ake room for h ydrogen ion s an d th e potas- sium level in creases.

b . In alkalosis, th e cells release h ydrogen ion s in to th e blood in an attem pt to in crease th e acidity of th e blood ; th is forces th e potas- sium in to th e cells an d potassium levels decrease.

When the client experiences an acid-base imbal- ance, monitor the potassium level closely because the potassium moves in or out of the cells in an attempt to maintain acid-base balance. The resulting hypokale- mia or hyperkalemia predisposes the client to associated complications.

7.35 7.45

7.806.80

Acidos is

Norma l Alka los is

De a thDe a th

1 pa rt ca rbonic a cid

20 pa rts bica rbona te

FIGURE 9-1 Acid-base balance. In the healthy state, a ratio of 1 part car- bonic acid to 20 parts bicarbonate provides a normal serum pH between 7.35 and 7.45. Any deviation to the left of 7.35 results in an acidotic state. Any deviation to the right of 7.45 results in an alkalotic state.

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III. Respiratory Acidosis A. Description : Th e total con cen tration of buffer base is

lower th an n orm al, with a relative in crease in h ydro- gen ion con cen tration ; th us a greater n um ber of h ydrogen ion s is circulatin g in th e blood th an can be ab sorbed by th e buffer system .

B. Causes (Box 9-1) 1. Resp iratory acido sis is cau sed by prim ary defects

in th e fun ction of th e lu n gs or ch an ges in n orm al respiratory pattern s.

2. An y con dition th at causes an obstru ction of th e airway or depresses th e respiratory system can cau se respiratory acido sis.

If the client has a condition that causes an obstruc- tion of the airway or depresses the respiratory system, monitor the client for respiratory acidosis.

C. Assessm en t: In an attem pt to com pen sate, th e kid- n eys retain bicarbo n ate an d excrete excess h ydrogen ion s in to th e urin e ( Table 9-1).

D. In terven tion s 1. Mon itor for sign s of respiratory distress. 2. Adm in ister O 2 as prescribed . 3. Place th e clien t in a sem i-Fowler’s position . 4. En cou rage an d assist th e clien t to turn , co ugh ,

an d deep-breath e. 5. En cou rage h ydration to th in secretio n s.

K+K+

K+

K+

K+ K+

K+

K+

K+

K+

K+

K+

K+

K+ K+

K+

K+ K+

K+

K+

K+

K+

K+ K+

K+

K+

H+

In a lka los is , more hydroge n ions a re pre s e nt in the intra ce llula r fluid tha n in the e xtra ce llula r fluid. Hydroge n ions move from the intra ce llula r fluid into the e xtra ce llula r fluid. To ke e p the intra ce llula r fluid e le ctrica lly ne utra l, pota s s ium ions move from the e xtra ce llula r fluid into the intra ce llula r fluid, cre a ting a re la tive hypoka le mia .

In a cidos is , the e xtra ce llula r hydroge n ion conte nt incre a s e s , a nd the hydroge n ions move into the intra ce llula r fluid. To ke e p the intra ce llula r fluid e le ctrica lly ne utra l, a n e qua l numbe r of pota s s ium ions le a ve the ce ll, cre a ting a re la tive hype rka le mia .

Unde r norma l conditions , the intra ce llula r pota s s ium conte nt is much gre a te r tha n tha t of the e xtra ce llula r fluid. The conce ntra tion of hydroge n ions is low in both compa rtme nts .

H+

H+

H+

H+

H+ H+

H+

H+

H+

H+

H+

H+

H+ H+

H+

H+

H+ H+

H+

K+

K+

K+

K+ K+

K+

K+

K+

K+

K+

K+

K+

H+ H+

H+

FIGURE 9-2 Movement of potassium in response to changes in the extracellular fluid hydrogen ion concentration.

BOX 9-1 Causes of Respiratory Acidosis

▪ Asthma: Spasms resulting from allergens, irritants, or emo- tions cause the smooth muscles of the bronchioles to con- strict, resulting in ineffective gas exchange.

▪ Atelectasis: Excessive mucus collection, with the collapse of alveolar sacs caused by mucous plugs, infectious drainage, or anesthetic medications, results in ineffective gas exchange.

▪ Brain trauma: Excessive pressure on the respiratory center or medulla oblongata depresses respirations.

▪ Bronchiectasis: Bronchi become dilated as a result of inflam- mation, and destructive changes and weakness in the walls of the bronchi occur.

▪ Bronchitis: Inflammation causes airway obstruction, result- ing in inadequate gas exchange.

▪ Central nervous system depressants: Depressants such as sedatives, opioids, and anesthetics depress the respiratory center, leading to hypoventilation (excessive sedation from medications may require reversal by opioid antagonist med- ications); carbon dioxide (CO2) is retained and the hydrogen ion concentration increases.

▪ Emphysema and COPD: Loss of elasticity of alveolar sacs restricts air flow in and out, primarily out, leading to an increased CO2 level.

▪ Administering high oxygen levels per nasal cannula to cli- ents who are CO2 retainers (i.e., emphysema and COPD).

▪ Hypoventilation: Carbon dioxide is retained and the hydro- gen ion concentration increases, leading to the acidotic state; carbonic acid is retained and the pH decreases.

▪ Pneumonia: Excess mucus production and lung congestion cause airway obstruction, resulting in inadequate gas exchange.

▪ Pulmonary edema: Extracellular accumulation of fluid in pul- monary tissue causes disturbances in alveolar diffusion and perfusion.

▪ Pulmonary emboli: Emboli cause obstruction in a pulmo- nary artery resulting in airway obstruction and inadequate gas exchange.

99CHAPTER 9 Acid-Base Balance

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6. Redu ce restlessn ess by im provin g ven tilation rath er th an by adm in isterin g tran quilizers, sed a- tives, or opioids because th ese m ed ication s fur- th er dep ress respiration s.

7. Prepare to adm in ister respiratory treatm en ts as prescribed.

8. Suction th e clien t’s airway, if n ecessary. 9. Mon itor electrolyte values, particularly th e potas-

sium level an d arterial blood gas (ABG) levels. 10. Adm in ister an tibiotics for respiratory in fectio n

or oth er m ed ication s as prescribed.

11. Prepare for endotracheal intubation and m echanical ventilation if CO2 levels rise above 50 m m Hg and if signs of acute respiratory distress are present.

Clients with a historyofemphysema or chronic obstruc- tive pulmonarydisease (COPD) usuallyare not given oxygen greater than 2 liters bycannula since high levels of oxygen in the blood may decrease the stimulus to breathe leading to CO2 retention and respiratory acidosis.

IV. Respiratory Alkalosis A. Descrip tion : A deficit of carbon ic acid an d a decrease

in h ydrogen io n con cen tration th at results from th e accum ulation of base or fro m a lo ss of acid with ou t a com parable lo ss of base in th e body flu ids.

B. Causes: Resp iratory alkalosis results fro m con dition s th at cause overstim ulation of th e respiratory system (Box 9-2).

If the client has a condition that causes overstimu- lation of the respiratory system, monitor the client for respiratory alkalosis.

C. Assessm en t: In itially th e h yperven tilatio n an d respi- ratory stim ulation cause abn o rm al rapid respiratio n s (tach yp n ea); in an attem p t to com pen sate, th e kid- n eys excrete excess circulatin g bicarbon ate in to th e urin e ( Table 9-2).

D. In terven tion s 1. Mon itor for sign s of respiratory distress. 2. Provid e em otion al support an d reassuran ce to

th e clien t. 3. En cou rage appropriate breath in g pattern s. 4. Assist with breath in g tech n iqu es an d breath in g

aids as prescribed. a . En cou rage volun tary h old in g of th e breath if

appropriate. b . Provid e use of a rebreath in g m ask as

prescribed. c. Provid e CO 2 breath s as prescribed (rebreath -

in g in to a paper bag). 5. Provid e cau tious care with ven tilator clien ts so

th at th ey are n ot forced to take breath s too deeply or rapidly.

6. Mon itor electrolyte values, particularly potas- sium an d calcium levels; m on itor ABG levels.

TABLE 9-1 Clinical Manifestations of Acidosis Respiratory (" PaCO2) Metabolic (# HCO32 )

Neurological Drowsiness Drowsiness

Disorientation Confusion

Dizziness Headache

Headache Coma

Coma

Cardiovascular Decreased blood pressure Decreased blood pressure

Dysrhythmias (related to hyperkalemia from compensation)

Dysrhythmias (related to hyperkalemia from compensation)

Warm, flushed skin (related to peripheral vasodilation)

Warm, flushed skin (related to peripheral vasodilation)

Gastrointestinal No significant findings Nausea, vomiting, diarrhea,

abdominal pain

Neuromuscular Seizures No significant findings

Respiratory Hypoventilation with hypoxia (lungs are unable to compensate when there is a respiratory problem)

Deep, rapid respirations (compensatory action by the lungs); known as Kussmaul’s respirations

From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St. Louis, 20 14, Mosby.

BOX 9-2 Causes of Respiratory Alkalosis

▪ Fever: Causes increased metabolism, resulting in overstimu- lation of the respiratory system.

▪ Hyperventilation: Rapid respirations cause the blowing off of carbon dioxide (CO2), leading to a decrease in carbonic acid.

▪ Hypoxia: Stimulates the respiratory center in the brainstem, which causes an increase in the respiratory rate in order to increase oxygen (O2); this causes hyperventilation, which results in a decrease in the CO2 level.

▪ Hysteria: Often is neurogenic and related to a psychoneuro- sis; however, this condition leads to vigorous breathing and excessive exhaling of CO2.

▪ Overventilation by mechanical ventilators: The administra- tion of O2 and the depletion of CO2 can occur from mechan- ical ventilation, causing the client to be hyperventilated.

▪ Pain: Overstimulation of the respiratory center in the brain- stem results in a carbonic acid deficit.

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7. Prepare to adm in ister calcium gluco n ate for tet- an y as prescribed.

V. Metabolic Acidosis A. Description : A total con cen tration of buffer base th at is

lower than n orm al, with a relative in crease in th e h ydro- gen ion con cen tration , resultin g from loss of too m uch base an d/ or reten tion of too m uch acid.

B. Causes (Box 9-3)

An insufficient supply of insulin in a client with diabetes mellitus can result in metabolic acidosis known as diabetic ketoacidosis.

C. Assessm en t: To com pen sate for th e acido sis, deep an d rapid respiration s, kn own as Kussm aul’s respira- tion s, occur as th e lun gs attem p t to exh ale th e excess CO 2 (see Table 9-1).

D. In terven tion s 1. Mon itor for sign s of respiratory distress. 2. Assess level of con scio usn ess for cen tral n ervou s

system depression .

3. Mon itor in take an d outp ut an d assist with fluid an d electrolyte replacem en t as prescribed.

4. Prepare to adm in ister solution s in traven ously as prescribed to in crease th e buffer base.

5. In itiate safety an d seizu re precaution s. 6. Mon itor th e ABG levels an d th e potassium level

clo sely; as m etab olic acido sis resolves, potassium m oves back in to th e cells an d th e potassium level decreases.

E. In terven tion s in diabetes m ellitus an d diabetic ketoacidosis 1. Give in sulin as prescribed to h asten th e m ove-

m en t of gluco se in to th e cells, th ereby decreasin g th e con cu rren t ketosis.

2. Wh en gluco se is bein g properly m etabolized, th e body will stop con vertin g fats to glucose.

3. Mon itor for circulatory collapse caused by poly- uria, wh ich m ay result from th e h yperglycem ic state; osm o tic diuresis m ay lead to extracellular volu m e deficit.

Monitor the client experiencing severe diarrhea for manifestations of metabolic acidosis.

F. In terven tion s in kidn ey disease 1. Dialysis m ay be used to rem ove protein an d waste

produ cts, th ereby lessen in g th e acidotic state. 2. A diet low in protein an d h igh in calories

decreases th e am oun t of protein waste products, wh ich in turn lessen s th e acido sis.

VI. Metabolic Alkalosis A. Descrip tio n : A d eficit o f carb o n ic acid an d a

d ecrease in h yd ro gen io n co n cen tratio n th at resu lts fro m th e accu m u latio n o f b ase o r fro m a lo ss o f acid

TABLE 9-2 Clinical Manifestations of Alkalosis Respiratory (# PaCO2) Metabolic (" HCO32 )

Neurological Lethargy Drowsiness

Lightheadedness Dizziness

Confusion Nervousness

Confusion

Cardiovascular Tachycardia Tachycardia

Dysrhythmias (related to hypokalemia from compensation)

Dysrhythmias (related to hypokalemia from compensation)

Gastrointestinal Nausea Anorexia

Vomiting Nausea

Epigastric pain Vomiting

Neuromuscular Tetany Tremors

Numbness Hypertonic muscles

Tingling of extremities Muscle cramps

Hyperreflexia Tetany

Seizures Tingling of extremities

Seizures

Respiratory Hyperventilation (lungs are unable to compensate when there is a respiratory problem)

Hypoventilation (compensatory action by the lungs)

From Lewis S, Dirksen S, Heitkemper M, Bucher L, Camera I: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St. Louis, 2014, Mosby.

BOX 9-3 Causes of Metabolic Acidosis ▪ Diabetes mellitus or diabetic ketoacidosis: An insufficient

supply of insulin causes increased fat metabolism, leading to an excess accumulation of ketones or other acids; the bicarbonate then ends up being depleted.

▪ Excessive ingestion of acetylsalicylic acid: Causes an increase in the hydrogen ion concentration.

▪ High-fat diet: Causes a much too rapid accumulation of the waste products of fat metabolism, leading to a buildup of ketones and acids.

▪ Insufficient metabolism of carbohydrates: When the oxy- gen supply is not sufficient for the metabolism of carbohy- drates, lactic acid is produced and lactic acidosis results.

▪ Malnutrition: Improper metabolism of nutrients causes fat catabolism, leading to an excess buildup ofketones and acids.

▪ Renal insufficiency, acute kidney injury, or chronic kidney disease: Increased waste products of protein metabolism are retained; acids increase, and bicarbonate is unable to maintain acid-base balance.

▪ Severe diarrhea: Intestinal and pancreatic secretions are normally alkaline; therefore, excessive loss of base leads to acidosis.

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with o u t a co m p arab le lo ss o f b ase in th e b o d y flu id s.

B. Causes: Metabolic alkalosis results from a dysfun c- tion of metabolism th at cau ses an in creased am oun t of available base solution in th e blood or a decrease in available acids in th e blood (Box 9-4).

C. Assessm en t: To com pen sate, respiratory rate an d depth decrease to con serve CO 2 (see Table 9-2).

Monitor the client experiencing excessive vomiting or the client with gastrointestinal suctioning for manifes- tations of metabolic alkalosis.

D. In terven tion s 1. Mon itor for sign s of respiratory distress. 2. Mon itor ABGs an d potassium an d calcium levels. 3. In stitute safety precaution s. 4. Prepare to adm in ister m edication s an d in trave-

n ous fluids as prescribed to prom ote th e kidn ey excretion of bicarbo n ate.

5. Prepare to replace potassium as prescribed. 6. Treat th e un derlyin g cause of th e alkalosis.

VII. Arterial Blood Gases (ABGs) (Table 9-3) A. Collection of an ABG specim en

1. O btain vital sign s. 2. Determ in e wh eth er th e clien t h as an arterial lin e

in place (allo ws for arterial blood sam plin g with - out furth er pun cture to th e clien t) .

3. Perform th e Allen’s test to determ in e th e presen ce of collateral circulation (see Priority Nursin g Actions).

PRIORITY NURSING ACTIONS Performing the Allen’s Test Before Radial Artery Puncture 1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries

simultaneously. 3. Ask the client to open and close the hand repeatedly. 4. Release pressure from the ulnar artery while compressing

the radial artery. 5. Assess the color of the extremity distal to the

pressure point. 6. Document the findings.

The Allen’s test is performed before obtaining an arterial blood specimen from the radial artery to determine the pres- ence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To per- form the test, the nurse applies direct pressure over the client’s ulnar and radial arteries simultaneously. While applying pres- sure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pres- sure point. If pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Other sites, such as the brachial or femoral artery, can be used if the radial artery is not deemed adequate.

Reference Perry, Potter, Ostendorf (2014), pp. 1091–10 92.

4. Assess facto rs th at m ay affect th e accuracy of th e results, such as ch an ges in th e O 2 settin gs, suc- tion in g with in th e past 20 m in u tes, an d clien t’s activities.

5. Provid e em o tion al support to th e clien t. 6. Assist with th e specim en draw; prepare a h epa-

rin ized syrin ge (if n ot already prepackaged). 7. Apply pressure im m ediately to th e pun cture site

followin g th e blood draw; m ain tain pressure for 5 m in utes or for 10 m in utes if th e clien t is takin g an an ticoagulan t.

8. Approp riately label th e specim en an d tran spo rt it on ice to th e laborato ry.

9. O n th e laborato ry form , record th e clien t’s tem - perature an d th e typ e of supp lem en tal O 2 th at th e clien t is receivin g.

BOX 9-4 Causes of Metabolic Alkalosis ▪ Diuretics: The loss of hydrogen ions and chloride from

diuresis causes a compensatory increase in the amount of bicarbonate in the blood.

▪ Excessive vomiting or gastrointestinal suctioning: Leads to an excessive loss of hydrochloric acid.

▪ Hyperaldosteronism: Increased renal tubular reabsorption of sodium occurs, with the resultant loss of hydrogen ions.

▪ Ingestion of and/ or infusion of excess sodium bicarbon- ate: Causes an increase in the amount of base in the blood.

▪ Massive transfusion of whole blood: The citrate anticoagulant used for the storage of blood is metabolized to bicarbonate.

TABLE 9-3 Normal Arterial Blood Gas Values Normal Range

Laboratory Test Conventional Units SI Units

pH 7.35-7.45 7.35-7.45

PaCO2 35-45 mm Hg 35-45 mm Hg

Bicarbonate (HCO3À ) 21-28 mEq/ L 21-28 mmol/ L

PaO2 80-100 mm Hg 80-100 mm Hg

kPa, Kilopascal; mmol, millimole (10 À3 mole); PaCO2, partial pressure of carbon dioxide in arterial blood; PaO2, partial pressure of oxygen in arterial blood. Note: Because arterial blood gases are influenced by altitude, the value for PaO2 decreases as altitude increases.

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B. Resp iratory acid-b ase im balan ces (Table 9-4) 1. Rem em ber th at th e respiratory fun ctio n in dica-

tor is th e PaCO 2. 2. In a respiratory im balan ce, you will fin d an

oppo site relation sh ip between th e pH an d th e PaCO 2; in oth er words, th e pH will be elevated with a decreased PaCO 2 (alkalosis) or th e pH will be decreased with an elevated PaCO 2 (acidosis).

3. Loo k at th e pH an d th e PaCO 2 to determ in e wh eth er th e con d ition is a respiratory problem .

4. Respiratory acidosis: Th e pH is decreased; th e PaCO 2 is elevated .

5. Respiratory alkalosis: Th e pH is elevated ; th e PaCO 2 is decreased.

C. Metab olic acid-b ase im balan ces (see Table 9-4) 1. Rem em ber, th e m etab olic fun ctio n in dicator is

th e bicarbon ate io n (HCO 3 À ). 2. In a m etab olic im balan ce, th ere is a correspo n d-

in g relation sh ip between th e pH an d th e HCO 3 À ; in oth er words, th e pH will be elevated an d HCO 3 À will be elevated (alkalosis), or th e pH will be decreased an d HCO 3 À will be decreased (acidosis).

3. Look at the pH an d the HCO 3 À to determ in e wh eth er th e con dition is a m etabolic problem .

4. Metabolic acidosis: Th e pH is decreased; th e HCO 3 À is decreased.

5. Metabolic alkalosis: Th e pH is elevated ; th e HCO 3 À is elevated.

In a respiratory imbalance, the ABG result indicates an opposite relationship between the pH and the PaCO2. In a metabolic imbalance, the ABG result indicates a cor- responding relationship between the pH and the HCO3À .

D. Compensation (see Table 9-4) 1. Com pen sation refers to the body processes th at

occur to coun terbalan ce th e acid-base disturban ce. 2. Wh en full com pen sation h as occurred, th e pH is

with in n orm al lim its. E. Steps for an alyzin g ABG results ( Box 9-5) F. Mixed acid-b ase disorders

1. O ccurs wh en 2 or m ore disorders are presen t at th e sam e tim e.

2. Th e pH will depen d on th e typ e an d severity of th e disorders in volved, in cludin g an y com pen sa- tory m ech an ism s at work, e.g., respiratory acido- sis com bin ed with m etab olic acido sis will result in a greater decrease in pH th an eith er im balan ce occurrin g alon e.

3. Exam ple: Mixed alkalosis can occur if a clien t begin s to h yperven tilate due to postoperative pain (respiratory alkalosis) and is also losin g acid due to gastric suction in g (m etabolic alkalosis).

CRITICAL THINKING What Should You Do? Answer: Failure to determine the presence of adequate col- lateral circulation before drawing an arterial blood gas spec- imen could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Upon release of pressure on the ulnar artery, if pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtain- ing a blood specimen. Another site needs to be selected for the arterial puncture and the health care provider needs to be notified of the finding.

Reference: Perry, Potter, Ostendorf (20 14), p. 1091.

TABLE 9-4 Acid-Base Imbalances: Usual Laboratory Value Changes Imbalance pH HCO3À PaO2 PaCO2 K

+

Respiratory acidosis

U: Decreased PC: Decreased C: Normal

U: Normal PC: Increased C: Increased

Usually decreased U: Increased PC: Increased C: Increased

Increased

Respiratory alkalosis

U: Increased PC: Increased C: Normal

U: Normal PC: Decreased C: Decreased

Usually normal but depends on other accompanying conditions

U: Decreased PC: Decreased C: Decreased

Decreased

Metabolic acidosis U: Decreased PC: Decreased C: Normal

U: Decreased PC: Decreased C: Decreased

Usually normal but depends on other accompanying conditions

U: Normal PC: Decreased C: Decreased

Increased

Metabolic alkalosis

U: Increased PC: Increased C: Normal

U: Increased PC: Increased C: Increased

Usually normal but depends on other accompanying conditions

U: Normal PC: Increased C: Increased

Decreased

U, uncompensated; PC, partially compensated; C, compensated.

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P R A C T I C E Q U E S T I O N S 53. Th e n urse reviews th e arterial blood gas results of a

clien t an d n otes th e followin g: pH 7.45, PaCO 2 of 30 m m Hg (30 m m Hg), an d HCO 3 À of 20 m Eq/ L (20 m m o l/ L). Th e n urse an alyzes th ese results as in dicatin g wh ich co n dition ? 1. Metab olic acido sis, com pen sated 2. Resp iratory alkalosis, com pen sated 3. Metab olic alkalosis, un co m pen sated 4. Resp iratory acido sis, un co m pen sated

54. Th e n urse is carin g for a clien t with a n aso gastric tube th at is attach ed to lo w suction . Th e n urse m on - itors th e clien t for m an ifestation s of wh ich disorder th at th e clien t is at risk for? 1. Metab olic acido sis 2. Metab olic alkalosis 3. Resp iratory acidosis 4. Resp iratory alkalosis

55. A clien t with a 3-day h istory of n ausea an d vom itin g presen ts to the em ergen cy departm en t. Th e clien t is h ypoven tilatin g an d h as a respiratory rate of 10 breaths/m in ute. Th e electrocardiogram (ECG) m oni- tor displays tach ycardia, with a h eart rate of 120 beats/ m in ute. Arterial blood gases are drawn and the n urse reviews the results, expectin g to n ote wh ich fin din g? 1. A decreased pH an d an in creased PaCO 2 2. An in creased pH an d a decreased PaCO 2 3. A decreased pH an d a decreased HCO 3 À 4. An in creased pH an d an in creased HCO 3 À

56. Th e n urse is carin g for a clien t h avin g respiratory distress related to an an xiety attack. Recen t arterial blood gas values are pH ¼7.53, PaO2 ¼72 m m Hg (72 m m Hg), PaCO2 ¼32 m m Hg (32 m m Hg), an d HCO 3 À ¼28 m Eq/ L (28 m m ol/ L). Wh ich con clusion about the clien t sh ould th e n urse m ake? 1. Th e clien t h as acidotic blood. 2. Th e clien t is probably overreactin g. 3. Th e clien t is flu id volum e overloaded . 4. Th e clien t is probably h yperven tilatin g.

57. Th e n urse is carin g for a clien t with diab etic ketoaci- dosis an d docum en ts th at th e clien t is experien cin g Kussm aul’s respiration s. Wh ich pattern s did th e n urse observe? Select all th at ap p ly.

1. Respiration s th at are sh allow 2. Resp iration s th at are in creased in rate 3. Resp iration s th at are abn o rm ally slow 4. Respiration s th at are abn orm ally deep 5. Resp iration s th at cease for several secon ds

58. A clien t wh o is foun d un respon sive h as arterial blood gases drawn an d th e results in dicate th e followin g: pH is 7.12, PaCO2 is 90 m m Hg (90 m m Hg), an d HCO 3 À is 22 m Eq/ L (22 m m ol/ L). Th e n urse in terprets the results as in dicatin g wh ich con dition ? 1. Metab olic acido sis with com pen sation 2. Resp iratory acido sis with com pen sation 3. Metab olic acidosis with ou t com pen sation 4. Respiratory acido sis with out com pen satio n

BOX 9-5 Analyzing Arterial Blood Gas Results If you can remember the following Pyramid Points and Pyramid Steps, you will be able to analyze any blood gas report.

Pyramid Points In acidosis, the pH is decreased. In alkalosis, the pH is elevated. The respiratory function indicator is the PaCO2. The metabolic function indicator is the bicarbonate ion (HCO3À ).

Pyramid Steps Pyra mid Step 1 Look at the blood gas report. Look at the pH. Is the pH elevated or decreased? If the pH is elevated, it reflects alkalosis. If the pH is decreased, it reflects acidosis.

Pyra mid Step 2 Look at the PaCO2. Is the PaCO2 elevated or decreased? If the PaCO2 reflects an opposite relationship to the pH, the condition

is a respiratory imbalance. If the PaCO2 does not reflect an oppo- site relationship to the pH, go to Pyramid Step 3.

Pyra mid Step 3 Look at the HCO3À . Does the HCO3À reflect a corresponding relationship with the pH? If it does, the condition is a metabolic imbalance.

Pyra mid Step 4 Full compensation has occurred if the pH is in a normal range of 7.35 to 7.45. If the pH is not within normal range, look at the respiratory or metabolic function indicators.

If the condition is a respiratory imbalance, look at the HCO3À to determine the state of compensation.

If the condition is a metabolic imbalance, look at the PaCO2 to determine the state of compensation.

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59. Th e n urse n otes th at a clien t’s arterial blood gas (ABG) results reveal a pH of 7.50 an d a PaCO 2 of 30 m m Hg (30 m m Hg) . Th e n urse m on itors th e clien t for wh ich clin ical m an ifestation s associated with th ese ABG results? Select all th at ap p ly.

1. Nausea 2. Con fusion 3. Bradypn ea 4. Tach ycardia 5. Hyperkalem ia 6. Ligh th eadedn ess

60. Th e n urse reviews th e blood gas results of a clien t with atelectasis. Th e n urse an alyzes th e results an d determ in es th at th e clien t is experien cin g respi- ratory acido sis. Wh ich result validates th e n urse’s fin din gs? 1. pH 7.25, PaCO 2 50 m m Hg (50 m m Hg) 2. pH 7.35, PaCO 2 40 m m Hg (40 m m Hg) 3. pH 7.50, PaCO 2 52 m m Hg (52 m m Hg) 4. pH 7.52, PaCO 2 28 m m Hg (28 m m Hg)

61. Th e n urse is carin g for a clien t wh o is on a m ech an - ical ven tilator. Bloo d gas results in dicate a pH of 7.50 an d a PaCO 2 of 30 m m Hg (30 m m Hg). Th e n urse h as determ in ed th at th e clien t is experien cin g respiratory alkalosis. Wh ich labo ratory value would m o st likely be n oted in th is con d ition ? 1. Sodium level of 145 m Eq/ L (145 m m ol/ L) 2. Potassium level of 3.0 m Eq/ L (3.0 m m o l/ L) 3. Magn esium level of 1.3 m Eq/ L (0.65 m m o l/ L) 4. Ph osph orus level of 3.0 m g/ dL (0.97 m m ol/ L)

62. Th e n urse is carin g for a clien t with several broken ribs. Th e clien t is m o st likely to exp erien ce wh at type of acid-b ase im balan ce? 1. Resp iratory acido sis from in adeq uate ven tilation 2. Resp iratory alkalosis from an xiety an d

h yperven tilation 3. Metab olic acido sis from calcium loss due to

broken bon es 4. Metab olic alkalosis from takin g an algesics co n -

tain in g base produ cts

A N S W E R S 53. 2 Ra t ion a le: Th e n orm al p H is 7.35 to 7.45. In a resp irato ry co n - ditio n , an o pp o site effect will b e seen between th e pH an d th e PaCO 2. In th is situ ation , th e pH is at th e h igh en d o f th e n o rm al value an d th e PCO 2 is low. In an alkalotic co n d itio n , th e p H is elevated. Th erefo re, th e values id en tified in th e qu estio n in di- cate a resp irato ry alkalo sis th at is com pen sated by th e kid n eys th ro ugh th e ren al excretio n o f b icarb on ate. Becau se th e pH h as retu rn ed to a n orm al value, com pen sation h as occurred. Test -Ta kin g Str a tegy: Focus o n th e su b ject , arterial blo o d gas results. Rem em ber th at in a respiratory im balan ce you will fin d an o pp osite respo n se b etween th e pH an d th e PCO 2 as in d icated in th e q uestion . Th erefo re, you can elim in ate th e o ptio n s reflective of a prim ary m etabolic problem . Also, rem em ber th at th e pH in creases in an alkalotic co n d ition an d co m pen sation can be evid en ced by a n orm al p H. Th e correct o ptio n reflects a resp irato ry alkalotic co n d itio n an d com pen satio n an d describes th e blo o d gas values as in d icated in th e q uestion . Review: Th e step s related to a n a lyzin g a r t er ia l b lo o d ga s r esu lt s an d th e fin din gs n o ted in r esp ir a t o r y a lk a lo sis Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Fun dam en tals of Care—Acid-Base Pr ior ity Con cepts: Acid -Base Balan ce; Clin ical Ju dgm en t Refer en ce: Lewis et al. (2014), p . 304.

54. 2 Ra t ion a le: Metab olic alkalo sis is d efin ed as a deficit or lo ss o f h ydrogen io n s or acids o r an excess of b ase ( bicarbo n ate) th at results fro m th e accum ulatio n of base or from a loss of acid with ou t a co m parable lo ss of base in th e bo d y fluid s. Th is occu rs in con dition s resu ltin g in h yp o vo lem ia, th e loss of gas- tric fluid , excessive b icarbo n ate in take, th e m assive tran sfusion

o f wh o le b lo od , an d h yp eraldo stero n ism . Lo ss o f gastric fluid via n aso gastric suction o r vom itin g cau ses m etab o lic alkalo sis as a resu lt o f th e loss of h yd roch lo ric acid. Th e rem ain in g o p tion s are in co rrect in terp retatio n s. Test -Ta kin g Str a tegy: Fo cus o n th e su b ject , a clien t with a n asogastric tub e attach ed to suctio n . Rem em berin g th at a clien t receivin g n aso gastric su ction loses h ydroch lo ric acid will direct yo u to th e o ptio n iden tifyin g an alkalo tic co n d ition . Becau se th e q u estion ad dresses a situ atio n o th er th an a respirato ry o n e, th e acid-b ase d iso rd er wou ld be a m etab olic co n d ition . Review: Th e ca u ses o f m et a b o lic a lk a lo sis Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Acid-Base Pr ior ity Con cepts: Acid -Base Balan ce; Clin ical Jud gm en t Refer en ce: Lewis et al. (2014), pp . 304–305.

55. 4 Ra t ion a le: Clien ts exp erien cin g n au sea an d vom itin g wo uld m o st likely p resen t with m etabo lic alkalo sis resu ltin g fro m lo ss o f gastric acid, th u s causin g th e pH an d HCO 3 À to in crease. Sym pto m s experien ced b y th e clien t wo uld in clud e h yp oven ti- lation an d tach ycard ia. O ption 1 reflects a respiratory acid otic co n dition . O ptio n 2 reflects a respiratory alkalotic co n d itio n , an d op tion 3 reflects a m etabo lic acido tic con d itio n . Test -Ta kin g Str a tegy: Focus on th e su b ject , exp ected arterial b lo od gas fin d in gs. Note th e data in th e q uestion an d th at th e clien t is vo m itin g. Recallin g th at vom itin g m ost likely causes m etab o lic alkalo sis will assist in d irectin g you to th e co r- rect op tio n . Review: Th e ca u ses o f m et a b o lic a lk a lo sis Level of Cogn it ive Ability: Syn th esizin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t

105CHAPTER 9 Acid-Base Balance

Con ten t Ar ea : Fu n d am en tals o f Care—Acid -Base Pr ior it y Con cept s: Acid-Base Balan ce; Clin ical Jud gm en t Refer en ces: Ign atavicius, Workm an (2016), pp. 183–184; Lewis et al. (2014), pp . 303–305.

56. 4 Ra tion a le: Th e ABG values are ab n o rm al, wh ich su pp orts a p h ysio logical prob lem . Th e ABGs in d icate respiratory alkalosis as a resu lt o f h yperven tilatin g, n ot acid osis. Con clu din g th at th e clien t is o verreactin g is an in su fficien t an alysis. No co n clu - sio n can b e m ade abo u t a clien t’s flu id vo lu m e statu s from th e in form atio n provid ed . Test-Ta kin g St r a t egy: Fo cu s o n th e d a t a in t h e q u e s t io n . No te th e ABG valu es an d u se kn o wled ge to in terp ret th em . No te th at th e p H is elevated an d th e PaCO 2 is d ecreased fro m n o rm al. Th is will assist yo u in d eterm in in g th at th e clien t is exp erien cin g resp irato ry alkalo sis. Next, th in k ab o u t th e cau ses o f resp irato ry alkalo sis to an swer co rrectly. Review: Th e ca u ses o f r esp ir a t o r y a lk a lo sis Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—An alysis Con ten t Ar ea : Fu n d am en tals o f Care—Acid-Base Pr ior it y Con cept s: Acid-Base Balan ce; Clin ical Jud gm en t Refer en ce: Lewis et al. (2014), p p . 304–305.

57. 2, 4 Ra tion a le: Kussm au l’s respiratio n s are abn orm ally d eep an d in creased in rate. Th ese occu r as a resu lt o f th e co m p en sato ry action b y th e lu n gs. In bradyp n ea, resp iratio n s are regular b ut ab n o rm ally slo w. Ap n ea is d escrib ed as respiratio n s th at cease fo r several seco n d s. Test-Ta kin g Str a tegy: Fo cu s o n th e su b ject , th e ch aracteristics o f Kussm au l’s resp iratio n s. Use kn o wled ge of th e d escrip tion o f Kussm aul’s respiration s. Recallin g th at th is type o f resp ira- tio n occurs in d iab etic keto acid osis will assist you in an swerin g correctly. Review: Th e ch aracteristics o f Ku ssm a u l’s r esp ir a t io n s Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n d am en tals o f Care—Acid -Base Pr ior it y Con cept s: Acid-Base Balan ce; Clin ical Jud gm en t Refer en ce: Perry, Po tter, O sten d orf (2014), p. 89.

58. 4 Ra tion a le: Th e acid-b ase d isturb an ce is respiratory acid osis with out com p en sation . Th e n o rm al pH is 7.35 to 7.45. Th e n o rm al PaCO 2 is 35 to 45 m m Hg ( 35 to 45 m m Hg) . In resp i- rato ry acido sis th e pH is d ecreased an d th e PCO 2 is elevated . Th e n o rm al b icarbo n ate ( HCO 3 À ) level is 21 to 28 m Eq/ L (21 to 28 m m o l/ L) . Because th e b icarbo n ate is still with in n orm al lim its, th e kidn eys h ave n o t h ad tim e to ad ju st fo r th is acid - b ase disturban ce. In add itio n , th e pH is n ot with in n orm al lim its. Th erefo re, th e con d itio n is with ou t co m pen sation . Th e rem ain in g o ptio n s are in co rrect in terpretation s. Test-Ta kin g St r a t egy: Fo cu s on th e su b ject , in terpretation of arterial b lo od gas resu lts. Rem em ber th at in a respiratory im b alan ce yo u will fin d an op po site resp on se between th e p H an d th e PaCO 2. Also, rem em ber th at th e pH is decreased

in an acido tic con d itio n an d th at co m p en satio n is reflected b y a n o rm al pH. Review: Th e p rocedu re for a n a lyzin g b lo o d ga s r esu lt s Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Acid -Base Pr ior it y Con cept s: Acid-Base Balan ce; Clin ical Ju d gm en t Refer en ce: Lewis et al. (2014), p . 304.

59. 1, 2, 4, 6 Ra tion a le: Resp iratory alkalo sis is defin ed as a deficit o f car- b on ic acid o r a d ecrease in h ydrogen io n co n cen tration th at results from th e accum u lation o f base o r from a loss of acid with out a com parable loss of base in th e body fluids. Th is o ccurs in co n d itio n s th at cause o verstim u lation of th e resp ira- to ry system . Clin ical m an ifestatio n s o f resp irato ry alkalo sis in clu de leth argy, ligh th ead ed n ess, con fu sio n , tach ycard ia, d ys- rh yth m ias related to h ypokalem ia, n au sea, vo m itin g, epigastric p ain , an d n um b n ess an d tin glin g o f th e extrem ities. Hyperven - tilatio n (tach yp n ea) occu rs. Brad ypn ea d escrib es resp iratio n s th at are regu lar b u t abn o rm ally slo w. Hyp erkalem ia is asso ci- ated with acido sis. Test-Ta kin g Str a tegy: Fo cu s o n th e su b ject , th e in terp retation o f ABG valu es. No te th e data in th e q u estion to determ in e th at th e clien t is exp erien cin g resp irato ry alkalosis. Next, it is n eces- sary to th in k ab ou t th e p ath op h ysio lo gy th at o ccurs in th is con - d ition an d recall th e m an ifestation s th at occu r. Review: Th e clin ical m an ifestation s o f r esp ir a t o r y a lk a lo sis Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Acid -Base Pr ior it y Con cept s: Acid-Base Balan ce; Clin ical Ju d gm en t Refer en ce: Lewis et al. (2014), p . 305.

60. 1 Ra tion a le: Atelectasis is a con dition ch aracterized by th e col- lap se of alveoli, p reven tin g th e respiratory exch an ge of o xygen an d carb on dio xid e in a p art of th e lun gs. Th e n orm al pH is 7.35 to 7.45. Th e n o rm al PaCO 2 is 35 to 45 m m Hg ( 35 to 45 m m Hg) . In respiratory acido sis, th e pH is decreased an d th e PaCO 2 is elevated . O p tion 2 id en tifies n orm al valu es. O ptio n 3 iden tifies an alkalo tic con dition , an d o p tion 4 id en - tifies resp irato ry alkalo sis. Test-Ta kin g Str a t egy: Focu s on th e su b ject , th e arterial bloo d gas resu lts in a clien t with atelectasis. Rem em ber th at in a respi- ratory im balan ce you will fin d an o pp o site respo n se b etween th e p H an d th e PaCO 2. Also, rem em b er th at th e p H is d ecreased in an acido tic co n d itio n . First elim in ate o ption 2 b ecau se it reflects a n orm al blood gas result. O p tion s 3 an d 4 iden tify an elevated pH, in dicatin g an alkalotic co n dition . Th e co rrect o ptio n is th e on ly o n e th at reflects an acido tic co n d itio n . Review: Blo od gas fin d in gs in r esp ir a t o r y a cid o sis Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysiological In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Fu n dam en tals o f Care—Acid -Base Pr ior it y Con cept s: Acid-Base Balan ce; Clin ical Ju d gm en t Refer en ce: Lewis et al. (2014), p p. 305, 550.

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106 UNIT III Nursing Sciences

61. 2 Ra t ion a le: Resp irato ry alkalosis is d efin ed as a d eficit of car- bo n ic acid or a decrease in h yd rogen io n co n cen tratio n th at results fro m th e accum ulatio n of base or from a loss of acid with ou t a co m parable lo ss of base in th e bo d y fluid s. Th is occu rs in con dition s th at cau se overstim ulatio n o f th e respira- to ry system . Clin ical m an ifestation s o f respiratory alkalo sis in clud e leth argy, ligh th ead edn ess, co n fu sion , tach ycardia, dys- rh yth m ias related to h ypokalem ia, n ausea, vom itin g, epigastric pain , an d n u m bn ess an d tin glin g of th e extrem ities. All th ree in correct o ptio n s iden tify n o rm al lab o rato ry valu es. Th e co r- rect option iden tifies th e presen ce of h ypokalem ia. Test -Ta kin g St r a tegy: Note th e st r a t egic wo r d s , most likely. Fo cu s on th e d a t a in t h e q u est io n an d use kn o wledge abo u t th e in terp retatio n o f arterial bloo d gas values to determ in e th at th e clien t is experien cin g resp irato ry alkalosis. Next, recall th e m an ifestation s th at o ccur in th is con dition an d th e n o rm al lab - orato ry valu es. Th e on ly ab n o rm al labo rato ry value is th e po tassium level, th e correct o ptio n . Review: Th e clin ical m an ifestatio n s of r esp ir a t o r y a lk a lo sis Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Fun dam en tals of Care—Acid-Base

Pr ior ity Con cepts: Acid -Base Balan ce; Clin ical Ju dgm en t Refer en ce: Lewis et al. (2014), p. 305.

62. 1 Ra t ion a le: Respiratory acido sis is m o st often caused b y h ypo - ven tilatio n . Th e clien t with b ro ken ribs will h ave d ifficu lty with b reath in g adequ ately an d is at risk for h yp oven tilatio n an d resu ltan t resp irato ry acid osis. Th e rem ain in g op tio n s are in co r- rect. Respiratory alkalosis is asso ciated with h yperven tilatio n . Th ere are n o data in th e q u estion th at in dicate calciu m lo ss o r th at th e clien t is takin g an algesics co n tain in g b ase prod ucts. Test -Ta kin g St r a t egy: Focus on th e d a t a in t h e q u est io n . Th in k ab ou t th e location of th e rib s to d eterm in e th at th e clien t will h ave difficulty breath in g adequately. Th is will assist in d irectin g yo u to th e co rrect o ptio n . Rem em b erin g th at h yp o - ven tilatio n resu lts in resp irato ry acido sis will d irect you to th e co rrect o p tion . Review: Ca u ses o f r esp ir a t o r y a cid o sis Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Acid-Base Pr ior ity Con cepts: Acid -Base Balan ce; Clin ical Jud gm en t Refer en ce: Lewis et al. (2014), pp . 305, 598.

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107CHAPTER 9 Acid-Base Balance

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C H A P T E R 10 Vital Signs and Laboratory Reference Intervals

PRIORITY CONCEPTS Cellular Regulation; Perfusion

CRITICAL THINKING What Should You Do? The nurse has just received a client from the postanesthesia care unit (PACU) and is monitoring the client’s vital signs. On arrival to the unit, the client’s temperature was 37.2 °C (98.9 °F) orally, the blood pressure was 142/ 78 mm Hg, the heart rate was 98 beats per minute, the respiratory rate was 14 breaths per minute, and the oxygen saturation was 95% on 3 L of oxygen via nasal cannula. The nurse returns to the room 30 minutes later to find the client’s temperature to be 36.8 °C (98.2 °F) orally, the blood pressure 95/ 54 mm Hg, the heart rate 118 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 92% on 3 L of oxygen via nasal cannula. On the basis of these data, what actions should the nurse take? Answer located on p. 119.

I. Vital Signs A. Description : Vital sign s in clude tem p erature, pulse,

respiration s, blood pressure (BP) , oxygen saturation (pulse oxim etry), an d pain assessm en t.

B. Guidelin es for m easu rin g vital sign s 1. In itial m easu rem en t of vital sign s provides base-

lin e data on a clien t’s h ealth status an d is used to h elp iden tify ch an ges in th e clien t’s h ealth status.

2. Som e vital sign m easurem en ts (tem perature, pulse, respiration s, BP, pulse oxim etry) m ay be delegated to un licen sed assistive perso n n el (UAP), but th e n urse is respo n sible for in terp ret- in g th e fin din gs.

3. Th e n urse collabo rates with th e h ealth care pro- vider (HCP) in determ in in g th e frequen cy of vital sign assessm en t an d also m akes in depen - den t decision s regardin g th eir frequen cy on th e basis of th e clien t’s status.

The nurse always documents vital sign measure- ments and reports abnormal findings to the HCP.

C. Wh en vital sign s are m easured 1. O n in itial con tact with a clien t (e.g., wh en a cli-

en t is adm itted to a h ealth care facility) 2. Durin g ph ysical assessm en t of a clien t 3. Before an d after an in vasive diagn ostic procedure

or surgical procedure 4. Durin g th e adm in istration of m ed ication th at

affects th e cardiac, respiratory, or tem p erature- con trollin g fun ction s (e.g., in a clien t wh o h as a fever) ; m ay be required before, durin g, an d after adm in istration of th e m ed ication

5. Before, durin g, an d after a blood tran sfusion 6. Wh en ever a clien t’s con d ition ch an ges 7. Wh en ever an in terven tion (e.g., am bulation )

m ay affect a clien t’s con dition 8. Wh en a fever or kn own in fection is presen t

(every 2 to 4 h ours)

II. Temperature A. Descrip tion

1. Norm al body tem p erature ran ges from 36.4° to 37.5° Celsius (C) (97.5° to 99.5° Fah ren h eit [F]); th e average in a h ealth y yo un g adult is 37.0 °C (98.6 °F).

2. Com m on m easu rem en t sites are th e m ou th , rec- tum , axilla, ear, an d across th e foreh ead (tem po - ral artery site); various types of electron ic m easu rin g devices are com m on ly used.

3. Rectal tem p eratures are usually 1 °F (0.5 °C) h igh er an d axillary tem peratures about 1 °F (0.5 °C) lower th an th e n orm al oral tem p erature.

4. Kn ow h ow to con vert a tem p erature to a Fah ren - h eit or Celsius value ( Box 10-1).

B. Nursin g con sideration s 1. Tim e of day

a . Tem perature is gen erally in th e low-n orm al ran ge at th e tim e of awaken in g as a result of m uscle in activity.

b . Aftern oon body tem p erature m ay be h igh - n orm al as a result of th e m etab olic process, activity, an d en viron m en tal tem p erature.

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2. En viron m en tal tem perature: Body tem p erature is lower in cold weath er an d h igh er in warm weath er.

3. Age: Tem perature m ay fluctuate durin g th e first year of life because th e in fan t’s h eat-regulatin g m ech an ism is n ot fully developed.

4. Ph ysical exercise: Use of th e large m uscles creates h eat, cau sin g an in crease in body tem p erature.

5. Men strual cycle: Tem perature decreases sligh tly just befo re ovulation but m ay in crease to 1 °F ab ove n orm al durin g ovulation .

6. Pregn an cy: Bod y tem perature m ay con sisten tly stay at h igh -n orm al because of an in crease in th e wom an ’s m etab olic rate.

7. Stress: Em otion s in crease h orm on al secretio n , lead in g to in creased h eat produ ction an d a h igh er tem perature.

8. Illn ess: In fective agen ts an d th e in flam m ato ry respo n se m ay cau se an in crease in tem perature.

9. Th e in ability to obtain a tem perature sh ould n ot be ign ored because it could represen t a con dition of h ypoth erm ia, a life-th reaten in g con d ition in very youn g an d older clien ts.

C. Meth od s of m easu rem en t 1. O ral

a. If th e client h as recently con sum ed h ot or cold foods or liquids or h as sm oked or ch ewed gum , th e n urse m ust wait 15 to 30 m in utes before takin g the tem perature orally.

b . The th erm om eter is placed un der th e ton gue in 1 of th e posterior sublingual pockets; ask th e cli- en t to keep th e ton gue down and th e lips closed an d to not bite down on th e th erm om eter.

2. Rectal a. Place th e clien t in th e Sim s position . b . Th e tem perature is taken rectally wh en an

accu rate tem p erature can n ot be obtain ed orally or wh en th e clien t h as n asal con ges- tio n , h as un dergon e n asal or oral surgery or h ad th e jaws wired, h as a n asogastric tube in place, is un ab le to keep th e m outh closed , or is at risk for seizu res.

c. Th e th erm om eter is lubricated an d in serted in to th e rectum , toward th e um b ilicus, ab out 1.5 in ch es (3.8 cm ) (n o m ore th an 0.5 in ch [1.25 cm ] in an in fan t).

The temperature is not taken rectally in cardiac cli- ents; the client who has undergone rectal surgery; or the client with diarrhea, fecal impaction, or rectal bleeding or who is at risk for bleeding.

3. Axillary a. Th is m eth od of takin g th e tem p erature is used

wh en th e oral or rectal tem p erature m easure- m en t is con train dicated.

b . Axillary m easu rem en t is n ot as accu rate as th e oral, rectal, tym pan ic, or tem poral artery m eth od but is used wh en oth er m eth od s of m easu rem en t are n ot possible.

c. Th e th erm om eter is placed in th e clien t’s dry axilla an d th e clien t is asked to h old th e arm tigh tly again st th e ch est, restin g th e arm on th e ch est; follow th e in struction s accom pan y- in g th e m easurem en t device for th e am oun t of tim e th e th erm om eter sh ould rem ain in th e axillary area.

4. Tym pan ic a. Th e au ditory can al is ch ecked for th e presen ce

of redn ess, swellin g, disch arge, or a foreign body befo re th e probe is in serted; th e probe sh ould n ot be in serted if th e clien t h as an in flam m ato ry con d ition of th e auditory can al or if th ere is disch arge fro m th e ear.

b . Th e readin g m ay be affected by an ear in fec- tion or excessive wax blockin g th e ear can al.

5. Tem po ral artery a. En su re th at th e clien t’s foreh ead is dry. b . Th e th erm om eter probe is placed flush

again st th e skin an d slid across th e foreh ead or placed in th e area of th e tem poral artery an d h eld in place.

c. If th e clien t is diaph o retic, th e tem poral artery th erm om eter probe m ay be placed on th e n eck, just beh in d th e earlobe.

III. Pulse A. Description

1. Th e average adult pulse (h eart) rate is 60 to 100 beats/ m in .

2. Ch an ges in pulse rate are used to evalu ate th e cli- en t’s toleran ce of in terven tion s such as am bula- tion , bath in g, dressin g, an d exercise.

3. Ped al pulses are ch ecked to determ in e wh eth er th e circulation is blocked in th e artery up to th at pulse poin t.

4. Wh en th e pedal pulse is difficult to locate, a Do ppler ultrasoun d steth oscope (ultrason ic steth oscope) m ay be n eeded to am plify th e soun ds of pulse waves.

B. Nursin g con sideration s 1. Th e h eart rate slows with age. 2. Exercise in creases th e h eart rate. 3. Em otion s stim ulate th e sym path etic n ervou s sys-

tem , in creasin g th e h eart rate.

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BOX 10-1 Body Temperature Conversion To convert Fahrenheit to Celsius: Degrees Fahrenheit –

32 Â 5/ 9 ¼Degrees Celsius Example: 98.2 °F – 32 Â 5/ 9 ¼36.7 °C

To convert Celsius to Fahrenheit: Degrees Celsius  9/ 5 + 32¼Degrees Fahrenheit Example: 38.6 °C 9/ 5+ 32¼101.5 °F

109CHAPTER 10 Vital Signs and Laboratory Reference Intervals

4. Pain in creases th e h eart rate. 5. In creased body tem perature causes th e h eart rate

to in crease. 6. Stim ulan t m ed ication s in crease th e h eart rate;

dep ressan ts an d m edication s affectin g th e car- diac system slow it.

7. Wh en th e BP is lo w, th e h eart rate is usually in creased.

8. Hem o rrh age in creases th e h eart rate. C. Assessin g pulse qualities

1. Wh en th e pulse is bein g co un ted, n ote th e rate, rh yth m , an d stren gth (force or am plitude).

2. O n ce yo u h ave ch ecked th ese param eters, use th e gradin g scale for pulses to assess th e in form ation you h ave elicited (Box 10-2).

D. Pulse poin ts an d location s 1. Th e tem poral artery can be palp ated an terior to

or in th e fron t of th e ear. 2. Th e carotid artery is located in th e groove

between th e trach ea an d th e stern ocleidom as- toid m uscle, m edial to an d alon gside th e m uscle.

3. Th e apical pulse m ay be detected at th e left m id- clavicular, fifth in tercostal space.

4. Th e brach ial pulse is located above th e elbow at th e an tecu bital fossa, between th e biceps an d tri- ceps m uscles.

5. Th e radial pulse is located in th e groo ve alon g th e radial or th u m b side of th e clien t’s in n er wrist.

6. Th e fem oral pulse is located below th e in guin al ligam en t, m idway between th e sym ph ysis pubis an d th e an terosuperior iliac spin e.

7. Th e popliteal pulse is located beh in d th e kn ee. 8. Th e posterior tibial pulse is lo cated on th e in n er

side of th e an kle, beh in d an d below th e m edial m alleolus (an kle bon e).

9. Th e dorsalis pedis pulse is located on th e top of th e foot, in lin e with th e groo ve between th e exten sor ten don s of th e great an d first toes.

The apical pulse is counted for 1 full minute and is assessed in clients with an irregular radial pulse or a heart condition, before the administration of cardiac medications such as digoxin and beta blockers, and in children younger than 2 years.

E. Pulse deficit 1. In th is con dition , th e periph eral pulse rate

(radial pulse) is less th an th e ven tricular con trac- tion rate (apical pulse).

2. A pulse deficit in dicates a lack of peripheral perfu- sion ; can be an in dication of cardiac dysrh yth m ias.

3. O n e-exam in er tech n iqu e: Auscultate an d coun t th e apical pulse first an d th en im m ediately coun t th e radial pulse.

4. Two-exam in er tech n iqu e: O n e perso n coun ts th e apical pulse an d th e oth er coun ts th e radial pulse sim ultan eously.

5. A pulse deficit in dicates th at cardiac con traction s are in effective, failin g to sen d pulse waves to th e periph ery.

6. If a differen ce in pulse rate is n oted, th e HCP is n otified.

IV. Respirations A. Descrip tion

1. Resp iratory rates vary with age. 2. Th e n orm al adult respiratory rate is 12 to 20

breath s/ m in . B. Nursin g con sideration s

1. Man y of th e facto rs th at affect th e pulse rate also affect th e respiratory rate.

2. An in creased level of carbo n dioxide or a lower level of oxygen in th e blood results in an in crease in respiratory rate.

3. Head in jury or in creased in tracran ial pressure will depress th e respiratory cen ter in th e brain , result- in g in sh allow respiratio n s or slowed breath in g.

4. Medication s such as opioid an algesics depress respiration s.

C. Assessin g respiratory rate 1. Coun t th e clien t’s respiration s after m easurin g

th e radial pulse. (Co n tin ue h old in g th e clien t’s wrist wh ile coun tin g th e respiration s or position th e h an d on th e clien t’s ch est.)

2. O n e respiration in cludes both in spiration an d expiration .

3. Th e rate, dep th , pattern , an d soun ds are assessed.

The respiratory rate may be counted for 30 seconds and multiplied by 2, except in a client who is known to be very ill or is exhibiting irregular respirations, in which case respirations are counted for 1 full minute.

V. Blood Pressure A. Descrip tion

1. BP is th e force on th e walls of an artery exerted by th e pulsatin g blood un der pressure fro m th e h eart.

2. Th e h eart’s con traction forces blood un d er h igh pressure in to th e ao rta; th e peak of m axim u m pressure wh en ejection occurs is th e systolic pres- sure; th e blood rem ain in g in th e arteries wh en th e ven tricles relax exerts a force kn own as th e diastolic pressure.

3. Th e differen ce between th e systolic an d diastolic pressures is called th e pulse pressure.

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BOX 10-2 Grading Scale for Pulses 4 +¼Strong and bounding 3+¼Full pulse, increased 2 +¼Normal, easily palpable 1+¼Weak, barely palpable 0 ¼Absent, not palpable

110 UNIT III Nursing Sciences

4. For an ad ult (age 18 an d older) , a n orm al BP is a systolic pressure below 120 m m Hg an d a dia- stolic pressure below 80 m m Hg.

5. Classification s in clude preh yperten sion an d stage 1 an d stage 2 h yperten sion ( Box 10-3).

6. In postu ral (orth ostatic) h ypo ten sion , a n orm o- ten sive clien t exh ibits sym pto m s an d low BP on risin g to an uprigh t position .

7. To obtain orth ostatic vital sign m easurem en ts, ch eck th e BP an d pulse with th e clien t supin e, sit- tin g, an d stan din g; readin gs are obtain ed 1 to 3 m in u tes after th e clien t ch an ges position .

B. Nu rsin g con sideration s 1. Facto rs affectin g BP

a. BP ten ds to in crease as th e agin g process progresses.

b . Stress results in sym path etic stim ulation th at in creases th e BP.

c. Th e in ciden ce of h igh BP is h igh er am on g African Am erican s th an am on g Am erican s of European descen t.

d . An tih yperten sive m ed ication s an d opioid an algesics can decrease BP.

e. BP is typ ically lowest in th e early m orn in g, gradually in creases durin g th e day, an d peaks in th e late aftern oon an d even in g.

f. After puberty, m ales ten d to h ave h igh er BP th an fem ales; after m en op ause, wom en ten d to h ave h igh er BP th an m en of th e sam e age.

2. Guidelin es for m easurin g BP a. Determ in e th e best site for assessm en t. b . Avo id applyin g a cuff to an extrem ity in to

wh ich in traven ous (IV) fluids are in fusin g, wh ere an arterioven o us sh un t or fistula is presen t, on th e side on wh ich breast or axil- lary surgery h as been perform ed, or on an extrem ity th at h as been traum atized or is diseased.

c. Th e leg m ay be used if th e brach ial artery is in accessible; th e cuff is wrapp ed arou n d th e th igh an d th e steth oscope is placed over th e popliteal artery.

d . En su re th at th e clien t h as n ot sm oked or exer- cised in th e 30 m in u tes befo re m easurem en t because both activities can yield falsely h igh readin gs.

e. Have th e clien t assum e a sittin g (with feet flat on flo or) or lyin g position an d th en rest for 5 m in utes befo re th e m easurem en t; ask th e clien t n ot to speak durin g th e m easu rem en t.

f. En su re th at th e cuff is fully deflated , th en wrap it even ly an d sn ugly arou n d th e extrem ity.

g. En su re th at th e steth oscope bein g used fits th e exam in er an d does n ot im pair h earin g.

h . Do cum en t th e first Korotkoff soun d at ph ase 1 (h eard as th e blood pulsates th rou gh th e vessel wh en air is released from th e BP cuff an d pressure on th e artery is reduced) as th e systolic pressure an d th e begin n in g of th e fifth Korotkoff soun d at ph ase 5 as th e dia- stolic pressure.

i. BP readin gs obtain ed electron ically with a vital sign m on itorin g m ach in e sh o uld be ch ecked with a m an u al cuff if th ere is an y con - cern about th e accu racy of th e readin g.

When taking a BP, select the appropriate cuff size; a cuff that is too small will yield a falsely high reading, and a cuff that is too large will yield a falsely low one.

VI. Pulse Oximetry A. Description

1. Pulse oxim etry is a n on in vasive test th at registers th e oxygen saturation of th e clien t’s h em oglobin .

2. Th e capillary oxygen saturation (SaO 2) is recorded as a percen tage.

3. Th e n orm al value is 95% to 100%. 4. After a h ypo xic clien t uses up th e readily avail-

able oxygen (m easured as th e arterial oxygen pressure, PaO 2, on arterial blood gas [ABG] test- in g), th e reserve oxygen , th at oxygen attach ed to th e h em oglobin (SaO 2), is drawn on to pro- vide oxygen to th e tissues.

5. A pulse oxim eter readin g can alert th e n urse to h ypo xem ia befo re clin ical sign s occur.

6. If pulse oxim etry readin gs are below n orm al, in struct th e clien t in deep breath in g tech n ique an d rech eck th e pulse oxim etry.

B. Proced ure 1. A sen sor is placed on th e clien t’s fin ger, toe, n ose,

earlobe, or foreh ead to m easu re oxygen satura- tion , wh ich th en is displayed on a m on itor.

2. Main tain th e tran sducer at h eart level. 3. Do n ot select an extrem ity with an im ped im en t

to blood flo w.

A usual pulse oximetry reading is between 95% and 10 0%. A pulse oximetry reading lower than 90% neces- sitates HCP notification; values below 90 % are accept- able only in certain chronic conditions. Agency procedures and HCP prescriptions are followed regard- ing actions to take for specific readings.

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BOX 10-3 Hypertension Classifications Prehypertension: A systolic blood pressure (BP) of 120 to

139 mm Hg or a diastolic pressure of 80 to 89 mm Hg Stage 1: A systolic BP of 140 to 159 mm Hg or a diastolic pres-

sure of 90 to 99 mm Hg Stage 2: A systolic BP equal to or greater than 160 mm Hg or a

diastolic pressure equal to or greater than 10 0 mm Hg

111CHAPTER 10 Vital Signs and Laboratory Reference Intervals

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VII. Pain A. Types of pain

1. Acute: Usually associated with an in jury, m edical con d ition , or surgical procedure; lasts h ours to a few days

2. Ch ron ic: Usually associated with lo n g-term or ch ron ic illn esses or disorders; m ay con tin ue for m on th s or even years

3. Ph an tom : O ccurs after th e loss of a body part (am p utation ); m ay be felt in th e am putated part for years after th e am putation

B. Assessm en t 1. Pain is a h igh ly in dividual exp erien ce. 2. Ask th e clien t to describe pain in term s of degree,

quality, area, an d frequen cy. 3. Ask th e clien t about th e use of com plem en tary

an d altern ative th erapies to alleviate pain . 4. Pain experien ced by th e older clien t m ay be m an -

ifested differen tly th an pain exp erien ced by m em bers of oth er age groups (e.g., sleep distur- ban ces, ch an ges in gait an d m ob ility, decreased socialization , depression ).

5. Clien ts with cogn itive disorders (e.g., a clien t with dem en tia, a com atose clien t) m ay n ot be able to describe th eir pain experien ces.

6. Th e n urse sh ould be alert to n on verbal in dicators of pain ( Box 10-4).

7. Ask th e clien t to use a n um ber-based pain scale (a picture-based scale m ay be used in ch ildren or clien ts wh o can n ot verbally describe th eir pain ) to rate th e degree of pain (Fig. 10-1).

8. Evaluate clien t respon se to n on ph arm acolo gical in terven tion s.

Consider the client’s culture in assessing pain; some cultures, including many Asian cultures, frown on the outward expression of pain.

C. Con ven tion al n on ph arm aco logical in terven tion s 1. Cutan eous stim ulation

a . Tech n iques in clude h eat, cold, an d pressure an d vibration . Therapeutic touch an d m assage are also cutan eous stim ulation an d m ay be con sidered com plem en tary an d altern ative tech n iques.

b . Such treatm en ts m ay require an HCP’s prescription .

2. Tran scutan eou s electrical n erve stim ulation (TENS) a . TENS is also referred to as percutan eous elec-

trical n erve stim ulation (PENS) . b . Th is tech n iqu e, wh ich m ay require an HCP’s

prescription , in volves th e application of a battery-operated device th at delivers a low electrical curren t to th e skin an d un derlyin g tissues to block pain .

3. Bin ders, slin gs, an d oth er supp ortive devices a . Cloth s or oth er m aterials or devices, wrapp ed

aroun d a lim b or body part, can ease th e pain of strain s, sprain s, an d surgical in cision s.

b . Such devices m ay require an HCP’s prescription . c. Elevation of th e affected body part is an oth er

in terven tion th at can reduce swellin g; sup- portin g an extrem ity on a pillow m ay lessen discom fort.

4. Heat an d cold a . Th e application of h eat an d cold or altern at-

in g ap plication of th e two can sooth e pain resultin g from m uscle strain .

b . Such treatm en t m ay require an HCP’s pre- scrip tion .

BOX 10-4 Nonverbal Indicators of Pain ▪ Moaning ▪ Crying ▪ Irritability ▪ Restlessness ▪ Grimacing or frowning ▪ Inability to sleep ▪ Rigid posture ▪ Increased blood pressure, heart rate, or respiratory rate ▪ Nausea ▪ Diaphoresis

0 No hurt

1 or 2 Hurts

little bit

2 or 4 Hurts

little more

3 or 6 Hurts

e ve n more

4 or 8 Hurts

whole lot

5 or 10 Hurts wors t

B

A

No pa in 0 1 2 3 4 5 6 7 8 9 10

S e ve re pa in

Nume ric al

De s c riptive

No pa in Mild pa in Mode ra te pa in

Unbe a ra ble pa in

S e ve re pa in

Vis ual analo g

No pa in Unbe a ra ble pa in

Clie nts de s igna te a point on the s ca le corre s ponding to the ir pe rce ption of the pa in’s s e ve rity a t the time of a s s e s s me nt.

FIGURE 10-1 Pain assessment scales. A, Numerical, descriptive, and visual analog scales. B, Wong-Baker FACES® Pain Rating Scale. (B, Copy- right 1983, Wong-Baker FACES® Foundation, www.WongBakerFACES.org. Used with permission. Originally published in Whaley & Wong’s Nursing Care of Infants and Children. ©Elsevier Inc.)

112 UNIT III Nursing Sciences

c. Heat application s m ay in clude warm -water com presses, warm blan kets, th erm al pads, an d tub an d wh irlpool bath s.

d . Th e tem p erature of th e application m ust be m on itored carefully to h elp preven t burn s; th e skin of very yo un g an d older clien ts is extra sen sitive to h eat.

e. Th e application of cold can reduce swellin g an d m uscle spasm s an d ease pain in join ts an d m uscles.

f. Th e clien t sh ould be advised to rem ove th e source of h eat or cold if ch an ges in sen sation or discom fort occur. If th e ch an ge in sen sa- tio n or discom fort is n ot relieved after rem oval of th e application , th e HCP sh ould be n otified.

Ice or heat should be applied with a towel or other barrier between the pack and the skin, but should not be left in place for more than 15 to 30 minutes.

D. Com p lem en tary an d altern ative th erap ies 1. Description : Th erapies are used in addition

to con ven tion al treatm en t to provid e h ealin g resou rces an d focus on th e m in d -body con n ec- tio n (Box 10-5).

2. Nu rsin g con sid eration s a. Som e com plem en tary an d altern ative th era-

pies require an HCP’s prescription . b . Herbal rem edies are con sidered ph arm aco -

lo gical th erap y by som e HCPs; because of th e risk for in teraction with prescription m ed- ication s, it is im portan t th at th e n urse ask th e clien t about th e use of such th erap ies.

c. If spiritu al m easu res are to be em plo yed, th e n urse m ust elicit fro m th e clien t th e preferred form s of spiritual expressio n an d learn wh en th ey are practiced so th at th ey m ay be in te- grated in to th e plan of care.

VIII. Pharmacological Interventions A. Non o pioid an algesics

1. No n steroidal an tiin flam m ato ry drugs (NSAIDs) an d acetylsalicylic acid (Aspirin ) ( Box 10-6) a. Th ese m ed ication types are con train dicated if

th e clien t h as gastric irritatio n or ulcer disease or an allergy to th e m edication .

b . Bleedin g is a con cern with th e use of th ese m ed ication types.

c. In struct th e clien t to take oral doses with m ilk or a sn ack to reduce gastric irritatio n .

d . NSAIDs can am plify th e effects of an ticoagulan ts.

e. Hypo glycem ia m ay result for th e clien t takin g ibuprofen if th e clien t is con cu rren tly takin g an oral h ypo glycem ic agen t.

f. A h igh risk of toxicity exists if th e clien t is tak- in g ibuprofen con curren tly with a calcium ch an n el blocker.

2. Acetam in oph en a. Acetam in oph en , com m on ly kn own as Tyle-

n ol, is co n train d icated in clien ts with h epatic or ren al disease, alcoh olism , or h ypersen sitivity.

b . Assess th e clien t for a h isto ry of liver dys- fun ction .

c. Mon itor th e clien t for sign s of h epatic dam age (e.g., n ausea an d vom itin g, diarrh ea, abdom in al pain ).

d . Mon itor liver fun ction param eters. e. Tell th e clien t th at self-m edication sh o uld n ot

con tin ue lon ger th an 10 days in an adult or 5 days in a ch ild because of th e risk of h epatotoxicity.

f. Th e an tidote to acetam in oph en is acetylcys- tein e.

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BOX 10-5 Complementary and Alternative Therapies

Acupuncture and acupressure Biofeedback Chiropractic manipulation Distraction techniques Guided imagery and meditation techniques Herbal therapies Hypnosis Laughter and humor Massage Relaxation and repositioning techniques Spiritual measures (e.g., prayer, use of a rosary or prayer

beads, reading of scripture) Therapeutic touch

BOX 10-6 Side and Adverse Effects of NSAIDs and Acetylsalicylic Acid

NSAIDs ▪ Gastric irritation ▪ Hypotension ▪ Sodium and water retention ▪ Blood dyscrasias ▪ Dizziness ▪ Tinnitus ▪ Pruritus Acetylsalicylic Acid ▪ Gastric irritation ▪ Flushing ▪ Tinnitus ▪ Drowsiness ▪ Headaches ▪ Vision changes

113CHAPTER 10 Vital Signs and Laboratory Reference Intervals

The major concern with acetaminophen is hepatotoxicity.

B. O pioid an algesics 1. Description

a . Th ese m ed ication s suppress pain im pulses but can also suppress respiration an d co ugh - in g by actin g on th e respiratory an d cough cen ter, located in th e m edulla of th e brain stem .

b . Review th e clien t’s h isto ry an d n ote th at cli- en ts with im paired ren al or liver fun ctio n m ay on ly be able to tolerate low doses of opioid an algesics.

c. In traven ous route adm in istration produ ces a faster effect th an oth er routes but th e effect lasts sh o rter to relieve pain

d . O pioids, wh ich produ ce euph o ria an d sed a- tion , can cau se ph ysical depen den ce.

e. Adm in ister th e m edication 30 to 60 m in u tes befo re pain ful activities.

f. Mon itor th e respiratory rate; if it is slower th an 12 breath s/ m in in an adult, with h old th e m ed ication an d n otify th e HCP.

g. Mon itor th e pulse; if bradycardia develo ps, with h old th e m ed ication an d n otify th e HCP.

h Mon itor th e BP for h ypo ten sion an d assess befo re adm in isterin g pain m ed ication s to decrease th e risk of adverse effects.

i. Auscu ltate th e lun gs for n orm al breath soun ds.

j. En cou rage activities such as turn in g, deep breath in g, an d in cen tive spirom etry to h elp preven t atelectasis an d pn eum on ia.

k . Mon itor th e clien t’s level of con scio usn ess. l. In itiate safety precaution s. m . Mon itor in take an d outp ut an d assess th e cli-

en t for urin e reten tion . n . In struct th e clien t to take oral doses with m ilk

or a sn ack to reduce gastric irritatio n . o . In struct th e clien t to avoid activities th at

require alertn ess. p . Assess th e effectiven ess of th e m edication

30 m in utes after ad m in stration . q . Have an opioid an tagon ist (e.g., n aloxo n e),

oxygen , an d resuscitation equipm en t avail- able.

An electronic infusion device is always used for con- tinuous or dose-demand IV infusion of opioid analgesics.

2. Codein e sulfate a . Th is m edication is also used in low doses as a

cough suppressan t. b . It m ay cause con stipation . c. Com m on m edication s in th is class are h ydro-

codon e an d oxycodon e (syn th etic form s) .

3. Hydro m orph on e a . Th e prim ary con cern is respiration depres-

sion . b . O th er effects in clude drowsin ess, dizzin ess,

an d orth ostatic h ypoten sion . c. Mon itor vital sign s, especially th e respiratory

rate an d BP. 4. Morph in e sulfate

a . Morph in e sulfate is used to ease acute pain resultin g from m yocardial in farctio n or can - cer, for dyspn ea resultin g fro m pulm on ary edem a, an d as a preoperative m edication .

b . Th e m ajo r con cern is respiratory dep ression , but postu ral h ypoten sion , urin e reten tion , con stipation , an d pupillary con striction m ay also occur; m on itor th e clien t for adverse effects.

c. Morph in e m ay cause n ausea an d vom itin g by in creasin g vestibular sen sitivity.

d . It is con train dicated in severe respiratory dis- orders, h ead in juries, severe ren al disease, or seizure activity, an d in th e presen ce of in creased in tracran ial pressure.

e. Mon itor th e clien t for urin e reten tion . f. Mon itor bowel soun ds for decreased peristal-

sis; con stipation m ay occur. g. Mon itor th e pupil for ch an ges; pin poin t

pupils m ay in dicate overdose.

IX. Laboratory Reference Intervals For referen ce th rou gh out th e ch apter, see

Figure 10-2. A. Meth od s for drawin g blood (Table 10-1) B. Serum sodium

1. A m ajor cation of extracellular fluid. 2. Main tain s osm otic pressure an d acid-b ase bal-

an ce, an d assists in th e tran sm ission of n erve im pulses.

3. Is absorbed from th e sm all in testin e an d excreted in th e urin e in am oun ts depen den t on dietary in take.

4. Norm al referen ce in terval: 135 to 145 m Eq/ L (135 to 145 m m o l/ L).

Drawing blood specimens from an extremity in which an IV solution is infusing can produce an inaccu- rate result, depending on the test being performed and the type of solution infusing. Prolonged use of a tourni- quet before venous sampling can increase the blood level of potassium, producing an inaccurate result.

C. Serum potassium 1. A m ajor in tracellular cation , potassium regulates

cellular water balan ce, electrical con duction in m uscle cells, an d acid-b ase balan ce.

2. Th e body obtain s potassium th rou gh dietary in gestion an d th e kidn eys preserve or excrete potassium , depen din g on cellu lar n eed.

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114 UNIT III Nursing Sciences

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TOTAL BODY WEIGHT

WHOLE BLOOD (pe rce nta ge by volume )

PLAS MA (pe rce nta ge by we ight)

Blood 8%

Othe r fluids a nd

tis s ue s 92%

Ce ntrifuge d s a mple of blood

Buffy coa t

PLAS MA 55%

Albumins Globulins Fibrinoge n P rothrombin

54% 38%

4% 1%

PROTEINS

Ga s e s Ions Nutrie nts

Re gula tory s ubs ta nce s Wa s te products

OTHER S OLUTES

LEUKOCYTES

FORMED ELEMENTS 45%

P la te le ts

P rote ins

Wa te r

Othe r s olute s

7%

91%

2%

Ne utrophils 60-70%

Lymphocyte s 20-25%

Monocyte s 3-8%

Eos inophils 2-4%

Ba s ophils 0.5-1%

150,000-400,000 mm3

(150-400 × 109/L)

White blood ce lls

5000-10,000 mm3

(5.0-10.0 × 109/L)

FORMED ELEMENTS

FIGURE 10-2 Approximate values for the components of blood in a normal adult.

TABLE 10-1 Obtaining a Blood Sample Venipuncture Peripheral Intravenous Line Central Intravenous Line

Check health care provider’s (HCP’s) prescription.

Check HCP’s prescription. Check HCP’s prescription.

Identify foods, medications, or other factors that may affect the procedure or results.

Identify foods, medications, or other factors such as the type of solution infusing that may affect the procedure or results.

Identify foods, medications, or other factors such as the type of solution infusing that may affect the procedure or results.

Gather needed supplies, including gloves, needle (appropriate gauge and size), transfer/ collection device per agency policy, specimen containers per agency policy, tourniquet, antiseptic swabs, 2 Â 2 inch gauze, tape, tube label(s), biohazard bag, requisition form or bar code per agency policy.

Gather needed supplies, including gloves, tourniquet, transparent dressing or other type of dressing, tape, 2 Â 2 inch gauze, antiseptic agent, extension set (optional), two 5- or 10-mL normal saline flushes, one empty 5- or 10 -mL syringe (depending on the amount of blood needed), transfer/ collection device per agency policy, specimen containers per agency policy, alcohol- impregnated intravenous (IV) line end caps, tube labels, biohazard bag, requisition form or bar code per agency policy.

Gather needed supplies, including gloves, transfer/ collection device per agency policy, specimen containers per agency policy, two 5- or 10-mL normal saline flushes, one empty 5- or 10-mL syringe (depending on the amount of blood needed), antiseptic swabs, alcohol- impregnated IV line end caps, 2 masks, biohazard bag, requisition form or bar code per agency policy.

Perform hand hygiene. Identify the client with at least 2 accepted identifiers.

Perform hand hygiene. Identify the client with at least 2 accepted identifiers.

Perform hand hygiene. Identify the client with at least 2 accepted identifiers.

Explain the purpose of the test and procedure to the client.

Explain the purpose of the test and procedure to the client.

Explain the purpose of the test and procedure to the client.

Apply clean gloves. Place the client in a lying position or a semi-Fowler’s position. Place a small pillow or towel under the extremity.

Prepare extension set if being used by priming with normal saline. Attach syringe to extension set. Place extension set within reach while maintaining aseptic technique and keeping it in the package.

Place mask on self and client or ask client to turn the head away. Stop any running infusions for at least 1 minute.

Apply tourniquet 5 to 10 cm above the venipuncture site so it can be removed in 1 motion.

Apply tourniquet 10 to 15 cm above intravenous site. Clamp all ports. Scrub port to be used with antiseptic swab.

Ask the client to open and close the fist several times, then clench the fist.

Apply gloves. Scrub tubing insertion port with antiseptic solution or per agency policy.

Attach 5- or 10-mL normal saline flush and unclamp line. Flush line with appropriate amount per agency policy and withdraw 5- 10 mL of blood to discard (per agency policy). Clamp line and detach flush.

Continued

115CHAPTER 10 Vital Signs and Laboratory Reference Intervals

3. Potassium levels are used to evaluate cardiac fun ction , ren al fun ction , gastro in testin al fun c- tion , an d th e n eed for IV replacem en t th erapy.

4. If th e clien t is receivin g a potassium supplem en - tatio n , th is n eeds to be n oted on th e labo ratory form .

5. Clien ts with elevated wh ite blood cell (WBC) coun ts an d platelet coun ts m ay h ave falsely ele- vated potassium levels.

6. No rm al referen ce in terval: 3.5 to 5.0 m Eq/ L (3.5 to 5.0 m m o l/ L)

D. Activated partial th rom boplastin tim e (aPTT) 1. Th e aPTT evaluates h ow well th e coagu lation

seq uen ce (in trin sic clottin g system ) is fun ctio n - in g by m easu rin g th e am oun t of tim e it takes in secon ds for recalcified citrated plasma to clot after partial th rom bop lastin is added to it.

2. Th e test screen s for deficien cies an d in h ibitors of all factors, except facto rs VII an d XIII.

3. Usually, th e aPTT is used to m on itor th e effec- tiven ess of h eparin th erapy an d screen for coag- ulatio n disorders.

4. No rm al referen ce in terval: 28 to 35 secon ds (con ven tion al an d SI un its), depen din g on th e type of activator used.

5. If th e clien t is receivin g in term itten t h eparin th er- apy, draw th e blood sam ple 1 h our before th e n ext sch eduled dose.

6. Do n ot draw sam ples from an arm in to wh ich h eparin is in fusin g.

7. Tran sport specim en to th e laborato ry im m e- diately.

8. Provid e direct pressure to th e venipuncture site for 3 to 5 m in utes.

9. Th e aPTT sh ould be between 1.5 an d 2.5 tim es n orm al wh en th e clien t is receivin g h eparin th erap y.

If the aPTT value is prolonged (longer than 87.5 sec- onds or per agency policy) in a client receiving IVheparin therapy or in any client at risk for thrombocytopenia, initiate bleeding precautions.

E. Proth ro m bin tim e (PT) an d in tern ation al n orm al- ized ratio (INR) 1. Proth rom bin is a vitam in K–depen den t glyco-

protein produced by th e liver th at is n ecessary for fibrin clo t form ation .

2. Each labo ratory establish es a n orm al or con tro l value based on th e m eth od used to perform th e PT test.

3. The PT m easures th e am ount of tim e it takes in secon ds for clot form ation an d is used to m on itor respon se to warfarin sodium th erapy or to screen for dysfun ction of th e extrin sic clottin g system resultin g from liver disease, vitam in K deficien cy, or dissem in ated in travascular coagulation .

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TABLE 10-1 Obtaining a Blood Sample—cont’d Venipuncture Peripheral Intravenous Line Central Intravenous Line

Inspect to determine the vein to be used for venipuncture. Select the vein based on size and quality. Use the most distal site in the nondominant arm if possible. Palpate the vein with the index finger for resilience.

Attach 5- or 10-mL normal saline flush and unclamp line. Flush line with appropriate amount per agency policy and withdraw 5-10 mL of blood to discard (per agency policy). Clamp line and detach flush syringe.

Scrub port with antiseptic swab. Attach 5- or 10-mL syringe or transfer/ collection device to port (depending on available equipment), unclamp line, and withdraw needed sample or attach specimen container to withdraw using vacuum system. Clamp line and detach syringe or transfer/ collection device.

Clean site with antiseptic swabs or per agency policy, using a circular scrubbing motion, inward to outward for 30 seconds. Insert the needle bevel up at a 15- to 30- degree angle. Collect blood in collection device per agency policy.

Scrub tubing insertion port. Attach 5- or 10-mL syringe, extension set, or transfer/ collection device to port (depending on available equipment), unclamp line, and withdraw needed sample or attach specimen container to withdraw using vacuum system. Clamp line and detach syringe or transfer/ collection device.

Scrub port with antiseptic swab. Attach a 5- or 10-mL normal saline flush. Unclamp line and flush with amount per agency policy. Clamp line, remove flush, and place end cap on IV line. Remove masks.

Release tourniquet. Apply 2 Â 2 inch gauze over insertion site. Remove needle and engage safety on needle. Apply pressure for 2 minutes. If the client is on anticoagulants, apply pressure for several minutes. Perform hand hygiene.

Remove tourniquet and flush with normal saline to ensure patency.

Transfer specimen to collection device per agency policy if not previously collected.

Send specimen to the laboratory in biohazard bag with associated requisition forms or bar codes per agency policy.

Send specimen to the laboratory in biohazard bag with associated requisition forms or bar codes per agency policy.

Send specimen to the laboratory in biohazard bag with associated requisition forms or bar codes per agency policy.

116 UNIT III Nursing Sciences

4. A PT value with in 2 secon ds (plus or m in us) of th e con trol is con sidered n orm al.

5. Th e INR is a frequen tly used test to m easu re th e effects of som e an ticoagulan ts.

6. Th e INR stan dardizes th e PT ratio an d is calcu- lated in th e laborato ry settin g by raisin g th e observed PT ratio to th e power of th e in tern a- tio n al sen sitivity in dex specific to th e th rom bo- plastin reagen t used.

7. If a PT is prescribed , baselin e specim en sh ould be drawn before an ticoagulation th erap y is started; n ote th e tim e of collectio n on th e labo ra- tory form .

8. Provide direct pressure to th e ven ipu n cture site for 3 to 5 m in utes.

9. Con curren t warfarin th erap y with h eparin th er- ap y can len gth en th e PT for up to 5 h ours after dosin g.

10. Diets h igh in green leafy vegetables can in crease th e ab sorption of vitam in K, wh ich sh orten s th e PT.

11. O rally adm in istered an ticoagulation th erap y usually m ain tain s th e PT at 1.5 to 2 tim es th e lab- oratory con trol value.

12. No rm al referen ce in tervals a. PT: 11 to 12.5 secon ds (con ven tion al an d

SI un its) b . INR: 2 to 3 for stan d ard warfarin th erap y c. INR: 3 to 4.5 for h igh -d ose warfarin th erap y

Ifthe PT value is longer than 32 seconds and the INRis greater than 3.0 in a client receiving standard warfarin ther- apy (or per agency policy), initiate bleeding precautions.

F. Platelet coun t 1. Platelets fun ction in h em ostatic plug form ation ,

clo t retraction , an d coagulation factor activation . 2 Platelets are produced by th e bon e m arro w to

fun ction in h em ostasis. 3. Norm al referen ce in terval: 150,000-400,000 m m 3

(150–400 Â 109/ L) 4. Mon itor th e ven ipu n ctu re site for bleedin g in cli-

en ts with kn own th rom bocytopen ia. 5. High altitud es, ch ron ic cold weath er, an d exer-

cise in crease platelet coun ts. 6. Bleedin g precaution s sh ould be in stituted in cli-

en ts wh en th e platelet co un t falls sufficien tly below th e n orm al level; th e specific value for im plem en tin g bleedin g precaution s usually is determ in ed by agen cy policy.

Monitor the platelet count closely in clients receiv- ing chemotherapy because of the risk for thrombocyto- penia. In addition, any client who will be having an invasive procedure (such as a liver biopsy or thoracen- tesis) should have coagulation studies and platelet counts done before the procedure.

G. Hem o globin an d h em atocrit 1. Hem o globin is th e m ain com po n en t of eryth ro-

cytes an d serves as th e veh icle for tran spo rtin g oxygen an d carbo n dioxide.

2. Hem atocrit represen ts red blood cell (RBC) m ass an d is an im portan t m easu rem en t in th e pres- en ce of an em ia or polycyth em ia ( Table 10-2).

3. Fastin g is n ot required for th is test. H. Lipids

1. Bloo d lipids con sist prim arily of ch olestero l, tri- glycerides, an d ph o sph olipids.

2. Lipid assessm en t in cludes total ch olestero l, h igh - den sity lipoprotein (HDL), low-den sity lipopro- tein (LDL), an d triglycerides.

3. Ch o lesterol is presen t in all body tissues an d is a m ajo r com pon en t of LDLs, brain an d n erve cells, cell m em bran es, an d som e gallblad der ston es.

4. Triglycerides con stitute a m ajor part of very low- den sity lipoprotein s an d a sm all part of LDLs.

5. Triglycerides are syn th esized in th e liver from fatty acids, protein , an d glucose, an d are obtain ed fro m th e diet.

6. In creased ch olestero l levels, LDL levels, an d tri- glyceride levels place th e clien t at risk for coro- n ary artery disease.

7. HDL h elps to protect again st th e risk of coron ary artery disease.

8. O ral co n tracep tives m ay in crease th e lipid level. 9. In struct th e clien t to abstain from food an d fluid,

except for water, for 12 to 14 h ours an d from alcoh ol for 24 h ou rs before th e test.

10. In struct th e clien t to avoid con sum in g h igh - ch olesterol food s with th e even in g m eal before th e test.

11. No rm al referen ce in tervals ( Table 10-3). I. Fastin g blood glucose

1. Glu cose is a m on osacch aride foun d in fruits an d is form ed from th e digestion of carbo h ydrates an d th e con versio n of glycogen by th e liver.

2. Glu cose is th e m ain source of cellular en ergy for th e body an d is essen tial for brain an d eryth ro- cyte fun ction .

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TABLE 10-2 Hemoglobin and Hematocrit: Reference Intervals

Blood Component Reference Interval

Hemoglobin (altitude dependent) Male adult 14-18 g/ dL (140-180 mmol/ L) Female adult 12-16 g/ dL (120-160 mmol/ L)

Hematocrit (altitude dependent) Male adult 42%-52% (0.42-0.52) Female adult 37%-47% (0.37-0.47)

117CHAPTER 10 Vital Signs and Laboratory Reference Intervals

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3. Fastin g blood glucose levels are used to h elp diagn ose diabetes m ellitus an d h ypo glycem ia.

4. In struct th e clien t to fast for 8 to 12 h ours before th e test.

5. In struct a clien t with diabetes m ellitus to with - h old m orn in g in sulin or oral h ypoglycem ic m ed- ication un til after th e blood is drawn .

6. No rm al referen ce in terval: gluco se (fastin g) 70-110 m g/ dL (4-6 m m ol/ L)

J. Glycosylated h em oglobin (HgbA1C) 1. HgbA1C is blood gluco se boun d to h em oglobin . 2. Hem o globin A1c (glycosylated h em oglobin A;

HbA1c) is a reflection of h ow well blood gluco se levels h ave been con trolled for th e past 3 to 4 m on th s.

3. Hyperglycem ia in clien ts with diabetes is usually a cau se of an in crease in th e HbA1c.

4. Fastin g is n ot required befo re th e test. 5. No rm al referen ce in tervals: 4.0%–6.0% (4.0%–

6.0%)

6. HgbA1C an d estim ated average gluco se (eAG) referen ce in tervals (Table 10-4).

K. Ren al fun ctio n studies 1. Serum creatin in e

a . Creatin in e is a specific in dicator of ren al fun ction .

b . In creased levels of creatin in e in dicate a slow- in g of th e glom erular filtration rate.

c. In struct th e clien t to avoid excessive exercise for 8 h ours an d excessive red m eat in take for 24 h ours befo re th e test.

d . Norm al referen ce in terval: 0.6–1.3 m g/ dL (53–115 µm ol/ L)

2. Bloo d urea n itrogen (BUN) a . Urea n itrogen is th e n itrogen portion of urea,

a substan ce form ed in th e liver th rough an en zym atic protein breakdown process.

b . Urea is n orm ally freely filtered th rough th e ren al glom eruli, with a sm all am oun t reab- sorbed in th e tubu les an d th e rem ain der excreted in th e urin e.

c. Elevated levels in dicate a slowin g of th e glo- m erular filtration rate.

d . BUN an d creatin in e ratios sh ould be an alyzed wh en ren al fun ctio n is evaluated.

e. Norm al referen ce in terval: 6–20 m g/ dL (2.1– 7.1 m m o l/ L)

L. Wh ite blood cell (WBC) coun t 1. WBCs fun ction in th e im m un e defen se system of

th e body. 2. Th e WBC differen tial provides specific in form a-

tion on WBC types. 3. A “sh ift to th e left” (in th e differen tial) m ean s

th at an in creased n um ber of im m ature n eutro- ph ils is presen t in th e blood.

4. A low total WBC coun t with a left sh ift in dicates a recovery from bon e m arrow depression or an in fec- tion of such in ten sity th at th e dem an d for n eutro- ph ils in the tissue is high er th an th e capacity of the bon e m arrow to release th em in to the circulation .

5. A h igh total WBC coun t with a left sh ift in dicates an in creased release of n eutroph ils by th e bon e m arro w in respo n se to an overwh elm in g in fec- tion or in flam m ation .

6. An in creased n eutroph il coun t with a left sh ift is usually associated with bacterial in fectio n .

7. A “sh ift to th e righ t” m ean s th at cells h ave m ore th an th e usual n um ber of n uclear segm en ts; foun d in liver disease, Down syn drom e, an d m egaloblastic an d pern iciou s an em ia.

8. Norm al referen ce in terval: 5000–10,000 m m 3

(5.0–10.0 Â 109/ L)

Monitor the WBC count and differential closely in cli- ents receiving chemotherapy because of the risk for neu- tropenia; neutropenia places the client at risk for infection.

TABLE 10-3 Lipids: Reference Intervals Blood Component Reference Interval

Cholesterol < 200 mg/ dL (< 5.2 mmol/ L)

High-density lipoproteins (HDLs)

Male: > 40 mg/ dL (> 1.04 mmol/ L) Female: > 50 mg/ dL (> 1.3 mmol/ L)

Low-density lipoproteins (LDLs)

Recommended: < 10 0 mg/ dL (< 2.6 mmol/ L) Near optimal: 100-129 mg/ dL (2.6-3.34 mmol/ L) Moderate risk for coronary artery disease (CAD): 130-159 mg/ dL (3.37-4.12 mmol/ L) High risk for CAD: > 160 mg/ dL (> 4.14 mmol/ L)

Triglycerides < 150 mg/ dL (< 1.7 mmol/ L)

TABLE 10-4 Glycosylated Hemoglobin (HgbA1C) and Estimated Average Glucose (eAG)

HgbA1C % eAG mg/ dL eAG mmol/ L

6 126 7.0

6.5 140 7.8

7 154 8.6

7.5 169 9.4

8 183 10.1

8.5 197 10.9

9 212 11.8

9.5 226 12.6

10 240 13.4

American Diabetes Association, DiabetesPro: Estimated average glucose, eAG/ A1C Conversion Calculator (website): http:/ / professional.diabetes.org/ diapro/ glucose_calc.

118 UNIT III Nursing Sciences

CRITICAL THINKING What Should You Do? Answer: The client’s vital signs are showing a significant change, particularly the blood pressure, heart rate, and oxy- gen saturation levels. The nurse should first compare the vital signs to the set of baseline vital signs obtained when the client arrived to the unit. This provides information about how much of a change has occurred in these parameters. The nurse should quickly consider the following when determin- ing the next action: (1) Is the equipment working properly? (2) Is the correct equipment being used? (3) Is there a con- dition or procedure in the client’s history that can be attrib- uted to this change? (4) Are there environmental factors that could influence the change in the client’s vital signs? (5) Does this change necessitate contacting the surgeon? Given the significant change from the baseline vital signs, and after checking equipment to ensure it is working properly, the nurse should then determine that it is necessary to contact the surgeon to inform him or her of this change, especially considering that the client recently had surgery and there is a potential for bleeding. The nurse should determine if there is any sign of bleeding, ie, drainage on the dressing, bloody output in a surgical drain, swelling in the surgical area suggestive of hematoma. The charge nurse should also be informed of the change in client status.

References: Lewis et al. (2014), pp. 350 , 354; Potter et al. (20 15), p. 272.

P R A C T I C E Q U E S T I O N S 63. A clien t with atrial fibrillatio n wh o is receivin g

m ain ten an ce th erap y of warfarin sodium h as a pro- th rom bin tim e (PT) of 35 (35) secon ds an d an in ter- n ation al n orm alized ratio (INR) of 3.5. O n th e basis of th ese labo ratory values, th e n urse an ticipates wh ich prescription ? 1. Addin g a dose of h eparin sodium 2. Holdin g th e n ext dose of warfarin 3. In creasin g th e n ext dose of warfarin 4. Adm in isterin g th e n ext dose of warfarin

64. A staff n urse is preceptin g a n ew graduate n urse an d th e n ew graduate is assign ed to care for a clien t with ch ron ic pain . Wh ich statem en t, if m ade by th e n ew graduate n urse, in dicates th e n eed fo r fu rth er teach in g regardin g pain m an agem en t? 1. “I will be sure to ask m y clien t wh at h is pain level

is on a scale of 0 to 10.” 2. “I kn ow th at I sh ould follo w up after givin g m ed-

ication to m ake sure it is effective.” 3. “I kn ow th at pain in th e older clien t m igh t m an -

ifest as sleep disturban ces or depression .” 4. “I will be sure to cue in to an y in dicators th at th e

clien t m ay be exaggeratin g th eir pain .”

65. A clien t h as been adm itted to th e h ospital for urin ary tract in fectio n an d deh ydratio n . Th e n urse determ in es th at th e clien t h as received ad equate volu m e replacem en t if th e blood urea n itrogen (BUN) level drops to wh ich value? 1. 3 m g/ dL (1.05 m m ol/ L) 2. 15 m g/ dL (5.25 m m o l/ L) 3. 29 m g/ dL (10.15 m m ol/ L) 4. 35 m g/ dL (12.25 m m o l/ L)

66. Th e n urse is explain in g th e appropriate m eth od s for m easu rin g an accu rate tem perature to an un licen sed assistive person n el (UAP) . Wh ich m eth od , if n oted by th e UAP as bein g an appropriate m eth od , in di- cates th e n eed fo r fu rth er teach in g? 1. Takin g a rectal tem p erature for a clien t wh o h as

un dergon e n asal surgery 2. Takin g an oral tem p erature for a clien t with a

co ugh an d n asal con gestion 3. Takin g an axillary tem perature for a clien t wh o

h as just con sum ed h ot coffee 4. Takin g a tem poral tem perature on th e n eck

beh in d th e ear for a clien t wh o is diaph o retic

67. A clien t is receivin g a con tin uo us in traven ous in fu- sion of h eparin sodium to treat deep vein th rom bo- sis. Th e clien t’s activated partial th rom boplastin tim e (aPTT) is 65 secon ds (65 secon ds). Th e n urse an ticipates th at wh ich action is n eeded? 1. Discon tin uin g th e h eparin in fusio n 2. In creasin g th e rate of th e h eparin in fusion 3. Decreasin g th e rate of th e h eparin in fusion 4. Leavin g th e rate of th e h eparin in fusion as is

68. A clien t with a h istory of cardiac disease is due for a m orn in g dose of furosem ide. Wh ich serum potas- sium level, if n oted in th e clien t’s laborato ry report, sh ould be reported before ad m in isterin g th e dose of furosem ide? 1. 3.2 m Eq/ L (3.2 m m o l/ L) 2. 3.8 m Eq/ L (3.8 m m ol/ L) 3. 4.2 m Eq/ L (4.2 m m ol/ L) 4. 4.8 m Eq/ L (4.8 m m o l/ L)

69. Several labo ratory tests are prescribed for a clien t, an d th e n urse reviews th e results of th e tests. Wh ich laborato ry test results sh o uld th e n urse report? Select all th at ap p ly.

1. Platelets 35,000 m m 3 (35 Â 109/ L) 2. Sodium 150 m Eq/ L (150 m m o l/ L) 3. Potassium 5.0 m Eq/ L (5.0 m m o l/ L) 4. Segm en ted n eutroph ils 40% (0.40) 5. Serum creatin in e, 1 m g/ dL (88.3 µm ol/ L) 6. Wh ite b lo o d cells, 3000 m m 3

( 3.0 Â 109/ L)

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119CHAPTER 10 Vital Signs and Laboratory Reference Intervals

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70. Th e n urse is carin g for a clien t wh o takes ibuprofen for pain . Th e n urse is gath erin g in form ation on th e clien t’s m edication h isto ry, an d determ in es it is n ec- essary to con tact th e h ealth care provider (HCP) if th e clien t is also takin g wh ich m ed ication s? Select all th at ap p ly.

1. Warfarin 2. Glim epirid e 3. Am lodipin e 4. Sim vastatin 5. Hydroch loroth iazide

71. A clien t with diabetes m ellitus h as a glycosylated h em oglobin A1c level of 9%. O n th e basis of th is test result, th e n urse plan s to teach th e clien t about th e n eed for wh ich m easu re? 1. Avoidin g in fectio n 2. Takin g in adequate fluids 3. Preven tin g an d recogn izin g h ypoglycem ia 4. Preven tin g an d recogn izin g h yperglycem ia

72. Th e n urse is carin g for a clien t with a diagn osis of can cer wh o is im m un osuppressed. Th e n urse would con sider im plem en tin g n eutropen ic precaution s if th e clien t’s wh ite blood cell co un t was wh ich value? 1. 2000 m m 3 (2.0 Â 109/ L) 2. 5800 m m 3 (5.8 Â 109/ L) 3. 8400 m m 3 (8.4 Â 109/ L) 4. 11,500 m m 3 (11.5 Â 109/ L)

73. A clien t brough t to th e em ergen cy dep artm en t states th at h e h as acciden tally been takin g 2 tim es h is pre- scrib ed dose of warfarin for th e past week. After n ot- in g th at th e clien t h as n o evid en ce of obvious bleed in g, th e n urse plan s to take wh ich action ? 1. Prepare to adm in ister an an tidote. 2. Draw a sam ple for type an d cro ssm atch an d

tran sfuse th e clien t. 3. Draw a sam ple for an activated partial th rom bo-

plastin tim e (aPTT) level.

4. Draw a sam ple for proth rom bin tim e (PT) an d in tern ation al n orm alized ratio (INR).

74. Th e n urse is carin g for a postoperative clien t wh o is receivin g dem an d-dose h ydrom orph on e via a patien t-con trolled an algesia (PCA) pum p for pain con trol. Th e n urse en ters th e clien t’s room an d fin ds th e clien t drowsy an d records th e follo win g vital sign s: tem p erature 97.2 °F (36.2 °C) orally, pulse 52 beats per m in u te, blood pressure 101/ 58 m m Hg, respiratory rate 11 breath s per m in u te, an d SpO 2 of 93% on 3 liters of oxygen via n asal can n ula. Wh ich action sh ould th e n urse take n ext? 1. Docum en t th e fin din gs. 2. Attem pt to arou se th e clien t. 3. Con tact th e h ealth care provid er (HCP)

im m ediately. 4. Ch eck th e m ed ication adm in istration h isto ry on

th e PCA pum p.

75. An adult fem ale clien t h as a h em oglobin level of 10.8 g/ d L (108 m m ol/ L). Th e n urse in terp rets th at th is result is m o st likely caused by wh ich con ditio n n oted in th e clien t’s h istory? 1. Deh ydration 2. Heart failure 3. Iron deficien cy an em ia 4. Ch ron ic obstru ctive pulm o n ary disease

76. A clien t with a h istory of gastroin testin al bleedin g h as a platelet coun t of 300,000 m m 3 (300 Â 109/ L). Th e n urse sh ould take wh ich action after seein g th e laboratory results? 1. Repo rt th e abn orm ally low coun t. 2. Repo rt th e abn o rm ally h igh coun t. 3. Place th e clien t on bleedin g precaution s. 4. Place th e n orm al report in th e clien t’s m edical

record.

A N S W E R S 63. 2 Ra tion a le: Th e n o rm al PT is 11 to 12.5 secon ds (co n ven tion al th erapy an d SI u n its). Th e n o rm al INR is 2 to 3 for stan d ard warfarin th erapy, wh ich is used for th e treatm en t of atrial fibril- latio n , an d 3 to 4.5 fo r h igh -do se warfarin th erap y, wh ich is u sed for clien ts with m ech an ical h eart valves. A th erap eutic PT level is 1.5 to 2 tim es h igh er th an th e n orm al level. Becau se th e values of 35 seco n d s an d 3.5 are h igh , th e n urse sh ou ld an ticip ate th at th e clien t wo uld n ot receive furth er do ses at th is tim e. Th erefore, th e p rescrip tio n s n o ted in th e rem ain in g o ptio n s are in co rrect. Test-Ta kin g Str a t egy: Fo cu s o n th e su b ject , a PT o f 35 seco n d s an d an INR of 3.5. Recall th e n o rm al ran ges for th ese valu es

an d rem em ber th at a PT greater th an 32 seco n ds an d an INR greater th an 3 fo r stan dard warfarin th erap y places th e clien t at risk fo r bleedin g; th is will direct yo u to th e correct o ptio n . Review: Th e n o r m a l p r o t h r o m b in t im e a n d INR levels Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—An alysis Con ten t Ar ea : Fu n dam en tals o f Care—Labo rato ry Valu es Pr ior it y Con cept s: Clin ical Ju dgm en t; Clo ttin g Refer en ces: Lewis et al. ( 2014) , p . 627; Ro sen jack Bu rch u m , Ro sen th al (2016), p p. 622–623.

64. 4 Ra tion a le: Pain is a h igh ly in dividual experien ce, an d th e n ew grad uate n u rse sh o u ld n o t assu m e th at th e clien t is

120 UNIT III Nursing Sciences

exaggeratin g h is p ain . Rath er, th e n urse sh ou ld freq uen tly assess th e pain an d in terven e acco rd in gly th ro ugh th e use o f bo th n on ph arm aco logical an d p h arm aco lo gical in terven tio n s. Th e n urse sh ou ld assess p ain u sin g a n um b er-b ased scale o r a picture-b ased scale fo r clien ts wh o can n o t verbally d escrib e th eir p ain to rate th e d egree o f p ain . Th e n urse sh o uld fo llo w up with th e clien t after givin g m ed ication to en su re th at th e m ed ication is effective in m an agin g th e pain . Pain exp erien ced by th e older clien t m ay be m an ifested d ifferen tly th an p ain experien ced by m em b ers o f o th er age grou p s, an d th ey m ay h ave sleep d istu rb an ces, ch an ges in gait an d m ob ility, decreased so cializatio n , an d d epressio n ; th e n u rse sh ou ld b e aware o f th is attrib u te in th is po p ulatio n . Test-Ta kin g Str a tegy: Note th e st r at egic wo r d s, need for further teaching. These words in dicate a n egat ive even t q u er y an d the n eed to select th e in correct statem en t as th e an swer. Recall that pain is a h igh ly in dividual exp erien ce, an d th e n urse sh o uld n ot assum e th at th e clien t is exaggeratin g pain . Review: Ma n a gem en t o f p a in Level of Cogn it ive Ability: Evaluatin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Teach in g an d Learn in g Con t en t Ar ea : Fun dam en tals of Care—Pain Pr ior ity Con cepts: Clin ical Jud gm en t; Pain Refer en ce: Lewis et al. (2014), p p. 122, 134.

65. 2 Ra t ion a le: Th e n orm al BUN level is 6 to 20 m g/ d L ( 2.1 to 7.1 m m o l/ L) . Values o f 29 m g/ d L (10.15 m m o l/ L) an d 35 m g/ d L (12.25 m m o l/ L) reflect co n tin u ed deh ydration . A value of 3 m g/ dL (1.05 m m ol/ L) reflects a lower th an n o rm al value, wh ich m ay o ccur with fluid volu m e overlo ad, am on g oth er co n dition s. Test -Ta kin g St r a t egy: Fo cu s on th e su b ject , ad equ ate fluid rep lacem en t an d th e n orm al BUN level. Th e correct option is th e on ly o ptio n th at iden tifies a n orm al value. Review: Th e n o rm al b lo o d u r ea n it r o gen level Level of Cogn it ive Ability: Evaluatin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Evalu ation Con t en t Ar ea : Fun dam en tals of Care—Lab oratory Valu es Priority Concepts: Clin ical Ju dgm en t; Fluid an d Electrolyte Balan ce Refer en ces: Lewis et al. (2014), p. 1057; Pagan a, Pagan a (2014) , p p. 511–514.

66. 2 Ra t ion a le: An o ral tem perature sh ou ld b e avoided if th e clien t h as n asal con gestion . O n e of th e o th er m eth o d s o f m easu rin g th e tem perature sh ou ld b e used accordin g to th e eq uipm en t availab le. Takin g a rectal tem perature fo r a clien t wh o h as u n d er- go n e n asal su rgery is ap prop riate. O th er, less in vasive m easu res sh ou ld be u sed if available; if n ot availab le, a rectal tem p eratu re is accep table. Takin g an axillary tem perature o n a clien t wh o ju st co n su m ed co ffee is also acceptab le; h o wever, th e axillary m eth od o f m easu rem en t is th e least reliable, an d o th er m eth od s sh ou ld b e used if available. If tem p oral eq uipm en t is availab le an d th e clien t is diap h o retic, it is accep table to m ea- sure th e tem p eratu re o n th e n eck b eh in d th e ear, avoid in g th e fo reh ead .

Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d s, need for fur- ther teaching. Th ese words in dicate a n ega t ive even t q u er y an d th e n eed to select th e in correct actio n as th e an swer. Recall th at n asal co n gestio n is a reaso n to avo id takin g an oral tem - p eratu re, as th e n asal con gestion will cause p ro b lem s with b reath in g wh ile th e tem perature is bein g taken . Review: Tem p er a t u r e m ea su r em en t m et h o d s Level of Cogn it ive Ability: Evaluatin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Teach in g an d Learn in g Con t en t Ar ea : Fun d am en tals of Care—Vital Sign s Pr ior ity Con cepts: Teach in g an d Learn in g; Th erm o regu lation Refer en ce: Perry, Po tter, O sten do rf (2014), p p. 68–69, 76.

67. 4 Ra t ion a le: Th e n o rm al aPTT varies b etween 28 an d 35 secon ds (28 an d 35 seco n d s), d ep en d in g on th e type of activator used in testin g. Th e th erapeu tic do se of h ep arin for treatm en t o f d eep vein th rom bo sis is to keep th e aPTT b etween 1.5 (42 to 52.5) an d 2.5 ( 70 to 87.5) tim es n o rm al. Th is m ean s th at th e clien t’s value sh ou ld n o t b e less th an 42 seco n d s or greater th an 87.5 seco n d s. Th us th e clien t’s aPTT is with in th e th erap eu tic ran ge an d th e do se sh ou ld rem ain u n ch an ged . Test-Ta king Stra tegy: Fo cu s o n th e su b ject, th e exp ected aPTT fo r a clien t receivin g a h ep arin so d iu m in fu sio n . Rem em b er th at th e n o rm al ran ge is 28 to 35 seco n d s an d th at th e aPTT sh o u ld b e b etween 1.5 an d 2.5 tim es n o rm al wh en th e clien t is receivin g h ep arin th erap y. Sim p le m u ltip licatio n o f 1.5 an d 2.5 b y 28 an d 35 will yield a ran ge o f 42 to 87.5 seco n d s) . Th is clien t’s valu e is 65 seco n d s Review: Th e a PTT level an d th e expected level if th e clien t is receivin g h ep a r in Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—An alysis Con t en t Ar ea : Fun d am en tals of Care—Lab oratory Values Pr ior ity Con cepts: Clin ical Jud gm en t; Clottin g Refer en ce: Lewis et al. (2014), p. 627.

68. 1 Ra t ion a le: Th e n orm al seru m p otassiu m level in th e ad ult is 3.5 to 5.0 m Eq/ L ( 3.5 to 5.0 m m ol/ L) . Th e co rrect op tio n is th e o n ly value th at falls below th e th erapeu tic ran ge. Ad m in is- terin g furosem id e to a clien t with a low p otassium level an d a h isto ry of card iac prob lem s co uld p recip itate ven tricular dys- rh yth m ias. Th e rem ain in g o p tion s are with in th e n orm al ran ge. Test -Ta kin g Str a tegy: N o te th e s u b ject o f th e q u estio n , th e level th at sh o u ld b e rep o rted . Th is in d icates th at yo u are lo o kin g fo r an ab n o rm al level. Rem em b er, th e n o rm al seru m p o tassiu m level in th e ad u lt is 3.5 to 5.0 m Eq / L ( 3.5 to 5.0 m m o l/ L) . Th is will d irect yo u to th e co rrect o p tio n . Review: Th e n o rm al ser u m p o t a ssiu m level Level of Cogn it ive Abilit y: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Fun d am en tals of Care—Lab orato ry Values Pr ior ity Con cept s: Clin ical Ju d gm en t; Flu id an d Electrolyte Balan ce

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121CHAPTER 10 Vital Signs and Laboratory Reference Intervals

Refer en ces: Lewis et al. (2014), p . 296; Pagan a, Pagan a (2014), p . 409.

69. 1, 2, 4, 6 Ra tion a le: Th e n orm al values in clud e th e followin g: p latelets 150,000–400,000 m m 3 (150–400 Â 109/ L); sodium 135– 145 m Eq / L (135–145 m m ol/ L) ; p otassiu m 3.5–5.0 m Eq/ L (3.5–5.0 m m ol/ L); segm en ted n eu tro ph ils 60%–70% (0.60– 0.70); seru m creatin in e 0.6–1.3 m g/ d L ( 53–115 µm o l/ L); an d wh ite b lo od cells 5000–10,000 m m 3 (5.0–10.0 Â 109/ L). Th e p latelet level n oted is low; th e sod iu m level n o ted is h igh ; th e p otassiu m level n oted is n orm al; th e segm en ted n eu tro ph il level n o ted is lo w; th e seru m creatin in e level n o ted is n o rm al; an d th e wh ite b lo od cell level is lo w. Test-Ta kin g St r a t egy: Focus o n th e su b ject , th e abn o rm al lab- o rato ry values th at n eed to b e rep orted. Recallin g th e n orm al lab oratory values for th e bloo d stu dies iden tified in th e op tion s will assist in an swerin g th is q uestion . Review: Th e n orm al la b o r a t o r y va lu es Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n d am en tals o f Care—Labo rato ry Valu es Pr ior it y Con cept s: Clin ical Ju dgm en t; Co llabo ration Refer en ce: Lewis et al. (2014), p p . 626, 661, 1702–1703

70. 1, 2, 3 Ra tion a le: Non stero id al an tiin flam m ato ry drugs (NSAIDs) can am p lify th e effects of an tico agulan ts; th erefo re, th ese m ed - ication s sh o uld n o t b e taken togeth er. Hyp oglycem ia m ay result fo r th e clien t takin g ib u profen if th e clien t is co n curren tly takin g an oral h ypo glycem ic agen t su ch as glim ep iride; th ese m edicatio n s sh o uld n ot b e com b in ed . A h igh risk of toxicity exists if th e clien t is takin g ibu p ro fen con cu rren tly with a cal- cium ch an n el blo cker su ch as am lod ip in e; th erefo re, th is com - b in atio n sh ou ld b e avoid ed . Th ere is n o kn o wn in teractio n b etween ibu profen an d sim vastatin o r h yd ro ch lo ro th iazid e. Test-Ta kin g Str a tegy: Note th e su b ject of th e question , data p ro vided by th e clien t n ecessitatin g co n tactin g th e HCP. Deter- m in in g th at ibu profen is classified as an NSAID will h elp you to d eterm in e th at it sh ou ld n o t be com b in ed with an ticoagu - lan ts. Also recallin g th at h ypo glycem ia can o ccu r as an adverse effect will h elp yo u to recall th at th ese m ed icatio n s sh o uld n o t b e com b in ed . Fro m th e rem ain in g o p tion s, it is n ecessary to rem em b er th at toxicity can result if NSAIDs are co m b in ed with calciu m ch an n el blockers. Review: Med icatio n in teractio n s for NSAIDs, sp ecifically ib u p r o fen Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n d am en tals o f Care—Pain Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Rosen jack Bu rch um , Ro sen th al (2016), p p. 861, 866–868.

71. 4 Ra tion a le: Th e n orm al referen ce ran ge fo r th e glyco sylated h em o glob in A1c is 4.0% to 6.0%. Th is test m easures th e am ou n t o f glu cose th at h as b ecom e perm an en tly bo un d to

th e red bloo d cells from circu latin g gluco se. Eryth rocytes live fo r ab o ut 120 days, givin g feed back abo ut b lo od glu co se fo r p ast 120 days. Elevation s in th e bloo d glu cose level will cause elevatio n s in th e am ou n t of glycosylatio n . Th us th e test is use- fu l in id en tifyin g clien ts wh o h ave p erio d s of h yp erglycem ia th at are un d etected in oth er ways. Th e estim ated average glu - cose fo r a glyco sylated h em oglo b in A1c o f 9% is 212 m g/ d L (11.8 m m ol/ L). Elevation s in dicate co n tin ued n eed fo r teach - in g related to th e preven tio n o f h yperglycem ic ep isod es. Test-Ta kin g Str a tegy: Focus on th e su b ject , a glyco sylated h em o glob in A1c level of 9%. Recallin g th e n o rm al valu e an d th at an elevated valu e in dicates h yperglycem ia will assist in d irectin g yo u to th e correct o ptio n . Review: Glyco syla t ed h em o glo b in A1c Level of Cogn itive Ability: Ap plyin g Clien t Need s: Health Pro m otio n an d Main ten an ce In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Fu n dam en tals o f Care—Labo rato ry Valu es Pr ior it y Con cept s: Clien t Ed ucation ; Glu co se Regulation Refer en ces: Lewis et al. (2014), p p. 1150, 1175; Pagan a, Pagan a (2014), p . 266.

72. 1 Ra tion a le: Th e n o rm al WBC co un t ran ges fro m 5000– 10,000 m m 3 (5–10 Â 109/ L). Th e clien t wh o h as a d ecrease in th e n u m ber o f circu latin g WBCs is im m u n o sup pressed . Th e n urse im p lem en ts n eu tro p en ic p recautio n s wh en th e cli- en t’s values fall sufficien tly below th e n orm al level. Th e sp ecific valu e fo r im plem en tin g n eutrop en ic p recaution s u sually is d eterm in ed b y agen cy p olicy. Th e rem ain in g op tion s are n or- m al valu es. Test-Ta kin g St r a t egy: Fo cu s o n th e su b ject , th e n eed to im ple- m en t n eutrop en ic p recautio n s. Recallin g th at th e n o rm al WBC cou n t is 5000–10,000 m m 3 (5–10 Â 109/ L) will d irect yo u to th e correct o ptio n . Review: Th e n orm al ad ult wh it e b lo o d cell d iffer en t ia l co u n t Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Plan n in g Con ten t Ar ea : Fu n dam en tals o f Care—Labo rato ry Valu es Pr ior it y Con cept s: Clin ical Ju dgm en t; In fectio n Refer en ces: Lewis et al. (2014), p p . 625–626.

73. 4 Ra tion a le: Th e actio n th at th e n u rse sh o u ld take is to d raw a sam p le fo r PT an d INR level to d eterm in e th e clien t’s an ti- co agu latio n statu s an d risk fo r b leed in g. Th ese resu lts will p ro vid e in fo rm atio n as to h o w to b est treat th is clien t (e.g., if an an tid o te su ch as vitam in K o r a b lo o d tran sfu sio n is n eed ed ) . Th e aPTT m o n ito rs th e effects o f h ep arin th erap y. Test-Ta kin g St r a t egy: Fo cu s o n th e su b ject , a clien t wh o h as taken an excessive do se o f warfarin . Elim in ate th e o ptio n with aPTT first because it is un related to warfarin th erap y an d relates to h ep arin th erapy. Next, elim in ate th e op tion s in d icatin g to adm in ister an an tido te an d to tran sfuse th e clien t because th ese th erapies wou ld n o t be im plem en ted un less th e PT an d INR levels were kn own . Review: Care to th e clien t receivin g wa r fa r in th erap y Level of Cogn itive Ability: Ap plyin g

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122 UNIT III Nursing Sciences

Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Plan n in g Con t en t Ar ea : Fun dam en tals of Care—Lab oratory Valu es Pr ior ity Con cepts: Clin ical Jud gm en t; Clottin g Refer en ce: Lewis et al. (2014), p . 627.

74. 2 Ra t ion a le: Th e p rim ary con cern with op ioid an algesics is resp i- ratory depression an d h ypoten sion . Based on th e assessm en t fin d in gs, th e n urse sh ou ld su spect o p ioid o verd ose. Th e n u rse sh ou ld first attem p t to arou se th e clien t an d th en reassess th e vital sign s. Th e vital sign s m ay begin to n o rm alize on ce th e cli- en t is aro used becau se sleep can also cause decreased h eart rate, blo od p ressu re, respirato ry rate, an d oxygen saturation . Th e n urse sh ou ld also ch eck to see h ow m u ch m ed ication h as been taken via th e PCA p um p , an d sh o uld co n tin ue to m o n ito r th e clien t clo sely to d eterm in e if fu rth er action is n eed ed . Th e n u rse sh ou ld con tact th e HCP an d d ocum en t th e fin din gs after all data are co llected , after th e clien t is stab ilized, an d if an abn or- m ality still exists after arou sin g th e clien t. Test -Ta kin g St r a tegy: First, n ote th e st r a t egic wo r d , n ext. Fo cu s o n t h e d a t a in t h e q u est io n an d d et er m in e if a n a b n o r m a lit y exist s. It is clear th at an ab n o rm ality exists because th e clien t is d rowsy an d th e vital sign s are ou tside o f th e n o rm al ran ge. Recall th at attem p tin g to arou se th e clien t sh ou ld com e b efore fu rth er assessm en t o f th e pu m p . Th e clien t sh ou ld always be assessed befo re th e equ ip m en t, b efore co n - tactin g th e HCP, an d befo re do cum en tatio n . Review: Man agem en t o f p o ten tial o p io id o ver d o se. Level of Cogn it ive Ability: Syn th esizin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Fun dam en tals of Care—Pain Pr ior ity Con cepts: Clin ical Jud gm en t; Pain Refer en ce: Lewis et al. (2014), p . 164.

75. 3 Ra t ion a le: Th e n o rm al h em oglobin level for an adult fem ale clien t is 12–16 g/ dL (120–160 m m o l/ L). Iron deficien cy

an em ia can result in lower h em o glo bin levels. Deh yd ratio n m ay in crease th e h em o glob in level b y h em ocon cen tratio n . Heart failu re an d ch ron ic ob stru ctive pu lm on ary d isease m ay in crease th e h em o glob in level as a result o f th e bo dy’s n eed fo r m ore o xygen -carryin g cap acity. Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d s , most likely. Evalu ate each o f th e co n dition s in th e o ptio n s in term s of th eir p ath o ph ysiology an d wh eth er each is likely to raise or lower th e h em o glob in level. Also , n o te th e relation sh ip between h em oglo bin level in th e qu estio n an d th e correct op tio n . Review: Th e n o rm al h em o glo b in level Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Fun d am en tals of Care—Lab orato ry Values Pr ior ity Con cepts: Clin ical Jud gm en t; Gas Exch an ge Refer en ce: Lewis et al. (2014), pp . 628, 638.

76. 4 Ra t ion a le: A n o rm al platelet co un t ran ges from 150,000 to 400,000 m m 3 (150 to 400 Â 109/ L). Th e n urse sh o u ld place th e repo rt co n tain in g th e n orm al labo rato ry valu e in th e clien t’s m edical record. A p latelet co un t o f 300,000 m m 3

(300 Â 109/ L) is n o t an elevated cou n t. Th e co u n t also is n ot low; th erefo re, b leed in g p recautio n s are n ot n eeded . Test -Ta kin g Str a tegy: Fo cu s on th e su b ject , a platelet coun t of 300,000 m m 3 (300 Â 109/ L). Rem em ber th at op tio n s th at are co m p a r a b le o r a lik e are n ot likely to b e co rrect. With th is in m in d, elim in ate op tio n s in dicatin g to repo rt th e abn orm ally low co un t an d p lacin g th e clien t on bleedin g precau tio n s first. From th e rem ain in g o ptio n s, recallin g th e n orm al ran ge fo r th is lab o ratory test will direct you to th e co rrect op tion . Review: Th e n o rm al p la t elet co u n t Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Fun d am en tals of Care—Lab oratory Values Pr ior ity Con cepts: Clin ical Jud gm en t; Clottin g Refer en ce: Lewis et al. (2014), p. 626.

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123CHAPTER 10 Vital Signs and Laboratory Reference Intervals

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C H A P T E R 11 Nutrition

PRIORITY CONCEPT Health Promotion; Nutrition

CRITICAL THINKING What Should You Do? A client has been placed on a fluid restriction due to acute kidney injury. The client complains of thirst and asks what can be done to relieve this discomfort. What measures should the nurse tell the client to take to relieve thirst while adhering to the fluid restriction? Answer located on p. 130.

I. Nutrients A. Carb oh ydrates

1. Carb oh ydrates are th e preferred source of en ergy. 2. Sugars, starch es, an d cellulose provide 4 cal/ g. 3. Carb oh ydrates prom o te n orm al fat metabolism,

spare protein , an d en h an ce lower gastro in testi- n al fun ction .

4. Majo r food sources of carboh ydrates in clude m ilk, grain s, fru its, an d vegetables.

5. In ad equate carbo h ydrate in take affects m etab olism .

B. Fats 1. Fats provide a con cen trated source an d a stored

form of en ergy. 2. Fats protect in tern al organ s an d m ain tain body

tem p erature. 3. Fats en h an ce absorption of th e fat-solub le

vitam in s. 4. Fats provide 9 cal/ g. 5. In ad equate in take of essen tial fatty acids leads to

clin ical m an ifestatio n s of sen sitivity to cold, skin lesion s, in creased risk of in fectio n , an d am en or- rh ea in wom en .

6. Diets h igh in fat can lead to obesity an d in crease th e risk of cardiovascular disease an d som e can cers.

C. Protein s 1. Am in o acids, wh ich m ake up protein s, are critical

to all aspects of growth an d developm en t of body tissues, an d provide 4 cal/ g.

2. Protein s build an d repair body tissues, regulate fluid balan ce, m ain tain acid-b ase balan ce, pro- duce an tibod ies, provide en ergy, an d produce en zym es an d h orm on es.

3. Essen tial am in o acids are required in th e diet because th e body can n ot m an u facture th em .

4. Com p lete protein s con tain all essen tial am in o acids; in com plete protein s lack som e of th e essen tial fatty acids.

5. In adequ ate protein can cau se protein en ergy malnutrition an d severe wastin g of fat an d m uscle tissue.

Major stages of the lifespan with specific nutritional needs are pregnancy, lactation, infancy, childhood, and adolescence. Adults and older adults may experience physiological aging changes, which influence individual nutritional needs.

D. Vitam in s ( Box 11-1) 1. Vitam in s facilitate m etab olism of protein s, fats,

an d carboh ydrates an d act as catalysts for m eta- bolic fun ction s.

2. Vitam in s prom ote life an d growth processes, an d m ain tain an d regulate body fun ctio n s.

3. Fat-solub le vitam in s A, D, E, an d K can be stored in th e body, so an excess can cause toxicity.

4. Th e B vitam in s an d vitam in C are water-solub le vitam in s, are n ot stored in th e body, an d can be excreted in th e urin e.

E. Min erals (Box 11-2) 1. Min erals are co m pon en ts of h orm on es, cells, tis-

sues, an d bon es. 2. Min erals act as catalysts for ch em ical reactio n s

an d en h an cers of cell fun ction . 3. Alm ost all foods con tain som e form of m in erals. 4. A deficien cy of m in erals can develo p in ch ron i-

cally ill or h ospitalized clien ts. 5. Electro lytes play a m ajor role in osm olality

an d body water regulation , acid-b ase balan ce, en zym e reaction s, an d n eurom u scular activity (see Ch apter 8 for addition al in form ation regardin g electrolytes).124

Always assess the client’s ability to eat and swallow and promote independence in eating as much as is possible.

II. MyPlate (Fig. 11-1) A. Provid es a description of a balan ced diet th at in cludes

grain s, vegetables, fruits, dairy produ cts, an d protein food s (see h ttp :/ / www.ch oosem yplate.gov/ )

B. A n utrition ist sh o uld be con sulted for in dividualized dietary recom m en dation s.

C. Guidelin es 1. Avoid eatin g oversized portion s of food s. 2. Fill h alf of th e plate with fru its an d vegetables. 3. Vary th e type of vegetables an d fruits eaten . 4. Select at least h alf of th e grain s as wh o le grain s. 5. En su re th at food s fro m th e dairy grou p are h igh

in calcium. 6. Drin k m ilk th at is fat-free or low fat (1%).

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BOX 11-1 Food Sources of Vitamins Water-Soluble Vitamins Folic acid: Green leafy vegetables; liver, beef, and fish; legumes;

grapefruit and oranges Niacin: Meats, poultry, fish, beans, peanuts, grains Vitamin B1 (thiamine): Pork and nuts, whole-grain cereals, and

legumes Vitamin B2 (riboflavin): Milk, lean meats, fish, grains Vitamin B6 (pyridoxine): Yeast, corn, meat, poultry, fish Vitamin B12 (cobalamin): Meat, liver Vitamin C (ascorbic acid): Citrus fruits, tomatoes, broccoli,

cabbage

Fat-Soluble Vitamins Vitamin A: Liver, egg yolk, whole milk, green or orange vegeta-

bles, fruits Vitamin D: Fortified milk, fish oils, cereals Vitamin E: Vegetable oils; green leafy vegetables; cereals; apri-

cots, apples, and peaches Vitamin K: Green leafy vegetables; cauliflower and cabbage

BOX 11-2 Food Sources of Minerals

Calcium Cheese Collard greens Milk and soy milk Rhubarb Sardines Tofu Yogurt

Chloride Salt

Iron Breads and cereals Dark green vegetables Dried fruits Egg yolk Legumes Liver Meats

Magnesium Avocado Canned white tuna Cauliflower Cooked rolled oats Green leafy vegetables Milk Peanut butter Peas Pork, beef, chicken Potatoes Raisins Yogurt

Phosphorus Fish Nuts Organ meats Pork, beef, chicken Whole-grain breads and

cereals

Potassium Avocado Bananas Cantaloupe Carrots Fish Mushrooms Oranges Pork, beef, veal Potatoes Raisins Spinach Strawberries Tomatoes

Sodium Bacon Butter Canned food Cheese Cured pork Hot dogs Ketchup Lunch meat Milk Mustard Processed food Snack food Soy sauce Table salt White and whole-wheat

bread

Zinc Eggs Leafy vegetables Meats Protein-rich foods

FIGURE 11-1 MyPlate. (From U.S. Department of Agriculture. Available at http:/ / www.choosemyplate.gov.)

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7. Eat protein food s th at are lean . 8. Select fresh food s over fro zen or can n ed food s. 9. Drin k water rath er th an liquids th at con tain

sugar.

Always consider the client’s cultural and personal choices when planning nutritional intake.

III. Therapeutic Diets A. Clear liquid diet

1. In dication s a . Clear liqu id diet provid es flu ids an d som e

electrolytes to preven t deh ydratio n . b . Clear liquid diet is used as an in itial feedin g

after com plete bowel rest. c. Clear liquid diet is used in itially to feed a m al-

n ourish ed person or a person wh o h as n ot h ad an y oral in take for som e tim e.

d . Clear liqu id diet is used for bowel preparation for surgery or diagn ostic tests, as well as post- operatively an d in clien ts with fever, vom it- in g, or diarrh ea.

e. Clear liquid diet is used in gastro en teritis. 2. Nu rsin g con sideration s

a . Clear liquid diet is deficien t in en ergy (calo- ries) an d m an y nutrients.

b . Clear liquid diet is easily digested an d absorbed.

c. Min im al residue is left in th e gastro in testin al tract.

d . Clien ts m ay fin d a clear liquid diet un ap petiz- in g an d borin g.

e. As a tran sition diet, clear liquids are in ten ded for sh ort-term use.

f. Clear liquid s an d food s th at are relatively tran sparen t to ligh t an d are liquid at body tem p erature are con sidered “clear liquid s,” such as water, bouillon , clear broth , carbo n - ated beverages, gelatin , h ard can dy, lem on - ade, ice pops, an d regular or decaffein ated coffee or tea.

g. By lim itin g caffein e in take, an upset stom ach an d sleeplessn ess m ay be preven ted.

h . Th e clien t m ay con sum e salt an d sugar. i. Dairy produ cts an d fru it juices with pulp are

n ot clear liquid s.

Monitor the client’s hydration status by assessing intake and output, assessing weight, monitoring for edema, and monitoring for signs of dehydration. Each kilogram (2.2 lb) of weight gained or lost is equal to 1liter of fluid retained or lost.

B. Full liqu id diet 1. In dication : May be used as a tran sition diet after

clear liqu ids followin g surgery or for clien ts wh o h ave difficu lty ch ewin g, swallowin g, or tolerat- in g solid food s

2. Nursin g con sideration s a . A full liqu id diet is n utrition ally deficien t in

en ergy (calories) an d m an y n utrien ts. b . Th e diet in cludes clear an d opaqu e liqu id

food s, an d th ose th at are liquid at body tem perature.

c. Food s in clude all clear liqu ids an d item s such as plain ice cream , sh erbet, breakfast drin ks, m ilk, pudd in g an d custard, soup s th at are strain ed , refin ed cooked cereals, fruit juices, an d strain ed vegetable juices.

d . Use of a com plete n utrition al liqu id supp le- m en t is often n ecessary to m eet n utrien t n eeds for clien ts on a full liquid diet for m ore th an 3 days.

Provide nutritional supplements such as those high in protein, as prescribed, for the client on a liquid diet.

C. Mech an ical soft diet 1. In dication s

a . Provid es foods th at h ave been m ech an ically altered in texture to require m in im al ch ewin g

b . Used for clien ts wh o h ave difficulty ch ewin g but can tolerate m ore variety in texture th an a liqu id diet offers

c. Used for clien ts wh o h ave den tal problem s, surgery of th e h ead or n eck, or dysph agia (requires swallowin g evalu ation an d m ay require th icken ed liquid s if th e clien t h as swallowin g difficu lties)

2. Nursin g con sideration s a . Degree of texture m od ification depen ds on

in dividual n eed, in cludin g pureed, m ash ed, groun d , or ch op ped.

b . Foods to be avoided in m ech an ically altered diets in clude n uts; dried fruits; raw fruits an d vegetables; fried foods; tough , sm oked, or salted m eats; an d foods with coarse textures.

D. Soft diet 1. In dication s

a . Used for clien ts wh o h ave difficulty ch ewin g or swallowin g

b . Used for clien ts wh o h ave ulceration s of th e m ou th or gum s, oral surgery, broken jaw, plastic surgery of th e h ead or n eck, or dysph a- gia, or for th e clien t wh o h as h ad a stroke

2. Nursin g con sideration s a . Clien ts with m ou th sores sh ould be served

food s at cooler tem p eratures. b . Clien ts wh o h ave difficulty ch ewin g an d swal-

lowin g because of dry m ou th can in crease sal- ivary flow by suckin g on sour can dy.

c. En cou rage th e clien t to eat a variety of foods. d . Provid e plen ty of fluids with m eals to ease

ch ewin g an d swallowin g of food s. e. Drin kin g flu ids th rou gh a straw m ay be easier

th an drin kin g fro m a cup or glass; a straw m ay

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n ot be allowed for clien ts with dysph agia (because of th e risk of aspiration ) .

f. All food s an d season in gs are perm itted; h owever, liqu id, ch op ped, or pureed foods or regular food s with a soft con sisten cy are tolerated best.

g. Food s th at con tain n uts or seeds, wh ich easily can beco m e trapped in th e m ou th an d cau se discom fort, sh ould be avoided.

h . Raw fru its an d vegetables, fried foods, an d wh ole grain s sh o uld be avoided.

Consider the client’s disease or illness and how it may affect nutritional status.

E. Low-fib er (low-residue) diet 1. In dication s

a. Supp lies foods th at are least likely to form an obstru ctio n wh en th e in testin al tract is n ar- ro wed by in flam m ation or scarrin g or wh en gastro in testin al m otility is slowed

b . Used for in flam m atory bowel disease, partial obstruction s of th e in testin al tract, gastroen ter- itis, diarrh ea, or oth er gastroin testin al disorders

2. Nu rsin g con sid eration s a. Foods th at are low in fiber in clude white bread,

refin ed cooked cereals, cooked potatoes with - out skin s, wh ite rice, and refin ed pasta.

b . Food s to lim it or avoid are raw fruits (except ban an as), vegetables, n uts an d seeds, plan t fib er, an d wh ole grain s.

c. Dairy produ cts sh ould be lim ited to 2 serv- in gs a day.

F. High -fiber (h igh -residue) diet 1. In dication : Used for con stipatio n , irritable bowel

syn drom e wh en th e prim ary sym pto m is alter- n atin g con stipatio n an d diarrh ea, an d asym p- tom atic diverticu lar disease

2. Nu rsin g con sid eration s a. High -fiber diet provides 20 to 35 g of dietary

fib er daily. b . Volum e an d weigh t are ad ded to th e stool,

speedin g th e m ovem en t of un digested m ate- rials th rou gh th e in testin e.

c. High -fiber food s are fruits an d vegetables an d wh ole-grain produ cts.

d . In crease fiber gradually an d provide adequate flu ids to reduce possible un d esirable side effects such as ab dom in al cram ps, bloatin g, diarrh ea, an d deh ydratio n .

e. Gas-form in g food s sh o uld be lim ited (Box 11-3).

G. Card iac diet ( Box 11-4) 1. In dication s

a. In dicated for ath erosclerosis, diabetes m ellitus, h yperlipidem ia, h yperten sion , m yocardial in farction , n eph rotic syn drom e, an d ren al failure

b . Redu ces th e risk of h eart disease c. Dietary Approach es to Stop Hyperten sion

(DASH ) diet: recom m en ded to preven t an d con trol h yperten sion , h yperch olesterolem ia, an d obesity

d . Th e DASH diet in cludes fruits, vegetables, wh o le grain s, an d low-fat dairy food s; m eat, fish , poultry, n uts, an d bean s; an d is lim ited in sugar-sweeten ed food s an d beverages, red m eat, an d added fats.

2. Nu rsin g con sideration s a. Restrict total am oun ts of fat, in cludin g satu-

rated, tran s, polyun saturated, an d m on oun - saturated; ch olesterol; an d sodium.

b . Teach th e clien t about th e DASH diet or oth er prescribed diet.

H. Fat-restricted diet 1. In dication s

a. Used to reduce sym pto m s of abdom in al pain , steato rrh ea, flatu len ce, an d diarrh ea associ- ated with h igh in takes of dietary fat, an d to decrease n utrien t losses caused by in gestion of dietary fat in in dividuals with m alabsorp- tion disorders

b . Used for clien ts with m alab sorption disor- ders, pan creatitis, gallblad der disease, an d gastro esoph ageal reflux

2. Nu rsin g con sideration s a. Restrict total am oun t of fat, in cludin g saturated,

tran s, polyun saturated, an d m on oun saturated. b . Clien ts with m alab sorption m ay also h ave

difficu lty toleratin g fiber an d lactose.

BOX 11-3 Gas-Forming Foods

Apples Artichokes Barley Beans Bran Broccoli Brussels sprouts Cabbage Celery Figs

Melons Milk Molasses Nuts Onions Radishes Soybeans Wheat Yeast

BOX 11-4 Sodium-Free Spices and Flavorings

Allspice Almond extract Bay leaves Caraway seeds Cinnamon Curry powder Garlic powder or garlic

Ginger Lemon extract Maple extract Marjoram Mustard powder Nutmeg

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c. Vitam in an d m in eral deficien cies m ay occur in clien ts with diarrh ea or steato rrh ea.

d . A fecal fat test m ay be prescribed an d in di- cates fat m alab sorption with excretion of m ore th an 6 to 8 g of fat (or m ore th an 10% of fat con sum ed) per day durin g th e 3 days of specim en collectio n .

I. High -calorie, h igh -protein diet 1. In d icatio n : Used fo r severe stress, b u rn s, wo u n d

h ealin g, can cer, h u m an im m u n o d eficien cy viru s, acq u ired im m u n o d eficien cy syn d ro m e, ch ro n ic o b stru ctive p u lm o n ary d isease, resp ira- to ry failu re, o r an y o th er typ e o f d eb ilitatin g d isease

2. Nu rsin g con sideration s a . En cou rage n utrien t-d en se, h igh -calorie, h igh -

protein food s such as wh o le m ilk an d m ilk produ cts, pean ut butter, n uts an d seeds, beef, ch icken , fish , pork, an d eggs.

b . En cou rage sn acks between m eals, such as m ilksh akes, in stan t breakfasts, an d n utri- tion al supp lem en ts.

Calorie counts assist in determining the client’s total nutritional intake and can identifya deficit or excess intake.

J. Carb oh ydrate-con sisten t diet 1. In dication : Used for clien ts with diabetes m elli-

tus, h ypo glycem ia, h yperglycem ia, an d obesity 2. Nu rsin g con sideration s

a . Th e Exch an ge System for Meal Plan n in g, developed by th e Academ y of Nu trition an d Dietetics an d th e Am erican Diabetes Asso ciation , is a food guide th at m ay be recom m en ded .

b . Th e Exch an ge System grou ps food s acco rdin g to th e am oun ts of carboh ydrates, fats, an d protein s th ey con tain ; m ajor food groups in clude th e carboh ydrate, m eat an d m eat sub- stitute, an d fat grou ps.

c. Acarboh ydrate con sisten t diet focuses on m ain - tain in g a con sisten t am oun t of carboh ydrate in take each day an d with each m eal; also kn own as “carb coun tin g.” For addition al in form ation, refer to: h ttp:/ / www.livestron g.com / article/ 436101-th e-consistent-carboh ydrate-diet-for- diabetics/

d . Th e MyPlate diet m ay also be recom m en ded. K. Sodium -restricted diet (see Box 11-4)

1. In dication : Used for h yperten sio n , h eart failure, ren al disease, cardiac disease, an d liver disease

2. Nu rsin g con sideration s a . In dividualized; can in clude 4 g of sodium

daily (n o-add ed-salt diet), 2 to 3 g of sodium daily (m oderate restriction ), 1 g of sodium daily (strict restriction ), or 500 m g of sodium daily (severe restriction an d sel- dom prescribed)

b . En cou rage in take of fresh food s, rath er th an processed food s, wh ich con tain h igh er am oun ts of sodium .

c. Can n ed , fro zen , in stan t, sm o ked , p ickled , an d b o xed fo o d s u su ally co n tain h igh er am o u n ts o f so d iu m . Lu n ch m eats, so y sau ce, salad d ressin gs, fast fo o d s, so u p s, an d sn acks su ch as p o tato ch ip s an d p ret- zels also co n tain large am o u n ts o f so d iu m ; teach p atien ts to read n u tritio n al facts o n p ro d u ct p ackagin g regard in g so d iu m co n - ten t p er servin g.

d . Certain m ed ication s con tain sign ifican t am oun ts of sodium .

e. Salt substitutes m ay be used to im prove palat- ability; m ost salt substitutes con tain large am oun ts of potassium an d sh ould n ot be used by clien ts with ren al disease.

L. Protein -restricted diet 1. In dication : Used for ren al disease an d en d-stage

liver disease 2. Th e n utrition al status of critically ill clien ts with

protein -losin g ren al diseases, m alabsorption syn d rom es, an d co n tin uou s ren al replacem en t th erap y or dialysis sh ould h ave th eir protein n eeds assessed by estim atin g th e protein equiva- len t of n itrogen appearan ce (PNA); a n utrition ist sh ould be con sulted.

3. Nursin g con sideration s a . Provid e en ough protein to m ain tain n utri-

tion al status but n ot an am oun t th at will allow th e buildup of waste produ cts from protein m etab olism (40 to 60 g of protein daily).

b . The less protein allowed, the m ore im portan t it becom es th at all protein in th e diet be of h igh biological value (con tain all essen tial am in o acids in recom m en ded proportion s).

c. An adequ ate total en ergy in take from food s is critical for clien ts on protein -restricted diets (pro tein will be used for en ergy, rath er th an for protein syn th esis).

d . Special lo w-protein produ cts, such as pastas, bread, cookies, wafers, an d gelatin m ade with wh eat starch , can im prove en ergy in take an d add variety to th e diet.

e. Carb oh ydrates in powdered or liquid form s can provide addition al en ergy.

f. Vegetables an d fruits con tain som e protein an d, for very low-protein diets, th ese food s m ust be calculated in to th e diet.

g. Food s are lim ited from th e m ilk, m eat, bread, an d starch groups.

M. Gluten -free diet: A treatm en t for celiac disease an d gluten sen sitivity for clien ts n eedin g th e protein fraction “glu ten ” elim in ated from th eir diet. See Ch apter 37 for in form ation on th is diet.

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Fluid restrictions may be prescribed for clients with hyponatremia, severe extracellular cellular volume excess, and renal disorders. Ask specifically about client preferences regarding types of oral fluids and tempera- ture preference of fluids.

N. Ren al diet (see Box 11-2) 1. In dication : Used for th e clien t with acu te kidn ey

in ju ry or ch ron ic kidn ey disease an d th o se requirin g h em od ialysis or periton eal dialysis

2. Nu rsin g con sid eration s a. Con trolled am oun ts of protein , sodium ,

phosphorus, calcium , potassium , an d fluids m ay be prescribed; m ay also n eed m od ifica- tio n in fib er, ch olesterol, an d fat based on in dividual requirem en ts; clien ts on perito- n eal dialysis usually h ave diets prescribed th at are less restrictive with fluid an d protein in take th an th ose on h em od ialysis.

b . Most clien ts receivin g dialysis n eed to restrict flu ids ( Box 11-5).

c. Mon itor weigh t daily as a prio rity because weigh t is an im portan t in dicator of fluid status.

An initial assessment includes identifying allergies and food and medication interactions.

O. Potassium -m o dified diet (see Box 11-2) 1. In dication s

a. Low-p otassium diet is in dicated for h yperka- lem ia, wh ich m ay be caused by im paired ren al fun ction , h ypo aldo steron ism , Addi- son ’s disease, an gioten sin -con vertin g en zym e in h ibitor m ed ication s, im m un osuppressive m ed ication s, potassium -retain in g diuretics, an d ch ron ic h yperkalem ia.

b . High -potassium diet is in dicated for h ypo- kalem ia, wh ich m ay be cau sed by ren al tubu lar acido sis, gastroin testin al losses (diarrh ea, vom itin g), in tracellular sh ifts, potassium -losin g diuretics, an tibiotics, m in eraloco rticoid or gluco cortico id excess resultin g from prim ary or secon dary aldo ste- ro n ism , Cush in g’s syn dro m e, or exogen ous corticosteroid use.

2. Nu rsin g con sid eration s a. Food s th at are low in potassium in clude

ap plesauce, green bean s, cabbage, lettuce, pep pers, grapes, blueberries, cooked sum m er

squash , cooked turn ip green s, pin eapple, an d rasp berries.

b . Box 11-2 lists food s th at are h igh in potassium .

P. High -calcium diet 1. In dication : Calcium is n eeded durin g bon e

growth an d in adulth o od to preven t osteo- porosis an d to facilitate vascular con traction , vaso dilation , m uscle con traction , an d n erve tran sm ission .

2. Nu rsin g con sideration s a. Prim ary dietary sources of calcium are dairy

produ cts (see Box 11-2 for food item s h igh in calcium ).

b . Lactose-in toleran t clien ts sh ould in corpo rate n on dairy sources of calcium in to th eir diet regularly.

Q. Low-p urin e diet 1. In dication : Used for go ut, kidn ey ston es, an d ele-

vated uric acid levels 2. Nu rsin g con sideration s

a. Purin e is a precurso r for uric acid, wh ich form s ston es an d crystals.

b . Food s to restrict in clude an ch ovies, h errin g, m ackerel, sard in es, scallop s, organ m eats, gravies, m eat extracts, wild gam e, goose, an d sweetbreads.

R. High -iron diet 1. In dication : Used for clien ts with an em ia 2. Nu rsin g con sideration s

a. Th e h igh -iron diet replaces iron deficit from in adeq uate in take or loss.

b . Th e diet in cludes organ m eats, m eat, egg yolks, wh ole-wh eat products, dark green leafy vegetables, dried fruit, an d legum es.

c. In form th e clien t th at con curren t in take of Vitam in C with iron food s en h an ces absorp- tion of iron .

IV. Vegan and Vegetarian Diets A. Vegan

1. Vegan s follow a strict vegetarian diet an d con - sum e n o an im al food s.

2. Eat on ly foods of plan t origin (e.g., wh ole or en rich ed grain s, legum es, n uts, seeds, fruits, vegetables).

3. Th e use of soybean s, soy m ilk, soybean curd (to fu), an d processed soy protein produ cts en h an ce th e n utrition al value of th e diet.

B. Lacto-vegetarian 1. Lacto-vegetarian s eat m ilk, ch eese, an d

dairy food s but avoid m eat, fish , poultry, an d eggs.

2. A diet of wh o le or en rich ed grain s, legum es, n uts, seeds, fruits, an d vegetables in sufficien t quan tities to m eet en ergy n eeds provides a balan ced diet.

BOX 11-5 Measures to Relieve Thirst ▪ Chew gum or suck hard candy. ▪ Freeze fluids so they take longer to consume. ▪ Add lemon juice to water to make it more refreshing. ▪ Gargle with refrigerated mouthwash.

129CHAPTER 11 Nutrition

C. Lacto-o vo-vegetarian 1. Lacto-o vo-vegetarian s follo w a food pattern th at

allows for th e con sum ptio n of dairy produ cts an d eggs.

2. Con sum ption of adequate plan t an d an im al food sources th at exclud es m eat, poultry, pork, an d fish poses n o n utrition al risks.

D. O vo-vegetarian s: Th e on ly an im al foods th at th e ovo-vegetarian con sum es are eggs, wh ich are an excellen t source of com plete protein s.

E. Nursin g con sideration s 1. Vegan an d vegetarian diets are n ot usually pre-

scrib ed but are a diet ch oice m ade by a clien t. 2. En su re th at th e clien t eats a sufficien t am oun t

of varied food s to m eet n utrien t an d en ergy n eeds.

3. Clien ts sh ould be edu cated about con sum in g com plem en tary protein s over th e course of each day to en sure th at all essen tial am in o acids are provided.

4. Poten tial deficien cies in vegetarian diets in clude en ergy, protein , vitam in B12, zin c, iron , calcium, om ega-3 fatty acids, an d vitam in D (if lim ited exposu re to sun ligh t).

5. To en h an ce absorption of iron , vegetarian s sh ould con sum e a good source of iron an d vita- m in C with each m eal.

6. Food s eaten m ay in clude tofu, tem peh , soy m ilk an d soy produ cts, m eat an alo gs, legum es, n uts an d seeds, sprouts, an d a variety of fru its an d vegetables.

7. Soy protein is con sidered equ ivalen t in quality to an im al protein .

Body mass index (BMI) can be calculated by dividing the client’s weight in kilograms by height in meters squared. For example, a client who weighs 75 kg (165 pounds) and is 1.8 m (5 feet, 9 inches) tall has a BMI of 23.15 (75 divided by 1.82¼23.15). From: Potter et al. (2013), p. 100 8.

V. Enteral Nutrition A. Description : Provides liqu efied food s in to th e gastro -

in testin al tract via a tube B. In dication s

1. Wh en th e gastro in testin al tract is fun ction al but oral in take is n ot m eetin g estim ated n utrien t n eeds

2. Used for clien ts with swallowin g problem s, burn s, m ajor traum a, liver or oth er organ failure, or severe malnutrition

C. Nursin g con sideration s 1. Clien ts with lactose in toleran ce n eed to be

placed on lactose-free form ulas. 2. See Ch apter 20 for in form ation regardin g th e

adm in istration of gastroin testin al tube feedin gs an d associated com plication s.

CRITICAL THINKING What Should You Do? Answer: The client with acute kidney injury may be placed on fluid restriction because of decreased renal function and glomerular filtration rate, resulting in fluid volume excess. To allow the kidneys to rest, decreased fluid consumption may be indicated. When a client is placed on this restriction, increased thirst may be a problem. The nurse should instruct the client in measures to relieve thirst in order to promote adherence to the fluid restriction. These measures include chewing gum or sucking hard candy, freezing fluids so they take longer to consume, adding lemon juice to water to make it more refreshing, and gargling with refrigerated mouthwash.

References: Lewis et al. (20 14), p. 1115; Potter et al. (20 13), p. 904.

P R A C T I C E Q U E S T I O N S 77. Th e n urse is teach in g a clien t wh o h as iron defi-

cien cy an em ia about food s sh e sh o uld in clude in th e diet. Th e n urse determ in es th at th e clien t un der- stan d s th e dietary m odification s if wh ich item s are selected from th e m en u? 1. Nuts an d m ilk 2. Coffee an d tea 3. Cooked rolled oats an d fish 4. O ran ges an d dark green leafy vegetables

78. Th e n urse is plan n in g to teach a clien t with m alab- sorption syn drom e about th e n ecessity of follo win g a low-fat diet. Th e n urse develops a list of h igh -fat foods to avoid an d sh ould in clude wh ich food item s on th e list? Select all th at ap p ly.

1. O ran ges 2. Broccoli 3. Margarin e 4. Cream ch eese 5. Lun ch eon m eats 6. Broiled h add ock

79. Th e n urse in structs a clien t with ch ron ic kidn ey dis- ease wh o is receivin g h em od ialysis about dietary m od ification s. Th e n urse determ in es th at th e clien t un derstan ds th ese dietary m odification s if th e clien t selects wh ich item s from th e dietary m en u? 1. Cream of wh eat, blueb erries, coffee 2. Sau sage an d eggs, ban an a, oran ge juice 3. Bacon , can taloupe m elon , tom ato juice 4. Cured pork, grits, strawberries, oran ge juice

80. Th e n urse is con d uctin g a dietary assessm en t on a clien t wh o is on a vegan diet. Th e n urse provid es die- tary teach in g an d sh o uld focus on foods h igh in wh ich vitam in th at m ay be lackin g in a vegan diet?

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1. Vitam in A 2. Vitam in B12 3. Vitam in C 4. Vitam in E

81. A clien t with h yperten sion h as been told to m ain - tain a diet lo w in sodium . Th e n urse wh o is teach in g th is clien t about foods th at are allowed sh ould in clude wh ich food item in a list provided to th e clien t? 1. To m ato soup 2. Boiled sh rim p 3. In stan t oatm eal 4. Sum m er squash

82. A postoperative clien t h as been placed on a clear liq- uid diet. Th e n urse sh ould provid e th e clien t with wh ich item s th at are allowed to be con sum ed on th is diet? Select all th at ap p ly.

1. Broth 2. Coffee 3. Gelatin 4. Puddin g 5. Vegetable juice 6. Pureed vegetables

83. Th e n urse is in structin g a clien t with h yperten sion on th e im portan ce of ch oosin g food s low in sodium . Th e n urse sh o uld teach th e clien t to lim it in take of wh ich food ? 1. Apples 2. Ban an as 3. Sm oked sausage 4. Steam ed vegetables

84. A clien t wh o is recoverin g from surgery h as been advan ced from a clear liquid diet to a full liqu id diet. Th e clien t is lookin g forward to th e diet ch an ge because h e h as been “bored” with th e clear liqu id diet. Th e n urse sh ould offer wh ich full liquid item to th e clien t? 1. Tea 2. Gelatin 3. Custard 4. Ice pop

85. A clien t is recoverin g from abdom in al surgery an d h as a large abdom in al woun d. Th e n urse should encour- age th e clien t to eat which food item th at is n aturally h igh in vitam in C to prom ote woun d h ealing? 1. Milk 2. O ran ges 3. Ban an as 4. Ch icken

86. Th e n urse is carin g for a clien t with cirrh osis of th e liver. To m in im ize th e effects of th e disorder, th e n urse teach es th e clien t about food s th at are h igh in th iam in e. Th e n urse determ in es th at th e clien t h as th e b est un derstan din g of th e dietary m easures to follow if th e clien t states an in ten tion to in crease th e in take of wh ich food? 1. Milk 2. Ch icken 3. Broccoli 4. Legu m es

A N S W E R S 77. 4 Ra t ion a le: Dark green leafy vegetab les are a go od so urce o f iro n an d o ran ges are a goo d sou rce of vitam in C, wh ich en h an ces iro n abso rptio n . All o th er o ption s are n ot foo d sou rces th at are h igh in iro n an d vitam in C. Test -Ta kin g St r a t egy: Focus on th e s u b ject , d iet ch o ices for a clien t with an em ia. Th in k ab ou t th e p ath o ph ysiology o f an e- m ia an d d eterm in e th at th e clien t n eeds foo ds h igh in iro n an d recall th at vitam in C en h an ces iron ab so rp tion . Use kn o wledge of fo o ds h igh in iron an d vitam in C. Rem em ber th at green leafy vegetables are h igh in iro n an d oran ges are h igh in vitam in C. Review: Foo d so urces o f vit a m in C an d ir o n Level of Cogn it ive Ability: Evaluatin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Evalu ation Con t en t Ar ea : Fu n d am en tals of Care—Nutritio n Pr ior ity Con cepts: Clien t Edu catio n ; Nu tritio n Refer en ces: Lewis et al. (2014), p. 889; Nix (2013), pp . 108, 144.

78. 3, 4, 5 Ra t ion a le: Fruits an d vegetab les ten d to b e lo wer in fat becau se th ey do n ot co m e fro m an im al so urces. Bro iled h add ock is also n aturally lower in fat. Margarin e, cream ch eese, an d lu n ch eo n m eats are h igh -fat foo ds. Test -Ta kin g Str a t egy: Fo cus on th e su b ject of th e qu estio n , th e h igh -fat foo ds. O ran ges an d b ro cco li (fruit an d vegetable) can be elim in ated first. Next elim in ate h ad do ck because it is a b ro iled foo d. Rem em b er th at m argarin e, ch eese, an d lu n ch eo n m eats are h igh in fat co n ten t. Review: High -fa t fo o d s Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Teach in g an d Learn in g Con t en t Ar ea : Fun d am en tals of Care—Nu tritio n Pr ior ity Con cepts: Clien t Ed u catio n ; Nu tritio n Refer en ce: Nix (2013), p. 38.

79. 1 Ra tion a le: Th e diet for a client with ch ron ic kid n ey disease wh o is receivin g h em odialysis sh ould in clud e con tro lled am o un ts o f sodium , p h osp h orus, calcium , p otassium , and fluids, wh ich

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131CHAPTER 11 Nutrition

is in d icated in th e correct o ption . Th e food item s in th e rem ain - in g option s are h igh in sodiu m , ph osph o ru s, or p otassium . Test-Ta kin g St r a tegy: Focu s on th e su b ject , dietary m od ifica- tio n for a clien t with ch ro n ic kid n ey d isease. Th in k ab ou t th e p ath op h ysio lo gy of th is disorder to recall th at so dium n eeds to b e lim ited . Notin g th e item s sausage, b aco n , an d cu red po rk will assist in elim in atin g th ese optio n s. Review: Diet a r y gu id elin es fo r th e clien t with ch r o n ic k id - n ey d isea se Level of Cogn it ive Abilit y: Evalu atin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Evaluatio n Con ten t Ar ea : Fu n dam en tals o f Care—Nu trition Pr ior it y Con cept s: Clien t Ed ucation ; Nutritio n Refer en ce: Lewis et al. (2014), p p . 1114–1115.

80. 2 Ra tion a le: Vegan s d o n o t co n sum e an y an im al prod ucts. Vita- m in B12 is fo un d in an im al p rod ucts an d th erefore wou ld m ost likely be lackin g in a vegan d iet. Vitam in s A, C, an d E are fou n d in fresh fru its an d vegetab les, wh ich are co n su m ed in a vegan d iet. Test-Ta kin g St r a t egy: Fo cu s o n th e su b ject , a vegan diet an d th e vitam in lackin g in th is d iet. Recallin g th e fo o d item s eaten an d restricted in th is d iet will direct you to th e correct o ption . Rem em ber th at vegan s d o n ot con sum e an y an im al prod ucts an d as a resu lt m ay b e d eficien t in vitam in B12. Review: Th e vega n d iet an d sou rces of vit a m in s Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Fu n dam en tals o f Care—Nu trition Pr ior it y Con cept s: Health Pro m otio n ; Nu trition Refer en ces: Lewis et al. (2014), p. 889; Nix (2013), p . 55.

81. 4 Ra tion a le: Fo ods th at are lower in sodium in clude fruits an d vegetab les (su m m er squ ash ), b ecau se th ey do n o t con tain p h ysio logical salin e. High ly p ro cessed o r refin ed fo od s (tom ato so up , in stan t oatm eal) are h igh er in so dium un less th eir foo d lab els sp ecifically state “low so diu m .” Saltwater fish an d sh ellfish are h igh in so d ium . Test-Ta kin g Str a tegy: Fo cu s o n th e su b ject , foods low in so diu m . Begin to an swer th is qu estio n b y elim in atin g b oiled sh rim p, recallin g th at saltwater fish an d sh ellfish are h igh in so diu m . Next, elim in ate to m ato so up an d in stan t oatm eal b ecau se th ey are p ro cessed fo od s. Review: Fo od s h igh in so d iu m Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Fu n dam en tals o f Care—Nu trition Pr ior it y Con cept s: Health Pro m otio n ; Nu trition Refer en ce: Nix (2013), p p. 141, 389.

82. 1, 2, 3 Ra tion a le: A clear liq u id diet co n sists o f foo d s th at are rela- tively tran sparen t to ligh t an d are clear an d liqu id at ro o m an d bo dy tem peratu re. Th ese fo od s in clud e item s su ch as water, bouillon , clear broth , carb on ated beverages, gelatin ,

h ard can dy, lem on ade, ice p o ps, an d regular o r d ecaffein ated coffee o r tea. Th e in co rrect foo d item s are item s th at are allo wed o n a full liqu id diet. Test-Ta king Str a tegy: Focus o n th e s u b ject , a clear liquid d iet. Recallin g th at a clear liq uid d iet con sists o f foo ds th at are rela- tively tran sparen t to ligh t and are clear will assist in an swerin g th e q uestio n. Review: Clea r liq u id d iet an d fu ll liq u id d iet Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fun dam en tals o f Care—Nu trition Pr ior it y Con cept s: Health Pro m o tio n ; Nu tritio n Refer en ce: Perry, Potter, O sten dorf (2014), p. 765.

83. 3 Ra tion a le: Sm o ked fo o ds are h igh in sod iu m , wh ich is n oted in th e co rrect op tion . Th e rem ain in g op tion s are fru its an d veg- etab les, wh ich are low in sod iu m . Test-Ta kin g St r a t egy: Note th e su b ject , th e foo d item th at is h igh in sod iu m . Rem em ber th at sm o ked foo d s are h igh in so diu m . Also elim in ate o ptio n s 1, 2, an d 4 becau se th ey are co m p a r a b le o r a lik e an d are n o n p ro cessed fo od s. Review: Fo od item s h igh in so d iu m Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Teach in g an d Learn in g Con ten t Ar ea : Fu n dam en tals o f Care—Nu trition Pr ior it y Con cept s: Health Pro m otio n ; Nu trition Refer en ce: Nix (2013), p . 389.

84. 3 Ra tion a le: Full liquid food item s in clude item s such as plain ice cream , sh erb et, breakfast drin ks, m ilk, p ud din g an d custard, so up s th at are strain ed, refin ed co o ked cereals, an d strain ed vegetable juices. A clear liq uid diet con sists o f fo od s th at are rel- atively tran sparen t. Th e foo d item s in th e in correct o ptio n s are clear liq uids. Test-Ta kin g Str a t egy: Focu s o n th e su b ject , a fu ll liq uid item . Rem em ber th at a clear liq u id diet con sists of fo o ds th at are rel- atively tran sparen t. Th is will assist yo u in elim in atin g tea, gela- tin , an d ice p op s; in ad ditio n , th ese are co m p a r a b le o r a lik e o ptio n s. Review: Clea r liq u id d iet an d fu ll liq u id d iet Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Fu n dam en tals o f Care—Nu trition Pr ior it y Con cept s: Health Pro m otio n ; Nu trition Refer en ce: Perry, Potter, O sten d orf ( 2014), p . 765.

85. 2 Ra tion a le: Citrus fruits an d juices are especially h igh in vitam in C. Ban an as are h igh in p otassium . Meats an d d airy prod ucts are two fo od gro u ps th at are h igh in th e B vitam in s. Test-Ta kin g St r a tegy: Note th e su b ject , fo od item s n atu rally h igh in vitam in C. It is n ecessary to recall th at citrus fruits an d ju ices are h igh in vitam in C; th is will d irect yo u to th e cor- rect option .

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Review: Foo d item s h igh in vit a m in C Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Fu n d am en tals of Care—Nutritio n Pr ior ity Con cepts: Nutrition ; Tissu e In tegrity Refer en ce: Nix (2013), pp . 108, 451.

86. 4 Ra t ion a le: Th e clien t with cirrh o sis n eeds to con sum e foo ds h igh in th iam in e. Th iam in e is p resen t in a variety of foo ds o f plan t an d an im al o rigin . Legu m es are especially rich in th is vitam in . O th er go od foo d sou rces in clu de n uts, wh o le-grain cereals, an d po rk. Milk co n tain s vitam in s A, D, an d B2. Pou ltry

co n tain s n iacin . Bro ccoli con tain s vitam in s C, E, an d K an d fo lic acid. Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d , best. Th is m ay in d icate th at m o re th an o n e op tion m ay b e a foo d th at co n tain s th iam in e. Rem em b erin g th at legu m es are especially rich in th iam in e will d irect yo u to th e co rrect o ption . Review: Foo d item s h igh in t h ia m in e Level of Cogn it ive Ability: Evaluatin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Evalu ation Con t en t Ar ea : Fun d am en tals of Care—Nu tritio n Pr ior ity Con cepts: Health Prom o tion ; Nutritio n Refer en ces: Lewis et al. (2014), p p. 1023–1024; Nix (2013), p . 109.

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133CHAPTER 11 Nutrition

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C H A P T E R 12 Parenteral Nutrition

PRIORITY CONCEPTS Fluids and Electrolytes; Nutrition

CRITICAL THINKING What Should You Do? A client has a triple-lumen central venous catheter that is being used for the administration of parenteral nutrition, medications, and laboratory draws. The nurse is preparing to administer medication through the catheter, and the port being used for medication administration is sluggish and not flushing properly. What should the nurse do? Answer located on p. 138.

I. Parenteral Nutrition (PN) A. Description

1. Paren teral n utrition (also term ed h yperalim en ta- tion ) supp lies n utrien ts via th e vein s.

2. PN con sists of both partial parenteral nutrition (PPN) an d total parenteral nutrition (TPN) . Th e in dication of th e type used dep en ds on th e cli- en t’s n utrition al n eeds.

3. PN supp lies carboh ydrates in th e form of dex- trose, fats in an em ulsified form , protein s in th e form of am in o acids, vitam in s, m in erals, electrolytes, an d water.

4. PN preven ts subcutan eous fat an d m uscle protein from bein g catabolized by th e body for en ergy.

5. PN solution s are h yperton ic due to th e h igh er con cen tration s of glucose an d addition of am in o acids.

B. In dication s 1. Clien ts with severely dysfun ction al or n on fun c-

tion al gastroin testinal tracts who are un able to process n utrien ts m ay ben efit from PN.

2. Clien ts wh o can take som e oral n utrition , but n ot en ough to m eet th eir n utrien t requirem en ts, m ay ben efit from PN.

3. Clien ts with m ultiple gastroin testin al surgeries, gastro in testin al traum a, severe in toleran ce to en teral feedin gs, or in testin al obstru ction s, or wh o n eed to rest th e bowel for h ealin g, m ay ben - efit from PN.

4. Clien ts with severe n utrition ally deficien t con d i- tion s such as acquired im m un od eficien cy syn - drom e, can cer, burn in juries, or malnutrition, or clien ts receivin g ch em oth erapy, m ay ben efit from PN.

PN is a form of nutrition and is used when there is no other nutritional alternative. Administering nutrition orally or through a nasogastric tube is usually initiated first, before PN is initiated.

C. Adm in istration of PN (Fig. 12-1) 1. Partial paren teral n utrition

a . PPN: Usually adm in istered through a large dis- tal vein in the arm with a stan dard periph eral in traven ous (IV) cath eter or m idlin e or through a peripherally in serted cen tral cath eter (PICC). A m idlin e is placed in an upper arm vein such as th e brachial or cephalic vein with the tip en d- in g below th e level of the axillary lin e.

b . If a PICC can n ot be establish ed, th e subcla- vian vein or in tern al or extern al jugular vein s can be used for PPN.

2. TPN: Adm in istered th rough a cen tral vein ; th e use of a PICC is acceptable. O th er sites th at can be used in clude th e subclavian vein an d th e in tern al or extern al jugu lar vein s.

3. If th e bag of in traven o us solution is em pty an d th e n urse is waitin g for th e delivery of a n ew bag of solution from th e ph arm acy, a 10 % dex- trose in water solution sh ould be in fused at prescribed rate to preven t h ypo glycem ia; th e pre- scrib ed solution sh o uld be obtain ed as soon as possib le.

The delivery of hypertonic solutions into peripheral veins can cause sclerosis, phlebitis, or swelling. Monitor closely for these complications.

II. Components of Parenteral Nutrition A. Carboh ydrates

1. Th e stren gth of th e dextrose solution depen ds on th e clien t’s n utrition al n eeds, th e ro ute of134

ad m in istration (cen tral or periph eral), an d agen cy protoco ls.

2. Carb oh yd rates typically provide 60% to 70% of calorie (en ergy) n eeds.

B. Am in o acids (pro tein ) 1. Con cen tration s ran ge fro m 3.5% to 20%; lower

con cen tration s are m ost com m on ly used for periph eral vein ad m in istration an d h igh er con - cen tration s are m ost often adm in istered th rou gh a cen tral vein .

2. Abou t 15% to 20% of total en ergy n eeds sh ould com e from protein .

C. Fat emulsion (lipids) 1. Lipids provid e up to 30% of calorie (en ergy)

n eeds. 2. Lipids provide n on protein calories an d preven t

or correct fatty acid deficien cy. 3. Lipid solution s are isoton ic an d th erefore can be

ad m in istered th rou gh a periph eral or cen tral vein ; th e solution m ay be adm in istered th rou gh a separate IV lin e below th e filter of th e m ain IV ad m in istration set by a Y-con n ector or as an ad m ixture to th e PN solution (3-in -1 ad m ixture con sistin g of dextrose, am in o acids, an d lipids).

4. Most fat em u lsion s are prepared fro m soybean or safflower oil, with egg yolk to provid e em u lsifica- tio n ; th e prim ary com pon en ts are lin oleic, oleic, palm itic, lin olen ic, an d stearic acids (assess th e clien t for allergies).

5. Glucose-in toleran t clien ts or clien ts with diabe- tes m ellitus m ay ben efit from receivin g a larger percen tage of th eir PN fro m lipids, wh ich h elps to con tro l blood glucose levels an d lower in sulin requirem en ts cau sed by in fused dextrose.

6. Exam in e th e bottle for sep aration of em ulsio n in to layers or fat glob ules or for th e accum ulation of froth ; if observed, do n ot use an d return th e solution to th e ph arm acy.

7. Additives sh ould n ot be put in to th e fat em ulsion solution .

8. Follo w agen cy policy regardin g th e filter size th at sh ould be used; usually a 1.2-µm filter or larger sh ould be used because th e lipid particles are too large to pass th rough a 0.22-µm filter.

9. In fuse solution at th e flo w rate prescribed— usually slowly at 1 m L/ m in ute in itially— m on itor vital sign s every 10 m in utes, an d observe for adverse reaction s for th e first 30 m in utes of th e in fusion . If sign s of an adverse reaction occur, stop th e in fusion an d n otify th e h ealth care provider (HCP) ( Box 12-1).

10. If n o adverse reaction occurs, adju st th e flow rate to th e prescribed rate.

11. Mon itor serum lipids 4 h ours after discon tin uin g th e in fusion .

Fat emulsions (lipids) contain egg yolk phospho- lipids and should not be given to clients with egg allergies.

D. Vitam in s 1. PN solution s usually con tain a stan d ard m ultivi-

tam in preparation to m eet m ost vitam in n eeds an d preven t deficien cies.

2. In dividual vitam in preparation s can be added , as n eeded an d as prescribed.

E. Min erals an d trace elem en ts: Com m ercial m in eral and trace elem en t preparation s are available in various con cen tration s to prom ote n orm al metabolism.

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Incis ionFrom IV fe e de r

S ubcla via n ve in

Ca the te r ins ide s upe rior ve na ca va

B

S upe rior ve na ca va

Ce pha lic ve in

A

P ICC s ite s

Pe riphe ra lly ins e rte d ce ntra l ca the te r

Ba s ilic ve in

FIGURE 12-1 A, Placement of peripherally inserted central catheter through antecubital fossa. B, Placement of central venous catheter inserted into subclavian vein. IV, Intravenous; PICC, peripherally inserted central catheter.

BOX 12-1 Signs and Symptoms of an Adverse Reaction to Lipids

▪ Chest and back pain ▪ Chills ▪ Cyanosis ▪ Diaphoresis ▪ Dyspnea ▪ Fever

▪ Flushing ▪ Headache ▪ Nausea and vomiting ▪ Pressure over the eyes ▪ Thrombophlebitis ▪ Vertigo

135CHAPTER 12 Parenteral Nutrition

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F. Electro lytes: Electrolyte requirem en ts for in dividuals receivin g PN th erap y vary, depen din g on body weigh t, presen ce of m aln utrition or catabo lism , degree of electrolyte depletion , ch an ges in organ fun ction , on go in g electrolyte losses, an d th e disease process.

G. Water: Th e am oun t of water n eeded in a PN solution is determ in ed by electrolyte balan ce an d fluid requirem en ts.

H. Regular in sulin : May be added to con trol th e blood gluco se level because of th e h igh con cen tration of gluco se in th e PN solution .

I. Heparin : May be ad ded to reduce th e buildup of a fibrin ous clot at th e cath eter tip.

III. Administration and Discontinuation A. Types of ad m in istration

1. Con tin uous PN a . In fused con tin uo usly over 24 h ours b . Most com m on ly used in a h ospital settin g

2. In term itten t or cyclic PN a . In gen eral, th e n utrien t solution in fusion reg-

im en varies an d is com m on ly ad m in istered overn igh t.

b . Allows clien ts requirin g PN on a lon g-term basis to participate in activities of daily livin g durin g th e day with out th e in con ven ien ce of an IV bag an d pum p set

c. Mon itor gluco se levels closely because of th e risk of h ypoglycem ia due to lack of gluco se durin g n on -in fusion tim es.

B. Discon tin uin g PN th erapy 1. Evaluation of n utrition al status by a n utrition ist

or ph arm acist is don e befo re PN is discon tin u ed. 2. If discon tin uation is prescribed, gradually

decrease th e flo w rate for 1 to 2 h ou rs wh ile in creasin g oral in take (th is assists in preven tin g h ypo glycem ia).

3. After rem oval of th e IV cath eter, ch an ge th e dress- in g daily un til th e in sertion site h eals. No te th at cen tral lin es sh ould n ot be left in with out a rea- son due to risk of in fectio n , but in som e situa- tion s are left in place an d used for oth er n ecessary reason (ven ou s access, m edication adm in istration ).

4. En cou rage oral n utrition . 5. Record oral in take, body weigh t, an d labo ratory

results of serum electrolyte an d glucose levels.

Abrupt discontinuation of a PN solution can result in hypoglycemia. The flow rate should be decreased gradually when the PN is discontinued.

IV. Complications (Table 12-1) A. Pn eum oth orax an d air embolism are associated with

cen tral lin e placem en t; air em bolism is also associ- ated with tubin g ch an ges.

B. O th er com plication s in clude in fectio n (cath eter- related) , h ypervo lem ia, an d m etab olic alteration s such as h yperglycem ia an d h ypoglycem ia; th ese com plication s are usually caused by th e PN solution itself (see Priority Nursin g Actio n s).

V. Additional Nursing Considerations A. Ch eck th e PN solution with th e HCP’s prescription

to en sure th at th e prescribed com pon en ts are con - tain ed in th e solution ; som e h ealth care agen cies require validation of th e prescription by 2 registered n urses.

B. To preven t in fectio n an d solution in com patib ility, IV m ed ication s an d blood are n ot given th rou gh th e PN lin e.

C. Blood for testin g m ay be drawn from th e cen tral ven ous access site; a port oth er th an th e port used to in fuse th e PN is used for blood draws after th e PN h as been stopp ed for several m in utes

PRIORITY NURSING ACTIONS Central Venous Catheter Site with a Suspected Infection 1. Notify the health care provider (HCP). 2. Prepare to remove the catheter and for possible restart at

a different location. 3. Remove the tip of the catheter and send it to the labora-

tory for culture if prescribed by the HCP. 4. Prepare the client for obtaining blood cultures. 5. Prepare for antibiotic administration. 6. Document the occurrence, the actions taken, and the cli-

ent’s response.

Signs of infection at the catheter site include redness or drainage. The client will also exhibit chills, fever, and an ele- vated white blood cell count. If the nurse suspects infection, the HCP is notified because of the risk for sepsis. The cath- eter is removed and the client is prepared for a possible restart at a different location as prescribed. A central line may be removed by a nurse who has been trained in approved protocol to remove a central line. If requested, the catheter tip may be sent to the laboratory for culture to identify the bacteria present so that the effective antibiotic is prescribed. Intravenous (IV) antibiotics may be prescribed and an IV site will be needed for administration. Blood cul- tures are also performed to determine the presence of bacte- ria in the blood. Antibiotics are not started until blood cultures are obtained; otherwise the results of the cultures may not be accurate. Finally, the nurse documents the occur- rence, actions taken, and the client’s response. Additionally, per agency protocol, pictures of the infected catheter site may be taken and added to the documentation.

References Lewis et al. (2014), p. 311; Perry, Potter, Ostendorf (2014), pp. 798, 801.

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TABLE 12-1 Complications of Parenteral Nutrition Complication Possible Cause Signs or Symptoms Intervention Prevention

Air embolism ▪ Catheter system opened or IV tubing disconnected ▪ Air entry on IV

tubing changes

▪ Apprehension ▪ Chest pain ▪ Dyspnea ▪ Hypotension ▪ Loud churning sound

heard over pericardium on auscultation ▪ Rapid and weak pulse ▪ Respiratory distress

▪ Clamp all ports of the IV catheter ▪ Place the client in a left

side-lying position with the head lower than the feet ▪ Notify the HCP ▪ Administer oxygen

▪ Make sure all catheter connections are secure (use tape per agency protocol) ▪ Clamp the catheter when not in use and

when changing caps (follow agency protocol for flushing and clamping the catheter and cap changes) ▪ Instruct the client in the Valsalva maneuver

for tubing and cap changes ▪ For tubing and cap changes, place the

client in the Trendelenburg position (if not contraindicated) with the head turned in the opposite direction of the insertion site; client should hold breath and bear down

Hyperglycemia ▪ High concentration of dextrose in solution ▪ Client receiving

solution too quickly ▪ Not enough insulin ▪ Infection

▪ Restlessness ▪ Confusion ▪ Weakness ▪ Diaphoresis ▪ Elevated blood glucose

level > 200 mg/ dL (10 .9 mmol/ L) ▪ Excessive thirst ▪ Fatigue ▪ Kussmaul respirations ▪ Coma (when severe)

▪ Notify the HCP ▪ The infusion rate may

need to be slowed ▪ Monitor blood

glucose levels ▪ Administer regular

insulin as prescribed

▪ Assess the client for a history of glucose intolerance ▪ Assess the client’s medication history

(corticosteroids increase blood glucose) ▪ Begin infusion at a slow rate as prescribed

(usually 40-60 mL/ h) ▪ Monitor blood glucose levels per agency

protocol ▪ Administer regular insulin as prescribed ▪ Use strict aseptic technique to prevent

infection

Hypervolemia ▪ Excessive fluid administration or administration of fluid too rapidly ▪ Renal dysfunction ▪ Heart failure ▪ Hepatic failure

▪ Bounding pulse ▪ Crackles on lung

auscultation ▪ Headache ▪ Increased blood pressure ▪ Jugular vein distention ▪ Weight gain greater than

desired

▪ Slow or stop IV infusion ▪ Notify the HCP ▪ Restrict fluids ▪ Administer diuretics ▪ Use dialysis (in

extreme cases)

▪ Assess client’s history for risk for hypervolemia ▪ Administer via an electronic infusion device

and ensure proper function of the device ▪ Never increase the rate of infusion of the

device to “catch up” if the infusion gets behind ▪ Monitor intake and output ▪ Monitor weight daily (ideal weight gain is

1-2 lb per week)

Hypoglycemia ▪ PN abruptly discontinued ▪ Too much insulin

being administered

▪ Anxiety ▪ Diaphoresis ▪ Hunger ▪ Low blood glucose level

< 70 mg/ dL (4 mmol/ L) ▪ Shakiness ▪ Weakness

▪ Notify the HCP ▪ Administer IV

dextrose ▪ Monitor blood

glucose level

▪ Gradually decrease PN solution when discontinued ▪ Infuse 10% dextrose at same rate as the

PN to prevent hypoglycemia for 1-2 hours after the PN solution is discontinued ▪ Monitor glucose levels and check the level

1 hour after discontinuing the PN

Infection ▪ Poor aseptic technique ▪ Catheter

contamination ▪ Contamination of

solution

▪ Chills ▪ Fever ▪ Elevated white blood cell

count ▪ Redness or drainage at

insertion site

▪ Notify the HCP ▪ Remove catheter ▪ Send catheter tip to

the laboratory for culture ▪ Prepare to obtain

blood cultures ▪ Prepare for antibiotic

administration

▪ Use strict aseptic techniques (PN solution has a high concentration of glucose and is a medium for bacterial growth) ▪ Monitor temperature (fever could indicate

infection) ▪ Assess IV site for signs of infection

(redness, swelling, drainage) ▪ Change site dressing, solution, and tubing

as specified by agency policy ▪ Do not disconnect tubing unnecessarily

Pneumothorax ▪ Inexact catheter placement resulting in puncture of the pleural space

▪ Chest or shoulder pain ▪ Sudden shortness of

breath ▪ Cyanosis ▪ Tachycardia ▪ Absence of breath sounds

on affected side

▪ Notify the HCP ▪ Prepare to obtain a

chest x-ray ▪ Small pneumothorax

may resolve ▪ Larger pneumothorax

may require chest tube

▪ Monitor for signs of pneumothorax ▪ Obtain a chest x-ray after insertion of

the catheter to ensure proper catheter placement ▪ PN is not initiated until correct catheter

placement is verified and the absence of pneumothorax is confirmed

HCP, Health care provider; IV, intravenous; PN, parenteral nutrition. Adapted from Ignatavicius D, Workman M: Medical-surgical nursing: patient-centered collaborative care, ed 7, St. Louis, 20 13, Saunders.

137CHAPTER 12 Parenteral Nutrition

(per agen cy proced ure) because th e PN solution can alter th e results of th e sam ple. Th e clien t with a cen - tral ven ous access site receivin g PN sh ould still h ave a ven ipu n cture site.

D. Mon itor partial th rom boplastin tim e an d proth rom - bin tim e for clien ts receivin g an ticoagulan ts.

E. Mon itor electrolyte an d album in levels an d liver an d ren al fun ction studies, as well as an y oth er prescribed laborato ry studies. Bloo d studies for blood ch em is- tries are n orm ally don e every oth er day or 3 tim es per week (per agen cy procedures) wh en th e clien t is receivin g PN; th e results are th e basis for th e HCP con tin uin g or ch an gin g th e PN solution or rate.

F. Mon itor blood gluco se levels as prescribed (usually every 4 h ours) because of th e risk for h yperglycem ia from th e PN solution com po n en ts.

G. In severely deh ydrated clien ts, th e album in level m ay drop in itially after in itiatin g PN, because th e treat- m en t restores h ydration .

H. With severely m aln ou rish ed clien ts, m on itor for “refeedin g syn dro m e” (a rapid drop in potassium, magnesium, an d ph osph ate serum levels) .

I. Th e electrolyte sh ift th at occurs in “refeedin g syn - drom e” can cau se cardiovascular, respiratory, an d n eurological problem s; m on itor for sh allow respira- tion s, con fusion , weakn ess, bleed in g ten den cies, an d seizures. If n oted, th e HCP is n otified im m ediately.

J. Abn orm al liver fun ction values m ay in dicate in toler- an ce to or an excess of fat em u lsion or problem s with m etab olism with glucose an d protein .

K. Abn orm al ren al fun ctio n tests m ay in dicate an excess of am in o acids.

L. PN solution s sh ould be stored un der refrigeration an d ad m in istered with in 24 h ours fro m th e tim e th ey are prepared (rem ove from refrigerator 0.5 to 1 h our befo re use).

M. PN solution s th at are cloudy or darken ed sh ould n ot be used an d sh ould be return ed to th e ph arm acy.

N. Addition s of substan ces such as n utrien ts to PN solu- tion s sh ould be m ade in th e ph arm acy an d n ot on th e n ursin g un it.

O. Con sultation with th e n utrition ist sh o uld be don e on a regular basis (as prescribed or per agen cy protoco l).

VI. Home Care Instructions (Box 12-2)

P R A C T I C E Q U E S T I O N S 87. A clien t is bein g wean ed from paren teral n utrition

(PN) an d is expected to begin takin g solid food today. Th e on goin g solution rate h as been 100 m L/ h ou r. Th e n urse an ticipates th at wh ich

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BOX 12-2 Home Care Instructions Teach the client and caregiver how to obtain, administer, and

maintain parenteral nutrition fluids. Teach the client and caregiver how to change a sterile

dressing. Obtain a daily weight at the same time of day in the same

clothes. Stress that if a weight gain of more than 3 lb/ week is noted,

this may indicate excessive fluid intake and should be reported.

Monitor the blood glucose level and report abnormalities immediately. Teach the client how to monitor for and man- age hypoglycemia and hyperglycemia.

Teach the client and caregiver about the signs and symptoms of side effects or adverse effects such as infection, throm- bosis, air embolism, and catheter displacement.

Teach the client and caregiver the actions to take if a compli- cation arises and about the importance of reporting com- plications to the health care provider.

For signs and symptoms of thrombosis, the client should report edema of the arm or at the catheter insertion site, neck pain, and jugular vein distention.

Leaking of fluid from the insertion site or pain or discomfort as the fluids are infused may indicate displacement of the catheter; this must be reported immediately.

Encourage the client and caregiver to contact the health care provider if they have questions about administration or any other questions.

Inform the client and caregiver about the importance of follow-up care.

Teach the client to keep electronic infusion devices fully charged in case of electrical power failure.CRITICAL THINKING What Should You Do?

Answer: Difficulty with flushing the catheter indicates that the catheter is partially or fully blocked. Possible causes of a blockage include a clamped or kinked catheter, the tip of the catheter against the vein wall, thrombosis, or a precipi- tate buildup in the lumen. The nurse should not try to force the flushing because this could dislodge a clot or disrupt the integrity of the catheter. If the catheter becomes fully

blocked, it may not be usable. The nurse should assess for and alleviate clamping or kinking. The nurse should also instruct the client to change position, raise the arm, and cough. If the blockage is due to a positional issue, this inter- vention will correct it. The nurse should attempt to flush again to see if the problem has been corrected. If it has not, this difficulty should be reported to the necessary per- sonnel (i.e., health care provider or intravenous nurse) so that full functionality can be regained. Fluoroscopy may be performed to determine the cause of the blockage and anti- coagulant or thrombolytic medications may be instilled into the catheter as prescribed to alleviate blockage.

References: Lewis et al. (20 14), p. 312; Perry, Potter, Ostendorf (2014), p. 50 4.

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prescription regardin g th e PN solution will accom - pan y th e diet prescription ? 1. Discon tin ue th e PN. 2. Decrease PN rate to 50 m L/ h ou r. 3. Start 0.9% n orm al salin e at 25 m L/ h our. 4. Con tin ue curren t in fusio n rate prescription s

for PN.

88. Th e n u rse is p rep arin g to ch an ge th e p aren teral n u tritio n ( PN) so lu tio n b ag an d tu b in g. Th e clien t’s cen tral ven o u s lin e is lo cated in th e righ t su b clavian vein . Th e n u rse asks th e clien t to take wh ich essen tial actio n d u rin g th e tu b in g ch an ge? 1. Breath e n orm ally. 2. Turn th e h ead to th e righ t. 3. Exh ale slowly an d even ly. 4. Take a deep breath , h old it, an d bear down .

89. A clien t with paren teral n utrition (PN) in fusin g h as discon n ected th e tubin g from th e cen tral lin e cath - eter. Th e n urse assesses th e clien t an d suspects an air em b olism . Th e n urse sh ould im m ed iately place th e clien t in wh ich position ? 1. O n th e left side, with th e h ead lo wer th an th e feet 2. O n th e left side, with th e h ead h igh er th an

th e feet 3. O n th e righ t side, with th e h ead lower th an th e feet 4. O n th e righ t side, with th e h ead h igh er th an the feet

90. Wh ich n ursin g action is essen tial prior to in itiatin g a n ew prescription for 500 m L of fat em ulsio n (lipids) to in fuse at 50 m L/ h ou r? 1. En su re th at th e clien t does n ot h ave diabetes. 2. Determ in e wh eth er th e clien t h as an allergy

to eggs. 3. Add regular in sulin to th e fat em ulsio n , usin g

aseptic tech n iqu e. 4. Con tact th e h ealth care provider (HCP) to h ave a

cen tral lin e in serted for fat em u lsion in fusion .

91. Th e n urse m on itors th e clien t receivin g paren teral n utrition (PN) for com plication s of th e th erap y an d sh ould assess th e clien t for wh ich m an ifesta- tio n s of h yperglycem ia? 1. Fever, weak pulse, an d th irst 2. Nausea, vom itin g, an d oliguria 3. Sweatin g, ch ills, an d abdom in al pain 4. Weakn ess, th irst, an d in creased urin e outp ut

92. Th e n urse is ch an gin g th e cen tral lin e dressin g of a clien t receivin g paren teral n utrition (PN) an d n otes th at th e cath eter in sertion site appears redden ed. Th e n urse sh ould n ext assess wh ich item ? 1. Clien t’s tem p erature 2. Expiration date on th e bag 3. Tim e of last dressin g ch an ge 4. Tigh tn ess of tubin g con n ection s

93. Th e n urse is preparin g to h an g fat em u lsion (lipids) an d n otes th at fat globules are visible at th e top of th e solution . Th e n urse sh ould take wh ich action ? 1. Roll th e bottle of solution gen tly. 2. O btain a differen t bottle of solution . 3. Sh ake th e bottle of solution vigorou sly. 4. Run th e bottle of solution un der warm water.

94. A clien t receivin g paren teral n utrition (PN) suddenly develops a fever. Th e n urse n otifies th e h ealth care provider (HCP), an d the HCP in itially prescribes that th e solution an d tubin g be chan ged. Wh at sh ould th e n urse do with th e discon tin ued m aterials? 1. Discard th em in th e un it trash . 2. Return th em to th e h ospital ph arm acy. 3. Save th em for return to th e m an ufacturer. 4. Prepare to sen d th em to th e labo ratory for culture.

95. A clien t h as been disch arged to h om e on paren teral n utrition (PN). With each visit, th e h om e care n urse sh ould assess wh ich param eter m o st closely in m on - itorin g th is th erapy? 1. Pulse an d weigh t 2. Tem peratu re an d weigh t 3. Pulse an d blood pressure 4. Tem perature an d blood pressure

96. Th e n urse, carin g for a group of adult clien ts on an acute care m edical-surgical n ursing un it, determ ines th at wh ich clien ts would be th e m o st likely can didates for paren teral n utrition (PN)? Select all th at ap p ly.

1. A clien t with exten sive burn s 2. A clien t with can cer wh o is sep tic 3. A clien t wh o h as h ad an open ch olecystectom y 4. A clien t with severe exacerbation of Cro h n ’s

disease 5. A clien t with persisten t n ausea an d vo m itin g

from ch em oth erapy

97. Th e n urse is preparin g to h an g th e first bag of paren - teral n utrition (PN) solution via th e cen tral lin e of an assign ed clien t. Th e n urse sh ould obtain wh ich m o st essen tial piece of equ ipm en t before h an gin g th e solution ? 1. Urin e test strips 2. Bloo d glucose m eter 3. Electron ic in fusion pum p 4. Non in vasive blood pressure m on itor

98. Th e n urse is m akin g in itial roun ds at th e begin n in g of th e sh ift an d n otes th at th e paren teral n utrition (PN) bag of an assign ed clien t is em p ty. Wh ich solu- tion sh ould th e n urse h an g un til an oth er PN solu- tion is m ixed an d delivered to th e n ursin g un it? 1. 5% dextrose in water 2. 10% dextrose in water 3. 5% dextrose in Rin ger’s lactate 4. 5% dextrose in 0.9% sodium ch loride

139CHAPTER 12 Parenteral Nutrition

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99. Th e n urse is m on itorin g th e status of a client’s fat em ulsion (lipid) in fusion an d n otes th at th e in fusion is 1 h our beh in d. Wh ich action should th e n urse take? 1. Adjust th e in fusion rate to catch up over th e

n ext h our. 2. In crease th e in fusio n rate to catch up over th e

n ext 2 h ours. 3. En su re th at th e fat em ulsion in fusio n rate is in fus-

in g at th e prescribed rate. 4. Adjust th e in fusion rate to run wid e open un til

th e solution is back on tim e.

100. A clien t receivin g paren teral n utrition (PN) in th e h om e settin g h as a weigh t gain of 5 lb in 1 week. Th e n urse sh ould n ext assess th e clien t for th e pres- en ce of wh ich con d ition ? 1. Th irst 2. Polyuria 3. Decreased blood pressure 4. Crackles on auscultation of th e lun gs

101. Th e n urse is carin g for a restless clien t wh o is begin - n in g n utrition al th erapy with paren teral n utrition (PN) . Th e n urse sh ould plan to en sure th at wh ich action is taken to preven t th e clien t from sustain in g in ju ry? 1. Calculate daily in take an d outp ut. 2. Mon itor th e tem p erature on ce daily. 3. Secure all con n ection s in th e PN system . 4. Mon itor blood gluco se levels every 12 h ours.

102. A clien t receivin g paren teral n utrition (PN) com - plain s of a h eadach e. Th e n urse n otes th at th e cli- en t h as an in creased blood pressure, boun din g pulse, jugu lar vein disten tion , an d crackles bilater- ally. Th e n urse determ in es th at th e clien t is experien cin g wh ich com plication of PN th erapy? 1. Sepsis 2. Air em bolism 3. Hypervolem ia 4. Hyperglycem ia

A N S W E R S 87. 2 Ra tion a le: Wh en a clien t b egin s eatin g a regular d iet after a p erio d o f receivin g PN, th e PN is decreased gradu ally. PN th at is d iscon tin u ed ab ru ptly can cau se h yp oglycem ia. Clien ts often h ave an o rexia after bein g with ou t foo d fo r som e tim e, an d th e d igestive tract also is n o t u sed to p ro d ucin g th e digestive en zym es th at will be n eed ed. Gradu ally decreasin g th e in fu sio n rate allo ws th e clien t to rem ain adeq uately n o urish ed du rin g th e tran sition to a n o rm al diet an d p reven ts th e o ccurren ce o f h yp o glycem ia. Even b efore clien ts are started o n a so lid d iet, th ey are given clear liq uids fo llo wed by fu ll liq u ids to furth er ease th e tran sitio n . A solu tio n of n o rm al salin e d oes n ot p ro - vid e th e glu cose n eed ed du rin g th e tran sitio n o f d isco n tin uin g th e PN an d co uld cau se th e clien t to exp erien ce h yp oglycem ia. Test-Ta kin g Str a tegy: Focu s on th e su b ject, wean in g th e clien t fro m th e PN. Recallin g th e effects o f PN an d th e com p lication s th at o ccu r will direct yo u to th e co rrect op tio n . If you can recall th at a clien t can exp erien ce hyperglycem ia wh en started o n PN, it m ay h elp yo u to rem em b er th at hypoglycem ia can occu r if th e PN is discontinued ab rup tly. Review: Paren teral n u tritio n Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Plan n in g Con ten t Ar ea : Critical Care—Paren teral Nutrition Pr ior it y Con cept s: Glucose Regulatio n ; Nu tritio n Refer en ces: Lewis et al. (2014), p . 902; Perry, Po tter, O sten d orf (2014), pp . 799, 802.

88. 4 Ra tion a le: The clien t should be asked to perform the Valsalva m an euver d urin g tu bin g ch an ges. Th is h elp s avoid air em bo lism d urin g tubin g chan ges. Th e n urse asks th e clien t to take a deep b reath, h old it, an d b ear d own . If th e in traven ous lin e is o n th e righ t, th e clien t turn s h is o r h er h ead to th e left. Th is positio n in creases in trath o racic p ressure. Breath in g n orm ally and

exh alin g slo wly an d even ly are in appropriate an d could enh an ce th e poten tial for an air em b olism d urin g th e tubin g ch ange. Test-Ta kin g St r a tegy: No te th e strategic wo rd , essential. Recal- lin g th at air em bo lism is a co m p licatio n th at can o ccu r du rin g tub in g ch an ges an d th in kin g abo ut th e m easu res th at will p re- ven t th is com p licatio n will d irect yo u to th e co rrect o p tion . Review: Th e procedure for p aren teral n u tritio n bag an d tub- in g ch an ge an d air em b o lism Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ces: Ign ataviciu s, Wo rkm an ( 2013) , p. 225; Perry, Potter, O sten do rf (2014), p . 798.

89. 1 Ra tion a le: Air em bo lism o ccu rs wh en air en ters th e cath eter system , such as wh en th e system is o pen ed fo r in traven ou s (IV) tub in g ch an ges o r wh en th e IV tub in g d isco n n ects. Air em bo lism is a critical situatio n ; if it is su spected , th e clien t sh o u ld b e p laced in a left sid e-lyin g p osition . Th e h ead sh o u ld b e lower th an th e feet. Th is po sitio n is used to m in im ize th e effect of th e air travelin g as a bo lu s to th e lun gs b y trap pin g it in th e righ t side o f th e h eart. Th e p o sition s in th e rem ain in g o ptio n s are in ap prop riate if an air em b o lism is su sp ected . Test-Ta kin g Str a tegy: No te th e strategic wo rd , immediately. Focus o n th e su b ject, th e o ccurren ce of an air em b olism . Recall th at th e goal in th is em ergen cy situ ation is to trap air in th e righ t side of th e h eart. Th in k about th e p osition th at will ach ieve th is goal; th is will d irect you to th e correct op tio n . Review: Actio n s to take if an air em b o lism is susp ected Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nu rsin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Gas Exch an ge; Perfusion Refer en ce: Perry, Po tter, O sten d orf (2014), p. 798.

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90. 2 Ra t ion a le: Th e clien t b egin n in g in fu sion s o f fat em ulsion s m u st b e first assessed fo r kn o wn allergies to eggs to preven t an aph ylaxis. Egg yo lk is a com p on en t o f th e so lu tion an d pro- vides em ulsificatio n . Th e rem ain in g o ptio n s are u n n ecessary an d are n ot related sp ecifically to th e ad m in istration o f fat em u lsio n . Test -Ta kin g St r a t egy: Focu s o n th e strategic wo rd , essential, wh en exam in in g each op tion an d recall kn owled ge o f fat em u l- sion s. Recall th e co m p on en ts of fat em u lsio n to direct yo u to th e co rrect op tion . Review: Fat em u lsio n an d p aren teral n u tritio n Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ces: Lewis et al. (2014), p. 901; Gah art, Nazaren o (2015) , p . 527.

91. 4 Ra t ion a le: Th e h igh glu cose co n cen tration in PN p laces th e cli- en t at risk for h yp erglycem ia. Sign s o f h yp erglycem ia in clu de excessive th irst, fatigu e, restlessn ess, co n fu sio n , weakn ess, Kussm aul resp iratio n s, diuresis, an d co m a wh en h yp erglyce- m ia is severe. If th e clien t h as th ese sym pto m s, th e b lo od glu - co se level sh o uld b e ch ecked im m ed iately. Th e rem ain in g op tion s do n ot id en tify sign s sp ecific to h yperglycem ia. Test -Ta kin g Str a tegy: Fo cu s on th e su b ject, sign s of h yp ergly- cem ia. Fo r an op tio n to b e correct, all o f th e p arts of th at o ptio n m u st b e co rrect. Begin to an swer th is qu estio n b y elim in atin g op tion s th at in clu de fever an d ch ills b ecau se th ey are in dicative of in fectio n . Ch oo se th e correct op tion o ver th e o ption th at in clud es oligu ria b ecau se th e clien t with h yp erglycem ia h as in creased urin e o u tp u t rath er th an d ecreased u rin e o utp ut. Review: Sign s of h yp erglycem ia Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Glu co se Regu lation ; Nu trition Refer en ce: Perry, Potter, O sten do rf (2014), p . 798.

92. 1 Ra t ion a le: Red n ess at th e cath eter in sertio n site is a p ossible in d icatio n o f in fectio n . Th e n urse wo uld n ext assess for o th er sign s of in fectio n . O f th e o ption s given , th e tem perature is th e n ext item to assess. Th e tigh tn ess o f tu bin g con n ection s sh ou ld be assessed each tim e th e PN is ch ecked ; lo ose con n ec- tion s wo uld resu lt in leakage, n o t skin redn ess. Th e exp iration date o n th e bag is a viab le op tio n , b ut th is also sh o uld b e ch ecked at th e tim e th e solutio n is h u n g an d with each sh ift ch an ge. Th e tim e o f th e last d ressin g ch an ge sh o uld be ch ecked with each sh ift ch an ge. Test -Ta kin g Str a tegy: No te th e strategic wo rd , next. Th is q ues- tion requ ires th at you p rio ritize based on th e in form ation pro- vided in th e qu estio n . Also n ote th e relatio n sh ip between site appears reddened in th e q u estio n an d th e word temperature in th e correct op tion . Fo cusin g o n th e su b ject of in fection will direct yo u to th e correct o ptio n . Review: Sign s of in fectio n an d p aren teral n u tritio n

Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; In fectio n Refer en ce: Perry, Po tter, O sten do rf (2014), p p. 798, 800.

93. 2 Ra t ion a le: Fat em ulsion ( lip id s) is a wh ite, op aq ue solutio n ad m in istered in traven ou sly d urin g p aren teral n u tritio n th er- ap y to p reven t fatty acid deficien cy. Th e n urse sh o uld exam in e th e b ottle of fat em u lsio n fo r sep aratio n o f em ulsion in to layers o f fat glo bu les o r for th e accu m ulation of fro th . Th e n u rse sh ou ld n ot h an g a fat em u lsio n if an y o f th ese are o bserved an d sh o uld retu rn th e so lu tion to th e ph arm acy. Th erefore, th e rem ain in g op tion s are in ap prop riate actio n s. Test -Ta kin g Str a tegy: Rem em b er th at op tio n s th at are co m p a- rab le o r alike are n ot likely to be correct. With th is in m in d, elim in ate ro llin g th e b o ttle an d sh akin g th e bo ttle first. Select b etween th e rem ain in g op tio n s by recallin g th e sign ifican ce o f fat glo b ules in th e so lu tion . Also, th in k ab o ut th e po ten tial ad verse effect of fat glo bu les en terin g th e clien t’s bloo dstream . Review: Ad m in istratio n o f fat em u lsio n Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ce: Gah art, Nazaren o (2015), p . 525.

94. 4 Ra t ion a le: Wh en th e clien t wh o is receivin g PN develop s a fever, a cath eter-related in fectio n sh ou ld be susp ected. Th e so lu tio n an d tu bin g sh ou ld b e ch an ged, an d th e d iscon tin u ed m aterials sh o uld be cu ltured fo r in fectiou s organ ism s p er HCP p rescription . Th e o th er o ptio n s are in co rrect. Becau se cu lture fo r in fectio us o rgan ism s is n ecessary, th e d iscon tin u ed m ate- rials are n o t d iscarded o r retu rn ed to th e ph arm acy o r m an u factu rer. Test -Ta kin g St r a t egy: Id en tifyin g th e su b ject o f th e qu estio n , in fection , an d co rrelatin g th e fever with in fectio n asso ciated with th e in traven ous lin e sh ould direct you to th e correct o p tion . Rem em b er th at th e d iscon tin u ed m aterials n eed to b e cu ltured . Review: Paren teral n u tritio n an d in fectio n Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; In fectio n Refer en ces: Lewis et al. (2014), p . 899; Perry, Po tter, O sten d o rf (2014), p . 804

95. 2 Ra t ion a le: Th e clien t receivin g PN at h o m e sh ou ld h ave h er o r h is tem p eratu re m o n ito red as a m ean s o f detectin g in fec- tion , wh ich is a po ten tial co m p lication o f th is th erap y. An in fection also co u ld result in sepsis because th e cath eter is in a bloo d vessel. Th e clien t’s weigh t is m o n ito red as a m ea- su re o f th e effectiven ess of th is n u tritio n al th erapy an d to d etect h ypervolem ia. Th e p ulse an d blo od p ressure are

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im p ortan t p aram eters to assess, bu t th ey d o n ot relate sp ecif- ically to th e effects of PN. Test-Ta kin g Str a tegy: Note th e strategic wo rd , most, wh ich tells yo u th at m ore th an 1 or all of th e op tio n s m ay be p artially o r totally correct. Rem em ber also th at wh en th ere are m u ltip le p arts to an op tio n , all p arts m u st b e correct fo r th at o p tion to be correct. Recallin g th at in fection an d h yp ervo lem ia are co m p li- cation s of PN an d th at weigh t is m on itored as a m easu re o f th e effectiven ess o f th is n u tritio n al th erap y will direct yo u to th e correct o ptio n . Review: Paren teral n u tritio n Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Clin ical Ju dgm en t; In fection Refer en ces: Lewis et al. (2014), p . 902; Perry, Po tter, O sten d orf (2014), pp . 800, 804.

96. 1, 2, 4, 5 Ra tion a le: PN is in d icated in clien ts wh ose gastro in testin al tracts are n ot fu n ction al or m u st be rested, can n ot take in a diet en terally fo r exten d ed p eriod s, o r h ave in creased m etab olic n eed. Exam p les o f th ese con d itio n s in clu de th o se clien ts with b urn s, exacerbation o f Cro h n ’s d isease, an d persisten t n ausea an d vo m itin g d ue to ch em oth erap y. O th er clien ts wou ld be th o se wh o h ave h ad exten sive su rgery, h ave m u ltip le fractu res, are sep tic, o r h ave ad van ced can cer or acqu ired im m u n o defi- cien cy syn drom e. Th e clien t with th e o p en ch o lecystecto m y is n o t a can didate because th is clien t wo uld resu m e a regular d iet with in a few days followin g su rgery. Test-Ta kin g St r a t egy: Note th e strategic wo rd s, most likely, wh ich tell yo u th at th e correct option s are th e clien ts wh o requ ire th is typ e of n utritio n al su pp ort. Use n u rsin g kn owled ge o f th ese variou s co n d ition s in th e o ption s an d baselin e kn owl- ed ge o f th e p urp oses of PN to m ake you r selectio n . Review: Paren teral n u tritio n Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Nutritio n Refer en ce: Perry, Po tter, O sten d orf (2014), p. 797.

97. 3 Ra tion a le: Th e n urse ob tain s an electro n ic in fu sion p u m p b efore h an gin g a PN so lu tion . Becau se o f th e h igh glu co se con - ten t, u se o f an in fu sio n p um p is n ecessary to en su re th at th e so lution d oes n ot in fuse to o rap idly o r fall b eh in d. Because th e clien t’s bloo d glucose level is m on itored every 4 to 6 h o urs d urin g ad m in istration of PN, a blo o d glu co se m eter also will b e n eeded , b u t th is is n o t th e m o st essen tial item n eed ed befo re h an gin g th e so lu tion because it is n o t directly related to ad m in - isterin g th e PN. Urin e test strip s (to m easu re glu co se) rarely are u sed because of th e ad ven t o f b lo od glu cose m on itorin g. Alth ou gh th e blo o d p ressure will be m o n ito red, a n o n in vasive b loo d p ressure m on itor is n ot th e m ost essen tial p iece of eq uipm en t n eeded fo r th is p ro ced ure. Test-Ta kin g St r a tegy: No te th e strategic wo rd s, most essential. Th ey tell yo u th at th e co rrect op tio n iden tifies th e item n eed ed to start th e in fu sio n . Visu alizin g th e p ro cedu re fo r in itiatin g PN

an d fo cu sin g o n th e strategic wo rd s will d irect you to th e cor- rect option . Review: Paren teral n u tritio n Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Plan n in g Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Perry, Po tter, O sten d orf (2014), pp . 801, 803.

98. 2 Ra tion a le: Th e clien t is at risk for h ypo glycem ia; th erefo re, th e so lutio n co n tain in g th e h igh est am o u n t of gluco se sh o uld be h u n g u n til th e n ew PN solutio n beco m es availab le. Because PN solu tio n s co n tain h igh glu co se con cen tratio n s, th e 10% d extro se in water solutio n is th e b est o f th e ch o ices presen ted . Th e solutio n selected sh ou ld be on e th at m in im izes th e risk of h yp oglycem ia. Th e rem ain in g op tio n s will n o t b e as effective in m in im izin g th e risk of h yp oglycem ia. Test-Ta kin g St r a t egy: Focu s on th e su b ject, th at th e clien t is at risk for h ypoglycem ia. With th is in m in d, yo u wou ld th en select th e solutio n th at m in im izes th is risk to th e clien t. Also , rem em ber th at option s th at are co m p arab le o r alike are n o t likely to b e correct. Each of th e in co rrect op tio n s represen ts a so lutio n th at co n tain s 5% d extro se. Review: Th e n ursin g actio n s to p reven t h yp o glycem ia in th e clien t receivin g p aren teral n u tritio n Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Glucose Regu latio n ; Safety Refer en ce: Perry, Po tter, O sten d orf (2014), p. 802.

99. 3 Ra tion a le: Th e n urse sh o uld n o t in crease th e rate o f a fat em u l- sio n to m ake up th e differen ce if th e in fu sion tim in g falls b eh in d. Doin g so cou ld p lace th e clien t at risk fo r fat overlo ad. In ad dition , in creasin g th e rate sud den ly can cause flu id o ver- lo ad. Th e sam e prin ciple (n o t in creasin g th e rate) ap plies to p aren teral n utritio n o r an y in traven o us in fu sio n . Th erefo re, th e rem ain in g o ptio n s are in co rrect. Test-Ta kin g St r a t egy: Focu s o n th e data in th e q uestion . Rem em ber also th at o ptio n s th at are co m p arab le o r alike are n o t likely to b e co rrect. Th is gu id es yo u to elim in ate th e o ptio n s referrin g to catching up. Ch o ose th e co rrect op tio n o ver run n in g th e in fusion wide op en , recallin g th at th e n urse n ever in creases th e in fu sio n rate or adjusts an in fu sio n rate if an in fu- sio n is b eh in d. Review: Safety prin ciples related to in traven o u s th erap y Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Paren teral Nutritio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ces: Gah art, Nazaren o ( 2015) , pp . 526–527; Lewis et al. ( 2014) , p. 901.

100. 4 Ra tion a le: O ptim al weigh t gain wh en th e clien t is receivin g PN is 1 to 2 lb/ week. Th e clien t wh o h as a weigh t gain o f 5 lb / week

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wh ile receivin g PN is likely to h ave fluid reten tion . Th is can result in h ypervolem ia. Sign s of h ypervolem ia in clude in creased b loo d p ressu re, crackles o n lun g auscultation , a bo un din g p ulse, ju gular vein disten tio n , h ead ach e, p eriph eral edem a, an d weigh t gain m o re th an d esired. Th irst an d p o lyuria are associated with h yp erglycem ia. A d ecreased b lo od pressu re is likely to b e n oted in deficien t fluid vo lu m e. Test -Ta kin g St r a tegy: Fo cus on th e su b ject of th e qu estio n , a weigh t gain of 5 lb in 1 week, an d n o te th e strategic wo rd , next. Th is sh ou ld d irect you r th in kin g to th e po ten tial fo r h yp er- vo lem ia. With th is in m in d , select th e op tio n th at id en tifies th e sign o f h yp ervolem ia. Review: Sign s an d sym pto m s o f h yp ervo lem ia Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Assessm en t Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p . 292.

101. 3 Ra tion a le: Th e n urse sh o uld p lan to secure all con n ection s in th e tub in g (con n ection s are used per agency p ro to co l). This h elps to p reven t th e restless clien t fro m p ullin g th e con n ection s apart acciden tally. Th e n urse should also m on itor in take an d o utp ut, b ut th is does n ot relate specifically to a risk for in jury as p resen ted in th e question . Also, m on ito r- in g th e tem perature an d b lood glu cose levels d oes n ot relate to a risk fo r in jury as p resen ted in the q uestion . In add i- tion , th e clien t’s tem p eratu re and b lood glu co se levels are m o n itored m ore frequen tly th an th e tim e fram es iden tified in th e o ption s to detect sign s of in fectio n and h yp erglycem ia, resp ectively.

Test -Ta kin g Str a tegy: Fo cu s on th e su b ject, safety, an d n o te th e wo rd s restless, ensure, prevent, an d injury. Th is will direct yo u to th e co rrect o ption . Review: Precautio n s related to p aren teral n u tritio n Level of Cogn it ive Ability: App lyin g Clien t Need s: Safe an d Effective Care En viron m en t In t egr a ted Pr ocess: Nu rsin g Pro cess—Plan n in g Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ce: Lewis et al. (2014), pp . 899, 901.

102. 3 Ra t ion a le: Hyp ervo lem ia is a critical situatio n an d occurs fro m excessive flu id adm in istration o r adm in istratio n o f flu id too rap - id ly. Clien ts with card iac, ren al, o r h ep atic dysfu nction are also at in creased risk. Th e clien t’s sign s an d sym pto m s presented in th e question are con sisten t with h yp ervolem ia. Th e in creased in travascu lar volum e in creases the blood p ressure, wh ereas th e pulse rate in creases as th e h eart tries to pum p th e extra fluid volum e. Th e in creased volum e also cau ses n eck vein d isten tio n an d sh iftin g o f flu id in to th e alveo li, resultin g in lun g crackles. Th e signs an d sym ptom s presen ted in the q uestion d o n ot in d i- cate sepsis, air em bolism , or h yperglycem ia. Test -Ta kin g Str a tegy: Focus o n th e su b ject, a co m plicatio n o f PN, an d o n th e d ata in th e q u estio n . Recallin g th e sign s of h ypervolem ia will direct you to th e correct op tio n . Review: Sign s of h yp ervo lem ia Level of Cogn it ive Ability: Syn th esizin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—An alysis Con t en t Ar ea : Critical Care—Paren teral Nu tritio n Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p. 292.

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C H A P T E R 13 Intravenous Therapy

PRIORITY CONCEPTS Fluids and Electrolytes; Safety

CRITICAL THINKING What Should You Do? A client with a peripherally inserted central catheter (PICC) in the right upper extremity suddenly exhibits chest pain, dys- pnea, hypotension, and tachycardia. The nurse suspects an embolism related to the PICC line. What should the nurse do? Answer located on p. 153.

I. Intravenous Therapy A. Purpo se an d uses

1. Used to sustain clien ts wh o are un able to take substan ces orally

2. Replaces water, electrolytes, an d nutrients m ore rapidly th an oral adm in istration

3. Provides im m ediate access to th e vascu lar system for th e rapid delivery of specific solution s with - out th e tim e required for gastro in testin al tract absorption

4. Provides a vascu lar route for th e ad m in istration of m edication or blood com po n en ts

B. Types of solution s (Table 13-1) 1. Iso ton ic solution s

a . Have th e sam e osm o lality as body fluids b . In crease extracellular fluid volum e c. Do n ot en ter th e cells because n o osm o tic

force exists to sh ift th e flu ids 2. Hypo ton ic solution s

a . Are m ore dilute solution s an d h ave a lower osm o lality th an body fluid s

b . Cause th e m ovem en t of water in to cells by osm o sis

c. Sh o uld be adm in istered slowly to preven t cellu lar edem a

3. Hyperton ic solution s a . Are m ore con cen trated solution s an d h ave a

h igh er osm olality th an body fluids b . Cause m ovem en t of water from cells in to th e

extracellular fluid by osm osis

4. Colloids a . Also called plasm a expan d ers b . Pull flu id from th e in terstitial com partm en t

in to th e vascu lar com partm en t c. Used to in crease th e vascu lar volum e rapidly,

such as in h em orrh age or severe h ypovolem ia

Administration ofan intravenous (IV) solution or med- ication provides immediate access to the vascular system. This is a benefit of administering solutions or medications via this route but can also present a risk. Therefore, it is critical to ensure that the health care provider’s (HCP’s) prescriptions are checked carefully and that the correct solution or medication is administered as prescribed. Always follow the 6 rights for medication administration.

II. Intravenous Devices A. IV can n ulas

1. Butterfly sets a . Th e set is a win g-tip n eedle with a m etal can -

n ula, plastic or rubber win gs, an d a plastic cath eter or h ub.

b . Th e n eedle is 0.5 to 1.5 in ch es in len gth , with n eedle gauge sizes from 16 to 26.

c. Infiltration is m ore com m on with th ese devices. d . Th e butterfly in fusion set is used com m on ly

in ch ildren an d older clien ts, wh ose vein s are likely to be sm all or fragile.

2. Plastic can n ulas a . Plastic can n ulas m ay be an over-th e-n eedle

device or an in -n eedle cath eter an d are used prim arily for sh ort-term th erapy.

b . The over-th e-n eedle device is preferred for rapid in fusion an d is m ore com fortable for th e clien t.

c. Th e in -n eedle cath eter can cause catheter embolism if th e tip of th e can n ula breaks.

B. IV gauges 1. Th e gauge refers to th e diam eter of th e lu m en of

th e n eedle or can n ula. 2. Th e sm aller th e gauge n um ber, th e larger th e

diam eter of th e lum en ; th e larger th e gauge n um - ber, th e sm aller th e diam eter of th e lum en .144

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3. Th e size of th e gauge used depen ds on th e solu- tio n to be adm in istered an d th e diam eter of th e available vein .

4. Large-diam eter lum en s (sm aller gauge n um bers) allow a h igh er fluid rate th an sm aller diam eter lu m en s an d allow th e adm in istration of h igh er con cen tration s of solution s.

5. For rapid em ergen cy flu id adm in istration , blood products, or an esth etics, preoperative an d post- operative clien ts, large-diam eter lum en n eedles or can n ulas are used, such as an 18- or 19-gauge lu m en or can n ula.

6. For periph eral fat emulsion (lipids) in fusio n s, a 20- or 21-gauge lum en or can n ula is used.

7. For stan dard IV fluid an d clear liquid IV m edica- tion s, a 22- or 24-gauge lum en or can n ula is used.

8. If th e clien t h as very sm all vein s, a 24- to 25- gauge lum en or can n ula is used.

C. IV con tain ers 1. Con tain er m ay be glass or plastic. 2. Squeeze th e plastic bag to en sure intactn ess and

assess th e glass bottle for an y cracks before h an gin g. 3. Recon stitute an y m ed ication s per agen cy proto-

col an d ph arm acy in struction .

Do not write on a plastic IV bag with a marking pen because the ink may be absorbed through the plastic into the solution. Use a label and a ballpoint pen for writ- ing on the label, placing the label onto the bag.

D. IV tubin g ( Fig. 13-1) 1. IV tubin g co n tain s a spike en d for th e bag or bot-

tle, drip ch am b er, roller clam p , Y site, an d ad apter en d for attach m en t to th e can n ula or n eedle th at is in serted in to th e clien t’s vein .

2. Sh o rter, secon dary tubin g is used for piggyback solution s, con n ectin g th em to th e in jection sites n earest to th e drip ch am b er (Fig. 13-2).

3. Special tubin g is used for m ed ication th at absorbs in to plastic (ch eck specific m edication adm in istration guid elin es wh en ad m in isterin g IV m edication s).

4. Ven ted an d n on ven ted tubin g are available. a. A ven t allows air to en ter th e IV con tain er as

th e fluid leaves. b . A ven ted adapter can be used to add a ven t to

a n on ven ted IV tubin g system . c. Use n on ven ted tubin g for flexible con tain ers.

TABLE 13-1 Types of Intravenous Solutions Solution and Type Uses

0.9% saline (NS): Isotonic Extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic acid-base imbalances. Used before or after the infusion of blood products.

Ringer’s lactate solution: Isotonic Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydration from loss of bile or diarrhea.

5% dextrose in water (D5W): Isotonic at the time of administration; within a short time after administration, dextrose is metabolized and the tonicity decreases in proportion to the osmolarity or tonicity of the nondextrose components (electrolytes) within the water (may become hypotonic).

Replaces deficits of total body water. Not used alone to expand extracellular fluid volume because dilution of electrolytes can occur.

5% dextrose in 0.225% saline (5% D/ 1/ 4 NS): Isotonic at the time of administration; within a short time after administration, dextrose is metabolized and the tonicity decreases in proportion to the osmolarity or tonicity of the nondextrose components (electrolytes) within the water (may become hypertonic).

Used as initial fluid for hydration because it provides more water than sodium. Commonly used as maintenance fluid.

5% dextrose in 0.9% saline (5% D/ NS): Hypertonic Extracellular fluid deficits in clients with low serum levels of sodium or chloride and metabolic alkalosis.

5% dextrose in 0.45% saline (5% D/ 1/ 2 NS): Hypertonic Used as initial fluid for hydration because it provided more water than sodium. Commonly used as maintenance fluid.

5% dextrose in Ringer’s lactate solution: Hypertonic Extracellular fluid deficits, such as fluid loss from burns, bleeding, and dehydration from loss of bile or diarrhea.

S pike e nd for IV ba g or bottle

Drip cha mbe r

Rolle r cla mp

Ada pte r e nd of tubing to ne e dle

Y s ite

FIGURE 13-1 Intravenous (IV) tubing.

145CHAPTER 13 Intravenous Therapy

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d . Use ven ted tubin g for glass or rigid plastic con tain ers to allow air to en ter an d displace th e flu id as it leaves; fluid will n ot flow from a rigid IV con tain er un less it is ven ted.

Extension tubing can be added to an IVtubing set to provide extra length to the tubing. Add extension tubing to the IV tubing set for children, clients who are restless, or clients who have special mobility needs.

E. Drip ch am b ers (Fig. 13-3) 1. Macrodrip ch am b er

a . Th e ch am b er is used if th e solution is th ick or is to be in fused rapidly.

b . Th e drop factor varies from 10 to 20 drops (gtt) / m L, depen din g on th e m an ufactu rer.

c. Read th e tubin g package to determ in e h ow m an y drops per m illiliter are delivered (drop facto r).

2. Micro drip ch am b er a . Norm ally, th e ch am b er h as a sh ort vertical

m etal piece (stylet) wh ere th e drop form s. b . Th e ch am b er delivers about 60 gtt/ m L. c. Read th e tubin g package to determ in e th e

drop factor (gtt/ m L). d . Micro drip ch am b ers are used if flu id will be

in fused at a slow rate (less th an 50 m L/ h our) or if th e solution con tain s poten t m edication th at n eeds to be titrated, such as in a critical care settin g or in ped iatric clien ts.

F. Filters 1. Filters provide protectio n by preven tin g particles

from en terin g th e clien t’s vein s. 2. Th ey are used in IV lin es to trap sm all particles

such as un dissolved substan ces, or m edication s th at h ave precipitated in solution .

3. Ch eck the agency policy regardin g th e use of filters. 4. A 0.22-µm filter is used for m ost solution s; a 1.2-

µm filter is used for solution s con tain in g lipids or album in ; an d a special filter is used for blood com po n en ts.

5. Ch an ge filters every 24 to 72 h ou rs (depen d in g on agen cy policy) to preven t bacterial growth .

G. Needleless in fusion devices 1. Needleless in fusio n devices in clude recessed n ee-

dles, plastic can n ulas, an d 1-way valves; th ese system s decrease th e exposu re to con tam in ated n eedles.

2. Do n ot adm in ister parenteral nutrition or blood produ cts th rough a 1-way valve.

H. In term itten t in fusion devices 1. In term itten t in fusion devices are used wh en

in travascular accessibility is desired for in term it- ten t adm in istration of m edication s by IV push or IV piggyback.

2. Paten cy is m ain tain ed by periodic flush in g with n orm al salin e solution ( sodium chloride an d nor- mal saline are in terch an geab le n am es).

3. Depen din g on agen cy policy, wh en adm in ister- in g m ed ication , flush with 1 to 2 m L of n orm al salin e to con firm placem en t of th e IV can n ula; adm in ister th e prescribed m ed ication an d th en flush th e can n ula again with 1 to 2 m L of n orm al salin e to m ain tain paten cy.

I. Electro n ic IV in fusion devices 1. IV in fusion pum ps con tro l th e am oun t of flu id

in fusin g an d sh o uld be used with cen tral ven ous lin es, arterial lin es, solution s con tain in g m edica- tion , an d paren teral n utrition in fusion s. Most agen cies use IV pum ps for th e in fusio n of an y IV solution .

2. A syrin ge pum p is used wh en a sm all volum e of m edication is adm in istered; th e syrin ge th at con - tain s th e m ed ication an d solution fits in to a pum p an d is set to deliver th e m ed ication at a con trolled rate.

3. Patien t-con tro lled an algesia (PCA)

IV ba g with me dica tion

FIGURE 13-2 Secondary bag with medication. IV, Intravenous.

Ma crodrip 10-20 gtt/mL

Microdrip 60 gtt/mL

FIGURE 13-3 Macrodrip and microdrip sizes.

146 UNIT III Nursing Sciences

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a. A device th at allows th e clien t to self- ad m in ister IV m ed ication , such as an an alge- sic; th e clien t can adm in ister doses at set in ter- vals an d th e pum p can be set to lock out doses th at are n ot with in th e preset tim e fram e to preven t overdose.

b . Th e PCA regim en m ay in clude a basal rate of in fusion alon g with th e dem an d dosin g, basal rate in fusion alon e, or dem an d dosin g alon e.

c. A bolus dose can be given prio r to an y of th e settin gs an d sh ould be set based on th e HCP’s prescription .

d . PCAs are always kept locked an d setup requires th e witn ess of an oth er registered n urse (RN).

Check electronic IV infusion devices frequently. Although these devices are electronic, this does not ensure that they are infusing solutions and medications accurately.

III. Latex Allergy A. Assess th e clien t for an allergy to latex. B. IV supplies, in cludin g IV cath eters, IV tubin g, IV

ports (particularly IV rubber in jection ports), ru bber stopp ers on m ultidose vials, an d adh esive tape, m ay con tain latex.

C. Latex-safe IV supplies n eed to be used for clien ts with a latex allergy; m ost agen cies carry th ese n ow, but th is still n eeds to be ch ecked.

D. See Ch apter 66 for ad dition al in form ation regardin g latex allergy.

IV. Selection of a Peripheral IV Site A. Vein s in th e h an d, forearm , an d an tecubital fossa are

suitable sites (Fig. 13-4). B. Vein s in th e lower extrem ities (legs an d feet) are n ot

suitable for an adult clien t because of th e risk of th rom - bus form ation an d th e possible poolin g of m edication in areas of decreased ven ous return (Box 13-1).

C. Vein s in th e scalp an d feet m ay be suitable sites for in fan ts.

D. Assess th e vein s of both arm s clo sely befo re selectin g a site.

E. Start th e IV in fusion distally to provide th e option of proceedin g up th e extrem ity if th e vein is ruptured or infiltration occurs; if in filtration occurs from th e an te- cubital vein , th e lo wer vein s in th e sam e arm usually sh ould n ot be used for furth er pun cture sites.

F. Determ in e th e clien t’s dom in an t side, an d select th e opposite side for a venipuncture site.

G. Ben d in g th e elbow on th e arm with an IV m ay easily obstru ct th e flo w of solution , cau sin g in filtration th at could lead to th rom boph leb itis.

H. Avoid ch eckin g th e blood pressure on th e arm receiv- in g th e IV in fusion if possible.

I. Do n ot place restrain ts over th e ven ipun ctu re site. J. Use an arm board as n eeded wh en th e ven ipu n cture

site is located in an area of flexion .

In an adult, the most frequently used sites for insert- ing an IV cannula or needle are the veins of the forearm because the bones of the forearm act as a natural sup- port and splint.

V. Initiation and Administration of IV Solutions A. Ch eck th e IVsolution again st the HCP’s prescription for

the type, am oun t, percentage of solution , an d rate of flow; follow th e 6 righ ts for m edication adm in istration.

B. Assess th e h ealth status an d m ed ical disorders of th e clien t an d iden tify clien t con d ition s th at con train d i- cate use of a particular IV solution or IV equipm en t, such as an allergy to clean sin g solution , ad h esive m aterials, or latex. Ch eck com patibility of IV solu- tion s as appropriate.

C. Ch eck clien t’s iden tification an d explain th e proce- dure to th e clien t; assess clien t’s previous exp erien ce with IV th erapy an d preferen ce for in sertio n site.

D. Wash h an ds th orough ly before in sertin g an IV lin e an d befo re workin g with an IV lin e; wear gloves.

E. Use sterile tech n iqu e wh en in sertin g an IV lin e an d wh en ch an gin g th e dressin g over th e IV site.

F. Ch an ge th e ven ipun cture site every 72 to 96 h ours in accordan ce with Cen ters for Disease Con trol an d Pre- ven tion (CDC) recom m en dation s an d agen cy policy.

G. Ch an ge th e IV dressin g wh en th e dressin g is wet or con tam in ated , or as specified by th e agen cy policy.

H. Ch an ge th e IV tubin g every 96 h ours in acco rdan ce with CDC recom m en dation s an d agen cy policy or with ch an ge of ven ipu n cture site.

Ce pha lic ve in

Ce pha lic ve in

Ra dia l ve in

A

Ba s ilic ve in

Ba s ilic ve in

Me dia n ve in of fore a rm

Me dia n cubita l ve in

Ce pha lic ve in B Ba s ilic ve in

Dors a l ve nous a rch

S upe rficia l dors a l ve ins

FIGURE 13-4 Common intravenous sites. A, Inner arm. B, Dorsal surface of hand.

BOX 13-1 Peripheral Intravenous Sites to Avoid ▪ Edematous extremity ▪ An arm that is weak, traumatized, or paralyzed ▪ The arm on the same side as a mastectomy ▪ An arm that has an arteriovenous fistula or shunt for

dialysis ▪ A skin area that is infected

147CHAPTER 13 Intravenous Therapy

I. Do n ot let an IV bag or bottle of solution h an g for m ore th an 24 h ours to dim in ish th e poten tial for bacterial con tam in ation an d possibly sepsis.

J. Do n ot allow th e IV tubin g to touch th e floor to pre- ven t poten tial bacterial co n tam in ation .

K. See Prio rity Nursin g Action s for in struction s on in sertin g an IV.

L. See Prio rity Nursin g Action s for in struction s on rem ovin g an IV.

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PRIORITY NURSING ACTIONS Inserting a Peripheral Intravenous Line 1. Check the health care provider’s (HCP’s) prescription,

determine the type and size of infusion device, and prepare intravenous (IV) tubing or extension set and solution; prime IV tubing or extension set to remove air from the system; explain procedure to the client.

2. Select the vein for insertion based on vein quality, client size, and indication of IV therapy; apply tourniquet and pal- pate the vein for resilience (see Fig. 13-4).

3. Clean the skin with an antimicrobial solution, using an inner to outer circular motion, or as specified bythe Centers for Disease Control and Prevention (CDC) guidelines and agency policy.

4. Stabilize the vein below the insertion site and puncture the skin and vein, observing for blood in the flashback chamber; when observed, lower the catheter so that it is flush with the skin and advance the catheter into the vein (if unsuccessful, a new sterile device is used for the next attempt at insertion).

5. Remove the tourniquet. Apply pressure above the insertion site with the middle finger of the nondominant hand and retract the stylet from the catheter; connect the end of the IV tubing or extension set to the catheter tubing, secure it, and begin IV flow. Ask the client about comfort at the site and assess site for adequate flow.

6. Tape and secure insertion site with a transparent dressing as specified by agency procedure; label the tubing, dressing, and solution bags clearly, indicating the date and time.

7. Document the specifics about the procedure such as num- ber of attempts at insertion; the insertion site, type and size of device, solution and flow rate, and time; and the client’s response. In addition, follow agency procedure for docu- mentation of procedure.

The nurse checks the HCP’s prescription for the IV line and then determines the type and size of infusion device. The type and size are important to ensure adequate flow of the prescribed solution. For example, if a blood product is prescribed, the nurse would need to insert an appropriate catheter gauge size for blood delivery. The nurse also considers the client’s size, age, mobility, and other factors in selecting the type and size of the infusion device. The nurse prepares the appropriate IV tubing or extension set and primes the IV tubing or extension set to remove air from the system. The appropriate vein is selected, the tourniquet is applied, and the vein is checked and palpated for resilience. Strict surgical asepsis is employed and the skin is cleaned with an antimicrobial solution (as specified by agency policy), using an inner to outer circular motion. The vein is stabilized to prevent its movement and the skin is punctured. Blood in the flashback chamber indicates that the device is in the vein and when noted the catheter is carefully advanced to avoid puncture of the back wall of the vein. The tourniquet is removed, the stylet is removed from the catheter device, the IVtubing or extension set is connected, and the IVflow is started. Following assessment of the client and site, the nurse tapes and secures the site and labels the tubing, dressing, and solution bag appropriately and according to agency policy. The nurse checks the site and ensures that the solution is flowing. Finally, the nurse documents the specifics about the procedure.

Reference Perry, Potter, Ostendorf (2014), pp. 697, 701-703.

PRIORITY NURSING ACTIONS Removing a Peripheral Intravenous Line 1. Check the health care provider’s (HCP’s) prescription and

explain the procedure to the client; ask the client to hold the extremity still during cannula or needle removal.

2. Turn off the intravenous (IV) tubing clamp and remove the dres- sing and tape covering the site, while stabilizing the catheter.

3. Apply light pressure with sterile gauze or other material as specified by agency procedure over the site and withdraw the catheter using a slow, steady movement, keeping the hub parallel to the skin.

4. Apply pressure for 2 to 3 minutes, using dry sterile gauze (apply pressure for a longer period of time if the client has a bleeding disorder or is taking anticoagulant medication).

5. Inspect the site for redness, drainage, or swelling; check the catheter for intactness.

6. Apply dressing as needed per agency policy. 7. Document the procedure and the client’s response.

The nurse checks for an HCP’s prescription to remove the IV line and then explains the procedure to the client. The nurse asks the client to hold the extremitystill during removal. The IVtubing clamp is placed in the off position and the dressing and tape are removed. The nurse is careful to stabilize the catheter so that it is not pulled, resulting in vein trauma. Light pressure is applied over the site to stabilize the catheter and it is removed using a slow, steady movement, keeping the hub parallel to the skin. Pressure is applied until hemostasis occurs. The site is inspected for redness, drainage, or swelling and the catheter is checked for intactness to ensure that no part of it has broken off. A dressing is applied as needed per agency policy. Finally, the nurse documents the procedure and the client’s response.

Reference Perry, Potter, Ostendorf (2014), pp. 723-724.

148 UNIT III Nursing Sciences

VI. Precautions for IV Lines A. O n in sertio n , an IV lin e can cause in itial pain an d

discom fort for th e clien t. B. An IV pun cture provides a route of en try for m icro-

organ ism s in to th e body. C. Med ication s adm in istered by th e IV route en ter th e

blood im m ediately, an d an y ad verse reaction s or allergic respo n ses can occur im m ediately.

D. Fluid (circulatory) overload or electrolyte im bal- an ces can occur from excessive or too rapid in fusion of IV flu ids.

E. In com patibilities between certain solution s an d m ed ication s can occur.

A client with heart failure or renal failure usually is not given a solution containing saline because this type of fluid promotes the retention of water and would there- fore exacerbate heart failure or renal failure by increasing the fluid overload.

VII. Complications (Table 13-2) A. Air embolism

1. Description : A bolus of air en ters th e vein th rou gh an in adeq uately prim ed IV lin e, from a lo ose con n ection , durin g tubin g ch an ge, or durin g rem oval of th e IV.

2. Preven tion an d in terven tion s a. Prim e tubin g with fluid befo re use, an d m on -

ito r for an y air bubb les in th e tubin g. b . Secure all con n ection s. c. Replace th e IV fluid befo re th e bag or bottle

is em p ty. d . Mon itor for sign s of air em b olism ; if sus-

pected, clam p th e tubin g, turn th e clien t on th e left side with th e h ead of th e bed lo wered (Tren delen b urg position ) to trap th e air in th e righ t atrium , an d n otify th e HCP.

B. Catheter embolism 1. Description : An obstruction th at results from

breakage of th e cath eter tip durin g IV lin e in ser- tio n or rem oval

2. Preven tion an d in terven tion s a. Rem o ve th e cath eter carefully. b . In spect th e cath eter wh en rem oved. c. If th e cath eter tip h as broken off, place a tour-

n iqu et as proxim ally as possible to th e IV site on th e affected lim b , n otify th e HCP im m edi- ately, prepare to obtain a radiograph , an d pre- pare th e clien t for surgery to rem ove th e cath eter piece(s) , if n ecessary.

C. Circulatory overload 1. Description : Also kn own as fluid overload; results

fro m th e adm in istration of fluids too rapidly, esp ecially in a clien t at risk for fluid overload

2. Preven tion an d in terven tion s

a. Iden tify clien ts at risk for circulatory overload.

b . Calculate an d m on itor th e drip (flow) rate frequen tly.

c. Use an electron ic IV in fusion device an d fre- quen tly ch eck th e drip rate or settin g (at least every h ou r for an ad ult).

d . Add a tim e tape (label) to th e IV bag or bottle n ext to th e vo lum e m arkin gs. Mark on th e tape th e expected h ou rly decrease in volu m e based on th e m L/ h ou r calculation (Fig. 13-5).

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TABLE 13-2 Signs of Complications of Intravenous Therapy

Complication Signs

Air embolism Tachycardia Chest pain and dyspnea Hypotension Cyanosis Decreased level of consciousness

Catheter embolism Decrease in blood pressure Pain along the vein Weak, rapid pulse Cyanosis of the nail beds Loss of consciousness

Circulatory overload Increased blood pressure Distended jugular veins Rapid breathing Dyspnea Moist cough and crackles

Electrolyte overload Signs depend on the specific electrolyte overload imbalance

Hematoma Ecchymosis, immediate swelling and leakage of blood at the site, and hard and painful lumps at the site

Infection Local—redness, swelling, and drainage at the site Systemic—chills, fever, malaise, headache, nausea, vomiting, backache, tachycardia

Infiltration Edema, pain, numbness, and coolness at the site; may or may not have a blood return

Phlebitis Heat, redness, tenderness at the site Not swollen or hard Intravenous infusion sluggish

Thrombophlebitis Hard and cordlike vein Heat, redness, tenderness at site Intravenous infusion sluggish

Tissue damage Skin color changes, sloughing of the skin, discomfort at the site

149CHAPTER 13 Intravenous Therapy

e. Mon itor for sign s of circulatory overload. If circulatory overload occurs, decrease th e flow rate to a m in im u m , at a keep-vein -open rate; elevate th e h ead of th e bed ; keep th e clien t warm ; assess lun g soun ds; assess for edem a; an d n otify th e HCP.

Clients with respiratory, cardiac, renal, or liver dis- ease; older clients; and very young persons are at risk for circulatory overload and cannot tolerate an excessive fluid volume.

D. Electro lyte overload 1. Description : An electrolyte im balan ce is cau sed

by too rapid or excessive in fusio n or by use of an in approp riate IV solution .

2. Preven tion an d in terven tion s a . Assess labo ratory value reports. b . Verify th e correct solution . c. Calculate an d m on itor th e flo w rate. d . Use an electron ic IV in fusion device an d fre-

quen tly ch eck th e drip rate or settin g (at least every h ou r for an ad ult).

e. Add a tim e tape (label) to th e IV bag or bottle (see Fig. 13-5).

f. Place a red m ed ication sticker on th e bag or bottle if a m edication h as been added to th e IV solution (see Fig. 13-5).

g. Mon itor for sign s of an electrolyte im balan ce, an d n otify th e HCP if th ey occur.

Lactated Ringer’s solution contains potassium and should not be administered to clients with acute kidney injury or chronic kidney disease.

E. Hem atom a 1. Description : Th e collection of blood in th e tis-

sues after an un successful ven ipun ctu re or after th e ven ipu n ctu re site is discon tin ued an d blood con tin ues to ooze in to th e tissue

2. Preven tion an d in terven tion s a . Wh en startin g an IV, avoid piercin g th e poste-

rior wall of th e vein . b . Do not apply a tourniquet to the extrem ity im -

m ediately after an unsuccessful venipuncture. c. Wh en discon tin uin g an IV, apply pressure to

th e site for 2 to 3 m in u tes an d elevate th e extrem ity; apply pressure lon ger for clien ts with a bleedin g disorder or wh o are takin g an ticoagulan ts.

d . If a h em atom a develops, elevate th e extrem ity an d ap ply pressure an d ice as prescribed.

e. Docum en t acco rdin gly, in cludin g takin g pictures of th e IV site if in dicated by agen cy policy.

F. In fection 1. Description

a . In fection occurs from th e en try of m icroor- gan ism s in to th e body th rough th e ven ipun c- ture site.

b . Venipuncture in terrupts th e in tegrity of th e skin , th e first lin e of defen se again st in fectio n .

c. Th e lon ger th e th erapy con tin ues, th e greater th e risk for in fectio n .

d . In fection can occur locally at th e IV in sertio n site or system ically fro m th e en try of m icroor- gan ism s in to th e body.

2. At-risk clien ts a . Im m un ocom p rom ised clien ts with diseases

such as can cer, h um an im m un od eficien cy virus or acquired im m un odeficien cy syn - drom e, th ose receivin g biologic m odifier respo n se m edication s for treatm en t of auto- im m un e co n dition s, or status post organ tran splan t are at risk for in fectio n .

b . Clien ts receivin g treatm en ts such as ch em o- th erap y wh o h ave an altered or lo wered wh ite blood cell coun t are at risk for in fectio n .

c. O lder clien ts, because agin g alters th e effec- tiven ess of th e im m un e system , are at risk for in fectio n .

d . Clien ts with diab etes m ellitus are at risk for in fectio n .

3. Preven tion an d in terven tion s a . Assess th e clien t for predisposition to or risk

for in fectio n . b . Main tain strict asepsis wh en carin g for th e

IV site. c. Mon itor for sign s of local or system ic

in fectio n .

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FIGURE 13-5 Intravenous fluid bag with medication label and time- tape. (From Potter et al., 2013.)

150 UNIT III Nursing Sciences

d . Mon itor wh ite blood cell coun ts. e. Ch eck fluid con tain ers for cracks, leaks, clo ud-

in ess, or oth er eviden ce of con tam in ation . f. Ch an ge IV tubin g every 96 h ours in acco r-

dan ce with CDC recom m en dation s or acco rdin g to agen cy policy; ch an ge IV site dressin g wh en soiled or con tam in ated an d acco rdin g to agen cy policy.

g. Label th e IV site, bag or bottle, an d tubin g with th e date an d tim e to en sure th at th ese are ch an ged on tim e acco rdin g to agen cy policy.

h . En su re th at th e IV solution is n ot h an gin g for m ore th an 24 h ours.

i. If in fectio n occurs, th e HCP is n otified; dis- con tin ue th e IV, an d place th e ven ipu n cture device in a sterile con tain er for possible culture.

j. Prepare to obtain blood cultures as pre- scrib ed if in fection occurs an d docum en t acco rdin gly.

k . Restart an IV in th e opposite arm to differen - tiate sepsis (system ic in fection ) fro m local in fectio n at th e IV site.

l. Do cum en t accordin gly, in cludin g takin g pictures of th e IV site if in dicated by agen cy policy.

A client with diabetes mellitus usually does not re- ceive dextrose (glucose) solutions because the solution can increase the blood glucose level.

G. Infiltration 1. Description

a. In filtration is seepage of th e IV fluid out of th e vein an d in to th e surroun din g in terstitial spaces.

b . In filtration occurs wh en an access device h as beco m e dislodged or perforates th e wall of th e vein or wh en ven o us backpressure occurs because of a clo t or ven o spasm .

2. Preven tion an d in terven tion s a. Avo id ven ipun ctu re over an area of flexion . b . An ch or th e can n ula an d a loop of tubin g

securely with tap e. c. Use an arm board or splin t as n eeded if th e cli-

en t is restless or active. d . Mon itor th e IV rate for a decrease or a cessa-

tio n of flo w. e. Evaluate th e IV site for in filtration by occlu d-

in g th e vein proxim al to th e IV site. If th e IV flu id con tin ues to flo w, th e can n ula is proba- bly outside th e vein (in filtrated); if th e IV flow stops after occlu sion of th e vein , th e IV device is still in th e vein .

f. Lower th e IV flu id con tain er below th e IV site, an d m on itor for th e appearan ce of blood in

th e IV tubin g; if blood ap pears, th e IV device is m ost likely in th e vein .

g. If infiltration h as occurred, rem ove th e IV device im m ediately; elevate th e extrem ity an d apply com presses (warm or cool, depen d- in g on th e IV solution that was in fusin g an d the HCP’s prescription ) over th e affected area.

h . Do n ot ru b an in filtrated area, wh ich can cau se h em atom a.

i. Do cum en t accord in gly, in cludin g takin g pic- tures of th e IV site if in dicated by agen cy policy.

H. Phlebitis an d th rom boph leb itis 1. Description

a. Ph lebitis is an in flam m ation of the vein that can occur from m ech an ical or ch em ical (m ed- ication ) traum a or from a local in fection .

b . Ph lebitis can cause th e developm en t of a clot (th rom boph lebitis).

2. Preven tion an d in terven tion s a. Use an IV can n ula sm aller th an th e vein , an d

avoid usin g very sm all vein s wh en adm in is- terin g irritatin g solution s.

b . Avoid usin g th e lower extrem ities (legs an d feet) as an access area for th e IV.

c. Avoid ven ipu n ctu re over an area of flexion . d . An ch or th e can n ula an d a loop of tubin g

securely with tape. e. Use an arm board or splin t as n eeded if th e cli-

en t is restless or active. f. Ch an ge th e ven ipun ctu re site every 72 to

96 h ou rs in accord an ce with CDC recom - m en dation s an d agen cy policy.

g. If ph lebitis occurs, rem ove th e IV device im m ediately an d restart it in th e opposite extrem ity; n otify th e HCP if ph lebitis is sus- pected, an d apply warm , m oist com presses, as prescribed.

h . If th rom bop h lebitis occurs, do n ot irrigate th e IV cath eter; rem ove th e IV, n otify th e HCP, an d restart th e IV in th e opposite extrem ity.

i. Do cum en t accord in gly, in cludin g takin g pic- tures if in dicated by agen cy policy.

I. Tissue dam age 1. Description

a. Tissues m ost co m m on ly dam aged in clude th e skin , vein s, an d subcu tan eous tissue.

b . Tissue dam age can be un com fo rtable an d can cau se perm an en t n egative effects.

c. Extravasation is a form of tissue dam age cau sed by th e seepage of vesican t or irritan t solution s in to th e tissues; th is occurren ce requires im m ediate HCP n otification so th at treatm en t can be prescribed to preven t tissue n ecrosis.

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2. Preven tion an d in terven tion s a . Use a careful an d gen tle approach wh en

applyin g a tourn iquet. b . Avoid tappin g th e skin over th e vein wh en

startin g an IV. c. Mon itor for ecch ym osis wh en pen etratin g th e

skin with th e can n ula. d . Assess for allergies to tape or dressin g adhesives. e. Mon itor for skin color ch an ges, slough in g of

th e skin , or discom fort at th e IV site. f. No tify th e HCP if tissue dam age is susp ected. g. Do cum en t accord in gly, in cludin g takin g pic-

tures if in dicated by agen cy policy.

Always document the occurrence of a complication, assessment findings, actions taken, and the client’s response according to agency policy.

VIII. Central Venous Catheters A. Description

1. Cen tral ven o us cath eters (Fig. 13-6) are used to deliver h yperosm o lar solution s, m easu re cen tral ven o us pressure, in fuse paren teral n utrition , or in fuse m ultiple IV solution s or m ed ication s.

2. Cath eter position is determ in ed by radiograph y after in sertion .

3. Th e cath eter m ay h ave a sin gle, doub le, or triple lu m en .

4. Th e cath eter m ay be in serted periph erally an d th read ed th rou gh th e basilic or ceph alic vein in to th e superio r ven a cava, in serted cen trally th rough th e in tern al jugular or subclavian vein s, or surgi- cally tun n eled th rough subcu tan eous tissue.

5. With m ultilum en cath eters, m ore th an 1 m edica- tion can be ad m in istered at th e sam e tim e with - out in com patibility problem s, an d on ly 1 in sertio n site is presen t.

For central line insertion, tubing change, and line removal, place the client in the Trendelenburg position if not contraindicated or in the supine position, and instruct the client to perform the Valsalva maneuver to increase pressure in the central veins when the IV system is open.

B. Tun n eled cen tral ven ous cath eters 1. A m ore perm an en t typ e of cath eter, such as th e

Hickm an , Broviac, or Grosh on g cath eter, is used for lon g-term IV th erapy.

2. The cath eter m ay be sin gle lum en or m ultilum en. 3. Th e cath eter is in serted in th e operatin g room ,

an d th e cath eter is th read ed in to th e lower part of th e ven a cava at th e en tran ce of th e righ t atrium (en tran ce site), an d tun n eled un d er th e

S ubcla via n ca the te r s ite A B

Pe riphe ra lly ins e rte d ce ntra l ca the te r (P ICC) C

Fe mora l ca the te r s ite

D Hickma n ca the te r s ite

E F S ubcla via n ca the te r with

impla nta ble va s cula r a cce s s port Impla nta ble

va s cula r a cce s s port

S e lf-s e a ling s e ptum

S kin line

S uture Fluid flow

Ca the te r

FIGURE 13-6 Central venous access sites. A, Subclavian catheter. B, Peripherally inserted central catheter (PICC). C, Femoral catheter. D, Hickman catheter. E, Subclavian catheter with implantable vascular access port. F, Implantable vascular access port.

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skin to th e exit site wh ere th e cath eter com es out of th e ch est; th e cath eter at th e exit site is secured by m ean s of a "cuff" just un der th e skin at th e exit site.

4. Th e cath eter is fitted with an in term itten t in fu- sion device to allow access as n eeded an d to keep th e system closed an d in tact.

5. Paten cy is m ain tain ed by flush in g with a diluted h eparin solution or n orm al salin e solution , dep en din g on th e type of cath eter, per agen cy policy.

C. Vascular access ports (im p lan table port) 1. Surgically im planted un der th e skin , ports such as a

Port-a-Cath , Mediport, or In fusaport are used for lon g-term adm in istration of repeated IV therapy.

2. For access, th e port requires palpation an d in jec- tion th rough th e skin in to th e self-sealin g port with a n oncorin g n eedle, such as a Huber poin t n eedle.

3. Paten cy is m ain tain ed by periodic flush in g with a diluted h eparin solution as prescribed an d as per agen cy policy.

D. PICC lin e 1. Th e cath eter is used for lo n g-term IV th erap y, fre-

quen tly in th e h om e. 2. Th e basilic vein usually is used, but th e m edian

cubital an d ceph alic vein s in th e an tecubital area also can be used.

3. Th e cath eter is th read ed so th at th e cath eter tip m ay term in ate in th e subclavian vein or superior ven a cava.

4. A sm all am oun t of bleed in g m ay occur at th e tim e of in sertio n an d m ay con tin ue for 24 h ours, but bleedin g th ereafter is n ot expected.

5. Phlebitis is a com m on com plication .

IX. Epidural Catheter (Fig. 13-7) A. Cath eter is placed in th e epidu ral space for th e

adm in istration of an algesics; th is m eth od of ad m in - istration reduces th e am oun t of m edication n eeded to co n trol pain ; th erefore, th e clien t experien ces fewer side effects.

B. Assess clien t’s vital sign s, level of con sciousn ess, an d m oto r an d sen sory fun ctio n of lo wer extrem ities.

C. Mon itor in sertio n site for sign s of in fectio n an d be sure th at th e cath eter is secured to th e clien t’s skin an d th at all con n ection s are tap ed to preven t discon n ection .

D. Ch eck HCP’s prescription regardin g solution an d m edication adm in istration .

E. For con tin uo us in fusion , m on itor th e electron ic in fusion device for proper rate of flo w.

F. For bolus dose adm in istration , follow th e procedure for ad m in isterin g bolus doses th rou gh th e cath eter an d follow agen cy proced ure.

G. Aspiration is don e before in jectin g m edication ; if m ore th an 1 m L of clear fluid or blood return s, the m edication is n ot in jected an d the HCP or an esth esi- ologist is n otified im m ediately (cath eter m ay h ave m igrated in to the subarach n oid space or a blood vessel).

Contraindications to an epidural catheter and administration of epidural analgesia include skeletal and spinal abnormalities, bleeding disorders, use of anti- coagulants, history of multiple abscesses, and sepsis.

CRITICAL THINKING What Should You Do? Answer: When a client has any type of central venous cath- eter, there is a risk for breaking of the catheter, dislodgement of a thrombus, or entry of air into the circulation, all of which can lead to an embolism. Signs and symptoms that this com- plication is occurring include sudden chest pain, dyspnea, tachypnea, hypoxia, cyanosis, hypotension, and tachycardia. If this occurs, the nurse should clamp the catheter, place the client on the left side with the head lower than the feet (to trap the embolism in the right atrium of the heart), adminis- ter oxygen, and notify the health care provider.

Reference: Ignatavicius, Workman (20 16), p. 20 7.

P R A C T I C E Q U E S T I O N S 103. A clien t h ad a 1000-m L bag of 5% dextrose in

0.9% sodium ch loride h un g at 1500. Th e n urse m akin g roun ds at 1545 fin ds th at th e clien t is com plain in g of a poun din g h eadach e an d is dys- pn eic, experien cin g ch ills, an d ap preh en sive, with an in creased pulse rate. Th e in traven ous (IV) bag h as 400 m L rem ain in g. Th e n urse sh ould take wh ich action first? 1. Slo w th e IV in fusion . 2. Sit th e clien t up in bed. 3. Rem ove th e IV cath eter. 4. Call th e h ealth care provider (HCP).

104. Th e n urse h as a prescription to h an g a 1000-m L in traven ous (IV) bag of 5% dextrose in water with 20 m Eq of potassium ch loride. Th e n urse also n eeds to h an g an IV in fusion of piperacillin /

S ke le ta l ve rte bra

Epidura l ca the te r

FIGURE 13-7 Tunneled epidural catheter.

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tazobactam . Th e clien t h as on e IV site. Th e n urse sh o uld plan to take wh ich action first? 1. Start a secon d IV site. 2. Ch eck com patibility of th e m ed ication an d IV

fluids. 3. Mix th e prepackaged piperacillin / tazobactam

per agen cy policy. 4. Prim e th e tubin g with th e IV solution , an d back-

prim e th e m edication .

105. Th e n urse is com pletin g a tim e tape for a 1000-m L in traven ous (IV) bag th at is sch eduled to in fuse over 8 h ours. Th e n urse h as just placed th e 1100 m arkin g at th e 500-m L level. Th e n urse would place th e m ark for 1200 at wh ich n um erical level (m L) on th e tim e tap e? Fill in th e b lan k. An swer: ______ m L

106. Th e n urse is m akin g in itial ro un ds on th e n ursin g un it to assess th e con dition of assign ed clien ts. Wh ich assessm en t fin din gs are con sisten t with in filtration ? Select all th at ap p ly.

1. Pain an d eryth em a 2. Pallor an d cooln ess 3. Nu m bn ess an d pain 4. Edem a an d blan ch ed skin 5. Form ation of a red streak an d purulen t

drain age

107. Th e n urse is in sertin g an in traven ous (IV) lin e in to a clien t’s vein . After th e in itial stick, th e n urse would con tin ue to ad van ce th e cath eter in wh ich situation ? 1. Th e cath eter advan ces easily. 2. Th e vein is disten ded un der th e n eedle. 3. Th e clien t does n ot com plain of discom fort. 4. Bloo d return sh ows in th e backflash ch am b er of

th e cath eter.

108. Th e n urse is assessin g a clien t’s periph eral in trave- n ou s (IV) site after co m pletio n of a van com ycin in fusion an d n otes th at th e area is redden ed, warm , pain ful, an d sligh tly edem atous proxim al to th e in sertion poin t of th e IV cath eter. At th is tim e, wh ich action by th e n urse is b est? 1. Ch eck for th e presen ce of blood return . 2. Rem ove th e IV site an d restart at an oth er site. 3. Docum en t th e fin din gs an d con tin ue to m on i-

tor th e IV site. 4. Call th e h ealth care provider (HCP) an d request

th at th e van com ycin be given orally.

109. Th e n urse is preparin g a con tin uous in traven ous (IV) in fusion at th e m ed ication cart. As th e n urse go es to in sert th e spike en d of th e IV tubin g in to th e IV bag, th e tubin g drops an d th e spike en d h its th e top of th e m ed ication cart. Th e n urse sh ould take wh ich action ?

1. O btain a n ew IV bag. 2. O btain n ew IV tubin g. 3. Wipe th e spike en d of th e tubin g with povidon e

io din e. 4. Scrub th e spike en d of th e tubin g with an alco-

h ol swab.

110. A h ealth care provider h as written a prescription to discon tin ue an in traven o us (IV) lin e. Th e n urse sh ould obtain wh ich item from th e un it supply area for applyin g pressure to th e site after rem ovin g th e IV cath eter? 1. Elastic wrap 2. Povidon e iodin e swab 3. Adh esive ban dage 4. Sterile 2 Â 2 gauze

111. A clien t rin gs th e call ligh t an d com plain s of pain at th e site of an in traven o us (IV) in fusion . Th e n urse assesses th e site an d determ in es th at ph lebi- tis h as developed. Th e n urse sh ould take wh ich action s in th e care of th is clien t? Select all th at ap p ly.

1. Rem o ve th e IV cath eter at th at site. 2. Apply warm m oist packs to th e site. 3. No tify th e h ealth care provider (HCP) . 4. Start a n ew IV lin e in a proxim al portion of

th e sam e vein . 5. Docum en t th e occurren ce, action s taken ,

an d th e clien t’s respo n se.

112. A clien t in volved in a m otor veh icle crash presen ts to th e em ergen cy departm en t with severe in tern al bleed in g. Th e clien t is severely h ypo ten sive an d un respon sive. Th e n urse an ticip ates th at wh ich in traven ous (IV) solution will m o st likely be pre- scrib ed for th is clien t? 1. 5% dextrose in lactated Rin ger’s solution 2. 0.33% sodium ch loride (1/ 3 n orm al salin e) 3. 0.45% sodium ch loride (1/ 2 n orm al salin e) 4. 0.225% sodium ch loride (1/ 4 n orm al salin e)

113. Th e n urse provid es a list of in struction s to a clien t bein g disch arged to h om e with a periph erally in serted cen tral cath eter (PICC) . Th e n urse deter- m in es th at th e clien t n eed s fu rth er in stru ctio n s if th e clien t m ade wh ich statem en t? 1. “I n eed to wear a MedicAlert tag or bracelet.” 2. “I n eed to restrict m y activity wh ile th is cath eter

is in place.” 3. “I n eed to keep th e in sertio n site protected wh en

in th e sh ower or bath .” 4. “I n eed to ch eck th e m arkin gs on th e cath eter

each tim e th e dressin g is ch an ged.”

114. A clien t h as just un dergon e in sertion of a cen tral ven o us cath eter at th e bedside un der ultraso un d. Th e n urse would be sure to ch eck wh ich results

154 UNIT III Nursing Sciences

before in itiatin g th e flow rate of th e clien t’s in trave- n ous (IV) solution at 100 m L/ h ou r? 1. Serum osm o lality 2. Serum electrolyte levels 3. In take an d outp ut record 4. Ch est radiolo gy results

115. In traven ou s (IV) fluid s h ave been in fusin g at 100 m L/ h ou r via a cen tral lin e cath eter in th e righ t in tern al jugular for approxim ately 24 h ours to in crease urin e output an d m ain tain th e clien t’s

blood pressure. Upo n en terin g th e clien t’s ro om , th e n urse n otes th at th e clien t is breath in g rapidly an d cough in g. For wh ich addition al sign s of a com - plication sh ould th e n urse assess based on th e pre- viou sly kn own data? 1. Excessive bleedin g 2. Crackles in th e lun gs 3. In com p atibility of th e in fusion 4. Ch est pain radiatin g to th e left arm

A N S W E R S 103. 1 Ra t ion a le: Th e clien t’s sym pto m s are co m patib le with circula- to ry overload . Th is m ay b e verified by n otin g th at 600 m L h as in fu sed in th e co urse of 45 m in u tes. Th e first action o f th e n u rse is to slo w th e in fusion . O th er actio n s m ay fo llo w in rap id seq uen ce. Th e n u rse m ay elevate th e h ead o f th e bed to aid th e clien t’s breath in g, if n ecessary. Th e n u rse also n otifies th e HCP. Th e IV cath eter is n ot rem o ved; it m ay b e n eed ed for th e ad m in istration o f m ed ication s to resolve th e co m p lication . Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d , first. Th is tells yo u th at m o re th an 1 or all of th e o ptio n s are likely to be co rrect actio n s an d th at th e n u rse n eeds to p rio ritize th em acco rdin g to a tim e seq uen ce. You m u st b e able to reco gn ize th e sign s o f cir- cu latory o verload . From th is p oin t, select th e o ptio n th at pro- vides th e in terven tio n sp ecific to circu lato ry overload . Review: Nu rsin g actio n s for cir cu la t o r y o ver lo a d Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Critical Care—Med icatio n s an d In traven o us Th erap y Pr ior ity Con cepts: Flu id an d Electrolytes; Perfusion Refer en ce: Ign atavicius, Workm an (2016), p . 207.

104. 2 Ra t ion a le: Wh en h an gin g an IV an tibio tic, th e n urse sh o uld first ch eck co m p atibility o f th e m ed ication an d th e IV fluid s cu rren tly p rescribed . If th e fluid s an d m ed icatio n are in com - patib le, it wou ld th en b e ap prop riate to start a secon d IV site. If th ey are com p atible, th e n u rse sh ou ld h an g th em to geth er so as to avoid h avin g to start an o th er IV site. After th is, th e n u rse sh ou ld p repare th e p rep ackaged pip eracillin / tazo b actam per agen cy po licy, th en prim e th e tub in g with th e IV so lu tion , an d th en back-p rim e th e m edicatio n . Back-prim in g p reven ts an y m edicatio n from bein g lo st d urin g th e p rim in g p ro cess. Test -Ta kin g Str a tegy: No te th e st r a t egic wo r d , first. Th is im p lies a co rrect tim e sequ en ce, an d you n eed to prioritize. Visualize an d th in k th ro ugh th e step s o f h an gin g an IV an tibi- otic o r secon dary m ed ication , an d m ake yo ur ch o ice accordin gly. Review: Ad m in ist r a t io n o f a n IV m ed ica t io n Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Ph ysiolo gical In tegrity

In t egr a ted Pr ocess: Nu rsin g Pro cess—Im plem en tation Con t en t Ar ea : Critical Care—Med icatio n s an d In traven o us Th erap y Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ce: Perry, Potter, O sten d orf ( 2014) , pp . 568, 573-574.

105. 375 Ra t ion a le: If th e IV is sch edu led to run o ver 8 h ou rs, th e h ou rly rate is 125 m L/ h o ur. Usin g 500 m L as th e referen ce p oin t, th e n ext h ou rly m arkin g wou ld be at 375 m L, wh ich is 125 m L less th an 500. Test -Ta kin g Str a tegy: Focus o n th e su b ject , in traven o us in fu - sion calcu latio n s. Use basic prin cip les related to do sage calcu- lation an d IV adm in istratio n to an swer th is q u estio n . Sub tract 125 fro m 500 to yield 375. Review: Ad m in istratio n o f in t r a ven o u s m ed ica t io n s Level of Cogn it ive Ability: App lyin g Clien t Need s: Ph ysio lo gical In tegrity Integra ted Process: Nursin g Pro cess—Im p lem en tatio n Con t en t Ar ea : Fun d am en tal of Care—Medication / IV Calcu latio n s Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ce: Perry, Po tter, O sten do rf (2014), p p. 710-711.

106. 2, 3, 4 Ra t ion a le: An in filtrated in traven o us (IV) lin e is o n e th at h as d islo d ged fro m th e vein an d is lyin g in sub cu tan eo u s tissue. Pallo r, co oln ess, edem a, pain , n u m b n ess, an d b lan ch ed skin are th e resu lts of IV fluid bein g dep o sited in th e sub cutan eo u s tissue. Wh en th e pressu re in th e tissu es exceeds th e pressu re in th e tu b in g, th e flo w of th e IV solutio n will sto p, an d if an elec- tron ic p um p is b ein g u sed , it will alarm . Eryth em a can b e asso- ciated with in fectio n , p h leb itis, or th ro m bo sis. Fo rm atio n of a red streak an d p urulen t drain age is asso ciated with p h leb itis an d in fection . Test -Ta kin g Str a tegy: Focu s on th e su b ject , clin ical m an ifes- tatio n s at th e IV site. Rem em b er th at p allo r, co oln ess, p ain , n um b n ess, an d swellin g are sign s o f in filtratio n , an d th at in fec- tion , p h lebitis, an d th ro m bo sis are asso ciated with warm th at th e IV site. Review: Sign s of in filt r a t io n Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Critical Care—Medicatio n s an d In traven ou s Th erap y

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Pr ior it y Con cept s: Clin ical Ju dgm en t; Tissu e In tegrity Refer en ce: Ign ataviciu s, Wo rkm an (2016), p. 204.

107. 4 Ra tion a le: Th e IV cath eter h as en tered th e lum en of th e vein su ccessfu lly wh en blo od b ackflash sh o ws in th e IV cath eter. Th e vein sh o uld h ave been d isten d ed b y th e tou rn iq uet befo re th e vein was can n ulated, an d if fu rth er d isten tio n occurs after ven ipu n cture, th is cou ld m ean th e n eed le wen t th ro u gh th e vein an d in to th e tissu e; th erefo re, th e cath eter sh ou ld n o t be ad van ced . Clien t d iscom fort varies with th e clien t, th e site, an d th e n u rse’s in sertion tech n iq ue an d is n ot a reliable m easure of cath eter placem en t. Th e n u rse sh o uld n ot advan ce th e cath eter un til p lacem en t in th e vein is verified by bloo d return . Test-Ta kin g Str a tegy: Fo cu s o n th e su b ject o f th e q u estion , correct placem en t o f an IV cath eter. Notin g th e wo rd s blood return in th e correct o ption will direct you to th is option b ecau se a bloo d retu rn is exp ected if th e cath eter is in a vein . Review: In sertio n o f an in t r a ven o u s ca t h et er Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Medication s an d In traven ous Th erap y Pr ior it y Con cept s: Clin ical Ju dgm en t; Perfu sion Refer en ce: Perry, Po tter, O sten d orf (2014), pp . 703-704.

108. 2 Ra tion a le: Ph leb itis at an IV site can b e d istin gu ish ed b y cli- en t discom fo rt at th e site an d by red n ess, warm th , an d swell- in g p ro xim al to th e cath eter. If ph lebitis occu rs, th e n urse sh o u ld rem ove th e IV lin e an d in sert a n ew IV lin e at a d iffer- en t site, in a vein oth er th an th e on e th at h as d evelo p ed p h le- b itis. Ch eckin g for th e presen ce of b loo d return sh o uld be d on e b efo re th e ad m in istratio n o f van co m ycin b ecau se th is m edicatio n is a vesican t. Docu m en tin g th e fin din gs an d con - tin uin g to m o n ito r th e IV site an d callin g th e HCP an d requ estin g th at th e van co m ycin be given orally d o n o t ad d ress th e im m ed iate prob lem . Ad dition ally, th ere cou ld b e in d ica- tio n s for th e prescrip tion of IV as op p osed to oral van co m ycin fo r th e clien t. Th e HCP sh o uld b e n otified o f th e co m p lica- tio n s with th e IV site, b ut n o t asked fo r a prescrip tion fo r oral van com ycin . Test-Ta kin g St r a t egy: Note th e st r a t egic wo r d , best. Also, d et er m in e if a n a b n o r m a lit y exist s. Based on th e assessm en t fin din gs n o ted in th e qu estio n , it is clear th at an abn orm ality d oes exist, so elim in ate do cu m en tin g an d co n tin u in g to m o n - ito r. Next, recallin g th e ap p ro priate n u rsin g in terven tio n fo r p h leb itis will direct yo u to th e correct o ptio n . Review: Sign s an d sym ptom s of p h leb it is an d th e associated n u rsin g in terven tio n s Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Medication s an d In traven ous Th erap y Pr ior it y Con cept s: Clin ical Ju dgm en t; Tissu e In tegrity Refer en ce: Ign ataviciu s, Wo rkm an (2016), p. 205.

109. 2 Ra tion a le: Th e n urse sh ou ld ob tain n ew IV tub in g b ecause con tam in ation h as o ccu rred an d cou ld cau se system ic in fec- tio n to th e clien t. Th ere is n o n eed to o btain a n ew IV b ag b ecau se th e bag was n o t co n tam in ated . Wipin g with p ovido n e io din e or alcoh o l is in sufficien t an d is con train d icated b ecause th e sp ike will b e in serted in to th e IV bag. Test-Ta kin g Str a tegy: Focus o n th e su b ject , th at th e tubin g was co n tam in ated . Use kn o wledge o f basic in fectio n con tro l m easures an d IV th erap y co n cep ts to an swer th is q uestion . Rem em ber th at if an item is con tam in ated, discard it an d o btain a n ew sterile item . Review: Su r gica l a sep t ic t ech n iq u e Level of Cogn itive Ability: Ap plyin g Clien t Need s: Safe an d Effective Care En viro n m en t In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Medication s an d In traven ous Th erapy Pr ior it y Con cept s: Clin ical Ju dgm en t; In fectio n Refer en ce: Perry, Po tter, O sten d orf (2014), p. 700.

110. 4 Ra tion a le: A d ry sterile dressin g such as a sterile 2 Â 2 gauze is u sed to app ly pressu re to th e disco n tin u ed IV site. Th is m aterial is ab sorben t, sterile, an d n o n irritatin g. A p o vido n e iod in e swab wo u ld irritate th e op en ed p un ctu re site an d wo uld n ot sto p th e b loo d flow. An adh esive b an d age o r elastic wrap m ay be u sed to cover th e site o n ce h em o stasis h as occurred . Test-Ta king Stra tegy: Fo cu s on th e su b ject, care to th e IV site after rem o val o f th e cath eter, an d n ote th e words applying pressure. Visu alize th is proced ure, th in kin g abo u t each o f th e item s id en tified in th e o p tion s to d irect you to th e co rrect o ptio n . Review: In t r a ven o u s ca t h et er r em o va l Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Medication s an d In traven ous Th erapy Pr ior it y Con cept s: Clin ical Ju dgm en t; Clo ttin g Refer en ce: Perry, Po tter, O sten d orf (2014), p. 723.

111. 1, 2, 3, 5 Ra tion a le: Ph leb itis is an in flam m atio n o f th e vein th at can o ccur from m ech an ical o r ch em ical (m edicatio n ) trau m a or fro m a lo cal in fectio n an d can cause th e develop m en t o f a clot ( th rom b op h leb itis) . Th e n urse sh o uld rem o ve th e IV at th e p h leb itic site an d ap ply warm m o ist co m p resses to th e area to sp eed resolu tio n o f th e in flam m ation . Becau se ph lebitis h as occurred , th e n urse also n otifies th e HCP ab ou t th e IV com plicatio n . Th e n u rse sh o u ld restart th e IV in a vein oth er th an th e on e th at h as d evelo ped p h lebitis. Fin ally, th e n urse d ocum en ts th e occurren ce, actio n s taken , an d th e clien t’s respon se. Test-Ta king Stra tegy: Focus on th e su b ject, action s to take if p h leb itis o ccu rs. Recall th at ph lebitis is an in flam m atio n of th e vein . Th is will assist in elim in atin g th e op tio n th at in d icates to u se th e sam e vein becau se an IV sh o uld b e restarted in a vein o th er th an th e o n e th at h as d evelo ped ph leb itis. Review: P h leb it is

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156 UNIT III Nursing Sciences

Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Critical Care—Med icatio n s an d In traven o us Th erap y Pr ior ity Con cepts: Clin ical Jud gm en t; In flam m ation Refer en ce: Ign atavicius, Workm an (2016), p . 205.

112. 1 Ra t ion a le: Fo r th is clien t, th e go al of th erap y is to exp an d in tra- vascu lar vo lum e as qu ickly as p ossible. In th is situatio n , th e cli- en t will likely experien ce a d ecrease in in travascular volum e fro m b lo od loss, resu ltin g in decreased bloo d p ressu re. Th ere- fo re, a so lu tion th at in creases in travascular volu m e, rep laces im m ed iate bloo d loss vo lum e, an d in creases b lo od p ressu re is n eed ed . Th e 5% d extrose in lactated Rin ger’s (h yp erto n ic) solu tio n wou ld in crease in travascu lar vo lu m e an d im m ed i- ately rep lace lo st flu id vo lu m e un til a tran sfu sio n co uld b e ad m in istered , resu ltin g in an in crease in th e clien t’s b loo d pres- sure. Th e so lu tion s in th e rem ain in g op tio n s wo uld n o t b e given to th is clien t b ecause th ey are h yp oto n ic so lutio n s an d, in stead of in creasin g in travascular sp ace, th e so lutio n s wo uld m o ve in to th e cells via o sm o sis. Test -Ta kin g St r a t egy: Focu s on th e su b ject , th at th e clien t h as been in a trau m atic accid en t. Also, n o te th e st r a t egic wo r d s , most likely. Also n o te th at th e in co rrect o p tion s are co m p a r a b le o r alike an d in clu d e a % o f n o rm al salin e. Determ in in g th at th is clien t will likely experien ce d ecreased in travascular volum e an d blo o d pressure du e to bloo d loss an d recallin g IV fluid typ es an d h ow h ypo ton ic an d h yp erto n ic so lu tion s fu n ction with in th e in travascu lar space will d irect yo u to th e co rrect op tion . Review: In t r a ven o u s flu id s Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Plan n in g Con t en t Ar ea : Critical Care—Med icatio n s an d In traven o us Th erap y Pr ior ity Con cepts: Clin ical Jud gm en t; Perfu sio n Refer en ce: Perry, Potter, O sten do rf (2014), p . 694.

113. 2 Ra t ion a le: Th e clien t sh o uld be taugh t th at o n ly m in or activity restriction s apply with th is type of cath eter. Th e clien t sh ould carry or wear a Med icAlert id en tificatio n an d sh ou ld protect th e site d urin g b ath in g to p reven t in fectio n . Th e clien t sh o uld ch eck th e m arkin gs on th e cath eter du rin g each d ressin g ch an ge to assess fo r cath eter m igratio n o r d islo dgem en t. Test -Ta kin g St r a t egy: No te th e st r a t egic wo r d s , needs further instructions. Th ese wo rd s in d icate a n ega t ive even t q u er y an d th e n eed to select th e in correct clien t statem en t. Recallin g th at th e PICC is fo r lon g-term u se will assist in directin g yo u to th e co rrect op tio n . To restrict activity with su ch a cath eter is un reaso n able. Review: Per ip h er a lly in ser t ed in t r a ven o u s ca t h et er s Level of Cogn it ive Ability: Evaluatin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Teach in g an d Learn in g

Con t en t Ar ea : Critical Care—Med icatio n s an d In traven o us Th erap y Pr ior ity Con cepts: Clien t Ed u catio n ; Fun ctio n al Ab ility Refer en ce: Perry, Po tter, O sten do rf (2014), p . 735.

114. 4 Ra t ion a le: Befo re begin n in g ad m in istratio n o f IV so lutio n , th e n urse sh o uld assess wh eth er th e ch est rad iology resu lts reveal th at th e cen tral cath eter is in th e p ro per p lace. Th is is n ecessary to p reven t in fusion of IV flu id in to pu lm on ary o r sub cutan eo u s tissues. Th e o th er op tio n s rep resen t item s th at are u sefu l fo r th e n urse to be aware o f in th e gen eral care o f th is clien t, b ut th ey d o n o t relate to th is proced ure. Test -Ta kin g St r a t egy: Note th e su b ject , care to th e clien t with a cen tral ven o u s cath eter. No te th e wo rd s insertion of a central venous catheter at the bedside. Recallin g th e p o ten tial co m plica- tion s asso ciated with th e in sertio n o f cen tral ven o us cath eters will direct you to th e correct option . Review: Nursin g actio n s related to cen t r a l ven o u s ca t h et er s Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Assessm en t Con t en t Ar ea : Critical Care—Medicatio n s an d In traven ou s Th erap y Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ces: Ign atavicius, Wo rkm an (2016), pp . 190-191, 193; Perry, Potter, O sten do rf (2014), p . 735.

115. 2 Ra t ion a le: Circu latory (flu id ) overlo ad is a com p lication o f IV th erap y. Sign s in clud e rapid b reath in g, d ysp n ea, a m oist co ugh , an d crackles. Bloo d pressure an d h eart rate also in crease if circu latory overlo ad is p resen t. Th erefo re, sin ce th e n u rse pre- viou sly n o ted rapid breath in g an d cou gh in g, th e n u rse sh o uld th en assess fo r a m o ist co u gh an d crackles. Hem ato m a is an oth er po ten tial co m plicatio n an d is ch aracterized by ecch y- m o sis, swellin g, an d leakage at th e IV in sertio n site, as well as h ard an d p ain fu l lum ps at th e site. Allergic reactio n is a co m - p licatio n of adm in istratio n o f IV fluids o r m ed ication an d is ch aracterized b y ch ills, fever, m alaise, h ead ach e, n ausea, vo m itin g, backach e, an d tach ycardia; th is typ e o f reactio n co uld also occu r if th e IV so lution s in fu sed are in com p atible; h owever, th ere was n o in d ication o f m ultiple solu tio n s b ein g in fused sim u ltan eo u sly in th is qu estio n . Ch est pain radiatin g to th e left arm is a classic sign of card iac co m prom ise an d is n ot sp ecifically related to a co m plicatio n o f IV th erapy. Test -Ta kin g St r a t egy: Fo cus on t h e d a t a in t h e q u est io n an d n ote th e su b ject , a co m plicatio n . No tin g th at th e clien t is experien cin g rapid b reath in g an d is co u gh in g will assist in d irectin g you to th e co rrect op tio n . Review: Sign s of cir cu la t o r y o ver lo a d Level of Cogn it ive Ability: Syn th esizin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—An alysis Con t en t Ar ea : Critical Care—Medicatio n s an d In traven ou s Th erap y Pr ior ity Con cepts: Clin ical Jud gm en t; Perfu sio n Refer en ce: Ign atavicius, Workm an (2016), p . 207.

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157CHAPTER 13 Intravenous Therapy

C H A P T E R 14 Administration of Blood Products

PRIORITY CONCEPTS Perfusion; Safety

CRITICAL THINKING What Should You Do? The nurse is administering 1 unit of packed red blood cells (PRBCs) to a client who has never received a blood transfu- sion. The client suddenly becomes apprehensive and com- plains of back pain after the first 10 minutes of administration. What should the nurse do? Answer located on p. 163.

I. Types of Blood Components A. Packed red blood cells (PRBCs)

1. PBRCs are a blood product used to replace eryth - rocytes; in fusion tim e for 1 un it is usually between 2 an d 4 h ours.

2. Each un it in creases th e h em oglobin level by 1 g/ dL (10 m m ol/ L) an d h em atocrit by 3% (0.03); th e ch an ge in laborato ry values takes 4 to 6 h ours after com pletion of th e blood tran sfusion .

3. Evaluation of an effective respo n se is based on th e resolution of th e sym pto m s of an em ia an d an in crease in th e eryth rocyte, h em oglobin , an d h em atocrit coun t.

4. Leukocyte-poor or leukocyte-depleted units are unitsin wh ich leukocytes, protein s, an d plasm a have been reduced. They are used to restore oxygen- carryingcapacityofblood an d in travascular volum e.

Washed red blood cells (depleted of plasma, plate- lets, and leukocytes) may be prescribed for a client with a history of allergic transfusion reactions or those who underwent hematopoietic stem cell transplant. Leuko- cyte depletion (leukoreduction) by filtration, washing, or freezing is the process used to decrease the amount of white blood cells (WBCs) in a unit of packed cells.

B. Platelet transfusion 1. Platelets are used to treat th rom bocytop en ia an d

platelet dysfun ction s. a . Clien ts receivin g m ultiple un its of platelets

can becom e “alloim m un ized” to differen t

platelet an tigen s. Th ese clien ts m ay ben efit from receivin g on ly platelets th at m atch th eir specific h um an leuko cyte an tigen (HLA).

2. Crossmatching is n ot required but usually is don e (platelet con cen trates con tain few red blood cells [RBCs]).

3. Th e volum e in a un it of platelets m ay vary; always ch eck th e bag for th e vo lum e of th e blood com po n en t (in m illiliters).

4. Platelets are ad m in istered im m ediately upon receipt fro m th e blood ban k an d are given rap- idly, usually over 15 to 30 m in u tes.

5. Evaluation of an effective respo n se is based on im provem en t in th e platelet coun t, an d platelet coun ts n orm ally are evalu ated 1 h ou r an d 18 to 24 h ours after th e tran sfusio n ; for each un it of platelets ad m in istered, an in crease of 5000 to 10,000 m m 3 (5 to 10 Â 109/ L) is exp ected.

C. Fresh-frozen plasma 1. Fresh -frozen plasm a m ay be used to provide clot-

tin g factors or volum e expan sion ; it con tain s n o platelets.

2. Fresh -frozen plasm a is in fused with in 2 h ou rs of th awin g, wh ile clo ttin g factors are still viable, an d is in fused over a period of 15 to 30 m in u tes.

3. Rh compatibility an d ABO com patibility are required for th e tran sfusion of plasma products.

4. Evaluation of an effective respon se is assessed by m on itorin g coagu lation studies, particularly th e proth rom bin tim e an d th e partial th rom bo- plastin tim e, an d resolutio n of h ypo volem ia.

D. Cryoprecipitates 1. Prepared from fresh -frozen plasm a, cryoprecipi-

tates can be stored for 1 year. O n ce th awed, th e produ ct m ust be used; 1 un it is adm in istered over 15 to 30 m in utes.

2. Used to replace clo ttin g facto rs, especially facto r VIII an d fib rin ogen

3. Evaluation of an effective respon se is assessed by m on itorin g coagulation studies an d fibrin ogen levels.

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158

E. Gran ulocytes 1. May be used to treat a clien t with sep sis or a n eu-

tro pen ic clien t with an in fection th at is un re- spon sive to an tibiotics

2. Evaluation of an effective respo n se is assessed by m on itorin g th e WBC an d differen tial coun ts.

Document the necessary information about the blood transfusion in the client’s medical record (follow agency guidelines). Include the client’s tolerance and response to the transfusion and the effectiveness of the transfusion.

II. Types of Blood Donations A. Autologous

1. A don ation of th e clien t’s own blood before a sch eduled proced ure is an autologous don ation ; it reduces th e risk of disease tran sm issio n an d poten tial tran sfusion co m plication s.

2. Autologous don ation is n ot an option for a clien t with leukem ia or bacterem ia.

3. A don ation can be m ade every 3 days as lon g as th e h em oglobin rem ain s with in a safe ran ge.

4. Do n ation s sh ould begin with in 5 weeks of th e tran sfusion date an d en d at least 3 days before th e date of tran sfusio n .

B. Bloo d salvage 1. Bloo d salvage is an autologous don ation th at

in volves suction in g blood fro m body cavities, join t spaces, or oth er closed body sites.

2. Bloo d m ay n eed to be “wash ed,” a special pro- cess th at rem oves tissue deb ris before rein fu sion .

C. Design ated don or 1. Design ated don ation occurs wh en recipien ts

select th eir own com patible don ors. 2. Do n ation does n ot reduce th e risk of con tractin g

in fectio n s tran sm itted by th e blood ; h owever, recipien ts feel m ore com fo rtable iden tifyin g th eir don ors.

III. Compatibility (Table 14-1) A. Clien t (th e recipien t) blood sam ples are drawn an d

labeled at th e clien t’s bed side at th e tim e th e blood sam ples are drawn ; th e clien t is asked to state h is or h er n am e, wh ich is com pared with th e n am e on th e clien t’s id en tification ban d or bracelet.

B. Th e recip ien t’s ABO typ e an d Rh typ e are id en tified .

C. An an tibody screen is don e to determ in e th e pres- en ce of an tibodies oth er th an an ti-A an d an ti-B.

D. To determ in e com patibility, crossmatching is don e, in wh ich don or red blood cells are com bin ed with th e recipien t’s serum an d Coom bs’serum ; the crossm atch is com patible if n o RBC agglutin ation occurs.

E. Th e un iversal RBC don or is O n egative; th e un iversal recip ien t is AB positive.

F. Clien ts with Rh -positive blood can receive RBC tran sfusion from an Rh -n egative don or if n ecessary; h owever, an Rh -n egative clien t sh ould n ot receive Rh -p ositive blood .

The donor’s blood and the recipient’s blood must be tested for compatibility. If the blood is not compatible, a life-threatening transfusion reaction can occur.

IV. Infusion Pumps A. In fusion pum ps m ay be used to ad m in ister blood

produ cts if th ey are design ed to fun ction with opaqu e solution s; special in traven ous (IV) tubin g is used specifically for blood produ cts to preven t h em olysis of red blood cells.

B. Always con sult m an ufacturer guidelin es for h ow to use th e pum p an d compatibility for use with blood tran sfusion s.

C. Special m an u al pressure cuffs design ed specifically for blood produ ct adm in istration m ay be used to in crease th e flow rate, but it sh ould n ot exceed 300 m m Hg.

D. Stan d ard sp h ygm o m an o m eter cu ffs are n o t to b e u sed to in crease th e flo w rate b ecau se th ey d o n o t exert u n ifo rm p ressu re again st all p arts o f th e b ag.

V. Blood Warmers A. Bloo d warm ers m ay be used to preven t h ypo th erm ia

an d ad verse reaction s wh en several un its of blood are bein g ad m in istered.

B. Special warm ers h ave been design ed for th is pur- pose, an d on ly devices specifically approved for th is use can be used.

If blood warming is necessary, use only warming devices specifically designed and approved for warming blood products. Do not warm blood products in a micro- wave oven or in hot water.

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TABLE 14-1 Compatibility Chart for Red Blood Cell Transfusions

Recipient

Donor A B AB O

A X X

B X X

AB X

O X X X X

The ABO type of the donor should be compatible with the recipient’s. Type A can receive from type Aor O; type B from type B or O; type AB can receive from type A, B, AB, or O; type O only from type O. From Ignatavicius D, Workm an ML: Medical-surgical nursing: patient-centered collaborative care, ed 7, Philadelphia, 20 13, Saunders.

159CHAPTER 14 Administration of Blood Products

VI. Precautions and Nursing Responsibilities (Box 14-1)

Check the client’s identity before administering a blood product. Be sure to check the health care pro- vider’s (HCP’s) prescription, that the client has an appropriate venous access site, that crossmatching pro- cedures have been completed, that an informed consent has been obtained, and that the correct client is receiving the correct type of blood. Use barcode scanning systems per agency policy to ensure client safety.

VII. Complications (Box 14-2) A. Transfusion reactions

1. Description a . A tran sfusion reaction is an adverse reactio n

th at h appen s as a result of receivin g a blood tran sfusion .

b . Types of tran sfusion reactio n s in clude h em o- lytic, allergic, febrile or bacterial reactio n s ( septicemia), or tran sfusion -associated graft- versus-h ost disease (GVH D).

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BOX 14-1 Precautions and Nursing Responsibilities General Precautions A large volume of refrigerated blood infused rapidly through a

central venous catheter into the ventricle of the heart can cause cardiac dysrhythmias.

No solution other than normal saline should be added to blood components.

Medications are never added to blood components or piggy- backed into a blood transfusion.

To avoid the risk of septicemia, infusions (1 unit) should not exceed the prescribed time for administration (2 to 4 hours for packed red blood cells); follow evidence-based practice guidelines and agency procedure.

The blood administration set should be changed with each unit of blood, or according to agency policy, to reduce the risk of septicemia.

Check the blood bag for the date of expiration; components expire at midnight on the day marked on the bag unless oth- erwise specified.

Inspect the blood bag for leaks, abnormal color, clots, and bubbles.

Blood must be administered as soon as possible (within 20 to 30 minutes) after being received from the blood bank, because this is the maximal allowable time out of monitored storage.

Never refrigerate blood in refrigerators other than those used in blood banks; if the blood is not administered within 20 to 30 minutes, return it to the blood bank.

The recommended rate of infusion varies with the blood com- ponent being transfused and depends on the client’s condi- tion; generally blood is infused as quickly as the client’s condition allows.

Components containing few red blood cells (RBCs) and plate- lets may be infused rapidly, but caution should be taken to avoid circulatory overload.

The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every 30 minutes to 1 hour (per agency policy) until 1 hour after the transfusion is completed.

Client Assessment Assess for any cultural or religious beliefs regarding blood

transfusions. A Jehovah’s Witness cannot receive blood or blood products;

this group believes that receiving a blood transfusion has eternal consequences.

Ensure that an informed consent has been obtained.

Explain the procedure to the client and determine whether the client has ever received a blood transfusion or experienced any previous reactions to blood transfusions.

Check the client’s vital signs; assess renal, circulatory, and respiratory status and the client’s ability to tolerate intrave- nously administered fluids.

If the client’s temperature is elevated, notify the health care pro- vider (HCP) before beginning the transfusion; a fever may be a cause for delaying the transfusion in addition to masking a possible symptom of an acute transfusion reaction.

Blood Bank Precautions Blood will be released from the blood bank only to personnel

specified by agency policy. The name and identification number of the intended recipient

must be provided to the blood bank, and a documented permanent record of this information must be maintained.

Blood should be transported from the blood bank to only 1client at a time to prevent blood delivery to the wrong client.

Only 1 unit of blood should be transported at a time, even if the client is prescribed to have more than 1 unit transfused.

Client Identity and Compatibility Check the HCP’s prescription for the administration of the

blood product. The most critical phase of the transfusion is confirming product

compatibility and verifying client identity. Universal barcode systems for blood transfusions should be

used to confirm product compatibility, client identity, and expiration.

Two licensed nurses (follow agency policy) need to check the HCP’s prescription, the client’s identity, and the client’s identification band or bracelet and number, verifying that the name and number are identical to those on the blood component tag.

At the bedside, the nurse asks the client to state his or her name, and the nurse compares the name with the name on the identification band or bracelet.

The nurs e checks the blood bag tag, label, and blood requi- sition form to ensure that ABO and Rh types are com pat- ible. The nurse uses the barcode scanning system per agency policy.

If the nurse notes any inconsistencies when verifying client identity and compatibility, the nurse notifies the blood bank immediately.

160 UNIT III Nursing Sciences

2. Sign s of an im m ediate tran sfusion reactio n a. Ch ills an d diaph o resis b . Muscle ach es, back pain , or ch est pain c. Rash es, h ives, itch in g, an d swellin g d . Rap id, th ready pulse e. Dysp n ea, cough , or wh eezin g

f. Pallor an d cyan osis g. Appreh en sion h . Tin glin g an d n um bn ess i. Headach e j. Nausea, vom itin g, abdom in al cram p in g, an d

diarrh ea 3. Sign s of a tran sfusion reactio n in an un co n scious

clien t a. Weak pulse b . Fever c. Tach ycardia or brad ycardia d . Hypo ten sion e. Visible h em oglob in uria f. O liguria or an uria

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BOX 14-1 Precautions and Nursing Responsibilities—cont’d

Administration of the Transfusion Maintain standard and transmission-based precautions and

surgical asepsis as necessary. Insert an intravenous (IV) line and infuse normal saline; main-

tain the infusion at a keep-vein-open rate. An 18- or 19-gauge IV needle will be needed to achieve a maxi-

mum flow rate of blood products and to prevent damage to RBCs; if a smaller gauge needle must be used, RBCs may be diluted with normal saline (check agency procedure).

Acentral venous catheter is an acceptable venous access option for blood transfusions; for a multilumen catheter, use the largest catheter port available or check the port size to ensure that it is adequate for blood administration.

Always check the bag for the volume of the blood component. Blood products should be infused through administration sets

designed specifically for blood; use a Y-tubing or straight tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumu- late during blood storage (Fig. 14-1).

Premedicate the client with acetaminophen or diphenhydra- mine, as prescribed, if the client has a history of adverse reactions; if prescribed, oral medications should be admin- istered 30 minutes before the transfusion is started, and intravenously administered medications may be given immediately before the transfusion is started.

Instruct the client to report anything unusual immediately. Determine the rate of infusion by the HCP’s prescription or, if

not specified, by agency policy. Begin the transfusion slowly under close supervision; if no reac-

tion is noted within the first 15 minutes, the flow can be increased to the prescribed rate.

During the transfusion, monitor the client for signs and symp- toms of a transfusion reaction; the first 15 minutes of the transfusion are the most critical, and the nurse must stay with the client.

If an ABO incompatibility exists or a severe allergic reaction occurs, the reaction is usually evident within the first 50 mL of the transfusion.

Document the client’s tolerance to the administration of the blood product.

Monitor appropriate laboratory values and document effective- ness of treatment related to the specific type of blood product.

Reactions to the Transfusion If a transfusion reaction occurs, stop the transfusion, change

the IV tubing down to the IV site, keep the IV line open with normal saline, notify the HCP and blood bank, and return the blood bag and tubing to the blood bank.

Do not leave the client alone, and monitor the client’s vital signs and monitor for any life-threatening signs or symptoms.

Obtain appropriate laboratory samples, such as blood and urine samples (free hemoglobin indicates that RBCs were hemo- lyzed), according to agency policies.

FIGURE 14-1 Tubing for blood administration has an in-line filter. (From Potter et al., 2013.)

BOX 14-2 Complications of a Blood Transfusion

▪ Transfusion reactions ▪ Circulatory overload ▪ Septicemia ▪ Iron overload

▪ Disease transmission ▪ Hypocalcemia ▪ Hyperkalemia ▪ Citrate toxicity

161CHAPTER 14 Administration of Blood Products

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4. Delayed tran sfusion reaction s a . Reaction s can occur days to years after a

tran sfusion . b . Sign s in clude fever, m ild jaun dice, an d a

decreased h em atocrit level.

Stay with the client for the first 15 minutes of the infu- sion of blood and monitor the client for signs and symp- toms of a transfusion reaction; the first 15 minutes of the transfusion are the most critical, and the nurse must stay with the client. Vital signs are monitored every 30 minutes to one hour according to institutional protocol.

5. In terven tion s (see Priority Nu rsin g Action s)

Stop the transfusion immediately if a blood transfu- sion reaction is suspected.

PRIORITY NURSING ACTIONS Transfusion Reaction: Nursing Interventions 1. Stop the transfusion. 2. Change the intravenous (IV) tubing down to the IV site

and keep the IV line open with normal saline. 3. Notify the health care provider (HCP) and blood bank. 4. Stay with the client, observing signs and symptoms and

monitoring vital signs as often as every 5 minutes. 5. Prepare to administer emergency medications as

prescribed. 6. Obtain a urine specimen for laboratory studies (perform

any other laboratory studies as prescribed). 7. Return blood bag, tubing, attached labels, and transfu-

sion record to the blood bank. 8. Document the occurrence, actions taken, and the client’s

response.

If the client exhibits signs of a transfusion reaction, the nurse immediately stops the transfusion and changes the IV tubing down to the IV site to prevent the entrance of addi- tional blood solution into the client. Normal saline solution is hung and infused to keep the IV line open in the event that emergency medications need to be administered. The HCP is notified and the nurse also notifies the blood bank of the occurrence. The nurse stays with the client and monitors the client closely while other personnel obtain needed sup- plies to treat the client. As prescribed by the HCP, the nurse administers emergency medications such as antihistamines, vasopressors, fluids, and corticosteroids. The nurse then obtains a urine specimen for laboratory studies and any other laboratory studies as prescribed to check for free hemoglobin indicating that red blood cells were hemolyzed. The blood bag, tubing, attached labels, and transfusion record are returned to the blood bank so that the blood bank can check the items to determine the reason that the reaction occurred. Finally the nurse documents the occurrence, actions taken, and the client’s response.

Reference Ignatavicius, Workman (2016), pp. 824-825.

B. Circulatory overload 1. Description : Caused by th e in fusion of blood at a

rate too rapid for th e clien t to tolerate 2. Assessm en t

a . Cough , dyspn ea, ch est pain , an d wh eezin g on auscultation of th e lun gs

b . Headach e c. Hyperten sion d . Tach ycardia an d a boun din g pulse e. Disten d ed n eck vein s

3. In terven tion s a . Slow th e rate of in fusion . b . Place th e clien t in an uprigh t position , with

th e feet in a depen den t position . c. Notify th e HCP. d . Adm in ister oxygen , diuretics, an d m orph in e

sulfate, as prescribed. e. Mon itor for dysrh yth m ias. f. Ph leboto m y also m ay be a m eth od of pre-

scrib ed treatm en t in a severe case.

If circulatory overload is suspected, immediately slow the rate of infusion and place the client in an upright position, with the feet in a dependent position.

C. Septicemia 1. Description : O ccurs with th e tran sfusio n of

blood th at is con tam in ated with m icro organ ism s 2. Assessm en t

a . Rapid on set of ch ills an d a h igh fever b . Vom itin g c. Diarrh ea d . Hypoten sion e. Sh ock

3. In terven tion s a . Notify th e HCP. b . O btain blood cultures an d cultures of th e

blood bag. c. Adm in ister oxygen , IV fluids, antibiotics, vaso-

pressors, an d corticosteroids as prescribed. D. Iron overload

1. Description : A delayed tran sfusion com plication th at occurs in clien ts wh o receive m ultiple blood tran sfusion s, such as clien ts with an em ia or th rom bocytop en ia

2. Assessm en t a . Vom itin g b . Diarrh ea c. Hypoten sion d . Altered h em atological values

3. In terven tion s a . Deferoxam in e, adm in istered in traven ously or

subcu tan eously, rem oves accu m ulated iron via th e kidn eys.

b . Urin e turn s red as iron is excreted after the ad- m in istration of deferoxam in e; treatm en t is dis- con tin ued wh en serum iron levels return to n orm al.

162 UNIT III Nursing Sciences

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Contact the HCP immediately if a transfusion reac- tion or a complication of blood administration arises.

E. Disease tran sm issio n 1. Th e disease m ost com m on ly tran sm itted is h ep-

atitis C, wh ich is m an ifested by an orexia, n ausea, vo m itin g, dark urin e, an d jaun dice; th e sym p- tom s usually occur with in 4 to 6 weeks after th e tran sfusion .

2. O th er in fectio us agen ts an d diseases tran sm itted by blood tran sfusion in clude h epatitis B virus, h um an im m un od eficien cy virus (HIV), h um an h erpes virus type 6, Epstein -Barr virus, h um an T-cell leukem ia, cytom egalovirus, an d m alaria.

3. Do n or screen in g h as greatly reduced th e risk of tran sm issio n of in fectio us agen ts; in addition , an tibody testin g of don ors for HIV h as greatly reduced th e risk of tran sm ission .

F. Hypo calcem ia 1. Citrate in tran sfused blood bin d s with calcium

an d is excreted. 2. Assess serum calcium level befo re an d after th e

tran sfusion . 3. Mon itor for sign s of h ypo calcem ia (h yperactive

reflexes, paresth esias, tetan y, m uscle cram p s, positive Trousseau’s sign , positive Ch vostek’s sign ) .

4. Slo w th e tran sfusion an d n otify th e HCP if sign s of h ypo calcem ia occur.

G. Hyperkalem ia 1. Stored blood liberates potassium th rough

h em olysis. 2. Th e older th e blood, th e greater th e risk of h yper-

kalem ia; th erefore, clien ts at risk for h yperkale- m ia, such as th ose with ren al in sufficien cy or ren al failure, sh ould receive fresh blood.

3. Assess th e date on th e blood an d th e serum potassium level befo re an d after th e tran sfusion .

4. Mon itor th e potassiu m level an d for sign s an d sym ptom s of h yperkalem ia (paresth esias, weak- n ess, abdom in al cram p s, diarrh ea, an d dysrh yth m ias).

5. Slo w th e tran sfusion an d n otify th e HCP if sign s of h yperkalem ia occur.

H. Citrate toxicity 1. Citrate, th e an ticoagulan t used in blood prod-

ucts, is m etab olized by th e liver. 2. Rap id ad m in istratio n o f m u ltip le u n its o f

sto red b lo o d m ay cau se h yp o calcem ia an d h yp o m agn esem ia wh en citrate b in d s calciu m an d magnesium; th is resu lts in citrate to xicity, cau sin g m yo card ial d ep ressio n an d co agu lo p ath y.

3. Th ose m ost at risk in clude in dividuals with liver dysfun ction or n eon ates with im m ature liver fun ction .

4. Treatm en t in cludes slowin g or stopp in g th e tran sfusion to allow th e citrate to be m etabo- lized; h ypo calcem ia an d h ypom agn esem ia are also treated with replacem en t th erapy.

CRITICAL THINKING What Should You Do? Answer: Signs of an immediate transfusion reaction include the following: chills and diaphoresis; muscle aches, back pain, or chest pain; rash, hives, itching, and swelling; rapid, thready pulse; dyspnea, cough, or wheezing; pallor and cyanosis; apprehension; tingling and numbness; headache; and nausea, vomiting, abdominal cramping, and diarrhea. In the event that a transfusion reaction is suspected, the nurse should first stop the infusion. The nurse should then change the intravenous (IV) tubing down to the IVsite, keep the IVline open with nor- mal saline, notify the health care provider and the blood bank, and return the blood bag and the tubing to the blood bank. The nurse should also collect a urine specimen. The nurse imple- ments prescriptions, stays with the client, and monitors the client closely until the client is stabilized.

Reference: Ignatavicius, Workman (20 16), pp. 824-825.

P R A C T I C E Q U E S T I O N S 116. Packed red blood cells h ave been prescribed for a

fem ale clien t with a h em oglobin level of 7.6 g/ d L (76 m m o l/ L) an d a h em atocrit level of 30% (0.30) . Th e n urse takes th e clien t’s tem p erature befo re h an gin g th e blood tran sfusion an d records 100.6 °F (38.1 °C) orally. Wh ich action sh ould th e n urse take? 1. Begin th e tran sfusio n as prescribed. 2. Adm in ister an an tih istam in e an d begin th e

tran sfusion . 3. Delay h an gin g th e blood an d n otify th e h ealth

care provid er (HCP) . 4. Adm in ister 2 tablets of acetam in oph en an d

begin th e tran sfusion .

117. Th e n urse h as received a prescription to tran sfuse a clien t with a un it of packed red blood cells. Before exp lain in g th e proced ure to th e clien t, th e n urse sh o uld ask wh ich in itial question ? 1. “H ave you ever h ad a tran sfusion befo re?” 2. “Wh y do you th in k th at you n eed th e

tran sfusion ?” 3. “Have you ever gon e in to sh ock for an y reason

in th e past?” 4. “Do you kn ow th e com plication s an d risks of a

tran sfusion ?”

118. A clien t receivin g a tran sfusion of packed red blood cells (PRBCs) begin s to vom it. Th e clien t’s blood pressure is 90/ 50 m m Hg fro m a baselin e of 125/ 78 m m Hg. Th e clien t’s tem perature is 100.8 °F

163CHAPTER 14 Administration of Blood Products

(38.2 °C) orally from a baselin e of 99.2 °F (37.3 °C) orally. Th e n urse determ in es th at th e clien t m ay be experien cin g wh ich com plication of a blood tran sfusion ? 1. Septicem ia 2. Hyperkalem ia 3. Circulatory overload 4. Delayed tran sfusion reaction

119. Th e n urse determ in es th at a clien t is h avin g a tran s- fusion reaction . After th e n urse stops th e tran sfu- sion , wh ich action sh ould be taken n ext? 1. Rem o ve th e in traven o us (IV) lin e. 2. Run a solution of 5% dextrose in water. 3. Run n orm al salin e at a keep-vein -open rate. 4. O btain a culture of th e tip of th e cath eter device

rem oved from th e clien t.

120. Th e n urse h as just received a un it of packed red blood cells from th e blood ban k for tran sfusion to an assign ed clien t. Th e n urse is careful to select tubin g especially m ade for blood produ cts, kn ow- in g th at th is tubin g is m an u factured with wh ich item ? Refer to figu res 1-4. 1.

2.

3.

4.

121. A clien t h as received a tran sfusion of platelets. Th e n urse evaluates th at th e clien t is ben efitin g m ost fro m th is th erap y if th e clien t exh ibits wh ich fin din g?

1. In creased h em atocrit level 2. In creased h em oglobin level 3. Declin e of elevated tem perature to n orm al 4. Decreased oozin g of blood from pun cture sites

an d gu m s

122. Th e n urse h as obtain ed a un it of blood from th e blood ban k an d h as ch ecked th e blood bag prop- erly with an oth er n urse. Just before begin n in g th e tran sfusion , th e n urse sh ould assess wh ich p ri- o rity item ? 1. Vital sign s 2. Skin color 3. Urin e outp ut 4. Latest h em atocrit level

123. Th e n urse h as just received a prescription to tran s- fuse a un it of packed red blood cells for an assign ed clien t. Wh at action sh ould th e n urse take n ext? 1. Ch eck a set of vital sign s. 2. O rder th e blood from th e blood ban k. 3. O btain Y-site blood adm in istration tubin g. 4. Ch eck to be sure th at con sen t for th e tran sfusio n

h as been sign ed .

124. Follo win g in fusion of a un it of packed red blood cells, th e clien t h as developed n ew on set of tach y- cardia, boun din g pulses, crackles, an d wh eezes. Wh ich action sh ould th e n urse im plem en t first? 1. Main tain bed rest with legs elevated . 2. Place th e clien t in h igh -Fowler’s position . 3. In crease th e rate of in fusion of in traven ous fluids. 4. Con sult with th e h ealth care provider (HCP)

regardin g in itiation of oxygen th erapy.

125. Th e n urse, listen in g to th e m orn in g report, learn s th at an assign ed clien t received a un it of gran ulo- cytes th e previous even in g. Th e n urse m akes a n ote to assess th e results of wh ich daily serum labora- tory studies to assess th e effectiven ess of th e tran sfusion ? 1. Hem atocrit level 2. Eryth rocyte coun t 3. Hem oglobin level 4. Wh ite blood cell coun t

126. A clien t is brough t to th e em ergen cy dep artm en t h avin g experien ced blood loss related to an arterial laceration . Wh ich blood com po n en t sh ould th e n urse expect th e h ealth care provider to prescribe? 1. Platelets 2. Gran ulocytes 3. Fresh -frozen plasm a 4. Packed red blood cells

127. Th e n urse wh o is about to begin a blood tran sfu- sion kn ows th at blood cells start to deterio rate after

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164 UNIT III Nursing Sciences

a certain period of tim e. Th e n urse takes wh ich action s in order to preven t a com plication of th e blood tran sfusion as it relates to deterio ration of blood cells? Select all th at ap p ly.

1. Ch ecks th e expiration date 2. In spects for th e presen ce of clo ts 3. Ch ecks th e blood grou p an d type 4. Ch ecks th e blood iden tification n um ber 5. Han gs th e blood with in th e specified tim e

fram e per agen cy policy

128. A clien t requirin g surgery is an xious about th e possible n eed for a blood tran sfusio n durin g or after th e proced ure. Th e n urse suggests to th e cli- en t to take wh ich action s to reduce th e risk of pos- sible tran sfusio n com plication s? Select all th at ap p ly.

1. Ask a fam ily m em ber to don ate blood ah ead of tim e.

2. Give an autologous blood don atio n before th e surgery.

3. Take iron supp lem en ts before surgery to boost h em oglobin levels.

4. Requ est th at an y don ated blood be screen ed twice by th e blood ban k.

5. Take ad equate am oun ts of vitam in C several days prio r to th e surgery date.

129. A clien t with severe blood lo ss resultin g fro m m ul- tiple traum a requires rapid tran sfusion of several un its of blood. Th e n urse asks an oth er h ealth team m em ber to obtain wh ich device for use durin g th e

tran sfusion proced ure to h elp reduce th e risk of cardiac dysrh yth m ias? 1. In fusion pum p 2. Pulse oxim eter 3. Cardiac m on itor 4. Bloo d-warm in g device

130. A clien t h as a prescription to receive a un it of packed red blood cells. Th e n urse sh ould obtain wh ich in traven ous (IV) solution fro m th e IV stor- age area to h an g with th e blood produ ct at th e clien t’s bedside? 1. Lactated Rin ger’s 2. 0.9% sodium ch loride 3. 5% dextrose in 0.9% sodium ch loride 4. 5% dextrose in 0.45% sodium ch loride

131. Th e n urse is carin g for a clien t wh o is receivin g a blood tran sfusion an d is com plain in g of a cough . Th e n urse ch ecks th e clien t’s vital sign s, wh ich in clude tem p erature of 97.2 °F (36.2 °C), pulse of 108 beats per m in ute, blood pressure of 152/ 76 m m Hg, respiratory rate of 24 breath s per m in ute, an d an oxygen saturatio n level of 95% on room air. Th e clien t den ies pain at th is tim e. Based on th is in form ation , wh at in itial action sh o uld th e n urse take? 1. Collect a urin e sam ple for an alysis. 2. Place th e clien t in an uprigh t position . 3. Com pare cu rren t data to baselin e data. 4. Slow th e rate of th e blood tran sfusion .

A N S W E R S 116. 3 Ra t ion a le: If th e clien t h as a tem perature h igh er th an 100 °F (37.8 °C), th e u n it o f bloo d sh ou ld n ot b e h u n g un til th e HCP is n o tified an d h as th e op po rtu n ity to give furth er p re- scription s. Th e HCP likely will p rescribe th at th e bloo d b e ad m in istered regard less of th e tem perature, o r m ay in stru ct th e n u rse to ad m in ister prescrib ed acetam in o ph en an d wait un til th e tem p eratu re h as decreased b efo re ad m in istration , bu t th e d ecisio n is n o t with in th e n u rse’s scop e of p ractice to m ake. Th e n urse n eed s an HCP’s prescrip tion to ad m in ister m ed ication s to th e clien t. Test -Ta kin g St r a t egy: Elim in ate all op tio n s th at in d icate to begin th e tran sfusio n , n o tin g th at th ey are co m p a r a b le o r a lik e. In add itio n , th e op tion s in clud in g an tih istam in e an d acetam in o ph en in dicate adm in isterin g m edicatio n to th e cli- en t, wh ich is n ot d on e with ou t an HCP’s prescrip tion . Review: Nu rsin g respo n sib ilities related to b lo o d t r a n sfu sio n Level of Cogn it ive Ability: Syn th esizin g An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Critical Care—Blo od Ad m in istration

Pr ior ity Con cepts: Clin ical Jud gm en t; Safety Refer en ce: Lewis et al (2014), p . 677.

117. 1 Ra t ion a le: Askin g the clien t about person al experien ce with tran sfusion th erapy pro vides a good startin g poin t for clien t teach in g about th is p ro cedure. Q uestio n in g abo ut p revio us h is- tory of sh o ck an d kn o wledge o f com plication s an d risks o f tran s- fusion is n ot h elpfu l b ecause it m ay elicit a fearful respon se fro m th e clien t. Altho ugh d eterm in in g wh eth er th e clien t kn ows th e reason for th e tran sfusion is im p ortan t, it is n ot an appropriate statem en t in term s o f elicitin g in fo rm ation fro m th e clien t regard in g an u n derstan d in g of th e n eed for th e tran sfu sion . Test -Ta kin g St r a t egy: No te th e st r a t egic wo r d , initial. Th is tells yo u th at th e co rrect o p tion is th e best startin g p o in t fo r d iscus- sion abo ut th e tran sfusio n th erapy. Elim in ate th e op tion s th at h ave em o tio n ally lad en trigger wo rd s, in clud in g gone into shock an d risks, wh ich m ake th em in co rrect. Fro m th e rem ain in g o p tion s, focus o n th e st r a t egic wo r d an d use t h er a p eu t ic co m - m u n ica t io n t ech n iq u es to d irect you to th e co rrect o p tion . Review: Blo o d t r a n sfu sio n proced ures Level of Cogn it ive Abilit y: App lyin g Clien t Need s: Ph ysio lo gical In tegrity

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165CHAPTER 14 Administration of Blood Products

In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ces: Ign ataviciu s, Wo rkm an (2016), p . 117; Perry, Po tter, O sten d o rf (2014), p . 31.

118. 1 Ra tion a le: Sep ticem ia o ccu rs with th e tran sfusion o f bloo d con tam in ated with m icro organ ism s. Sign s in clu de ch ills, fever, vo m itin g, d iarrh ea, h yp oten sion , an d th e d evelop m en t of sh o ck. Hyperkalem ia cau ses weakn ess, p aresth esias, ab do m i- n al cram ps, diarrh ea, an d d ysrh yth m ias. Circulato ry o verload causes co ugh , d yspn ea, ch est pain , wh eezin g, tach ycardia, an d h yp erten sio n . A d elayed tran sfusion reaction can occur d ays to years after a tran sfusion . Sign s in clu d e fever, m ild jau n d ice, an d a decreased h em ato crit level. Test-Ta kin g Str a tegy: Fo cus on th e su b ject , a com plicatio n of a bloo d tran sfu sion . No tin g th at th e clien t’s tem perature is ele- vated will direct yo u to th e correct o ptio n . Review: Co m p lica t io n s o f b lo o d t r a n sfu sio n s Level of Cogn it ive Abilit y: Syn th esizin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—An alysis Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; In fection Refer en ce: Perry, Po tter, O sten d orf, (2014), p . 742.

119. 3 Ra tion a le: If th e n urse su spects a tran sfusio n reaction , th e n u rse sto ps th e tran sfusion an d in fu ses n orm al salin e at a keep-vein -op en rate p en d in g fu rth er h ealth care provid er pre- scrip tio n s. Th is m ain tain s a p aten t IV access lin e an d aids in m ain tain in g th e clien t’s in travascu lar vo lum e. Th e n urse wou ld n o t rem ove th e IV lin e b ecause th en th ere wo uld b e n o IV access rou te. O b tain in g a cu ltu re of th e tip of th e cath eter d evice rem oved fro m th e clien t is in co rrect. First, th e cath eter sh o u ld n o t b e rem oved . Seco n d , cultu res are p erfo rm ed wh en in fectio n , n o t tran sfu sio n reactio n , is susp ected. Norm al salin e is th e solutio n of ch o ice over solutio n s co n tain in g dextro se b ecau se salin e do es n o t cau se red bloo d cells to clu m p. Test-Ta kin g St r a tegy: Note the st r at egic wo r d , next. Knowin g th at th e IV lin e should n ot be rem o ved assists in elim in atin g th e o ptio n s d irectin g th e n urse to d isco ntin ue th e d evice. Recallin g th at n orm al salin e, n ot dextrose, is used wh en adm in isterin g a u n it o f b lood will direct you to th e correct option . Review: Tr a n sfu sio n r ea ct io n s Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Perry, Po tter, O sten d orf (2014), p. 741.

120. 3 Ra tion a le: Th e tub in g u sed fo r blo od adm in istratio n h as an in - lin e filter. Th e filter h elps to en sure th at an y p articles larger th an th e size o f the filter are caught in th e filter an d are n ot in fu sed in to th e clien t. Tin ted tubin g (o ptio n 2) is in correct because b lood does n ot n eed to b e pro tected fro m ligh t. The tub in g

sho uld b e m acro drip , n ot m icro drip (option 4), to allow blood to flow freely th rou gh th e drip ch am b er. An air ven t ( op tio n 1) is u nn ecessary because the b lo od b ag is n ot m ade of glass. Test-Ta kin g St r a t egy: Fo cu s on th e su b ject , in traven o us tub - in g used to adm in ister bloo d. Lo o k at each op tio n carefully an d visualize th e pro cess of b lo od adm in istratio n . Rem em ber th at tu bin g u sed for b lo od ad m in istration h as an in -lin e filter. Review: Blo o d a d m in ist r a t io n Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ces: Ign ataviciu s, Wo rkm an (2016), p . 822; Perry, Po tter, O sten d orf (2014), p . 744.

121. 4 Ra tion a le: Platelets are n ecessary fo r p ro per b loo d clo ttin g. Th e clien t with in sufficien t p latelets m ay exh ib it fran k bleedin g o r o o zin g of blo od fro m pu n cture sites, wou n d s, an d m ucou s m em bran es. In creased h em oglo bin an d h em ato crit levels would occur wh en th e clien t h as received a tran sfusion of red blood cells. An elevated tem p eratu re wo uld declin e to n or- m al after in fusion of gran u lo cytes b ecau se th ese cells were in stru m en tal in figh tin g in fectio n in th e b od y. Test-Ta kin g Str a tegy: Use kn owled ge regardin g th e p oten tial u ses an d b en efits o f th e variou s types o f b loo d p ro du ct tran s- fu sion s. Elim in ate in creased h em ato crit an d in creased h em o- glo bin first b ecause th ey are co m p a r a b le o r a lik e. From th e rem ain in g option s, recallin g th at p latelets are n ecessary for p ro per b lo od clo ttin g will direct yo u to th e correct o ptio n . Review: Typ es o f b lo o d p r o d u ct s Level of Cogn itive Ability: Evalu atin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Evaluatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Clo ttin g Refer en ce: Ign ataviciu s, Wo rkm an (2016), p. 824.

122. 1 Ra tion a le: A ch an ge in vital sign s d urin g th e tran sfu sion from b aselin e m ay in dicate th at a tran sfusion reactio n is occu rrin g. Th is is wh y th e n urse assesses vital sign s befo re th e p ro cedu re an d again after th e first 15 m in utes an d th ereafter per agen cy p olicy. Th e o th er o ptio n s d o n ot id en tify assessm en ts th at are a p rio rity ju st before b egin n in g a tran sfusion . Test-Ta king Str a t egy: Note th e st r at egic wo r d , priority. Th is tells you that m o re th an on e o f th e o ptio n s m ay b e partially o r totally correct an d th at th e correct o ptio n n eeds to be assessed fo r possible com pariso n d urin g th e tran sfu sion . Use th e ABCs— air way, b r ea th in g, a n d cir cu la tio n —to d irect you to th e cor- rect optio n . Review: Blo o d t r a n sfu sio n s Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Assessm en t Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ces: Lewis et al. (2014), p p . 677-679; Perry, Po tter, O sten d orf (2014), p . 744.

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123. 4 Ra t ion a le: After receivin g a prescrip tion fo r a b lo od tran sfu - sion , th e first actio n th e n u rse sh o uld take sh ou ld b e to ch eck to b e su re th at co n sen t fo r th e tran sfusion h as been sign ed by th e clien t. If th e clien t h as co n sen ted, th e n urse sh o uld th en ch eck a set of vital sign s to be sure th ere is n o con train dicatio n fo r a tran sfu sio n at th at tim e, su ch as an elevatio n in tem per- atu re. If th e vital sign s are acceptab le, th e n u rse can th en gath er sup plies to ad m in ister th e tran sfusio n an d ord er th e b lo od fro m th e b loo d b an k. Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d , next. Th is wo rd tells yo u th at all op tio n s m ay b e p artially or to tally co r- rect, an d you n eed to ch oose th e best next ch o ice. Th e n u rse sh ou ld n o t take an y p ro cedu ral step s u n til th e clien t h as co n - sen ted to th e b loo d tran sfusion . Review: Blo o d t r a n sfu sio n s Level of Cogn it ive Ability: Ap plyin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Plan n in g Con t en t Ar ea : Critical Care—Blo od Ad m in istration Pr ior ity Con cepts: Care Co ordin ation ; Health Care Law Refer en ce: Ign atavicius, Workm an (2016), p p. 226, 822.

124. 2 Ra t ion a le: New on set of tach ycardia, b ou n d in g p u lses, an d crackles an d wh eezes p o sttran sfu sio n is eviden ce of fluid over- load , a co m plicatio n asso ciated with blo o d tran sfusio n s. Plac- in g th e clien t in a h igh -Fowler’s (up righ t) p osition will facilitate b reath in g. Measu res th at in crease b loo d return to th e h eart, su ch as leg elevation an d ad m in istration of IV flu id s, sh ou ld be avo ided at th is tim e. In ad dition , adm in istratio n o f fluid s can n ot b e in itiated with ou t a prescrip tio n . Con sultin g with th e HCP regardin g adm in istratio n o f o xygen m ay b e n ec- essary, b ut p o sitio n al ch an ges take a sh ort am o u n t o f tim e to do an d sh ou ld be in itiated first. Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d , first. Ap p ly kn o wledge of sign s an d sym pto m s of circu latory overlo ad an d u se th e ABCs—a ir wa y, b r ea t h in g, a n d cir cu la t io n —to assist yo u with selectin g th e priority actio n . Rem em ber th at placin g th e clien t in a h igh -Fowler’s (up righ t) po sitio n will facilitate b reath in g. Review: Sign s o f cir cu la t o r y o ver lo a d an d associated n u rsin g actio n s Level of Cogn it ive Ability: An alyzin g Clien t Needs: Ph ysiolo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Process—Im plem en tation Con t en t Ar ea : Critical Care—Blo od Ad m in istration Pr ior ity Con cepts: Clin ical Jud gm en t; Perfu sio n Refer en ce: Perry, Potter, O sten do rf (2014), p . 742.

125. 4 Ra t ion a le: Th e clien t wh o h as n eutrop en ia m ay receive a tran sfu sio n of gran u lo cytes, o r WBCs. Th ese clien ts o ften h ave severe in fection s an d are u n respo n sive to an tib io tic th erap y. Th e n u rse n o tes th e results of follow-up WBC cou n ts an d differen tial to evaluate th e effectiven ess of th e th erapy. Th e n urse also co n tin ues to m on itor th e clien t fo r sign s an d sym p- to m s of in fection . Eryth ro cyte cou n t an d h em o glob in an d h em atocrit levels are d eterm in ed after tran sfusion of packed red bloo d cells.

Test -Ta kin g St r a t egy: Note th e st r a t egic wo r d , effectiveness. Recallin g th at gran u locytes are a com p on en t o f WBCs will assist in d irectin g yo u to th e co rrect o p tion . In add itio n , n o te th at th e rem ain in g o p tion s are co m p a r a b le o r a lik e in th at th ese o p tion s all refer to red blo o d cells. Review: Typ es o f b lo o d p r o d u ct s an d gr a n u lo cyt es Level of Cogn it ive Ability: Evaluatin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Evalu ation Con t en t Ar ea : Critical Care—Blo od Ad m in istration Pr ior ity Con cepts: Evid en ce; In fectio n Refer en ce: Lewis et al. (2014), p. 676.

126. 3 Ra t ion a le: Fresh -fro zen p lasm a is o ften u sed for volum e expan sion as a result of flu id an d b lo od lo ss. It is rich in clo t- tin g facto rs an d can b e th awed qu ickly an d tran sfu sed qu ickly. Platelets are used to treat th ro m b ocytop en ia an d p latelet dys- fu n ctio n . Gran u lo cytes m ay b e used to treat a clien t with sepsis o r a n eu tro p en ic clien t with an in fectio n th at is u n respo n sive to an tibiotics. Packed red blo od cells are a b lo od p ro du ct used to rep lace eryth ro cytes. Test -Ta kin g Str a t egy: Fo cus o n th e s u b ject , th e type of tran s- fu sio n th erap y for th e clien t experien cin g b loo d lo ss. Note th e relatio n sh ip between th e wo rd s experienced blood loss an d th e word plasma co rrect o p tion . Review: Fr esh -fr o zen p la sm a Level of Cogn it ive Ability: An alyzin g Clien t Need s: Ph ysio lo gical In tegrity In t egr a ted Pr ocess: Nu rsin g Pro cess—Plan n in g Con t en t Ar ea : Critical Care—Blo od Ad m in istration Pr ior ity Con cepts: Clin ical Jud gm en t; Flu id an d Electro lytes Refer en ce: Lewis et al. (2014), p. 676.

127. 1, 5 Ra t ion a le: Th e n u rse n otes th e exp iration d ate o n th e u n it o f b lo od to en sure th at th e b lo od is fresh . Bloo d cells begin to d eteriorate o ver tim e, so safe sto rage usu ally is lim ited to 35 days. Carefu l n otatio n o f th e expiratio n d ate by th e n u rse is an essen tial p art of th e verification process befo re h an gin g a u n it o f b loo d. Th e n urse also n eeds to h an g th e b lo od with in th e specified tim e fram e after receivin g it fro m th e b loo d b an k p er agen cy po licy to en sure th at th e b loo d bein g tran sfu sed is fresh . Th e blo o d b an k keep s th e bloo d regulated at a specific tem p eratu re, an d th erefo re it m u st b e in fu sed with in a sp eci- fied tim e fram e o n ce received o n th e u n it. Th e n u rse also n otes th e bloo d id en tificatio n (u n it) n u m b er, b lo od gro up an d typ e, an d clien t’s n am e, bu t th is is n o t sp ecifically related to th e degradatio n of b loo d cells. Th e n urse also in sp ects th e u n it of b lo od for leaks, ab n o rm al co lo r, clo ts, an d b ub b les an d return s th e u n it to th e b lo od b an k if clots are n oted . Again , th is is n o t related to th e d egrad ation o f b lo od cells o ver tim e. Test -Ta kin g Str a tegy: Focu s on th e su b ject , m easures to verify p rior to blo o d ad m in istration . Note th e wo rd deteriorate. To an swer th is q u estion co rrectly, yo u m u st kn o w wh ich part o f th e p retran sfu sio n verification p rocedu re relates to th e freshness o f th e un it of b lo od . Keepin g th is in m in d sh o uld d irect you to th e co rrect o p tion s. Review: Blo o d t r a n sfu sio n

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167CHAPTER 14 Administration of Blood Products

Level of Cogn it ive Abilit y: Ap p lyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Perry, Po tter, O sten d orf (2014), pp . 744-745.

128. 1, 2 Ra tion a le: A don atio n of th e clien t’s own blood before a sch ed uled proced ure is au tolo go us. Don atin g au to logo us b loo d to be rein fu sed as n eeded du rin g or after su rgery redu ces th e risk of d isease tran sm ission an d p oten tial tran sfu sio n com - p lication s. Th e n ext m o st effective way is to ask a fam ily m em - b er to do n ate b lo od before su rgery. Blo od ban ks d o n o t p ro vide extra screen in g on req uest. Preo perative iron su p ple- m en ts are h elp fu l fo r iron d eficien cy an em ia b ut are n ot h elp - fu l in replacin g b loo d lo st d urin g th e su rgery. Vitam in C en h an ces iro n ab sorption , bu t also is n o t h elp fu l in replacin g b loo d lo st d u rin g surgery. Test-Ta kin g Str a tegy: Fo cus on th e su b ject , red ucin g th e risk o f p ossible tran sfu sion co m p licatio n s. Recallin g th at an au to l- o gou s tran sfu sion is th e collectio n o f th e clien t’s own bloo d an d also th at fam ily do n atio n of blo o d is u sually effective will d irect yo u to th e co rrect o p tion s. Review: Blo o d d o n a t io n p r o ced u r es Level of Cogn it ive Abilit y: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: An xiety; Safety Refer en ce: Ign ataviciu s, Wo rkm an (2016), pp . 825-826.

129. 4 Ra tion a le: If several un its o f blo o d are to b e ad m in istered rap- id ly, a b loo d warm er sh ou ld b e u sed. Rap id tran sfusio n of coo l b loo d p laces th e clien t at risk fo r card iac d ysrh yth m ias. To pre- ven t th is, th e n urse warm s th e b loo d with a b lo od -warm in g d evice. Pulse oxim etry an d card iac m o n ito rin g equ ip m en t are u sefu l fo r th e early assessm en t of com p lication s b u t d o n o t red uce th e o ccurren ce of cardiac d ysrh yth m ias. Electro n ic in fusio n d evices are n ot h elp ful in th is case b ecause th e in fu- sio n m u st be rap id , an d in fusion d evices gen erally are u sed to con tro l th e flo w rate. In add itio n , n ot all in fu sio n d evices are m ad e to h an d le b lo od o r b lo od p rod ucts. Test-Ta kin g St r a t egy: No te th e wo rd s rapid an d reduce the risk. Th ese words tell you th at th e b loo d will in fu se q uickly an d th at th e correct o ptio n is th e on e th at will m in im ize th e risk o f car- d iac d ysrh yth m ias. Elim in ate th e pu lse oxim eter an d card iac m on itor first b ecau se th ese item s are co m p a r a b le o r a lik e an d are u sed to assess fo r rath er th an red uce th e risk o f co m p li- cation s. Fro m th e rem ain in g op tion s, use kn owled ge related to th e com p lication s of tran sfu sio n th erap y an d n ote th e relation - sh ip b etween th e words several units of blood in th e q uestion an d blood-warming device in th e co rrect o p tion . Review: Blo o d t r a n sfu sio n s Level of Cogn it ive Abilit y: Ap p lyin g

Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Plan n in g Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Perfu sion ; Th erm oregulatio n Refer en ce: Lewis et al. (2014), p . 679.

130. 2 Ra tion a le: So diu m ch lo ride 0.9% (n orm al salin e) is a stan - d ard iso ton ic solutio n u sed to p reced e an d follow in fu sio n o f b loo d prod u cts. Dextro se is n o t used b ecau se it cou ld result in clu m p in g an d su bseq u en t h em o lysis o f red blo od cells (RBCs). Lactated Rin ger’s is n o t th e so lutio n o f ch o ice with th is p ro ced ure. Test-Ta kin g St r a t egy: Elim in ate op tio n s th at con tain dextro se first because th ey are co m p a r a b le o r a lik e. Fro m th e rem ain - in g op tio n s, rem em ber th at n orm al salin e is an iso ton ic so lu- tio n an d th e so lu tion co m p atib le with RBCs. Review: Blo o d t r a n sfu sio n p ro cedu res Level of Cogn itive Ability: Ap plyin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Ign ataviciu s, Wo rkm an (2016), p. 825.

131. 3 Ra tion a le: Fo r th e clien t receivin g a b loo d tran sfusio n , th e n u rse sh o uld m on itor fo r po ten tial co m p licatio n s of a tran sfu- sio n . O n e of th e co m p lication s is circulato ry overlo ad . Sign s an d sym pto m s o f circulato ry overlo ad in clu de cou gh , dysp n ea, ch est pain , wh eezin g o n auscu ltation o f th e lu n gs, h ead ach e, h yp erten sio n , tach ycard ia an d a bo u n d in g p ulse, an d d is- ten d ed n eck vein s. Based o n th e d ata in th e q uestion , th e n urse sh o u ld com p are cu rren t data to b aselin e d ata. Th e n urse sh o u ld also furth er assess th e clien t for o th er sign s an d sym p - to m s o f circulatory o verlo ad. If th e n urse still su sp ects th is com plicatio n after co m p arin g to baselin e data, th e n urse sh o u ld th en p lace th e clien t in an up righ t p osition with th e feet in a dep en d en t po sitio n an d slo w th e rate of th e in fu sio n . Co l- lectio n of a urin e sam ple sh o uld o ccu r if th e n u rse susp ects a tran sfusio n reactio n , such as a h em o lytic reaction . Test-Ta kin g St r a t egy: No te th e st r a t egic wo r d , initial. Th is wo rd in d icates th at so m e o r all o f th e o ptio n s m ay b e p artially o r to tally co rrect, b ut th e n urse n eed s to p rio ritize. Also , d et er - m in e if a n a b n o r m a lit y exist s . No tin g th at th e clien t is com - p lain in g o f cou gh an d th e vital sign s are sligh tly abn orm al sh o u ld h elp you to determ in e th at fu rth er assessm en t is n eed ed at th is tim e. Review: Actio n s to take if a b lo o d t r a n sfu sio n co m p lica t io n is susp ected Level of Cogn itive Ability: An alyzin g Clien t Need s: Ph ysio logical In tegrity In tegr a t ed Pr ocess: Nursin g Pro cess—Im p lem en tatio n Con ten t Ar ea : Critical Care—Bloo d Adm in istratio n Pr ior it y Con cept s: Clin ical Ju dgm en t; Safety Refer en ce: Ign ataviciu s, Wo rkm an (2016), p. 825.

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UNIT IV

Fundamentals of Care

Pyramid to Success

O n th e NCLEX-RN®, safety an d infection con trol con - cepts, includin g stan dard precaution s and tran sm ission- based precaution s, related to clien t care are a priority focus. Medication or in traven ous (IV) calculation ques- tion s are also a focus on th e NCLEX-RN exam in ation . Fill-in -th e-blan k question s m ay require that you calculate a m edication dose or an IV flow rate. Use th e on -screen calculator for th ese m edication and IV problem s an d then rech eck the calculation before selectin g an option or typ- ing th e an swer.

Th e Pyram id to Success also focuses on th e proce- dures for perform in g a h ealth an d ph ysical assessm en t of th e ad ult clien t an d collectin g both subjective an d objective data. Perioperative n ursin g care an d m on itor- in g for posto perative com plication s is a prio rity. Clien t safety related to position in g an d am bulation , an d care to th e clien t with a tube such as a gastro in testin al tube or ch est tube are im portan t con cepts ad dressed on th e NCLEX. Because m an y surgical proced ures are per- form ed th rou gh am bulatory care un its (1-day-stay un its), Pyram id Poin ts also focus on preparin g th e clien t for disch arge, teach in g related to th e prescribed treat- m en ts an d m edication s, follow-up care, an d th e m obili- zation of h om e care supp ort services.

Client Needs: Learning Objectives Safe and Effective Care Environment Actin g as an advocate regardin g th e clien t’s wish es Collaboratin g with in terprofession al h ealth care m em bers En surin g en viron m en tal, perso n al, an d h om e safety En surin g th at th e clien t’s righ ts, in cludin g in form ed con -

sen t, are uph eld Establish in g priorities of assessm en ts an d in terven tion s Followin g advan ce directives regardin g th e clien t’s docu-

m en ted requests

Fo llo win g gu id elin es regard in g th e u se o f safety d evices

Han dlin g h azardous an d in fectio us m aterials safely In form in g th e clien t of th e surgical process an d en surin g

th at in form ed con sen t for a surgical proced ure an d oth er proced ures h as been obtain ed

Kn owin g th e em ergen cy respon se plan an d action s to take for exposure to biological an d chem ical warfare agen ts

Main tain in g con fiden tiality Main tain in g con tin uity of care an d in itiatin g referrals to

h om e care an d oth er support services Main tain in g precaution s to preven t errors, acciden ts,

an d in ju ry Position in g th e clien t ap propriately an d safely Preparin g an d adm in isterin g m edication s, usin g th e

righ ts of m edication adm in istration Preven tin g a surgical in fectio n Protectin g th e m edicated clien t fro m in jury Uph oldin g th e clien t’s righ ts Usin g equ ipm en t safely Usin g ergon om ic prin ciples an d body m ech an ics wh en

m ovin g a clien t Usin g stan dard an d tran sm ission -based precaution s an d

surgical asepsis proced ures

Health Promotion and Maintenance Assistin g clien ts an d fam ilies to id en tify en viron m en tal

h azards in th e h om e Perform in g h om e safety assessm en ts Perform in g th e tech n iqu es associated with th e h ealth

an d ph ysical assessm en t of th e clien t Providin g h ealth an d welln ess teach in g to preven t

com plication s Discussin g h igh -risk beh aviors an d lifestyle ch oices Respectin g lifestyle ch oices an d h ealth care beliefs an d

preferen ces Teach in g clien ts an d fam ilies about acciden t preven tion Teach in g clien ts an d fam ilies about m easu res to be

im plem en ted in an em ergen cy or disaster

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Teach in g clien ts an d fam ilies about preven tin g th e spread of in fectio n an d preven tin g diseases

Teach in g th e clien t about prescribed m edication (s) or IV th erap y

Psychosocial Integrity Assessin g an d m an agin g th e clien t with sen sory an d per-

ception alteration s Discussin g expected body im age ch an ges an d situation al

role ch an ges Facilitatin g clien t an d fam ily copin g Iden tifyin g supp ort system s Iden tifyin g th e cultural, religious, an d spiritual facto rs

in fluen cin g h ealth Keepin g th e fam ily in form ed of clien t progress Provid in g em o tion al supp ort to sign ifican t oth ers

Physiological Integrity Adm in isterin g m edication s an d IV th erapy safely Assessin g for expected an d un expected effects of ph ar-

m acological th erap y Assessin g th e m obility an d im m ob ility level of th e clien t Assistin g th e clien t with activities of daily livin g Calculatin g m ed ication doses an d IV flow rates Docum en tin g th e clien t’s respo n se to basic life supp ort

(BLS) m easu res Han dlin g m ed ical em ergen cies Iden tifyin g clien t allergies an d sen sitivities

Iden tifyin g th e adverse effects of an d con train dication s to m ed ication or IV th erap y

Im plem en tin g priority n ursin g action s in an em ergen cy or disaster

In itiatin g n ursin g in terven tion s wh en surgical com plication s arise

Man agin g an d providin g care to clien ts with in fectio us diseases

Mon itorin g for alteration s in body system s Mon itorin g for surgical com plication s Mon itorin g for woun d in fectio n Preparin g for diagn ostic tests to con firm accu rate place-

m en t of a tube Preven tin g th e com plication s of im m ob ility Prom otin g an en viron m en t th at will allow th e clien t to

express con cern s Providin g com fo rt an d assistan ce to th e clien t Providin g n utrition an d oral in take Providin g in terven tion s com patible with th e clien t’s age;

cultural, religious, spiritual an d h ealth care beliefs; education level; an d lan guage

Providin g perso n al h ygien e as n eeded Recogn izin g ch an ges in th e clien t’s con dition th at in di-

cate a poten tial com plication an d in terven in g appropriately

Usin g assistive devices to preven t in ju ry Usin g special equipm en t

170 UNIT IV Fundamentals of Care

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C H A P T E R 15 Health and Physical Assessment

of the Adult Client PRIORITY CONCEPTS Clinical Judgment; Health Promotion

CRITICAL THINKING What Should You Do? The nurse is performing a cardiovascular assessment and notes the presence of a blowing, swishing sound over the carotid artery. What should the nurse do? Answer located on p. 188.

I. Environment/ Setting A. Establish a relation sh ip an d explain th e proced ure to

th e clien t. B. En su re privacy an d m ake th e clien t feel com fo rtable

(com fortable room tem p erature, sufficien t ligh tin g, rem ove distraction s such as n oise or objects, an d avoid in terrup tion s).

C. Sit down for th e in terview (avoid barriers such as a desk), m ain tain an ap propriate social distan ce, an d m ain tain eye level.

D. Use th erapeutic com m un ication tech n iqu es an d open -en ded question s to obtain in form ation about th e clien t’s sym pto m s an d con cern s; allow tim e for th e clien t to ask question s.

E. Co n sid er religio u s an d cu ltu ral ch aracteristics su ch as lan gu age ( th e n eed fo r an in terp reter) , valu es an d b eliefs, h ealth p ractices, eye co n tact, an d to u ch .

F. Keep n ote-takin g to a m in im u m so th e clien t is th e focus of atten tion .

G. Types of h ealth an d ph ysical assessm en ts ( Box 15-1)

II. Health History A. Gen eral state of h ealth : Body features an d ph ysical

ch aracteristics, body m ovem en ts, body posture, level of con scio usn ess, n utrition al status, speech

B. Ch ief com plain t an d h isto ry of presen t illn ess (doc- um en t direct clien t quotes) th at leads th e clien t to seek care

C. Fam ily h isto ry: Th e h ealth status of direct blood rel- atives as well as th e clien t’s spouse

D. Social h istory 1. Data ab out th e clien t’s lifestyle, with a focus on

facto rs th at m ay affect h ealth 2. In form ation ab out alcoh ol, drug, an d tobacco

use; sexual practices; tattoos; body piercin g; travel h istory; an d work settin g to iden tify occu- patio n al h azards

E. Dom estic violen ce screen in g 1. Do n e to determ in e wh eth er th e clien t is

experien cin g an y form of dom estic violen ce 2. Con ducted durin g a 1-to-1 in terview with

th e clien t wh ile obtain in g th e h ealth h isto ry

III. Mental Status Exam A. Th e m en tal status can be assessed wh ile obtain in g

subjective data fro m th e clien t durin g th e h ealth h is- tory in terview.

B. Appearan ce 1. No te appearan ce, in cludin g postu re, body m ove-

m en ts, dress, an d h ygien e an d groo m in g. 2. An in approp riate ap pearan ce an d poor h ygien e

m ay be in dicative of dep ression , m an ic disorder, dem en tia, organ ic brain disease, or an oth er disorder.

C. Beh avior 1. Level of con scio usn ess: Assess alertn ess an d

awaren ess an d th e clien t’s ability to in teract appropriately with th e en viron m en t.

2. Facial exp ression an d body lan guage: Ch eck for appropriate eye con tact an d determ in e wh eth er facial expressio n an d body lan guage are appro- priate to th e situation ; th is assessm en t also pro- vides in form ation regardin g th e clien t’s m ood an d affect.

3. Speech : Assess speech pattern for articulation an d appropriaten ess of con versation .

D. Cogn itive level of fun ction in g ( Box 15-2)

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IV. Physical Exam A. O verview

1. Gath er equ ipm en t n eeded for th e exam in ation . 2. Use th e sen ses of sigh t, sm ell, touch , an d h earin g

to collect data. 3. Assessm en t in cludes inspection, palpation, per-

cussion, an d auscultation; th ese skills are per- form ed on e at a tim e, in th is order (except th e abdom in al assessm en t) .

B. Assessm en t tech n iqu es 1. In spection

a . Th e first assessm en t tech n iqu e, wh ich uses vision an d sm ell sen ses wh ile observin g th e clien t

b . Requ ires go od ligh tin g, adequ ate body exposu re, an d possibly th e use of certain in strum en ts such as an otosco pe or oph th al- m osco pe

2. Palp ation a . Uses th e sen se of touch ; warm th e h an ds

befo re touch in g th e clien t.

b . Iden tify ten der areas an d palpate th em last. c. Start with ligh t palp ation to detect surface

ch aracteristics, an d th en perform deeper palpation .

d . Ligh t palpation is don e with 1 h an d by pressin g th e skin gen tly with th e tips of 2 or 3 fingers h eld close togeth er; deep palpation is don e by placin g 1 h an d on top of th e oth er an d pressin g down with th e fin gertips of both h an ds.

e. Assess texture, tem perature, an d m oistu re of th e skin , as well as organ lo cation an d size an d sym m etry if appropriate.

f. Assess for swellin g, vibration or pulsation , rigidity or spasticity, an d crepitation .

g. Assess for th e presen ce of lum ps or m asses, as well as th e presen ce of ten dern ess or pain .

3. Percussion a . In volves tappin g th e clien t’s skin to assess

un derlyin g structures an d to determ in e th e presen ce of vibration s an d soun ds an d, if pre- sen t, th eir in ten sity, duration , pitch , quality, an d lo cation

b . Provid es in form ation related to th e presen ce of air, fluid, or solid m asses as well as organ size, sh ap e, an d position

c. Description s of fin din gs in clude reson an ce, h yperreson an ce, tym pan y, dulln ess, or flatn ess

4. Auscu ltation : In vo lves listen in g to soun ds pro- duced by th e body for presen ce an d quality, such as h eart, lu n g, or bowel soun ds

C. Vital sign s 1. In clu des tem perature, radial pulse (apical pulse

m ay be m easu red durin g th e cardiovascular assessm en t), respiration s, blood pressure, pulse oxim etry, an d presen ce of pain (refer to Ch apter 10 for in form ation on vital sign s, pulse oxim etry, an d pain )

2. Heigh t, weigh t, an d n utrition al status are also assessed.

V. Body Systems Assessment A. In tegum en tary system : In vo lves in spection an d pal-

pation of skin , h air, an d n ails. 1. Subjective data: Self-care beh aviors, h istory of

skin disease, m edication s bein g taken , en viron - m en tal or occupation al h azards an d exposu re to toxic substan ces, ch an ges in skin color or pig- m en tation , ch an ge in a m ole or a sore th at does n ot h eal

2. Objective data: Color, tem p erature (h ypoth erm ia or h yperth erm ia); excessive dryn ess or m oistu re; skin turgor; texture (sm ooth n ess, firm n ess); excessive bruisin g, itch in g, rash ; h air loss (alope- cia) or n ail abn o rm alities such as pittin g; lesion s (m ay be in spected with a m agn ifier an d ligh t or with th e use of a Wood ’s ligh t [u ltraviolet ligh t

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BOX 15-1 Types of Health and Physical Assessments

Complete Assessment: Includes a complete health history and physical examination and forms a baseline database.

Focused Assessment : Focuses on a limited or short-term prob- lem, such as the client’s complaint.

Episodic/ Follow-up Assessment: Focuses on evaluating a cli- ent’s progress.

Emergency Assessment: Involves the rapid collection of data, often during the provision of life-saving measures.

BOX 15-2 The Mental Status Examination: Cognitive Level of Functioning

Orienta t ion: Assess client’s orientation to person, place, and time.

At tention Spa n: Assess client’s ability to concentrate. Recent Memory: Assessed by asking the client to recall a

recent occurrence (e.g., the means of transportation used to get to the health care agency for the physical assessment).

Remote Memory: Assessed by asking the client about a verifi- able past event (e.g., a vacation).

New Lea rning: Used to assess the client’s ability to recall unre- lated words identified by the nurse; the nurse selects 4 words and asks the client to recall the words 5, 10, and 30 minutes later.

Judgment: Determine whether the client’s actions or decisions regarding discussions during the interview are realistic.

Thought Processes a nd Perceptions: The way the client thinks and what the client says should be logical, coherent, and relevant; the client should be consistently aware of reality.

172 UNIT IV Fundamentals of Care

used in a darken ed room ]); scars or birth m arks; edem a; cap illary fillin g tim e (Boxes 15-3 an d 15-4; Table 15-1)

3. Dark-skin n ed clien t a. Cyan osis: Ch eck lips an d ton gue for a gray

color; n ail bed s, palm s, an d soles for a blue color; an d con jun ctivae for pallor.

b . Jau n dice: Ch eck oral m ucou s m em bran es for a yellow color; ch eck th e sclera n earest to th e iris for a yello w color.

c. Bleedin g: Look for skin swellin g an d darken - in g an d com pare th e affected side with th e un affected side.

d . In flam m ation : Ch eck for warm th or a sh in y or taut an d pittin g skin area, an d com pare with th e un affected side.

4. Refer to Ch apter 46 for diagn ostic tests related to th e in tegu m en tary system

To test skin turgor, pinch a large fold of skin and assess the ability of the skin to return to its place when released. Poor turgor occurs in severe dehydration or extreme weight loss.

5. Clien t teach in g a. Provide in form ation ab out facto rs th at can be

h arm ful to th e skin , such as sun exposu re.

b . En cou rage perform in g self-exam in ation of th e skin m on th ly.

B. Head, n eck, an d lym p h n odes: In volves in spection an d palpatio n of th e h ead, n eck, an d lym ph n od es 1. Ask th e clien t about h eadach es; episo des of diz-

zin ess (ligh th eadedn ess) or vertigo (spin n in g sen sation ); h istory of h ead in jury; loss of con - sciousn ess; seizures; episo des of n eck pain ; lim i- tatio n s of ran ge of m otion ; n um bn ess or tin glin g in th e sh oulders, arm s, or h an ds; lum ps or swell- in g in th e n eck; difficu lty swallowin g; m edica- tion s bein g taken ; an d h istory of surgery in th e h ead an d n eck region .

2. Head a. In spect an d palpate: Size, sh ape, m asses or

ten dern ess, an d sym m etry of th e sku ll b . Palp ate tem poral arteries, lo cated above th e

ch eekbon e between th e eye an d th e top of th e ear.

c. Tem po rom an d ibular join t: Ask th e clien t to open h is or h er m ou th ; n ote an y crepitation , ten dern ess, or lim ited ran ge of m otion .

d . Face: In spect facial structures for sh ape, sym - m etry, in volun tary m ovem en ts, or swellin g, such as periorbital edem a (swellin g arou n d th e eyes).

3. Neck a. In spect for sym m etry of accessory n eck

m uscles. b . Assess ran ge of m otion . c. Test cran ial n erve XI (spin al accesso ry n erve)

to assess m uscle stren gth : Ask th e clien t to push again st resistan ce applied to th e side of th e ch in (tests stern ocleidom astoid m us- cle); also ask th e clien t to sh rug th e sh oulders again st resistan ce (tests trapezius m uscle).

d . Palp ate th e trach ea: It sh o uld be m idlin e, with ou t an y deviatio n s.

e. Th yroid glan d: In spect th e n eck as th e clien t takes a sip of water an d swallows (th yroid tissue m oves up with a swallow); palp ate usin g an an terior-po sterior approach

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TABLE 15-1 Pitting Edema Scale Scale Description “Measurement”*

1+ A barely perceptible pit 2 mm (3=32 in)

2+ 4

mm

1+ 2

mm

3+ 6

mm

4+ 8

mm

2 + A deeper pit, rebounds in a few seconds

4 mm (6

32 in)

3+ A deep pit, rebounds in 10 -20 sec 6 mm (1=4 in)

4 + A deeper pit, rebounds in > 30 sec 8 mm (5=16 in)

*“Measurement” is in quotation marks because depth of edema is rarely actually measured but is included as a frame of reference. Data from Wilson AF, Giddens JF: Health assessment for nursing practice, ed 5, St. Louis, 20 13, Mosby. Description column data from Kirton C: Assessing edema, Nursing 96 26(7):54, 1996.

BOX 15-4 Assessing Capillary Filling Time 1. Depress the nail bed to produce blanching. 2. Release and observe for the return of color. 3. Color will return within 3 seconds if arterial capillary perfu-

sion is normal.

BOX 15-3 Characteristics of Skin Color Cya nosis: Mottled bluish coloration Eryt hema : Redness Pa llor: Pale, whitish coloration Ja undice: Yellow coloration

173CHAPTER 15 Health and Physical Assessment of the Adult Client

(usually th e n orm al adult th yroid can n ot be palp ated); if it is en larged, auscultate for a bruit.

4. Lym ph n od es a . Palp ate usin g a gen tle pressure an d a circular

m otion of th e fin ger pads. b . Begin with th e preauricular lym p h n odes (in

fron t of th e ear); m ove to th e posterio r auric- ular lym ph n odes an d th en down ward toward th e supraclavicular lym p h n odes.

c. Palp ate with both h an ds, com parin g th e 2 sides for sym m etry.

d . If n od es are palpated, n ote th eir size, sh ap e, location , m ob ility, con sisten cy, an d ten dern ess.

5. Clien t teach in g: In struct th e clien t to n otify th e h ealth care provider (HCP) if persisten t h ead- ach e, dizzin ess, or n eck pain occurs; if swellin g or lum ps are n oted in th e h ead an d n eck region ; or if a n eck or h ead in ju ry occurs.

Neck movements are never performed if the client has sustained a neck injury or if a neck injury is suspected.

C. Eyes: In cludes in spection , palpation , vision -testin g procedures, an d the use of an oph th alm oscope 1. Subjective data: Difficulty with vision (e.g.,

decreased acuity, double vision , blurrin g, blin d spots); pain , redn ess, swellin g, watery or oth er disch arge from th e eye; use of glasses or con tact len ses; m ed ication s bein g taken ; h isto ry of eye problem s

2. O bjective data a . In spect th e extern al eye structures, in cludin g

eyeb rows, for sym m etry; eyelash es for even distribution ; eyelids for ptosis (dro opin g); eyeb alls for exoph th alm o s (protru sion ) or en oph th alm o s (recession in to th e orbit; sun ken eye).

b . In spect th e con jun ctiva (sh ould be clear), sclera (sh ould be wh ite), an d lacrim al appara- tus (ch eck for excessive tearin g, redn ess, ten - dern ess, or swellin g) ; corn ea an d len s (sh ou ld be sm ooth an d clear) ; iris (sh ou ld be flat, with a roun d regular sh ape an d even coloration ); eyelids; an d pupils

3. Sn ellen eye ch art a . Th e Sn ellen eye ch art is a sim ple tool used to

m easu re distan ce vision . b . Position th e clien t in a well-lit spot 20 feet (6

m eters) from th e ch art, with th e ch art at eye level, an d ask th e clien t to read th e sm allest lin e th at h e or sh e can discern .

c. In struct th e clien t to leave on glasses or leave in con tact len ses; if th e glasses are for readin g on ly, th ey are rem oved because th ey blur dis- tan ce vision .

d . Test 1 eye at a tim e. e. Record th e result usin g th e fraction at th e en d

of th e last lin e successfully read on th e ch art. f. Norm al visual acuity is 20/ 20 (distan ce in feet

at wh ich th e clien t is stan din g fro m th e ch art/ distan ce in feet at wh ich a n orm al eye could h ave read th at particular lin e) .

4. Near vision a . Use a h an d-h eld vision screen er (h eld about

14 in ch es [35.5 cen tim eters] from th e eye) th at con tain s various sizes of prin t or ask th e clien t to read fro m a m agazin e.

b . Test each eye sep arately with th e clien t’s glasses on or con tact len ses in .

c. Norm al result is 14/ 14 (distan ce in inch es at wh ich the subject h olds th e card from th e eye/ distan ce in inch es at wh ich a n orm al eye could h ave read th at particular lin e).

5. Con fron tatio n test a . A crude but rapid test used to m easu re periph -

eral vision an d com pare th e clien t’s periph - eral vision with th e n urse’s (assum in g th at th e n urse’s periph eral vision is n orm al)

b . Th e clien t covers 1 eye an d looks straigh t ah ead ; th e n urse, position ed 2 feet away (60 cen tim eters), covers h is or h er eye opposite th e clien t’s covered eye.

c. Th e n urse advan ces a fin ger or oth er sm all object from th e periph ery from several direc- tion s; th e clien t sh ould see th e object at th e sam e tim e th e n urse does.

6. Corn eal ligh t reflex a . Used to assess for parallel align m en t of th e

axes of th e eyes b . Clien t is asked to gaze straigh t ah ead as th e

n urse h old s a ligh t about 12 in ch es (30 cen ti- m eters) from th e clien t.

c. Th e n urse looks for reflection of the ligh t on the corn eas in exactly th e sam e spot in each eye.

7. Cover test a . Used to ch eck for sligh t degrees of deviated

align m en t b . Each eye is tested sep arately. c. Th e n urse asks th e clien t to gaze straigh t

ah ead an d cover 1 eye. d . Th e n urse exam in es th e un co vered eye,

expectin g to n ote a steady, fixed gaze. 8. Extraocular m uscle fun ction (6 cardin al posi-

tion s of gaze) (Fig. 15-1) a . Th e 6 m uscles th at attach th e eyeball to its

orbit an d serve to direct th e eye to poin ts of in terest are tested.

b . Clien t h old s h ead still an d is asked to m ove h is or h er eyes an d follow a sm all object.

c. Th e exam in er n otes an y parallel m ovem en ts of th e eye or n ystagm u s, an in volun tary, rh yth m ic, rapid twitch in g of th e eyeb alls.

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174 UNIT IV Fundamentals of Care

9. Color vision a. Tests for color vision in volve pickin g n um -

bers or letters out of a co m plex an d colorful picture.

b . Th e Ish ih ara ch art is used for testin g an d con - sists of n um bers com po sed of colored dots lo cated with in a circle of colored dots.

c. Th e clien t is asked to read th e n um bers on th e ch art.

d . Each eye is tested separately. e. Readin g th e n um bers correctly in dicates n or-

m al color vision . f. Th e test is sen sitive for th e diagn osis of red-

green blin dn ess but can n ot detect discrim in a- tio n of blue.

The first slide on the Ishihara chart is one that every- one can discriminate; failure to identify numbers on this slide suggests a problem with performing the test, not a problem with color vision.

10. Pupils ( Box 15-5) a. Th e pupils are roun d an d of equal size. b . Increasin g ligh t causes pupillary con striction .

c. Decreasin g ligh t cau ses pupillary dilation . d . Con striction of both pupils is a n orm al

respo n se to direct ligh t. 11. Sclera an d corn ea

a. No rm al sclera color is wh ite. b . A yellow color to th e sclera m ay in dicate jaun -

dice or system ic problem s. c. In a dark-skin n ed perso n , th e sclera m ay n or-

m ally appear yellow; pigm en ted dots m ay be presen t.

d . Th e co rn ea is tran sparen t, sm ooth , sh in y, an d brigh t.

e. Cloudy areas or specks on th e corn ea m ay be th e result of an acciden t or eye in jury.

12. O ph th alm o scopy a. Th e oph th alm oscop e is an in strum en t used to

exam in e th e extern al structures an d th e in te- rior of th e eye.

b . Th e ro om is darken ed so th at th e pupil will dilate.

c. Th e in strum en t is h eld with th e righ t h an d wh en exam in in g th e righ t eye an d with th e left h an d wh en exam in in g th e left eye.

d . Th e clien t is asked to look straigh t ah ead at an object on th e wall.

e. Th e exam in er sh ould approach th e clien t’s eye from about 12 to 15 in ch es (30.5 to 38 cen tim eters) away an d 15 degrees lateral to th e clien t’s lin e of vision .

f. As th e in strum en t is directed at th e pupil, a red glare (red reflex) is seen in th e pupil.

g. Th e red reflex is th e reflection of ligh t on th e vascu lar retin a.

h . Absen ce of th e red reflex m ay in dicate opacity of th e len s.

i. Th e retin a, optic disc, optic vessels, fun dus, an d m acula can be exam in ed .

13. Refer to Ch apter 60 for diagn ostic tests related to th e eye.

14. Clien t teach in g a. In struct th e clien t to n otify th e HCP

if alteration s in vision occur or an y red- n ess, swellin g, or drain age from th e eye is n oted.

b . In form th e clien t of th e im portan ce of regular eye exam in ation s.

D. Ears: In cludes in spection , palpatio n , h earin g tests, vestibular assessm en t, an d th e use of an otosco pe 1. Subjective data: Difficulty h earin g, earach es,

drain age from th e ears, dizzin ess, rin gin g in th e ears, exp osure to en viron m en tal n oise, use of a h earin g aid, m edication s bein g taken , h istory of ear problem s or in fection s

2. O bjective data a. In spect an d palpate th e extern al ear, n otin g

size, sh ap e, sym m etry, skin color, an d th e presen ce of pain .

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BOX 15-5 Assessing and Documenting Pupillary Responses

Pupillary Light Reflex 1. Darken the room (to dilate the client’s pupils) and ask the

client to look forward. 2. Test each eye. 3. Advance a light in from the side to note constriction of the

same-side pupil (direct light reflex) and simultaneous con- striction of the other pupil (consensual light reflex).

Accommodation 1. Ask the client to focus on a distant object (dilates the pupil). 2. Ask the client to shift gaze to a near object held about

3 inches (7.5 centimeters) from the nose. 3. Normal response includes pupillary constriction and

convergence of the axes of the eyes.

Documenting Normal Findings: PERRLA P¼pupils E¼equal R¼round RL¼reactive to light A¼reactive to accommodation

III

III

III

III

VI

IVIII

III

VI

FIGURE 15-1 Checking extraocular muscles in the 6 cardinal positions. This indicates the functioning of cranial nerves III, IV, and VI.

175CHAPTER 15 Health and Physical Assessment of the Adult Client

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b . In spect the extern al auditory m eatus for size, swellin g, redn ess, disch arge, an d foreign bod- ies; som e cerum en (earwax) m ay be presen t.

3. Auditory assessm en t a . Soun d is tran sm itted by air con duction an d

bon e con duction . b . Air con duction takes 2 or 3 tim es lon ger th an

bon e con duction . c. Hearin g loss is categorized as co n ductive, sen -

sorin eural, or m ixed con d uctive an d sen sorin eural.

d . Con ductive h earin g loss is cau sed by an y ph ysical obstru ction to th e tran sm ission of soun d waves.

e. Sen sorin eural h earin g loss is cau sed by a defect in th e coch lea, eigh th cran ial n erve, or th e brain itself.

f. A m ixed h earin g loss is a com bin ation of a con d uctive an d sen sorin eural h earin g lo ss; it results from problem s in both th e in n er ear an d th e outer ear or m iddle ear.

4. Voice (Wh isper) test a . Used to determ in e wh eth er h earin g loss h as

occurred b . O n e ear is tested at a tim e (th e ear n ot bein g

tested is occluded by th e clien t). c. Th e n urse stan ds 1 to 2 feet (30 to 60 cen tim e-

ters) from th e clien t, covers his or h er m outh so th at th e clien t can n ot read th e lips, exh ales fully, an d softly whispers 2-syllable words in th e direction of th e un occluded ear; the clien t poin ts a fin ger up durin g the test wh en th e n urse’s voice is h eard (a ticking watch m ay also be used to test h earin g acuity).

d . Failure to h ear th e soun ds could in dicate pos- sible fluid collection an d/ o r con solidation , requirin g furth er assessm en t.

5. Watch test a . A tickin g watch is used to test for h igh -

frequen cy soun ds. b . Th e exam in er h old s a tickin g watch about 5

in ch es (12.5 cen tim eters) from each ear an d asks th e clien t if th e tickin g is h eard.

6. Tun in g fork tests a . Used to m easure h earin g on th e basis of air

con d uction or bon e con duction ; in cludes th e Weber an d Rin n e tests

b . To activate th e tun in g fork, th e n urse h olds th e base an d ligh tly taps th e tin es again st th e oth er h an d, settin g th e fork in vibration .

7. Weber test a . Determ in es wh eth er th e clien t h as a con duc-

tive or sen sorin eural h earin g loss b . Stem of th e vibratin g tun in g fork is placed in

th e m idlin e of th e clien t’s sku ll an d th e clien t is asked if th e ton e soun ds th e sam e in both ears or better in 1 ear.

c. Th e clien t h ears th e ton e by bon e con duction an d th e soun d sh o uld be h eard equ ally in both ears.

d . In con d uctive loss, th e soun d travels toward th e im paired ear.

e. In sen sorin eural lo ss, th e soun d travels toward th e go od ear.

8. Rin n e test a . Stem of th e vibratin g tun in g fork is placed on

th e clien t’s m astoid process. b . Wh en th e clien t n o lo n ger h ears th e soun d,

th e tun in g fork is quickly in verted an d placed n ear th e ear can al; th e clien t sh o uld still h ear a soun d.

c. Norm ally th e soun d is h eard twice as lon g by way of air con duction (AC) (n ear th e ear can al) th an by way of bon e con duction (BC) (at th e m astoid process); AC > BC.

d . In sen sorin eural h earin g loss, air con duction is h eard lon ger th an bon e con d uction , but it is n ot h eard to be twice as lon g.

e. In con d uctive h earin g loss, th e bon e con duc- tion soun d is lon ger th an or equal to th e air con duction soun d.

9. Vestibu lar assessm en t ( Box 15-6) 10. O tosco pic exam

Before performing an otoscopic exam and inserting the speculum, check the auditory canal for foreign bod- ies. Instruct the client not to move the head during the examination to avoid damage to the canal and tympanic membrane.

a . Th e clien t’s h ead is tilted sligh tly away an d th e otoscope is h eld upside down as if it were a large pen ; th is perm its th e exam in er’s h an d to lay again st th e clien t’s h ead for support.

b . In an adult, pull th e pin n a up an d back to straigh ten th e extern al can al.

c. Visualize th e extern al can al wh ile slowly in sertin g th e speculum .

d . Th e n orm al extern al can al is pin k an d in tact, with ou t lesion s an d with varyin g am oun ts of cerum en an d fin e little h airs.

e. Assess th e tym pan ic m em bran e for in tactn ess; th e n orm al tym pan ic m em bran e is in tact, with ou t perforation s, an d sh ould be free from lesion s.

f. Th e tym pan ic m em bran e is tran sparen t, o- paque, pearly gray, an d sligh tly con cave.

g. A fluid lin e or th e presen ce of air bubbles is n ot n orm ally visible.

h . If th e tym pan ic m em bran e is bulgin g or retractin g, th e edges of th e ligh t reflex will be fuzzy (diffu se) an d m ay spread over th e tym pan ic m em bran e.

176 UNIT IV Fundamentals of Care

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The otoscope is never introduced blindly into the external canal because of the risk of perforating the tym- panic membrane.

11. Refer to Ch apter 60 for diagn ostic tests related to th e ear.

12. Clien t teach in g a. In struct th e clien t to n otify th e HCP if an

alteration in h earin g or ear pain or rin gin g in th e ears occurs, or if redn ess, swellin g, or drain age from th e ear is n oted.

b . In struct th e clien t in th e proper m eth od of clean in g th e ear can al.

c. Th e client should clean se th e ear can al with the corn er of a m oisten ed wash cloth an d sh ould n ever in sert sh arp objects or cotton -tipped applicators in to th e ear can al.

E. No se, m ou th , an d th roat: In cludes in spection an d palp ation

1. Subjective data a. No se: Ask about disch arge or n oseb leed (epi-

staxis) , facial or sin us pain , h isto ry of fre- quen t colds, altered sen se of sm ell, allergies, m ed ication s bein g taken , h istory of n ose traum a or surgery.

b . Mou th an d th roat: Ask ab out th e presen ce of sores or lesion s; bleed in g from th e gum s or elsewh ere; altered sen se of taste; tooth ach es; use of den tures or oth er applian ces; tooth an d m outh care h ygien e h abits; at-risk beh av- iors (e.g., sm okin g, alcoh ol con sum p tion ); an d h istory of in fection , traum a, or surgery.

2. O bjective data a. Extern al n ose sh ould be m idlin e an d in pro-

portion to oth er facial features. b . Paten cy of th e n ostrils can be tested by push -

in g each n asal cavity closed an d askin g th e cli- en t to sn iff in ward th rough th e oth er n ostril.

c. A n asal speculum and penlight or a sh ort, wide- tipped speculum attach ed to an otoscope h ead is used to in spect for redn ess, swellin g, dis- ch arge, bleedin g, or foreign bodies; th e n asal septum is assessed for deviation .

d . Th e n u rse p resses th e fro n tal sin u ses ( lo cated b elo w th e eyeb ro ws) an d o ver th e m axillary sin u ses ( lo cated b elo w th e ch eek- b o n es) ; th e clien t sh o u ld feel firm p ressu re b u t n o p ain .

e. Th e extern al an d in n er surfaces of th e lips are assessed for color, m oistu re, crackin g, or lesion s.

f. Th e teeth are in spected for con d ition an d n um ber (sh ou ld be wh ite, spaced even ly, straigh t, an d clean , free of debris an d decay).

g. Th e align m en t of th e upper an d lo wer jaw is assessed by h avin g th e clien t bite down .

h . Th e gum s are in spected for swellin g, bleed- in g, discoloration , an d retraction of gin gival m argin s (gum s n orm ally appear pin k).

i. Th e ton gue is in spected for color, surface ch aracteristics, m oistu re, wh ite patch es, n od- ules, an d ulceration s (do rsal surface is n or- m ally rough ; ven tral surface is sm oo th an d glisten in g, with visible vein s).

j. Th e n urse retracts th e ch eek with a ton gue dep ressor to ch eck th e buccal m ucosa for color an d th e presen ce of n odules or lesion s; n orm al m ucosa is glisten in g, pin k, soft, m oist, an d sm oo th .

k . Usin g a pen ligh t an d ton gue dep ressor, th e n urse in spects th e h ard an d soft palates for color, sh ap e, texture, an d defects; th e h ard palate (roof of th e m outh ) , wh ich is located an teriorly, sh ould be wh ite an d dom e- sh ap ed, an d th e soft palate, wh ich exten ds posteriorly, sh ould be ligh t pin k an d sm oo th .

BOX 15-6 Vestibular Assessment

Test for Falling 1. The examiner asks the client to stand with the feet together,

arms hanging loosely at the sides, and eyes closed. 2. The client normally remains erect, with only slight swaying. 3. A significant sway is a positive Romberg sign.

Test for Past Pointing 1. The client sits in front of the examiner. 2. The client closes the eyes and extends the arms in front,

pointing both index fingers at the examiner. 3. The examiner holds and touches his or her own extended

index fingers under the client’s extended index fingers to give the client a point of reference.

4. The client is instructed to raise both arms and then lower them, attempting to return to the examiner’s extended index fingers.

5. The normal test response is that the client can easily return to the point of reference.

6. The client with a vestibular function problem lacks a nor- mal sense of position and cannot return the extended fin- gers to the point of reference; instead, the fingers deviate to the right or left of the reference point.

Gaze Nystagmus Evaluation 1. The client’s eyes are examined as the client looks straight

ahead, 30 degrees to each side, upward and downward. 2. Any spontaneous nystagmus—an involuntary, rhythmic,

rapid twitching of the eyeballs—represents a problem with the vestibular system.

Dix-Hallpike Maneuver 1. The client starts in a sitting position; the examiner lowers

the client to the exam table and rather quickly turns the cli- ent’s head to the 45-degree position.

2. If after about 30 seconds there is no nystagmus, the client is returned to a sitting position and the test is repeated on the other side.

177CHAPTER 15 Health and Physical Assessment of the Adult Client

l. Th e uvula is in spected for m idlin e location ; th e n urse asks th e clien t to say “ah h h ” an d watch es for th e soft palate an d uvula to rise in th e m idlin e (th is tests 1 fun ction of cran ial n erve X, th e vagus n erve).

m . Usin g a pen ligh t an d ton gue dep ressor, th e n urse in spects th e th roat for color, presen ce of ton sils, an d th e presen ce of exudate or lesion s; 1 tech n ique to test cran ial n erve XII (th e h ypo glossal n erve) is askin g th e clien t to stick out th e ton gue (sh ou ld protrude in th e m idlin e).

n . To test th e gag reflex, touch th e posterior ph aryn x with th e en d of a ton gue blade; th e clien t sh ould gag m om en tarily (th is tests th e fun ctio n of cran ial n erve IX, th e glossoph aryn geal n erve).

3. Clien t teach in g a . Em ph asize th e im portan ce of h ygien e an d

tooth care, as well as regular den tal exam in a- tion s an d th e use of fluorid ated water or fluo- ride supp lem en ts.

b . En cou rage th e clien t to avoid at-risk beh av- iors (e.g., sm okin g, alcoh ol con sum p tion ).

c. Stress th e im portan ce of reportin g pain or abn o rm al occurren ce (e.g., n odules, lesion s, sign s of in fection ).

F. Lun gs 1. Su b jective d ata: Co u gh ; exp ecto ratio n o f sp u -

tu m ; sh o rtn ess o f b reath o r d ysp n ea; ch est p ain o n b reath in g; sm o kin g h isto ry; en viro n - m en tal exp o su re to p o llu tio n o r ch em icals; m ed icatio n s b ein g taken ; h isto ry o f resp irato ry d isease o r in fectio n ; last tu b ercu lo sis test, ch est rad io grap h , p n eu m o n ia, an d an y in flu - en za im m u n izatio n s. Reco rd th e sm o kin g h is- to ry in p ack-years ( th e n u m b er o f p acks p er d ay tim es th e n u m b er o f years sm o ked ) . Fo r exam p le, a clien t wh o h as sm o ked o n e-h alf p ack a d ay fo r 20 years h as a 10 –p ack-year sm o kin g h isto ry.

2. O bjective data: In cludes in spection , palpation , percussion , an d auscultation

3. In spection of th e an terior an d posterio r ch est: No te skin color an d con d ition an d th e rate an d quality of respiration s, look for lum ps or lesion s, n ote th e sh ap e an d con figuration of th e ch est wall, an d n ote th e position th e clien t takes to breath e.

4. Palp ation : Palpate th e en tire ch est wall, n otin g skin tem p erature an d m oistu re an d lo okin g for areas of ten dern ess an d lum ps, lesion s, or m asses; assess ch est excu rsion an d tactile or vocal frem itus (Box 15-7).

5. Percussion a . Startin g at th e apices, percuss across th e top of

th e sh oulders, m ovin g to th e in tersp aces,

m akin g a side-to -side com parison all th e way down th e lun g area ( Fig. 15-2).

b . Determ in e th e predom in an t n ote; reson an ce is n oted in h ealth y lun g tissue.

c. Hyperreson an ce is n oted wh en excessive air is presen t an d a dull n ote in dicates lun g den sity.

6. Auscu ltation a . Usin g th e flat diaph ragm en dpiece of th e

steth oscope, h old it firm ly again st th e ch est wall, an d listen to at least 1 full respiration in each location (an terior, posterior, an d lateral).

b . Posterior: Start at th e apices an d m ove side to side for co m parison (see Fig. 15-2).

c. An terior: Auscu ltate th e lu n g fields from th e apices in th e supraclavicular area down to th e 6th rib; avoid percussion an d au scultatio n over fem ale breast tissue (disp lace th is tissue) because a dull soun d will be produ ced (see Fig. 15-2).

d . Com p are fin din gs on each side. 7. Norm al breath soun ds: Th ree types of breath

soun ds are con sidered n orm al in certain parts of th e th orax, in cludin g vesicular, bron ch ovesicular, and bron ch ial; breath soun ds sh ould be clear to auscultation (Fig. 15-3).

8. Abn orm al breath soun ds: Also kn own as adven- titious sounds (Table 15-2)

9. Voice soun ds (Box 15-8) a . Perform ed wh en a path o logical lun g con d i-

tion is susp ected

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BOX 15-7 Palpation of the Chest

Chest Excursion Posterior: The nurse places the thumbs along the spinal pro-

cesses at the 10 th rib, with the palms in light contact with the posterolateral surfaces.

The nurse’s thumbs should be about 2 inches (5 centimeters) apart, pointing toward the spine, with the fingers pointing laterally.

Anterior: The nurse places the hands on the anterolateral wall with the thumbs along the costal margins, pointing toward the xiphoid process.

The nurse instructs the client to take a deep breath after exhaling.

The nurse should note movement of the thumbs and chest excursion should be symmetrical, separating the thumbs approximately 2 inches (5 centimeters).

Tactile or Vocal Fremitus The nurse places the ball or lower palm of the hand over the

chest, starting at the lung apices and palpating from side to side.

The nurse asks the client to repeat the words “ninety-nine.” Symmetrical palpable vibration should be felt by the nurse.

178 UNIT IV Fundamentals of Care

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