Physiological Integrity
Physiological Integrity
Physiological Integrity
In the Physiological Integrity part of your examination, you will be expected to demonstrate the
knowledge and skills necessary to promote physical health and wellness by providing care and
comfort, reducing client risk potential and managing health alterations.
The four subsections under Physiological Integrity are Basic Care and Comfort, Pharmacological
Therapies, the Reduction of Risk Potential and Physiological Adaptation.
Assist client to compensate for a physical or sensory impairment (e.g., assistive devices,
positioning, compensatory techniques)
Assess and manage a client with an alteration in elimination (e.g., bowel, urinary)
Perform irrigations (e.g., of the bladder, ear, eye)
Perform skin assessment and implement measures to maintain skin integrity and prevent skin
breakdown (e.g., turning, repositioning, pressure-relieving support surfaces)
Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts)
Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings,
sequential compression devices)
Implement measures to promote circulation (e.g., active or passive range of motion, positioning,
and mobilization)
Assess client need for pain management
Provide non-pharmacological comfort measures
Manage the client's nutritional intake (e.g., adjust diet, monitor height, and weight)
Provide client nutrition through continuous or intermittent tube feedings
Evaluate client intake and output and intervene as needed
Assess and intervene in client performance of activities of daily living
Perform post-mortem care
Assess client need for sleep/rest and intervene as needed
Assistive Devices
Elimination
Mobility/Immobility
Non-Pharmacological Comfort Interventions
Nutrition and Oral Hydration
Personal Hygiene
Rest and Sleep
Assess the client for actual/potential difficulty with communication and speech/vision/hearing
problems
Assess the client's use of assistive devices (e.g., prosthetic limbs, hearing aid)
Assist client to compensate for a physical or sensory impairment (e.g., assistive devices,
positioning, compensatory techniques)
Manage the client who uses assistive devices or prostheses (e.g., eating utensils,
telecommunication devices, dentures)
Evaluate the correct use of assistive devices by the client
Grooming self care: Adaptive hair brushes and combs and special nail clippers
Dressing self care: Long shoe horns, button hooks, oversized buttons, sock pulls, oversized
loops, zipper pulls and Velcro closures for clothing
Hygiene and bathing self care: Shower chairs, grab bars, nonskid tub and shower floors,
spray nozzles, and long handled back brushes
Eating self care: Weighted plates, scoop dishes, food guards around the plate, assistive utensils,
weighted and tip proof drinking glasses and cups
Oral self care: Special tooth paste holders, special tooth brushes and easy to use and manipulate
dental floss.
Dentures, another prosthetic and assistive device, are cleaned with a soft tooth brush and a denture
cleaner. When these dentures are removed they are then placed in a safe place, like a labeled denture
cup, with an overnight denture cleaner. Despite the client's use of dentures, the gums and cheeks
should be gently brushed and a mouth wash should be used in the same manner that other clients
do.
Elimination: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of elimination in order to:
Assess and manage client with an alteration in elimination (e.g., bowel, urinary)
Perform irrigations (e.g., of bladder, ear, eye)
Provide skin care to clients who are incontinent (e.g., wash frequently, barrier
creams/ointments)
Use alternative methods to promote voiding
Evaluate whether the client's ability to eliminate is restored/maintained
Some of the commonly used terms relating to urinary elimination, also referred to as micturition,
are:
Polyuria
Polyuria is an excessive amount of urine production in excess of 2.5 liters over a 24 hour period of
time. Some clients may be affected with nocturnal polyuria only during the night time hours and
others may be affected with polyuria throughout the course of the entire day.
Some frequently occurring causes of polyuria are the consumption of large amounts of fluids, the
use of diuretic medications, renal disease, psychogenic polydipsia which is a psychiatric mental
disorder causing excessive thirst, sickle cell, anemia diabetes mellitus and diabetes insipidus.
Excessive and prolonged polyuria can lead to dehydration which can cause fluid and electrolyte
imbalances in the client. The normal urinary output is about 2 liters per day.
Oliguria
Oliguria is a less than the normal amount of urinary output at less than 400 mLs over the course of
24 hours. The most commonly occurring causes of oliguria are impaired renal blood flow, renal
disease, decreased fluid intake and dehydration, hypovolemic shock and other diseases and disorders
associated with excessive bodily fluid losses, and an anatomical urinary stricture.
Anuria
Anuria is a lack of the production of urine or a severely scant amount of urine less than 50 mLs in a
24-hour period of time.
Dysuria
Dysuria is painful burning upon urination. It often occurs as the result of a urinary tract infection
and trauma.
Urinary Incontinence
Urinary incontinence is the involuntary leakage of urine and a loss of bladder control. The types of
urinary incontinence include functional urinary incontinence, reflex urinary incontinence, stress
urinary incontinence, urge urinary incontinence, and total urinary incontinence. The causes of
urinary incontinence are numerous and they can include a neurological deficit, a lack of sphincter
control musculature, and an overactive bladder.
Urinary Retention
Urinary retention is the accumulation of urine in the bladder because, for one reason or another, the
patient is not able to effectively empty their bladder.
Urgency
Urgency is defined as strong, sudden and relentless need to immediately urinate without delay.
Some of the commonly used terms relating to bowel elimination are:
Constipation
Constipation is defined as less than three bowel movements per week. Under normal circumstances,
clients should typically defecate from once a day to every 3 to 5 days. Some of the commonly
occurring causes of constipation are immobility, a lack of fluid intake, some medications like opioid
drugs, and impaired neurological functioning.
Diarrhea
Diarrhea is a watery loose stool. Some of the causes of diarrhea are a gastrointestinal infection, some
foods, stress, anxiety, some medications, malabsorption syndrome and a parasite infection.
Technically, diarrhea is defined as three or more loose stools over a 24 hour period of time.
Fecal Impaction
Fecal impaction is a collection of hardened stool in the rectum. Fecal impaction can occur from
some medications and also secondary to constipation, among other causes.
Flatulence
Flatulence is the expulsion of often odorous gastrointestinal gas. Flatulence can result from some
foods and medications.
Enemas
The four types of enemas are a:
Carminative Enema: Carminative enemas are used to relieve flatus or flatulence and to
simulate peristalsis.
Cleansing Enema: Cleansing enemas remove feces. These types of enemas are used to relieve
constipation and also to cleanse the bowel of fecal material prior to some surgical procedures
and to prep the bowel prior to some diagnostic tests like a screening and diagnostic colonoscopy
examination when the visualization of the bowel without fecal contents is necessary.
Retention Enema: This type of enema consists of an oil solution or a medication added
solution that is administered and then retained and held by the client for an hour or more. A
retention enema is used to administer a medication, to soften stool and to lubricate the rectum
so that it is easier and more comfortable for the client to defecate.
Return-Flow Enema: Return-flow enemas, similar to a carminative enema, are used to relieve
flatus and stimulate peristalsis which is frequently a problem after a client has received
anesthesia. The fluid is instilled into the rectum and sigmoid colon and, then, the enema bag is
lowered so that the flatus and fluid returns back into the enema bag. The instillation and
removal of this fluid is typically done five to six times and more often if necessary.
Renal infections
A urinary tract infection
Urinary stones
A vitamin B12 deficiency
Nocturnal enuresis
A distended bladder
Changes in urinary pH
Mucous plugs and ostomy clogs which can be corrected with Marlen MucoSperse
Urinary pH changes, the formation of salts and stones, and infections can be prevented with ample
oral intake of fluids. Patients should also be instructed to dissolve mucous plugs that are clogging
the pouch by using Marlen MucoSperse.
Urinary Catheterization
In addition to keeping the incontinent client clean and dry, there are a number of topical agents used
for the protection of the skin, including skin sealants that protect the skin from urine, stool, exudate,
chemicals, dirt, and debris, zinc oxide based moisture barrier ointments that also protect the area,
thick moisture barrier pastes that seal the area off and protect it from any moisture, solid skin
barriers in the form of rings, strips or wafers that protect the skin and wounds, and skin barrier
powders that are sprinkled lightly on denuded skin to increase the sticking power of ointments,
pastes and solid skin adhesive barriers.
Performing Irrigations
Nurses irrigate bodily orifices and therapeutic interventions such as the irrigation of the bladder, the
ear, the eye and an ostomy. All of these irrigations are done using sterile technique, with the
exception of a fecal diversion irrigation which uses clean technique. Additionally, a gown is donned
to protect the nurse from sprays and splashes; protective masks or goggles when a spray or splash
can be reasonably possible and gloves are used during these doctor ordered irrigations.
Bladder Irrigations
Bladder irrigations are done when a client has an indwelling urinary catheter that is blocked and not
patent.
The procedure for bladder irrigation is as follows:
1. Empty and measure the contents of the existing urinary drainage bag.
2. Hang the irrigation solution on an IV pole above the level of the client to facilitate the flow of
the irrigation solution using gravity.
3. Prime the irrigating solution.
4. Swab the irrigation port on the three way catheter and then connect the irrigation solution to
this port.
5. Open the clamp on the irrigation solution and allow the fluid to flow into the bladder at the
ordered rate which is typically about 40 to 60 gtts per minute.
6. The irrigation solution is allowed to remain in the bladder when the doctor has ordered a closed
intermittent bladder irrigation.
7. The irrigation solution is allowed to flow out of the bladder with a closed intermittent bladder
irrigation by opening the urinary catheter clamp to allow the contents of the bladder to empty
into the urinary drainage bag.
8. Measure and document the volume of the irrigation solution that was used for the irrigation and
also the volume of urinary catheter collection bag. The amount of urine produced as the result
of the irrigation is calculated by subtracting the amount of irrigation solution instilled during the
irrigation from the total volume that was collected in the urinary catheter drainage bag. For
example, if the nurse instills 1200 mLs of irrigating solution into the bladder and the volume in
the urinary drainage bag after this instillation of irrigating solution is 1400 mLs, the urinary
output is 1400 – 1200 = 200 mLs in terms of urinary output.
Clamp the catheter between the injection port and the extension tubing.
Clean the port with antiseptic wipes.
Insert a syringe and slowly inject the irrigation solution.
Remove the syringe and then finally
Remove the clamp and permit the irrigation solution to drain into drainage bag.
Ear Irrigations
Ear irrigations are done to cleanse the ears and also to irrigate the ears with an otic medication,
according to the doctor's order. Ear irrigations and instillations are done with slightly warm solutions
and these instillations and irrigations, including medications, are a little different for children less
than three years of age and children and adults over three years of age because of anatomical
differences.
The nurse will gently pull the pinna, or ear lobe, downwards and backwards for children less than
three years of age because the ear canal is still directed upward, and the nurse will gently pull the
pinna upwards and backwards for children older than three years of age and for adults.
The procedure for ear irrigation is as follows:
1. Place the client on their side with the affected ear up in a comfortable position.
2. Cleanse the pinna and the external ear canal with a cotton tipped applicator to remove
extraneous debris and to prevent this debris from entering the inner ear during an instillation or
irrigation.
3. Pull the pinna downwards and backwards for children less than three years of age and upwards
and backwards for clients over three years of age.
4. Insert the syringe with the irrigation solution into the ear.
5. Direct the flow of the solution towards the top of the ear and with gentle pressure.
6. Place the client on their treated ear downward and over a basin to allow the irrigation solution to
freely flow out of the ear.
Eye Irrigations
Ear irrigations are done to cleanse the eyes, to remove debris and to instill optic medications and
solutions.
The procedure for eye irrigations and instillations is as follows:
Moisture Barrier Ointments: Moisture barrier ointments like Lantiseptic Skin Protectant,
Caloseptine Ointment, and Proshield Plus Skin are zinc oxide containing products that are used
to prevent incontinence dermatitis. These products are reapplied after all episodes of
incontinence and the washing of the affected areas.
Moisture Barrier Pastes: Moisture barrier pastes like Remedy Calazime Protectant Paste and
Ilex Skin Protectant Paste are thick topical skin preparations that permit the nurses' assessment
of the underlying skin while protecting the skin from impaired skin integrity secondary to
incontinence.
Skin Sealants: Skin sealants, in contrast to moisture barrier pastes and ointments, last up to
about 14 days after application. These products, including Film Wipe, Shield Skin, Bard
Protective Barrier, and Convatec's Allkare, consist of a fast drying polymer transparent film that
can be applied relatively simply with a wipe or a spray.
Provide the client with privacy and explain the insertion procedure to the client to alleviate any
anxiety and discomfort which is something that is frequently encountered because this
procedure invades the client's intimate space.
Position the client in a supine position with the thighs separated so that they do not interfere
with this sterile procedure.
Lubricate the lower section of the catheter with a sterile water soluble lubricant.
Cover the surrounding area with a sterile drape.
Clean the urinary meatus with an antiseptic solution using sterile technique. The male urinary
meatus is cleansed using a circular pattern from the meatus and then outwards. The female
urinary meatus is cleansed with an antiseptic solution beginning with the labia from the front to
the back while holding the area open.
Insert the urinary catheter into the urinary meatus.
Advance the catheter about 3 cms past the point when urine appears in the urinary catheter
tubing.
Inflate the balloon for an indwelling catheter.
Secure the catheter to the client's leg.
Connect the urinary drainage bag to the tubing and maintain the level of the urinary drainage
bag below the level of the client's abdomen to prevent any back flow of urine.
After placement, the urinary catheter needs care and maintenance. For example, the insertion site is
washed with soap and water at least on a daily basis and every time the area becomes soiled with
feces. The drainage bag must be maintained below the client's abdominal level, the urinary drainage
bag should be emptied each shift and more often when necessary, and the tubing should be
inspected to make sure that there is no kinking or twisting of the tubing because this will obstruct
the free flow of urinary output that could back up into the bladder.
Urinary System
As the result of immobility, the urinary system can be adversely affected with urinary retention,
urinary stasis, renal calculi, urinary incontinence and urinary tract infections.
Gastrointestinal System
Constipation, impaction and difficult to evacuate feces can occur as the result of immobility and the
lack of exercise that is needed to promote normal bowel functioning. These bowel alterations are
further confounded when the client is not getting adequate fluid intake.
Musculoskeletal System
The muscles, joints and bones are adversely affected by immobility.
The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse
osteoporosis, hypercalcemia, and fractures. At times a tilt table can be used to prevent this damage
by placing the client in a position of weight bearing to avoid these complications.
The joints are affected with stiffness, pain, impaired range of motion and contractures including foot
drop which is a plantar flexion contracture. Some of these joint disorders can be prevented with
frequent and proper positioning of the client in correct bodily alignment, the provision of range of
motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed
board to prevent contractures of the hands and feet, respectively.
Muscles are adversely affected with weakness and atrophy as the result of immobility. These hazards
of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic,
isometric and isokinetic muscular exercises.
Respiratory System
Some adverse respiratory system effects relating to immobility include the thickening of respiratory
secretions, the pooling of respiratory secretions and an increased inability of the client to mobilize
and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and
respiratory tract infections. Immobility can also lead to shallow, ineffective respirations, decreased
respiratory movement, and a decrease in terms of the client's vital capacity.
Some of these complications of immobility can be prevented with respiratory hygiene measures such
as deep breathing, coughing, postural drainage, percussion and vibration. These techniques will be
discussed below immediately after this section.
Circulatory System
The circulatory system is jeopardized by immobility; some of these respiratory complications and
risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation,
thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with
client falls.
Some of these complications can be prevented with leg exercises, the use of sequential compression
devices or antiembolism stockings, and the initiation of falls risk prevention measures when an
immobilized client is adversely affected with orthostatic hypotension.
Metabolic System
The metabolic system alterations associated with immobility are a decreased rate of metabolism
which can lead to unintended weight gain, a negative calcium balance secondary to the loss of
calcium from the bones during immobilization, a negative nitrogen balance secondary to an increase
in terms of catabolic protein breakdown, and anorexia.
Integumentary System
Immobility places clients at risk for skin breakdown, pressure ulcers, and poor skin turgor.
Preventive measures and the treatments of these skin integrity disorders will be discussed below in
the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin
Integrity and Prevent Skin Breakdown".
Psychological Alterations
Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered
mood, and depression.
Some nursing diagnoses related to immobility can include:
Simply defined, gait is the way the person walks, or ambulates. Gait is a function of a number of
different things including balance, coordination, muscular strength, and joint mobility.
Balance and equilibrium can be impaired when the client is affected with a middle ear disorder that
affects the vestibule and/or the semicircular canal of the ear's cochlea, poor posture, and a
musculoskeletal or neurological disorder; muscular coordination is the ability of the person to
smoothly and safely use gross motor and fine motor coordination. Coordination can be adversely
affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular
strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis,
flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of
the bone.
Muscular strength is classified on a scale of zero to five, as below.
Joint mobility and range of motion are assessed for the client. Simply defined, full range of motion is
defined as the maximum movement of a joint specific to that joint. For example, the elbow should
normally be able to perform extension, flexion, rotation for supination and notation for pronation
and the neck should be fully able to perform extension, flexion, lateral flexion, hyperextension and
rotation.
After the client is assessed, the mobility of the client, in addition to other functional activities, can be
graded and classified as follows in terms of this level of functional ability:
Level 2: The client needs an assistive device and the coaching and supervision of another
person
Level 3: The client needs an assistive device and the direct assistance of another person
Level 4: The client is totally dependent on others for their mobility needs
Performing a Skin Assessment and
Implementing Measures to Maintain
Skin Integrity and Prevent Skin
Breakdown
Skin Assessment
The skin, which is the first line of defense against infection, should be intact and not broken, it
should be warm and without any excessive moisture, and the skin should also have good elasticity,
which is referred to as good skin turgor.
Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors
and forces. Some of these intrinsic factors include the client's urinary and/or fecal incontinence,
poor nutritional and fluid intake, diabetes, hyperthermia, hypothermia, hypotension, a decreased
cardiac output, obesity, an altered sensory perception, some medications, an alteration in terms of
the client's perfusion and peripheral circulation, some of the normal changes of the aging process,
cachexia and emaciation, an alteration in terms of the client's metabolic status, and the client's body
build as well as the size of their boney prominences.
Some of the extrinsic factors that impact on the skin and its integrity are environmental humidity,
chemical irritants, extremes in terms of hot and cold weather, radiation, and mechanical forces such
as pressure, shearing and friction.
Some of the nursing diagnoses related to skin and skin integrity can include:
All skin areas that are not within normal limits and indicate any signs of skin breakdown are assessed
and described according to its color, size, location, odor, drainage, margins, texture, distribution and
underlying bed tissue.
Color
The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched
and reddened, for example.
Size
The area of an abnormality is measured with a disposable rule in terms of centimeters. The length
and width of all areas are measured and the depth of wounds is also measured. The depth of a
wound is measured using a sterile cotton applicator which is then compared to the disposable rule
for an accurate measurement. After the wound is assessed and measured, the wound dimension is
calculated by multiplying the length by the width by the depth of the wound. For example when the
length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm,
the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm.
Location
The skin area that has impaired skin integrity is also described according to its exact location and in
reference to its anatomical location. For example, an area of skin breakdown can be described as on
the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. Some assessment
forms allow the nurse to draw the area of concern on it to graphically show both the location and
the relative size of the skin area that is affected with impaired skin integrity.
Odor
Some wounds and wound drainage have odors and others do not. Odors can be described as
malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic
odor.
Drainage or Exudate
Wound discharge, which is also referred to as wound exudate, is assessed and described as the lack
of any drainage or the presence of some drainage which be described in terms of color, amount and
characteristics.
The quantity or amount of drainage can be described as minimal, moderate or excessive and copious
when a wound drain is not being used to measure drainage precisely. Wound drainage is also
described in terms of its color and characteristics. For example, serous drainage is clear or a slight
yellowish color because it consists of serum which is the clear portion of the blood; sanguineous
drainage is bloody and red because it consists of red blood cells; serosanguinous drainage is pinkish
in color because it is a combination of serum and red blood cells; and purulent drainage can be
yellow, green, rust color or brown and this drainage indicates the presence of infection and thick
pus.
Texture
Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or
normal.
Distribution
The distribution of impaired skin integrity can be described as generalized and across many areas of
the body, localized to one area of the body, asymmetrical and on only one side of the body and also
symmetrical which affects both sides of the body bilaterally.
Margins
The margins around the wound are also assessed and described in terms of their color, their
characteristics and their texture which can be classified and documented as macerated, edematous,
swollen, indurated or normal. Wound margins can be described as open, attached, unattached, well
defined and with a healing ridge.
The screening of all clients for their potential for skin breakdown and then initiating special
preventive measures
Performing skin assessments and reassessments on a regular basis
Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as
debris
Turning and positioning clients at least every two hours when the client is unable to move about
in bed to turn and position on their own
Maintaining the client's nutritional and fluid needs
The utilization of supportive and assistive devices such as a wedge, pillow, and a pressure
relieving mattress
The elimination of pressure, friction, shearing and moisture on the client's body and bodily parts
The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the
most popular standardized screening tools that are used to screen and assess clients in order to
determine if they are at risk for skin breakdown. Both of these standardized screening tools are
deemed valid and reliable for identifying those at risk.
Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result
from the mechanic forces of pressure, friction and shearing, all of which can, and should, be
prevented.
Pressure
Pressure, particularly over boney prominences, areas of poor tissue perfusion, and areas affected
with poor circulation, is a physical force associated with the development of pressure ulcers and skin
breakdown. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage
because harmful substances, such as toxins, accumulate in the area where the pressure is exerted.
Pressure can be eliminated and reduced with out of bed activity, pressure relieving surfaces, the
provision of sitting and lying surfaces free of any objects and wrinkles, and by turning and
repositioning clients frequently to prevent this damaging mechanic force.
Friction
Friction occurs when a person's body is being rubbed against a surface such as a bed.
Shearing is a combination of both pressure and friction that can cause some distortion of the client's
skin and its underlying tissues. Shearing can be prevented by elevating the head of the bed no more
than 30 degrees unless contraindicated, using a lift or a lifting team, if you have one, by transferring
clients carefully, getting help when turning and positioning a client, getting as much client
cooperation as possible during turning, positioning and transfers, using a pressure relieving bed, and
lubricating the skin with a lubricating moisturizer to prevent the damaging skin effects associated
with pressure, friction and shearing. Corn starch is NOT used.
Pressure ulcers are costly both in terms of health care costs and the human costs that the client
suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and
osteomyelitis. When pressure ulcers are not prevented, the nurse must assess and care for it.
Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. These
stages are:
Stage I: The skin remains unbroken and intact. The skin among those with a light skin tone may
have some redness or blanching of the affected area; and those with darker skin tones may have
a blue, purple or ashen tinge to the affected area. Additionally, all clients may have some
sensitivity and burning, coolness or increased warmth to the affected area.
Stage II: The closed and intact skin is now open. The epidermis and the dermis are damaged.
The wound may appear as a blister, crack or a wound that is pink in color.
Stage III: The wound is now considered a deep wound; the subcutaneous tissue and all the
layers of the skin, including the epidermis and dermis and even adipose tissue may be exposed
and affected. The wound has a blood tinged drainage as well as dark areas and yellow colored
area of dead and necrotic tissue, referred to as eschar and slough, respectively, appear.
Stage IV: The deep pressure ulcer extends to underlying areas including the muscle, fascia,
connective tissue, tendons, and even the bone under the skin and subcutaneous tissue. Signs of
necrotic tissue including eschar and slough are evident.
The treatment of pressure ulcers is complex and it often includes a combination of treatments and
therapies. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment
options. RYB stands for the colors of red, yellow and black. The rules of treatment for these three
colors are:
Red: Protect the area. A new reddened area is protected from further harm and damage with
interventions such as turning and positioning the client, keeping the client's skin clean and dry,
keeping bed linens wrinkle and object free and avoiding all pressure, friction and shearing. When
the wound is red as the result of healing of a previous pressure, the healing of this pressure ulcer
is in the stage of granulation with renewal tissue that remains fragile and prone to another
breakdown so it has to be protected with a barrier film, covering with a dressing such as a
hydrocolloid film, turning and positioning the client and avoiding pressure, friction and shearing;
and the healing of this wound is maintained and promoted with gentle cleansing of this area
using a solution that is not cytotoxic.
Yellow: Cleanse the area. This wound needs cleansing using an alginate dressing, a hydrogel
dressing or damp normal saline dressings to remove the slough and purulent wound drainage.
Black: Debridement of the area to remove the black necrotic eschar. There are several methods
of debridement including surgical laser debridement, mechanical debridement, autolytic
debridement, enzymatic debridement and sharp instrument debridement.
Surgical Debridement
Surgical debridement using a laser is perhaps the fastest of all methods of debridement and it is the
method that is least likely to damage the healthy tissue surrounding the necrotic area. One of its
disadvantages, when compared to some other method of debridement, is the need to anesthetize the
client which, in itself, has some risks.
Mechanical Debridement
Mechanical debridement is often the preferred form of treatment for pressure ulcers that only have a
moderate amount of necrotic tissue that has to be removed. This relatively inexpensive type of
debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected
area to remove the debris. This method is not used as much today as it was previously used. Some of
the disadvantages of mechanical debridement include the fact that it nonselective and, as such can
damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of
debridement, and it is more time consuming on the part of the person performing this procedure,
when compared to other methods of debridement.
Autolytic Debridement
Autolytic debridement promotes the body's use of its own enzymes to debride the wound. This
process is referred to as autolysis. Autolytic debridement is most often used to treat Stage 3 and
Stage 4 pressure ulcers.
The procedure for autolytic debridement entails the use of a semi-occlusive, occlusive, hydrocolloid,
alginate, or hydrogel treatment and a transparent dressing to keep the area moist while the body uses
its own enzymes like its fibrinolytic, proteolytic, and collagenolytic enzymes, as well as its on white
blood cells to debride a wound and remove its eschar and slough.
The advantages of this kind of wound debridement include its effectiveness, its ease in terms of
performing it, its relative safety, and lack of pain for the client. Some of its disadvantages, however,
include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its
effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this
type of debridement.
Cadexomer iodine
Gentamicin
Metroidazole
Mupirocin
Polymyxin B sulphate
Silver sulfadiazine
Applying a Knowledge of Nursing
Procedures and Psychomotor Skills
When Providing Care to Clients with
Immobility
Nursing care consists of all of the phases of the nursing process including assessment, nursing
diagnosis, planning implementation and evaluation.
In terms of assessment, the nurse assesses and reassess the client for actual and potential
complications of immobility as fully discussed above under the section entitled "Identifying the
Complications of Immobility" and the clients' needs in reference to mobility, gait, strength and
motor skills as fully discussed in the section entitled "Assessing the Client for Mobility, Gait,
Strength and Motor Skills"
Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above
in these same sections.
Planning is done according to the actual and potential health problems that were assessed and then
expected client outcomes or goals and interventions are planned to meet these needs. Some of the
expected client outcomes relating to immobility and mobility can include specific goals such as:
The client will perform active range of motion to all joints two times a day
The client will safely transfer from the bed to the chair with assistance
The client will ambulate 30 feet three times a day with a walker and the assistance of another
The client will increase their level of exercise and physical activity
The client will demonstrate the proper use of their assistive device
Urinary System: Maintain adequate fluid intake, measure, document and monitor the client's
intake and output to insure an adequate fluid balance status.
Gastrointestinal System: Maintain an adequate fluid intake, encourage a high fiber diet,
encourage out of bed activity including ambulation unless it is contraindicated, and the
administration of treatments such as stool softeners, fiber additives, enemas, and laxatives, as
ordered.
Musculoskeletal System: Range of motion exercises to all bodily parts, muscle strengthening
exercises including isotonic, isometric and isokinetic exercises, aids to assist in positioning the
client in correct bodily alignment, and early weight bearing activity
Respiratory System: Encouraging the client to perform deep breathing and coughing, and the
provision of postural drainage, percussion, inspiratory respiratory exercises and vibration.
Coughing, deep breathing, postural drainage, percussion, vibration and inspiratory respiratory
exercises will be detailed in the section immediately following this one.
Circulatory System: Active or passive range of motion, positioning, mobilization, leg exercises,
the use of sequential compression devices or antiembolism stockings, and the initiation of falls
risk prevention measures when an immobilized client is adversely affected with orthostatic
hypotension.
Metabolic System: The encouragement and provision of a healthy diet with ample protein
Integumentary System: Maintain good nutrition, encourage fluids, turn and position every two
hours and maintain clean and dry skin without any pressure, friction or shearing.
Splint any painful or tender abdominal areas with a pillow or the client's hand
Take the deepest possible diaphragmatic breath through the nose
Exhale through the mouth
Do this deep breathing three times
Cough after the third breath
Repeat this coughing and deep breathing as often as necessary to clear the airways
An incentive spirometer is used to coach the client in terms of deep breathing and coughing. An
incentive spirometer consists of a plastic chamber with a ball, a mouthpiece and tubing. While the
client is in an upright semi-Fowler's position or sitting in the chair, the client is instructed to put the
mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while
observing the ball rise to the level of their goal. The client should be reminded and encourage to
take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake.
Postural drainage is done by the nurse or the certified respiratory therapist. This technique entails
the positioning of the client in different positions so that all areas of the lungs and airways are able
to be drained of respiratory secretions using the force of gravity. For example, the client is
positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45
degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the
lateral bronchus.
Percussion is also performed by the nurse or the certified respiratory therapist. This technique
entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about
one minute while the client is hyper inflating their lungs and holding the breath as long as possible.
The client is placed in the same positions that are used for postural drainage, as discussed
immediately above. In fact, percussion is most often done in combination with postural drainage.
Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on
the lung area and doing rapid vibrating movements on the area while the client is positioned for
postural drainage.
Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine
position, to relax, and then to take deep breaths with a mouth piece with an increasingly smaller
lumen so that the client has to progressively take deeper and deeper breaths using their diaphragm
while overcoming the resistance of the obstructive mouth piece.
Traction
Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Traction is
used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is
used to reduce pain and it is used to decrease muscle spasms.
Traction forces are classified and categorized as Inline or running traction and balanced traction.
Balanced traction utilizes the weight of the client's bodily part, rather than externally placed weights,
to exert the traction force to the body. Hamilton Russell traction is an example of balanced traction.
Inline traction, also referred to as running traction and Buck's skin traction, exerts the traction force
along the long axis of the bone and along one plane.
The three basic traction techniques can also be classified as manual traction, skeletal traction and
skin traction. Manual traction, which is applied with the hands, is done to properly align a bone after
a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment.
Skeletal traction is applied directly to an affected bone with a continuous traction force and with the
use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone.
Lastly, skin traction applies the traction force to the skin overlying the affected bone. The purpose
of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired
with internal fixation. Skin traction is the most commonly used type of traction.
The externally placed skin traction must be applied firmly but without any potentially damaging
pressure and in a smooth manner without any creases. The weights are gently applied, as ordered,
and left to hang freely and without any interference. The skin underneath skin traction must be
inspected on a regular and ongoing basis to prevent some of the possible complications associated
with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory
impairment, neurological impairment, and areas of necrosis. Also, the skin around the surgical site
for skeletal traction must also be inspected for any signs of infection.
Splints
The primary purposes of splinting for limb fractures are to protect soft tissue from further damage,
to reduce the client's pain, to reduce the possibility of a fat embolism, and to minimize painful
muscular spasms. Some splints, like an inflatable arm splint, a Downey splint and a Sager splint, are
temporarily placed on clients by paramedics in the field prior to their arrival at the emergency
department of a hospital. Splints are also used the immobilization of the spine, to support a
weakened area of articulation such as a knee from damage and to support it after a knee
replacement, for example.
Braces
Braces are applied to various parts of the body to provide support and alignment of the part. Some
commonly used braces are neck braces, back braces, and elbow braces.
Casts
Skeletal fractures are classified and described in several ways, many of which are not mutually
exclusive.
A complete fracture involves the entire cross section of the fractured bone; an incomplete fracture
affects only part of the bone and not the entire cross section; stable fractures are defined as fractures
that are not likely to be displaced, therefore, reduction is not indicated; an unstable fracture, unlike a
stable fracture, necessitates reduction because it is likely that this fracture is displaced; a closed
fracture is defined as one that does not break through the surface of the skin and this type of
fracture and this type of fracture is also referred to as a simple fracture; an opened fracture, on the
other hand, breaks through the skin surface to the exterior of the body and, as such, an opened
fracture is prone to infection because the skin lacks integrity; and a pathological fracture is one that
results from a disease process rather than undue stress or trauma as other fractures do.
Fractures can also be categorized and categorized according to it pattern.
These patterns include:
A greenstick fracture occurs when only one side of the bone is fractured.
An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its
tendon or ligamentous attachment.
A comminuted fracture is one that splinters the fractured bone into small fragments as a result
of a traumatic force.
A transverse fracture is one that occurs straight across the fractured bone.
An oblique fracture is one that occurs at an angle across the fractured bone.
A spiral fracture occurs when the pattern twists around the fractured bone.
An impacted fracture is one that occurs when a bone fragment of the fractured bone is pushed
and wedged into another bone fragment of the fractured bone.
Compression fractures occur when the fractured bone collapses as occurs with vertebral spinal
fractures.
A depressed fracture occurs when bone fragments of the fractured bone is pushed in beyond the
surrounding skin. This type of fracture occurs with depressed skull fractures.
Fractures are treated to prevent deformity. In addition to traction and splints, many fractures are
also casted. Casts can be made with plaster or fiberglass. Some casts are solid and others are what
are referred to as a bivalve cast which has two pieces. Fiberglass casts are lighter in terms of weight
than plaster casts; and bivalve casts, unlike solid casts, permit some swelling after the traumatic
fracture and, as such, prevent compartment syndrome, a complication associated with casting.
Casts must be applied in a smooth manner and they should also be allowed to dry without any
external pressure applied to them. External pressure can cause creases and denting which can impair
the skin below in terms of its neurological and circulatory status.
The signs and symptoms of compartment syndrome include intense pain that cannot be relieved
with raising the affected limb and/or the client's ordered analgesic medications. The later signs of
compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to
neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool
and pale skin.
Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the
affected limb. The treatment plan includes the removal of the cast and, at times, a fasciotomy or
epimysiotomy are indicated.
The neurological condition of the areas of traction must be frequently assessed and inspected, the
skin should be assessed and cared for, and the client should be repositioned as much as possible in a
frequent manner, typically every 2 to 4 hours.
Range of Motion
Range of motion exercises can be active, active assisted and passive. Patients able to perform full
joint movement on their own and without the assistance of another should be encouraged to do so
several times a day to promote circulatory functioning and also to maintain full joint mobility. The
nurse should monitor these clients to insure that they are performing these active range of motion
exercises in the correct manner and to the greatest possible extent of movement for all of the joints
of the body.
Nurses assist patients with range of motion exercises several times a day when patients are not
completely independent in terms of their own performance of range of motion exercises. Passive
range of motion is done by the nurse when the client is not able to even assist with range of motion
exercise. Patients in a coma, for example, should be given complete passive range of motion to all
joints several times a day.
Meditation
Prayer
Magnets
Chiropractic services
Homeopathy
Reiki
Music therapy
Acupuncture
Acupressure
Massage
Deep breathing
Progressive muscular relaxation
Distraction
Guided imagery
Biofeedback
Hypnosis and self hypnosis
Mind Body Exercises and
Herbs and Dietary Supplements
All of the above alternative and complementary comfort measures were fully discussed previously in
the section entitled "Evaluating the Client on Alternative or Homeopathic Health Care Practices".
The Specificity Theory of Pain: The Specificity Theory of Moritz Schiff in the 1850s
described pain as a sensation that was different from all the other senses in that pain had its own
specific nervous system pathways from the spinal cord that traveled to the brain. According to
this theory, there are no psychological responses to pain.
Intensive Theory: This theory of pain debunked the Specificity Theory and it is based on the
belief that pain is an emotional state, rather than a sensory phenomenon. Pain occurs with an
intense stimulus such as intense heat and pressure.
The Peripheral Pattern Theory: The Peripheral Pattern Theory of pain, which is often
referred to simply as the Pattern Theory of pain, was proposed by Sinclair and Weddell during
the 1950s. Pain, according to this theory, is transmitted by nerve endings in the skin when an
intense stimulus is applied. This theory also does not recognize the psychological aspects of pain
as we know it today.
The Neuromatrix Theory of Pain: This theory of pain supports the fact that pain is a dynamic
and multidimensional process with physical, behavioral, perceptual, psychological and social
responses and one that can only be described by the person who is experiencing it. The four
parts of the nervous system according to the Neuromatrix Theory of pain components of the
nervous system, according to this theory, consist of the body self neuromatrix, cyclical
processing, the sentient neural hub which produces the client's awareness, and the patterns of
movement.
Gate Control Theory: Melzack and Wall are credited with the Gate Control Theory of pain.
Pain, according to this theory, is a combination of sensory, cognitive, affective and psychological
responses to a painful stimulus. Pain is transmitted by rapidly transmitting nerve fibers, slowly
transmitting nerve fibers, small and large nerve fibers along the dorsal horn of the spinal cord
and its substantia gelatinosa. The substantia gelatinosa is the "gate" that facilitates or blocks the
transmission of pain. Some of the factors that open this "gate" and create pain include the
person's level of anxiety and their paucity of endorphins. Some of the factors that close this
"gate" are the lack of anxiety, adequate levels of endorphins and the person's belief that the pain
can be managed and controlled.
The pain process consists of four phases which, in correct sequential order are transduction,
transmission, modulation and perception.
Pain can be described in a number of different ways. Pain can be acute and chronic; it can also be
described as nociceptive, neuropathic, superficial, deep, somatic, radicular, referred, visceral,
localized, diffuse, and mild, moderate, and severe.
Acute Pain: Simply defined, acute pain is pain that lasts less than 3 months; it has a rapid onset,
it is typically localized, it is accompanied with sympathetic nervous system responses such as
pupil dilation, diaphoresis, and increases in terms of the client's blood pressure, pulse rate and
adrenal hormone secretion as well as other signs and symptoms such as anxiety, muscular
tension and tightness, all of which can increase the severity and the duration of the pain.Acute
pain is most often self-limiting and manageable with sound pain management interventions.
Acute pain is a predictable, physiological warning that something is wrong.
Chronic Pain: In contrast to acute pain, chronic pain is long lasting pain that can continue for
extended periods of time, it is more difficult for the client to describe, it is less definable than
acute pain, it is more difficult for the nurse to assess, it can be continuous or intermittent and it
is also often difficult to treat than acute pain. For example, some pain, like malignant pain, is
sometimes intractable. Chronic pain is typically not associated with vital sign changes as they are
associated with acute pain because the body has somewhat adjusted to it; but, chronic pain is
associated with physical, emotional, psychological and behavioral changes such as distress,
depression, anorexia, insomnia, fatigue, and withdrawal.
Neuropathic Pain: This pain is typically described by the client as a burning and sharp
pain.Neuropathic pain can occur as the result of damage to the nervous system; central
neuropathic pain occurs as the result of damage to the central nervous system; and peripheral
neuropathic pain occurs as the result of damage to the peripheral nervous system. Spinal cord
injury pain is an example of central neuropathic pain and examples of peripheral neuropathic
pain include the pain associated with phantom pain and peripheral neuropathy secondary to
diabetes.
Nocicetive Pain: Nocicetive pain includes both somatic pain and radicular pain which include
deep abdominal pain and the pain resulting from a herniated spinal disk, respectively.
Deep Pain: Deep pain is pain that it is deep inside of the body.
Somatic Pain: Somatic pain, which is a type of nocicetive pain, occurs as the result of injuries
to the skin, bone, muscle, connective tissues and joints.
Visceral Pain: Visceral pain, which is also a type of nocicetive pain, is pain that originates in
and around the organs of the body.
Radicular Pain: Radicular pain is pain that radiates to the lower extremities with transmission
that occurs along the spinal nerve.
Referred Pain: Referred pain spreads to an area of the body which is not the source of the pain.
Localized Pain: Localized pain is pain that is restricted to one identifiable area.
Pain is assessed by the nurse by collecting and analyzing subjective and objective data. Pain is a
subjective experience that cannot be scientifically proven to be or not be present. Current research
clearly supports the fact that the client's subjective complaints of pain are far more accurate than
other indicators of pain, such as the client's vital signs and behavioral changes such as crying and
guarding the area of the body affected by the pain.
The PQRST method is a useful way for nurses to assess pain. The PQRST method consists of:
P: Precipitation: What precipitated the pain symptoms? What things precipitate an increase in
the amount of pain and what things precipitate a relief from the pain?
Q: Quality: What is the quality of the pain? Is it dull, sharp, deep, superficial, burning, aching, or
stabbing?
R: Region: Where is the pain? What region or area is painful? Does the pain travel and radiate to
another area of the body like the jaw and your leg?
S: Severity and Symptoms: What is the intensity of the pain on a scale of 1 to 10 with 1 being
minimal pain and 10 as the most intense pain? What other symptoms are you experiencing in
addition to the pain?
T: Triggers and Timing: What triggers and starts your pain? What triggers make the pain worse
and more severe? When did the pain begin? Tell me about the timing of the pain. How long
does the pain last? How often does the pain appear?
The quality of pain as sharp, burning, etc. is also described by the client as the nurse is assessing the
client's pain. At times, the quality of the pain can suggest its cause. For example, cramping may
indicate that the source of the pain is musculoskeletal in terms of its origin. The standardized McGill
Pain Questionnaire has a large number of these quality of pain descriptors including descriptors like
unbearable, hot, and pricking needle like pain.
Behavioral signs and symptoms associated with pain can include insomnia, anorexia, muscular
tension, rigidity, a narrow focus of attention and crying. Some of the objective physiological signs
and symptoms of pain include like increased blood pressure, diaphoresis, tachycardia, adrenal
hormone secretion and dilation of the pupils. The signs and symptoms are assessed for by the nurse,
particularly when the client, such as an infant, is not able to provide the nurse with full subjective
data which describes their pain.
Observational behavioral pain assessment scales for the pediatric population are used among
children less than three years of age. Some of these standardized pediatric pain scales include the
FACES Pain Scale, the neonatal CRIES Pain Scale, Toddler Preschooler Postoperative Pain Scale
(TPPPS), the Neonatal Infant Pain Scale (NIPS), the Children's Hospital of Eastern Ontario Pain
Scale (CHEOPS), the Faces Legs Activity Cry Consolability Pain Scale (FLACC), the Visual Analog
Scale (VASobs) the Observation Scale of Behavioral Distress (OSBD), the COMFORT Pain Scale
and the Pre-Verbal Early Verbal Pediatric Pain Scale (PEPPS) that is used with toddlers.
At the current time, most nurses use a pain scale from 0 to 10 along the scale with 0 being the
absence of pain and 10 being the worst possible level of pain for adults who are cognitively aware
and other tools like faces pain assessment scale with adult clients who are affected with the lack of
cognitive abilities, such as those who are demented or in a lethargic state of consciousness..
The consequences of uncontrolled pain are severe and they adversely affect the client's quality of
life. Many clients, like the population at large, have misconceptions about pain and pain
management. Some of these misconceptions include:
Applying a Knowledge of
Pathophysiology to Non-
Pharmacological Comfort/Palliative
Care Interventions
As previously listed in the Introduction to "End of Life Care", some of the signs and symptoms
associated with the end of life include those below. These signs and symptoms and some possible
non-pharmacological comfort and palliative care interventions are discussed below.
Excessive sleeping: Excessive sleeping is more of a concern for the family members than it is
for the client. Family members should be instructed about the fact that excessive sleeping is a
commonly occurring occurrence at the end of life. They should also be taught about the
importance of their mere presence and gentle touches are comforting to the client even when
they are sleeping.
A decreased desire for food and fluids: Anorexia and a lack for fluid and food intake are
common at the end of life. Many clients elect to forgo tube feedings and intravenous fluids for
fluid rehydration in their advance directive so these choices must be supported.
Incontinence of the bowels and bladder: The end of life is probably not the time to do bowel
and bladder training so the nurse must, instead, insure that the client is always clean and dry.
Restlessness and agitation: Some clients at the end of life may experience agitation and
restlessness. In addition to insuring the safety of the client, the underlying cause of this agitation
and restlessness must be identified and treated if possible. For example, restlessness can occur as
the result of hypernatremia, renal impairment, poor hepatic function, blood pH changes and
other causes. When the underlying cause cannot be determined and treated, the client may be
given an antipsychotic medication like haloperidol or an antianxiety agent like lorazepam to
correct restlessness and agitation.
A lack of orientation: Nurses assess the clients' level of orientation to person, time and place.
When a lack of orientation occurs as the result of an identifiable and treatable cause like
delirium, the underlying cause should be treated and corrected. When the cause of the lack of
orientation is not identifiable and/or not treatable, the client should be frequently oriented by
the nurse and other members of the health care team.
Body pallor and coolness: Pallor can result from a number of causes including anemia, a low
blood glucose level and exposure to cold. When correctable, treatable causes of this body pallor
are identified, and then they should be treated when the client at the end of life chooses to have
these treatments.
Social withdrawal: Many clients want to be alone at the end of life. Again, this choice should
be supported and upheld by the members of the health care team and the family.
Vision like experiences: It appears that many clients at the end of life have vision like
experiences of relatives and friends that have predeceased the client. According to clients who
have experienced these visions, they find them comforting and with a lot of meaning. If, and
when, clients and family members express concerns about these visions and appearances, they
should be told that these things commonly occur at the end of life for some clients.
Saying goodbyes to loved ones: Although saying goodbye to a loved one is a sad experience
and often associated with grief, saying goodbye allows the client and their loved ones to express
their love, to ask for forgiveness and, for family members, it is a time to tell the loved one that
they have your permission to let go and leave when the client is ready.
Letting go: Letting go, ideally, occurs when the client has reached a level of acceptance about
their own death. This letting go facilitates the client to reconcile with others and tap into the
spiritual dimension when this is something that the client is connected to.
Nurses monitor the client's responses to non-pharmacological interventions in terms of the client's
level of comfort. As with pharmacological interventions, nonpharmacological interventions have
expected outcomes like a reported or observed decrease in the levels of pain and discomfort and
increased levels of comfort as reported by the patient or observed by the nurse.
In essence, the outcomes of palliative care interventions are evaluated in terms of whether or not the
client and family members have had their physical, psychological, emotional, religious, social and
spiritual needs effectively met, including the client's freedom from pain.
Incorporating Alternative and
Complementary Therapies Into the
Client's Plan of Care
As fully described above in the section entitled "Evaluating the Client on Alternative or
Homeopathic Health Care Practices", nurses assess the clients' needs for alternative and
complementary therapies such as progressive relaxation and music therapy and then incorporate
these therapies into the client's plan of care.
Dehydration
Fluid and electrolyte imbalances may occur at the end of life as a result of the client's loss of appetite
and their refusal of food and fluids as the end of lie is near. The signs and symptoms of moderate
dehydration include dry skin, thirst, oral dryness, constipation, headache, a diminished urinary
output, orthostatic hypotension, and dizziness; the signs of severe dehydration have the signs and
symptoms of moderate dehydration in addition to possible anuria and renal failure, hypotension,
poor skin turgor, tachycardia, delirium, tachypnea, sunken eyes, confusion, a high fever, and
electrolyte imbalances.
Some clients at the end of life may elect to have fluid rehydration and other things like total
parenteral nutrition and tube feedings to correct dehydration and, others choose to not have these
interventions at the end of life. Some of the interventions that should be rendered to clients with
dehydration for symptom relief include things like ice chips or an ice pop for oral dryness,
antipyretic medication for a high temperature, and the maintenance of safety when the client is
adversely affect with dizziness, orthostatic hypotension, confusion and/or hypotension.
More information about fluids and electrolytes, and fluid and electrolyte imbalances will be fully
described in detail later in this NCLEX-RN review with the section entitled "Fluid and Electrolyte
Imbalances".
Cardiac Tamponade
Cardiac tamponade results from the collection of fluid in the pericardial sac around the heart which
impedes the compression, filling and pumping actions of this vital organ. Oncology clients who are
affected with tumors near or invading the pericardial sac, those who had therapeutic radiation to this
area, and clients who have had a traumatic chest puncture wound are at risk for cardiac tamponade.
Oliguria, a narrow pulse pressure, tachycardia, diminished peripheral pulses, jugular vein distention,
high central venous pressure and hypotension are some of the signs and symptoms of cardiac
tamponade. Treatments for this life threatening disorder can include medication to correct
hypotension, oxygen supplementation, intravenous fluids and, at times a pericardicentesis may be
indicated for the client affected with cardiac tamponade.
Septic Shock
Septic shock at the end of life is a risk for clients at the end of life particularly if they are
immunosuppressed and not able to combat infections as the result of the client's disease process
such as can occur with HIV/AIDS, leukemia, and lymphoma. Some of the signs and symptoms of
septic shock include a high temperature, confusion, pulmonary edema, massive vasodilation, lethargy
and hypoxia.
Some of the treatments used for septic shock, should the client want these treatments, are
intravenous fluid replacements, antibiotics, oxygen supplementation, mechanical ventilation, dialysis,
and medications to increase the blood pressure.
Hypovolemic Shock
Hypovolemic shock can occur at the end of life and at other times as the result of severe and
prolonged dehydration, hemorrhage, and other causes of bodily fluid losses such as vomiting and
diarrhea. In addition to death from hypovolemic shock, the client can be affected with progressive
and severe dehydration, metabolic acidosis, decreased cardiac output, and multisystem failure and
shutdown.
Some of the intervention for hypovolemic shock, in addition to correcting an underlying cause such
as bleeding and dehydration, are intravenous fluid replacements with fluids like lactated Ringers, the
administration of blood, blood components and plasma expanders, and placing the client in the
Trendelenburg position.
Hypercalcemia
Hypercalcemia, which is elevated calcium in the blood, occurs at the end of life especially among
clients who are affected with bone cancer, multiple myeloma, and breast cancer. Some of the signs
and symptoms of hypercalcemia include anorexia, nausea, vomiting, paresthesia, muscular weakness,
and pain.
The symptomatic relief of hypercalcemia at the end of life, in addition to intensive intravenous fluid
replacement therapy, are increasing oral fluid intake, vitamins D and A, pain medications to relieve
the pain, and medications such as diuretics to increase urinary output and clear the body of the
calcium, and other medications like pamidronate and alendronate. Client safety is also important
because the client with hypercalcemia is at risk for pathological bone fractures secondary to bone
decalcification. Again, some clients may elect to have one or more of these interventions and other
clients may not elect to have one or more of these interventions.
Providing Non-Pharmacological
Comfort Measures
Non-pharmacologic comfort measures have been previously listed and discussed in the section
above entitled "Introduction to End of Life Care".
Evaluating the Client's Response to
Non-Pharmacological Interventions
In actuality, this topic heading is somewhat misleading because both the non-pharmacologic
comfort measures and the pharmacologic comfort measures are evaluated in the same manner. Both
are evaluated in terms of the expected outcomes that were established for the client in terms of their
level of comfort and their freedom from pain and discomfort.
Some of these expected outcomes that are considered in terms of whether or not the client has
achieved them include, for example:
The client will express relief of pain after performing progressive relaxation techniques
The client will decrease their level by 4 on a scale from 1 to 10 with a numeric pain assessment
scale
The client will demonstrate the procedure for meditation
The infant will demonstrate a decreased level of pain according to the CRIES pain scale
The preschool age client will demonstrate a decreased level of pain according to the FACES
pain scale
The cognitively impaired client will demonstrate a relief from pain with better periods of rest
and sleep
The client will have an expressed decreased level of pain after the administration of the ordered
narcotic analgesic
The client will have an expressed decreased level of pain after the administration of the ordered
NSAID for the relief of pain
The client will list and describe five non-pharmacological pain control methods that they can use
for the relief of pain
Have the client and family members verbalized a knowledge of palliative care?
Have the client and family members demonstrated an understanding of the end of life signs and
symptoms?
Have the client and family members demonstrated a lack of depression and a level of acceptance
in terms of the imminent death?
Is the client without any signs of respiratory distress?
Is the client without any signs of pain or discomfort?
Is the client without any signs of skin breakdown?
Are the family members participating in the end of life care for the client?
Are the client and family members free of psychological and emotional distress?
Are the client and family members free of anger and hostility?
Are the client and family members free of guilt?
Are the client and family members effectively coping with grief and loss?
Is the client meeting their spiritual and/or religious needs?
Does the client have a sense of meaning and connectedness?
Is the client free of any spiritual and religious distress?
Are the client and family members free of depression?
Are the client and family members free of fear and anxiety?
Are the client's choices at the end of life supported and accepted by family members?
Is the client free of any agitation and restlessness?
Have the client's last wishes been expressed to others and accepted by others?
Adequate nutrition consists of the ingestion and utilization of water, essential nutrients, vitamins and
minerals to maintain and sustain health and wellness.
A normal diet should consist of all of the food groups including fruits, vegetables, dairy foods,
protein and grains according to the United States Department of Agriculture.
Like other basic human needs such as elimination, nutrition can be negatively impacted by a number
of factors and forces such as diseases and disorders like anorexia, nausea, vomiting, anorexia,
dysphagia and malabsorption, cultural and ethnical beliefs about nutrition and foods, personal
preferences, level of development, lifestyle choices, economic restraints, psychological factors and
disorders such as eating disorders, medications, and some treatments like radiation therapy and
chemotherapy.
Some of the terms and terminology relating to nutrition and hydration that you should be familiar
with include those below.
Anabolism: Anabolism is one of the three things that occur with protein metabolism.
Anabolism occurs when these cells utilize amino acids to build tissue up. The other two
mechanisms of protein metabolism are catabolism and a nitrogen balance.
Catabolism: Catabolism, which also occurs with protein metabolism, occurs when excessive
amino acids are broken down in the tissue and the liver.
Nitrogen balance: Nitrogen balance occurs as the result of the client's level of protein
nutrition. It reflects protein metabolism and the gains and losses of nitrogen.
Basal metabolism rate: The basal metabolism rate reflects the extent to which the body meets
the energy demands of the body with the metabolism of food.
Body mass index: Body mass index is an indication of how much fat there is in the body. Body
mass index is used as a measurement that is useful in determining whether or not the client is
overweight and/or retaining fluids or if their body mass index is acceptable for the client's
height and weight.
Calorie: A calorie is a measure of heat. The number of calories varies among the food groups.
For example, there are 9 calories per gram of fat and there are 4 calories per gram of protein and
carbohydrates.
Complete protein: A complete protein is a protein that consists of all of the essential amino
acids in addition to some non-essential ones. Examples of complete proteins include poultry,
meats, fish and eggs.
Incomplete protein: An incomplete protein is a protein that is without one or more of the
essential amino acids. Vegetables of all kinds are considered an incomplete protein.
Essential amino acids: Essential amino acids are those amino acids that cannot be made by
the body. The nine essential amino acids include tryptophan, valine, methionine, phenylalanine,
histidine, leucine, threoline, isoleucine, and lysine.
Nonessential amino acids: Nonessential amino acids are those amino acids that can be made
by the body. Examples of nonessential amino acids are cystine, glutamic acid, alanine, aspartic
acid, proline, serine, hydroxyproline and tyrosine.
Fat soluble vitamins: Fat soluble vitamins are vitamins that cannot be produced by the body
and those that can be stored in the body. A client can also overdose on fat soluble vitamins
because they can accumulate these kinds of vitamins with this storage. Examples of fat soluble
vitamins are vitamins A, D, E and K.
Water soluble vitamins: Water soluble vitamins are vitamins that cannot be produced by the
body and those that cannot be stored in the body. These vitamins are not stored in the body.
Examples of water soluble vitamins are vitamins B and C.
Assessing the Client's Ability to Eat
Adequate nutrition is dependent on the client's ability to eat, chew and swallow.
In addition to a complete assessment of the client's current nutritional status, nurses also collect data
that can suggest that the client is, or possibly is, at risk for nutritional deficits. The assessment of the
client's nutritional status is done with a number of subjective and objective data that is collected and
analyzed. For example, the client is assessed using the A, B, C and Ds of a nutritional assessment in
addition to the use of some standardized tools such as the Patient Generated Subjective Global
Assessment and the Nutrition Screening Inventory. The A, B, C and Ds of nutritional assessment
include:
A: Anthropometric Data: This data includes variables such as height, weight, body mass index
and arm measurements such as the mid arm circumference and the triceps skin fold.
B: Biochemical Data: Laboratory testing data like serum albumin, hemoglobin, urinary
creatinine, and serum transferrin.
C: Clinical Data: The client's skin condition, level of activity and status of the client's mucous
membranes.
D: Dietary Data: This data includes the client's subjective reports of their food and fluid intake
over the last 24 hours and the types of foods that are typically eating.
Some of the factors that impact on the client's nutrition, their nutritional status and their ability to
eat include:
Level of health
Psychological influences and disorders
Ethnicity
Culture
Personal preferences
Religious practices and rituals
Gender
Level of development
Lifestyle choices
Personal beliefs about food and food intake
Medications
Therapeutic treatments
Level of health
Psychological influences and disorders
Economic status
Swallowing disorders
Chewing disorders
Dentition
Swallowing disorders, chewing disorders and poor dentition are factors that can impede the client's
mechanical ability to eat. For example, a client with a chewing disorder, such as may occur secondary
to damage to the trigeminal nerve which is the cranial nerve that controls the muscle of chewing,
may have impaired nutrition in the same manner that these clients are at risk:
Clients with a swallowing disorder are often assessed and treated for this disorder with the
collaborative efforts of the speech and language therapist, the dietitian, the nurse and other members
of the health care team. Clients with poor dentition and missing teeth can be assisted by a dental
professional, the nurse and the dietitian in terms of properly fitting dentures and, perhaps, a special
diet that includes pureed foods and liquids that are thickened to the consistency of honey so that
they can be swallowed safely and without aspiration when the client is adversely affected with a
swallowing disorder.
Intracellular fluids: Intracellular fluids are those fluids that are within the cells of the body.
Most of the bodily fluids, that is about two thirds of the total bodily fluids, are intracellular
fluids.
Extracellular fluids: Extracellular fluids are those fluids that are found outside of the cells of
the body. About one third of the total bodily fluids are extracellular fluids and extracellular fluids
include both intravascular fluids which are fluids contained in the vessels of the body and
interstitial fluids which are fluids around the cells but neither in the vascular system or within the
cells.
Electrolytes: Electrolytes are electrically charged salts in the body. Electrolytes consist of both
cations and anions.
Cations: Cations are electrically charged electrolytes with a positive charge. Examples of cations
are sodium, calcium, magnesium and potassium.
Anions: Anions are electrically charged electrolytes with a negative charge. Examples of anions
include phosphate, bicarbonate, sulfate and chloride.
Diffusion: Diffusion is the principle of physics that establishes the fact that molecules will
move, or diffuse, from an area that is more concentrated than the area that these molecules
move to. Molecules will diffuse from an area of high concentration to an area of low
concentration across a semipermeable membrane. Diffusion is a mechanism that attempts to
create a balance on both sides of the semipermeable membrane.
Osmosis: Osmosis is the principle of physics which states that water will move across the
membrane from areas of high concentration to an area of low concentration. Osmosis is similar
to diffusion but diffusion is the movement of molecules and osmosis is the movement of water
from the area of high concentration to the area of lower concentration.
Filtration: Filtration is the principle of physics that states that solutes, in combination with
fluids, move across the membrane from areas of high concentration to an area of low
concentration.
Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. Generally speaking
fluid balance and fluid imbalances can be impacted by the client's age, body type, gender, some
medications like steroids which can increase bodily fluids and diuretics which can deplete bodily
fluids, some illnesses such as renal disease and diabetes mellitus, extremes in terms of environmental
temperature, an increased bodily temperature, and some life style choices including those in
relationship to diet and fluid intake.
The aging population as well as Infants and young children are at greatest risk for fluid imbalances
and the results of these imbalances. For example, the elderly is at risk for alterations in terms of fluid
imbalances because of some of the normal changes of the aging process and some of the
medications that they take when they are affected with a chronic disorder such as heart failure. Some
of the normal changes of the aging process that can lead to an imbalance of fluid include the aging
person's loss of the thirst which, under normal circumstances, would encourage the client to drink
oral fluids, decreased renal function, and the altered responses that they have in terms of fluid and
electrolyte imbalances during the aging process
Infants and young children at risk for alterations in terms of fluid imbalances because of their
relatively rapid respiratory rate which increases inpercernible fluid losses through the lungs, the
child's relatively immature renal system, and a greater sensitivity to fluid losses such as those that
occur with vomiting and diarrhea.
Women, in contrast to male clients, are at greater risk for alterations in terms of bodily fluids
because they tend to have more fat, which contains less fluid, than muscle which contains more
bodily fluid. Lastly, clients who are febrile and clients who are exposed to prolonged hot
environmental temperatures will lose bodily fluids as the result of sweating and these unpercernable
fluid losses. Sweating is a cooling off response to intrapersonal and extrapersonal hot temperatures.
Fluid Excesses
Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the
body. Fluid excesses are the net result of fluid gains minus fluid losses. When fluid gains, and fluid
retention, is greater than fluid losses, fluid excesses occur.
Specific risk factors associated with fluid excesses include poor renal functioning, medications like
corticosteroids, Cushing's syndrome, excessive sodium intake, heart failure, hepatic failure and
excessive oral and/or intravenous fluids. Fluid excesses are characterized with unintended and
sudden gain in terms of the client's weight, adventitious breath sounds such as crackles, tachycardia,
bulging neck veins, occasional confusion, hypertension, an increase in terms of the client's central
venous pressure and edema.
Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces.
Edema is a sign of fluid excesses because edema occurs as the result of increases in terms of
capillary permeability, decreases in terms of the osmotic pressure of the serum and increased
capillary pressure. In combination, these forces push fluids into the interstitial spaces.
Edema is most often identified in the dependent extremities such as the feet and the legs; however,
it can also become obvious with unusual abdominal distention and swelling. Nurses assess edema in
terms of its location and severity.
Pitting edema is assessed and classified as:
Fluid Deficits
Dehydration occurs when fluid loses are greater than fluid gains. Fluid losses occur as the result of
vomiting, diarrhea, a high temperature, the presence of ketoacidosis, diuretic medications and other
causes.
The signs and symptoms of mild to moderate dehydration include, among others, orthostatic
hypotension, dizziness, constipation, headache, thirst, dry skin, dry mouth and oral membranes, and
decreased urinary output. The signs and symptoms of severe dehydration include, among others,
oliguria, anuria, renal failure, hypotension, tachycardia, tachypnea, sunken eyes, poor skin turgor,
confusion, fluid and electrolyte imbalances, fever, delirium, confusion, and unconsciousness.
Significant fluid losses can result from diarrhea, vomiting and nasogastric suctioning; and abnormal
losses of electrolytes and fluid and retention can result from medications, such as diuretics or
corticosteroids. Clients at risk for inadequate fluid intake include those who are confused and unable
to communicate their needs.
Dehydration occurs when one loses more fluid than is taken in. Fluid losses occur with normal
bodily functions like urination, defecation, and perspiration and with abnormal physiological
functions such as vomiting and diarrhea.
Applying a Knowledge of
Mathematics to the Client's Nutrition
Similar to the calculation of calories, as above, mathematics is also used to calculate other indicators
about the client's nutritional status. For example, the client's body mass index (BMI) and the "ideal"
bodily weight can be calculated using relatively simple mathematics.
The body mass index is calculated using the client's bodily weight in kg and the height of the client
in terms of meters. The mathematical rule for calculating the client's BMI is:
BMI = kg of body weight divided by height in meters squared
So, the BMI for a client weighing 75 kg who is 1.72 meters tall is calculated as follows:
BMI = 75 kg / 2.96 = 28.8 BMI
The ideal body weight is calculated using the client's height, weight and body frame size as classified
as small, medium and large. The mathematical rule for calculating this ideal weight for males and
females of small, medium and large body build are:
Ideal body weight for females with a medium body build = 100 pounds per 5 feet of height
+ 5 pounds for every inch over 5 feet tall for females with a medium body build
Ideal body weight for females with a small body build = 100 pounds per 5 feet of height +
5 pounds for every inch over 5 feet tall – 10% of the client's weight for females with a small
body build
Ideal body weight for females with a large body build = 100 pounds per 5 feet of height +
5 pounds for every inch over 5 feet tall + 10% of the client's weight for females with a large
body build
Ideal body weight for males with a medium body build = 106 pounds per 5 feet of height
+ 6 pounds for every inch over 5 feet tall for males with a medium body build
Ideal body weight for males with a small body build = 106 pounds per 5 feet of height + 6
pounds for every inch over 5 feet tall – 10% of the client's weight for males with a small body
build
Ideal body weight for males with a large body build = 106 pounds per 5 feet of height + 6
pounds for every inch over 5 feet tall + 10% of the client's weight for males with a large body
build
Components: Clear fluids including clear broth, juices like apple juice, water, tea, ginger ale,
clear Italian ice, and Jell-O
Components: All clear fluids in addition to vegetable juice, milk, all fruit juices, yogurt and
pudding
Components: Soft foods except those with fiber like fruits and vegetables
Components: Ground meats, mashed potatoes, clear and full fluids, and soft vegetables and
fruits
Components: All foods with the exception of frozen and canned foods, cold cuts, smoked
meats like bacon and sausage
Components: All food that are low in cholesterol; limited in terms of fats and meats
Dysphagia Diet
Indications: Swallowing disorders
Components: Honey consistency thickened fluids and easy to swallow ground and pureed
foods
Components: Meats, eggs, fish and dairy products in addition to protein supplements
Diabetic Diet
Indications: Diabetes
Aspiration
Prevention: Maintaining the head of the bed up at 30 degrees
Interventions: Emergency suctioning, placing the client on their side and addressing any
respiratory distress
Diarrhea
Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate
and formula when necessary
Interventions: Slowing the rate down, changing the formula and medications to stop the
diarrhea
Abdominal Pain
Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate
and formula when necessary
Interventions: Slowing the rate down, changing the formula and analgesics as indicated
Dehydration
Prevention: Monitor the client for any signs and symptoms of dehydration, measure intake and
output and notify the doctor of any abnormalities
Interventions: Provide any ordered oral and/or intravenous fluids
Tube Dislodgment
Prevention: Secure and monitor the tube
Interventions: Notify the doctor and discontinue the tube feeding
Personal hygiene, which is one of the basic activities of daily living, includes:
Bathing, showering and washing
Foot care
Hair care
Nail care
Perineal care
Shaving
Mouth and oral care
Denture care
Bathing Standards
The primary purpose of bathing is to cleanse the body of all dirt, sweat, germs, exfoliated skin, and
other things. This cleansing protects our first level defense against infection, and it also promotes
good circulation and client comfort.
In the health care setting, there are three different types of baths. They are a complete bed bath, a
partial bath, and a tub or shower bath.
A compete bed bath is one that is given in the bed to the client by a nurse or another member of
the health care team like an unlicensed assistive staff member such as a nursing assistant or a
patient care technician.
A partial bed bath is one that is given in the bed, like the complete bed bath, but the client only
needs the assistance of the nurse or another member of the health care team. The client
themselves is able to perform some or most of the bathing tasks. For example, the nursing staff
member may only have to collect and present the client with the necessary supplies and
equipment or wash the client's back.
A tub bath is a bath that the clients are usually able to take themselves, but they may still need
assistance, such as getting in or out of the tub or shower, so it is important for the nursing staff
member to be available and present to help the client as needed.
With all types of baths, the water temperature must be checked to insure that it is safe and < 110
degrees. A shower chair, tub chair, grab bars, a nonskid bath or shower mat are also highly
important to prevent accidents. When clients prefer to shower or tub bathe rather than take a bed
bath, they will often need assistance getting in and out of the shower or tub to prevent a fall and
injury.
The following are the steps for a complete bath and a partial bath.
Identify the client, introduce yourself and explain the bathing procedure to the client.
Provide privacy.
Raise the client's bed to a height that is the most comfortable and safe, in terms of body
mechanics, for you to work at. Make sure that the side rail on the side of the bed opposite to
you is up and locked in place. Raise the head of the bed to a height that is comfortable for the
client.
Place towels under the areas that are being washed to protect the fitted bottom sheet from
moisture and only uncover the areas that are being washed rather than the entire area to
maintain client warmness.
If a bath mitt is not available, a washcloth should be wrapped around your hand in a mitt like
fashion.
Each part of the client's body is washed, rinsed, dried and then covered with a bath towel or a
blanket.
Rinse the wash mitt or washcloth after each part of the body is washed.
Change the bath water in the basin when it cools off or becomes too soapy.
Make sure that every area, including the face, behind the ears, chest, back, arms, legs, hands,
fingernails, perineal area, and feet are thoroughly washed, rinsed and dried thoroughly.
Like physical assessment, the bath is given from head to toe. The first area to be washed is the
inner canthus of each eye; the neck area is the face and neck, after which the bath is given
downwards towards the toes.
After the bath is complete, the height of the bed to lowered to its lowest position to insure client
safety.
Perineal Care
Perineal care, like bathing of the skin, prevents infections, odors and irritation in that area. Perineal
care is done with the bed bath, shower or tub bath and it is done more often for patients affected
with incontinence and diaphoresis, for example. Special perineal care is given to patients with an
indwelling urinary catheter.
Shaving
Male clients often want a facial shave once a day or once every couple of days; female patients
usually want their underarms and legs about once a week. Shaving for patients is often not risky
except when the patient is taking an anticoagulant blood thinner which places them at risk for nicks
and bleeding.
Oral Hygiene
Oral hygiene is done at least twice a day and more often as needed. Oral hygiene consists of
brushing the teeth, flossing the teeth, and rinsing the mouth. Partial and full dentures are also
brushed and rinsed.
Foot Care
Feet are washed with the bath and more often as needed. Diabetics and other patients at risk for
infections should get special foot and toe nail care and monitoring. For example, the feet must be
completely cleaned and dried and examined daily for any signs of skin breakdown, corns, bleeding,
broken, chipped or absent nails, as well as blue or pale nail beds.
Hair Care
Patient's hair can be washed with shampoo and conditioner in the shower, bathtub and in bed with a
special bed tray or dry shampoo. Patients should also be encouraged to comb or brush their hair a
couple of times a day.
Nail Care
Client nail care is another important area of hygiene and client's nails need to be checked daily, to
observe them for any irregularities. The client's nails should appear clean, because dirt can cause
infection, trimmed short, and smooth, as jagged nails have the ability of causing injuries to the client
or to the staff attending to them.
Some of the terms and terminology that you should be familiar with in terms of rest and sleep are
described below.
Insomnia
Insomnia, simply defined, is the absence of sleep. The two basic types of insomnia are inducement
insomnia and maintenance insomnia. Clients affected with inducement insomnia have difficulty
falling asleep and clients with maintenance insomnia have difficulty maintaining sleep and staying
asleep once they have fallen asleep. Some clients are affected with both inducement insomnia and
maintenance insomnia. Additionally, some clients may have an acute, short lived episode of
insomnia, and other clients may have chronic insomnia. Both types of insomnia are caused by a
number of different physical and psychological factors such as pain and anxiety. Insomnia, which is
the most commonly occurring sleep disorder, can also be classified as chronic-intermittent which is a
combination of periods of insomnia interspersed with period of restful sleep. The two populations
that are at greatest risk for insomnia are females and members of the aging population.
Insomnia causes the affected person to wake up without feeling that they are rested as well as day
time sleepiness, irritability and problems in terms of cognitive functioning such as decreased levels
of mental concentration and poor problem solving.
REM Sleep
Rapid eye movement sleep is a state of deep sleep that is accompanied with rapid eye movements
and dreams. Some of the physiological changes that occur during REM sleep include increased brain
activity dreams, and a decrease in terms of muscular and reflex activity.
Narcolepsy
Narcolepsy is defined as excessive day time sleepiness that a person can be affected with secondary
to the paucity of hypocretin within the area of the central nervous system that controls sleep.
Hypersomnia
Hypersomnia, which can also be caused by a number of different factors and forces, is defined as
the client's failure to stay awake during day time hours even when they have had enough sleep the
night before. Some of the risk factors associated with hypersomnia, all of which are physical in
nature, include disorders such as hypothyroidism, central nervous system dysfunction, and
alterations of the client's metabolism including diabetic ketoacidosis.
Parasomnia
Parasomnia is defined as a sleep disorder that interferes with sleep. There are a number of
parasomnias including sleep walking, sleep talking, grinding of the teeth that is referred to as
bruxism, nocturnal enuresis and restless leg syndrome.
Sleep Apnea
Simply stated, sleep apnea is apnea that occurs during sleep. There are a couple of types of sleep
apnea including obstructive sleep apnea that is typically caused by large anatomical structures such as
the tongue and the collapse of the oropharynx when the client is sleeping, central sleep apnea which
results from some deficit of the central nervous system such as an insult to the brain stem, and
mixed sleep apnea, which occurs as the result of the combination of both central and obstructive
sleep apnea, and results from multiple related disorders and diseases.
Circadian Rhythm
Circadian rhythm is the human's natural and innate 24 hour a day clock. Circadian rhythms are
sometimes referred to as our body clock. In essence, humans take on cyclical 24 hour periods of
time that are associated not only with sleep, but also in terms of their hormone secretion, their
bodily temperature and other physiological and other psychological variations.
Good sleep habits and rest promote better health and well-being in people. A lack of sleep and rest
do not. Poor sleep habits can lead to inability to mentally focus, adversely affect moods, and increase
the risk of depression, heart attack, high blood pressure, obesity, and other health problems.
Infants from 4 months of age to 11 months of age should normally sleep about 12 to 15 hours a
day
Older infants and toddlers up to 3 years of age should sleep 11 to 14 hours a day
School age children from 6 to 12 years of age need 9 to 11 hours of sleep each day
Young adults and middle aged adults need about 7 to 9 hours of sleep
Older adults over 65 years of age tend to require slightly less sleep than the middle age adults
and only 7 to 8 hours of sleep per night
The factors that impact on sleep, its duration and its quality are described below.
Illnesses: Despite the fact that clients with physical diseases and disorders require more sleep
than normal for recovery, they tend to get less because of some of the signs and symptoms of
the illness or disorder that they are affected with. For example, pain, respiratory, genitourinary
and gastrointestinal system disorders often interfere with the client's getting enough sleep,
hypothyroidism can decrease stage IV sleep, and pyrexia can impair and reduce the amount of
REM and delta sleep that the client gets.
Medications: Some medications increase the client's sleepiness and the duration of sleep and
other medications impair and impede the quality and quantity of the sleep that the client gets
while they are on a particular medication. For example, beta blockers used for hypertension can
lead to insomnia and a decrease in the amount of REM sleep that the client gets; and, narcotic
medications, steroid medications, antidepressant medications, and bronchodilating medications
can decrease the duration of sleep and also impair the onset of sleep and the quality of the
person's REM sleep.
Environment: The environmental factors and forces that can interfere with sleep include things
like an uncomfortable environmental temperature, noise, sleeping in a strange bed, an
uncomfortable mattress and/or pillows, the presence or absence of light, and a snoring partner,
for example.
Emotional and Psychological Distress and Stress: The National Sleep Foundation, states
that stress is the number one cause of insomnia. Stress makes it more difficult to relax and,
therefore, it can easily lead to sleep induction and sleep maintenance disorders.
Lifestyle Choices: Consumption patterns such as cigarette smoking and alcohol use interfere
with sleep and other life style choices such as those related to exercise also impact on sleep, the
duration of sleep and the quality of sleep. Daily exercise facilitates sleep; however, exercise
immediately before bed time may interfere with the client's sleep.
Work Schedules: Long work hours and working night time hours interfere with sleep. For
example, humans, including nurses, who work the night tour of duty, are often unable to go to
sleep and stay asleep during day time hours when they are off from work. Night time work and
activity disrupts the person's normal circadian rhythms in a similar manner that people suffer
from jet lag when they travel across time zones.
Clients are assessed by the nurse for their sleep and rest patterns and any sleep disturbances. After a
complete physical assessment of the client is assessed using other subjective and objective data, as
discussed immediately below.
The physical assessment may reveal some data that can suggest a sleep disorder. Some of this data
can include a deviated nasal septum, enlarged tonsils and obesity, all of which can lead to a sleep
disorder or disturbance.
Other assessments can include:
The review of the client's reports about their sleep: The nurse may ask a client to record their sleep
patterns and record it in a sleep log or diary for a week or more, after which, the nurse will assess
and analyze this data to determine any sleep disturbances. Some of the data that is recorded in this
sleep log can include:
Interventions for sleep disturbances are described below. These interventions are often referred to
as sleep hygiene measures.
Insomnia: The establishment of and adherence to a regular to bed routine, the avoidance of
alcohol and exercise prior to sleep, using the bed for sleep only and not for watching television
or doing work, the use of stress and relaxation techniques, arising from bed if sleep induction
does not occur within a reasonable amount of time, pain management, the correction of any
assessed sleep disorders, the avoidance of caffeine and heavy meals prior to bed time, cognitive
behavioural therapy, and medications to promote sleep as the last resort, and then, only on a
temporary basis.
Hypersomnia: Since hypersomnia occurs as the result of a physical rather than a psychological
cause, the underlying physical cause, such as hypothyroidism, should be corrected.
Narcolepsy: Narcolepsy, which is caused by the lack of the chemical hypocretin in the area of
the CNS that regulates sleep, leads to day time sleepiness and sleep attacks that cause the person
to fall asleep at unpredictable times, such as when driving an automobile. The client who is
assessed as having narcolepsy should be educated about the dangers of using heavy equipment
and motor vehicles and they can also be treated with central nervous system stimulant
medications like an amphetamine or an antidepressant to control this sleep disorder and its
effects.
Sleep Apnea: The treatment for sleep apnea depends on the cause. For example if the apnea is
related to enlarged oropharyngeal anatomy such as the tongue, tonsils and pharynx, laser
reduction may be indicated, if the cause of the sleep apnea is obesity, the client should be on a
weight reduction diet, and if the cause is not treatable, the client will be given a CPAP machine
for daily use while the client is sleeping. CPAP, which is continuous positive airway pressure, is
delivered to the client with a CPAP machine, tubing and a full face mask, a nasal prong or a
partial face mask. Full face masks are recommended for clients who are mouth breathers,
however, some clients may reject a full face mask because they feel somewhat claustrophobic
when they are in place. The treatment and correction of sleep apnea is necessary because, left
untreated, sleep apnea can lead to complications such as pulmonary hypertension, hypertension
and cardiac arrhythmias.
Parasomnias: Parasomnias like bruxism can be treated with dental correction, stress
management techniques, muscle relaxants, or a botulinum toxin A, which is Botox, in severe
cases, and the use of a splint or mouth guard that is a dental appliance that prevents damage to
the teeth as the result of bruxism.
Nocturnal Enuresis: Nocturnal enuresis can be treated with a bed wetting alarm, positive
reinforcement and medications such as imipramine and desmopressin.
Sleepwalking: Sleepwalking can be treated with a sleep hygiene program to decrease sleep
deprivation, the elimination of problematic medications, the avoidance of alcohol and the
correction of any causal underlying illnesses, all of which can lead to sleep walking.
Periodic Limb Movement and Restless Leg Syndrome: These sleep disrupting disorders can
be treated with the correction of an underlying disorder, such as peripheral neuropathy, the
avoidance of alcohol and tobacco, the use of some medications such as those that increase
dopamine, benzodiazepines and anticonvulsant medications, when indicated.
Applying a Knowledge of the Client's
Pathophysiology to Rest and Sleep
Interventions
As mentioned immediately above and in other sections of "Rest and Sleep", many interventions for
sleep disorders and disturbances are based on the needs of the specific client as specific to their
physiological and psychological pathologies. For example, stress and relaxation, in addition to other
complementary and non pharmacological interventions are used when the client is adversely affected
with anxiety that disrupts sleep, continuous positive airway pressure (CPAP) is used when the
client's anatomical structures are abnormally large or they abnormally relax and collapse during sleep,
and analgesics are administered to relieve pain as the result of an acute or chronic physical disorder
or disease.
Establishing and adhering to a regular sleep time and wake time for the client based on their
patterns and needs
Limiting the duration and frequency of day time naps
The promotion of daily exercise
The avoidance of alcohol, caffeine, heavy meals and exercise at least a couple of hours before
bedtime
The promotion of comfort using techniques such as white noise, dim lighting, pain
management, stress reduction techniques, massage and the elimination of environmental noise
Many hospitals and nursing homes have established policies and procedures to promote sleep by
decreasing the noisiness of client care areas. For example, the hospital may stop over head paging
after a certain hour; they may turn down the telephone ringer volume after a certain hour and turn
down the lights in the hallways.
II) Pharmacological and Parenteral
Therapies
The registered nurse provides care related to the administration of medications and parenteral
therapies.
Registered nurses must be able to:
Some of the commonly used terms and terminology relating to pharmacological and parenteral
treatments that you must be aware of and knowledgeable about include those briefly described
below:
The administration of medications involves far more than handing an ordered medication to a client.
The administration of medications entails the nurse's application of critical thinking skills, their
professional judgment, their application of pathophysiology, and a thorough knowledge of the client
and their condition.
When medications are ordered, the nurse must be knowledgeable about the indications,
contraindication, side effects, adverse effects and the interactions associated with the medication, as
found in a reliable resource such as the Physician's Desk Reference. If, and when, the nurse's
knowledge of these things and the nurse's knowledge about the client and their condition are not
consistent and congruent with each other, the nurse must question the order and discuss their
concerns with the ordering physician or licensed independent practitioner such as a physician's
assistant or nurse practitioner.
After a medication has been administered, the nurse is also responsible and accountable for closely
monitoring the client for any side effects and adverse actions.
Prior to the administration of medications, the nurse must be fully knowledgeable about the
contraindications of the medications, the client's condition and determine whether or not the
ordered medication is contraindicated for this client. When a nurse identifies that fact that a
medication is contraindicated for a client, the nurse must communicate with the ordering physician
in order to clarify this medication order.
Identify the client according to facility/agency policy prior to administration of red blood cells/
blood products (e.g., prescription for administration, correct type, correct client, cross matching
complete, consent obtained)
Check the client for appropriate venous access for red blood cell/blood product administration
(e.g., correct gauge needle, integrity of access site)
Document necessary information on the administration of red blood cells/blood products
Administer blood products and evaluate client response
Blood transfusions are indicated for the client who has hypovolemia secondary to hemorrhage,
anemia or another disease process that is associated with a deficiency in terms the client's clotting or
another component of blood, for example. Although hypovolemia can be treated with fluid
replacement, this fluid does not provide the client with the oxygen carrying components that only
blood has. In addition to blood's components in terms of oxygen transporting red blood cells, blood
also transports carbon dioxide, and it contains white blood cells to combat infection, clotting factors
and essential blood proteins.
There are four blood types each of which has its antigen in its red blood cells. These blood types are
A with A antigens, B with B antigens, AB with both A and B antigens, and O which has neither A
nor B antigens. People with O type blood are universal donors but they are universal suckers
because type O blood can be given to clients with A, B, AB and O blood type clients but the type O
blood type client can only receive type O blood. Each blood type also has antibodies, which are
referred to as agglutinins. Type A blood has B agglutinins; type B blood has A agglutinins, type AB
blood has no antibodies, or agglutinins, and type O blood has both A and B agglutinins.
People also have a rhesus, or Rh, factor antigen or the lack of it. Clients with an Rh positive blood,
which is the vast majority of people, have Rh positive blood and people without the Rh factor
antigen have Rh negative blood.
Members of the Christian Science religion do not typically accept blood transfusions and members
of Jehovah's Witness religion are prohibited from receiving blood. Plasma expanders without any
blood or blood products, however, are acceptable to members of both of these religions.
Most clients get blood and blood products that are donate by others through the blood bank,
however, some clients can choose to donate their own blood prior to an elective surgery, for
example, and then use this blood rather than the blood of a blood donor. This type of blood
transfusion is referred to as an autologous blood donation.
Blood and blood components are selected and given as based on the client's specific needs. The
different blood products and their components are described below.
Packed red blood cells: Packed red blood cells are used when the client is in need of increased
oxygen transporting red blood cells as may occur post operatively and with an acute
hemorrhage.
Platelets: Platelets are administered to clients who are adversely affected with a platelet
deficiency or a serious bleeding disorder, such as thrombocytopenia or platelet dysfunction that
requires the clotting factors that are in platelets.
Fresh frozen plasma: Fresh frozen plasma, which does not contain any red blood cells, is
administered to clients who are in need of clotting factors or are in need of increased blood
volume as occurs with hypovolemia and hypovolemic shock. Fresh frozen plasma does not have
to be typed and cross matched to the client's blood type because plasma does not contain
antigen carrying red blood cells.
Albumin: Albumin is administered to clients who need expanded blood volume and/or plasma
proteins.
Clotting factors and cryoprecipitate: Clotting factors and cryoprecipitate are administered to
clients affected with a clotting disorder including the lack of fibrinogen.
Whole blood: Whole blood is typically reserved for only cases of severe hemorrhage. Whole
blood contains clotting factors, red blood cells, white blood cells, plasma, platelets, and plasma
proteins.
Febrile Reactions
Febrile reactions are the most commonly occurring reaction to blood and blood products
administration. Although a febrile reaction can occur with all blood transfusions, it is most
frequently associated with packed red blood cells and this reaction is not accompanied with
hemolysis. The signs and symptoms of this transfusion reaction include fever, nausea, anxiety,
chilling and warm flushed skin.
Hemolysis
Hemolysis occurs as the result of an incompatibility of the donor's and recipient's blood which is
referred to as an ABO incompatibility. This incompatibility can occur as the result of a laboratory
error in terms of typing and cross matching and a practitioner error in terms of checking the blood
and matching it to the client's blood type. This complication is signaled when the client has flank
pain, chest pain, restlessness, oliguria or anuria, respiratory distress, brown urinary output,
hypotension, fever, low blood pressure and tachycardia. The treatment of hemolysis includes the
administration of normal saline after the transfusion is stopped and all the tubing is changed to
prevent kidney failure and circulatory collapse. Although rare, a delayed, rather than an acute and
immediate, hemolytic reaction can occur up to about 4 weeks after the transfusion. This delayed
reaction is not as severe as an acute hemolytic reaction and it is characterized with jaundice,
discolored urine and anemia.
The intravenous tubing, the blood filter, the blood bag with its remaining contents are retained and
sent to the laboratory. A sample of the client's blood and urine are also taken and sent for diagnostic
testing.
Allergic Reactions
Allergic reactions to a blood transfusion can range from mild to severe. A mild allergic reaction
typically occurs as the result of an allergy to the plasma proteins in the blood, and severe allergic
reactions occur from a severe antibody - antigen reaction. Mild allergic reactions are accompanied
with possible itching, pruritic erythema, swelling of the lips, tongue or pharynx and eyelids, and
flushing of the skin; severe allergic reactions can manifest with chest pain, decreased oxygen
saturation, loss of consciousness, flushing, shortness of breath and respiratory stridor. Mild allergic
responses are treated with the administration of a corticosteroid and/or antihistamine medication;
severe allergic reactions are treated with the administration of supplemental oxygen and medications.
At times, a serious allergic reaction can be life threatening.
Sepsis
Sepsis is characterized with fever, hypotension, oliguria, chilling, nausea and vomiting This
transfusion reaction occurs as the result of some contaminate in the blood. This complication is
treated with intravenous fluids and antibiotics. The intravenous tubing, the blood filter, the blood
bag with its remaining contents are retained and sent to the laboratory. A sample of the client's
blood and urine are also taken and sent for diagnostic testing as is also done when the client has a
hemolytic reaction.
Educate the client on the reason for and care of a venous access device
Access venous access devices, including tunneled, implanted and central lines
Provide care for client with a central venous access device (e.g., port-a-cath, Hickman)
Explain the procedure to the client and use sterile supplies and sterile technique to start an
intravenous line.
Choose a suitable vein.
Place the tourniquet on the client's arm about 3 to 4 inches above the selected site.
Palpate the vein.
Clean the site with an alcohol prep pad with a circular pattern from the site of the venipuncture
to the area surrounding the site of the venipuncture Permit the area to dry.
Ask the patient to make a fist. Warm compresses and moving the limb to a dependent position
can also be used to dilate the vein. The client should not pump the limb.
Pull the skin taunt so the vein is accessible.
Insert the catheter needle into the vein at a 15 to 30 degree angle with the bevel up.
Look for the flashback of blood into the catheter.
Lower the angle of the catheter needle.
Gently advance the catheter so it is at the same level as the surrounding skin.
Remove the tourniquet and connect the intravenous tubing to the hub of the catheter.
Secure and stabilize the catheter with a manufactured catheter stabilization device to prevent
vein irritation and an inadvertent dislodgment.
Adjust the infusion rate according to the doctor's order.
After the intravenous catheter is successful inserted, the intravenous line and the insertion site is
monitored and maintained by the nurse. The intravenous line is monitored to insure that the line is
patent and that the rate of flow is as ordered. The intravenous site is inspected for any signs of
infiltration and infection. The dressing is changed and dated according to the particular healthcare
facility's policy and procedure which is typically every 24 hours.
Central venous catheters are inserted into the right atrium of the heart through the central venous
superior vena cava. Central venous catheters can be advanced into the superior vena cava through a
peripheral vein, as is the case with a peripherally inserted central venous catheter, or PICC, and also
into the central venous system through the subclavian or jugular vein. Some of these catheters have
multiple lumens, up to 3, and they vary in terms of how long they can remain in place. For example,
a percutaneous, non tunneled subclavian catheter is used when immediate and short term treatments
are anticipated, and other central venous catheters are tunneled and cuffed. For example, an
implanted tunneled and cuffed central venous catheter can have a port that is subcutaneously placed
and accessed with a non coring needle into the port's reservoir.
Central venous catheters are a preferred method of venous access when the client is getting
intravenous fluids or therapies in the home and also when the client:
Strict sterile technique is used for maintain and caring for a central venous catheter. Central venous
catheter dressings are changed at least every forty eight hours unless it is an occlusive transparent
dressing. These occlusive transparent dressings can be changed every 7 days unless they are wet,
soiled or loosened.
Some central venous catheters have a couple or several lumens. Each lumen must be flushed with a
heparin solution on a daily basis in order to maintain patency. The injection cap on each lumen
should be changed every 7 days or any time that the cap is leaking.
Some of the complications associated with central venous catheters include infection,
pneumothorax, hemothorax, thrombosis, emboli and an accidental cardiac perforation during the
insertion procedure.
Patient and family education about venous access devices begins with the informed consent
procedure and it continues throughout the client's use of these devices. Some of the components of
this education should include:
The nurse identifies the patient and informs the patient about the medication that will be
administered
Insure that the intravenous solution is compatible with the piggyback medication
The piggyback is hung
The primary intravenous site is cleansed with alcohol
The piggyback is inserted into the primary intravenous line
The primary intravenous and the piggyback are then allowed to run together until the piggyback
administration is completed
Dosage Calculations:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of dosage calculations in order to:
The apothecary measurement system has weight measurements like dram, ounce, grain (gr), scruple,
and pound. The volume units of measurement in the apothecary measurement system are a fluid
ounce, a pint, a minim, a fluid dram, a quart and a gallon.
Lower case Roman numerals are used in this system of measurement and these Roman numerals
follow the unit of measurement. For example, 4 grains is written as gr iv.
Below is a table showing the weight and volume apothecary system measures and their approximate
equivalents:
1 gallon 4 quarts
The metric measurement system has volume measurements including liters (L), cubic milliliters (ml)
and cubic centimeter (cc); its units of weight are (kg), grams (g), milligrams (mg) and micrograms
(mcg).
Below is a table displaying the metric length, volume and weight measurements and their
equivalents:
1 millimeter (mm) 0.001 meter 1 milliliter (mL) 0.001 liter 1 milligram 0.001
(mg)
1 centimeter (cm) 0.01 meter 1 centiliter (cl) 0.01 liter 1 centigram (cg) 0.001
1 kilometer (km) 1000 meters 1 kiloliter (kl) 1000 liters 1 kilogram (kg) 1000
10 millimeters (mm) 1 centimeter (cm) 10 milliliters (mL) 1 centiliter (cl) 1 pound (lb) 45,35
LENGTH EQUIVALENT VOLUME EQUIVALENT WEIGHT EQU
(cm)
10 centimeters (cm) 1 decimeter (dm) 10 centiliters (cl) 1 deciliter (dl) 1 pound (lb) 4,535
Fractions
The two types of fractions are proper fractions and improper fractions. Proper fractions are less
than 1 and improper fractions are more than one 1.
Fractions are written as:
1/2, 6/8 and 12/4, for example; the numerators for each of these fractions are 1, 6 and 12,
respectively; and the denominators for each of these fractions are 2, 8 and 4, respectively.
Both proper and improper fractions can be reduced to their lowest common denominator. Reducing
fractions make them more understandable and easier to work with. You have to determine which
number can be divided evenly into both the numerator and the denominator to reduce fractions. A
fraction cannot be reduced when there is no number that can be divided evenly into both.
For example, 24 / 56 has a numerator and denominator that can be equally divided by 8. To reduce
this fraction you would divide 24 by 8 which is 3 and you would then divide the 56 by 8 which is
which is 7. This calculation is performed as seen below.
24/56 = 3/7
Mixed Numbers
Mixed numbers are a combination of a whole number greater than one and a fraction. Some
examples of mixed numbers are 4 1/4, 3 5/6 and 24 6/7.
You have to convert all mixed numbers into improper fractions before you can perform calculations
using them.
The procedure for converting mixed numbers into improper fractions is:
The calculation below shows how you how you convert a mixed number into a fraction.
3 2/8 = (8 x 3 + 2) / 8 = (24 + 2 = 26) / 8
Decimals
Decimals express numbers more or less than one in combination with a decimal number of less than
one like a mixed number is.
All decimals are based on our system of tens; in fact the "dec" of the word decimal means 10.
For example, 0.7 is 7 tenths; 8.13 is 8 and 13 hundredths; and likewise, 9.546 is 9 and 546
thousandths. The first place after the decimal point is tenths; the second place after the decimal
point is hundredths; the third place after the decimal point is referred to as thousandths; the fourth
place after the decimal point is ten thousandths, and so on.
When the decimal point is preceded with a 0, the number is less than 1; and when there is a whole
number before the decimal point, the decimal number is more than 1.
For example:
2.7 = Two and 7 tenths or 2 7/10
21.98 = 21 and 98 hundredths or 21 98/100
Decimal numbers are often rounded off when pharmacology calculations are done. For example, if
your answer to an intravenous flow rate is 67.8 drops per minutes, you would round the number off
to the nearest whole drop because you cannot count parts of a drop. When you have to round off a
number like 67.8 o the nearest whole number, you must look at the number in the tenths place
which is 8. If the number in the tenths place is 5 or more, you would round up the 67 to 68 drops.
Similarly, if you have to round off the number 23.54 to the nearest tenth place, you would look at
the number in the hundredths place and if this number is 5 or more, you would round up the
number in the tenths place, but if the number is less than 5, you would leave the number in the
tenths place as it is.
Here are some decimal numbers rounded off to the nearest whole:
23.8 = 24
65.4 = 65
Here are some decimal numbers rounded off to the nearest tenth:
23.84 = 23.8
67.47 = 67.5
And here are some decimal numbers rounded off to the nearest hundredth:
23.847 = 23.85
67.472 = 67.47
60 milligrams 1 grain
The most frequently used conversions are shown below. It is suggested that you memorize these. If
at any point you are not sure of a conversion factor, look it up. Do NOT under any circumstances
prepare and/or administer a medication that you are not certain about. Accuracy is of paramount
importance.
1 Kg = 1,000 g
1 Kg = 2.2 lbs
1 L = 1,000 mL
1 g = 1,000 mg
1 mg = 1,000 mcg
1 gr = 60 mg
1 oz. = 30 g or 30 mL
1 tsp = 5 mL
1 lb = 454 g
1 tbsp = 15 mL
1/6
1:6
1 to 6
When comparing ratios, they should be written as fractions. The fractions must be equal. If they are
not equal they are NOT considered a ratio. For example, the ratios 2 : 8 and 4 : 16 are equal and
equivalent.
In order to prove that they are equal, simply write down the ratios and simply criss cross multiply
both the numerators and the denominators, as below.
2 x 16 = 32 and 8 x 4 = 32.
Because both multiplication calculations are equal and 32, this is a ratio.
On the other hand, 2/5 and 8/11 are not proportions because 8 x 5 which is 40 is not equal to 11 x
2 which is 22.
Calculating Proportions
Proportions are used to calculate how one part is equal to another part or to the whole. For these
calculations, you criss cross multiply the known numbers and then divide this product of the
multiplication by the remaining number to get the unknown or the unknown number.
For example:
2/4 = x/12
12 x 2 = 24
4 x = 24
x = 24/4 so x = 6
Monitor the client's adherence to and compliance with their medication regimen
Assess and reassess the client in terms of the achievement of the expected outcomes of the
medication(s) over time
Monitor the client for any side effects, interactions and adverse effects
Monitor and assess the client for the presence of any cumulative effects of their medication that
has been taken over a period of time
Additionally, the nurse caring for the client over time will periodically perform the medication
reconciliation process to insure that the nurse is aware of all medications that the client is taking,
some of which may have been ordered by a physician other than the client's primary care doctor and
some of which are over the counter or alternative therapies that the client has added. The complete
and current list of medications is then reviewed by the nurse and possible interactions are identified
and addressed with the client.
Medication Administration:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of medication administration in order to:
1. Medication
2. Dose
3. Time or frequency
4. Patient
5. Route
6. Client education
7. Documentation
8. Right to refuse
9. Assessment and
10. Evaluation
In addition to the Ten Rights of Medication Administration and identifying the patient using at least
two unique identifiers, nurses must also insure medication safety in respect to the storage of
medications, the checking for expiration dates, checking for any patient allergies, and checking for
any incompatibilities.
Nurses must use at least two (2) unique identifiers, other than room number, prior to all procedures
including the administration of medications. Some examples of unique identifiers include the client's
first, middle and last name, a unique password or code number assigned to that person upon
admission, the client's complete birthday in terms of the month, the day and the year, a photograph,
and an encoded bar code containing two (2) or more unique identifiers.
Narcotics must be in a locked and secured in a safe place; other medications must be stored in a
place that is secure and one that prevents accidental poisonings among the pediatric population and
also among those who are confused and/or cognitively impaired. Additionally, medications that
need refrigeration must be refrigerated.
Tablets
Capsules (regular and sustained release)
Ointments
Pastes
Creams
Oral suspensions
Syrups
Tinctures
Elixirs
Ear and eye drops
Suppositories
IV suspensions and solutions
Inhalers
Oral
Subcutaneous
Intramuscular
Intravenous or parenteral
Buccal
Sublingual
Topical
Ophthalmic
Otic
Vaginal
Rectal
Nasal
With a nasogastric or gastrostomy tube
Inhalation
Intradermal
Transdermal
Intracardial
Intra-articular
Intrathecal
The oral route of administration is the preferred route of administration for all clients but the oral
route is contraindicated for clients adversely affected with a swallowing disorder or a decreased level
of consciousness. Oral medications can, at times, be crushed and put into something like apple
sauce, for example, for some clients who have difficulty swallowing pills and tablets, but, time
release capsules, enteric coated tablets, effervescent tablets, medications irritating to the stomach,
foul tasting medications and sublingual medications should not be crushed. An alternative route for
some clients is a liquid form of the medication.
Toddlers: Liquid oral medications are given with a spoon or a cup, the vastus lateralis, rectus
femoris and ventrogluteal sites are used for intramuscular injections, the gluteus maximus
muscle can be used after the toddler has been walking for at least a year, flavors can be used to
improve the taste of oral medications, and the dosages continue to be based on kilograms of
weight.
Preschool and school age children: These children are usually able to take capsules and
tablets, the gluteus maximus muscle and the deltoid muscle can now be used for intramuscular
injections, in addition to the vastus lateralis, rectus femoris and ventrogluteal intramuscular
injection sites, and dosages continue to be based on kilograms of weight.
The Elderly: Adult dosages may be decreased because the normal physiological changes of the
aging process make this age group more susceptible to side effects, adverse drug reactions, and
toxicity and over dosages. Renal function is decreased which can impair the elimination and
clearance of medications, the liver function can be decreased, absorption in the gastrointestinal
tract may be decrease, and the distribution of medications can be decreased because the elderly
client may have decreased serum albumin, for example. All of these factors increase the elderly
client's risk for side effects, adverse drug reactions, and toxicity and over dosages. For example,
the risk of toxicity is increase when the elderly client is taking aminoglycosides, thiazides, a
nonsteroidal anti-inflammatory medication, heparin, long acting benzodiazepines, warfarin,
isoniazid and many antiarrhythmics.
Nurses must, therefore, begin a new medication with the lowest possible dosage and then increase
the dosage slowly over time until the therapeutic effect is achieved. The initial dosage may be as low
as ½ of the recommended adult dosage.
1. Prep the top of the longer acting insulin vial with an alcohol swab.
2. Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe.
Do NOT withdraw the longer acting insulin yet.
3. Prep the top of the shorter acting insulin with an alcohol swab
4. Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin
syringe.
5. Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe.
6. And, then lastly, withdraw the ordered dosage of the longer acting insulin using the same insulin
syringe.
For example, if the client has an order for 10 units of NPH insulin in the morning and they also
need 3 units of regular insulin according to their sliding scale for coverage, the client will draw up
both insulins according to the above procedure and then inject 13 units total for the NPH and the
regular insulins.
Administering and Documenting
Medications Given by a Common
Route
The procedures for the administration of medications using different routes are briefly described
below. Note that the verification of the order, its appropriateness for the client, client identification
using at least two unique identifiers, and explaining the medication and the procedure for it
administration is done BEFORE any medication is given to a client.
1. Don gloves.
2. Place the buccal medication in the buccal pouch and the sublingual medication under the client's
tongue.
3. Instruct the client to not chew or swallow the medication but, instead, to leave the drug in its
position until it is completely dissolved.
1. Don gloves.
2. Position the patient in a sitting position or in a supine position.
3. Have the patient tilt their head back and toward the eye getting the drops or ointment in order
to prevent the medication from entering and collecting in the client's tear duct.
4. Have the patient look up and away to prevent the tip of the tube or dropper from touching the
client's eye. .
5. Rest your hand against the client's forehead to steady it.
6. To administer drops, pull down the lower lid and instill the ordered number of drops into the
conjunctival space.
7. To administer an ointment, pull down the lower lid and squeeze the ointment into the
conjunctival space from the inner to the outer canthus of the eye without letting the tip of the
tube or dropper from touch the client's eye.
8. Instruct the client to close their eyes, roll their eyes and blink. Blinking will spread the drops and
rolling the closed eyes will spread the ointment over the eye.
9. Clean off any excess drops or ointment gently using a facial tissue from the inner to the outer
canthus of the client's eye(s).
1. Make sure that the medication is compatible with the IV solution and any additives.
2. Don gloves.
3. Close the flow clamp on the IV tubing or pinch the tubing just above the injection port.
4. Prep the injection port with alcohol.
5. Inject the medication slowly over several minutes.
6. Open the flow clamp and readjust the flow rate to the ordered rate.
1. Make sure that the medication is compatible with the IV solution and any additives.
2. Hang the secondary IV set (piggy back).
3. Clean the injection port on the primary intravenous line with alcohol.
4. Insert the secondary set needle or needless system into the injection port of the primary IV
tubing.
5. Lower the primary IV using an extension hook to run only the piggy back medication. This
allows the higher piggy back to run until it is finished, after which the primary intravenous will
automatically run at the established rate. If you want to run the primary intravenous solution at
the same time as the piggy back, keep the primary and the secondary containers at the same
height.
6. Remove the secondary set when the medication is completely administered.
More information about intravenous fluid and medication administration and how to start an
intravenous line was discussed in the section entitled "Educating the Client on the Reason For and
Care of a Venous Access Device" of this NCLEX-RN review guide.
The doctor must be notified whenever the nurse has any concerns or problems with these things.
Nursing Procedures
The intravenous line and the insertion site are monitored and maintained by the nurse. The
intravenous line is monitored to insure that the line is patent and that the rate of flow is as ordered.
The intravenous site is routinely assessed and inspected for any signs of infiltration and infection.
The dressing is changed and dated according to the particular healthcare facility's policy and
procedure which is typically every 24 hours.
All of these nursing procedures can only be done by licensed nurses, and not unlicensed assistive
staff.
Psychomotor Skills
The psychomotor skills associated with venipuncture and starting an intravenous line was fully
discussed step by step in the section entitled "Educating the Client on the Reason For and Care of a
Venous Access Device".
Infection
Infiltration
Extravasation with vesicant medications
Hematoma
Phlebitis
Embolus formation
Fluid overload
Infection
The signs and symptoms of intravenous therapy infection include the classic signs of infection such
as swelling, soreness, redness at the site, pain, and fever. This complication can be prevented by only
using intravenous therapy when necessary, by discontinuing the intravenous therapy and catheters as
soon as possible and by maintaining strict sterile asepsis when care for and dressing the site of the
intravenous therapy. In addition to documenting this complication and notifying the doctor, the
nurse should also discontinue the intravenous flow and catheter, elevate the client's affected limb,
apply warm compresses, and administer any ordered antipyretic and/or antibiotic medications.
Infiltration
Infiltration occurs when intravenous fluid is infused into the subcutaneous tissues instead of the
vein. When the client is adversely affected with an infiltration, the nurse should be able to identify its
signs and symptoms which can include site pain, swelling in the area of the catheter insertion site,
coolness of the skin near the site, slowing down of the intravenous fluid rate, and paleness of the
skin around the insertion site. Nurse should, again, stop the infusion, remove the intravenous
catheter, elevate the affected limb and apply warm compresses to the area.
Extravasation
Extravasation is a serious form of infiltration that occurs when a caustic medication, like some
chemotherapeutic medications, infiltrates into the tissue. In severe cases, extravasation can lead to
necrosis and the loss of an affected limb. The signs and symptoms in the early stage of extravasation
are the lack of blood return, a lowered rate of infusion, burning, tingling, severe pain in the limb,
erythema, swelling, redness, and blistering; and the signs and symptoms during the later stages of
extravasation include the worst possible unrelenting pain, ulceration, blistering, and severe necrosis
secondary to extravasation.
The interventions for extravasation include the immediate cessation of the infusion, the placement
of a syringe after the removal of the intravenous line near the site, aspirating as much blood and
infused fluid as possible, elevating the limb, applying warm compresses initially to rid the area of any
remaining drug that is in the tissues which is then followed by cool compresses to reduce any
swelling, and the administration of an ordered substance specific medication such as dexrazoxane.
Hematoma
Hematomas secondary to intravenous therapy and other injuries present with ecchymosis. The
treatment of an intravenous therapy related hematoma includes the cessation of the intravenous
therapy, the removal of the intravenous catheter, the application of pressure and a pressure dressing
over the site, the elevation of the limb and the application of warm compresses. This complication
does not typically lead to a serious condition other than minor bruising.
Phlebitis
The signs and symptoms of intravenous therapy related phlebitis include redness, swelling, pain,
fever, the slowering of the intravenous flow, and the possible appearance of a palpable red streak at
the intravenous insertion site and beyond. Phlebitis is treated with the cessation of the intravenous
therapy, the elevation of the limb, the application of warm compresses and the possible
administration of analgesics for the pain and/or antipyretics for the client's fever.
Embolus Formation
The signs and symptoms of an embolus can include shortness of breath and chest pain. In addition
to notifying the doctor, the nurse should monitor the client for life threatening complications, and
place a tourniquet above the site to prevent further migration of broken catheter pieces.
Fluid Overload
Fluid overload can occur when the flow rate of the intravenous fluids exceed the client's capacity to
cope with this volume. The signs and symptoms of fluid overload include hypertension, adventitious
breath sounds such as rales and crackles, tachycardia, shortness of breath, distended neck veins and
edema. Fluid overload is a high risk for elderly clients and those affected with heart failure. The
nurse monitoring the client who suspects fluid overload will notify the doctor and decrease the rate
of the intravenous fluids to prevent further overload.
Pharmacological Pain
Management: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of pharmacological pain management in order to:
Assess client need for administration of a PRN pain medication (e.g., oral, topical, subcutaneous,
IM, IV)
Administer and document pharmacological pain management appropriate for client age and
diagnoses (e.g., pregnancy, children, older adults)
Administer pharmacological measures for pain management
Administer controlled substances within regulatory guidelines (e.g., witness, waste)
Evaluate and document the client's use and response to pain medications
Assessing the Client's Need for the
Administration of a PRN Pain
Medication
Some orders for pain medications are PRN which means that the client will only receive the pain
medication when there is pain or discomfort that can be assessed and documented by the nurse.
PRN pain medications can be given using a number of routes including the intramuscular,
intravenous, oral, subcutaneous, and topical route as is used for skin irritation and itchiness, for
example.
RELATED: Pain Management Nursing Careers
As more fully discussed earlier in the section entitled "Assessing the Client's Need for Pain
Management", pain can be classified as acute and chronic, nociceptive and neuropathic, superficial,
somatic, radicular, referred or visceral pain, localized or diffuse, and as mild, moderate, or severe.
As also detailed in this same section, pain that is not controlled and managed can lead to severe
consequences for the client. For example, the client's psychological and emotional state can be
adversely affected with depression, a poor quality of life, and anxiety, and the client's physical status
and hemostasis is also affected with things like alterations in terms of their vital signs and perhaps
even neurogenic shock.
Despite all the misinformation about pain and pain management, pain must be managed according
the external regulatory bodies like the Joint Commission on the Accreditation of Healthcare
Organizations, and the American Nurses Association.
There are several ways of assessing pain. These pain assessment methods include:
The PQRST method of pain assessment which includes precipitating events, the quality of pain
(dull, sharp, deep, superficial, burning, aching, or stabbing?), region and location of the pain, the
severity of the pain, and the triggers and timing of the pain.
Using a standardized pain assessment scale specifically for adults, children and infants, such as
the CRIES and McGill Pain Assessment tools
Using a graphic or numerical pain rating scale with faces and on a scale from 0 to 10, for
example
The assessment of behavioral signs and symptoms of pain such as tachycardia, hypertension and
diaphoresis
Administering and Documenting
Pharmacological Pain Management
That is Appropriate for the Client's
Age and Diagnoses
Pharmacological pain management medications have some age specific implications along the
lifespan and for some diagnoses, conditions and diseases. For example, infants, children, the elderly
and clients affected with a normal and expected developmental change, such as pregnancy, have
special needs that the nurse must be knowledgeable about before administering a pharmacological
pain medication.
Neonates and infants are given dosages of medications based on their weight in terms of kilograms
or based on their body surface area. Oral pain medications are given as a liquid using a dropper or a
nipple.
Young children are also given pain medications with a dosage as based on their kilograms of body
weight or based on their body surface area. Young children may be able to take some oral pills and
tablets. The vastus lateralis, rectus femoris and ventrogluteal sites are used for intramuscular
injections until the young toddler has been walking for at least one year to develop the gluteus
maximus muscle which can now be used for intramuscular injections.
The elderly population and the normal changes of the aging process also have implications in terms
of pharmacological pain management medications. The normal changes of the aging process such as
decreased renal, hepatic and gastrointestinal functioning place the client at risk for side effects,
adverse drug reactions, toxicity and over dosages. Nurses must, therefore, begin a new medication
with the lowest possible dosage and then increase the dosage slowly over time until the therapeutic
effect is achieved. The initial dosage may be as low as ½ of the recommended adult dosage.
Many pain management medications are contraindicated during pregnancy and lactation. For
example, opioids used during pregnancy can lead to premature births, miscarriages, and other
complications of pregnancy. The fetus may also have withdrawal symptoms from this medication.
Administering Pharmacological
Measures for Pain Management
Analgesic pharmacological medications are broadly categorized as opioid analgesics and non-opioid
analgesics. They can also be categorized as adjuvant medications and primary analgesic medications.
Opioids are narcotics; they are used for moderate to severe pain; non-opioids are non-narcotic
analgesics that are used to treat mild pain and they also to serve as adjuvant medication for the relief
of pain.
The non-narcotic, non opioid medications that are used for pain management include those listed
below along with their examples and possible side effects.
Tylenol: The side effects can include hepatotoxicity, renal damage and, in very severe cases,
hepatic failure
NSAIDS: Ibuprofen and Ibuprofen like drugs such as Advil, Motrin, Naprosyn, Naproxen and
Clinoril are associated with side effects such as nausea, indigestion, a headache, fecal occult
blood and anorexia. Although not that common, some of the severe side effects and adverse
effects of these drugs can include aplastic anemia, gastrointestinal tract bleeding, edema, and
renal failure.Selective COX-2 (cyclooxygenase 2 ) inhibitors like Celebrex are also associated
with both mild and very severe side effects. Some of the commonly occur side effects include
abdominal pain, gastrointestinal gas, headache, insomnia, nausea and bloating. Some of the most
serious and life threatening side effects of these medications are gastrointestinal hemorrhage, a
cerebrovascular accident and a myocardial infarction.
Salicylate NSAIDS: Salicylate NSAIDS include aspirin and disalcid, for example. Some of the
mild side effects include abdominal pain, ulcers and heartburn; more serious side effects and
adverse reactions include hemolytic anemia, bronchospasm and anaphylactic shock.
Centrally Acting Non Opioid Analgesics: Centrally acting non opioid analgesics such as
Clonidine are associated with side effects such as oral dryness, drowsiness, sedation,
constipation, hypotension and fatigue.The narcotic, opioid medications that are used for pain
management include those listed below along with their examples and possible side effects.
Opioid Agonists: Opioid agonists such as codeine, OxyContin, Darvon, Dilaudid, Demerol
and Percocet have the side effects of constipation, sedation, nausea, dizziness, pruritus, and
sedation. Some of the more severe side effects and adverse effects of the opioid agonists include
respiratory depression and arrest, hepatic damage, an anaphylactic reaction, circulatory collapse
and cardiac arrest.
Opioid Antagonists: Opioid antagonists, also referred to as opioid receptor antagonists, such
as naloxone and naltrexone, can have side effects such as hepatic damage, joint pain, insomnia,
vomiting, anxiety, headaches and nervousness.
Opioids with Mixed Agonist - Antagonist effects: Opioids with mixed agonist- antagonist
effects include analgesics like Talwin and Stadol can have side effects such as nausea,
drowsiness, dizziness, diaphoresis and clammy skin.
RELATED: How Can Pain Management Nurses Help to Identify and Manage Addictions?
The signature of the nurse picking up the narcotics from the pharmacy to confirm that this
nurse picked up the medications
A narcotics sheet which is delivered to the nursing care unit together with the narcotics that
were picked up by the nurse at the pharmacy
Locking and securing controlled substances in a secure manner to prevent diversion and/or
theft
The assignment of the accountable nurse who will count and verify the narcotics count at the
beginning and the end of each shift
The removal of narcotics from the locked cabinet by this accountable nurse and the immediate
signature of the nurse removing it for administration to the client
The witnessing and signatures of two nurses for any wasting and discarding of controlled
substances
The client will state that their level of pain has decreased by at least 3 after the administration of
a pain medication
The infant will be free of any behavioral or physiological signs and symptoms of pain
The client is able to transfer and ambulate without pain after the administration of their pain
medication
The client states that they are able to sleep after they have received their ordered pain
medication
Identify side effects/adverse events related to TPN and intervene as appropriate (e.g.,
hyperglycemia, fluid imbalance, infection)
Educate client on the need for and use of TPN
Apply knowledge of nursing procedures and psychomotor skills when caring for a client
receiving TPN
Apply knowledge of client pathophysiology and mathematics to TPN interventions
Administer parenteral nutrition and evaluate client response (e.g., TPN)
Complications associated with the insertion of the TPN catheter: Some of the
complications associated with the insertion of the TPN catheter include an accidental and
inadvertent pneumothorax, hemothorax or hydrothorax when the TPN catheter perforates the
vein and fluid enters the pleural space. The signs and symptoms of these insertion complications
include chest pain, shortness of breath and pain.
Infection: Infection is probably the most commonly occurring complication associated with
total parenteral nutrition. This complication can be prevented and minimized by using total
parenteral nutrition only when necessary, by discontinuing the total parenteral nutrition as soon
as possible, and by using strict sterile technique during its insertion, care, and maintenance. Most
sources of infectious pathogens enter this closed system during insertion, tubing changes,
dressing changes, and when total parenteral nutrition solutions are mixed. The signs and
symptoms of these infections include the classical signs of infection including a fever, malaise,
swelling and redness at the insertion site, diaphoresis, chilling and pain in the area of the TPN
catheter insertion site.
Fluid overload: Fluid overload can occur for the same reasons that fluid overload can occur
with a regular peripheral intravenous flow. The rate is too fast and rapid for the client. The signs
and symptoms of fluid overload include hypertension, edema, adventitious breath sounds like
crackles and rales, shortness of breath, and bulging neck veins. This complication can be
prevented by monitoring the client and adjusting the rate of the total parenteral nutrition to
prevent fluid overload.
Hyperglycemia: Hyperglycemia can occur as the result of the high dextrose content of the total
parenteral nutrition solution as well as the lack of a sufficient amount of administered insulin.
The signs and symptoms of hyperglycemia secondary to total parenteral nutrition are the same
as those associated with poorly managed diabetes and they include a high blood glucose level,
thirst, excessive urinary output, headache, nausea and fatigue. This total parenteral nutrition
complication can be prevented with the continuous monitoring of the client's blood glucose
levels and the titration of insulin administration as based on these levels.
Hypoglycemia: Hypoglycemia secondary to total parenteral nutrition are the same as those
associated with poorly managed diabetes and they include a headache, a low blood glucose level,
shakiness, clammy and cool skin, blurry vision, diaphoresis and unconsciousness and seizures.
This complication of total parenteral nutrition, like hyperglycemia, can be prevented with the
close monitoring of the client's blood glucose levels and an adequate dosage of insulin as based
on these levels.
Embolism: Embolism can occur when air is permitted to enter this closed system during tubing
changes and when a new bottle or bag of hyperalimentation is hung. This complication can be
prevented by instructing the client to perform the Valsalva maneuver and the nurse's rapid
changing of tubings and solutions when the closed system is opened to the air. The signs and
symptoms of an embolism include dyspnea, shortness of breath, coughing, chest pain and
respiratory distress.
Imbalanced nutrition less than the body requirements related to advanced debilitating disease
Imbalanced nutrition less than the body requirements related to a negative nitrogen balance
secondary to a severe burn
Imbalanced nutrition less than the body requirements related to an impairment of
gastrointestinal tract functioning
At risk for hypoglycemia related to total parenteral nutrition
At risk for hyperglycemia related to total parenteral nutrition
At risk for sepsis related to total parenteral nutrition
At risk for sepsis related to total parenteral nutrition
The planning phase of the nursing process in respect to total parenteral nutrition includes the
establishment of client goals or expected outcomes and planning interventions. Some appropriate
expected outcomes can include:
The client will be free of any complications associated total parenteral nutrition
The client will have adequate nutrition
The client will maintain normal blood glucose levels during treatment with total parenteral
nutrition
The client will be able to verbalize an understanding of total parenteral nutrition and the need
for sterile asepsis
The evaluation of the total parenteral nutrition for the client is based on comparing the client's
baseline data and information to the data and information that is collected during these treatments
and after the total parenteral nutrition feedings are completed, as will be discussed just below in the
section entitled "Administering Parenteral Nutrition and Evaluating the Client Responses".
Some of the psychomotor skills that nurses used when caring for a client receiving TPN include the
nurse's application of sterile asepsis techniques, changing the tubings and the total parenteral
nutrition feeding bags and bottles, the maintenance of the site of insertion of the total parenteral
nutrition catheter, and manipulating and controlling the rate of the infusion of the total parenteral
nutrition. More information about these psychomotor procedures will be discussed just below in the
section entitled "Administering Parenteral Nutrition and Evaluating the Client Responses."
Total parenteral nutrition feedings are refrigerated until they are ready to hang
Strict sterile asepsis is used.
Regular insulin can be added to the TPN solution to prevent hyperglycemia
Any time that this closed system is opened, as occurs with a tubing or solution bag change, the
client must perform the Valsalva maneuver to prevent an embolus and the nurse must perform
these tasks as quickly as possible.
The total parenteral nutrition tubing should be changed every 24 hours and the dressing should
be changed at least every 24 hours for the first several days of treatment. These changes can vary
from facility to facility, so nurses must refer to their facility specific policies and procedures
III) Reduction of Risk Potential
The Reduction of Risk Potential questions will test the ability of the nurse to reduce the likelihood
that clients will develop complications or health problems related to existing conditions, treatments
or procedures.
The nurse must be able to:
Respirations
Respirations are assessed and monitored using inspection for the rise and fall of the chest or
abdomen or by gently placing your hand on the chest or abdomen to monitor and assess the rate,
regularity, depth and quality of the client's respirations.
A decreased respiratory rate can indicate and signal a number of disorders such as central nervous
system depression secondary to opioids or central nervous system damage, a coma, planned sedation
and sedation as a side effect to a medication and alkalosis; increased respiratory rates can occur
secondary to a fever, pain, acidosis and anxiety.
The normal respiratory rates along the life span are as follows:
Pulses
Pulses are assessed with both palpation and auscultation. Peripheral pulses are assessed with
palpation, often bilaterally. These peripheral pulses include the radial pulse, the femoral pulse, the
brachial pulse, the popliteal pulse, the dorsalis pedis pulse of the foot and the posterior tibial pulse
near the ankle. During the palpation of the pulse the index finger and/or the middle finger is used to
count the number of beats and to assess other characteristics of the pulse such as its regularity,
fullness or volume, and other characteristics. At times, a Doppler is used for difficult to palpate and
assess peripheral pulses.
The apical pulse is assessed with auscultation and the point of maximum intensity for the adult is on
the left side of the chest at the fifth intercostal space. This point differs somewhat along the lifespan
until adolescence and during later years secondary to an enlarged heart.
The normal parameters for pulse rates along the life span are:
Blood Pressure
Blood pressure results from the pressure of the blood flow as it moves through the arteries. The
blood pressure is what it is as the result of a combination of the blood volume, the peripheral
vascular resistance, the pumping action of the heart and the thickness, or viscosity, of the blood.
Systolic blood pressures reflect the pressure that occurs with the heart's contraction and diastolic
blood pressure reflects the pressure that is exerted when the heart is at rest. Blood pressures are
measured most commonly over the brachial artery just above the client's antecubital space.
The normal blood pressures along the life span are:
Intracranial pressure is assessed and monitored with invasive and noninvasive tests. A CT scan can
diagnose and monitor intracranial pressure and invasive direct monitoring of the intracranial
pressure can be done with a intraventricular catheter, also referred to as a ventriculostomy, which is
placed into the lateral ventricle of the brain, a subarachnoid bolt and an epidural bolt. Some of these
devices also drain excess intracranial fluid to relieve the pressure.
The treatments of increased intracranial pressure are often dependent on the cause of the increase
and the severity of the increased intracranial pressure. In addition to the identification and treatment
of an underlying disorder when possible, some of the medications that are used include intravenous
osmotic diuretics, like mannitol, to remove fluid, corticosteroids to reduce edema, and
anticonvulsant medications to prevent seizures. At times, a barbiturate coma may be induced to
preserve brain functioning by decreasing the metabolic demands of the brain. Life saving measures,
including cardiopulmonary resuscitation and mechanical ventilation may be indicated.
Decorticate posturing is abnormal rigid bodily posturing that is characterized with the tight
clenching of the fists on the chest while the arms are turned inward; and decerebrate posturing is
rigid and abnormal bodily posturing that is characterized with the extension and arching backward
of the client's head while the arms and the legs are extended and the toes are point upward. These
abnormal posturings can be unilateral or bilateral.
Hemodynamic Monitoring
Hemodynamic monitoring provides health care providers with current data and information relating
to the client's blood pressure, pulmonary artery pressures, pulmonary artery wedge pressure, central
venous pressure, cardiac output, intra-arterial pressure, mixed venous oxygen saturation and other
data.
The normal values for hemodynamic monitoring measurements are as below:
Apply knowledge of related nursing procedures and psychomotor skills when caring for clients
undergoing diagnostic testing
Compare client diagnostic findings with pre-test results
Perform diagnostic testing (e.g., electrocardiogram, oxygen saturation, glucose monitoring)
Perform fetal heart monitoring
Monitor results of maternal and fetal diagnostic tests (e.g., non-stress test, amniocentesis,
ultrasound)
Monitor the results of diagnostic testing and intervene as needed
The verification of the doctor's order for the particular diagnostic test
The verification and validation of the client's identity using at least two unique identifiers
Providing the client and/or significant others with an explanation of the diagnostic test, the
purpose of the diagnostic tests and the procedure that will be followed for the specific
diagnostic test, in addition to any specific preparation such as NPO after midnight, as indicated
for the particular diagnostic test
The proper adherence to universal precautions, medical or surgical asepsis as indicated by the
type of the diagnostic test
Proper handwashing before and after each specimen collection and/or bedside diagnostic
testing
The proper, complete and accurate labeling of all specimens that are obtained by the nurse at the
bedside that minimally includes the client's full name, the date and time of the specimen
collection
The proper preservation and transportation of the specimen to the laboratory in a timely
manner along with the proper laboratory requisition slip
The use of the proper receptacle or container for the specific specimen that contains any
necessary preservatives, chemical or anticoagulants
The proper disposal of all supplies and equipment that was used for the diagnostic test
Performing an Electrocardiogram (EKG/ECG)
An electrocardiogram traces the electrical activity of the heart over a period to time with an
electrocardiograph which is connected to the patient with the external application of
electrocardiogram leads. The procedure for performing a 12 lead electrocardiogram is:
Secure the electrodes to flat areas on each of the patient's extremities above wrists and ankles
Place the other six electrodes on the chest in the correct areas.
Run the ECG strip
Print the electrocardiogram data off and then place it into the client's medical record, according
to the particular facility's policy or procedure
Notify the doctor of any unexpected or abnormal findings
Oxygen Saturation
Oxygen saturation reflects the amount of oxygen saturation in arterial blood. It is measured and
monitored by placing a sensor on a client's finger or, when necessary, on their forehead, nose, or ear.
Oxygen saturation levels are often checked with the same frequency as the patient's vital signs using
a pulse oximeter and this noninvasive procedure can be done by trained and competent certified
nursing assistants in the same manner that they can take and record patients' vital signs.
Verify and confirm that the code strip corresponds to the meter code.
Disinfect the client's finger with an alcohol swab.
Prick the side of the finger using the lancet.
Turn the finger down so the blood will drop with gravity.
Wipe off the first drop of blood using sterile gauze.
Collect the next drop on the test strip.
Hold the gauze on the client's finger after the specimen has been obtained.
Read the client's blood glucose level on the monitor.
Ask the patient to void a small amount of urine into the toilet without collecting it.
Then ask the patient to void into the laboratory collection bottle.
Tighten the lid on the receptacle and use a disinfectant to clean the outside of container.
Transport the specimen to the laboratory as quickly as possible.
Identify laboratory values for ABGs (pH, PO2, PCO2, SaO2, HCO3), BUN, cholesterol (total)
glucose, hematocrit, hemoglobin, glycosylated hemoglobin (HgbA1C), platelets, potassium,
sodium, WBC, creatinine, PT, PTT & APTT, INR
Compare client laboratory values to normal laboratory values
Educate client about the purpose and procedure of prescribed laboratory tests
Obtain blood specimens peripherally or through central line
Obtain specimens other than blood for diagnostic testing (e.g., wound, stool, urine)
Monitor client laboratory values (e.g., glucose testing results for the client with diabetes)
Notify primary health care provider about laboratory test results
Electrolytes
Ammonia: 15-50 µmol/L
Ceruloplasmin: 15-60 mg/dL
Chloride: 95-105 mmol/L
Copper: 70-150 µg/dL
Creatinine: 0.8-1.3 mg/dL
Blood urea nitrogen: 8-21 mg/dL
Ferritin: 12-300 ng/mL (men), 12-150 ng/mL (women)
Glucose: 65-110 mg/dL
Inorganic phosphorous: 1-1.5 mmol/L
Ionized calcium: 1.03-1.23 mmol/L
Magnesium: 1.5-2 mEq/L
Phosphate: 0.8-1.5 mmol/L
Potassium: 3.5-5 mmol/L
Pyruvate: 300-900 µg/dL
Sodium: 135-145 mmol/L
Total calcium: 2-2.6 mmol/L
Total iron-binding capacity: 45-85 µmol/L
Total serum iron: 65-180 µg/dL (men), 30-170 µg/dL (women)
Transferrin: 200-350 mg/dL
Urea: 1.2-3 mmol/L
Uric acid: 0.18-0.48 mmol/L
Zinc: 70-100 µmol/L
Hematology
Hemoglobin: 13-17 g/dL (men), 12-15 g/dL (women)
Hematocrit 40%-52% (men), 36%-47%
Glycosylated hemoglobin 4%-6%
Mean corpuscular volume (MCV): 80-100 fL
Red blood cell distribution width (RDW): 11.5%-14.5%
Mean corpuscular hemoglobin (MCH): 0.4-0.5 fmol/cell
Mean corpuscular hemoglobin concentration (MCHC): 30-35 g/dL
Reticulocytes 0.5%-1.5%
White blood cells (WBC) 4-10 x 10^9/L
Neutrophils: 2-8 x 10^9/L
Bands: < 1 x 10^9/L
Lymphocytes: 1-4 x 10^9/L
Monocytes: 0.2-0.8 x 10^9/L
Eosinophils: < 0.5 x 10^9/L
Platelets: 150-400 x 10^9/L
Prothrombin time: 11-14 sec
International normalized ratio (INR): 0.9-1.2
Activated partial thromboplastin time (aPTT): 20-40 sec
Fibrinogen: 1.8-4 g/L
Bleeding time: 2-9 min
Lipids
Triglycerides: 50-150 mg/dL
Total cholesterol: 3-5.5 mmol/L
High-density lipoprotein (HDL): 40-80 mg/dL
Low-density lipoprotein (LDL): 85-125 mg/dL
Gastrointestinal Tests
Albumin: 35-50 g/L
Alkaline phosphatase: 50-100 U/L
Alanine aminotransferase (ALT): 5-30 U/L
Amylase: 30-125 U/L
Aspartate aminotransferase (AST): 5-30 U/L
Direct bilirubin: 0-6 µmol/L
Gamma glutamyl transferase: 6-50 U/L
Lipase: 10-150 U/L
Total bilirubin: 2-20 µmol/L
Total protein: 60-80 g/L
Cardiac Enzymes
Creatine kinase: 25-200 U/L
Creatine kinase MB (CKMB): 0-4 ng/mL
Troponin: 0-0.4 ng/mL
Hormones
17 hydroxyprogesterone (female, follicular): 0.2-1 mg/L
Adrenocorticotropic hormone (ACTH): 4.5-20 pmol/L
Estradiol: 1.5-5 ng/dL (male), 2-14 ng/dL (female, follicular), 2-16 ng/dL (female, luteal), < 3.5
ng/dL (postmenopausal)
Free T3: 0.2-0.5 ng/dL
Free T4: 10-20 pmol/L
Follicle-stimulating hormone (FSH): 1-10 IU/L (male), 1-10 IU/L (female, follicular/luteal), 5-
25 IU/L (female, ovulation), 30-110 IU/L (postmenopause)
Growth hormone (fasting) : 0-5 ng/mL
Progesterone: 70-280 (ovulation), ng/dL
Prolactin: < 14 ng/mL
Testosterone (male): 10-25 nmol/L
Thyroxine-binding globulin: 12-30 mg/L
Thyroid-stimulating hormone (TSH): 0.5-5 mIU/L
Total T4: 4.9-11.7 mg/dL
Total T3: 0.7-1.5 ng/dL
Free T3: 0.6-1.6 ng/mL
Vitamins
Folate (serum) : 7-36 nmol/L
Vitamin A: 30-65 µg/dL
Vitamin B12: 130-700 ng/L
Vitamin C: 0.4-1.5 mg/dL
Vitamin D: 5-75 ng/mL
Tumor Markers
Alpha fetoprotein: 0-44 ng/mL
Beta human chorionic gonadotropin (HCG): < 5 IU/I
CA19.9: < 40 U/mL
Carcinoembryonic antigen (CEA): < 4 ug/L
Prostatic acid phosphatase (PAP): 0-3 U/dL
Prostate-specific antigen (PSA): < 4 ug/L
Miscellaneous
Alpha 1-antitrypsin: 20-50 µmol/L
Angiotensin-converting enzyme: 23-57 U/L
C-reactive protein: < 5 mg/L
D-dimer: < 500 ng/mL
Erythrocyte sedimentation rate (ESR): Less than age/2 mm/hour
Lactate dehydrogenase (LDH): 50-150 U/L
Lead: < 40 µg/dL
Rheumatoid factor: < 25 IU/ml
Comparing the Client's Laboratory
Values to Normal Laboratory Values
The client's current laboratory values are compared to the normal laboratory values, as above, in
order to determine the physiological status of the client and to compare the current values during
treatment to the laboratory values taken prior to a treatment.
Gather and organize the correct laboratory tubes for the specimens that you will be collecting.
Choose a suitable site for the venipuncture.
Place the tourniquet on the client's arm about 3 to 4 inches above the selected site.
Palpate the vein.
Clean the site with an alcohol prep pad with a circular pattern from the site of the venipuncture
to the area surrounding the site of the venipuncture.
Allow the area to air dry.
Ask the patient to make a fist.
Pull the skin taunt so that the desired and suitable vein is accessible.
Insert the sterile needle into the vein at a 15 to 30 degree angle.
Pop the tube onto the tubing.
Take the tourniquet off when the last tube is filled.
Take the needle out.
Place sterile gauze on the site using sufficient pressure to prevent bleeding for about 1 or 2
minutes.
Remove the gauze.
Place an adhesive bandage over the site.
Label the specimen with the data that is required according to your facility's policy and
procedure for laboratory blood samples.
Gently irrigate the wound with sterile normal saline to remove any debris and extraneous matter.
Remove the swab from the Culturette tube.
Gently place the swab and rotate the swab on the wound's granulating tissue.
Place the swab into the Culturette tube.
Crack the Culturette tube so the culture medium soaks into the swab
Monitoring the Client's Laboratory
Values
Client's laboratory values are monitored prior to, during and after therapeutic interventions and
treatments. For example, diabetic clients should have their blood glucose levels are taken and
monitored by the nurse and they are also monitored by the client in their home. This monitoring
permits the nurse and the client the opportunity to evaluate how well the diabetes is being managed.
Identify client potential for aspiration (e.g., feeding tube, sedation, swallowing difficulties)
Identify client potential for skin breakdown (e.g., immobility, nutritional status, incontinence)
Identify client with increased risk for insufficient vascular perfusion (e.g., immobilized limb,
post-surgery, diabetes)
Educate client on methods to prevent complications associated with activity level/diagnosed
illness/disease (e.g., contractures, foot care for client with diabetes mellitus)
Compare current client data to baseline client data (e.g., symptoms of illness/disease)
Monitor client output for changes from baseline (e.g., nasogastric [NG] tube, emesis, stools,
urine)
Identifying the Client's Potential for
Aspiration
The risk for aspiration, as defined by the North American Nursing Diagnosis Association
(NANDA), is "At risk for the entry of gastrointestinal secretions, oropharyngeal secretions, solids,
or fluids into the tracheobronchial passages".
The risk factors associated with the risk for aspiration include:
Some of the external, extrinsic risk factors associated with impaired skin integrity include:
The Norton Scale and the Braden Scale are two standardized scales that are used to identify clients
at risk for skin breakdown.
Hypervolemia
Hypovolemia
Low hemoglobin
An immobilized limb
Hypotension
Hypoxia
Decreased cardiac output
Diabetes
Impaired oxygen transportation
Hypoventilation
Identifying the Client with Increased
Risk for Cancer
The following are the most common risk factors for cancer:
Tobacco Use and Second Hand Smoke Including Smokeless Tobacco: Cancers of the lung,
bladder, mouth, esophagus, pancreas and larynx.
Family History: Genetics and Familial Tendency: Cancers of the colon, breast, ovaries, and
uterus.
Chemicals and Other Substances: Asbestos, benzene, benzidine, cadmium, nickel, and vinyl
chloride may cause cancer.
Ionizing Radiation and Radon Gas: Radioactive fallout, radon gas, which is an odor less gas
found in many buildings, x-rays, therapeutic radiation for cancer, and other sources.
Viruses and Bacteria: Human papillomaviruses (HPV) (Cancer of the cervix, vagina, penis, anus
and mouth), Hepatitis B and C (Liver cancer), Helicobacter pylori ((Cancer of the stomach) and
the Epstein-Barr virus (Burkitt's lymphoma).
Poor Diet, Lack of Physical Activity, Being Overweight: Cancer of the colon, rectum, pancreas,
kidney, prostate, gall bladder, ovary, uterus, breast, esophagus
Assess client for an abnormal response following a diagnostic test/procedure (e.g., dysrhythmia
following cardiac catheterization)
Apply knowledge of nursing procedures and psychomotor skills when caring for a client with
potential for complications
Monitor the client for signs of bleeding
Position the client to prevent complications following tests/treatments/procedures (e.g., elevate
head of bed, immobilize extremity)
Insert, maintain and remove a gastric tube
Insert, maintain and remove a urinary catheter
Insert, maintain and remove a peripheral intravenous line
Maintain tube patency (e.g., NG tube for decompression, chest tubes)
Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
Provide care for client undergoing electroconvulsive therapy (e.g., monitor airway, assess for
side effects, teach client about procedure)
Intervene to manage potential circulatory complications (e.g., hemorrhage, embolus, shock)
Intervene to prevent aspiration (e.g., check NG tube placement)
Intervene to prevent potential neurological complications (e.g., foot drop, numbness, tingling)
Evaluate responses to procedures and treatments
Assessing the Client for an Abnormal
Response Following a Diagnostic
Test/Procedure
Practically all diagnostic tests and procedures can lead to complications, particularly when these tests
and procedures are invasive.
Cardiac dysrhythmias can result from a cardiac catheterization; therapeutic radiation for cancer
treatment can lead to radiation pneumonitis and multiple systems fibrosis, skin erythema and skin
sloughing; cancer chemotherapy can lead to alopecia, ulcerations of the oral mucous membranes,
and an increased risk of infection.
Adults: 10 to 16 Fr
Pediatric Clients From 1 ½ Years of Age Through Adolescence: 10 to 16 Fr
Neonates and Infants Less Than 1 ½ Years of Age; 5 to 8 Fr
Suctioning is a sterile procedure. Artificial airway suctioning can be done with open airway
suctioning and closed airway suctioning. Open airway suctioning is done while the client is breathing
room air without oxygen; and closed airway suctioning is done when the client is receiving
supplemental oxygen. The latter is the preferred method because pre procedure oxygenation and the
administration of oxygen during suctioning prevents hypoxia during the suctioning episode.
Suctioning episodes should be done as rapidly as possible because it can cause client anxiety as well
as hypoxia.
The correct placement of an endotracheal tubes can be determined and validated in a number of
different ways including:
Diagnostic capnography to detect for carbon dioxide when the client exhales
Diagnostic chest x-ray to validate the artificial airway's proper placement
Auscultating for the presence of breath sounds in both lung areas and NOT in the area of the
stomach
Using an esophageal detection device to confirm proper placement
Inspecting the chest rise and fall in a symmetrical manner
The nurse will do the following things when a client with a tracheostomy tube has a partial or
complete airway obstruction:
If the nurse cannot pass the suction catheter into the airway, the nurse should deflate the cuff
Attempt to advance the suction catheter with the cuff deflated. It the catheter is still meeting
with resistance, it is highly possible that a mucous plug is obstructing the airway and interfering
with the patency of the artificial airway
Remove the inner cannula of the tube and remove the mucous plug
Using Precautions to Prevent Injury
and/or Complications Associated with
a Procedure or Diagnosis
At times, special precautions are implemented to prevent injuries and complications associated with
a procedure or diagnosis. As previously discussed, clients who are receiving continuous tube
feedings are placed in a semi Fowler's position of at least 30 degrees to prevent aspiration, clients
who have just had a cast applied to an extremity fracture will be monitored for compartment
syndrome and they will be advised to NOT exert any pressure on the cast until it is completely dried
to prevent denting which could lead to circulatory and neurological impairment; all preoperative
clients are NPO prior to surgery to prevent aspiration, seizure precautions are initiated and
maintained when the client has a seizure disorder, suctioning equipment and supplies are readily
accessible and available at the bedside when the client is at risk for aspiration, special screenings and
assessments are done to identify clients who are at risk for skin breakdown and/or falls, and nurses
implement a wide variety of preventive measures and special precautions to prevent the many
complications of immobility and inactivity, including contractures, urinary stasis and venous
thrombosis.
Fluid replacements
Oxygen supplementation therapy
Mechanical ventilation and intubation, as indicated
The correction of the underlying disorder like the infection
The symptomatic treatment of the signs and symptoms of septic shock including the metabolic
acidosis and respiratory alkalosis
Dialysis as indicated
Applying a Knowledge of
Pathophysiology to the Monitoring for
Complications
Nurses apply their knowledge of pathophysiology to their monitoring of complications. For
example, nurses apply their knowledge of the etiology, risk factors, signs and symptoms and the
complications of various health related diseases and disorders. As these basic principles are applied
to the care of the client, the nurse also is cognizant of the many complications that may occur as
well as their risk factors, signs and symptoms to prevent these complications. For example, the nurse
will integrate a knowledge of the risk factors, signs and symptoms of complications such as
infection, impaired wound healing, an inadvertent puncture of a major vessel, a pneumothorax,
hemorrhage and thrombocytopenia, for example.
Thrombocytopenia
Thrombocytopenia, a decreased level of platelets in the blood can be caused by a number of physical
diseases and disorders as well as from a number of therapeutic treatments and interventions. For
example, thrombocytopenia can result from aplastic anemia, HIV infection, Immune
thrombocytopenic purpura, as a prenatal complication, a genetic disorder, cancer, particularly cancer
that affects the bones, some viral pathogens like those that cause mononucleosis, as well as from
therapeutic radiation therapy, chemotherapy and some medications such as Depakote.
The signs and symptoms of thrombocytopenia include indirect evidence with vital signs, for
example, that detect bleeding and other data. Thrombocytopenia is often asymptomatic, and it is
often diagnosed with a thorough medical history, including a history of bleeding problems, renal and
liver disease, and a physical examination which should include an inspection of the body for any
evidence of purpura or petechiae and laboratory diagnostic tests such as a complete blood count, a
platelet count, liver function tests, electrolytes and a complete coagulation panel.
Infection
The signs of infection include the local signs of inflammation including swelling heat, swelling, pain,
redness, and at times, a lack of local function like not being able to use an affected limb. The
systemic signs of infection are feelings of malaise, a fever, tachycardia, anorexia, diarrhea, nausea,
cramping, chilling and feelings of fatigue.
Diagnostic laboratory data that can be used to identify the possible presence of infection include:-
White blood cell count: A complete white blood cell count includes data relating to all of the
major types of white blood cells including lymphocytes, monocytes, eosinophils, basophils and
neutrophils. White blood cells increase with infection, leukemia, and the inflammatory process;
and white blood cell counts decrease with leukopenia. The normal white blood cell count is
from 4,500 to 11,000 white blood cells per mcL.
Erythrocyte Eedimentation Rate (ESR): The erythrocyte sedimentation rate increases with
infection. The normal erythrocyte sedimentation rate is 0 to 20 mLs per hour for females and 0
to 15 millimeters per hour for males, however, at times, the normal erythrocyte sedimentation
rate can be higher among members of the elderly population.
C-reactive protein: The normal C reactive protein is < 1.0 mg/dL or less than 10 mg/L. C
reactive protein can increase 1,000 times the normal level with infection as well as with massive
burns.
Plasma viscosity: Plasma or blood viscosity is the thickness of the blood that is affected with a
number of factors including the client's temperature, the hematocrit and the red blood cell
aggregation. High temperatures, when the client has a fever from an infection, will lower the
viscosity of the blood in the same manner that Jell-O will thin with heat; and blood viscosity will
increase when the temperature is lower.
Other laboratory diagnostic tests such as urine testing and spinal fluid testing are also done to assess,
monitor and follow up on system specific infections:
Pneumothorax
Pneumothorax can occur secondary to the placement of a central venous catheter, the placement of
a total parenteral nutrition catheter, during a thoracentesis, spontaneously, with a penetrating gun
shot or knife wound, a fractured rib and for other reasons such as the presence of lung pathology
like chronic obstructive pulmonary disease and cystic fibrosis when these disorders, traumatic
injuries and diseases for one reason or another create positive pressure with the collection of air or
blood in the plural space.
The signs and symptoms of pneumothorax and hemothorax include dyspnea, chest pain, shortness
of breath and pain. The treatment of a pneumothorax includes the correction of the underlying
cause whenever possible and the placement of a chest tube to remove the blood and/or air in the
pleural space which will re-expand the affected lung and recreate the negative pressure of the pleural
space.
Hemorrhage
Hemorrhage and excessive bleeding can occur as the result of all invasive procedures, particularly
when the procedure is extensive in nature, when the procedure is of extensive duration, when the
client has a clotting disorder, and when the client has been taking anticoagulation medications.
As previously discussed in the section entitled "Monitoring the Client for Signs of Bleeding", the
signs of bleeding, hemorrhage and hypovolemic shock include alterations in terms of diagnostic
laboratory data, the client's intake and output, vital signs, central venous pressure, arterial blood
gases, renal functioning and hemodynamic monitoring in addition to decreased urinary output,
metabolic acidosis, and increased blood viscosity.
The goal of treatments for hypovolemic shock include the correction of any underlying cause, fluid
replacements, blood and blood products plasma expanders, and maintaining the client in a
Trendelenburg position, as indicated.
Immobility
As detailed in the previous section entitled "Identifying the Complications of Immobility",
immobility can adversely affect virtually all bodily systems. For example some of the hazards of and
complications of immobility include venous and urinary stasis, renal calculi, urinary retention,
atelectasis, the loss of calcium from the bones, respiratory secretion accumulation and pneumonia,
decreased pulmonary vital capacity, orthostatic hypotension, a decrease in terms of cardiac reserve,
edema, emboli, thrombophlebitis, and constipation, among other complications.
The prevention of the complications associated with immobility include early out of bed activity as
soon as possible after surgery and complication related preventive interventions, such as weight
bearing activity to prevent the loss of calcium from the bones and a high fiber diet and plenty of
fluids to prevent constipation.
The client should be free of all complications associate4d with immobility during the post-operative
phase of the perioperative time period.
Paralytic Ileus
A paralytic ileus is a complication of anesthesia used during surgery. The client should be
encouraged to get out of bed as soon as possible and to delay food and fluids until the normal bowel
sounds have returned. The nurse should monitor the client's bowel sounds and assess the client for
any signs abdominal pain and distention.
The expected outcomes related to the prevention of a paralytic ileus should be that the client has
resumed peristalsis and is free of any abdominal distention and pain.
Infection
Infection is probably the most commonly occurring post-operative complication. The local and
systemic signs and symptoms of infection as well as diagnostic laboratory data that are indicative of
infection were previously discussed in the section entitled "Standard Precautions/Transmission-
Based Precautions/Surgical Asepsis". Examples of these local and systemic signs of infection
include wound redness and an elevated body temperature, respectively.
Assess the client for abnormal peripheral pulses after a procedure or treatment
Assess the client for abnormal neurological status (e.g., level of consciousness, muscle strength,
and mobility)
Assess the client for peripheral edema
Assess the client for signs of hypoglycemia or hyperglycemia
Identify factors that result in delayed wound healing
Recognize trends and changes in client condition and intervene as needed
Perform a risk assessment (e.g., sensory impairment, potential for falls, level of mobility, skin
integrity)
Perform focused assessment
0: Absent pulses
1: Weak pulse
2: Normal pulse
3: Increased volume
4: A bounding pulse
Mobility
The needs of the client in terms of their mobility, movement, activity and exercise are impacted by a
number of different factors including neurological function, joint mobility, bodily alignment,
coordination, balance and gait. Many of these factors are neurological in nature. For example, joint
mobility can be impaired as the result of paralysis secondary to a cerebrovascular accident, bodily
alignment can be negatively impacted when the client has a lack of balance as the result of altered
visual ability, impaired neurological stretch receptors, and the nerves within labyrinth of the ear; and
impaired coordination can occur as the result of cerebral cortex, basal ganglia and cerebellum
abnormalities.
The cranial nerves are assessed in terms of their sensory and motor functioning. As previously
discussed in the section entitled "The Assessment of the Neurological System", the twelve unique
cranial nerves include:
Reflexes, including the primitive reflexes are assessed as previously detailed and described in the
section entitled "The Assessment of the Neurological System". For example the primitive Moro or
startle reflex, the primitive step reflex, the reflexes of the pupils are assessed for dilation and pupil
accommodation, and the plantar reflex is assessed by stroking the soles of the client's foot.
Assessing the Client for Peripheral
Edema
Peripheral edema, sometimes referred to as dependent edema, can be present with a number of
physiological disorders such as fluid overload, infection, poor venous circulation, and some cardiac
disorders. Edema results when fluids collect and accumulate in the interstitial and/or intravascular
spaces.
Nurses assess edema in terms of its location and severity. Pitting edema is classified as 1+ to 4+
edema with 1+ pitting edema as edema that remains indented 1 cm or less and 5+ as pitting edema
that remains indented 5 cm; and it can also be described and documented as 1+ to 4+ with 1+
pitting edema as edema that is difficult to detect and 4+as pitting edema that remains indented > 75
cm.
Hypoglycemia also has a number of signs and symptoms including a headache, anxiety, slurred
speech, dizziness, lightheadedness, a headache, diaphoresis, irritability and hunger which are the
early signs of hypoglycemia. The later signs of hypoglycemia include:
Initial signs and symptoms of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) include:
Excessive thirst
A fever
Muscular weakness
Convulsions
Seizures
Increased urination
Lethargy
Nausea
Confusion
Coma
Identifying Factors That Result in
Delayed Wound Healing
Some of the factors that can result in delayed and other wise impaired wound healing include:
Age: Advancing age is a risk factor associated with delayed and impaired wound healing because
of some of the normal and expected changes related to the aging process and also because aging
clients are more likely to be affected with chronic and long term diseases and disorders, such as
diabetes, that can delay wound healing.Some of the normal and expected changes related to the
aging process that impact on poor wound healing include slower cell renewal, a decreased
immune system which impedes the production of monocytes and antibodies that are necessary
for wound healing, vascular changes that interfere with the blood flow to and the oxygenation of
the wound area, and less elastic collagen and scar tissue which could make the wound more
fragile and more easily disrupted.
Nutritional Status: Obesity and poor nutrition in terms of the inadequate intake of protein,
lipids, carbohydrates, vitamins like vitamins C and A, copper, zinc, iron and minerals can lead to
delayed and impaired wound healing.
Lifestyle Choices: Lifestyle choices including poor dietary habits and cigarette smoking which
reduces the oxygenation of the healing tissue can impede optimal wound healing.
Some Medications: Some medications that can delay and disrupt optimal wound healing
include antineoplastic medications, steroids, and other anti-inflammatory medications including
aspirin.
Some Diseases and Disorders: Diabetes, cardiovascular, circulatory and respiratory disorders
are examples of diseases and disorders that can impair wound healing.
The different types of wound healing including primary secondary and tertiary healing, the phases of
the wound healing process and other aspects of wound healing were previously discussed in the
section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin
Integrity and Prevent Skin Breakdown".
Recognizing Trends and Changes in
Client Condition and Intervening as
Needed
Nurses recognize and monitor trends and changes in the client's condition and, after this
assessment, they intervene as needed.
Many of these interventions include notifying the doctor of these significant changes, performing
further assessments to refine the nurse's decision making, and performing independent nursing
functions that are within the nurse's scope of practice as indicated by these client changes and
trends.
Assess the client response to recovery from local, regional or general anesthesia
Apply knowledge of related nursing procedures and psychomotor skills when caring for clients
undergoing therapeutic procedures
Educate client about treatments and procedures
Educate client about home management of care (tracheostomy and ostomy)
Use precautions to prevent further injury when moving a client with a musculoskeletal condition
(e.g., log-rolling, abduction pillow)
Monitor the client before, during, and after a procedure/surgery (e.g., casted extremity)
Monitor effective functioning of therapeutic devices (e.g., chest tube, drainage tubes, wound
drainage devices, continuous bladder irrigation)
Provide preoperative and postoperative education
Provide preoperative care
Provide intraoperative care
Manage client during and following a procedure with moderate sedation
A topical anesthesia such as lidocaine or benzocaine is used for less invasive procedures as well
as prior to the administration of a local anesthetic for procedures such as the removal of a skin
lesion. These same topical agents are used to decrease localized pain such as the pain associated
with a burn.
A local anesthetic such as lidocaine or tetracaine is injected into the affected area for minor
surgical procedures such as suturing a clean, open wound.
A nerve block entails the injection of an anesthetic into the area around nerves and groups of
nerves. Some nerve blocks are referred to as minor nerve blocks when they are only introduced
to anesthetize to a single nerve; others are referred to as a major nerve block when they are
introduced into a plexus or groups of nerves; and still more are referred to as a field block which
is a subcutaneous injection of local anesthesia into the area around the intended area to be
anesthetized.
A Beir's block is the administration of an intravenous regional anesthetic into a limb vein that
has subjected to the temporary interruption of circulation to the area with a tourniquet to
localize the intended effect of the anesthetic to the tissues and nerves in the area that is getting
the procedure or surgical intervention.
Epidural anesthesia, also referred to as peridural anesthesia, entails the administration of a local
anesthetic is into the epidural space outside of the dura mater of the spinal cord. This type of
anesthesia is used for chest and abdominal surgeries.
Conscious sedation, which is often used for endoscopic examinations and procedures, involves
the intravenous administration of a narcotic such as midazolam, diazepam or morphine which
are intended to decrease the client's awareness, to increase pain tolerance and to induce amnesia.
Although this type of anesthesia has more complications and risks than local anesthesia, it is less
problematic than general anesthesia.
General anesthesia produces analgesia, amnesia, sleep and muscular relaxation, but it also
produces unconsciousness, and the lack of life protective reflexes such as the gag and cough
reflexes. This lose places the client at risk for respiratory problems, therefore, continuous
monitoring of the client is necessary. General anesthesia can be administered with a medical gas
or an intravenous transfusion of an anesthetizing agent.
Stage 1 - The Induction Stage: During this stage the client begins to lose consciousness and
feel the analgesic effects of the general anesthesia, however, the client is not yet affected with
amnesia.
Stage 2 - The Excitement Stage: This stage is characterized with irregular respirations, an
irregular cardiac rhythm, uncontrollable muscular activity, and, at times, vomiting. Because of
these risks, the duration of this stage of general anesthesia is minimized to the greatest extent
possible.
Stage 3 - The Surgical Anesthesia Stage: The client is totally unconscious, the pupils are
dilated, the client is in the maximum state of analgesia and amnesia; they are experiencing a deep
yet artificial sleep; there is total muscular relaxation, and the client is vulnerable because they are
without any protective gag, laryngeal or cough reflexes.
Stage 4 - The Emergence Stage: During this stage of anesthesia the client begins to return to
their preanesthesia state. Prior to the client's full return to their preanesthesia state, the client
may be agitated, confused, tachycardic, and experience some shivering and changes in terms of
their blood pressure. The client is still at risk for complications during this stage.
For this reason, the client is continuously monitored in terms of their blood pressure, pulse
oximetry, cardiac rhythm, and temperature in order to determine whether or not the client is
affected with malignant hyperthermia which can occur when some medical gases are used. The
artificial airway remains in place and managed by the nurse until the client is able to spontaneously
and safely breathe on their own with the return of the gag, cough and laryngeal reflexes.
All forms and types of anesthesia have risks. As stated previously, local and regional anesthesia have
less risks than conscious sedation and conscious sedation has less risks and complications than
general anesthesia.
The expected outcomes post anesthesia include the client's return to their preanesthesia state and
without any complications.
The complications of local anesthesia, such as that done by a dentist, are typically associated with an
over dosage or too rapid administration of the anesthetizing medication. Mild and moderate
complications can include excitability, seizures, central nervous system depression, respiratory
and/or cardiac distress and collapse.
Regional anesthesia can include complications such a headache, injection site soreness, infection,
bleeding, hematoma, decreased urination, hypotension, nausea, vomiting and nerve damage as well
as complications which may or may not vary in terms of the site that was used. For example, a
pneumothorax, hoarseness of the voice, ptosis, temporary or permanent weakness or paralysis can
occur.
Conscious sedation is associated with complications such as agitation, uncontrollable muscular
activity, respiratory distress, respiratory arrest, unstable vital signs, cerebral hypoxia. The nurse must
insure that the crash cart and other resuscitative equipment is readily available for use when
indicated.
Conscious sedative is rapid in terms of its actions and it is relatively rapid in terms of the client's
return to their preanesthesia state, however, the client remains a risk for complications and at risk
for falls and other accidents until they have fully recovered.
General anesthesia can lead to mild and very serious complications such as a sore throat from the
artificial airway, fatigue, dizziness, damage to dentition as the result of the placement of an artificial
airway, myocardial infarction, serious malignant hyperthermia, a cerebrovascular accident,
respiratory depression, hypoxia, cardiac arrest, respiratory arrest, coma and death.
The complete physical assessment and medical history that are done prior to the surgery
The laboratory and other diagnostic tests what will be done prior to the surgery
Medications and anesthesia that will be administered prior to the surgery
The medical markings of the surgical site that must be done prior to the surgery
The informed consent and the elements of the informed consent including the benefits, risks
and alternatives related to the planned surgical procedure
Special preoperative preparation including shaving and an enema, for example
The preoperative checklist and its components
The removal of valuables and prosthetics, including dentures, and their safe keeping
How pain will be managed
During the preoperative period of time, the client is also taught about the various exercises and
routines that they should practice during the preoperative period of time so that the client is able to
effectively perform these exercises and routines after surgery when they may be in pain and still
under the effects of their general anesthesia.
The components of this preoperative education should include:
Postoperative education should include the reinforcement of and coaching the client in terms of all
of the components of preoperative exercises and routines as listed above in addition to how to care
for the surgical wound and any alterations of the normal bodily anatomy such as caring for an
ostomy, for example.
Positioning of the client: The correct positioning of the client is based on the need for the
surgeon to be able to fully visualize the operative area and the need to prevent the complications
that can result from client positioning including skin breakdown and/or damage as the result of
pressure, friction and shearing, nerve damage, and postoperative joint pain. The most common
position that is used for surgical procedures is the supine position; for this position, the nurse
will pad and protect pressure points such as the head, sacrum, coccyx, olecranon and scapula.
Preparing and maintaining the sterile field: As fully discussed and detailed in the section
entitled "Using Appropriate Technique to Set up a Sterile Field and Maintaining Asepsis", nurses
set up, maintain and add to the sterile field during the intraoperative phase. Whenever the sterile
field becomes contaminated with an inadvertent action, the entire sterile field and its contents
are promptly discarded because the sterile field is no longer sterile. The entire set up must be
redone from the very beginning. Nurses also add to the sterile fields during surgery when they
open and place the needed supplies for the particular surgical procedure.
Counting and rectifying sponges, sharps and other instruments: Nurses count sponges,
sharps and other instruments used during the surgical procedure in order to insure that no
foreign bodies are inadvertently left within the client's bodily cavities. The scrub nurse, or tech,
in addition to the circulating registered nurse are responsible and accountable for the final
sponge and instrument counts at the end of the surgical procedure.
Continuously assessing and monitoring the client: Nurses are also responsible for
continuously assessing and monitoring the client in terms of their vital signs, responses to
anesthesia, their ECG readings, their pulse oximetry, their loss of blood, their intravenous fluid
intake and their output, their laboratory values and their pulmonary artery, arterial and venous
pressures.
Managing and maintaining the client's drains, catheters and tubes: Nurses manage and
maintain the client's lines, drains, tubes and catheters such as their intravenous catheters, urinary
drainage catheters and nasogastric tubes to suction, as indicated.
All members of the surgical team also participate in a mandatory "time out" before surgery that aims
to prevent surgical medical errors such as wrong patient surgery, wrong procedure, and wrong site
surgery.
According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO),
time outs are done after surgical site marking is done, after all verification procedures are complete
and all questions and concerns have been addressed and resolved. Time outs are done immediately
prior to the beginning of the invasive procedure and:
All relevant members of the procedure team actively communicate during the time-out.
During the time- time-out, the team members agree, at a minimum, on the following:
o correct patient identity
o procedure to be done
o correct site
When the same patient has two or more procedures: If the person performing the procedure
changes, another time-out needs to be performed before starting each procedure.
Document the completion of the time-out. The organization determines the amount and type of
documentation." (JCAHO, 2016)
Note: Determining some of the monitoring parameters as frequently as outlined above may not be
possible during some procedures. For example, if the purpose of conscious sedation/analgesia is to
help the patient remain as still as possible, frequent inflation of the BP cuff may stimulate the patient
and prove to be counterproductive. In these cases, close observation and monitoring of other
parameters is invaluable.
Coping Mechanisms
Crisis Intervention
End of Life Care
Support Systems
Grief and Loss
Family Dynamics
Some of these interventions include patient education, behavioral cognitive therapy and the
adoption of more effective coping mechanisms after which the outcomes of these interventions are
evaluated in terms of how well the client and family members are able to psychologically adapt to
any acute, chronic, temporary and permanent health alterations, illnesses and diseases.
Nurses also assess the physiological adaptation of the client and the family members to health
alterations, illnesses and diseases. For example, registered nurses assess the physical adaptation of
the client in terms of all interventions and therapeutic procedures including medications,
chemotherapy, therapeutic radiation therapy, total parenteral nutrition, artificial ventilation and
many, many other medical and nursing therapeutic interventions.
Cardiac Disease
Infections of all types both sexually transmitted and otherwise
Diabetes
Hypertension
Preeclampsia
Eclampsia
Preterm Labor
Post term Pregnancy
Subchorionic Hematoma
Hydatidform Moles
Hyperemesis Gravidarum
The Effects of Drugs and Substances
An Incompetent Cervix
Anemias
Cardiopulmonary Maternal Collapse
Disseminated Intravascular Coagulation
Ectopic Pregnancy
Substance Use and Abuse
Spontaneous Abortions
Premature Rupture of the Membranes
Multiple Gestations
Fetal Growth Restriction
Oligohydramnios
Polyhydramnios
Identifying the Signs, Symptoms and
Incubation Periods of Infectious
Diseases
The local signs and symptoms, in addition to the visual signs such as a skin pustule, include pain at
the site of the infection, redness, heat, swelling and some bodily part dysfunction. The systemic signs
and symptoms of infection include a fever, fatigue, prodromal malaise, chills, tachycardia, nausea,
vomiting, anorexia, and confusion, in addition to infection specific signs and symptoms such as
dysuria, hematuria, and urinary frequency when the client has a urinary tract infection; and
respiratory infections lead to coughing, dyspnea and adventitious breath sounds.
As more fully described in the section entitled "Understanding Infections and Communicable
Diseases and the Modes of Organism Transmission", incubation periods are simply defined as the
durations of time between the entry of the pathogenic organism into the body upon initial exposure
until the signs and symptoms of the infection begin; and periods of communicability, simply
defined, is the duration of time that a pathogen can indirectly or directly transmit an infection to
another. This period of time varies according to the microorganism.
Some pathogens are associated with brief periods of communicability, others are characterized with
longer periods of communicability; and some pathogens are associated with short periods of
incubation and others are associated with longer periods of incubation.
M: Monitors like blood pressure, pulse oximetry, and ECG monitors or telemetry
S: Suctioning equipment and supplies
M: Machines like a mechanical ventilator
A: Airway supplies like artificial airways and a laryngoscope
I: Intravenous supplies, equipment and intravenous access
D: Drugs for emergencies and anesthetics
The procedure specific procedures for a diagnostic bronchoscopy, in addition to the general
guidelines listed above, include:
Maintaining the client's NPO status for at least 6 hours prior to the procedure whenever possible
The administration of atropine to decrease respiratory secretions
The administration of moderate conscious sedation or general anesthesia
The administration of nebulized lidocaine to numb the patient's pharynx and vocal cords
The lubrication of the bronchoscope
Passing the bronchoscope into the bronchi of the lungs
Positioning and maintaining the client's position so that the site of the needle biopsy is exposed
Prepping the site with betadine
Covering the surrounding site with a sterile fenestrated drape
The administration of a topical local lidocaine if ordered
The administration of a local anesthetic
Obtaining the specimen using the needle
Labelling and transporting the specimen to the diagnostic laboratory for processing
Covering the site with a sterile dressing
Positioning the client in a sitting and leaning forward position over a bedside table to expose the area that
will be used for the withdrawal of excessive fluids
Prepping the site with betadine
Covering the surrounding site with a sterile fenestrated drape
The administration of a topical local lidocaine if ordered
The administration of a local anesthetic
The withdrawal of the fluid with a 16 gauge needle attached to a 50 cc syringe
Labelling and transporting the specimen to the diagnostic laboratory for processing
Covering the site with a sterile dressing
The procedure specific procedures for the placement of a central line are:
The procedure specific procedures for a spinal tap, also referred to as a lumbar puncture,
are:
Positioning and maintaining the position of the client on their side with their back arched so that the
client's knees are up to their chest OR sitting and leaning over a bedside table
Prepping the site with betadine
Covering the surrounding site with a sterile fenestrated drape
The administration of a local anesthetic to the entry site area
The insertion of the needle into the two lowest vertebrae
Withdrawing the cerebrospinal fluid, measuring its pressure and assessing the color and amount
Placing and maintaining the client in a flat position to avoid post procedure headaches
Labelling and transporting the specimen to the diagnostic laboratory for processing
Covering the site with a sterile dressing
Skin for changes in color that may indicate an increase or decrease in the amount of bilirubin in the
client's blood
Laboratory bilirubin levels to determine whether or not the client's bilirubin levels are decreasing as the
result of the phototherapy
Volume, color and characteristics of the stool because phototherapy can lead to frequent, loose stools as
well as a color change to green colored stools
Implementing Interventions to
Address Side/Adverse Effects of
Radiation Therapy and Radiation
As discussed in the section entitled "Identifying the Client with Increased Risk for Cancer", one of
the risk factors associated with cancer is exposure to sunlight and external ultraviolet radiation and
another is exposure to the ionizing radiation that is in diagnostic x-rays and therapeutic radiation
therapy for cancer.
Nurse address the adverse effects of radiation from sunlight and external ultraviolet radiation by
educating the client relating to the risks of tanning beds and sun bathing as well as the use of
preventive measures such as the use of sun screen lotions, the use of protective clothing such as a
hat, and avoiding the worst times of the day to be in the sun. They also educate clients about the
signs of skin cancer including changes of the skin and the signs of a possible precancerous lesion, a
basil cell carcinoma, a squamous cell carcinoma and multiple myeloma.
As previously discussed in the above section entitled "Assessing the Client for the Signs and
Symptoms of the Adverse Effects of Radiation Therapy", the short term effects of therapeutic
radiation therapy include alopecia, damage to the skin and mucosa, dry mouth and bone marrow
suppression; and some of the long term affects are ulcerations, dental caries, fatigue,
immunosuppression, radiation pneumonia, pulmonary fibrosis, cataracts, atrophy and strictures
depending on the area(s) treated. Other commonly occurring side effects and adverse effects include
nausea, vomiting, diarrhea, and anorexia, all of which can jeopardize the client's nutritional status.
Some of the interventions to address the side effects and adverse effects of radiation therapy and
chemotherapy include:
Alopecia: Psychological support for this alteration in terms of body image, adopting a shorter hair style
until the hair begins to regrow, wearing a wig or a hair piece, wearing a cold cap to protect the hair, and
gently caring for the hair with a mild shampoo, a soft brush, and protecting the head from the sun with a
hat.
Damage to the skin: Blanching, ulcerations, cracking, erythema, sloughing and desquamation of the
skin can occur. Topical skin lubricants and lidocaine may be helpful. More severe skin damage must be
assessed and treated according to the nature and extent of the skin damage.
Xerostomia or dry mouth: Xerostomia, or dry mouth, can lead to damage to the mucosa of the mouth
and dental caries. Dry mouth is a complication of both therapeutic radiation and chemotherapy; it occurs
because these treatments decrease the production of saliva from the salivary glands. The treatment of
xerostomia can consist of a preventive medication such as amifostine, salivary gland stimulating
medications such as pilocarpine or cevimeline, sucking on sugar free hard candies or chewing gum,
mouth rinses with carmellose, hyprolose or hyetellose, using a cool mist humidifier, sucking on ice chips,
and using fluoride mouth rinses and small sips of water throughout the day to relieve this oral dryness
and to prevent the complications associated with it.
Damage to the mucosa: Severe pain can result from ulcerations of mucous membranes, and the patient
can be more susceptible to infection as the result of this damage and mouth sores. In addition to the
interventions discussed above for dry mouth, other interventions for oral sores and lesions can include a
mouth wash that contains lidocaine for relief from the pain, rinsing the mouth with a baking soda and
salt mixture, the administration of a mild over the counter analgesic such as acetaminophen, a bland food
diet and minimizing the use of dentures.
Dental caries and oral infections: Regular professional dental examinations and care, brush, flossing
and oral mouth rinsing at least 3 times per day, and the administration of antibiotics, antiviral drugs,
and/or antifungal drugs to treat any oral infections.
Fatigue: Fatigue can be alleviated with a number of different interventions including the correction of
any and all underlying causes of sleep deprivation such as pain, anemia, depression and anxiety, the
promotion of stress and relaxation techniques, and the promotion of exercise and a healthy diet,
Nausea and vomiting: Nausea and vomiting can be controlled by treating any underlying cause such as
changing a medication that can be leading to the nausea and vomiting, in addition to stress, relaxation
and distraction techniques, herbs like ginger, medications such as metoclopramide to prevent vomiting,
and antiemetics as ordered.
Anorexia: Anorexia can sometimes be successfully treated with appetite stimulants such as megestrol
acetate, steroid medications, metoclopramide, dronabinol, the guidance of a dietitian, eating smaller more
frequent meals, dietary supplements like Ensure and, when necessary and elected to by the client, enteral
or parenteral nutrition to maintain the client's nutritional status and fluid balances.
Diarrhea: Diarrhea can be controlled by treating any underlying cause such as changing a medication
that can be leading to it, in addition to the avoidance of spicy and troublesome foods, the consumption
of foods such as rice and bananas, consuming a low fiber, low residue diet, and medications such as
dipenoxylate in combination with atropine (Lomotil) and loperamide (Imodium).
Radiation pneumonia, radiation pneumonitis and radiation pulmonary fibrosis: These respiratory
complications result from the destruction of normal, healthy cells with radiotherapy, particularly when
the chest area is treated. Radiation pneumonitis typically occurs during a long duration of radiation
therapy and up to even 6 months after the therapeutic radiation therapy has been completed. Radiation
pneumonitis, an inflammation of lung tissue, can be asymptomatic and it can also lead to a fever,
coughing and shortness of breath. It can also be characterized with an elevated sedimentation rate and
abnormal white blood cell counts. When it is not treated with anti-inflammatory medications such as
steroid medications, it can lead to often irreversible pulmonary radiation fibrosis that can occur a year
after the completion of the radiotherapy because the tissue continues to be altered after the course of
radiotherapy has been completed.
Other fibrosis: Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons,
and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein
accumulation within normal irradiated tissue. It can be treated according to the symptoms and the
severity of this disorder. For example, physical and occupational restorative and rehabilitation therapy
may be indicated when the neuromuscular system is adversely affected with this complication of
therapeutic radiation therapy and it leads to treatable atrophy and strictures, for example.
Cataracts: Cataracts, which is the clouding of the lens of the eye, can also be a complication of radiation
therapy as well as other causes. Cataracts can be treated with ocular surgery, including laser surgery.
Alveolar Over Distention: Alveolar over distention is the most frequently occurring complication
associated with mechanical ventilation. This complication occurs as the result of causes such as high tidal
volume, high ventilating pressures and atelectrauma as a result of the rapid opening and closing of the
alveoli accompanied with low lung volume. Alveolar over distention can lead to increased work of
breathing, subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, a
decrease in lung compliance and leaking around the client's endotracheal tube. The correction and
treatment of alveolar over distention include decreasing PEEP and the tidal volume, high frequency
oscillatory ventilation or high frequency jet ventilation and extracorporeal membrane oxygenation.
Oxygen Toxicity: Oxygen toxicity can result from oxygen supplementation therapy when the level of
oxygen concentration is too high; and this complication can be identified by closely monitoring the
client's arterial oxygen and carbon dioxide blood gases and insuring that the PaO2 level is maintained
between 50 and 60.
Hypoventilation: Hypoventilation and under inflation of the lungs can occur as the result of an
inadvertent extubation or disconnection from the mechanical ventilator. This complication can be
prevented with the use of and prompt attention to low pressure and disconnect safety alarms and the
careful handling of the tubings and artificial airways, particularly when the client is being moved about in
bed, when the client is being transferred from the bed to a chair, and also during transport to another
area of the health care facility. These complications are monitored for in terms of the client's flow
volumes, pressure volumes and resistance.
Hospital Acquired Ventilator Infections: The most commonly occurring ventilator related infections
include pneumonia and other pathogens that can lead to respiratory distress syndrome. These infections
can be prevented with basic infection control procedures and techniques such as handwashing, standard
precautions and the adherence to the principles and procedures relating to asepsis. For example,
suctioning of the client is a sterile procedure. In addition to following infection control procedures,
nurses also monitor the client for the signs of infection and any respiratory complications.
Ventilator Related Airway Complications: Examples of ventilator related air way complications
include vocal cord trauma, airway obstructions secondary to mucus plugs and the kinking of any tubings,
tracheal trauma, glottis injuries and trauma,
Other Complications: Other possible ventilator related complications are renal impairment, fluid
retention, increased intracranial pressure, periventricular leukomalacia, and interventricular hemorrhage.
Hemodialysis
Hemodialysis treatments are typically given to long term renal failure clients 3 times per week and
each session can last for three to five hours in duration. Hemodialysis is given through an AV fistula,
an AV graft, or a vascular access central line. The vascular access central line is typically reserved for
clients who will only be getting short term dialysis and also for those clients who cannot get an AV
fistula or graft because the risk of an infection with a vascular access central line is the greatest when
compared to the other hemodialysis access lines.
AV fistulas are surgically placed by a vascular surgeon into the client's upper arm of their lower
forearm. This is the access of choice for dialysis because it can remain usable for a longer period of
time than other devices, and it is less prone to infection and clotting than other hemodialysis
accesses.
Prior to the surgical placement of an AV fistula, the vascular surgeon does vascular mapping using a
Doppler ultrasound to evaluate the adequacy of the blood vessels that may be used and to determine
which vessel is the best. After the AV fistula is done it takes about two or three months for it to
mature to the point that it can be used for the client's dialysis treatments.
When the AV fistula is matured, an arterial needle is inserted into the fistula to transport the client's
blood from their body to the hemodialysis machine; and a venous needle is inserted to transport the
blood back to the client's body after processing,
AV grafts are done when an AV fistula placement is not possible because the client's veins are not
adequate enough to support it or a placed AV fistula does not mature that way it should to
accommodate for hemodialysis.
AV grafts are more prone to clotting off and infection when compared to AV fistulas.
An AV graft, like an AV fistula, is surgically placed by a vascular surgeon using a local anesthetic.
AV grafts also take time to develop and mature before they can be used for hemodialysis treatments.
Using an AV graft or fistula prior to this complete maturation process can lead to blood clotting and
low blood flow through it.
A venous catheter can also surgically placed by a vascular surgeon into the groin area, the chest or
the neck. These catheters split into two tubes at the exterior to the body; these two tubes are
covered with caps and sterile technique is used when taking off and replacing these caps.
Additionally, the client should wear a mask and turn their head to the opposite direction when the
caps are removed and replaced and these two tubes are clamped off during cap changes and
whenever a cap is removed and not immediately replaced. One of these tubes is connected to the
dialyzing machine to carry and transport blood from the client to the dialyzing machine and the
other transports blood back to the client after it has passed through the hemodialysis machine.
The complications associated with venous dialysis include infection, blood clots, and the narrowing
of the vein as the result of scar tissue formation. Except under unusual circumstances, therefore,
venous access devices are used only when the anticipated course of the dialysis is less than three
weeks in duration.
Prior to the hemodialysis treatment, the nurse collects pre-procedure data such as the client's vital
signs, weight, and blood glucose levels; they also assess the access site and patency. For example,
graph patency is assessed and deemed as patent when a thrill or bruit is present.
During the hemodialysis treatment, the nurse monitors, provides care and reassesses the client and
the dialysis treatment. For example, the nurse can administer any ordered anticoagulants; the nurse
will measure and document the client's intake and output in terms of the amount of dialysate that
was instilled and the amount of fluid that was drained off the client during this treatment. They will
monitor the hemodialyzer for proper functioning and trouble shoot problems when they arise, they
will assess and document the color of the drainage, and they will monitor and assess the client for
any complications that can arise from this renal treatment such as disequilibrium syndrome, extreme
fatigue, infection, clotting, hypotension and hypovolemia.
After the hemodialysis session is completed the nurse will then monitor and document the duration
of the session, the client's weight, their post treatment vital signs, blood glucose levels and any
laboratory values.
Peritoneal Dialysis
Peritoneal dialysis is done through a catheter that is placed in the peritoneal space; this type of
dialysis is indicated for clients at risk for complications associated with the anticoagulant medications
that are necessary for hemodialysis and when the client has poor venous access. Like hemodialysis,
peritoneal dialysis can also be done in the home, but unlike hemodialysis, peritoneal dialysis is done
on a daily basis and most often during the night time hours when the client is sleeping. This renal
treatment consists of a fill, a dwell and a drain cycle using the ordered dialysate.
Prior to the hemodialysis treatment, the nurse collects pre-procedure data such as the client's vital
signs, weight, and blood glucose levels; they also assess the access site and patency.
During the peritoneal dialysis treatment, the nurse monitors, provides care and reassesses the client
and the dialysis treatment. For example, the nurse will measure and document the client's intake and
output in terms of the amount of dialysate that was instilled and the amount and color of fluid that
was drained off the client during this treatment. This drainage should be clear, light yellow and
without any clots. They will monitor the dialyzer for proper functioning and trouble shoot problems
when they arise, and they will monitor and assess the client for any complications that can arise from
this renal treatment such as peritonitis, tube insertion site infections, respiratory distress, protein
depletion, hyperglycemia and mechanical problems such as an obstruction of the periotoneal dialysis
catheter.
When the flow is obstructed, the nurse will insure that the drainage bag is kept below the level of the
abdomen and they can also milk the tube to release any fibrin clots and reposition to client to
promote better inflow and outflow.
After the peritoneal dialysis session is completed the nurse will again assess, monitor and document
the duration of the session, the client's weight, their post treatment vital signs, blood glucose levels
and any laboratory values.
Performing Suctioning
Oral, nasopharyngeal, endotracheal, and tracheal airways, including artificial airways, must be
maintained with suctioning. In addition to the content that was more fully discussed in the previous
section entitled "Maintaining Tube Patency: Artificial Airway Tube Patency: Endotracheal and
Tracheostomy Tubes", the procedure for suctioning the client is as follows.
Hydrotherapy
Hydrotherapy is sometimes indicated when the client has a severe wound such as a severe burn, or
the wound has otherwise untreatable necrosis and when the wound is very large in size.
Hydrotherapy is done with a therapeutic whirlpool at about 37 degrees centigrade and, at times, an
ordered antiseptic solution can be added to the water. Hydrotherapy is not indicated for client's
affected with arterial insufficiency or venous ulcer wounds. Some of the complications of
hydrotherapy include the cross contamination of infections because these whirlpools are used by
multiple clients; this complication can sometimes be prevented with scrupulous disinfection of the
whirlpool after each client use and rinsing the client's wound area after exposure to the water in the
therapeutic whirlpool.
Pulsed Lavage
Pulsed lavage is employed by using saline and a pulsatile high pressure lavage device to irrigate a
wound and remove exudate. The complications associated with pulsed lavage include wound
disruption when the pressure of the pulsed lavage is too great and occupational related infection
when impervious personal protective equipment such as googles, face masks, gowns and gloves is
not used to protect the staff members from sprays and splashes.
Sterile wound dressings are selected as based on its stage of healing and other characteristics. Some
of these wound dressings include traditional gauze dressings, interactive and transparent dressings
which contain polymeric, and bioactive dressings that contain alginate, collagen and hydrocolloids.
The Biological Dimension of Health: Favorable genetics, full term pregnancies, and protective
immunizations enhance recovery; and comorbid diseases like heart disease and diabetes prevent optimal
recovery.
The Psychological Dimension of Health: An internal locus of control, high levels of cognition, the
effective use of stress management techniques, and the client's orientation x 3 enhance recovery; and
psychiatric mental diseases, high levels of incapacitating stress, and an external locus of control prevent
optimal recovery.
The Environmental Dimension of Health: Fluorinated water, clean air without toxins, and clean
drinking water and food enhance recovery; and contaminated water and contaminated food sources
prevent optimal recovery.
The Behavioral Dimension of Health: Active participation in the treatment plan and adherence to the
medication and other treatment regimens enhance recovery; and a lack of adherence to the treatment
regimen and depression prevent optimal recovery.
The Sociocultural Dimension of Health: Available resources in the community and the presence of a
good social support system enhance recovery; and the lack of economic resources and follow up care
prevent optimal recovery.
The Health Systems Dimension of Health: Culturally competent care and the accessibility of
community health care resources enhance recovery; and the lack of affordable and accessible heath care
systems and resources in the community prevent optimal recovery.
A generalized tonic-clonic or grand mal seizures: Convulsions, muscular rigidity and a state of
unconsciousness
An absence seizure: This type of seizure is characterized with simply a short lived and brief state of
unconsciousness.
A clonic seizure: A clonic seizure presents with ongoing and repetitive muscular jerking.
A myoclonic seizure: A myoclonic seizure presents with intermittent and sporadic muscular jerking.
An atonic seizure: This seizure entails the loss of muscular tone and muscular movement.
Infectious Disease
Diphtheria Respiratory symptoms such as dyspnea, coughing and a Symptomatic relief of the respirato
sore throat. cardiovascular symptoms; mechan
indicated and the correction of res
Myocarditis, cardiac arrhythmias, and a
with diphtheria toxin.
pseudomembrane on the nasal passages, pharynx, and
tonsils.
Cytomegalovirus A rash, sore throat, oral lesions, fever and enlarged Symptomatic relief of the symptom
infections lymph nodes, headache, chest pain, jaundice, analgesic and mouth rinses.
splenomegaly, and photosensitivity.
Rubella (German Fetal abnormalities when the woman is pregnant, a sore Supportive and symptomatic care
measles) throat, lymphadenopathy, cough, coryza, and a classical the affected client from all woman
rash that begins on the face and spreads in a downward to protect a developing fetus.
manner to the neck, shoulders, trunk and legs. Later,
this rash disappears in an upward manner.
Varicella A very pruritic rash on the trunk and scalp, oral and Skin care with topical calamine lot
(Chickenpox) perineal area lesions, vesicles that change to pustules fingernails short or mittened if the
and then develop a crust which disappears over time. and teaching the child to put press
rather than scratching.
Skin scars can result when the affected client scratches
the itchy areas.
Influenza A productive or dry cough, overall aches and pains, Supportive and symptomatic relie
hoarseness, photophobia, fever, nasal congestion, chills, rest, and analgesics other than Asp
diaphoresis and myalgia to Reyes syndrome. Antiviral med
Tamiflu or Relenza, may be given
duration of the flu and to prevent
complications.
Pertussis A whooping cough, respiratory changes including in Supportive and symptomatic relie
(Whooping cough) terms of the depth of the respirations, cyanosis and rest, analgesics, respiratory care an
respiratory exhaustion, increased lacrimation, the care and treatment of any serio
rhinorrhea, conjunctivitis, and vomiting. with suctioning, mechanical ventil
supplementation, as indicated.
The administration of erythromyc
azithromycin, or clarithromycin m
Thick mucus that occludes the bronchioles, wheezing, Treatment includes supportive car
respiratory stridor, dyspnea, respiratory distress, management and antibiotics if a se
Respiratory
tachynpea, cyanosis, respiratory hypercapnia and apnea infection is suspected. Hydration s
Syncytial Virus
in severe cases. and other respiratory intervention
(RSV)
Chills, dyspnea, dyspnea, muscular aches, fatigue, The treatment of pneumonia can
enlarged lymph nodes, a sore throat and chest pain. for bacterial pneumonia, fluids an
Pneumonia
supplementation, as indicated.
The Upper Lobe Anterior bronchus Supine with a pillow under the knees
The Lingula (The small projection Apical bronchus: Prone position and a pillow under the client's
from the lower portion of the upper
Medial bronchus: A 45 degree Trendelenburg position and turned on
lobe)
18 to 20 inch elevation of the foot of the bed and t
Lateral bronchus:
side
Posterior
A 45 degree Trendelenburg position and turned on
bronchus:
18 to 20 inch elevation of the foot of the bed and t
Superior and side
inferior bronchus
A 45 degree prone Trendelenburg position and a p
client's hip
Percussion is performed by placing a cupped over the area and doing percussion to remove
secretions. Each area is percussed for at least one minute while the client is holding his or her
breath. Vibration is performed by laying the hand on the area and applying rapid vibrating
movements while the client is deeply exhaling.
The correct hand placement for percussion and vibration is shown in the table below:
Lobe of the
Lung
The anterior bronchus
The Upper The apical bronchus The area immediately under the clavicles over the anterior chest
Lobe
The posterior The area over the shoulder blades to the clavicle
bronchus
The area over the shoulder blades and on both sides
The apical bronchus The bilateral area over the lower third of the posterior rib cage
The Lingula The medial bronchus The area over the lower third of the left posterior rib cage
The lateral bronchus The area over the lower third of the right posterior rib cage
The posterior bronchus The lower third of the posterior rib cage bilaterally
The superior and inferior The area extending from the left axillary fold to the midanterior chest
bronchus
Staples are removed using the same procedure without the use of sterile forceps and scissors, but
instead, by using a special surgical staple remover.
Collecting data related to client's current condition and the established expected outcome
The analysis of this data
Comparing this analyzed data to the expected outcomes
Connecting the interventions to the data and the expected outcomes
Drawing conclusions about the success of the interventions and treatments using critical thinking and
professional judgment skills
Making a decision about whether to continue the plan of care, or to modify it or to discontinue it all
together
Tuberculosis (TB)
Tuberculosis is an airborne transmitted infection that is caused by the tubercle bacilli.
The signs and symptoms of tuberculosis include pallor, fever, chills, night sweats, anorexia, a
productive purulent cough that can sometimes contain blood, dyspnea, chest pain and extreme
fatigue. The most serious complication of TB is the emergence of an untreatable drug resistant strain
of tuberculosis.
Some of the medications that are used to treat TB include rifampin, rifabutin, rifapentine, INH,
pyrazinamide, ethambutol, streptomycin, capreomycin, aminosalicylate sodium, cycloserine and
ethionamide. Combination therapy, rather than a single medication, is the most effective form of
treatment.
Like AIDS/HIV and other diseases and disorders, the outcomes of these medications and other
treatments for TB are evaluated in terms of the client's ongoing physical status from diagnosis
through recovery.
Evaluating and Monitoring the
Client's Responses to Radiation
Therapy
The client responses to radiation therapy, like their responses to other therapies and treatments
including side effects, adverse side effects, and therapeutic effects are evaluated and monitored by
the nurse.
The responses to radiation therapy were previously detailed and discussed under the sections entitled
"Implementing Interventions to Address Side/Adverse Effects of Radiation Therapy and Radiation"
and "Assessing the Client for the Signs and Symptoms of the Adverse Effects of Radiation Therapy
and Chemotherapy".
Electrolytes are ions that can have either a negative or positive charge. Electrolytes and the levels of
electrolytes play roles that are essential to life. For example, these electrically charged ions contract
muscles, move fluids about within the body, they produce energy and they perform many other roles
in the body and its physiology.
Electrolytes, similar to endocrine hormones, are produced and controlled with feedback
mechanisms when the kidneys or adrenal gland sense a deficit of the particular electrolyte and an
imbalance in terms of the client's electrolyte balance.
The body's electrolytes are positively or negatively charged as shown below:
Sodium
The normal range for sodium is 135 to 145 milliequivalents per liter (mEq/L).
Sodium plays a primary role in terms of the body's fluid balance and it also impacts on the
functioning of the bodily muscles and the central nervous system. This electrolyte is most abundant
in the blood plasma; and bodily water goes where sodium is. For example, high levels of fluid in the
plasma will occur when the plasma has high sodium content and the converse is also true.
Hypernatremia, that is a sodium level higher than 145, can result from a number of different factors
and forces such as diabetes insipidus, dehydration, as the result of a fever, vomiting, diarrhea,
diaphoresis, extensive exercise, exposures of long duration to environmental heat, and Cushing's
Syndrome.
The signs and symptoms of hypernatremia, among others, include agitation, thirst, restlessness, dry
mucous membranes, edema, confusion and, in more severe cases, seizures and coma.
The treatment of hypernatremia, like other electrolyte disorders includes the correction and
management of any underlying causes and dietary sodium restrictions. It must be noted, however,
that a rapid reduction of sodium in the body can lead to the rapid flow of water which can result in
cerebral edema, permanent brain damage which is often referred to as central pontinemyolysis, and
even death.
Hyponatremia, that is a sodium level of less than 135, can result from the syndrome of inappropriate
antidiuretic hormone, some medications like diuretics, some antidepressants, water intoxication and
as the result of diseases and disorders such as a disorder of the thyroid gland, cirrhosis, renal failure,
heart failure, pneumonia, diabetes insipidus, Addison's disease, hypothyroidism, primary polydipsia,
severe diarrhea or vomiting, cancer, and cerebral disorders.
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The signs and symptoms associated with hyponatremia include confusion, vomiting, seizures,
muscle weakness, nausea, headaches, loss of energy, fatigue, and restlessness and irritability.
The treatments of hyponatremia include the correction and management of any underlying causes,
diuretic medications, fluid restrictions, intravenous sodium, and, if Addison's disease is the cause
then hormone replacement may be necessary.
Potassium
The normal potassium level is 3.7 to 5.2 mEq/L.
Unlike sodium that is an extracellular electrolyte that is found in the blood plasma, potassium is
most abundant in the cells of the body; it is primarily an intracellular electrolyte. This electrolyte
promotes and facilitates electrical impulses that are necessary for muscular contractions and also for
the normal functioning of the brain.
Hyperkalemia, which is a potassium level greater than 5.2 mEq/L, can be life threatening; the signs
and symptoms associated with hyperkalemia include muscular weakness, paralysis, weakness, nausea
and possible life threatening cardiac dysrhythmias. Hyperkalemia is most frequently associated with
renal disease, but it can also occur as the result of some medications.
Life threatening hyperkalemia is treated with renal dialysis and potassium lowering medications.
Lower less threatening levels of hyperkalemia can sometimes be treated with the restriction of
dietary potassium containing foods.
Hypokalemia, which is a potassium level less than 3.7 mEq/L, most often as the result of bodily
fluid losses that occur as the result of diarrhea, vomiting, and diaphoresis as well as some
medications like diuretics and laxatives, and with other disorders and diseases such as ketoacidosis.
Mild cases of hypokalemia can be asymptomatic but moderate and severe hypokalemia can be
characterized with muscular weakness, muscular spasms, tingling, numbness, fatigue, light
headedness, palpitations, constipation, bradycardia, and, in severe cases, cardiac arrest can occur.
In addition to treating the underlying cause of this electrolyte imbalance, supplemental potassium is
typically administered.
Calcium
The normal level of calcium is between 8.5 - 10.6 mg/dL.
The levels of calcium in the body are managed by calcitonin which decreases calcium levels and
parathyroid hormone which increases the calcium levels. Calcium is essential for bone health and
other functions.
Hypercalcemia, which is a calcium level of more than 10.6 mg/dL, is most often associated with the
endocrine disorder of hyperparathyroidism, but it is also associated with some medications such as
thiazide diuretics and lithium, some forms of cancer such as breast cancer and cancer of the lungs,
with multiple myeloma, Paget's disease, non weight bearing activity and elevated levels of calcitriol as
can occur with sarcoidosis and tuberculosis.
Hypercalcemia is characterized with thirst, renal stones, anorexia, paresthesia, urinary frequency,
bone pain, muscular weakness, confusion, abdominal pain, depression, fatigue, lethargy,
constipation, nausea and vomiting.
The treatment of hypercalcemia can include intravenous fluid hydration and medications like
prednisone, diuretics, and bisphosphonates. Symptomatic relief measures and interventions can
include analgesia to decrease the client's level of pain, vitamins D and A, and the protection of the
client against injuries and accidents, such as falls, because pathological bone fractures can occur
secondary to the bone decalcification that occurs in many cases of hypercalcemia.
Because magnesium levels are highly associated with calcium levels, it is often necessary to also
correct and treat the magnesium levels before the calcium levels can be corrected.
Hypocalcemia, which is a calcium level less than 8.5 mg/dL, can occur as the result of renal disease,
inadequate dietary calcium, a vitamin D deficiency because vitamin D is essential for the absorption
of calcium, a low level of magnesium, pancreatitis, hypoparathyroidism, an eating disorder, and
certain medications such as anticonvulsants, alendronate, ibandronate bisphosphonates, rifampin,
phenytoin, phenobarbitol, corticosteroids, plicamycin and others.
Symptoms can range from mild and barely noticeable to severe and life threatening. Some of these
signs and symptoms include muscular aches and pain, bronchospasm which can cause respiratory
problems, seizures, tetany, life threatening cardiac arrhythmias, and tingling of the feet, fingers,
tongue and lips.
The treatment of hypocalcemia includes the monitoring of the client's respiratory and cardiac status
in addition to providing the client with calcium supplements coupled with vitamin D because
vitamin D is necessary for the absorption of calcium.
Magnesium
The normal level of magnesium in the blood is 1.7 to 2.2 mg/dL.
Magnesium plays an important role in the body in terms of enzyme activities, brain neuron activities,
the contraction of skeletal muscles and the relaxation of respiratory smooth muscles. Magnesium
also plays a role in terms of the metabolism of calcium, potassium and sodium.
Hypermagnesemia, which is a blood magnesium level of more than 2.2 mg/dL, is most frequently
found secondary to renal failure, dehydration, diabetic acidosis, hyperparathyroidism,
hypothyroidism, Addison's disease, and with the excessive and prolonged use of magnesium
containing laxatives or antacids.
The signs and symptoms associated with hypermagnesemia include nausea, vomiting, respiratory
disturbances, overall and muscular weakness, cardiac arrhythmias, respiratory paralysis, central
nervous system depression and hypotension.
The treatment for hypermagnesemia typically includes the cessation of causative medications like
magnesium containing laxatives, renal dialysis, and the administration of calcium gluconate, calcium
chloride and/or intravenous dextrose and insulin.
Hypomagnesemia, on the other hand, is a blood magnesium level less than 1.7 mg/dL.
Hypomagnesemia often occurs as the result of the prolonged use of diuretics, uncontrolled diabetes,
hypoparathyroidism, diarrhea and gastrointestinal disorders such as Chron's disease, severe burns,
malnutrition, alcoholism and medications such as cisplatin, cyclosporine, amphotericin, proton
pump inhibitors and aminoglycoside antimicrobial drugs.
The signs and symptoms of hypomagnesemia are numbness and tingling, muscular weakness,
convulsions, muscle spasms, cramps, fatigue, and nystagmus.
The treatment of hypomagnesemia can include medications to decrease pain and discomfort as well
as the administration of intravenous fluids and magnesium.
Phosphate
The normal level of serum phosphate is from 0.81 to 1.45 mmol/L.
Hyperphosphatemia is defined as a phosphate level greater than 1.45 mmol/L. The greatest risk
factor for hyperphosphatemia is severe and advanced renal disease, but other risk factors can include
hypoparathyroidism, diabetic ketoacidosis, serious systemic infections, and rhabdomyoysis which is
the destruction of muscular tissue.
Hyperphosphatemia can be asymptomatic but when it is pronounced the client may have signs and
symptoms of muscular spasms and cramping, weakness of the bones, tetany, and crystal
accumulations in the circulatory system and in the body's tissue that can lead to sometimes severe
itchiness and palpable calcifications in the subcutaneous tissue. This electrolyte disorder also has
complications such as impaired circulation, cerebrovascular accidents, myocardial infarctions and
atherosclerosis.
The treatment of hyperphosphatemia includes the restriction of dietary food products containing
phosphates including foods like milk and egg yolks, and phosphate binders such as lanthanum and
sevelamer which make it hard for the client's body to absorb phosphates. These medications are
taken with meals.
Hypophosphatemia, which is defined as a phosphate level less than 0.81 mmol/L, is associated with
risk factors such as chronic diarrhea, severe burns, hyperparathyroidism, severe malnutrition,
pronounced alcoholism, lymphoma, leukemia, hepatic failure, osteomalacia, genetics, the long term
use of some diuretics and aluminium antacids, and the long term use of theophylline.
This sometimes life threatening electrolyte disorder can be accompanied with cardiac dysrhythmias,
death, respiratory alterations including respiratory alkalosis, irritability, confusion, coma and death.
Treatments for hypophosphatemia include cardiac monitoring, oral and intravenous potassium
phosphate, and the encouragement of high phosphorous foods like milk and eggs.
Chloride
The normal level of chloride is from 97 to107 mEq/L.
Hyperchloremia, which is a chloride level greater than 107 mEq/L can adversely affect the oxygen
transportation in the body. Hyperchloremia can occur as the result of dehydration, some
medications, renal disease, diabetes, diarrhea, hyperparathyroidism, hyponatremia, and some
medications such as supplemental hormones and some diuretics.
The client affected with hyperchloremia may be asymptomatic or symptomatic. Some of the signs
and symptoms of hyperchloremia are similar to those signs and symptoms associated with
hypernatremia, and they include extreme thirst, pitting edema, dehydration, diarrhea, vomiting,
Kussmaul's breathing, dyspnea, tachypnea, hypertension, decreased cognition, and coma.
The treatments, in addition to identifying and treating an underlying disorder, include the cautious
administration of fluids because too rapid rehydration efforts can lead to cerebral edema and other
complications, the elimination of problematic medications, and the correction of any renal disease
and hyperglycemia.
Hypochloremia, which is a low chloride level of less than 97 mEq/L, can occur as the result of
vomiting, hypoventilation, cystic fibrosis, metabolic alkalosis, respiratory acidosis, high bicarbonate
levels and hyponatremia.
The signs and symptoms of hypochloremia may include dehydration, hyponatremia, nausea,
vomiting, muscular spasticity, tetany, respiratory depression, muscular weakness and/or muscular
twitching, diaphoresis and a high temperature.
Treatments for this electrolyte imbalance can include the administration of chloride replacements,
and, at times, the administration of hydrochloric acid and a carbonic anhydrase inhibitor like
acetazolamide for an acute episode of hypochloremic alkalosis.
Applying a Knowledge of
Pathophysiology When Caring for the
Client with Fluid and Electrolyte
Imbalances
The pathological etiology, risk factors and the signs and symptoms related to fluid and electrolyte
imbalances were fully discussed immediately above in the section entitled "Identifying the Signs and
Symptoms of the Client's Fluid and/or Electrolyte Imbalances".
Assess client for decreased cardiac output (e.g., diminished peripheral pulses, hypotension)
Identify cardiac rhythm strip abnormalities (e.g., sinus bradycardia, premature ventricular
contractions [PVCs], ventricular tachycardia, fibrillation)
Apply knowledge of pathophysiology to interventions in response to client abnormal
hemodynamics
Provide client with strategies to manage decreased cardiac output (e.g., frequent rest periods,
limit activities)
Intervene to improve client cardiovascular status (e.g., initiate protocol to manage cardiac
arrhythmias, monitor pacemaker functions)
Monitor and maintain arterial lines
Manage the care of a client with a pacing device (e.g., pacemaker)
Manage the care of a client on telemetry
Manage the care of a client receiving hemodialysis
Manage the care of a client with alteration in hemodynamics, tissue perfusion and hemostasis
(e.g., cerebral, cardiac, peripheral)
Sinus Rhythms
Sinus cardiac rhythms begin in the sintoatrial (SA) node of the heart. The five types of sinus rhythms
are:
The normal sinus rhythm which has a cardiac rate of 60 to 100 beats per minute
Sinus bradycardia which has a cardiac rate of less than 60 beats per minute
Sinus tachycardia which has a cardiac rate of more than 100 beats per minute
A sinus arrhythmia which is an irregular heart rate that can range from 60 to 100 beats per
minute
Sinus arrest
This abnormal sinus rhythm can occur secondary to hyperthyroidism, some medications,
hypertension, hyperpyrexia, extreme stress and anxiety, the presence of pain, some electrolyte
imbalances, preexisting heart disease and the intake of illicit substances like cocaine and the
excessive intake of nicotine, alcohol and caffeine.
Some of the signs and symptoms of sinus tachycardia include:
o Chest pain
o Dizziness
o Shortness of breath
o Lightheadedness
o Palpitations
o Syncope
Some of the treatments for sinus tachycardia include the treatment of an underlying disorder or a
problematic medication and no treatments when the client is asymptomatic. When the client is,
however, symptomatic, the client can be treated symptomatically with supplemental oxygen because
this rhythm increases the heart's muscle need for increased oxygenation. Some of the complications
associated with sinus tachycardia include a decrease in terms of the client's cardiac output and a
myocardial infarction.
Sinus Bradycardia
Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the
number of beats per minute. Sinus bradycardia has a cardiac rate less than 60 beats per minute, the
atrial and the ventricular rhythms are regular, the P wave occurs prior to each and every QRS
complex, the P waves are uniform in shape, the length of the PR interval is form 0.12 to 0.20
seconds, the QRS complexes are uniform and the length of these QRS complexes are from 0.06 to
0.12 seconds.
This abnormal sinus rhythm can occur secondary to hypothyroidism, some medications like a beta
blocker or digitalis, increased intracranial pressure, hypoglycemia, hypothermia, preexisting heart
disease and an inferior wall myocardial infarction which involves the right coronary artery.
Some of the signs and symptoms of sinus bradycardia include:
o Chest pain
o Cool, clammy skin
o Weakness
o Fatigue
o Confusion
o Syncope
o An intolerance for exercise
o Shortness of breath
Some of the treatments for sinus bradycardia include the treatment of an underlying disorder or a
problematic medication and no treatments when the client is asymptomatic. When the client is,
however, symptomatic, the client can be treated with atropine and cardiac pacing when the client is
compromised and at risk for reduced cardiac output.
Atrial Arrhythmias
Atrial arrhythmias occur when the heart's natural pacemaker, the sinoatrial node does not generate
the necessary impulses that are required for the normalfunctioning of the heart. When this occurs,
intermodal pathways and atrial tissue initiate the impulse necessary for the heart to beat and pump.
The four types of atrial arrhythmias include atrial flutter, atrial fibrillation, supraventricular
tachycardia and premature atrial contractions or complexes (PAC).
Atrial Flutter
Atrial flutter, which is a relatively frequently occurring tachyarrhymia, is characterized with a rapid
atrial rate of 250 to 400 beats per minute, a variable ventricular rate, a regular atrial rhythm, a
possibly irregular ventricular rhythm. The P waves are not normal, the flutter wave has a saw tooth
looking appearance, the PR interval is not measurable, QRS complexes are uniform and the length
of these QRS complexes are from 0.06 to 0.12 seconds.
Atrial flutter is associated with the aging process, chronic obstructive pulmonary disease, a mitral
valve defect, cardiomyopathy, ischemia; and the possible signs and symptoms of atrial flutter include
weakness, shortness of breath, chest palpitations, angina pain, syncope and anxiety.
The risks and complications of atrial flutter include atrial clot formation, a pulmonary embolus, a
cerebrovascular accident, and a drop in cardiac output.
Atrial flutter can be treated with anticoagulant therapy to prevent clot formation, cardioversion, and
medications like the antiarrhymic medications of procainamide to correct the flutter and a beta
blocker or digitalis to slow down the rate of the ventricles.
Atrial Fibrillation
Atrial fibrillation is characterized with an rapid atrial rate of 350-400 beats per minute, a variable
ventricular rate, an irregular rhythm, the P waves are nonexistent and they are replaced with f waves,
the PR interval is not present, the QRS complexes are uniform and they look alike, and the length of
these QRS complexes are from 0.06 to 0.12 seconds.
Some of the diseases and disorders associated with this cardiac arrhythmia include hypertension,
heart failure, impaired sinus node functioning, hypoxia, a mitral valve defect, pericarditis, rheumatic
heart disease, coronary artery disease, hyperthyroidism, the aging process and the presence of a
pulmonary embolus.
Some of the signs and symptoms of atrial fibrillation include chest tightness, palpitations, shortness
of breath, dyspnea, fluttering in the chest, dizziness, confusion, fainting, and fatigue.
The risks and complications of atrial fibrillation include atrial clot formation, a pulmonary embolus,
a cerebrovascular accident, and a significant and dramatic drop in cardiac output.
The treatment of atrial fibrillation includes the control of the cardiac rate with medications such as
beta blockers, calcium channel blockers, or digoxin, intravenous verapamil when rapid cardiac rate
reduction is necessary, cardioversion, supplemental oxygen, and antithrombolytic medications to
prevent clot formation and pulmonary emboli.
Premature atrial contractions, which result from the atrial cells taking over the SA impulses, is
associated with a number of different diseases and disorders such as hypertension, ischemia,
hypoxia, some electrolyte disorders, digitalis use, stress, fatigue, the use of stimulants such as
caffeine and nicotine products, some valve abnormalities, some infectious diseases, and also among
clients without any cardiac disease or other disorder.
The signs and symptoms of premature atrial contractions include palpitations and client reports that
they feel a "missed beat" which results from the compensatory pause.
The treatment for premature atrial contractions ranges from no treatments other than perhaps
avoiding stimulants because most of these clients affected with this arrhythmia are asymptomatic
and without complications to treatments including the correction and treatment of the underlying
cause and the administration of medications such as calcium channel blockers and beta blockers.
Supraventricular Tachycardia
Supraventricular tachycardia, simply defined is all tachyarrhythmias with a heart rate of more than
150 beats per minute.
The atrial and ventricular cardiac rates are from 150 to 250 beats per minute, the cardiac rhythm is
regular, the p wave may not be visible because it is behind the QRS complex, the PR interval is not
discernable, the QRS complexes look alike, and the length of the QRS complexes ranges from 0.06
to 0.12 seconds.
The risk factors associated with supraventricular tachycardia include atherosclerosis, hypokalemia,
hypoxia, stress, and stimulants; and some of the signs and symptoms include polyuria, palpitations,
syncope, dizziness, chest tightness, diaphoresis, fatigue, and shortness of breath.
The treatments for supraventricular tachycardia include the performance of the vagal maneuvers
such as the Valsalva maneuver and coughing, as well as oxygen supplementation when the client is
asymptomatic; and medications such as adenosine and cardioversion when the client is symptomatic.
A complication of this cardiac arrhythmia is heart failure.
Ventricular Arrhythmias
Ventricular arrhythmias occur when the AV junction and the sinoatrial node fail to send their
electrical impulses. As a result of this failure, the ventricles take over the role of the heart's
pacemaker. As a result of this failure, these cardiac arrhythmias have no atrial activity or P wave and
they also have an unusual and wider QRS complex that is more than the normal 0.12 seconds.
Ventricular arrhythmias include:
An idioventricular rhythm, also referred to as a ventricular escape rhythm, has a rate of less than
20 to 40 beats per minute
An accelerated idioventricular rhythm with more than 40 beats per minute
An agonal rhythm with less than 20 beats per minute
Ventricular tachycardia with more than 150 beats per minute
Ventricular fibrillation
Asystole or cardiac standstill
Torsades de Pointes
Idioventricular Rhythm
An idioventricular rhythm is characterized with a ventricular rate of 20 to 40 beats per minute, a
regular rhythm, the absence of a P wave, a PR interval that cannot be measured, a deflection of the
T wave, and a wide QRS complex that is greater than 0.12 seconds.
Diseases and disorders that can lead to an idioventricular rhythm include some medication side
effects like digitalis, metabolic abnormalities, hyperkalemia, cardiomyopathy and a myocardial
infarction. The client with an idioventricular rhythm may present with mottled, cool and pale skin,
dizziness, hypotension, weakness, and changes in terms of the client's mental status and level of
consciousness.
The treatments for an idioventricular rhythm include a cardiac pacemaker, the administration of
atropine, the administration of dopamine when the client is adversely affected with hypotension, and
cardiopulmonary resuscitation when this cardiac arrhythmia leads to cardiac stand still and asystole.
Agonal Rhythm
An agonal rhythm, simply defined, is a type of an idioventricular rhythm with a cardiac rate of less
than 20 beats per minute. Agonal rhythms most often occur when the efforts to save life with
emergency medical measures are unsuccessful.
The rate is slow and less than 20 beats per minute, the rhythm is typically regular, the P wave is
absent, the PR interval is not measurable, and the QRS interval is abnormally wide and more than
0.12 seconds with an abnormal T wave deflection.
Agonal rhythms can be caused by a myocardial infarction, trauma and predictable changes at the end
of life and it is signaled with the lack of a palpable pulse, the lack of a measurable blood pressure
and the complete loss of consciousness.
The treatment of this serious and highly life threatening dysrhythmia includes the initiation of CPR
and the advanced cardiac life support (ACLS) protocols, if the client has chosen these life saving
treatments.
Ventricular Tachycardia
Ventricular tachycardia occurs when no impulses come from the atria; this life threatening
arrhythmia will progress to ventricular fibrillation and then cardiac arrest and cardiac asystole unless
emergency medical care is immediately rendered.
The cardiac rate can range from 101 to 250 beats per minute, the ventricular rhythm is regular but
the atrial rhythm cannot be distinguished, there are no P waves, the PR interval is not measurable,
and the QRS complex is greater than 0.12 seconds.
The risk factors associated with ventricular tachycardia include severe cardiac disease, myocardial
ischemia, a myocardial infarction, digitalis toxicity, some electrolyte imbalances, heart failure and
some medications.
Some of the signs and symptoms include hemodynamic compromise, unconsciousness, angina chest
pain, palpitations, shortness of breath, dizziness, syncope, hypotension, and the absence of a pulse
or a rapid pulse rate. Additionally, the client may not have any signs or symptoms when there are
less than 30 seconds of ventricular tachycardia.
The complications can include ventricular fibrillation which can lead to cardiac arrest. Immediate
CPR and ACLS protocols, cardioversion, the placement of an internal pacemaker, amiodarone,
lidocaine and antiarrhythmic medications may be used for the treatment of ventricular fibrillation
according to the client's condition and their choices.
Ventricular Fibrillation
The two types of ventricular fibrillation that can be seen on an ECG strip are fine ventricular
fibrillation and coarse ventricular fibrillation; ventricular fibrillation occurs when there are multiple
electrical impulses from several ventricular sites. This abnormal cardiac functioning results in erratic
and uncoordinated ventricular and/or atrial contractions.
The rate of contraction cannot be determined, the rhythm is not detectable because it is highly
erratic and disorganized, there are no P waves, no PR interval and no QRS complexes.
Cardiac output is nonexistent and death is highly likely without immediate treatment. The risk
factors associated with ventricular fibrillation include non treated ventricular tachycardia, illicit drug
overdoses, a myocardial infarction, severe trauma, some electrolyte imbalances, and severe
hypothermia.
The client loses consciousness and there is an absent pulse during ventricular fibrillation; emergency
measures include CPR, ACLS protocols including defibrillation, and other life saving measures are
indicated for the client with this highly serious life threatening cardiac arrythmia.
Asystole
Asystole is a flat line. There is no cardiac rate, no rhythm, no P waves, no PR interval and no QRS
complex.
Asystole occurs most frequently when ventricular fibrillation is not corrected, but it can also occur
suddenly as the result of a myocardial infarction, an artificial pacemaker failure, a pulmonary
embolus and cardiac tamponade.
Immediate BLS and advanced life support is necessary. Intravenous adrenaline, sodium bicarbonate
and atropine, as well as 100% oxygen are done in hopes of saving the person's life.
Torsades de Pointes
The classical features of torsades de pointes are a long QT interval in addition to a downward and
upward deflection of the QRS complexes that are seen on the cardiac strip. The cardiac rate can
range from 150 to 250 beats per minute, the rhythm can be irregular or regular, the PR interval is
not measurable, and the QRS complex is widened with upward and downward deflections.
Torsades de pointes can occur as the result of an over dosage of a tricyclic antidepressant drug of
phenothiazine, hypomagnesemia and hypokalemia. It can be short lived and self-limiting without any
treatment but it can also lead to ventricular fibrillation when it is not corrected and treated.
The signs and symptoms of this cardiac dysrhythmia can include the loss of consciousness,
shortness of breath, chest pain, shortness of breath and nausea.
The treatment of torsades de pointes, which can be life threatening, includes the initiation of CPR
and ACLS protocols, the bolus administration of magnesium sulfate, cardioversion, and the
correction of any underlying and causal factor or condition.
Heart Block
There are several types of heart block including:
The most common causes of first degree heart block are an AV node deficit, a myocardial infarction
particularly an inferior wall myocardial infarction, myocarditis, some electrolyte disorders, and
medications like beta blockers, cardiac glycoside medications, calcium channel blockers and
cholinesterase inhibitors.
Most episodes of transient first degree heart block are benign and asymptomatic, but at times, it can
lead to atrial fibrillation and other cardiac irregularities of varying severity according to the length of
the PR interval prolongation.
The treatment of first degree heart block includes the correction of the underlying disorder, the
elimination of problematic medications, and routine follow up and care.
Treatments for this heart block can include intravenous atropine, supplemental oxygen, and, in some
cases, a temporary or permanent pacemaker, as indicated.
Some of the conditions and disorders that can lead to complete heart blood include rheumatic fever,
coronary ischemia, an inferior wall myocardial infarction, the presence of an atrial septal defect, and
some medications including digoxin and beta blockers, for example.
The signs and symptoms of this cardiac arrhythmia can include syncope, dizziness, fainting, chest
pain and a loss of consciousness.
Third-degree AV block is treated with a pacemaker, medications to control atrial fibrillation and the
client's blood pressure, as well as the treatment of any identifiable causes including life style choices
and other modifiable risk factors.
Applying a Knowledge of
Pathophysiology to Interventions in
Response to Client Abnormal
Hemodynamics
As consistent with other abnormal client changes, nurses apply a knowledge of pathophysiology in
terms of the interventions that are employed in response to the client's abnormal hemodynamics.
Some of the knowledge of pathophysiology that is essential to this nursing responsibility includes
both cognitive and psychomotor knowledge.
The cognitive domain knowledge includes:
The definition of hemodynamics as the flow of blood as ejected from the heart to circulate
throughout the body in order to effectively oxygenate the tissues of the body.
The physiology and pathophysiology related to cardiac flow rate and cardiac output
Cardiac output as the function of the volume of pumped blood by the heart and the factors and
forces that alter normal cardiac output
The blood pressure and the mean arterial pressure which is a function of the blood pressure and
the resistance to the flow of blood within the body's circulatory system
The resistance to blood flow as a function of the blood's thickness or viscosity, the width of the
vessel that the blood is flowing through and the length of the vessel that the blood is flowing
through, as mathematically calculated with the Hagen Poiseuille equation. For example,
narrowing of the vessels as the result of atherosclerosis and plaque buildup will impede the flow
of blood in the body.
The normal parameters for hemodynamic monitoring values, as shown below.
The psychomotor domain knowledge includes the nurse's ability to set up, maintain and collect data
from a wide variety of invasive and noninvasive hemodynamic monitoring devices such as:
The psychological alterations, signs and symptoms associated with decreased cardiac output include:
Restlessness
Anxiety
Changes in terms of mental status and level of consciousness
Confusion
Life style alterations may interfere with the client's activity level because the client with decreased
cardiac output has a decrease in terms of their tolerance to exercise, fatigue, and weakness. They
may also be at risk for accidents such as falls when the client with decreased cardiac output is
affected with weakness, fatigue, confusion and other changes in terms of their level of consciousness
and mental status.
Based on these signs and symptoms of decreased cardiac output, some of the interventions and
strategies for clients with decreased cardiac output include can include rest interspersed with light
exercise, frequent rest periods, pain management, supplemental oxygen as indicated by the client's
doctor's orders, mild analgesia if chest pain occurs, the maintenance of a restful sleep environment
and when to call the doctor as new signs and symptoms arise.
Illness Management:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills illness management in order to:
The pathophysiology of the health related concern, disease, condition, and/or illness
The risk factors associated with the health related concern, disease, condition, and/or illness
The modifiable risk factors, such as dietary modifications, medication adherence and exercise,
that can be changed to improve one's state of heath and to decrease the risks associated with the
disease and its possible complications
The non modifiable risk factors that cannot be changed, but however, may be able to be
compensated for with some client actions and changes in term of their behavior
The procedures, such as diagnostic tests, that will be used to diagnose and also be used for the
ongoing monitoring of the client with an acute or chronic disease
The signs and symptoms of the acute or chronic disorder, ways to symptomatically treat
treatable signs and symptoms and what signs and symptoms should be reported to the client's
doctor
All of the treatments and interventions, including medications, that the client will and may
receive. This information should include all of the educational components necessary for
informed consent including the benefits and risks associated with these interventions, possible
alternatives to the intervention or procedure, and the risks and benefits associated with these
alternative interventions.
Self care strategies for the client
The available community resources, including financial resources, that can assist the client with
coping with and recovering from a chronic or acute condition or disorder
The frequency of follow up care in the community and the need for follow up care
Implementing Interventions to
Manage the Client's Recovery from an
Illness
As discussed in the previous section entitled "Promoting Client Progress Toward Recovery From an
Alteration in Body Systems", recovery from an illness is a function of both intrinsic and extrinsic
factors and forces.
These factors and forces were organized into the framework associated with the Dimensions of
Health model which is helpful to apply to the client's recovery. Examples of these dimensions and
their applications to the client's recovery from an illness were discussed in this same section of this
review and these dimensions include:
Lavage is then done according to the doctor's order after the correct placement of the
gastrointestinal tube in the stomach is confirmed. This procedure is somewhat similar to that of
irrigating a nasogastric tube with the exception of connecting the tube to suction and the type of
solution that is used.
The procedure for gastric lavage is listed below:
Pulmonary function tests, often done by a certified respiratory therapists or pulmonologist, consist
of an array of diagnostic tests and measurements including:
Pulse oximetry: Pulse oximetery measures the oxygen saturation of arterial blood by using a
sensor on a client's finger or, when necessary, on their forehead, nose, or ear. In addition to the
certified respiratory therapist's measuring pulse oximetry, this measurement is and can be
measured by nurses and specially trained unlicensed assistive personnel such as nursing
assistants at the bedside. The normal value for the oxygen saturation of arterial blood should be
from 94 to 100%.
Spirometry: Some of the data that can be obtained with diagnostic spirometry testing include
tidal volume, forced vital capacity, non forced vital capacity, maximum inspiratory pressure,
maximum expiratory pressure, lung capacity, lung volumes other than residual lung volumes and
other measures of pulmonary functioning.
Tidal Volume: Tidal volume is the volume of air in terms of mLs that is normally inhaled and
exhaled during the client's normal respiratory cycle including their inhalation and exhalation
without the any exertion on the part of the client and without any obstructive force. The normal
tidal volume of adults is typically about 500 mL and, mathematically, the normal can be
determined mathematically for non-adult clients by knowing that the normal tidal volume
should be 7 mLs per kilogram of body weight.
Maximum Inspiratory Pressure: Maximal inspiratory pressure, or MIP, which is also referred
to as negative inspiratory force, is similar to the MEP and it is the amout of pressure that the
client can exert against an occlusion. Again, the MIP can vary with age and gender. Those with
an MIP of less than – 20 cm H2O have moderate to severe respiratory problems. The lowest
acceptable limit for males is – 75 cm H2O and the lowest acceptable limit for females is – 50 cm
H2O. The client's maximal inspiratory pressure is a function of the client's strength of their
accessory muscles of respiration during inspiration, the strength of the client's diaphragmatic
muscles, the client's lung volume during occlusion, the length of time that the airway is
occluded, and the client's ventilatory drive and efforts.
Airway Resistance: Airway resistance measurements reflect the airways' resistance to and
opposition to the normal flow of air through the bronchopulmonary system.
Forced Vital Capacity: Forced vital capacity reflects the measurement of the client's volume of
air that they can expel against resistance. Forced vital capacity reflects the strength of the client's
muscles of respiration.
Forced Expiratory Volume: Also measured with spirometry, forced expiratory volume consists
of lung's ability to exhale forcibly for a one second.
I:E Ratio: The I:E ratio is the ratio of the client's duration of inspiration and the client's
duration of expiration. The normal I:E ratio is 1:2; this ratio becomes greater, such as 1:3, when
the client is affected with an air flow that is not sufficient or it is obstructed as is the case with
respiratory disorders such as asthma, chronic bronchitis, and emphysema. At times the client can
be symptomatic as the result of an abnormal I:E ratio and at other times the client can present
with Kussmaul's, Biot's and/or Cheyne-Stokes respiratory patterns.
Minute Volume: Minute volume is the amount of air that the client exhales or inhales in one
minute, which is referred to as the expired minute volume and inhaled minute volume,
respectively.
Expiratory Reserve Volume: Expiratory reserve volume is the greatest volume of air that can
be exhaled after the end expiratory phase of the client's respiratory cycle.
Inspiratory Reserve Volume: Inspiratory reserve volume is the greatest volume of air that can
be inhaled at the end of the inspiratory phase of the client's respiratory cycle.
Residual Volume: Residual volume is the volume of air that is left as residual in the lungs after
the client has exercised a forceful and maximal exhalation.
Exercise Testing: The Exercise Induced Bronchoconstriction Test: The most commonly
employed forms of diagnostic cardiopulmonary exercise testing Include exercise induced
bronchoconstriction testing, full cardiopulmonary exercise testing and the Six Minute Walk test .
Exercise induced bronchoconstriction tests consist of measuring the forced expiratory volume
in one second (FEV1) and the forced vital capacity (FVC) prior to exercise, 5 minutes after the
client began to exercise and ½ hour after exercise on a treadmill while the pulse rate is 80% of
its predicted maximum rate. Bronchoconstriction is suspected when the results show a drop in
the FEV1 or the FVC of more than 15% during this test.
Exercise Testing: Full Cardiopulmonary Exercise Testing: Full and complete cardiopulmonary
exercise testing is done to collect assessment data related to the person's air flow, cardiac rate,
arterial blood gases, oxygen consumption, and carbon dioxide production when the client is
resting as well as when they are exercising on a treadmill, as discussed immediately above. The
aim of this test is to determine and differentiate between the client's maximal exercise capacity
and their reduced exercise cardiopulmonary status.
Exercise Testing: The Six-Minute Walk Test: This diagnostic test measures the ability of the
client to walk at their own rate for six minutes in terms of their respiratory data.
In addition to the nurse assessing the client's signs and symptoms of respiratory disorders, the nurse
also considers all of the pertinent respiratory data that are collected by others, as described above,
and then the nurse plans care and monitoring accordingly.
Depending on the medical diagnoses, the medical doctors' orders and the nursing diagnoses in
addition to the scopes of practice, roles and responsibilities of the other members of the health care
team such as the physicians, the physician assistants, the nurse practitioner, the certified respiratory
therapist and the nurse, complete care and follow up care of the client is provided by the health care
team.
Medical Emergencies:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of medical emergencies in order to:
Apply knowledge of pathophysiology when caring for a client experiencing a medical emergency
Apply knowledge of nursing procedures and psychomotor skills when caring for a client
experiencing a medical emergency
Explain emergency interventions to a client
Notify primary health care provider about client unexpected response/emergency situation
Perform emergency care procedures (e.g., cardio-pulmonary resuscitation, respiratory support,
automated external defibrillator)
Provide emergency care for wound disruption (e.g., evisceration, dehiscence)
Evaluate and document the client's response to emergency interventions (e.g., restoration of
breathing, pulse)
The immediate medical care and interventions, in addition to the correction of any underlying
disorder or condition and emergency cardiopulmonary resuscitation, for a number of cardiovascular
emergencies, in addition to the previously discussed cardiac arrest, include the following:
Heart Failure
Brief Description: Heart failure occurs when the heart can no longer pump the ample amount of
oxygenated blood that the body needs and demands to sustain life and to maintain the necessary
bodily functions. Although left sided heart failure and left ventricular malfunctioning is more
common than right sided heart failure and right ventricular malfunctioning, heart failure can be both
right sided and left sided.
Signs and Symptoms: The signs and symptoms associated with heart failure include tachycardia,
hypotension, lethargy, an intolerance of activity, dyspnea, related anxiety, the retention of excessive
bodily fluid and skin pallor.
Interventions and Treatments: ACE inhibitors, angiotensin II receptor antagonists, beta blockers,
diuretics, a sodium restricted diet, an implanted cardioverter and or pacemaker and a physician
approved exercise regimen may be indicated for the client, as based on their current cardiac status.
Complications: Virtually, all bodily systems and tissues can be jeopardized and compromised with
heart failure; these systems and tissues can include the renal system, the client's hemodynamic
stability, and the pulmonary system. Respiratory and cardiac arrest can occur when treatment is not
successfully rendered to the affected client.
Cardiac Tamponade
Brief Description: Cardiac tamponade causes the heart to not fill, contract and pump in the normal
manner because an abnormal accumulation of fluid is present in the pericardial sac around the heart.
Signs and Symptoms: The signs and symptoms of cardiac tamponade include high central venous
pressure, scant urinary output, severe hypotension, impaired peripheral perfusion, impaired
peripheral pulses, narrowing of the pulse pressure, tachycardia, tachypnea, dyspnea, a loss of
consciousness, and jugular vein distention.
Interventions and Treatments: Emergency measures to correct hypotension, oxygen
supplementation, and a pericardiocentesis may be indicated for the client.
Complications: Cardiac arrest.
Hypertensive Crisis
Brief Description: Hypertensive crisis is a sudden, significant rise in the client's blood pressure that
typically occurs unpredictably and without warning.
Signs and Symptoms: The signs and symptoms can include chest pain, the signs and symptoms of
heart failure and/or a myocardial infarction, an altered level of consciousness, headache,
cardiovascular compromise, oliguria, renal compromise, and renal failure.
Interventions and Treatments: Immediate treatment with emergency intravenous antihypertensive
medications such as nitroprusside in combination with an ACE inhibitor or a beta blocker which
should decrease the blood pressure by about 30 percent in one half an hour.
Complications: Renal failure, myocardial infarction, heart failure, and cardiac arrest.
Septic Shock
Brief Description: Massive systemic infection that leads to massive vasodilation throughout the
entire body
Signs and Symptoms: Massive hypotension, adventitious breath sounds, decrease cardiac output,
microemboli, peripheral vasoconstriction, a widened pulse pressure, metabolic acidosis and
respiratory alkalosis
Interventions and Treatments: Fluid replacement, mechanical ventilation, oxygen supplementation,
treatment of the underlying cause, the correction of metabolic acidosis and respiratory alkalosis, and
at times, dialysis
Complications: Multisystem failure and death.
Hypovolemic Shock
Brief Description: The depletion of bodily fluids secondary to a number of different causes such as
hemorrhage and severe dehydration
Signs and Symptoms: Decreased cardiac output, progressive and severe dehydration, and metabolic
acidosis
Interventions and Treatments: Fluid replacement with lactated Ringers, blood, blood components
and plasma expanders, and placing the client in the Trendelenburg position.
Complications: Multisystem failure and shutdown.
Myocardial Infarction
Brief Description: Ischemia of the heart muscle secondary to the lack of oxygenated blood flow
through the coronary arteries.
Signs and Symptoms: Some are "silent" and asymptomatic; others can present intermittent or
constant diaphoresis, severe chest pain, shortness of breath, nausea and vomiting.
Interventions and Treatments: Oxygen supplementation, unfractionated heparin, intravenous fluids,
nitroglycerin, pain management, aspirin, clopidogrel, anticoagulant therapy; and, at times, a
percutaneous coronary intervention or a coronary artery bypass graft is indicated.
Complications: Life threatening cardiac arrhythmias, cerebrovascular accidents, emboli formation,
and a weakened heart muscle.
Anaphylactic Shock
Brief Description: Massive, systemic circulation collapse and relaxation secondary to the body's
impaired immune response to an allergen such as occurs with an allergic response to a drug such as
penicillin, a food or an insect bite, for example
Signs and Symptoms: Severe and significant hypotension, laryngeal edema, respiratory distress, a
lowered cardiac output, venous pooling and venous stasis, tachycardia, and a bounding pulse
Interventions and Treatments: If the cause of the anaphylaxis is an IV antibiotic the IV must be
immediately removed. The immediate injection of epinephrine, rRespiratory support,
cardiopulmonary resuscitation, and ACLS protocols as indicated.
Complications: Respiratory and cardiac arrest
Neurogenic Shock
Brief Description: The massive relaxation and collapse of the venules and arterioles of the
circulatory system which most often occurs as the result of a spinal cord injury, including but not
limited to, a traumatic spinal injury or one that results from the administration of spinal anesthesia
Signs and Symptoms: Fainting, syncope, hypotension and bradycardia
Interventions and Treatments: Medications to stimulate the sympathetic nervous system such as
metarminol or atropine
Complications: Massive circulatory collapse and death
Obstructive Shock
Brief Description: A sudden obstruction of circulatory flow to the heart that occurs with the
obstruction of a major vessel which can occur secondary to such disorders as cardiac tamponade, an
embolus, aortic stenosis, and a pneumothorax
Signs and Symptoms: Hypotension, clammy, cool and pale skin, tachycardia, a thready pulse,
hypothermia, distended neck veins, a change in the level of consciousness, shallow respirations, oral
dryness, confusion, restlessness, anxiety, and cyanosis
Interventions and Treatments: The treatment of the underlying cause with a pericardiocentesis for
cardiac tamponade or chest tube insertion and drainage for a pneumothorax, for example, in
addition to fluid replacements and the management of the complications, signs and symptoms such
as hypothermia and respiratory support for respiratory compromise.
Complications: Multisystem organ failure and death
Intussusception
Brief Description: The loss of perfusion to an area of the intestine because the affected part of the
intestine slides into another part of the intestine near the affected area
Signs and Symptoms: Knee to chest posturing, abdominal pain, bloody stool, fever, constipation,
vomiting and diarrhea.
Interventions and Treatments: Decompression of the bowel with a nasogastric tube to suction,
intravenous fluid replacements, and a surgical repair of the affected part of the intestine
Complications: Peritonitis, sepsis, shock and death when left untreated
Appendicitis
Brief Description: An acute infection and inflammation of the appendix which is attached to the
cecum of the gastrointestinal tract.
Signs and Symptoms: Constant or intermittent classical McBurney's point pain in the lower right
quadrant of the abdomen, a tense and rigid abdomen, rebound tenderness, a temperature, projectile
vomiting, anorexia, malaise, lethargy and nausea
Interventions and Treatments: Antibiotics and an emergency appendectomy
Complications: A ruptured appendix, gangrene, peritonitis, sepsis, and death
Peritonitis
Brief Description: A massive inflammation and infection of the peritoneum which can result from a
number of causes such as a perforated gastrointestinal ulcer and a ruptured appendix when the
gastrointestinal contents, including E coli, enter the peritoneal space
Signs and Symptoms: The presence of severe and the abrupt onset of abdominal pain accompanied
with abdominal guarding, rebound tenderness, decreased or absent bowel sounds, nausea and
vomiting, abdominal distention, a fever, malaise, tachypnea, tachycardia, oliguria, anuria, and the
other signs and symptoms of shock.
Interventions and Treatments: Pain management, the administration of antibiotics, intestinal
decompression, and emergency surgical interventions to correct the underlying cause
Complications: Massive sepsis, shock and death
Gastrointestinal Hemorrhage
Brief Description: Massive bleeding in the gastrointestinal tract; this bleeding can originate at any
point of the upper gastrointestinal tract and the lower gastrointestinal tract.
Signs and Symptoms: Changes in the color of the stools that can vary from a black and tarry looking
stool, to a burgundy color stool, to a coffee grounds color stool, to a bright red stool with or
without evidence of blood clots depending on the section of the gastrointestinal tract that is
adversely affected. Some of the other signs and symptoms can be vomiting, hypotension, vomiting
blood, skin pallor, weakness, shortness of breath and the signs and symptoms of hypovolemic
shock, as previously discussed in this section of the NCLEX RN review.
Interventions and Treatments: Gastric lavage and suctioning, the administration of blood and blood
products, intravenous fluid replacement and medications to support the client's cardiovascular
functioning
Complications: Hypovolemic shock and death
Esophageal Varices
Brief Description: The pathophysiological enlargement of the veins of the lower esophagus that
most often result from hepatic failure and portal hypertension
Signs and Symptoms: They are asymptomatic until they rupture and lead to hemorrhage, shock,
vomiting of bright red blood and black stools
Interventions and Treatments: The administration of medications to decrease the portal
hypertension, surgical interventions such as banding off the bleeding vessels, and measures to
correct the hypovolemic shock if it has occurred as the result of this medical emergency.
Complications: Hypovolemic shock and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of respiratory medical emergencies include the following:
Aspiration
Brief Description: The abnormal entry of bodily fluids, food or another foreign body into the
respiratory tract.
Signs and Symptoms: Coughing, chocking, and the signs and symptoms of a respiratory obstruction,
as discussed above.
Interventions and Treatments: Correction of the obstruction, prophylactic antibiotic therapy to
prevent aspiration pneumonia, oxygen supplementation, intubation and mechanical ventilation
Complications: Aspiration pneumonia, airway obstruction, respiratory distress, respiratory arrest and
death
Pleural Effusion
Brief Description: The abnormal collection of fluid around the lung(s) in the pleural space as the
result of an abnormal decrease in the absorption of this fluid and/or the overproduction of this fluid
Signs and Symptoms: Shortness of breath, dyspnea, coughing, chest pain and a possible fever
Interventions and Treatments: In addition to treating any underlying causes, the emergency
interventions for this potentially life threatening disorder include supplemental oxygen, a
thoracentesis, chest tube placement and drainage, and other measures to correct any of the signs and
symptoms
Complications: Respiratory distress, respiratory failure and respiratory arrest which can lead to death
when this medical emergency is not promptly and effectively treated.
Pneumothorax
Brief Description: The complete or partial collapse of the lung because air has entered the pleural
space and created positive pressure on the lung and eliminated the normal negative pressure of the
pleural space which is necessary for the expansion of the lung during the respiratory cycle.
Signs and Symptoms: An increase in the work of breathing, shortness of breath, dyspnea, the use of
the accessory muscles of breathing, hypoxia, tachycardia, tachypnea, hypotension, chest pain, the
shifting of the trachea and the mediastinum to the side opposite of the tension pneumothorax,
hyperextension of the chest, and circulatory collapse
Interventions and Treatments: The insertion of and maintenance of a chest tube to drainage, the
aspiration of the abnormal air collection in the pleural space, a surgical repair of the injured lung
area, and respiratory support such as oxygen supplementation
Complications: Respiratory distress, hypoxia and respiratory arrest
Atelectasis
Brief Description: The collapse of the lung as the result of one of many causes such as aspiration,
the poor placement of an endotracheal tube, pleural effusion and a pneumothorax
Signs and Symptoms: Decreased lung volumes, chest pain, dyspnea and the signs and symptoms of
hypoxia when severe
Interventions and Treatments: Coughing, deep breathing and any respiratory support that is
indicated by the severity of the atelectasis
Complications: Respiratory distress, hypoxia, multisystem failure and respiratory arrest
Flail Chest
Brief Description: An instability of the chest wall and a decrease in the expansion of the chest wall
as the result of some trauma such as fractured ribs
Signs and Symptoms: Evidence of chest trauma, palpable rib fractures, the presence of subcutaneous
air at the site of the injury, inspiratory chest wall retraction, and paradoxical chest wall movement.
Interventions and Treatments: Pain management, gentle pressure over the affected area, fixation of
the fractured ribs, oxygen supplementation, chest tube insertion to prevent a pneumothorax, and
mechanical ventilation when indicated
Complications: Pneumothorax, pneumonia, respiratory distress, respiratory failure, hypoxia and
death
Hemothorax
Brief Description: The complete or partial collapse of the lung because blood has entered the pleural
space and created positive pressure on the lung and eliminated the normal negative pressure of the
pleural space which is necessary for the expansion of the lung during the respiratory cycle
Signs and Symptoms: The same signs and symptoms as discussed immediately above under
"Pneumothorax"
Interventions and Treatments: The interventions and treatments as discussed immediately above
under "Pneumothorax"
Complications: The same complications as discussed immediately above under "Pneumothorax"
Fat Emboli
Brief Description: The entry and presence of fat globule emboli from the marrow of the bone into
the circulatory system. This life threatening emergency can occur as the result of a skeletal fracture,
severe burns, blunt trauma to the liver and some severe infections.
Signs and Symptoms: Restlessness, a headache, a decreased level of consciousness and/or cognition,
seizures, dilation of the pupils, pulmonary infiltration, hypoxia, right sided heart failure, a petechial
rash, venous and capillary stasis, a low hematocrit level, fever, tachycardia, diminished urinary
output, anuria, and evidence of fat globules in the urine.
Interventions and Treatments: Symptomatic and supportive care including supplemental oxygen
administration, and other respiratory interventions, such as intubation and mechanical ventilation,
when it is indicated
Pulmonary Emboli
Brief Description: The formation of and the travelling of an embolus into the lungs.
Signs and Symptoms: Increased work of breathing, shortness of breath, tachypnea, tachycardia,
hypoxia, cyanosis, dyspnea, chest pain, coughing, anxiety and panic.
Interventions and Treatments: Respiratory support, the administration of streptokinase or a tissue
plasminogen activator, anticoagulation therapy and oxygen supplementation are often indicated
Complications: Respiratory distress, respiratory arrest and death
Pulmonary Edema
Brief Description: The filling of the alveoli with fluid that leads to the poor gas exchanges of oxygen
and carbon dioxide
Signs and Symptoms: Adventitious breath sounds, fatigue, cyanosis, dyspnea, shortness of breath,
tachypnea and hypoxia
Interventions and Treatments: The administration of diuretics, suctioning, intubation, oxygen
supplementation and mechanical ventilation as indicated by the client's respiratory status
Complications: Respiratory distress, severe hypoxia, respiratory arrest and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of renal medical emergencies include the following:
Renal Calculi
Brief Description: Renal calculi, often referred to as kidney stones, are small, hard mineral and acidic
salt deposits that abnormally form in the kidney
Signs and Symptoms: Asymptomatic until these calculi begin to move into the ureter at which time
the presenting signs and symptoms can include intermittent or constant and severe pain located in
the side and back below their ribs, pain spreading to the lower abdomen and groin, dysuria, pink,
red, or brown urine, cloudy, foul smelling urine, urinary frequency, urinary urgency, nausea,
vomiting and the signs of infection such as a temperature and chills when this medical emergency is
accompanied with an infection.
Interventions and Treatments: Increased oral fluid intake, pain management, the administration of
an alpha blocker, extracorporeal shock wave lithotripsy, and a surgical percutaneous
nephrolithotomy
Complications: Hemorrhage, chronic urinary tract infections, renal damage and renal failure
Pyelonephritis
Brief Description: Pyelonephritis is a kidney infection that originates in the urethra or bladder and
then spreads to the kidneys. Immediate medical attention is required, and if not treated or not
treated effectively, this infection can permanently damage renal function and sepsis can occur.
Signs and Symptoms: Upper back and flank pain, a high fever, urinary frequency, urinary urgency,
chills, nausea, vomiting, pus in the urine, hematuria, and burning while urinating.
Interventions and Treatments: The administration of antimicrobial therapy, often coupled with the
need for hospitalization and intravenous antibiotic therapy
Complications: Renal damage, massive sepsis, shock and renal failure
Renal Failure: Acute and Chronic
Brief Description: Renal failure can be acute or chronic. Acute renal failure can be possibly result
from a number of different causes including poor renal perfusion, infection, poisoning, hemorrhage,
dehydration, obstructions, hypertension, and some medications like gentamicin, streptomycin,
naproxen and ACE inhibitors
Signs and Symptoms: Nausea, vomiting, confusion, oliguria, anuria, edema, anorexia, anxiety and
flank pain
Interventions and Treatments: Hemodialysis, peritoneal dialysis, kidney transplantation, fluid
restrictions, and the administration of medication such as phosphate binders, ferrous sulfate for the
treatment of anemia, erythropoietin, and blood transfusions when indicated.
Complications: Renal shutdown and death
Cerebrovascular Accidents
Brief Description: An insult to the brain that can lead to permanent disability and even death.
Cerebrovascular accidents, also referred to as strokes, can result from ischemia secondary to
atherosclerosis, vasculitis, emboli, cerebral hypoperfusion and also as the result of a cerebral
hemorrhage secondary to hypertension, a brain tumor, a ruptured cerebral aneurysm, and cerebral
vascular abnormalities.
Signs and Symptoms: The signs and symptoms of a cerebrovascular accident vary according to the
severity of the cerebrovascular accident and the region of the brain that is adversely affected with
the cerebrovascular accident. Dysphagia, impaired vision, personality changes, unilateral neglect and
impaired urinary elimination can occur as the result of a cerebrovascular accident that adversely
affects the anterior region of the brain; and ataxia, vertigo, nystagmus, diplopia, visual disturbances,
and bilateral or unilateral sensory and motor deficits can occur as the result of a cerebrovascular
accidents that adversely affect the anterior region of the brain; and, brain stem cerebrovascular
accidents are usually accompanied with altered level of consciousness, severe respiratory
compromise, hypoxia, and respiratory arrest.
Interventions and Treatments: Complications are prevented with the administration of thrombolytic
medications within 3 or 4 hours after the symptoms appear when the client has had a thrombolytic
stroke, oxygen supplementation, the control of hypertension with antihypertensive drugs,
anticonvulsant medications such as phenytoin, intubation, and possible mechanical ventilation when
the client indicates the need for these treatments
Complications: Seizures, increased intracranial pressure, post ischemic inflammatory encephalitis and
death.
Meningitis
Brief Description: This life threatening infection leads to the inflammation of the pia layers of the
meninges and the cerebrospinal fluid. There are a number of pathogens that can cause meningitis
including viruses, fungi and bacteria such as neisseria meningitis, haemophilius influenzae,
streptococcus pneumoniae, group B streptococcus, and gram negative pathogens such as
Escherichia coli, serratia and enterobacter
Signs and Symptoms: Classical nuchal rigidity, a decrease in terms of the clients mental status, a
positive Brudzinski sign, a positive Kernig's sign, a fever, headache, a purpural or petechial skin rash,
arching of the back and neck, seizures, photophobia, and bulging fontanels when an infant is
affected with meningitis prior to the closing of these fontanels.
Interventions and Treatments: Seizure precautions, the frequent monitoring of the client's
neurological signs, maintaining a quiet environment, medications such as antipyretics, antibiotics and
intravenous fluids as ordered and the close monitoring of the client's neurological and vital signs.
Complications: Permanent and irreversible cerebral damage and death
Encephalitis
Brief Description: Encephalitis, which is somewhat similar to meningitis, is an inflammation of
cerebral tissue as the result of a virus such as the West Nile virus, herpes simplex, and toxoplasma
and, at times, as the result of post ischemic inflammatory encephalitis after a cerebrovascular
accident.
Signs and Symptoms: Nausea, vomiting, fever, headache, altered neurological functioning, motor
weakness, disorientation, seizures and unusual behavioral changes.
Interventions and Treatments: Seizure precautions, the frequent monitoring of the client's
neurological signs, maintaining a quiet environment, bed rest, increased fluid intake, medications
such as antipyretics and antiviral drugs such as ganciclovir, foscarnet and acyclovir, intravenous fluid
replacements as ordered and monitoring of the client's vital signs.
Complications: Long lasting or permanent changes in terms of the client's personality, muscular
weakness, a lack of fine and/or gross motor coordination, paralysis, fatigue, impaired memory,
impaired hearing, visual deficits, impaired speech, coma and death.
Brain Herniation
Brief Description: The abnormal protrusion and herniation of the brain stem through the foramen
magnum at the base of the skull; this life threatening emergency is typically the result of increased
intracranial pressure which was fully described and discussed in the previous section entitled
"Assisting the Client in Receiving Appropriate End of Life Physical Symptom Management".
Signs and Symptoms: Cushing's reflex, Cheyne Stokes respirations, decorticate or decerebrate
posturing, hypoxia, apnea, and respiratory failure.
Interventions and Treatments: The preservation of life if this is possible, the administration of
anticonvulsant medications to prevent seizure activity, intravenous osmotic diuretics, like mannitol,
to decrease the increased intracranial pressure, corticosteroids to decrease cerebral edema,
anticonvulsant medications to prevent seizures, a planned barbiturate come to decrease the client's
metabolic demands, intubation and mechanical ventilation as indicated
Complications: Permanent brain damage, seizures, coma, respiratory arrest and death.
Subarachnoid Hemorrhage
Brief Description: Hemorrhage and bleeding in the subarachnoid space which is the space between
the brain and the meninges which are the thin tissues surrounding and covering the brain. This
medical emergency occurs as the result of head trauma, a serious bleeding disorder and a bleeding
cerebral aneurysm.
Signs and Symptoms: This medical emergency can be asymptomatic as well as symptomatic and
presenting with signs and symptoms such as a severe, crushing headache which is often referred to
as a thunder clap headache, a sensation of popping in the head, a decreased level of consciousness,
nausea, vomiting, photophobia, a postcoital headache, confusion, irritability, numbness, a stiff neck
and/or back, visual changes such as the development of blind spots, double vision and/or the loss
of vision in one eye, seizures, muscular pain, unequal pupils, and drooped eyelids.
Interventions and Treatments: Bed rest, constipation prevention, the control of hypertension, the
administration of nimodipine to prevent vasospasm, and the correction of the underlying cause such
as the treatment of an aneurysm with a bypass, clip or endovascular coils.
Complications: Chemical meningitis, hydrocephalus, brain edema, vasospasm, coma and death.
Epidural Hematoma
Brief Description: A hematoma and bleeding into the region of the skull between the skull and the
brain and into the dura mater. This emergency medical crisis is usually caused by head trauma and
skull fractures.
Signs and Symptoms: Loss of consciousness, confusion, unilateral pupil dilation, a severe and
crushing headache, nausea, vomiting, seizures, and lethargy
Interventions and Treatments: All interventions to preserve life, to prevent possible complications
and to control the symptoms. Some interventions can include Burr holes in the skull to decrease the
intracranial pressure, a craniotomy, the administration of anticonvulsant medications such as
phenytoin and the administration of hyperosmotic agents such as hypertonic saline, mannitol and
glycerol to reduce the brain swelling.
Complications: Permanent brain damage, brain herniation, paralysis, coma and death
Spinal Cord Injuries
Brief Description: A traumatic injury of the spinal cord which is part of the central nervous system.
The American Spinal Injury Association (ASIA) classifies these injuries from A to E, as based on the
severity of the sensory and motor losses that are sustained by the client.
A grade A spinal cord injury is the most severe of all; all sensory and motor function is lost. In
contrast to the A grade spinal cord injury, grades B, C and D are incomplete injuries. Grade B spinal
cord injuries consists of the loss of motor function at and below the level of the injury but some
sensory functioning, including anal sensation, is preserved; a grade C spinal cord injury reflects the
preservation of some muscular function below the level of the spinal cord injury; a grade D spinal
cord injury is characterized with the preservation of more than 50% of muscular movement at and
below the level of the injury; and a grade E spinal cord injury preserves normal sensory and motor
function.
Spinal cord injuries can also categorized as tetraplegia and paraplegia injuries, which are the loss of
or the impairment of the client's sensory and/or motor function originating at the cervical portion
of the spinal cord which leads to poor or absent functioning of the legs, pelvic organs, arms and
trunk and the pelvic organs and legs and the loss or impairment of, sensory and/or motor function
originating at the thoracic, sacral or lumbar region of the spinal cord.
Lastly, spinal cord injuries are also categorized according to the type of force that was exerted to
produce it and as penetrating and non penetrating. These forces include flexion, extension,
compression and rotation. Penetrating spinal cord injuries, such as those that occur as the result of a
gun shot wound, are serious and unstable because the cerebral neural tissue is lacerated and torn.
Signs and Symptoms: This medical emergency, in addition to the sensory and motor losses discussed
immediately above, these injuries present with different signs and symptoms depending on the level
of the injury and the completeness of the injury; the diaphragm, intercostal muscles and accessory
breathing muscles may be impaired, the arterial blood gases are impaired, respiratory secretions can
accumulate, aspiration, pain, nausea, vomiting, impaired urinary function, paralytic ileus, and
hypothermia can also occur.
Interventions and Treatments: All interventions to preserve life and to prevent any possible
complications such as further spinal cord damage are done. The ABCs, ACLS protocols, intubation,
mechanical ventilation, immobilization and stabilization of the spinal cord using sand bags, head
restraints and a Kendrick Extrication Device (KED) in the field, pain management, a nasogastric
tube to suction and/or antiemetic medication can be used for nausea and vomiting and to avoid
distention and aspiration, the administration of stool softeners and laxatives to prevent autonomic
dysreflexia secondary to constipation and the correction of any hypothermia.
Complications: Spinal neurogenic shock, respiratory distress, respiratory arrest, poikilothermia which
is the body's loss of ability to control and regulate the body temperature, autonomic dysreflexia
which is a life threatening disorder that occurs most often with an over distention of the bowel or
bladder, life threatening hypertension, compensatory bradycardia, all the hazards of immobility, fear
and anxiety, permanent brain damage, seizures, coma and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of musculoskeletal system medical emergencies include
the following.
Skeletal Fractures
Brief Description: The breakage of a bone as the result of some trauma. As discussed in the previous
section entitled "Applying, Maintaining and Removing Orthopedic Devices", some of the several
types of fractures are a greenstick fracture, an avulsion fracture, a comminuted fracture, a transverse
fracture, an oblique fracture, a spiral fracture, an impacted fracture, a compression fracture, an open
fracture and a depressed fracture such as that which may occur when the skull bones are pushed into
the cranial space. Other types of fractures include a stress fracture which occurs among athletes,
stable fractures, unstable fracture which are displaced thereby necessitating reduction, a closed
fracture which is not accompanied with a breakage of the skin at the site, an incomplete fracture
which affects only part of the bone, a complete fracture which adversely affects the entire cross
section of the bone, and a pathological fracture which can occur as the result of a pre existing
disease or disorder such as cancer.
Signs and Symptoms: Abnormal rotation such as occurs when the hip is fractured and the leg on the
affected side externally rotates, shortening of the limb, muscular spasms, crepitus at the site,
deforming angulation, pain, impaired neurological functioning such as cool skin proximate to the
affected area, swelling, ecchymosis at the site, limited or absent muscular movement, impaired skin
integrity and bleeding as may occur with an open fracture, impaired circulation, skin cyanosis and
skin pallor such as occurs when the venous and/or arterial blood flow to the site is impaired and the
area is deprived of adequate perfusion, distal ischemia which is assessed with the 5 Ps of pallor,
paresthesia, pain, polar skin coolness and paralysis, impaired distal pulses, swelling, edema, thrills,
bruits, and poor capillary refill times.
Interventions and Treatments: Pain management, immobilization of the affected limb, elevation of
the affected limb, the application of cold to decrease the swelling, edema, and associated pain,
internal or external fixation, casting, splinting and traction.
Complications: Deformity, compartment syndrome after a casting of a limb, a fat embolism,
neurological and vascular impairments, osteomyelitis with an open compound fracture, and, at times,
lifelong deformity and disability.
Traumatic Amputation
Brief Description: The traumatic loss of a limb or a part of it. Traumatic amputations are classified
as avulsion amputations, crush amputations, and guillotine amputations.
Signs and Symptoms: Pain, bleeding, haemorrhage, and the signs and symptoms of hypovolemic
shock
Interventions and Treatments: The ABCs, ACLS protocols, the maintenance of the client's
hemodynamics, the preservation and care of the amputated body part by keeping it dry and cool
after it is cleaned with sterile saline and placed in a sealed plastic bag in the field and in the
emergency department until surgical interventions are planned and done, the administration of
broad scope antibiotics, surgical reattachment when possible,
Complications: The permanent loss of the limb, infection, neurological and circulatory compromise,
disability, hypovolemic shock, and death
Mangled Limb
Brief Description: The traumatic mangling of an extremity that is classified according to a scale such
as the Mangled Extremity Severity Score (MESS), the Mangled Extremity Syndrome Index (MESI),
the Hannover Fracture Scale, the Predictive Salvage Index, and/or the Limb Salvage Index. These
scoring scales guide decision making in terms of whether or not the limb can be saved or the need to
amputate the affected limb is necessary.
Signs and Symptoms: Pain, fear, anxiety, and altered neurological and circulatory perfusion to the
affected limb
Interventions and Treatments: The salvage, reconstruction and restoration of the limb when
possible, pain management, the prevention of infection, measures to correct any hemorrhage and
hypovolemic shock, immobilization, and the administration of broad scope antibiotics and the
tetanus vaccine.
Complications: The loss of the mangled limb because restoration and reconstruction were not
possible, infections, a planned surgical amputation, disability and possible impaired neurological and
circulatory perfusion to the affected limb
Maternal collapse and cardiopulmonary arrest which was previously discussed and detailed in the
section entitled "Assessing the Maternal Client For Antepartal Complications"
Pulmonary embolus which was previously discussed and detailed in this section
Ectopic pregnancy which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
Preeclampsia and eclampsia which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
Toxic shock syndrome which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
Endometritis which was previously discussed and detailed in the section entitled "Assessing the
Maternal Client For Antepartal Complications"
Salpingitis which was previously discussed and detailed in the section entitled "Assessing the
Maternal Client For Antepartal Complications"
Tubo-Ovarian abscesses which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
Amniotic fluid embolism which is discussed below
Vaginal bleeding which is discussed below
Pelvic inflammatory disease which is discussed below
Ovarian hyperstimulation syndrome which is discussed below
Vaginal Bleeding
Brief Description: Abnormal vaginal bleeding can affect women of all ages. The types of vaginal
bleeding include primary dysmenorrhagia, dysfunctional uterine bleeding, and abnormal uterine
bleeding
Signs and Symptoms: The signs and symptoms of primary dysmenorrhagia are cramping and pain
during menstruation; the signs and symptoms of dysfunctional uterine bleeding are an irregular
menstrual cycle and heavy bleeding during menstruation; and the sign and symptom of abnormal
uterine bleeding is vaginal bleeding that occurs at times other than that which is expected during the
normal menstrual cycle such as after sexual intercourse.
Interventions and Treatments: Primary dysmenorrhagia is treated with an oral contraceptive, a non-
steroidal anti-inflammatory drugs, the application of a heating pad, exercise, acupuncture, hypnosis,
message and/or using transcutaneous electrical nerve stimulation (TENS); dysfunctional uterine
bleeding can be treated, according to its cause, with the administration of oral contraceptives,
estrogen, progestins and desmopressin when the client has a coagulation disorder, a hysterectomy,
and an endometrial ablation.
Complications: Sterility with a hysterectomy, hemorrhage, and hypovolemic shock
Mastoiditis
Brief Description: A serious middle ear infection that adversely affects the mastoid bone
Signs and Symptoms: Tenderness, swelling and redness around the mastoid bone which lies behind
the ear, irritability, severe ear pain, a temperature, pus and other ear drainage, and a displaced pinna
which has been pushed away from the side of the head
Interventions and Treatments: Intravenous antibiotics, a myringotomy, and a mastoidectomy
Complications: The spread of this infection to the brain which can, like meningitis, can be life
threatening, abscess formation, necrosis and permanent hearing loss
Epistaxis
Brief Description: Epistaxis is a nasal hemorrhage that can occur as the result of picking the nose,
trauma, the insertion of a foreign body into the nose, multiple traumas, nasal dryness and the use of
anticoagulant medications.
Signs and Symptoms: Hemodynamic instability and hypovolemia when the hemorrhage is severe,
panic, and fear
Interventions and Treatments: The application of continuous and firm pressure at Little's area just
below the nasal bone for about 15 seconds or more while the client is sitting up with their head
forward, blood vessel cauterization, nasal packing, the placement of a large bore cannula or a
balloon catheter when pressure does not successfully stop the epistaxis
Complications: Infections such as sinusitis and aspiration of and airway obstruction secondary to the
dislodgement and displacement of any nasal packing or catheter
Foreign Bodies in the Nose
Brief Description: A foreign body like a piece of food, a button or a bead that is placed in the nose.
Again, children are at risk for this trauma and other traumas associated with foreign objects being
placed in bodily orifices.
Signs and Symptoms: Unilateral nose drainage which can be bloody and nasal pain
Interventions and Treatments: Having the client blow out the affected nostril while pinching off and
occluding the unaffected nostril, and the careful removal of the foreign body using forceps while
insuring that the foreign body does not get pushed into the nostril any further during this effort, a
Complications: Nasal trauma and bleeding
Globe Rupture
Brief Description: Globe rupture is a highly serious ocular emergency that results from a blunt or
penetrating trauma such as occurs with the entry of a projectile or a knife into the globe. These
traumatic injuries are classified and described as posterior and anterior globe ruptures. Posterior
globe injuries affect the retina, sclera, and vitreous; and anterior globe injuries adversely affect the
cornea, anterior chamber, iris and lens.
Signs and Symptoms: Chemosis, decreased intraocular pressure, pain, conjunctival pigmentation,
impaired eye movement, nausea, diplopia and other visual impairments, a tear drop shaped pupil,
and vitreous hemorrhage
Interventions and Treatments: Patching the unaffected eye is patched to decrease eye movement,
pain management, corticosteroid drugs to decrease the risk of sympathetic ophthalmia, the
avoidance of activities that can dangerously increase intraocular pressure such as heavy lifting,
straining while moving the bowels, coughing, and bending over, and surgical interventions, as
indicated and based on the location and the severity of the trauma, including the surgical enucleation
of the affected eye to prevent sympathetic ophthalmia.
Complications: Enucleation and blindness
Hyphemia
Brief Description: Hyphemia is bleeding into the anterior chamber of the eye between the cornea
and the iris. Hyphemia can occur as the result of external compression of the eye, a blunt trauma,
falls and fist fights as well as from spontaneous, nontraumatic disorder related causes such as
retinoblastoma, neurovascularization, xanthogranuloma which is a pediatric vascular abnormality,
myotonic dystrophy, uveitis, Von Willebrand disease, rubeosis iridis, leukemia, hemophilia, and the
use of anticoagulating medications.
Hyphemia is categorized and classified from a grade of 1 to 4. A grade 1 hyphemia is characterized
with less than one third of the anterior chamber filled with blood; a grade 2 hyphemia is
characterized with the anterior chamber's filling with more than one third but less than two thirds of
the chamber; a grade 3 hyphemia is characterized with more than two thirds of the anterior chamber
filled with blood but not with complete filling; and a grade 4 hyphemia is characterized with the
complete filling of the eye's anterior chamber with blood.
Signs and Symptoms: Light sensitivity, pain, blurry vision, a small pool of blood in the cornea or at
the bottom of the iris, a reddish colored tinge to the eye, and the loss of vision.
Interventions and Treatments: The goals of treatments and interventions include the prevention of
secondary corneal blood staining, decreasing the possibility of any rebleeding within the eye, the
elimination of risks associated with atrophy of the optic nerve and increased intraocular pressure.
Interventions to achieve these goals include pharmacologic interventions to reduce intraocular
pressure, pain management, patching the affected eye, surgical procedures to empty the anterior
chamber of the eye of pooled blood and also prevent possible corneal blood staining.
Complications: Increased intraocular pressure and blindness
Retinal Detachment
Brief Description: Retinal detachments occur when the retina of the eye peels away from its
underlying layer of support tissue. This serious disorder is a medical emergency; irreversible and
permanent vision loss can occur when it evolves and progresses to a complete detachment without
immediate and effective treatment. Retinal detachments are typically unilateral.
Signs and Symptoms: Client complaints of flashing lights, floaters and veiling or curtain effects in
their visual field, photopsia, heaviness in the eye, the loss of central vision, and straight lines
suddenly appear as though they are curved
Interventions and Treatments: Laser surgery or cryotherapy, vitrectomy and the placement of a
scleral buckle to move the wall of the eye against the detached retina.
Complications: Permanent, complete and total blindness
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of oral medical emergencies include the following:
Dental Avulsions
Brief Description: The traumatic loss of a tooth or teeth
Signs and Symptoms: Pain, bleeding and the loss of a tooth or multiple teeth
Interventions and Treatments: Reimplantation of the tooth, immersion of the lost tooth in milk or
normal saline to preserve its viability for reimplantation, and splinting of the oral area around the
reimplantation after the reimplantation of the tooth is successfully accomplished
Complications: The permanent loss of the tooth or teeth
Dental Luxations
Brief Description: Dental luxation injuries are injuries that result in the partial displacement of a
tooth or teeth from its socket.
Signs and Symptoms: Pain, bleeding and the partial loss of a tooth or multiple teeth
Interventions and Treatments: Like dental avulsions, there is no attempt to reposition the deciduous
teeth so these affected deciduous teeth are typically extracted, permanent teeth are treated with
repositioning of the teeth under local anesthesia while using the adjacent teeth as a guide and firm
digital pressure is used for this repositioning and later splinting with glass ionomer cement powder
alone or a combination of glass ionomer cement powder and a fine stabilizing wire.
Complications: The permanent loss of the tooth or teeth
Explaining Emergency Interventions
to the Client
All emergency treatments and interventions should be explained to the client and informed consent
should be obtained except under special circumstances such as when an emergency is occurring and
the client is not mentally competent, alert and conscious enough to do so. Healthcare surrogates and
proxies often make decisions for the client when they are not able to do so. However, when the
client and/or the family are able to receive complete information, at a later time, this complete
information must be given in the same manner that is done with clients who are competent enough
to understand this information and to give informed consent.
Pathophysiology: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of pathophysiology in order to:
Identify pathophysiology related to an acute or chronic condition (e.g., signs and symptoms)
Understand general principles of pathophysiology (e.g., injury and repair, immunity, cellular
structure)
Identifying Pathophysiology Related
to an Acute or Chronic Condition
The pathophysiology of many acute, chronic and emergency disorders and conditions, including
etiologies, risk factors, signs, symptoms, diagnostic findings, complications, and expected outcomes
were discussed throughout this NCLEX RN review.
The incubation stage: The incubation stage begins with the entry of the pathogen into the
host and this stage ends when the signs and symptoms of the infection begin to appear.
The prodromal stage: The prodromal stage begins with the onset of symptoms and this stage
is characterized with the replication and reproduction of the pathogen; and the signs and
symptoms of the prodromal stage include generalized malaise, joint and muscular aches and
pains, anorexia, and the presence of a headache.
The illness stage: The illness stage is the period of time that begins with continuation of the
signs and symptoms and it continues until the symptoms are no longer as serious as they were
before.
The convalescence stage: The convalescence stage is the period of recovery during which time
the symptoms completely disappear. .
The inflammatory process is the naturally occurring protective response of the body to a threat in
terms of tissue damage; this process defends the body against harm, it aims to rid the body of
damaged tissue and it promotes the restoration of normal tissue.
The five classic signs and symptoms of inflammation are:
Pain: Pain occurs with the release of chemicals secondary to the damage of cells and tissues
Redness: Redness results from the vasodilation of blood vessels that occurs in response to the
injury.
Swelling: Swelling occurs as the body's fluids enter the area of the injury and tissue damage.
Heat and warmth: Heat and warmth occur as the result of the vasodilation and the increased
blood flow to the affected area.
Dysfunction of the area: Local dysfunction occurs as the result of the swelling and pain
associated with the inflammatory process.
The lag phase of bacterial growth: The lag phase of bacterial growth consists of the bacteria's
slow growth as it adjusts to its new environment in the human body. The rate of biosynthesis is
high because the bacteria need these proteins for their future period of rapid growth and
replication.
The lag phase of bacterial growth: The lag phase of bacterial growth, which is sometimes
referred to as the exponential phase of bacterial growth, is characterized with a period of rapid
and continuous growth until one or more of the nutrients necessary for this rapid growth is no
longer available to the pathogen.
The stationary stage of bacterial growth: The stationary stage of bacterial growth marks the
end of the bacteria's growth and metabolic activity because all the nutrients for these activities
have been exhausted and depleted.
The death stage of bacterial growth: This stage is characterized with the end of the bacteria's
life because there are no nutrients to sustain it and no metabolic activity.
The attachment stage: The attachment stage consists of the virus' attachment to a receptor on
the host's cellular surface. A limited or low host range in terms of attachment means that some
of these attachments are relatively limited and highly specific to only some receptors; and the
converse is also true, there are pathogens with a wide host range in terms of attachment which
means that the attachments are greater in terms of possibility and not highly specific.
The penetration stage: The penetration stage is marked with the entry of the virus into the
host's cell.
The uncoating stage: The uncoating stage entails the shedding of the virus coating, or its viral
capsid, which now allows the virus to deposit its own nucleic material into the human's host
cells.
The replication stage: The replication stage consists of the duration of time during which the
virus is able to replicate and multiple.
The self-assembly stage: During the self-assembly stage, the virus matures and makes
modifications to its proteins.
The release and lysis stage: During the release and lysis stage the virus is released from the
host cells with lysis and the resulting death of the virus.
Some professional resources refer to the stages of the inflammatory process as the vascular and
cellular response stage, the exudate stage, and the reparative phase of the inflammation process
instead of tissue injury phase, the release of chemicals stage and the final stage of the inflammatory
process, respectively.
The stages of wound healing are the:
The inflammation phase: The inflammation phase, which is also referred to as the lag or
exudate phase, is accompanied with pain, swelling , edema, and the beginning of wound debris
removal with phagocytosis to prevent infection.
The proliferative and granulation phase: The proliferative and granulation phase is
accompanied with the fibroblastic production of granulation tissue and collagen.
The maturation phase: The maturation phase of wound healing is characterized with the
continued development and maturation of the fragile skin over the wound. This phase can last
up to two years during which time the wound remains at risk and vulnerable for injury until full
healing and good tensile strength is complete.
Immunological bodily responses are both innate and adaptive. Innate immunity is the natural,
intrinsic nonspecific immunity mechanisms that protects the body and resists infection with its
physical, cellular, and chemical mechanisms and means. For example, when a pathogen breaks
through the skin or mucus membranes, our first lines of defense, chemical cytokines and other
antimicrobial substances and phagocytic activity prepare the host cells to prevent the pathogen's
entry, colonization, spread and replication.
Adaptive immunity is categorized as active and passive immunity which, simply stated, are the
deliberate or undeliberate exposure to a pathogen and the acquisition of antibodies or activated T
cells in the body, respectively.
Active immunity occurs as the result of our bodily response to the presence of an antigen, with the
development of antibodies. Active immunity can be both natural and artificial. Natural active
immunity occurs when the body produces antibodies after the client is infected with a pathogen; and
artificial active immunity occurs when the body produces antibodies to an immunization vaccine
such as those for pneumonia and a wide variety of childhood infectious diseases.
Passive immunity occurs when an antibody is introduced into the body by either natural or artificial
means. Passive natural immunity occurs when the fetus and neonate receive immunity as a natural
process through the placenta; and passive artificial immunity occurs when the client receives an
injection of immune globulin.
Unexpected Responses to
Therapies: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of unexpected responses to therapies in order to:
Assess the client for unexpected adverse response to therapy (e.g., increased intracranial
pressure, hemorrhage)
Recognize signs and symptoms of complications and intervene appropriately when providing
client care
Promote recovery of the client from unexpected response to therapy (e.g., urinary tract
infection)
Maternal trauma, lacerations, pelvic floor damage, bleeding and an inadvertent extension of the
episiotomy to the anus when a forceps delivery of a new born is done
Tube leakage, improper placement and the dislodgment of a nasogastric or another gastric tube
The punctures of major vessels can occur during a number of surgical interventions, invasive
procedures and some invasive diagnostic tests such as the puncture of the descending aorta
during a major abdominal surgical procedure, during the placement of an epidural catheter for
anesthesia and during a lung biopsy or the placement of a chest tube
The prevention, signs, symptoms and treatments for these inadvertent and accidental and
unexpected responses unexpected responses to therapy and procedures have been discussed
throughout this NCLEX RN review.
Some of the normal and/or relatively commonly occurring, but undesirable, responses to
treatments, therapies, interventions and procedures include:
Healthcare associated infections (HAI) such as ventilated associated pneumonia (VAP), central
line associated blood infections (CLABI), surgical site infections (SSI), ventilator associated
pneumonia (VAP), and catheter associated urinary tract infections (CAUTI) and other infections
such as pneumonia which can occur simply as the result of infections spread in facilities and
institutions that have many clients with multiple infections and the infectious complications of
intravenous catheters
The undesirable side effects, complications and adverse responses to medications and fluid
administration
The prevention, signs, symptoms and treatments for these unexpected responses to various other
treatments, therapies, interventions and procedures have been discussed throughout this NCLEX
RN review.