RN Fundamentals of Nursing

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About the Authors

BOBBIE BERKOWITZ, PHD, RN, CNAA, FAAN, is a professor and the chair of the University of Washington School of Nursing, Department of Psychosocial and Community Health. She is also the director of the Turning Point National Program office. Dr. Berkowitz received her masters degree from the University of Washington and her PhD in Nursing Science with Executive Focus from Case Western Reserve University. She is on the board of directors for the Public Health Foundation and PROWest. She is a consultant for the University of Nebraska Medical Center College of Nursing and a reviewer for Prentice Hall Health and the Health Career Awards Program, Social Sciences and Humanities Research Council of Canada. Dr. Berkowitzs recent publications have appeared in Washington Public Health and the Journal of Public Health Management and Practice. She has a chapter in the book Public Health Informatics and Information Systems: A Contributed Work and wrote Using Informatics Systems to Build Capacity: A Public Health Improvement Toolbox.
SHARON FISH MOONEY, RN, MSN, PHD, is an affiliate faculty member for distance nursing education at Regis University in Denver, Colorado, and Indiana Wesleyan University in Marion, Indiana. She teaches nursing courses in research and gerontology. She has worked as a research nurse with the University of Colorado Health Sciences Center, Center on Aging Research, and as an adjunct faculty member for parish nursing at McMaster Divinity College in Hamilton, Ontario, Canada. Dr. Mooney received her BSN from Alfred University and her MSN and Ph.D. from the University of Rochester. She has coauthored both Spiritual Care: The Nurses Role and Instruments to Measure Aspects of Spirituality in Instruments for Clinical Health-Care Research and is the author of two books, Alzheimers: Caring for Your Loved One, Caring for Yourself, and Quiet Moments for Nurses. Recent articles on developing a ministry of memory for persons with dementia are published in the Journal of Christian Nursing and the Journal of Long-Term Home Health Care. She is a contributing author for the Christian Research Journal on issues related to worldviews and alternative and complementary therapies. She teaches workshops and is a conference speaker on aging and spirituality, alternative health care modalities, parish nursing, and philosophical and theoretical frameworks of nursing.
MARIANNE FRASER, MSN, teaches community health nursing as an assistant professor (clinical) at the University of Utahs College of Nursing. She currently holds bachelors level clinical certification in community health from the American Nurses Association and is a member of Sigma Theta Tau International Nursing Honor Society. She received her bachelors degree in nursing in 1972 from the University of Utah and her masters degree from the University of Washington in 1977. She has also served as an assistant professor of community health at the University of Arizona. Her past publications include The Development of an Educational Support Group for Families of Children with Seizure Disorders in Epilepsia, studies on coal miners in Utah Historical Quarterly
and Utah History, and Community Health Nursing: A Specialty Area for the 21st Century in Excellence. Marianne Fraser has served as a regional patient education coordinator for the VA Hospital System, a project coordinator for the Merck Drug Research Project, and a data collector for the Robert Wood Johnson National Rehabilitation Alternatives Study. She has also worked as a weekend case manager for IHC-LDS Hospital in Salt Lake City, Utah.
PATRICIA A. JAMERSON, PHD, RNC, has served as an assistant professor at the University of Missouri-St. Louis College of Nursing. She received her BSN from the University of Illinois and her MSN from St. Louis University. She earned her doctorate in nursing in 1998 from the University of Kansas. She was awarded a Jean Johnson Research Award in 1996 and is a member of AWHONN, Sigma Theta Tau, and the Midwest Nursing Research Society. Jamerson also has NCC certification in neonatal intensive care nursing. Jamerson has published articles in journals and contributed chapters to numerous nursing textbooks, including Fundamentals of Nursing and Nursing Care of Infants and Children. She is a coauthor of (among other titles) Nursing Leadership and Management in Action.
MARY ANN LAVIN, SCD, is an associate professor at Saint Louis University School of Nursing in Saint Louis, Missouri. She received her post-masters ANP from Saint Louis University School of Nursing. She currently holds ANP recognition and an RN license from the Missouri State Board of Nursing. Previously, she served as an adult nurse practitioner for the HOPE Consortium (Rural Health Outreach Demonstration Program) in Washington County, Missouri, and a research associate at Washington University School of Medicine in Saint Louis. She has also been an assistant professor at Catholic University of Quito, Ecuador, and a community health nurse in La Paz, Bolivia. Her published work includes Advanced Practice and the Use of Nursing Diagnoses in Rantz, M. and LeMone in Classification of Nursing Diagnoses: Proceedings of the 13th Conference of NANDA, and she is the primary author of Interdisciplinary Health Professional Education: A Historical Review in Advances in Health Sciences Education. Other publications include work in Journal of Allied Health and American Journal of Maternal-Child Nursing and the prologue to the third edition of Diagnosticos Enfermeros. Dr. Lavin is currently working as Principal Investigator on the Community and University Partnership in Promoting Health and Health Profession Education as part of a $25,000 award from the Group Health Foundation.
TABLE OF CONTENTS
UNIT I: THEORY AND FOUNDATIONS CHAPTER 1: THE NURSING PROCESS CHAPTER 2: PRINCIPLES OF TEACHING AND LEARNING CHAPTER 3: THEORETICAL MODELS OF HEALTH, WELLNESS, AND ILLNESS CHAPTER 4: THE LAW AND NURSE AND PATIENT RIGHTS AND RESPONSIBILITIES UNIT II: PRINCIPLES OF BASIC CARE AND COMFORT CHAPTER 5: PAIN AND PAIN MANAGEMENT CHAPTER 6: REST AND SLEEP CHAPTER 7: CARING FOR PATIENTS WITH CANCER UNIT III: PRINCIPLES OF NUTRITION CHAPTER 8: CONCEPTS AND COMPONENTS OF NUTRITION CHAPTER 9: COMMON NUTRITIONAL DISTURBANCES CHAPTER 10: ASSESSMENT OF AND DIAGNOSTIC TESTS FOR NUTRITIONAL HEALTH CHAPTER 11: INTERVENTIONS FOR PROMOTING, MAINTAINING, AND RESTORING NUTRITIONAL HEALTH CHAPTER 12: APPLYING THE NURSING PROCESS TO MEET BASIC NUTRITIONAL NEEDS UNIT IV: SAFETY AND INFECTION CONTROL CHAPTER 13: THEORETICAL FRAMEWORKS USED AS THE BASIS OF CARE TO ENSURE ENVIRONMENTAL SAFETY CHAPTER 14: THE NURSING PROCESS RELATED TO INJURY PREVENTION CHAPTER 15: THEORETICAL FRAMEWORKS UNDERLYING PRINCIPLES OF BIOLOGICAL SAFETY CHAPTER 16: THE NURSING PROCESS AND BIOLOGICAL SAFETY REFERENCES
Pediatric Text Icons

Take note of the special pediatric information throughout the series. Pediatric patients often have different symptoms, require different diagnostic exams, and have different needs than adult patients. Throughout the books, the pediatric symbol (pictured below) will indicate new information that applies only to pediatric patients. You will be expected to know how nursing care treatments differ across age groups on the NCLEX examination. Be sure to note these special pediatric sections as you study. Please note that when the icon is found adjacent to a chapter title, it means that all of the information in the chapter pertains to the pediatric population. Similarly, when the icon is found adjacent to the title of a specific section within a chapter, it applies to all (or most) of the content in that section. Pediatric Symbol
UNIT I: THEORY AND FOUNDATIONS

Chapter 1: The Nursing Process
Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Describe the nursing process and its specific components or steps. Describe the various types of nursing assessments. Differentiate between primary, secondary, baseline, subjective, and objective data. Explain the subject matter of a nursing diagnosis and its various components. Explain the ANA standards for nursing outcomes. Discuss the attributes of a nursing plan of care. Explain the relationship of nursing goals to expected outcomes. Discuss the purpose of nursing interventions. Explain the ANA standards of care for implementing interventions. Explain the focus of an evaluation assessment. Describe the techniques used to assess the neurological system. Describe the techniques used to assess the respiratory system. Describe the techniques used to assess the cardiovascular system. Describe the techniques used in an abdominal assessment. Compare activities of daily living (ADL) to instrumental activities of daily living (IADL). Explain techniques for testing orientation and memory in a mental status assessment.
Key Terms
activities of daily living (ADL) assessment auscultation baseline data diagnosis evaluation expected outcomes focused health assessment Glasgow coma scale goals implementation initial nursing assessment inspection instrumental activities of daily living (IADL) nursing nursing process objective data palpation percussion planning practice of nursing primary data secondary data subjective data
Introduction
This chapter discusses the foundation for professional nursing practicethe nursing process. The nursing process framework provides the structure for the unique combination of knowledge, skills, and caring that constitutes the art and science of nursing. We begin our discussion by defining the steps in the nursing process and analyzing the American Nurses Associations definition of each component. We consider the first component, the nursing assessment, and then look at the attributes of a focused nursing assessment and the difference between primary, secondary, and baseline data sources. We also differentiate between two important primary, patient-derived information sources: subjective data and objective data. Our discussion then turns to the components of the second part of the nursing process, the nursing diagnosis. From there, we move into a detailed discussion of the planning phase and consider such issues as identifying patient goals and outcomes, the ANA Standards of Care for Outcome Identification and Planning, and the qualities of nursing goals. We analyze expected outcomes that are included in the goal statements and look at ordering nursing interventions. We then discuss implementing nursing interventions and the ANA Standards of Care on Implementation. Finally, we examine the last phase of the nursing processevaluationin which we describe assessments of the neurological, respiratory, and cardiovascular systems, the abdomen, and mental status.
Definition of the Nursing Process

According to the American Nurses Association Social Policy Statement (2003), nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations. Effective nursing employs the nursing process, which is a systematic method of assessing, diagnosing and identifying outcomes, planning, implementing, and evaluating the care required by any patient in any setting. Nurses use the nursing process in the care of all patients in all settings. This nursing process is a clinical framework and the means by which the majority of the Nurse Practice Acts in the United States define the practice of nursing. In fact, each standard of the American Nurses Association is an elaboration upon a step in the nursing process. The American Nurses Association definitions of each of the component parts of or steps in the nursing process are presented in Table 1.1.
Table 1.1 The Nursing Process

Assessment Assessment is a systematic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client. Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional ability, developmental, economic, and lifestyle. Diagnosis is a clinical judgment about the clients response to actual or potential health conditions or needs. The diagnosis provides the basis for determination of expected outcomes that are individualized to the patients needs or circumstances. A plan of care is a comprehensive outline of care to be delivered to attain expected outcomes. Implementation may include any or all of these activities: intervening, delegating, and coordinating. The client, significant others, or health care providers may be designated to implement interventions within the plan of care. Evaluation is the process of determining both the clients progress toward attaining expected outcomes and the effectiveness of nursing care.
Diagnosis (Outcomes Identification) Planning Implementation
Evaluation
The components of the nursing process relate to each other in a cyclical, dynamic, and patient-centered manner. Figure 1.1 The Components of the Nursing Process
The process is cyclical because each component of the nursing process naturally flows into the next. The process is dynamic because it changes as the patients clinical status improves or worsens. The process is patient centered in several ways: The patient is the chief collaborator with the nurse throughout the process. The patient is the main source of the data collected and assessed. Patient responses are the substance of nursing diagnoses. Expected outcomes guide planning. The nurse prescribes the strategies implemented for each patient.
The nurse evaluates care on the basis of the outcomes attained. Evaluation data feed into ongoing assessment, and the cycle continues.
Assessment
Types of Assessment An initial nursing assessment is performed upon admission of a patient to a hospital or extended care facility or upon a first encounter with a patient in a home or primary care setting. An initial assessment includes a nursing history, including a review of systems. An initial assessment may also include a complete physical health examination, which includes checking vital signs, general appearance, mental status, skin, hair, nails, head, eyes and vision, ears and hearing, nose, nasal passages, and sinuses, mouth and oropharynx, neck, thorax and lungs, heart, peripheral perfusion, breast and axillae, abdomen, musculoskeletal system, neurological system, female genitalia and inguinal lymph nodes, male genitalia and inguinal lymph nodes, anus, and rectum. The performance of an initial assessment depends upon the policies of the agency, the patients presenting needs and condition, and the nurses clinical judgment. Performing selected portions of the history and examination is called a focused health assessment. Assessment techniques focusing on the abdomen and the neurological, respiratory, and the cardiovascular systems are presented below. A focused health assessment is performed when: A patient complains of a new or changed symptom (e.g., new onset of pain or an increase in its severity) A new or changed sign occurs (e.g., observable behavior change or a change in color, blood pressure, heart rate, respiratory rate, temperature, level of consciousness, nausea/vomiting, or intake/output) Laboratory, telemetry, electrocardiogram, or x-ray results indicate a change in the patients health status A new or changed nursing diagnosis is being considered A particular diagnosis requires the frequent assessment of repeated measures, monitoring, or vigilance Focused assessments are one of the primary tools by which nurses nurture and sustain life and contribute to the success of the health care team. Data Data is another word for information. Data that the nurse derives directly from interaction with the patient is called primary data and is either subjective or objective data. Data derived from all other sources is called secondary data. The sum of all primary and secondary information collected on any one patient is called the patient database.
Baseline data is another term frequently used in nursing. It refers to the data taken at the time of the first encounter. For example, a patients admission weight is called the baseline weight and serves as a marker against which future weights may be compared.
Primary, Patient-Derived Data
Whether a complete or a focused health assessment is being performed, the nurse collects both subjective and objective data. Symptoms are frequently defined as reports of subjective patient experiences. For example, nausea is a subjective experience or symptom that cannot be objectively observed or verified. Thus, subjective data relies on a conscious patient providing a narrative statement or report, such as, I feel nauseated. Signs or observations made directly by the nurse that are capable of being verified by another are called objective data. Thus, cyanosis is a sign that a nurse observes that can be objectively verified by another. Objective data may also include diagnostic report data such as laboratory blood values, radiography, and culture and sensitivity results from urine, stool, or sputum specimens.
Secondary Data
Data that is not derived from the patient directly is called secondary data. Sources of secondary data are the patients family and friends; other nurses and health professionals on the patients health care team; the clinical record, including laboratory reports and reports of the results of diagnostic procedures; and relevant literature (such as published protocols, standards, guidelines, classification manuals, reference manuals, or articles) related to the patients condition.
Nursing Diagnosis
Definition of Nursing Diagnosis Diagnoses flow from (are derived from) assessment. Diagnoses are also conclusions drawn from an analysis of the assessment data, clinical inferences made on the basis of assessment, or clinical judgments the nurse makes after assessing the patient. The subject of the nursing diagnosis may be a patient, family, or community. An example of a patient-focused nursing diagnosis is body image disturbance. An example of a family-focused nursing diagnosis is ineffective family coping. An example of a community-focused nursing diagnosis is ineffective community management of a therapeutic regimen. The latter might occur when a community does not have the resources it needs to manage a public health problem, such as tuberculosis. The subject matter of the diagnosis may be a health problem or a life process. Examples of diagnoses that represent health problems are constipation, risk for fluid volume deficit, impaired bed mobility, and impaired social interaction. Examples of diagnoses that focus on life processes are impaired home maintenance management, altered family processes (alcoholism), and anticipatory grieving. The nursing diagnosis directs the planning of
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patient goals and the selection of appropriate nursing interventions designed to achieve outcomes for which the nurse is accountable. Diagnoses require validation. Often, it is the patient who validates the diagnosis. For example, before making a diagnosis that the patient is grieving, the registered nurse validates this diagnosis with the patient. Sometimes, it is the family that validates the diagnosis. For example, the nurse may be thinking that a family with three children in high school is ready for developing enhanced parenting skills. Before inviting a parent to attend a series of classes on the modern teenagers and parenting strategies, the nurse validates the readiness diagnosis first. The nurse may say, In my interactions with you, I get the impression that you are interested in learning new parenting strategies. Is that so? Diagnoses may also be validated with colleagues. For example, a nurse indicates during the report, I think the patient may be experiencing some decisional conflict about being discharged home. Would you assess the patient and see if you agree? Validation of diagnoses with patients, families, and even colleagues does not mean that the registered nurse suspends clinical judgment. A patient taking a drug that is hepatotoxic may attribute the experience of fatigue to stress, while the nurse suspects that the fatigue is related to drug therapy. Acquiescing to the patients hunch is not validating the diagnosis. The diagnosis that is of a higher priority is a drug-related fatigue, and steps need to be taken to ensure that liver function tests are obtained as soon as possible. This case requires laboratory validation and collaboration with the physician. If the liver function tests are negative, then the nurse may proceed with a diagnosis of fatigue related to sleep deprivation. This does not mean that the nurse avoids the complaint of stress. This complaint may be addressed even as the laboratory tests are being obtained. It is possible for patients to have two diagnosesstress as well as fatigue related to hepatoxic effects of drug therapy. This example points out the necessity for validating nursing diagnoses. Components of the Nursing Diagnosis A nursing diagnosis consists of a diagnostic label, the definition of the diagnosis, and its defining characteristics, related factors, and risk factors. The diagnostic label is the name of the diagnosis. Each diagnosis has its own definition. Definitions capture the meaning of the diagnosis and differentiate one diagnosis from another. Outcomes Identification The criteria established for the ANA Standard of Practice (ANA, 2003) on outcomes identification provides an excellent method of organizing study content.
Formulating Outcomes
When formulating outcomes, the registered nurse consults with patients with ineffective management of the therapeutic regimen and their families. The nurse may need to meet with both the patient and family so that mutually agreed upon outcomes can be achieved. Without this meeting, the patients therapeutic management is not likely to improve.
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Fundamentals of Nursing
When formulating outcomes, it is often necessary to obtain the cooperation of other health care providers on the team, such as nurses, physicians, social workers, or others. Sometimes, the outcomes will need to be reformulated; other times, they will just need to be communicated. Again, the likelihood of the desired outcome being attained is greater when all members of the team are working together. On the other hand, sometimes it is not possible to consult with others, and outcomes will need to be formulated independently. For example, if, on a home visit, a nurse finds that a patients breathing is ineffective, then the nurse is responsible for setting in motion interventions needed to achieve effective breathing. These interventions can include keeping the patient calm, calling 911, maintaining an airway, and initiating resuscitation, if needed. The point in each of these examples, however, is that the nurse knows and formulates outcomes that are specific to the diagnosis with which the patient presents.
Develops Expected Outcomes that are Culturally Appropriate
There are many ways in which outcomes may be achieved. For example, if the outcome is that the patient with diabetes will achieve better blood sugar control, there is no single diet plan that will accomplish this for all patients. Patients from the Mideast will achieve blood sugar control using a diet that is different than someone whose heritage is traced back to Northern Europe or to South America or to Asia. The nurse must keep cultural differences in mind when developing patient outcomes and planning methods of attaining those outcomes.
Considers Risks, Benefits, Costs, Evidence, and Clinical Expertise when Formulating Outcomes
An outcome may be that the patient on a mechanical ventilator will not aspirate. To accomplish this outcome, it is best to keep the head of the bed elevated between 30 to 45 degrees. However, this cannot be done if the patient has a spinal injury. Does the outcome change, therefore? Perhaps. It may be more realistic to establish an outcome that risk for aspiration will reduce. To accomplish this outcome, multiple factors that play into risk for aspiration will have to be considered, such as location of the feeding tube in the gastrointestinal tract, end gastric volume, volume of feedings, location, and oral hygiene. For the single diagnosis of risk for aspiration, therefore, there may be multiple parameters identified, each of which decreases or reduces the risk for aspiration. Therefore, the outcome is not that the patient will not aspirate but that the risk for aspiration will be reduced. It should be apparent from this example that the evidence underlying the relationship between gastric tube placement, end gastric volume, volume of feedings, and oral hygiene needs to be explored and applied in practice. It should also be apparent that the clinical expertise of the registered nurse comes into play as well. A registered nurse who is a novice will need assistance not only in formulating such diagnoses but also help in developing a plan to achieve their attainment.
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Ensures that Outcomes are Consistent with the Patients Values, Beliefs, and Environment and Considers the Ethical Implications of the Outcomes
These criteria are similar to those that discuss the need for outcomes that are culturally sensitive. In addition, it seems appropriate to add that outcomes also need to be consistent with the patients financial situation. Sometimes, when outcomes are formulated with the patient, the patient will simply say something like, I dont walk just for the sake of walking. Therefore, there is no point in saying in three weeks I will be walking eight blocks, because I wont. Obviously, the patient does not value walking just to walk. Another outcome will need to be explored that is consistent with the patients values. This holds true for the patients belief system as well. Environment is also an important factor. In the case of the walking example, sometimes the environment is not conducive to its attainment. For example, walking outdoors is not an achievable outcome when there are no sidewalks and the patient would have to walk in the streets. It is perhaps an achievable outcome, but the risks of being hit by a car outweigh the benefits of walking in the street. These are examples of considerations that need to be made when addressing outcomes identification.
Develops a Time Plan Within Which the Outcomes are Expected to Occur
Outcomes are expected to occur within a specified period of time. Sometimes the time period is quite short, as in the reestablishment of an effective breathing pattern. Sometimes, the time frame is considerably longer, for example, the time frame needed to lose thirty pounds. The point is, however, that a timeframe needs to be established.
Modifies Outcomes on the Basis of Changes in the Patients Condition or Situation
Sometimes outcomes are changed minute by minute, as in the case of critically ill patients in intensive care units. On the other hand, sometimes outcomes are achieved over a period of days, weeks, or months. The point is that outcomes, once identified, are not static; they are dynamic and require ongoing evaluation as to their appropriateness for the patients present condition.
Documents Outcomes as Measurable Goals
Although this seems to be a clear-cut criteria, nurses sometimes indicate that they have difficulty documenting outcomes. Remember, outcomes are diagnostic-specific. Therefore, for any one diagnosis, the expected outcomes may simply be bulleted in the patients health record. Lets say that the patient has a diagnosis of health-seeking behavior and wants to know more about what screening procedures are recommended. Documentation may be as simple as: Patient exhibits health-seeking behavior. Mutually agreed upon disease prevention activities to be achieved over the next six months follow. Patient will: Obtain PSA in the next month Obtain a lipid panel in the next three months Measure weight weekly
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Achieve a 10 lb weight loss over the next six months Engage in a daily exercise program of 30 minutes
Note that these goals are patient-centered, future-oriented, and action/direction-oriented. Because goals are patient-centered, they are always expressed in terms of patient goals to be achieved and not in terms of the nurses work goals. Because patient goals are futureoriented, they are expressed in the future tense, usually by using the verb will. Because goals are action-oriented, verbs that express an action or a behavior (such as achieve, maintain, walk, and cough) are used to refer to these goals. Goals include modifiers when a modifier is needed. If a patient with impaired mobility has the goal patient will walk with assistance, then the phrase with assistance is a modifier. Patient goals do not refer to a to-do list for the nurse. Empty the drainage bottle is what the nurse will do or have a nursing assistant do. It is not a patient goal. Patient goals are not statements of what treatments are to be performed. Thus, a statement such as patient will be turned every two hours is not a patient goal. It is a nursing strategy or an intervention that a nurse or nurse assistant will be employing. A goal using the word will in the passive tense (e.g., the patient will be taken to surgery) is not a patient goal. A patient goal uses the word will in the active tense. Thus, the patient will maintain a heart rate between 60100/minute is a patient goal. Another example of a patient goal is the patient will correctly administer insulin prior to discharge.
ANA Standard of Practice on Outcomes Identification The Registered Nurse Identifies Expected Outcomes for a Plan Individualized for the Patient or Situation
Each of the above divisions refers to a criteria established by the ANA (2003) to measure whether or not the practice of the registered nurse is in accord with the standard on outcomes identification. As such, each of the headings may be used in the evaluation of ones own practice in this regard.
Planning
Plans Prescribe Strategies to Achieve Expected Outcomes All plans share common characteristics. Plans specify nursing strategies used to achieve patient outcomes. The ANA speaks of these activities in its Standards of Practice (ANA, 2003). Prescribing Nursing Strategies Once patient goals and outcomes have been identified, appropriate and diagnosis-specific nursing strategies are selected and prescribed. Nursing strategies must be written precisely. It is not sufficient to write maintain adequate oral intake. Instead, write distribute oral intake over twenty-four hours so that patient receives 1200 ml between 07001500; 1000 ml between 15002300; and 500
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ml between 23000700. Such documentation is necessary as a reference for other health professionals involved in the care of the patient, as a legal record, and as evidence that standards have been met. Characteristics of the Plan Nursing plans need to: Be individualized for each patient or situation, age-appropriate, and culturally appropriate Be developed in conjunction with the patient and family when appropriate Be diagnostic-specific, with a set of strategies written for each diagnosis Provide for continuity of care Include a pathway or a timeline for goal achievement Prioritize diagnoses and related strategies appropriately Available for communication with and use by other members of the professional nursing and interprofessional health care team Integrate current trends, research, and evidence-based practice Take into consideration the economic impact of the plan Rely on standardized language for documentation purposes
These characteristics represent the criteria that the ANA has established for its Standard of Practice on Planning, that is: The Registered Nurse Develops a Plan that Prescribes Strategies and Alternatives to Attain Expected Outcomes (ANA, 2003). Coordinating Nursing and Medical Plans For the patient to become well as quickly as possible, both medical and nursing treatments need to be effective. Effective medical treatment has a positive impact on nursing outcomes; effective nursing treatment has a positive impact on medical outcomes. This aspect is described more thoroughly under implementation. Discharge Planning Discharge planning: Begins at the time of the patients admission to a nursing unit Involves the active participation of the patient and the patients family or friends Is facilitated by an interdisciplinary team approach Requires teaching so that the patient or the patients primary caregiver is capable of therapeutically managing post-discharge care
To accomplish the teaching requirement, the nurse has as an objective that the patient or caregiver at the time of discharge will know how to do the following tasks: Accomplish activities of daily living Implement appropriate disease prevention and health promotion strategies
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Administer medication safely Perform needed procedures safely Use specialized equipment correctly Evaluate signs of progress Detect complications or any undesired sequelae Make return appointments for follow-up care Obtain emergency treatment, if needed
Types of Plans
Handwritten Care Plans
The traditional care plan is handwritten onto a Kardex, which includes the following information: Patient identification and background information (such as allergies, likes, dislikes) Listing of patient problems or diagnoses Listing of problem or diagnosis-specific interventions
Kardex information is updated as the patients condition and related interventions change.
Standardized Care Plans
Standardized care plans refer to preprinted plans that accomplish the following guidelines: Are specific for particular diagnoses Allow for additions or deletions to accommodate the standards and policies of the agency in which the nurse is working Use a nursing process format Provide space for the nurse to tailor the standardized plan to the individual needs of the patient Are included in the patients chart
Electronic Care Plans
Electronic care plans remain in an early stage of development. Some systems are CDROM based, while others are web-based. Preferred systems are password protected, secure, and interoperable. These systems allow plans to be shared across departments or units within hospitals when patients are transferred. These systems can also be available to home health or other health care agencies when proper statutory and legal guidelines have been met. Entry is by means of the nursing diagnosis, which is selected from drop-down menus. At that point, some systems rely on standardized care plans specific to that diagnosis. Other systems allow the user to create an individualized plan from a drop-down list of nursing
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activities or strategies. Outcomes may be standardized (that is, the type of outcome is preselected and included in the care plan) or non-preselected. This allows the nurse to select an outcome from the drop-down list. Preferred systems also allow for the care plan and electronic reports of patient progress to be incorporated into a patients electronic health record. Finally, preferred systems allow for narrative input by the nurse. The rationale is that while vocabulary can be standardized, care must remain individualized. Opportunity to provide narrative input provides flexibility in individualizing care. Regardless of the electronic record used within a health care system, it is imperative that nursing documentation is included and stored. This allows for retrieval for patient care and professional and legal purposes. Finally, any electronic care plan needs to have electronic access to a clinical information database available. Additionally, the ANA Nursing Information and Dataset Evaluation Center recommends that Specific principles, standards, policies, procedures, and processes are part of any documentation system and help present the content in meaningful ways (2007). Policies, Protocols, Procedures, and Standing Orders Policies are written instructions designed to address a commonly occurring problem in an institutionally approved manner, e.g., infection control policies to prevent infection spread. Protocols are institutionally approved, preprinted instructions governing interventions or actions to be taken in the care of groups of patients with particular problems, e.g., protocols governing wound care. Procedures are institutionally approved, preprinted, detailed instructions on how to perform specific clinical tasks, e.g., placement of nasogastric tubes. Standing orders are institutionally and departmentally approved instructions granting the nurse the authority to act in the absence of a physician, e.g., standing orders authorizing coronary care nurses to administer antiarrhythmic medication.
Implementation
The plan is the vehicle by which care is coordinated. It consists primarily of implementing nursing strategies, which is the next step in the nursing process. The purposes of nursing strategies are to achieve the following objectives: Manage health problems or nursing diagnoses Provide patient information and instructional needs related to the patients health problem Tailor health-promotion and disease-prevention strategies Address continuity-of-care issues such as referring the patient to appropriate patient care and community resources
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ANA Standard of Practice on Implementation: The Registered Nurse Implements the Identified Plan The criteria established to measure the attainment of this standard are expressed as the following questions: Is the plan implemented in a safe and timely manner? Are the plan and any modifications documented? Is the plan evidence-based, and are the interventions or treatment diagnosticspecific? 4. Does the plan incorporate the use of community resources or systems? 5. Does the registered nurse collaborate with nursing colleagues and others in implementing the plan? (ANA, 2003) Steps in Implementing Interventions 1. 2. Conduct nursing rounds, and reassess the patients need for an intervention. Determine the amount of assistance needed to implement the intervention in a way that minimizes patient discomfort, maximizes patient safety (includes using reference and other resource material), and decreases worker strain (as in turning an unconscious, 250-pound patient). When implementing an intervention, gather needed equipment or supplies, check the identity of the patient, provide for patient privacy, explain the intervention, elicit the patients cooperation/consent, organize any needed equipment and supplies in a suitable manner, use universal precautions when indicated, perform the specific nursing action and explain the process to the patient, begin to teach the procedure to the patient if the patient will eventually bear responsibility for its implementation, observe the patients response during and after the action is performed, assist the patient in becoming comfortable, and be sure the patient has access to call buttons in a hospital situation. In a community setting, be sure the patient has access to telephone or beeper numbers. Document the intervention and the patients response during and after implementation. Consult as needed with other health professionals. This is especially true with medically ordered interventions in which the patients condition has changed, indicating a needed change in the order, or if the patient had an untoward response to the intervention. 1. 2. 3.
3.
4. 5.
Each of the above steps is intended to ensure that interventions are implemented safely and in a manner that respects the dignity and individuality of the patient.
Evaluation
Evaluation involves assessment of the patients responses to care received, including progress made toward the anticipated outcomes or goals set during the planning stage. It
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also focuses on the effectiveness of nursing interventions utilized to meet those goals. If a goal set in the planning stage of the nursing process stated, the patient will correctly administer his own insulin prior to discharge, evaluation would include an assessment of whether or not this goal was met. ANA Standard of Care on Evaluation: The Nurse Evaluates Progress Toward Attainment of Outcomes The measurement includes the following criteria: Evaluation is systematic, ongoing, and criterion-based Patient, family, and other health care providers are involved in the evaluation process, as appropriate Effectiveness of interventions is evaluated in relation to outcomes Results of the evaluation are documented Ongoing assessment data are used to revise diagnoses, outcomes, and the plan of care, as needed Appropriately disseminates results to patients, family, and other providers involved in care (ANA, 2003) Comparing Expected and Obtained Outcomes When comparing the expected outcomes with the obtained outcomes, choose one of the following decision paths: 1. If the expected outcomes were obtained, continue with the same nursing interventions if indicated, adapt the nursing interventions to adjust to the current clinical situation, or discontinue nursing interventions that are no longer needed. For example, a patient is assessed as having acute pain with a rating of 8 on a 10 point pain scale. The diagnosis is acute pain. An analgesic is given for pain. How is the effectiveness of the analgesic to be evaluated? The answer is that the nurse asks the patient after the medication has had time to take effect how much pain is now experienced on a scale of 1 to 10. If the patient answers 2, pain relief (expected outcome) has been achieved. If the patient answers 7 or higher, no pain relief has been obtained; a different strategy or an adjunct strategy needs to be employed. If the expected outcomes were not obtained, ensure the measure is reliable. In the case of the question about pain, we can assume reliability. There are other instruments, however, that may not measure reliably one moment to the next. When evaluating patients, be sure to notice any related changes in the patients condition. Any changes require reassessment.
2.
Most patient outcomes in a hospital setting are evaluated in an ongoing manner at specified time intervals, e.g., every two hours, every four hours, or once each shift. Some
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outcomes, such as heart rhythms, are evaluated continuously by telemetry. Evaluation of outcomes may occur intermittently. For example, in hospital settings, outcomes related to wound care might be evaluated every other day or every third day, depending on how the order is written. In a community setting, outcomes (e.g., those related to compliance with lead poisoning prevention strategies) may be evaluated on a weekly or monthly basis. Evaluation of outcomes also occurs prior to the discharge of a patient from the hospital or prior to a case being closed in a community setting.
Techniques for Physical Assessment of the Major Body Systems

In this section we will be concentrating on a review of techniques used in the physical assessment of the neurological, respiratory, and cardiovascular systems and of the abdomen. The Neurological System Techniques used in the physical assessment of the neurological system include assessments of the cranial nerves, deep tendon reflexes, sensory and motor function, and level of consciousness. We will start with an assessment of the cranial nerves, moving in a head-to-toe or top-to-bottom direction. The specific nerve tested is listed in brackets.
Cranial Nerves
Inspect the forehead for alignment of the eyebrows and the patients ability to wrinkle the forehead and raise the eyebrows first in general and then symmetrically [cranial nerve V, trigeminal branch to the forehead, and cranial nerve VII, facial]. Inspect the eyelids for ptosis or drooping, bilaterally or unilaterally. There should be no drooping [cranial nerve III, oculomotor]. Inspect the eyes for visual acuity using the Snellen chartnormal vision is 20/20. Covering one of the patients eyes, assess peripheral vision in the uncovered eye by testing the visual fields [cranial nerve II, optic]. Normally, a person sees objects in the periphery. Ask if there is any double vision [cranial nerve VI, abducens]. Normally there is none. Assess the pupils for equality and reaction to light and accommodation [cranial nerve III, oculomotor]. Normally, pupils are equal and reactive to light and accommodation. Assess eye movement in all six directions, with upward and outward movement being controlled by cranial nerve IV [trochlear], outward movement controlled by cranial nerve VI [abducens], and downward movement controlled by cranial nerve III [oculomotor]. Normally, eyes move symmetrically in all directions. While inspecting for symmetry, ask the patient to close eyelids tightly [cranial nerve VII, facial]. Test for or ask patient about the sense of smell [cranial nerve I, olfactory nerve]. Inspect for symmetrical alignment of face, mouth, and lips while the patient is first at rest and then while attempting to smile and whistle [cranial nerve VII, facial].
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Assess cranial nerve VIII [vestibulocochlear] by testing hearing (whisper test, Weber and Rinne tests) and asking if patient experiences ringing in the ears (tinnitus), dizziness or vertigo, or nausea and vomiting. Test taste by asking patient to identify foods [cranial nerve IX, glossopharyngeal] and, if swallowing is assumed to be intact, test the quality of swallowing with small amounts of food and water [cranial nerve IX, glossopharyngeal and cranial nerve X, vagus]. Normally, a patient swallows easily, without choking. Inspect the ability of the patient to extend the tongue without it deviating to one side or another and clarity of speech without slurring of words [cranial nerve XII, hypoglossal]. Assess cranial nerve XI [spinal accessory] by inspecting symmetry of shoulders or the drooping of one more than the other and by the patients ability to move head side to side even when opposed with mild pressure.
Deep Tendon Reflexes
We will now assess the deep tendon reflexes, moving in a head-to-toe or top-to-bottom direction. There are five deep tendon reflexesbiceps [spinal cord level C3 and C6], triceps [spinal cord level C7 and C8], brachioradialis [spinal cord level C3 and C6], patellar [spinal cord level L2, L3, and L4], and the Achilles [spinal cord level S1 and S2]. We will also assess the plantar (Babinski) reflex, which is a superficial, not a deep tendon reflex. Biceps: Resting the patients arm on his or her thigh, flex the arm at the elbow, with the palm of the hand down. Place your thumb over the biceps tendon. Using the percussion hammer, tap your thumb, using a slightly downward motion. Feel the biceps muscle contract under your thumb. Observe slight elbow flexion. Triceps: Supporting the patients flexed arm with your nondominant hand, find the triceps tendon two to five cm (one to two inches) above the elbow. With your dominant hand, take the percussion hammer and tap the tendon directly while observing slight elbow extension. Brachioradialis: Resting the patients arm in your nondominant arm or on the patients thigh, find the brachioradialis tendon situated along the radium about two to five cm (one to two inches) above the wrist. Using the percussion hammer, tap the tendon directly, while observing arm flexion and supination. Patellar: With the patient in a sitting position and the legs hanging freely, find the patellar tendon directly inferior to the patella (kneecap). Using the percussion hammer, tap the tendon directly, while observing extension (kicking up) of the leg as the quadriceps muscle contracts.
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Achilles: With the patient in the same sitting position with the legs hanging freely, support the patients foot in your nondominant hand and dorsiflex it (move it up toward the head) slightly. This movement stretches the Achilles tendon slightly. Find the large Achilles tendon immediately above the heel. Using the percussion hammer, tap the tendon directly, while observing plantar flexion (jerking downward) of the foot. Plantar (Babinski): Using the percussion hammer handle or a key, stroke the lateral foot, moving from the heel to the ball of the foot and then moving across the ball to the great toe, while observing a bending downward of the toes. This is the normal response and it is called a negative plantar or a negative Babinski response. In an abnormal response, the toes flare and move upward. Note that an infant normally has a positive Babinski until about six months of age.
Sensory Function
Light touch may be used to assess sensory function. It may be performed by using a wisp of rolled cotton and touching the patients face, neck, upper and lower arms, upper and lower legs, and feet. When assessing arms, legs, and feet, be sure to perform lateral and medial assessments. Document exactly those areas in which sensation was decreased or absent.
Motor Function
A variety of tests are used to assess motor function. They are described below, categorized according to whether they are performed in sitting, lying, or standing positions. Ask the patient to sit on the examining table and perform the following: Finger-to-nose test Finger-to-nurses-finger test Finger-to-fingers test Finger-to-thumb test Alternating supination/pronation of hands on thighs test
Ask the patient to lie down and perform the following: Heel-down-shin test Toe-to-nurses finger test
Ask the patient to stand and perform the following: Walking gait test. Normal gait includes upright posture and unaided, steady, balanced gait while swinging opposing arms. Romberg test. Facing the patient so that you may steady or catch the patient should loss of balance occur, ask the patient to stand upright, with feet close together, with eyes open, and arms at sides. Now ask the patient to assume the
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same stance with eyes closed. Observe sway or its absence. If sway occurs, document the direction, i.e., to the right, to the left, frontward, or backward. Once sway occurs, the patient will move the feet apart to maintain balance. Observation of sway or of moving the legs apart to maintain balance is an abnormal result. Standing on one foot with eyes closed test. Ask the patient to stand on one foot with the eyes closed. Normally, a person can maintain this stance for at least five seconds. Be sure to stand near the client to steady or catch the client should loss of balance occur. Heel-to-toe walking test. Observe ability to walk a straight line while placing the heel of one foot directly in front of the toes of the other. Normally, this ability is present. Toe walking, heel walking tests. Ask the patient to walk for several steps on the toes. Then ask patient to walk for several steps on the heels. These abilities are normally present.
Level of Consciousness
The assessment of level of consciousness is part of the neurological examination. Consciousness exists along a continuum from fully alert and oriented to comatose, with no eye, motor, or verbal response. This continuum has been scaled and is called the Glasgow Coma Scale. A score of fifteen is the best possible score and a score of seven or less indicates coma. The lowest possible score is three. Table 1.2 Level of Consciousness as Measured by the Glasgow Coma Scale Response Score Spontaneously 4 Opens eyes (circle one score) To speech 3
To pain Absent 2 1 6 5 4 3 2 1 5 4 3 2 1
Motor response (circle one Obeys verbal command score) Localizes pain
Flexes and withdraws Abnormal flexion (decorticate rigidity) Abnormal extension (decerebrate rigidity) Absent Converses and is oriented Converses but is disoriented Uses words inappropriately Uses words incomprehensibly Absent
Verbal response (circle one score)
(Teasdale 1974)
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The Respiratory System Techniques used in the physical assessment of the respiratory system are inspection, palpation, percussion, and auscultation. Inspect for normal chest size and shape, deformities, intercostal retractions, abscesses, wounds, or injuries. Observe the anterior-posterior (A-P) diameter in relationship to the transverse diameter, as well as the overall shape. In the infant, the shape is like a round cylinder, and the A-P diameter equals the transverse. By six years of age, the shape is less round because the A-P diameter is decreasing in relationship to the transverse. In the adult, the shape is oval and elliptical, with the apex being smaller than the base (think of the shape of the adult lung x-ray). Also, in the adult, the A-P diameter is two times smaller than the transverse. Aging, with its osteoporosis and resultant kyphosis, changes the shape of the chest. While examining the chest for size and shape, also be sure to check for other deformities (e.g., pectus excavatum), chest abscesses, wounds (knife or puncture), and nonpenetrating injuries (bruises, hematomas). Palpate for chest excursion (equal bilateral movement on inspiration and expiration), expansion (35 cm or 1.52.0 inches) on inspiration, fremitus (bilaterally symmetrical tactile sensations in palmar surface of fingertips upon patients vocalization of words, e.g., blue moon). Gently palpate areas of suspected chest abscesses, wounds, and injuries, and describe findings. Percuss intercostal spaces of anterior and posterior chest wall for flatness, dullness, resonance, hyperresonance, and tympany. Go back and forth from the right side to the left side while progressing from the apex to the base of the lungs. The back-and-forth movement is to make sure that you are making accurate bilateral comparisons. Auscultate for normal and abnormal (adventitious) breath sounds. Normal breath sounds are called bronchial, bronchovesicular, and vesicular. Note that the inspiratory to expiratory ratio is 1:2 (short inspiration, long expiration) at the bronchial level 1:1 ratio (inspiratory time equals expiratory time) at the bronchovesicular level 5:2 ratio (very long inspiration with an expiration less than half as long) at the vesicular level Sounds are high-pitched and harsh at the bronchial level moderately pitched and softening at the bronchovesicular level low-pitched and softly sighing at the vesicular level The various sounds correspond to the following locations: bronchial sounds correspond to apex of the lung bronchovesicular sounds correspond to the area between the apex and the base of the lungs vesicular sounds correspond to the base of the lungs
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Abnormal breath sounds (or adventitious sounds) that include wheezing, gurgles (rhonchi), and crackles (rales). Wheezing is a high-pitched, whistling sound heard especially over the anterior and posterior bronchial areas, but also throughout the lungs. It is caused by bronchoconstriction due to bronchial edema (causing a narrowing of the lumen) and secretions (as occurs in asthma) or bronchial obstruction (as occurs with a tumor). It is not usually relieved by coughing. Gurgles (rhonchi) are low-pitched gurgling sounds heard best on expiration and frequently cleared on coughing. These sounds are usually emitted by secretions in the bronchi and hence, are heard best over the bronchial areas. Crackles (rales) sound like noise emitted when salt is thrown into fire or like the noise that occurs when you use your fingers to rub a lock of hair harshly and quickly near your ear (i.e., fine, short, crackling noises). Heard at the base of the lungs, rales may or may not be cleared on coughing. To evaluate clearing, ask the patient to cough and then take a deep breath. Listen to determine if the crackles cleared on coughing. Be sure to document results. The pleural friction rub, which is heard best along the lateral or anterior chest, sounds like the noise that occurs when you use your fingers to rub a lock of hair back and forth slowly and gently near your ear. It occurs throughout inspiration and expiration and is not cleared by coughing. It is caused by a rubbing together of the surfaces of the pleural membrane surrounding the lung.
The Cardiovascular System Techniques used in the physical assessment of the cardiovascular system vary according to what part of the system is being assessed. Moving in a head-to-toe direction, assess the neck for jugular venous distention (inspection) and the carotids (inspection, palpation [only one carotid at a time], and auscultation). Assess the heart using inspection, palpation, and auscultation. Assess the peripheral vascular system, usually by using inspection and palpation only; however, on occasion the femoral arteries may be auscultated.
Assessment of the Jugular Veins
Inspect the jugular veins with the patient lying at a forty-five-degree angle in semiFowlers position. Visualize the sternal angle and look between it and the ear tip. Now, find the jugular vein. Inspect for distention of the jugular vein. If there is distention, measure the height of the distention in centimeters or inches above the sternal angle. Inspect both jugulars to see if the distention is symmetrical. If there is no distention, lower the head of the bed to thirty degrees and observe for distention. If there is distention, measure its height in centimeters or inches above the sternal angle. Distention that extends more than three to four centimeters above the sternal angle is considered abnormal.
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Assessment of the Carotid Arteries
Inspect both carotids for visible, pulsating masses. Normally, there should be none. Palpate gently only one carotid artery at a time so that carotid blood flow to the brain is maintained at all times. Palpate in the middle area of the neck to avoid the carotid sinus. To avoid stimulating a carotid sinus response and a possibly injurious bradycardia, never massage nor apply pressure to the carotid artery. To make the carotid more accessible, ask the patient to turn slightly to the side being examined. The main reason for palpation is simply to locate the position of the artery so that you know where to place the stethoscope for auscultation. Auscultate the carotid, listening for a bruit, a murmur-like sound caused by turbulence in carotid artery blood flow. Turbulence occurs in the presence of a partial obstruction or arterial narrowing. Normally, a bruit is not heard.
Assessment of the Heart
Inspect the anterior chest, visually locating the aortic area (second intercostal space to the right of the sternal border), the pulmonic area (second intercostal space to the left of the intercostal border), the tricuspid or right ventricular area (fifth intercostal space to the left of the sternal border), and the apex (at the fifth or sixth intercostal space along the mid-clavicular line). Inspect for abnormal pulsations, lifts, or heaves. Palpate the same areas for abnormal pulsations, lifts, or heaves. Auscultate the same areas for heart sounds and murmurs with the patient lying in a semiFowlers position at a thirty to forty-five degree angle. The first (S1) and second (S2) heart sounds are normal sounds. S1 may be thought of as the lub sound and S2 may be thought of as the dub sound. S1 is followed by systole and S2 is followed by diastole. In children and in young adults, a physiologic third heart sound may be heard. This is the sound that occurs immediately after the second heart sound. A pathologic S3 occurs in the presence of left ventricular failure, whether before or after age forty. If failure is suspected, but no S3 is heard with the patient in the supine position, ask the patient to turn to the left side. This brings the left ventricle closer to the chest wall, and an S3 may be detected more easily. The fourth (S4) sound is abnormal in the child or adult, although it may be present in a healthy-appearing older adult. This is the sound that occurs immediately before the first heart sound. It is found with decreased flexibility of the wall of the left ventricle. This occurs in the presence of left ventricular hypertrophy or with significant hypertension. When a third, fourth, or both sounds are heard, the resulting combination of sounds is called a gallop rhythm, because it sounds like a horse galloping. When auscultating, listen first with the diaphragm and then with the bell of the stethoscope and concentrate on identifying each sound separately before moving on to the next. Realize, however, that auscultating heart sounds is like being able to identify the various instruments in Beethovens Ninth Symphony. It takes a very good ear and much practice. Beginners need to concentrate on obtaining an accurate apical heart rate and an accurate description of the rhythm. An appreciation of the sounds will follow.
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Murmurs are not normal heart sounds, although some murmurs may be considered benign in children and young adults (e.g., soft systolic murmurs heard over the pulmonic area). Murmurs are swooshing noises that occur during systole, diastole, or throughout the cardiac cycle. They are caused by turbulent blood flow through one or more heart valves. A pericardial friction rub occurs when the surfaces of the pericardial membrane rub together. The sound can be distinguished from a pleural friction rub by asking the patient to hold his or her breath for a second. If the friction rub continues when the breath is being held, it is a pericardial friction and not a pleural rub.
Assessment of the Peripheral Vascular System
Inspect fingernails for early or late clubbing and fingernails and toenails for capillary refill (color returns normally in less than three seconds). Perform Buergers test (arterial adequacy test). A delay in capillary refill is associated with arterial insufficiency. Inspect the hand and feet digits for temperature, blanching, cyanosis, rubor (ruddy redness), and gangrene; the hands, arms, legs, and feet for edema; and the legs for venous stasis ulcers. Inspect the feet of patients with diabetes mellitus carefully, especially between the toes. The diabetic patients increased susceptibility to infection, neuropathy and its decreased sensation, along with decreased peripheral circulation, predispose the patient to undetected skin infections that may become gangrenous. Palpate the pulses bilaterally, moving in a head-to-toe direction: brachial, radial, femoral, posterior popliteal, posterior tibial, and dorsalis pedis. Assess asymmetry in volume and strength. Unequal pulses may indicate circulatory impairment on the weaker side. Bilaterally weak pulses may indicate decreased cardiac output. Excessively strong pulses bilaterally may indicate a high cardiac output state. Normally, pulses are full and strong, bilaterally. Auscultate the femoral artery if one side is exceptionally weak or absent. Absence of a pulse indicates a complete obstructiona definite emergency. A bruit indicates turbulent flow caused by a partial femoral obstruction, requiring prompt notification of the patients physician. The Abdomen Inspect the skin for normal findings (silver-white striae, scars) and abnormal findings (rash, tense or glistening skin indicative of ascites, purple striae indicative of Cushings disease). Inspect for contour and symmetry in supine, semi-Fowlers, and standing positions, looking for abdominal distension, protrusions, masses, and pulsations. If distention is present, measure the girth at the level of the umbilicus. Auscultate for bowel (peristalsis) and arterial sounds. Listen for hypoactive, normal (gurgling sounds every five to twenty seconds), or hyperactive bowel sounds in all four quadrants of the abdomen. Before saying that bowel sounds are absent, listen for a full three to five minutes. Listen for arterial bruit over the abdominal, iliac, femoral, and renal arteries.
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Percuss the abdomen to locate the outline and position of the liver. Beginning in the right lower quadrant, percuss in a straight line upward until the sounds of tympany change to dullness. Mark this area; it is the lower right margin of the liver. Beginning at the umbilicus, percuss upward until tympany changes to dullness. Mark this area; it is the lower left margin of the liver. Beginning at the right midclavicular line, percuss downward until the sounds of lung resonance change to dull sounds. Mark this area; it is the upper right margin of the liver. Beginning at the upper right sternal border, percuss downward until lung resonance sounds change to the dullness associated with the liver. Mark this area; it is the upper left margin of the liver. Measure the distance between the upper and lower marks to estimate the lateral and medial liver span. It is a good idea to percuss the abdomen to obtain an idea of liver size before beginning palpation. Palpate to assess outline and position of organs and to assess tenderness, abdominal muscle guard, masses, ascites, or distention (intestinal or bladder). Palpate the colon, beginning at the ileocecal area in the right lower quadrant, progressing up over the ascending colon, across over the transverse colon, and down over the descending colon. Palpate the periumbilical area, especially noting tenderness (indicative of appendicitis) or protrusion (indicative of umbilical hernia). After light palpation is concluded, perform deep palpation. Gently palpate the liver border, normally absent or soft and smooth at the level of the costal border upon inspiration. Tenderness along the liver border or in the right upper quadrant may indicate liver tenderness or gallbladder tenderness. Palpate the area above the pubic symphysis for a smooth, round, tense mass, indicative of a distended bladder. Normally, the bladder is not palpable. Palpate the inguinal areas for the presence or absence of tenderness or protrusions indicative of a hernia.
Functional Assessment Techniques

Activities of daily living (ADL) refer to the basic self-care tasks of living. These are feeding and eating, bathing and hygiene, dressing and grooming, toileting and continence, and moving and transferring (or locomotion). ADL assessment is performed upon admission of a client to the hospital or health-care agency and at those points in time when changes are expected. For example, patients recovering from major surgery experience temporary impairments in the ability to perform some ADL. They need to be assessed for the type and severity of the impairment so that appropriate interventions can be planned and implemented. For example, a hospitalized patient may need assistance with turning in bed, bathing, eating, walking, and toileting during the immediate postoperative period. These temporary needs require assessment by the nurse. Advancing years or debilitating illnesses may cause permanent impairments. The nurse assesses permanent impairments to plan for the provision of services, not only while the patient remains in the hospital, but also upon discharge. Instrumental activities of daily living (IADL) refer to tasks involving the basic tools or instruments of daily life needed to live independently. These include the ability to: use a telephone, prepare meals, launder clothes, clean house, take medicine, and handle finances (including writing checks and balancing accounts). Age or illness may interfere
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temporarily or permanently with a patients ability to perform these instrumental activities. Mental Status Assessment A mental status assessment is part of the neurological examination. It involves attention span, ability to calculate, memory, an assessment of speech and language, and assessment of orientation to person, place, and time. Speech and language ability has sensory (receptive) and motor components. Sensory ability is either visual (ability to interpret written words) or auditory (ability to interpret spoken words). Loss of the ability to interpret both written and spoken words is sensory aphasia. Loss of ability to interpret only written words is visual aphasia. Loss of the ability to interpret spoken words is auditory aphasia. To test for visual aphasia, have the patient match written words to pictures. To test for auditory aphasia, have the patient follow simple commands, such as point to your nose or open your mouth. Motor language or speech ability is characterized by using words appropriately. It may be tested by having a patient name common objects like a wristwatch, a pair of eyeglasses, or a pencil. Loss of the ability to use words appropriately is called motor or expressive aphasia. Orientation is characterized by correct references to person, place, or time. This may be assessed by asking a patient the name of their significant other (person), the city and state in which the patient resides (place), and the days date and time (time). If there is a suspicion that orientation may be impaired, ask more specific questions, such as: Who is the President of the United States? In what city are we? What year are we in? What month? What day? What date?
People accept these questions if they are introduced as routine, and they are routine for anyone who has experienced a head injury, cerebral hypoxia (e.g., during a resuscitation procedure), memory problems or confusion, or someone who is reported to have memory problems or confusion. Memory may be classified as immediate recall, recent, and remote. For immediate recall, ask the patient to repeat three to eight digits. Start with three digits and build up to eight. The ability to repeat five to eight digits is considered to be within normal limits. Another test of immediate recall is to ask the patient to repeat a sequence of three to eight digits in reverse. The ability to recall four to six digits in reverse order is considered to be normal. Recent memory is assessed by asking a patient to recall todays events, assuming that the nurse has a way of validating the information obtained. Another way is to give the patient the names of three common objects, such as bed, book, and clock. Tell the patient that you will be asking him or her to recall
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the names of those objects later in the interview. If recent memory is intact, the patient will be able to recall the objects. Immediate and recent memory are categorized as short-term memory. Remote memory is assessed by asking the patient to recall and describe an event from the past. This assumes that the information can be validated. Another way is to ask the patient to recall each of the Presidents in reverse order. This assumes that the nurse knows the reverse order of Presidents, also (Bush, Clinton, Bush, Reagan, Carter, Ford, Nixon, Johnson, Kennedy, Eisenhower, Truman, Roosevelt). Remote memory is also called long-term memory.
Attention span is assessed by asking a patient to count backwards from one hundred or to recite the alphabet. Calculation ability is assessed by asking a patient to subtract seven or three from one hundred and then to continue subtracting seven or three from each answer obtained (100, 93, 86, 79, 72, 65, 58, 51, 44, 37, 30, 23, 16, 9, 2). These tests are called the serial threes or the serial sevens. Normally, a person can complete this task within ninety seconds. However, where there is a suspicion that a person never had this ability in the past, then the test is not a valid test. The test also may not be valid if English is a second language.
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Chapter 2: Principles of Teaching and Learning

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. Define teaching and learning. Explain Blooms three domains of learning. List the three principles of learning the nurse must consider when preparing to teach a patient. Describe intrinsic and extrinsic motivation and readiness. Identify and explain the steps involved in planning a specific educational or learning session. Describe the components of an effective educational objective.
Key Terms
affective domain cognitive domain conclusions extrinsically motivated behaviors intrinsically motivated behaviors learning learning environment motivation psychomotor domain readiness teaching
Introduction
This chapter analyzes the concepts of teaching and learning. We first discuss how learning occurs, which includes engaging in an internal experience or an evolving process. Next, we identify Blooms classic domains of learning. We then look at principles of learning, such as motivation, readiness, and the learning environment. The chapter is concluded by exploring the flip side of learningteaching. Establishing priorities, writing educational objectives, and teaching methods are topics discussed.
A Conceptual Framework for Teaching and Learning

Before exploring the principles of teaching and learning, it is good to define what teaching and learning mean and to place learning within a particular framework. Thus, definitions of teaching and learning follow, along with a brief explanation of Blooms
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three domains of learning. The latter classification helps us conceptualize the various kinds of learning. According to Berman et al. (2008), teaching is a system of activities intended to produce learning. The focus in teaching is on the transmission of new knowledge and skill. It involves a dynamic interaction between the teacher and the learner. Teaching occurs with individual clients and families and in the community. Nurses are often asked to teach health personnel. Practicing nurses are often asked to assist with the instruction of nursing students. Learning is a change in human disposition or capability that persists and that cannot be solely accounted for by growth (Berman et al. 2008). The focus of learning is on the acquisition of new knowledge and skill. There are many ways in which learning occurs. Learning is an internal experience, although the results or effects are visible; the discovery of the meaning and relevance of ideas; an experiential event, occurring as a function of experience and a reflection upon experience; a collaborative and cooperative process; an evolving process, occurring over time; an intellectual accomplishment (the ah ha! experience); and an emotional experience (e.g., the sense of accomplishment that accompanies successfully ice skating or bicycle riding for the first time).
In 1956, Bloom identified three domains of learning: cognitive, affective, and psychomotor (Anderson and Sosniak 1994). 1. The cognitive domain is involved with thinking. It addresses the intellectual skills of knowing, comprehending, and applying knowledge. These skills progress from the simple to the complex. The affective domain is involved with emotional responsiveness. This domain addresses feelings, emotions, attitude, and appreciation. The term appreciation is used here as in art or music appreciation. The psychomotor domain addresses motor skills. Skiing, swimming, giving an injection, and inserting a catheter are psychomotor skills.
2.
3.
Each of these domains may be applied to client education. For example, in the cognitive domain, patients with diabetes mellitus need thinking skills as they master their diet and its exchanges. In the affective domain, patients with diabetes need to accept their condition in an emotionally healthy manner. In the psychomotor domain, patients with diabetes need to master finger sticks, glucometer readings, and, in some cases, selfadministration of insulin.
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Basic Principles of Learning In preparing to teach a patient, the nurse not only needs to know how to teach, but also how the patient learns. Three principles of learning need to be considered: 1. 2. 3. The clients motivation to learn The clients readiness to learn The learning environment
Motivation to learn refers to a desire to learn. People learn when they experience a need. A person learns how to use a VCR when they need or want to see videos. A person learns how to surf the Web for medical or nursing information when they need quick access to information. A client with diabetes mellitus needs or wants to know about the condition when diagnosed with diabetes. At this point, we say the client is motivated to learn. Level of motivation, type of motivation and level of self-esteem are determinants in health. Intrinsic and extrinsic refer to the origins of the desire to engage in a particular behavior. Intrinsically motivated behaviors are ones for which the rewards are internal to the person; extrinsically motivated behaviors are a response to external rewards or punishments. Higher levels of self-esteem are generally associated with more intrinsically motivated people. Higher levels of intrinsic relative to extrinsic motivation predict successful cessation of smoking and weight loss. Nurses can target specific interventions with a better understanding of how a person is motivated. Readiness to learn refers not only to motivation to learn, but also to an ability to learn. Just as there are three domains of learning, we can speak of three domains of readiness to learn: 1. A client needs to be cognitively ready to learn. Ask if the client is thinking in a sufficiently clear manner to learn. Anesthesia, narcotics, and some sedatives may interfere with cognitive readiness to learn. In such cases, a better moment for teaching must be selected. A client must also be affectively (emotionally) ready to learn. Severe anxiety, depression, or grieving over a perceived loss of wellness are emotional conditions or responses that impair learning. Such emotional issues have to be addressed before a person is affectively ready to learn. A client must be ready to learn from a psychomotor or physical development point of view. The need for physical readiness to learn is apparent in working with clients with Type I diabetes mellitus. For example, a young child may not be cognitively ready to learn dosage amounts, but may have sufficient psychomotor readiness to self-administer the injection. To accommodate the childs readiness to learn, the childs mother may prepare the dose and allow the child to administer it. Psychomotor readiness to learn involves adequacy of muscle strength, motor coordination, energy, and sensory acuity.
2.
3.
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The learning environment is an essential part of learning. Therefore, the nurse provides for adequate lighting; minimal distraction; quiet, comfortable room temperature and air ventilation; and minimal interruptions. In the hospital, this means that the nurse selects time when patient visitors will not interrupt learning. Also, in teaching clients various procedures, the nurse recognizes the need for privacy and provides it. Assessment of the clients motivation to learn, readiness to learn, and adequacy of the learning environment leads to the formation of conclusions (diagnoses), e.g., the client is motivated and ready to learn insulin self-administration. Subsequent planning involves understanding the basic principles of teaching. Basic Principles of Teaching Steps in planning a specific educational or learning class or session involve establishing teaching priorities, writing learning objectives (analogous to patient goals and expected outcomes), and selecting content and methods (analogous to identifying interventions). These steps are analogous to the planning phase of the nursing process.
Establish Priorities
First, establish priorities. In education, learning is promoted if students have a role to play or some choice in setting the teaching/learning priorities. In teaching clients, a nurse may elicit client interest areas or encourage a client to rank content areas from a list generated by the nurse. The content areas that the client ranks may have the same relative priority level. For example, the nurse may give the client a list of content areas that include fingersticks, reading a glucometer, drawing up and administering insulin, calculating the proper insulin dose, recognizing hypoglycemia, treating hypoglycemia, and recognizing signs of hyperglycemia. These tasks have the same relative priority level because they address physiologic needs, the most basic of all needs in Maslows hierarchy. After the client successfully learns content in this area, Maslow ranks content that addresses safety needs next, which the nurse ranks according to the patients interests (e.g., foot care, eye care, preventing hypoglycemia, preventing hyperglycemia). Maslows hierarchy of needs may be used to help establish teaching priorities.
Schedule and Plan
Schedule and plan for the teaching and learning session or class. Determine the date and the time of the session, the length of the session, and the interval between sessions (if more than one class is planned). When selecting the time, consider the clients preference for morning, afternoon, or evening sessions. When selecting the length of the session, consider the clients energy level and the workload of the nurse. Intervals between sessions may depend on the length of the patients hospital stay.
Write Educational Objectives
Once priorities are established and a time has been assigned for the class, develop educational (or learning) objectives. Again, learning is maximized if these objectives are a collaborative effort on the part of the client and nurse and the clients family. Learning objectives are to be stated behaviorally. That is, they must be demonstrable. Words like
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understanding are to be avoided because understanding cannot be observed. Instead, use behavioral terms that can be observed, e.g., demonstrates, illustrates, discusses, articulates, expresses, withdraws, injects, reads, etc. Objectives are best if they contain an expected outcome within them. Thus, an appropriate objective for a client learning to self-administer insulin is, At the end of this teaching/learning session, the client will be able to draw up the right dose of insulin into the insulin syringe, using proper technique. Of course, this would not be the only objective, but it serves as an example. Note that the objective contains four parts: 1. 2. 3. 4. Client behavior, e.g., By the end of this session, the client will draw up the right dose of insulin into the syringe, using proper technique. Observable behavior, e.g., By the end of this session, the client will draw up the right dose of insulin into the syringe, using proper technique. Modifier (if necessary), e.g., By the end of this session, the client will draw up the right dose of insulin into the syringe, using proper technique. Time period needed to accomplish objective, e.g., By the end of this session, the client will draw up the right dose of insulin into the syringe, using proper technique.
Guide Content with Objectives
Content needs to progress logically. For example, it would not be logical to begin a session on insulin administration by discussing how to dispose of the syringe and needle after use. It is logical to begin with the gathering of equipment needed. Content must also focus on the significant or relevant elements. Insulin pumps and sophisticated dosing methods are complex information. It is not relevant content for the person who is learning to self-administer insulin for the first time. Mastery of simple content is needed before progressing to the complex. It may be a year or two before this newly diagnosed, insulin-dependent diabetic client decides he wants to explore insulin pumps. There are other principles involved in choosing content. It must be accurate, current, and adjusted to the clients age, culture, and cognitive, affective, and psychomotor ability. Build on what the patient already knows. In other words, progress from what the client knows to what the client does not know. Address anxiety as it arises, but in general, begin with a low-level anxiety issue and progress to a higher-level anxiety issue when the client shows a readiness to handle more anxiety-producing material. Teach basics before showing the client how to adjust the basics. Schedule sufficient time for questions and answers.
Select Appropriate Teaching Methods
The content being taught to a great extent determines the methods of teaching. There are many methods of learning: lecture, role-playing, discussion, video, handouts, reading with question and answer periods, computer-assisted learning, guided or discovery learning, modeling, and practice or demonstration/return demonstration. A client learning how to administer insulin needs more than a lecture, discussion, video, or a handout. The client needs a hands-on experience under supervision because insulin
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administration is a psychomotor skill. It does have cognitive and affective components, but the psychomotor component must be taught for learning to occur. Demonstration and return demonstration, along with practice, are excellent methods of teaching psychomotor skills to clients learning any self-care procedure. For example, in this particular case, demonstrate how insulin is withdrawn into a syringe and then ask the client to return the demonstration. Allow for practice with the same skill. When the client shows evidence that he can perform the skill correctly and then repeat the correct performance, the skill has been learned. Learning can be considered retained if the client can perform the same skill the following day without coaching.
Evaluation
Evaluation depends on the degree to which the client achieves the behavioral objectives. In other words, for each behavioral objective, ask, Did the client achieve this objective? For example, if the objective is that the client will draw up the right dose of insulin into the syringe using the correct technique, watch and then evaluate how well the client has mastered this skill. Allow the client time to practice as needed to perfect the skill, and evaluate the last performance of the day.
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Chapter 3: Theoretical Models of Health, Wellness, and Illness

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. Describe four models of health. Define health status, health beliefs, and health behaviors. Explain the various models used to examine a persons beliefs about health, their tendency to engage in healthy behavior, and factors that influence health behavior change. Relate wellness to personal responsibility. Compare Traviss illness-wellness continuum with Dunns high-level wellness grid. Explain the relationship between the agent, host, and environment. Differentiate between illness, sickness and disease. Provide examples of developmentally related health problems from infanthood through adulthood. Describe Parsonss sick role.
4. 5. 6. 7. 8. 9.
Key Terms
adaptive model agent clinical model environment eudemonistic model health behaviors health beliefs Health Belief Model Health Promotion Model health status host locus of control role performance model self-efficacy theory sick role
Introduction
This chapter covers such topics as general models of health, wellness, and illness; health beliefs, promotion, and behavior change models; the concept of wellness; continuums of health, wellness, and illness; and ecologic models of health and illness. Although this chapter covers considerable content, it is logically related. To master this content, it may be necessary to relate the major concepts and approaches to real-life situations with which you are familiar.
Models of Health, Wellness, and Illness

Berman et al. (2008) described a variety of models that relate to health, wellness and illness. The clinical model most narrowly defines health as the absence of disease; it
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often limits the analysis to physiologic systems. The eudemonistic 1 model focuses on health as well-being, self-fulfillment, and self-actualization. The adaptive model views health as adaptation to the physical and social world in which a person lives, and views disease as maladaptation. The role performance model views health in functional terms: If I can function, I am healthy. We will now compare these definitions with other commonly employed or referenced definitions. To define health as the absence of disease is called a clinical model, in which emphasis on disease treatment outweighs emphasis on health promotion and disease prevention. This clinical definition of health might also be called a traditional definition. MerriamWebsters Collegiate Dictionary defines health as a condition of being sound in mind, body, and spirit, especially freedom from physical disease or pain. Only secondarily does Websters define health as well-being. Florence Nightingale defined health as being well and using every power the individual possesses to the fullest extent. The World Health Organization defines health as a state of complete physical, mental, and social well-being and not just the absence of disease (Berman et al. 2008). These definitions are consistent with the eudemonistic model of health as well-being, self-fulfillment, and self-actualization. Sister Callista Roy, who developed Roys Adaptation Model, thinks of health as adaptation and of illness as maladaptation. This is consistent with the adaptive model or view of health. Talcott Parsons, a sociologist, studied the sick role. He found that the assumption of the sick role confers upon the person a release from his or her usual roles, responsibilities, or expectations. Conversely, giving up the sick role, and presumably assuming a well role, means the resumption of ones social role, with its responsibilities and expectations. Thinking of health in terms of the ability to function within ones role is the role performance model of health. Related Health Concepts: Health Status, Health Beliefs, and Health Practices Health status refers to a persons health state or condition at one particular point in time. The aspect of the persons health this definition refers to depends upon the context in which the phrase is used. Sometimes it refers to acuity, as in mildly, moderately, or severely ill, or it can refer to condition, such as critical, serious, fair, or satisfactory. Sometimes it refers to whether the patient is in a stable or unstable condition. When the health status (meaning stable/unstable) is questioned, the expected response is that a nurse should report on the patients vital signs. Health status is sometimes used in terms of a patients level of alertness (e.g., alert, confused, semi-comatose). Finally, it may
This is the spelling provided by Berman (2008). This spelling is supported by others who write in nursing literature. There is an alternative spelling: eudaimonistic. The latter is used by Laffrey (1986), who developed a Health Conception Scale.
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refer to a descriptor related to a patients health condition (e.g., undernourished, fatigued, stressed, anxious, depressed). Health beliefs refer to health-related convictions. The Aymara of the Bolivian altiplano (high plateau) believe that loss of blood is associated with loss of the persons spirit. Therefore, they hesitate to have blood drawn for laboratory purposes or to donate blood to a blood bank. Health beliefs reflect the influence of a persons culture and can also influence the health behaviors of a group or person. Health behaviors refer to actions taken to promote health, protect health, or prevent illness and disease. Examples of health-promoting behaviors include a healthy diet, adequate exercise, and sufficient rest. Examples of personal life- or health-protecting behaviors are looking both ways before crossing a street, driving safely, wearing seat belts, using child safety seats, and having home fire detectors and extinguishers. There are also government health-protection standards and those developed by industry. Examples of disease-preventing behaviors are practicing safe sex, keeping immunizations up to date, using sunscreen, and conducting monthly breast or testicular selfexaminations.
Health Beliefs, Health Promotion, and Health Behavior Change Models

A number of models examine a persons beliefs about health, their tendency to engage in healthy behavior, and factors that influence health behavior change. These are the locus of control model, self-efficacy theory, Rosenstock and Beckers Health Belief Model, Penders Health Promotion Model, and Prochaska and DiClementes Stages of Behavior Change Model. Locus of Control Model Jullian B. Rotter developed the locus of control model in 1966, which, when applied to nursing, translates to some people being internally controlled and others externally controlled. The former believe they can change their own behavior (internally controlled). The latter believe that factors or forces external to them are responsible for any change that occurs (externally controlled). Internally controlled people are selfmotivated or self-directed in effecting healthy behavior change. So, the health professional helps internally controlled people build up internal rewards. Externally controlled people require external motivators. So, the health professional helps to provide or build in external reinforcement or positive rewards in response to healthy behavior change. Self-Efficacy Theory Developed by Bandura (1977, 1997), the self-efficacy theory simply says that if a person believes they can do it, they do it. Applied to health promotion, if a person believes they can quit smoking, they are more likely to do it than the person who believes they cant. Research is needed to determine what means are most effective in moving a person from
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a low to a high self-efficacy level. Pender incorporates self-efficacy in her Health Promotion Model, which is presented below. Health Belief Model Rosenstock and Beckers Health Belief Model (1974) examines motivational influences on health behavior change as it relates primarily to compliance with a treatment regimen for a disease. The model examines the following: Individual perceptions (perceived susceptibility to and perceived severity of the disease) Modifying factors Personal o Demographic characteristics (age, gender, income, education, etc.) o Sociopsychologic characteristics (personality, social reference groups, peer pressure, etc.) o Structural characteristics (prior experience with health-care providers and/or the disease, knowledge about the disease) Perceived threat of disease Cues to action (e.g., media advertising; news articles; health professional prompting; illness of relative, friend, acquaintance, or prominent figure) Likelihood of action variables (perceived benefit and perceived barriers to health behavior change)
Health Promotion Model Penders (1996) Health Promotion Model shares similarities with the Health Belief Model, but its emphasis is on health promotion behavior change (Berman et al., 2008). It, too, examines three categories of variables: 1. 2. Individual characteristics and experiences (prior related behaviors and personal behavioral, psychologic, and sociocultural factors) Behavior-specific cognitions and affect (perceived barriers, action barriers, selfefficacy, and activity-related affect as well as situational and interpersonal influences) Behavioral outcomes (immediate competing demands, commitment to an action plan, and health-promoting behavior)
3.
Stages of Behavior Change Prochaska and DiClementes (1983, 1992) Stages of Behavior Change examines any kind of behavior change. Therefore, it may be applied to health-promotion, health-protection, or disease-prevention behavior change.
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Its stages are as follows: 1. 2. 3. The precontemplation stage, in which the person is unready for change. The costs of change outweigh the benefits. In the contemplation stage, the person is considering change. The costs and benefits are being weighed. During the preparation stage, the person has decided that the benefits of the change outweigh its costs. Cognitively and behaviorally, the person begins to plan the change. The actual change occurs in the action stage. Strategies are initiated to effect the change. During the maintenance stage, the person continues to integrate the change into daily life. During the termination stage, the individual experiences freedom from the prior behavior to the extent that the individual feels that the issue never existed. However, there are some individuals who may never arrive at this stage and require lifelong maintenance.
4. 5. 6.
Relapse may occur. To prevent its occurrence, the strategies initiated in the action stage may need to continue for months or years. If relapse does occur, then the person reenters the change process at the precontemplation or contemplation stage and moves forward again.
WellnessA Concept Directly Related to Personal Responsibility

High-level wellness requires making healthy lifestyle choices daily to maximize ones health potential. Examples of these healthy choices are to allow for sufficient rest and sleep, make healthy food and nutrition choices, practice good hygiene, recreate, exercise to maximize physical fitness, incorporate preventive health care (e.g., immunizations, self-breast examination, self-testicular examination) into ones schedule, and engage in positive mental health practices (e.g., improve stress management techniques and communication skills). High-level wellness requires deciding to modify those behaviors that place a person at high risk of injury or illness. Examples designed to decrease the risk for injury or illness include using seat belts and practicing safe sex. There are also organized wellness programs in which clients join support groups, actively participate in their own recovery, discuss healthy choices, share commitment and motivation, attend health education classes, and practice stress management techniques, all while continuing under medical care. Such programs in whole or in part are common. Cardiovascular rehabilitation is one example, as suggested by Leighton (1998). High-level wellness requires making those parental and personal decisions needed to promote the achievement of lifes developmental tasks. Each of the following developmental stages looks at the many parental or personal behaviors required for a healthy life as viewed by leading scientists and psychologists.
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Berman et al. (2008) describes the Anspaugh, Hamrik, and Rosato model. This model includes the following levels of wellness: physical, spiritual, intellectual, occupational, environmental, social, and emotional. These levels of health can be examined independently, but each level overlaps in the human person.
Continuums and Grids Relating To Health, Wellness, and Illness

The Health-Illness Continuum The health or illness status of a person is not an absolute state, but a relative placement along a continuum of health and illness. For example, a patient with a chronic disease may consider themselves healthy compared to where they were six months ago or compared with a friend who has the same condition. This concept helps the nurse to work with patients or groups, well or ill, to achieve higher personal levels of health. Figure 3.1 The HealthIllness Continuum
Illness Health
Traviss Illness-Wellness Continuum In 1988, John W. Travis and Regina Sara Ryan differentiated the term wellness from the term health. Their reasoning was that wellness is a choice, a philosophy or way of life, the integration of body-mind-spirit, and high-level self-acceptance. In the wellness model, the person chooses healthy lifestyles and makes healthy choices regarding food, exercise, sleep, rest, and work. The person actively seeks out and engages in healthpromoting behaviors. Movement toward wellness is characterized by passage through increasing wellness awareness, wellness education, and wellness growth and away from disease, its signs and symptoms, and premature death. On the other hand, lack of a wellness orientation that inhibits the person from engaging in wellness behaviors may lead to premature death.
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Figure 3.2 Traviss Illness-Wellness Continuum
(Berman et al., 2008) Dunns High-Level Wellness Grid Dunn (1973) looked at two dimensions. One is environment, varying from favorable to unfavorable. The other is the wellness-death dimension. Dunn does not emphasize distinctions between health and wellness as Travis does. Dunn looks at the person within the context of the family, community, and society.
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Figure 3.3 Dunns High-Level Wellness Grid
Very Favorable Environment
LUQ
Death
RUQ
Peak Wellness
LLQ
RLQ
Very Unfavorable Environment RUQ = right upper quadrant; peak wellness in a very favorable environment (e.g., people engaging in positive health behaviors and living within functional families, communities, and societies) RLQ = right lower quadrant; emergent wellness in a less than favorable environment (e.g., flood victims exposed to high levels of stress who are provided with crisis intervention, shelter, health, and social resources needed to survive and rebuild) LUQ = left upper quadrant; poor health, moving toward death, but in a very favorable environment (e.g., a fetus infected with HIV, but whose mother receives AZT during pregnancy and infant is born HIV negative) LLQ = left lower quadrant; poor health, moving toward death, in a very unfavorable environment (e.g., infants born with AIDS because mothers did not receive AZT during pregnancy)
(Berman et al. 2008)
The 4+ Model of Wellness

The 4+ Wellness Model consists of two layers. One layer concerns the inner self and consists of four domains: the intellectual, emotional, physical, and spiritual. The inner self interacts with and engages with the systems in the outer layer. The outer layer consists of factors that surround the self, such as the environment, culture, safety, nutrition, education, world events, finances, and many other external systems. Visualizing wellness in this manner is intended to help the nurse identify factors that deplete or nurture wellness. Strengths within one domain, when not in excess, strengthen other domains. Depletion within any domain weakens the other domains. Excess within any domain creates an imbalance within the self. Excessive striving within any one domain can be destructive to wellness within all domains. The role of the nurse is to assist the patient in achieving inner balance among the four domains and to mitigate the negative influences, whether inner or outer, while nurturing the positive inner strengths and outer influences.
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Ecologic or Epidemiologic Model of Health and Illness

We began this chapter discussing health and wellness. Now we will discuss the concept of illness. A discussion of the ecologic or epidemiologic model of health and illness facilitates this transition. Figure 3.4 The Agent, Host, Environment Triad
Agent
Host
Environment
In the ecologic model, illness or disease occurs due to an interaction between the diseasecausing agent; the person, animal, or insect hosting the disease; and the environment in which both the agent and the host exist (Leavell and Clark 1965). For example, bacteria (the agent) are more likely to grow and flourish in an unhygienic kitchen (environment), causing illness in a person (host). This model is called an ecologic model because it looks at the agent, host, and environment within an interactive system where each component is interdependent on the other. It is called an epidemiologic model because it looks at the causes of and influences on disease. It may be used as a conceptual nursing or health education model as well. For example, take the case of a nurse or health educator (change agent) who brings to people (hosts) concepts and practices that prevent illness within their homes and the community (environment).
Illness
A Comparison of Terms: Illness, Sickness, and Disease The terms illness, sickness, and disease are related but not synonymous terms. A disease is a specific pathologic state with defined signs and symptoms. An illness is an unhealthy state or condition of the mind or body in which physical, social, emotional, intellectual, or spiritual functioning is compromised. Sickness is the opposite of wellness, a state of not being well; but, it has also entered the vernacular to mean disgust, as in, That kind of vulgarity makes me sick.
While these definitions overlap to some extent, they do help us clarify the distinctions.
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The Effects of Age on Illness and Injury When the probability or chance that people in certain groups will become ill, develop a disease, or have an accident is greater than what would be expected in the population as a whole, then those persons are said to be at increased risk. Developmental level influences the risk of illness, disease, and injury. Table 3.1 presents a list of developmentally related health problems. This list is not exhaustive, but demonstrates the fact that groups of people are more or less vulnerable to various health problems as a function of their developmental and age categories. Table 3.1 Examples of Developmentally Related Health Problems
Developmental Level Infants Developmentally Related Health Problems Crying (more than one to two hours of crying or fussiness/day) and/or colic Failure to thrive Child abuse, including shaken baby syndrome Sudden infant death syndrome Respiratory tract infections Ear infections Dental caries Strabismus and amblyopia Accidents are leading cause of death Respiratory tract infections Other communicable diseases Ear infections Dental caries Congenital defects are frequently corrected surgically during this time period Accidents remain the leading cause of death Communicable disease, including impetigo Dental caries Infestations (scabies, lice) Accidents Substance abuse (drugs, alcohol, nicotine) Homicide/violence Motor vehicle crashes Nonmotor accidents, e.g., roller blades, sports Dental caries Malalignment of teeth requiring orthodontics Increasing incidence of obesity and hypertension Child abuse Prolonged or unresolved grief Depression Suicide attempts, thoughts Homicide/violence Substance abuse
Toddlers
Preschoolers
School-aged children
Adolescents
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Table 3.1 Examples of Developmentally Related Health Problems

Developmental Level Young adults Developmentally Related Health Problems Hypertension Sexually transmitted diseases Substance abuse Domestic violence (e.g., battered woman syndrome) Testicular cancer Accidents (motor vehicle, sports related, e.g., swimming, boating) Homicide/violence Suicide attempts or thoughts Obesity Alcoholism Cardiovascular disease Cancer Accidents Mental health difficulties Chronic illness/disease (e.g., arthritis, osteoporosis, cardiovascular disease, chronic obstructive pulmonary disease, mild to severe hearing and vision impairment, cognitive dysfunctions, dementia)
Middle-aged adults
Older adults
(Berman et al. 2008) Illness Effects In addition to the physical effects of illness, such as fatigue, pain, or discomfort, illness causes varying degrees of change in role performance, understanding of the self, psychological functioning, spiritual integrity, family relationships, and finances. Alterations in role performance may include self-care deficit, need for increase in time to complete tasks, decrease in earning ability, and loss of autonomy or control. Alterations in the way a person relates to his or her own self may be expressed in changes in body image, self-concept, or self-esteem. Psychological and spiritual issues may arise, including fear of decreased functional ability, prolonged illness, inability to recover, or death. Other psychological issues may be anxiety, irritability, and depression. Spiritual issues may arise, including questioning the meaning of suffering. Illness of a family member impacts the family as a whole. Roles change. Tasks increase. A sense of separation, isolation, loneliness, or loss may occur. Customs and routines are interrupted. Financial threat may loom. The Sick Role Talcott Parsons (1972), a sociologist, described the role a person assumes when feeling sick. Sickness at least partially excuses a person from ordinary role functions within home, work, school, or other social settings. According to Parsons, sickness, which begins with the experience of signs or symptoms of illness and the assumption of the sick role, carries with it responsibilities that include a search for the health care needed to
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recover, dependence on health-care providers for recovery, and participation in recovery and/or rehabilitation behaviors. In other words, the patient is expected to assume responsibility for getting well as quickly as possible.
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Chapter 4: The Law and Nurse and Patient Rights and Responsibilities
Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Explain why it is important for nurses to have a basic understanding of the law. Explain the difference between civil and criminal law. Define torts and provide examples of intentional and unintentional torts. Explain the two types of restraints and provide nursing-specific examples for each type. Explain the need-to-know aspect of patient confidentiality. Describe what is included in a states nurse practice act. List and define the four specific elements that must exist beyond a reasonable doubt and in a court of law to prove that a nurse committed malpractice. Differentiate between criminal and common law. Identify clients legal rights guaranteed by the Patients Bill of Rights. Define at least four implications of the Health Insurance Portability and Accountability Act (HIPAA). Discuss the five basic rights used to protect human research subjects. Explain informed consent. Discuss the central ethical issue in the Cruzan case. Explain the purpose of advance directives and describe the various types. Discuss the purpose and focus of the ANA Code of Ethics for Nurses with Interpretive Statements.
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Key Terms
abandonment advance directive advocate American Nurses Association Code of Ethics for Nurses with Interpretive Statements assault battery breach of duty character defamation chemical restraints civil law common law criminal law do not resuscitate order durable power of attorney false imprisonment felony fraud gross negligence health care proxy Health Insurance Portability and Accountability Act of 1996 informed consent invasion of privacy law libel living will malpractice misdemeanor Nancy Cruzan case negligence nurse practice act Patient Self-Determination Act Patients Bill of Rights physical restraints power of attorney PRN professional liability right to anonymity and confidentiality right to fair treatment right to privacy right to protection from harm and discomfort right to self-determination slander statutory restriction tort
Introduction
Law refers to the principles and regulations established by authorities in a community and applied to its people. It can be in the form of legislation or customs and policies enforced by judicial decisions. This chapter explains why it is important for nurses to understand specific aspects of the law. We begin by comparing and contrasting the two primary subdivisions of law that directly relate to nursing: civil law and criminal law. We then investigate the definitions of intentional and unintentional torts and provide nursing-specific examples for each type of violation. In the section on intentional torts, we look at particularly sensitive nursing areas such as the use of restraints and the issue of patient confidentiality. We also consider unintentional torts and issues of nursing negligence, gross negligence, and malpractice. We then build on these legal issues related to nursing by identifying and discussing basic legal rights of clients in the health care system. We also consider clients rights when they are involved in human subject research and the issues of informed consent. In addition, we investigate the different types of legal advance directive documents that can be prepared by people when they are mentally competent. We also discuss the definition of a do not resuscitate order and its usual location in a clients chart. Finally, we explore nurses responsibilities to their patients, themselves, and their profession. The critical nursing role of an advocate is discussed and specific examples of advocacy are identified. The chapter concludes by defining the elements of the American Nurses Association Code of Ethics for Nurses with Interpretive Statements. The Code
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provides detailed guidelines to govern nurses responsibilities and obligations to patients, colleagues, employers, and society.
Nursing and the Law

Law is the branch of knowledge that deals with rules and regulations. The word law literally means laid down or settled. Law is all the rules of conduct established and enforced by various governing bodies and authorities (local, state, and national). This includes the accumulated decisions made by various courts. It is important for nurses to have a basic understanding of the subject of law because law governs most actions in nursing. A violation of law can result in severe penalties, including the revocation of a nursing license. Nurses are morally and ethically responsible for their actions. A violation of ethical principles related to nursing can make nurses legally liable for their actions as well. One specific example of law governing nursing practice is the nurse practice act from the state that the nurse works in. In a more general sense, a basic understanding of law makes the nurse a more informed citizen. Laws are generally based on community needs; this includes the community of the nation, state, and locality where one lives and the various communities to which one belongs, like the health care community in general and the nursing community in particular. The language of law may seem foreign, but it is important for nurses to have a working knowledge and understanding of some basic concepts in order to better understand their own legal responsibilities to patients and to ensure that patients are protected from injury or harm.
Primary Types of Laws

There are two primary subdivisions of law that directly apply to nurses: civil law and criminal law. Civil law, which generally involves the protection of both the person and personal property, is concerned with issues that arise between individuals or businesses. Civil law is also considered private law. Criminal law is a type of public law that is designed to protect society (the public) from harmful and criminal acts of individuals. Civil Law If ones person or property has been violated in some way, legal action (also known as a lawsuit) can be brought against another person, a group of people, or a business for breaking a civil law. People or businesses are considered guilty in a civil court of law if there is a preponderance of evidence against them. Penalties for violations of civil law might include compensation in the form of monetary remuneration and repair of any damages incurred.
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A violation of a civil law that results in personal injury or personal property damage is called a tort. A tort generally involves a violation of a personal right and is the most common violation of law in nursing practice. A tort can be a wrongful act, an injury, or some other type of damage affecting another person or a group of people. This can include verbal damage that results in psychological trauma, physical damage or injury, or even economic damage or loss. Torts can be classified as intentional (willful with the intent to cause injury or harm) or unintentional. Table 4.1 lists common torts that have occurred or could occur in nursing. Table 4.1 Torts
Intentional torts Assault Battery Abandonment Character defamation (libel and slander) False imprisonment Fraud Invasion of privacy Unintentional torts Negligence Malpractice Intentional Torts
In the legal sense, an assault is an intentional verbal threat or an attempt to inflict physical harm on someone that results in a reasonable and present fear of immediate physical danger. An example of assault is threatening another person with a gun (loaded or unloaded). Even if the person did not intend to shoot the gun or would not be able to injure anyone with the gun because it was not loaded, the person threatened would have no way of knowing that. Battery is any unjustified and intentional application of force. It can be the completion of an assault, or it can occur without assault having taken place. Battery implies that there was no verbal or implied consent to the physical contact that occurred. An example of battery would be slapping another persons face or physically forcing someone into a chair. Physically restraining a resident and forcing the resident to eat or drink could be considered battery. The use of force to defend oneself or others is usually not considered battery. Both assault and battery violate ones right to personal safety and security. Assault and battery are usually considered violations of civil law, but depending on the circumstances, they may also be considered violations of criminal law. Threatening and physically abusing a patient is an example of assault and battery that could be tried in a criminal court rather than a civil court.
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In health care, the most common case of abandonment is leaving a patient unattended. A patient admitted to a busy emergency room, placed on a stretcher, moved to the end of the hall, and forgotten by the ER staff could charge the hospital as well as an individual health care worker with abandonment. Abandonment can also be charged if a health care professional begins emergency first aid at the scene of an accident and then leaves the scene before another competent health care worker arrives to take over. Character defamation means attacking or injuring the reputation of another person by making false and malicious statements. Two specific types of character defamation are libel and slander. Libel is defamation of character that occurs through printed statements, including written words, photos, or some other representation of the person (for example, a cartoon). Slander is verbal defamation of a persons character. Character defamation violates the right to maintain and enjoy a good reputation. There are frequent examples of character defamation in the media today, especially in relation to celebrities who sue tabloid newspapers for libelous statements about them. People running for political office may experience character defamation in the form of slander. Examples of libel in nursing might involve false statements written about a patient in a chart. Slanderous statements might also be made about a patient by one nurse to another nurse and overheard by the patient or the patients relative. Verbal character defamation of a coworker can also constitute slander. False imprisonment, or unlawful detention, is another common tort. To imprison means to restrict, limit, or confine in any way. To detain means to keep from going on or to hold back. With this tort, imprisonment or detention must have occurred against the persons will. The detention or imprisonment also must have prevented the person from moving about freely and must have been accomplished by threat, force, or command. False imprisonment violates a persons right to personal liberty or freedom. In health care settings, it is usually considered a violation of civil law. In nursing, an example of false imprisonment is applying some type of restraint (for example, a wrist or waist restraint) on a patient without a physicians order and for the convenience of the nursing staff. There are two types of restraints: physical restraints and chemical restraints. Physical restraints include cloth devices that limit movement of ones hands, extremities, or torso. Side rails are considered a physical restraint if they are used for reasons other than mobility; half side rails may be considered an assistive device rather than a restraint but must be specifically ordered as such. Chemical restraints are medications given to prevent or moderate certain behaviors like agitation or physical violence. These are usually psychotropic medications. There must be a medical reason for a chemical restraint, like a diagnosis of dementia with severe agitation. Restraints might be ordered if there is a reasonable fear that patients might harm themselves by pulling out an intravenous line or a feeding tube, for example. In rare instances, a patient might be restrained for striking other patients or staff; for example, a patient in an emergency room who exhibits violent behavior might be restrained. The general rule for restraints is that all possible alternatives must be explored.
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Most nursing homes and hospitals now have restraint-free environments or are working toward this goal. If physical restraints must be used, the only valid and legal reason for their use is to protect patients from harming themselves. A physicians order is always needed for a restraint, and the order must include the type of restraint, the reason for the restraint, the length of time the restraint is to be applied, and criteria for restraint removal. Restraints cannot be ordered PRN. (PRN means on an as-needed basis; a PRN order for a restraint would mean that the nurse could decide whether to use the restraint.) Only in an emergency situation would a nurse be justified in using a restraint without a physicians order. Research has shown that restraints have contributed to falls and other injuries that might have been more severe than injuries that could have occurred if the patient had fallen without being restrained. Improper use of restraints can result in health professionals and institutions being charged with negligence if injury to a patient occurred and also with assault or false imprisonment if evidence indicates that a restraint was not needed. Regulatory agencies look carefully at reasons for any types of restraints ordered for hospital patients or nursing home residents and may cite facilities with violations if surveyors believe that a restraint was ordered or applied unnecessarily. Fraud is an intentionally false statement made by one person to another with the intent to deceive the other person (usually for financial gain). There are numerous instances of this in society in the form of insurance fraud, which often involves fraudulent claims made to vulnerable people like the elderly. Historically, health care institutions have been convicted of specific types of fraud, such as Medicare or Medicaid fraud, which usually involves falsifying records for financial gain. Fraud can be a violation of either civil law or criminal law. Invasion of privacy, or breach of confidentiality, is another tort. In general, the right to privacy prohibits the use of ones name, picture, or even likeness for commercial or advertising purposes without specific written consent. This also prohibits unauthorized release of any data about patients diagnoses and treatments. Personal privacy can also be violated when nurses or other health care personnel fail to take steps to ensure privacy (for example, not closing a door not when giving a bath or not pulling a curtain around a patients bed when doing a treatment). The issue of confidentiality specifically related to patient information frequently surfaces in nursing practice. The law is clear that any information about a patient can only be given to other health care workers who are involved in the patients care and need to know the information. Information can be given to other people only with the patients permission or the permission of a legal guardian of the patient. Visitors might stop at nursing stations and ask how a patient is doing or friends of a patient might even call nursing stations. Without permission, nurses are not allowed to divulge information; otherwise, a patient can sue for invasion of privacy. Patient records are also considered confidential and are to be viewed and used only by people involved in diagnosis, treatment, and general care of the patient. There might be times when confidential information can be disclosed without fear of litigation, such as when a patient threatens to commit suicide or to injure someone else. Reporting child or adult abuse or suspected abuse may also necessitate revealing confidential information.
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Unintentional Torts
Negligence means failure to do the required thing or to exercise the reasonable amount of care that a person of ordinary prudence in a similar circumstance would. Negligent acts may result in injury to another person or in damage to property owned by another person. Negligence is an example of an unintentional tort that can be committed by anyone, irrespective of training. The person who commits negligence is usually unaware that he or she has failed to exercise a reasonable amount of care until an accident occurs, causing damage, injury, or even death of another person. Investigations are often conducted following plane crashes, for example, to determine if negligence on the part of anyone who serviced or flew the plane may have occurred. In nursing, an example of negligence might be the following scenario: A call bell on a patients bed is broken. The patient knows not to get out of bed unassisted. The patient reports that the call bell is broken when the nursing assistant comes in to administer a bath. The nursing assistant fails to notify the maintenance department. The patient needs to use the bathroom and is unable to summon help. The patient gets up unassisted, falls, and fractures a hip. Another example of negligence is failure to assess that a patient has developed a serious medical condition because symptoms leading up to the condition that should have been obvious to the nurse and reported to a physician are ignored. (This example might also be considered malpractice, depending on patient outcomes.) Gross negligence has been defined in Missouri as a deviation from the professional standards so egregious that it demonstrates a conscious indifference to a professional duty (Duncan v. Missouri Board for Architects, Professional Engineers, and Land Surveyors 1988). Texas law defines gross negligence as more than momentary thoughtlessness, inadvertence, or error in judgment but an entire want of care as to establish that the act or omission was the result of actual conscious indifference to the rights, safety, or welfare of the person affected (Convalescent Services v. Schultz 1996). An example of gross negligence occurred in the case of a nursing home resident who was admitted from a hospital with an initial stage I or II decubitus ulcer. Nursing care was deemed to be substandard in many respects. The nursing home staffs failure to turn the resident every two hours, to notify the residents physician of his deteriorating condition, to give the resident whirlpool baths and a special mattress as ordered, to attend to the residents nutritional needs, and to start a separate nursing skin-care flow sheet was cited during the hearing. The primary evidence against the nursing home was lack of any nursing documentation, specifically in respect to turning the resident. The nursing home was sued for both negligence and gross negligence following the residents readmission to the hospital with a stage IV decubitus ulcer with bone exposure (Legal Eagle Eye Newsletter 1996). Malpractice is a special type of negligence and also an unintentional tort that can involve omissions as well as commissions. Malpractice means misconduct or improper practice by any professional or official (though in the public mind, it is usually associated with physicians) that results in injury or harm. Nurses have also been found guilty of malpractice when carrying out professional duties. Malpractice may cause a patient to experience physical injury, emotional suffering, or even death due to poor professional judgment, lack of knowledge and skill in treatment and care, or lack of fidelity or
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faithfulness to carrying out the practices of the profession. Malpractice lawsuits are frequently brought against health care professionals who have knowingly or unknowingly engaged in unprofessional behavior. Often in malpractice suits, more than one professional as well as the employing institution will be sued. In nursing, malpractice could occur if nursing practice fails to coincide with acceptable standards of nursing care. One example of acceptable standards of care would be the nurse practice act of the state in which the nurse is licensed and practices nursing. Each nurse practice act includes information about the boundaries of the scope of nursing practice, types of nursing licenses, licensure requirements, and grounds for disciplinary action and revocation as well as a definition of nursing. If a nurse engages in an activity not identified as a nursing function by the nurse practice act, this could be considered a breach of standards of care or a breach of duty. Breach of duty has been defined as a failure to act as a prudent professional, according to the standard of care for the profession in a particular situation (Fiesta 1988). Malpractice suits have been brought against nurses for failing to carry out a physicians order and for carrying out orders that were not correct (for example, giving the wrong dosage of a drug). Improperly identifying a patient could lead to a malpractice suit if the patient receives the wrong treatment, such as an incompatible blood transfusion. There have also been cases in which the wrong patient was operated on or the wrong organ or limb was removed because of faulty identification. Proof of malpractice in nursing is dependent on the existence of four specific elements, all of which must be proven beyond a reasonable doubt in a court of law: 1. 2. 3. 4. Duty: The nurse who is being sued must have been responsible in some capacity for the care of the patient. Breach of duty: The nurse failed to provide acceptable care according to nursing standards of care. Causation: The failure to provide acceptable nursing care caused the injury. Injury: Harm must have occurred and be proved.
Negligence and malpractice, as stated previously, are considered unintentional torts; with an unintentional tort, the court would consider there to have been no deliberate attempt to harm a person. All of the other torts are generally considered intentional torts. Criminal Law Criminal law is law that is designed to protect the public from harmful and criminal acts of individuals. It is concerned with the peace, order, and protection of all members of society. The public welfare can be threatened or disturbed when certain types of crimes (for example, theft or murder) are committed. Depending on the nature of the crime and other factors such as the age, the number of prior offenses, and the perceived motive of the perpetrator, punishment for violations of criminal law varies. The court process is designed to ensure that the person accused of a crime has a fair trial and is not unjustly accused. In a trial, the accused party is called the defendant. In criminal cases, guilt
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must be proved beyond a reasonable doubt in order for the defendant to be convicted of a crime. Nurses and other health care workers can be guilty of the same things that individuals in society are guilty of, though the location of the crime may be a health care venue. Three specific examples of violations of criminal law in nursing could be negligence, physical or psychological patient abuse, and assisted suicide. Criminal acts of nurses could also include violations of specific laws governing nursing practice such as the nurse practice act of the state where the nurse practices. Even if no injury is incurred by a patient, a nurse who is accused of violating a specific law could be found guilty of a crime. This highlights the need for nurses to be aware of the content of their states nurse practice acts. Various places of employment also have institutional standards of practice. Adhering to acceptable standards of practice can help protect health care workers from litigation (lawsuits) or allegations of professional liability. To be liable means to be legally bound, obligated, or responsible for ones actions. Professional liability means that professionals are under obligation to practice according to the standards of their profession. There are two classifications of crimes: misdemeanors and felonies. Misdemeanors are less serious crimes. Punishment for a misdemeanor is often a fine. Examples of misdemeanors in nursing are theft of a patients possessions and pushing or striking a patient. Felonies are considered more serious crimes. Punishment for a felony might include fines, incarceration in a prison, loss of some privilege such as a drivers license or a license to practice ones profession, or a probationary period, which frequently involves some type of public service. Examples of felonies that have occurred in nursing include falsification of narcotic records or of research study information, withholding life support from a terminally ill patient, and administering a drug to hasten death. For example, two clinical research nurses were convicted of felony charges in California for falsifying information for a drug-related study on patients. One of the nurses who acted as a study coordinator was being paid for providing specimens of her own urine, which routinely tested positive for protein; patients who did not meet study eligibility criteria were also enrolled in the study by these nurses. They were subsequently debarred by the Food and Drug Administration (FDA) from working in a clinical research capacity (PharmSource Information Services 2003). Common Law Common law can be defined as the law of a country or a state based on common customs and the various accumulated judicial decisions and opinions of law courts. Common laws may change over time and may not apply to every individual. One example of the application of common law in society can be seen when a business like a topless bar tries to locate in a neighborhood; typically there are people in the community who protest. The court would examine the standards of the community as a whole, and a ruling could be based on the prevailing customs of the community.
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Clients Rights
Nurses often are in positions of advocacy and need a clear understanding of clients rights in relation to health care and the health care system. Health care facilities post a Patients Bill of Rights in public places and give copies to each new client on admission. The following are considered some important legal rights of clients: The right to choose a provider. Clients should be able to choose a specific physician or nurse practitioner for their care, though external limiting factors often occur, for example, in family practice settings, physicians may state they are unable to take on any more new clients. The right to treatment in an emergency. Even if they are unable to pay and are without insurance, people have a right to emergency medical care, including transportation to the hospital via a local emergency transportation system. This does not exempt them from future payment obligations, however. The right to receive treatment in a hospital of their choice. This is generally a right, though sometimes hospitals may need to divert patients coming in for emergency treatment to other hospitals due to issues like lack of beds or lack of appropriate personnel to handle particular cases. The right to receive an acceptable standard of care without discrimination. Health care agencies are regulated by a variety of governmental or voluntary agencies that provide guidelines for acceptable standards of care for people of all ages. The right to privacy. National standards have been set to protect patient privacy and the privacy of personal health information. The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that gives people rights to privacy over their health information. All health care facilities are mandated to have patients read and sign an information sheet concerning this law. The law sets limits and rules on who can access private health information. Health information cannot be shared without a patients written permission unless the law allows it. All health care employees receive mandated training on privacy rules and regulations. The right to informed consent. Prior to receiving any treatments, including diagnostic tests and surgery, clients must be fully informed of the purpose of the treatment or procedure and voluntarily make a decision to receive or reject the test or treatment. Issues of informed consent are also applicable in research situations. The right to make their own choices concerning quality-of-life and end-oflife issues. This includes the right to refuse certain treatments to maintain or extend life. The criterion of mental competency is considered with respect to this right.
Statutory restrictions may apply to some of the foregoing rights. A statutory restriction is a legally binding or lawful restriction. An organization like a Health Maintenance Organization (HMO), for example, may legally restrict an enrollees or subscribers choice of a primary physician or other provider to those in a preselected group, specified
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in its evidence of coverage. The HIPAA law generally allows a parent to have access to the medical records about his or her child as his or her minor childs personal representative, when such access is not inconsistent with state or other statutory restrictions. If a minor child received medical care under court order, for example, the parents may be restricted from seeing the childs health records. Rights about Human Subjects in Research Human research subjects are protected by a special set of rights. There are five basic rights that are based on ethical principles of research. These include the following: 1. 2. 3. 4. 5. Right to self-determination Right to privacy Right to anonymity and confidentiality Right to fair treatment Right to protection from harm and discomfort
The right to self-determination is predicated on the assumption that people have the right to autonomous decisions, free of coercion. Researchers are obligated to fully inform potential research subjects of the purpose of any study and allow them to make an informed decision about agreeing to participate in the study. They are also free to withdraw from a study at anytime. Subjects must also be informed that refusal or withdrawal from a study will not adversely affect their care in any way. There should be no external pressure placed on a person to agree to participate in a study. A right to selfdetermination and the ethical principle of personal respect would be violated if a patient was entered into a study without his or her knowledge or consent. Special care must be taken with human subjects considered especially vulnerable to coercion, for example, minor children, the mentally and cognitively impaired, the terminally ill, the frail and elderly, and prisoners who are confined to institutions. The right to privacy for research subjects means they alone have a right to share information about themselves with the researcher; this is a right related to informed consent. Information should not be shared outside the study without the human subjects permission. During the study there may be times when the study participant would prefer privacy to being interviewed or observed; researchers must respect this right. The right to anonymity and confidentiality means that once a study is completed, no one should be able to link any aspect of the study results to a specific subject. Generally, this is accomplished through some type of coding system for quantitative research; in qualitative research, names and some identifying information are generally changed to ensure anonymity. Confidentiality means the researcher can only share study information as indicated by the terms of the study. Articles are often written for publication keeping this principle in mind; researchers should not share any identifying information about human subjects in conversations with other health care personnel, friends, or family.
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The right to fair treatment and the right to protection from harm and discomfort are related to the principle of justice. There should be clear and compelling reasons for choosing certain subjects for a research study, and study subjects must be ensured they will receive fair and safe treatments. This can be particularly important in the case of randomized clinical drug trials, and whenever vulnerable subjects are included. Historically, this right has been violated in research, for example during World War II when many life-threatening medical experiments were conducted in Germany in concentration camps. Benefits for human subjects should outweigh risks; there may be times when temporary discomfort occurs, but this should fall under the category of minimal risk. Human subjects must be made aware through the informed consent process of any potential risks from study participation. This may include emotional risks when highly personal information might be shared, for example women who might agree to participate in a study and share their personal stories of abuse. Informed Consent for Treatment or Research Consent forms for various treatments and procedures, including surgery, should be in writing, signed, and witnessed. Usually surgeons are responsible for surgery consent forms and anesthesiologists are responsible for anesthesia consent forms. Nurses may also be responsible for some consent forms, such as those involving patient participation in nursing research studies. All consent forms should be signed with informed consent (i.e., patients should be aware of all the procedures, proposed benefits, and risks of surgery or special procedures as well as the potential side effects from medications that might be used for treatments; usually these are put in writing). A person must be mentally competent to sign an informed consent form. Patients must be able to fully understand the information and the implications of the consent form that they sign, or the signed consent will not be legally valid in a court of law. For people who are not considered competent to legally sign a consent form (for example, people with advanced dementia, people who have suffered a stroke that results in cognitive impairment, and people with a developmental disability), informed consent can be obtained from their legal guardians. In emergency situations in which a person is unconscious, others (such as a spouse, child, or parent) may be able to sign a consent form for emergency treatment or surgery. In an emergency situation two physicians are required to sign a consent form for surgery. The legal age for consent varies from state to state; depending on state laws, minors may or may not be able to consent to certain procedures. Consent should also be solicited for all nursing activities, such as changing a dressing or giving an injection. In these cases, consent can be verbal or behavioral (which is called implied informed consent) rather than written or signed (which is called expressed informed consent). In both cases, consent must be voluntary. An example of behavioral or implied informed consent occurs when a nurse asks a patient to elevate his leg so that she can change a dressing. If the patient does elevate his leg, consent is implied. The person responsible for obtaining informed consent depends on the situation; it is usually the responsibility of the person who will be providing a treatment, doing a diagnostic test, or conducting research. If there is any doubt about a nurses role in obtaining informed consent, the nurse should clarify the correct procedure with a supervisor.
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Patients have the right to change their minds after consent is given. The patients right to stop a treatment, refuse surgery, or drop out of a research project overrides the original consent. A statement indicating this is generally included in a consent form. If a patient believes that he or she was not adequately informed about a treatment or procedure or that he or she was coerced in any way, the patient could conceivably file a lawsuit for battery. End-of-Life and Quality-of-Life Issues and Rights Ethical dilemmas often arise surrounding issues of technological advances and end of life and quality of life. One question that new technology has raised is: Should life be preserved at any or all costs? One argument raised in ethical discussions about end-oflife procedures is often related to the economic costs to individuals, families, and society. Other arguments might focus on the emotional costs for individuals and families who are struggling to make end-of-life and quality-of-life decisions.
Cruzan Case
Withholding nutrition or hydration is one ethical issue related to the quality and extension of life that nurses are often faced with in hospitals, nursing homes, and home care situations. The most well-known case that publicized this issue was the Nancy Cruzan case. Following a car accident in 1983, Cruzan, then age twenty-five, was resuscitated at the accident scene but never regained consciousness; a gastrostomy tube was instituted to maintain nutrition and hydration. Months after the accident, her parents made a request to the hospital and their daughters physician that the feeding tube be removed. Cruzans physician and the hospital refused to remove the feeding tube, and the case went to court. Initially, a judge ruled that the tube could be removed at the parents request, but the Missouri court appealed the decision. The court claimed that it was in the states best interest to preserve life and that Nancy Cruzan was not terminally ill, nor did she appear to be suffering; the court claimed that there was no clear and convincing evidence that she would want the tube removed. The Supreme Court upheld this decision after an appeal by the parents. In 1990, the parents again appealed to a local court, saying that prior to the accident, their daughter had indicated to friends that she would not want to be kept alive if she ever had to live in a vegetative state. Cruzans physician also agreed that it was no longer in her best interests to continue artificial nutrition. The tube was removed, and Cruzan died two weeks later (Cruzan v. Director, Missouri Department of Health [MDH] 1990). The Cruzan case was highly significant. As a result of the Cruzan decision, the Patient Self-Determination Act was passed and became effective in December 1991. This act stipulated that any facility receiving federal Medicare reimbursement must inform patients about their right to refuse treatments like artificial hydration and nutrition. Facilities are also required to ask patients if they want to prepare an advance directive like a living will or a durable power of attorney for health care and to specifically indicate in writing their wishes concerning such things as resuscitative efforts and the institution and withdrawal of supportive and life-sustaining therapies like artificial nutrition and hydration. Physicians are also required to include specific DNR (do not resuscitate)
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orders in charts if patients choose that option; prior to the Cruzan ruling, there was no universal formal mechanism for this in patients charts (Pence 1995). Nurses might be asked questions by patients and their family members about their right to treatment or their right to refuse treatment. A nurse might also care for a patient who has made an end-of-life decision that the nurse may be uncomfortable with or may disagree with; it is important for nurses to acknowledge their own beliefs and values in emotionally charged practice situations and to seek appropriate support and counsel.
Advance Directives
Advance directive is the umbrella term for various types of written legal documents that are prepared by people when they are mentally competent and preferably in good health. A durable power of attorney, a healthy care proxy, and a living will are all examples of advance directives. These documents are prepared in advance of any need for them and include specific instructions or directives for family members and health care workers about the use of various medications, procedures, and treatments for the person if he or she is faced with a chronic or terminal illness or a life-threatening situation in which the patients physical and mental condition may render him or her incapable of making autonomous decisions. All advance directives need to be signed by the person desiring the directive and by another person (known as a witness) who is not a relative, an heir to the patients estate, or an employee of a health care institution. Some also need to be notarized by a notary public. Copies of advance directives are placed in patients charts and are also generally kept at home and often given to family physicians as well. As a result of the Omnibus Budget Reconciliation Act (OBRA) of 1990, all states are required to provide patients with the option of preparing advance directives. Living Will A living will is a written legal document that a person prepares and signs when he or she is mentally competent. A living will includes specific instructions about various measures that may prolong and affect the quality of ones life. This can include the persons wishes regarding the following: Tube feeding institution and maintenance The use of intravenous fluids for treatments, hydration, or nutrition Antibiotic use in a terminal stage of illness Intubation and ventilation Manual cardiopulmonary resuscitation and defibrillation (electric shock to the heart) in case of cardiac arrest
A living will may also include information about whom patients desire to be their power of attorney or health care proxy should they be unable to make their own decisions in the future. Power of Attorney A power of attorney is a written statement and legal document that authorizes one person to act as a proxy or surrogate for another person under certain conditions. There
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are various types of powers of attorney; the most comprehensive is the durable power of attorney. Like a living will, a durable power of attorney should be prepared and signed when a person is mentally competent or it will not be honored in a court of law. When a person signs a durable power of attorney, that person is essentially relinquishing his or her decision-making capabilities about health care decisions to another person in the event that he or she becomes mentally or terminally ill or physically or mentally incapacitated and unable to make autonomous decisions. Whoever acts as ones durable power of attorney is able to make financial decisions for the person; a general durable power of attorney (compared with a limited power of attorney) can also make the persons personal decisions. The power of attorney can act only if the person becomes incapable of making decisions concerning his or her health and well-being. Because this document obligates the person designated to abide by the wishes of the person preparing it, the designated person must understand future responsibilities and agree to take on this role if needed. In health care facilities, a power of attorney may also contain specific information about procedures that the person may or may not wish to have instituted or maintained if he or she becomes incapacitated. These include beginning, maintaining, and discontinuing various life extension and life support measures, such as tube feedings, intravenous medications, resuscitation, intubation and ventilator support, pain management, and comfort care measures. Preferences about organ donation are also usually included in this document. Health Care Proxy A health care proxy is similar in some ways to a durable power of attorney, but it does not involve financial decision making and is generally less formal in nature. The person designated verbally or in writing by a patient as his or her health care proxy would be able to make autonomous decisions about health care issues in the event that the patient becomes unable to do so and has not indicated in writing any advance directives with respect to end-of-life decisions. Powers of attorney and health care proxies must be considered competent of making decisions. Do Not Resuscitate Orders DNR is the abbreviation for do not resuscitate. Although the patients desires about resuscitation may be noted in a living will, hospitals and nursing homes generally have a separate DNR form or order as well. A do not resuscitate order in a chart means that if a patient has a cardiac or respiratory arrest, no attempt should be made to revive the patient. The DNR order is usually placed in the front of the chart. Every place of employment has its own procedure manual that details what health care staff should do when patients with or without DNR orders arrest; nurses should be familiar with these procedures. Nurses working in environments in which patients are frequently transferred (for example, from a nursing home to a hospital) need to remember that a copy of the DNR order is usually transferred with the patient. This is often the responsibility of the nurse in charge of a unit.
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Nurses Rights and Responsibilities

Nursing Responsibilities Because of patient or consumer rights, nurses have certain responsibilities, many of which are identified in the various nursing codes. Nurses have the responsibility, for example, to exercise professional competence in accordance with the standards of professional nursing. In addition to responsibilities to their patients, nurses have a responsibility to themselves to identify and know their own personal and practice limitations. They have a duty to participate in the growth of the profession as well as to actively seek continuing education to further their own knowledge and keep abreast of current practices. Accepting an assignment that a nurse does not feel personally or professionally equipped to handle could be considered an ethical violation and could result in legal action if harm comes to a patient. Nurses may also act as a patients advocate in situations in which the patients rights are violated or in danger of being violated. In some cases, nurses may need to advocate for themselves if they believe that their own rights are being violated or may need to advocate for their profession as a whole. Examples of situations in which a nurse might act as an advocate include the following: A hospitalized patient believes that he or she signed a consent form to be in a randomized clinical trial research project without full knowledge and understanding of the possible side effects of a medication that he or she might receive. A nurse believes that he or she has been falsely accused of unethical behavior by a colleague. A nurse believes that a serious nursing shortage in the hospital is contributing to increased death rates on the intensive care unit.
In each of the previous cases, the nurse can act as an advocate by voicing concerns, ideally through the appropriate chain of command in the health care facility. Ethical Codes for Nurses Ethics in nursing always relates in some way to professional judgment and professional practice. A number of ethical codes have been developed for the nursing profession by nurses. Nursing codes make explicit the primary goals, values, and obligations of the nursing profession (American Nurses Association 2001). Two of these codes are the American Nurses Association Code of Ethics for Nurses with Interpretive Statements (2001) and the ICN Code of Ethics for Nurses (2000). Codes of ethics, like nursing practice standards, are considered part of the regulatory criteria for professional nursing.
The ANA Code of Ethics for Nurses with Interpretive Statements
The American Nurses Association Code of Ethics for Nurses with Interpretive Statements (2001) does not address specific ethical dilemmas in nursing but is designed
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to provide detailed guidelines that can govern nurses responsibilities and obligations to patients, colleagues, employers, and society as a whole. Originally drafted in 1985 as the American Nurses Association Code for Nurses with Interpretive Statements, it was revised and renamed in 2001. The ANA Code of Ethics for Nurses with Interpretive Statements focuses on some of the following key ethical issues for nurses. (Interpretive statements flesh out the general statements of the code and make them more practical.) Respect for human dignity and the uniqueness of all patients or clients The patients or clients right to privacy and the need to maintain confidentiality The responsibility to practice in a safe, competent, ethical, and legal manner Responsibility and accountability for nursing judgments and actions The need to be involved in upgrading professional standards of nursing The right to safeguard the patient and the public from any unethical or unsafe behavior
The focus of the code is both broad with respect to the welfare of the general public and specific with respect to the individual patient or client. Nurses are personally and professionally accountable to this code. One aspect of professional accountability requires reporting unethical conduct of other health care personnel, which is a difficult ethical dilemma that nurses may be faced with. A copy of the complete ANA Code of Ethics for Nurses with Interpretive Statements can be ordered online through http://nursingworld.org/books. An excellent independent study module on the ANA code can be found at http://nursingworld.org/mods/mod580/code.pdf. Kevin Hook and Gladys White, both nurses and authors of the module, trace the evolution of nursings code of ethics beginning with the Nightingale Pledge of 1893. They note that the primary concerns of many ethical codes for nursing include doing no harm, benefiting others, and practicing with loyalty and justice.
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UNIT II: PRINCIPLES OF BASIC CARE AND COMFORT

Chapter 5: Pain and Pain Management
Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Explain the nursing definition of pain, the two principles supporting the definition, and the three categories of pain. Describe the various origins and locations of pain. Describe the various concepts associated with pain. Describe the seven standard pain related assessment areas used to develop intervention strategies. Explain the harmful effects of acute and chronic pain. Discuss the importance of understanding the effects of pain on ADLs, the patients use of coping strategies, and the patients emotional response. Describe the behavioral and physiologic responses indicating pain. Provide an overview of the physiology of pain including peripheral mechanisms, central mechanisms, and pain perception. Explain the gate control theory and discuss the various pain management measures based on gate control theory. Explain the bodys response to pain and the psychology of pain. Discuss common myths held by providers and clients related to pain and pain management. Discuss special considerations related to management of pain in children. Explain the World Health Organizations ladder approach to cancer pain management. Define placebo and placebo effect, and discuss nursing guidelines related to their use. Identify and define the three general categories of analgesia agents and identify the routes, goals of treatment, and common side effects for each category. Differentiate between the traditional pro re nata (PRN) approach and a preventive approach to pain control. Explain patient controlled analgesia (PCA), the delivery routes that use PCAs, and the resulting implications for education of the patient and family. Describe the various nonpharmacologic interventions for pain control. Discuss the significant assessment areas related to comfort and pain. Discuss the major nursing roles in pain management. Apply each phase of the nursing process to pain management.
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Key Terms
acute pain biofeedback bradykinin breakthrough pain chronic pain cutaneous pain deep somatic pain drug tolerance endorphins enkephalins gate control theory guided imagery intractable pain multimodal (balanced) analgesia myelinated A-delta fibers narcotic addiction neuromodulation neuropathic pain nociceptors non-nociceptors non-noxious stimuli noxious stimuli pain pain reaction pain syndromes pain threshold pain tolerance patient controlled analgesia (PCA) phantom pain phantom sensation physical dependence placebo placebo effect radiating pain referred pain substance P transcutaneous electrical nerve stimulator (TENS) unit unmyelinated C fibers visceral pain
Introduction
Historically, the goal of pain management was reducing discomfort to a tolerable level. With the advent of evidence-based research that illustrates the harmful effects of uncontrolled pain, the goal of making the pain tolerable has been replaced by the goal of relieving the pain. The nurse spends more time with the patient in pain than any other health professional and, because of this, plays a critical role in pain management and control. The purpose of this chapter is to provide an overview of the types and characteristics of pain, effective pain management, and the nurses role in pain management and control. We begin our discussion by looking at the nursing definition of pain (i.e., whatever bodily hurt the client says exists, whenever the client reports it hurts). We then discuss the two important nursing principles upon which this statement is based. We also look at the types of pain and discuss the origins and locations of the ten most common categories of pain. After this, we define the three pain-related subjective concepts that only the patient can identify and define. We also consider the essential characteristics of pain and effective nursing-assessment strategies. Our discussion then turns to the harmful effects of uncontrolled acute and chronic pain and the effects of pain on activities of daily living. We look at the physiology of pain, including information on peripheral and central nervous system factors involved in pain perception and response. We also discuss the gate control theory and its implications on pain management. In addition to these physiological responses to pain, we also consider the psychology of pain and some common psychological reactions of patients who are experiencing pain. We discuss pain misconceptions and the importance of the nurses awareness of pain-
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related myths. This awareness allows the nurse to be both an educator for the patient and family, as well as a patient advocate, so that appropriate pain management can be achieved. We take a special look at the issue of pain management among children and the World Health Organizations ladder approach to cancer pain management. In addition, we investigate the misconceptions about placebos and the placebo effect. Our discussion then shifts to pharmacologic pain interventions and we look at the current standard of practice for balanced pain management. We also consider the different analgesia agents used to attain and maintain good pain control. We then investigate nonpharmacologic interventions and eight basic factors that influence a persons response to both comfort and pain. The chapter concludes with a discussion of the nursing process as it applies to the nurses role in effective pain management.
The Definitions of Pain

The nursing definition of pain is whatever bodily hurt the client says exists, whenever the client reports it hurts. In nursing, the cardinal rule for pain management is that all pain is real, even if its cause is unknown. Validation of the fact that pain exists is based simply on the clients statement that it is there. This definition is founded on two important principles: 1. The client is always believed: Assessing pain involves collecting information from the client on both the physical causes of pain and any mental or emotional stimuli that influence the individuals perception of pain. Nursing interventions are geared to meet both of these areas. A nurse who suspects pain when a client denies it explores the concern with the client: Knowledge of nonverbal, pain-related cues is essential to quality care. Sometimes, clients are hesitant to admit pain even in situations in which it is expected to occur. Perception is reality: The nurse is ethically obligated to record the pain intensity just as it is reported by the client. Not believing the clients assessment jeopardizes the therapeutic relationship and prevents fulfillment of the advocacy role called for in the American Nurses Associations Pain Management in Nursing: Scope and Standards of Practice (2005).
2.
3.
Types of Pain Generally, three basic categories of pain are recognized: acute, chronic, and cancerrelated pain. These categories are defined in the following sections.
Acute Pain
Acute pain is of recent onset and is usually associated with a specific illness or injury. The pain indicates that tissue injury or damage has occurred. If the client has suffered no permanent damage, the pain usually resolves with healing. By definition, acute pain lasts less than six months, but it generally disappears after one month.
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Injuries or diseases that cause acute pain may require treatment or may resolve spontaneously. For example, a fracture would require medical treatment, and the pain would decrease as the bone healed. A prick of the finger with a needle, on the other hand, would result in pain, but that pain would rapidly subside. In acute pain, the client appears restless and anxious and generally reports that the pain exists. He or she may also exhibit behaviors that are indicative of pain. Some of these behaviors include crying, rubbing the injured site, or holding the area. Physiological changes are also apparent with acute pain. Some of these include increased pulse and respiratory rates, elevated blood pressure, diaphoresis, and dilated pupils.
Chronic (Nonmalignant) Pain
Chronic pain is constant or intermittent pain that persists over a period of time. Many clinicians use the interval of six months duration to define pain as chronic. Six months is an arbitrary period for differentiating acute from chronic pain. Indeed, some pain may have chronic characteristics long before six months, while some may remain primarily acute in nature for longer than six months. The reason why some people develop chronic pain after an injury or disease is not known. Some pain experts believe that the pain may result in nerve-related changes. For example, nerve endings that normally do not transmit pain may develop the ability to evoke painful sensations, or nerve endings that normally transmit only noxious (painful) stimuli may transmit previously non-noxious (nonpainful) stimuli as painful stimuli. Clients with chronic pain may appear depressed and withdrawn. Often, these clients will not mention their pain unless directly asked by the provider. Additionally, the overt painrelated behavior seen with acute pain is often absent, as are the physiological responses. Parasympathetic nervous system responses to chronic pain include normal vital signs; dry, warm skin; and pupils that are normal or dilated. Table 5.1 further compares the characteristics of acute and chronic pain. Table 5.1 Comparison of Acute and Chronic Pain
Area Vital signs Acute pain Increased pulse, respirations, and blood pressure; diaphoresis; dilated pupils Mild to severe Sympathetic Related to tissue injury; resolves with healing Clients behavior is indicative of pain (e.g., crying, rubbing or holding affected area) Client reports pain Chronic pain Normal vital signs
Intensity Nervous system response Etiology Client behavior
Mild to severe Parasympathetic Continues beyond healing Pain behavior often absent
Client response
Client often fails to mention pain unless asked
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Cancer-Related Pain
The nature of cancer-related pain can either be acute or chronic. The fear of cancerrelated pain is so pervasive that in newly diagnosed cancer clients, it is second only to the fear of death. Cancer-associated pain can result directly from the cancer (e.g., nerve compression or infiltration of cancer cells into the bone), from cancer treatment (e.g., surgery or radiation), or from pain that is not directly associated with the cancer (e.g., injuries). Most cancer-related pain, however, is the direct result of tumor involvement. Origins and Locations of Pain Pain can also be categorized according to its point of origin. Some of the more common categories are as follows: Cutaneous pain originates in the subcutaneous tissue or skin. A paper cut that causes a sharp pain is an example of cutaneous pain. Deep somatic pain comes from injured ligaments, bones, tendons, blood vessels, and nerves. This type of pain lasts longer than cutaneous pain. An example of deep somatic pain could be an ankle sprain. Visceral pain results from the stimulation of pain receptors in the thorax, abdominal cavity, or cranium. Visceral pain sometimes feels like deep somatic pain (i.e., burns, aches, or gives the sense of pressure). Tissue stretching, muscle spasms, or ischemia frequently cause this type of pain. Referred pain is felt in a part of the body that is considerably removed from the tissues causing the pain. Examples of this include gallbladder pain in the right shoulder, cardiac pain in the center of the back, and kidney pain on the lateral aspect of the thigh. Radiating pain is initially perceived at the source of the pain and extends to nearby tissues. Cardiac pain, for example, may be felt in the chest and then down the left shoulder and arm. Neuropathic pain is the result of disturbances in the peripheral or central nervous system that result in pain. It may or may not be associated with ongoing tissue damage. This type of pain is described by clients as shooting or stabbing and is often severe. The vast majority (estimated at 95 percent) of people with AIDS have evidence of peripheral nerve disease, and about 50 percent of these individuals experience severe neuropathic pain. Phantom pain is another example of neuropathic pain. It is a painful sensation perceived in a body part that is missing or paralyzed by a spinal cord injury. The incidence of phantom pain can be decreased when analgesics are administered via epidural catheter prior to an amputation. Phantom pain is not the same as phantom sensation, where the client feels that the missing body part is still present.
Furthermore, pain can be additionally described based on its relationship to various treatment approaches. This method of classification yields the following categories of pain:
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Intractable pain is pain that cannot be relieved satisfactorily by the usual approaches, including medications. This type of pain can be seen in advanced malignancies, especially cancer of the cervix, bladder, prostate, and lower bowel. Breakthrough pain is pain that occurs despite continuous analgesic efforts but is relieved with supplemental medications. For example, a client with a specific type of burn may be medicated at a dose generally considered therapeutic for pain control. However, due to client-specific factors (e.g., a low pain threshold), the client may experience a severe, unanticipated onset of pain. At that time, interventions related to pain control would be reassessed. Either additional analgesic medications or other analgesic medications used to prevent future breakthrough episodes would be administered. Pain syndromes are associated with prolonged or severe pain. Examples of pain syndromes include peripheral pain syndromes (e.g., postherpetic neuralgia), central pain syndromes (e.g., trigeminal neuralgia), and pain with underlying pathology (e.g., myofacial pain syndrome).
Concepts Associated with Pain A number of concepts are also commonly discussed in relation to pain. Since these concepts are based on the subjective experience of the client, only the client can identify and define their levels. Some of these concepts include the following: Pain threshold is the least experience of pain that a subject can recognize. Pain reaction includes the autonomic nervous system and behavioral responses to pain. For example, the immediate withdrawal of a hand from boiling water is the autonomic nervous system response. This response often protects the individual from further harm. The behavioral response is the learned response that is used to cope with the pain (e.g., putting the hand in cool water). Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure.
Characteristics and Assessment of Pain

The clients pain experience is unique and must be assessed within his or her own descriptive framework and developmental level. No matter what the clients presenting complaint is, however, most institutions and agencies consider pain assessment a standard component of any history and physical. It is a central assessment piece for any client problem related to the neurological system and/or the musculoskeletal system. Seven important standard assessment areas related to pain provide data for use in developing effective intervention strategies. These areas describe the characteristics of the clients experience with pain and are summarized in the following sections.
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Location The nurse should ask the client for the specific location of the pain. It is helpful to use a drawing of a body and have the client mark the location on the chart. For young children, having them show where their parent would put a Band-Aid can sometimes help them better identify the pain location. Discussing with the parents the vocabulary a child uses to describe pain and certain body parts can also help with pain location. The nurses documentation would include further clarification through the use of words such as proximal, distal, medial, diffuse, and lateral. Intensity The clients report of the severity of the pain is the most accurate way to measure it. It has long been shown that health care providers generally underrate or overrate a clients pain. Numerous pain rating scales can be used to evaluate pain. Most scales use a zero to five or zero to ten range, with zero indicating no pain and the highest number indicating the worst pain possible. Not all clients can relate to numerical pain intensity scales. These people include nonEnglish-speaking clients, nonverbal children, cognitively disabled children and adults, and cognitively impaired older adults. For these individuals, use of the face scale may be appropriate. The scale has simple drawings of five faces illustrating varying degrees of distress. It includes a number scale that relates to each expression so that the intensity of the pain can be documented. Before the client completes the pain-rating scale, the nurse should explain how the pain intensity information will be used. The client should also be asked what level of comfort is acceptable to his or her lifestyle. This information will ensure that adequate clientdefined pain management will be achieved. Quality Nurses need to use direct quotes when documenting how the client describes pain. Exact information is important both for diagnosis of pain etiology and for treatment choices. Examples include pain described as hot or electrical. Pain with these descriptors tends to be neuropathic in origin and will be more responsive to anticonvulsants (e.g., Tegretol) than opioids (e.g., morphine). Pattern Evaluating the pattern of pain means documenting the time of onset, duration, and recurrence (or intervals without pain). Constancy of pain can be ascertained through such questions as Do you have periods of time with no pain? and How long do they last? For children and many adults who experience chronic pain, it is also important to ask whether they tell others when they are experiencing pain. For children, finding out who they tell (e.g., a parent or a trusted pet) can add valuable information to the pain assessment.
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Precipitating Factors A number of factors can precipitate pain. These include environmental factors such as extremes in heat, cold, or humidity. Physical and emotional stress can also precipitate pain. Intense physical exertion can bring on angina, while emotional stressors can precipitate a migraine. Alleviating Factors A comprehensive history includes documentation of anything the client has done to reduce or eliminate the pain. This includes a careful evaluation of culture-specific healing strategies (e.g., specific herbs or compresses), medications, rest, distractions, prayer, or the application of heat or cold. The success or failure of each intervention should be noted along with whether the client is currently using the therapy. Asking children nonthreatening questions can elicit good information on their pain-relief strategies. Examples of such questions include the following: What do you do for yourself when you are hurting? What helps the most to take your pain away? What do you want others to do (and not do) for you when you are hurting?
Associated Symptoms Any other symptoms that occur with the onset or presence of pain should be documented. Common symptoms include nausea, dizziness, vomiting, and diarrhea.
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Harmful Effects of Pain

No matter whether pain is acute or chronic, it has harmful effects that extend beyond the clients immediate level of discomfort if the pain is inadequately treated. These negative effects have both physiological and psychosocial components. Harmful Effects of Acute Pain Researchers have found that frail, older adults respond to postoperative pain by lying absolutely still, a behavior that that can easily result in postoperative complications. Some of these complications include problems with the cardiovascular, gastrointestinal, and pulmonary systems. In all age groups, unrelieved postoperative pain impairs the ability to sleep. In addition, the stress response found with trauma also occurs with severe pain. Widespread inflammatory endocrine changes have serious effects that may be tolerated by a young, healthy person but can seriously hamper the recovery of an elderly, debilitated, or critically ill client. The stress response generally consists of increased cardiac output, increased metabolic rate, impaired insulin response, increased retention of fluids, and increased production of cortisol. This response increases the clients risk for such physiological disorders as thromboembolism, prolonged paralytic ileus, pulmonary infection, and myocardial infarction. Harmful Effects of Chronic Pain As with acute pain, chronic pain also produces adverse physiological and psychosocial effects. Chronic pain results in suppression of the immune system. This suppression may promote tumor growth. In addition to the physiological problems, long-term pain can result in depression, anger, and disability. Disabilities associated with chronic pain can range from mild inconveniences, like the inability to continue with an infrequent physical activity, to a complete disability, when an individual can no longer perform even simple activities of daily living like getting dressed. While health care providers are sometimes hesitant to prescribe the large quantities of opioid 1 drugs required to control chronic pain, it is critical to use these medications in chronic, progressive (e.g., cancer-related) pain situations.
The term opioid refers to a natural or synthetic analgesic with morphine-like actions. It is now preferred to the term narcotic, which is used in a legal context and refers to any substance that causes psychological dependence, such as cocaine (which is not an opioid). It has also been found that the term narcotic instills an unwarranted fear of addiction in older children, parents, and adults. This fear is unwarranted when opioids are used for pain control.
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Effects of Pain on Activities of Daily Living Understanding the impact of pain on a clients activities of daily living (ADLs) will help the nurse understand the clients evaluation of the pains severity. A rating scale can be used to determine the pains effect on such things as concentration, sleep, work/school, driving/walking, appetite, marital relations, and level of emotional stress (e.g., irritability, depression, or anxiety).
Coping Strategies
For both adults and children, coping strategies may relate to past pain experiences. For some clients, coping responses reflect cultural or religious influences. Knowledge of what coping mechanisms the client uses can help the nurse encourage, support, and understand why certain strategies are employed. Some strategies may include withdrawal, prayer, distraction, or support from significant others. Asking a child a question like What helps the most to take the hurt away? can elicit a wealth of information on coping behaviors.
Affective Responses
It is very important to assess the clients emotional response to pain. People who suffer from chronic pain, for example, can become severely depressed and suicidal. In situations in which there is concern about suicidal behavior, the nurse needs to ask the client such questions as Do you ever feel so bad you want to die? and Do you feel that way now? These questions may seem direct to the point of being blunt. However, a person in a crisis situation, such as someone with suicidal thoughts or plans, needs a direct, concrete interviewing technique that can then lead to immediate crisis-oriented interventions.
Behavioral and Physiologic Responses
A number of behavioral signs can indicate the presence of pain. Some of these include moaning, clenched teeth, biting the lower lip, facial grimaces, and immobilization of the affected body part. Purposeless movements can also represent pain; an example of this is tossing and turning in bed. Individuals with cognitive impairments and developmental delays require astute nursing assessments and observational skills. Many times, pain symptoms in these clients will present only as restlessness and slight blood pressure changes. This is one reason why accurate baseline data for special needs clients is essential for quality care. Early in the bodys response to acute pain, the sympathetic nervous system is stimulated, and the nurse would observe increased blood pressure, respiratory rate, pallor, diaphoresis, and pupil dilatation. With visceral pain, signs of parasympathetic stimulation may be observed, such as decreased blood pressure and pulse rate, pupil constriction, and warm, dry skin. However, when pain is chronic, there may not be overt behavioral responses since the individual develops a personal coping style for dealing with pain, discomfort, and suffering. Physiologic responses are most likely to be absent in people with chronic pain because of central nervous system adaptation.
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Physiology of Pain
This section provides a very broad, general overview of pain physiology. The exact nature of pain transmission and pain perception is not understood. It is known that the interaction between the bodys analgesia system and the nervous systems transmission and interpretation of stimuli are major factors in the pain response process. Peripheral Mechanisms The peripheral nervous system includes primary sensory neurons that are specialized to detect tissue damage and to evoke the sensations of touch, heat, cold, pain, and pressure. The receptors that transmit pain sensation are called nociceptors. These receptors can be excited by thermal, mechanical, or chemical stimuli. The physiologic processes related to pain perception are described as nociception, and the system involved in the transmission and reception of pain is referred to as the nociceptive system. The sensitivity of this system varies among individuals. Not all people exposed to the same stimuli will experience the same intensity of pain. In addition, a stimulus may result in pain on one occasion and not on another. When there are enough painful stimuli, biochemical mediators are released that sensitize or activate the nociceptors. Bradykinin, one of a group of endogenous peptides that acts on nociceptive nerve endings, directly activates the nociceptors and causes the release of inflammatory chemicals, such as histamine. It also causes vasodilation and increased capillary permeability, resulting in reddened and tender tissues. Bradykinin additionally stimulates the release of prostaglandin, which is thought to increase the sensitivity of pain receptors by enhancing the pain-provoking effect of bradykinin. Next, a chemical called substance P increases the inflammatory response and acts on blood vessels in the damaged area to release chemicals that contribute to the conduction of nociception. This substance also works as a neurotransmitter by enhancing the movement of impulses across the nerve synapse from the primary afferent neuron to the second-order neuron in the dorsal horn of the spinal column. Within the nervous system, pain impulses travel in myelinated A-delta fibers and unmyelinated C fibers. The myelinated A-delta fibers have a relatively large diameter and rapidly conduct impulses. These fibers are associated with the sensation of sharp, pricking pain. The smaller-diameter unmyelinated C fibers transmit impulses more slowly and result in long-lasting, burning pain. Nociception is conducted on both types of fibers to the spinal cord via both the dorsal and the ventral roots. The descending control system is a system of fibers that originate in the lower and midportion of the brain (specifically the periaqueductal gray matter) and terminate on the inhibitory interneuronal fibers in the dorsal horn of the spinal cord. Cognitive processes
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may stimulate endorphin production (discussed later in more detail) in the descending control system. Central Mechanisms The terminals of the A-delta and C fibers end in the dorsal horn of the spinal column. The dorsal horn has various functions, one of which is sensory processing. Mechanical and thermal pain are conducted via the fast A fibers. They synapse with second-order neurons (long fibers) that cross immediately to the opposite side of the spinal column and enter the neospinothalamic tract and ascend to the brain. Most of these fibers terminate in the thalamus. From the thalamus, signals are sent to the basal area of the brain and to the somatic sensory cortex. The slower C fibers conduct impulses from chemical, thermal, and mechanical stimuli. They often pass through one or more additional short neurons before traveling to the brain by the paleospinothalamic tract. Research has found that chronic pain results in a number of complex changes in the nociceptive pathways. Pain management interventions are seriously affected by these changes since they include alterations in nerve cells, receptor sites, and transmitters. Pain Perception In the central nervous system, pain transmission continues through the reticular formation, the thalamus, the limbic system, and the cortex. It is thought that conscious recognition of the pain probably occurs initially at the brain stem and thalamic level. Interpretation, localization, and monitoring of the sensation take place in the cortex. The perception of pain is modulated by a number of factors, including such things as culture, age, developmental level, past pain experiences, and anxiety. As the pain impulses stimulate regions of the midbrain, descending fibers transmit impulses from the brain to the spinal column, where ascending impulses are inhibited at the first synapse in the dorsal horn by the release of endogenous (produced by the body) opioids. Chemicals that reduce or inhibit pain include endorphins and enkephalins. These substances bind to opiate receptor sites in the central and peripheral nervous systems. This binding results in a decrease or blockage of the pain impulse. These chemicals are thought to stimulate the inhibitory interneuronal fibers, which then reduce the transmission of noxious stimuli via the ascending system. The term endorphin is a combination of the terms endogenous and morphine. Enkephalin is also an endogenous, morphine-like neurotransmitter. Endorphins and enkephalins are found in heavy concentrations in the central nervous system. Morphine and other opioid medications mimic enkephalin and endorphin. This mimicking ability allows these drugs to inhibit the transmission of noxious stimuli.
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Inhibitory neuronal fibers are the interconnections between the descending neuronal system and the ascending sensory tract. These fibers contain enkephalins and are primarily activated through the activity of the non-nociceptor peripheral fibers. The nonnociceptors normally do not transmit painful or noxious stimuli. The existence of endorphins and enkephalins helps explain why the same stimuli result in different pain responses from different people. Not only do endorphin and enkephalin levels vary among people, but so do other factors that influence endorphin levels, such as anxiety. People with more endorphins and enkephalins feel less pain, while those with fewer endorphins and enkephalins feel more pain. Gate Control Theory One particularly important idea regarding the physiology of pain is gate control theory, which was introduced by Melzack and Wall in 1965. This theory postulates that synapses in the dorsal horns of the spinal column act as gates; these gates close to keep impulses from reaching the brain and open to permit impulses to ascend to it. More specifically, according to this theory, small-diameter nerve fibers carry pain stimuli through a gate, but large-diameter nerve fibers going through the same gate can inhibit the transmission of those pain impulses. In other words, large-diameter fibers close the gates. Because a limited amount of sensory information can reach the brain at any given time, gate control theory argues that certain cells can interrupt pain impulses. In particular, stimulation of the inhibitory interneuronal fibers of the ascending system closes the gates to pain input and prevents the transmission of pain sensations. This theory helps explain how certain behaviors serve to decrease pain. Stimulation of a large number of non-nociceptive fibers (which synapse on inhibitory fibers in the dorsal horn) inhibits to a certain extent the transmission of painful stimuli in the ascending pathways. For example, a person who strikes a finger with a hammer immediately wants to put the finger under cold water or in the mouth. This action stimulates nonpain (nonnociceptive) fibers in the same receptor field as the just-activated pain fiber. In addition to the influence of nerve fibers, this theory also postulates that the brain can influence whether the gate is opened or closed. For example, a persons previous experiences with pain affect how he or she responds to pain. While gate control theory is not unanimously accepted, it does help explain why certain pain management interventions work. For example, back massage stimulates impulses in the large nerves, which in turn close the gate to back pain.
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Pain Management Measures Based on Gate Control Theory
Gate control theory has led to the recognition that pain can be controlled or modulated at four points: 1. The peripheral nerve site of pain 2. The spinal cord 3. The brain stem 4. The cerebral cortex While gate control theory remains incomplete, it is nonetheless used as the basis for many pain management interventions. In the clinical setting, nurses can use this theory to stop nociceptors from firing by treating the underlying cause of pain. Topical therapies, such as heat, ice, and electrical stimulation, can also be used. Enhancing the clients mood to decrease fear, anxiety, and anger are also clinical applications of gate control theory. Ascending modulation of pain can occur with the stimulation of large-diameter sensory fibers through massage, heat and cold application, or the use of a transcutaneous electrical nerve stimulator (TENS) unit. The TENS unit is a method of suppressing pain by supplying controlled, low-voltage electrical stimulation, or neuromodulation. It is believed that TENS achieves pain relief through the blocking of painful stimuli or by stimulating the release of endogenous opioids (endorphins). The administration of opioid analgesics will also inhibit pain impulses by binding to the receptor sites within the peripheral and central nervous systems. The descending control system is probably always somewhat active. It prevents continuous transmission of stimuli as painful, partially through the action of endorphins. In addition to the release of endorphins and enkephalins previously described, descending modulation can occur through the cognitive and affective response to pain. The reduction of anxiety and fear through education and support and the use of relaxation and guided imagery can alter the perception or interpretation of the pain response. Activities that distract from the pain, such as listening to music or watching TV, can also modulate and inhibit the pain response.
The Bodys Response to Pain

Once a pain impulse is interpreted by the brain, the bodys initial response involves activation of the sympathetic nervous system, resulting in a fight-or-flight reaction. As pain continues, the body adapts, and the parasympathetic nervous system takes command, reversing many of the bodys initial physiological responses. This adaptation occurs after several hours or days of pain. Throughout this period, however, a persons actual pain receptors adapt very little and continue to send the pain message. Thus, the person may cope with the pain through cognitive or behavioral strategies, such as diversions and excessive sleeping. The client
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also may respond by seeking out physical interventions to manage the pain, such as analgesics, massage, and exercise. Within the body, a proprioceptive reflex also occurs with the stimulation of pain receptors. Here, the impulse travels along sensory pain fibers to the spinal cord. At this point, the fibers synapse with motor neurons, and impulses travel back via these motor fibers to the muscles near the site of the pain. The muscles then contract in a protective fashion. For example, when a person hits his or her finger with a hammer, the hand reflexively draws back from the area even before the person is aware of the pain.
Psychology of Pain
The uniqueness of a pain experience to each client has already been mentioned. While each person must be evaluated in terms of individual psychological responses, some general principles can be mentioned. Typically, people who see pain as short-term or who associate pain with a positive outcome may accept the discomfort more readily than others. For example, knee surgery on a cross-country athlete that will allow him or her to run again or a woman giving birth are pain experiences that should both have positive outcomes. On the other hand, individuals who are faced with chronic pain may suffer despair, anxiety, and depression because they cannot see an end to the pain or attach a positive reason to their suffering. In chronic pain, the discomfort is many times looked upon not only as a threat to body image but sometimes as a sign of possible impending death. In chronic pain, depression is a major issue. It seems to be related to the major life changes associated with the limiting effects of the pain, such as unemployment. The longer the pain persists, the greater the incidence of depression is. Unrelieved cancer pain has a dramatic negative impact on a persons life. Providing pain relief in this type of situation may decrease the depression. Past pain experiences also alter a clients sensitivity to and interpretation of pain. Research has shown that children often do not receive adequate pain control interventions. It has also been shown that adults who experience medical pain in their childhood are fearful of medical pain as adults and tend to avoid seeking care when it is needed. Anxiety often accompanies pain. The routine use of antianxiety agents, however, is not recommended since it may prevent the client from reporting pain due to excessive sedation. These agents may also impair the postoperative clients ability to take deep breaths, get out of bed, and cooperate with the treatment plan. There is also scant evidence to support the old belief that antianxiety agents increase the effectiveness of analgesics. The most effective method to treat pain is to direct the intervention at the pain and not at the anxiety surrounding the pain.
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Inability to control the situation and fear of the unknown often accompany pain-related experiences. People who feel they have control over their pain experience have a lower level of anxiety. When pain interferes with sleep, fatigue and muscle tension also increase the pain, resulting in a cycle of pain, fatigue, and more pain. Clients who participate in their pain management decisions and who have an attentive listener regarding their pain management needs tend to fare better emotionally. Suffering When discussing the psychological effects of pain, suffering deserves special mention. Suffering is a feeling of severe distress related to events that challenge the basic emotional and physical intactness of a person. These events can be physical, emotional, or spiritual, and the demands they generate may be so great that they create severe conflicts for a person. When a person is in pain and this pain is managed correctly, an improved quality of life results. On the other hand, when pain is not appropriately managed because of a lack of provider knowledge, disbelief in the clients reports of pain, or a lack of standardized assessment and follow-up procedures, the client will suffer needlessly. Pain Misconceptions There are numerous and interrelated fallacies about pain and pain management. It is important for the nurse to be aware of some of the more common beliefs so that both clients and providers can be educated. Common myths held by providers and clients are listed below.
Pain as Normal Aging
Often, people believe that pain is simply a part of normal aging. This, however, is absolutely not the case. Thus, pain in elderly clients necessitates aggressive assessment, diagnosis, and management similar to that of younger patients.
Pain Sensitivity and Perception Decrease with Age
Another common misconception is that a persons pain sensitivity and perception decrease with his or her age. The consequences of accepting this myth are dangerous for the patient and can result in needless suffering and undertreatment of both pain and its underlying cause.
Pain as a Personality Disorder
Pain is sometimes also viewed as a personality disorder, and there is widespread belief that many people report pain merely in an attempt to garner attention or some other secondary gain. In reality, affective responses to pain are as individualized as the pain experience. They vary according to the type and duration of pain, the clients interpretation of the pain, and the environmental situation. Evidence suggests that only 5 percent of the people seeking relief for pain discomfort are dishonest and in pursuit of
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personal gain. The other 95 percent are honestly seeking help and relief (Berman et al. 2008).
Likelihood of Addiction
A belief in the high likelihood of addiction to pain medication is probably the most common myth held by both the general public and health care providers. For clients, it results in decreased reporting of pain. For providers, it results in undertreatment of pain, which can result in the complications mentioned earlier. Clients are unlikely to become addicted to an analgesic provided to treat pain. Providers confuse three terms related to opioid use and erroneously equate all three with addiction. These are drug tolerance, physical dependence, and narcotic addiction. Drug tolerance is a physiologic, involuntary need for larger doses of opioids to maintain the original effect. Physical dependence is a physiologic, involuntary effect manifested by withdrawal symptoms when chronic use of opioids is abruptly discontinued or an opioid antagonist, such as naloxone (Narcan), is administered. Narcotic addiction is a behavioral, voluntary pattern characterized by compulsive drug-seeking behavior, leading to an overwhelming involvement in the procurement and use of a drug for purposes other than pain relief.
Likelihood of Respiratory Depression
Yet another common misconception related to pain medication is the belief that these drugs are likely to produce respiratory depression, especially in children. However, with proper opioid administration (e.g., dose, route, etc.) and attention to the additive effects of other drugs the client is taking, this side effect is a rare occurrence, even in children.
Pain and Surgery
Many clients believe that pain only occurs after major surgery. Even minor surgeries can result in intense pain.
Signs that Pain Exists
There is a common belief that there are always physiologic or behavioral signs that pain exists. Periods of behavioral and physiologic adaptation occur, even with acute, severe pain.
No Complaint Equals No Pain
The belief that an absence of complaints means that a person is not experiencing pain is a misconception when caring for patients of all ages, particularly the elderly. In many cases, older adults may be experiencing pain but may not complain because of fear. For example, they may fear what the pain means, what diagnostic work will be required, what economic costs the pain will bring, and, most importantly, what change in lifestyle the pain may necessitate. In addition, these patients may also believe the aforementioned myth that pain is a normal part of aging.
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Pain Management
Once, the goal of pain management was to reduce the pain to a level the client could tolerate. Knowledge of the harmful effects of pain and inadequate pain management, however, has replaced the idea of tolerable control with that of relieving the pain. Often, this involves the administration of medications, which should be in done in accordance with existing standards and practices, including those established by the World Health Organization and American Nurses Association. World Health Organizations Ladder Approach to Cancer Pain Management One leader in the establishment of international standards for pain management is the World Health Organization (WHO). The WHO has developed recommendations for the treatment of pain. Although cancer-specific, this approach can be applied to pain from other causes. The three steps in the WHO ladder approach are as follows: 1. A nonopioid/nonsteroidal anti-inflammatory drug is administered. If the client receives the maximum recommended dose of nonopioids and continues to experience pain, step 2 is implemented. A weak opioid is given and increased until the ceiling dose is reached. If the client continues to experience pain, step 3 is started. A strong opioid is used and gradually increased in strength until relief occurs.
2. 3.
The regimes are based on pain ranging from mild (step 1) to severe (step 3). Various opioid and nonopioid medications may be combined with other medications at each step to control the pain. Placebo Effect When discussing the administration of pain medication, questions regarding the use of placebos often arise. A placebo is an inert substance used in research or clinical practice to determine the effects attributable to the placebo as compared to the pharmacological effects of a legitimate drug or treatment. In some instances, a phenomenon known as the placebo effect occurs; here, a person responds to a medication or treatment because of an expectation that treatment will work, rather than because it actually does work. Thus, with the placebo effect, simply receiving a medication or treatment produces a positive effect not attributable to the medication or treatment. There are many misconceptions about placebos and placebo effects. The nurse should keep the following guidelines in mind: A placebo effect is a true physiologic response. It is not an indication that a person does not have pain. The effect results from the endogenous (natural) production of endorphins in the descending control system. It can be reversed by naloxone (Narcan), an opioid antagonist.
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Placebos should never be used to test a persons truthfulness about pain or as the first line of treatment. This is unethical and unacceptable pain management. A positive response to a placebo (i.e., pain reduction) should never be interpreted as an indication that the persons pain is not real. A client should never be given a placebo (e.g., a sugar pill or saline injection) as a substitute for an analgesic medication. Although a placebo can produce analgesia, clients may report that their pain is relieved or that they feel better simply to avoid disappointing the nurse.
Also, it must be noted that the use of placebos to assess the presence or nature of pain raises serious ethical questions for nurses in relation to the ANA Code of Ethics. Furthermore, the American Society for Pain Management Nursing and various other professional organizations have strongly opposed the use of placebos without patient consent. Pharmacologic Interventions Pharmacologic pain management requires the close collaboration of the client, physician, and nurse. The physician prescribes a specific medication and a particular route (e.g., IV or epidural), but the nurse administers, maintains, and evaluates the effectiveness of the interventions. In the home setting, it is often the family who manages the clients pain and evaluates the treatments effectiveness. The home care nurse reinforces teaching and ensures communication between the client, physician, and pharmacist. Before administering any medications, the nurse must ask about allergies, previous responses to medications, medication history, and the clients current status. This includes the intensity of the current pain, the change in pain intensity after the last dose of medication, and any side effects. After this, the nurse can turn his or her attention to issues of administration and scheduling.
Medication Administration
Medications are most effective when both the dose and the interval between doses are individualized to the clients needs. The only safe way to administer analgesics is to observe the clients response to the medication and have the client rate the pain. The current accepted method of pain control is called multimodal or balanced analgesia. The three general categories of analgesia agents are opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Since each of these agents works through different mechanisms, using two or three types of agents simultaneously can maximize pain relief while minimizing the potential toxic effects of one drug. When one agent is used alone, it takes higher doses to control the pain. However, if one drug is combined with others, lower doses can be used. For example, it may take fifteen milligrams of morphine to control a certain pain. However, if morphine is combined with thirty milligrams of ketorolac (an NSAID), it may take only eight milligrams of morphine to control the discomfort.
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Medication Schedules
The traditional pro re nata (PRN) approach to pain control counts on the client to inform the nurse of pain. As a result, many clients remain in pain because they do not know to ask for medication or are hesitant to bother a busy staff nurse. Also, just by its method of operation, the PRN approach leaves the client either sedated or in pain. This is because opioids provide pain relief through the maintenance of a therapeutic serum level, and by the time a client complains of pain, the drug is below this level. In addition, the lower the opioid level, the more difficult it is to achieve a therapeutic level with the next dose. Thus, with the PRN method, the only way to ensure significant periods of analgesia is to give doses large enough that sedation is produced. Today, a preventive approach to pain control is considered the most effective clinical strategy. In this approach, analgesics are administered at set intervals so that the medication acts before the pain becomes severe and the serum opioid level falls to a subtherapeutic level. Not only is pain better controlled in this system, but smaller doses of medications are needed because the pain does not escalate to severe intensity. Before the routine dose is administered, the nurse assesses the client. If the client is sedated or has absolutely no pain, it would not be safe to administer the dose. The dose is adjusted depending on the clients response. This adjustment relates to the need for individualized dosing. People absorb and metabolize medications at different rates. They also experience different levels of pain. It is critical that response to opioids is monitored when the first dose is administered, when a dose is changed, or when the dose is given more frequently. With the first dose, the nurse needs to record blood pressure and respiratory rate and complete a pain-rating scale based on the clients answers. If the pain does not decrease within thirty minutes (or sooner with IV administration), some change in analgesia is needed. Clients can control the administration of their pain medication within predetermined safety limits through the use of patient controlled analgesia (PCA). This approach can be used with continuous infusions of opioid analgesics by IV, subcutaneous (SQ), or epidural routes. PCA can be used in the hospital or home setting. A timing device controls a PCA pump and clients administer small amounts of pain medication directly into their IV, SQ, or epidural catheter by pressing a button. The pump then delivers a preset amount of medication. The pump can also be programmed to deliver a continuous background infusion of medication or basal rate and still allow the client to administer additional bolus doses as needed. Clients who use the PCA device require less pain medication than those who use a PRN system. Because the client controls the dose, periods of severe pain and sedation occur less frequently. Education for the client and the family on how the pump functions is critical. This is especially true in the home setting. Family members must understand that they cannot push the button for the client when the client is sleeping, even if it looks like he or she is uncomfortable.
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Analgesia Agents
As previously mentioned, analgesic agents can be categorized as opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Tricyclic and anticonvulsant medications are also used for difficult-to-control pain syndromes. These agents are briefly summarized in the following sections. Opioids Various routes, including IV, SQ, intraspinal, rectal, and transdermal methods, can deliver opioids. The characteristics of the pain, the overall status of the client, the clients response to analgesics, and his or her report of pain determine the route. The goal of opioid medications is to relieve pain and improve the clients quality of life. No matter what route is used for opioids, the nurse must anticipate side effects and do anticipatory teaching to help both the client and the clients family manage them. Minimizing side effects increases the likelihood that the client will take the medication as prescribed and receive adequate pain control. The most frequently occurring side effects are respiratory depression and sedation, nausea and vomiting, constipation, and inadequate pain relief. These medications have traditionally been administered through the oral, subcutaneous, intramuscular, rectal, and intravenous routes. To circumvent problems associated with these traditional routes, newer methods are also being used. Examples of these include transnasal and transdermal drug therapy, peripherally inserted central catheters, and continuous subcutaneous infusions. Nasal administration has the advantage of rapid action due to direct absorption through the vascular nasal mucosa. A commonly used agent is butorphanol (Stadol) for acute headaches. Transdermal therapy is advantageous because it delivers a relatively stable plasma level and is noninvasive. Fentanyl (Duragesic) is an opioid currently available as a skin patch with various dosages. This method provides drug therapy for up to seventy-two hours if the patch remains in place for the prescribed amount of time. Peripherally inserted central catheters are placed in the basilic or cephalic vein just above or below the antecubital space of the right arm. These catheters are frequently used for long-term intravenous access when the client will be managing IV therapy at home. Continuous subcutaneous infusion (CSCI) of narcotics is particularly helpful for clients whose pain is poorly controlled by oral medications, who are experiencing dysphasia or gastrointestinal obstruction, or who have a long-term need for the use of parenteral narcotics. CSCI involves the use of a batteryoperated pump that administers the drug through a twenty-three or twenty-five gauge butterfly needle. The needle is inserted into the anterior chest, the subclavicular region, the abdominal wall, or the outer aspects of the upper arms or thighs. A shoulder bag or holster holds the pump so the clients mobility is
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not impaired. The nurse needs to provide comprehensive education on the use of CSCI, since the client or family administers the medication and changes and cares for the injection site. Caregivers need to be able to do the following: Describe the parts and symbols on the pump Explain how to tell whether the pump is working Demonstrate how to change the battery, change the medication, and stop and start the pump Demonstrate tubing care, site care, and changing the injection site List the signs indicating the injection site needs to be changed Describe general care of the pump when the client is traveling, bathing, or sleeping Identify actions to take when the alarm signals Nonsteroidal Anti-Inflammatory Drugs Nonsteroidal anti-inflammatory drugs (NSAIDs) are very helpful in the treatment of arthritis and cancer-related bone pain. These drugs are also effectively combined with opioids to treat severe postoperative pain and other types of severe pain. NSAIDs are thought to decrease pain by inhibiting the production of prostaglandin from traumatized tissue. This inhibition prevents pain receptors from becoming sensitive to previously non-noxious stimuli. NSAIDs may also have a central action in pain reduction. NSAIDs are well tolerated by most clients. However, people with impaired renal function may need smaller doses and must be closely monitored. Attention must also be paid to other medications the clients are using, particularly drugs such as warfarin (Coumadin), since NSAIDs increase their effects. High or prolonged doses can irritate the stomach and, in some cases, have resulted in gastrointestinal bleeds. The oldest NSAID is aspirin, but because of its frequent and severe side effects, it is not frequently used to treat pain. Ibuprofen (Advil, Motrin) is a commonly used NSAID that is effective in relieving pain and has a low incidence of adverse side effects. Local Anesthetics Local anesthetics block nerve conductions when applied directly to the nerve fibers. This can be done through topical administration or intraspinal administration. In topical applications, medications are applied directly to the injury (e.g., a topical anesthetic for a cut). In intraspinal administration, the drug is administered directly to nerve fibers by injection at the time of surgery. Intermittent or continuous administration of local anesthetics through an epidural or spinal catheter has been used for years to produce anesthesia during labor. Tricyclic Antidepressants and Anticonvulsant Agents Pain of neurologic origin (e.g., tumor impingement on a nerve) can be very difficult to treat and may be unresponsive to opioid therapy. When these pain syndromes are accompanied by dysesthesia (burning or cutting pain), they may be responsive to tricyclic antidepressants or anticonvulsant agents. The client needs to be alerted to the fact that the therapeutic effect of an antidepressant may not occur for up to three weeks since the dose prescribed is much smaller than that given for clinical depression. The
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anticonvulsants (e.g., phenytoin or carbamazepine) are also used in lower doses than those used for seizure control. Because of the variety of medications that may be tried in these difficult cases, the nurse must be aware of the adverse side effects of these drugs and educate the client and the family. Nonpharmacologic Interventions While medication-induced pain relief is the most powerful relief measure possible, other nursing interventions can reduce pain and are usually associated with low client risk. Some of the more common interventions are described below.
Cutaneous Stimulation and Massage
Cutaneous stimulation and massage is based on the gate control theory of pain management and includes rubbing the skin to block or decrease the transmission of painful stimuli. Massage, which is generalized cutaneous stimulation of the skin, often focuses on the back and shoulders. It does not stimulate the nonpain receptors but may have an effect through the descending control system. Massage also promotes comfort by producing muscle relaxation and decreasing stress.
Therapeutic Touch
Therapeutic touch is a technique that may be employed when it is culturally appropriate. It is an expression of concern and empathy. For instance, touching a patients arm during a painful procedure conveys understanding and reinforces the nurses presence to the person in pain.
Heat or Cold
When a client is experiencing pain, the use of heat or cold can sometimes increase comfort and promote healing of injured tissues. Such activities as warm baths, cold massage, hot or cold compresses, and warm or cold sitz baths can all bring comfort. For greatest effect, cold should be applied on the injury site immediately after surgery or injury. For ongoing comfort of a chronic condition, application of cold after exercise or during periods of exacerbation decreases pain and swelling to the area. Heat, on the other hand, increases blood flow to the area and contributes to pain reduction by speeding the healing process. Also, heat used before exercise increases blood flow to the muscles and can reduce pain. Generally, moist heat is recommended. Both cold and heat therapy must be monitored closely to avoid injuries to the skin. Neither cold nor heat should be applied to areas with impaired circulation.
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Acupuncture and Acupressure
Acupuncture and acupressure are both techniques used to cure certain illnesses, promote wellness, and relieve pain. Acupuncture uses needles to stimulate certain points of the body, whereas acupressure uses finger pressure. These treatments are based in the Eastern philosophy of qi or life energy. The goal of acupuncture and acupressure wellness care is to recognize and manage changes in the clients life energy before an illness or a disease occurs. A number of clinical trials have shown the effectiveness of acupuncture and acupressure for the symptoms of osteoarthritis and low back pain. These techniques have also been shown to improve memory, orientation, and activities of daily living for individuals with certain types of dementia.
Transcutaneous Electrical Nerve Stimulation
As previously mentioned, transcutaneous electrical nerve stimulation (TENS) uses a battery-operated unit with electrodes applied to the skin. The unit delivers a tingling, vibrating, or buzzing sensation in the area of pain. This method is believed to decrease pain by stimulating the non-nociceptor fibers in the same area that transmits the pain. Again, it is consistent with gate control theory and explains the effectiveness of TENS when applied to the same area as the injury. In postoperative clients, for example, the electrodes are placed around the surgical wound.
Distractions
Distractions include visual, auditory, tactile, and intellectual activities that focus the clients attention on something other than the chronic or acute pain. Distraction is thought to reduce pain by stimulating the descending control system, resulting in fewer painful stimuli being transmitted from the brain. The effectiveness of distraction depends on the clients ability to receive sensory input other than pain. For example, the client may engage in reading books or magazines, watching TV, guided imagery, music, humor, slow rhythmic breathing, crossword puzzles, card games, or hobbies.
Relaxation Techniques
Relaxation techniques aimed at tense muscles can relieve pain. Considerable evidence supports relaxation techniques as effective in reducing low back pain, but there is not a great deal of evidence that supports its effectiveness in reducing postoperative pain. A simple relaxation technique is slow, rhythmic, abdominal breathing. Relaxation techniques require practice before the client can become skilled in using them. Almost all people with chronic pain can benefit from relaxation techniques, since regular relaxation periods can help combat the fatigue and muscle tension that occur with and contribute to chronic pain. For certain clients, meditation is also an effective tool to help with stress reduction and relaxation.
Biofeedback
Biofeedback teaches clients to achieve generalized states of relaxation. This technique brings bodily processes normally thought to be beyond bodily command under conscious control. The feedback is usually provided through meters that indicate skin temperature changes or an electromyogram (EMG) that shows the electric potential created by the contraction of muscles. Reduced EMG activity reflects muscle relaxation.
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Guided Imagery
Guided imagery uses a persons creative thoughts to achieve a positive effect. The nurse instructs the client to close his or her eyes and breathe slowly in and slowly out. With each slowly exhaled breath, the client imagines muscle tension and discomfort being breathed out, carrying away pain and leaving behind a relaxed and comfortable body. Each inhaled breath is seen as delivering healing energy into the body. Guided imagery requires a great deal of time and explanation for the client to be able to effectively use it.
Hypnosis
Hypnosis may decrease pain in difficult pain control situations. This method has proven effective in relieving pain or decreasing the amount of analgesics required in people suffering from both acute and chronic pain. How hypnosis works is unclear, but it is not believed to be mediated by the endorphin system. Its effectiveness seems to be related to the susceptibility of the individual. Usually, a person trained in hypnosis induces the treatment. Sometimes, clients can be taught self-hypnosis.
Hydrotherapy
Hydrotherapy uses water as a healing treatment. Specifically, hot or cold moisture in the form of solid, liquid, or gas is used to trigger the bodys response to temperature and produce comfort. Hydrotherapy must be done with great care in the very young and the very old, because these individuals have poor heat regulation. This therapy must also be used with caution in people who have suffered from prolonged weakness or fatigue.
Aromatherapy
Aromatherapy uses the essential oils of plants to illicit an odor. The chemicals found in these oils and therefore in the accompanying odors are absorbed into the body and produce specific physiological or psychological effects. Aromatherapy oils can be massaged into the skin, placed in baths, mixed into ointments, or used as compresses. They have been shown to calm, improve sleep, and boost the immune system. Lavender, for example, is a sedative and can help decrease insomnia; chamomile soothes muscle aches; and jasmine is uplifting and stimulating.
Untested, Unproven Therapies
Finally, desperate people with chronic debilitating pain often employ untested, unproven therapies in the quest for comfort. Often, they will try anything and at any price. Many of these therapies (with the exception of the macrobiotic diet) are not harmful, but they have not been proven effective. In fact, the National Institutes of Health has established an office to examine the effectiveness of alternative therapies. The nurse must weigh the clients hope of relief with the responsibility to protect the client from costly and potentially dangerous therapies. The nurse can help the client and the clients family understand current scientific information while not diminishing the
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positive effects the client may be experiencing. This knowledge empowers the client to make an informed decision. If the client believes in alternative therapy use, the priority is maintaining a trusting, respectful relationship between nurse, physician, client, and family. If clients feel safe sharing what alternative therapies they are using, the medical team can work in a collaborative rather than oppositional manner. This approach is ultimately much safer for the client.
Factors Influencing Comfort and Pain

The physiological and psychological complexity of pain and the pain response are apparent. While the information a nurse receives from the pain assessment discussed earlier helps identify and prioritize goals, an awareness of other pain-related areas is also important. These areas are discussed in the following sections. Gender Because pain-related behaviors are part of the socialization process, gender-related differences in pain response are common. Some American men may be more hesitant to express discomfort because they perceive it as a sign of weakness. Similarly, in some situations, girls and women may be expected to express discomfort more than boys or men. Family role can also have an impact on the pain response. For example, a single father supporting two children may ignore pain so he will not lose days at work. Age and Developmental Level Age and developmental level are significant factors in effective pain management. The clients response to pain will be directly related to his or her developmental level. Knowledge of age-related pain response is particularly important for effective pain management among children and the elderly.
Children and Pain
Because people experience such drastic physical and developmental changes during childhood, pain management for young patients can be challenging, and it varies greatly depending on a childs exact age and characteristics. Infants Caring for infants can be particularly daunting, as these patients cant yet verbalize their pain experience. Thankfully, knowledge in pain management for infants has grown significantly. It is now understood that, regardless of their gestational age, newborns have the anatomic, biochemical, and physiologic elements necessary for pain transmission. However, the infant shows no association between approaching stimulus and subsequent pain. Behavioral observations of infant behaviors can help the nurse assess the degree of pain. Young infants may show a generalized body response of thrashing or rigidity. Loud crying and facial expressions of pain (e.g., brows lowered and
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drawn together, eyes tightly closed, and mouth squarish) are indicators of pain. Providing a glucose pacifier can sometimes be an appropriate comfort measure. Toddlers and Preschoolers Like infants, toddlers and preschool children often respond to pain with crying and anger, but they do so because pain is seen as a threat to security. Because a child in this age group may consider pain a punishment, it is important for the nurse to explore misconceptions about pain with the patient. In some cases, the childs belief in magic can be used to provide comfort. For example, the nurse may use a magic blanket to help take the pain away. Holding the child (if it is acceptable to him or her) can also help ease the discomfort. School-Aged Children Unlike their younger counterparts, school-aged children try to be brave when facing pain and can usually describe the location and the type of pain. Children in this age group may perceive pain as being related to body destruction and death. The child also may view pain as punishment for infractions. If the pain becomes chronic, the child may revert to an earlier developmental level. Providing rehearsals for this child of what will happen and how it may feel can help the child prepare. A supportive, nurturing interaction is critical. Adolescents Adolescents may be hesitant to acknowledge pain because it may be seen as giving in and not being brave enough to handle the discomfort. This reticence to talk about pain may be particularly evident if peers are present. An opportunity to discuss pain in private is very important. Providing appropriate distractions, such as music or TV, can also help increase the teenagers level of comfort. Medicating Children It has consistently been shown that providers undermedicate children for pain. A number of controlled studies have analyzed pain management between matched diagnostic groups of children and adults. In these studies, the adults received routine medicationrelated pain intervention. However, for the children, undermedication occurred across all client care areas studied. In each of these studies, all of the children had orders for PRN analgesics. The responsibility for adequate pain control rested solely with the nurse, and all studies showed that the nurse provided inadequate pain control. This lack of adequate pain control was even more serious with infants, which may be due to the nurses inability to evaluate pain in infants. When caring for patients in this age group, nurses can benefit from learning how to use age-appropriate pain assessment tools and being sensitive to the idea that children can and do experience significant levels of pain.
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Assessing Pain in Children One goal for quality care of young patients is for the nurse to assess these patients for pain every time he or she checks for pulse, blood pressure, temperature, and respirations. Because pain is both a physical and an emotional experience, different assessment strategies should be used to gather information. For example, Baker and Wong (1987) have developed an approach to comprehensive pediatric pain assessment called QUESTT. This approach is described in Table 5.2.
Table 5.2 QUESTT Approach to Pediatric Pain Assessment

Area Question the child Nursing strategy Childrens verbal statements and descriptions of their pain are the most important factor in assessment. To gather this information, use age-appropriate words and ask patients to locate the pain. When caring for children who are not native English speakers, use appropriate foreign language words to describe pain as a child would in that language. Pain rating scales provide a quantitative self-reporting measure of pain. Be sure to select a scale that is suitable to the childs developmental age. Behavioral changes are valuable in all children, especially those who are nonverbal. Physiological responses vary and are related to acute and chronic pain response, as well as anxiety, fear, or anger. Parents know how their child exhibits pain and are an excellent source of assessment data. Interviewing parents about a childs previous pain response is also helpful. Reasons for the childs discomfort should be taken into account. The pathological condition may give clues to the severity (e.g., the pain with vaso-occulsive crises in sicklecell anemia). Evaluation is essential. Complete pain relief through the use of combined pharmacological and nonpharmacological methods is the goal. Family members are excellent assessment partners when evaluating pain-relief measures.
Use a pain rating scale
Evaluate behavioral and physiological changes
Secure parents involvement
Take the cause of pain into account
Take action and evaluate results
Guidelines for Caring for Children in Pain Attempts have been made to help practitioners effectively manage pain, including pain in children. For example, in the United States, the Agency for Health Care Policy and Research 2 (AHCPR) has published guidelines by pain experts that focus on issues of postoperative, procedure-related, trauma, and cancer pain.
Agency for Health Care Policy and Research (AHCPR) Publications, P.O. Box 8527, Silver Spring, MD 20907; (800) 358-9295; Web site: www.ahcpr.gov.
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The nurse can obtain copies of the AHCPR guidelines and compare his or her institutional pain practice standards against this agencys recommendations. After all, pain relief is not a matter of personal opinion; it must be based on scientific research.
Adults and Pain
Adults may exhibit pain-related behaviors that they learned as a child. Some of these may be gender-related behaviors (e.g., girls can cry if they are injured, boys cannot, etc.). This gender-based behavior sometimes results in ignoring pain because admitting the discomfort would be seen as a sign of weakness or failure. Some adults may use pain for secondary gains or to get attention. Still other adults refuse to have pain evaluated because of the fear of what it may mean (e.g., cancer). The nurse allays fears and anxieties and provides education on both pain and the rationale for the types of interventions being used (e.g., balanced analgesia).
Elders and Pain
As previously mentioned, older adults might not admit to pain because they consider it a normal part of aging. Older patients are also particularly likely to withhold complaints of pain because of fear of treatment or the possible lifestyle changes that may be involved, particularly becoming dependent on someone else for care. Concern over the cost of medications can be an additional barrier to discussing pain. For the nurse, taking time to listen to older patients and develop trusting relationships is very important. Providing education that clarifies misconceptions and allays anxieties can also help the older adult both acknowledge pain and agree to appropriate pain-related interventions. Pain Presentation and Assessment Pain presentation varies widely in the elderly population. This variation can range from heightened pain related to previously unresolved pain to no pain sensation due to tissue damage. In some situations, pain may present in atypical fashion, with symptoms such as confusion, disorientation, and agitation. This type of behavior is particularly true for elders with dementia who cannot verbalize their discomfort. Even when an older patient doesnt report pain, the nurse should look for signs of anorexia, lethargy, and fatigue that are actually pain-related behaviors. Also, its important to note that an older adults definition of pain may differ from that used by patients in other age groups, and words such as hurt or ache are commonly employed. When dealing with older patients, pain scales are an easy and relatively reliable way of determining the clients pain intensity. Typically, these scales ask patients to rate their pain on a scale ranging from 0 to 10, with 0 being no pain and 10 being the worst pain possible. The addition of word modifiers can help clients who have difficulty applying a number to their pain. However, when patients cannot verbalize their pain due to communication impairments or diminished mental capacity, other scales will need to be used. For example, the nurse may opt to use a faces scale, as discussed earlier in the chapter.
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Yet another assessment method is to evaluate the extent of the patients pain awareness and the degree to which the pain interferes with the patients functioning. It is widely believed that the degree of functional interference caused by pain is a good indicator of its severity. Pain Control Pain control is critical in the elderly. Without adequate pain control, all areas of an elders life are impacted, including mobility, sleep, ADLs, ability to socialize, and ability to remain independent. Thus, the goal of pain control is to provide relief while maintaining the highest possible level of functional ability. Collaborative care that involves the client, family, pharmacist, and physician is central to success. When medicating elders, the classic dictum of start low and go slow is the safest pain control approach. Usually, an older patients starting dose is reduced by 25 to 50 percent and then increased based on effect. One reason for this cautious approach is decreased renal function in older patients, which increases the risk of toxicity. Comorbid conditions can also alter pain medication metabolism and excretion in the elderly. Individual Preferences Throughout this chapter, the unique nature of pain as the individuals own experience has been stressed. Providing time for clients to express in their own words how they view the pain will help the medical team provide appropriate interventions. For someone with acute pain, the initial assessment is brief, since rapid intervention is needed. The nurse may focus on allergies to medications, previous pain treatment and effectiveness, when and what analgesics were last taken, and any other medications currently used. For people with chronic pain, the nurse would do a comprehensive pain assessment and gather information on coping mechanisms used, effectiveness of current pain management, and ways in which the pain has affected activities of daily living. Physical Condition Determining the impact of pain on the client is part of a comprehensive pain assessment. This information is essential to effective pain management, especially for the person living with chronic pain. Impact of pain on ADLs is a helpful way to determine the physical impact of the pain. Questions that can help determine this impact include the following: How does the pain affect your sleeping patterns? Have your recreational activities changed because of the pain? Does it interfere with your ability to eat? Has your work or social life been affected by the pain? The nurse would follow each question with additional open-ended statements. This would allow the interviewer to acquire additional information on what the client has done to self-manage the pain. Cultural and Spiritual Beliefs
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Culture and ethnicity have an impact on how pain is explained and described. These beliefs influence the meaning given to pain. However, they do not affect pain perception. It is often believed that individuals from non-Anglo-Saxon origins have a lower pain tolerance than people with Anglo-Saxon backgrounds. The outdated research that purported these beliefs, however, is seriously flawed and unacceptable by todays research standards. Despite the erroneousness of this belief as well as research findings demonstrating that pain perception varies by individual and not ethnicity, people of nonAnglo-Saxon descent are still prescribed and receive significantly less analgesia in emergency rooms. Individuals learn from early childhood what responses to pain are acceptable and unacceptable. For some, the cultural expectation may be to moan, complain, or wail audibly about pain, to refuse pain relief measures that do not cure the cause of the pain, and to use words such as unbearable when describing pain. A client from a different culture may behave in a stoic, quiet manner, rather than expressing the pain loudly. In some instances, the nurses cultural values may differ from those of the patient. For instance, the nurses belief system may include the avoidance of loud expressions of pain, such as crying or moaning. The nurse may also believe in seeking immediate relief from pain, giving complete descriptions of pain, and accepting the relief measures offered. Thus, when dealing with issues of pain control, the culturally competent nurse must be sure to do the following: Become aware of his or her own cultural expectations and beliefs about pain and pain control Demonstrate knowledge and understanding of the clients cultural beliefs and behaviors related to pain Accept and respect cultural differences and avoid stereotyping Adapt pain relief measures in a way that is congruent with the clients cultural values and health care beliefs
The nurse must respond to the clients perception of pain and not react to the pain behavior. A nurse who acknowledges and respects cultural differences in pain behavior will have a greater understanding of a persons pain and make more effective interventions. The Nurses Beliefs As just mentioned, a nurses personal beliefs often influence how he or she deals with patients who are experiencing pain. In fact, despite ethical standards guiding a nurses response to a clients report of pain, research has shown that nurses are still hesitant to believe a person unless there are objective signs of pain (Horbury, Henderson, and Bromley 2005). This is consistent with similar findings over ten years ago that found poor nursing assessment strategies and exaggerated concerns over the use of pain relievers as major professional barriers to better pain control. Given the lack of traditional continuing education methods to change nurses beliefs, new strategies are
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needed to help nurses change their behaviors about pain management. The stakes are high, because inadequate pain control can have devastating short- and long-term effects on clients functional abilities, no matter what their age. Ethical and Legal Factors Effective pain management raises significant issues in terms of ethical nursing practice. The use of placebos has already been discussed. In addition, the use of opioids for pain relief in terminal illness, the clients use of illegal substances such as marijuana, and the underusage of pain-relieving substances for infants, children, and certain ethnic groups are significant problem areas. Constructive dialogue among the health team members, use of the hospital or agencys ethics committee, and keeping up to date on state-of-theart practices in pain management can all help the nurse work effectively. The nurses role as a client advocate is central when ethical dilemmas arise. Socioeconomic Factors The financial cost of pain control and its impact on health-seeking behavior cannot be underestimated. An older adult on a fixed income, for example, may suffer severe pain rather than seek care. Anxiety over the potential cost of medications is a major barrier to pain relief. Younger clients without health insurance may also either not seek care or underreport the level of discomfort because of the lack of money to cover a prescription. Other factors, such as lack of transportation, can also influence the clients health-seeking behavior and make adherence to follow-up a problem. The nurse acquires information on these areas during assessment and makes appropriate referrals to help the client and family. Environmental Factors Extreme variations in temperature can have a direct effect on a persons pain. In addition, intense physical exertion, such as climbing stairs, can cause angina in susceptible people. The clients home environment and activities that precipitate pain are important assessment areas. A strange environment, such as a hospital with its noises, activity, cold examination rooms, and bright lights, can compound pain. This may be particularly true for the person who is alone and has no support network. Alterations in the environment, such as noise reduction and a comfortable room temperature, can assist in pain relief measures. Psychological Factors Psychologically, unresolved pain can result in anxiety, anger, and fear. These emotions can be complex and related to such things as unresolved pain in the past, uncertainty about the future, or unmet expectations, and they can amplify the pain. Thus, it is important for clients to have an opportunity to talk about their pain, the fears associated with it, and their perceptions and reactions to it. Client education can be very helpful in these situations. Explaining the range of pain expected for the clients condition and the
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types of discomforts that signal the potential for problems will help alleviate the clients fear and anxiety. Clients who have chronic, unresolved pain may experience not only the aforementioned emotions, but also exhaustion, depression, and a sense of failure. Furthermore, some people with chronic pain who are severely depressed can become suicidal. Again, this is another example of why accurate nursing assessmentsincluding believing the clients self-reports of painare critical to client safety. If there is a concern about possible suicidal ideation, the client should be asked directly. A question such as Do you ever feel so bad that you want to die? can help begin the discussion. It is essential that appropriate follow-up measures are taken if there is any indication of risk.
The Nurses Role in Pain Management

The nurse plays several active and crucial roles in the management of pain. Some of these roles and associated functions are listed in Table 5.1. Table 5.1 The Nurses Role in Pain Management
Nursing role Provider of care Examples of functions Manager of care Educator Assess pain based on the clients perception and definition of pain. Assess pain within a holistic framework (i.e., physical, emotional, cultural, and socioeconomic factors that affect pain control). Administer pain relief medications, evaluate their effect, and work with the team to alter ineffective interventions. Collaborate with other team members to determine best pain relief measures. Identify high-risk clients and refer for needed additional services (e.g., counseling and financial help). Facilitate understanding of health beliefs and practices among providers, clients, and clients families. Develop mutual teaching goals with the client and clients family. Teach the client and family to manage the pain relief regime themselves, when appropriate. Educate physicians and staff on appropriate pain relief interventions. Maintain state-of-the-art knowledge on pain management. Intervene with physicians and nurses when care is not acceptable (e.g., withholding medications from neonates and certain ethnic groups, or use of placebos). Help clients and families interface with the medical team regarding use of alternative therapies.
Client advocate
Application of the Nursing Process Of course, the nurses other major responsibility in pain management comes through proper application of the nursing process. The nursing process is a systematic problem-
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solving approach used to provide effective, appropriate client care. This process consists of assessment, diagnosis, planning, intervention, and evaluation. The nursing process provides an effective approach for identifying, intervening, and evaluating care related to pain relief and comfort measures.
Assessment
The first step in a systematic analysis of a clients pain control is a thorough assessment. Because pain is subjective and experienced only by the individual client, the nursing assessment must analyze all factors influencing the pain experience. Those factors include the physiological, psychological, behavioral, emotional, and sociocultural. The depth and frequency of the assessment will vary with each client encounter. For example, the type of assessment done for a client in the emergency room with a fracture will be different than that done on a client with terminal breast cancer in an oncology clinic. Because it has been found that most people will not voice pain concerns unless asked, the nurse must initiate pain assessments. As has already been stressed, the nurse relies on the clients perception of pain. Believing the client and conveying that belief to the client is central to establishing a trusting relationship. Comprehensive pain assessments consist of a pain history, a physical examination, a skilled interview, and appropriate laboratory work. Observations of a clients behavioral and physiological responses are also documented. In a comprehensive pain assessment, the nurse should ask about the location and quality of the clients discomfort. Intensity can be measured by asking the person to respond on a scale of 0 to 10, with 0 representing an absence of pain and 10 representing the worst pain possible. The degree of discomfort felt at the time of the interview should be documented. Information associated with the pattern, time of onset, duration, and constancy of the pain must also be also collected. In addition, precipitating factors should be considered, such as what triggers the pain. The nurse should inquire about any strategies the client uses to alleviate the pain and what pain medications he or she is taking. The nurse should also document associated symptoms that occur with the pain, such as nausea, dizziness, or blurred vision. Functional questions that identify the pains effect on the patients ADLs and questions regarding the patients past pain history should also be posed. Toward the end of the history, after a certain level of trust has developed, the nurse can ask more sensitive questions. These relate to issues such as the emotional and perhaps spiritual meaning of pain to the client, available coping resources, and the clients affective responses. It is through these types of questions that the nurse will gain insight into the meanings the patient attaches to the pain experience. In addition to the patients verbal history, his or her behavioral and physiological responses must also be assessed. For clients who are unable to communicate, are
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disoriented, or are very young, nonverbal cues may be the nurses only indicator of pain. Table 5.2 identifies some of the observable behaviors associated with a pain response. Table 5.2 Observable Behaviors Associated with a Pain Response
Indicator Facial expressions Vocalizations Immobilization Purposeless body movements Rhythmic body movements Behaviors Clenched teeth, tightly shut eyes, open somber eyes, biting of the lower lip Moaning, groaning ,crying, screaming Affected body part is protected (e.g., arm across the chest, knees and hips flexed) Tossing and turning in bed, flinging arms about, reflexive jerking away from a needle Rubbing, rocking, massaging area of pain
Physiological responses vary with the origin and duration of pain. In acute pain, the sympathetic nervous system is stimulated, resulting in increased blood pressure, increased pulse rate, pallor, diaphoresis, and pupil dilation. After a time, the body adapts and makes this response less evident or even absent. In people with chronic pain, the clients autonomic nervous system adapts, so measures of physiological response (e.g., blood pressure, pulse) are poor indicators of the presence, absence, or severity of pain and should not be used.
Analysis
After an accurate assessment has been completed, a diagnosis is made that both facilitates individual care and promotes professional accountability for that care. Since the presence of pain can affect so many other facets of a persons life, pain may be the etiology of other nursing diagnoses. Examples of the North American Nursing Diagnosis Associations (NANDA) pain-related diagnoses include the following: Sleep pattern disturbance related to increased pain perception at night Chronic pain related to reduced blood supply to tissues Risk for injury due to medication side effects Acute pain related to physical injury Altered health maintenance due to chronic pain and fatigue Ineffective airway clearance related to postoperative incisional chest pain Ineffective coping related to prolonged, continuous back pain; ineffective pain management; and inadequate support systems
The diagnoses are validated with the client and documented in a manner that facilitates an outcome evaluation. Prioritization of diagnoses is based on the clients immediate needs (e.g., the airway clearance would take priority over the coping problem). The prioritization is also influenced by the persons developmental level, the availability of resources, and sociocultural considerations. For example, a client may have a
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dysfunctional family system and need additional social support. Cultural beliefs, however, may dictate that assistance from people outside the family is not acceptable.
Planning
In the planning phase, the nurse in conjunction with the client and family derives clientcentered goals from the diagnostic statements as well as activities that will meet these goals. The purpose and end product of this step is a holistic plan of care tailored to the clients problems and strengths. Established goals will vary depending on the diagnoses and their defining characteristics. Expected outcomes will relate to health promotion, health maintenance, and health restoration. Examples of such goals include the following: Patient reports pain level has decreased to a 3 on a 10-point scale Patient describes positive effects of guided imagery as evidenced by decreased need for medication Patient sleeps seven hours each night
Established nursing standards and protocols are used to identify measures related to these goals. The ANA Standards of Practice, various state nursing practice acts, the taxonomy of nursing interventions, and documentation from the American Society for Pain Management Nursing may all be of assistance in this regard. The measures and outcomes described in these resources help identify whether goals have been reached. Consideration of other factors that influence the clients response to pain must also be factored into planning. Examples of these include various comfort measures the client has used, the clients cultural and spiritual practices, nonpharmacological therapies employed by the client, and the clients use of alternative or nonproven pain treatments. For example, the patients usual relief measures may provide insight into what interventions he or she would consider valid pain-relief plans. Similarly, the persons cultural background may indicate not only what pain alternatives are considered viable, but also which family members may be key in helping the person comply with the medication regime. The next step in planning is identification of the rationale for nursing interventions related to pain, particularly in relation to ethical considerations. For example, cannabis, usually sold as marijuana, has been found to have a number of potential benefits related to symptom management. However, sale and possession of cannabis is generally illegal throughout the United States. As previously mentioned, another important ethical area in pain management deals with the use of placebos. The American Society for Pain Management Nursing and other professional organizations consider the use of placebos outside the context of an approved research study as deceptive, fraudulent, and representative of unethical treatment.
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When engaging in planning efforts, its also critical that the nurse considers any available evidence-based research. For instance, the nurse could access evidence-based outcome measures for pain-relief interventions such as music therapy, distraction, and postoperative analgesia administration. Research that shows the nurses bias related to the use of pain medications, particularly for infants and children, can be overcome when using outcome measures that are based in the reality of clinical practice. After the rationale for various nursing interventions has been identified, the nurse can then assign care activities to other appropriate members of the health care team. For example, a nursing assistant may be asked to distract a patient who is in pain, or other team members may be asked to help reposition a patient who is in acute pain. The priority in making such assignments relates to the comfort and safety of the patient.
Implementation
In the implementation phase, the nurse initiates and completes the nursing plans. This phase attempts to move the client and family toward the expected outcomes. These outcomes can be related to activities in health promotion, health restoration, and health maintenance. Basic to all strategies for reducing pain is that nurses convey to the client that they believe the client is having pain. The alleviation of pain involves the two basic approaches previously described: pharmacologic and nonpharmacologic. Basic to all pharmacologic interventions are the five rights: right client, right drug, right dose, right route, and right time. In general, nonpharmacologic, noninvasive measures can be performed as an independent nursing function; on the other hand, administration of analgesic medications requires a physicians order. However, the decision to administer the medication belongs to the nurse. It is based on the assessment of the clients condition, the dose, and the timing of administration. If a client is at home, implementation of care includes an evaluation of the client and the familys level of knowledge, self-care abilities for analgesics administration, and the familys willingness to assist with pain management. These educational areas are very important when clients are going home with technologies used to moderate pain, such as peripherally inserted central catheter (PICC) lines, transcutaneous electrical nerve stimulation (TENS), or continuous subcutaneous infusion pumps (CSCI). Education includes not only the proper administration of analgesics and use of equipment, but also safety-related information. Examples of family issues include such things as positioning a client to maintain an open airway and the use of safety devices (e.g., side rails) when the client experiences sedation. For clients, it is important to educate them on the risks of driving or using heavy machinery after taking analgesics. Nursing interventions to modify the environment can also help increase comfort. Such things as lighting, noise, and temperature can all be modified to increase the clients level of comfort. Referrals to appropriate community resources can also assist clients and families. National resources, such as the American Chronic Pain Society or the
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American Pain Society, or local support groups and pain clinics must all be considered when helping a client deal with pain. Finally, during implementation, the nurse must also supervise patient care activities assigned to other members of the health care team. This role not only involves the delegation of pain-related tasks, but also the validation that staff members are able to implement these tasks according to established guidelines. For example, a staff nurse may be asked to assist a client with a relaxation strategy. In this situation, it is the supervising nurses responsibility to ensure that the staff nurse understands both the purpose and the techniques of relaxation therapy.
Evaluation
It is critical to reassess the clients pain perception after the interventions have been implemented. The assessments are based on the clients perception of the pain. Using a systematic method to document this pain, such as a pain rating scale, is central to determining what kind of change has or has not occurred. If the interventions were not effective, the nurse needs to consider other strategies. For example, if the client does not want to use meditation techniques, the use of guided imagery may be a useful alternative. If these are ineffective, the physician and the nurse need to collaboratively reassess the situation with the client. The nurse works as the clients advocate in obtaining pain relief. After additional interventions have had a chance to work, the client is again asked to rate the pain. These interval evaluations provide the data needed to reassess interventions and make appropriate alterations in care. Data on the clients response to the interventions is also gathered from other members of the health care team and, when appropriate, family members as well.
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Chapter 6: Rest and Sleep

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. Differentiate between rest and sleep. Describe the two primary stages of sleep. Explain the sleep-wake cycle and the role of the reticular activating system (RAS) in wakefulness. Describe the most common disturbances to rest and sleep seen in various health care settings and those disturbances related specifically to age. Discuss the major assessment areas related to rest and sleep disturbances. Discuss the diagnostic information gathered when assessing sleep and rest, including the various tests used to assess sleep patterns and oxygenation. Describe the various interventions used to promote sleep and rest. Describe the nursing process used to help patients meet basic sleep and rest needs.
Key Terms
biorhythm bruxism central apnea circadian rhythms diurnal pattern electroencephalogram (EEG) electromyogram (EMG) electrooculogram (EOG forebrain hypnotic drugs insomnia narcolepsy noctual enuresis non-rapid eye movement sleep (NREM) obstructive apnea paradoxical sleep pulse oximetry rapid eye movement sleep (NREM) rest reticular activating system (RAS) sleep sleep apnea sleep deprivation sleep terrors sleep-wake cycle slow-wave sleep somnambulism sundowning tryptophan white noise
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Introduction
A restful nights sleep is as essential to good health as nutritional food, water, and exercise. With too little sleep, we run the risk of accidents, poor work performance, increased stress, and problematic social interactions. Nurses work with patients who are at high risk for sleep disturbancesdisturbances that can negatively impact the patients ability to recover. This chapter helps us look at basic concepts related to rest and sleep. We begin by establishing basic definitions of rest, sleep, and the stages and cycles of sleep. We discuss common sleep disturbances and the relationship of some sleep pattern disturbances to age and developmental levels. Our discussion then turns to seven basic factors nurses can evaluate related to rest and sleep. We also discuss diagnostic tests that are helpful in identifying sleep-related disturbances. We then investigate specific interventions used to promote rest and sleep, including medications, psychological modifications, and alternative and complementary therapies. Finally, we use the nursing process to assess, analyze, develop a nursing diagnosis, plan, and evaluate interventions for patients with sleep disturbances.
Defining Rest and Sleep

Rest can be thought of as a state of peace, ease, or relative quiet. It can mean physical inactivity or it can be related to emotions; a person can be physically active but at rest (at peace) emotionally. People can be physically inactive, but in an emotional state of unrest. Normally, good rest combines both less physical activity and a quiet, peaceful emotional state. Emotional unrest is usually characterized by anxiety. Sleep usually contributes to rest. A state of restfulness can also be conducive to sleep. Sleep is an altered state of consciousness or change of awareness of and reactions to ones environment. In sleep, the eyes are usually closed and there is little or no conscious thought, though there may be unconscious dreaming. Generally there is little physical movement and no conscious awareness of ones environment; however, environmental factors can affect sleep. Sleep can be deep or it can be fitful; people can awake from a state of sleep feeling rested or tired, depending on the quality of the sleep. People of all ages generally require more sleep and rest when they have acute or chronic diseases or have suffered accidents in order for their bodies, minds, and emotions to recover.
Stages and Cycles of Sleep

There are two primary stages of sleep: non-rapid eye movement sleep (NREM) and rapid eye movement sleep (REM).
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Non-rapid eye movement sleep (NREM) makes up about 80 percent of sleep. If effective, it aids in physical regeneration of the body systems. Defining characteristics throughout the four-stage cycle of NREM sleep include the following: Some rolling of the eyes Skeletal muscle relaxation Slow metabolism, including a slow pulse, lowered blood pressure, and lower than normal heart rate, respirations, and body temperature Energy expenditure is less due to the slower metabolism, allowing more opportunity for physiological repair of body tissues
NREM sleep is progressive and can be characterized by restlessness and light sleep in the early stages with a deep sleep, otherwise known as slow-wave sleep, in the fourth and final stage. People normally go through four to six cycles of NREM sleep per night. A night is considered approximately eight hours, though it varies with age. Rapid eye movement (REM) sleep, also called paradoxical sleep, generally ranges from 20 to 50 percent of all sleep, depending on a persons age. In adults, it generally makes up ninety to one hundred and twenty minutes of total sleep each night. Total sleep time for newborns is about six hours in a twenty-four-hour day. REM sleep declines with age and then appears to plateau, though various disease processes like certain types of dementia may adversely affect REM sleeping patterns. The defining characteristics of REM sleep include the following: Rapid brain metabolism Active and remembered dreaming Decreased muscle tone Rapid eye movement Increased gastric secretions Irregular heart and respiratory rates
REM sleep is believed to relate more to psychological well-being and improved memory. REM sleep increases proportionately to how well rested a person is. REM sleep generally follows each NREM sleep cycle. REM occurs about every sixty to ninety minutes and can last to up to thirty minutes. Circadian Rhythms A biorhythm can be defined as any biological cycle in the body involving periodic changes in body temperature, pulse, and blood pressure. The menstrual cycle is a common example of a biorhythm. The sleep cycle and circadian rhythm are two others. The phrase circadian rhythm is derived from the Latin words circa, meaning about, and dies, meaning day. A day, twenty-four hours, is thought of as a sleep-wake cycle. This is also called a diurnal pattern, meaning that it occurs each day. While all people have the same twenty-four hours available to them for each cycle, the sleep-wake activity
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within the cycle can vary from person to person and between different ages and developmental levels. A number of things can affect the normal sleep-wake cycle. Nurses experience this when they alternate shifts during a week, working days and then nights and then back to the day shift. Travelers may experience jet lag if they change time zones and can have symptoms of disorientation, fatigue, and insomnia. Recent research related to bipolar disorder indicates circadian rhythm disturbances; the medication lithium appears to offer a corrective. Sleep Regulation Wakefulness is regulated by the central nervous system and by a structure in the brain stem called the reticular activating system (RAS). When someone sleeps, the RAS seems to shut down. Sleep may be enhanced by a hormone and neurotransmitter called serotonin from the parts of the brain called the pons and the forebrain. The RAS releases norepinephrine, a stimulant, during waking hours that keeps the mind alert.
Rest and Sleep Disturbances

Alterations in normal patterns of rest and sleep can have deleterious effects all systems of the body even though they may not directly contribute to acute or chronic disease. Diseases of the respiratory, musculoskeletal, and urinary system in particular can affect level of rest and sleep. Common disturbances of rest and sleep that nurses are most likely to see in various health care settings include insomnia, sleep apnea, narcolepsy, and sleep deprivation. Insomnia Insomnia is the most common sleep disorder, and the term is derived from the Latin insomnis, meaning sleepless. This disorder is characterized by a prolonged inability to sleep. People with insomnia may have difficulty initially falling asleep (initial insomnia) or getting back to sleep with frequent periods of wakefulness if they wake up (intermittent insomnia). They also may wake up very early (terminal insomnia). When they wake up, they feel as if they hadnt slept or their sleep was insufficient. The defining characteristics of nighttime insomnia are seen during the day, and they can include drowsiness and general fatigue if the insomnia is a chronic problem. Insomnia, however, is often situational; when stressful circumstances change or problems are resolved, sleep patterns may return to normal. Hospitalization can contribute to insomnia because it is a strange environment. Some patients may experience fears and anxieties associated with illness. Often insomnia is related to hypnotic drugs, the very medication people take to induce sleep. Overuse of hypnotics that normally depress the central nervous system can cause insomnia. Chronic use of hypnotics can result in a significant decrease in REM sleep. Older adults especially may become more wakeful and sometimes confused after taking hypnotic drugs.
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Sleep Apnea Apnea means without wind. Sleep apnea is a temporary cessation of breathing that occurs during sleep. A persons breathing can stop for ten seconds up to two minutes.
Obstructive Apnea
Obstructive apnea can be the result of a mechanical problem; it can be caused by enlarged tonsils, polyps (mucous membrane growth) in the nares, or a deviated septum. Obese patients, especially older men, may experience this type of apnea, particularly just before the usual time of waking. If apnea is prolonged, it can lead to cardiac dysrhythmias, severe hypertension, and even death. The defining characteristics during sleep include snoring followed by an apneic period when snoring ceases. When breathing resumes, a loud snorting sound occurs. The person may wake up suddenly after a period of sleep apnea due to increased carbon dioxide levels in the blood. During the day, people with sleep apnea may complain of fatigue and morning headaches.
Central Apnea
Central apnea is triggered by an abnormality in the respiratory center that controls breathing. Specific diseases and conditions that trigger this type of apnea are brain stem injuries and brain infections like encephalitis. Muscular dystrophy also can prompt central apnea. Defining characteristics include a complete stoppage of gas exchange and absence of chest wall movement. Narcolepsy Narcolepsy is an uncontrollable and frequent desire for sleep, usually at inappropriate times and in inappropriate places, for example, while at work or when driving a car. The word is derived from the Greek word narkoun, meaning to benumb. Narcolepsy occurs during the waking hours of the day. The exact cause is unknown, but it appears to be related to a central nervous system abnormality related to REM sleep. Sleep Deprivation Hospitalization, especially when a hospital stay is frequently interrupted (e.g., for patients in intensive care or on units that are very busy and noisy), can result in sleep deprivation. Sleep deprivation means being deprived of sleep, specifically REM and NREM sleep, as the regular cycles become disrupted. The following are defining characteristics of sleep deprivation in relation to body systems and structures: Central nervous system (CNS): Tremors of the hands; decreased reflexes; impaired judgment, memory, and ability to reason; general irritability; and exaggerated reactions to pain Cardiac: Cardiac dysrhythmias Eyes and ears: Decreased or blurred vision, decreased hearing, visual or auditory hallucinations
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Rest and Sleep Pattern Disturbances

Some sleep pattern disturbances are related specifically to age and developmental level. Somnambulism (sleepwalking) is characteristic of some children. Other sleep disturbances seen in children are nocturnal enuresis (bed-wetting) and bruxism (grinding of teeth when asleep). Nightmares (frightening dreams) or sleep terrors can also be common to children. Sleep terrors are characterized by a partial arousal from sleep; there is no dreaming. Adolescent boys may also experience nocturnal erections during REM sleep. Age-related changes often create sleep disturbances in older adults. Alzheimers disease is characterized by sundowning, a period of extreme restlessness and agitation that occurs in the late afternoon.
Assessment of Rest and Sleep

A number of factors can influence a persons rest and sleep patterns in the hospital, nursing home, or home care settings. The following are major categories to consider while formulating nursing diagnoses and planning interventions related to the factors that most frequently influence a patients rest and sleep. Gender, Age, and Developmental Level A number of physiological differences based on age and developmental level can affect rest and sleep. The need for sleep varies greatly from individual to individual, but it is also based on age. The newborn infant requires a minimum of sixteen hours of sleep per day, and some newborns sleep several hours more. Approximately 50 percent of a newborns sleep is REM sleep; more advanced stage NREM sleep accounts for the other 50 percent. Infants still require at least twelve to fourteen hours a day of sleep. Babies sleep through the night generally at age three to four months. Toddlers also may require twelve hours of sleep a night, but they may also waken during the night for a variety of reasons including nightmares or frightening dreams. This pattern can continue through the preschool years. As children grow, sleep requirements range from eight to ten hours for adolescents. Sleep needs decrease through adulthood; the older adult may sleep about six hours a night, and then they may sleep in short naps, sleeping or dozing lightly throughout the day for short periods of time. Older adults, especially older adults with dementia, may be awake much of the night; they seem to lose the sense of time. And, as noted, older men who are also obese may experience obstructive apnea just prior to waking. Preferences and Dietary Habits Employment habits can influence a persons rest and sleep habits. Nurses and others engaged in shift work may sleep very few hours because of the difficulty for the body to adjust to time changes. This sleep deprivation can put them at risk for accidents on the job and on the road.
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Some people drink excessive amounts of caffeine in coffee, tea, and soda as a stimulant to keep them awake. Caffeine stimulates nerve receptors and can also cause restlessness and irritability. Caffeine intake can also stimulate urine production, and a full bladder can waken people in the night several times. Alcohol causes people to become drowsy and initially go to sleep because it is a hypnotic drug and a CNS (central nervous system) depressant, but it adversely affects the quality of sleep, particularly REM sleep. The nicotine in cigarettes also has a stimulant effect that can keep people from falling asleep; when combined with caffeine, this can add to central nervous system stimulation. Medication History Many medications have side effects that can affect sleep patterns and the quality and quantity of both NREM and REM sleep. Sedatives (opiates or narcotics), pain relievers, and many over-the-counter cold medications may induce drowsiness. Some cold and allergy medications contain ephedrine or pseudoephedrine; common side effects are restlessness and irritability. Pseudoephedrine has been known to cause cardiac problems and hypertension. Pseudoepinephrine, also found in cold and allergy medications, has been known to have harmful effects; three infants and toddlers who died in 2005 were found to have high levels of pseudoepinephrine in their bloodstreams. New laws are in effect now governing the sale of medications that include these ingredients and they are not as readily available now over the counter. Physicians generally discourage cold (decongestant) and cough suppressant medications containing these drugs, especially for infants and toddlers, encouraging instead the use of saline nose drops, Tylenol for fever control, plenty of fluids, comfort care, and rest. Other medication effects include insomnia or a prolonged inability to sleep; this is a side effect of many cardiac medications. Nightmares are a symptom of drug withdrawal, including the drug alcohol. If diuretics like Lasix are given in the late afternoon, they can cause nocturia, frequent nighttime urination, or urinary incontinency. Physical Condition How well are all the systems of the patients body functioning? An admission assessment by the nurse may uncover physical problems that can affect normal patterns of rest and sleep or put the person at risk for developing sleep disturbances. Normal physical activity, a good exercise program early in the day, and moderate exercise in the evening generally contribute to nighttime sleep. Vigorous exercise late in the evening often has a stimulating effect. People who are overweight or obese may also suffer from heartburn or esophageal reflux, one of the most common disorders of the gastrointestinal tract. Gastric acid is regurgitated into the esophagus, and this condition can cause wakefulness. In general, people who are obese tend to sleep more, and older people may often doze off during the day. Conditions like anorexia contribute to sleep deprivation.
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Many chronic illnesses contribute to ineffective sleep because of associated pain, as is often true with arthritis. Patients with various forms of lung disease may have difficulty sleeping if they are short of breath, and the anxiety and panic associated with this can further inhibit a desire to sleep. Even the common cold can affect sleep if people have difficulty breathing or experience much nasal drainage. Impaired renal (kidney) function, especially in the older adult, can contribute to nocturia. Untreated urinary tract infections can also lead to confusion and restlessness in older people that can keep them awake at night. Ulcer formation in the stomach or duodenum can disrupt REM sleep and this type of sleep increases the secretions causing pain in the abdomen. Endocrine disorders can also disrupt sleep. Cultural Practices and Religious Beliefs Are there any cultural, ethical, or spiritual/religious beliefs, practices, or preferences that might influence the patients rest and sleep? For example, in some cultures, parents and children sleep together; when hospitalized, the need to sleep alone for either the child or the adult can cause stress and wakefulness if the patient was used to sleeping with another person at home. Sleep rituals are also important, and events like hospitalization can disrupt these; some rituals are of a religious nature, such as prayer or reading from the Bible or other religious literature. Socioeconomic and Environmental Factors What socioeconomic and environmental factors might influence sleeping patterns? Does the patient live in a crowded and noisy environment? Noise affects people in different ways. Some people are unable to initiate sleep in a noisy environment; others are used to noise and can sleep well. In nursing homes, noise from other restless patients can create adverse conditions for rest and sleep. The hospital environment of the intensive care unit and noise from the nursing unit or nursing stations may also affect rest and sleep. Temperature extremes can also affect sleep; both very hot and very cold environments inhibit sleep. Excessive amounts of air (e.g., from air conditioners or fans) or too much light can inhibit sleep. Some people are unable to sleep even with night-lights on.
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Psychological Factors At various stages of the life cycle, certain social and psychological factors may influence rest and sleep. Emotions like loneliness and depression can contribute to a more sedentary lifestyle and more time spent sleeping and napping. Depression can also lead to sleeplessness if the person is anxious and worried about his or her situation.
Diagnostic Information Related to Rest and Sleep

Diagnostic information includes any data that can influence a persons rest and sleep status; this can include subjective information based on a patients health history and any other data that can be objectively measured. The nurse should obtain a history from the patient or the patients significant others on admission to the health care facility related to such things as recent changes in sleep patterns and sleep history. Any other factors that may influence the needs for rest and sleep should also be assessed; for example, assess the patients prescription and over-the-counter medications for sleep or other physiologic conditions, such as renal impairment or respiratory distress, that might impact sleep and rest. Assessment of routine sleep patterns for children and older adults with Alzheimers dementia are especially important, as is assessment information about any bedtime rituals used at home that may enhance sleep. Objective nursing assessment data in hospital and nursing home settings includes checking for any alteration in vital signs, observing sleep patterns at night, and noting rest patterns and sleep patterns during the day. General observations about facial appearance can be important. The following are some questions to consider: Does the patient have dark circles around the eyes? Does he or she appear anxious and restless? Is he or she constantly dozing off during the day? Does he or she have any tremors of the hands?
Observations specific to the central nervous and cardiovascular systems, (e.g., dysrhythmias) may indicate disturbances in sleep. Also be aware of statements the patient might make indicating a need for sleep, for example, comments about being tired or fatigued. A number of diagnostic tests can be done to assess sleep patterns. One that might be done by nurses on the unit is pulse oximetry. Other tests are generally not done by nurses on the nursing unit, so the patient may be referred to a special sleep disorder unit or clinic within the hospital. The quality and stages of REM and NREM sleep are often evaluated by tests including an electroencephalogram (EEG), an electromyogram (EMG), and an electrooculogram (EOG).
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An electroencephalogram (EEG) measures the level of activity in the cerebral cortex of the brain; brain waves are recorded through electrodes placed on the scalp. Electromyogram (EMG) readings measure muscle tone that is affected with REM sleep. An electrooculogram (EOG) measures eye movements that are also specific to REM or NREM sleep patterns.
Pulse oximetry may be done by nurses or in the sleep disorder clinic to determine adequacy of oxygenation. Pulse oximetry measures oxygen saturation in the capillaries. A machine called a pulse oximeter is used. Normally a sensor with an infrared light is clipped to a patients middle finger (or foot in the case of infants). The machine will calibrate the percentage of oxygen saturation in the body. If a patient is hypoxic, for example, a reading might be 88 percent. Anything less than 70 percent would indicate a respiratory emergency. Values between 70 and 95 percent would indicate the need for oxygen and further evaluation. This noninvasive test is often done on patients with nocturnal or sleep apnea.
Interventions to Promote Rest and Sleep

A number of common nursing interventions can be used to promote, maintain, and restore rest and sleep and treat disturbances of rest and sleep across the life span. These treatments range from basic physical and environmental modifications to medication, dietary management, and the use of complementary therapies and psychological modifications. If possible, the underlying cause of the sleep disturbance should be eliminated. Physical and Environmental Modifications The most common interventions for facilitating sleep include physical and environmental modifications. For instance, proper positioning by placing the body in good alignment can be conducive to sleep. The nurse can explore with patients the position they normally sleep in at home and the number of pillows they normally use; this position can be encouraged in the hospital if it has been conducive to sleep. Elevating the head of the bed can help patients breathe more effectively if they have respiratory disease. Some patients might benefit from back rubs to induce a state of relaxation. If at all possible, noise should be reduced for patients with sleep disturbances; this may mean relocation to a room that is quieter. A nurse may provide uninterrupted times for sleep during the day if the patient is unable to sleep well at night. Nurses should be aware of all the various noises, including voices that are associated with giving care, and seek to minimize them. Noise can be particularly distressing for patients in pain, since it seems to increase sensitivity. Earplugs can be used if needed. Call lights should always be available to patients so they will feel less anxious should they require assistance from nursing personnel. The knowledge that help is instantly
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available can decrease anxiety and aid patients in falling asleep. Some patients may need night-lights in their room or in the bathroom if they are ambulatory at night. Night-lights can also be comforting to children in the strange environment of the hospital. Other patients may not be able to sleep at all if there is any light in the room; doors may need to be shut and blinds pulled to close out the light from hallways and the outside lights surrounding a busy hospital. Eyeshades can also be used. Attention should also be paid to providing a comfortable room temperature with adequate ventilation. Patients who are chilled because of air conditioning or fans blowing directly on them will not sleep as well. The older adult, especially, and the young child may require extra blankets for warmth. In home situations, people might benefit from flannel or outing sheets for extra warmth. Hot water bottles or heating pads should not be used because of the danger of burning, especially with the older adult. Dietary Management If a person eats a large meal one to three hours prior to sleep, it is generally counterproductive to sleep, especially a meal with hot and spicy foods that can cause heartburn. Beverages containing caffeine should also be avoided at night because of their stimulant effect on the central nervous system and their diuretic effect on the bladder, promoting increased urination. Alcohol also has a diuretic effect. Plain, warm milk, not chocolate milk, is often encouraged for insomnia; chocolate can have a stimulating effect to the nervous system. Some patients benefit from a light protein and carbohydrate snack, for example, crackers and cheese. Tryptophan is an amino acid found in both milk and cheese, and it is thought to induce sleep. Medications Though many drugs have side effects that adversely affect the need for rest and sleep, some patients may benefit from short-term treatments of sedatives or hypnotics. Medications should never be used, however, as a chemical form of restraint. The primary purpose of sedative-hypnotic drugs is to induce sleep, not manage behavior. Most sedative-hypnotic drugs depress the central nervous system. Ideally they should not disrupt the normal cycles and stages of sleep but enhance them. Chronic use can decrease required amounts of REM sleep and increase confusion in older adults. Obese patients may experience more sleep apnea if sedative-hypnotics are used to induce sleep. The primary drugs used to induce sleep are the benzodiazepines: flurazepam (Dalmane), oxazepam (Serax), clonazepam (Klonopin), diazepam (Valium), and temazepam (Restoril). For example, restless leg syndrome (RLS) is a common disorder that can cause people difficulty in falling asleep and remaining asleep because of repeated leg jerking; benzodiazepines have been prescribed. Warm baths and leg massage may also help relieve symptoms. (Note: Leg massage may be contraindicated for some patients. The increased blood flow from leg massage is not recommended for people with hematomas, edema, blood clots, and varicosities. If there is a fracture or skin infection on the leg, massage would also be contraindicated. Vigorous massage should also be avoided for people with osteoporosis, bleeding disorders, low platelet counts and people
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taking heparin or Warfarin. Pregnant women should consult their physicians, as leg massage may be contraindicated during the first three months of pregnancy.) Common non-benzodiazepine hypnotics include the sedatives chloral hydrate and zolpedim (Ambien). Warm milk given with these and other hypnotic drugs aids in their absorption. Many patients in the hospital, nursing home, or at home are on diuretic therapy to reduce edema and fluid retention (e.g., Lasix and Diuril). These should generally be given early in the morning to ensure the patient will have a restful sleep at night. Pain can inhibit rest and sleep; often a pain-relieving analgesic like acetaminophen (Tylenol) or extra-strength Tylenol can be more effective to induce sleep than a sedative or hypnotic. Over-the-counter pain relievers have minimal side effects and provide the added benefit of pain relief. Anti-inflammatories for arthritis like Motrin (ibuprofen) may also be used. Psychological Modifications A number of psychological modifications can be considered as interventions. For example, it is important to reduce sensory stimuli as much as possible several hours before sleep. People who work or study using computers until just before bedtime may have difficulty turning off their minds. Restful, quiet activities are preferred. This might include mild exercise, like a walk. The process of getting ready for bed can also induce sleep. This ritual is particularly important for children and people with various forms of dementia who may be used to bedtime routines like brushing their teeth, removing dentures, and washing the face and hands. The nurse can also provide an opportunity for patients to unwind or talk about any fears or anxieties associated with their illness, hospitalization, or nursing home placement, all of which may also help induce sleep. Various forms of relaxation exercises and guided imagery techniques can be taught. Deep breathing exercises that may help the patient to relax incorporate contracting and relaxing various muscle groups. Some guided imagery exercises may pose ethical or religious concerns for patients. Nurses should be aware of the patients underlying worldview or belief system when offering these interventions. Soft music from a bedside radio may induce sleep. Music can also help block out the distraction of other noise in the environment. White noise is a sound that contains a blending of all the audible frequencies that are distributed equally over the range of a frequency band and is also considered an intervention. Alternative and Complementary Therapies A number of nursing interventions considered alternative or complementary may be used. There are a variety of touch therapies from both Eastern and Judeo-Christian traditions
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that nurses have incorporated into care for patients to aid in relaxation. Some of these therapies, like therapeutic touch, healing touch, and various forms of guided imagery, may pose ethical or religious concerns for patients who do not subscribe to the underlying philosophy or belief system on which they are based. Some people pray every night before going to bed, including children. Nurses can provide opportunities for this bedtime ritual by incorporating parents into the bedtime routine of the child or assigning a nurse who is comfortable with that complementary intervention to the patient. It is important to explore with parents of children and with family members of persons with dementia any other specific bedtime rituals that enhance sleep for them, for example, reading a bedtime story or book. Children and also some older adults may sleep with stuffed animals.
Applying the Nursing Process to Meet Basic Needs for Rest and Sleep
Once the nurse has done a thorough assessment of the patients rest and sleep status based on objective and subjective data and is aware of the variety of interventions that can be utilized for related disturbances, care planning can be done utilizing the nursing process and other theoretical frameworks. This process includes the analysis and synthesis of all data, culminating in one or more nursing diagnoses. Diagnoses are then prioritized, and planning, implementation, and evaluation follow in logical order. Assessment To briefly review, the following are considerations for a nursing assessment: Obtain a history from the patient and/or the patients significant others related to the patients rest and sleep patterns. For example: Question the patient about any recent changes in ability to sleep, or ask him or her to keep a sleep diary for a week. Assess other factors that could influence the patients ability to rest and sleep. For example: Explore with the mother of a hyperactive toddler who has difficulty sleeping the types of foods the child might be eating before bedtime, or ask about environmental factors that might impede sleep, such as noise. Utilize nursing skills for physical assessment. For example: Observe the sleep pattern of a patient admitted with sleep apnea. Obtain and review laboratory and other diagnostic data. For example: Review results of pulse oximetry readings over the course of a week for a patient with COPD and insomnia.
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Analysis Once objective and subjective data have been gathered, the nurse synthesizes the data in order to identify the patients actual or potential health problems that are amenable to some type of nursing intervention. Other health team members such as the physician and personnel from a sleep disturbance clinic might also be involved in analysis. Nursing diagnoses are then formulated and prioritized. Nursing Diagnoses The nursing diagnosis will include an actual or potential problem related to sleep and rest, and the etiology of the problem or potential condition of risk. Defining characteristics based on objective and subjective data help define the diagnoses. The general nursing diagnoses based on NANDA-I and criteria related to disturbances in rest and sleep are sleep deprivation and readiness for enhanced sleep. Specific nursing diagnoses that address actual problems or situations of risk can be phrased as follows: Sleep deprivation related to sleep apnea secondary to morbid obesity Sleep deprivation disturbance related to frequency of nocturnal voiding secondary to urinary tract infection At risk for sleep deprivation related to severe pain associated with bone cancer Fatigue and depression related to alteration in sleep patterns following death of spouse Activity intolerance related to disturbed sleep pattern secondary to severe COPD At risk for injury when driving related to narcolepsy
Nursing diagnoses that relate to complications associated with inactivity and immobility or to specific needs on Maslows hierarchy may also be considered: At risk for cardiac dysrhythmias and hypertension related to sleep apnea High risk for falls or injury related to somnambulism
Nursing diagnoses that imply a readiness for sustaining a lifestyle that will foster healthy sleep patterns include: Readiness for enhanced sleep indicated by adherence to recommended sleep routines. This might be applicable to a child or adolescent who had been refusing to go to bed at recommended times but decides to follow the guidelines of his parents in order to feel more rested for school.
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Prioritizing, Planning, and Setting Goals

Prioritizing
Priorities can also be set for various nursing diagnoses based on Maslows hierarchy of needs and optimal use of resources. Consider this example: A fifty-three-year-old patient with recent weight gain is admitted to the hospital due to sleep apnea. Laboratory tests reveal borderline hypoxia with pulse oximetry. An EKG reveals a cardiac dysrhythmia. The patient has symptoms of left-sided heart failure, including hypertension. Needs that could be life threatening if unmet or that put the patient at risk for more serious complications would be considered top priority, such as the basic physiological need for adequate gas exchange and prevention of carbon dioxide buildup. If pulse oximetry continues to reveal abnormally low oxygenation values, oxygen can be given by nasal cannula using an oxygen concentrator at night. Blood gases can be monitored. A device called a continuous positive pressure airway (CPAC) can be used at night to relieve sleep apnea. An assessment by a respiratory therapist could help determine what specific treatments might be indicated. Health restoration needs would precede needs for health promotion. Dietary management will also be indicated, and thus a thorough dietary assessment by the hospital dietitian is indicated. The patient might be placed on a low-fat, lowcholesterol, 1,500 calorie diet during the course of hospitalization and given a discharge diet planned with the patient as well as referral to a support group for weight management.
Planning
Planning includes patient-centered goal setting related to health promotion, maintenance, and restoration with strategies to meet the goals. A goal for a patient who has been admitted for exhaustion related to inability to sleep is that the patient would demonstrate decreased signs of sleep deprivation, including increased alertness, decreased fatigue, and ability to sleep for at least six continuous hours at night. The person might also verbalize feeling refreshed upon awakening. A goal for a morbidly obese patient who is experiencing sleep apnea is that he or she would lose five pounds a month. Planning also needs to include various other influencing factors. The nurse could plan to incorporate teaching concerning alcohol consumption and its effect on sleep patterns with a patient who consumed several beers prior to retiring each night and complained of difficulty sleeping at home. Specific nursing standards and protocols can be used to plan interventions to meet needs. Discharge planning with the wife of a patient with Alzheimers dementia who has
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difficulty sleeping would be that the wife be able to incorporate dietary changes into her husbands bedtime routine (for example, a carbohydrate snack of a cheese sandwich and warm milk), or that she might play music tapes or the radio to enhance sleep. A patient with severe arthritis could be given Motrin one half hour before bedtime with a glass of warm milk. An occupational therapist could be consulted to provide any splinting devices that might aid in keeping hands and feet in proper alignment when sleeping. The child on the pediatric unit who is afraid of the dark and unable to sleep can be provided with a night-light by the bed and stuffed animals from home. Specific factors that could influence rest and sleep should also be incorporated in planning. Any normal routines a patient engaged in prior to hospital or nursing home placement that enhanced sleep should be encouraged, such as a bedtime story, nightly prayers, readings from a devotional book, or a warm bath. Sleep centers associated with various medical centers like the Mayo Clinic or the Cleveland Clinic is good sources of information to aid in the planning process. Information about different topics related to dysfunctional sleep patterns and habits is also available from the National Sleep Foundation (NSF). The A-to-Z listing on their web site (http://www.sleepfoundation.org) can be helpful to nurses, patients, family members, and other health professionals in planning care. For example, the NSF recommendations to help alleviate bruxism (nocturnal teeth grinding) include reducing stress levels prior to retiring, engaging in soothing bedtime routines, having a cool, comfortable, dark, and quiet room to sleep in, and, if possible, sleeping on the stomach or in a side-lying position rather than on the back. The guidelines also note that sleep deprivation can exacerbate symptoms of bruxism. Some relaxation techniques recommended include progressive muscle relaxation to relieve muscle tension and diaphragmatic breathing and autogenic training to increase blood flow in the extremities. Various relaxation techniques are often part of a specific training program at sleep clinics and in private practices.
Setting Goals
Goals also require measurement. How will you know if a goal has been met? If a goal is for the person to be able to be less fatigued during the day at work, one measurement of that goal could be verbalization of feeling more alert and the ability to accomplish shortterm goals that are work related. Goal setting also includes assigning patient care activities to others. Nursing assistants could be assigned to give a back rub to a patient prior to sleep, read a bedtime story to a child, or change the patients bath to the evening hours to see whether that promotes sleep in a nursing home setting. Implementation Interventions should be targeted to move the patient toward the expected outcomes related to health promotion, maintenance, and restoration with respect to rest and sleep. For example:
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Promote rest and sleep. Bedtime rituals can be promoted. Voiding can be encouraged immediately prior to bedtime. A back rub can be administered or a protein snack given to the patient. Proper positioning of the patient to maintain good body alignment should be a priority. Give medications to maximize effects and minimize side effects. Diuretics should be given to patients in the morning to avoid nocturnal awakenings. Chronic use of sedatives and hypnotics should be avoided, and these medications should not be used as chemical restraints. Make modifications to the environment. Eliminate as much noise as possible or mask noise with music, close doors, and adjust lighting to suit patient preferences. Provide information and instruction regarding rest and sleep. The patient can be instructed on how to do relaxation exercises and what types of exercise and work activities are appropriate for different times of the day to prevent nighttime overstimulation of the nervous system and sensory overload. Promote continuity of care. Referrals to sleep clinics can be made if needed for people experiencing sleep apnea. Follow-up referrals can be made to community health facilities to monitor a depressed patient who has been experiencing sleeplessness following an amputated limb. Collaborate with the patient on enhancing sleep patterns. A home care nurse might encourage a client to keep a sleep diary that would include number of hours slept, time of day of sleeping, number of times awakened and possible reasons, and types of strategies used to enhance sleep in order to better determine an ongoing plan of care to provide adequate rest.
Evaluation Once the care plan has been implemented, it will be important to evaluate the patients response on an ongoing basis and any progress made toward the patient-centered goals. The following are general categories for evaluation and questions or aspects of care to consider: Record and report the patients response to any nursing actions. Did changes in sleep patterns occur after dietary and environmental modifications were made? How is the patient responding to the newly ordered sedative for sleep? Is he or she experiencing any side effects? Does the patient indicate that he or she is sleeping better? Reassess and revise the patients care plan as needed. If the nursing diagnosis indicates the patient is at risk for developing activity intolerance related to sleep deprivation, attention should be given to ongoing daily patterns of activity tolerance including any shortness of breath, any confusion, and observance of gait. Additional modifications to the care plan might be needed to enhance sleep if activity intolerance increases.
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Determine the patients response to the care provided by other members of the health care team. LPNs/LVNs can be asked to record and describe a patients sleep pattern during their shift report.
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Chapter 7: Caring for Patients with Cancer

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. Define the word cancer, and list several factors that can cause genes to malfunction, mutate, and lead to cancer. Differentiate between benign and malignant tumors and between carcinomas and sarcomas. Explain the grading of neoplasms and the staging of neoplastic disease. Discuss the changes in lifestyle and the diet recommended to prevent cancer. Identify three cancer-screening exams and their recommended frequency. Explain tumor markers and identify examples of lab tests used for tumor markers. Describe the four therapies used for cure, control, and palliation of neoplasia. Discuss the major family of pharmacologic agents used for chemotherapy, and list at least eight adverse effects associated with chemotherapeutic drugs. Apply each phase of the nursing process to a patient who is in the following stages: undergoing cancer surgery, receiving antineoplastic agents, receiving radiation therapy, or undergoing rehabilitation or terminal care for cancer. Apply each phase of the nursing process to the family of a patient who is receiving treatment for cancer. Explain how the nursing process can be applied to cancer education and prevention in a community.
10. 11.
Key Terms
afterloading benign tumors biologic response modifiers brachytherapy cachexia cancer carcinoma chemotherapy computed tomography (CT) debulking endoscopy grading immunotherapy interstitial radiation intracavitary radiation laparoscopy leukemia magnetic resonance imaging (MRI) malignant tumors mammography metastasis neoplasia palliative treatment positron-emission tomography (PET) radiation radioisotope studies remission sarcoma staging systemic radiation teletherapy TNM system tumor tumor lysis syndrome tumor marker
Introduction
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Cancer nursing is a dynamic area of practice that covers all health care-delivery settings and all age groups. The specialty area is called oncology nursing and the scope, responsibilities, and goals of cancer nursing are as diverse and complex as any nursing specialty area. The purpose of this chapter is to provide a very general overview of cancer and nursing care for cancer patients and their families. The chapter begins by defining cancer, identifying factors that can lead to cancer, and classifying neoplasms. We discuss a variety of patient-level interventions that can help prevent cancer from developing. We then discuss screening for neoplasms, laboratory studies, and radiographic procedures that are sometimes used to help in the differential diagnosis of cancer. We also explore the four general treatment options for individuals diagnosed with cancer and apply the nursing process to each alternative. Our discussion then turns to general nursing care for individuals with cancer and for families who have a member diagnosed with cancer. The chapter concludes with a discussion of cancer-related preventive care provided to the community as a whole.
Basic Concepts of Cancer

A dreaded diagnosis today, cancer is the second-leading cause of death in the United States (Garfinkel 1995). Cancer is a group of disorders defined by abnormal cellular differentiation and growth (neoplasia). Normally, cell division and proliferation are regulated; in cancer, the affected cells are unresponsive to normal control mechanisms and are less differentiated than the parent cells. This results in increased numbers of cells with altered anatomy and function. This increase in cells may result in tumors (groups of neoplastic cells clumped together) or leukemias (abnormal proliferation of white blood cells). Individuals with cancer commonly experience pain, fatigue, anemia, infection, and cachexia. Cachexia is a severe form of malnutrition that includes anorexia, weight loss, altered taste, and altered protein, carbohydrate, and lipid metabolism. Anemia is commonly seen in cancer because of malnutrition, chronic bleeding, iron deficiency, chemotherapy, and radiation. Infection also is a common complication of the cancer process and its treatment modalities. Treatment with radiation or surgery also can lead to devastating changes in physical appearance from burns or scars. Cancer additionally has a significant psychosocial impact on its victims. The life of an individual who has been diagnosed with cancer is full of uncertainties. For example, clients might ask What is the prognosis for this type of cancer? or How long do I have to live? It is not uncommon for the individual with cancer to experience fear, anxiety, depression, helplessness, hopelessness, hostility, anger, and loss of control. The patients self-esteem may be threatened by changes in role function, body image, and loss of work.
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A number of different factors cause the genes that control cellular growth and differentiation to mutate and malfunction, leading to cancer. Examples include the following: Viruses Chemical agents, such as nicotine, alcohol, pesticides, and nitrites Physical agents, such as radiation and UV light Hormones, such as estrogen Drugs, such as cytotoxic medications Heredity Environmental and occupational exposures to certain agents, such as mustard gas, pesticides, and asbestos Obesity and high-fat, low-fiber diets Stress (causes a depressed immune system)
Genes have been identified that are associated with certain types of cancer. Some chromosomal syndromes increase the risk of certain types of cancers. For example, individuals with Down syndrome have an increased incidence of leukemia when compared to the rest of the population. Cancer rates are highest in the elderly. More males are diagnosed and die from cancer than females. Likewise, the incidence of cancer is higher in the lower socioeconomic groups. The diagnosis, treatment, and management of patients with cancer will be discussed in this chapter.
Classification of Neoplasms
Tumors are classified as either benign or malignant. Benign tumors usually contain well-differentiated cells that resemble the cell of origin; grow slowly by expansion; are encapsulated and localized; and rarely cause tissue damage or death. On the other hand, malignant tumors contain undifferentiated cells that grow at the periphery, infiltrating and destroying surrounding tissue; exhibit a variable rate of growth; metastasize (travel to and proliferate at distant sites causing a secondary tumor); cause generalized effects, such as anemia; and cause death if uncontrolled. Because both benign and malignant tumors may arise from any source, the different types are differentiated by a common nomenclature. Malignant tumors are called carcinomas or sarcomas, based on their cells of origin. Carcinomas are derived from epithelial cells, whereas sarcomas develop from mesenchymal cells. For example, a benign tumor in bone tissue is called an osteoma, whereas a malignant tumor is called an osteosarcoma. Once the malignancy has been eradicated, an individual is said to be in remission. Depending on the type of cancer, an individual is considered to be cured if he or she has been in remission for anywhere from one to seven years.
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Grading Grading is the first step in evaluating a malignant neoplasm. Neoplastic cells are compared with their parent cells to determine the extent to which cellular changes have occurred, and they are graded on a scale from G1 to G4. G1 cells closely resemble their parent cells, while G4 cells are poorly differentiated and determination of parent cells is difficult. Staging The extent of neoplastic disease is described in terms of the size of the tumor, whether or not there is lymph node involvement, and metastasis. The TNM (tumor-node-metastasis) system is commonly used to describe most neoplastic disease through a process called staging. The TNM system is a standardized set of codes. T codes depict the size and characteristics of the tumor, N codes denote the extent of lymph node involvement, and M codes relate to the presence of metastasis.
Prevention of Neoplasms
The first objective of medical management of cancer is to prevent neoplasia. Based on factors known to lead to cancer, the following changes in lifestyle and diet are recommended: Decrease consumption of saturated and unsaturated fats, alcohol, excess calories, and smoked, nitrite-preserved, or salt-cured foods. Individuals should be taught what is acceptable and how to read the labels on food items. Individuals also may need to be instructed in alternative ways to prepare and cook meals. For example, instead of frying chicken, broil or bake it; instead of salt, use other spices to flavor foods. Increase consumption of foods rich in vitamins A and C, fruits (citrus), carotene (e.g., carrots) and cruciferous (e.g., broccoli, brussels sprouts, or cauliflower) vegetables, and high-fiber foods, such as whole grain cereal products and legumes. Again, individuals may need information about food items rich in these nutrients. Stop using tobacco products. Individuals should be informed about the availability of agents designed to stop smoking, such as Nicorette gum or nicotine patches; they may need referral to smoking cessation programs. It is also important to inform individuals who use smokeless tobacco that chewing tobacco and snuff are associated with oral cancer. Avoid exposure to the sun (especially between 10 a.m. and 3 p.m.), excessive sun tanning, and sunburns. Individuals should be informed about how to dress to decrease their exposure to the sun and about the difference between sun tanning oils, lotions, and blocks (and which products are the best to use). Minimize occupational exposure to chemicals by dressing properly and using designated safety equipment.
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Diagnosis of Neoplasms
Screening Early detection provides the best prognosis for most cancers. Several procedures have been recommended. First, annual physical and oral examinations are important to identify changes and catch neoplasia early when intervention is still possible. It is recommended that women perform breast self-exams monthly and obtain annual pelvic examinations and Pap smears to detect reproductive system cancers. Men should perform monthly testicular self-exams. With age, the incidence of cancer increases; therefore, after the age of forty, women should have regular mammograms and breast exams. After forty, both men and women should have digital rectal exams and fecal occult blood assessments to check for colorectal cancer. After the age of fifty, sigmoidoscopy is recommended every three to five years (American Cancer Society 1995). Laboratory Studies A number of laboratory studies may be done, including a complete blood count with differential, as well as other blood and biochemical tests (depending on the type of cancer suspected or the risk factors present). Certain agents, such as antigens, enzymes, hormones, metabolites, and oncogenes, are known to be produced by specific types of neoplasia and measurable in an affected individuals serum. These agents are called tumor markers. Unfortunately, the sensitivity (ability to detect cancer) and specificity (ability to exclude those without cancer) of the markers vary, and many are associated with other diseases (e.g., insulin and diabetes, HCG and pregnancy, LDH and myocardial infarction, etc.). Table 7.1 provides an overview of some of the tumor markers that are available. Table 7.1 Tumor Markers
Legend: = increased; = decreased Test Acid phosphatase ACTH Alkaline phosphatase (ALP) Neoplasia Prostate cancer Lung cancer Bone cancer, liver cancer, kidney cancer, lymphoma, leukemia, metastasis to bone and liver Liver cancer, pancreatic cancer, stomach cancer, colon cancer, renal cancer, lung cancer, breast cancer, testicular cancer Multiple myeloma, lung cancer, liver cancer, breast cancer Breast cancer Pancreatic cancer, liver cancer, colorectal
Alpha-fetoprotein
beta2-microglobulin CA 153 CA 199
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Table 7.1 Tumor Markers

Legend: = increased; = decreased Test CA 27, 29 CA 50 CA 125 Calcitonin Calcium Neoplasia cancer, stomach cancer Breast cancer Stomach cancer, pancreatic cancer, colorectal cancer Ovarian cancer, uterine cancer, cervical cancer, pancreatic cancer, liver cancer Thyroid cancer, lung cancer, liver cancer, kidney cancer, breast cancer Bone cancer, breast cancer, lung cancer, kidney cancer, bladder cancer, liver cancer, leukemia, lymphoma Bone cancer, breast cancer, pancreatic cancer, liver cancer, kidney cancer, lung cancer, stomach cancer, thyroid cancer, colorectal cancer, ovarian cancer, bladder cancers, leukemia, neuroblastoma Breast cancer, lung cancer Pancreatic cancer Stomach cancer, pancreatic cancer Pancreatic cancer Gestational trophoblastic tumors, testicular cancer, ovarian cancer, pancreatic cancer, liver cancer, stomach cancer, kidney cancer Lung cancer Liver cancer, leukemia, lymphoma, Ewings sarcoma, neuroblastic carcinoma of the testes Neuroblastoma, small-cell lung cancer, pancreatic cancer, thyroid cancer, Wilms tumor, pheochromocytoma
Carcinoembryonic antigen (CEA)
Creatine kinase (BB isoenzyme) DU-PAN-2 Gastrin Glucagon Human chorionic gonadotropin
Insulin Lactate dehydrogenase (LDH) Neuron specific enolase (NSE)

Legend: = increased; = decreased Test Parathyroid hormone Prostatic specific antigen (PSA) Neoplasia Lung cancer, kidney cancer, pancreatic cancer, ovarian cancer Prostate cancer
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125

Legend: = increased; = decreased Test SGPT SGOT Squamous cell carcinoma antigen (SCC) Testosterone Tissue polypeptide antigen (TPA) Neoplasia Liver metastasis Liver metastasis Head and neck cancer, esophageal cancer, lung cancer, cervical cancer Ovarian cancer Breast cancer, head and neck cancer, lung cancer, thyroid cancer, pancreatic cancer, stomach cancer, colorectal cancer, prostate cancer, ovarian cancer Leukemia Hodgkins disease, lung cancer Neuroblastoma, retinoblastoma, pheochromocytoma Intestinal cancer
Uric acid Uric acid Vanillylmandelic (VMA)/homovanillic acid (HVA) Vasoactive intestinal peptide (VIP)
Cellular analysis of suspect cells also may be conducted. Cells may be obtained from urine, sputum, a Pap smear (a slide of sloughed cervical cells), or needle aspiration of bone marrow, liver, kidney, spleen, lung or breast tissue. Radiographic Procedures Common tests used to diagnose and characterize the size and location of solid tumors include radiographs (with or without contrast), radioisotope studies, positron-emission tomography, computed tomography, and magnetic resonance imaging. In radioisotope studies, a radioisotope is injected through an IV, and uptake by the suspect organ is measured by a scintillation scanner. Positron-emission tomography (PET) is another imaging technique in which radioisotopes are injected, but a PET scanner is used to obtain cross-sectional images of the organs of interest. Computed tomography (CT) is a radiographic technique that produces sequential, cross-sectional images of the body that may be obtained with or without the use of a contrast dye. Magnetic resonance imaging (MRI) also obtains cross-sectional images, but with the use of magnetic fields. Mammography uses radiography to view the breasts and visualize tumors.
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Direct Visualization Direct visualization of the respiratory, gastrointestinal, and genitourinary tracts may be done through endoscopic procedures or surgery. In endoscopy, a flexible, lighted tube is inserted into the tract of the patients orifice to view the internal anatomy. Tissue biopsies may be obtained at the same time. A diagnostic or exploratory laparoscopy is a surgical procedure in which the contents of the abdomen are inspected. Again, tissue samples may be obtained during the procedure.
Treatments for Neoplasms

The goal of treatment is a cure, but sometimes a cure is not possible. During these times, palliative treatment modalities are used to control tumor growth and relieve symptoms. Four therapies are used for cure, control, and palliation: (1) surgery, (2) chemotherapy, (3) immunotherapy, and (4) radiation. Cancer-specific treatments also may be available, such as bone marrow transplants for leukemia. Pain management and symptom control are major aspects of therapy. In addition, adjuvant therapies, including additional radiation or chemotherapy, are sometimes used to prevent recurrence of a tumor after it has been eradicated.
Surgery
Surgery may be performed prophylactically to prevent the development of cancer. For example, undescended testes may be surgically moved to the scrotum in young boys, in part to decrease the development of testicular cancer later in life. Some women at high risk for breast cancer may undergo radical mastectomies before cancer is identified. Those with familial polyposis may undergo a subtotal colectomy because of the high association of this condition with colorectal cancer. Surgery may also be used in the diagnosis of cancer. It is often used to verify the location and size of tumors, as well as to biopsy and stage tumors. Surgery is also used to cure. If localized, tumors may be eradicated through resection. Sometimes, complete removal of the tumor is not possible. In this situation, as much of the tumor as possible may be removed to reduce the tumor burden (debulking) and to facilitate other forms of treatment, such as chemotherapy or radiotherapy. Endocrine glands are sometimes removed as well, because they produce hormones that promote tumor growth. Surgery can also be used to correct damage or complications associated with tumor growth. For example, obstructions may be relieved or tissues may be reconstructed, as in a mammaplasty. Additionally, surgery may be used to insert devices needed for treatment (venous access devices, implantable pumps, etc.).
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Nursing Care of the Individual with Cancer Who Undergoes Surgery

Assessment
The needs of an individual with cancer who undergoes surgery are similar to those of any other patient undergoing surgery. However, there may be significant changes in body image and function because of the invasive nature of cancer. Therefore, it is vital that the nurse ascertain the meaning of the procedure to the patient by asking questions such as the following: Does the individual fully understand what to expect after the surgery? Will the individual have a visible scar or obvious loss of a body part? Will all the hair on the individuals head need to be shaved? Will the individual need to learn a self-care procedure, such as tracheostomy care? Will the individual need to learn how to use adaptive equipment, such as an artificial limb or larynx? Will the individual need extensive physical and/or occupational therapy? What anxieties and fears has the individual identified? Are the fears realistic? Are there concerns about role performance or relationships? Can the individual identify coping mechanisms or supports to help him or her adjust following the surgery?
After the surgery is performed, the nurse should evaluate the individuals reaction by considering the following topics: Is the individual able to view the surgical site? Is the individual open to information and teaching? Is the individual able to meet self-care needs, or is he or she depressed, withdrawn, and preoccupied with bodily changes?
Analysis
When caring for individuals who have had surgery related to cancer, the risks for infection and poor wound healing are often heightened due to the immunocompromised state of the individual. Other concerns include the following: Activity intolerance related to the fatigue associated with cancer Impaired adjustment due to changes in body image, role performance, body functions, and adaptations to equipment Anxiety and fear related to unknown outcomes and change Ineffective coping due to inadequate or ineffective coping mechanisms Grieving for the lost body part and associated functions Ineffective role performance and body image changes related to the surgery Pain (acute or chronic) related to the surgical intervention
Planning and Implementation
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The goals of care for anyone undergoing surgery related to cancer are to prevent complications, promote healing, ameliorate pain, facilitate understanding, and promote integration of a positive body image. These goals can be accomplished by taking the following nursing actions: Assess the clients physical and mental well-being, body image, and selfconcept. Administer analgesics, antibiotics, and other medications as ordered. Provide the client with plenty of opportunities to verbalize concerns, fears, and anxieties. Listen with empathy and acceptance. Encourage the client to look at the surgical site and assist with the sites care. Teach the client how to perform self-care activities related to the surgery (e.g., tracheostomy or ostomy care). Assist the client with the use of adjuncts, such as crutches or an artificial larynx. Provide the client with information about community resources and programs (e.g., American Cancer Society, Reach for Recovery, etc.). Arrange for visits from prior patients who have adapted well to the changes associated with surgery. Inform the individual about ways to disguise scars or otherwise improve appearance, body image, and self-concept (e.g., wear scarves to hide a thyroidectomy scar or tracheostomy, wigs while hair grows back in, or breast or limb prostheses). Make referrals as needed to social services, a psychologist, pastoral care, or counseling for assistance in adjusting to role and lifestyle changes associated with the surgery.
Evaluation
Expected outcomes for the patient undergoing surgery for cancer include the following: Verbalizing an understanding of the surgical procedure and the implications for role and lifestyle changes Accepting body image changes as evidenced by visualization of the affected body part and management of self-care needs Identifying a system of support and using positive coping methods Recuperating without evidence of infection or other complications
Chemotherapy
Chemotherapy is the use of pharmacologic agents to eradicate or inhibit the growth of neoplastic cells. These agents may also be used to reduce the tumor bulk (palliation) or as an adjuvant to radiation or surgery. The major family of pharmacologic agents used in chemotherapy consists of antineoplastic (or cytotoxic) drugs. Unfortunately, cytotoxic drugs kill normal as well as tumor cells, affecting rapidly dividing cells, such as those in the gastrointestinal tract, the most. As a result, a number of adverse effects are associated with chemotherapeutic agents, including the following:
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Alopecia (hair loss) Anorexia Bone marrow suppression Immunosuppression Gonadal suppression Nausea Vomiting Mucositis (inflammation and ulceration of gastrointestinal mucous membranes) Stomatitis (inflammation and ulceration of the mouth and tongue) Diarrhea
Many chemotherapeutic agents administered via IV are highly irritating and may cause extensive tissue damage. Extreme caution must be used to avoid extravasation. Some agents have been found to be toxic to cardiac, pulmonary, renal, neural, and liver tissues; these may respectively result in cardiomyopathy and congestive heart failure, pneumonitis and fibrosis, acute renal failure and hematuria, central or peripheral neuropathy, and cirrhosis. Tumor lysis syndrome may occur within one to five days after the start of chemotherapy due to the rapid destruction of tumor cells. Tumor lysis syndrome is characterized by oliguria, hematuria, flank pain, cardiac dysrhythmias, neuromuscular cramps, tetany, confusion, hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Longterm effects of chemotherapy include development of leukemia and other secondary tumors. Antineoplastic/Cytotoxic Agents Antineoplastic/cytotoxic agents are classified by their modes of action. The most common categories are alkylating agents, antimetabolites, antitumor antibiotics, and plant alkaloids. Hormones (such as estrogens and androgens) and hormone inhibitors (such as tamoxifen) are also used, especially for reproductive system tumors. Table 7.2 depicts common antineoplastic agents used in the fight against cancer. Table 7.2 Antineoplastic Agents
Drug class Alkylating agents: Nitrogen mustard Busulfan Carmustine Action on cancer cells Damage DNA, preventing replication
Table 7.2 Antineoplastic Agents

Drug class Action on cancer cells
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Table 7.2 Antineoplastic Agents

Drug class Antimetabolites: Methotrexate 5-fluorouracil 6-mercaptopurine Antitumor antibiotics: Adriamycin Bleomycin Actinomycin D Plant alkaloids: Vincristine Vinblastine Action on cancer cells Compete for or replace metabolites, blocking DNA synthesis
Damage DNA; interfere with DNA repair; inhibit RNA and protein synthesis
Prevent or arrest mitosis
Cytotoxic drugs are most effective when given in combination. As a result, protocols combining two or more cytotoxic agents have been developed for many types of cancer. For example, MOPP (nitrogen mustard, Oncovin, procarbazine, prednisone) is a protocol used to treat Hodgkins lymphoma. The efficacy of these agents is demonstrated by tumor shrinkage and overall improvement. Antineoplastic agents are administered through a number of routes, most commonly IV. Because of the potential damage associated with IV administration and the need for repeated administrations, vascular access devices are often inserted. Common forms include peripherally inserted central catheters (PICC), tunneled central venous catheters (e.g., Hickman and Groshong), and implantable or peripheral ports (e.g., Port-A-Cath or PAS-Port). Other routes used for administration of chemotherapeutic agents are per os, intra-arterial, intrathecal, intracavitary, and topical.
Nursing Care of the Individual Receiving Antineoplastic Agents
Assessment Administration of antineoplastic agents is usually limited to registered nurses or physicians who have specialized training regarding these drugs. Special handling is required to protect the provider as well as the patient. Prior to administration of antineoplastics, the nurse should ascertain the status of the patient. A complete physical exam is usually conducted, and baseline laboratory studies are obtained to determine the hematologic status and liver and renal function. The nurse should note the presence of any manifestations associated with infection, especially the presence of a fever. The nurse should also verify the patency of the vascular access device before administering chemotherapy. The nurse should also ascertain the patients understanding of the therapeutic plan and associated adverse effects. This includes consideration of the following:
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Is the client prepared for the body image changes associated with chemotherapy? Has the client been adequately prepared regarding ways to cope physically and emotionally with treatment? What are the individuals fears and concerns? If the individual has previously received chemotherapy, what was his or her response?
Analysis Common diagnoses associated with the administration of chemotherapy include the following: Altered comfort related to nausea and vomiting Altered nutrition (less than body requirements) related to anorexia, nausea, vomiting, and stomatitis Altered oral mucous membranes related to stomatitis Altered urinary elimination related to nephrotoxicity Body image disturbance related to loss of hair Diarrhea related to gastrointestinal cell damage Fatigue related to cellular damage and anemia Peripheral neurovascular dysfunction related to paresthesias secondary to neurotoxicity Risk for infection related to immunosuppression Risk for injury related to myelosuppression and lung, liver, cardiac, kidney, CNS, and tissue damage Sexual dysfunction related to gonadal suppression
Planning and Implementation The goals of care for someone undergoing chemotherapy are maximizing the therapeutic benefits of the drug, minimizing the associated complications, and facilitating emotional adaptation to the effects of chemotherapy. These goals can be attained by taking the following nursing actions: Administer antineoplastic agents as ordered. Ensure that the site of administration is patent and without evidence of infiltration or thrombophlebitis. Administer antiemetics before nausea and vomiting occur and at regular intervals, as ordered. Administer sedatives. Teach relaxation and distraction techniques, such as guided imagery, to relieve anxiety, nausea, and vomiting. Eliminate odors and unpleasant stimuli that stimulate nausea. Perform mouth care regularly with a soft-bristled toothbrush or disposable mouth sponge to prevent irritation and nausea.
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Avoid the use of dental floss, water picks, and commercial mouthwashes that contain alcohol and may further irritate the oral mucosa. Administer swishes as ordered, warning the client not to swallow the mixture. Avoid foods with strong odors or those known to be irritating to the GI tract (e.g., fatty, spicy foods) to prevent nausea and diarrhea. Irritating food should also be avoided in the individual with mucositis. Encourage frequent, small meals and high-protein snacks and supplements. Administer viscous Xylocaine as ordered to promote mouth comfort. Instruct the client to avoid the use of tampons, enemas, rectal suppositories, and rectal thermometers because they may traumatize the tissues, leading to an infection. Provide perianal care following diarrhea. Stress the importance of good hand washing and the avoidance of crowds, children, and sick people. Keep fresh flowers, fruits, vegetables, and potted plants out of the patients room. Explain ways to disguise hair loss (scarves, caps, wigs, etc.). Encourage the use of pH-balanced shampoos and discourage procedures that damage hair, such as blow-drying, tints, or perms. Inform the client to minimize handling of hair. Instruct the client and family to report the presence of white patches in the mouth, diarrhea, and signs of bleeding (petechiae, bleeding gums, nose bleeds, unexplained bruises, and gross or occult blood in stool, urine, and emesis). Explain the importance of protecting the skin from injury and infection by wearing shoes, using an electric razor, and avoiding sunburn.
Evaluation Expected outcomes for an individual on chemotherapy include the client verbalizing his or her understanding of the side effects associated with chemotherapy and methods used to minimize complications.
Immunotherapy
Immunotherapy is the use of pharmacologic agents called biologic response modifiers to stimulate the individuals own immune system to damage and destroy neoplastic cells. Commonly used agents include interleukins, interferon, monoclonal antibodies, colonystimulating factors, and erythropoietin. The major concern with these medications is precipitation of a generalized inflammatory reaction. Common signs of a reaction are fever, chills, and malaise. Care is supportive.
Radiation
Radiation kills rapidly dividing cells, so it also is used to control, cure, and palliate. However, rapidly dividing non-neoplastic cells, such as bone marrow, hair, ovaries,
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testes, and gastrointestinal and genitourinary mucosal linings, are also affected. Therapy may involve high-energy radiation administered externally (teletherapy) or radioisotope implants placed internally (brachytherapy). Teletherapy uses ionizing forms of radiation to cause cellular damage and death. Electrons, protons, neutrons, alpha particles, negative pi-mesons, and photons are all sources of ionizing radiation. Reactions to radiation may be acute or delayed. Skin reactions may occur, as well as local and systemic effects. Common skin reactions include redness, desquamation, hyperpigmentation, dryness, itching, and anhidrosis. Alopecia also is common. Systemic reactions include nausea, fatigue, weakness, and bone marrow suppression. Local reactions are those that occur in the irradiated tissue. Examples are listed in Table 7.3. Table 7.3 Local Reactions from Radiation Therapy
Tissue Head/neck Thorax Abdomen Pelvis Reaction Oral mucositis, dry mouth, tooth decay Esophagitis, dysphagia, pneumonitis, pericarditis Anorexia, nausea, vomiting, diarrhea, bleeding, cramping, hepatitis Cystitis, proctitis, hematuria, vaginal dryness, painful intercourse
Brachytherapy is usually used as an adjunct to teletherapy. Commonly used brachytherapy radioisotopes are radium, cesium, iodine, gold, iridium, and cobalt. Administration of radioisotopes may be intracavitary (placed within a hollow organ), interstitial (placed within a solid tumor), or systemic (affecting the body generally). Intracavitary radiation is primarily used for cervical and endometrial cancers. An applicator is placed within the organ in the operating room. Once the patient is back in his or her hospital room, the radiation source is inserted in a procedure called afterloading. Interstitial radiation is most commonly used for breast, brain, head, neck, and prostate tumors. A radioisotope seed, wire, ribbon, or needle is placed within the tumor. Systemic radiation is most often used for thyroid cancer. Oral radioactive iodine is administered and absorbed by the thyroid gland. Nursing Care of the Individual Receiving Radiation Therapy
Assessment
When caring for an individual undergoing radiation therapy, it is important to know why radiation is being used, what type of therapy is being employed, and how therapy is to be administered. It is also important to know the dose, since reactions are (to some degree) dose-dependent. Know how often the patient will undergo radiation treatments, or how long an implant will be in place. It also is important to assess the clients level of knowledge by exploring the following areas of concern: 1. Does the client understand why radiation therapy is being used?
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2. 3. 4.
Is the client aware of the treatment plan? Is the client knowledgeable about possible adverse effects? Is the client aware of any restrictions imposed by the radiation therapy, such as bed rest or room confinement?
Analysis
The primary diagnoses associated with radiation therapy include the following: Knowledge deficit related to a lack of understanding about the treatment mode and plan, adverse effects, and restrictions Risk for injury related to cellular damage and death
However, anxiety, fear, ineffective individual coping, alterations in body image, altered nutrition, diarrhea, fatigue, altered mucous membranes, pain, and impaired skin and tissue integrity also may be pertinent diagnoses.
Planning and Implementation
The goals of care are to facilitate the patients understanding of the procedure and minimize injury and reactions. These goals can be met by taking the following actions: Monitor the clients status, vital signs, input and output, CBC, and weight. Keep the client informed about the treatment plan. Provide information about the purpose of therapy and what adverse effects to report to the physician. Instruct the client regarding any restrictions in activity, such as bed rest or room confinement. Tell the client not to remove skin markings. Encourage the client to pace his or her activities and to plan for periods of rest. Organize care to facilitate rest periods. Limit visitors and length of visits. Arrange the room for minimal exertion of energy. Encourage the client to avoid exertion. Encourage the client to minimize skin irritation by doing the following: Washing the skin gently with lukewarm water, rinsing thoroughly, and patting to dry Wearing loose clothing to prevent friction and rubbing Avoiding the use of tape on or the shaving of the affected area Avoiding the application of creams, lotions, powders, and similar items on the affected area unless ordered by the physician Protecting the affected area from the sun Instruct individuals receiving brain irradiation to avoid the use of electric hair dryers, curlers, and curling irons. Provide relief for symptoms of oral mucositis, dysphagia, and mouth dryness by encouraging the following: Avoiding alcohol, chewing or smoking tobacco, mouthwashes, citrus juices, highly seasoned foods, hot or cold liquids, and hard toothbrushes Eating soft or pureed foods that are moist Rinsing or gargling with warm water or using artificial saliva preparations
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Chewing sugarless gum Using viscous Xylocaine Placing a cool mist humidifier in the room Taking in an adequate amount of fluids Encourage individuals experiencing nausea to avoid spicy or greasy food. Instruct individuals in distraction and relaxation techniques to reduce nausea and vomiting. Remove noxious stimuli from the patients environment to prevent nausea and vomiting.
Evaluation
Evaluate the physical response of the client to radiation therapy and modify the plan as needed. Is the tumor responding as desired? Is the client experiencing any skin or systemic reactions? Is pain under control? Also, evaluate the psychosocial response of the client. How is the clients self-concept and body image? Is the client depressed or coping well with treatment?
General Nursing Care for Individuals with Cancer

Nurses are actively involved in the prevention, detection, diagnosis, treatment, rehabilitation, and terminal care of clients with cancer. This involves application of the nursing process as described in the following sections. Assessment Obtain an in-depth history of familial factors, diet, and lifestyle behaviors to determine individuals at risk for cancer. Also, determine whether there is a history or physical evidence of neoplasia. The seven common warning signs of cancer are as follows: 1. 2. 3. 4. 5. 6. 7. Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty in swallowing Obvious change in wart or mole Nagging cough or hoarseness
Once cancer has been diagnosed, ascertain the physical and psychosocial impacts on the client and family by considering the following: What is the clients response to the diagnosis? How well does the client understand the procedures, diagnosis, prognosis, and treatment plan? Is the individual ready, willing, and able to learn about the diagnosis, procedures, and self-care management?
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How does having cancer or cancer treatments affect the clients body function, body image, self-concept, role relationships, and growth and development? Is the client weak or in pain? Is the individual having difficulty sleeping? Are skin changes present? How is the client coping with the diagnosis, treatments, and changes in routine? Is there any evidence of fear, anxiety, anger, guilt, sorrow, helplessness, or despair? What are the individuals strengths, resources, and coping mechanisms? Does the individual have a system of support? What are the individuals feelings about the isolation procedure? Are there any financial concerns? If the client is terminal, is he or she ready to die?
Analysis There are numerous diagnoses associated with the care of individuals with cancer. These include the following: Activity intolerance related to weakness Imbalanced nutrition (less than body requirements) related to nausea, vomiting, and altered metabolism Impaired oral mucous membranes related to chemotherapy and radiation effects Ineffective role performance related to diagnosis and treatment Anticipatory grieving related to potential loss of life Anxiety related to diagnosis, treatments, and threat to life Disturbed body image related to tumors, surgery, or the adverse effects of radiation and chemotherapy Constipation related to chemotherapy and immobility Chronic sorrow related to loss of hope Diarrhea related to medications and radiation Deficient fluid volume related to vomiting, diarrhea, or insufficient intake Impaired skin and tissue integrity related to poor nutrition or radiation Ineffective individual coping related to situational crisis presented by diagnosis of cancer Fatigue related to disease process, altered nutrition, and emotional demands Hopelessness related to deterioration in condition or lack of treatment or cure Deficient knowledge related to lack of understanding about pathophysiology, tests, procedures, and self-care needs Pain related to disease process or adverse effects of radiation or chemotherapy Risk for infection related to altered defense mechanisms, invasive procedures, chemotherapy, and adverse effects of radiation Self-care deficits (bathing/hygiene, dressing/grooming, feeding, toileting) related to weakness and fatigue
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Sexual dysfunction related to disease process, surgery, radiation, or chemotherapy Disturbed sleep pattern related to fear, anxiety, disease process, or adverse effects of chemotherapy and radiation Spiritual distress related to suffering and questioning the purpose of life
Planning and Implementation Because the role of the nurse in caring for clients with cancer is so diverse, there are a number of goals and interventions. Goals include cancer prevention, providing information as needed, achieving remission, preventing complications, managing discomfort, providing emotional support, and facilitating a dignified, peaceful death. To attain these goals, take the following nursing actions: Identify individuals at risk and provide information about ways to prevent cancer (such as diet modification, smoking cessation, and alcohol avoidance) and detect cancer early (such as monthly breast self-exams and testicular exams). Ascertain knowledge deficits and provide information about pathology, diagnostic procedures, treatments, side effects, and resources. Assist with tests and procedures as needed. Administer blood components and pharmacologic agents (such as analgesics, antinauseants, chemotherapy, and immunotherapy) as ordered, being careful to handle and discard chemotherapeutic agents with caution and according to agency protocols. Avoid extravasation of chemotherapeutic agents. Schedule and facilitate radiation and other treatments. Monitor the clients vital signs, input and output, specific gravity, laboratory results, nutritional status, lung sounds, and skin integrity. Monitor the client for signs and symptoms of complications associated with the disease process (e.g., increased intracranial pressure, altered level of consciousness, or dyspnea) or treatment modalities (such as anemia, extravasation, infection, and lymphedema). Teach the client about manifestations associated with complications and when to notify the physician. Manage pain by administering pain medications as ordered around the clock and by using nonpharmacologic methods (such as distraction and massage). Stomatitis may be relieved by applying viscous Xylocaine, avoiding spicy or fried foods and carbonated beverages, rinsing the mouth frequently, and increasing fluid intake. Keep irradiated areas clean and dry; protect with a bed cradle if necessary. Minimize nausea by administering antinauseants as needed. Eliminate odors and unpleasant sights (e.g., bedpan) in the room. Provide oral care. Provide popsicles or hard candy to suck on. Collaborate with nutritional services to combat anorexia and meet caloric requirements. Provide four to six small, high-calorie, high-protein meals per day and supplements. Encourage family and friends to bring in the clients
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favorite foods. Consider tube or IV feedings if PO feedings are not tolerated. Tell the client to avoid fatty, fried, and gas-producing foods and to drink liquids after meals. Elevate the head of the bed to promote food retention. If the client is constipated, administer stool softeners and laxatives as ordered. Encourage mobility, ingestion of high-fiber foods, and the intake of fluids. If diarrhea is present, administer antidiarrheal medications as ordered. Monitor the clients fluid-electrolyte and acid-base status. Keep anal area clean. Warm soaks may alleviate anal irritation. Suggest makeup and grooming ideas that will facilitate adaptation to a changing body image. Inform the client that hair loss is temporary and may be disguised with a wig, hairpiece, scarf, or hat. Also, teach the client measures to decrease hair loss, such as avoid damaging the hair with chemicals or heat; minimize handling of the hair; and wash hair with a gentle, pH-balanced shampoo. Provide skin and oral care. Emollients may be added to bath water or lotion to soothe dry skin, but irradiated sites should be avoided. Protectants may be applied to the anal area; moisturizers may be applied to lips. Irradiated areas should be exposed to air. Cool, moist compresses may be used to control itching. The client should be advised to avoid sun exposure. A soft sponge toothbrush may be used to clean the mouth; frequent mouth rinses with normal saline or baking soda in water are soothing, and local anesthetics may be applied (viscous Xylocaine). Maintain protective isolation, if ordered. Decrease risk of infection by washing hands well, having visitors wear masks when ill, using an electric razor or soft toothbrush, and avoiding rectal temperatures, injections, or invasive procedures. The client should be instructed in proper hand washing techniques and advised to avoid exposure to ill or recently vaccinated individuals. Provide a calm, quiet, and comfortable environment to promote rest and relaxation. Encourage relaxation techniques, such as reading or watching TV. Arrange personal articles within reach of the client. Organize care to minimize interruptions so that the client can rest or sleep. Provide emotional support to the client, and encourage expressions of fear, anxiety, loss, and grief in order to facilitate coping and a realistic understanding of the clients condition. Evaluate the clients feelings about death and dying. Determine the clients readiness to die. Discuss how to deal with body changes and how to respond to others. Refer the client to social services, support groups (e.g., American Cancer Society), hospices, counseling, or pastoral care, as needed. Instruct the client regarding the use of technology (e.g., artificial larynx) or new procedures (e.g., colostomy care) as needed. Assist the client to make decisions about end-of-life issues (e.g., do-notresuscitate orders, advance directives, hospice, and funeral arrangements). Facilitate a peaceful and dignified death by respecting the clients wishes while still meeting comfort and basic needs.
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Evaluation Evaluate the physical response of the client to therapy, and modify the plan of care as needed. Also evaluate the psychosocial response of the client to the disease process and treatment modalities. This may involve asking questions such as the following: Has the clients pain been reduced to an acceptable level? Is the client getting adequate rest and sleep? Have the clients nausea and vomiting been controlled? Is the client free from infection? Are positive coping methods being used? Can the individual verbalize understanding of the diagnosis, prognosis, tests, procedures, surgeries, and self-care management practices?
Nursing Care for the Cancer Patients Family

The nurse can also use the steps in the nursing process to provide care to the cancer patients family, as detailed in the following sections. Assessment Because the loss of a loved one is a realistic possibility associated with cancer, families often are anxious and distraught. They may respond in a variety of ways, including denial and anger. They may seek out unorthodox approaches and try unproven therapies in desperation. Thus, it is important to assess the familys response and understanding of the disease process and any related tests, procedures, treatments, and care needs. This includes examination of the following: Is depression present? Does the family feel hopeless and helpless? Does the family have the ability to cope? What are the familys strengths? Is there a viable support system? Is there a willingness to use support groups? Is the family able to make necessary decisions, honor the clients wishes, or accept death if it is pending?
Analysis Numerous nursing diagnoses also apply to the family, such as the following: Impaired parenting related to frequent hospitalization of a child with cancer Anticipatory grieving related to potential loss of loved one and current lifestyle Anxiety related to diagnosis and potential loss of loved one Caregiver role strain related to inability to juggle responsibilities Decisional conflict related to indecision about end-of-life choices
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Fear related to the unknown Hopelessness related to lack of available cure Ineffective family coping related to inadequate coping skills or support systems Deficient knowledge related to lack of understanding about diagnosis, tests, procedures, surgeries, and care needs Powerlessness related to an inability to control the outcome
Planning and Implementation Care of the family is focused on helping family members accept and cope with the clients diagnosis and related changes in relationships and lifestyle. This includes the following nursing actions: Keep the family informed about the status of the client. Give the family information related to the diagnosis, prognosis, tests, procedures, and treatment modalities. Teach family members how to meet the clients comfort or special care needs. Teach preventative measures, such as hand washing and avoiding individuals who are ill. Reassure the family about the temporary nature of alopecia and other side effects related to chemotherapy and radiation. Give emotional support and allow the family to verbalize their concerns and fears. Refer the family to social services, a psychologist, pastoral care, hospice, and community agencies (e.g., American Cancer Society, Candlelighters, etc.) as needed. Help the family plan for the future and make difficult decisions, such as choices related to childbearing, stopping treatment, or making funeral plans.
Evaluation Finally, determine the effectiveness of interventions and make modifications as needed. Several important questions to consider are as follows: Is the family able to verbalize understanding of teaching provided? Is the family able to express feelings and concerns? Is the family able to verbalize the use of effective coping methods? Is the family able to make decisions as needed? Is the family able to provide home care needed?
Nursing Care for the Community

The nurse can also provide cancer-related care to the community as a whole by applying the specific steps in the nursing process that are outlined below. Assessment and Analysis
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Based on knowledge about the community, it is important to develop educational and service programs that meet community needs and inform clients and families about available services. First, become familiar with the rates of cancer in the community by considering the following: What types of cancer are most prevalent? Are there groups within the community at high risk for certain types of cancer?
Next, determine what services are available: Are there oncologists in the community? Are hospice services present? What community agencies are available for support? Is there a local chapter of the American Cancer Society, Candlelighters, or Reach for Recovery? What types of rehabilitative services are available for individuals after an amputation or mastectomy? Are image services that provide breast prostheses, wigs, or similar items present in the community?
Evaluation It is also critical to evaluate the communitys knowledge level about the causes of cancer and preventative measures. Related questions include the following: Are screening programs, such as hemoccult testing or mobile mammography units, available? Are educational programs that provide instruction in breast self-exams, testicular exams, and other early detection and preventative measures present?
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UNIT III: PRINCIPLES OF NUTRITION

Chapter 8: Concepts and Components of Nutrition
Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Define nutrition. Explain the concepts of metabolism and basal metabolic rate (BMR). Differentiate between calories and kilocalories. List the recommended daily intake of water for an adult and identify the two groups of people most affected by inadequate fluid intake. Define each of the four macronutrients, describe their composition and purpose in the body, and list examples of food sources for each macronutrient. Define insulin and explain its function related to glucose transport. Explain proteins function in the maintenance of nitrogen balance. List the characteristics of water-soluble vitamins and fat-soluble vitamins, and provide examples of food sources for each. Differentiate between macrominerals and microminerals, and list the daily requirement for each category. Identify nine important minerals for a healthy body, and list food sources for each. Describe the groups of the USDA MyPyramid, including general recommendations for good health and nutrition. Explain the use of recommended dietary allowance (RDA) tables. Describe at least three benefits of breastfeeding. Describe the purpose and nutritional focus of Healthy People 2010.
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Key Terms
adipose tissue alpha-linolenic acid amino acids anabolic reactions basal metabolic rate (BMR) calorie carbohydrates catabolic reactions catalytic effect cholesterol complete proteins diabetes mellitus dietary exchanges energy enzymes fiber fruits glucose glycogen grains Healthy People 2010 hydration incomplete proteins insulin kilocalorie (kcal) lactose linoleic acid lipids macrominerals macronutrients meat and beans metabolism microminerals micronutrients milk minerals MyPyramid nutrients nutrition oils peristalsis polyunsaturated fats proteins recommended dietary (or daily) allowance (RDA) satiety saturated fats trans fat triglycerides unsaturated fats vegetables vitamins
Introduction
Nutrition refers to the bodys ability to take in and utilize food. To maintain health, it is important that the food used enhances rather than endangers a persons physiological well-being. Basic nutritional knowledge is essential to professional nursing practice because good nutrition is central to both the promotion and maintenance of health and its restoration after illness. In this chapter, we look at the basic principles of nutrition, including definitions of nutrition, nutrients, metabolism, and basic metabolic rate (BMR). We build on this information by defining the types of nutrients our bodies need and the types of food sources that contain them. We also begin to look at some of the problems that can occur with macronutrient problems such as diabetes mellitus, nitrogen imbalance, and elevated triglycerides. Our discussion then turns to micronutrients, where we discuss the organic compounds of water-soluble and fat-soluble vitamins. We investigate mineralsthe bodys inorganic micronutrientswhich are also essential to good nutrition. We discuss the new USDA MyPyramid and explain the meaning of the recommended daily allowance (RDA). The chapter concludes with information on breastfeeding and a brief overview of the nutritional focus of Healthy People 2010.
Defining Nutrition
The phrase we are what we eat may sound trite, but it is quite accurate. The link between the foods and fluids we ingest daily and the maintenance of good health and
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prevention of illness is the subject of considerable health-related research. This research can be incorporated into nursing assessments and care plans for all age groups. The word nutrition is derived from the Latin root words nutrix, meaning nurse, and nutrire, meaning to nourish. Both definitions remind us of how foundational good nutrition is for attaining, maintaining, and restoring health. Nutrition can be generally defined as a series of processes by which human beings take in, assimilate, or use food for promoting growth and development; maintaining the integrity of tissues; and strengthening and replacing tissues that have been injured by trauma or acute and chronic diseases. Assessment, planning, and implementation of various nutritional strategies often involves dietitians with specialized nutritional knowledge, but it is the role of nurses to integrate basic principles of good nutrition into all of their patient care. Nutritional or diet therapy has always been a concept foundational to nursing, but it is sometimes not given the attention it should in practice, especially in relation to vulnerable populations like infants and the elderly. Nutritional assessment is the foundation of the maintenance and promotion of overall health.
Basic Principles of Nutrition

Metabolism Ingestion, digestion, absorption, and elimination are the four basic processes related to metabolism. Metabolism encompasses all the chemical and physical processes that are constantly going on in all cells of the body. Foods are normally ingested (taken into the body) through the mouth. The process of digestion that breaks down foods begins as they are chewed, swallowed, and combined with ingested fluids into forms capable of being absorbed by the small and large intestines. In order for digestion and absorption through intestinal mucosa to occur, chemical compounds known as enzymes act as catalysts to break down the more complex substances in the foods into simple substances. The products of digestion are circulated through the blood, through the lymphatic system, and to cells and tissues. Foods that are not absorbed and utilized for growth, tissue maintenance, and everyday bodily activities are eliminated as waste products through the bladder in the form of urine, through the rectum as stool or feces, and sometimes through the pores of the skin as sweat. The basal metabolic rate (BMR) is the energy required by a person to function at the lowest or most basic level of cellular function, or in other words, the basic energy required by a person who is in a state of wakefulness but at rest. It might be thought of as the minimum energy requirements of the body to function. A body in health will have its basic energy requirements met by ingesting enough calories to meet its needs, yet this amount will not exceed the bodys ability to digest and absorb those calories. Energy can be simply defined as strength or power. A persons energy, or basal metabolic and nutritional requirements, will vary at different stages of the life cycle, and
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it can be affected by many things in addition to age. Other influences on a persons metabolic requirements include weight and sex. The primary source of energy is food, more specifically defined as anything ingested or taken into the body that provides the body with the energy needed to keep it alive, growing, and able to repair itself. Food energy is often measured in terms of calories. The word calorie is derived from the Latin calor, meaning heat. A calorie is the amount of heat needed to raise the temperature of one gram of water by one degree Celsius. A kilocalorie (kcal), or Calorie (also called a large calorie), is the amount of heat needed to raise the temperature of one kilogram of water by one degree Celsius. When we say we count calories for a diet, what we are actually counting is kilocalories, or large calories. When food is metabolized after eating, energy or heat is freed to enable us to move and breathe. This allows our bodies to grow and repair themselves and otherwise carry out all the normal activities of daily living. A healthy body uses calories for all its normal daily internal and external activities. Increased activity, such as aerobic or other forms of exercise, and certain abnormal physical conditions, such as fever, can increase the BMR, which creates a need for more calories to maintain weight and optimal tissue function. Decreased activity below the bodys metabolic needs accompanied by increased food intake generally results in weight gain in the absence of any disease. Types of Nutrients Everyone has a basic understanding of what constitutes food, but not necessarily of what constitutes good food. Not all foods have the same value nutritionally. Foods that are of value and supply the energy the body requires for maintenance, growth, and repair are called nutrients. A nutrient is a food that nourishes. The word nutrient is also based on the Latin words for nurse and nourish, another good reminder of the foundational importance of nutrition to basic nursing care. Seven primary categories of nutrients are essential for building and maintaining a healthy body at any age. The categories include fluids, carbohydrates, fiber, proteins, lipids (fats), vitamins, and minerals. Carbohydrates, fiber, proteins, and lipids are more commonly known as macronutrients. Vitamins and minerals are micronutrients. Both macronutrients and micronutrients are essential to metabolism. Some nutrients serve as catalysts for the metabolic process to occur. A number of common food sources can supply a person with all the essential nutrients in the absence of disease. While these foods can be thought of as interventions, for practical purposes they are included early in our discussion of nutrition as the basis for good nutritional care.
Fluids
Fluid, more specifically, water, is needed by the body because all other nutrients are dependent on water to carry out their functions. The processes of ingestion, digestion, absorption, and elimination require that nutrients be in solutions, and water quite literally provides the solution. A term that is often used in relation to water is hydration.
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Hydration requirements, or water requirements in relation to total body weight, vary depending on age. Sixty to 70 percent of normal body weight consists of water in a normal adult. Infants body weights have a greater percentage of water, and the percentage is less in older adults. These two groups of people are most adversely affected by an inadequate intake of water. The recommended daily intake of water for an adult is eight to ten 8-oz. glasses per day. This amount will vary when a person is acutely or chronically ill, since greater demands are placed on the body for fluid replacement. There may also be a need to limit fluid intake related to circulatory overload for patients with compromised cardiac statuses (e.g., older people with congestive heart failure). Water also is present in certain foods, specifically fresh fruits and vegetables. When these foods are eaten, the water is released into the body.
Macronutrients
Carbohydrates Carbohydrates are organic chemical compounds made up of carbon, hydrogen, and oxygen. Their primary purpose is to provide the body with energy in much the same fashion and for the same reasons that gas provides fuel for a car. The process of digestion breaks down carbohydrates into glucose for the bodys immediate energy requirements. Excess carbohydrates are stored as glycogen in the liver and in muscle; glycogen can be readily converted to glucose when needed for energy or to maintain blood levels. Excess glucose over and above that which is needed for normal activities of daily living, extra energy requirements, and blood level maintenance can be stored by the body as fat or adipose tissue. The metabolism of glucose for conversion into energy is controlled by insulin secretion. Insulin is an endocrine hormone produced by the beta cells of the islets of Langerhans in the pancreas. Insulin promotes glucose transport into cells through cell membranes, enabling glucose to be used as an energy source. If insufficient insulin is present, glucose can also accumulate in the blood, causing hyperglycemia. The specific disease associated with hyperglycemia is diabetes mellitus. Carbohydrates come in two basic forms: simple carbohydrates (sugars) and complex carbohydrates (starches and fiber). The recommended range for carbohydrates is 50 to 60 percent of an adult persons total caloric intake. Simple sugars are frequently ingested in the form of fruit, but they are also added in processed foods and fluids like cookies, candy, childrens cereals, fruit-flavored drinks, and soft drinks. The primary source of the more complex and nutritive-rich carbohydrates to meet energy requirements comes from plant foods including vegetables (especially starchy vegetables like corn) and various grains and legumes, such as beans and peas. Food sources of carbohydrates are commonly available and relatively inexpensive as compared to foods supplying the other basic nutrients. The following vegetables and processed foods are high in complex carbohydrates: brussels sprouts, corn, winter squash, potatoes, whole grain breads, and fortified cereals.
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Other vegetables, such as lettuce, cucumbers, and dark, leafy green vegetables like spinach, contain trace or few carbohydrates. Lactose, or milk sugar, is a type of simple carbohydrate. Carbohydrates in the form of rice cereal are generally introduced to babies at around six months of age, unless there is a strong history of allergies in the family, according to the American Academy of Pediatrics (AAP). Note: Introducing solids to infants before four months of age may cause food allergies. The recommended range for carbohydrate is 45 to 65 percent of an adults total caloric intake. Ranges for carbohydrates and other nutrients are revised periodically based on the latest research; these are the most recent ranges cited by the Food and Nutrition Board of the Institute of Medicine (2006). Fiber Fiber is a nutrient that is an important nutritional subcategory of starchy, complex carbohydrates. Fiber has little nutritional value in the traditional sense of directly supplying the body with energy, but fiber does play a significant role in nutrition. Fibercontaining foods are high in roughage and are not digestible. Once ingested, they move down the esophagus, into the stomach, and then into the small and large intestines to aid in the process of peristalsis, the rhythmic, wavelike motions that help move food through the large intestine. Fiber is then eliminated out of the body through the rectum. Foods high in fiber also are thought of as foods high in bulk or high in volume; they can assist in eliminating other waste products from the body. Dieters are often encouraged to eat plenty of foods high in fiber since these foods give the person a sense of fullness. According to the American Cancer Society, a long-term diet high in saturated fats from animal sources like red meats and processed meats can increase risk of colorectal cancer. The organization therefore recommends increasing food intake from fibrous plant sources. Whole grain versus processed foods, legumes, raw fruits, and vegetables are all high in fiber (and low in fat). Furthermore, phytochemicals found in some vegetables may interfere with the process of cancer growth. Though research to date is inconclusive, five or more servings of fruits and vegetables are still recommended. Researchers at the Harvard School of Public Health reviewed 14 studies that tracked over 750,000 participants for 6 to 20 years and analyzed the association between fruit and vegetable intake and colon cancer. The researchers did not find a strong association for lower colon cancer risk, but there was some indication that there might be a lower risk of cancer of the distal (left side) colon among the largest consumers of fruits and vegetables (2007). Total fiber recommendations for people age 50 and younger are 38 grams (males) and 25 grams (females); over age 50, the recommendations are 30 grams (males) and 21 grams (females). Females generally require fewer overall calories, so fiber gram counts are also lower. Common direct food sources of fiber can be found in breakfast cereals (especially those that contain bran), whole grain breads, nuts, and many fruits and vegetables. Uncooked, raw, and unpeeled fruits and vegetables are higher in fiber than cooked fruits and vegetables. Fruits and vegetables recommended for higher-fiber diets include raw fruits with seeds and/or skins, raw berries, prunes, raw pineapple, rhubarb, vegetables in the cabbage family, vegetables with seeds and/or peels (cucumbers, squash, peas), dried
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cooked beans, corn, lentils, and legumes. Fruits and vegetables recommended for lowerfiber diets include applesauce, fruit cocktail, bananas, melon, cooked fruits without peels, strained fruit juice, lettuce, cooked vegetables (mashed potatoes, cooked spinach, canned vegetables without seeds or peels), and vegetable juice. Proteins Proteins, like carbohydrates, also consist of three primary elements: carbon, hydrogen, and oxygen. However, proteins also contain nitrogen. The atoms of these four primary elements form nine essential amino acids. The essential amino acids the body requires can be obtained through various food sources. Protein, like carbohydrate, is also an energy source, but its chief role is to aid in the growth, maintenance, repair, and replacement of body tissue. One gram of protein equals four kilocalories. Proteins are often called the building blocks of the body, and they are able to carry out this task of construction very well if enough carbohydrates are available to meet the bodys needs. Protein is said to be spared for this building-up process. To spare means to refrain from using, or to not be taken up by regular work duties. One regular work duty of metabolism is to provide an energy supply for the body. When carbohydrates are burned to meet the bodys needs for energy, protein is not needed for this regular work duty; instead, it can be utilized to meet the metabolic need for tissue growth and repair. Another important function of protein is the maintenance of nitrogen balance in the body. Nitrogen builds and repairs tissues. This is possible when nitrogen (protein) intake and protein anabolism are equal to or exceed nitrogen (protein) output or protein catabolism. Anabolic reactions, derived from the Greek word anabole, meaning rising up, include all the processes that turn or convert protein into living tissue. Anabolism, for example, is a characteristic of pregnancy when women require additional protein, and it occurs during periods of rapid growth (infancy and adolescence). Under normal conditions, these anabolic states are considered to be periods of positive nitrogen balance. Protein metabolism is a special type of metabolism that involves primarily anabolic reactions. In contrast, catabolic reactions (the Greek word kata means throwing down) more commonly characterize carbohydrate and fat metabolism, which involves the conversion of complex substances into simpler substances for energy. Catabolic reactions can also involve the destruction of tissue, as in negative states of nitrogen balance. Certain conditions, such as prolonged states of infection or fever, starvation, severe burns, or other injuries, can result in the body losing more nitrogen that it retains, resulting in a negative nitrogen balance. People who are immobile due to paralysis, coma, or a physically debilitated state are also prone to negative nitrogen balance and its associated tissue breakdown due to catabolic reactions. Wounds heal more slowly when protein is depleted or there is inadequate dietary intake. Protein is contained in foods that are often less readily available in many diets than carbohydrate or fiber because the foods with high amino acid content are usually more expensive. Some foods are known as complete proteins since they provide the body
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with all the essential amino acids needed by the body. Complete protein foods include all varieties of meat and poultry, in both unprocessed and nonartificial forms. Eggs, milk, and other dairy products, including all forms of unprocessed cheese, are also complete protein foods. Most fish are considered complete proteins. When combined with each other in the same meal or when combined with a complete protein food such as meat, milk, or cheese, incomplete proteins make up a complete protein. The following are examples of incomplete plant proteins: 1. 2. 3. Various grains: brown rice, whole wheat breads, or oatmeal Nuts and seeds of all types: almonds, cashews, or sunflower seeds Starchy vegetables and legumes: corn, kidney beans, lentils, or dried/split peas
If any two of these incomplete proteins are combined (e.g., combine 1 with 2, 2 with 3, or two starchy 3 vegetables), a complete protein is formed. This is an important consideration for nutritional planning for persons with low or fixed incomes or for people on vegetarian diets. Recommended levels of protein are 0.8 grams per kilogram of body weight for adults. A kilogram equals 2.2 pounds, so, for example, a person weighing 150 lbs. would require 150 lbs. divided by 2.2 kg/lb. and multiplied by 0.8 g/kg, or 54.4 g of protein. The general recommended range for adults is 56 g/day (males) and 46 g/day (females). An additional 25 g/day is recommended for pregnant and lactating women and children in their growth years. Also, because protein can aid in the repair of tissues damaged by trauma or disease, higher protein diets are generally recommended for people who are critically ill; these patients may have protein requirements of up to 2.0 g/kg of body weight. Lipids Lipids are also known as fats. The chemical composition of lipids is similar to that of carbohydrates, though the percentages of carbon, hydrogen, and oxygen differ. The most common form of lipids, known as triglycerides (lipids containing three fatty acids), have been implicated in the development of diseases such as coronary artery diseases (CAD), specifically atherosclerosis (hardening of the arteries), and certain cancers when ingested or present in the body in saturated forms. Saturated fats or lipids come in solid form. These macronutrients are saturated with hydrogen or contain as much hydrogen as they are capable of containing. Margarine and butter are examples of saturated fats. Unsaturated and polyunsaturated fats can take the form of oils and contain the element hydrogen in lesser degrees. Examples of these kinds of lipids are vegetable oils like safflower and corn oil. Olive oil is also unsaturated. A common term associated with saturated fats is cholesterol. The literal meaning of cholesterol is solid or stiff. High cholesterol intake or inadequate utilization of cholesterol has been associated with atherosclerosis and cerebral vascular accidents (strokes). Animal fats are the primary source of saturated fats; examples of such foods are fatty cuts of beef and pork and most organ meats. Eggs, specifically egg yolks, are
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also high in cholesterol, as is whole milk. Polyunsaturated oils may actually decrease cholesterol, although they tend to be high in calories. Trans fat is another category of fat. It can be found in some margarines, vegetable shortenings, snack foods like crackers, cookies, and other foods made with or fried in partially hydrogenated oils. Food manufacturers may add hydrogen to vegetable oil to increase its shelf life and maintain its flavor; the end result is a solid fat that can elevate LDL cholesterol and increase risks for CAD. If a product contains trans fat, this information should be on the nutrition label directly under the line for saturated fat. Some fat, however, is essential to maintaining good health. Two types of essential fatty acids are linoleic acid (an omega-6, or n-6, fatty acid) and alpha-linolenic acid (an n-3 fatty acid). Sources of linoleic acid are corn, safflower, cottonseed, and soybean oils; wheat germ; and nuts. Sources of alpha-linolenic acid include canola, flaxseed, and soybean oils; wheat germ; and walnuts. Fish (salmon, canned tuna, halibut) are also high in n-3 fatty acid. Note: women who are pregnant or nursing and also young children should limit their intake of low-mercury fish (canned light tuna, salmon, shrimp, pollock) to two meals a week maximum and should avoid fish higher in mercury (swordfish, mackerel). Mercury is a heavy metal and research continues on its adverse effects on various organs of the body and the neurological system with high concentrations. Recommended intake for linoleic acids is 17 grams/day (males) and 12 grams/day (females); for alpha-linolenic acids, the Institute of Medicine recommends 1.6 grams/day (males) and 1.1 grams/day (females). Fats add flavor to foods and increase the length of time food remains in the stomach, which gives people a feeling of fullness. A diet with no fat can result in poor growth and development in childhood and adolescence. Breast milk, for example, is high in essential fatty acids. Fats are stored in the body and can be converted into energy in the form of glucose when needed. During periods of starvation, stored body fat can also be converted to energy. One gram of fat provides the body with nine kilocalories. It is recommended that only 2035% of daily calories be fat calories; however, more active and underweight people will require more fat intake.
Micronutrients
In addition to macronutrients, a number of micronutrients are required for optimum health and well-being. These take the form of vitamins and minerals. Vitamins Vitamins are micronutrients and organic compounds essential to normal metabolic processes. While not direct suppliers of energy, vitamins have a catalytic effectthey act as a stimulus to help release energy from the macronutrients of carbohydrate and fat. A common misconception is that most vitamins come in bottles, but in fact, many foods are excellent sources of vitamins. A well-balanced diet, in the absence of disease or a developmental change such as pregnancy, can usually provide what the body requires.
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Vitamins can be categorized as either water-soluble substances that cannot be stored in the body or fat-soluble substances that can be stored. Water-soluble vitamins include vitamin C (ascorbic acid) and a number of vitamins categorized as B complex vitamins. Table 8.1 lists these vitamins and some common food sources. Table 8.1 Water-Soluble Vitamins and Their Sources
Vitamin C (ascorbic acid) Food source Citrus and other fruits (cantaloupe, grapefruit, oranges, strawberries, tomatoes, etc.) and vegetables (broccoli, greens, cabbage, green peppers, potatoes, etc.) Whole grain bread, cereal (oatmeal), eggs, fish, legumes, meat (beef, pork, etc.), and wheat germ
B1 (thiamine)
Table 8.1 Water-Soluble Vitamins and Their Sources

Vitamin B2 (riboflavin) Niacin B6 (pyridoxine) Folic acid or folate B12 (cobalamin) Pantothenic acid Biotin Food source Milk, whole grains, organ meats (liver), and green vegetables (broccoli and spinach) Cereals, dairy products, meat, tuna, and whole grains Fish, liver, nuts, poultry, green beans, potatoes, and whole grains Fish, liver, meat, poultry, leafy green vegetables, and whole grains Eggs, cheese, saltwater fish, liver, milk, and meat Whole grain cereals, legumes, and meats Egg yolks, green beans, kidney, liver, and dark green vegetables
Water-soluble vitamins can be adversely affected by various environmental factors such as heat, light, and exposure to air and water; special storage and cooking processes can help retain vitamin content. Fresh foods are generally the highest in vitamin content. Fat-soluble vitamins are less sensitive to environmental conditions than their watersoluble counterparts. Fat-soluble vitamins that may not require daily intake and their common food and environmental sources are included in Table 8.2. For example, 7dehydrocholesterol, a precursor or source of vitamin D, accumulates in the epidermal (outermost) layer of the skin. Ultraviolet light from the sun activates vitamin D for use in the body by transforming this precursor. The final synthesis of vitamin D occurs in the epidermis. Table 8.2 Fat-Soluble Vitamins and Their Sources
Vitamin A Food source Eggs (yolks), yellow fruits (apricots), liver, whole milk and whole milk products, and green leafy or yellow vegetables (broccoli, carrots, spinach, and winter squash)
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Table 8.2 Fat-Soluble Vitamins and Their Sources

D E K Egg yolks, fortified milk, fortified margarine, fish oils, liver, and sunlight Cereals (wheat germ), eggs, meat, milk, vegetables (green and leafy), and vegetable oils Egg yolks, cheese, liver, and leafy green vegetables
Minerals Minerals are inorganic micronutrients that also play a catalytic role in nutrition. These micronutrients help regulate enzyme metabolism, facilitate the transfer of chemical substances across cell membranes, and play an important role in maintaining the health of nerves and muscles. There are two basic categories of minerals: macrominerals and microminerals. The prefixes micro- or macro- have nothing to do with the importance of the mineralsthey simply note the amount of the mineral required by the body for optimum health. The minimum daily requirement for macrominerals is over 100 mg; for microminerals, the minimum daily requirement is less than 100 mg. The recommended daily allowance (RDA) for calcium, for example, is 1000 mg (ages 1950) and 1200 mg (over age 51); calcium would be considered a macromineral. The RDA for iron, an equally important mineral, is only 10 mg (males) and 15 mg (females); iron is considered a micromineral. One of the easiest ways to gain a better understanding of vitamins and minerals is get out a cereal box and look at the label. Included on most labels is the amount of calories or energy for a single serving of that food. Vitamins and minerals are also listed, often by percentage per serving in comparison with minimum daily requirements. Macronutrients are also listed in grams. Macrominerals include calcium, chloride, magnesium, phosphorus, potassium, sodium, and sulfur. Note that some of the minerals are considered trace elements, in particular the microminerals: cobalt, chromium, copper, fluoride, iodine, iron, manganese, selenium, and zinc. Functions and some food sources for some of the most common macrominerals and microminerals are outlined in Table 8.3. Table 8.3 Important Minerals and Their Sources
Mineral Calcium Food source Fish (sardines, salmon, etc.), fruit (oranges, rhubarb, etc.), milk and all dairy products (cheese, ice cream, yogurt, etc.), and green, leafy, or orange vegetables (broccoli, carrots, collard greens, etc.) Whole grains, legumes, nuts, and green vegetables Legumes (dried peas, beans, etc.), meats (beef, pork, etc.), milk, and all milk products Eggs, fresh and dried fruits (grapefruit, oranges, pineapple, tomatoes, apricots, bananas, etc.), juices, milk, and whole grains Smoked or salted luncheon meats, canned and frozen vegetables, some
Magnesium Phosphorus Potassium Sodium
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Table 8.3 Important Minerals and Their Sources

Mineral Fluoride Iodine Iron Food source fresh vegetables (beets, celery, etc.), and table salt Fluoridated water, toothpaste, and seafood Seafood or table salt (iodized) Egg yolks, shellfish (oysters, shrimp, etc.), dried fruits (dates, prunes, raisins, etc.), unprocessed red meats and organ meats (liver, kidneys, etc.), whole grain cereals, enriched bread, and dark green vegetables (spinach) Legumes, liver, poultry, nuts, and oysters
Zinc
MyPyramid and Dietary Guidelines

The original Food Guide Pyramid and logo was introduced in 1992 by the United States Department of Agriculture (USDA) to serve as an identifiable and easy-to-use guide to help people plan meals and purchase food that would meet the minimum daily requirements of good nutrition. The MyPyramid has replaced the older Food Guide Pyramid; it was formulated by the Center for Nutrition Policy and Promotion, an organization of the United States Department of Agriculture (USDA), in 2005. While there are many similarities to the Food Guide Pyramid, there are also differences for the population in general and also for people with special dietary needs. The new food guide pyramid can be viewed on the official government web site, http://www.mypyramid.gov/. You can also see the new pyramid in Figure 1.3.
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Figure 1.3 The USDAs Food Guidelines and MyPyramid
Sources: U.S. Department of Agriculture; U.S. Department of Health and Human Services, and U.S. Department of Agriculture 2005.
The logo retains the look of a pyramid but in a more simplified format; steps running up the side of the pyramid are a reminder to consumers to be physically active. Steps to a Healthier You is the new motivational slogan. The logo itself is a visual reminder of the five daily food groups and exercise recommendations. The MyPyramid guidelines are appropriate for those over two years of age. Current nutritional requirements expand on the original concept of basic food groups and can be found in the Dietary Guidelines for Americans 2005. The current focus on dietary guidelines is based on scientific evidence about health promotion and risk reduction for chronic conditions as well as evidence relating certain diseases to an inadequate diet coupled with a sedentary lifestyle. Examples of these conditions include obesity, high cholesterol, type 2 diabetes, cardiovascular disease, hypertension, and osteoporosis. Certain types of cancers may also be related to diet (for example, colon cancer). The typical American diet is deficient in the following: fruits, dark green and orange vegetables, legumes, whole grains, and low-fat milk products. In contrast, there is an overconsumption of saturated fats and refined white sugars.
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One basic premise of the Dietary Guidelines is that food, rather than dietary supplements, should be the primary means of meeting nutrient needs for all age groups. The USDA reference level for recommended caloric intake is based on a 2000-calorie diet; this level will vary based on gender, physical activity level, body size/height, and age. Food and caloric requirements can be individually calculated using the MyPyramid web site. Nutrient-dense food and beverages are encouraged for consumption among all basic food groups. The five food groups (and one additional group for oils and fats) in MyPyramid include: 1. 2. 3. 4. 5. 6. Grains Vegetables Fruits Milk Meat and beans Oils
Grains Grains consist of whole grains and refined grains. Examples of whole grains are oatmeal, breads, and pasta made from whole-wheat flour, and brown rice. Examples of refined grains are breads, pasta, and other food made from white flour, and white rice. Refining removes essential nutrients like iron, dietary fiber, and certain B vitamins (niacin, riboflavin, thiamin, folic acid), although some products are enriched with B vitamins and iron. Food labels should be read carefully. Vegetables Vegetables and 100-percent vegetable juice comprise this category. The five subgroups of vegetables are the following: dark green (broccoli, greens, romaine lettuce); orange (winter squashes, carrots, sweet potatoes); dry peas and beans (lentils, kidney beans); starchy (white potatoes, corn, peas, lima beans); and a miscellaneous category of general lower-calorie vegetables (iceberg lettuce, mushrooms, tomatoes, cucumbers). Dark green and orange vegetables have the highest nutrient content. Broccoli, for example, is high in potassium. Raw vegetables are good sources of fiber. Fruits Fruits and 100-percent fruit juice comprise this category that includes melons, berries, and all other varieties of fruit. Raw fruits are generally high in fiber; fruits contain carbohydrates and are good sources of vitamin A and vitamin C. Fruits as well as vegetables can be fresh, frozen, canned, or dried. Milk, Dairy, and Dairy Substitutes Milk is a category that includes yogurt and cheese and is generally high in calcium. Food in this category may be high-fat (whole milk), low-fat (1% milk), or fat-free
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(fat-free yogurt). Milk supplies protein, fat, calcium, phosphorus, riboflavin, vitamin D, and vitamin A (when fortified). Research indicates that up to 75% of the worlds population is at some risk for lactose intolerance related to a deficiency of the digestive enzyme lactase in the small intestine, which breaks lactose down into simple sugars for absorption. Symptoms of lactose intolerance generally appear 30 minutes to two hours after ingesting foods or fluids containing lactose and can include diarrhea, nausea, abdominal cramping, gas, and bloating. Lactose intolerance is most common in Asian, Hispanic, black, and Native American populations. Further information on causes and risk factors can be found online from The Mayo Clinic at http://www.mayoclinic.com. Several lactose-free products are available for the lactose intolerant/lactase deficient. Lactose-free products are available in most regular grocery or health food stores and should be labeled as such. Soymilk, oat milk, nut milks, and rice milk are lactose-free. Foods that do not contain lactose should have one of the following indications on the label: Lactose-free Pareve (neither meat or dairy) Lactic acid Lactate Lactoalbumin
Enzyme replacements before eating or drinking a lactose-containing food are often recommended. Meat and Beans The meat and beans category also includes poultry, fish, eggs, and nuts. The food in this group is generally high in protein and ranges from low- to high-fat. Meat also supplies iron, zinc, and B-complex vitamins (niacin, thiamine). Some fish is rich in healthy omega-3 fatty acids (salmon, trout, herring). Nuts (almonds) and seeds (sunflower, sesame) are high in vitamin E. However, keep in mind that all processed meats are high in sodium, and organ meats (liver) and egg yolks are high in cholesterol. Oils Oils are a liquid form of fat. Oils high in polyunsaturated or monounsaturated fats (canola, olive, corn) are preferred over oils high in saturated fats (coconut, palm kernel). Some common food containing oil may also be high in trans fat (such as some margarines). Solid fats include butter, shortening, and stick margarine.
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General MyPyramid Recommendations The following is a summary of recommendations based on the food groups in MyPyramid: Limit intake of the following: saturated and trans fats, food high in cholesterol, added sugars, salt, and alcohol. Gradual weight loss comes from balancing calories taken in from food and beverages with calories expended; daily exercise is encouraged. At least 30 minutes of moderate to intense physical activity can reduce risk of chronic disease; 60 minutes of moderate to vigorous activity can help maintain normal weight; 6090 minutes of moderate-intensity activity can sustain weight loss. The three primary types of activity recommended are: Cardiovascular conditioning (e.g., brisk walking, running, cycling) Stretching exercises to increase and maintain flexibility Resistance exercises to increase and maintain muscle strength and endurance
Recommendations for daily consumption based on a 2000-calorie diet are: Fruit: 2 cups. Vegetables: 2 cups, with a variety of dark green, orange, and starchy vegetables. Legumes such as peas, beans, and lentils can also be considered part of this category. Whole-grain products: at least 3 ounce-equivalents in addition to any enriched products. Fat-free or low-fat milk or milk products: 3 cups Fats and oils: 2035 percent of daily calories. The majority should be from polyunsaturated and monounsaturated fats (nuts, fish, and vegetable oils). Saturated fats and trans fats should make up less than 10 percent of calories. Meats and poultry should be lean, low fat, or fat free. Fiber-rich fruits, vegetables, and whole grains are the recommended source for carbohydrates; food and beverages containing sugars and starches should be consumed less to prevent weight gain and dental caries. Food high in potassium includes fruits and vegetables. Sodium consumption should not exceed 2,300 mg (1 teaspoon) per day. Alcoholic beverage recommendations include up to one drink/day for women and up to two drinks/day for men. Alcohol is not recommended for women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents, and people who may be taking medications that could interact with alcohol. Discretionary calories are extra calories over and above the minimum daily requirements and might include solid fats and sugar that is added to some food and beverages; alcohol is also included in this category. Discretionary calories should be limited to 100300 calories a day, especially if physical activity is low. Examples are sodas, candy, sweetened cereals, or butter added to a potato.
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Calculating Weight Loss Based on MyPyramid As MyPyramid advises, gradual weight loss comes from balancing calories taken in from food and beverages with calories expended; daily exercise is encouraged. Based on these guidelines, a simple calculation for use in a gradual weight loss plan is presented in this section. In one pound of stored body fat there are 3500 calories. In order to lose one pound a week, a person must create a 3500-calorie deficit based on their required number of calories. This averages 500 calories a day 7 days. A deficit of 7000 calories would result in a two-pound loss over two weeks, or 500 calories a day 14 days. A calorie deficit forces the body to draw on its fat reserves for energy. This can best be done through a combination of calorie counting and exercise. One common formula for calculating weight loss is the following: A. Determine current weight and multiply by 10 (women) or 11(men) B. Determine general activity level: Generally inactive; low-intensity activities daily (add 300 to above result) Moderately active, e.g., housework, walking at work, 30-minute brisk walk (add 500 to above result) Very active, e.g., engaging in physical sports or labor-intense occupation (add 700 to above result)
C. Add results of A and B. This number is the total number of calories you need daily to maintain your current weight. To lose a pound a week, a recommendation would be to take in 500 fewer calories a day than what your body needs. For example: For a generally inactive female weighing 175 pounds, the recommended number of calories needed by the body to maintain that weight is (175 10) + 300 = 2050 calories. To lose a pound a week, plans might include consuming a diet of 2050 500 calories a day, or 1550 calories a day. In one week, this would be a difference of 3500 calories and a loss of one pound. To check ideal weight, there are also weight charts made available by the federal government based on gender, age, and height. However, the basic formula for weight loss would be the same no matter what ones current weight. Planning Menus Based on MyPyramid We live in a visual society, so a visual aid like the food pyramid can be helpful to people when planning menus and purchasing foods. Making choices from the food pyramid based on recommended food groups and servings is not a guarantee that a persons complete nutritional requirements will be met, but it does provide recommendations for a
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well-rounded diet that includes ingestion of essential nutrients, with the exception of water, on a daily basis. A person using the Food Guide Pyramid to plan meals should be able to avoid the extremes of both overnourishment and undernourishment, which are often associated with either excessive intake of fats and simple carbohydrates or a deficiency of vitaminrich fruits and vegetables. Both overnourishment and undernourishment are associated with fast-food cultures. Various dietary exchanges can also be made if serving sizes are known. Diabetic diets are based on the concept of food exchanges. Diabetic food exchanges can be made within exchange groups based on recommended amounts, measurements, or weights. For example, two tablespoons of peanut butter can be exchanged for one egg; one slice of bread can be exchanged for one-half cup of cooked rice; and an 8-oz. glass of milk can be exchanged for a 2-oz. slice of processed cheese. For more information on diabetic diets, see the American Diabetes Association web site at https://www.diabetes.org.
Recommended Daily Allowances

Recommended dietary (or daily) allowance (RDA) tables are also readily available for the following groups of people: infants, children, men, women in general, and pregnant or lactating women in particular. These categories are further broken down into age groups. Vitamin, mineral, and protein allowances are calculated, as is recommended daily caloric intake based on weight and height. These charts are revised every five years based on the most current research. (These are not charts that require memorization, and they can be found online or in any nursing or nutrition textbook.) In health care settings, diets planned by dietitians generally adhere to RDA requirements, since these requirements are more stringent than the Food Guide Pyramid guidelines. The majority of processed and unprocessed foods are now labeled with percentages of nutrient content. This information can be used for purchasing foods that are low in fats and simple sugars and high in the essential nutrients like protein and complex carbohydrates.
Special Developmental Issues Involving Nutrition

For infants, fluid comes primarily in the form of milk. Infants do not need added water under normal circumstances, although environmental factors (for example, very high environmental temperatures) may necessitate a need for more fluid. Breast milk is especially recommended for infants. In addition to its fluid content, it contains all the essential nutrients needed by the growing infant to at least six months of age. Breast milk has a higher lipid and cholesterol content than bottled milk. This higher fat content is believed to function in infants in a similar fashion as with dieters who eat high-fiber foods. It provides what is known as satiety, a feeling of fullness.
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Recent research indicates that breast-fed babies are less obese when older. Breast milk also contains antibodies that serve a protective function in relation to food allergies. The bonding between mother and baby due to breast-feeding is well-known. Newborns, even those who are breast-fed, will lose some weight during the first few days of life; however, they should not lose more than 10 percent of their birth weight, and they should regain any weight lost within two weeks.
Healthy People 2010

Healthy People 2010 is a national health promotion program that includes goals and objectives for better nutrition. Published by the United States Department of Health and Human Services (HHS) and the Public Health Service (PHS), the focus is on choosing foods from the five primary groups of nutrients and specifically adopting a diet that will prevent chronic diseases like heart disease, diabetes, and obesity. Additional guidelines include decreasing the percentage of fat in the diet, such as by eating lean meats and poultry or substituting dried legumes such as beans and peas for protein. Tofu is also a high-protein food, sometimes classified in the legume group, that can be combined with other incomplete proteins to make a complete protein. Limiting but not necessarily eliminating consumption of egg yolks and organ meats is also encouraged because of their high fat and cholesterol content.
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Chapter 9: Common Nutritional Disturbances

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. Identify the four common physiological alterations that can occur with nutritional disturbances. Provide an overview of undernutrition and overnutrition, including associated disorders. Describe the effects of the various micronutrient and macronutrient deficiencies and excesses on the body. List the effects, signs, and symptoms of macromineral deficiencies and excesses. List the effects, signs, and symptoms of micromineral deficiencies and excesses. Provide an overview of the various types of routine and special diets used as nutrition interventions. Discuss the benefits of vitamin and mineral supplementation for various client populations.
Key Terms
altered-consistency diets amenorrhea anorexia anorexia nervosa beriberi bulimia clear liquid diets cretinism diabetic diets dysphagia full liquid diets glycemic index (GI) healthy heart diets hemolysis high-carbohydrate diets high-fiber/high-residue diets high-protein diets hyperbilirubinemia hypocalcemia hypoglycemia hypokalemia hypothyroidism ideal body weight (IBW) low-fat diets low-fiber/low-residue diets macrocytic anemia malnutrition morbid obesity nothing by mouth (NPO) obesity osteomalacia osteoporosis overnutrition pellagra protein-calorie malnutrition (PCM) prothrombin pureed diet regular/house diet rickets scurvy soft diet tetany undernutrition xerophthalmia
Introduction
Nutritional disturbancesincluding alternations in the bodys ability to ingest, digest, absorb, and metabolize nutrientsare commonly found among patients suffering from catastrophic health events, acute diseases, and chronic illnesses. Because of this, nurses need to understand the signs and symptoms of common nutritional disturbances and some of the special diets used to support the nutritional needs of people when they are ill.
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This chapter begins by discussing the concept of malnutrition and some of the clinical nursing issues surrounding the problems of undernutrition and overnutrition. We then begin a more detailed look at factors related to macronutrient and micronutrient deficiencies and excesses. Related to that discussion, we also discuss the signs and symptoms of macromineral and micromineral deficiencies and excesses. Our discussion then turns to situations where patients have nutritional disturbances that require special diets. In addition to the regular diet, a number of common, specialized, and altered consistency diets are described. These diets are generally used when the patient suffers from metabolic issues related to ingestion or digestion. We pay special attention to diabetic diets, the use of the glycemic index, and the treatment of hypoglycemia. We conclude the chapter by discussing certain situations where the use of vitamin and mineral supplementations are appropriate.
Malnutrition
Malnutrition is a term usually associated with pictures of starving children with distended abdomens and spindly extremities who live in countries where there is drought and famine. Malnutrition, however, is actually an umbrella term for a wide variety of conditions that can include overnourishment as well as undernourishment. It can affect all age groups and populations in both developed and underdeveloped countries. Undernutrition Undernutrition of a general nature is a common nutritional problem. An undernourished persons caloric intake is less than what is required for normal daily functioning and weight loss. Undernutrition may be related to problems with ingestion or dysphagiadifficulty chewing or swallowing foods. Difficulty chewing might be related to facial trauma or poor dentition. A variety of conditions causing nausea and/or vomiting can also result in undernutrition and problems with digestion. Disease processes and treatments for disease, such as radiation, chemotherapy, and antibiotics, can cause nausea and problems with absorption. Some gastrointestinal disturbances cause disturbances in elimination that, in turn, can contribute to a state of undernourishment. Some chronic and acute diseases may make it difficult for the body to absorb nutrients. The most common form of severe undernutrition is protein-calorie malnutrition (PCM). This type of malnutrition, while endemic in underdeveloped countries among children, can also occur in developed countries in other age groups. For example, older people suffer more from chronic and malignant diseases that deplete protein due to catabolic reactions. Inadequate fat deposits beneath the skin, muscle wasting, and weight loss characterize chronically malnourished people experiencing PCM.
Anorexia and Bulimia
Anorexia is a condition commonly associated with undernutrition. Anorexia simply means without a desire for food. Many conditions of anorexia are related to various
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disease processes. Anorexia can be associated with age and immobility. Anorexia can also be a side effect of some medications. People with cancer may be anorexic since the malignant cancer cells feed on nutrients at the expense of nonmalignant cells, a process that speeds up metabolism. Chemotherapy and radiation therapy to treat malignancies affecting various parts of the gastrointestinal tract often cause side effects that negatively impact nutritional intake (e.g., nausea, vomiting, and diminished sense of taste). Malignancies of the head and neck may also require radiation therapy; such treatments may compromise patients nutrition due to the loss of sense of smell as well as taste. The ability to salivate can also be diminished or destroyed by these treatments and swallowing can be affected, resulting in dysphagia. Teenagers, especially teenage girls, are prone to a condition known as anorexia nervosa. Many factors underlie this condition, the majority of which are related to what is perceived as the cultural norm of slimness. Signs of this disorder are related to the effects of starvation on various systems of the body. For example, the lack of nutrients on the endocrine system can result in amenorrhea (absence of menses) and delayed sexual development. Dangerous cardiac arrhythmias can also occur related to electrolyte imbalances that are sometimes self-induced by vomiting. Electrolyte imbalance is further complicated if the teen resorts to over-the-counter products to speed up weight loss; for example, a girl may use laxatives and diet pills that contain diuretics to prompt increased urinary secretion, which results in a fluid volume deficit. Increased susceptibility to infection can occur related to a compromised immune system. General weight loss can be marked, leaving these patients emaciated, weakened, and fatigued. Adolescent girls in particular may also experience bulimia, otherwise known as the binge and purge disease. Bingeing means unrestrained imbibing or eating, and purging means getting rid of. Food is consumed, generally in very large amounts, and then vomited prior to digestion. Laxatives and enemas are also often used to frustrate the absorption of nutrients by the body, enabling the person to remain slim. A person can be bulimic but not anorexic; however, bulimia frequently accompanies anorexia. Bulimia alone is not as easy to detect as anorexia because the bingeing and purging usually occur when the person is alone. As with anorexia, body systems can be adversely affected. The irritation from daily vomiting can affect the teeth, resulting in dental caries. Acid from undigested stomach contents can irritate the esophagus, and esophageal lesions can form. Serious deficiencies of a number of electrolytes can occur; for example, the patient may have a deficiency of the mineral potassium (a condition called hypokalemia) that may be accompanied by cardiac symptoms or even lead to death. Overnutrition Overnutrition is a type of malnutrition that occurs when a persons intake of calories exceeds that which is required for normal daily functioning. The energy provided by calories, rather than being used to build up and maintain body tissues or normally expended in activities such as exercise, is stored in the tissues in the form of fat or adipose tissue. Over time, people who continue to take in more calories than they need develop an excess of adipose tissue.
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If a persons body weight is 20 percent or more above his or her ideal or normal body weight, he or she is considered obese. Obesity is considered to be one of the primary diseases of our highly industrialized Western civilization, and it is a major risk factor for a variety of chronic conditions including diabetes, heart and blood vessel diseases, hypertension, and stroke. Obesity is a growing concern among grade-schoolers and teenagers. According to recent research, obesity is related to a more sedentary lifestyle and the abundance of fast foods that are high in calories, fat, and simple carbohydrates. There is also a condition known as morbid obesity. The Latin word morbidus means sickly or diseased, and people who are morbidly obese often have difficulty carrying out routine activities of daily living because their condition affects their ability to breathe and to walk. Formulas can be used to calculate morbidity and obesity in relation to ideal body weight. Ideal Body Weight The concept of ideal body weight (IBW) is based on the belief that there should be a balance between nutritional intake and energy expenditure. When that balance is maintained, people maintain their weight. There are standardized tables of normal weight ranges correlated with age and height available in all health care facilities and textbooks of nursing and nutrition. Many people have difficulty maintaining or attaining their ideal body weight for various reasons and require assistance from others in the health care professions to do so.
Macronutrient Deficiencies and Excesses

Protein deficiencies over a long period of time can result in negative nitrogen balance in the body if the body is losing more nitrogen than it is taking in for optimum health. This loss of nitrogen, a major component of protein, contributes to the destruction of tissue. A number of acute and chronic conditions can contribute to this loss (e.g., prolonged fever or infection, injury/trauma to the body, cancer, prolonged immobilization, and starvation). Destruction of body tissues depletes nitrogen; the primary action of nitrogen is to build up body tissue. The defining characteristics of low nitrogen levels include muscles that appear wasted, fat deposits that diminish beneath the skin, and excessive weight loss. These symptoms are similar to the defining characteristics of PCM. Protein excess is less common but can occur; recently there has been an emphasis on high-protein, low-fat, and low-carbohydrate diets. Protein excess can contribute to the development of kidney damage. Older adults with impaired renal function and pregnant women are particularly at risk if protein intake is unreasonably high. There has been considerable research on various types of weight loss diets emphasizing protein, but results are inconclusive to date. One theory is that eating more protein and fat and fewer carbohydrates makes a person feel fuller so they eat less, thereby reducing calorie intake and increasing weight loss.
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Lipid excesses have been implicated in nutritional imbalances. Ninety percent of the fat stored in the human body is composed of a chemical compound called triglyceride. Triglycerides also compose 98 percent of the fat content in foods. Higher than normal triglyceride levels have been linked to elevated blood cholesterol levels. Abnormally high triglyceride levels may be a precursor to atherosclerosis. Elevated triglyceride and blood cholesterol levels may also contribute to cerebral vascular accidents (CVAs or stokes) and myocardial infarctions (MIs). The American Heart Association (AHA) recommends a dietary intake of cholesterol no greater than 300 mg/day. A 3.5-oz. serving of chicken (no skin) contains 77 mg of cholesterol; a 3.5-oz. serving of lean ground beef contains 107 mg of cholesterol.
Micronutrient Deficiencies and Excesses

Vitamin and mineral deficiencies and excesses can also result in nutritional imbalances with accompanying signs and symptoms. Vitamin Deficiencies Deficiencies in vitamins A, D, E, K, and C can all occur with detrimental effects. Vitamin A maintains visual acuity (especially in dim light), skin (epithelial) tissue, and immune function. Vitamin A deficiency can result in the condition known as xerophthalmia, or night blindness, related to corneal drying. In adults, dry, scaly skin and decreased resistance to infection is also a result of too little vitamin A. In children, insufficient vitamin A intake can adversely affect the development of teeth and bones. Vitamin D is responsible for the deposit of calcium salts and the absorption of calcium in teeth and bones. Vitamin D deficiency in older adults can lead to osteomalacia, or a softening of the bones. People who are lactose intolerant may develop this deficiency due to the inability to drink milk or ingest other dairy products. Breast-fed infants need more of this vitamin coupled with vitamin C. In children, a deficiency of this vitamin can delay tooth formation and bone development. Rickets, a disease characterized by the softening or bending of the bones, is evidenced in children with this deficiency. Postmenopausal women with vitamin D deficiency coupled with inadequate calcium intake may develop osteoporosis. Osteoporosis, from the Greek osteon and the Latin porosis (meaning a porous condition), is a bone disorder characterized by a decrease in bone density with an increase in bone brittleness and porosity. Vitamin E synthesizes heme, or builds up red blood cells. Vitamin E deficiency can result in increased hemolysis, or destruction of red blood cells, in adults and macrocytic anemia, or anemia characterized by large red blood cells, in premature infants. Vitamin K forms prothrombin in the blood, which aids in blood clotting. Vitamin K deficiency can contribute to prolonged clotting/bleeding times in adults and hemorrhagic disease in newborns.
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Vitamin C builds strong capillary walls and red blood cells and aids in the metabolism of amino acids and in wound healing. Vitamin C deficiency can lead to bleeding gums, bruising, scurvy, and wounds that do not heal. Symptoms of scurvy include weakness, anemia, spongy gums, and bleeding from mucous membranes. Purple spots under the skin of elderly people are common due to a tendency to easily bruise related, in part, to this deficiency. Breast-fed infants need more of this vitamin. Infants with deficiencies may experience diarrhea, vomiting, and pallor; cry when they are picked up; and move less. Children who are deficient in vitamin C may experience growth retardation.
Deficiencies of B Vitamins
A number of vitamin B deficiencies are also common, and described below: Vitamin B1 (thiamine) is necessary for the normal function of nerves, muscles, and the heart. In less developed countries, vitamin B1 deficiency can lead to a condition known as beriberi. Beriberi is a disease that affects the cardiac and nervous systems, especially the peripheral nerves. Pronounced signs of vitamin B1 deficiency in infants are pallor, facial edema, and irritability. Mental confusion, muscle weakness, and tachycardia can occur in children and adults, and deficiency can also result in enlarged heart and cardiac failure. Vitamin B6 (pyridoxine) is necessary for healthy blood and nerve cells, and other nutrients are dependent on it for their metabolism. It stimulates production of heme. Deficiency of vitamin B6 manifests itself in anemia, cracks at the corners of the mouth, and other skin lesions. Vitamin B12 (cobalamin) is necessary for red blood cell production. Deficiency can result in pernicious anemia that includes neurological and gastrointestinal symptoms. This is seen especially in the elderly, since gastric secretions, which are often reduced in older adults, aid in B12 absorption. Folic acid aids in the maturation of red blood cells. Deficiency can result in macrocytic anemia. Pregnant women may develop this anemia. Deficiency of folic acid in pregnant women can also result in neural tube defects in their children, causing spinal deformities. Niacin synthesizes fat and contributes to the utilization of protein. Deficiency can result in pellagra, a chronic disease characterized by anorexia and generalized weakness if mild, and neurological and gastrointestinal disorders and skin eruptions if severe.
Vitamin Excesses Vitamin excesses can also occur but are more rare. Excesses do not generally occur from food intake but from megadoses of vitamins, especially the fat-soluble vitamins. Megadoses of vitamin A can cause abnormal fetal development. Physicians and nurses usually do general assessments upon admission to a health care facility for prescription medications, but many people take over-the-counter medications, including herbal products and vitamins, that can be toxic in sufficient dosages or in combination with
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other prescription or nonprescription drugs. These over-the-counter drugs are rarely selfreported. Nausea and vomiting are two of the most common symptoms of vitamin excess. Allergic reactions include hives, difficulty breathing, and itching. Excess vitamin D can also dangerously increase blood levels of calcium. In infants, a condition called hyperbilirubinemia, characterized by an excessive amount of bilirubin in the blood and resulting jaundice, can develop related to an excess of vitamin K. Macromineral Deficiencies and Excesses Both deficiencies and excesses in the macrominerals are nutritional imbalances that will occur more frequently in the various health care settings nurses work in. They may be related to an insufficiency or excess of nutrients ingested by the patient, or the patient may experience side effects if these minerals are taken in pill form. Calcium facilitates the bodys nerve impulse transmission, cardiac function, muscle contraction, and formation of bones. Calcium deficiency, or hypocalcemia, is not uncommon. Tingling sensations around the mouth and of the fingers are common, as are muscle cramping and spasms of the toes or thumb. Convulsions can occur if hypocalcemia is severe. Tetany, which is marked by involuntary muscle spasms, is a side effect. Children may experience stunted growth, and older people may experience bone loss. Pathological fractures can occur, especially in older people. Calcium excess can cause cardiac irregularities and a state of overrelaxation of the skeletal muscles. Magnesium helps the body maintain electrical activity in nerves and muscles and enables calcium and protein utilization. Magnesium deficiencies may manifest in confusion, hallucinations, irritability of the nervous system, and failure to grow. Potassium is important to both cardiac impulse transmission and muscle contraction. Deficits result in muscle weakness, fatigue, and various cardiac irregularities, including weak and rapid pulse. Potassium excess can cause confusion, abnormally slow pulse, muscle weakness, and decreased urinary output. Sodium is important to the maintenance of acid-base and fluid balance. Deficiencies are characterized by hypotension, weakness, decreased level of consciousness, muscle twitching, nausea, vomiting, and abdominal cramps. Sodium excess can manifest itself in skin edema (swelling), shortness of breath, thirst, dry tongue, and restlessness.
Micromineral Deficiencies and Excesses Micromineral deficiencies can also occur, especially in relation to fluoride, iodine, zinc, and iron. Fluoride aids in tooth formation and cavity prevention. Fluoride deficiency has been implicated in poor overall dental health. Breast-fed infants need additional fluoride. Excess fluoride can cause discoloration of tooth enamel.
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Iodine regulates thyroid hormones. Iodine deficiency can result in cretinism, or low thyroid function producing arrested physical and mental development, in infants and hypothyroidism, characterized by fatigue, cold intolerance, and sluggishness, in adults. Iodine excess can produce toxic goiters. Zinc helps the body maintain connective tissue, like skin. Zinc deficiency may result in impaired wound healing and skin lesions and a decreased sense of smell and taste.
Iron deficiency bears special mention because it is probably the most common mineral deficiency, resulting in iron-deficiency anemia. Iron forms hemoglobin and aids in the formation of antibodies. Oxygen is carried to the cells by iron for energy release. Infants ages six to eighteen months are especially vulnerable to deficiencies, and they need ironfortified cereals. Children who drink large amounts of milk in lieu of solid foods can be iron deficientthe phosphate in whole milk combines with iron and removes it from the body. Adolescent girls with menstrual blood loss may be anemic. Older people may have low hemoglobin levels if they are overconsuming foods high in bulk, such as bran cereals. The bulk may interfere with iron absorption from other foods. Lack of meat in a diet, related to vegetarianism or the inability to chew, can result in iron deficiency. People with arthritis who regularly consume aspirin may be iron deficient related to some internal bleeding that is a side effect of aspirin given in high or frequent doses. Persons with anemia are also subject to infections related to an impaired immune system. Lethargy, fatigue, and sometimes dyspnea (shortness of breath) on exertion can occur. Children may exhibit irritability and a decreased attention span.
Routine and Special Diets

A number of diets are considered interventions. The most common diet to meet all basic nutritional needs and prevent the various deficiencies is called a regular diet. In hospital and nursing home settings, this might also be known as the house diet. It contains all the basic nutrients from the Food Guide Pyramid based on a persons height, weight, gender, and activity level. Sometimes, however, nutritional disturbances require special diets. In addition to the regular diet, a number of common specialized and altered-consistency diets might be used in certain situations. The theoretical basis for their use relates to issues of metabolism (e.g., difficulty with ingestion or digestion). Altered-Consistency Diets Altered-consistency diets may be used for a variety of reasons to aid in nutritional promotion. The three most typical are the clear liquid diet, the full liquid diet, and the soft diet. These diets are often used in relation to physically limiting conditions (e.g., acute or chronic intestinal infections).
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Clear Liquid Diets
Clear liquid diets are generally short-term in nature. They consist of no solid foodonly liquids or semisolids that are clear or transparent, including coffee, tea, clear broths, and clear gelatin. Carbonated beverages are considered clear liquids, as are strained juices that are transparent. One primary rationale for a clear liquid diet is to provide rest for the gastrointestinal tract following intestinal surgery, and this diet may be used prior to surgery to prevent any aspiration from vomiting. There may be some calories in a clear liquid diet in the form of simple carbohydrates (sugars) in liquids such as apple or white grape juice, but nutritionally, this diet lacks other essential nutrients. Clear liquids are usually given at room temperature with enough fluid intake to prevent dehydration.
Full Liquid Diets
Full liquid diets may include any type of food that melts into liquid at room temperature (e.g., ice cream). Juices of all kinds are included. Milk and foods containing milk are typical of this diet, including custards, puddings, and creamed soups. Dietary supplementation is usually needed to ensure adequate protein, iron, and calories if the diet is used on a long-term basis. This can be given in the form of liquid dietary supplements and oral vitamin supplements that can be in liquid form. Smaller, more frequent intake of fluids with a variety of tastes to stimulate taste buds generally helps the palatability of this diet because it tends to be quite bland in nature. Foods can be combined to increase protein intakefor instance, instant breakfast drinks or egg substitutes can be added to milk shakes. Raw eggs should not be used because of the risk of contamination with salmonella. Although the risk is relatively small, any infection from these bacteria can be especially dangerous to the elderly, infants, children, and others compromised by illness.
Soft Diets
Soft diets are used for patients who may have difficulty chewing and swallowing more solid foods (e.g., accident victims with facial injuries or the elderly with dental concerns). Soft diets cause less irritation to the lining of the gastrointestinal tract. Various types of baked, broiled, or boiled poultry and meats are included if they are minced or ground. Foods are not highly seasoned on this diet. A version of the soft diet that is thinner in consistency is the pureed diet; foods are mixed (pureed) in a blender with liquids. The thicker the consistency of the diet, the more variety there can be in the types of foods, with less need for additional vitamin and mineral supplementation. All types of fruits and vegetables in addition to meat and poultry can be cooked without skins and blended or pureed. Special Diets In addition to the aforementioned diets, nurses should be familiar with a number of common special diets, including NPO diets, fiber diets, diabetic diets, and several other variations.
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Nothing by Mouth
In addition to the three traditional diets, a diet commonly called nothing by mouth (NPO) may be ordered. (NPO stands for nothing by mouth in Latin: non per os.) NPO diets are, of course, not strictly diets, and they are usually ordered before and after surgery. On this diet, no oral intake is allowed in any form. The primary rationale for such a diet is to prevent the patient from aspirating gastric contents. General anesthesia used during surgery can cause nausea and vomiting, which increases the risk of aspiration during and after surgery as well as the development of aspiration pneumonia. Once bowel sounds return, people can begin to take fluids by mouth (PO) as ordered by the physician. Generally, they begin with clear liquids and progress to a regular diet.
Fiber Diets
While fiber is a required nutrient and important to peristalsis, it may cause excessive irritation if a patient is suffering from a disease like ulcerative colitis or Crohns disease or if he or she has had surgery on the lower bowel. Low-residue or low-fiber diets may be ordered for these cases. High-residue or high-fiber diets are recommended for conditions like chronic diverticulosis, when extra roughage is needed to increase peristalsis and the movement of the products of digestion through the intestines. These diets are also recommended for simple constipation.
Diabetic Diets
Diabetic diets are also common and recommended for both diabetics and general weight loss, depending on the number of calories they contain. The American Diabetes Association (ADA) has guidelines for diabetic diets for people of all ages based on the USDA MyPyramid guidelines (and the former Food Guide Pyramid), though there are some differences. For instance, the USDA classifies according to type of food; the American Diabetes Association classifies based on a food's carbohydrate and protein gram count. For example, a serving of pasta or rice in the Diabetes Food Pyramid is onethird cup, compared to one-half cup in the USDA MyPyramid. A serving of fruit juice is one-half cup in the Diabetes Pyramid but three-fourths cup in the USDA Pyramid. This difference in serving sizes reflects the higher carbohydrate count of pasta and fruit juice. Starchy and high-carbohydrate vegetables like potatoes, dry beans, peas, and corn are considered part of the mostly carbohydrate bread, cereal, rice, and pasta grouping of foods in the diabetic food plan; potatoes are grouped with vegetables in the USDA plan. Cheese, a part of the milk product group in the USDA Pyramid, is considered part of the meat and meat substitutes group for the Diabetic Pyramid; cheese is a low-carbohydrate and high-protein food. Exchanges can be made between the two pyramids as long as quantities are consistent with the diabetic plan. For example, one slice of whole grain bread could be exchanged for one-third cup of rice or one-half cup of oatmeal or cream of wheat. People with diabetes generally follow a specific diet recommended by their physician with different percentages of protein, fat, and carbohydrates. A popular alternative to the diabetic food exchange is calculating carbohydrate grams. This makes it easy to determine the amount of insulin coverage needed for a meal for a person with type-I or insulin-dependent diabetes. Carbohydrate foods are foods from the carbohydrate exchange group. This method may allow the person to consume more
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carbohydrates than the basic exchange plan, as long as there is sufficient insulin coverage. One concept diabetic patients and health care workers should understand is that of the glycemic index. The glycemic index (GI) is a ranking of foods based on their immediate effect on blood glucose (blood sugar) levels. Carbohydrate foods that break down quickly during digestion have the highest glycemic indexes; blood sugar response is fast, and levels rise immediately after eating or drinking. Carbohydrates that break down slowly, releasing glucose gradually into the bloodstream, have lower glycemic indexes. Lower glycemic index diets can help improve sensitivity to insulin and stabilize blood sugar and are recommended for long-term management of diabetes. Examples of foods appropriate with these diets are breakfast cereals with wheat bran, barley, and oats, and pasta and rice in place of potatoes; white potatoes have a high glycemic index. A person with diabetes who might be experiencing very low blood sugar may drink fruit juice to quickly increase blood glucose levels, since juice has a higher GI than actual fruit. Orange juice is generally recommended to bring very low blood sugar up quickly for diabetics and people with hypoglycemia who may be experiencing adverse symptoms like shakiness, weakness, perspiration, and confusion. Hypoglycemia, or low blood sugar, can occur in diabetics, sometimes as a side effect of a diabetic medication like insulin, but it can also occur in people who do not have diabetes because of different causes, such as excess secretion of insulin from the pancreas, binge drinking of alcohol, or tumors. People with chronic hypoglycemia may also need a diet with foods with a lower GI to help stabilize blood sugars, although like people with diabetes, they may also need to consume high glycemic foods or beverages to increase blood sugar quickly if they experience adverse symptoms. Other recommendations for chronic hypoglycemia include more complex carbohydrates and high-fiber, protein-rich meals with a variety of fruits and vegetables. A typical diabetic diet for an average-weight adult might consist of a one cup of melon, a half of a bagel with a teaspoon of butter, and an eight-ounce glass of skim milk for breakfast (exchanges include 1 fruit, 1 bread/starch, 1 milk, and 1 fat). Lunch might include a three-ounce luncheon meat sandwich with two slices of wheat bread, one mixed salad, one teaspoon salad dressing, a banana, and a glass of low-fat milk or cup of yogurt (exchanges include 3 meat, 2 starch/bread, 1 vegetable, 1 fruit, 1 fat, and 1 milk). Dinner might include three ounces of chicken or beef, a cup of green beans or a roll, and a cup of lettuce salad with tomato and fruit (exchanges include 3 meat, 2 starch/bread, 2 vegetable, and 1 fruit).
Other Diets
Low-fat diets are recommended for people with difficulty absorbing fats and people with gallbladder disease. Skim milk and low-fat dairy products are part of this diet. Highprotein and high-carbohydrate diets are used in cases of severe burns, wounds, and general malnutrition. Healthy heart diets that address the growing number of people at risk for heart and blood vessel disease are generally low in saturated fat, cholesterol, and
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simple sugars, moderate in protein, and higher in complex carbohydrates. Sodium in this diet may also be restricted.
Vitamin and Mineral Supplementation

While vitamins and minerals can be ingested naturally through foods, sometimes vitamin and mineral supplements are necessary to maintain nutrition if people are on any of these special diets for long periods of time. Certain conditions may also increase the need for vitamins and minerals above and beyond what food will supply. Pregnancy, for example, increases the bodys need for these elements, since deficiencies can affect both mother and growing fetus. The specific vitamins needed in supplemental (vs. food) form for pregnant women are vitamin A and B vitamins (especially folic acid). The thyroid gland also increases its activity during pregnancy and iodine needs may increase. Iron needs also increase to 30 mg/day and can best be met by supplemental iron or a multivitamin with iron. Calcium needs increase to approximately 1,200 mg/day. A middle-aged adult may also need calcium in pill form along with vitamin D for the prevention of osteoporosis.
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Chapter 10: Assessment of and Diagnostic Tests for Nutritional Health

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Provide several examples of factors and variables nurses need to know about related to a patients nutritional status. Discuss the impact of gender on nutritional requirements. Describe the most common effects of age and developmental level on metabolism and nutritional needs. Describe various dietary habits and preferences and their impact on nutritional status. Explain the role of antioxidants and the impact of free radicals. Explain the importance of investigating an individuals medication history and physical condition when completing a nutrition assessment. Discuss the impact of various serious medical conditions on the bodys nutritional status. Explain how religious beliefs and cultural practices can impact nutrition. Explain how socioeconomic, psychological, and environmental factors can influence nutrition. Define six noninvasive anthropometric measures that the nurse can use to track a patients nutritional status. Explain a complete blood count (CBC) and describe the three specific tests included in a CBC that give a picture of a persons nutritional status. Explain what serum readings measure, and provide examples of their implications for a patients nutritional status. Explain the nutritional implications of both low and high blood urea nitrogen (BUN) levels.
Key Terms
anthropometric data antioxidants blood urea nitrogen (BUN) celiac disease complete blood count (CBC) free radical gluten hematocrit (Hct) hemoglobin level lacto-ovo-vegetarians lactovegetarians midarm circumference (MAC) serum albumin serum cholesterol serum transferrin skin turgor thrush total lymphocyte count (TLC) triceps skin fold thickness (TSF) triglyceride counts twenty-four-hour urine collection urea urinary creatinine excretion vegans/pure vegetarians vegetarians white blood cell count (WBC)
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Introduction
Our knowledge of a patients nutritional status allows us to provide holistic, quality nursing care. Not only does nutritional information help us plan for immediate nursing interventions, it also allows us to develop preventive health interventions for both patients and their families. In order to reach this level, we must practice a comprehensive approach to nutritional assessments. This chapter helps us understand how to do that by first identifying eight critical assessment areas. We look at specific metabolic and nutritional needs across the life span and analyze special dietary preferences and lifestyle choices that directly impact a persons nutritional status. We also discuss the importance of a comprehensive medication history as it relates to nutritional status. We analyze the fact that, in some cases, specific nutrients may interfere with the absorption of a drug, while, in other cases, a medication may interfere with the absorption of nutrients. Our discussion then turns to the types of nutrition-related assessment data we can use, including anthropometric data and laboratory data. The chapter concludes with an investigation of the importance of specific lab results and lists reasons these lab values are directly related to a persons nutritional status.
Nutritional Assessments
A dietitian in a hospital setting will generally do an in-depth nutritional assessment of a patient; however, nurses should be knowledgeable about the factors and variables relative to the patients nutritional status in any setting. For example, nurses should be aware of the patients daily intake patterns, including amounts, food types, food intolerances and allergies, and food preferences. Nurses should note any health factors that might compromise nutritional status, including anorexia (lack of desire for food), dysphagia (difficulty swallowing), nausea and/or vomiting, or mechanical difficulties with chewing. In many cases, an initial nutritional assessment on admission might indicate the need for a more comprehensive nutritional screening by a dietitian. In nursing home settings, extensive nutritional evaluation and planning is done by dietitians for every resident. Good nutrition is essential for preventing adverse conditions, such as pressure sores in the elderly and physically debilitated, as well as for maintaining health for all ages. Admission assessments can uncover potential situations of risk. The following are more specific considerations for nursing assessment that can aid in formulating nursing diagnoses and planning interventions related to the categories that most frequently influence a persons nutritional status across the life span. Many of these influencing factors can also directly or indirectly affect the patients BMR.
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Gender The basic rule of thumb is that men require more calories than women due to their increased metabolism both at rest and when active. Caloric needs overall are generally greater for men due to increased height and weight. Protein needs are also greater for men related to increased muscle mass. Different physiological changes related to stages of the life cycle based on gender should also be considered; for example, blood loss during menstruation can trigger an increased need for iron in women. Similarly, pregnant women have increased needs for protein, calcium, iron, folic acid, and vitamins C and D. Age and Developmental Level Age and developmental level also affect a patients nutritional status. Table 10.1 lists the most common effects of age and developmental level in relation to metabolism and nutritional needs. Table 10.1 Metabolic and Nutritional Needs across the Life Span
Life stage Infants Developmental needs Metabolic requirements and energy consumption increase due to rapid growth and higher metabolic rate; extra iron needed from four to six months; water accounts for a high percentage of total body weight in infants; water loss and hydration needs can be high Metabolic/caloric requirements decrease as growth stabilizes; protein needs remain high for muscle tissue growth Calcium needs are high to ensure tooth formation Need for protein is high, especially for breakfast; 2,400 kcal per day needed for adequate nutrition Metabolic/caloric requirements increase due to growth and activity, especially in boys; needs for the following nutrients increase: protein, calcium, iron, zinc, vitamins B and C Women may need more vitamin C and iron Postmenopausal women need additional calcium and vitamin D to maintain or increase bone density and prevent osteoporosis Increased needs for protein, iron, folic acid, calcium, vitamin C, and vitamin D Metabolic/caloric requirements decrease due to decreased metabolism; decreased gastric secretion and diminished taste buds and sense of smell; increased need for calcium, iron, vitamins C, B1, B12, and fiber; decreased need for calories, fat, and sodium
Toddlers Preschoolers School-age children Adolescents
Young adults Middle-aged adults Pregnant and/or lactating women Older adults
Many different variables, including gender and age, can contribute to dietary habits and regular and irregular eating patterns. Adolescent teenage girls, for example, are more prone to undernutrition. This can be related to a desire to remain slim or to attain slimness; anorexia and bulimia can then be contributing factors that impact metabolic and nutritional needs.
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Dietary Habits and Preferences The patients cooking and work habits should be explored. Busy work schedules may force people to resort to dining out at fast-food restaurants or eating more microwavable processed foods that can be high in sodium. If patients are on a sodium-restricted diet, do they know how to cook tasty meals using herbs and spices? Methods of cooking should also be explored. Do they bake, broil, boil, or fry most foods? Individual preferences and dietary habit patterns can influence nutrition across the life span. Food allergies and intolerances can be assessed. Many people are lactose intolerant and require lactose-free milk substitutes, like LACTAID Milk, or medications, like a lactase enzyme tablet (e.g., Lactaid tablets), available in drug stores without a prescription. Lactase enzyme is also available in liquid form that can be added to foods or beverages to make lactose more digestible. Many supermarkets also carry lactose-free breads and other products. Soymilk is one of the post popular alternatives to dairy milk and is carried in many supermarkets as well as health food stores. Soy milk is made from ground soybeans and is a good source of magnesium and thiamine, though it does not naturally contain calcium and vitamin D. Other options are almond, rice, and nut milks. The word parve or pareve on a product means it contains neither meat nor any dairy-based ingredients; these products adhere to Jewish dietary laws requiring the separation of meats and milk at the same meal and thus may be used in a lactose-free diet. Whole milk may cause gastrointestinal bleeding and iron-deficiency anemia in infants. A protein known as gluten, found in wheat, rye, barley, and oats, can also contribute to celiac disease in children with muscle wasting, anorexia, and abdominal distention. Most supermarkets also contain gluten-free products like breads made from alternative flours, such as rice, soya, sorghum, or potato flour. People often have preferences for the type of foods they eat, the texture of foods, and modes of cooking. All of these preferences can be capitalized on at different stages in life to ensure good nutrition. Well-loved foods from childhood might appeal to people with end-stage illnesses (terminal cancer or dementia) and can be incorporated into their diet; for example, patients may be served milk shakes with powdered protein supplements or with an egg for added protein and iron. Flavored yogurts that are high in calcium and iron provide older people with a sweet taste, which is more appealing to diminished taste buds. Yogurt can often be combined with cereals for added fiber. Children gravitate to fast foods and finger foods like peanut butter sandwiches, which are good sources of protein.
Vegetarianism
Many people are vegetarians, often prompted by concerns that are religious or ethical in nature. The primary source of food for vegetarians is plant foods. All vegetarians avoid meat, poultry, and fish. Actually, the vegetarian diet is classified by three primary variations: pure vegetarians, or vegans, consume plant foods and plant foods only; lacto-ovo-vegetarians eat eggs and milk in addition to plant foods; and lactovegetarians consume milk but not eggs in addition to plant foods. Assessment of a vegetarian diet should consider whether patients adequately combine foods to ensure that complete
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proteins are part of the diet and that they eat other food groups in a balanced fashion. Vitamin and mineral supplements may also be needed. Table 10.2 indicates vitamins and minerals and food sources that vegetarians would especially need to consider for adequate nourishment; many are normally plentiful in foods that are not in a vegetarian diet, for example meat and eggs. If it is not possible to obtain these through food sources, vitamin and mineral supplements can be taken. Table 10.2 Vitamins and Minerals for Vegetarian Diets
Vitamin or mineral Calcium Iron B12 Vitamin D Vitamin C Food source Soy products (e.g., soybean milk, tofu) and leafy vegetables (important for pure vegetarians) Leafy and green vegetables, whole grains, and iron-fortified breads and cereals Brewers yeast, fortified breads, and cereals Fortified milk Citrus and other fruits (cantaloupe, grapefruit, oranges, strawberries, tomatoes, etc.); vegetables (broccoli, cabbage, potatoes, etc.); extra vitamin C is needed to aid in the absorption of iron from plant sources
Alcohol and Drugs
Excessive alcohol consumption has been implicated in the development of both liver disease and dementia. Nutritionally, people who consume excessive amounts of alcohol are frequently malnourished due to the substitution of alcohol for food and/or the adverse effect of alcohol on the liver and internal organs of digestion, which results in decreased absorption of essential nutrients. The primary vitamin deficiency associated with excessive alcohol consumption is a B vitamin deficiency. If people are dependent on drugs like cocaine, they may be neglecting their nutritional needs. Cigarette smoking can also decrease desire for food.
Heart Disease, Diabetes, and Obesity
Do work habits influence the patients nutrition? Is he or she dependent on high-calorie, high-fat fast foods? An excessive intake of sweets and carbohydrates can contribute to diseases like diabetes and obesity. Excessive animal fat intake can contribute to obesity and heart disease. Diabetes, a chronic disease involving inadequate utilization of glucose, can often be controlled by diet alone if it is adult-onset. A diabetic diet generally includes limiting the intake of simple carbohydrates (refined sugars) and taking in more complex carbohydrates and protein. Acid indigestion, more commonly known as heartburn, can be a problem in the latter part of middle age; it is often related to obesity but is also related to decreased levels of gastric juice in the stomach. Foods high in fat content can precipitate this, especially when patients lie flat.
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Caffeine
Excessive caffeine intake has not been associated with breast cancer, but it has been associated with fibrocystic disease of the breast. Persons with cardiac disease are often advised to avoid the stimulating effects of caffeine in tea, coffee, or colas. Chocolate is also high in caffeine.
Sodium-Restricted Diets
Sodium, a chemical element foundational to good nutrition, is contained in many natural foods. However, salt is often prohibited due to health concerns. People who are forced to eliminate salt from their diet may consume fewer calories because food has little flavor. Additional sodium in the form of table salt, however, is often contraindicated for people with vascular diseases like hypertension or congestive heart failure. Many canned, packaged, frozen, and other processed foods have high sodium content that people may not be aware of.
Antioxidants
Patients should be knowledgeable about the role of antioxidants in relation to good nutrition. Antioxidants appear to reduce or eliminate damage caused by molecules known as free radicals. Free radicals contain oxygen and are generally important to a well-functioning immune system, unless present in excessive amounts. People who are exposed to pollution or radiation, experience stress, smoke, or overexercise may evidence an excess of free radicals. Free radicals have been implicated in heart and blood vessel disease, Alzheimers dementia, and cancer. Vitamins E and C are considered antioxidant vitamins, as is beta-carotene, a precursor of vitamin A. Medication History A medication history is an important component of a comprehensive nutritional assessment. Here, the nurse should consider the following questions: Is the person using over-the-counter vitamin and mineral supplements and/or herbal products? Is he or she taking prescription or over-the-counter medications that might have side effects like nausea, vomiting, or anorexia, which can affect nutrition?
A nurses drug book is helpful to identify the many food and medication interactions that can occur. In some cases, specific nutrients may interfere with the absorption of a drug; in other cases, a medication may interfere with the absorption of nutrients. Milk and other dairy products, for example, can interfere with the absorption of some antibiotics; thus, tetracycline and dairy products should not be taken concurrently. Antibiotics sometimes cause gastrointestinal upset, nausea, and vomiting; people may neglect to eat as a result. Antibiotic therapy can also cause thrush, a disease that affects the tongue that makes chewing and swallowing of food very painful. Patients with arthritis who take many doses of aspirin daily may have iron deficiencies; a side effect of aspirin can be internal bleeding.
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Physical Condition A head-to-toe assessment by the nurse on admission may uncover physical problems that can affect normal nutrition or put the person at risk for becoming malnourished. Often people with dementia are unable to chew, or chewing is painful due to tooth abscesses that are not assessed. Meat may be avoided because it is painful to chew. Confused people are often unable to communicate discomfort verbally and may simply fail to eat. Are elderly patients eating foods that are extremely sweet or salty to compensate for loss of taste buds? Are they not eating at all because all food tastes bland to them? As people age, taste acuity diminishes, particularly those taste buds responsible for detecting sweet and salty tastes. People with Alzheimers disease or other chronic illnesses who live alone may neglect to feed themselves properly. They may forget not only what they ate, but whether they ate. They may be unable to meet their nutritional needs adequately because they can no longer drive themselves to the grocery store, or they may not be able to prepare foods due to conditions such as arthritis. As people become increasingly dependent on others or on mechanical aides, they may become less inclined to eat. Chronic diseases like arthritis that cause pain with muscle motion may make people less able to feed themselves and reluctant to ask for help. Older people as a rule will have a lower metabolism due to decreased physical activity, and their caloric requirements will be less than that for younger or even middle-aged adults. Older and younger people confined to beds or wheelchairs are more prone to kidney stones; increased fluid intake may help prevent this. What is the status of the patients circulatory system? Fluids may need to be limited if the person has or is at risk for congestive heart failure. What is the status of the patients urinary system? Impaired renal (kidney) function, especially in older adults, compromises the ability to process protein. What is the status of the patients gastrointestinal tract, especially with regard to peristalsis? Is the patient drinking enough fluids and eating foods high in fiber content to ensure adequate elimination? This is especially important for older adults. Does the patient take over-the-counter laxatives? People with gastrointestinal conditions such as ulcerative colitis will require low-roughage foods that cause minimal irritation to the lining of the intestines. Celiac disease, related to a sensitivity to gluten found in rye, wheat, or barley, can cause children to be undernourished though they may appear to be eating adequate amounts of food. Nurses should be alert to symptoms related to delayed growth and should observe for or question parents about any skin rashes (blistering, usually located on the elbows, knees, and buttocks). Symptoms may also include digestive problems related to the small intestine that can manifest in nausea, stomach pain, and mouth sores. Anemia can also develop related to this disease. Signs that too few nutrients are being absorbed to meet developmental needs may include paleness, thin extremities, and a protuberant stomach;
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all of these symptoms are marked in developing countries where children are malnourished. Celiac disease in adults can also occur; an adult with celiac disease might complain of feeling tired and depressed or may manifest irritability. Blood tests might reveal anemia, and an assessment of bone density could indicate osteoporosis. Children with undiagnosed type-I diabetes may exhibit weight loss. Children, especially ages six to twelve, may also have intestinal bowel disorder (IBD), which causes the bowel wall to become inflamed. Ulcers can develop on the intestinal lining and the intestines can narrow. The two primary diseases classified as IBD are Crohns disease and ulcerative colitis. A primary symptom is failure to grow with marked weight loss. Puberty may be delayed. If undetected, IBD can result in overall stunted growth as an adult. Ulcerative colitis and Crohns disease are two major diseases classified as IBD. Crohns disease (CD) usually develops between ages fifteen and forty and is more prevalent in people of Jewish heritage. The innermost layer of the digestive tract, particularly in the small intestine, develops inflamed patchy areas and ulcers. Nurses should be alert to symptoms of mild to severe diarrhea (with or without blood), abdominal pain and bloating. Weight loss, poor appetite and fatigue may be present as well as nausea and vomiting. An assessment might include stool samples to test for occult blood or any infection and blood tests for anemia and white blood cell count. An elevated WBC could indicate infection.
Serious Medical Conditions and Nutrition
Two treatments for malignancies, chemotherapy and radiation, can compromise and debilitate the bodys ability to salivate, swallow, digest, or absorb nutrients, depending on the part of the body treated. These treatments often cause nausea, vomiting, and anorexia. Diseases that affect the gastrointestinal tract can cause problems at any stage of the metabolic cycle, from ingestion to elimination. Severe back pain after eating a meal high in fat content can indicate gallbladder disease (contractions of the gallbladder) and a related inability to absorb fats. Gastric secretions diminish with age, compromising digestion. Older people may also experience a very dry mouth related to decreased production of saliva, adversely affecting nutrition. Chronic conditions such as arthritis can affect a persons mobility and ability to purchase and prepare their own food. Preparing and eating food can be difficult with severe arthritis, including activities like opening cans and boxes. Cultural Practices and Religious Beliefs What role do culture and religion play in patients nutrition? Are there any religious practices, preferences, restrictions, or taboos that might influence their diet in positive or negative ways that affect essential nutrients? Patients maintenance of religious ties and a sense of their ethnicity, for example, is an important value for many older adults and younger people who are recent immigrants (e.g., college students). A diet with liberal amounts of meat and potatoes might suit someone whose ethnic origins are from Eastern
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Europe, but someone from an Asian country like China or Korea might prefer a diet rich in rice and vegetables. (Note: If rice and starchy vegetables are eaten at the same meal, they would constitute a complete protein, but if eaten at different meals, they would not.) When people are ill, they may respond more favorably to foods that were part of their cultural and religious patterns. Are these foods readily available and affordable? Some people may also consider particular foods and beverages taboo, often in accordance with a belief system related to a specific religion or culture/ethnicity. Strict rules and regulations may govern what is eaten and when, how the food is prepared (e.g., how meat is slaughtered), and what foods and beverages can be eaten in combination with what other foods and beverages. Some people observe certain days for special feasting or, alternatively, fasting, either absolute or partial. Many Hindus are vegetarian. The cow is considered sacred in Hindu society and is generally considered a taboo food for all Hindus, even those who might eat other types of meat or fish. Cows milk and milk products are generally not considered taboo, however. Food with very strong flavors like onions and garlic may be taboo for some who practice Buddhism or Hinduism, based on a belief that these foods can inflame baser emotions. Increasingly people are choosing a vegetarian lifestyle related to personal beliefs about the way animals are treated or health-related issues, e.g., a belief that a vegetarian diet is generally a more healthful diet. 7th Day Adventists are one group that generally adheres to this belief. Pork is traditionally considered a taboo food for Jews and 7th Day Adventists based on Biblical injunctions found in the Old Testament books of Leviticus and Deuteronomy. These laws, called kosher laws, indicate that certain foods are taboo, for example, meat from any animal with a cloven (split) hoof or an animal that does not chew its cud. Only fish with fins and scales should be eaten. Kosher law also prohibits the eating of animal blood; thus, meat is generally treated by salting. According to kosher laws, milk products and meat products cannot be eaten at the same time or at the same meal. On certain religious holy days like the Passover, only unleavened bread can be eaten. Orthodox and Conservative Jews in particular might adhere to all these dietary laws; however, a nurse should assess these preferences and not make assumptions. These preferences may also impact nutrition. For example, kosher meats are high in sodium content. Alcohol is a taboo beverage according to the traditions of Islam, Mormonism (Church of Jesus Christ of the Latter-day Saints), and some more conservative Christian denominations. Mormons also may abstain from coffee, tea, and any other beverages containing caffeine. Socioeconomic and Psychological Influences on Nutrition Socioeconomic factors can influence the choice and availability of foods. Factors can include the persons weekly income and how much he or she chooses to budget for food. High-protein foods are generally more expensive, and people on fixed or low incomes need to make sure they are getting enough protein from less expensive sources.
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At various stages of the life cycle, certain social and psychological factors may influence nutrition. An adolescent might experience peer pressure to eat or drink a certain type of food that might be injurious to health if eaten or drunk in excess (e.g., beer). Adolescent females may suffer from bulimia, a cycle of bingeing and purging, in an attempt to stay slim if they are influenced by the pressure of peers and media messages that slender is better. TV and magazine advertisements are a powerful influence on food habits. Sometimes this influence is positive if it encourages people to exercise and eat nutritious food that is lower in fat content. But, more often, the focus of the ads is on high-fat, high-calorie fast food. A persons mental state can also affect his or her nutritional status. Physiologically, depression and anxiety are believed to trigger or inhibit the release of hormones that regulate digestive juices or digestive secretions that enable enzymes to be released in the process of metabolism. Loneliness, anxiety, and depression can contribute to both malnutrition and overnutrition, depending on the persons coping patterns. Loneliness has been implicated in both overeating (especially with younger adults and teenagers) and underconsumption of calories (with older adults). A person with minimal social supports may be malnourished. Environment and Nutrition What role does the persons environment play in his or her nutritional health? From either what the person tells you or what you are able to observe on a home visit, what do you know about the means of food procurement, food storage and refrigeration, and eating and cooking facilities? Is the eating environment conducive to good nutrition? If not, how could it be modified?
Assessment Data
When assessing a patients nutritional health, it is also vital for the nurse to consider diagnostic data. Diagnostic information for a basic nutritional assessment includes the primary factors that influence a patients nutritional state and any other data that can be objectively measured and observed by the nurse. A twenty-four-hour food diary over the course of several days, for example, could be recorded by the patient and then evaluated by the nurse, who can use the MyPyramid guidelines to discern whether the patient enjoys adequate nutrition. Other important categories of diagnostic information include anthropometric data and laboratory data. Anthropometric Data Anthropometric data, from the root words anthropos meaning man and morphe meaning shape, include various assessments that can be made by the nurse that are noninvasive in nature. These assessments are measurements related to the size, shape, and condition of the body, specifically those areas of the body that reflect a persons nutritional status.
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Anthropometric Measurements
A head-to-toe assessment involves the following general observations that can reflect nutritional status: the condition of the skin, specifically skin turgor, and the condition of the hair and nails. Skin turgor refers to the elasticity of the skin. If the nurse pinches and elevates the patients skin between fingers (usually over the abdomen), it will form a peak. Normal elastic skin in a well-hydrated person will return to normal immediately when released. In a dehydrated person, the skin may remain peaked and wrinkled. This is especially evident in the elderly. Dry hair and split nails might also indicate dehydration. Height and weight are the most common anthropometric measures. Nurses should obtain accurate measurements on admission of each patient and not simply rely on patients subjective appraisal of their own height and weight. Subsequent weights after the baseline weight has been determined should be measured on the same scale, preferably at the same time of day and with similar articles of clothing on. The admission data can be compared to normal weight and height charts for different age groups. Any weight changes should be explored as to their rationale; for example, intentional weight loss related to attendance at a weight loss clinic. Weight loss that has not been intentional may indicate an underlying and undiagnosed disease process, such as cancer. Any accompanying illness or disability should be noted to better determine what is considered normal weight for the individual. Amount, type, and level of physical activity will also affect weight. It should also be noted that weight is a primary defining characteristic of fluid overload related to interventions like total parenteral nutrition. Assessment of body fat is a primary category for noninvasive assessment. One important objective measurement of body fat includes a measurement of the triceps skin fold thickness (TSF). This is the most common measure of the fat content of subcutaneous tissues. The skin on the back of the upper arm is grasped at midpoint between the nurses thumb and forefingers and calipers are then placed one centimeter below the nurses grasp to measure the skin fold thickness in millimeters. Normal skin fold values on average are approximately twelve millimeters for men and eighteen millimeters for women. The midarm circumference (MAC) can also be measured by the nurse using a tape measure at the midpoint of the upper arm that is hanging relaxed by the patients side, or, in the case of a bed-bound patient, with the patients arm across his or her chest. MAC is a measurement of muscle wasting. If the person is right-handed, the left arm is generally measured, since false readings related to increased musculature in the dominant arm can occur. Abdominal skin fold measurements over abdominal muscles may also be done and are often used in fitness centers for determining lean muscle mass.
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Laboratory Data Laboratory values are an example of objective data that should be used in making both baseline and ongoing nutritional assessments in conjunction with other assessments. The nurses primary role is to know which laboratory tests are most useful to identify any nutritional deficiencies or conditions of risk and what the normal ranges are for these values. The most common laboratory values based on blood or urine samples are part of the complete blood count (CBC), which generally includes the number of red blood cells; hemoglobin and hematocrit values; the number of white blood cells; and mean corpuscular volume. Additional laboratory values related to nutrition are triglyceride counts and blood cholesterol; serum albumin and serum transferrin values; and creatinine and blood urea nitrogen (BUN) levels.
Complete Blood Count
A complete blood count (CBC) will indicate levels of circulating red blood cells (RBCs). RBCs can be depleted in cases of nutritional anemia. The word anemia literally means without blood. More specifically, when anemia is present, the blood suffers from a deficit of the mineral iron. Low numbers of RBCs can indicate malnutrition with related deficiencies of folate, vitamin B12, or vitamin B6. RBC range varies with altitude and gender. Normal range for males at sea level is 4.7 to 6.1 million cells/mcL. Normal range for females is 4.2 to 5.4 million cells/mcL. One blood test that is included in the complete blood count is a hemoglobin level. Hemoglobin (Hb) is the protein molecule in RBCs that carries oxygen and gives blood its color. Nutritionally, low hemoglobin levels can be related to iron-deficiency anemia and/or fluid retention, and high hemoglobin levels can be related to dehydration, which may result from conditions like diarrhea as well as inadequate fluid intake. Hemoglobin levels can also be lower if there has been blood loss through some type of external or internal trauma or chronic disease process, so it is important to assess the causative factors for the anemia and not assume it is nutritionally related. Normal hemoglobin values for women range from 12 to 16 g/100 ml and from 14 to 18 g/100 ml in men. The range is slightly less for children. A hematocrit (Hct) is the volume of red blood cells compared to the volume of the whole blood; it is a measure of cell volume and iron status. Low hematocrits can indicate the presence of excess fluid, various types of anemia, or protein-calorie malnutrition (PCM). High hematocrits may indicate dehydration, a finding similar in high hemoglobin levels. The average range of hematocrit values for women is 37 to 47 percent and, for men, 40 to 54 percent. The range for children varies with age but it is generally between 35 to 49 percent with newborns ranging from 49 to 54 percent. These are ranges for persons who live at sea level. Hematocrits are higher at higher altitudes due to low oxygen tension. A white blood cell count (WBC) count is the number of white blood cells in a volume of blood. This may also be referred to as a total lymphocyte count (TLC). The normal range for a lymphocyte count is between 4,300 and 10,800 cells per cubic millimeter (cmm). A lowered lymphocyte count is reflective of a depressed immune system. A
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depressed immune system can be related to inadequate intake of essential nutrients, specifically protein and PCM. Persons with malignancies or other depressed immune disorders (e.g., AIDS) may exhibit low lymphocyte counts related to inadequate protein intake or protein metabolism, and they are also more susceptible to infections.
Serum Readings
Serum albumin readings measure serum protein levels in the blood. Low levels can indicate protein depletion, generally of a long-term nature, related to PCM. General malnutrition and malabsorption syndromes like Crohns disease, sprue, and Whipples disease may also cause low levels of albumin. Pregnant women will normally have lower albumin levels. Normal range is 3.4 to 5.4 g/dL (grams per deciliter). Serum transferrin, a measure of iron transport, can also indicate insufficient dietary protein intake when low; it may be a better indicator of protein-calorie depletion than serum albumin. Abnormally low serum transferrin (sometimes called serum iron) levels can also reflect iron-deficiency anemia related to inadequate dietary iron and/or poor absorption of iron. Pregnancy also can lower this value. Higher than normal levels related to nutrition include deficiencies of vitamin B12 and vitamin B6. Normal range is 60 to 170 mcg/dl (micrograms per deciliter). Elevated triglyceride counts and blood or serum cholesterol levels have been associated with heart disease and susceptibility to stroke and heart attack. Normal triglyceride value should be less than 150 mg/dL (milligrams per deciliter). Borderline high range is from 150 to 199 mg/dL, high range is from 200 to 499 mg/dL, and very high range is 500 mg/dL or above. High triglyceride values may be due to a diet low in protein and high in carbohydrates or to poorly controlled diabetes. Low triglyceride levels (below normal) may relate to malabsorption syndrome (inadequate absorption of nutrients from the intestinal tract), malnutrition, and a very low-fat diet. Normal serum cholesterol values should be under 200 mg/dL. Borderline high levels are considered to be in the range of 200 to 239 mg/dL and high risk is 240 mg/dL and over. High-fat diets and uncontrolled diabetes can contribute to elevations in cholesterol, as can heredity, e.g., familial hyperlipidemia (increased lipids/fat in the blood). Low serum cholesterol could be an indicator of malnutrition or malabsorption.
Blood Urea Nitrogen and Creatinine
Low blood urea nitrogen (BUN) levels can indicate insufficient protein intake, malnutrition, and over-hydration, and high BUN levels can indicate that too much protein has been ingested. Urea, formed as a result of the metabolism of amino acids, circulates through the blood and is excreted in urine after traveling through the kidneys. Too much protein adversely affects kidney function and can contribute to kidney diseases and even kidney failure. In addition to this blood test, a twenty-four-hour urine collection may be ordered to determine a persons balance of nitrogen. A person is said to be in negative nitrogen balance if nitrogen excretion exceeds nitrogen intake in the form of protein. Normal range for BUN is 7 to 20 mg/dl.
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Urinary creatinine excretion can also be measured in a twenty-four-hour urine collection. This value is related to skeletal muscle mass that atrophies or shrinks if a patient is severely malnourished, which results in decreased excretion of creatinine. Diets high in meat can also lower values. Age can also influence values. Normal values can range from 500 mg/day to 2000 mg/day. Note: Laboratory value ranges may differ slightly from laboratory to laboratory. Values in this chapter are based on information from the National Institutes of Health.
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Chapter 11: Interventions for Promoting, Maintaining, and Restoring Nutritional Health
Objectives
Upon completion of this chapter, you should be able to do the following: 1. Explain the impact of proper dental care, positioning and eating atmosphere on good nutrition. 2. Describe enteral nutrition and the various types of tubes used for enteral feeding. 3. Explain the three most common methods for administering enteral tube feedings. 4. Discuss important nursing techniques for correct nasogastric tube placement. 5. Identify nursing strategies for the safe administration of bolus intermittent feedings. 6. Explain the nursing techniques used to check for proper feeding tube placement and identify objective findings for each technique that indicate it is safe to administer the feeding. 7. Identify eight side effects of tube feedings and describe the appropriate nursing assessments and nursing actions for each. 8. Define total parenteral nutrition (TPN) and explain how it is delivered. 9. Define lipid emulsions and total nutrient admixtures, and give the rationales for their use. 10. Describe the side effects of hypertonic solutions, the resulting symptoms and required nursing actions. 11. List the side effects of lipid emulsions and identify the nursing assessment and nursing action appropriate for these problems. 12. Identify two ethical and legal issues that are appropriate to consider before initiating enteral feedings.
Key Terms
bolus intermittent feedings continuous feedings cyclic feedings dumping syndrome enteral/tube feeding enteral nutrition (EN) gastrostomy tubes hyperalimentation hyperosmotic reactions jejunostomy tubes lipid/fat emulsions nasoenteric/nasointestinal tubes nasogastric tube percutaneous endoscopic gastrostomy (PEG) tube percutaneous endoscopic jejunostomy (PEJ) tube stoma total nutrient admixture (three-in-one) total parenteral nutrition (TPN)
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Introduction
As we have seen, a patients nutritional status can be compromised by numerous factors. An important area of nursing knowledge related to the promotion, maintenance, and restoration of a compromised patients nutritional health is the safe use of artificial feeding techniques. This chapter investigates nutritional interventions that are appropriate for the hospital, nursing home, or home care setting. We begin by looking at very basic physiological and environmental strategies that can enhance good nutrition specifically oral care, proper patient positioning, and a pleasant eating environment. Our discussion then turns to nutritional interventions used when oral nutrition is not possible. We define enteral nutrition (EN) and describe the different substitute nutritional interventions that can be used as either temporary or permanent feeding methods. We also discuss the different ways enteral feedings can be administered and the critical nursing skills needed to correctly place a nasogastric tube. In addition, we describe the appropriate technique for the administration of bolus intermittent feedings and the responsibility of the nurse to be certain a feeding tube is in the correct location before any tube feeding is administered. Finally, we explore the side effects of tube feedings, lipid emulsions, and total nutrient admixtures. We also discuss the side effects of hypertonic solutions. The chapter then concludes with a discussion of the ethical and legal issues surrounding enteral feedings.
Physiological and Environmental Considerations

A number of physiological and environmental variables can enhance good nutrition when health and the ability to exercise self-care are compromised. These include proper dental care, positioning, and eating atmosphere. Dental Care Oral care is especially important for people in hospitals and nursing homes who are unable to carry out activities of daily living independently, including brushing teeth and cleaning dentures. Though mouth care is generally part of bedtime care for all ages, giving mouth care prior to eating can perk up taste buds and improve appetite; however, it is generally neglected. Increased activity can also enhance nutritional intake since it increases the metabolic rate. Positioning Patients Proper positioning of patients is important to good nutrition and to prevent complications such as food aspiration. If the patient is in bed, the head should be elevated to approximate a sitting position (if possible) both during and following the meal, for at least half an hour. Patients should be sitting in a chair for meals whenever possible.
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Eating Atmosphere Nurses should try to reduce patients stress and create and maintain a pleasant environment, all of which are crucial to patients nutrition. In nursing home, hospital, and home care settings, equipment like a bedside commode and its associated odors should be considered potential hindrances to good nutrition. Quiet atmospheres generally enhance nutrition. This is true for children who are easily distracted at mealtime and for older adults who have dementia.
Enteral Nutrition
Even with attention to basic nursing measures, there may be times when oral nutrition is not possible, such as when people can no longer independently feed themselves due to age or disability or they are not able to receive oral nutrition from others. Special nutritional methods may also be needed because of acute or chronic illness that interferes with the bodys normal means of ingesting or digesting foods. Enteral nutrition (EN) includes any form of nutrition that involves nutrients that are directly digested and absorbed through the gastrointestinal tract. The word enteral means intestine. The normal access route for foods and fluids to be initially ingested is the oral route, but various acute and chronic disease processes and other conditions, like facial trauma or other head and neck injuries following an accident, can make it difficult for people to chew or swallow. Several types of catheters or tubes inserted through the nose or the mouth and then into the stomach or intestine (or inserted directly into the stomach or the small intestine) can serve either as a temporary or permanent alternative to the traditional oral route of ingestion. These substitute interventions include nasogastric, nasoenteric or nasointestinal, and gastrostomy and jejunostomy tubes. The supplementary or substitutional nutritional treatment associated with enteral nutrition is called a tube feeding or enteral feeding. Feeding Tubes The tube, or enteral, feedings themselves are liquid solutions mixed in plastic bags in the hospital pharmacy or dietary department or solutions in cans that can be poured into bags and hung on a special device next to the patients bed or chair. They contain all the essential nutrients, including carbohydrates, protein, fat, water, vitamins, and minerals. Percentages of each nutrient will vary based on the persons age and nutritional need. Specific orders will be written by the physician indicating the type and amount of feeding.
Nasogastric Tubes
The nasogastric route for enteral feeding involves the insertion of a flexible catheter or nasogastric tube through one nostril, down the back of the throat into the nasopharynx, and then into the stomach. This is a normal route for adults. In both premature and older infants, the tubes may be inserted through the mouth and pharynx. Nasogastric tubes are generally used to meet short-term nutritional needs.
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Nasoenteric or Nasointestinal Tubes
Nasoenteric or nasointestinal tubes are inserted through one nostril and empty into the small intestine. There is less risk of aspiration of stomach contents with these longer tubes since the tubes do not terminate in the stomach.
Gastrostomy Tubes
Gastrostomy tubes are very common methods for the administration of nutrients enterally, especially in nursing home settings and any time a person requires long-term substitutionary or supplemental nutrition. In addition to regular gastrostomy tubes, a special and commonly used type of gastrostomy tube is the percutaneous endoscopic gastrostomy (PEG) tube. For both types of devices, an incision is made through the skin over the upper left quadrant of the abdomen, then a catheter is inserted through the abdominal opening (also called a stoma) into the stomach. Gastrostomy tubes may be removed and reinserted by the nurse between feedings after the surgical site is well healed. An inflatable balloon keeps the PEG tube in place between feedings in much the same way as the balloon on a urinary catheter keeps the catheter in the bladder. In many settings, it is the nurses responsibility to insert a new PEG tube if the old tube falls out; it is important to do so as soon as possible, because the opening into the stomach will quickly seal over.
Jejunostomy Tubes
Jejunostomy tubes are similar in theory to gastrostomy tubes. These tubes or catheters are inserted through the skin directly into the jejunum. A common type of jejunostomy tube is the percutaneous endoscopic (PEJ) jejunostomy tube.
Administering Feedings Through Tubes

Enteral feedings can be administered several ways. The following are the three most common methods: 1. Bolus intermittent feedings: The word bolus means small, round lump or mass. Bolus intermittent feedings are given using a syringe directly through a tube into the stomach. Continuous feedings: Continuous feedings usually consist of a hanging plastic bag filled with the enteral feeding solution that the nurse attaches to a feeding pump or infusion pump that is plugged into an electrical outlet. The pump, when calibrated, delivers the patients feeding at a prescribed rate over a twentyfour-hour period. Cyclic feedings: Cyclic feedings are also administered using an infusion pump, usually at night. The patient might be able to ingest and swallow foods and fluids by the oral route during the day, but the oral feedings themselves are not sufficient to provide all the daily nutrient requirements. Cyclic feedings are considered supplemental feedings.
2.
3.
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Feeding Tube Placement The nurses role may involve placement of the feeding tube. Nasogastric, or NG, tubes are the most common tubes nurses will independently insert at the bedside. Procedures for tube insertions may vary depending on the health care facility, and procedure manuals should be available. The nurse should check for tube placement prior to tube feedings and prior to medication administration through the tube. The following are tips for nasogastric tube placement: If not premeasured, measure the length of the tube from the tip of the nose, to the earlobe, and to the xiphoid process at the tip of the sternum. Mark the tube with tape prior to insertion. Lubricate the tube prior to insertion with water or a water-based lubricant; oilbased lubricants like petroleum jelly can adversely affect the lungs if the tube is accidentally inserted into the lungs. Place adult patients in a high-Fowlers position (90 angle) for tube placement. Check nares (nostrils) prior to tube placement for any deformities like a deviated septum. When placing the tube, ask the patient to hyperextend his or her neck as you advance the tube through the nose and back toward the ear into the nasopharynx. Once the tube enters the back of the throat, the client should tilt his or her head forward, drink sips of water, and swallow. Never force a tube; if resistance is met, evaluate the problem (e.g., coiling in the back of the throat).
The following are tips for administration of bolus intermittent feedings: Correctly position the patient to prevent aspiration and ensure good flow of the feeding solution, e.g., a high-Fowlers position (a 90 angle) or lying on the right side with the head elevated to at least a 30 angle. Assess tube placement as noted in feeding tube checks section. Check for any residual (remaining) feeding using a syringe to aspirate gastric contents. A general rule is if more than one hundred milliliters of undigested tube feeding is withdrawn, the next feeding may be held (or a smaller amount of feeding given, depending on the physicians orders and agency policy). Always reinsert any undigested tube feeding back into the stomach to maintain electrolyte balance. When giving tube feeding by syringe as opposed to a continuous drip, let feeding flow into the tube by gravity instead of using a plunger. The syringe can be raised or lowered to adjust rate. If the tubing is clogged, a small amount of pressure with a syringe and tap water can be used to ensure patency. Coca-Cola is sometimes used to clear feeding tubes, depending on agency policy. The patient should remain in a Fowlers or an elevated, right-lateral position for at least thirty minutes after the feeding to prevent potential aspiration into the lungs if the patient vomits.
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Feeding Tube Checks Tube placement should be initially checked by radiography or X ray prior to any feeding being instituted. This is the only reliable method for ensuring a tube is correctly positioned. The American Association of Critical Care Nurses recommends this type of confirmation prior to administering feedings or medications for critically ill patients, but it should apply to any patient. There is a risk for tracheobronchial aspiration of gastric contents, a serious complication, if the tube is not correctly placed or does not remain in place for each feeding. Once a tube is in place, and prior to feedings if given on an intermittent basis, the nurse should attempt to verify that the tube is in the stomach or the intestine by doing the following: Observe for signs of any displacement of the tube by observing the external length; there should be a note made on the chart about the original length of the tube. Research studies of critically ill patients who were tube fed have indicated external tube length increases of up to 32 cm. A nasal tube might have moved from the stomach into the esophagus, for example, to cause this. Aspirate approximately 20 cc of stomach or intestinal contents with a syringe and check color and pH. Gastric contents are usually green or clear and colorless with off-white or tan mucus shreds; intestinal contents are a bright goldenrod or brownish darker green; fluid is usually thicker and more translucent than gastric fluid. The pH of normal gastric juice ranges between 4 and 5; tube feedings, antacids, and some other medications can increase this range to 6. Intestinal/small bowel contents normally have a pH of 6 or 7. Respiratory contents are 6 or greater and more alkaline; contents can vary in color depending on what part of the respiratory tract it is in, from straw-colored to blood-tinged if the tube has perforated the pleura. For aspirations with pH greater than 6, notify the physician, who may order X rays to check tube placement. A tube initially placed in the small bowel could become displaced to the stomach, resulting in a lower pH; this should also be reported. The nurse should know where the tube originates in order to better evaluate pH results. Note: Medications can alter pH. Wait one hour after medications are given by tube to check pH for feedings; also check tube placement prior to giving medications. It is not always possible to tell when tubes are misplaced from patient symptoms (e.g., coughing). pH tests are not often done with patients on continual feedings as pH levels will register nearly neutral. Accurate pH measurement requires that feedings be stopped one hour or more prior to pH testing. Auscultate with a stethoscope over the left upper quadrant of the stomach or epigastric area while at the same time quickly and forcefully inserting 5 to10 cc of air with a syringe into the tip of the feeding tube. Signs that the tube is in the stomach rather than the lungs should be bubbling, gurgling, or whooshing sounds. This method to determine tube placement is not as safe or accurate as testing stomach or intestinal contents for pH. According to more recent research
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and supporting evidence summarized by the AACN, auscultation is the most unreliable method for determining placement, though it is still used. This information on tube feeding placement and evaluation is based on the guidelines and current health care research of the American Association of Critical Care Nurses. The following is a summary of their most important guidelines for practice: Make sure an X ray is done/has been done to visualize a newly inserted tube prior to the first administration of any tube feeding solution or medication. Review your agencys policy, procedures, and standards for care. This should include information about when and how initial X rays are obtained, methods for marking feeding tubes, how to document exit sites, and how frequently this information should be documented. Information should also be included on policies for checking placement and administering the feedings.
Side Effects of Tube Feedings

Serious side effects can result from tube feeding administration, and the nurse should be aware of those effects and their accompanying signs and symptoms. A nurses knowledge of reasons that side effects occur is often a key to prevention. In each case, immediate nursing action can be taken if symptoms occur. Dumping Syndrome Dumping syndrome can occur in patients with jejunostomies. There is a sudden movement of body fluids from the circulatory system across intestinal cell membranes in an attempt to compensate for the sudden dumping of highly concentrated enteral solution into the jejunum. Nursing assessment: Symptoms can include diaphoresis (sweating), nausea and vomiting, pallor, heart palpitations and tachycardia, cramping and diarrhea, and sometimes fainting or loss of consciousness immediately following a tube feeding. Nursing action: Immediately stop tube feeding and treat symptoms.
Hyperglycemia Hyperglycemia may occur if the glucose concentration in the enteral feeding is too high or the tube feeding is given at too rapid a rate. Older adults may be particularly susceptible to too-rapid infusion. Nursing assessment: Monitor glucose and acetone levels in urine at least once per shift. Symptoms may include nausea, headache, generalized weakness, and dehydration.
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Nursing action: Never increase the rate of a tube feeding to make up for lost time, which can happen if a feeding tubes becomes clogged. Insulin may be ordered to facilitate the metabolism of glucose.
Hypoglycemia Hypoglycemia can occur if a tube feeding is suddenly discontinued for any reason, including due to a clogged feeding tube. The high glucose content of the tube feeding stimulates the release of insulin from the pancreas, and a sudden discontinuation of the feeding can result in high levels of circulating insulin. Sometimes people on continuous tube feedings are also on routine insulin injections. Nursing assessment: Watch for cold and clammy skin, lightheadedness or dizziness, headache (occipital region), confusion, and tachycardia. Nursing action: If a tube feeding is to be discontinued, the rate of the tubefeeding infusion is usually decreased gradually, not suddenly. Infusion rates should be accurately monitored. Following discontinuation of tube feedings, solutions of glucose and water (5 or 10 percent) may be ordered for a twentyfour-hour period to stabilize blood sugar levels.
Dehydration Dehydration can occur if enteral feeding is too highly concentrated. High protein content in enteral feedings combined with dehydration may also prevent a patients kidneys from excreting nitrogen wastes. Nursing assessment: Monitor lab values. Hematocrit and the specific gravity of urine can be high due to dehydration. Serum BUN and sodium levels may increase. Nursing action: Extra water may be ordered between feedings.
Aspiration One research study indicated that 30 of 40 critically ill patients who were mechanically ventilated and also received gastric feedings had at least one microaspiration (defined by the presence of pepsin in tracheal secretions) during the early course of their tube feedings. In a similar study with a larger sample, patients who aspirated gastric contents more frequently, even in small amounts, were four times more likely to develop pneumonia (Metheny, 2006). Preventing and lowering the risk for aspiration is a vital part of nursing care. Aspiration of tube feeding products into the lungs can occur for a number of reasons, including misplacement of the tube and failure to elevate the head of the bed during and after feedings. Nursing assessment: The patient may be coughing. Shaking chills and a fever twenty-four hours after an episode of aspiration can occur. Nursing action: Prevention is the key. Tube placement should always be checked prior to feedings. Head should be elevated at least at a 30 angle
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(unless contraindicated) during the feeding and for thirty minutes following the feeding. Allergic Reactions Allergic reactions can occur with tube feedings in the same way they can occur with oral feedings. Nursing assessment: The patient may experience hives, itching, or difficulty breathing. Identify any food allergies on admission (e.g., eggs and milk) prior to feeding. Check the contents of a tube feeding to make sure it is the correct one. Nursing action: Stop tube feeding and notify the physician. Be prepared to administer antihistamines.
Abdominal Distention Abdominal distention can occur if the stomach is not emptying between tube feedings. Nursing assessment: Take a baseline measurement of the abdomen at the level of the umbilicus and subsequent measurements prior to feedings if the abdomen appears distended. Nursing action: If distention is suspected, abdominal measurements can be taken and compared to baseline measurements.
Bowel Disturbances Bowel disturbances can occur related to the liquid and highly concentrated nature of the tube-feeding solution. Nursing assessment: Diarrhea can occur. Constipation may also be a problem since tube feedings are low in roughage and bulk. Note that a liquid stool may indicate constipation, not diarrhea. Nursing action: Notify the physician; adjustments to the concentration of the feeding formula may be needed.
Parenteral Nutrition
Parenteral nutrition is an intravenous method of nutrition. Total parenteral nutrition (TPN) involves administration of a highly concentrated, hypertonic intravenous (IV) solution that contains a variety of nutrients in different amounts, depending on the persons daily nutritional needs. Another term often associated with TPN is hyperalimentation. TPN is indicated when digestion and absorption of nutrients is a problem and there is a need to bypass the gastrointestinal system. Examples of chronic diseases that might indicate a need for TPN are Crohns disease or severe ulcerative colitis. TPN solutions include protein (amino acids), glucose (dextrose), lipids, vitamins and minerals, water, and electrolytes. Glucose supplies the greatest percentage of nutrients.
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TPN infusion occurs through either an indwelling peripheral or central venous catheter that feeds into the superior vena cava by means of an infusion pump to ensure accurate regulation of flow. Large veins rather than small veins are used to accommodate the solution, which is highly concentrated compared to a traditional intravenous solution like normal saline or a blood transfusion. Conditions that indicate TPN include very severe malnutrition, severe trauma or burns, febrile conditions, conditions affecting the intestines, and some types of malignancies. People of all ages can receive TPN; however, concentration levels of dextrose will be less for infants and children. More and more frequently, TPN is done in the patients home; thus, teaching a patient and family members how to administer TPN is an important nursing task prior to the patients discharge from the hospital. Lipid Emulsions Lipid or fat emulsions are another form of parenteral nutrition. They can be given in addition to TPN through a separate intravenous line or through the same site as the TPN using Y-connector tubing. Sometimes fat emulsions are also added to the TPN solution. The theoretical rationale for a lipid emulsion is a patients need for extra calories and supplemental fatty acids. Total Nutrient Admixture A total nutrient admixture (three-in-one) is another type of TPN solution. Three-inone solutions combine amino acids, dextrose, IV fat emulsions, and other nutrients into a single admixture.
Side Effects of Hypertonic Solutions

Most solutions involved in parenteral feeding are highly concentrated and therefore hypertonic, meaning they have higher osmotic pressure than normal body fluids. Hypertonic solutions, if infused too rapidly, can cause serious side effects, so the nurse must be alert. Fluid Overload Fluid overload is a complication that can occur with any IV solution (not just hypertonic solutions) if the flow rate is too rapid. Symptoms of overload primarily affect the respiratory, cardiac, and urinary systems as extracellular fluid increases above the bodys ability to adjust to the extra fluid volume. Listen and watch for the following: confusion, shortness of breath, pitting edema, and decreased urinary output. Assess for a weak and rapid pulse (tachycardia), hypotension or hypertension, and adventitious breath sounds (e.g., crackles in the lungs). Fluid overload can precipitate pulmonary edema and congestive heart failure. Preventive measures include monitoring and maintaining the flow rate. The nurse might also monitor central venous pressure (CVP). Stop infusion if symptoms appear, notify the physician immediately, and treat the symptoms.
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Hyperglycemia Hyperglycemia can occur during the course of infusion with hypertonic solution because of the high glucose concentration of the solution. Nursing assessment: Watch for signs and symptoms including nausea, headache, generalized weakness, and dehydration. Nursing action: Infuse TPN gradually, usually 1 liter per 24 hours initially, with orders to increase the drop rate over a period of several days if tolerated, generally up to 3 liters per 24 hours. Never increase the flow rate without an order. Monitor blood glucose levels every six hours. Monitor glucose and acetone levels in urine during each shift. Administer insulin if ordered.
Hypoglycemia Hypoglycemia can occur following a course of TPN due to sudden discontinuation of the concentrated glucose solution. While the patient is on TPN, the glucose in the solution has been stimulating the pancreas to secrete more insulin naturally to maintain blood levels. Insulin may also have been given by injection. Nursing assessment: Watch for signs and symptoms of hypoglycemia that include cold and clammy skin, lightheadedness or dizziness, numbness and tingling of the extremities, headache (occipital region), confusion, and tachycardia. Nursing action: TPN should not be stopped suddenly. The flow rate should be reduced gradually and in accordance with the physicians orders. Make sure tubing is patent; infusion pumps generally signal if the tubing becomes clogged or twisted, but nurses should visually check equipment every hour. Monitor glucose levels and report changes to the physician. Parenterally administer carbohydrates if ordered in the form of a dextrose and water solution. Allow time (twelve to twenty-four hours) for the patients glucose levels to return to normal.
Hyperosmotic Reactions Hyperosmotic reactions related to imbalanced osmotic rates can also result from toorapid infusion rates and electrolyte imbalances. Such reactions include osmotic diuresis, dehydration, and even death. Nursing assessment: Closely monitor people receiving TPN for signs and symptoms of dehydration (e.g., tenting of the skin). Nursing action: Assessments should be made hourly.
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Infection Infection can occur related to contamination of the intravenous infusion site. Nursing assessment: Symptoms of a septic condition include shaking chills, a fever, and redness and swelling around the infusion site. Nursing action: TPN tubing should be changed every twenty-four hours using sterile technique. Strict aseptic technique should be used if changing dressings or handling any components of the infusion apparatus. Temperature should be monitored at least once every eight hours. As a rule, do not infuse any other solutions or medications in the same line unless specifically ordered.
Air Embolism Air embolism is another complication of TPN. Nursing assessment: Watch for sudden onset of rapid respirations (tachypnea) and possible chest pain. Nursing action: Follow protocol for a respiratory emergency. Prevention includes ensuring no air is in the intravenous line.
Side Effects of Lipid Emulsions

Side effects and safety tips for lipid or fat emulsions are similar to those for hypertonic solutions with respect to hyperglycemia and hypoglycemia. Emulsion reactions are the most important side effect of this form of parenteral feeding, however. These reactions can suddenly occur as a result of too-rapid infusion rates. Nursing assessment: Watch for sudden onset of symptoms including allergic reactions (swelling or difficulty breathing), back or chest pain, cyanosis, dyspnea, complaints of dizziness, headache or pressure over the eyes, nausea and vomiting. Nursing action: Immediately turn off the flow of the emulsion and notify the physician. Flow rates are slow and generally set at 1 mL/min. If no side effects occur, the physician may increase the flow rate gradually, but the flow rate should never be increased without an order.
Ethical and Legal Issues

There are often ethical and legal issues to consider before initiating enteral feedings, especially with persons who have terminal conditions. In most facilities, do not resuscitate (DNR) orders are given by the patient or the patients family on admission. These orders should include not only information about cardiopulmonary resuscitation and mechanical ventilators/respirators but also the persons wishes regarding artificial feedings in an emergency or, if needed, on a long-term basis for nutritional support. The desire of the
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patient and/or his or her family should be ascertained upon admission to the hospital or nursing home. In many nursing homes and hospitals and also in the home, hospice care is available. Individual hospices may have their own guidelines and recommendations as to what is considered comfort care and what is considered a heroic measure. Patients and families need to find out this information from the hospice personnel as they plan for end-of-life care that is congruent with the beliefs and feelings of the patient and family. The American Society for Parenteral and Enteral Nutrition publishes standards of practice and clinical guidelines to help practitioners provide safe and efficacious nutritional care in a variety of settings, including pediatric hospitalization and long term care facilities for older adults. Recommendations are based on current research evidence. The standards are defined as benchmarks and are discipline-specific. Their enteral nutrition standards are currently under development. For more information you can register without charge on their web site and view various documents. See http://www.nutritioncare.org.
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Chapter 12: Applying the Nursing Process to Meet Basic Nutritional Needs
Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. List the considerations for nursing assessment related to a patients nutritional status. Describe the type of information included in a nursing diagnosis related to nutritional needs. Explain reasons why health restoration and health maintenance needs generally take priority over health promotion needs in a hospitalized patient. Identify several factors to consider when planning a nutrition-related nursing intervention. Identify two target areas of nursing interventions related to nutritional deficits and provide examples of each. Discuss the general categories and questions to consider when evaluating implemented care plans.
Introduction
This chapter synthesizes the information in the previous discussions. Through specific examples, we investigate how the nursing process can be used as a clinical problemsolving framework in the identification and implementation of effective nutrition-related care planning. We begin by reviewing the initial subjective and objective data necessary for a comprehensive nursing assessment. We investigate how this data is analyzed and synthesized to include actual or potential problems through the development of nursing diagnoses. We then consider the range of nutritional issues a patient may have and discuss criteria to help prioritize, plan, and set nursing goals. Finally, we explore implementation of the plans and discuss how nursing strategies should be targeted to address any underlying causative or associated factors, as well as any immediate concerns that threaten the patients health. We conclude by looking at evaluationthe last phase of the nursing processand providing examples of general categories, questions, and aspects of nutrition-related care that can be used in evaluation strategies.
Applying the Nursing Process

Once the nurse has performed a thorough assessment of a patients nutritional status based on objective and subjective data and is aware of the variety of interventions that can be utilized for nutritional disturbances, care planning can be done utilizing the nursing process and other theoretical frameworks, such as Maslows hierarchy of needs. This process includes the analysis and synthesis of all data, culminating in one or more
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nursing diagnoses. Diagnoses are prioritized, and planning, implementation, and evaluation follow in logical order.
Nutritional Assessment
To briefly review, the following are considerations for nursing assessment related to a patients nutritional status: Obtain a history from the patient and/or the patients significant others related to the patients nutritional health status in a specific area. For example: Interview the patient and/or significant others about daily nutritional intake over the past two weeks and compare it with the Food Guide Pyramid for adequacy. Assess various factors that could influence the patients health status. For example: Explore with the patient the effect of reduced income or religious/ ethical beliefs on nutritional status. Utilize nursing skills for physical assessment of the patient. For example: Evaluate skin turgor and any weight changes over time. Obtain objective laboratory and other diagnostic report data such as laboratory values, radiography, and specimens. For example: Check the patients BUN, serum albumin, serum transferrin, total lymphocyte count, hemoglobin, and hematocrit values and compare them to normal ranges to assess for protein and iron deficiencies. Obtain any relevant health status information from the patient chart and other health professionals. For example: Read the dietitians consultation or admission notes.
Analysis
Once objective and subjective nutritional data have been gathered, the nurse synthesizes it in order to identify the patients actual or potential health problems that are amenable to some type of nursing intervention. Other health team members such as the physician and dietitian and friends and family members of the patient may also be involved in analysis. Nursing diagnoses are then formulated and prioritized. The nursing diagnosis will include an actual or potential nutritional problem and the etiology of the problem or potential condition of risk. Defining characteristics based on objective and subjective data help define diagnoses. Nursing Diagnoses The general nursing diagnosis based on NANDA-I terminology and criteria related to nutritional disturbances is imbalanced nutrition; this might include imbalanced nutrition: less than body requirements or imbalanced nutrition: more than body requirements. Both diagnoses can be dependent on other factors; for example, imbalanced nutrition: less than body requirements could be related to impaired mobility for an elderly person
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with severe arthritis or to a hectic schedule for a middle-aged accountant who rarely takes time to eat well balanced meals. Nursing diagnoses could be phrased as follows: Imbalanced nutrition less than body requirements related to impaired mobility from arthritis with inability to purchase food Imbalanced nutrition less than body requirements related to hectic schedule resulting in frequently missed meals
Imbalanced nutrition: more than body requirements might be related to a poor self-image for a teenage girl who is five feet tall but weighs 180 pounds. The associated diagnosis might be as follows: Imbalanced nutrition more than body requirements related to caloric intake consistently over and above daily requirements related to poor self-image
Another diagnostic category could be an alteration in health maintenance related to nutrition. A nursing diagnosis in this category might read as follows: Ineffective health maintenance related to insufficient knowledge of ones own nutritional needs
Related diagnoses that specifically focus on essential nutrients, including water, can be developed with respect to fluid volume excess or fluid volume deficit. Patients receiving TPN, for example, who have a history of congestive heart failure might be at risk for excess fluid volume, and the following diagnosis could apply: At risk for excess fluid volume related to TPN therapy and history of congestive heart failure
Nursing diagnoses that relate to other concepts like activity and mobility or elimination may also be considered because of their relationship to nutrition: At risk for impaired tissue integrity (i.e. development of a stage III or IV pressure ulcer) related to immobility and insufficient intake of calories and protein Impaired urinary elimination with frequency related to insufficient intake of fluids and urinary tract infection At risk for constipation related to abdominal muscle weakness
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Prioritizing, Planning, and Setting Goals

Prioritizing Priorities can be set for various nursing diagnoses based on Maslows hierarchy of needs and optimal use of resources. There may be several diagnoses related to nutrition that need to be prioritized. Health restoration needs and health maintenance needs would take precedence over health promotion needs. Important but not urgent needs can be addressed after the urgent needs are met. In the long run, however, if health promotion needs are not addressed, acute problems of health restoration might be recurring. Consider this example: A patient with arthritis and impaired mobility is unable to go to the grocery store independently and purchase food. The patients presenting symptoms in the hospital emergency room following a fall at home are consistent with iron-deficiency anemia. The patients lab values for hemoglobin and hematocrit are abnormally low. Immediate needs for this patient might be a blood transfusion or iron supplementation. Once the patient is stabilized and nutritional needs for health restoration have been met, the nurses attention can turn to long-term planning. The nurse might also assess the need for occupational and physical therapy consults to evaluate and improve mobility while the patient is hospitalized. A community health referral to assess the patient in her home situation could also be part of discharge planning. Planning Planning includes patient-centered goal setting and nutritional strategies to meet those goals. For example, one goal for patients with arthritis who are able to do their own shopping would be to identify foods from the Food Guide Pyramid that are accessible and easy to prepare. Or, a goal for an overworked and overweight office worker who frequents fast-food restaurants for lunch every day might be that he or she learns to select low-calorie foods from the menus. Planning also needs to include various influencing factors, such as religious or ethical beliefs and specific socioeconomic factors. For example, patients with arthritis may also be subsisting on a fixed income, which can impact choice of food in addition to their problems with immobility. A nurse would plan to teach that patient about inexpensive high-protein food and food combinations. Planning can include drawing on a number of outside resources: standards and protocols from state nursing practice acts; the ANA Standards of Practice; specific standards and practices (often called protocol) where one works, for example, a hospital, nursing home, or home care agency; and standards and protocols drafted by nursing specialty associations, like the American Association of Critical Care Nurses. The University of
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Iowa has also developed a taxonomy of nursing interventions known as NIC (Nursing Interventions Classification). The Center for Nursing Classification and Clinical Effectiveness facilitates ongoing research of these classifications and also nursing outcomes, commonly referred to as NOC (Nursing Outcomes Classification). Interventions suggested throughout this text are consistent with NIC classifications. There is currently no one single nomenclature or language for nursing interventions, so there may be some variation in terminology between NIC, nursing texts, and specific health care settings. The American Society for Parenteral and Enteral Nutrition (ASPEN) and The American Dietetic Association (ADA) also have guidelines. Most of the standards and protocols are available online at no charge. Specialty organizations in health care strive to keep up to date and draw from current research to help ensure an evidence-based practice. Setting Goals Goals also require measurement. How will a nurse know whether a goal has been met? If a goal is for the patient to attain a certain weight, then the nurse should record the actual weight on a daily basis and at the same time each day. Weight is one of the best anthropometric measures related to a number of diagnoses, including fluid excess or deficit as well as caloric excess or deficit. Goal setting also includes assigning patient-care activities to others. Nursing assistants, for example, can be assigned to feed patients. Evaluation methods should also be included when care is planned, such as by monitoring and recording accurate intake of foods and fluids.
Implementation
Interventions should be targeted to address any underlying causative or associated factors as well as any immediate concerns that threaten health. Patients themselves may be directly responsible for goal achievement, but often the nurse must directly intervene to ensure a goal is met in the areas of health promotion, maintenance, and restoration. The following are some examples: Assist the patient with food selection. For example: A patient with dementia might need assistance filling out and choosing appropriate foods from a menu to provide a nutritionally balanced meal (health maintenance or restoration). Use appropriate nursing measures to promote nutritional intake. For example: Specific interventions would include checking tube placement prior to giving medications or feedings, administering medications and feedings at ordered times, or monitoring TPN on an hourly basis (health restoration). An evaluation of the patients age and physical condition might lead to measures such as assistive feeding devices for infants born prematurely or older people with arthritis (health maintenance and promotion). Adaptive feeding devices for
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older adults, for example, include utensils with wider handles and built up spoons. Plate guards might be helpful for a person with dementia to prevent food spills while allowing the person to eat independently. Use nursing measures specific to any nutritional supplements ordered by the physician. For example: Iron is frequently given as a supplement in liquid or pill form; the nurses knowledge that vitamin C aids in iron absorption could lead to giving the iron supplement with a glass of orange juice. If the patient is already receiving a supplement such as iron, the nurse would also check laboratory hemoglobin and hematocrit values weekly (health restoration). Provide information and instruction about nutrition. For example: The nurse might instruct a patient on how to read food labels utilizing a cereal box or other types of packaging, or the nurse might teach lactose-intolerant patients about alternative food sources to meet their needs for increased calcium. A nurse might teach a vegetarian patient about combining incomplete plant proteins to make complete proteins. A nurse might instruct the patients family members prior to hospital discharge about tube-feeding administration and provide an opportunity for them to demonstrate their knowledge (health promotion). Use nursing measures to promote continuity of care. In addition to teaching, nurses can give patients referrals to community health agencies for follow-up home care after hospitalization. Nurses can also provide patients with information about community support groups for weight loss and other community resources related to nutrition, such as Meals on Wheels or other community-based lunch programs (health maintenance and promotion). Provide nursing supervision and direction to certified nursing assistants for all patient care activities.
Evaluation
Once the nutritional care plan has been implemented, it is important to evaluate the patients response on an ongoing basis. This includes progress made toward the patientcentered goals. The following are general categories, questions, or aspects of care to consider for evaluation: Record and report the patients response to any nursing actions. For example: Were there any weight changes following the patients first week on a 1,200 calorie, diabetic diet? How much weight was lost? Was this weight loss appropriate? Did skin turgor and laboratory values improve following three days of TPN? Was the patient compliant or noncompliant with a 1,500 calorie, low-fat diet at home? Did the patient keep a daily food diary for a month? Reassess and revise the patients nutritional care plan as needed. For example: A patient with anorexia might not be able to eat three meals a day according to the initial care plan, but he or she might be able to tolerate six small feedings throughout the day. A new mother might not be able to follow a written teaching plan for a child who is lactose intolerant because she finds it too complicated and has difficulty with reading comprehension. A revised plan
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could be written simplifying the instructions, or perhaps the nurse could teach her using pictures or a video. Determine the patients response to the care provided by other members of the health care team. For example: To determine whether the patient in the nursing home had adequate nutrition for supper, the nurse could check the intake records of the nursing assistant assigned to the dining room. This would be important information if the patient were diabetic, for example, since the patient might have an insulin reaction at night if he or she has had insufficient caloric intake during the evening meal. Review the nutritional care plan with other health care personnel. For example: Review the care plan and daily menus with the personal care aide for a homebound client with severe arthritis. Review the plan of care for ambulation of a newly discharged home-care client following a fractured hip; confer with the certified home health aide on a weekly basis to determine the patients progress and any need for change based on client response and discussion with the home care agencys physical therapist.
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UNIT IV: SAFETY AND INFECTION CONTROL

Chapter 13: Theoretical Frameworks Used as the Basis of Care to Ensure Environmental Safety
Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Explain the seven basic terms related to environmental safety. Describe the most common types of environmental hazards and preventive techniques for each. Explain the seven factors that influence a patients environmental safety and identify at least four examples of each factor. Identify the major categories of interventions designed to produce a safe environment and provide examples of each. Identify resistance-avoidance strategies and provide examples for each. Explain the principles and government regulations to abide by in all cases where restraints are used. Identify the five criteria used to select an appropriate restraint and use it in the safest manner possible. List the critical documentation pieces the nurse must provide when restraints are used. Describe the various types of restraints and their application. List the principles of restraint use a nurse needs to follow in order to preserve patients rights and minimize the chance of a lawsuit. Discuss research findings related to restraint use and fall prevention.
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Key Terms
adaptive equipment chemical hazards ecological hazards elbow restraints environment hazard Hendrich II Fall Risk Model injury internal risk factors limb restraints mechanical hazard mitts/hand restraints mummy restraint para-aminobenzoic acid (PABA) physical/mechanical hazards RACE radiation risk of injury safe environment safety safety straps/belts sun protection factor (SPF) thermal hazards ultraviolet light vest restraints
Introduction
One of the unique aspects of professional nursing is the comprehensive nature of our approach to patient needs. Our attention to environmental safety is an example of this comprehensiveness. This chapter takes an in-depth look at the theoretical frameworks nurses use to assess safety. We begin by defining the terminology of environmental safety and explaining the common safety hazards found in the environment. From there, we look at seven basic factors that influence patients environmental safety. We also discuss interventions designed to produce a safe environment. Our discussion then turns to the serious nursing-related issues surrounding the use of patient restraints. We take a detailed look at restraint alternatives, including correcting the underlying problem and individualizing the nursing approach. In addition, we discuss specific clinical situations (such as the use of IV infusions, gastrostomy tubes, and nasogastric tubes) and strategies than can be used to avoid patient agitation, discomfort, and the possible need for restraints. We also examine the basic principles governing the use of restraints, including critical government regulations about their use. The chapter then turns to the types of documentation needed when restraints are used and how to select an appropriate restraint and use it in the safest manner possible. Finally, we explore nine basic steps the nurse needs to follow to ensure a patients dignity and protect the nurse when restraints are used. We conclude the chapter by analyzing research related to patient outcomes when restraints are used and the effectiveness of fall prevention interventions with vulnerable populations.
The Terminology of Environmental Safety

Principles of environmental safety and the terms commonly associated with this topic are woven throughout this unit. Before beginning, however, some basic terms need to be defined. These terms are explained in Table 13.1.
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Table 13.1 Terms Related to Environmental Safety

Environment The sum of the physical and psychological factors that influence life and survival. Also refers to the sum of the factors external and internal to a person that influence life and survival. A condition or phenomenon that increases the risk of injury. May be categorized as physical (e.g., spills on a floor), mechanical (e.g., shearing, friction, and pressure forces), thermal (e.g., excess heat or cold), chemical (e.g., ammonia fumes), radiation-related (e.g., exposure of a fetus to maternal chest X ray, especially in the first trimester), and ecological (e.g., exposure of a fetus to maternal smoking). A sustained hurt, damage, or loss. Internal variables that increase a persons vulnerability to injury. An increased probability or chance of injury due to factors internal (e.g., health status) and external (e.g., environmental conditions) to the individual. An environment in which the kind and number of hazards are reduced and accidents are prevented. The safety of an environment is relative to a persons vulnerability. For example, a home environment that is safe for an adult is not necessarily safe for a toddler. Freedom from the risk of injury.
Hazard
Injury Internal risk factors Risk of injury
Safe environment
Safety
Common Safety Hazards in the Environment

As described in Table 13.1, hazards are conditions or phenomena that increase a persons risk of injury. There are many types of common safety hazards in the environment, each of which can cause specific types of damage. The most common categories of hazards are physical/mechanical, thermal, chemical, radiation, and ecological. Basic principles related to these types of hazards are outlined in the following sections, and examples of specific hazards in each category are provided in Table 13.2. Physical and Mechanical Hazards Physical and mechanical hazards relate to the application of force on the body. Injuries arising from these hazards include contusions, sprains, fractures, head injuries, and internal damage to the abdominal and thoracic organs. Severe injuries cause shock. Therefore, it is important to keep the injured person flat and warm. Never move a patient with a suspected spine or neck injury until a spinal board is obtained and the patient can be correctly immobilized. Immobilize any extremities in which a fracture is suspected. The number of physical and mechanical hazards in an environment can be reduced by proper lighting and by instituting common-sense accident-prevention measures, such as decreasing obstacles in pathways, controlling bathroom hazards (e.g., encouraging use of grab bars), driving safely on streets and highways, and controlling and reducing workplace hazards.
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Thermal Hazards Thermal hazards involve exposure to extremes in temperature. Heat can produce heat exhaustion and heat stroke, and when applied directly to the skin, it can produce burns. Cold can produce hypothermia, and when applied directly to the skin, it can result in frostbite. Prevention measures include maintaining an environmental temperature within the usual comfort zone of 18.323.9C (6575F). Other measures include fire and burn precautions and extreme-cold precautions (e.g., adequate clothing and covering, especially for the digits and nose). Chemical Hazards Chemical hazards are related to internal or external exposure to substances that, in kind or in amount, were not intended for ingestion. Therefore, medication errors or medication interactions may result in chemical injuries. Vomiting is sometimes suggested by a physician or by a poison control center when medicine is wrongly ingested. Other chemical substances that people may accidentally ingest include oil, acids, and alkalies. Vomiting is never recommended when these substances are ingested because: Vomiting oil-based substances carries with it an extremely high risk of aspiration, and the resultant oil-related pneumonitis is serious. Vomiting acid increases esophageal damage. (Burned once when the acid is ingested, the esophagus is burned again when regurgitation occurs during vomiting.) Vomiting alkalies increases esophageal damage for the same reason associated with vomiting acid.
Radiation Hazards Radiation by means of exposure to x-ray or any other source damages fetal development, especially during the first trimester. If the dose is sufficiently high, overexposure to radiation in adults may immediately result (within hours or days) in radiation sickness. If the patient survives the initial exposure, he or she is at increased risk of developing cancer in subsequent years. Radiation exposure may also result in skin burns. Ecological Hazards Ecological hazards are several and include secondary smoke, air and water pollution, and noise pollution. The amount of damage and appropriate steps for treatment depend on the type and amount of exposure.
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Table 13.2 Examples of Various Kinds of Hazards

Type of hazard Physical/ mechanical Common examples Crib suffocation; strangulation threat posed by non-childproofed cords on window blinds; newborn/infant crib or playpen injuries; falls (e.g., due to wet floors, scatter rugs, toys on floor, other clutter on floor, or poor lighting); bumps, lacerations, abrasions, and puncture wounds; aspiration of liquids, especially in newborns and infants; aspiration of foreign objects, especially in infants, toddlers, and preschoolers; obstruction of ear canal with foreign objects, especially in preschoolers; motor vehicle or other vehicular crashes, especially with failure to use infant/child safety seats or seat belts; pedestrian injuries; traffic/playground injuries; drowning; firearm injuries; injuries secondary to improper use of restraints; injuries secondary to defective equipment or incorrect placement of equipment Newborn/infant burns from hot bath water or hot liquid spills; fires/burns (all ages); electrical shock secondary to defective wiring, equipment, lightning strikes, or fallen electrical lines; frostbite Exposure of fetus to maternal consumption of alcohol and/or additive or teratogenic drugs; exposure of fetus to chemicals, especially certain pesticides; poisoning, especially in infants, toddlers, and preschoolers; medication errors; carbon monoxide, radon, and lead poisoning. Common sources of lead exposure are lead paint, contaminated surface dirt, and discarded automobile batteries that contain lead. Lead paint exposure occurs primarily by living in old homes built before the removal of lead paint from the market. Today, lead exposure occurs by children consuming chips of wall or plaster containing lead paint. With the 2007 U.S. recall of Mattel and Fisher-Price toys, the public has been made aware that lead paint has been used in the production of toys manufactured and imported from China. Exposure of fetus to X ray, especially in first trimester; sunburn (all ages); tanning booths; heat lamps; overexposure to radiation therapy Exposure of fetus to maternal smoking; secondary smoke (all ages); other forms of air pollution; water pollution; noise pollution
Thermal
Chemical
Radiation Ecological
Factors Influencing Patients Environmental Safety

There are several factors that influence patients environmental safety. These may be categorized as age/developmental factors, individual preferences and patterns, health status/physical condition, cultural and spiritual/religious factors, socioeconomic factors, psychological factors, and environmental conditions. Each of these factors is elaborated upon in the sections that follow. Age and Developmental Level Age and developmental level influence a persons vulnerability to an accident or injury. Examples of safety risks across the life span are presented in Table 13.3. Please note that sun exposure is also a threat for people of all age groups and developmental levels.
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Table 13.3 Examples of Safety Hazards Across the Life Span

Stage of life Developing fetus Newborns and infants Toddlers Preschoolers Adolescents Young adults Middle-aged adults Older adults Common safety hazards Maternal nicotine and alcohol/illicit drug consumption; teratogenic medications; X ray, especially in the first trimester; pesticides Suffocation; strangulation; choking; falling; motor vehicle crashes; burns; electric shock; crib/playpen accidents Falls; lacerations and abrasions; head injuries; burns; electric shock; poisoning; drowning Traffic and playground injuries; choking; suffocation; drowning; poisoning; fire/burns; harm from other people Vehicular accidents; sports injuries; recreational injuries; firearm injuries; substance abuse; harm from other people Vehicular accidents; sports injuries; recreational injuries; firearm injuries Home-related injuries; falls; lawn mower injuries; fire Falls; fire/burns; pedestrian and motor vehicle injuries
Best Practices: A Diagnostic Test for Fall Risks Any one of the previously mentioned hazards may be turned into nursing diagnoses by identifying each hazard as a risk, for example, risk for fire/burns or risk for vehicular accidents. Risk for falls is already listed as a nursing diagnosis. To develop a sound evidence-based nursing practice, however, valid and reliable diagnostic tests are needed. The Hendrich II Fall Risk Model, which is a fall risk assessment for older adults, is an example of a diagnostic test. This tool, developed by Hendrich and colleagues, is described online at http://www.hartfordign.org/publications/trythis/issue08.pdf. The Hendrich II Fall Risk Model targets adults at risk of falling within an acute care environment. It is currently being validated for use with pediatric and obstetric populations. The content validity of the tool was established by a literature review. There is a statistically significant relationship between the risk factors incorporated within the tool and patient falls. Its interrater reliability is 100%. The probability that the score is positive given a fall occurring (sensitivity) is 74.9%. The probability that the score is negative given a fall not occurring (specificity) is 73.9%. Later cross-validation revealed a sensitivity of 83% and a specificity of 66%. The Hendrich II Fall Risk Model assigns points to the risk factors of confusion/ disorientation (4 points), depression (2 points), altered elimination (1 point), dizziness/vertigo (1 point), male gender (1 point), administered/prescribed anticonvulsants (1 point), administered/prescribed benzodiazepines (1 point), ability to rise in one attempt (0 points), pushes up successfully in one attempt (1 point), multiple attempts but successful (3 points), and unable to rise without assistance (4 points). A total score above 5 indicates the patient is at high risk for falling. This tool is an important advance in nursing. Just as medical practice uses the electrocardiogram to assess for or confirm the diagnosis of myocardial infarction, nursing will someday have tests to assess for or confirm the diagnoses of risk of falling.
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Best Practices: Testing the Placement of Feeding Tubes Although neither physicians nor nurses think of themselves as an environmental safety hazard, errors of misjudgments or miscalculations made by health care professionals do place patients at risk. This section examines patients at risk for aspiration due to incorrectly placed or dislodged feeding tubes and methods of decreasing that risk by testing for correct placement. It is based on the work of the renowned NIH National Institute of Nursing Research investigator, Dr. Norma Metheny. The items in this section summarize years of research and provide added insight into evidence-based nursing practice.
Need for Radiography
While the registered nurse is not responsible for ordering an X ray, the registered nurse is responsible for being reasonably assured that a feeding tube is correctly placed before giving a tube feeding, for notifying the responsible physician when an X ray is required, and by refusing to administer a feeding without the requisite X rays. Radiography is needed to confirm correct placement of any blindly placed feeding tube. It is also needed to confirm the placement of any feeding tube when a major change in the external length of the tube occurs, as this may indicate dislodgement. While a major change in the external length of the tube indicates possible dislodgement of the feeding tube and requires an X ray to confirm or rule out dislodgement, displacement of the tube can occur without an increase in the external length of the tube. This may occur when the tube is displaced but curls upon itself. If the volume of gastric fluid aspirated from a tube increases, it may mean that the tube placed in the small bowel has been displaced into the stomach. Confirm placement with an X ray.
Elevation of the Head of the Bed
A simple nursing strategy prevents aspiration in patients with feeding tubes. However, nurses are frequently unaware of the importance of this intervention. Unless contraindicated, the nurse should keep the head of the bed elevated 40 or more to prevent aspiration. Patients aspirate significantly more frequently when the head of the bed is elevated less than 40.
Role of Gastric Emptying and Aspiration
The association between delayed gastric emptying and aspiration requires further research. It is known, however, that when gastric emptying is delayed, it is logical to assume that the probability of reflux and hence risk for aspiration is greater. Therefore, continuing gastric feeding in the presence of delayed gastric emptying is likely to increase the risk for reflux and hence risk for aspiration.
Testing the pH of Gastric Tube Aspirate
The use of pH testing of gastric aspirate to determine placement of the gastric feeding tube has limited benefits. PH testing of gastric tube aspirate possesses very limited benefit when patients are receiving gastric tube feedings because the feeding will neutralize the pH. PH may have benefit, however, in assessing dislodgement of a small
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bowel tube into the stomach. This is because the pH changes from, for example, 7.0 to a pH of 5.0 or less. If multiple signs indicated dislodgement, confirm placement with an X ray.
Auscultory Method
There is no evidence that supports the accuracy of the auscultory method in confirming correct placement of feeding tubes. This method does not differentiate placement accurately within the GI tract or between the GI and respiratory tracts. Feeding a patient through a gastric tube that is misplaced (usually in the respiratory system or even in the esophagus) can cause death. Therefore, the registered nurse must be reasonably assured, using the above mentioned methods, that the feeding tube is correctly placed before administering feedings. Individual Preferences and Patterns Individual preferences and patterns influence ones safety and risk of injury. People may be risk takers, risk neutral, or risk averse. Risk takers may be tempted to reject the use of seat belts, bicycles helmets, life jackets when boating, and other common-sense precautions. Such unsafe choices are decisions made by the individual and are therefore under the individuals control. Berman et al. (2008) give other examples of environmentally unsafe lifestyles that are beyond a persons control. For example, a work environment may not be environmentally safe, but a person may feel financially constrained to work in such an environment. Another example listed by Berman et al. is that of an unsafe neighborhood. All too frequently, neighborhoods are stereotyped or profiled, not because their crime statistics are necessarily higher than other neighborhoods, but because of the racial or ethnic character of the neighborhood. Nurses need to be aware of this kind of negative attitude in themselves and in others before drawing conclusions about a neighborhoods safety. On the other hand, certain blocks or portions of neighborhoods may be environmentally unsafe due to criminal activity. While this may be beyond the control of any one person, it may not be beyond the control of an organized group of neighbors, church pastors, store owners, and home owners, who can develop various safetypromotion strategies like neighborhood watches. Nurses, trusted in the community, have contributed to such movements by teaching children nonviolent conflict resolution techniques, advocating for gun control, and becoming politically active at city, county, and state levels. Other environmentally unsafe lifestyle issues revolve around access to guns and ammunition and access to illicit drugs. If guns are used for hunting purposes, then all those who use them need to be schooled in safe use in the field and safe storage at home. Furthermore, those who hunt need to wear brightly colored, identifying clothing so that they are not mistaken as animal targets. Choosing to buy illicit drugs is an unsafe choice for at least three reasons. The first is that the drugs have a high probability of being addictive and physically harmful. The second reason is that they may bring the buyer into close contact with an element of the criminal world and lead to further involvement
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in the future. The third reason is that it is illegal, with capture more likely to lead to prison than to enrollment in a treatment program. An issue that is not a function of lifestyle but rather one that limits and affects lifestyle is a persons or familys socioeconomic level. In some circumstances, income may be insufficient to cover the cost of needed safety repairs. Still another issue that affects a persons or a familys lifestyle and that is related to environmental safety is that of landlords who refuse to make needed repairs, thereby allowing environmentally unsafe conditions to continue. In all of these circumstances, nurse advocacy is needed. Health Status/Physical Condition A persons physical condition and/or health status also influences that persons safety within his or her environment. A number of physical conditions place a person at an increased risk of environmental injury: 1. Impaired emotional responsiveness may increase an individuals injury risk. Clients who overreact emotionally may be so frightened that their judgment becomes impaired. For example, those who are afraid of fire may run in the wrong direction when faced with an actual fire. On the other hand, depressed people may underreact to threat and fail to move quickly enough to escape from the source of threat. Impaired verbal communication may increase risk. As a result of auditory aphasia (inability to interpret words correctly), an individual may not be able to interpret spoken warnings of threats to his or her safety. As a result of motor or expressive aphasia (impairment in speaking and/or writing or pointing at an object of interest), clients may not be able to inform others of an actual injury or threat or point to an area causing pain or pressure. Impaired mobility or motor dysfunction increases the risk of injury. Here, people perceive pain or threat of injury but are unable to move away (either at all or rapidly enough) from the source of pain or the threat. Sensory/perceptual alterations increase risk of injury. Clients with touch/ pressure/pain disturbances (e.g., those with paralysis, diabetes neuropathy, or some older adults) may allow injury to occur because they do not feel it, or they may not perceive an injury that has occurred. They are especially susceptible to burns and to infection secondary to an unperceived pressure, friction, laceration, abrasion, or embedding of a foreign body in the skin. Clients with visual problems may not see obstacles (e.g., toys on the floor or electric cords) that might cause a fall. People with hearing deficits may not hear sounds of impending danger or audible warnings (e.g., fire alarms, sirens, or verbal warnings). Clients with olfactory nerve deficits may not smell escaping gas, smoke, or burning food. Individuals with taste deficits may not know that a food has turned sour, which increases their risk of food poisoning. Cognitive impairments decrease a persons ability to recognize and/or interpret threats. For example, sleep deprivation may cause a motor vehicle accident crash. Any decrease in the level of consciousness, from mild impairments to comatose states, decreases the ability of the person to respond appropriately to risk.
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Disorientation to person, place, or time may cause a person to become lost. Wandering, associated with confusion, may lead a patient to leave a home or a facility, or to wander into unsafe places within an institution. Confusion may cause a person to not remember where objects are located or to think that anothers belongings are his or her own. Delusions may lead a person to respond violently to threats that, in reality, do not exist. Hallucinations may so absorb a person that threat is not perceived, or hallucinations may cause a person to behave in an unsafe manner with regard to self or another. Drug-related side effects (e.g., from narcotics, tranquilizers, sedating antihistamines, hypnotics, or sedatives) may alter a persons level of consciousness, decrease coordination, or cause ataxia. Cultural and Spiritual Factors Cultural and spiritual/religious considerations additionally influence environmental safety. For example, some traditional remedies contain lead. Greta and azarcon are lead-containing traditional Mexican treatments used for digestive problems. Paylooah is a lead-containing traditional remedy for skin rash in Southeast Asia. Surma is a leadcontaining cosmetic used in India to improve eyesight. Other cultural remedies contain mercury. Azoque is a mercury-containing substance some Latin American cultures use to treat diarrhea. If children from these cultures present with elevated lead or mercury levels, then exposure to these agents needs to be investigated, as do other more common sources of exposure. Health care professionals from these same cultures may be needed to explain to the families why these substances need to be avoided (Hockenberry 2005). Other types of traditional treatment may also increase the risk of injury or give the appearance of injury. Coining and cupping are practices that require the application of a heated coin or the heated mouth of a cup (or glass or jar) to the back or posterior neck. Both may create round, first-degree burns on the back or neck. It is conceivable that more serious burns could occur. There is also a problem of misinterpreting the lesion unless health professionals are informed about the practice (Hockenberry 2005). A word of caution is needed here about using the children of the family as interpreters for parents. Children raised primarily in the United States may be competent interpreters of the language but not necessarily of the culture of their parents. When in doubt as to the nature or cause of a lesion, symptom, or illness, seek someone to interpret who is a linguistically and culturally competent interpreter. Other traditional cultural and religious remedies may lead to burns. For instance, a traditional remedy for Yemenite Jews is the application of topical garlic to the wrist to treat infectious disease. This may result in the formation of blisters or garlic burns. Traditional Catholic cultures burn blessed candles in Advent wreaths as part of their preparation for the feast of Christmas. Some also burn blessed candles when faced with a severe illness, death, crisis, or a natural disaster (e.g., a severe storm or tornado). Family members may need to be instructed on the safe burning of candles within the home and cautioned to never leave a burning candle unattended. Other cultures (e.g., Middle Eastern cultures) burn incense when gathered to celebrate. Again, fire safety precautions are needed (Hockenberry 2005).
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These examples bring up a good point: Just because a culture, ours or anothers, engages in a certain practice, this does not mean that that practice is safe or that it can be practiced without taking safety precautions into consideration. At the same time, we need to approach the practices of other cultures with sensitivity. In the United States, the dominant culture permits adolescents to engage in a large number of contact sports, where some injuries may occur, possibly even serious ones. At the same time, the culture minimizes injury by fostering certain safety measures (e.g., rules of the game, shoulder pads and helmets in football, etc.). However, it is known that these measures reduce but do not eliminate injury severity. It is as if we have decided to live with a small but known risk of severe injury as a trade-off for the benefits of a game. Another culture or certain subcultures within the United States may perceive this approach as unnecessarily risky. The point is that the notion of what is or is not permitted within the bounds of being safe is culturally influenced. The many subtleties involved and the need for serious reflection on cultural factors and sensitivity should not deter nurses from intervening when necessary, teaching when appropriate, and appreciating the wealth that diversity offers. Socioeconomic Factors Socioeconomic factors also influence environmental safety. Families who cannot afford to buy food are not likely to invest in safety equipment. Furthermore, those who lack wealth or income often feel as if they lack power. For example, if a mother lives in public housing and reports that there is no screen or safety device on her sixth-floor apartment window and that her toddler is in danger of falling out, she does not feel as if she has actual control over whether the repair is made. In addition, she may not know to whom to complain if the repair is not made. Even in less drastic circumstances, if it comes to buying fire extinguishers or food, a family is most likely to choose food. Thus, socioeconomic status does in fact influence safety. Environmental Factors Finally, environmental factors affect environmental safety. Home safety and workplace and community risks all fall within this category.
Home Hazards
Various factors within a home may increase a persons risk of injury. Table 13.4 provides examples of these factors in the form of a home hazard appraisal.
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Table 13.4 Home Hazard Appraisal for Adults

When conducting a home hazard appraisal for an adult patient, the nurse should be sure to assess each of the following areas: Indoor and outdoor walkways and stairs: Is the pavement or flooring broken or uneven? Are there loose steps or holes in the steps? Are stairs uncluttered? Is there adequate night lighting on stairs? Handrails: Are handrails present on both sides of all steps or stairs? Are handrails secured? Hallways: Are hallways uncluttered? Is there adequate night lighting? Floors: Are floors uneven, cluttered, highly polished, or slippery? Are there unanchored floor mats or rugs? Furniture: Are there sharp corners on exposed furniture? Are chairs, sofas, and stools too low to sit on with ease? Do they provide adequate support? Bathroom(s): Are there grab bars around tubs and toilets? Is there a nonslip/nonskid surface in tub and/or shower? Is there a handheld showerhead? Is night lighting adequate? Is there a raised toilet seat, if needed? Is there a bath/shower chair, if needed? Is the water temperature less than 120F at its maximum? Kitchen: Are pilot lights (gas stove) in need of repair? Is the storage space accessible? Is furniture safely placed? Is area adequately clean for safe eating? Bedrooms: Is lighting adequate? Are night-lights present? Are light switches easily accessible? Is commode present, clean, and accessible, if needed? Are urinals/bedpans present, clean, and accessible, if needed? Is hospital bed present, if needed? If present, is it functional? Electrical: Are cords unanchored? Do cords present a fall hazard? Are cords frayed? Are outlets overloaded? Are outlets near water? Fire protection: Are there appropriately located and working smoke detectors, carbon monoxide detectors, and fire extinguishers? Does the family have a fire escape plan? Is there a second-floor ladder? Are combustibles (e.g., gasoline) and corrosives (e.g., rust remover) properly stored? Are emergency telephone numbers (fire, police) readily accessible? Toxic substances: Are toxic substances properly labeled and stored? Communication devices: Are telephones, intercoms, etc., properly located and in working condition? Medications: Are expired medications present? Is there adequate lighting where medications are prepared? Is the medication storage area adequate and safely located? Is the medication storage area locked if children live in the home? Is there a safe method of disposal of sharp objects, such as needles used for injections? Are emergency phone numbers readily accessible?
Adapted from Berman et al. 2008.
Workplace Hazards
Workplace-related hazards may be categorized as physical/ mechanical (e.g., injuries secondary to machinery, industrial belts, pulleys), thermal (e.g., burns secondary to an explosion in a fireworks factory), chemical (e.g., farm workers exposure to pesticides), radiation-related (e.g., an explosion in an area where radioactive material is stored), and ecological (e.g., miners exposure to coal dust). Nurses also face environmental safety
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issues in their workplace. For example, there are physical/mechanical hazards related to heavy lifting; thermal hazards related to possible electrical shock, especially in intensive care units; chemical hazards such as latex allergies; radiation hazards including bedside chest x-ray exposure; and ecological hazards, such as those associated with working in a high-stress environment. Employers and employees alike should take steps to minimize these risks whenever possible.
Community Hazards
Community safety demands safe water and sewage treatment, safe sewage disposal, appropriate street lighting, adherence to food selling and buying regulations (e.g., vendors selling only state-inspected meat), and food handling regulations. Other safety concerns are freedom from excess noise, traffic congestion, hazardous intersections, dilapidated housing, and crime. Creeks and landfills need to be protected. Rivers and lakes require pollution standards and inspection. Recreational water safety laws require enforcement. Maintenance of air quality requires regulation and monitoring. In addition, mechanisms need to be in place to do the following: Provide shelters during episodes of excessive heat to prevent heat-related deaths among those without air-conditioning Prevent deaths from the cold for those who cannot afford heat Provide first aid, safety, and shelter during natural disasters (floods, wildfires, tornados, hurricanes, and earthquakes)
Interventions Designed to Produce a Safe Environment

Thankfully, a number of interventions can be implemented to help reduce the risk of various environmental hazards. Major categories of interventions relate to environmental modifications, safety instructions, sun protection, poison precautions, use of safety devices, and proper use (when necessary) of patient restraints. Environmental Modifications in Hospital and Home Various types of environmental modifications can be implemented both in the hospital and in the home. Some of the most common modifications include those related to lighting, furniture type and placement, adaptive equipment, toxic substance storage, and medication storage.
Lighting
Changes in lighting are one type of environmental modification. In the hospital, the nurse should take steps to reduce lighting and glare, which can cause the patient to squint and interfere with the patients view of the room and furniture. Light cords should also be kept from underfoot so that the patient does not trip over them. In the home, there should be adequate night lighting for the medicine cabinet, bathroom, halls, and bedroom. Night-lights are particularly important in the bedroom, and light switches need to be readily accessible. It is also critical to note unanchored light cords over which a patient might trip, frayed cords, overloaded electric outlets, and electric outlets near water.
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Furniture Type and Placement
Furniture type and placement may pose a hazard to personal safety. Thus, in the hospital setting, the nurse should orient patients to the layout of the furniture upon admission. He or she should be sure to place bedside tables and over-bed tables within the patients reach to prevent overextending on the part of the patient and a possible fall. It is also important to always keep the hospital bed in the low position so that patients may enter and leave the bed without difficulty. Unnecessary furniture and equipment should be stored out of the patients way to maintain an adequate walkway. The nurse should also obtain a commode for patients with diarrhea, increased urinary frequency, ataxia, weakness, or fatigue. In addition, when beds, stretchers, and wheelchairs are not being moved, the nurse should be sure that they are locked in place. When and if a home visit is made, the nurse should note the following in all rooms of a clients home: Furniture with sharp corners that may cause injury Hazardous placement of furniture Chairs or stools that are so low that getting in or out of them is difficult Chairs or stools that provide inadequate support
Adaptive Equipment
Adaptive equipment is intended to assist a person deal with limitation and risk by modifying the environment. In a hospital setting, the nurse can undertake the following actions related to patient use of adaptive equipment: Make sure the patients own adaptive equipment (e.g., eyeglasses or hearing aids) is functional. If the patients vision is impaired, mark doorways as needed. Encourage nonskid footwear. Make sure the patient uses ambulatory and mobility devices as prescribed (e.g., canes, crutches, walkers, braces, wheelchairs). Encourage the use of railings along corridors. Encourage the use of grab bars in the bathroom (for ease and safety in rising and lowering to toilet and in entering and exiting the shower or tub). Make sure nonskid bathmats are available in the tub or shower. Place a bath chair in the patients tub or shower, if needed. Provide a raised toilet seat if the patient has difficulty with the height of the toilet. Attach side rails to the beds of patients who are confused, sedated, restless, or unconscious. Always make sure that the call button is within the patients reach.
All of the above adaptive equipment can also be installed in the home. Consider handrails, for example. While handrails are readily available in hospitals, they are not always present in homes. When necessary, the nurse should encourage their purchase
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and appropriate placement. In the home, handrails need to be securely attached and present on both sides of the stairway.
Toxic Substance Storage
Toxic substance storage includes the storage of poisonous substances and medications. Toxic substances that may be ingested include paint thinners, cleaning fluids/granules, disinfectants, and insecticides. These substances should all be placed out of reach on a high shelf, separated from food, and preferably locked. They should be stored in their original childproof containers labeled with manufacturers information. All should be kept tightly closed, and excess substances should be discarded. It is also vital to discard toxic houseplants or keep them out of the reach of children. Poisonous plants have become one of the nations leading causes of toxic ingestions. A partial list of toxic plants includes arrowhead, azalea, bird of paradise, caladium, calla lily, Christmas rose, daffodil, dieffenbachia, elephant ear, English ivy, four-oclocks, holly berries, hyacinth, hydrangea, Jerusalem cherry, jonquil, lily of the valley, mistletoe, morning glory, mother-in-law plant, narcissus, oleander, peony, periwinkle, philodendrons, poinsettia, poison ivy, primrose, rhododendron, tulip bulb, Virginia creeper, and wisteria. A complete list may be obtained from the Regional Poison Control Center located at Cardinal Glennon Childrens Hospital in St. Louis, Missouri (314-5775600). Although there is no national phone number to call for poison emergencies, the American Association of Poison Control Centers has a listing of certified regional poison control centers that can be accessed on the Internet at http://www.aapcc.org. A listing is also available in each edition of the Physicians Desk Reference. When taken improperly, medications can also be toxic substances. Therefore, it is important to keep medicines in their original bottles and to use childproof bottles only. All medications should be stored out of the reach of children. Be sure to reevaluate what is out of reach as a child grows. (For example, what is out of reach for the toddler may not be out of reach of the four-year-old who is capable of climbing.) Also note that no medication should be kept beyond its expiration date. Some medications (e.g., aspirin) become less potent with age, while other medications become toxic. For example, outdated and degraded tetracycline has been associated with nausea, vomiting, polyuria, polydipsia, proteinuria, acidosis, glycosuria, and gross aminoaciduria. Therefore, the overriding principle for safe medicine storage is to dispose of all outdated medications and discard unused prescription drugs. Safety Instructions Safety instructions represent another important set of environmental interventions. Examples include instruction in the proper use of sports equipment, infant car seats, infant footwear, and RACE fire procedures.
Sports Equipment
Sports equipment safety instructions involve recommending the use of all appropriate football, soccer, ice hockey and field hockey gear and the appropriate use of hockey
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sticks. These are general recommendations for contact sports. There are also safety recommendations for relatively specialized sports, such as scuba diving and horseback riding. For example, scuba divers need to be certified prior to diving, and horseback riders require helmet protection to prevent a head injury if thrown. Bicycle riding, skateboarding, and in-line skating bear special mention because they are sports that a great number of children, adolescents, and adults enjoy. One well-known set of bicycle safety instructions comes from the American Academy of Pediatrics (1995): At all times, wear a properly fitted helmet approved by the Consumer Products Safety Association. Abide by the Rules of the Road adapted from the American Academy of Pediatrics Rules of the Road at http://www.aap.org/family/bicycle.htm. Helmets must always be worn. Hand signals are to be used when turning or stopping. At corners or driveways, look both ways for oncoming traffic. Ride with and not against traffic. This means always ride on the right side of the road or street. Stop signs mean stop and look both ways. Dont drive off curbs; stop first and look for oncoming traffic. When on the sidewalk, slow down and be careful of not hitting or scaring people. Learn how to interpret traffic lights, stops, stoplights, and other traffic ordinances. Dusk, dawn and night riding requires special precautions. Children should never ride at dusk or dawn. If adolescents are permitted to ride at night, they must wear light colors and include fluorescent material on clothing. Use a bicycle light and reflectors, and attach fluorescent material, substance, or paint to bicycle for night riding. When riding with others, ride in single file. Never ride double. Be cognizant of miscellaneous admonitions. Do not obstruct vision with packages or drag an object behind the bicycle. Never hitch a ride on a truck or other vehicle. Be as wary of strangers in cars, trucks or on the street when riding a bicycle as when walking. A bicycle needs to be sized for the child. Use a bicycle that is correctly sized for you as the rider. Balls of the feet must be able to touch the ground, when the child is seated with hands on the handle bar. When straddling the center bar, the child must be able to place both feet flatly on the ground with an inch to spare between the center bar and the childs crotch. When buying a new bicycle, take the child with you shopping so that the bicycle may be sized to the child before purchase.
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Do not encourage or push children into riding two-wheeled bicycles before they are ready, usually around age five or six. Learning to ride is an important task that parents need to teach children. Wear shoes that fit securely; beware of loose shoe ties. Age and maturity of the child and parental directions guide the use of the bicycle. Young children are only to ride with parental supervision and never in the street. Permission to ride in the street depends on several factors: chronological and maturational age of child, traffic patterns, condition of streets, and adequate knowledge of the Rules of the Road. Maintenance of bicycles is another safety factor. Children need to be taught how to fill bicycle tires and how to change and patch a tire.
Bicycle-related injuries present a problem not only to those who are injured and their families but also to the health of the nation. The CDC reports that these injuries account for more than 500,000 emergency room visits, and more than 700 people die annually from bicycle trauma. Children are at the highest risk. Of the 500,000 bicycle injury visits to the emergency rooms, 59% are experienced by children age 15 and younger. Children age 1014 years account for the highest death rate. Males are more than twice as likely as females to be killed while riding a bicycle on any given trip. Nurses advocate for helmet use through both legislative and non-legislative means. Legislated bicycle helmet use is associated with a reduction in bicycle-related injury and death. Non-legislative means include community-based health education drives, participation in the distribution of free or subsidized helmets, and helmet education within the schools. An innovative approach is that of the home safety visit. Such visits, which use simple and focused messages, were made to families of children admitted to emergency departments with various traumas, including bicycle injury. Results indicated modest but sustained behavior change (King, LeBlanc & Barrowman, et al., 2005). As previously mentioned, skateboarding and in-line skating are increasingly popular sports. Some specific safety guidelines related to these activities are as follows: Skateboards and in-line skates are not for children younger than five years of age, since the younger child is not developmentally ready and cannot protect him or herself from injury. Children, adolescents, and adults who ride skateboards or who in-line skate need to observe the following precautions (American Academy of Pediatrics 1995): Protect the head with a helmet. Protect joints (knees, wrist, and elbows) from injury with protective pads. Never skateboard or in-line skate near traffic. Skateboards and in-line skates should be prohibited from streets and highways. Avoid games that bring the boards together, e.g., catching a ride, since these games are especially dangerous.
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Avoid jumping, riding ramps, and similar activities on any kind of skate, since they are particularly dangerous. (American Academy of Pediatrics 1995)
Infant Car Seats
Infant car seat or infant restraint instructions are also important safety measures and are to be accompanied by assurance that the car restraint will be correctly installed and maintained. Childrens hospitals have classes for the public at regular intervals, teaching the proper installation of car seats and testing the adequacy of ones already installed. Parents need to be encouraged to attend these classes. Some general guidelines for proper use of car seats are as follows: The always use a car safety seat rule begins with the first trip home with the infant from the hospital. There are age and weight rules for infants. Rear-facing car safety seats are for all infants who are at least one year of age and are 20 pounds. Both age and weight are factored into the rule. If a child weighs 20 pounds prior to age one, the child still needs to use a rear-facing car safety seat. Rear-facing car safety seats are never to be placed in the front seat of a vehicle that has a passenger airbag. Keep the child in the rear-facing car seat until the child reaches the highest allowable age and weight recommendations for the particular car safety seat. Once a child is one year old and weighs 20 pounds or more, a forward-facing car safety seat may be used, of which there are several types. The American Academy of Pediatrics web site provides an overview of these types at http://www.aap.org/family/carseatguide.htm. Some car safety seats can be used as both a forward-facing seat for the younger child and a booster seat for the older child. Weight as well as height limits vary with the model. Instructions for each model must be read. These seats use harness straps for children in the 4065 pound range. (Again, the weight limit is model-specific.) Other indicators that harness limits have been met are that the childs shoulders are above the harness slots or the ears have reached the top of the seat. After harness weight and/or height limits have been met, the seat can be used as a booster seat. The harness is removed and the vehicles lap and shoulder seat belts are used with the booster seat. Booster seats are used until the child reaches 49 in height and is between the ages of 812 years of age or until the adult seat belts fit properly. There is a never rule and a remember rule as children use booster seats and then transition into adult car safety belts. o NEVER use a lap belt alone with a booster seat, as serious injury may occur in the event of an accident. You must use both lap and shoulder belts. o REMEMBER that seat belts are for adults, and place child safety first. Parameters are established for car safety seat belts and answering the question of when the child is old enough or large enough to wear adult seat belts. Indicators include the following:
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The shoulder belt lies across the middle of the chest and shoulder, not the neck or throat. o The lap belt is low and snug across the upper thighs, not the stomach. o The child is tall enough to sit against the vehicle seat back with legs bent, without slouching, and can stay in this position comfortably throughout the trip. All car seats must be properly installed. o Each car seat is different. Read instructions and keep them handy for reference; follow the instructions at all times. o Be sure to read the car owners manual when installing car seats. o If needed, ask for help when installing a car safety seat. Contact a certified Child Passenger Safety (CPS) Technician at a child safety seat inspection station or call toll-free (866) SEATCHECK (866-732-8243). For help or additional information, visit www.seatcheck.org. All car safety restraints must be tightly buckled in the vehicle. All children must be buckled in snugly in their car safety seat.
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Infant Footwear
Footwear also influences safety, especially in infants. The following are safety instructions for ensuring that parents understand the importance of proper infant footwear (Hockenberry 2005): Instruct mothers on footwear before the baby begins walking. Buy soft, flexible shoes that retain fit, are durable, and have a smooth interior with few construction seams. (Inflexible shoes do not provide better support and may cause delays in walking and in development of foot musculature, and they may aggravate in-toeing or out-toeing.) The main purpose of infant footwear is that of protection. A good shoe conforms to foot shape, has a rounded toe, and has plenty of toe space. The space between the shoe and the end of the longest toe should be one half of a thumbs width. Adequate infant walking shoes include inexpensive, well-constructed sneakers or soft leather moccasins. Check shoe size at three-month intervals between twelve and thirty-six months and buy new shoes accordingly. Observe for curled toes or reddened skin on the bottom of toes when removing shoes. These are signs that the shoes have become too small.
Fire Safety
Finally, fire safety procedures represent yet another important area of safety instruction. Fire procedures need to be implemented immediately in the event of a fire. Remembering the letters RACE can help nurses remember the proper fire procedure steps (Potter and Perry 2004).
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R = Rescue and remove clients who are in immediate danger. A = Alarm activation. C = Confine the fire. Close all fire doors, regular doors, and windows. E = Extinguish the fire. To use the fire extinguisher correctly, remember the letters PASS: Pull pin. Aim. Squeeze handles. Sweep the fire from side to side, coating the area involved.
Sun Protection Skin safety interventions, along with associated issues of medications, topical agents, and treatments for contact dermatitis, represent another critical category of environmental interventions. Among the most important of these skin-related measures relate to protecting oneself from the effects of the sun. An understanding of sun protection necessitates knowing the difference between UVA and UVB waves. UV stands for ultraviolet light. Ultraviolet A (UVA) waves are longer waves responsible primarily for photosensitivity, photoallergic, or phototoxic reactions. Think of the A as representing allergy. Ultraviolet B (UVB) waves are shorter and are responsible primarily for burning, tanning, and skin cancer. Think of the B as representing burn. There are certain safety principles to remember regarding UVA and UVB waves: Maximum exposure occurs between 10:00 a.m. and 3:00 p.m. Exposure is greater in higher altitudes. Haziness may decrease but does not eliminate UVB wave penetration. Windows screen out UVB but not UVA rays. Some substances, such as water and some kinds of sand, reflect ultraviolet waves. Sun blockers (e.g., zinc oxide and titanium dioxidethe oxides) reflect ultraviolet waves. (Adapted from Hockenberry 2005)
Other substances partially absorb ultraviolet waves. Among these are the sunscreens, which contain a sun protection factor (SPF). A sun protection factor is a number that indicates how long a person may remain in the sun before burning. Lets look at some typical sunscreen protection numbers: Say that a product has an SPF of 8. If it normally takes a person 10 minutes of sun exposure to burn, then this product will allow the person to remain in the sun for 80 minutes before burning (SPF 10 minutes, or 8 10 minutes = 80 minutes). Say that a product has an SPF of 15. If it normally takes a person 10 minutes of sun exposure to burn, then this product will allow the person to remain in the sun for 150 minutes before burning (SPF 10 minutes, or 15 10 minutes = 150 minutes).
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Say that a product has an SPF of 30. If it normally takes a person 10 minutes of sun exposure to burn, then this product will allow the person to remain in the sun for 300 minutes before burning (SPF 10 minutes, or 30 10 minutes = 300 minutes).
Para-aminobenzoic acid (PABA) is one substance frequently included in sunscreens that increases their effectiveness. It should be noted, though, that a small percentage of people are allergic to PABA. It should also be noted that some sunscreens claim they are effective against both UVA and UVB radiation. However, this claim is frequently unsubstantiated unless the screen contains a substance called Parson 1789. When this substance is added to the sunscreen, then the product does screen out both UVA and UVB waves. No matter what type of sunscreen a person uses, it should be applied to all exposed skin areas, including skin folds and those areas that may become exposed when clothing moves, such as under halters or under swimming suit straps. It is vital to follow the manufacturers instructions regarding application. Special precautions should also be taken to protect infants from sun exposure, including the following: Keep infants out of the sun or physically shaded from it. For clothing, use tight weave fibers (e.g., cotton) and darker colors. Do not apply sunscreen to infants less than six months of age.
Although those who are most susceptible to serious burning are lightly pigmented individuals, those with darker pigmentations may also burn, and they are also susceptible to the carcinogenic effects of the sun. Therefore, sunscreen is needed by all people, regardless of skin pigmentation, and by people of all ages (except those under six months of age). Poison Precautions Poison precautions make up an additional class of environmental safety interventions. Poisoning can occur through contact or ingestion. For example, poisonous plants affect the skin when contact is made. Contact dermatitis caused by poison ivy, oak, or sumac causes an allergic (or immune) reaction characterized by erythema, itching, edema, vesicular (blister) formation, and vesicular weeping that lasts from ten to fourteen days. Treatment typically consists of the following: Use of antipruritic lotions (e.g., Caladryl lotion) and Aveeno baths Application of diphenhydramine (Benadryl) lotion to the affected skin Use of topical corticosteroid cream or gel, especially when the reaction is detected early and the cream or gel is applied prior to blister formation Administration of oral corticosteroids if the case is severe
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Administration of sedating antihistamines, such as Benadryl, in the case of poison ivy, oak, or sumac, more for their sedating effect than for their antipruritic effect Encouraging the patient not to scratch and/or distracting the patient from the itching that is involved
Poison ivy may be prevented by wearing a long-sleeved shirt and long pants when walking in the woods. It is important to shower and wash clothes immediately upon return. People should also learn to identify poisonous plants and avoid them. Just because a person has never had a poison ivy (or poison oak or poison sumac) reaction does not mean the person will remain nonreactive. A reaction may require multiple exposures, and in some cases, it may require years of exposure before developing. Poisonous plants and other poisonous substances also pose a major safety threat when ingested. Here, poison prevention requires observing the following guidelines: Keep all toxic substances (cleaning fluids, disinfectants, medications, etc.) locked in cabinets or in a storage space above the reach of children. Never store toxic liquids in food containers, because someone may think that the substance is food because it is in a food container. Keep the label on toxic substance containers. This label contains vital information in the event of a poisoning (e.g., the antidote and the manufacturer, should they need to be contacted). In addition, there is the basic safety principle that no substance should ever be unlabeled or incorrectly labeled. Never place one toxic substance in a container used for storing another toxic substance. Toxic gases may form. Never mix toxic substances, since the mixed substances may emit poisonous gases. Never rely on cooking or heating to destroy toxic substances. Label toxic substances with poison warning stickers. Read and follow instructions on all labels before using any product. Never call medicine candy or pretend enjoyment. In other words, do not glamorize medicine taking in front of children. Treat the taking of medicine matter-of-factly. Never drink teas or medicines made from wild plants or trees. Wild plants and trees may be poisonous. Teach children to never eat any part of a wild plant or berry and to never put a wild plant or berry or the leaves, stems, or bark of wild plants or berries in their mouth unless a parent absolutely knows that the plants are wild blueberries, wild blackberries, or some other form of edible berry. Even then, they may be eaten safely only after being properly cleaned. Few people know how to correctly identify edible wild mushrooms or distinguish the edible from the poisonous. Mushrooms, however, are more popular today than ever. Because of their increasing popularity, poisonous mushrooms are being accidentally picked and eaten by people who think they know which are poisonous and which are not. As a result, the number of
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mushroom poisoning cases is increasing. Mushroom poisoning causes hepatic failure, and in some instances, survival depends on receiving a liver transplant. Onset of symptoms may be delayed, sometimes not occurring for twenty-four to forty-eight hours. The safest approach is to teach adults and children never to pick and eat wild mushrooms. Keep syrup of ipecac on hand at all times, but do not use it unless instructed to do so by a regional poison control center, pediatrician, or family physician. Not all poisonings require vomiting, and some may be worsened by vomiting. In the event of a poisoning, contact the regional poison control center immediately to find out how to proceed. Keep the phone number of the regional poison control center near or on all phones. Be sure to notify all babysitters, family members, and friends of the location of the number.
Safety Devices There are also a range of devices available to increase the safety of the environment. For example, toilet and shower/tub grab bars have already been discussed. Other safety devices include smoke detectors, carbon monoxide detectors, and motion sensors.
Smoke Detectors
Smoke detectors save lives if they are properly maintained. Smoke detectors should be tested monthly, and their batteries should be replaced at least once per year. The United States Consumer Product Safety Commission recommends a monthly check. Owner neglect has resulted in unnecessary deaths from smoke and fire. A smoke detector that is properly installed and maintained is considered one of the best and least-expensive ways of preventing these deaths. In fact, the risk of death from fire is twice as high in homes without detectors. When battery failure begins to occur, the smoke detector will emit a chirping sound, and the battery should be immediately replaced. One good idea is to replace detector batteries with each resetting of the clocks in the fall and spring. This ensures continued protection. Smoke detectors should not be disabled in the event of nuisance alarms, which occur during cooking, due to a smoking fireplace, and so on. Instead, the windows should be opened to rid the house of smoke, the detector should be relocated, or purchasing a smoke detector with a delay switch should be considered. If the fire department responds to a persons nuisance alarm, he or she should not let embarrassment lead him or her to disable the detector. Never disable a smoke detector! There should be one smoke detector properly placed on every floor in a house. The most important location is near the bedrooms to alert sleeping members of the household. This is because most deaths from smoke inhalation or fire occur during the night. Note that the fire department in many localities will properly install household alarms.
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The United States Consumer Product Safety Commissions urges all families to have and rehearse a fire escape plan so that if or when the smoke detector sounds, all family members will know how they are to react and do so promptly.
Carbon Monoxide Detectors
Carbon monoxide detectors also save lives. Carbon monoxide is a colorless, odorless, toxic gas. Any fuel-burning appliance, vehicle, or tool (e.g., nonelectric furnaces, gas water heaters, gas stoves, gas dryers, fireplaces, woodstoves, charcoal grills, lawn mowers, and automobiles) may produce excessively high levels of carbon monoxide. Excessive amounts of carbon monoxide in the home may occur from malfunctioning appliances, running fuel-burning equipment in the home or an attached garage, or inadequate home ventilation. Symptoms of carbon monoxide poisoning increase as blood levels of the gas increase. Exposure to very small amounts is asymptomatic. As the gas continues to accumulate in a room or a car, headache occurs. This progresses to severe headache and is accompanied by nausea. Recovery at this stage is quick with treatment by oxygen or fresh air. If exposure to carbon monoxide continues, unconsciousness results. The most vulnerable victims are infants and elderly individuals. Unless intervention occurs, unconsciousness is followed by death. Carbon monoxide detectors alert households to the build up of dangerous carbon monoxide levels in the air. A number of different brands are on the market, with two major distinctions: some are operated by household current, and others by battery. Whether one buys a household-current or a battery-operated detector, it must be approved by the Underwriters Laboratory (UL). Check the device for the UL label. Both types of carbon monoxide detectors are in the same price range. The householdcurrent detector is more difficult to install, but once installed, it will not need replacement for five to ten years. Some companies that install security systems also install householdcurrent carbon monoxide detectors. The battery-operated model requires replacement every two to three years. The United States Consumer Product Safety Commission recommends that a carbon monoxide detector be placed on each floor of a residence with an additional detector on the floor on which the major gas-burning appliances are kept. The latter detector should be placed at a distance greater than five feet from the appliances. For most effective use, the detectors should be placed near the ceiling. The commission also recommends that all fuel-burning appliances (e.g., stoves, furnaces, etc.) in the home receive regular maintenance checks by qualified personnel. If the detector sounds, every person in the home should be checked for symptoms of headache, nausea, and drowsiness. If any one person has symptoms, everyone in the house should be immediately evacuated. Failure to leave immediately increases carbon monoxide exposure. Once evacuated at a distance from the home, symptoms will likely
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disappear in the fresh air. The home should not be reentered until someone calls 911 from a nearby location and firemen arrive to determine the source of the problem. Even if all are accounted for and no one is symptomatic, the safest procedure is to leave the home when a detector sounds, even if it turns out to be false alarm. In this situation, a qualified heating and service contractor can be called to determine the cause for the alarm.
Motion Sensors
Motion sensors and alarms are used to detect unassisted movement that is likely to place a patient at risk. These sensors can be placed under the mattress of a bed at the level of the buttocks (preferred position) or at shoulder level (alternative position). The alarm sounds if the patient attempts to get out of bed without assistance. The same kind of device can be used under the cushion of a chair, with the sensor sending an alarm if the patient attempts to get out of the chair without assistance. There are also leg-band sensors that send an activating signal when the leg approaches a near-vertical position (e.g., walking or throwing ones legs over side rails or the end of the bed). These devices, which are position sensitive, are called bed- or chair-exit safety monitoring devices. All of these systems have a sensor and an alarm or control device. The sensor on or near the patient sends out a signal to a control box, and an alarm is activated. When using these methods, the nurse should intervene in the following manner (Berman et al. 2008): Explain the purpose of the sensor and the device to the client, family, and assistive personnel. Be sure to explain that the device does not limit mobility but is an alerting device for the staff. Instruct the client to call the nurse whenever he or she needs to get up. Instruct staff to respond promptly to the clients call. Be sure that the call button is placed within reach of the client and that the patient has been instructed on its use. Obtain the proper sensor and control unit. Test the battery and alarm sound. Apply the sensor pad beneath the bed mattress or chair cushion in the proper location or apply the leg pad following the manufacturers instructions. For the bed mattress or chair cushion device, set the time delay for determining attempt-to-rise-without-assistance movement from one to twelve seconds. Make the necessary sensor-to-control-box connections so that the alarm will sound if triggered. Deactivate the alarm when assisting the client to rise. Activate the alarm after returning the client to the bed or chair. In addition to making sure that the call button is within reach, place monitoring device stickers on the patients door, chart, and Kardex. Document relevant events.
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Document all assessments, revised diagnoses, interventions, and the extent to which the expected outcomes were met. (Adapted from Berman et. al 2008)
Even when motion sensors are in place, it is sometimes necessary to implement other measures to prevent clients from injuring themselves if they do manage to attempt to stand up. For example, nursing homes are now using comfortable, thick mattresses that may be placed on the floor as low beds. That way, if a client falls out of bed, he or she falls or rolls off a ten- to twelve-inch edge only. Other types of similar protective devices are actual very low beds and/or the placement of thick, rubber mats underneath beds to cushion any fall that might occur. Patients may also be placed in reclining chairs at an angle that maximizes comfort but prevents them from rising without assistance. Use of Restraints: The Standard of Care is Federal Law Patients have the human right to freedom of movement and freedom from restraint. These basic human rights demand that any use of restraint be justified ethically and medically. Indeed, the standard of care is not to use restraints. When restraints are used, the standard of care is federal law. A summary of the federal legislation includes the following: Does justice to the rights of patients, patient safety, or to the need for registered and advanced practice nurses to know the legislation that governs their practice in any setting in which Medicare or Medicaid funds are received Makes care of patients who require restraints any more transparent or clear Presents more strongly even to students just entering the field the legal responsibilities of the registered and advanced practice nurse
Therefore, the Department of Health and Human Services regulations pertinent to 42 CFR Part 482.13 as reported in the December 8, 2006 Federal Register are reprinted below. The Joint Commission on Accreditation of Healthcare Organizations concurs with these regulations. You will find that the terminology is clinically based and readily understood. Table 13.5 HHS 482.13 Condition of Participation: Patients Rights
(e) Standard: Restraint or seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. (1) Definitions. (i) A restraint is (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or
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Table 13.5 HHS 482.13 Condition of Participation: Patients Rights

(B) A drug or medication when it is used as a restriction to manage the patients behavior or restrict the patients freedom of movement and is not a standard treatment or dosage for the patients condition. (C) A restraint does not include devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examinations or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm (this does not include a physical escort). (ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. (2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient a staff member or others from harm. (3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. (4) The use of restraint or seclusion must be (i) In accordance with a written modification to the patients plan of care; and (ii) Implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. (5) The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. (6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as-needed basis (PRN). (7) The attending physician must be consulted as soon as possible if the attending physician did not order the restraint or seclusion. (8) Unless superseded by State law that is more restrictive (i) Each order for restraint or seclusion used for the management of violent or selfdestructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or (C) 1 hour for children under 9 years of age; and
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(ii) After 24 hours, before writing a new order for the use of restraint or seclusion for the management of violent or self-destructive behavior, a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 482.12(c) of this part and authorized to order restraint or seclusion by hospital policy in accordance with State law must see and assess the patient. (iii) Each order for restraint used to ensure the physical safety of the nonviolent or nonself-destructive patient may be renewed as authorized by hospital policy. (9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. (10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed independent practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. (11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. (12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to face within 1 hour after the initiation of the intervention (i) By a (A) Physician or other licensed independent practitioner; or (B) Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section. (ii) To evaluate (A) The patients immediate situation; (B) The patients reaction to the intervention; (C) The patients medical and behavioral condition; and (D) The need to continue or terminate the restraint or seclusion. (13) States are free to have requirements by statute or regulation that are more restrictive than those contained in paragraph (e)(12)(i) of this section.
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(14) If the face-to-face evaluation specified in paragraph (e)(12) of this section is conducted by a trained registered nurse or physician assistant, the trained registered nurse or physician assistant must consult the attending physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 482.12(c) as soon as possible after the completion of the 1-hour face-to-face evaluation. (15) All requirements specified under this paragraph are applicable to the simultaneous use of restraint and seclusion. Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored (i) Face-to-face by an assigned, trained staff member; or (ii) By trained staff using both video and audio equipment. This monitoring must be in close proximity to the patient. (16) When restraint or seclusion is used, there must be documentation in the patients medical record of the following: (i) The 1-hour face-to-face medical and behavioral evaluation if restraint or seclusion is used to manage violent or self-destructive behavior; (ii) A description of the patients behavior and the intervention used; (iii) Alternatives or other less restrictive interventions attempted (as applicable); (iv) The patients condition or symptom(s) that warranted the use of the restraint or seclusion; and (v) The patients response to the intervention(s) used, including the rationale for continued use of the intervention.
(f) Standard: Restraint or seclusion: Staff training requirements. The patient has the right to safe implementation of restraint or seclusion by trained staff. (1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. (2) Training content. The hospital must require appropriate staff to have education, raining, and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. (ii) The use of nonphysical intervention skills. (iii) Choosing the least restrictive intervention based on an individualized assessment of the patients medical, or behavioral status or condition. (iv) The safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (for example, positional asphyxia); (v) Clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary. (vi) Monitoring the physical and psychological well-being of the patient who is restrained
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or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1-hour face-to-face evaluation. (vii) The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification. (3) Trainer requirements. Individuals providing staff training must be qualified as evidenced by education, training, and experience in techniques used to address patients behaviors. (4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. (g) Standard: Death reporting requirements: Hospitals must report deaths associated with the use of seclusion or restraint. (1) The hospital must report the following information to CMS: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patients death. Reasonable to assume in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation. (2) Each death referenced in this paragraph must be reported to CMS by telephone no later than the close of business the next business day following knowledge of the patients death. (3) Staff must document in the patients medical record the date and time the death was reported to CMS.
Proper Use of Restraints In some instances, restraints may be necessary. However, because restraints pose a serious environmental threat, alternatives must be sought in all cases before restraints are used. In addition, different types of restraints call for different standards for application. The following sections detail different restraint alternatives and guidelines for use.
Restraint-Avoidance Strategies
Since restraints should be a last resort, there are a number of creative alternatives to their use. Some popular restraint-avoidance or restraint-substitute strategies, as outlined by Rogers and Bocchino (1999), are described in the subsequent sections. Correcting the Underlying Problem A number of restraint-avoidance strategies are related to correcting a clients underlying health problem(s). Nursing interventions in this category include the following:
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Assess for hypoxemia (e.g., monitor color, respiratory rate, and pulse oximetry readings). Assess for infection (e.g., monitor for temperature, obvious signs of pulmonary or urinary tract infection, etc.). Assess for medication toxicity or interactions. Consult with the pharmacist as needed. Be especially concerned about drugs that cross the blood-brain barrier (e.g., narcotics, sedatives, psychotropics, anticholinergics, and some antibiotics, such as the quinolones). Assess electrolytes during the last twenty-four hours or request an order for such. If abnormalities are present, notify the physician. Assess for depression. Symptoms include changes in sleeping and eating patterns, withdrawal, crying, hopelessness/helplessness, symbolic gestures, verbal indicators of suicide, or suicide plans. Assess for pain. When present, diagnose and treat the pain (obtain an analgesic order, if needed) and then evaluate effects of the treatment. Monitor for acute urinary retention, which is uncomfortable. Confusion dissipates when the bladder is drained and comfort is restored. Document each category that was assessed, the conclusions drawn or diagnoses made, and the interventions initiated. Evaluate nursing outcomes.
Individualizing the Nursing Approach Other restraint-avoidance strategies involve individualizing ones nursing approach. These strategies are as follows: Interpret a clients behavior. Frequent attempts to get up from bed may indicate that the patient needs to void or evacuate his or her bowel. Again, check for bladder distention, and it may be necessary to check for an impaction. A bedside commode, with offers of assisting the patient in its use at frequent intervals, may eliminate or significantly reduce the threat of falling. If a patient pulls on the nasal cannula, this may indicate that the patient needs the oxygen to be humidified or lubrication applied or that the cannula needs to be taped in place more comfortably. Check the patients pulse oximetry when he or she is breathing room airoxygen administration may not be necessary. Determine the patients normal sleeping and rising habits. Perhaps the patient only retires at 1:00 a.m. and sleeps until 8:00 a.m. He or she may not be ready to retire at 9:00 or 9:30 p.m. Allow the patient to sit in a chair near the nurses station until drowsiness occurs. Establish simple rituals and structure the day. Keep trying new alternatives.
Evaluating the Need for All Tubes To help avoid the use of restraints, it is also vital to evaluate the patients need for all types of tubes, since the presence of tubes can be upsetting. Some general principles include the following:
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Capped IV lines are a much preferable alternative to keep open IVs. With this method, a tube is eliminatedtubes distract and may be a source of discomfort to patients. Suggest preparing the patient for the removal of a urinary catheter. Sometimes catheters are left in longer than is necessary. Feeding tubes may no longer be necessary in some clients. Thus, assess patients to determine their need.
Administering IV Infusions Sometimes, the administration of IV infusions may upset a patient and increase his or her likelihood of needing restraints. To help the patient remain calm, the following steps are recommended: Wrap IV tubing and the clients arm in a compression dressing. This may be all that is necessary. Move tubing and bags out of the clients visual field, since these can cause confusion or be a source of agitation. Consider using an arm board or a freedom splint, since they are preferable to tying down the wrist or arm. However, patients with arm boards or a freedom splint still require frequent full, passive range of motion exercises.
Dealing with Gastrostomy Tubes In some cases, a client may require a gastronomy tube. In order to help prevent patient agitation and avoid the use of restraints, consider using these strategies: Cover the insertion site with a loose abdominal binder. Tuck the clients shirt or gown into his or her pants so that the tube cannot be seen. If these measures are ineffective, consider using dummy tubes for the client to pull on.
Dealing with Nasogastric Tubes Just as gastronomy tubes are sometimes necessary, so are nasogastric tubes. Restraintavoidance measures related to NG tubes include the following: Guide the patients hands over the tube while gently explaining its use. Stabilize the tube to prevent unnecessary movement. Provide good and frequent mouth care to maximize comfort. Provide frequent care at the site of insertion to maximize comfort.
Dealing with Urinary Catheters Clients also sometimes require urinary catheters, which can be upsetting. To help the patient avoid agitation, discomfort, and the possible need for restraints, try the following actions:
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Cover the catheter with loose underwear or pants. Distract the patient with an activity gown containing zippers and buttons. Place the catheter bag at the foot of the bed and allow the tubing to run comfortably between the patients legs. Do not try to convince the patient with a catheter that the urge to void is not real. Instead, walk him or her to the bathroom. Use catheter leg bags for patients who forget to carry their bag when walking.
Adapting Furniture Restraint use can sometimes also be avoided through proper adaptation of furniture. As previously mentioned, it may be possible to use leg, bed, or chair sensors in preference to restraints. It may also be helpful to position the client in a reclining chair or fashion a wedge cushion for a regular chair to keep the clients legs higher than his or her hips and prevent him or her from rising unattended. Using Consultations and Therapy Consultations with other staff members and various forms of therapy can also be helpful restraint-avoidance measures. Consider using the following strategies: Consult with a physical therapist to increase the clients muscle strength and decrease his or her chances of falling. Consult with an occupational therapist to increase the clients number and variety of activities to decrease boredom and engage the mind. Try nurse-initiated or occupational therapyinitiated music therapy. Patients respond favorably to their favorite music and object less to restraints.
Minimizing the Probability of Combativeness Other strategies are aimed at minimizing the patients probability of combativeness. These include the following guidelines: Always explain what you are going to do in anticipation of doing it. Never touch a cognitively impaired person before telling the patient your intent. Establish eye contact, and the patient may return eye contact. Talk calmly and the patient may become calm.
Implementing Security Measures One final restraint-avoidance strategy is to implement security measures. For example, close exit doors and leave a sign on them indicating that visitors may enter. Explain that the doors are closed only to keep a patient from leaving.
Principles Governing the Use of Restraints
In some cases, even after the aforementioned strategies are attempted, it may still be necessary to use restraints with a client. Since the application of restraints is associated with a number of environmental risks, there are several important principles that must be observed in all cases. These include the following:
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Obtain a physician order for restraints. If it is an emergency situation, obtain the order within twenty-four hours of application. In the process of obtaining consent, assure the patient/guardian that the restraint is temporary and intended to keep him or her safe. Restraints are never to be used punitively or for the convenience of the nurse or staff. While restraints are to be secure, they must not be applied so tightly as to impair circulation. Apply all restraints so that they may be released quickly in the event of an emergency. Apply restraints with the related body part in a normal anatomic position. Provide emotional support verbally and through touch during and after restraint application.
Six other vital principles to be observed with regard to restraint use are as follows: 1. 2. 3. 4. 5. 6. Assess the patient thoroughly for the cause of the agitation or confusion. Consider alternatives to restraints and implement them. Evaluate the results of these alternatives. If restraints are necessary, use the least restrictive ones (e.g., leg bands, sensors) possible. Consider physical restraint only as a last resort and limit the time of its use. Document all steps thoroughly.
In cases in which physical restraints are needed as a last resort, it is also critical to observe the following government regulations: Restraints may only be applied with a physicians order. The order must specify why the restraint is being used and the length of time it is to be used. The client or the clients guardian must agree to restraint of the client. The client must be free of restraints not required to treat his or her medical symptoms.
If a restraint must be applied, it must be applied safely. To select an appropriate restraint and use it in the safest manner possible, keep the following five criteria in mind: 1. Restrict the patients movement as little as possible. For example, if the patient needs wrist restraints to prevent removal of an endotracheal tube, then apply the restraints so that the patient is in a comfortable position and has some elbow mobility, but not enough to remove the tube. If both wrists need to be restrained, do not restrain the ankles as well. Restraints must not interfere with the patients treatment or health. The use of restraints does not mean that the patient is not turned or that the restraints are applied so tightly that circulation is impaired. The restraint must be readily changeable (and with the least possible amount of disturbance to the client).
2.
3.
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4.
5.
The restraint must be safe for the particular client. The restraint should not be the means by which the patient self-inflicts injury. For example, use a jacket restraint with a child rather than restraining him or her by one wrist. A child could climb out of a crib and be left hanging by the one-wrist restraint, inflicting injury. On the other hand, a child could not climb out of a crib with a jacket restraint. The restraint must be discreet. This means it must be the least obvious kind of restraint to others, since restraints cause embarrassment to patients and to their visitors. The objective is to minimize embarrassment.
Finally, in all cases in which restraints are applied, it is vital that the nurse document the following: Nursing assessment and diagnoses. Any alternative interventions that were attempted. The time the physician was notified, the restraint order that was given, and the reason for the restraint. Client/guardian permission for restraint and the explanation given. The time the restraint was applied. The patients response to the restraint(s) at thirty-minute intervals. Here, the nurse should log the response. He or she should check the patients signs (color and warmth of skin distal to the restraint, looking for pathologic signs of pallor, cyanosis, coolness) and symptoms (pain, tingling, numbness). At the first sign, the nurse should loosen the restraint, exercise the limb, and note the patients response. If necessary, the nurse should remove the restraint, but he or she should not leave the patient unattended. Any persistent signs or symptoms should be immediately reported to the nurse in charge or to the physician. The times at which the patient was given joint mobility exercises and skin care (e.g., at two- to four-hour intervals). At these times, the nurse should document the mobility of the joint (i.e., freely movable, impairment of flexion or extension, change in flexion or extension), the condition of the skin (e.g., intact, persistent redness, abraded areas), and any interventions made. If necessary, the nurse should remove the restraint but not leave the patient unattended. Persistent redness or any abraded areas must be reported immediately to the nurse in charge or to the physician.
The nurse should also reassess the patients need for restraint, including the presence or absence of the behavior that initiated the request for restraint, every eight hours. After restraint use is discontinued, he or she should also assess the patients skin condition and joint mobility.
Various Kinds of Restraints and Their Application
As previously mentioned, several different kinds of restraints are available for use with patients. These include vest restraints, safety straps or belts, mitts/hand restraints, limb restraints, elbow restraints, and mummy restraints.
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Vest Restraints Vest restraints are varied but all are sleeveless jackets with tails. The tails are tied to the bed frame under the mattress or to the back of a chair. According to FDA regulations, manufacturers need to label the front and the back of vest restraints. Kozier et al. (2000) suggest the following interventions for proper use of vest restraints: Make sure the vest is the proper size. Place the vest on the patient according to the manufacturers front and back indications. Pull one tie on one side of the vest and place it in the slit on the opposite side. Repeat this step for the other tie. Use a half-bow knot (quick-release knot) to secure each tie around the movable bed frame or behind the chair. Do not attach the ties to the top of the bed, since this applies pressure to the axilla and may result in a brachial plexus injury. Do attach the ties lateral to the chest on a part of the bed that does not move when the head of the bed is raised or lowered. Never attach the ties to a side rail or to the fixed frame portion of the bed, because when the head is elevated, the patient will be squeezed by the restraint. Make sure that the restraint allows for proper and full excursion of air and expansion of the chest wall. Leave the patient only after ensuring that he or she is properly positioned and that a call device is within reach. Check the patient frequently.
Safety Straps or Belts Safety straps or belts are used to protect a client from falling as he or she is being moved on a stretcher or wheelchair. They are placed around the clients waist and secured in the back of the wheelchair or stretcher. Interventions for proper safety strap use include the following: Check the condition of the safety belt, ensuring its adequacy. If Velcro ties are used, make sure both sections are functional. If the patient is in a chair or wheelchair, fasten the belt behind the chair. If the belt is being applied to a patient on a stretcher, place it over the patients hips or abdomen.
Mitts/Hand Restraints Mitts or hand restraints are used to prevent confused patients from scratching and injuring themselves. Mitts are also sometimes recommended for cognitively intact persons during sleep to prevent them from scratching severely itching areas of the body (e.g., in the case of severe poison ivy reactions). If mitts are used for several days, remove them every two to four hours, wash the patients hands, and provide passive exercises.
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Limb Restraints Limb restraints in the form of wrist or ankle restraints are mostly used to restrict movement in a patients limb during IV infusions. Some principles for their use are as follows: Before applying, pad the patients bony prominences to prevent skin breakdown if the patient is susceptible to such. Apply the padded portion of the restraint around the ankle or wrist. Pull the tie through the hole on its opposite side. Make sure two fingers can be inserted between the restraint and the wrist or ankle. Never use a tie that will tighten when pulled. Attach the tie to the bed, using a quick-release knot.
Elbow Restraints Elbow restraints are used in the care of infants or small children to prevent flexing an arm to scratch or touch a skin lesion on the face or head or when a scalp infusion is being administered. The restraint is composed of material containing elongated pockets into which tongue depressors are placed to immobilize the limb. Interventions associated with their use include the following: Insert tongue depressors after making sure they are unbroken. Make sure all tongue depressors are securely covered, including the ends, with the material. Place the childs elbow in the center of the restraint. Wrap the restraint smoothly around the arm, but do not cause discomfort or impair circulation. Secure the restraint by tying the ties. Make sure circulation is intact. Remove the restraint and exercise the childs arm at regular and frequent intervals.
Mummy Restraints A mummy restraint is a blanket wrapped in a special way to enclose a childs body to prevent movement during a procedure such as a gastric lavage or an eye irrigation or to draw a blood sample. Associated interventions include the following: Obtain a sheet or blanket large enough that the distance between two diagonal ends is about double the length of the childs body. Place the blanket on a dry, flat surface. Fold back one corner. Place the child on the blanket in a supine position, with the crease at the foldeddown corner slightly above the childs shoulders. Fold the right side of the blanket over the infants body, leaving the left arm free.
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Tuck the right side of the blanket under the child, but make sure that the right arm is in a natural position. Bring the point of the blanket below the childs feet up and over the childs body. Now, place the left arm of the infant beside the body. Position the arm naturally. Fold the left end of the blanket over the baby and tuck it under the body. Do not leave the baby alone with a mummy restraint on. Remain with the child the entire time, until the procedure is complete. Then, unwrap the child and provide comfort as needed.
Legal and Ethical Issues Related to Environmental Safety

Several important legal and ethical issues revolve around environmental safety. Some issues worth noting include those related to restraint use and safety programs and research.
Long-Term Care Facilities and Restraint Use

One component of the 1987 Omnibus Budget Reconciliation Act (OBRA) states that nursing home residents have the right to be free from physical or chemical restraints that are not required to treat specific medical symptoms. On June 22, 2007, the United States Centers for Medicare and Medicaid Services recognized this right as well as the need for clarification. On June 22, 2007, CMS issued a clarification of the December 8, 2006 federal regulations on human restraint in hospitals to address those rights within longterm facilities. This memorandum from CMS was designed to give the State Survey Agencies clarification on the definition of physical restraints and the implications of these requirements for long term care facilities. Table 3.5 presents the definitions outlined by this document. Table 13.6 CMS Definition and Interpretation of Patient Restraint Regulations Issue
The Centers for Medicare & Medicaid Services (CMS) is committed to reducing unnecessary physical restraint use in nursing homes and ensuring residents are free of physical restraints unless permitted by regulation. Proper interpretation of the physical restraint definition is necessary in order to understand whether or not nursing homes are accurately assessing devices as physical restraints and meeting the federal requirement for restraint use.
Background
42 C.F.R. 483.13(a) provides that the resident has the right to be free from any physical or chemical restraints imposed for discipline or convenience, and not required to treat the residents medical symptom. CMS defines physical restraints in the State Operations Manual (SOM), Appendix PP as, any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body. Albeit for different functions, this same
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Table 13.6 CMS Definition and Interpretation of Patient Restraint Regulations

definition is used in the SOM, the Resident Assessment Instrument Users Manual and subsequently the Minimum Data Set (MDS), and in the Quality Measure (QM). Despite using the same definition, the MDS and QM do not capture all physical restraints used because of the MDSs limited categories and the QMs calculation methods. Ultimately, surveyors should focus on the appropriate use of all physical restraints, whether or not those restraints are captured on the MDS or in the QM.
Discussion
The following clarifications are meant to be used in conjunction with the definition of physical restraints.
Definitions
Freedom of Movement means any change in place or position for the body or any part of the body that the person is physically able to control. Remove Easily means that the manual method, device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff (e.g., siderails are put down, not climbed over; buckles are intentionally unbuckled; ties or knots are intentionally untied; etc.) considering the residents physical condition and ability to accomplish objective (e.g., transfer to a chair, get to the bathroom in time). Medical Symptom is defined as an indication or characteristic of a physical or psychological condition. Objective findings derived from clinical evaluation and the residents subjective symptoms should be considered to determine the presence of a medical symptom. The residents subjective symptoms may not be used as the sole basis for using a restraint. In addition, the residents medical symptoms should not be viewed in isolation; rather, the symptoms should be viewed in the context of the residents condition, circumstances, and environment. Before a resident is restrained, the facility must determine that the resident has a specific medical symptom that cannot be addressed by another, less restrictive intervention and a restraint is required to treat the medical symptom, protect the residents safety, and help the resident attain or maintain his or her highest level of physical or psychological well-being. There must be a link between the restraint use and how it benefits the resident by addressing the medical symptom. Medical symptoms that warrant the use of restraints must be documented in the residents medical record, ongoing assessments, and care plans. While there must be a physicians order reflecting the presence of a medical symptom, CMS will hold the facility ultimately accountable for the appropriateness of that determination. The physicians order alone is not sufficient to justify restraint use. It is further expected, for residents whose care plans indicate the need for restraints that the facility engages in a systematic and gradual process towards reducing restraints (e.g., gradually increasing the time for ambulation and strengthening activities). This systematic process also applies to recently admitted residents for whom restraints were used in the previous setting.
Physical restraints as an intervention do not treat the underlying causes of medical symptoms. Therefore, as with other interventions, physical restraints should not be used without also seeking to identify and address the physical or psychological condition causing the medical symptom. Restraints may be used, if warranted, as a temporary symptomatic intervention while the actual cause of the medical symptom is being evaluated and managed. Additionally, physical restraints
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Table 13.6 CMS Definition and Interpretation of Patient Restraint Regulations

may be used as a symptomatic intervention when they are immediately necessary to prevent a resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less restrictive or less risky interventions exist. Note: Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Although restraints have been traditionally used as a falls prevention approach, they have major, serious drawbacks and can contribute to serious injuries. There is no evidence that the use of physical restraints, including but not limited to side rails, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries. If the resident needs emergency care, restraints may be used for brief periods to permit medical treatment to proceed, unless the resident or legal representative has previously made a valid refusal of the treatment in question. The resident's right to participate in care planning and the right to refuse treatment are addressed at 42 C.F.R. 483.10(b)(4) and 483.20(k)(2)(ii) respectively. The use of physical restraints should be limited to preventing the resident from interfering with life-sustaining procedures only and not for routine care. A resident who is injuring himself/herself or is threatening physical harm to others may be restrained in an emergency to safeguard the resident and others. A resident whose unanticipated violent or aggressive behavior places him/her or others in imminent danger does not have the right to refuse the use of restraints, as long as those restraints are used as a last resort to protect the safety of the resident or others and use is limited to the immediate episode. Conclusion Although the requirements describe the narrow instances when physical restraints may be used, growing evidence supports that physical restraints have a limited role in medical care. Restraints limit mobility and increase the risk for a number of adverse outcomes. Physical restraints certainly do not eliminate falls. In fact in some instances reducing the use of physical restraints may actually decrease the risk of falling.
Considerations of Restraint Use The Food and Drug Administration (FDA) also indicates that patients have a right to be free from restraint (Rogers and Bocchino 1999). In addition, the FDA lists the following legal considerations regarding restraint use: 1. 2. Health care facilities are obligated to have policies covering the use of restraints. Staff must document the need to restrain. Need for restraint implies that the patient has been assessed and other interventions or methods have been tried so that physical restraint is justified only as a last resort. Restraining devices must be appropriately selected and properly applied. Manufacturers need to label restraining devices so that the manufacturers brand name and the restraint size may be included when documenting their application. A patient in restraints requires frequent monitoring, which must be documented.
3. 4.
5.
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A nurse must know a health care agencys restraint policies. The nursing responsibility for patient safety or remaining with a client cannot be legally delegated to a family member. In discussing client consent, Berman et al. (2008) rightly distinguish between the competent adult client who has a right to make personal decisions regarding care and treatment and the person who is determined to be legally incompetent, either because of age or mental status. In the case of the former, competent individual, the agency may require the patients signature on a release from liability statement; or, in the face of a clients refusal to sign a release from liability statement, the agency may decide to refuse to continue care. In either case, the interaction and results need to be documented. If a patient is incompetent (e.g., recovering from anesthesia, sedated, compromised in terms of mental status for any reason, or under legal age), then the nurse who represents the agency has the obligation to obtain consent from an appointed guardian or surrogate. Finally, like OBRA and the FDA, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends that restraints only be used when clinically necessary and as a last resort. In citing JCAHOs concern, DiBartolo (1998) cites nine steps that the nurse needs to follow to minimize the chances of becoming involved in a lawsuit. These steps may be considered restraint use principles: 1. 2. Base your decision on the patients current, not past, condition. Evaluate the patients potential for injury and know your states laws. In some states, restraints may only be applied if there is imminent harm to the patient or to others, to prevent serious disruption of treatment, or to prevent significant property damage. Speak with the family or caregiver and enlist their help in seeking solutions other than restraint. Try alternative measures first. Reassess the patient to determine whether alternative measures are successful. Alert the physician, and of course, obtain a physician order if restraints are the last resort. Individualize restraint. Note important information in the patient chart. Place a time limit on the use of restraints.
3. 4. 5. 6. 7. 8. 9.
These recommendations dont just make sense from a legal point of view. They are ethical and common-sense positions that preserve not only the clients human rights, but human dignity, value, and respect as well. Issues Related to Safety Programs and Research Several research studies have been conducted on a number of different environmental safety issues. For example, Food and Drug Administration data indicate that, in 1992, there were at least one hundred restraint-related deaths, and this number is likely to be an underestimate of the actual number (Rogers and Bocchino 1999). Research has additionally shown that restraints double the length of a patients hospital stay (Janelli
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1995). Eighty-one percent of those patients who remove their endotracheal tubes are restrained at the wrists (Taggert and Lind 1994). Of those patients who fall from a hospital bed, 41 percent had their side rails up. Of these, 67 percent were restrained at the time of the fall (Janelli 1995). Restrained patients who fall sustain more serious injury than unrestrained patients (Tinetti et al. 1992; Kapp 1996). When the use of restraints decreases, falls increase slightly, but serious injuries decrease (Evans and Strumpf 1990). Bedrails can pose a threat; patients have been asphyxiated after becoming entrapped between a bedrail and a mattress (Parker and Miles 1997). Restraints predispose clients to depression, anger, infection, pressure ulcers, and deconditioning (Evans and Strumpf 1990). Restrained patients are eight times more likely to die than unrestrained patients (Robbins et al. 1987). Predictors of restraint use in this study were abnormal mental status exam, dementia diagnosis, surgery, and the use of monitoring or support devices, such as intravenous lines. The authors recommended that surveillance be heightened in this group of patients and prevention methods (e.g., the measures discussed in this chapter) be used. Fall-prevention studies have also been conducted. Ryan and Spellbring (1996) conducted a fall-prevention study to evaluate the effectiveness of fall-prevention instruction on changes in fall-prevention behavior. The sample consisted of forty-five women aged sixty-five years and older who were randomly assigned to a fall-prevention small group session, a fall-prevention one-on-one session, or to a control group. Control subjects received health promotion information but no information specific to fall prevention. Whether assigned to a small group session or to a one-on-one session, subjects who received fall-prevention instruction made more fall-prevention changes than those assigned to the control group. These changes included avoiding use of bath oils in the bathtub/shower; purchasing night-lights, flashlights, and nonskid mats; eliminating scatter rugs and clutter; and rearranging furniture to maximize safety. Furthermore, those assigned to small group fall-prevention instruction made more changes than those assigned to the one-on-one session.
Disaster Preparedness
The same standards of nursing practice and of performance apply when working in disaster preparedness. This preparedness occurs at the global, national, regional, state, local, and agency levels. In any professional activity, two factors need to be considered: process and task. For example, the standards of nursing practice, which are built on the nursing process, relate to process activities. These activities are expected whether the patients we are working with possess deficient knowledge, are managing a therapeutic regimen ineffectively, or have diabetes mellitus or depression. At the same time, the specific knowledge and skills that are used in working with these patients are diagnostic-specific. Acquiring this knowledge and skill and applying it successfully may be considered a professional task for which registered nurses are accountable.
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There are nine competencies associated with both process and task activities in the study of emergency preparedness. The first set of competencies discussed in this section may be considered process competencies. They are based on a CDC document titled Bioterrorism and Emergency Preparedness: Competencies for All Public Health Workers. This document was developed by the Columbia University School of Nursing Center for Health Policy in 2002. Before enumerating the core competencies, it is important to say that the phrase for all public health workers may lead some to think that these competencies are not applicable in acute care, rehabilitation, long-term care, or even primary care settings. This is incorrect thinking, because bioterrorism, natural disasters, or a disaster of any nature, (e.g., the collapse of the bridge over the Mississippi River in Minneapolis, Minnesota during the summer of 2007), is a public health event that affects health care professionals in all health care settings. At such times, all health professionals become members of a team that is responding to and sometimes directed by public health authorities. Given such reasoning, these competencies are for all registered nurses, all advanced practice nurses, and all health professionals. Another issue needs to be discussed before presenting these competencies. Any skill requires practice. Some skills are so seldom required that few obtain the practice they need to become proficient. Therefore, demonstration and return demonstration sessions are developed so that the skills can be practiced even though the skills may never be needed. The same holds true for these core competencies. Regardless of the care settings, structures need to be established so that these core competencies may be practiced and tested. Table 13.7 Core Competencies for All Public Health Workers: Process Skills Core Process Competency 1 Describe the public heath role in emergency response in a range of emergencies that might arise. (e.g., This department provides surveillance, investigation and public information in disease outbreaks and collaborates with other agencies in biological, environmental, and weather emergencies.) 2 Describe the chain of command in emergency response. 3 Identify and locate the agency emergency response plan (or the pertinent portion of the plan). 4 Describe his/her functional role(s) in emergency response and demonstrate his/her role(s) in regular drills. 5 Demonstrate correct use of all communication equipment used for emergency communication (phone, fax, radio, etc.)
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Table 13.7 Core Competencies for All Public Health Workers: Process Skills Core Process Competency 6 Describe communication role(s) in emergency response: within the agency using established communication systems With the media With the general public Personal (with family, neighbors) 7 Identify limits to own knowledge/skill/authority and identify key system resources for referring matters that exceed these limits. 8 Recognize unusual events that might indicate an emergency and describe appropriate action (e.g., communicate clearly within the chain of command.) 9 Apply creative problem solving and flexible thinking to unusual challenges within his/her functional responsibilities and evaluate effectiveness of all actions taken.
Core Bioterrorism and Disaster Preparedness Competencies: Professional Task or Functional Role Nursing Skills
At one time, emergency preparedness skills for nurses consisted of learning basic and advanced first aid skills, cardiopulmonary resuscitation, and, more recently, the use of the automated external defibrillator. These are no longer sufficient, however, in an age when massive bioterrorism events are a threat and in the wake of huge natural disasters such as Hurricane Katrina, which devastated the coast of New Orleans in the summer of 2005. The purpose of this section is to present the basic competencies needed in the face of such realities. To learn such skills will require effort on the part of all registered nurses. Because they were not an integral part of curriculum of yesterday, faculty will need to teach new content and practicing nurses will need to update their knowledge and skills bases. These competencies, however, are part of the basic knowledge and skill set of the new generation of professional nursestodays nursing students. Like the above process competencies for emergency situations, these competencies will not be practiced frequently. The key is to be prepared to practice should the event occur. The requisite knowledge is presented within the CDC Emergency Preparedness and Response site categories, accessible at http://www.bt.cdc.gov. These categories are the following: Bioterrorism emergencies, including outbreaks of anthrax, plague, Q fever, tularemia, and other diseases Mass casualties, including burns, explosions/blasts, and injuries Chemical emergencies, including exposure to chlorine, nerve agents, ricin, toxic alcohols, and others
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Natural diseases and severe weather, including floods, extreme heat, hurricanes, wildfires, and others Radiation emergencies, including acute radiation syndrome and exposure to dirty bombs, nuclear blasts, polonium, and other hazards Outbreaks and incidents, including exposure to salmonella, asbestos, or botulism and incidents such as bridge collapse
It should be obvious from the extent of this list that no one professional is going to be an expert in handling every potential emergency. There is a randomness to these events that cannot be predicted. Still, professionals prepare for the unpredictable. There is on the CDC web site a wealth of learning tools available. For example, on the web page of each of the above CDC categories, there is information for professional training and continuing education, including some video presentations. When learning new content, it is useful to be able to place the new information within a known knowledge base. Fortunately, the knowledge base for nursing is a resource that can be tapped to frame this new bioterrorism and emergency preparedness information. This knowledge base includes the following competencies for the registered nurse: Apply the principles needed to protect self so as to be able to assist others Conduct surveillance and report unusual occurrences or clinical findings to proper authorities Triage patients Assess individual patients Diagnose the risk involved Identify expected outcomes in the immediate future Plan emergency strategies individually as well as in collaboration with interprofessional teams Evaluate immediate outcomes of, reassess, and continue the nursing process
Once there is a framework for professional development and the acquisition of new competencies, the sense of being overwhelmed by the sheer amount of new information is lessened and preparedness is facilitated. The above competencies apply whether the event is an earthquake, an epidemic outbreak of salmonella in a community, or the release of a chemical agent in the broader population. Furthermore, an essential part of bioterrorism and emergency preparedness is staff education. Registered nurses will find themselves responsible for keeping up to date on disaster preparedness skills and for planning emergency strategies with supervised staff.
Mass Casualty Triage Protocols
A bioterrorism event or a major natural disease may result in mass casualties, necessitating triage. In such cases, health professionals rely on mass casualty triage protocols. These protocols are driven by algorithms prepared by the CDC in collaboration with other national agencies, such as the National Highway Traffic Safety Administration. The most current field triage decision scheme was prepared in 2006. Its aim is to provide criteria for pre-hospital personnel to use when transporting
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trauma victims. These personnel have the option of transporting trauma victims to a trauma center or to a non-specialized acute care facility. Since trauma centers lower trauma-associated mortality and since the clinical needs of the more severely injured are best addressed in trauma center settings, the goal of the triage decision scheme is to match the severity of the injury with the given allocation of resources and expertise. The CDC Field Triage Decision Scheme provides the basis for the development of nationally consistent field triage protocols used locally by EMS and trauma systems throughout the United States. Predictions of injury severity are another factor involved in the development of mass casualty triage protocols. For example, data indicate that when the weapon is a bomb, rocket, or missile, about one-third of the acute casualties are considered critical, meaning one-third of victims are dead on the scene, die at the hospital, require emergency surgery, or require hospitalization. About two-thirds of the casualties are less serious. These patients are treated and released from the emergency department.
Personal Protective Equipment (PPE)
The CDC, working in conjunction with the National Institute for Occupational Safety and Heath, has developed a resource base for Personal Protective Equipment (PPE), which is disease- and hazard-specific barrier gear. PPE is body partspecific. Examples of the organs protected by various kinds of PPE follow: skin (gowns, gloves), eyes (goggles), face (face shields); head (helmets); lungs (masks, respirators), and total body gear, as in the treatment of Ebola virus.
Infection Control Practices
In the event of a major epidemic, infection control practices are crucial in the prevention of the infections spread. The task would be overwhelming were measures for such an event not preplanned. Even preplanning, however, requires considerable use of resources. Issues that must be considered include standard precautions, protection of health workers, patient placement, and decontamination or disinfection. Infection control practices are disease-specific, but most plans comprise a similar set of basic principles and steps. These steps often include the following: Learning how the disease transmits and identifying transmission risks (e.g., specific hospital equipment, environments, or procedures) Ensuring proper use of Personal Protective Equipment (PPE) by health care workers Training health care personnel in recognition of early signs or symptoms of the infection and in procedures to follow up with symptomatic patients Initiating cleaning and disinfecting procedures in waiting rooms and common areas as well as in rooms and beds occupied by infected patients Collaborating with hospital staff, administration, and community and public health groups to coordinate practices and plan for emergency situations
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Mental Health and Equilibrium in a Crisis Professionals and patients alike are subject to stress in the midst of a crisis. Signs of acute stress include inability to function, acute anxiety, withdrawal, intrusive thoughts, insomnia, and exhaustion. It is as imperative for professionals to recognize these problems and seek help for psychological reactions to stress as it is for patients.
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Chapter 14: The Nursing Process Related to Injury Prevention

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. Explain why historical data is important to gather when doing a health history. Identify the key variables that play a role in a clients safety. Explain why laboratory and other diagnostic test results have safety implications for clients. Identify possible North American Nursing Diagnosis Association (NANDA) diagnoses that relate to environmental safety issues. Explain why it is imperative to consider the related to factors when the diagnosis is about patient safety. Identify possible outcomes related to safety measures in each of the eight life span stages. Explain how accumulation of risks affects the prioritization of safety needs when planning nursing interventions. Describe the role of the client during the implementation and evaluation phases of the nursing process.
Introduction
As previously discussed, the nursing process provides the framework for the unique combination of knowledge, skills, and caring that constitutes the art and science of nursing. This chapter provides a concrete example of the nursing process in action as we apply its components to injury prevention. We begin the chapter by discussing the assessment phase of the nursing process and the importance of collecting and analyzing a comprehensive health history, factors influencing a patients environmental safety, and specific laboratory findings that have safety implications. We then look at nursing diagnoses and the North American Nursing Diagnosis Association (NANDA) diagnoses that relate directly to environmental safety. We also explain why including the words related to in any diagnoses of a patients safety needs is so important. Our discussion then turns to the planning phase of the nursing process. It is here that we discuss an important nursing issue related to safetythe accumulation of risks. We investigate why this concept is so important in the prioritization of safety needs for different populations. The chapter then provides detailed examples of outcomes related to environmental safety issues for children and throughout the life span. In addition, we look at the implementation phase of the nursing process and the importance of anticipating client needs when discussing intervention strategies. We conclude by looking at evaluation, the last phase of the nursing process. Again, the
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importance of client input is stressed, along with the goal of an effective evaluation (i.e., the comparison of the expected outcomes versus those actually attained).
Assessment
Assessment refers to the gathering of health data. In relation to environmental safety, this data includes a health history, factors influencing a patients environmental safety, and laboratory findings and other objective health information. Health History One of the first things a nurse should consider during assessment related to injury prevention is a patients health history. Historical data is important. Prior history of falls, fractures, head injuries, or other serious injuries (e.g., burns) provides insight into a clients risk-taking behavior and exposure to violent behavior. This data also helps the nurse understand the safety level in prior environments that the client worked or lived in. Safety Factors Various factors influencing the clients environmental safety also need to be determined. Since these factors were described in detail in the preceding chapter, they will simply be categorized here. The following are variables that play a role in a clients safety: Age/developmental level Individual preferences and patterns (risk-taking or risk-avoidance behavior) Physical condition/health status, including: High-risk conditions (e.g., neurological conditions) Debilitating diseases that increase weakness or fatigue Debilitation (e.g., prolonged bed rest, disuse syndrome, pain, decreased caloric or protein intake) Impaired emotional responsiveness Gait or locomotion difficulties Sensory deficits Cognitive deficits Pharmacologic agents that may cause cognition, response time, or gait/ locomotion/coordination difficulties Cultural and spiritual/religious considerations Socioeconomic factors Environmental factors (home, community, workplace) Psychological factors
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Laboratory Findings Laboratory and other diagnostic test results also have safety implications. For example, do a patients X-ray reports indicate multiple prior fractures? If so, the nurse should consider the possibility of abuse and notify the physician for further assessment. Are the patients hematocrit and hemoglobin levels significantly reduced? If yes, the nurse should notify the physician immediately and think of the signs and symptoms that accompany anemia, including weakness, fatigue, dizziness, and syncope. He or she should also assist the patient in rising from lying or sitting positions and walking. Is the patients serum albumin level below normal? If yes, the nurse should consider possible malnutrition, notify the physician and the nutritionist, and take measures to increase the patients food intake, especially protein intake. Is the clients blood alcohol level significantly elevated? If so, the nurse should take measures to prevent the client from falling if he or she is still under the influence of alcohol. The nurse should also consult with the physician and a social worker regarding the development of an approach to address the issue of possible alcohol abuse.
Diagnosis
After collecting the assessment data, this information needs to be analyzed in order to derive nursing diagnoses. North American Nursing Diagnosis Association (NANDA) diagnoses that relate to environmental safety issues include the following: Acute confusion Chronic confusion Dysfunctional family processes (e.g., alcoholism) Fear (as in fear of falling) Altered home maintenance management Hyperthermia Hypothermia Risk for injury related to factors outside the health care agency (e.g., within the home, community, and workplace) and within the health care agency (e.g., procedure-related accidents such as medication errors and equipment-related accidents such as those related to improper grounding of electrical equipment) Risk for falls Risk for perioperative positioning injury Knowledge deficit in a specific area (e.g., knowledge deficit related to electrical safety in the home) Impaired memory Impaired physical mobility Rape-trauma syndrome (the syndrome itself as well as its compound and silent reactions) Sleep deprivation Impaired social interaction Risk for suffocation
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Altered thought processes Impaired tissue integrity Risk for violence directed at others Risk for self-directed violence
When a nurse diagnoses a patients safety needs, it is especially imperative that the related to or etiologic factors be considered. This is because nursing interventions are going to be shaped by the more specific related to factors than by the more generic overall diagnoses. For example, a patient may be at risk of injury related to impaired vision, or at risk of injury related to impaired mobility, or at risk of injury related to noncompliance with seat belt recommendations. Although the at risk of injury diagnostic stem is the same in each case, interventions will vary greatly depending upon the cause for the increased risk.
Outcomes Identification
According to the ANA Standards of Practice, outcomes are diagnostic-specific and framed within a goal statement. They may be developed once the diagnoses have been: Identified as specifically as possible Analyzed (especially noting the accumulation of multiple safety risks) Prioritized
Expected safety outcomes relate to more than one age group; they relate to all age groups and can be developed as such. For example, lets say a community health nurse followed up on the discharge of the aforementioned seventy-five-year-old client at the home of the clients daughter, where the client lives. After informing the clients daughter about the clients safety needs, the daughter says, My spouse and I would really like more detailed information about home safety for children. At this point, the nurse makes a mental note that the daughters diagnosis is a knowledge deficit related to home safety measures for children. One way of stating an expected outcome is to say that the parents will establish an environmentally safe home for their children. However, this expected outcome is very difficult to evaluate comprehensively, as no specific behavior outcomes are stipulated. It would be better to say that, within the home, the parents will institute the following proper measures: Fire, electrical hazard, and burn prevention measures Suffocation, aspiration, strangulation, and drowning prevention measures Poison prevention measures (see extended development of these measures in the preceding chapter) Fall prevention measures Other bodily injury prevention measures
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However, even these outcomes are not especially helpful for evaluation purposes because they say nothing about what the specific measures are. Remember that the basis for evaluation is a comparison of the expected and attained outcomes. So, the nurse develops even more specific expected outcomes. Detailed and Expected Outcomes Addressing Environmental Safety Issues for Children (Whaley and Wong 2000) To prevent fire, parents will ensure that: Smoke detectors are in adequate number, properly located, and in working condition. Each floor, including the basement, has a fire extinguisher. Upper floors have a fire escape ladder. Electrical fuse box and gas outlets are readily accessible so that they can be turned off in an emergency. The crib is away from windows, as infants and toddlers may strangle themselves in window blind cords. There is easy access to exits in the event of fire. All exits (windows and doors) are uncluttered and capable of being exited. The family has its own fire escape plan. Part of that plan is to keep the emergency and fire telephone number (in most locations 911) as well as the home address and the nearest cross streets posted near the phone at all times. Matches are kept away from the child. Guardrails are around any wood-burning stove, fireplace, or heating appliance. Hanging curtains, tablecloths, and holiday decorations are away from an open fire or from heated surfaces. Burning candles, cigarettes, and coffee pots are away from the reach or grasp of the child. No one wears loose clothing near a stove or fireplace.
To prevent electrical hazards, parents will ensure that: All electrical outlets, cords, and wires are intact. Outlets have plastic caps on them to prevent a child from inserting a finger or an object into them. Electrical wires and cords are not frayed or broken and are kept out of reach of the child. Small appliances with cords are disconnected from the wall when not in use and placed out of reach of the child. Lamps and electrical appliances are away from the crib of an infant or toddler.
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To prevent burns or scalding from hot water and other liquids, parents will ensure that: The hot water heat is set at no greater than 49 Celsius or 120 Fahrenheit. A cool mist vaporizer is used instead of hot mist. When cooking, pot handles are turned to the back or to the center of the stove beyond grasp of a child. They not drink hot liquids while holding a child.
To prevent suffocation, parents will do the following: Check that crib design is according to federal regulations (call 1-800-638-CPSC to contact the U.S. Consumer Product Safety Commission for a list of the regulations). Be sure that the mattress and pillows are not covered in plastic that could in any conceivable manner become loose and cover the childs face. Keep all plastic bags away from the reach of the child. After tying knots in them the plastic garment bags, discard the bags immediately in a place inaccessible to the child. Use toy chests without lids or chests with lids that lock securely in an open position. Keep the doors of stoves and appliances, such as washers, dryers, and refrigerators, closed at all times when not in use. If any appliances are unused and remain on the property, parents should padlock them closed or remove their doors. Never allow a child to play with inflated or uninflamed rubber or latex balloons. The child may try to swallow all or part of the balloons, or the child may accidentally inhale a small or large piece. The balloon creates a seal over the trachea, causing suffocation.
To prevent aspiration (inhalation of liquid, food, or small objects into the respiratory tree), parents will do the following: Keep all small objects out of the childs reach. Serve food in small, noncylindrical pieces. Keep hanging toys and mobiles out of reach of the child. Inspect toys and remove all small parts (e.g., eyes in stuffed animals).
To prevent strangulation, parents will do the following: Remove all strings and ties from toys. Keep belts and ropes out of reach of the child. Keep clotheslines above head level. Use only window blind cords that have been childproofed. Do not use accordion-style gates, as a child can get his or her head caught between the slats.
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To prevent drowning, parents will do the following: Keep toilet lids down, faucets tightly turned off, and the bathroom door closed securely at all times. Keep all buckets and wading pools empty when not in use. Fence in the pool and keep the fence locked when not in use. Have proper poolside safety equipment available. Follow Red Cross instructions for pool and swimming safety, the most basic instruction being that no swimming is permitted unless someone certified in lifesaving is in attendance. Advocate for basic life support (CPR and treatment of choking) training of at least one family member. Advocate for lifesaving certification for any family with a swimming pool.
For a detailed listing and discussion of measures to prevent poisoning, refer to the previous chapter. To prevent falls, parents will do the following: Lower the crib mattress level as the child grows. Keep crib side rails up at all times when in use. Use high chair restraint at all times when in use. Preferably elect that the child not use a walker. If used, keep restraint in place. Use guardrails on windows (however, do not completely enclose a window with railing or bars, as then the window cannot be used for fire escape purposes) or use windows that lock when raised to a certain height. If window locks are used, keep the window height less than that needed for the child to climb through. Keep the top and bottom of stairs gated for all children incapable of climbing them safely. Keep gated all elevated areas, e.g., first-floor porches, upper-level porches or balconies, or fire escapes. Keep stairs well lit with a light switch at the top and the bottom of the stairs. Keep stairs uncluttered. Do not use stairs for storage space. Be sure that all indoor and outdoor stairs or steps have sturdy handrails. Keep hallways well lit and uncluttered. Keep rooms free of toys, boxes, or furniture that obstruct walk areas and could be the cause of bumps or falls. Keep treads, risers, and rugs in good repair. Ensure that scatter rugs are nonskid or secured in place. Mark glass doors and windows with decals to prevent someone from attempting to walk or place their arm through them. Use safety glass on all doors, windows, or glass dividers. Use nonskid mats, strips, or surfaces in bathtubs and showers.
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Keep walkways, patio areas, and driveways in good repair. Fill in any lawn holes.
To prevent bodily injury from other causes, parents will do the following: Make sure that knives, power tools, firearms, and ammunition are stored safely and locked. Do not use a lock that is easily opened, and keep the key in a safe, out-of-reach place. All firearms kept in a home with children must be unloaded. Make sure that garden tools are returned to storage area or racks when not in use. Keep swings, slides, and other play-yard equipment in safe condition. Keep yard free of broken glass, nails, nail-studded boards, and other litter. Maintain fences and gates intact. Secure cement birdbaths and other yard sculptures so that child cannot overturn them. Be sure pets are properly restrained and under the owners control at all times. Be sure pets rabies immunizations are current.
The above safety measures, designed in detail as behaviors needed to prevent injury to children, are framed as expected outcomes. In the same way, safety measures throughout the life span may be framed as expected outcomes. One expected outcome that crosses all ages is to refer, when needed, to the emergency numbers posted near the telephone: police, fire, and poison control. Expected Outcomes Related to Safety Measures Throughout the Life Span (adapted from Berman et al. 2008) Clients who are parents of newborns and infants will teach the following regarding: Federally approved car seatsUse at all times when driving. Any raised surface (bed, sofa, or countertop) Never leave an infant unattended. Temperature of the infants bath water and formula prior to useWarm only. Never hot. Infants position during feedingUpright. Position of bottle during feedingNever propped. FoodCut in small pieces. Never feed peanuts, popcorn, or raisins. Infants cribCheck for compliance with federal safety regulations, maximum of two and three eighths inch slat width, lead-free paint, tight fit of mattress to crib, adjustable height of crib sides so that sides can be lowered as child grows to prevent rolling or climbing over. PlaypensBuy only with small-sized netting on sides. Never leave playpen sides down. ToysShould be large and soft. Make infant/toddler proof by removing sharp edges and small parts (e.g., eyes) that may detach from the toy. Do not allow
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any continued exposure to toys on lead paint recall list. If exposure has occurred, request a serum lead level from the pediatrician. Guard gates on stairs and screens on windowsUse at all times. Walkers, swings, and highchairsSupervise infant when these are in use. Electric outletsCover all outlets at all times. Electric cordsCoil them out of reach. Plants, household detergents, and wastebasketsPlace them out of reach. Potential poisons (drugs, paint, or cleaners) Place under lock and key. GasolineNever store on property.
Clients who are parents of toddlers will teach the following regarding: Federally approved car seat or seat beltsContinue to use at all times when driving. Place children in back seat, even when traveling short distances. Small objects and pillsTeach children not to place such objects in their mouths. Objects with sharp edgesKeep knives out of reach. Cover sharp edges of furniture or move out of reach. Hot pots and pansPlace on back burners. Turn handles inward toward the center of the stove. Potential poisons (cleaning solutions, insecticides, medicines) Keep locked. Windows and balconiesKeep securely screened. Swimming poolsTeach children to swim. Fence in pools. Supervise children at all times. Other water sourcesDo not overfill bathtub. Protect child from ditches or wells. Tricycle safetyKeep tricycle away from street, and teach children to stay away from the street. BedsObtain a low bed when the child begins to climb. Electrical outletsCover all outlets at all times.
Clients who are parents of preschoolers will teach the following regarding: Small objectsTeach children not to run with candy or any object in their mouths. Teach children not to put any object in their mouths (other than food), noses, and ears. Unused equipment, such as refrigeratorsRemove all doors. Street and corner safetyTeach children to cross streets safely and obey traffic signals. Halloween treatsCheck before allowing children to eat them. Discard unwrapped or opened candy. Safe areasTeach children to identify safe play areas and unsafe play areas (streets and railroad tracks) and to keep away from the latter. Matches, charcoal, fire, and heating appliancesTeach preschoolers fire safety and the dangers of the above items.
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StrangersTeach children to avoid strangers. Teach children to keep their parent(s) informed of whereabouts. PlaygroundsTeach preschoolers swing safety and playground manners (i.e., dont push playmates off of equipment, etc.).
Clients who are parents of school-age children will teach the following regarding: Recreational and sports activitiesTeach children never to swim alone, to always wear a life jacket when in a boat, and to wear a protective helmet and knee and elbow pads when needed. Contact sportsSupervise children when engaging in contact sports. Bicycling, skateboarding, and roller-skatingTeach children to obey all traffic signals and safety rules. Night walking or cyclingTeach children to wear light or reflective clothing. Stoves, garden tools, and other equipmentTeach children safe use. Saws, electric appliances, tools, and other potentially dangerous equipment Supervise children at all times. Fireworks, gunpowder, or firearmsTeach children not to play with any explosive or gun. Keep firearms unloaded, locked up, and out of reach. Caves, excavations, quarries, vacant buildings, and heavy machineryTeach children not to play in or around such areas. Drugs and alcoholTeach children effects of drugs and alcohol on judgment and coordination.
Clients who are parents of adolescents will teach the following regarding: Automobile drivingEnroll adolescents in a drivers education course. Allow them to drive only after passing the course. Practice driving with adolescents under various weather conditions. Set firm limits on automobile use. Teach them to never drive under the influence of alcohol or drugs and to never ride with a driver who has used alcohol or drugs. Have adolescents call home for a driver without fear of reprimand if no driver is available who has not used alcohol or drugs. Teach adolescents to obey traffic regulations in all circumstances. Motorcycles, scooters, and other sports vehiclesTeach adolescents to wear a safety helmet. SportsTeach adolescents to wear proper sports equipment. Schedule a sports physical each year when participating in sports. Check that medical supervision is available for all athletic activities. Swimming, jogging, and boatingEncourage adolescents to use the buddy system at all times. Teach adolescents to adhere to safety rules for each of these activities. Drugs, alcohol, and unprotected sexTeach the consequences of each. Be alert for mood and behavior changes in the adolescent. Listen to him or her and communicate openly. Adult exampleSet a good example.
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Young adults will perform the following regarding: Motor vehiclesDrive safely and defensively. Use designated drivers if alcohol is consumed; check brakes and tires routinely; always use seat and shoulder belts; and insist on seat and shoulder belts with all passengers. Fire hazardsCheck for potential hazards and repair promptly if found. Water safetyKnow the pool depth of a pool before diving, and never perform a deep-water dive in shallow water. Adhere to all safety and supervisory precautions regarding backyard pools and other water activities. Workplace/occupational safetyBe aware of dangers, and consider hazards when making employment decisions. Promote programs aimed at reducing hazards. Sun radiationAvoid excessive exposure, limit total exposure time, and wear sun-blocking agents and protective clothing. Skin changesAssess for changes that may indicate cancer. Mental healthSeek counseling when having difficulty coping with the pressures, responsibilities, and expectations of adulthood.
Middle-aged adults will perform the following regarding: Automobile drivingDrive car safely and maintain it in good condition. Use seat and shoulder belts at all times; drive within the speed limit; and test visual acuity and peripheral vision regularly. StairwaysKeep well lighted and uncluttered. BathroomsEquip bathrooms with grab bars and nonskid bath mats. Fire safetyPlace smoke detectors, fire alarms, fire extinguishers, and carbon monoxide detectors in appropriate places in home. Maintain these devices. Machine equipment and toolsKeep them in good working condition at home and work. Follow safety precautions when using equipment and tools.
Older adults will perform the following regarding: Vision and hearing testsObtain these tests regularly. Home safetyObtain a home hazard appraisal. ActivityKeep as active as possible. Muscle strength and agilityPerform active, passive, and stretching exercises daily.
Now that the expected outcomes have been specified within the framework of goal statements, the next step is planning strategies to address the goals.
Planning
Once nursing diagnoses are identified, they are prioritized according to those threats that are most imminent and most life threatening. One factor that affects the prioritization of safety needs is the accumulation of risks. For example, a twenty-year-old client with
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impaired mobility due to torn cartilage in the right knee is at less risk of falling than a seventy-five-year-old client with the same diagnosis. This is because the seventy-fiveyear-old client has accumulated multiple risks of falling over and above limited mobility due to the torn cartilage. Perhaps the seventy-five-year-old has a fear of falling, a sensory deficit of some kind (e.g., visual difficulties), a balance problem, or an unsteady gait. His accumulated risk is much greater than that of the twenty-year-old client. Given a choice as to who is to receive care first, preference would go to the seventy-five-yearold, since his risk of injury is greater than that of the twenty-year-old. Therefore, his safety must be ensured before moving on to care for the needs of the twenty-year-old. The older client will also require more resources than the younger one. Someone will need to be assigned to assist the older client when walking, whereas the twenty-year-old may do quite well on crutches. Thinking in terms of these priorities is consistent with Maslows hierarchy of needs. Physical needs for air, circulation, and so on are more basic and must be met before the higher-order need for safety. However, the clients safety needs (freedom from risk of injury) must be dealt with before those needs that are of a higher order than safety can be addressed. Once planning takes priorities into account, strategies designed to assist the patient achieve the expected outcome are developed.
Implementation
During the implementation portion of the nursing process, the intervention identified during the planning stage needs only to be put into place. As with any intervention, the nurse should schedule a time to meet with the patient, and he or she should establish and maintain rapport. It is also important to anticipate client needs during the intervention and explain the steps of the intervention as progress is being made in completing it. The nurse should allow sufficient time to answer the clients questions either during or after the intervention. Explaining what is to be done next is also critical. For example, the nurse may say something such as, I will leave this home safety list here for you. You may want to post it on your refrigerator. Is it all right if I phone in a couple of weeks to check on the progress you are making and to see if you have any questions that I may answer?
Evaluation
Evaluation arises from patient follow-up. For example, at the aforementioned two-week follow-up phone call, the nurse could refer to the list of desired outcomes and interventions to determine which goals and outcomes have and have not been met. He or she should ask if there is anything that can be done to help the client meet any unmet goals and whether there are any questions he or she may help answer. If necessary, the nurse should also determine a convenient time for further follow-up.
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Chapter 15: Theoretical Frameworks Underlying Principles of Biological Safety

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Differentiate between medical asepsis and surgical asepsis. Describe the six links in the medical asepsis chain of infection and the medical asepsis methods used at each link to control the spread of infection. Identify the eight steps used to establish a sterile field. Describe nonspecific defense and specific defense as they relate to the bodys shield against infections. Define the following terms related to the bodys specific defense against infections: antigen, autoantigen, active immunity, and passive immunity. Explain the four stages of the infectious process. Explain the four stages of wound healing. Differentiate between primary and secondary intention in wound healing. Describe ten common skin lesions. Describe the four stages of decubitus ulcers. Explain four serious complications of wound healing. Describe the seven factors that influence a clients biological safety. Provide an overview of the four basic nursing interventions for biological safety, including examples and the theoretical basis for each. Identify the nine principles governing the maintenance of a sterile field. Describe the types of dressings and the types of wounds each is used on. List ethical and legal nursing implications related to communicable diseases. List four ethical and legal nursing issues when communicable diseases are involved.
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Key Terms
abrasion abscess active immunity airborne transmission antibody-mediated response antigen asepsis autoantigen autoclaves barrier precautions cell-mediated response chain of infection cleaning cohorting contact precautions convalescence stage critical items Davol drainage system decolonization dehiscence destructive phase direct transmission disinfecting entry portals environmental measures evisceration external hemorrhage full thickness skin wound hemorrhage Hemovac drainage system illness stage immunoglobulin incubation period indirect transmission infection infectious agent infectious process inflammatory phase inflammatory response internal hemorrhage Jackson-Pratt drainage system laceration macule maturation phase medical asepsis mode of transmission nodule noncritical items nonspecific defenses papule partial thickness skin wound passive immunity Penrose drain portal of exit pressure ulcer primary intention prodromal stage proliferative phase pustule reservoir secondary intention semicritical items specific defenses sterilizing superficial skin wound surgical asepsis surgical field surgical scrub susceptible host tumor ulcer vesicle wheals Yates drain
Introduction
Understanding biological safety is central to the provision of quality nursing care since it is part of the nurses responsibility to protect patients against biological hazards and pathogenic agents like viruses, bacteria, and fungi. The purpose of this chapter is to provide an overview of central concepts related to biological safety. We begin by defining the principle of asepsis (maintenance of an environment free to some degree from infectious microorganisms) and the two types of biological asepsis: medical asepsis and surgical asepsis. We build on the concept of medical asepsis by analyzing the six links in the chain of infection and describing the medical asepsis methods used to control the spread of infection at each link in the chain. Our discussion then turns to principles underlying the bodys defense against infection and analyzes the bodys nonspecific and specific defenses. We discuss the stages of the inflammatory responses, one of the nonspecific defenses, and then look at specific defenses against infections through discussions of antibody-mediated responses and cellmediated responses.
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In addition, we explain the four stages in the infectious process and the four stages involved in wound healing. Common skin lesions are discussed along with a description of the four stages of pressure ulcers and complications of wound healing. In conjunction with this, we consider the seven critical factors that influence a clients biological safety. We look at four central biological safety interventions including medications, maintenance of asepsis, wound care, application of heat and cold, and dietary modifications. We explain the theoretical bases for each of these different types of interventions, with particular attention to specific issues related to the maintenance of medical and surgical asepsis. Finally, we explore ethical and legal nursing issues related to communicable disease management.
Principles of Asepsis
There are two categories of biological asepsis with which the nurse must be familiar: medical asepsis and surgical asepsis. Medical asepsis refers to biological safety techniques used during daily routine care to prevent infection or control its spread. To grasp the full significance of medical asepsis, a nurse must know the six links in the chain of infection and the medical asepsis methods that apply to control the spread of infection at each link in the chain. As opposed to medical asepsis, surgical asepsis refers to those techniques a nurse uses to establish and maintain a field free of all organisms, including spores (Potter and Perry 2004). Surgical asepsis is used in administering an intramuscular injection, starting an intravenous infusion, changing a surgical dressing on a wound, or establishing and maintaining a sterile field. Medical Asepsis and the Chain of Infection At the heart of the concept of medical asepsis is the idea of the chain of infection, or the set of six connected factors or links that allow for the spread of infectious and communicable disease. Specific steps toward creating or maintaining medical asepsis can be aimed at each of the six links, as described in the following sections and illustrated in Figure 15.1.
The First Link
The first link in the chain of infection is the infectious agent. This microorganism may be a bacterium, virus, fungus, protozoan, or rickettsia. Three medical asepsis methods used to control or eliminate infectious agents are cleaning (or cleansing), disinfecting, and sterilizing. Cleaning Cleaning refers to the removal of all foreign material from objects by cleansing, which inhibits the growth of organisms. According to Berman et al. (2008), six steps are involved in the process of cleaning an object:
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2.
3.
4. 5. 6.
Rinse the object in cold water to remove organic material. Hot water is not used because heat coagulates protein in the same way boiling an egg coagulates the egg white (albumin). When proteins are coagulated, they are harder to remove. Once the object is rinsed in cold water, you are ready to wash the object with soap and hot water. Soap is an emulsifying agent. It decreases surface tension and facilitates the removal of dirt. The act of washing removes the dirt brought to the surface by the soap. Antiseptic soaps may be used. An antiseptic is an agent that inhibits the growth of organisms. Clean the grooves and the corners of the object with an abrasive instrument, such as a stiff-bristled brush. The friction created by rubbing the brush across the grooves or in the corners helps dislodge foreign material. Rinse the object in warm to hot water, which readies the object for drying. Dry the article using clean cloths or clean material. The dried article is now considered clean. Clean or disinfect the brush, sink, and surrounding surface. These are considered soiled until they are cleaned or disinfected properly.
When cleansing equipment containing bodily fluids, secretions, or excretions, and when disinfecting the brushes, the sink, and sink area used in cleaning equipment, use a mask, protective eyewear, and waterproof gloves. Disinfecting Disinfecting is the process in which chemical solutions, such as alcohol, phenol, or chlorine, are used to rid inanimate objects and surfaces of pathogenic organisms other than spores. A germicide (e.g., isopropyl alcohol or sulfadiazine) is a chemical that can be applied to skin, tissue, or objects for disinfectant purposes. Disinfectants may be bactericidal or bacteriostatic. When disinfecting, the nurse needs to have an understanding of the type and number of infectious agents. Some infectious agents are readily destroyed on contact. Others require longer contact with a disinfectant. In addition to knowing the duration of contact, the nurse needs to know the concentration of the disinfectant to use. Be sure to read the manufacturers label. Most disinfectants are to be used at room temperature. Some are rendered ineffective in the presence of soap. Adding such a disinfectant to soapy water would, therefore, be contraindicated. The presence of organic materials (e.g., blood, pus, saliva) may render the disinfectant inactive. Before use of such disinfectants, the equipment must be cleaned. If a nurse intends to disinfect a surface area, the entire surface area must make contact with the disinfectant. In a similar way, if a nurse is soaking objects in a disinfectant, all objects must be completely submerged in the disinfectant. Areas floating above the surface are not disinfected. Sterilizing Sterilizing is a process of destroying all microorganisms, including spores (Potter and Perry 2004). Common forms of sterilization are moist heat (autoclave and free steam), gas, boiling, and radiation.
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Moist heat is applied in two ways. First, devices called autoclaves supply steam under pressure (usually fifteen to seventeen pounds) at temperatures of 121123C (250254F), usually for thirty minutes. Free steam is another form of moist heat used to sterilize objects that cannot tolerate the higher temperature and pressure of the autoclave. Free steam of 100C (212F) is applied for thirty minutes on three consecutive days. The intervals are needed to give spores time to return to their vegetative state and become vulnerable to heat. Gas sterilization uses ethylene oxide to destroy infectious agents by interfering with their metabolic processes. Gas penetrates well, kills spores and other pathogens, and may be used with heat-sensitive objects. A disadvantage is its toxicity for humans. Boiling objects in water at 212F for fifteen minutes is an effective method of sterilizing objects contaminated by pathogens other than spores or some viruses. It is a good method for use in the home. Radiation is another method of sterilizing or disinfecting objects. Ultraviolet radiation is nonionizing and can be used for disinfection. Its rays do not penetrate deeply. Ionizing radiation is used in industry to sterilize foods, drugs, and other heat-sensitive items.
The Second Link
The second link in the chain of infection is the reservoir in which the infectious agent lives or exists. A reservoir refers to any person, animal, arthropod (e.g., tick), plant, soil, or substance where an infectious agent lives and multiplies and on which it depends for survival. For example, food can be the reservoir for bacterial agents. Water is the reservoir for cholera. The gastrointestinal tract is the reservoir for typhoid. Blood is the reservoir for human immunodeficiency virus. Several medical asepsis methods are used to control or eliminate infectious disease reservoirs, including the following: Store/handle food and water properly. Bathe skin surfaces properly or assist clients in doing so. Provide for good oral hygiene. Protect potential reservoirs from insects and teach families to do likewise. Change dressings or bandages when they become wet or soiled. Dispose of contaminated articles (e.g., tissues, dressing, soiled linens) properly. Dispose of all contaminated needles appropriately. Maintain clean, dry table surfaces. Cover or cap all bedside water containers and suction or drainage bottles. Maintain patency of surgical drainage tubes to prevent stasis and accumulation of drainage under the skin. Date bottles when opened, cap them immediately after use, and keep them tightly capped when not in use. Empty drainage bags/bottles according to agency policies and at least once per shift unless ordered otherwise by physician.
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Never raise a drainage bag or bottle above the site being drained unless the tubing is clamped off.
If reservoirs of infection are not adequately controlled, pathogens multiply. However, for infection to spread, pathogens need a way of exiting the reservoir.
The Third Link
The third link in the chain of infection is the portal of exit from the reservoir. The portal of exit is the microorganisms exit gate from the reservoir. Infectious agents that occupy the respiratory tract (e.g., streptococcal infections, tuberculosis, influenza) exit by the mouth, nose, and endotracheal tubes. Infectious agents harbored in the gastrointestinal tract exit by means of the mouth (vomitus), anus (feces), and drainage tubes (e.g., Ttubes). Examples of these agents are hepatitis A, salmonella, and Clostridium dificile. Infectious urinary tract agents (e.g., E coli) exit by means of the urethra or by means of urinary diversion ostomies. Infectious agents that invade the reproductive tract (N. gonorrhea, Treponema pallidum, herpes simplex virus type 2) exit by whatever orifice they entered, such as the male urethra and the female vagina and their respective secretions. Agents that use blood as a reservoir exit by means of any open wound, puncture site, or other disruption in the skin or mucous membrane. Agents that invade skin and tissue exit by means of drainage at the site of the wound, abscess, or pustule. The scabies mite exits by direct skin contact. Pediculi exit by direct contact with another persons hair or by means of sharing combs, brushes, or hats. Several medical asepsis methods help control the spread of infection through control of portals by which microorganisms exit. These methods include the following: Cover the mouth with tissue when coughing, and instruct the patient to do likewise. Properly dispose of tissues after each use. Cover the nose with tissue when sneezing, and instruct the patient to do likewise. Again, properly dispose of tissue after each use. Avoid talking over, and never cough or sneeze over, an open wound or sterile field. Sneezing or coughing over a wound or sterile field contaminates it, and talking increases the likelihood that the wound or field will be contaminated. Use proper hand-washing technique after use of toilet, and remind patients to do likewise. Handle all excretions or exudate with gloves, and use a mask and protective eyewear. Handle all laboratory specimens as if infectious.
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The Fourth Link
The fourth link in the chain of infection consists of the mode of transmission, or the way in which the infectious agent travels between the reservoir and a portal of entry in a new host. There are three different modes of transmission: 1. The first mode is direct transmission, which refers to touching, biting, kissing, sexual intercourse, or droplet transmission (sneezing, coughing) within three feet. The second mode is indirect transmission, which may be by means of a vehicle (e.g., water, blood, handkerchiefs, toys, doorknobs) or a vector (e.g., mosquitoes, ticks). The third mode is airborne transmission by means of droplet nuclei or by dust particles. Droplet nuclei are small particles of droplets that are involved in the transmission of airborne infection. They may exist in the form of dried residue of excretions coughed or sneezed into the air. Once evaporated, they may be carried as dust particles. They may also exist or become airborne when they are dispersed in the form of a mist as a result of coughing, sneezing, or talking. The latter are called aerosolized droplet nuclei. They remain in the air for long periods. When emitted by a host with tuberculosis, they become an important element in its spread. Dust particles transmit disease (e.g., the spores of Clostridium difficile).
2.
3.
Several medical asepsis methods control the mode of transmission: Wash hands frequently, especially before and after eating, eliminating, client contact, touching secretions or any infectious material, performing invasive procedures, or touching open wounds. When exposed to clients with infections transmitted by droplet, wear masks and eye protection gear. Clean patient equipment properly, and never allow patients to share equipment. Bag all linen appropriately and discard in keeping with agency policies. Discarded soiled material needs to be placed in moisture-proof bags. Discard anything that touches the floor. For example, a towel that accidentally falls to the floor must be considered soiled and is not to be used in patient care. Wear gloves and handle all urine and feces carefully, so as to prevent spillage. Dispose properly in an appropriate receptacle. Wear gowns if there is danger of soiling clothing with bodily substances. Wear masks and eye protection gear when performing irrigation procedures if a spray of bodily fluids is possible.
The Fifth Link
The fifth link in the chain of infection is the control of entry portals (e.g., broken skin, disrupted mucous membranes, urinary meatus). The portal of entry is the gate through which an organism enters the body. It can be any orifice in the body or a break in the skin or mucous membranes. Entry frequently (but not always) occurs by the same route that the organism exited the other body. Entry portals also include invasive lines (e.g., IV
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lines, central venous catheters, urinary catheters). The following asepsis methods control the portal of entry: Ensure that the clients mucous membranes and skin remain intact to decrease the number of possible entry sites. Prevent accidental needlesticks by placing used disposable needles in punctureresistant containers. Instruct women to clean the perineum and anus by wiping front to back and discarding toilet paper after each swipe. This is to avoid contaminating the urethra with gastrointestinal organisms. Use sterile technique for invasive procedures (e.g., injections, catheterizations). Use sterile technique when exposing open wounds, cleaning open wounds, or handling dressings.
The Sixth Link
The sixth link in the chain of infection is the susceptible host. This refers to any person at risk for infection. A susceptible host is a person whose defenses against infection are weakened or compromised for whatever reason, such as immunosuppression, diabetes, surgery, burns, and advanced age. The main objective of infection control is to prevent the spread of infection to a susceptible host. Several ways to help do this are as follows: Maintain client hygiene at an optimal level. Ensure a balanced diet. Allow for sufficient sleep and rest. Educate clients and the public about the value of immunization. Body substance isolation (BSI) provides generic protection for all clients. Use universal blood and body fluid precautions with any anticipated contact with blood or body fluids. Adhere to disease-specific isolation (stop-sign) procedures, such as those for tuberculosis, rubella, and varicella. Use negative pressure isolation rooms to prevent organisms from leaving, as in the case of tuberculosis. Obtain PPD at intervals specified by the health care agency or more frequently, if needed. Use positive pressure isolation rooms to prevent entry of organisms into a room.
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Figure 15.1 The Chain of Infection
Surgical Asepsis Surgical asepsis refers to those techniques a nurse uses to establish and maintain a field free of all organisms, including spores. In regular, routine care, surgical asepsis or surgical technique is used in administering an intramuscular injection, starting an intravenous infusion, or changing a surgical dressing on a wound. The steps used to establish a sterile field are as follows: 1. 2. 3. 4. 5. 6. Organize the supplies and equipment needed. Clean and disinfect a flat work surface and allow it to dry. Check sterile package expiration dates on equipment and package labels. Wash hands thoroughly. Place the sterile pack on the work surface. Open the surgical drape one corner at a time, touching the outside surface of the cover only. Do not let the drape touch any object. Do not touch any object within the sterile package.
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7.
8.
Add sterile items to the sterile field by opening covers or lids and allowing the sterile objects to fall at an angle gently onto the field without the wrapper touching the sterile field. Dispose of the wrapper. Pick up the next item to be added to the field and repeat the procedure. Only sterile technique can be used to access and use items from the field.
Principles Underlying the Bodys Defense Against Infection

The body possesses both nonspecific defenses (anatomic and physiologic barriers and the nonspecific inflammatory response) and specific defenses (immune responses) against infection. Both types of defenses are described in the following paragraphs. Nonspecific Defenses Against Infection Anatomic and physiologic barriers against infection include intact skin and mucous membranes, cilia in the nasal passages, alveolar macrophages (large phagocytes) in the lungs, mucosal shedding in the oral cavity, microbial inhibition by substances in the saliva, and tears in the eyes. Additional physiologic barriers include high gastric acidity, resident flora in the GI tract, peristalsis, low pH in the vagina, and flushing and bacteriostatic action of urine. Another nonspecific defense is the inflammatory response, which is an adaptive mechanism that destroys or dilutes injurious agents. It is characterized by pain, swelling, redness, heat, and impaired function. Stressors are the stimuli that initiate the response, such as physical agents (e.g., trauma), chemicals (e.g., strong acids or bases, poisons, gases), internal agents (e.g., gastric hydrochloric acid), and microorganisms. There are three stages in the inflammatory response: Stage I consists of vascular and cellular responses. In this stage, the initial reaction is vasoconstriction followed by histamine release, which causes vasodilation resulting in hyperemia, redness, and heat. These are local signs of inflammation/infection. This reaction then alters capillary permeability, causing a leakage of leukocytes into injured tissue, which stimulates an increase in the production of leukocytes and results in leukocytosis or an elevated white blood count. If an infectious agent is the stimulus for the inflammatory response, and if stage I of the inflammatory response is ineffective in keeping the infection localized, then systemic signs of infection occur. These include leukocytosis, fever, malaise, fatigue, and anorexia. Stage II is the exudative stage. In this stage, the fluid that seeped through blood vessels, dead phagocytes, and dead tissue cells and their products form an exudate, or an accumulation of fluid or matter that has penetrated through a vessel wall. It is important to document the type of exudate present when documenting the characteristics of a wound and its drainage. Exudate may be: Serous: Clear, serum-like drainage Purulent: Pus-containing drainage Sanguinous: Dark or bright red bloody drainage Serosanguineous: Thin, bloody drainage diluted by serous fluid
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Stage III is the reparative phase. This phase occurs either by the regeneration of destroyed tissue with cells that are like or nearly like those destroyed or by fibrous tissue formation (growth of scar tissue). Fibrous tissue formation consists of two stages. First, a fragile tissue called granulation tissue is laid down. Next, a firm tissue called cicatrix (scar) tissue develops. This concludes the nonspecific inflammatory response.
Specific Defenses Against Infection In order to understand the bodys specific immune response, it is first necessary to be familiar with the various elements of that response that are defined in Table 15.1. Table 15.1 Terms Related to the Bodys Specific Defense Mechanisms
Antigen Autoantigen Active immunity A foreign protein that elicits an antibody reaction upon being introduced into the body. A persons own protein that elicits an antibody reaction because the body mistakenly identifies that protein as a foreign protein. Occurs when a persons own body produces antibodies in response to natural antigens (e.g., foreign proteins introduced by bacteria) or artificial antigens (e.g., vaccines). Occurs when a person receives antibodies naturally (e.g., those found in a mothers breast milk) or artificially (e.g., those obtained in an injection of immune serum).
Passive immunity
There are two types of specific immune responses: (1) antibody-mediated responses or defenses and (2) cell-mediated responses or defenses.
Antibody-Mediated Responses
The antibody-mediated response is sometimes also referred to as humoral or circulating immunity. This type of immunity resides in the B lymphocytes, and the antibodies produced in B cells mediate the response. Another word for antibody is immunoglobulin, a type of plasma protein. B cells are activated by a foreign antigen (e.g., a specific pathogen) and yield antibodies or immunoglobulins (IgM, IgG, IgA, IgD, or IgE) in response. When IgM immunoglobulins or antibodies are present, this indicates that the client is currently or actively infected. When IgG immunoglobulins or antibodies are present, the findings indicate the client was infected by this specific pathogen in the past. This immune response is the bodys way of defending itself or fighting against specific pathogens. Ig stands for immunoglobulin. Immunoglobulins are proteins. The letters M, G, A, D, and E refer to classes of immunoglobulins. Table 15.2 presents the functions associated with each of these classes.
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Table 15.2 Classes and Functions of Immunoglobulins

Immunoglobulin class IgM Function This is the first immunoglobulin produced during an immune response. Its production diminishes when IgG comes into play about one week after initial antigenic contact. IgG crosses the placental membrane and provides passive immunity during the gestational months and the early months of infancy. Immunoglobulins A are located in external secretions (e.g., saliva, tears, bile, colostrum) and are also found in the respiratory tract and in plasma. The function of IgD is unknown. Immunoglobulins E produce the typical signs and symptoms of allergy and of anaphylaxis.
IgG IgA
IgD IgE
Adapted from McKenry and Salerno 1995.
Cell-Mediated Responses
The cell-mediated response also has another name: cellular immunity. This kind of immune response resides in the T cell system. Upon exposure to an antigen, lymphoid tissue releases large numbers of T cells. Currently, three types of T cells have been identified: Helper T cells, which stimulate the action of B cells and other T cells Cytotoxic T cells, which attack and kill invading organisms and sometimes the bodys own cells Suppressor T cells, which suppress helper and cytotoxic T cells
T cells play an important part in helping the body fight infection. When the body loses this form of immunityas when it is infected with the human immunodeficiency virus (HIV)it loses its ability to defend itself against infection and becomes vulnerable to opportunistic infections. These are infections caused by organisms that ordinarily do not cause disease in healthy people; however, because of the loss of cellular immunity in immunocompromised individuals, these microorganisms cause serious and sometimes overwhelming infections.
The Stages in the Infectious Process

Once pathogens enter the body, a specific series of events occurs as the pathogens affect the body and the body begins to battle back through its immune responses. This series of events, commonly referred to as the infectious process, consists of four stages (Potter and Perry 2004): 1. The incubation period is the time interval between the invasion of the pathogen into the body and the first signs or symptoms of infection. The length of the incubation period varies according to the disease. For example, the incubation period for varicella or chicken pox is two to three weeks. The incubation period
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2.
3. 4.
for the common cold is much shorter, twelve hours to three days, while that of hepatitis A is fifteen to fifty days, with a mean of approximately thirty days. The prodromal stage is the time interval between the onset of nonspecific signs and symptoms of infection (e.g., malaise, achiness in joints) to more diseasespecific signs and symptoms. The disease is communicable during the prodromal stage of an infection. The illness stage is the stage during which the disease-specific signs and symptoms are present. The convalescence stage is the time period between the disappearance of the acute signs and symptoms of the disease and full recovery. The length of the convalescence stage depends upon many factors, such as illness severity and general health status.
Wounds and Wound Healing

Phases of Wound Healing Just as the infectious process consists of four stages, so does the process of wound healing. Here, the four stages are referred to as the inflammatory, destructive, proliferative, and maturation phases.
Inflammatory Phase
The inflammatory phase is the first stage in wound healing. In this phase, hemostasis occurs almost immediately. The blood vessels constrict and platelets accumulate at the wound, yielding a fibrin matrix that provides a foundation for later repair. Platelets also secrete growth hormone during this phase, which is useful in the later process of epithelialization. Next, injured tissue and the mast cells secrete histamine, which causes vasodilation. This vasodilation leads to increased permeability of the vessel wall through which serum and white blood cells pass, forming an exudate. Characteristic signs and symptoms are redness, edema, heat, and pain. The white blood cells that actively participate in the process are neutrophils and monocytes. Neutrophils begin to ingest bacteria and debris. This ingestion process is completed by the monocytes, which have become macrophages, responsible for the final cleaning of the wound. The macrophages also secrete growth hormone to help with epithelialization. As epithelial cells are laid down beneath the eschar (scab), they form a barrier to bacterial invasion. This entire inflammatory phase ends within three days of injury.
Destructive Phase
The destructive phase follows and lasts from two to five days. During this phase, macrophages continue to clean the wound and stimulate fibroblast formation. Fibroblasts synthesize collagen, the main ingredient in scar formation. To function properly, fibroblasts require vitamins B and C, along with amino acids and oxygen.
Proliferative Phase
The proliferative phase lasts from three to twenty-four days and is characterized by beginning wound closure and increasing strength of closure between opposing sides of
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the wound. As closure progresses, the risk of wound separation decreases. Healing during this stage may be impaired by age, anemia, hypoproteinemia, and zinc deficiency.
Maturation Phase
The maturation phase is the final stage of healing. It is characterized by increasing strength of closure over a period of several months and perhaps up to a year. Tissue in healed wounds does not possess the strength of the tissue prior to disruption. Types of Healing Wounds heal by primary or secondary intention. Primary intention occurs when the sides of the wound are approximated (brought closely together) and held in place by surgical suturing or butterfly sutures. Clean incisions are the best candidates for healing by primary intention. Wounds that heal by secondary intention are those in which the sides of the wound are not approximated but are allowed to close by filling with scar tissue. It takes far longer for a wound to heal by secondary intention than by primary intention. Types of Skin Lesions When discussing wounds, it is necessary to know how to identify or define the various kinds of common skin lesions. Table 15.3 presents these definitions, while Table 15.4 presents the three categories these lesions may fall into. Table 15.3 Definitions of Common Skin Lesions Type of Lesion
Abrasion Abscess Laceration Macule
Description
A wound characterized by scraped or excoriated skin tissue and removal of superficial layers of the skin. A saclike accumulation of pus that displaces tissues. A torn or jagged wound usually caused by a sharp object, e.g., a shard of glass or a knife. A small, red, nonraised spot or colored area on the skin. A macular rash refers to a number of macules that are flat and level with the surrounding skin. Macules are smaller than one centimeter. A firm, small node or aggregation of cells, frequently subcutaneous and nontender. They may be palpated through the skin. Some may cause an elevation of the skin, especially if found over a bony prominence. A red, elevated area on the skin that is solid, circumscribed, and smaller than 0.5 centimeters. An ulcer caused by unrelieved pressure over a bony prominence that leads to damage of the underlying tissue. Besides pressure, two other forces are commonly involved: Friction: A force acting parallel to the skins surface, such as an elbow friction rub caused by rubbing the skin surface of the elbow against sheets. Shearing force: A force resulting from a combination of friction
Nodule
Papule Pressure ulcer (also called decubitus ulcer, pressure sore, or bedsore)
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Table 15.3 Definitions of Common Skin Lesions

and pressure, commonly occurring in a semi-Fowlers position when the body tends to slide downward in bed, which transmits force over the sacrum. A saclike, usually elevated lesion of the skin that contains purulent material or pus. Distinct from an abscess, which displaces tissues. A spontaneous, new, independent, unrestrictive growth of tissue forming an abnormal mass. An open sore that may be associated with deep loss of skin surface. A blister-like elevation of the skin that contains serous fluid. They vary in size from a few millimeters to a centimeter. Vesicles larger than one centimeter are called bullae. Pale, elevated, irregularly shaped itching areas of the skin. In lay terms, wheals are called hives. Wheals vary in size. The eruption of wheals is called urticaria.
Pustule Tumor Ulcer Vesicle
Wheals
Table 15.4 Classification of Common Skin Lesions

Superficial skin wound Partial thickness skin wound Full thickness skin wound Damage only to the epidermis, which is the outer, thinner layer of skin. Damage to the epidermis and dermis (the inner, thicker layer of skin). Damage to both layers of the skin, plus underlying exposure of underlying structures, which may include any of the following (in descending order): fascia, muscle, bone, or organs.
Stages of Pressure Ulcers
Pressure ulcers (also called decubitus ulcers, pressure sores, or bedsores) bear special mention because they are common in the hospital environment but can be prevented with proper care. There are four stages in the formation of a pressure ulcer. In Stage I, the skin is intact but a nonblanching erythema is present. Stage II consists of a partialthickness skin loss that involves the epidermis and may extend into the dermis. The lesion presents as an abrasion, blister, or shallow crater. A Stage III pressure ulcer is a full-thickness skin loss, including damage to or necrosis of subcutaneous tissue but not the fascia. This lesion presents as a deep crater that may or may not undermine adjacent tissue. A Stage IV ulcer consists of full-thickness skin loss with damage to or necrosis of muscle, bone, and surrounding structure. Complications of Wound Healing Complications of wound healing can occur in several forms, most notably hemorrhage, infection, dehiscence, and evisceration. Hemorrhage is an abnormal loss of blood from a wound caused by a dislodged clot, a slipped ligature, or blood vessel tear or erosion. Hemorrhage may manifest itself in two ways:
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Internal hemorrhage is characterized by the formation of a hematoma, which is a collection of blood beneath the skin. It may appear as a reddishblue swelling. However, many internal hemorrhages (e.g., a retroperitoneal splenic or liver hemorrhage) are not visible but are assessed by the presence of characteristic pain and signs of systemic circulatory collapse. External hemorrhage is characterized by loss of fresh, bright red blood that saturates a dressing, escapes under the dressing, or pools beneath the client. Infection is the invasion of a wound by pathogenic organisms at the time of injury, during surgery, or postoperatively. Infection slows the healing process. Dehiscence is the partial or complete rupture of a sutured wound (usually an abdominal wound) and is most frequently accompanied by at least partial separation of the underlying tissue. Partial dehiscence places the patient at considerable risk of complete dehiscence and evisceration. Evisceration is the protrusion of viscera through a dehisced wound. Factors related to dehiscence are obesity, poor nutrition, dehydration, failure of suturing, or excessive stress placed on the incision by coughing or vomiting.
Factors Influencing a Clients Biological Safety

Like any other type of safety, a clients biological safety is affected by a number of factors, including age and developmental level; individual preferences and patterns; physical condition; cultural, spiritual, and religious considerations; socioeconomic factors; environmental factors; and psychological factors. Age and Developmental Factors Healthy children and adults heal well. Infants, however, have friable skin that may be slow to heal. They do not possess active immunity until six months of age. Older adults may be debilitated by chronic disease. With or without chronic disease, they may also experience the following conditions that negatively influence their biological safety: Vascular changes that impede flow of blood to a wound Less flexible collagen Poorly functioning immune systems Nutritional deficiencies Less elastic skin
Individual Preferences and Patterns Lifestyle choices influence exposure to pathogens (e.g., sexually transmitted diseases, IVdrug-related infections). Health habits (e.g., lack of exercise or smoking) may impair overall responsiveness to infection and prolong convalescence. Similarly, risk-taking behaviors among adolescents may predispose them to injury and open the door to infection or allow them to believe that they do not need condoms because they are invulnerable to disease. Lower educational levels and depressed socioeconomic
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conditions may result in poor hygienic practices and overcrowding, both of which contribute to increased susceptibility to and transmission of infectious disease. Physical Condition Poor nutritional status predisposes a person to infectious disease. Protein-deficient populations are more vulnerable to tuberculosis and other infections. Deficiencies in vitamins B and C lead to poor wound healing. Illnesses also increase vulnerability to infection. For example, clients with chronic obstructive pulmonary disease and asthma are at increased risk of dying from influenza. Patients living with human immunodeficiency virus (HIV) are more likely to contract opportunistic infections. Patients with a decreased level of consciousness are less likely to turn independently, and their immobility makes them more vulnerable to pulmonary infections and to pressure ulcers. Immunosuppressive therapy, used in the treatment of cancer and sometimes in the treatment of autoimmune diseases, increases a persons chances of infection, opportunistic or otherwise. Any kind of invasive procedure is accompanied by the risk of infection. Any intravenous line, catheter, or drainage tube increases infection risk. Cultural, Spiritual, and Religious Considerations Some people subscribe to faith systems that do not believe in medical interventions, and their children may not be vaccinated; this increases the childrens vulnerability to infectious diseases. Some cultures or subgroups within cultures rely on a shaman (one who uses magic to cure the sick) for treatment or cure in the event of an infection. Other cultures, not fully aware of disease processes, may think of diseases such as St. Vitus dance (a complication of a streptococcal infection of the throat) as possession by an evil spirit and not seek appropriate medical care. In the United States, people as a whole are dependent on meat from antibiotic-treated cattle and seek antibiotic treatment at the first sign of infection, and thus contribute to antibiotic resistance in general. Socioeconomic Factors Socioeconomic factors greatly influence peoples access to health care in the United States. The uninsured are more likely to have serious infections or wounds that go untreated. Socioeconomic status also influences crowding, as mentioned, and nutritional status. It influences whether people can buy the antibiotics they are prescribed. Some people, when faced with an inability to pay for an entire prescription, buy less than a full course of therapy. An incomplete trial of therapy is usually ineffective and contributes to the development of resistant organisms. Environmental Factors Environmental factors additionally influence a patients biological safety. For instance, garbage collection, sewage treatment, and the treatment of water supplies help control communicable disease. Other environmental factors include pollens that cause seasonal allergies, which then predispose the respiratory tract to infection. Secondary smoke is associated with otitis media. The availability of pasteurized milk in the United States and the industrial world contributes greatly to the control and elimination of gastrointestinal
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tuberculosis; lack of pasteurization in some developing countries of the world places those populations at increased risk of this disease. These are just a few links between the environment and biological safety. Psychological Factors Stress may predispose a patient to infection by altering the immune system. Stress also accompanies news of a diagnosis (e.g., HIV, gonorrhea, or even pneumonia). Another factor that has an impact on a persons well-being is that of the individuals right to privacy versus the states obligation to protect the public, as in the mandatory reporting of sexually transmitted diseases. Some infectious disease treatment methods have a psychological impact. For example, directly observed therapy (DOT) safeguards the states right to protect the public by ensuring a patients compliance with antituberculosis therapy. However, DOT may sometimes evoke anger or frustration if a patient feels his or her right to self-determination has been denied.
Theoretical Bases for Biological Safety Interventions

Biological safety interventions can take a variety of forms. These include medication, maintenance of asepsis, wound care, application of heat and cold, and dietary modifications. The theoretical bases for these different types of interventions are explained in the following sections. Medications Anti-infectives are used to treat infection. These include antibiotics, antivirals, antitubercular agents, antifungals, and antiprotozoal agents. For best results, the infecting organism is grown in a culture media and identified, and the sensitivity of the organism to a variety of antibiotics is evaluated. Obtaining a culture and sensitivity helps ensure that an appropriate antibiotic is used and decreases the probability that resistance will develop. Not infrequently, the severity of the infection demands that antibiotics be given on the basis of the physicians clinical judgment of the nature of the invading organism before receiving the results of a culture and sensitivity. This is called empirical therapy. If the sensitivity results indicate that the organism is sensitive to the antibiotic selected, then treatment is continued. If the sensitivity results indicate that the organism is resistant, then the antibiotic is changed. Anti-inflammatory agents include corticosteroid agents, nonsteroidal anti-inflammatory drugs (NSAIDs), and aspirin. Corticosteroids are anti-inflammatory agents that also suppress the immune system. Thus, they are usually not indicated in the treatment of infection; in fact, they may predispose to it. On the other hand, there may be times when both corticosteroids and antibiotics are administered together. For example, in an acute exacerbation of asthma precipitated by a sinus infection, the client most likely will need prednisone to treat the acute bronchial wall inflammation and antibiotics to treat the sinus infection. Patients sometimes take corticosteroids as an immunosuppressant for cancer therapy. Should the patient develop an infection, it is likely that the prednisone will be continued and an antibiotic added.
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NSAIDs share anti-inflammatory, antipyretic, and analgesic action with aspirin. Therefore, both classes of drugs are frequently used to control inflammation, fever, and pain associated with infection. Some words of caution are necessary, however. To minimize the probability of gastric irritation, NSAIDs should be taken with food. All NSAIDs may precipitate asthma attacks in asthmatic patients who are aspirin sensitive. Finally, the administration of aspirin to control fever in the treatment of varicella (chicken pox) in children twelve and younger has been associated with Reye syndrome, a serious condition that can lead to death or leave the child severely impaired. Acetaminophen (Tylenol) is an analgesic and antipyretic. It has no anti-inflammatory action. When taken in the doses prescribed, it is safe for children and adults. When toxic amounts are ingested or when large doses are given over time to patients with underlying liver disease, hepatotoxicity can occur. Maintenance of Medical Asepsis Medical asepsis is another common biological safety intervention. There are two options available when medical asepsis is considered: clean or dirty. Clean refers to the near absence of microorganisms. Dirty refers to soiled or contaminated objects capable of causing infection. Aseptic measures or interventions are designed to control and reduce the number of potentially infective agents. As previously mentioned, cleaning, disinfecting, and sterilizing are used to maintain medical asepsis. Spaulding (1968) and Rutala (1989) identified three principles that nurses can use to maintain medical asepsis. More specifically, they categorized items and equipment that came into contact with patients during the delivery of nursing care on the basis of their degree of sterility or cleanliness: 1. The first category is that of items entering the vascular system (e.g., intravenously or through central lines) and tissue (e.g., intramuscularly or subcutaneously). These items must be sterile because, if contaminated, the probability of or risk of infection is very high. Therefore, all surgical instruments, intravascular catheters, urinary catheters, and needles must be sterile. These are called critical items. The second category is that of all items that contact the mucous membranes or contact skin that is not intact (e.g., lacerated or abraded skin). These items must be free of all microorganisms except for bacterial spores. Such items include oral and endotracheal suctioning tubes and catheters, endoscopes, and thermometers. These are called semicritical items. They must be disinfected or sterilized. The third category is that of all items that contact intact skin (but not the mucous membranes). These items include bedpans, blood pressure cuffs, linens, and stethoscopes. These are called noncritical items and must be disinfected.
2.
3.
Health care agencies also establish infection control procedures governing hand washing; dressing changes; care of contaminated articles, including needles; the bedside unit; and drainage bottles and bags. Although hand washing was mentioned above, it is important
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for the nurse to know when hand washing is indicated. It is also important to know the distinction between hand washing (a medical asepsis method) and surgical scrub (a surgical asepsis method).
Hand Washing
To prevent the transmission of microorganisms from the nurse to the patient or to prevent the nurse from carrying microorganisms from one patient to another, Garner and Favero (1985) recommend that hand washing be performed for at least ten to fifteen seconds under each of the following circumstances: Prior to contact with newborns or any immunosuppressed patients (e.g., patients receiving glucocorticoids, or cancer chemotherapy, or patients with leukemia or HIV) After caring for an infected patient After disposing of or touching any organic material Before administering medications and performing any invasive procedure (e.g., intramuscular injections, catheterization, suctioning) Before and after change of any dressing or touching open wounds Between contact with all high-risk patients (e.g., infants, the elderly, intensive care patients, or immunosuppressed patients)
In addition, wearing gloves does not excuse the nurse from hand washing. Discard gloves and wash hands after contact with a patient. Maintenance of Surgical Asepsis Surgical asepsis has even stricter standards than medical asepsis, especially in relation to surgical scrubs, establishment of a surgical field, and proper protective gear.
Surgical Scrub
A surgical scrub is a much more intensive hand-washing technique than that already described. The following are the steps in a surgical scrub: Control water flow with knee or foot pedals. Remove watches and jewelry, including rings (safeguard them). Be sure your nail beds are short and filed. Inspect your hands and report lesions or breaks in the skin. Do not touch the sink with your hands, arms, or uniform. Turn on the water (avoid splashing and regulate flow). During washing, keep your hands below your elbows. Wet your hands and arms to the elbow. Apply soap via foot pedal in sufficient quantity to lather thoroughly. Lather a minimum of ten to fifteen seconds; however, length is determined by agency policy. Clean under and scrub your nails.
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Rinse, holding your hands above your elbows, and allow soap and water to be rinsed in the direction of hand to elbow. Repeat soap wash for one to three minutes (length of time is determined by the agency). Dry your hands first, then wrists, then elbows. Discard towel. Use knee or foot pedal to turn off water.
The Surgical Field
Establishing a surgical field is another aseptic method that has been discussed previously. Ease in its establishment and maintenance comes with practice. Fields can be inadvertently contaminated and go unnoticed unless the health care professional speaks out to say, The field is contaminated. Under such circumstances, a new sterile field needs to be established. In surgery, establishment of a sterile field requires a mask, sterile gown, sterile gloves, and proper techniques to maintain the sterile field. Outside of surgery, establishment of a sterile field requires sterile gloves and proper techniques to maintain a sterile field. Principles governing the maintenance of a sterile field are as follows (Potter and Perry 2004): Sterile touching sterile remains sterile. Sterile touching anything less than sterile becomes contaminated. Therefore, anything sterile touching anything clean, contaminated, or questionably contaminated is no longer sterile and is considered contaminated. Only sterile objects may go into a sterile field. Any object out of the nurses vision (e.g., an object below the waist) is considered contaminated. A sterile field from which the nurse has turned his or her back is considered contaminated. This is because inadvertent contamination of the field could conceivably occur and the nurse would not see it occur. Unless a field or an object is known to be sterile, it is not sterile. Any sterile field or object is considered contaminated in the following circumstances: Upon prolonged exposure to air When subjected to strong air currents or winds When coughed or sneezed upon (nurses with respiratory infections should not perform surgical procedures unless double masked) Because a 2.5 centimeter (1 inch) edge of a sterile field is considered contaminated, a sterile drape is first opened. This drape must not touch anything but air. The sterile field is established within the center of the sterile drape. Sterile objects must be removed from packages sterilely (for example, a sterilely gloved nurse can use sterile forceps to remove sterile dressings from a package being held and having been just opened by another nurse using sterile technique), or sterile objects may be dropped onto the field without touching the edges of the container or package from which they came.
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When pouring a liquid, pour a small portion out of the bottle into a receptacle for discarding. This cleanses the lip exposed to air. Now, pour the sterile liquid into a sterile bowl without touching the bottle or its neck to the bowl. (Potter and Perry 2004)
Protective Gear
Caps, masks, and protective eyewear are worn under various circumstances, such as surgery. Caps are not worn when performing sterile procedures on the nursing unit. Whether in surgery or on a nursing unit, masks are to be changed when they become moist or upon completing a procedure. They are considered contaminated once they become moist. Protective eyewear is worn any time there is a danger that bodily fluids may splash into the eye. Note that clean caps, masks, and protective eyewear are used in performing procedures within isolation rooms. Gowns and gloves are worn under various circumstances. In surgery, sterile gowns and sterile gloves are used. In isolation, clean gowns and gloves are used. In routine care, clean gloves are used wherever there is risk of exposure to bodily fluids. Wearing clean gloves in patient care does not eliminate the need for hand washing for medical asepsis purposes. Multi-drug Resistant Organisms and Related Interventions According to the CDC Multi-Drug Resistant Guidelines, multi-drug resistant organisms (MDROs) are an increasing threat to the biological safety of patients within health care settings. These organisms are usually bacteria and are resistant to one or more classes of antimicrobials. The most common organisms are MRSA, VRE, and GNB. MRSA stands for methicillin-resistant Staphylococci Aureus. VRE stands for Vancomycin-resistant enterococci. GNB stands for gram-negative bacteria. These organisms are found in all health care settings. The multi-drug resistant strategies discussed here are designed to limit exposure and decrease communication to other patients or staff within health care settings. According to CDC guidelines, these six strategies include contact precautions, cohorting, duration of contact precautions, barrier methods (to be used in care of patients with MDROs or with persons who colonize and carry such organisms), environmental measures, and decolonization. Contact precautions include placement in a private room with gown and glove precautions. Cohorting is another strategy in which MDRO patients and staff are assigned to a particular unit or set of rooms; other strategies are usually used alongside cohorting. Decisions regarding the duration of contact precautions vary. Guidelines formed in 1995 for VRE management required weekly negative stool cultures for three weeks before discontinuing contact precautions. Even so, a relatively high recurrence rate of VRE was found among these patients. Despite conflicting evidence, prudence and logic lead to the conclusion to continue contact precautions on all patients with MDRO until three negative cultures have been obtained or the patient is discharged from the facility.
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Contact precautions, cohorting, and duration of contact precautions, however, are associated with side effects. Contact measures can isolate patients and place them at risk for preventable adverse events. This is because isolation often involves decreased surveillance, greater patient dissatisfaction because of decreased contact with staff, and less quantity and quality of care. Because of these observations, nursing care strategies need to be planned to address these problems. Barrier precautions refer to the use of barrier methods such as gloves (with gowns or without), resuscitation masks, and goggles to prevent spread of infection. Studies report varying results as to the effectiveness of barrier methods. This is perhaps because adherence to barrier methods among staff is often low. Environmental measures refer to actions taken to disinfect all surfaces and equipment in the environment to decrease reservoirs of bacteria. Again, monitoring staff adherence is required. Educational programs targeting housekeeping personnel have been helpful in infection control. Decolonization refers to attempts to decrease the colonization in persons carrying the bacteria. Infectious disease experts need to prescribe and manage therapy if this strategy is chosen. There are also what are termed very multi-drug resistant organisms, for example, some strains of mycobacterium tuberculosis. Patients infected with these strains are resistant to treatment for four or five of the available antituberculosis agents. Without drug therapy, the only treatment strategy is that of surgery, removing the infected lung or portions thereof, as in the days prior to the discovery of streptomycin. In these patients, environmental control of air is mandatory.
Environmental Control of Air
Environmental control may be used to prevent the spread and reduce the concentration of infectious droplet nuclei in ambient air. Primary environmental controls consist of controlling the source of infection by using exhaust ventilation methods to facilitate the exit of airborne organisms from hoods, booths, and other small spaces. The second method is to simply dilute the contaminate air and facilitate its exit by general ventilation methods such as opening windows and avoiding closed, crowded spaces. Secondary environmental controls consist of controlling the airflow itself to prevent recirculation of contaminated air or to attempt to remove bacteria from contaminated air by the use of high efficiency particulate air (HEPA) filtration or UVGI (ultraviolet germicidal irradiation). The latter is a relatively new system used to improve the quality of indoor air and control disease, including biodefense applications. Within hospital environments, patients with tuberculosis are placed in Airborne Infection Isolation Rooms (AIIRs). The air pressure in these rooms is less than ambient air pressure. This prevents bacteria from exiting the room. Combined with special ventilation and filters, these rooms not only allow the patient to be separated from the public but also control the airborne flow of tuberculosis organisms.
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Respiratory Protection Controls
The control measures previously mentioned decrease the amount of air or air space that contains mycobacterium tuberculosis. Respiratory protective controls or personal respirators use equipment to limit exposure in high-risk environments. Such equipment also prevents droplet nuclei exposure. Integral to the successful use of respiratory protective control equipment is the establishment of an overall program, of which respiratory protective control measures are a part, and insuring that all health care workers are instructed on use. Patients with tuberculosis who are infectious or suspected to be infectious to others are instructed to wear a surgical mask to limit the exposure of others to the organisms if they are not hospitalized in an AIIR. Surgical masks are by no means foolproof but do help decrease exposure. All tuberculosis patients infectious to others need to be taught proper respiratory hygiene and best cough practices to help decrease exposure to others. The CDC teaches that when interviewing patients with infectious or suspected infectious tuberculosis in non-AIIR settings, health care workers should wear a personal respirator and patients should wear a surgical mask. The CDC also teaches that when in an AIIR, the patient need not wear a mask, but the health care worker should wear a personal respirator. Remember, while the organisms are exiting the AIIR safely, they are still in the room before they exit. While community-based patients who are infectious to others should wear a surgical mask inside and out of the home, they may not actually do this. The provider, in conjunction with the public health department, should do everything in his or her power to obtain admission for the client to an AIIR within a hospital.
Ethics and Legal Issues: Persons with Multi-drug Resistant Tuberculosis
Tuberculosis is a deadly disease that is capable of being communicated to others. Between the advent of antitubercular drugs in the late 1940s and early 1950s and the development of mycobacterium resistant to many of those same drugs, a degree of complacency occurred. Officials talked of tuberculosis eradication programs. The complacency period is now over. Public health law has again come to the forefront of the news. A relatively small but growing number of patients with multi-drug and very multidrug resistant tuberculosis are being ordered to isolation units within hospitals or to specialized respiratory disease hospitals by judges to protect the public. Community-based patients with tuberculosis who are not compliant with therapy may have directly observed therapy (DOT) prescribed by the prescribing practitioner. If compliance remains a problem, DOT may be also mandated by the court with the threat of mandated admission to a hospital should compliance remain an issue. The rationale underlying this approach is that non-compliance leads to drug and multi-drug resistance to an organism that has the potential for infecting others in the society. Tuberculosis is mandated by law as a notifiable communicable disease. This means that when physicians or nurse practitioners diagnose a case of tuberculosis, they are mandated
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to report the case to the public health department, which in turn follows the patient and evaluates all contacts. There are ethical issues involved in the care of persons with tuberculosis that concern the providers of services, the patient, the public health department, and the law. Health care providers and health care workers have an ethical obligation to protect themselves, others, and the patient. Protection of self and others means ensuring that all protective procedures are followed. Protection of the patient does not mean that proper public health procedures are overlooked; this is unethical and places the self and others at risk. At the same time, protection of the patient may, at times, require advocacy in the event that the patient is receiving less care or care that does not meet nursing, public health, or hospital standards. Patients with tuberculosis who are infectious to others have an ethical obligation to help in the prevention of its spread to others. Public health workers, including registered nurses, have an obligation to complete the following actions: Adhere to the treatment policies and procedures laid out by the CDC Ensure that instructions provided to patients are understood (Asking for feedback or recall of instructions is a good method.) Document care plans and progress at each encounter, including the instructions given and the patients comprehension of those instructions
There are ethical considerations as well. Tuberculosis is not a crime. People with tuberculosis are human persons who are ill with added concern over the diagnosis and recovery. They often have very real family and financial concerns. In all situations, they must be accorded the human rights they deserve, foremost of which is human respect. This holds true even for those patients who do not comply with public health law and find themselves in situations where they are mandated to receive therapy or enter a hospital. When caring for such persons, remember it is the behavior that is disapproved of and not the person. This is an important distinction. Remember, too, that patients who are separated from others in AIIR require special attention to maintain psychological health.
Occupational Safety and Health Administration and Personal Protective Equipment
The U.S. Occupational Safety and Health Administration (OSHA) is interested in the appropriate use of Personal Protective Equipment (PPE) by all health care workers. Registered nurses need to be aware of these regulations for their own benefit and for the benefit of assistive personnel for whom they are responsible. The General Requirements on PPE follow.
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Table 15.5 General Requirements on Use of Personal Protective Equipment Standard

1910.132(a)
Topic
Application
Regulation
Protective equipment, including personal protective equipment for eyes, face, head, and extremities, protective clothing, respiratory devices, and protective shields and barriers, shall be provided, used, and maintained in a sanitary and reliable condition wherever it is necessary by reason of hazards of processes or environment, chemical hazards, radiological hazards, or mechanical irritants encountered in a manner capable of causing injury or impairment in the function of any part of the body through absorption, inhalation or physical contact. Where employees provide their own protective equipment, the employer shall be responsible to assure its adequacy, including proper maintenance, and sanitation of such equipment. All personal protective equipment shall be of safe design and construction for the work to be performed. The employer shall assess the workplace to determine if hazards are present, or are likely to be present, which necessitate the use of personal protective equipment (PPE). If such hazards are present, or likely to be present, the employer shall: Select, and have each affected employee use, the types of PPE that will protect the affected employee from the hazards identified in the hazard assessment; Communicate selection decisions to each affected employee; and, Select PPE that properly fits each affected employee. Verify that the required workplace hazard assessment has been performed through a written certification that identifies the workplace evaluated; the person certifying that the evaluation has been performed; the date(s) of the hazard assessment; and, which identifies the document as a certification of hazard assessment. Defective or damaged personal protective equipment shall not be used.
1910.132(b)
Employee-owned equipment
1910.132(c) 1910.132(d)
Design Hazard assessment
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Table 15.5 General Requirements on Use of Personal Protective Equipment Standard

1910.132(d) [contd]
Topic
Training
Regulation
The employer shall provide training to each employee who is required by this section to use PPE. Each such employee shall be trained to know at least the following: When PPE is necessary; What PPE is necessary; How to properly don, doff, adjust, and wear PPE; The limitations of the PPE; and, The proper care, maintenance, useful life and disposal of the PPE. Each affected employee shall demonstrate an understanding of the training [specified in paragraph (f)(1) of section 1910.132], and the ability to use PPE properly, before being allowed to perform work requiring the use of PPE. When the employer has reason to believe that any affected employee who has already been trained does not have the understanding and skill required, the employer shall retrain each such employee. Circumstances where retraining is required include, but are not limited to, situations where: Changes in the workplace render previous training obsolete; or Changes in the types of PPE to be used render previous training obsolete; or Inadequacies in an affected employee's knowledge or use of assigned PPE indicate that the employee has not retained the requisite understanding or skill.
The employer shall verify that each affected employee has received and understood the required training through a written certification that contains the name of each employee trained, the date(s) of training, and that identifies the subject of the certification.
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The RYB Color Code and Wound Dressings The RYB Color Code represents red, yellow, and black wounds.
Red Wounds
Red wounds usually represent granulation tissue developing in the late regenerative stage of healing. The tissue is fragile at this stage. The rationale for treatment is to protect the affected and surrounding skin. These wounds require gentle care. The nurse removes the old dressing gently and cleanses the wound gently without pressure by using a cleaning agent that will not kill or damage cells. If moist dressings are used, loosely tuck normal saline saturated gauze that has been fluffed over the wound, making sure all surfaces are covered. Take a piece of dry gauze to cover the moist gauze and use tape to secure the dressing. Keep in place six hours or as directed, and then change the dressing again. If the gauze is dry or if the wound is dry, caked, or cracked, moisten the old gauze before removing very gently. Use a more moist dressing during this change. If the dressing is too moist, use less normal saline in changing the dressing. An alternative dressing is hydrogel, which will also keep the area moist. Hydrogel is either water- or glycerinbased. It is a transparent film, so it facilitates assessment of the wound site between dressing changes. If the intent is to keep the wound moist, an alginate dressing is not a good choice, as it absorbs moisture very well and may dry the site more than desired.
Yellow Wounds
Yellow wounds are suppurative, meaning they secrete purulent material along with seropurulent drainage. The rationale of treatment is to clean the skin of infectious drainage and debris and promote growth of viable tissue. To change the dressing, gently remove and discard the old dressing. Cleanse the wound of debris by irrigating it with normal saline solution. Apply absorbent dressing impregnated with alginate, which will absorb fluid and purulent material even as it keeps the area moist. A newer product, a calcium alginate dressing with antimicrobial silver, is also available. It contains more extensive antimicrobial activity because of the silver and requires fewer dressing changes. Avoid dressings with lesser absorbency.
Black Wounds
Black wounds are characterized by black, necrotic tissue and eschar, which is a dry scablike covering or slough covering all or part of a wound. Black wounds require debridement, of which there are four kinds. Sharp debridement uses sharp instruments (scalpel or scissors) to remove dead tissue. Physicians, advanced practice nurses, wound care nurses, and physical therapists (all with special training in wound care) are the only ones qualified to conduct sharp debridement. Chemical debridement is a process that relies on the use of proteolytic products such as papain-urea to remove necrotic tissue. Papain is derived from the papaya fruit, and urea is a protein denaturant. These substances help clean away necrotic tissue or eschar and prepare the wound bed for healing. Autolytic debridement uses dressings (e.g., hydrocolloid and clear, absorbent acrylic dressings) to capture the bodys own drainage and uses its own proteolytic products to debride the eschar. In the pre-antibiotic era, maggot debridement therapy (MDT) or larval therapy is an ancient therapy revisited at times during the twentieth
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century, when its use was usually a last resort measure in an attempt to prevent amputation. Its success led experts to adopt it as a debridement tool earlier in the wound care process. The rationale is that the larvae secrete proteolytic enzymes that debride necrotic tissue, which larvae ingest along with associated bacteria. They clear the eschar and leave healthy tissue intact. Once the eschar is removed, the wound bed is exposed as either a yellow or red wound. Types of Dressings Pneumonics are tools to nudge the memory into recalling words, represented by letters. Chi path is a pneumonic available for use in remembering the types of dressings commonly employed in wound care. C stands for clear absorbent acrylic, which is a clear, transparent wafer that allows the wound to remain moist and to be seen even as healing occurs. The dressing lasts 57 days and remains permeable to oxygen exchange. With a deep wound bed, clear absorbent acrylic can be used to cover alginates to facilitate wound packing. H represents hydrocolloids, which are wafers, pastes, or powders that contain two layers. The inner layer contains an adhesive product, which also absorbs exudates that help form a hydrogel covering over the wound. The outer layer provides an occlusive seal. The dressing can last up to seven days. The disadvantages of the dressing are that they are not transparent, and the condition of the wound cannot be directly assessed. Secondly, the occlusive nature of the dressing can promote anaerobic growth. I stands for impregnated non-adherent dressings made of woven or nonwoven cotton cloth impregnated with substances, such as petrolatum, saline, zinc-saline, or antimicrobial ointments. These dressings are used to cover, soothe, and protect the skin. P represents polyurethane foam, which is a hydrocolloid used to absorb large amounts of exudates while maintaining a moist environment. It requires the care of surrounding healthy tissue to prevent maceration. Edges of the hydrocolloid need to be taped down and the dressing covered with a second occlusive dressing. A stands for alginates, which are products of alginic acid, a substance found in seaweed off the coasts of the United States, Europe, and Ireland. Alginates come in various formulations: paste, granules, ropes, powder, or sheets. The formulation depends on the nature of the wound. Alginates are highly absorbent substances even as they help retain a moist environment. They require a secondary occlusive dressing. T is for transparent films, which are semipermeable, nonabsorbent, adhesive dressings. They are used to cover IV lines, central lines, and superficial wounds. Although they permit the exchange of oxygen, they are impermeable to water or bacteria. H represents hydrogels, which are water- or glycerin-based substances with various formulations, such as sheets, granules, or gels. They are permeable to oxygen and are
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used to soften and liquefy necrotic tissue, rehydrate the wound bed, and function as a filler within wound craters.
Drains and Drainage Evacuators
Care of drains and drainage evacuators is an important part of wound care. Be sure that when changing a dressing, drains are not dislodged. Drainage systems are of two types: a drain alone or a drain attached to continuous suction. Drains A surgical drain is a soft, pliable tube used to facilitate passage of suppurative, sanguinous, or serosanguineous material from the surgical site to the exterior surface of the body at the incision line. These drains are covered with sterile absorbent dressings and changed as frequently as needed to keep the dressing dry. When changing dressings where drains are located, use sterile technique. Begin at the surface of the surrounding skin and gently remove and discard the dressing, being careful not to dislodge the drain. After cleansing the skin, move up the tube by cleaning first the proximal and then the distal surface of the drain. Use sterile solution (e.g., sterile saline or a solution such as Betadine, if ordered) for cleansing. Special skin barriers are sometimes used around drain sites. These skin barriers are small, wafer-like plastic materials applied with an adhesive substance. They allow drainage material to flow over the barrier without damaging or irritating the skin. Complete the dressing change using the proper prescribed type of dressing. Drain dressings are usually changed twice daily, unless the amount of drainage necessitates more frequent changes. The Penrose drain is a commonly used soft, pliable, rubber, open tubing with a gauze wick in its center. It comes in varying lengths and sizes for adaptation to various kinds of wounds or surgical incisions. Fluid drains through the rubber tubing. However, the rubber tubing establishes a track through which fluids can continue to flow once the drain is removed and until the track heals. The Yates drain, consisting of a series of open capillary tubes, is made of polyethylene, which causes a less reactive tissue response. Once the drain is removed, the track tends to close. Drainage ceases more quickly than in the track made by the Penrose drain. Closed Drainage Systems A Hemovac drainage system is a round, flat drainage bag with springs. The Hemovac is fed by tubing connected to the surgical wound being drained. The Hemovac is usually emptied through its port twice daily. When the port is opened, the Hemovac bag expands and all accumulated fluid may be poured through the port and measured. Before closing the Hemovac with the stopper, place the Hemovac on a clean, flat surface and compress the bag with one hand while reinserting the stopper. The compressed air will create a vacuum exerting a pull on the fluid to be drained. The Jackson-Pratt drainage system consists of an elongated, oval shaped bulb that fits readily in the palm of the hand. The bulb is connected to a drain from a surgical site. On the bulb is a port, allowing for emptying of accumulated drainage. After opening the port, and draining the bulb, squeeze the bulb with one hand while closing the port. This creates a vacuum which exerts a pull on the fluid at the surgical site, facilitating drainage.
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The Davol drainage system consists of a port, allowing for emptying of the drainage bottle. The Davol system also consists of a tube, which drains fluid from the surgical site to the drainage bottle. Above the site where the tube inserts itself into the bottle is a rubber bulb. This rubber bulb, when pumped with the port of the drainage bottle open, feeds air into a balloon located within the drainage bottle. Pumping of the rubber bulb inflates the balloon. Once inflated, immediately seal the port. As the balloon inside the sealed drainage bottle gradually deflates, drainage of fluid from the surgical site is facilitated. Application of Heat and Cold Heat causes vasodilation and increases blood flow, with its supply of oxygen and nutrients, to the affected part. Heat also promotes soft-tissue healing. If heat is applied too early in the event of a closed, traumatic injury such as a sprained ankle, the resulting vasodilation will increase edema at the site and continue extravasation. This causes an increase in the amount of bruising. Exposure to excessive heat causes burns. When warm baths are recommended, instruct patients not to use excessively warm water or remain in the bath more than the recommended amount of time. Exposure of a large part of the body surface to heat causes vasodilation. When the patient stands to emerge from the bath, his or her blood pressure may drop dramatically due to orthostasis. Weakness or fainting may occur. Provide patients with the assistance they need during and after the bath to prevent weakness and/or falling. Cold causes vasoconstriction and reduces blood flow to the affected area, reducing edema and inflammation. Cold is often used for sports-related injuries and for joint injuries. Exposure to prolonged cold impairs circulation and may cause tissue damage (e.g., frostbite). When a large surface of the body is exposed to cold, the resultant vasoconstriction can result in an increase in blood pressure as blood is shunted from the bodys surface to internal organs. Shivering may occur. Take special precautions when considering the application of heat or cold. Avoid heat or cold applications in patients with neurosensory, neuromotor, or circulatory impairment. These patients are at greater risk of heat or cold injury because their ability to sense discomfort or pain may be decreased (neurosensory and/or circulatory impairment) or their ability to move away from the source of pain or discomfort may be decreased (neuromotor impairment). Heat or cold may be applied in patients who have impaired mental status, but only if the patient is monitored during the application. Do not apply heat after surgery because heat promotes bleeding. Avoid cold in the treatment of open wounds, because it decreases blood flow and consequently, healing. When applying warm heat (not hot, in order to prevent burning), it is also important to do the following: Determine the patients tolerance to treatment. Assess for conditions that contraindicate heat therapy. If present, do not apply heat, and notify the physician.
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Explain the procedure to the patient. Assess the patients skin. Apply the heat source to the affected area. Ask the patient to report any discomfort immediately. Stop application if any problem occurs. Be sure the patient has a call button within reach. Return in ten to fifteen minutes and observe the patients skin response. Again, discontinue heat application if a problem occurs. Discontinue application at the designated time unless signs indicate that the application needs to be removed prior to the designated time. Evaluate the area to which heat was applied.
Methods of heat application include hot water bottle, electric heating pad, aquathermia pad, or disposable heat pack. Wet heat is applied by hot soak or compress, hot pack, or sitz bath. The same steps are to be followed when applying cold. Dry methods include cold pack, ice bag, ice glove, or ice collar. Moist cold may be applied by compress or by cooling baths. Dietary Modifications to Improve Wound Healing Wounds heal best in the presence of adequate dietary and fluid intake. Patients need specific nutrients, including adequate amounts of protein; vitamins A, B1, B2, and C; and zinc. Unless contraindicated, an intake of 2,500 mL of fluid should be taken. If the wound is severe, the patient needs to have both intake and output measured.
Ethical and Legal Implications

When communicable diseases are involved, a patients right to privacy is weighed against societys need for protection. A list of communicable diseases that must be reported to the local health department may be obtained from that health department. Each state has its own regulations regarding the reporting of HIV infection. Such reporting may have insurance repercussions. Be sure that both agency and state policies are followed. Placing patients in isolation in a hospital also has privacy implications. Stop signs on doors are appropriate, whereas stating isolation or worse, naming the disease or type of organism, is not appropriate. Finally, it is important to make sure that conversations held among health professionals or with auxiliary staff are not overheard by patients, families, or visitors.
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Chapter 16: The Nursing Process and Biological Safety

Objectives
Upon completion of this chapter, you should be able to do the following: 1. 2. Explain the four nursing assessment areas needed for a comprehensive assessment related to biological safety. Describe the six different types of cells, their normal count (%), the meaning of elevated values, and the meaning of decreased values found in a white blood cell differential count. List the two situations that would have the highest intervention priority in the case of an infection. Explain what must be included in the nursing plan for a patient presenting with an infected wound. Describe the role of the nurse in maintaining biological safety during the implementation phase. Explain the two criteria used to determine how often outcome evaluations are done.
3. 4. 5. 6.
Introduction
The nursing process is the clinical problem-solving framework used to promote clients biological safety. This chapter provides specific examples of how this occurs. We begin by looking at four critical, infection-related nursing assessment areas. We pay particular attention to laboratory data, specifically assessments of the patients white blood count. Our discussion then turns to the diagnosis phase of the nursing process, where we illustrate how data from the nursing assessment results in infection-specific diagnostic labels. We analyze the planning phase and discuss examples of client-centered goals when infectious processes are involved. We then discuss various implementation strategies aimed at improving the health and well-being of patients with infections. We look at the evaluation phase and discuss various examples of questions that can be used to determine if the outcomes attained are the same as the expected outcomes. Finally, we discuss how frequently goals and outcomes need to be evaluated.
Assessment
Nursing assessment, as it relates to the biological safety of the client, involves the collection of infection-related historical data; historical data on factors influencing the clients biological safety; physical assessment data for localized and systemic infections; and relevant laboratory data.
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Infection-Related Historical Data Infection-related historical data is collected data that relates directly to the patients past biological safety issues. This data may be categorized in the following manner: 1. History of susceptibility to communicable diseases Look specifically for a history of significant disease (e.g., hepatitis, tuberculosis, and opportunistic infections like P. carinii) and the frequency of communicable diseases, because a high rate of infection frequency may indicate immunosuppression. Be sure to record what childhood diseases the patient has had (e.g., measles, mumps, varicella, pertussis). Obtain a vaccination history. History of response to the infectious process Inquire regarding the extent and severity of the infectious diseases reported by the patient and the amount of recovery time necessary. History of exposure (recent and past) to pathogens Whether or not the patient reports a history of tuberculosis, inquire about a history of exposure to persons with tuberculosis. Inquire about history of or fear of exposure to sexually transmitted diseases or HIV. Inquire about prior blood transfusions and record the year(s) in which they were received. Ask about travel outside of the United States (recent and past) and any known exposure to unusual pathogens in other countries. Ask about IV drug use. History of hygienic practices Inquire about the patients bathing frequency, oral hygiene practices, and safe-sex practices. Ask about condition of skin, breaks in skin surface, superficial infections, and presence of rash, lesions, or ulcers.
2.
3.
4.
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Historical Data on Factors Influencing Biological Safety Historical data on the factors influencing the clients biological safety must also be collected. This information provides a more complete and holistic picture of the client and includes the following: 1. Age/development factors If the patient is an infant, record his or her age. Infants have friable skin, which may slow skin healing. Also, they do not possess active immunity until six months of age If the patient is a child, record any child-care, preschool, and school settings he or she is exposed to. Children in these settings may come in contact with a large number of pathogens. If the patient is an adolescent, inquire about his or her behavior. Adolescents feel invulnerable to injury and disease and may engage in highrisk sexual behavior. If the patient is an adult, inquire about his or her overall health. Adults in good health should have relatively few infectious diseases. If the patient is an older adult, inquire about his or her history of circulatory changes and noticeable changes in skin, nutrition, and fluid intake as well as illnesses and medications. Older adults may be debilitated by chronic disease. Individual preferences/patterns Record lifestyle choices if these issues have not arisen previously (sexually transmitted diseases, IV-drug-related infections, alcohol intake). Inquire about health habits (e.g., lack of exercise, smoking). Physical condition Assess nutritional status (e.g., twenty-four-hour diet recall, vitamin supplements taken). Assess fluid intake per day. Assess sleep habits. Assess chronic illnesses (immune, autoimmune, cardiovascular, respiratory, gastrointestinal, neurologic, metabolic, and mental health). Assess immunosuppressive therapy. Assess presence or absence of IV lines, catheters, or drainage tubes. Cultural, spiritual, and religious considerations Inquire about health and religious beliefs regarding vaccinations and drug therapy. Inquire about health care providers (traditional and nontraditional). Inquire about alternative therapies used. Socioeconomic factors Does the patient have health insurance? Does the insurance cover prescription drugs? Does the patient have access to health care? Is housing adequate (in terms of heat, air conditioning, electricity)?
2.
3.
4.
5.
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6.
7.
Environmental factors Are garbage collection, sewage treatment, and water treatment services adequate? Inquire about allergies. Inquire about exposure to secondary smoke. Psychological factors Is the patient under undue stress? How many major/minor changes have occurred in the patients life in the past year? What stressors does the patient identify? What are the privacy issues that surround this patient? What are the confidentiality issues that surround this patient?
Physical Assessment Data Health examination or physical assessment data is collected next. Here, the nurse should take the following actions: 1. Assess for signs and symptoms of local infection. Examine the patient for: Localized pain/tenderness Localized edema Localized erythema (redness) Localized heat Appearance of skin Lesions/rash Functional ability/mobility at site of infection Drainage Assess for signs and symptoms of systemic infection or infection that may become systemic, including: Fever Blood pressure or hypotension as a sign of sepsis Tachypnea Tachycardia Lymphadenopathy Sore throat or sinus tenderness/pain Headache, photosensitivity, or nuchal rigidity Cough, hemoptysis, or sputum production Malaise Anorexia, nausea/vomiting, or abdominal tenderness/pain Urinary frequency, pain, tenesmus, or flank tenderness
2.
Laboratory Data Laboratory data is then gathered and assessed. Abnormal results must be reported. Perhaps the most important piece of laboratory data for the nurse to assess is the patients
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white blood count. The normal white blood count (or leukocyte count) for a healthy individual is between 4,50011,000 cells/mm3. The white blood count elevates in the presence of infection. In addition, the various types of white blood cells should be present in specific percentages in a healthy patient. Thus, it is critical that the nurse determine the patients white blood cell differential count, which indicates the percentage of each type of white blood cell present in the blood. Table 16.1 provides an overview of typical white blood cell levels in a healthy patient. Remember that healing is delayed by infection. Also remember that a wound provides a portal of entry for infectious agents. When infection occurs, leukocytosis occurs. Specific types of white blood cells also increase in number. The differential count allows us to look at the various kinds of white blood cells and track their responses to infection and better grasp their function as a defense against infection. However, when the infection is severe or overwhelming, the production of some types of cells may not be able to keep up with the demand, and decreases in cell production may be noted. Keeping this information in mind, review Table 16.1, which examines the action of the specific types of white blood cells and the meaning of increases or decreases in the values obtained. Table 16.1 White Blood Cell Differential Count
Type of cell Segmented neutrophils Normal Cells action count (%) 56 Neutrophils are phagocytes that provide early, rapid removal of large bacteria and cellular debris. Elevated values Values increase with infection (especially by staphylococci and streptococci), inflammation, and tissue necrosis. Severe rise may herald bone marrow malignancy. An increase in bands causes a shift to the left, meaning marrow is releasing immature rather than mature neutrophils. This is thought to be an early indicator of sepsis. Increases occur with inflammatory and allergic responses, parasitic infestations, tissue necrosis, and cancer metastases. Decreased values Values may decrease in severe infection, when the pool of available neutrophils becomes depleted, when circulating neutrophils are damaged, or when bone marrow damage occurs.
Bands
Bands are immature segmented neutrophils.
Eosinophils
2.7
These are granulocytes that contain toxic substances used to kill foreign cells.
Decreases occur in the presence of suppurative (purulent) infections.
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Table 16.1 White Blood Cell Differential Count

Type of cell Basophils Normal Cells action count (%) 0.3 These cells modify or moderate (calm) systemic allergic responses and anaphylaxis. They are similar to mast cells, which are called tissue basophils. Cells release histamine, heparin, and serotonin during acute inflammatory/ allergic reactions. 34 These are nongranulocytes that form two classes: B and T cells. All recognize foreign antigens. B cells make antibodies that complex with antigens. T cells are cytotoxic killer cells. T cells also help B cells. 4 These are nongranulocytes that are released by the bone marrow when they are still immature. Once released, they mature and become macrophages, capable of phagocytosis. Elevated values Increases occur: During the healing or chronic phases of inflammation In the presence of hypersensitivity reactions After radiation With myeloid leukemia Decreased values Decreases occur during acute infection, stress, and with hyperthyroidism.
Lymphocytes
Elevated values occur with bacterial, viral, and other kinds of infection and with lymphocytic leukemia.
Decreased values occur with impaired lymph drainage, bone marrow failure, and immunologic disorders that attack T cells (e.g., HIV).
Monocytes
Increases occur with infection, connective tissue disorders, and some blood disorders.
Decreases occur with bone marrow injury or failure.
After obtaining and analyzing the patients white blood cell differential count, the nurses actions should be as follows: 1. Evaluate the patients culture and sensitivity. Evaluate the culture to determine the organism responsible for the infection, and examine the sensitivity results to see to which antibiotics the organism is sensitive and resistant.
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2.
3.
Evaluate the patients erythrocyte sedimentation rate (ESR). The ESR is a nonspecific test that detects the presence of inflammation. It rises in autoimmune diseases, such as rheumatoid arthritis. It also rises with rheumatic heart disease, and it may rise with the inflammation that accompanies infection. Normal ESRs for various patient groups are as follows: Adult less than age fifty: 015 mm/hour in the male and 020 mm/hour in the female. Adult greater than age fifty: 020 mm/hour in the male and 030 mm/hour in the female. Child: 010 mm/hour Elevations occur with rheumatic fever, systemic lupus erythematosus, and other inflammatory conditions. Evaluate the patients serum albumin levels by age. Albumin is a reservoir for nitrogen, and nitrogen is needed for tissue growth and healing. When blood volume decreases, serum albumin level increases. An elevated serum albumin level may indicate dehydration. A low serum albumin level may indicate liver or renal disease or malnutrition. Normal levels are as follows: Adult over age sixty: 3.44.8 g/dL Adult age eighteen to sixty: 3.5 g/dL Child: 3.25.4 g/dL Newborn: 2.84.4 g/dL
Diagnosis
In the first part of the assessment, the nurse is collecting data on the patients history of susceptibility to communicable diseases, past response to the infectious process, exposure (recent and past) to pathogens, and history of hygienic practices. Diagnoses that may occur as a result of patient responses in these interview areas include the following: At risk of infection related to: Increased susceptibility Recent exposure Poor hygiene practices Knowledge deficit related to personal susceptibility Knowledge deficit related to hygienic practices
In the second part of the assessment, the nurse is collecting data on factors influencing biological safety (age/developmental factors, preferences/patterns, physical condition, cultural/spiritual factors, socioeconomic factors, environmental factors, and psychologic factors). Diagnoses that may occur as a result of patient responses in these interview areas include risks of infection secondary (or related) to the following: Infants lack of active immunity Exposure in institutional settings (e.g., daycare, preschool, school) High-risk sexual behavior
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Cigarette smoking (primary or secondary smoke) Circulatory changes in the legs Poor nutrition Inadequate sleep Poor stress management Chronic illness Immunosuppressive therapy Invasive lines Refusal of vaccinations due to health/spiritual beliefs Refusal to accept traditional therapy due to nontraditional health beliefs Overcrowding in the home Lack of heat in winter Lack of hot water or running water in the home Rat infestation in neighborhood because of poor garbage collection procedures Inadequately treated chronic or seasonal allergies Fear of loss of privacy/confidentiality
Each of these diagnoses may be complicated by a codiagnosis of knowledge deficit in the area of concern. In the third part of the assessment, the nurse is collecting health examination data. Diagnoses that may occur are collaborative in nature and require a notification of the patients physician. The nurse first assesses for signs and symptoms of localized infectious processes. The nurse may write that the patient presents with a particular constellation of signs and symptoms (be sure they are noted). The exact site must be noted. For example, the nurse may say that the patient presents with a two centimeter nondraining, abscess-like mass in the upper, outer quadrant of the right buttocks. The nurse also needs to combine this description of a localized inflammatory or infectious process with any systemic signs or symptoms. The nurses assesses for signs of systemic infection. These are collaborative findings and need to be reported immediately to prevent medication complications (e.g., sepsis or surgical complications such as a ruptured appendix). For instance, one report may read as follows: Fourteen-year-old male admitted with temperature of 100.6F with no associated hypotension. Respiratory rate of 20 breaths per minute, and heart rate and rhythm regular at 106 beats per minute. Complains of constipation lasting for four days, with onset of nausea this a.m. and one episode of vomiting (approximately one cup). Anorexic. States, I did not feel like eating breakfast or lunch. Complains of periumbilical pain with some radiation to the right lower quadrant. Abdominal guard present. Walks in a hunched position to guard abdomen and lies in bed in left lateral Sims position. (Note: The left lateral Sims position is a semi-prone position in which the client is lying on the left side with the right leg drawn up
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toward the chest. Clients with appendicitis assume this position in an attempt to relieve right lower quadrant pain.) This constellation of signs and symptoms is derived from the nursing assessment and needs to be reported to the physician immediately. In this case, the patient had acute appendicitis and was operated upon within one hour of admission. Another report may read: Twenty-year-old female in her fifth month of pregnancy admitted to the unit with a 104F fever and chills with onset about two hours ago. Fever preceded by two days of sinus pain and low-grade temperature. Respiratory rate of 24 breaths per minute. Heart rate of 126 beats per minute. Patient is complaining of a severe right frontal headache but denies photophobia. No nuchal rigidity noted. Denies cough, hemoptysis, and sputum production. Denies uterine contraction, bleeding, or passage of amniotic fluid. Blood pressure on admission was 104/72, and now, fifteen minutes post-admission, 96/66. Physician phoned stat. In this case, the immediate threat is sepsis. The life of both the mother and the fetus are at stake. A systematic assessment allows the nurse to pull together signs and symptoms that form a coherent constellation that may be summarized and presented to the physician. In the fourth part of the assessment, the nurse is collecting laboratory data, the results of which are collaborative in nature. In both of the cases presented above, an elevated white count accompanied by an increase in segmented neutrophils and bands would be expected and would need to be reported. It is unlikely that a serum albumin or an erythrocyte sedimentation rate would have been ordered in either case. The important conclusion or diagnosis that the nurse needs to make is that both cases represent emergencies and that immediate collaboration with a physician is in order. When infection is the problem, diagnoses (or constellations of signs and symptoms) that point to sepsis or to a need for rapid surgical intervention have the highest priority because these are the most life threatening. Using Maslows hierarchy of needs, they threaten the patients most basic physical need for life.
Planning
Planning is a conscious process in which the nurse establishes patient-centered goals stated in the form of expected outcomes. These goals/outcomes are derived from the diagnoses generated from the assessment. With regard to biological safety, a patient may present with an infected wound, which must be fully described. Then, plans and outcomes related to the wound need to be established and interventions planned, including the type of wound care to be applied. In addition, patients seldom present with a single problemthey usually have related problems or diagnoses that need to be addressed.
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As an example, take the case of a patient admitted for an accidentally self-inflicted gunshot wound. The injury occurred when the patient was hunting deer and could have been prevented had appropriate gun-safety measures been taken. Immediately after the injury, the patient sought medical care for the left upper-arm flesh wound and was discharged after emergency department treatment. Three days later, the patient returns with an infected wound draining a moderate amount of purulent material. The patient had not changed the dressing for two days and so had not observed the wound. The patient also did not comply completely with antibiotic therapy. Even though the patients temperature was only 100.6F and the white count was on the upper limits of normal, the physician decided to admit the patient to the hospital for IV antibiotic therapy to make sure the infection was promptly controlled, especially since the patient has Type II diabetes mellitus. After conducting the patients admission assessment, the registered nurse knows it is important to address infection control measures, especially medical asepsis, and to use sterile technique when changing dressings. The nurse decides to teach the patient these same measures to prepare for the discharge home. Gun safety also needs to be addressed. Furthermore, the nurse discovers while performing the nursing assessment that the patient is noncompliant with the diabetic regimen. With less than ideal blood glucose control, the infection will be more difficult to manage. On the basis of this information, at least two additional diagnoses need to be addressed: Noncompliance with diabetic therapy Risk of future injury related to poor gun-safety procedures
Family issues are important. The nurse, in talking with the patient, finds out that there are grandchildren staying in the home. Although they have parents with them, the grandchildren are at risk of injury, making the whole issue of gun safety even more important. The familial implications of diabetes mellitus also need to be addressed. Before the patient returns home, the following outcomes, framed as patient goals, will need to be obtained. In other words, the patient will: Describe and demonstrate how to change wound dressings using sterile technique. Commit to compliance with diabetic therapy. Discuss with primary relatives the need for regular screening for diabetes mellitus. Relate the gun-safety measures to be instituted immediately to protect the grandchildren as well as the patient.
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Still remaining is that part of the plan that focuses on wound care in the hospital. One way of approaching a subject that varies so greatly from patient to patient is to write overall objectives for a wound-care plan. Three examples are listed below: 1. 2. 3. Maintain and restore defenses (the issue of diabetic blood sugar control would be included within this objective). Avoid the spread of infection. Reduce or eliminate problems or other factors associated with infection.
Expected outcomes would be tailored for this particular patient. For example, under maintain and restore defenses, appropriate goals and outcomes are for the patient to do the following: Become afebrile within twenty-four to forty-eight hours. Maintain blood pressure, heart rate/rhythm, and respiratory rate within normal limits. Select appropriate foods that promote healing and that are consistent with a diabetic diet. (Be sure to select appropriate diet according to physician instructions and agency dietary policies/instructions. Consult with a nutritionist, if necessary.) Maintain a fluid intake of 2,500 mL per day. Maintain a urine output proportional to intake. Maintain fasting blood glucose at the level specified by the physician (perform blood glucose finger sticks as indicated by the physician). Report signs of increasing hunger, thirst, and voiding. (These are signs of diabetic coma. When a diabetic patient develops an infection, the patient is likely to develop hyperglycemia. If uncorrected, this leads to diabetic coma.) Practice proper skin and oral hygiene measures. Wash hands frequently as needed throughout the day, and definitely wash before and after dressing changes if the patient is assisting with the dressing. Keep the dressing dry and report any soiling. Maintain a clean environment. Report on medical asepsis procedures (cleaning, disinfecting, use of sterile technique) that the patient will employ at home upon discharge. Increase knowledge of medications and their proper administration. Obtain sufficient rest/sleep.
When the goals and expected outcomes are complete for each of these three planning objectives, then the nurse will need to develop goals and objectives for gun-safety instructions and the patients diabetic management at home. This planning phase is also the appropriate time for the nurse to gather agency policies and standards that relate to the interventions being implemented. For example, the nurse may need to review: Vital sign frequency in a stable patient upon admission Agency hand washing policies
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Dressing change policies/procedures Maintenance of a sterile field during dressing change Maintenance of a clean environment Diabetic management, including: Diet Blood glucose monitoring Educational materials Patient information sheets on diabetic medications (obtain from pharmacist)
The nurse needs to delegate tasks, not authority or responsibility. If the agency policy permits licensed practical nurses to perform sterile dressing changes, then assign these activities to an LPN. The LPN will also provide daily routine care for the patient. Review the nursing plan with the LPN, not to surrender responsibility for the care, but to enlist LPN support. Establish a time for patient teaching each day and outline topics to be covered. Enlist the help of a diabetic educator, if needed. For each intervention listed, the nurse will also be able to provide a rationale as to the selection of each particular strategy. In presenting this section and the preceding section, the rationales of therapy were presented and integrated throughout the material. The reader may want at this point to evaluate the ease with which a rationale is known for each of the above strategies listed.
Implementation
During implementation, it is vital to maintain medical asepsis (hand washing, sterile dressing changes, disposal of contaminated dressings, use of disposable equipment). Use standardized hand-washing technique. Use sterile technique when changing dressings. Practice universal precautions for blood and body fluids. Build up the patients nonspecific defenses. Provide proper diet, adequate intake, and measurement of output. Make sure the patient obtains enough rest and sleep. Be sure standard procedures (medical asepsis) are followed. Provide assistive and supportive care. Be sure that, in addition to providing wound care, the licensed practical nurse assists the patient with bathing, provides skin care, assists the patient with oral hygiene, cleans and trims nails, encourages participation in care, and assists the patient with walking until the patient is confident and capable of walking alone. Provide the patient with teaching and instruction on biological safety and medical asepsis, diabetic management, and gun safety. Have available a list of community resources on diabetes and diabetic management.
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Evaluation
Evaluation is a process whereby the outcomes obtained are compared with the expected outcomes. Therefore, the expected outcome list becomes an evaluation tool. In the case presented, it would be important to ask questions such as the following: Has the patient become afebrile within twenty-four to forty-eight hours? Have the blood pressure, heart rate/rhythm, and respiratory rate been maintained within normal limits? Has the patient selected appropriate foods that promote healing and that are consistent with a diabetic diet? Has the patients fluid intake met the goal of 2,500 mL/day? Has urine output been proportional to intake? Has the patients fasting blood glucose level met the goal specified by the physician? Has the patient maintained fasting blood glucose at the level specified by physician? Has the patient been performing blood glucose checks per finger stick as directed? Has the patient reported any polyphagia, polydipsia, and polyuria? Has the patient been practicing good skin and oral hygiene? Has the patient been washing hands frequently and appropriately? Has the patient kept the wound dressing dry and/or reported any soiling? Has the patient maintained a clean hospital room environment? Has the patient articulated or demonstrated the ways to clean and disinfect the home and the sterile technique to be used when changing the dressing? Does the patient demonstrate knowledge of the daily medications and their proper administration? Is the patient obtaining sufficient rest and sleep? The registered nurse also wants to know whether the teaching strategies were effective. To answer this question, patient goals and expected outcomes will be compared with the actual outcomes. Some goals and outcomes are evaluated continuously, such as with telemetry in the coronary care unit. Some goals are evaluated every fifteen, twenty, thirty, or sixty minutes. Others are evaluated at two- or four-hour intervals. Others are evaluated once every shift, some once a day, and some at even greater intervals. The frequency of outcome evaluation depends on the severity of the patients condition as well as the nature of the goal. When goals or outcomes are achieved, then the nurse needs to decide if the goal should remain in place or be discontinued. If a goal or outcome is not attained, then the patient or nursing intervention needs to be reassessed.
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RN Fundamentals of Nursing

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About the Authors

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UNIT I: THEORY AND FOUNDATIONS

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Definition of the Nursing Process

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Table 1.1 The Nursing Process

Diagnosis (Outcomes Identification) Planning Implementation

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Electronic Care Plans

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Techniques for Physical Assessment of the Major Body Systems

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Verbal response (circle one score)

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