ADVANCED CLINICAL CONCEPTS

ARDS is an unexpected, catastrophic pulmonary complication

occurring in a person with no previous pulmonary problems.
The mortality rate is high (5!"
#n ARDS, a common laboratory $inding is lowered %&'.
(owever, these clients are not very responsive to high
concentrations o$ oxygen.
Thin) about the physiology o$ the lungs by remembering
%**%+ %ositive *nd *xpiratory %ressure is the instillation and
maintenance o$ small amounts o$ air into the alveolar sacs to
prevent them $rom collapsing each time the client exhales.
The amount o$ pressure can be set with the ventilator and is
usually around 5 to , cm o$ water.
Suction only when secretions are present.
-e$ore drawing arterial blood gases $rom the radial artery,
per$orm the Allen test to assess collateral circulation. .a)e
the client/s hand blanch by obliterating both the radial and
ulnar pulses. Then release the pressure over the ulnar artery
only. #$ $low through the ulnar artery is good, $lushing will be
seen immediately. The Allen test is then positive, and the
radial artery can be used $or puncture. #$ the Allen test is
negative, repeat on the other arm. #$ this test is also negative,
see) another site $or arterial puncture. The Allen test ensures
collateral circulation to the hand i$ thrombosis o$ the radial
artery should $ollow the puncture.
#$ the client does not have &' to his0her brain, the rest o$ the
in1uries do not matter because death will occur. (owever,
they must be removed $rom any source o$ imminent danger,
such as a $ire.
%2"' 345 or %&' 56 on 5! &' signi$ies respiratory $ailure.
A child in severe distress should be on ,! &'.
*arly signs o$ shoc) are agitation and restlessness resulting
$rom cerebral hypoxia.
#$ cardiogenic shoc) exists with the presence o$ pulmonary
edema, i.e., $rom pump $ailure, position client to R*D72*
venous return ((#8( 9&:;*R/s with legs down" in order to
decrease venous return $urther to the le$t ventricle.
Severe shoc) leads to widespread cellular in1ury and impairs
the integrity o$ the capillary membranes. 9luid and osmotic
proteins seep into the extra vascular spaces, $urther reducing
cardiac output. A vicious cycle o$ decreased per$usion to A;;
cellular level activities ensues. All organs are damaged, and i$
per$usion problems exist, the damage can be permanent.
All vasopressors0vasodilator drugs are potent and dangerous
and re<uire weaning on and o$$. Do not change in$usion rates
simultaneously.
A client is brought into the hospital su$$ering shoc) symptoms
as a result o$ a bee sting. :hat is the $irst priority=
.aintaining an open airway (the allergic reaction damages the
lining o$ the airways causing edema". Also, )eep the client
warm without constricting clothing> )eep legs elevated (not
Trendelenburg because the weight o$ the lower organs
restricts breathing".
*pinephrine+ ,+,, .' to .5ml sub< $or mild
*pinephrine+ ,+,,, or 5ml #? $or severe
?olume expanding $luids are usually given to clients in
shoc). (owever, i$ the shoc) is cardiogenic, pulmonary
edema may result.
Drugs o$ choice $or shoc)
- Digitalis preparations+ #ncrease the contractility o$ the heart
muscle
- ?asoconstrictors (;evophed, Dopamine"+ 8enerali@ed
vasonconstriction to provide more available blood to the
heart to help maintain cardiac output.
A common volumeAexpanding substance is plasma and
possibly whole blood.
Bou are caring $or a woman who was in severe automobile
accident several days ago. She has several $ractures and
internal in1uries. The exploratory laparotomy was success$ul
in controlling the bleeding. (owever, today you $ind that this
client is bleeding $rom her incision, short o$ breath, has a
wea) thready pulse, has cold and clammy s)in, and
hematuria.
- :hat do you thin) is wrong with the client, and what would
you expect to do about it=
- These are typical signs and symptoms o$ D#2 crisis. *xpect
to administer #? heparin to bloc) the $ormation o$ thrombin
(2oumadin does not do this". (owever, the client described
is already past the coagulation phase and into the
hemorrhagic phase. (er management would be
administration o$ clotting $actors along with palliative
treatment o$ the symptoms as they arise. ((er prognosis is
poor".
C2;*DARC <uestions on 2%R o$ten deal with prioriti@ation
o$ actions. Euestion+ :hat actions are re<uired $or each o$
the $ollowing situations=
- A '4Ayear old motorcycle accident vistim with a ruptured
artery i$ the leg is pulseless and apneic.
- A F6Ayear old $irst time pregnant woman who arrests during
labor.
- A ,GAyear old with no pulse or respirations who is trapped in
an overturned car, which is starting to catch $ire.
- A 4Ayear old businessman who arrests two days a$ter a
cervical laminectomy.
:(*C T& S**H *.*R8*C2B .*D#2A; S*R?#2* (*.S"
- The American (eart Association recommends that those
with )nown angina pectoris see) emergency medical care i$
chest pain is C&T relieved by three nitroglycerin tablets 5
minutes apart over a ,5minute period.
- A person with previously unrecogni@ed coronary disease
experiencing chest pain persisting $or ' minutes or longer
should see) emergency medical treatment.
#t is important $or the nurse to stay current with the American
(eart Association/s guidelines $or -asic ;i$e Support (-;S"
by being certi$ied every two years as re<uired.
1
#$ one rescuer is per$orming 2%R, , ,5+' ratio o$ compression
to ventilations is per$ormed $or 4 cycles, then reassess $or
breathing and pulse. #$ two rescuers are per$orming 2%R, a
,5+' ratio is now recommended $or compressions to
ventilations. %er$orm $or ,5 cycles with a ,0min
compression rate. :hen trading o$$, start with compressions.
#nitiate 2%R with -;S guidelines immediately, then move on
to Advanced 2ardiac ;i$e Support (A2;S" guidelines.
:hen signi$icant arterial acidosis is noted, try to reduce %2&'
by increasing ventilation, which will correct arterial, venous,
and tissue acidosis. -icarbonate may exacerbate acidosis b
producing 2&'. Thus, the A2;S guidelines have
recommended bicarbonate C&T be used unless hyper)alemia
and0or preexisting acidosis is documented.
#n$ants0prematures may have problems with the $ollowing that
can predispose to arrest+ -eware o$ the I(/sJ K hypoxia,
hypoglycemia, hypothermia, increased (L (metabolic and0or
respiratory acidosis", hypercoagulability (i$ polycythemia
exists".
2hanges is osmolarity cause shi$ts in $luid. The osmolarity o$
the extracellular $luid (*29" is almost entriely due to sodium.
The osmolarity o$ intracellular $luid (#29" is related to many
particles, with potassium being the primary electrolyte. The
pressures in the *29 and the #29 are almost identical. #$
either *29 or #29 change in concentration, $luid shi$ts $rom
the area o$ lesser concentration to the area o$ greater
concentration.
Dextrose ,! is a hypertonic solution and should be
administered #?.
Cormal saline is an isotonic solution and is used $or irrigations,
such as bladder irrigations or #? $lush lines with intermittent #?
medication.
7se only isotonic (neutral" solutions in irrigations, in$usions,
etc., unless the speci$ic aim is to shi$t $luid into intracellular or
extracellular spaces.
%otassium imbalances are potentially li$eAthreatening, must be
corrected immediately. A low magnesium o$ten accompanies
a low HL, especially with the use o$ diuretics.
9luid ?olume De$icit+ Dehydration
- *levated -7C+ The -7C measures the amount o$ urea
nitrogen in the blood. 7rea is $ormed in the liver as the end
product o$ protein metabolism. The -7C is directly related to
the metabolic $unction o$ the liver and the excretory $unction o$
the )idneys.
- 2reatinine, as with -7C, is excreted entirely by the )idneys
and is there$ore directly proportional to renal excretory
$unction. (owever, unli)e -7C, the creatinine level is a$$ected
very little by dehydration, malnutrition, or hepatic $unction.
The daily production o$ creatinine depends on muscle mass,
which $luctuates very little. There$ore, it is a better test o$
renal $unction than is the -7C. 2reatinine is generally used in
con1unction with the -7C test and they normally are in a ,+'
ratio.
- Serum osmolality measures the concentration o$ particles in a
solution. #t re$ers to the $act that the same amount o$ solute is
present, but the amount o$ solvent ($luid" is decreased.
There$ore, the blood can be considered Imore
concentrated.J
- 7rine osmolality and speci$ic gravity increase.
2hec) the #? tubing container to determine the drip $actor
because drip $actors vary. The most common drip $actors
are ,, ,', ,5, and 6 drops per milliliter. A microdrip is 6
drops per milliliter.
9lushing a saline loc) re<uires approximately , M times the
amount o$ $luid that the tubing will hold in order to e$$iciently
$lush the tubing. R*.*.-*R to use sterile techni<ue to
prevent complications such as in$iltration, emboli and
in$ection.
A p( o$ less than 6.N or more than G.N is C&T
2&.%AT#-;* :#T( ;#9*.
The acronym R&.* can help you remember+ Respiratory,
&pposite, .etabolic, *<ual.
Review the order o$ blood $low to the heart+
- 7noxygenated blood $lows $rom the superior and in$erior
vena cava into the right atrium, then to the right ventricle. #t
$lows out o$ the heart through the pulmonary artery, to the
lungs $or oxygenation. The pulmonary vein delivers
oxygenated blood bac) to the le$t atrium, then to the le$t
ventricle (largest, strongest chamber" and out the aorta.
- Review the three structures that control the oneAway $low o$
blood through the heart+
1. ?alves Atrioventricular valves Tricuspid (right side"
.itral (le$t side"
Semilunar valves %ulmonary (in pulmonary
artery" Aortic (in aorta"
'. 2ordae Tendinae
F. %apillary muscles
Since the T waves represents repolari@ation o$ the ventricle,
this is a critical time in the heartbeat. This action represents
a resting and regrouping stage so that the next heartbeat
can occur. #$ de$ibrillation occurs during this phase, the
heart can be thrust into a li$eAthreatening dysrhythmia.
&bserve the client $or tolerance o$ the current rhythm. This
in$ormation is the most important data the nurse can collect
on the client with an arrythmia.
R*.*.-*R to monitor the client as well as the machineO #$
the *H8 monitor shows a severe dysrhythmia, but the client
is sitting up <uietly watching a T? without any sign o$
distress, assess to determine i$ the leads are attached
properly.
.ar)ing the operative site is re<uired $or procedures
involving right0le$t distinctions, multiple structures ($ingers,
toes", or levels (spinal procedures". Site mar)ing should be
done with the involvement o$ the client.
:ound dehiscence is separation o$ the wound edges and is
more li)ely to occur with vertical incisions. #t usually occurs
a$ter the early postoperative period, when the client/s own
granulation tissue is Ita)ing overJ the wound, a$ter
absorption o$ the sutures has begun. *visceration o$ the
2
wound is protrusion o$ intestinal contents (in an abdominal
wound" and is more li)ely in clients who are older, diabetic,
obese, or malnourished and have prolonged paralytic ileus.
C2;*DARC items will $ocus on the nurse/s role in terms o$ the
entire perioperative process. Sample+ A 4FAyear old mother o$
' teenage daughters enters the hospital to have her
gallbladder removed in a sameAday surgery using a scope
instead o$ an incision. :hat nursing needs will dominate each
phase o$ her short hospital stay=
- %reparation phase+ *ducation about postoperative care, C%&,
assist with meeting $amily needs.
- &perative phase+ Assessment, management o$ the operative
suite.
- %ostAanesthesia phase+ %ain management, postAanesthesia
precautions.
- %ostAoperative phase+ %revent and assess $or complications,
pain management, dietary restrictions, activity.
(#? clients with tuberculosis re<uire respiratory isolation.
Tuberculosis is the only real ris) to nonApregnant caregivers
that is not related to a brea) in universal precautions (i.e.,
needle stic)s, etc.".
STACDARD %R*2A7T#&CS+
- :ash hands, even i$ gloves have been worn to give care
- :ear gloves (latex" $or touching blood or body $luids, or any
nonAintact body sur$ace.
- :ear gowns during any procedure that might generate
splashes (changing clients with diarrhea".
- 7se mas)s and eye protection during activity which might
disperse droplets (suctioning".
- Do not recap needles, dispose o$ in punctureAresistant
containers.
- 7se mouth piece $or resuscitation e$$orts.
- Re$rain $rom giving care i$ you have open s)in lesions.
2aregivers who are pregnant may choose not to care $or a
client with 2ytomegalovirus (2.?".
%ediatric (#? is o$ten evidenced by lymphoid interstitial
pneumonitis.
The $ocus o$ C2;*DARC <uestions is li)ely to be assessment
o$ early signs o$ the disease and management o$
complications associated with (#?.
9or narcotic induced respiratory depression, administer
Caloxone .,mg to .4mg #? every 'AF minutes as needed,
until ,.mg is achieved.
7se nonAinvasive methods $or pain management when
possible+
- Relaxation techni<ues
- Distraction
- #magery
- -io$eedbac)
- #nterpersonal s)ills
- %hysical care+ altering positions, touch, hot and cold
applications.
Carcotic analgesics are prepared $or pain relie$ because they
bind to the various opiate receptor sites in the 2CS. .orphine
is o$ten the pre$erred narcotic (R*.*.-*R+ it causes
respiratory depression".
&ther agonists are meperidine and methadone. Carcotic
antagonists bloc) the attachment o$ narcotics to the
receptors, such as Carcan (naloxone". &nce Carcan has
been given, additional narcotics cannot be given until the
Carcan e$$ects have passed.
Do not ta)e away the coping style used in a crisis stateP
D*C#A;. #t is a use$ul and needed tool at the initial stage $or
some. Support, do not challenge, unless it hinders0bloc)s
treatment K endangering the patient.
MEDICAL SURGICAL NURSING
RESPIRATORY SYSTEM
9ever can cause dehydration $rom excessive $luid loss in
diaphoresis. #ncreased temperature also increases
metabolism and the demand $or oxygen.
(igh ris) $or pneumonia+
- Any person, who has altered level o$ consciousness, has
depressed or absent gag re$lex and cough re$lexes, is
susceptible to aspirating oropharyngeal secretions.
(Alcoholics, anesthesi@ed individuals, those with brain in1ury,
drug overdose, or stro)e victims".
- :hen $eeding, raise the head o$ the bed and position the
client on side K not on bac).
-ronchial breath sounds are heard over areas o$ density or
consolidation. Sound waves are easily transmitted over
consolidated tissue.
(ydration K enables li<ui$ication o$ mucous trapped in the
bronchioles and alveoli, $acilitating expectoration. *ssential
$or the client experiencing $ever. #mportant because F to
4 ml o$ $luid are lost daily by the lungs through
evaporation.
#rritability and restlessness are early signs o$ cerebral
hypoxia K the client is not getting enough oxygen to the
brain.
%neumonia preventatives+
- *lderly+ $lu shots> pneumonia immuni@ations> avoiding
sources o$ in$ection and indoor pollutants (dust, smo)e, and
aerosols"> do not smo)e.
- #mmunosuppressed and debilitated persons+ in$ection
avoidance, sensible nutrition, ade<uate inta)e, balance o$
rest and activity.
- 2omatose and immobile persons+ elevate head o$ bed to
$eed> turn $re<uently.
2ompensation occurs over time in clients with chronic lung
disease, and arterial blood gases (A-8s" are altered. #t is
imperative that baseline data are obtained on the client.
%roductive cough and com$ort can be $acilitated by SemiA
9owler/s or high 9owler/s positions, which lessen pressure
on the diaphragm $rom abdominal organs. 8astric distention
becomes a priority in these clients because it elevates the
diaphragm and inhibits lung expansion.
3
%in) pu$$er+ -arrel chest is indicative o$ emphysema and is
caused by use o$ accessory muscles to breathe, which causes
the person to wor) harder to breathe, but the amount o$ &'
ta)en in in ade<uate to oxygenate the tissues.
-lue bloater+ insu$$icient oxygenation occurs with chronic
bronchitis and leads to generali@ed cyanosis and o$ten rightA
sided heart $ailure.
2ells o$ the body depend on oxygen to carry out their
$unctions. #nade<uate arterial oxygenation is mani$ested by
cyanosis and slow capillary re$ill (5F seconds". A chronic sign
is clubbing o$ the $ingernails, and a late sign is clubbing o$ the
$ingers.
2aution must be used in administering &' to 2&%D client.
The stimulus to breathe is hypoxia (hypoxic drive" not the
usual hypercapnia, the stimulus to breathe $or healthy
persons. There$ore, i$ too much oxygen is given, the client
may stop breathingO
(ealth %romotion+
- *ating consumes energy needed $or breathng. &$$er
mechanically so$t diets, which do not re<uire as much chewing
and digestion. Assist with $eeding i$ needed.
- %revent secondary in$ections K avoid crowds, contact with
persons who have in$ectious diseases, and respiratory irritants
(tobacco smo)e".
- Teach client to report any change in characteristics o$ sputum.
- *ncourage client to hydrate well and to obtain immuni@ations
needed ($lu and pneumonia".
:hen as)ed to prioriti@e nursing actions, use the A-2 rule+
- Airway $irst
- Then breathing
- Then circulation
;oo) and listen. #$ breath sounds are clear, but the client is
cyanotic and lethargic, ade<uate oxygenation is not occurring.
The )ey to respiratory status assessment o$ breath sounds as
well as visuali@ation o$ the client. -reath sounds are better
Idescribed,J not named, e.g., sounds should be described as
Icrac)les,J Iwhee@e,J IhihgApitched whistling sound,J rather
than Irales,J Irhonchi,J etc., which may not mean the same
thing to each clinical pro$essional.
:atch $or C2;*DARC <uestions that deal with oxygen
delivery. #n adults, &' must bubble through some type o$
water solution so it can be humidi$ied i$ given at 34 ;0min or
delivered directly to the trachea. #$ given at , to 4 ;0min or by
mas) or nasal prongs, the oropharynx and nasal pharynx
provide ade<uate humidi$ication.
:ith cancer o$ the larynx, the tongue and mouth o$ten appear
white, gray, dar) brown, or blac), and may appear patchy.
Tracheostomy care involves cleaning the inner cannula,
suctioning, and applying a clean dressing.
Air entering the lungs is humidi$ied along the nasoAbronchial
tree. This natural humidi$ying pathway is gone $or the client
who has had a laryngectomy. #$ the air is not humidi$ied
be$ore entering the lungs, secretions tend to thic)en and
become crusty.
A laryngectomy tube has a larger lumen and is shorter than
the tracheostomy tube. &bserve the client $or any signs o$
bleeding or occlusion, which are the greatest immediate
postoperative ris)s ($irst '4 hours".
9ear o$ cho)ing is very real $or laryngectomy clients. They
cannot cough as be$ore because the glottis is gone. Teach
the Iglottal stopJ techni<ue to remove secretions (ta)e a
deep breath, momentarily occlude the tracheostomy tube,
cough, and simultaneously remove the $inger $rom the tube".
T- SH#C T*ST+ a positive T- s)in test is exhibited by an
induration ,mm or greater in diameter 4N hours a$ter s)in
test. Anyone who has received a -28 vaccine will have a
positive s)in test and must be evaluated using a chest xAray.
Teaching is very important with the T- client. Drug therapy
is usually long term (Q months or longer". #t is essential that
the client ta)e the medications as prescribed $or the entire
time. S)ipping doses or prematurely terminating the drug
therapy can result in a public health ha@ard.
T*A2(#C8 %&#CTS K
- Ri$ampin+ Reduces e$$ectiveness o$ oral contaceptives>
should use other birth control methods during treatment>
gives body $luids orange tinge> stains so$t contacts.
- #sonia@id (#C("+ #ncreases Dilantin levels.
- *thambutal+ ?ision chec) be$ore starting therapy and
monthly> may have to ta)e , to ' years longer.
- Teach rationale $or combination drug therapy to increase
compliance. Resistance develops more slowly i$ several
antiAT- drugs given, instead o$ 1ust one drug at a time.
Some tumors are so large that they $ill entire lobes o$ the
lung. :hen removed, large spaces are le$t. 2hest tubes
are not usually used with these clients because it is help$ul i$
the mediastinal cavity, where the lung used to be, $ills up
with $luid. This $luid helps prevent a shi$t o$ the remaining
chest organs to $ill the empty space.
#$ the chest tube remains disconnected, do not clampO
#mmediately place the end o$ the tube in a container o$
sterile saline or water until a new drainage system can be
connected.
#$ the chest tube is accidentally removed $rom the client, the
nurse should apply pressure immediately with an occlusive
dressing and noti$y the healthcare provider.
2hest Tube C2;*DARC content+ 9luctuations (tidaling" in
the $luid will occur i$ there is no external suction. These
$luctuating movements are a good indicator that the system
is intact and should move upward with each inspiration and
downward with each expiration. #$ $luctuations cease, chec)
$or )in)ed tubing, accumulation o$ $luid in the tubing,
occlusions, or change in the client/s position, since
expanding lung tissue may be occluding the tube opening.
Remember, when external suction is applied the $luctuations
cease. .ost hospitals D& C&T .#;H chest tubes as a
means o$ clearing or preventing clots K it is too easy to
remove chest tubes. .ediastinal tubes may have orders to
be stripped because o$ location, compared to larger thoracic
cavity tubes.
4
?arious pathophysiological conditions can be related to the
nursing diagnosis I#ne$$ective -reathing %atterns.J
,. #nability o$ air sacs to $ill and empty properly (emphysema,
cystic $ibrosis"
'. &bstruction o$ the air passages (carcinoma, asthma, chronic
bronchitis"
F. Accumulation o$ $luid in the air sacs (pneumonia"
4. Respiratory muscle $atigue (2&%D, pneumonia"
RENAL SYSTEM
Cormally, )idney excrete approximately ,ml o$ urine per )g o$
body weight per hour, which is about , to ' liters in a '4Ahour
period.
*lectrolytes are pro$oundly a$$ected by )idney problems.
There must be a balance between extracellular $luid and
intracellular $luid to maintain homeostasis. A change in the
number o$ ions or in the amount o$ $luid will cause a shi$t in
one direction or the other. Sodium and chloride are the
primary extracellular ions. %otassium and phosphate are the
primary intracellular ions.
#n some cases, persons in AR9 may not experience the
oliguric phase but may progress directly to diuretic phase
during which the urine output may be as much as , liters per
day.
-ody weight is a good indicator o$ $luid retention and renal
status. &btain accurate weights on all clients with renal $ailure
K done on the same scale at the same time every day.
9luid ?olume Alterations 9luid
*xcess symptoms+
- Dyspnea
- Tachycardia
- Rugular vein distention
- %eripheral edema
- %ulmonary edema
9luid de$icit symptoms+
- Decreased urine output
- Reduction in body weight
- Decreased body turgor
- Dry mucous membranes
- (ypotension
- Tachycardia
:atch $or signs o$ hyper)alemia+ di@@iness, wea)ness,
cardiac irregularities, muscle cramps, diarrhea, and nausea.
%otassium has a critical sa$e range (F.5 to 5. m*g0;"
because it a$$ects the heart, and any imbalance must be
corrected by medications or dietary modi$ication. ;imit high
potassium $oods (bananas, avocados, spinach, $ish" and salt
substitutes, which are high in potassium.
2lients with renal $ailure retain sodium. :ith water retention,
the sodium becomes diluted and serum levels may appear
near normal. :ith excessive water retention, the sodium
levels appear decreased dilution". ;imit $luid and sodium
inta)e in AR9 clients.
During oliguric phase, minimi@e protein inta)e. :hen the
-7C and creatinine return to normal, aR9 is determined to
be resolved.
Accumulation o$ waste products $rom protein metabolism is
the primary cause o$ uremia. %rotein must be restricted in
2R9 clients. (owever, i$ protein inta)e is inade<uate, a
negative nitrogen balance occurs causing muscle wasting.
The glomerular $iltration rate (89R" is most o$ten used as an
indicator o$ level o$ protein consumption.
D#A;BS#S 2&?*R*D -B .*D#2AR*+
- All persons in the 7nited States are eligible $or .edicare as
o$ their $irst day o$ dialysis under special *nd Stage Renal
Disease $unding.
- .edicare card will indicate *SRD.
- Transplantation is covered by .edicare procedure> coverage
terminates six months postoperative i$ dialysis is no longer
re<uired.
%rotein inta)e is restricted until blood chemistry shows ability
to handle protein catabolites+ urea, creatinine. *nsure high
calorie inta)e so protein is spared $or its own wor)+ give hard
candy, 1elly beans, $lavored carbohydrate powders.
As )idneys $ail, medications must o$ten be ad1usted. &$
particular importance is digoxin toxicity since digitalis
preparations are excreted by the )idneys. Signs o$ toxicity in
adults include nausea, vomiting, anorexia, visual
disturbances, restlessness, headache, cardiac arrythmias,
and pulse 56 beats per minute (bradycardia".
The ma1or di$$erence between dailysate $or hemodialysis and
peritoneal dialysis is the amount o$ glucose. %eritoneal
dialysis dialysate is much higher in glucose. 9or this reason,
i$ the dialysate is le$t in the peritoneal cavity too long,
hyperglycemia may occur.
The )ey to resolving 7T# with most antibiotics is to )eep the
blood level o$ the antibiotic constant. #t is important to tell
the client to ta)e the antibiotics roundAtheAcloc) and not s)ip
doses so that a consistent blood level can be maintained $or
optimal e$$ectiveness.
;ocation o$ the pain can help determine location o$ the
stone.
- 9lan) pain usually means the stone is in the )idney or upper
ureter. #$ it radiates in the abdomen or scrotum, the stone is
li)ely to be in the ureter or bladder.
- *xcruciating, spasticAtype pain is called colic.
- During )idney stone attac)s, it is pre$erable to administer
pain medications at regularly scheduled intervals rather than
%RC to prevent spasm and optimi@e com$ort.
%ercutaneous nephrostomy+ A needle0catheter is inserted
through the s)in into the calyx o$ the )idney. The stone may
be dissolved by percutaneous irrigation with a li<uid which
will dissolve the stone, or ultrasonic sound waves
(lithotripsy" can be directed through the needle0catheter to
brea) up the stone which then can be eliminated through the
urinary tract.
-ladder spasms $re<uently occur a$ter T7R%. #n$orm the
client that the presence o$ the oversi@ed balloon on the
5
catheter (F to 45 cc in$late" will cause a continuous $eeling o$
needing to void. The client should not try to avoid around the
catheter since this can precipitate bladder spasms.
.edications to reduce or prevent spasms should be given.
#nstillation o$ hypertonic or hypotonic solution into a body
cavity will cause a shi$t in cellular $luid. 7se only sterile saline
$or bladder irrigation a$ter T7R% since the irrigation must be
isotonic to prevent $luid and electrolyte imbalance.
#n$orm the client prior to discharge that some bleeding is
expected a$ter T7R%. ;arge amounts o$ blood or $ran) bright
bleeding should be reported. (owever, it is normal $or the
client to pass small amounts o$ blood during the healing
process as well as small clots. (e should rest <uietly and
continue drin)ing large amounts o$ $luid.
CARDIOVASCULAR SYSTEM
:hat is the relationship o$ the )idneys to the cardiovascular
system=
- The )idneys $ilter about a liter o$ blood per minute
- #$ cardiac output is decreased, the amount o$ blood going
through the )idneys is decreased> urinary output is decreased.
There$ore, a decreased urinary output may be a sign o$
cardiac problems.
- :hen the )idneys produce and excrete .5 ml o$ urine per )g
o$ body weight or average F ml0hr output, the blood supply is
considered to be minimally ade<uate to per$use the vital
organs.
Angina is caused by myocardial ischemia. :hich cardiac
medications would be appropriate $or acute angina=
- Digoxin K Cot appropriate K #ncreases the strength and
contractility o$ the heart muscle> the problem in angina is that
the muscle is not receiving enough oxygen. Digoxin will not
help.
- Citroglycerin K Appropriate K 2auses dilation o$ the coronary
arteries, allowing more oxygen to get to the heart muscle.
- Atropine K Cot appropriate K #ncreases heart rate by bloc)ing
vagal stimulation, which suppresses the heart rate. Does not
address the lac) o$ &' to the heart muscle.
- %ropanolol (#nderal" K Cot appropriate K $or acute angina
attac)> however, is appropriate $or longAterm management o$
stable angina because it acts as a betaAbloc)er to control
vasoconstriction.
-lood pressure is created by the di$$erence in the pressure o$
the blood as it leaves the heart and the resistance it meets
$lowing out to the tissues. There$ore, any $actor that alters
cardiac output or peripheral vascular resistance will alter blood
pressure. Diet and exercise, smo)ing cessation, weight
control, and stress management can control many $actors that
in$luence the resistance blood meets as it $lows $rom the
heart.
Remember the ris) $actors $or hypertension+ heredity, race,
age, alcohol abuse, increased salt inta)e, obesity, and use o$
oral contraceptives.
The number one cause o$ 2?A with hypertensive clients is
nonAcompliance with medication regime. (ypertension is
o$ten symptomless, and antihypertensive medications are
expensive and have side e$$ects. Studies have shown that the
more clients )now about their antihypertensive medications,
the more li)ely they are to ta)e them K teaching is important.
Decreased blood $low results in diminished sensation in the
lower extremities. Any heat source can cause severe burns
be$ore the client actually reali@es the damage is being done.
A client is admitted with severe chest pain and states that he
$eels a terrible, tearing sensation in his chest. (e is
diagnosed with a dissecting aortic aneurysm. :hat
assessment should the nurse obtain in the $irst $ew hours=
- ?ital signs <, hour
- Ceurological vital signs
- Respiratory status
- 7rinary output
- %eripheral pulses
During aortic aneurysm repair, the large arteries are
clamped $or a period o$ time and )idney damage can result.
.onitor daily -7C and creatinine levels. Cormal -7C is ,
to ' mg0dl and normal creatinine is '+,. :hen this ratio
increases or decreases, suspect renal problems.
A positive (omen/s sign is considered an early indication o$
thrombophlebitis. (owever, it may also indicate muscle
in$lammation. #$ a deep vein thrombosis has been
con$irmed, a (oman/s sign should not be elicited because o$
the increased ris) o$ emboli@ation.
(eparin prevents conversion o$ $ibrinogen to $ibrin and
prothrombin to thrombin, thereby inhibiting clot $ormation.
Since the clotting mechanism is prolonged, do not cause
tissue trauma which may lead to bleeding when giving
heparin subcutaneously. Do not massage area or aspirate>
give in the abdomen between the pelvic bones> ' inches
$rom umbilicus> rotate sites.
(*%AR#C+
- Antagonist+ %rotamine Sul$ate
- ;A-+ %TT or A%TT determines e$$icacy
- Heep ,.5 to '.5 times normal control
2&7.AD#C+
- Antagonist+ ?itamin H
- ;A-+ %T determines e$$icacy
- Heep ,.5 to '.5 times normal control
#CR+ Desirable therapeutic level usually ' to F seconds
(re$lects how long it ta)es a blood sample to clot".
A holter monitor o$$ers continuous observation o$ the client/s
heart rate. To ma)e assessment o$ the rhythm strips, most
meaning$ul, teach the client to )eep a record o$+
- .edication times and doses
- 2hest pain episodes K type and duration
- ?alsalva maneuver (straining at stool, snee@ing, coughing"
- Sexual activity
- *xercise
2ardioversion is the delivery o$ synchorni@ed electrical
shoc) to the myocardium.
Di$$erentiate in synchronous and asynchronous pacema)ers+
6
- Synchronous or demand pacema)er $ires only when the
client/s heart rate $alls below a rate set on the generator.
- Asynchronous or $ixed pacema)er $ires at a constant rate.
Restricting sodium reduces salt and water retention, thereby
reducing vascular volume and preload.
D#8#TA;#S+
- Side e$$ects o$ digitalis are increased when the client is
hypo)alemic.
- (as a negative chronotropic e$$ect, i.e., it shows the heart
rate. (old the digitalis i$ the pulse rate is 56, 3,', or has
mar)edly changed rhythm.
- -radycardia, tachycardia, or dysrhythmias may be signs o$
digitalis toxicity+ these signs include nausea, vomiting, and
headache in adults.
- #$ withheld, consult with physician.
#n$ective endocarditis damage to heart valves occurs with the
growth o$ vegetative lesions on valve lea$lets. These lesions
pose a ris) o$ emboli@ation> erosion0per$oration o$ the valve
lea$lets> or abscesses within ad1acent myocardial tissue.
?alvular stenosis or regurgitation (insu$$iciency", most
commonly o$ the mitral valve, can occur depending upon the
type o$ damage in$licted by the lesions, leading to symptoms
o$ le$t K or rightAsided heart $ailure.
Acute and Subacute #n$ective *ndocarditis A There are ' types
o$ in$ective endocarditis+
- Acute , which o$ten a$$ects individuals with previously normal
hearts and healthy valves, and carries a high mortality rate
- Subacute , which typically a$$ects individuals with preexisting
conditions, such as rheumatic heart disease, mitral valve
prolapse, or immunosuppression. #ntravenous drug abusers
are at ris) $or both acute and subacute bacterial endocarditis.
:hen this population develops Subacute #n$ective
*ndocarditis, the valves on the right side o$ the heart (tricuspid
and pulmonic" are typically a$$ected due to the introduction o$
common pathogens which coloni@e on the s)in (S. epidermis
and 2andida" into the venous system.
%ericarditis K presence o$ a $riction rub is an indication o$
pericarditis (in$lammation o$ the lining o$ the heart". ST
segment elevation and T wave inversion are also signs o$
pericarditis.
:ith mitral valve stenosis, blood is regurgitated bac) into the
le$t atrium $rom the le$t ventricle. #n early period, there may be
no symptoms> but, as the disease progresses, the client will
exhibit excessive $atigue, dyspnea on exertion, orthopnea, dry
cough, hemoptysis, or pulmonary edema. There will be a
rumbling apical diastolic murmur, and atrial $ibrillation is
common.
GASTROINTESTINAL SYSTEM
A 9owler/s or semiA9owler/s position is bene$icial in reducing
the amount o$ regurgitation as well as preventing the
encroachment o$ the stomach tissue upward through the
opening in the diaphragm.
Stress can cause or exacerbate ulcers. Teach stress
reduction methods and encourage those with a $amily history
o$ ulcers to obtain medical surveillance $or ulcer $ormation.
2;#C#2A; .AC#9*STAT#&CS &9 8# -;**D#C8+
- %allor+ con1uctival, mucous membranes, nail beds
- Dar), tarry stools
- -right red or co$$eeAground emesis
- Abdominal mass or bruit
- Decreased -%, rapid pulse, cool extremities (shoc)".
The 8# tract usually accounts $or only , to ' ml $luid
loss per day, although it $ilters up to N liters per day. ;arge
$luid losses can occur i$ vomiting and0or diarrhea exists.
&piate drugs tend to depress gastric motility. (owever, they
should be given with care, and those receiving them should
be closely monitored because a distended intestinal wall
accompanied by decreased muscle tone may lead to
intestinal per$oration.
Diverticulosis is the presence o$ pouches in the wall o$ the
intestine. There is usually do discom$ort, and the problem
goes unnoticed unless seen on radiological examination
(usually prompted by some other condition".
Diverticulitis is an in$lammation o$ the diverticula (punches",
which can lead to per$oration o$ the bowel.
A client admitted with complaints o$ severe lower abdominal
pain, cramping, and diarrhea is diagnosed with diverticulitis.
:hat are the nutritional needs o$ this client throughout
recovery=
- Acute phase K C%& graduating to li<uids.
- Recovery phase K no $iber or $oods that irritate the bowel.
- .aintenance phase K highA$iber diet, with bul)A$orming
laxatives to prevent pooling o$ $oods in the pouches where
they can become in$lamed. Avoid small, poorly digested
$oods such as popcorn, nuts, seeds, etc.
-owel obstructions+
- .echanical+ due to disorders outside the bowel (hernia,
adhesions", due to disorders within the bowel (tumors,
diverticulitis", or due to bloc)age o$ the lumen in the intestine
(intussusception, gall stone".
- ConAmechanical+ paralytic ileus, which does not involve any
actual physical obstruction, but results $rom inability o$ the
bowel itsel$ to $unction.
-lood gas analysis will show al)alotic state i$ the bowel
obstruction is high in the small intestine where gastric acid is
secreted. #$ the obstruction is in the lower bowel where base
solutions are secreted, the blood will be acidic.
A client admitted with complaints o$ constipation, thready
stools and rectal bleeding over the past $ew months is
diagnose with a rectal mass. :hat are the nursing priorities
$or this client=
- C%&
- C8 tube (possibly an intestinal tube such as a .illerAAbbott"
- #? $luids
- Surgical preparations o$ bowel (i$ obstruction is complete"
- Teaching (preoperative, nutrition, etc."
Diet recommended by the American 2ancer Society to
prevent bowel cancer+
7
- *at more cruci$erous vegetables ($rom the cabbage $amily
such as broccoli, cauli$lower, -russels sprouts, cabbage, and
)ale".
- #ncrease $iber inta)e.
- .aintain average body weight
- *at less animal $at.
A.*R#2AC 2AC2*R S&2#*TB R*2&..*CDAT#&CS $or
early detection o$ 2olon 2ancer+
- A digital rectal examination every year a$ter 4.
- A stool blood test every year a$ter 5.
- A sigmoidoscopy examination every F to 5 years a$ter the age
o$ 5, based on the advice o$ a physician.
2ancer o$ the colon is the most common cancer in the 7S
when considering men and women together. An early sign is
the rectal bleeding. *ncourage patients 5 years o$ age or
older, or those with increased ris) $actors, to be screened
yearly with $ecal occult blood testing. Routine colonoscopy at
5 is also recommended.
2;#C#2A; .AC#9*STAT#&CS &9 RA7CD#2*
- Bellow s)in, sclera, and0or mucous membranes (bilirubin in
s)in"
- Dar)Acolored urine (bilirubin in urine"
- 2hal)y or clayAcolored stools (absence o$ bilirubin in stools"
9etor hepaticus is a distinctive breath odor o$ chronic liver
disease. #t is characteri@ed by a $ruity or musty odor which
results $rom the damaged liver/s inability to metaboli@e and
detoxi$y mercaptan which is produced by the bacterial
degradation o$ metionine, a sul$urous amino acid.
9or treatment o$ ascities, paracentesis and peritoneovenous
shunts (;a?een and Denver shunts" may be indicated.
*sophageal varices may rupture and cause hemorrhage.
#mmediate management includes insertion o$ an
esophagogastric balloon tamponade K a -la)emoreA
Sengsta)en or .innesota tube. &ther therapies include
vasopressors, vitamin H, coagulation $actors, and blood
trans$usions.
Ammonia is not bro)en down as usual in the damaged liver>
there$ore, the serum ammonia level rises.
%R&?#D* AC *C?#R&C.*CT 2&CD72#?* T& *AT#C8 $or
clients who are anorexic and0or nauseated+
- Remove strong odors immediately> they can be o$$ensive and
increase nausea.
- *ncourage client to sit up $or meals> this can decrease the
propensity to vomit.
- Serve small, $re<uent meals.
;iver tissue is destroyed by hepatitis. Rest and ade<uate
nutrition are necessary $or regeneration o$ liver tissue being
destroyed by the disease. Since many drugs are metaboli@ed
in the liver, drug therapy must be scrutini@ed care$ully.
2aution the client that recovery ta)es many months, and
previously ta)en medications should not be resumed without
the healthcare provider/s directions.
Acute pancreatic pain is located retroperitoneally. Any
enlargement o$ the pancreas causes the peritoneum to stretch
tightly. There$ore, sitting up or leaning $orward will reduce
the pain.
9ollowing an endoscopic retrogade
cholangiopancreatography (*R2%", the client may $eel sic).
The scope is placed in the gallbladder and the stones are
crushed and le$t to pass on their own. These clients may be
prone to pancreatitis.
ConAsurgical management o$ the client with cholecystitis
includes+
- ;owA$at diet
- .edications $or pain and clotting i$ re<uired
- Decompression o$ the stomach via C8 tube
ENDOCRINE SYSTEM
Thyroid storm is a li$eAthreatening event that occurs with
uncontrolled hyperthyroidism due to 8rave/s disease.
Symptoms include $ever, tachycardia, agitation, anxiety, and
hypertension.
- %rimary nursing interventions include maintaining an airway
and ade<uate aeration.
- %ropylthiouracil (%T7" or methima@ole (Tapa@ole" are
antithyroid drugs used to treat thyroid storm. %ropanolol
(#nderal" may be given to decrease excessive sympathetic
stimulation.
%ostAoperative thyroidectomy+ be prepared $or the
possibility o$ laryngeal edema. %ut a tracheostomy set at
bedside along with oxygen and a suction machine> 2aLL
gluconate easily accessible.
Cormal serum calcium is Q. to ,.5 m*<0;. The best
indicator o$ parathyroid problems is a decrease in the client/s
calcium compared to the preoperative value.
#$ two or more parathyroid glands have been removed, the
chance o$ tetany increases dramatically+
- .onitor serum calcium levels (Q. to ,.5 mg0dl is normal
range"
- 2hec) $or tingling o$ toes, $ingers, and around the mouth.
- 2hec) $or 2hvoste)/s sign (tap over the parotid gland and
which $or twitching o$ lip S positive"
- 2hec) Trousseau/s sign (carpopedal spasm a$ter in$lating
-% cu$$ above systolic pressure S positive".
.yxedema coma can be precipitated by acute illness,
withdrawal o$ thyroid medication, anesthesia, use o$
sedatives, or hypoventilation (with the potential $or
respiratory acidosis and carbondioxide narcosis". The
airway must be )ept patent, and ventilator support as
indicated.
.any people ta)e steroids $or a variety o$ conditions.
C2;*DARC <uestions o$ten $ocus on the need to teach
clients the importance o$ precisely $ollowing the prescribed
regimen. They should be cautioned against suddenly
stopping the medications and be in$ormed that it is
necessary to taper o$$ ta)ing steroids.
ADD#S&CJS 2R#S#S #S A .*D#2A; *.*R8*C2B+
-rought on by sudden withdrawal o$ steroids or a stress$ul
event (trauma, severe in$ection"
8
- ?ascular 2ollpase+ (ypotension and tachycardia occur>
administer #? $luids at rapid rate until stabili@ed.
- (ypoglycemia+ Administer #? glucose
- AD.#C#ST*R %AR*CT*RA; (BDR&2&RT#S&C*+ *ssential
$or reversing the crisis.
- A;D&ST*R&C* R*%;A2*.*CT+ Administer $ludrocortisone
acetate(9lorine$" %& (only available as oral preparation" with
simultaneous administration o$ salt (sodium chloride" i$ client
has a sodium de$icit.
Teach clients to ta)e steroids with meals to prevent gastric
irritation. They should never s)ip doses. #$ they have nausea
or vomiting $or more than ,' to '4 hours, they should contact
the physician.
:hy do diabetics have trouble with wound healing= (igh
blood glucose contributes to damage o$ the smallest vessels,
the capillaries. This damage causes permanent capillary
scarring, which inhibits the normal activity o$ the capillary.
This phenomenon causes disruption o$ capillary elasticity and
promotes problems such as diabetic retinopathy, poor healing
or brea)s in the s)in, cardiovascular abnormalities, etc.
8lycosylated (gb ((gb A,2"
- #ndicates glucose control over previous ,' days (li$e o$ R-2"
- ?aluable measurement o$ diabetes control.
The body/s response to illness0stress is to produce glucose.
There$ore, any illness results in hyperglycemia.
#$ in doubt whether the client is hyperglycemic or
hypoglycemic, treat $or hypoglycemia.
S*;9A.&C#T&R#C8 -;&&D 8;72&S* (S.-8"
- %rovides tight glucose control thereby decreasing the potential
$or longAterm complications
- Techni<ue is speci$ic to each meter i$ meter is used.
- .onitor be$ore meals, at bedtime, and any time symptoms
occur.
- Record results and report to healthcare provider at time o$
visit.
MUSCULOSKELETAL SYSTEM
A client comes to the clinic complaining o$ morning sti$$ness,
weight loss, and swelling o$ both hands and wrists.
Rheumatoid arthritis is suspected. :hich methods o$
assessment might the nurse use and which methods would
the nurse not use=
- 7se inspection, palpation, and strength testing.
- Do not use range o$ motion (this activity promotes pain
because R&. is limited".
#n the 1oint, the normal cartilage becomes so$t, $issures and
pitting occur, and the cartilage thins. Spurs $orm and
in$lammation sets in. The result is de$ormity mar)ed by
immobility, pain, and muscle spasm. The prescribed
treatment regimen is corticosteroids $or the in$lammation>
splinting, immobili@ation, and rest $or 1oint de$ormity> and
CSA#DS $or the pain.
Synovial tissues line the bone o$ the 1oints. #n$lammation o$
this lining causes destruction o$ tissue and bone. *arly
detection o$ rheumatoid arthritis can decrease the amount o$
bone and 1oint destruction. &$ten the disease will go into
remission. Decreasing the amount o$ bone and 1oint
destruction will reduce the amount o$ disability.
:hat activity recommendations should the nurse provide a
client with rheumatoid arthritis=
- Do not exercise pain$ul, swollen 1oints.
- Do not exercise any 1oint to the point o$ pain.
- %er$orm exercises slowly and smoothly> avoid 1er)y
movements.
C2;*DARC <uestions o$ten $ocus on the $act that avoiding
sunlight is )ey in management o$ lupus erythematosus K this
is what di$$erentiates it $rom other connective tissue
diseases.
Degenerative 1oint disease (DRD" and osteoarthritis are o$ten
described as the same disease, and indeed they both result
in hypertrophic changes in the 1oints. (owever, they di$$er in
that osteoarthritis is an in$lammatory disease and DRD is
characteri@ed by nonAin$lammatory degeneration o$ the
1oints.
%ostmenopausal, thin, 2aucasian women are at highest ris)
$or development o$ osteoporosis. *ncourage exercise, a diet
high in calcium, and supplemental calcium. :hile T7.S is
an excellent source o$ calcium, it is also high in sodium and
hypertensive or edematous individuals should see) another
source $or supplemental calcium.
The main cause o$ $ractures in the elderly, especially
women, is osteoporosis. The main $racture sites seem to be
hip, vertebral bodies, and 2olles/ $racture o$ $orearm.
C2;*DARC <uestions $ocus on sa$ety precautions.
#mproper use o$ assistive devices can be very ris)y. :hen
using a nonAwheeled wal)er, the client should li$t and move
the wal)er $orward, then ta)e a step into it. The client should
avoid scooting the wal)er or shu$$ling $orward into it which
ta)es more energy and is less stable than a single
movement.
:hat type o$ $racture is more di$$icult to heal, an extra
capsular $racture (below the nec) o$ the $emur" or an
intracapsular $racture (in the nec) o$ the $emur"=
- The blood supply enters the $emur below the nec) o$ the
$emur. There$ore, an intraAcapsular $racture is much more
harder to heal and has a greater li)elihood o$ necrosis since
it is cut o$$ $rom the blood supply.
The ris) o$ a $at embolism, a syndrome in which $at globules
migrate into the bloodstream and combine with platelets to
$orm emboli, is greatest in the $irst F6 hours a$ter a $racture.
#t is more common in clients with multiple $ractures, $ractures
o$ long bones, and $ractures o$ the pelvis. The initial
symptom of a fat embolism is confusion due to hypoxemia
(chec) blood gases $or %&'". Assess $or respiratory
distress, restlessness, irritability, $ever, and petechiae. #$ an
embolus is suspected, noti$y physician STAT, draw blood
gases, administer oxygen, and assist with endotracheal
intubation.
#n clients with hip $ractures, thromboembolism is the most
common complication. %revention includes passive range o$
motion exercises, elastic stoc)ing use, elevation o$ the $oot
9
o$ the bed '5 degrees to increase venous return, and lowA
dose hepatin therapy.
2lients with $ractures, casts, or edema to the extremities need
$re<uent neurovascular assessment distal to the in1ury. S)in
color, temperature, sensation, capillary re$ill, mobility, pain and
pulses should be assessed.
Assess the I5 %sJ o$ neurovascular $unctioning+ pain,
paresthesia, pulse, pallor and paralysis.
&rthopedic wounds have a tendency to oo@e more than other
wounds. A suction drainage device usually accompanies the
client to the postoperative $loor. 2hec) drainage o$ten.
A big problem a$ter 1oint replacement is in$ection.
9ractures o$ bone predispose the client to anemia, especially
i$ long bones are involved. 2hec) hemtocrit every F to 4 days
to monitor erythropoiesis.
#nstruct the client not to li$t the leg upward $rom a lying position
or to elevate the )nee when sitting. This upward motion can
pop the prosthesis out o$ the soc)et.
#mmobile clients are prone to complications+ s)in integrity
problems, $ormation o$ urinary calculi (may limit mil) inta)e",
and venous thrombosis (may be on prophylactic
anticoagulants".
The residual limb should be elevated on one pillow. #$ the
residual limb (stump" is elevated too high, the elevation can
cause contracture.
NEUROSENSORY SYSTEM
8laucoma is o$ten painless and symptomA$ree. #t is usually
pic)ed up as part o$ a regular eye exam.
*ye drops are used to cause pupil constriction since
movement o$ the muscles to constrict the pupil also allows
a<ueous humor to $low out, thereby decreasing the pressure
in the eye. %ilocarpine is o$ten used. 2aution client that
vision may be blurred , to ' hours a$ter administration o$
pilocarpine and adaptation to dar) environments is di$$icult
because o$ pupillary constriction (desired e$$ect o$ the drug".
There is an increased incidence o$ glaucoma in the elderly
population. &lder clients are prone to problems associated
with constipation. There$ore, the nurse should assess these
clients $or constipation and postoperative complications
associated with constipation, and implement a plan o$ care
directed at prevention, and, i$ necessary, treatment $or
constipation.
The lens o$ the eye is responsible $or pro1ecting light, which
enters onto the retina so that images can be discerned.
:ithout the lens, which becomes opa<ue with cataracts, light
cannot be $iltered and vision is blurred.
:hen the cataract is removed, the lens is gone, ma)ing
prevention o$ $alls important. #$ the lens is replaced with an
implant, vision is better than i$ a contact lens is used (some
visual distortion" or i$ glasses are used (greater visual
distortion K everything has a curved shape".
The ear consists o$ three parts+ the external ear, middle ear,
and the inner ear. #nner ear disorders, or disorders o$ the
sensory $ibers going to the 2CS., o$ten are neurogenic in
nature and may not be helped with a hearing aid. *xternal
and middle ear problems (conductive" may result $rom
in$ection, trauma or wax buildup. These types o$ disorders
are treated more success$ully with hearing aids.
C2;*DARC <uestions o$ten $ocus on communicating with
older adults who are hearing impaired.
- Spea) in a lowApitched voice, slowly, and distinctly.
- Stand in $ront o$ the person with the light source behind the
client.
- 7se visual aids i$ available.
NEUROLOGICAL SYSTEM
7se o$ the 8lasgow 2oma Scale eliminates ambiguous
terms to describe neurologic status such as lethargic,
stuporous, or obtunded.
Almost every diagnosis in the CACDA $ormat is applicable,
as severely neurologically impaired persons re<uire total
care.
2lients with an altered state o$ consciousness are $ed by
enteral routes since the li)elihood o$ aspiration with oral
$eedings is great. Residual $eeding is the amount o$
previous $eeding still in the stomach. The presence o$ ,
ml residual in adults usually indicates poor gastric emptying
and the $eeding should be held.
%aralytic ileus is common in comatose clients. 8astric tube
aids in gastric decompression.
Any client on bedrest0immobili@ed must have range o$
motion exercises o$ten and very $re<uent position changes.
Do not leave the client in any one position $or longer than '
hours. Any position that decreases venous return is
dangerous, i.e., sitting with dependent extremities $or long
periods.
#$ temperature elevates, ta)e <uic) measures to decrease it
since $ever increases cerebral metabolism and can increase
cerebral edema.
Sa$ety measures $or immobili@ed clients+
- %revent s)in brea)down with $re<uent turning.
- .aintain ade<uate nutrition.
- %revent aspiration with slow, small $eedings or C8 $eedings.
- .onitor neurological signs to detect the $irst signs that
intracranial pressure may be increasing.
- %rovide range o$ motion exercises to prevent de$ormities.
- %revent respiratory complications K $re<uent turning and
positioning $or optimal drainage.

Restlessness may indicate a return to consciousness but
can also indicate anoxia, distended bladder, covert bleeding,
or increasing cerebral anoxia. Do not overAsedate, and
report any symptoms o$ restlessness.
The $orces o$ impact in$luence the type o$ head in1ury. They
include acceleration in1ury, which is caused by the head in
motion, and deceleration in1ury, which occurs when the head
10
stops suddenly. (elmets are a 8R*AT preventive measure
$or motorcyclists and bicyclists.
*ven subtle behavior changes, such as restlessness,
irritability, or con$usion, may indicate increased #2%.
2S9 lea)age carries the ris) o$ meningitis and indicates a
deteriorating condition. -ecause o$ 2S9 lea)age, the usual
signs o$ increased #2% may not occur.
Try not to use restraints> they only increase restlessness.
A?&#D narcotics since they mas) level o$ responsiveness.
%hysical assessment should concentrate on respiratory
status, especially in clients with in1ury at 2AF to 2A5, as
cervical plexus innervates diaphragm.
#t is imperative to reverse spinal shoc) as <uic)ly as possible.
%ermanent paralysis can occur i$ a spinal cord is compressed
$or ,' to '4 hours.
A common cause o$ death a$ter spinal cord in1ury is urinary
tract in$ection. -acteria grow best in al)aline media, so
)eeping urine diluted ad acidic is prophylactic against
in$ection. Also, )eeping the bladder emptied assists in
avoiding bacterial growth in urine, which is stagnated in the
bladder.
-enign tumors continue to grow and ta)e up space in the
con$ined area o$ the cranium causing neural and vascular
compromise $or the brain, increased intracranial pressure, and
necrosis o$ brain tissue K even benign tumors must be treated
as they may have malignant e$$ects.
2raniotomy postAoperative medications+
- 2orticosteroids to reduce swelling
- Agents and osmotic diuretics to reduce secretions (atropine,
robinul"
- Agents to reduce sei@ures (phenytoin"
- %rophylactic antibiotics
Symptoms involving motor $unction usually begin in the upper
extremities with wea)ness progressing to spastic paralysis.
-owel and bladder dys$unction occurs in Q! o$ the cases.
.S is more common in women. %rogression is not Iorderly.J
Drug therapy $or .S clients+ A2T(, cortisone, 2ytoxan, and
other immunosuppressive drugs. Cursing implications $or
administration o$ these drugs should $ocus on prevention o$
in$ection.
#n clients with .yasthenia 8ravis, be alert $or changes in
respiratory status K the most severe involvement may result in
respiratory $ailure.
-edrest o$ten relieves symptoms. -ladder and respiratory
in$ections are o$ten a recurring problem. Ceed $or health
promotion teaching.
.yasthenic crisis is associated with a positive edrophonium
(Tensilon" test, while a cholinergic crisis is associated with a
negative test.
C2;*DARC <uestions o$ten $ocus on the $eatures o$
%ar)inson/s disease K tremors (a coarse tremor o$ $ingers and
thumb on one hand which disappears during sleep and
purpose$ul activity K also called Ipill rollingJ", rigidity,
hypertonicity, and stooped posture. 9ocus+ SA9*TBO
An important aspect o$ %ar)inson/s treatment is drug
therapy. Since the pathophysiology involves an imbalance
between acetylcholines and dopamine, symptoms can be
controlled by administering dopamine precursor (;evodopa".
2CS involvement related to cause o$ 2?A+
- (emorrhagic+ caused by a slow or $ast hemorrhage into the
brain tissue K o$ten related to hypertension.
- *mbolytic+ caused by a clot, which has bro)en away $rom
some vessel and has lodged in one o$ the arteries o$ the
brain, bloc)ing the blood supply. #t is o$ten related to
atherosclerosis (may happen again".
Atrial $lutter0$ibrillation has a high incidence o$ thrombus
$ormation $ollowing arrythmias due to turbulence o$ blood
$low through all valves0heart chambers.
A woman who had a stro)e two days ago has le$tAsided
paralysis. She has begun to regain some movement in her
le$t side. :hat can the nurse tell the $amily about the client/s
recovery period=
- The <uic)er movement is recovered, the better the
prognosis is $or more or $ull recovery. She will need
patience and understanding $rom her $amily as she tries to
cope with the stro)e. .ood swings can be expected during
the recovery period, and bouts o$ depression and tear$ulness
are li)ely.
:ords that describe losses $rom 2?A+
- Apraxia+ inability to per$orm purpose$ul movements in the
absence o$ motor problems.
- Dysarthria+ di$$iculty articulating
- Dysphasia+ impairment o$ speech and verbal comprehension
- Aphasia+ loss o$ the ability to spea)
- Agraphia+ loss o$ the ability to write
- Alexia+ loss o$ the ability to read
- Dysphagia+ dys$unctional swallowing
Steroids are administered a$ter a stro)e to decrease cerebral
edema and retard permanent disability. (' inhibitors are
administered to prevent peptic ulcers.
HEMATOLOGY/ONCOLOGY
%hysical symptoms occur as a compensatory mechanism
when the body is trying to ma)e up $or a de$icit somewhere
in the system. 9or instance, cardiac output increases when
hemoglobin levels drop below Gg0dl.
&C;B use normal saline to $lush #? tubing or to run with
blood. C*?*R add medications to blood products. T:&
registered nurses should simultaneously chec) the
physician/s prescription, client/s identity, and blood bag
label.
A '4Ayear old is admitted with large areas o$ ecchymosis on
both upper and lower extremities. She is diagnosed with
acute myeologenous leu)emia. :hat are the expected
laboratory $indings $or this client and what is the expected
treatment=
- ;ab+ Decreased (gb, decreased (ct, decreased platelet
count, altered :-2 (usually <uite high".
11
- Treatment+ %revention o$ in$ection> prevention and0or control
o$ bleeding> high protein, high calorie diet> assistance with
AD;> drug therapy.
#n$ection in the immunosuppressed person may not be
mani$ested with an elevated temperature. #t is imperative,
there$ore, that the nurse per$orms a total and thorough
assessment o$ the client $re<uently.
.ost oncologic drugs cause immunosuppression. %revention
o$ secondary in$ections is vitalO Advise client to stay away
$rom persons with )nown in$ections such as colds. #n the
hospital, maintain an environment as sterile and as clean as
possible. These persons should not eat raw vegetables or
$ruits K only coo)ed to destroy any bacteria.
(odg)in/s is one o$ the most curable o$ all adult malignancies.
*motional support is vital. 2areer development is o$ten
interrupted $or treatment. 2hemotherapy renders many male
clients sterile. .ay ban) sperm prior to treatment, i$ desired.
REPRODUCTIVE SYSTEM
.enorrhagia (pro$use or prolonged menstrual bleeding" is the
most important $actor relating to benign uterine tumors.
Assess $or signs o$ anemia.
:hat is the anatomical signi$icance o$ a prolapsed uterus=
:hen the uterus is displaced, it impinges on other structures
in the lower abdomen. The bladder, rectum, and small
intestine can protrude through the vaginal wall.
;aser therapy or cryosurgery is used to treat cervical cancer
when the lesion is small and locali@ed. #nvasive cancer is
treated with radiation, coni@ation, hysterectomy, or pelvic
exenteration (a drastic surgical procedure where the uterus,
ovaries, $allopian tubes, vagina, rectum, and bladder are
removed in an attempt to stop metastasis". 2hemotherapy is
not use$ul with this type o$ cancer.
%ap smears should begin within F years o$ having intercourse
or no later than age ',, whichever comes $irst. Should be
done annually until age F and then may be done every ' to F
years i$ a woman has F consecutive normal results. A$ter age
G may stop i$ woman has F consecutive normal and no
abnormal pap smears in last , years. :omen at high ris)
should have annual screenings.
&varian cancer is the leading cause o$ death $rom gynecologic
cancers in the 7S. 8rowth is insidious, so it is not recogni@ed
until it is at an advanced stage.
The ma1or emphasis in nursing management o$ cancers o$ the
reproductive tract is early detection.
The importance o$ teaching $emale clients how to do sel$A
breast examination cannot be overemphasi@ed. *arly
detection is related to positive outcomes.
The presence or absence o$ hormone receptors is paramount
in selecting clients $or ad1uvant therapy.
.en whose testes have not descended into the scrotum or
whose testes descended a$ter age 6 are at high ris) $or
developing testicular cancer. The most common symptom is
the appearance o$ a small, hard lump about the si@e o$ a pea
on the $ront or side o$ the testicle. .anual testicular
examination should be done a$ter a shower by gently
palpating the testes and cord to loo) $or a small lump.
Swelling may also be a sign o$ testicular cancer.
STDs in in$ants and children usually indicate sexual abuse
and should be reported. The nurse is legally responsible to
report cases o$ child abuse. 2hlamydia is the most reported
communicable disease in the 7nited States.
%elvic in$lammatory disease (%#D" involves one more o$ the
pelvic structures. The in$ection can cause adhesions and
eventually result in sterility. .anage the pain associated
with %#D with analgesics and warm sit@ baths. -edrest in a
semiA9owler/s position may increase com$ort and promote
drainage. Antibiotic treatment is necessary to reduce
in$lammation and pain.
A client comes to the clinic with a chancre on his penis.
:hat is the usualy treatment=
- #. dose o$ penicillin (such as -en@athine penicillin 8 '.4
million units".
- &btain sexual history, including the names o$ his sex
partners, so that they can receive treatment.
BURNS
.assive volumes o$ #? $luids are given. #t is not uncommon
to give over ,, cc0hr during various phases o$ burn care.
(emodynamic monitoring must be closely observed to be
sure the client is supported with $luids but is not overloaded.
#n$ection is a li$eAthreatening ris) $or those with burns.
Dressing changes are ?*RB %A#C97;O .edicate client
prior to procedure.
%reAexisting conditions that might in$luence burn recovery
are age, chronic illness, diabetes, cardiac problems, etc.",
physical disabilities, disease, medications used routinely,
and drug and0or alcohol abuse.
PEDIATRIC NURSING
GROWTH AND DEVELOPMENT:
1. When doe !"#$h %en&$h do'!%e( S by 4 years
2. When doe $he )h"%d "$ 'n'**o#$ed( S N months
3. When doe + )h"%d +)h"e,e -./ o0 +d'%$ he"&h$( S '
years
4. When doe + )h"%d $h#o1 + !+%% o,e#h+nd( S ,N months
5. When doe + )h"%d *e+2 345 1o#d en$en)e( S ' years
6. When doe + )h"%d 'e )"o#( S 4 years
7. When doe + )h"%d $"e h"/he# hoe( S 5 years
-e aware that a girl/s growth spurt during adolescence
begins earlier than boys (as early as , years old".
Temper tantrums are common in the toddler, i.e., considered
Inormal,J or average behavior.
12
-e aware that adolescence is a time when the child $orms
his0her identity and that rebellion against $amily values is
common $or this age group.
Cormal growth and development )nowledge is used to
evaluate interventions and therapy. 9or example, I:hat
behavior would indicate that thyroid hormone therapy $or a 4A
monthAold is e$$ective=J Bou must )now what milestones are
accomplished by a 4AmonthAold. &ne correct answer would
be Ihas steady head controlJ which is an expected milestone
$or a 4AmonthAold and indicates that replacement therapy is
ade<uate $or growth.
7se $acts and principles related to growth and development in
planning teaching interventions. 9or example+ I:hat tas)
could a 5AyearAold diabetic boy be expected to accomplish by
himsel$=J &ne correct answer would be to pic) the in1ection
sites. This is possible $or a preschooler to do and gives the
child some sense o$ control.
SchoolAage children are in *ri)son/s stage o$ industry,
meaning they li)e to do and accomplish things. %eers are
also becoming important $or this age child.
Age groups concepts o$ bodily in1ury+
- #n$ants+ A$ter 6 months, their cognitive development allows
them to remember pain.
- Toddlers+ 9ear intrusive procedures.
- %reschoolers+ 9ear body mutilation.
- School Age+ 9ear loss o$ control o$ their body.
- Adolescent+ .a1or concern is change in body image.
CHILD HEALTH PROMOTION
Subcutaneous in1ection, rather than intradermal, invalidates
the .antoux test.
The common cold is not a contraindication $or immuni@ation.
9ollowing immuni@ation, what teaching should the nurse
provide to the parents=
- #rritability, $ever (5,'9", redness and soreness at in1ection
site $or ' to F days are normal side e$$ects o$ D%T and #%?
administration.
- 2all health care provider i$ sei@ures, high $ever, or highA
pitched crying occur.
- A warm washcloth on the thing in1ection site and IbicyclingJ
the legs with each diaper change will decrease soreness.
- Acetaminophen (Tylenol" is administered orally 4 to 6 hours
(, to ,5 mg0Hg".
2hildren with 8erman measles pose a serious threat to their
unborn siblings. The nurse should counsel all expectant
mothers, especially those with young children, to be aware o$
the serious conse<uences o$ exposure to 8erman measles
during pregnancy.
2ommon childhood problems are encountered by nurses
caring $or children in the community or hospital settings. The
child/s age directly in$luences the severity and management o$
these problems.
Teach proper coo)ing and storage to preserve potency, i.e.,
coo) vegetables in small amount o$ li<uid. Store mil) in
opa<ue container.
Add potassium to #? $luids &C;B with ade<uate urine
output.
7rinary output $or in$ants and children should be , to '
ml0)g0hr.
7se o$ syrup o$ ipecac is no longer recommended by the
American Academy o$ %ediatrics. Teach parents that it is
C&T recommended to induce vomiting in any way as it may
cause more damage.
RESPIRATORY DISORDERS
2hild needs ,5! o$ the usual calorie inta)e $or normal
growth and development.
Do not examine the throat o$ a child with epiglottis due to the
ris) o$ completely obstructing the airway, i.e., do not put a
tongue blade or any ob1ect in the throat.
#n planning and providing nursing care, a patent airway is
always a priority o$ care, regardless o$ ageO
Respiratory disorders are the primary reason most children
and their $amilies see) medical care. There$ore, these
disorders are $re<uently tested on the C2;*DARC. Hnowing
the normal parameters $or respiratory rates and the )ey
signs o$ respiratory distress in children is essentialO
The nurse should be sure a %T and %TT have been
determined prior to a tonsillectomy. .ore importantly, the
nurse should as) i$ there has been a history o$ bleeding,
prolonged0excessive, or i$ there is a history o$ any bleeding
disorders in the $amily.
:hen calculating a pediatric dosage, the nurse must o$ten
change the child/s weight $rom pounds to )ilograms.
(#CT+ weight expressed in )ilograms should always be a
smaller number than weight expressed in pounds.
CARDIOVASCULAR DISORDERS
%olycythemia is common in children with cyanotic de$ects.
The heart rate o$ a child will increase with crying or $ever.
#n$ants may re<uire tube $eeding to conserve energy.
-asic di$$erence between cyanotic and acyanotic de$ects+
- Acyanotic+ (as abnormal circulation, however, all blood
entering the systemic ciruclation is oxygenated.
- 2yanotic+ (as abnormal circulation with unoxygenated blood
entering systemic circulation.
2ongestive heart $ailure is more o$ten associated with
acyanotic de$ects.
2(9 is a common complication o$ congenital heart disease.
#t re$lects the increased wor)load o$ the heart resulting $rom
13
shunts or obstructions. The two ob1ectives in treating 2(9 are
to reduce the wor)load o$ the heart and increase cardiac
output.
:hen $re<uent weighings are re<uired, weigh client on the
same scale at same time o$ day so that accurate comparisons
can be made.
NEUROMUSCULAR DISORDERS
The nursing goal in caring $or children with Down syndrome is
to help the child reach his0her &%T#.A; level o$ $unctioning.
9eed in$ant or child with cerebral palsy using nursing
interventions aimed at preventing aspiration. %osition child
upright and support the lower 1aw.
The signs o$ #2% are the opposite o$ those o$ shoc).
- Shoc)+ #ncreased pulse, Decreased blood pressure.
- #ncreased #2%+ Decreased pulse, #ncreased blood pressure.
-aseline data on the child/s 7S7A; behavior and level o$
development is essential so changes associated with
increased #2% can be detected *AR;B.
Do not pump shunt unless speci$ically prescribed. The shunt
is made up o$ delicate valves, and pumping changes
pressures within the ventricles.
.edication noncompliance is the most common cause o$
increased sei@ure activity.
Do C&T use tongue blade, padded or not, during a sei@ure. #t
can cause traumatic damage to mouth0oral cavity.
.onitor hydration status and #? therapy care$ully. :ith
meningitis, there may be inappropriate AD( secretions
causing $luid retention (cerebral edema" and dilutional
hyponatremia.
(eadache upon awa)ening is the most presenting symptom o$
brain tumors.
.ost postoperative clients with in$ratentorial tumors are
prescribed to lie $lat and turn to either side. A large tumor may
re<uire that the child C&T be turned to the operative side.
Suctioning, coughing, straining, and0or causes increased #2%.
RENAL DISORDERS
Decreased urinary output is 9#RST sign o$ renal $ailure.
Surgical correction $or hypospadias is usually done be$ore
preschool years due to achieving sexual identity, castration
anxiety and toilet training.
GASTROINTESTINAL DISORDERS
Typical parent0$amily reaction to a child with an obvious
mal$ormation such as cle$t lip0palate are <uilt, disappointment,
grie$, sense o$ loss, and anger.
2hildren with cle$t lip0palate and those with pyloric stenosis
both have a nursing diagnosis Ialteration in nutrition> less
than body re<uirements.J
- 2le$t lip0palate is related to decreased ability to suc).
- %yloric stenosis is related to $re<uent vomiting.
Cutritional needs and $luid and electrolyte balance are )ey
problems $or children with 8# disorders. The younger the
child, the more vulnerable they are to $luid and electrolyte
imbalances and greater is the need $or caloric inta)e
re<uired $or growth.
Ta)e axillary temperature on children with congenital
megacolon.
HEMATOLOGICAL DISORDERS
Remember the (gb norms+
- Cewborn+ ,4 to '4 g0dl
- #n$ant+ , to ,5 g0dl
- 2hild+ ,, to ,6 g0dl
Teach $amily about administration o$ oral iron+
- 8ive on empty stomach (as tolerated $or better absorption"
- 8ive with citrus 1uices (vitamin 2" $or increased absorption
- 7se dropper or straw to avoid discoloring teeth
- Stools will become tarry
- #ron can be $atal in severe overdose> )eep away $rom
children. Do not give with dairy products.
#nherited bleeding disorders (hemophilia and sic)le cell
anemia" are o$ten used to test )nowledge o$ genetic
transmission patterns. Remember+
- Autosomal recessive+ -oth parents must be hetero@ygous,
or carriers o$ the recessive trait, $or the disease to be
expressed in their o$$spring. :ith each pregnancy, there is a
,+4 chance o$ the in$ant having the disease. (owever, all
children o$ such patterns 2AC get the disease K C&T '5!
o$ them. This is the transmission $or sic)le cell anemia,
cystic $ibrosis, and phenyl)etonuria (%H7".
- DAlin)ed recessive trait+ The trait is carried on the D
chromosome, there$ore, usually a$$ects male o$$spring, e.g.,
hemophilia. :ith each pregnancy o$ a woman who is a
carrier there is a '5! chance o$ having a child with
hemophilia. #$ the child is male, he has a 5! chance o$
having hemophilia. #$ the child is $emale, she has a 5!
chance o$ being a carrier.
(ydration is very important in treatment o$ sic)le cell disease
because it promotes hemodilution and circulation o$ red cells
through the blood vessels.
#mportant terms+
- (etero@ygous gene ((gbAS" sic)le cell trait
- (omo@ygous gene ((bSS" sic)le cell disease
- Abnormal hemoglobin ((8-S" disease and trait
Supplemental iron is not given to clients with sic)le cell
anemia. The anemia is not caused by iron de$iciency. 9olic
acid is given only to stimulate R-2 synthesis.
(ave epinephrine and oxygen readily available to treat
anaphylaxis when administering lAasparaginase.
14
%rednisone is $re<uently used in combination with
antineoplastic drugs to reduce the mitosis o$ lymphocytes.
Allopurinol, a xanthineAoxidase inhibitor, is also administered
to prevent renal damage $rom uric acid build up during cellular
lysis.
METABOLIC AND ENDOCRINE DISORDERS
An in$ant with hypothyroidism is o$ten described as a Igood,
<uiet babyJ by the parents.
*arly detection o$ hypothyroidism and phenylhetonuria is
essential in preventing mental retardation in in$ants.
Hnowledge o$ normal growth and development is important,
since a lac) o$ attaintment can be used to detect the existence
o$ these metabolic0endocrine disorders and attainment can be
used $or evaluating the treatment/s e$$ect.
Cutrasweet (aspartame" contains phenylalanine and should
not there$ore, be given to a child with phenyl)etonuria.
Diabetes mellitus (D." in children was typically diagnosed as
insulin dependent diabetes (Type #" until recently. A mar)ed
increase in Type ## D. has occurred recently in the 7S,
particularly among CativeAAmerican, A$ricanAAmerican, and
(ispanic children and adolescents. Adolescence $re<uently
causes di$$iculty with management since growth is rapid and
the need to be li)e peers ma)es compliance di$$icult.
Remember to consider the child/s age, cognitive level o$
development, and psychosocial development when answering
C2;*DARC <uestions.
:hen child is in )etoacidosis, administer regular insulin #? as
prescribed in normal saline.
There has been an increase in the number o$ children
diagnosed with Type ## diabetes. The increasing rate o$
obesity in children is thought to be a contributing $actor. &ther
contributing $actors include lac) o$ physical activity and a
$amily history o$ Type ## diabetes.
SKELETAL DISORDERS
9ractures in older children are common as they $all during play
and are involved in motor vehicle accidents.
Spiral $ractures (caused by twisting" and $ractures in in$ants
may be related to child abuse.
9ractures involving the epiphyseal plate (growth plate" can
have serious conse<uences in terms o$ growth o$ the a$$ected
limb.
S)in traction $or $racture reduction should not be removed
unless prescribed by healthcare provider.
%in sites can be sources o$ in$ection. .onitor signs o$
in$ection. 2leanse and dress pin sites as prescribed.
S)eletal disorders a$$ect the in$ant/s or child/s physical
mobility, and typical C2;*DARC <uestions $ocus on
appropriate toys or activities $or the child who is on bedrest
and0or immobili@ed.
2hildren do not li)e in1ections and will deny pain to avoid
Ishots.J
A brace does not correct the curve o$ a child with scoliosis, it
only stops or slows the progression.
2orticosteroids are used short term in low doses during
exacerbations. ;ongAterm use is avoided due to side e$$ects
and their adverse e$$ect on growth.
MATERNITY NURSING
ANATOMY 6 PHYSIOLOGY O7 REPRODUCTION
The menstrual phase varies in length $or most women.
9rom ovulation to the beginning o$ the next menstrual cycle
is usually exactly ,4 days. #n other words, ovulation occurs
,4 days be$ore the next menstrual period.
Sperm lives approximately F days and eggs live about '4
hours. A couple must avoid unprotected intercourse $or
several days be$ore the anticipated ovulation and $or F days
a$ter ovulation in order to prevent pregnancy.
-ecause some women experience implantation bleeding or
spotting, they do not )now they are pregnant.
;oo) $or signs o$ maternalA$etal bonding during pregnancy.
9or example+ tal)ing to $etus in utero, massaging abdomen,
nic)naming $etus are all healthy psychosocial activities.
9or many women, -ATT*R#C8 (emotional or physical
abuse" begins during pregnancy. :omen should be
assessed $or abuse in private, away $rom the male partner,
by a nurse who )nows local resources and how to determine
the sa$ety o$ the client.
%ractice determining gravidity and parity+ A woman who is 6
wee)s pregnant has the $ollowing maternal history+
- (as a ' yr. old healthy daughter.
- (ad a miscarriage at , wee)s, F years ago.
- (ad an elective abortion at 6 wee)s, 5 years ago. :ith this
pregnancy, she is a gravida 4, para , (only , delivery a$ter
' wee)s gestation".
%ractice calculating *D- (estimated date o$ birth". #$ the $irst
day o$ a women/s last normal menstrual period was &ctober
,G, what is her *D- using Cagele/s rule= Ruly '4. 2ount
bac) F months and add G days (always give 9ebruary 'N
days".
At approximately 'N to F' wee)s gestation, the maximum
plasma volume increase o$ '5 to 4! occurs, resulting in
normal hemodilution o$ pregnancy and (ct values o$ F' to
4'!. (igh (ct values may loo) Igood,J but in reality
represent pregnancyAinduced hypertension and a depleted
vascular space.
(gb0(ct data can be used to evaluate nutritional status.
*xample+ a ''Ayear old primigravida at ,' wee)s gestation
has a high (gb o$ Q.6 g0dl and a (ct o$ F,!. She has
gained F pounds during the $irst trimester. A weight gain
o$F.5 to 5 pounds during the $irst trimester is recommended
15
and this client is anemic. Supplemental iron and a diet higher
in iron are needed.
9oods high in iron+ $ish and red meats> cereal and yellow
vegetables> green lea$y vegetables and citrus $ruits> egg yol)s
and dried $ruits.
As pregnancy advances, the uterus presses on abdominal
vessels (vena cava and aorta". Teach the woman that a sideA
lying position increases per$usion to uterus, placenta, and
$etus. Recent research indicates that the )neeAchest position
is best $or increasing per$usion and that the sideAlying position
(either le$t or right sideAlying" is the second most desirable
position to increase per$usion. %rior to this research, the le$t
sideAlying position was usually encouraged.
9etal wellAbeing is determined by assessing $undal height,
$etal heart tones0rate, $etal movement and uterine activity
(contractions". 2hanges in $etal heart rate are the $irst and
most important indicator o$ compromised blood $low to the
$etus, and these changes re<uire actionO Remember, the
normal 9(R is ,, to ,6 bpm.
Danger signs during pregnancy. Teach clients to immediately
report any o$ the $ollowing danger signs. *arly intervention
can optimi@e maternal and $etal outcome.
%ossible indications o$ preeclampsia0eclampsia+
- ?isual disturbances
- Swelling o$ $ace, $ingers or sacrum
- Severe, continuous headache
- %ersistent vomiting
Signs o$ in$ection+
- 2hills
- Dysuria
- Temperature over ,.4 9
- %ain in abdomen
- 9luid discharge $rom vagina (anything other than normal
leu)orrhea"
- 2hange in $etal movement and0or increased 9(R
.ost providers prescribe prenatal vitamins to ensure that the
client receives an ade<uate inta)e o$ vitamins. (owever, only
the healthcare provider can prescribe prenatal vitamins. #t is
the nurse/s responsibility to teach about proper diet and ta)ing
prescribed vitamins, i$ prescribed by the healthcare provider.
#t is recommended that pregnant women drin) one <uart o$
mil)0day. This will ensure that the daily calcium needs are
met an help to alleviate the occurrence o$ leg cramps.
7ETAL/MATERNAL ASSESSMENT TECHNI8UES
#n some states, the screening $or neural tube de$ects through
either maternal serum A9% levels or amniotic $luid A9% levels
is mandated by state law. This screening test is highly
associated with both $alse positives and $alse negatives.
:hen an amniocentesis is done in early pregnancy, the
bladder must be $ull to help support the uterus and to help
push the uterus up in the abdomen $or easy access. :hen an
amniocentesis is done in late pregnancy, the bladder must be
empty to avoid puncturing the bladder.
*arly decelerations, caused by head compression and $etal
descent, usually occur between 4 and G cm and in the '
nd
stage. 2hec) $or labor progress i$ early decelerations are
noted.
#$ cord prolapse is detected, the examiner should position
the mother to relieve pressure on the cord (i.e., )neeAchest
position" or push the presenting part o$$ the cord until
#..*D#AT* 2esarean delivery can be accomplished.
;ate decelerations indicate uteroplacental insu$$iciency and
are associated with conditions such as postmaturity,
preeclampsia, diabetes mellitus, cardiac disease, and
abruptio placentae.
:hen deceleration patterns (late or variable" are associated
with decreased or absent variability and tachycardia, the
situation is &.#C&7S (potentially disastrous" and re<uires
immediate intervention and $etal assessment.
A decrease in uteroplacental per$usion results in late
decelerations> cord compression results in a pattern o$
variable decelerations. Cursing interventions should include
changing maternal position, discontinuing %itocin in$usion,
administering oxygen and noti$ying the healthcare provider.
The danger o$ nipple stimulation lies in controlling the IdoseJ
o$ oxytocin stimulated $rom the posterior pituitary. The
chance o$ hyperAstimulation or tetany (contractions over Q
seconds or contractions with less than F seconds in
between" is increased.
%ercutaneous umbilical blood sampling (%7-S" can be done
during pregnancy under ultrasound $or prenatal diagnosis
and therapy. (emoglobinopathies, clotting disorders,
sepsis, and some genetic testing can be done using this
method.
The most important determinant o$ $etal maturity $or extraA
uterine survival is the ;0S ratio ('+, or higher".
INTRAPARTUM NURSING CARE
-e able to di$$erentiate true labor $rom $alse labor.
True labor+
- %ain in lower bac) that radiates to abdomen
- Accompanied by regular, rhythmic contractions
- 2ontractions that intensi$y with ambulation
- %rogressive cervical dilation and e$$acement
9alse labor+
- Discom$ort is locali@ed in abdomen
- Co lower bac) pain
- 2ontractions decrease in intensity and0or $re<uency with
ambulation
Hnow normal $indings $or clients in labor+
- Cormal 9(R in labor+ ,, to ,6 bpm
- Cormal maternal -%+ 5,40Q
- Cormal maternal pulse+ 5, bpm
- Cormal maternal temperature+ 5,.4 9
16
Slight elevation is o$ten due to dehydration and the wor) o$
labor. Anything higher indicates in$ection and must be
reported immediately.
Admission procedures+
- vulvar0perineal shave (may not be done"
- enema+ may be re$used by woman due to preAlabor diarrhea
or recent, large bowel movement. An enema should not be
administered to a client in active labor. #$ head is $loating,
watch $or cord prolapse.
.econiumAstained $luid is yellowAgreen and may indicate $etal
stress.
-reathing techni<ues such as deep chest, accelerated, and
cued are not prescribed by the stage and phase o$ labor, but
by the discom$ort level o$ the laboring woman. #$ coping is
decreasing, switch to a new techni<ue.
(yperventilation results in respiratory al)alosis due to blowing
o$$ too much 2&'. Symptoms include+
- Di@@iness
- Tingling o$ $ingers
- Sti$$ mouth
- (ave woman breathe into her cupped hands or a paper bag in
order to rebreathe 2&'.
Determine cervical dilation be$ore allowing client to push.
2ervix should be completely dilated (, cm" be$ore the client
begins pushing. #$ pushing starts too early, the cervix can
become edematous and never $ully dilate.
8ive the oxytocin a$ter the placenta is delivered because the
drug will cause the uterus to contract. #$ the oxytocic drug is
administered be$ore the placenta is delivered, it may result in
a retained placenta, which predisposes the client to
hemorrhage and in$ection.
Application o$ perineal pads a$ter delivery+
- %lace two on perineum
- Do C&T touch inside o$ pad
- D& apply $rom $ront to bac), being care$ul not to drag pad
across the anus.
.ethergine is C&T given to clients with hypertension due to
its vasoconstrictive action. %itocin is given with caution to
those with hypertension.
97;; -;ADD*R is one o$ the most common reasons $or
uterine atony and0or hemorrhage in the $irst '4 hours a$ter
delivery. #$ the nurse $inds the $undus so$t, boggy, and
displaced above and to the right o$ the umbilicus, what action
should be ta)en $irst= 9irst, per$orm $undal massage> then
have the client empty her bladder. Rechec) $undus <,5
minutes D 4 (, hour"> <F minutes D ' hours.
#$ narcotic analgesics (codeine, meperidine" are given, raise
side rails and place call light within reach. #nstruct client not to
get out o$ bed or ambulate without assistance. 2aution client
about drowsiness as a side e$$ect.
A ,
st
degree tear involves only the epidermis. A '
nd
degree
tear involves dermis, muscle, and $ascia. A F
rd
degree tear
extends into the anal sphincter, and a 4
th
degree extends up
the rectal mucosa. Tears cause pain and swelling. Avoid
rectal manipulations.
#$ it was documented that the $etus passed meconium in
utero or the nurse noted ;AT* passage o$ meconium in
delivery room, the neonate .7ST be attended by a
pediatrician, neonatologist, and0or nurse practitioner to
determine, through endotracheal tube observation and
suction, the presence o$ meconium below the cords. #t can
result in pneumonitis0meconium aspiration syndrome, which
will necessitate a sepsis wor)up including a chest xAray early
in the transitional newborn period.
Do not wait until a , minute Apgar is assigned to begin
resuscitation o$ the compromised neonate.
Apgar scores o$ 6 or 5 at 5 minutes re<uire an additional
Apgar assessment at , minutes.
#? administration o$ analgesics is pre$erred to #. $or the
client in labor because the onset and pea) occurs more
<uic)ly and duration o$ the drug is shorter.

#? administration+
- %redictable onset+ 5 minutes
- %ea)+ F minutes
- Duration+ , hour
#. administration+
- &nset+ within F minutes
- %ea)+ , to F hours a$ter in1ection
- Duration+ 4 to 6 hours
Tran<uili@ers (ataractics and0or phenothia@ines" %henergan,
?istaril, are used in labor as analgesicApotentiating drugs to
decrease maternal anxiety.
Agonist narcotic drugs (Demerol, morphine" produce
narcosis and have a higher ris) $or maternal0$etal respiratory
depression. Antagonist drugs (Stadol, Cubain" have less
respiratory depression but .7ST be used with caution in a
mother with preexisting narcotic dependency since
withdrawal symptoms occur immediately.
%udendal bloc) and subarachnoid (saddle bloc)" are used
only $or second stage o$ labor. %eri0epidural may be used
$or all stages o$ labor.
The $irst sign o$ bloc) e$$ectiveness is usually warmth and
tingling o$ ball0big toe o$ $oot.
Discontinue continuous in$usion at end o$ Stage # or during
transition to increase pushing e$$ectiveness.
Regional bloc) anesthesia and $etal presentation
- #nternal rotation is harder to achieve when the pelvic $loor is
relaxed by anesthesia resulting in persistent occiput
posterior position o$ $etus.
- .onitor $or $etal position. R*.*.-*R, mother cannot tell
you she has bac) pain, which is the cardinal sign o$
persistent posterior $etal position.
- Regional bloc)s, especially epidural and caudal, o$ten result
in assisted ($orceps or vacuum" delivery due to the inability
to push e$$ectively in '
nd
stage.
17
Cerve bloc) anesthesia (spinal or epidural" during labor bloc)s
motor as well as nerve $ibers. ?asodilation below the level o$
the bloc) results in blood pooling in the lower extemities and
maternal hypotension. Approximately ' minutes prior to
nerve bloc) anesthesia, the client should be hydrated with 5
to , cc o$ lactated ringers #?. .onitor maternal vital signs
and 9(R <5 to ,5 minutes. #$ hypotension occurs K turn the
client to her side, administer &' at , ;0min by $acemas), and
increase #? rate.
NORMAL PUERPERIUM
Cormal leu)ocytosis o$ pregnancy averages ,', to ,5,
mmF. The $irst , to ,' days postAdelivery, values o$ '5,
mmF are common. *levated :-2 and the normal elevated
*SR may con$use interpretation o$ acute postpartal in$ections.
9or example, i$ the nurse assesses a client/s temperature to
be ,, 9 on the client/s second postpartum day, what
assessments should be made be$ore noti$ying the physician=
Assess $undal height and $irmness, perineal integrity, chec)
$or a positive (oman/s sign and other symptoms, i.e., burning
on urination, pain in leg, excessive tenderness o$ uterus.
2lient0$amily teaching is a common area $or C2;*DARC
<uestions. Remember, when teaching the $irst step is to
assess the client/s (parent/s" level o$ )nowledge and identi$y
their readiness to learn. 2lient teaching regarding lochia
changes, perineal care, breast$eeding, sore nipples are
commonly tested content.
A$ter the ,
st
%% day, the most common cause o$ uterine atony
is retained placental $ragments. The nurse must chec) $or
presence o$ $ragments in lochial tissue.
:omen can tolerate blood loss, even slightly excessive blood
loss, in the postpartal period due to the 4! increase in
plasma volume during pregnancy. #n postpartal period can
void up to F, cc0day to reduce this volume increase that
occurred during pregnancy.
2lient should void within 4 hours o$ delivery. .onitor closely
$or urine retention. Suspect retention i$ voiding is $re<uent and
5, cc per voiding.
:omen o$ten have a syncopal spell ($aint" on the $irst
ambulation a$ter delivery (usually related t ovasomotor
changes, orthostatic hypotension". The astute nurse will
chec) $or client/s (gb and (ct $or anemia and the blood
pressure, sitting and lying $or orthostatic hypotension.
Hegel exercises+ increase integrity o$ introitus and improve
urine retention. Teach client to alternate contraction and
relaxation o$ the pubococcygeal muscles.
Assess $or thromboembolism+ *xamine legs o$ %% client daily
$or pain, warmth, and tenderness or a swollen vein which is
tender to touch. 2lient may or may not exhibit a positive
(oman/s sign (dorsi$lexion o$ $oot causes compression o$ tibial
veins and pain i$ thrombus is present".
I%ostpartum bluesJ are usually normal, especially 5 to G days
a$ter delivery (unexplained tear$ulness, $eeling Idown,J and a
decreased appetite". *ncourage use o$ support persons to
help with housewor) $or $irst two postpartum wee)s. Re$er
to community resources.
Remember Rho8A. is given to a RhAnegative mother who
delivers a RhApositive $etus and has a negative direct
2oombs. #$ the mother has a positive 2oombs, there is no
need to give Rho8A. since the mother is already
sensiti@ed.
-ecause Rh #mmune 8lobulins suppress the immune
system, the client who receives both Rho8A. and the
Rubella vaccine should be tested $or rubella immunity at F
months.
THE NORMAL NEWBORN
%(BS#2A; ASS*SS.*CT+ A detailed physical assessment
is per$ormed by the nurse or physician. Regardless o$ who
per$orms the physical assessment, the nurse must )now
normal versus abnormal variations o$ the newborn.
&bservations must be recorded and the physician and the
physician noti$ied regarding abnormalities.
#t is di$$icult to di$$erentiate between caput succedaneum
(edema under the scalp" and cephalhematoma (blood under
the periosteum". The caput crosses suture lines and is
usually present at birth, while the cephalhematoma does
C&T cross suture lines and mani$ests a $ew hours a$ter birth.
The danger o$ cephalhematoma is increased by
hyperbilirubinemia due to excess R-2 brea)down.
These neurological re$lexes are transient, and, as such,
disappear usually within the $irst year o$ li$e. #n the pediatric
client, prolonged presence o$ these re$lexes can indicate
2CS de$ects. Anticipate C2;*DARC <uestions regarding
normal newborn re$lexes. %hysical assessment <uestions
$ocus on normal characteristics o$ the newborn and the
di$$erentiation o$ conditions such as caput succedaneum and
cephalhematoma.
The umbilical cord should always be chec)ed at birth. #t
should contain F vessels, , vein which carries oxygenated
blood to the $etus and ' arteries which carry unoxygenated
blood bac) to the placenta. This is the opposite o$ normal
circulation in the adult. 2ord abnormalities usually indicate
cardiovascular or renal anomalies.
%ostnatally, the $etal structures o$ $oramen ovale, ductus
arteriosus and ductus venosus should close. #$ they do not,
cardiac and pulmonary compromise will develop.
Suctioning the mouth $irst and then the nose. Stimulating
the nares can initiate inspiration which could cause
aspiration o$ mucus in oral pharynx.
2ircumcision has become controversial since there is no real
medical indication $or the procedure and it does not cause
trauma and pain to the newborn. #t was once thought to
decrease the incidence o$ penile and cervical cancer, but
some researchers say this is un$ounded.
(B%&T(*R.#A (heat loss" leads to depletion o$ glucose
and, there$ore, the use o$ brown $at (special $at deposits
$etus puts on in last trimester which are important to
thermoregulation" $or energy, resulting in )etoacidosis and
possible shoc). %revent by )eeping neonate warmO
18
%hysiologic 1aundice (normal inability o$ the immature liver to
)eep up with normal R-2 destruction" occurs at ' to F days o$
li$e. #$ it occurs be$ore '4 hours or persists beyond G days, it
becomes pathologic. Typically, C2;*DARC <uestions as)
about normal problem o$ physiologic 1aundice which occurs '
to F days a$ter birth due to the liver/s inability to )eep up with
R-2 destruction and bind bilirubin. Remember, uncon1ugated
bilirubin is the culprit.
Do not $eed a newborn when the respiratory rate is over 6.
#n$orm the physician and anticipate gavage $eedings in order
to prevent $urther energy utili@ation and possible aspiration.
A G lb. N o@. baby would need 5 calories D G lbs S F5
calories plus '5 calories (,0' lb. or N o@." S FG5 calories per
day. .ost in$ant $ormulas contain ' calories0ounce. Dividing
FG5 by ' S ,N.G5 ounces o$ $ormula needed per day.
Teach parents to ta)e in$ant/s temperature -&T( axillary and
rectally. :hile axillary is recommended, some pediatricians
will re<uest a rectal temperature (core".
- AD#;;ARB+ %lace thermometer under arm and hold
thermometer in place 5 minutes.
- R*2TA;;B+ 7se thermometer with -;7CT end. #nsert
thermometer T to M inch and hold in place $or 5 minutes.
(old $eet and legs $irmly.
HIGH4RISK DISORDERS
2lients with prior traumatic delivery, history o$ DU2, multiple
abortions (spontaneous or induced", or daughters o$ D*S
mothers may experience miscarriage or preterm labor related
to #C2&.%*T*CT 2*R?#D. The cervix may be surgically
repaired prior to pregnancy, or D7R#C8 gestation. A
2*R2;A8* (.cDonald/s suture" is placed around the cervix
to constrict the internal os. The cerclage may be removed
prior to labor i$ labor is planned or le$t in place i$ cesarean birth
is planned.
Suspect ectopic pregnancy in any woman o$ childbearing age
who presents at an emergency room, clinic, or o$$ice with
unilateral or bilateral abdominal pain. .ost are misdiagnosed
with appendicitis.
A client who is F' wee)s gestation calls the healthcare
provider because she is experiencing dar), red vaginal
bleeding. She is admitted to the emergency room where the
nurse determines the 9(R to be , bpm. The client/s
abdomen is rigid and boardli)e, and she is complaining o$
severe pain. :hat action should the nurse ta)e $irst= 9irst,
the nurse must use )nowledge base to di$$erentiate between
abruptio placentae (this client" $rom placenta previa (painless
bright red bleeding occurring in the third trimester". The nurse
should immediately noti$y the healthcare provider and no
abdominal or vaginal manipulation or exams should be done.
Administer &' per $ace mas). .onitor $or bleeding at #? sites
and gums due to the increased ris) o$ D#2. *mergency
2esarean section is re<uired since uteroplacental per$usion to
the $etus is being compromised by early separation o$ the
placenta $rom the uterus.
2lients with abruptio placentae or placenta previa (actual or
suspected" should have C& abdominal or vaginal
manipulation. C& ;eopold/s maneuvers. C& vaginal exams.
C& rectal exams, enemas, or suppositories. C& internal
monitoring.
Disseminated intravascular coagulation (D#2" is a syndrome
o$ abnormal clotting that is systematic and pathologic. ;arge
amounts o$ clotting $actors, especially $ibrinogen, are
depleted causing widespread external and0or internal
bleeding. D#2 is related to $etal demise, in$ection0sepsis,
pregnancyAinduced hypertension (%reeclampsia" and
abruptio palcentae.
%odophyllin, which is usually used to treat (%?, is
contraindicated in pregnancy because it is associated with
$etal death, preterm labor, and cervical carcinoma.
Toxoplasmosis is usually related to exposure to cats,
gardening (where cat $eces may be $ound", or eating raw
meat.
Rubella is teratogenic to the $etus during the 9#RST
trimester, causing congenital heart disease and0or
congenital cataracts. All women should have their titers
chec)ed during pregnancy. #$ a women/s titer/s are low, she
should receive the vaccine A9T*R delivery and be
instructed not to get pregnant within F months.
-reast$eeding mothers may ta)e the vaccine.
Although .etronida@ole (9lagyl" is the treatment o$ choice
$or some vaginal in$ections, its use is contraindicated in the
$irst trimester o$ pregnancy, and its use during the second
trimester is controversial. .edications usually
recommended $or the nonApregnant client with STDs may be
2&CTRA#CD#2AT*D $or the pregnant client due to e$$ect on
the $etus.
The outcome o$ adolescent pregnancy depends on prenatal
care. C7TR#T#&C is a )ey $actor since the adolescent/s
physiological needs $or growth are already increased, plus
the additional stress o$ pregnancy.
Although the toxic side e$$ects o$ magnesium sul$ate are well
)nown and watched $or, it is 1ust as important to get serum
blood levels o$ magnesium sul$ate above 4 mg0dl in order to
prevent convulsions and reach therapeutic range.
(old next dose o$ magnesium sul$ate and noti$y healthcare
provider i$ any toxic symptoms occur (5,'
respirations0minute, urine output 5, cc04 hours, absent
DTRs, .agnesium sul$ate 3 N mg0dl".
:hen administering magnesium sul$ate. A;:ABS have
antidote available (calcium gluconate, ' ml vial o$ ,!
solution".
Tachycardia is the ma1or sideAe$$ect o$ tocolytic drugs,
which are bete adrenergic agents such as terbutaline
(-rethine" or ritodrine (Butopar" used to stop preterm labor.
Teach the client to ta)e her pulse prior to administration and
withhold medication i$ pulse is not within the prescribed
parameters (usually whitheld i$ pulse 3,' to ,4". #$
administration is via a continuous pump, teach client to
monitor pulse periodically.
19
#n ,QGN, the 9DA banned the use o$ oxytocin $or *;*2T#?*
inductions. The healthcare provider must provide, $or the
record, the medical reason $or oxytocin use.
Dystocia $re<uently re<uires the use o$ oxytocin $or
augmentation or induction o$ labor. 7terine tetany is a harm$ul
complication and care$ul monitoring is re<uired. The desired
e$$ect is contractions <' to F minutes, with duration o$
contractions no longer than Q seconds. 2ontinuously
monitor 9(R and uterine resting tone. #$ tetany occurs, turn
o$$ %itocin, turn client to a sideAlying position, and administer
&' by $acemas). 2hec) output (should be at least , cc04
hours". &xytocin/s most important side e$$ects is its
antidiuretic (AD(" e$$ect, which can cause water intoxi$ication.
7sing #? $luids containing electrolytes decreases the ris) o$
water intoxi$ication.
The uterus is most sensitive to becoming tetanic at the
beginning o$ in$usion. The client must A;:ABS be attended
and contractions monitored. 2ontractions should last C&
longer than Q seconds to prevent $etal hypoxia.
:omen with previous uterine scars are prone to uterine
rupture especially i$ oxytocin or $orceps are used. #$ a woman
complains o$ a sharp pain accompanied by the abrupt
cessation o$ contractions, suspect uterine rupture, a .*D#2A;
*.*R8*C2B. #mmediate surgical delivery is indicated to
save the $etus and the mother.
Rarely are antihypertensive drugs used in the preeclamptic
client. They are given only in the event o$ diastolic blood
pressure over ,, mm(g. (2?A danger". Drug o$ choice is
(ydrala@ine (2; (Apresoline".
Altough delivery is o$ten described as the IcureJ $or
preeclampsia, the client can convulse up to 4N hours a$ter
delivery.
The ma1or goal o$ nursing care $or a client with preeclampsia
is to maintain uteroplacental per$usion and prevent sei@ures.
This re<uires the administration o$ magnesium sul$ate.
:ithhold administration o$ magnesium sul$ate i$ signs o$
toxicity exist+ respirations 5,'0minute, absence o$ DTRs, and
urine output 5F ml0hour.
Cursing care during labor and delivery $or the client with
cardiac disease is $ocused on prevention o$ cardiac
embarrassment, maintenance o$ uterine per$usion, and
alleviation o$ anxiety.
Should these clients experience preterm labor, the use o$
betaAadrenergic agents such as terbutaline (-rethine" and
ritodrine (2; (Butopar" are contraindicated due to the chance
o$ myocardial ischemia.
Cormal diuresis, which occurs in the postpartum period, can
pose serious problems to the new mother with cardiac disease
because o$ the increased cardiac output.
2oumadin may C&T be ta)en during pregnancy due to its
ability to cross the placenta and a$$ect the $etus. (*%AR#C is
the drug o$ choice> it does C&T cross the placental
membrane.
Recent research has $ound that (elicobacter pylori, (the
bacterium that causes stomach ulcers" in$ection is another
possible causative $actor in hyperemesis. &ther pregnancy
and nonApregnancy ris) $actors $or hyperemesis gravidarum
include $irst pregnancy, multiple $etuses, age under '4,
history o$ this condition in other pregnancies, obesity, and
high $at diets.
#n severe cases o$ hyperemesis gravidarum, the healthcare
provider may prescribe antihistamines, vitamin -6, or
phenothia@ines to relieve nausea. The provider also
prescribe metoclopramide (Reglan" to increase the rate the
stomach moves $ood into the intestines, or antacids to
absorb stomach acid and help prevent acid re$lux.
:omen who su$$er $rom hyperemesis gravidarum are o$ten
de$icient in thiamin, ribo$lavin, vitamin -6, vitamin A, and
retinolAbinding proteins.
8;72&S* S2R**C+ 2lient does C&T have to $ast $or this
test. 5 gm o$ glucose is given and blood is drawn a$ter one
hour. #$ the blood glucose is greater than ,F5 mg0dl, the na
threeAhour glucose tolerance test (8TT" is done.
(igh incidence o$ $etal anomalies occurs in pregnant diabetic
women. There$ore, $etal surveillance is very important.
7ltrasound exam. AlphaA$etoprotein (to determine neural
tube anomalies". ConAstress and contraction stress tests.
&ral hypoglycemics are not ta)en in pregnancy due to
potential teratogenic e$$ects on $etus. #nsulin is used $or
therapeutic management.
:hen a woman is admitted in labor with diagnosis o$
diabetes mellitus. She is more prone to preeclampsia,
hemorrhage and in$ection. Delivery is o$ten scheduled
between FG to FN wee)s gestation to avoid the end o$ the F
rd
trimester o$ pregnancy because this is a ?*RB di$$icult time
to maintain diabetic control.
#t is use$ul to discontinue longAacting insulin administration
on the day be$ore the delivery is planned since insulin
re<uirements are less in labor and drop precipitously a$ter
delivery.
*strogenAcontaining birth control pills a$$ect glucose
metabolism by increasing resistance to insulin. The
intrauterine device may be associated with an increased ris)
o$ in$ection in these already vulnerable women.
#$ a woman is medicated, the responsible adult
accompanying her must sign the necessary consent $orms.
State laws di$$er as to the acceptability o$ a $riend signing the
consent $orm rather than a relative.
-abies delivered abdominally miss out on the vaginal
s<uee@e and are born with more $luid in the lungs,
predisposing the newborn to transient tachypnea (TTC" and
respiratory distress.
The pre$erable lowAtransverse uterine incision usually results
in less postoperative pain, less bleeding, and less incidents
o$ ruptured uterus. The classical, vertical incision on the
uterus may involve part o$ the $undus, resulting in more
20
postoperative pain, bleeding, and an increased chance o$
uterine rupture.
Due to the exploration and cleansing o$ the uterus 1ust a$ter
delivery o$ the placenta, the amount o$ lochia may be scant in
the recovery room. (owever, pooling in the vagina and uterus
while on bedrest may result in blood running down the client/s
leg when she $irst ambulates. 2esarean birth clients have the
same lochial changes, placental site healing, and aseptic
needs as do vaginal birth clients.
A laparotomy o$ any )ind, including cesarean birth,
predisposes the client to postoperative paralytic ileus. :hen
the bowel is manipulated in surgery, it ceases preistalsis,
which may persist. Symptoms include+ absent bowel sounds,
abdominal distention, tympany on percussion, nausea and
vomiting, and o$ course, obstipation (intractible constipation".
*arly ambulation is an e$$ective nursing intervention.
POSTPARTUM HIGH4RISK DISORDERS
Curse must be especially supportive o$ postpartum client with
in$ection because it usually implies isolation $rom newborn
until organism is identi$ied and treatment begun. Arrange
phone calls to nursery and window viewing. #nvolve $amily,
spouse, signi$icant others in teaching, and encourage other
$amily members to continue neonatal attachment activities.
.ost common iatrogenic cause o$ 7T# is urinary
catheteri@ation. *ncourage clients to void $re<uently and not
ignore the urge. #? antibiotic are usually administered to
clients with pyelonephritis.
Remember, the ris) o$ postpartum in$ections increases $or
clients who experienced problems during pregnancy (e.g.,
anemia, diabetes" or experienced trauma during labor and
delivery.
2lients ta)ing anticoagulants can usually expect to have
heavy menstrual periods.
#n most cases, a mother who is on antibiotic therapy can
continue to breast$eed unless the healthcare provider thin)s
the neonate is at ris) $or sepsis by maternal contact. Sul$a
drugs are used cautiously in lactating mothers because they
can be trans$erred to the in$ant in breast mil).
.any times mastitis can be con$used with a bloc)ed mil)
sinus, which is treated by nursing closer to the lump and by
rotating the baby on the breast. -reast$eeding is not
contraindicated $or women with mastitis, unless pus is in the
breast mil), or the antibiotic o$ choice is harm$ul to the in$ant.
#$ either o$ these occurs, mil) production can still be $ostered
by manual expression.
During medical emergencies such as bleeding episodes,
clients need calm, direct explanations and assurance that all
is being done that can be done. #$ possible, allow support
person at bedside. Ris)Amanagement principles state that the
suitAprone client is one who $eels things are being hidden $rom
her or that ade<uate attention is C&T being give to (*R
problem.
Ris) $actors $or hemorrhage include+ dystocia, prolonged
labor, over distended uterus, abruptio placentae, and
in$ection.
:hat immediate nursing actions should be ta)en when a
postpartum hemorrhage is detected=
- %er$orm $undal massage
- Coti$y the healthcare provider i$ the $undus does not become
$irm with massage
- 2ount pads to estimate blood loss
- Assess and record vital signs
- #ncrease #? $luids (additional #? line may be indicated"
- Administer oxytocin in$usion as prescribed
NEWBORN HIGH4RISK DISORDERS
IRitterinessJ is a clinical mani$estation o$ hypoglycemia and
hypocalcemia. ;aboratory analysis is indicated to
di$$erentiate between two etiologies.
To avoid metabolic problems brought on by cold stress, the
$irst step and number one priority, in management o$ the
newborn is to prevent loss o$ body heat, $ollowed by A-2s.
Ceonates produce heat by nonAshivering thermogenesis, by
burning brown $at. The neonate is easily stressed by
hypothermia and develops acidosis $rom hypoxia. %revent
chilling ()eep under radiant warmer or in isolette". #$ cold,
the $irst signs exhibited are prolonged acrocyanosis, s)in
mottling, tachycardia, and tachypnea. #$ cold stressed, warm
slowly over ' to 4 hours since rapid warming may produce
apnea. The neonate needs glucose, he0she has little
glycogen storage and needs to be $ed.
The lower the score on the SilvermanAAnderson index o$
Respiratory Distress, the better the respiratory status o$ the
neonate. A score o$ , indicates that a newborn is in severe
respiratory distress. This is the exact opposite o$ the
method used $or Apgar scoring.
:AT2( the newborn (ct> it is di$$icult to oxygenate either an
anemic newborn (lac) o$ oxygenAcarrying capacity" or a
newborn with polycythemia ((ct 3N!, thich, sluggish
circulation".
The %&' should be maintained between 5 to Q mm(g.
%&' 55 signi$ies hypoxia, %&' 3 Q signi$ies oxygen
toxicity problems.
Antibiotic dosage is based on the neonate/s weight in
)ilograms. %ea) and trough drug levels are drawn to
evaluate i$ therapeutic drug levels have been achieved.
2losely monitor the neonate $or adverse e$$ects o$ A;;
drugs.
Sepsis can be indicated by both a temperature increase and
a temperature decrease.
Drugs used to treat neonatal in$ections can be ototoxic and
nephrotoxic. 2lose monitoring o$ therapeutic levels and
observation $or side e$$ects are re<uired.
Renal immaturity in the preterm in$ant ma)es the monitoring
o$ #? $luid administration and drug therapy crucial. 2losely
monitor -7C and creatinine levels when administering the
ImycinJ antibiotics to treat in$ections in the neonate.
21
#$ tube passes into trachea, newborn can ma)e C& noise, i.e.,
no crying. Cewborn may gag, cough, or become cyanotic.
To assess $or s)in 1aundice, apply with thumb over bony
prominences to blanch s)in. A$ter removing thumb, area will
loo) yellow be$ore normal s)in color reappears. The best
areas $or assessment are the nose, $orehead, and sternum.
#n dar)As)inned in$ants, observe con1unctival sac and oral
mucosa.
;ab tests measure total and direct (con1ugated, excretable,
nonA$at soluble" bilirubin levels. The dangerous bilirubin is the
uncon1ugated, indirect ($atAsoluble", which is measured by
subtracting the direct $rom the total bilirubin.
.aintenance o$ hydration is crucial $or all in$ants. The preterm
in$ant is already at ris) $or $luid and electrolyte imbalances due
to increased body sur$ace area $rom extended body
positioning and larger body area in related to body weight.
%hototherapy treatment $or hyperbilirubinemia (level 3 ,'
mg0dl" increases the ris) $or dehydration.
PSYCHIATRIC NURSING
THERAPEUTIC COMMUNICATION / TREATMENT MODALITIES
The purpose o$ therapeutic interaction with clients is to allow
them the autonomy to ma)e choices when appropriate. Heep
statements value $ree, advice $ree, and reassurance $ree.
Remember, R7ST T(* 9A2TSO C& &%#C#&CSO
:hat action should the nurse ta)e in a Ipsychiatric situationJ
when the client describes a physical problem= Assess,
assess, assessO #$ the client with paranoid schi@ophrenia on
the psychiatric unit complains o$ chest pain, ta)e his0her blood
pressure. #$ the &- client who has delivered a dead $etus
complains o$ perineal pain K loo) at the perineal area (she
may have a hematoma". Rust because the $ocus o$ the
client/s situation is on his0her psychological needs, it does not
mean that the nurse can ignore physiological needs.
Remember, nurses are IniceJ people, but they are also
therapeutic.
-asic communication principles can be applied to all clients+
- *stablish trust.
- Demonstrate a nonA1udgmental attitude
- &$$er sel$> be emphathetic, C&T sympathetic
- 7se active listening
- Accept and support client/s $eelings
- 2lari$y and validate client/s statement
- 7se matterAo$A$act approach
Remember, a nurse/s nonverbal communication may be more
important that his0her verbal communication.
A <uestion concerning nurseAclient con$identiality o$ten
appears on the C2;*DARC. 9or the nurse to tell a client
she0he will not tell anyone about their discussion, puts the
nurse in a di$$icult position. Some in$ormation .7ST be
shared with other team members $or the client/s sa$ety (e.g.,
suicide plan" and optimal therapy.
Causea is a common complaint a$ter *2T. ?omiting by the
unconscious client can lead to aspiration. -ecause postA
*2T clients are unconscious, the nurse must observe
closely $or the possibility o$ aspiration, i.e., .A#CTA#C A
%AT*CT A#R:ABO
AN9IETY DISORDERS
2ommon physiological responses to anxiety include
increased heart rate and blood pressure> rapid, shallow
respirations> dry mouth, tight $eeling in throat> tremors,
muscle tension> anorexia> urinary $re<uency> palmar
sweating.
Anxiety is very contagious and is easily trans$erred $rom
client to nurse ACD $rom nurse to client. 9#RST, the nurse
must assess his0her own level o$ anxiety and remain calm.
A calm nurse assists the client to gain control, decrease
anxiety, and increase $eelings o$ anxiety.
:hen a client described a phobia or expresses an
unreasonable $ear, the nurse should ac)nowledge the
$eeling ($ear" and re$rain $rom exposing the client to the
identi$ied $ear. A$ter trust is established, a desensiti@ation
process may be prescribed. Desensiti@ation is the nursing
intervention $or phobia disorders. The nurse should+
- Assist client to recogni@e $actors associated with $eared
stimuli that precipitate a phobic response.
- Teach and practice with client alternative adaptive coping
strategies such as the use o$ thought substitution (replacing
a $ear$ul thought with a pleasant thought", and relaxation
techni<ues. RoleAplaying is use$ul when the client is in a
calm state.
- *xpose client progressively to $eared stimuli, o$$ering
support with the nurse/s presence.
- %rovide positive rein$orcement whenever a decrease in
phobic reaction occurs.
- C&T*+ #n all li)elihood, the desensiti@ation process will be
overseen by a mental health practitioner (C% psych 2CS, or
psychologist".
The nurse should place an anxious client where there are
reduced environmental stimuli K a <uiet area o$ the unit,
away $rom the nurse/s station.
The best time $or interaction with a client is at the completion
o$ the per$ormed ritual. The client/s anxiety is lowest at this
time> there$ore, it is an optimal time $or learning.
2ompulsive acts are used in response to anxiety, which may
or may not be related to the obsession. #t is the nurse/s
responsibility to help alleviate anxiety. #nter$ering will
increase anxiety. These acts should be allowed as long as
the client/s acts are $ree o$ violence. The nurse should+
- Actively listen to the client/s obsessive themes
- Ac)nowledge e$$ects that ritualistic acts have on the client
- Demonstrate empathy
- Avoid being 1udgmental
9or clients with postraumatic stress disorder, the nurse
should+
- Actively listen to client/s stories o$ experiences surrounding
the traumatic event
- Assess suicide ris)
22
- Assist client to develop ob1ectivity about the event and
problem solve regarding possible means o$ controlling anxiety
related to the event
- *ncourage group therapy with other clients who have
experienced the same or related traumatic events
SOMATO7ORM DISORDERS
-e aware o$ your own $eelings when dealing with this type o$
client. #t is a challenge to be nonA1udgmental. The pain is real
to the person experiencing it. These disorders cannot be
explained medically+ they result $rom internal con$lict. The
nurse should+
- Ac)nowledge the symptom or complaint
- Rea$$irm that diagnostic test results reveal no organic
pathology
- Determine the secondary gains ac<uired by the client
DISSOCIATIVE DISORDERS
The nurse should be aware that A;; behavior has meaning.
Avoid giving clients with dissociative disorders too much
in$ormation about past events at one time. The various types
o$ amnesia, which accompany dissociative disorders, provide
protection $rom pain. Too much, too soon, may cause
decompensation.
PERSONALITY DISORDERS
%ersonality disorders are longAstanding behavioral traits that
are maladaptive responses to anxiety and cause di$$iculty in
relating and wor)ing with other individuals. C2;*DARC
<uestions test personality disorder content by describing
management situations.
%ersons with a personality disorder are usually com$ortable
with their disorder and believe that they are right and the world
is wrong. These individuals usually have very little motivation
to change. Thin) o$ them as a 2(A;;*C8*.
EATING DISORDERS
%eople with Anorexia gain pleasure $rom providing others with
$ood and watching them eat. These behaviors rein$orce their
perception o$ sel$Acontrol. Do not allow these clients to plan or
prepare $ood $or unitAbased activities.
%eople with -ulimia o$ten use syrup o$ ipecac to induce
vomiting which may cause cardiovascular problems such as
congestive heart $ailure (2(9". -ecause 2(9 is not usually
seen in young people, it is o$ten overloo)ed. Assess $or
edema and listen to breath sounds.
%hysical assessment and nutritional support are a priority> the
physiological implications are great. Cursing interventions
should increase sel$Aesteem and develop a positive body
image. -ehavior modi$ication is use$ul and e$$ective. 9amily
therapy is most e$$ective since issues o$ control are common
in these disorders. (Therapy is usually long term".
MOOD DISORDERS
Depressed clients have di$$iculty hearing and accepting
compliments because o$ their lowered sel$Aconcept. 2omment
on signs o$ improvement by noting the behavior, e.g., I#
noticed you cobed your hair todayJ C&T, IBou loo) nice
today.J
The most important signs and symptoms o$ depression are a
depressed mood with a loss o$ interest or pleasure in li$e.
The client has sustained a loss. &ther symptoms include+
- Signi$icant change in appetite o$ten accompanied by a
change in weight K either weight loss or gain
- #nsomnia or hyperinsomnia (usually sleeping during the day
K o$ten because the client is not sleeping at night due to
anxiety".
- 9atigue or a lac) o$ energy
- 9eelings o$ hopelessness, worthlessness, guilt, or overA
responsibility
- ;oss o$ ability to concentrate or thin) clearly
- %reoccupation with death or suicide
The nurse )nows depressed clients are improving when they
begin to ta)e an interest in their appearance or begin to
per$orm sel$Acare activities, which were previously o$ little or
no interest.
The nurse should suspect an imminent suicide attempt i$ a
depressed client becomes Ibetter,J e.g., happy or even
elated. -e aware K a happy a$$ect may signi$y that the client
$eels relieved that a plan has been made and he0she is
ready $or the suicide attempt.
:hen dealing with a depressed client, the nurse should
assist with personal hygiene tas)s and encourage the client
to initiate grooming activities even when he0she does not
$eel li)e doing so. This helps promote sel$Aesteem and a
sense o$ control.
An important intervention $or the depressed client is to sit
<uietly with the client. :hen answering C2;*DARC
<uestions, remember that you are wor)ing at 7topia 8eneral
and there is plenty o$ time and sta$$ to provide ideal nursing
care. Do not let realities o$ clinical situations deter you $rom
choosing the best nursing intervention. The best
intervention is to sit <uietly with the client, o$$ering support
with your presence.
There are always drug <uestions on the C2;*DARC. (ere
are some tips+ Hnow common side e$$ects $or drug groups.
9or example+
- AntiAanxiety drugs S sedation, drowsiness
- Antidepressant drugs S anticholinergic e$$ects, postural
hypotension
- .A& inhibitors S hypertensive crisis
Hnow speci$ic problems or concerns $or drug therapy. 9or
example+
- ;ithium re<uires renal $unction assessment and monitoring
- %henothia@ines cause extrapyramidal e$$ects (*%S"> tardive
dys)inesia can be permanent i$ client is not assessed
regularly $or signs o$ tardive dys)inesiaO
Hnow speci$ic client teaching $or drug therapy. 9or example+
- %henothia@ines S photosensitivity, need to wear protective
clothing, sunglasses
- .A& inhibitors S dietary restrictions to prevent hypertensive
crisis
23
.onitor serum lithium levels care$ully. The therapeutic range
is between .5 and ,.5 m*<0;. the therapeutic and toxic
levels are very close in reading. Signs o$ toxicity are evident
when lithium levels are more than ,.5 m*<0;. -lood levels
should be drawn ,' hours a$ter ;AST dose.
.anic clients can be very caustic toward authority $igures.
-e prepared $or personal Iput downs.J Avoid arguing or
becoming de$ensive.
:hat activities are appropriate $or a manic client= S
Concompetitive physical activities, which re<uire the use o$
large muscle groups.
:here should a manic client be placed on the unit= S
.a)e every attempt to reduce stimuli in the environment.
%lace the client in a <uiet part o$ the unit.
:hat interventions should the nurse use i$ a client
becomes abusive=
- Redirect negative behavior or verbal abuse in a calm, $irm,
nonA1udgmental, nonAde$ensive manner
- Suggest a wal) or physical activity
- Set limits on intrusive behavior. 9or example, I:hen you
interrupt, # cannot explain the procedure to the others> please
wait your turn.J
- #$ necessary, seclude or administer medication i$ client
becomes totally out o$ control. Always remember to use
compassion because nurses are IniceJ people.
Two atypical antipsychotic drugs are also indicated $or mania
(risperidone and olan@apine".
THOUGHT DISORDERS: SCHI:OPHRENIA
There are $ive types o$ schi@ophrenia speci$ied under the
DS.A#?ATR. The DS.A#?ATR is a diagnostic manual prepared
by the American %sychiatric Association that provides
diagnostic criteria $or all psychiatric disorders.
&bserve $or increased motor activity and0or erratic response
to sta$$ and other clients. The client may be experiencing an
increase in command hallucinations. :hen this occurs, there
is an increased potential $or aggressive behavior. T(#CH
%RCO
:hen evaluating client behaviors, consider the medications
the client is receiving. *xhibited behaviors may be
mani$estations o$ schi@ophrenia or a drug reaction.
7se -leuler/s $our As to help remember the important
characteristics o$ schi@ophrenia+
- Autism (preoccupied with sel$"
- A$$ect ($lat"
- Association (loose"
- Ambivalence (di$$iculty ma)ing decisions"
Do not argue with a client about their delusions. ;ogic does
C&T wor), it only increases the client/s anxiety. -e matterAo$A
$act and divert delusional thought to reality. Trust is the basis
$or all interactions with these clients. -e supportive and nonA
1udgmental. Stress increases anxiety and the need $or
delusions and hallucinations. Do not agree you hear voices
(you should be the client/s contact to reality", but
ac)nowledge your observation o$ the client, $or example,
IBou loo) li)e you/re listening to something.J
Hnow the side e$$ects o$ drugs commonly used to treat
schi@ophrenia since client behavioral changes may be due
to drug reactions instead o$ schi@ophrenia.
SUBSTANCE ABUSE
Hnow what de$ense mechanisms are used by chemically
dependent clients. Denial and rationali@ation are the two
most common coping styles used K their use must be
con$ronted so accountability $or the client/s own behavior
can be developed.
:hat basic needs have priority when wor)ing with
chemically dependent clients= Cutrition is a priority. Alcohol
and drug inta)e has superseded the inta)e o$ $ood $or these
clients.
:hat behaviors are expected during withdrawal= #n the
alcoholic, delirium tremens (DT" occurs ,' to F6 hours a$ter
the last inta)e o$ alcohol. Hnow the symptoms (tachycardia,
tachypnea, diaphoresis, mar)ed tremors, hallucinations,
paranoia". #n drug abuse, withdrawal symptoms are speci$ic
to the type o$ drug.
:hat medications can the nurse expect to administer to
chemically dependent clients= #n treating alcohol
withdrawal, ;ibrium or Ativan are commonly used. Antabuse
is o$ten used as s deterrent to drin)ing alcohol. 2lient
teaching should include the e$$ects o$ consuming any alcohol
while on Antabuse. *ncourage client to read all labels o$
overAtheAcounter medications and $ood products, which may
contain small amounts o$ alcohol.
:hat type o$ therapy is used with chemically dependent
clients= 8roup therapy is e$$ective as well as support
groups such as Alcoholics Anonymous, Carcotics
Anonymous, etc.
(arm reduction is a community health strategy designed to
reduce the harm o$ substance abuse to $amilies, individuals,
community, and society.
- .ore compassionate drug treatment options including
abstinence and drug substitution models.
- (#? related interventions such as needle exchanges
- Directed drug use management should the client wish to
continue use
- 2hanges in laws concerning possession o$ paraphernalia
ABUSE
Select only one nurse to care $or an abused child. Abused
children have di$$iculty establishing trust. The child will be
less anxious with one consistent caregiver.
:omen who are abused may rationali@e the spouse/s
behavior and unnecessarily accept the blame $or his actions.
The woman may or may not choose to press charges. -e
sure to give her the number o$ a shelter $or Ihelp lineJ $or
$uture occurrences, as well as develop a sa$ety plan.
#t is di$$icult $or an elderly person to admit abuse $or $ear
being placed in a nursing home or being abandoned.
24
There$ore, it is imperative to establish a trusting relationship
with the elderly client.
Rape victims are at high ris) $or %ost Traumatic Stress
Disorder (%TSD". #mmediate intervention to diminish distress
is vital. The nurse should also assess $or and intervene $or
se<uellae such as unwanted pregnancy, sexually transmitted
diseases, and (#? ris).
Euestions on the C2;*DARC regarding physical0sexual abuse
usually $ocus on three aspects+
- %hysical mani$estations o$ abuse
- 2lient sa$ety
- ;egal responsibilities o$ the nurse K #n children, the nurse is
legally responsible to report all suspected cases o$ abuse. #n
intimate partner abuse, it is the adult/s decision> the nurse
should be supportive o$ their decision. Remember to
document ob1ective $actual assessment data and the client/s
exact words in cases o$ sexual abuse0rape.
ORGANIC MENTAL DISORDERS
2on$usion in the elderly is o$ten IacceptedJ as part o$ growing
old. This con$usion may be due to dehydration with resulting
electrolyte imbalance. Thin) Isudden changeJ when obtaining
a history. Such changes are usually due to a speci$ic
stressor, and treatment $or the causative stressor will usually
result in correcting the con$usion.
2on$abulation is not lying. #t is used by the client to decrease
anxiety and protect the ego.
Cursing interventions $or the con$used elderly should $ocus on+
- .aintaining the client/s health and sa$ety
- *ncouraging sel$ care
- Rein$orcing reality orientation (e.g., IToday is .onday,J and
call the client by name".
- %roviding a consistent, sa$e environment K engage client in
simple tas)s, activities to build sel$Aesteem
%roviding consistent caregiver is a priority in planning nursing
care $or the con$used older client. 2hange increases anxiety
and con$usion.
.ay also use atypical antipsychotics such as resperidine,
<uetiapine, olan@apine, 2lo@aril is not a $rontAline agent due to
sideAe$$ects. .ay also give mood stabili@ers and antianxiety
medications as indicated.
The basic di$$erence between delirium and dementia is that
delirium is acute, and reversible, whereas dementia is gradual
and permanent.
CHILDHOOD AND ADOLESCENT DISORDERS
2hildren also experience depression, which o$ten presents as
headaches, stomachaches, and other somatic complaints. -e
sure to assess suicidal ris)s, especially in the adolescent.
The client/s lac) o$ remorse or guilt about their antisocial
behavior represents a mal$unction o$ the superego or
conscience. The id $unctions on the basic instinct level and
strives to meet immediate needs. The ego is in touch with
external reality and is the part o$ the personality that ma)es
decisions.
#mportant points to remember when answering C2;*DARC
<uestions+
- These children may be involved in sel$A$ul$illing prophecy
(e.g., I.om says that he0she is a troubleAma)er, there$ore,
he0she must live up to .om/s expectationsJ".
- 2on$ront the client with his0her behavior, e.g., lying. This
gives the client a sense o$ security.
- %rovide consistent interventions K helps to prevent
manipulation. #nconsistency does not help the client develop
sel$Acontrol.
GERONTOLOGICAL NURSING
2hanges in the heart and lungs result in less e$$icient
utili@ation o$ &', which reduces an individual/s capacity to
maintain physical activity $or long periods o$ time. %hysical
training $or older persons can signi$icantly reduce blood
pressure and increase aerobic capacity. C2;*DARC
<uestions as) about teaching and designing rehab programs
$or the elderly K they should contain something about
exercise and nutrition.
&lder persons o$ten complain that they cannot get to sleep
at night and do not sleep soundly even a$ter they $all asleep.
This is because they have shorter stages o$ sleep,
particularly shorter cycles $rom stages , to 4 and R*. sleep
(stage 4 is deep sleep". They are easily awa)ened by
environmental stimuli. They o$ten compensate by napping
during the day, which leads to $urther disruptions o$ night
sleep. A common response is use o$ prescription sleeping
pills which can create still $urther problems o$ disorientation,
etc.
-oth systolic and diastolic blood pressure tend to increase
with normal aging, but the elevation o$ the systolic is greater.
R*.*.-*R the physiologic o$ blood pressure, which is
expressed as a ratio o$ systolic to diastolic pressure.
Systolic re$ers to the level o$ blood pressure during the
contraction phase whereas diastolic re$ers to the stage when
the chambers o$ the heart are $illing with blood.
Dysrhythmias in the elderly are particularly serious since
older persons cannot tolerate decreased cardiac output,
which can result in syncope, $alls, and transient ischemic
attac)s (T#As". %ulse may be rapid, slow, or irregular.
Angina symptoms may be absent in the elderly or they may
be con$used with 8# symptoms.
:ith aging, the muscles that operate the lings lose elasticity
so that respiratory e$$iciency is reduced. ?ital capacity (the
amount o$ air brought into the lungs at one time" decreases.
-reathing may become more di$$icult a$ter strenuous
exercise or a$ter climbing up several $lights o$ stairs. The
rate o$ decline has been $ound to be slower in more active
persons. The nurse should encourage older persons to
remain physically active $or as long as possible. Declining
muscle strength may impair cough e$$iciency. This $act
ma)es older persons more susceptible to chronic bronchitis,
emphysema, and pneumonia.
2&%D is the ma1or cause o$ respiratory disability in the
elderly.
25
Aging changes that contribute to chronic constipation+
- The number o$ en@ymes in the small intestine is reduced and
simple sugars are absorbed more slowly, resulting in
decreased e$$iciency o$ the digestive process.
- The smooth muscle content and muscle tone o$ the wall o$ the
colon decrease. Anatomical changes in the large intestine
result in decreased intestinal motility.
- %sychological $actors, as well as abuse o$ overAtheAcounter
laxatives
- Decreases in $luid inta)e and mobility contribute to
constipation
Tooth loss is C&T a normal aging process. 8ood dental
hygiene, good nutrition, and dental care can prevent tooth
loss.
&lder persons appear to eat small <uantities o$ $ood at
mealtimes. This is because the digestive system o$ older
persons $eatures a decrease in contraction time o$ the
muscles and more time is needed $or the cardiac sphincter to
open. There$ore, it ta)es more time $or the $ood to be
transmitted to the stomach. Thus, the sensation o$ $ullness
may occur be$ore the entire meal is consumed.
&lder persons have a higher ris) o$ developing renal $ailure
because normal ageArelated changes result in compromised
renal $unctioning. The nurse should pay care$ul attention to
urinary output in older clients because it is the $irst sign o$ loss
o$ renal integrity.
Hegel exercises consist o$ tightening and relaxing the vaginal
and urinary meatus muscles. These exercises have been
very success$ul in reducing the incidence o$ incontinence.
They must be done consistently, and they can be done
unobtrusively at home.
The elderly with incontinence may see) isolation, thereby
predisposing themselves to loneliness.
,5 to F! o$ communityAbased elderly and almost 5! o$
elderly living in nursing homes su$$er $rom di$$iculties with
bladder control. &lder persons may be more sensitive to
alcohol and ca$$eine since these substances inhibit the
production o$ antidiuretic hormone (AD(". An assessment o$
sensitivity to bladder problems is essential when planning
nursing care.
.*D#2AT#&C A;*RT+
- As one ages, the total number o$ $unctioning glomeruli
decreases until $unction has been reduced by nearly 5!.
This decrease in the $iltration e$$iciency o$ the )idneys has
grave implications $or persons who are ta)ing medication. &$
particular importance are penicillin, tetracycline, and digoxin,
which are primarily cleared $rom the blood stream by the
)idneys. These drugs remain active longer in an older
person/s system. There$ore, they may be more potent,
indicating a need to ad1ust the dosage $re<uency o$
administration.
Al@heimer/s disease is the most common irreversible
dementia o$ old age. #t is characteri@ed by de$icits in attention,
learning, memory, and language s)ills. Discuss the problems
$amily members have in dealing with Al@heimer/s clients in
relation to the $ollowing disease mani$estations+
- Depression
- Cight wandering
- Aggressive or passiveness
- 9ailure to recogni@e $amily members
Stro)es $rom cerebral thrombosis are more common in older
persons than are stro)es $rom cerebral hemorrhage. 2lots
tend to develop when patient is awa)e or 1ust arousing.
Cormal loss o$ brain cells is compounded by alcohol,
smo)ing, and breathing polluted air. #n relation to such
losses, the nurse should teach to shop at uncrowded times
in stores that are $amiliar to them, slow down well in advance
o$ tra$$ic signals, stay in the slower lane o$ the $reeway, avoid
$reeways during rush hours, and leave $or appointments well
ahead o$ time.
The most common endocrine disorders in the older adult are
thyroid dys$unctions and diabetes.
#mpaired mobility, impaired s)in integrity, decreased
peripheral circulation, and a lac) o$ physical activity place
the elderly at ris) $or developing decubitus ulders.
:ays to help prevent0decrease the occurrence o$ $alls+
- Ade<uate lighting
- %ain the edges o$ stairs a bright color
- %lace a bell on the elderly person/s cat (since cats move
<uic)ly and get under$oot"
- :ear proper $ootwear that supports the $oot and contributes
to balance (made o$ nonAslippery materials".
%eripheral circulation decreases as one ages. Regular
assessment o$ the $eet is very important because it
increases the opportunity to discover and treat s)in care
problems early. These problems could become more
serious because o$ decreased circulation.
&lder persons have a dry, wrin)led s)in because they lose
subcutaneous $at and the second layer o$ s)in, the dermis,
becomes less elastic.
Diminished eyesight results in+
- A loss o$ independence (AD; and driving"
- A lac) o$ stimulation
- The inability to read
- A $ear o$ blindness
;ower the tone o$ your voice when tal)ing to an older person
who is hearingAimpaired. (ighApitched tones (i.e., women/s
voices" are the $irst hearing to go, there$ore, lowering the
pitch o$ your voice increases the li)elihood that an older
person with a hearing loss will be able to hear you spea).
%resbycusis (ageArelated hearing loss" can result in
decreased sociali@ation, avoidance o$ $riends and $amily,
decreased sensory stimulation, and ha@ardous conditions
when driving.
7se $re<uent touch to decrease the sense o$ isolation and to
compensate $or visual and sensory loss.
&lder persons undergo a great many changes, which are
usually associated with ;&SS (loss o$ spouse, $riends,
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career, home, health, etc.". there$ore, older persons are
extremely vulnerable to emotional and mental stress.
#CT*8R#TB ?S. D*S%A#R is *ri)son/s $inal stage o$ growth
and development. Reminiscing is a means o$ setting one/s li$e
in order (accepting li$e and sel$", which is the tas) o$ this stage
o$ *ri)son/s development theory. The goal o$ this stage is to
$eel a sense o$ meaning in one/s li$e, rather than to $eel
despair or bitterness that li$e was wasted. The ma1or tas) o$
old age is to rede$ine sel$ in relation to a changed role. Those
persons who had been in charge o$ situations most o$ their
lives may now $und themselves in dependent positions. The
role ad1ustment is a ma1or tas) o$ old age.
Thin) about the $ollowing situations and discuss the nursing
care $or each.
- A nursing supervisor who has had a stro)e and is sent to a
long term $acility $or rehabilitation.
- An oil company executive retires a$ter 4' years with the
company to travel in his recreational vehicle wit his wi$e and
dog.
- Shortly a$ter their 5F
rd
wedding anniversary, a woman who has
never wor)ed outside the home loses her husband to brain
cancer.
There are many conditions that can imitate dementia in the
older adult. A )ey role $or the nurse is to complete
assessment to rule out other possible causes.
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