Ns 2022

NS2022:03
Clinical Nursing Practice 3

Study Period 3, 2011 (External Mode)
Clinical Skills Workbook
Aim
The aim of this workbook is to assist you in preparing for and participating in the Nursing Sciences
Laboratory (NSL) and for clinical placement. By completing the preparatory work, related readings
and recommended activities you will develop the necessary skills to deliver safe nursing care.
Overall aims of nursing laboratories and self directed learning

On the successful completion of these sessions you will have opportunities to:
1. Integrate the professional knowledge, attitudes and skills necessary to meet the specified
ANMC competencies for clinical placement;
2. Demonstrate methods that can be used to provide a safe environment for patients, colleagues
and other health care providers;
3. Appropriately, systematically and expeditiously assess a patient's functional health status;
4. Plan quality patient care using diagnostic reasoning skills;
5. Demonstrate competent nursing skills in assisting patients toward meeting their health care
needs;
6. Apply effective interpersonal skills when interacting with patients, educators, colleagues and
other personnel; and
7. Appropriately identify situations when you require assistance from other staff.
NB.
• Students are expected to leave the labs as they found them, that is, neat and tidy after each
session.
• Standard precautions are to be practised (including the correct disposal of needles and
syringes) while working in the Nursing Science Laboratories.
• You are required to bring this workbook with you to every laboratory session.
• You will be required to wear Nursing uniform, as per The Mariner, to all nursing skills
laboratory sessions and OSCEs.
• You are required to complete a clinical hand wash upon entering and leaving the laboratory.
Guidelines for nursing practice

Completion of scheduled nursing laboratory sessions and preparatory work is mandatory prior to
clinical placement. Laboratory sessions provide you with the baseline skills which are further
developed on clinical placement. Attendance at these sessions is COMPULSORY as these sessions
are essential preparation for nursing practice. For this reason, a medical certificate or written reasons
of extenuating circumstances and makeup work is mandatory for any laboratory session missed.
Preparatory work is required for successful achievement in obtaining/refining important clinical skills.
This includes researching definitions and drugs, reading related literature, completing drug
calculations, and completing critical thinking activities. Critical thinking guides help to demonstrate
the mental process the nurse uses in gathering, organising and evaluating patient data. Nursing
interventions and patient teaching, which foster better patient outcomes, can then be planned. This
will help you develop your critical thinking while on clinical placement and help to prepare you as a
registered nurse.
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Nursing science lab structure
Each laboratory will simulate a clinical unit with relevant patient scenarios pertaining to each module.
Previous learning (including First Year nursing practice skills) will be reinforced during the sessions.
Using your problem-solving skills, you will be expected to assess patients, prioritise and perform the
necessary nursing management, and verbal handover/report as designated. All equipment will be
readily available in the laboratory for students to access and return/clean up when complete. This
includes forms, linen, etc. If you require something not in the lab, let your lab leader know.
Each student is assigned to a laboratory group which will collaboratively work through the designated
activities. Revise last Study Period's work and practice these skills as well. Students are expected to
bring to labs their completed drug profiles, for reference and brief discussion.
A drug profile includes the following:
• drug name (both generic and trade)

• drug use/action
• usual dose
• usual side-effects
• adverse reactions
• contraindications
• nursing considerations.
Insufficient preparation will necessitate make-up work as determined by the subject coordinator.
Your prescribed textbook Medical surgical nursing: Critical thinking in client care (First Australian
Edition) by LeMone et al. (2011) contains a CONCEPT CHECK at the end of each chapter. Answer
the questions as you complete each chapter. This will check your understanding and knowledge and
will also be useful for revision and exam preparation.
National Competency Standards for the Registered Nurse

National Competency Standards for the Registered Nurse (2006, 4th ed.) Addressed by this subject:
$ Professional Practice
$ Critical Thinking and Analysis
$ Provision and Coordination of Care
$ Collaborative and Therapeutic Practice.
The full text of the current competencies can be found at on the Australian Health Practitioner
Regulation Agency website at: http://www.nursingmidwiferyboard.gov.au/Codes-and-Guidelines.aspx
They can also be found in the back of your text: Clinical psychomotor Skills: Assessment tools for
nursing students (2010) by Tollefson.
Compulsory Blue Card
Nursing students are required to obtain a Suitability to Work with Children Card (Blue Card) prior to
undertaking clinical placement. Please logon to LearnJCU and go to the Clinical Placement
Information site, under the Communities tab on the top menu. Click on the Information tab, then
Compulsory Forms to download the Student Blue Card Application form.
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MODULE 1
Pain Management
Unit 1.1 – Concepts underpinning nursing care of a patient in pain
Learning outcomes
On completion of this unit you will be able to:
 Define pain;
 Identify types of pain, (chronic, acute, malignant) and pain syndromes;
 Discuss the physiologic, psychosocial and theoretical aspects related to the process of pain.
Introduction
Pain is the symptom that brings most people into contact with the health care system. This means
that most of you will be caring for people with pain throughout your careers.
Pain is a subjective experience. It is important to acknowledge that the patients’ experience of pain is
individual and dependant on many factors. Pain is what the patient says it is.
This module is only a brief overview of pain. There are books written about pain, and hundreds of
articles and research projects every year are adding to the body of knowledge about pain. Your
textbook gives a good overview of the phenomenon.
LEARNING ACTIVITY
Before reading the material on pain, take a moment to write down a definition of your own.
You might need to talk to others about their pain experiences if you have had limited experience of
pain in your life.
TEXTBOOK READING
Lison-Pick, M. (2011). Nursing care of clients experiencing pain. In P. LeMone, et al. Medical
surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol. 1, pp. 180-198).
Frenchs Forest: Pearson.
LEARNING ACTIVITY
Did your definition of pain include some of the elements in the definitions offered by the International
Association for the Study of Pain (IASP)? How did it differ?
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The following definition encompasses the various aspects of pain identified in the two definitions in
your text. It is broader and identifies the complexity of pain and suggests that pain management is
multimodal.
Pain is a subjective, personal sensation of hurt. It can occur as a result of potential of actual tissue damage or it
can occur without actual physical evidence of such damage. Once pain occurs, both physical and emotional
responses are evoked (ANZCA, 2005).
The physiology of the pain phenomenon is quite involved. Review your neurological anatomy to assist
in the comprehension of this material. Some of the terminology is widely used and you should
become familiar with it.
TERMINOLOGY
Define the terminology from your laboratory session pages.
Take note of the different peripheral nerve fibres that are described in this section. This knowledge
will become important when deciding on implementing specific management strategies for pain.
LEARNING ACTIVITY
Briefly outline the transmission of pain from the peripheries.
Religion and culture play a large role in some people’s perception of and reaction to pain.
• Religion can have a very powerful positive influence on a person’s ability to cope with pain
(through the use of prayer and the belief that suffering will gain them salvation).
• Conversely, it may also have a negative influence if pain is seen as punishment (adding guilt,
frustration and despair to the emotional dimension of the pain experience).
• Cultural beliefs and practices influence the perception of and behaviours surrounding pain.
Some cultural group have evolved rituals and rules around pain, and group members are
socialised to expect and tolerate pain in particular situations and must act ‘correctly’ during
pain experiences.
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TEXTBOOK READING
CRITICAL THINKING
To incorporate this knowledge into your care:

• Assess the person’s coping ability for positive mechanisms, and support these where
possible (contacting a religious adviser or another person from the same culture, obtaining
resources such as religious material or culturally appropriate objects).
• Do not assume that all people of a similar religion or culture will act the same – individuality
is paramount.
• Respect differences in attitudes and coping styles (including the families).
• Use culturally or religiously appropriate interventions whenever possible.
REFLECTIVE THINKING
Try to recall an episode of pain that you have experienced. Identify the dimensions (affective,
cognitive and behavioural) of this pain. Write an outline of each dimension as you experienced it.
Can you identify factors in your own life experiences that may have influenced these dimensions?
How might this exercise help you to understand the pain experiences of someone from a different
religion, cultural or societal background?
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Acute pain is the type of pain seen most often in hospital – people who have surgery or are
hospitalised for trauma, chest pain and so on. People with acute pain present the typical picture of
pain. Characteristically, they grimace, guard the affected area and report pain, their pulse and blood
pressure is elevated and they may be diaphoretic. There are often associated symptoms of anxiety
and nausea. The following table gives a concise outline of the problems associated with acute pain
that is not appropriately relieved.
Dangers of Unrelieved Acute Pain
Body System Pathophysiologic Responses to Complications

Unrelieved Acute Pain
Respiratory Reflex muscle spasms and muscle splinting Atelectasis and impaired oxygen
leads to decreased tidal volume, vital capacity, and carbon dioxide exchange lead
functional residual capacity, and alveolar to hypoxemia and pneumonia.
ventilation.
Cardiovascular Sympathetic over-activity leads to increased Increased cardiac work and

heart rate, peripheral resistance, blood myocardial oxygen use and
pressure, and cardiac output; decreased decreased oxygen delivery to
diastolic filling time; and coronary myocardium lead to increased risk
vasoconstriction. of hypoxemia, myocardial ischemia,
and myocardial infarction.
Gastrointestinal Increased sympathetic activity leads to Gastric stasis, paralytic ileus.

increased intestinal secretions and smooth
muscle sphincter tone and to decreased
intestinal motility.
Immune Decreased natural killer cell number and Host resistance decreased,
function. especially to cancer metastisis.
Neurologic Primary and secondary hyperalgesia with Neuropathic pain can occur and
changes in primary afferent nociceptor may persist for long periods of time
responses at peripheral terminal and changes after healing has occurred.
in the communication patterns of central
nervous system cells.
Musculoskeletal Muscle spasms increase pain leading to Impaired muscle metabolism and
increased sympathetic activity, which muscle atrophy.
increases sensitivity of nociceptors.
(Brown & Edwards, 2008, p.143)
Chronic pain is persistent and has ceased to function as a warning of impending or real tissue
damage. People with chronic pain are often not ‘visibly’ in pain – that is, there are no overt symptoms
of the pain. They have adapted physiologically and behaviourally to the constant pain, and continue
with the activities of daily living. This becomes a problem because health carers often do not believe
that the pain exists since there are no objective signs and consequently, the pain is under-treated.
Benign pain syndrome is a subset of chronic pain. It is caused by structural changes that stress
particular areas of the body – for instance, scar formation that entraps and compresses nerve tissue
following a back injury causing constant low back pain.
Malignant pain is associated with ongoing tissue damage or progression of a disease process. It has
elements of both chronic pain and acute pain. It also has associated psychological elements such as
severe frustration, anger and depression.
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TEXTBOOK READING
As you can see from this unit, understanding the complexities of pain is a career long task. In the
next unit, you will discover how to put some of this information together so that any assessment of the
patient that you do is comprehensive.
Unit 1.2 – Nursing assessment of a patient in pain

Learning Outcomes
• Develop the ability to accurately and appropriately assess a person in pain; acute and chronic
(using the seven dimensions; or PQRST acronym);
• Discuss some of the barriers to assessment and management of a person in pain. Conduct a
comprehensive pain assessment;
• Use appropriate pain assessment tools (VAS, The ‘Faces of Pain’);
• Identify pharmacological and non pharmacological methods to relieve pain.
Nurses are unique among the health care workers because of their perspective from the
bedside/home and the close professional relationship that is developed with the patient. This makes
it essential that the nurse become competent at assessing, reporting and documenting pain and then
utilising appropriate strategies for relieving pain.
Barriers to pain assessment and relief

Pain is often under-treated in hospitalised patients (LeMone, et al., 2010).
There are three main categories of reasons why pain is under-treated.
1. Attitudes (of the nurse, patient and/or care giver);

2. Lack of evidence based knowledge; and
3. Regulatory barriers.
Attitudes, rather than scientific knowledge are among the most influential forces that shape
clinical decision making for pain management.
The following attitudes can contribute to ineffective pain management.
Patient Attitudes:
• Fear of the treatment for pain (eg. Injections)
• Fear of addiction (with opiods/narcotics)
• The meaning of the pain
• Cultural, religious and societal meanings
• Pain is inevitable
Health Care Providers:

• How the patient expresses pain (i.e. stoically or very expressively)
• Their own perception of pain (e.g. patients who are 2 days post op should have only so much
pain)
• Pain that is visible is more ‘real’ (subjective reports of pain are not as valid)
• Pain with a physical diagnosis or definite physiological cause is more valid
• Failure to distinguish between the legitimate and illegitimate uses of narcotics in our society
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Knowledge deficits
Nurses and patients often express concern re using opiod medication to relieve pain for fear of
addiction. Narcotic use is one area where research in the past decade has demonstrated some
reassuring information. The pain stimulus does in fact modulate the pharmacodynamics and
pharmacokinetics of opioid or narcotic analgesia. This reduces the possibility of a patient on opioids
developing an addiction (to less than 1% of all patients taking opioids). Addiction is a psychological
dependence on the drug for effects other than pain relief (e.g. euphoria).
REFLECTIVE THINKING
Consider your own feelings and fears in relation to using and administering opioid (narcotic) drugs.
Write a list of pros and cons.
Research has also produced a greater understanding of the complexity of pain. It has demonstrated
that if a person continues to complain of pain even after customary treatment, they are not ‘drug
seekers’ or addicted, but genuinely have pain that has been under-treated.
Regulatory barriers
Due to the perception in our society that opioid use means drug abuse, and the close scrutiny that the
government keeps on prescriptions of opioids, some patient’s pain continues under-treated. This fear
has filtered through to the nursing staff, and studies have demonstrated that even if physicians
prescribe adequate amounts of opioid, nurses use the discretion given them to limit the amount given
to the patient. PRN medications are often not utilised effectively by nurses to manage, or as an
adjunct to, regular pain relief.
By now you will have explored your own perceptions of pain and considered how this may influence
your clinical assessment. In the following section, you will consider objective assessment strategies.
WEB LINK
Blackwell Publishing has a range of excellent articles – two of which are:

• Acute pain assessment and management.
• Chronic pain assessment and management.
These articles can be located via the Ingenta database via the Library at
http://www.library.jcu.edu.au/Resources/datasets.shtml
Children’s Acute Pain Assessment and Management Handbooks

http://www.wch.sa.gov.au/services/az/divisions/psurg/pdfs/pain_assessment.pdf
http://www.wch.sa.gov.au/services/az/divisions/psurg/pdfs/
acute_pain_management_handbook.pdf
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LEARNING ACTIVITY
When you were working in the clinical area, did you ever encounter an instance when you thought
the patient was not properly assessed or treated for pain? Describe it. Which of the above reasons
(or others) do you think contributed to the problems?
Nursing assessment of pain
TEXTBOOK READING
Clinical Skills Competency

Tollefson, J. (2010). Clinical psychomotor skills: Assessment tools for nursing students (4th ed.).
South Melbourne: Thomson Learning.
Pain assessment – pp. 46-47.
READING ON CDROM
Ersek, M., Irving, G., & Botti, M. (2008A). Pain management. In D. Brown, H. Edwards, S.L. Lewis,
M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher (Eds.), Lewis’s medical-surgical
nursing: Assessment and management of clinical problems (2nd ed.) (pp. 143-144). Sydney:
Elsevier Mosby.
In Unit 1.1 we discussed the subjective nature of pain. This makes pain more difficult to measure than
some of the other parameters used in patient assessment. However, there is clinically useful
information to be gathered that provides an objective perspective.
We must believe the patient. Pain is what the patient says it is. Studies demonstrated that health
care professionals’ consistently underrated patients’ pain when compared to the patient’s rating
(Dewar, 2006). Nurses also often make the mistake of assigning a ‘normal’ value to a type of pain.
Thus someone with a fresh appendicectomy is expected to have X amount of pain, and if the patient’s
rating varies from our expectation, we often do not believe the patient. Again, pain is individual and
should be viewed as a phenomenon that varies for that patient.
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There is another pain assessment acronym that is excellent for assisting to recall the dimensions of
assessment. It is the PQRST assessment. This method is often used in the patient who presents with
chest pain.
P: Precipitating factors
What events or activity precipitate the pain (during rest, with movement, at night, argument, exercise
etc)
Q: Quality of pain or discomfort

Characteristics of the pain – patient’s descriptors (ache, sharp, stabbing, dull, heaviness)
R: Radiation of pain
Where is the pain located? Does it radiate to other areas (eg. Back , arms, jaw, teeth).
S: Severity of pain
Degree or intensity of the pain (Use a pain scale e.g. 0-10 - visual analogue scale)
T: Timing
Discuss the onset of pain, when it began, has it changed since it began and if the patient has
experienced this pain before.
LEARNING ACTIVITY
Identify any beliefs about pain in children that you hold or are aware of. How would these beliefs
influence the pain assessment and management of a child?
READING ON CDROM
Garland, L., & Kenny, G. (2006). Family nursing and the management of pain in children.
Paediatric Nursing 18(6), 18.
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Measurement of pain
Quantitative measures
These are tools to assist in determining the intensity or severity of the pain. There are many tools
available but the Visual Analogue Scale (VAS), or its verbal counterpart, the numeric rating scale, are
widely used and understood by health care professionals. When asking the patient to determine the
severity of their pain using the numeric rating scale, ask them to call their pain a number, give them
the parameters (between ‘0’ and ‘10’ where ‘0’ is no pain and ‘10’ is the worst pain you could have).
Remember, pain is individual, so that a 5 to one patient may indicate moderate pain, but to another, it
may indicate severe pain that could get worse. Thus pain-rating scales are useful to evaluate trends
or changes over time or with treatment in the same patient. When obtaining a baseline pain rating, it
is also useful to determine the patient’s pain over the past 24 hours, asking for present pain, worst
pain and least pain in the previous 24 hours. VAS and numeric rating scales are understood by most
people from 8 years of age to the very elderly.
The Visual Analogue Scale (VAS)

The patient is asked to place a mark along the line that represents the pain that they are presently experiencing.
The nurse then measures and records the mark, measured from the left, in centimetres.
________________________________________________________
0 10
Worst pain imaginable
The ‘Faces of Pain’ scale is useful for children and those who do not understand English or the
concepts involved in the VAS. The ‘Faces of Pain’ scale is presented in Tollefson (2010, p.47).
Qualitative measures
There are tools for measuring qualitative aspects of pain. However, generally, you can gain a great
deal of information by listening to the words the patient uses to describe their pain. Ask them to
describe the pain, then document the exact words they use. Some words are very strongly tied to
different types of pain such as neuropathic (shooting, burning, tingling, shocking, jolting), or
nocioceptive pain i.e. that felt as a result of nocioceptive stimulation of an intact peripheral and central
nervous system (dull, heavy, sharp, aching).
Objective signs
Acute pain (severe) often causes sympathetic nervous system activation and a resulting increase in
blood pressure, pulse rate and respiratory rate. These parameters are often used to track pain and
the patient’s response to interventions. However, it must be remembered that many other events that
occur in the patient’s life can have the same effects. This is especially so in someone who is acutely
ill. The traditional vital signs should be regarded only as secondary (and not very reliable) indicators of
pain.
If a patient is unable to communicate effectively, or is not conscious, you can still determine to some
extent, that they are in pain. Moaning, restlessness, grimacing and agitation are signs that the patient
is in pain and these can be monitored to determine response to interventions.
Pain assessment should be carried out as a vital sign – i.e. more frequently when the pain is unstable
or there is little information, and less frequently as pain becomes controlled. If the patient’s condition
changes, the assessment schedule is increased.
All assessment must be appropriately documented to establish a central area where all providers of
care for that patient can keep themselves informed about the patient’s condition. When the patient is
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reporting pain as a symptom, the documentation becomes especially important as treatment
decisions are made on the written documentation in the patient’s chart.
LEARNING ACTIVITY
Find someone who is in pain – perhaps a friend or relative who has a toothache or headache, and
assess their pain using both a quantitative and qualitative tool. What is their behaviour like? Is their
pulse rate elevated? Would you know they were in pain if you did not ask? Take a few minutes to
‘document’ what you have found.
You may also want to visit the web links below to explore this subject further. In addition, you can
view Women’s and Children’s Hospital (Adelaide) guidelines for children’s acute pain assessment and
management. These web links and resources become useful, particularly if practicing in an isolated
area.
WEB LINK
Children’s Acute Pain Assessment and Management Handbooks

http://www.wch.sa.gov.au/services/az/divisions/psurg/pdfs/pain_assessment.pdf
http://www.wch.sa.gov.au/services/az/divisions/psurg/pdfs/
acute_pain_management_handbook.pdf
Unit 1.3 – Developing a Clinical Pathway for a Patient

Developing a clinical pathway for a patient begins with identifying a problem. After the patient has
been thoroughly assessed, you should have enough data to establish whether this is an actual
problem or a potential problem. From this information you should be able to identify a cause for the
problem. If the major symptom is the pain itself, you might write ‘Pain related to incisional discomfort’.
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Developing a Clinical Pathway (management plan) for a client:
PROBLEM RELATED TO/

DUE TO CAUSE
EXPECTED HEALTH INTERVENTIONS

OUTCOME
(PRIORITISED)
RATIONALES
DISCHARGE PLAN SUPPORTED BY
EVIDENCE-BASED
PRACTICE
In this case, you would direct your nursing interventions toward overcoming the incisional discomfort
that the patient is experiencing. Your interventions should be prioritised and supported by evidence-
based practice.
If pain is causing other symptoms, you might come up with a diagnosis such as: ‘Sleep disturbance
related to shoulder pain secondary to arthritis as evidenced by report of disrupted sleep, yawning,
sleeping during the day and report of fatigue’.
In this case, you would aim nursing interventions at overcoming the shoulder pain.
The expected health outcome is directed towards the pain.
Another common pain related diagnosis is: ‘Ineffective coping related to chronic pain as evidenced by
anxiety, report of despair and feelings of frustration’.
The chronic pain would be the focus of interventions in this instance – perhaps with an emphasis on
teaching the patient some pain management strategies.
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LEARNING ACTIVITY
Practice writing problems and causes remembering that the problem and cause must relate to a
nursing diagnosis and not a medical diagnosis.
Collaboration within the health care team is another important aspect of goal setting. Drug therapy for
pain management is a dependent nursing measure (i.e. to carry out the intervention, nurses rely on
directions or orders from the doctor). Consultation with the doctor about altering drugs, doses or
schedules may be needed. Other colleagues may need to be involved in solving the patient’s
problems. Pharmacists, senior nursing colleagues and physical therapists can all offer sound advice.
The patient’s family may need to be involved. They may assist the patient by helping them to keep a
pain diary or reinforcing newly learned pain management strategies.
Analgesia
TEXTBOOK READING

Tollefson, J. (2010). Clinical psychomotor skills: Assessment tools for nursing students (4rd ed.).
• Managing patient controlled analgesia – pp.178-182.
READING ON CDROM
Ersek, M., Irving, G., & Botti, M. (2008B). Pain management. In D. Brown, H. Edwards, S.L. Lewis,
Elsevier Mosby.
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Our administration of medications is dependent on the doctor’s written, verbal and/or standing orders.
The only category of nurse who is legally permitted to prescribe drugs in Australia is a specially
certified Nurse Practitioner.
Planning to manage patients’ pain is a very important priority for nurses. There are aspects of daily
care that can initiate or exacerbate pain.
READING
Hollinworth, H. (2005). The management of patients’ pain in wound care. Nursing Standard, 20(7),
65-73.
TERMINOLOGY
Define the following terms. For drug names, you will need to know action, onset, peak and duration
of action, side effects, toxic effects, interactions, contraindications and any nursing considerations.
This is a big task, however, this knowledge is directly applicable every day you work in an acute
care setting.
• Adjuvant drugs
• Agonist action
• Antagonist action
• Addiction
• Dependency
• Endogenous opioids
• Pethidine
• Morphine sulphate
• MS Contin
• Codeine phosphate
• Paracetamol (Panadol)
• Naloxone (Narcan)
• Tramadol
• NSAID
• Digesic (Cextropropoxyphene)
• Acetyl salicylic acid (ASA, Aspirin)
Non-pharmacological measures for pain relief

Non-pharmacological measures for pain relief are useful to reduce the amount of analgesia required
or, if the pain is moderate, to eliminate the need for analgesia. These measures give the patient back
some control and are useful to reduce anxiety and its consequential increase in pain levels.
TEXTBOOK READING

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• Dry heat and cold therapy – pp. 166—169.
• Massage – pp.170-173.
• TENS – pp.174-177.
READING ON CDROM
Ersek, M., Irving, G., & Botti, M. (2008C). Pain management. In D. Brown, H. Edwards, S.L. Lewis,
Elsevier Mosby.
The value of these measures lies in the fact that most of them are independent nursing measures that
can be used for patients if an analgesic order has not yet been obtained, or if there are no standing
orders, or as an adjunct therapy to increase effectiveness of an analgesic regime. Most are simple
measures and can be easily implemented.
REFLECTIVE THINKING
Have you ever employed any of the measures discussed to deal with your own pain. Has anyone in
the family? Write a brief reflection of using a non-pharmacological method of pain relief.
You will be able to practice the use of some of these measures during Residential School.
Unit 1.4 – Evaluation and documentation of the nursing

intervention/s
Evaluation should ideally follow every nursing intervention, but in pain management it is imperative.
The effects of the drugs need to be observed – using the same assessment tool that was used to
initially establish the problem. The VAS or numerical rating scale is usually asked of the patient at the
time of peak action and again prior to the next scheduled dose of the medication. This will establish
the effectiveness of the drug and scheduling. If the patient remains in pain, changes to the regime
are sought.
Evaluation is also carried out following the use of non-pharmacological measures for pain relief.
These typically have a shorter duration than does a medication regime, so may need to be
implemented more often.
In order for the effective management of pain, documentation of pain assessment and
implemented nursing interventions must occur. This allows a baseline for other health
professionals to continue to provide optimal patient-centred care.
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LEARNING ACTIVITY
Answer the questions in the CONCEPT CHECK activity in your text:
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Module 2
Advanced Wound Care
Unit 2.1 – Review of the structure and function of the
integumentary system (wounds)
Learning outcomes
• use the appropriate terminology when discussing wound anatomy and physiology;
• explain the processes of inflammation, regeneration, and repair of a wound.
Take a few minutes (or more if you need) to review the material from the science subjects and
Foundations of Nursing on the structure and function of the integumentary system. Be alert for
information that relates to wound care.
LEARNING ACTIVITY
The skin is the largest organ of the body at approximately two square metres and accounts for 16%
of the total body weight of the average adult. List the functions of skin and think about the effects on
the body from a loss of a substantial part of the skin.
TEXTBOOK READING
Carville, K., & Reid-Searl, K. (2011). Assessing clients with integumentary disorders. In P. LeMone,
et al. Medical surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol. 1, pp.
435-439). Frenchs Forest: Pearson.
READING ON CDROM
McKeehen, B., Hazzard, E., & Boxer, E. (2008). Nursing assessment: Integumentary system. In D.
Brown, H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher (Eds.),
Lewis’s medical-surgical nursing: Assessment and management of clinical problems (2nd ed.)
(pp. 507-516). Sydney: Elsevier Mosby.
Lewis, S., & Yates, P. (2008A). Nursing management: Inflammation, and wound healing. In D.
Brown, H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher (Eds.),
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LEARNING ACTIVITY
When reading about assessment, pay particular attention to table 15.2 p.439, Vol 1 in LeMone et al.
(2010) which describes variations when assessing people with light or dark skin.
Describe the stages or phases of wound healing (inflammatory, proliferative and maturation). You
may need to access your pathophysiology text for this exercise.
TERMINOLOGY
Define the terminology for wound care from the laboratory session pages.
Review the section on wound healing and care from Foundations of Nursing. From your study of
wound care, recall that wounds are classified according to their aetiology – e.g. surgical, traumatic,
venous stasis, arterial stasis or pressure ulcers.
TEXTBOOK READING
Kable, A., & Bourgeois, S. (2011). Nursing care of clients having surgery. In P. LeMone, et al.
Medical surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol. 1, pp 81).
Catzonis, L. (2011). Nursing care of clients with infections. In P. LeMone, et al. Medical surgical
nursing: Critical thinking in client care (1st Australian ed.) (Vol. 1, pp. 306-307). Frenchs
Forest: Pearson.
LEARNING ACTIVITY
The discussion on antibiotic resistant organisms is especially pertinent for hospital patients, as
Methicillin Resistant Staphylococcus Aureus (MRSA) is widespread in most health care facilities
throughout Australia. Vancomycin Resistant strains of bacteria is the ‘next step’ in this process of
resistance and could cause difficulties in the near future. Talk to a health care provider (nurse,
pharmacist, physician) about MRSA, and what is being done in their health care facility to combat
this problem.
19
Unit 2.2 – Assessment of the wound
Learning outcomes
On completion of this unit, and with practice, you will be able to:
• outline the elements of the nursing history for a patient with a wound;
• discuss the specific requirements of the physical assessment of the patient with a wound;
• discuss the nursing responsibilities associated with the various diagnostic studies and
procedures used to evaluate the wound.
TEXTBOOK READING
READING ON CDROM
Lewis, S., & Yates, P. (2008B). Nursing management: Inflammation, and wound healing. In D.
Brown, H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher
(Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems
(2nd ed.) (pp. 227-236). Sydney: Elsevier Mosby.
History taking
There are elements common to healing of a wound that should be ascertained for any patient who
has sustained (or will sustain, in the case of a surgical wound) a wound. These are:
• presence of infection, foreign bodies, dead space, irradiation;

• hypo/hyperthermia;
• nutritional deficiency – especially protein, Vitamins C, A, K, B;
• diabetes mellitus or other diseases (e.g. immunosuppression);
• age;
• circulatory changes;
• smoking history;
• excessive or long term alcohol intake;
• some drug therapies (corticosteroids);
• obesity.
LEARNING ACTIVITY
For each of the above factors, describe the alterations to healing that occur or can occur (as they are
potential problems).
20
READING ON CDROM
Vuolo, J. (2006). Assessment and management of surgical wounds in clinical practice. Nursing
Standard, 20(52), 46-58.
Physical assessment
Physical assessment of a wound (observation, documentation and reporting) are essential

components of clinical practice. Initially, classify the wound. The following classifications are usually
used:
• traumatic (acute, surgical, or chronic, e.g. pressure ulcer);

• cellulitis;
• vascular (e.g. venous stasis, or arterial stasis);
• burns or radiation;
• wound breakdown.
Be specific about the location – draw it on a body outline or measure the distance from an anatomical
landmark. Measure the size – length, width and depth with a wound ruler and probe. Be careful in
large wounds to determine if there is tunnelling or undermining (i.e. part of the wound goes much
deeper or goes up under the normal skin around it. Is there a sinus or fistula associated with the
wound? Determine the colour – red can be subdivided into pink (epitheliising) and red (granulating)
and yellow can also be subdivided into yellow (sloughy) and green (infected). Black denotes necrotic
tissue. Describe the exudate. Is it serous (watery, golden and clear), serosanguinous or haemoserous
(pink tinged serous fluid because of a bit of bleeding) or is it sanguinous (very bloody) or purulent (full
of pus). Is there an odour associated with the discharge? How much discharge is there? Dry
dressing means just that – no drainage. Minimal exudate indicates there is less than 5 ml of drainage
in a 24 hour period, moderate exudate indicates less than 10 ml of drainage in a 24 hour period and
heavy indicates a large amount (greater than 10 ml) of drainage in 24 hours. Describe the
surrounding skin. Is it normal, erythematous, macerated. Is there pain associated with the wound?
Assess the patient’s wound pain and determine if the pain is continuous, during movement or during
dressings only.
21
LEARNING ACTIVITY
Review the stages of pressure ulcers and construct a table to compare appearance, characteristics
and healing time.
Diagnostic procedures
Diagnostic procedures for wounds include taking swabs for culture and sensitivity for both aerobic and
anaerobic organisms. Swabs are taken and sent to pathology for culture and sensitivity to establish
the most appropriate treatment if an infection is suspected or present.
LEARNING ACTIVITY
Differentiate between colonisation of a wound and infection of a wound. What are the signs and
symptoms of each?
Unit 2.3 – Treatment goals for wound care
Learning outcomes
On completion of this unit, and with further practice, you will be able to:
• identify patient problems that are amenable to nursing interventions;

• set goals that are measurable, achievable, time limited and patient oriented.
Patient problems associated with wounds

Wounds cause a multitude of problems from the physical (such as limited mobility) to the
psychological (such as altered self esteem). Obviously, the type of wound (acute or chronic) and its
location will influence the nursing diagnosis and planning, as will other factors gleaned from the
assessment. Therefore the following is a general discussion only and should be taken as such.
Nursing diagnoses for acute (surgical) wounds include:

• immobility related to pain associated with surgical incision;
• potential for infection related to loss of skin integrity;
• anxiety, fear, shame related to the sight of the incision, associated drainage, individual
meaning of the surgery to the patient.
For chronic wounds, the nursing diagnoses are more comprehensive:
22
• potential for or actual impaired skin integrity related to nutritional deficiencies, impaired
mobility, prolonged immobility, altered blood values, advanced age, incontinence, altered
mental status, mechanical forces (pressure);
• potential for or actual infection related to lack of knowledge, altered nutrition, decreased
immune response, loss of skin integrity;
• impaired mobility related to activity intolerance, decreased strength, pain;
• self care deficit related to location of wound, immobility, treatment requirements;
• altered tissue perfusion related to pressure, decreased blood flow, immobility;
• altered body image related to aversion to the wound;
• altered self esteem related to inability to self care, inability to undertake usual activities, roles.
LEARNING ACTIVITY
For each of the above patient problems, list some cues you would expect to see if the patient had the
problem. For example, a potential for impaired skin integrity might be diagnosed if the patient
showed a patch of erythema on bony prominences that did not blanch with pressure, or remained
after 30 minutes of no pressure, had one or more of the predisposing factors for developing a
pressure ulcer, and complained of pain or numbness on the bony prominence.
Goals for patients with wounds
The ultimate goal is to restore the integrity of the skin with minimal complications or disability (e.g.
infections, dehiscence, contractures, excessive scarring) and maximum functionality of the affected
area. This is usually achievable with patience and persistence. Wound healing takes time – minimal
in the case of a superficial cut or abrasion however, it may be years for complete healing of a severe
burn or a deep, infected stage 4 pressure ulcer.
23
LEARNING ACTIVITY
Write a goal for each of the above nursing diagnosis. Make sure it is patient centred (give the patient
a name and start the goal with the patient’s name), addresses the first part of the diagnosis (the
patient problem), is achievable, realistic and time limited. For example, the potential for impaired skin
integrity problem might have a goal that states: John Mayer will maintain intact skin during
hospitalisation. This will be assessed on each shift.
Unit 2.4 – Nursing care of the patient with a wound (selected types)
Learning outcomes
On completion of this unit and with further practice, you will be able to:
• discuss the aetiology, incidence, clinical manifestations, complications and medical care of
patients who have acute surgical wounds and pressure ulcers;
• outline the nursing interventions and their rationales for the patient with each of the above
selected wounds.
Acute wounds
It is important for nurses to consider that some patients are profoundly affected by the sight of a
wound and will not, initially, look at their wound. This may be especially true if the wound is disfiguring
such as amputation, extensive facial burns or post mastectomy. Discuss the wound with the patient
and give them opportunities to come to terms with their new body image. Use pleasant terms and
facial expressions. Most patients will eventually look at their wound and may even wish to care for it
under supervision.
Some wounds are very unpleasant for the staff to view and care for including offensive odours. It may
be necessary to school your facial expression so that you do not offend the patient.
Tissue is held together with a variety of material – as follows:
• Sutures: These may be absorbable or non-absorbable. Absorbable sutures are placed in

deep tissue layers (fascia, body cavities, subcutaneous tissue) and are absorbed by the body
during the healing process. Non-absorbable sutures are used to hold together the skin layers
while healing occurs. One type of non-absorbable suture is used in deeper tissue. This is the
retention suture which keeps deeper tissues together to relieve tension on the superficial
24
layers while they heal. Retention sutures (also known as stay sutures or tension sutures) are
heavy gauge organic material (silk, nylon) or metal that pass through deep tissues and are
brought out onto the skin surface a short distance from the incision suture line. They are held
above the incision suture line by means of a tube or plastic bridge so there is no pressure on
the incision line. Non-absorbable sutures are removed when sufficient healing has occurred
and there is no danger of wound gaping or dehiscence. This is usually in 5-7 days, barring
complications.
• Staples and clips are composed of stainless steel and are used as an alternative to sutures.
• Sterile adhesive strips are strips of plastic that are used to hold superficial incisions closed.
They are non-traumatic and are sometimes used in conjunction with conventional sutures.
They are easily removed or replaced if necessary.
• Wound adhesive is an organic adhesive (tissue glue) that is also used to hold together
wound edges that are superficial or have no tension placed on them. The adhesive is
absorbed as the body heals.
Drains
Drains are used to remove fluid from a wound bed to keep the amount of exudate in the area from
putting tension on the wound. Removing the fluid also removes a culture medium so that infection is
less likely to occur in the wound bed. Gravity drains can, however, be a track for bacterial entry into
the wound bed. Gravity drains are used less frequently now than they have been in the past.
Drains also serve to alert the health carers to any incidence of haemorrhage, as usually the frank
blood is removed via the drain. Vacuum drains (Haemovac, Belovac) are self contained, closed
systems and are the most frequently seen drains.
Nursing interventions related to drains include assessment of the patency and amount, colour, and
consistency of drainage, and the re-establishment of the vacuum after the drain is emptied. Removing
the drain after the physician has ordered this is also a nursing responsibility. Always remember to give
adequate PRN pain relief and allow time for the pain relief to take effect prior to drain removal. This is
particularly important for chest drain removal.
TEXTBOOK READING – Clinical Skills Competency
• Drain removal – p.249
Pressure ulcers
Crisp and Taylor (2001, pp. 1558-1560) report that the incidence of pressure ulcers ranges from 3-
20% in acute care settings and from 3.5-23% in long term facilities. Patients who are paralysed
(quadriplegics, paraplegics, some patients following cerebrovascular accidents) are at far greater risk.
Crisp and Taylor (2001, p. 1558) also report the economic consequences. Prevention is expensive –
in time and extra resources, but not as expensive as treatment. The expense of treatment ranges
from US$5,000-$27,000 depending on the number and severity of the ulcers. These, of course, are
US statistics, but the incidence would be similar in Australia and the costs probably more. The
economic consequences do not take into account the anguish suffered by the patients and their
families. Burrell (1997, p. 2013) asserts that “the incidence of new pressure ulcer formation can be
almost eliminated with expert conscientious nursing care”.
25
TEXTBOOK READING
LEARNING ACTIVITY
The best treatment for pressure ulcers is prevention. To prevent pressure ulcers forming, you must
be aware of the vulnerable areas. List the points on the body which are vulnerable to pressure
when the patient is lying prone, on their side and supine. [Hint: if you cannot think of them all, lie
down on a hard surface in each position and feel the pressure areas.
Did you remember the back of the head, the ears, or toes? These areas are often forgotten – in both
the assessment and the prevention of pressure ulcers. Another large part of prevention is knowing
the patient - assessment, not just of the pressure areas but of the patient as a whole. There are
several tools that assist in determining a patient’s susceptibility to developing a pressure ulcer such
as the Waterlow scale.
LEARNING ACTIVITY
Recall your clinical placement from first year. What preventative devices or procedures did you see
in use to prevent pressure areas developing. Critique the effectiveness of these interventions. Were
the nursing interventions evidenced based?
26
TEXTBOOK READING
READING ON CDROM
Moore, Z. (2005). Pressure ulcer grading. Nursing Standard 19(52), 56-64.
Lewis, S., & Yates, P. (2008C). Nursing management: Inflammation, and wound healing. In D.
Mechanical debridement, either in a hydrobath or with forceps and scissors is undertaken by

experienced staff in order to remove devitalised tissue from the wound bed. This reduces the material
available for bacteria to colonise and permits granulation tissue to emerge. Your text describes wet-
to-dry dressings as a method of mechanical debridement.
An alternate treatment modality for complex wound management included larval therapy which has
been used historically to debride wounds. The following article discussed both human and animal
use. It is interesting because it explains the mechanisms of action
READING ON CDROM
Anderson, I. (2006). Debridement methods in wound care. Nursing Standard, 20(24), 65-72.
REFLECTIVE THINKING
What would you think about applying maggots to a wound? Why? Would it make a difference if the
wound was on you? Write your thoughts about this type of therapy.
Medical care of pressure ulcers is often confined to prescribing antibiotics for infections. Often,
following culture and sensitivity, topical antibiotics are prescribed for local infections and if necessary,
appropriate systemic antibiotic therapy is instituted. Chemical debriding materials are also prescribed
27
when necessary. Sometimes surgical debridement is required. Hyperbaric treatment is becoming
increasingly more common in the treatment of pressure ulcers.
The cleansing agent of choice is generally Normal Saline as it is non-toxic and non-irritating. Most of
the traditional solutions (Provodone-iodine, chlorhexidine, hydrogen peroxide, for example) are
cytotoxic and can impede the granulating tissue, however may still be used in specific cases.
Irrigation is the preferred cleansing technique as it removes slough and does not leave debris in the
wound. The irrigating solution should be warmed to prevent cooling of the wound, which slows
healing. The pressure of the irrigation is crucial – too little does not remove slough and exudate, too
much damages tissue. A pressure of 8 psi is sufficient to remove debris but not damage granulating
tissue. A 35 ml syringe with a 19 gauge catheter provides this pressure.
Tollefson, J. (2010). Clinical psychomotor skills: Assessment tools for nursing students (4th ed).
South Melbourne: Thomson Learning
• Wound irrigation – pp. 287-289.
READING ON CDROM
Worley, C. (2006). So, what do I put on this wound? Making sense of the wound dressing puzzle:
Part II. Medsurg Nursing, 15(3), 182-183, 174.
Worley, C. (2005). So, what do I put on this wound? The wound dressing puzzle: Part III.
Dermatology Nursing, 17(4), 299-300.
Wound Dressings
Dressing selection and wound cleansing agents are often dependent on the individual patient’s
circumstances, health care professionals clinical judgement and availability of products. The
cleansing agent of choice is generally Normal Saline as it is non-toxic and non-irritating. Most of the
traditional solutions (Provodone-iodine, chlorhexidine, and hydrogen peroxide, for example) are
cytotoxic and can impede the granulating tissue, however may still be used in specific cases.
Irrigation is the preferred cleansing technique as it removes slough and does not leave debris in the
wound. The irrigating solution should be warmed to prevent cooling of the wound, which slows
healing. The pressure of the irrigation is crucial – too little does not remove slough and exudate, too
much damages tissue. A pressure of 8 psi is sufficient to remove debris but not damage granulating
tissue. A 35 ml syringe with a 19 gauge catheter provides this pressure.
The choice of a dressing can be complex. The ideal dressing should:
• maintain a moist environment at the wound/dressing interface;

• provide thermal insulation;
• provide a barrier to micro-organisms;
• provide protection from trauma;
• be non-toxic, non-allergenic and non-sensitising;
• be easy to use;
• be absorptive;
• be flexible and conforming;
• be sterile;
• be cost effective;
• be easily removed.
28
This list is not exhaustive and more characteristics could be added for individual patients (for
example, for a paediatric patient, you might want a dressing that is NOT easy to remove). Most
facilities have protocols for use of dressings and limit the variety of dressings available for its patients
due to the costs. To choose an appropriate dressing, you need to first determine the aetiology of the
wound and the factors for each individual patient that affects their healing. Then you can select
appropriate dressings and develop a management plan. Broad descriptions of types of dressings
follow.
• Passive dressings: protect, absorb exudate (e.g. Gauze, lint); non-adherent (e.g. Melolin).
• Interactive dressings: protect, absorb, maintain or donate moisture, aid in autolytic

debridement – promote an environment that maximises healing potential.
• Polyurethane films consist of a thin polyurethane membrane coated with a layer of acrylic
adhesive. They are gas and water vapour permeable and bacteria impermeable. They allow
easy wound assessment and provide a moist environment that encourages autolysis and cell
migration. There are no absorption properties. Examples are Opsite and Bioclusive.
• Polyurethane foams meet many of the standard requirements for an ideal dressing. They
allow passage of exudate through the non-adherent surface to be absorbed into the main
body of the product while maintaining a moist environment and insulating and protecting the
wound. This can be used as a primary or secondary dressing. Examples are Allevyn and
Cavi-care.
• Hydrocolloids are a combination of polymers held in fine suspension in water. They

combine with exudate to form a soft moist gel. They encourage autolysis while maintaining a
moist protective environment. A possible complication is maceration of healthy skin.
Examples are Duoderm, CGF and Duoderm Thin.
• Hydrogels are cross linked polymer matrices in a gel or paste form that entrap water content
from 30-90% of their own volume. They rehydrate desiccated dead tissue so it is absorbed
into the matrix and removed, and they absorb exudate. This aids autolysis and debrides
sloughy and necrotic tissue. Examples are Intrasite Gel and Intrasite Conformable.
• Alginates are a group of products produced from seaweed. They interact with the wound by
absorbing exudate, creating a moist retentive gel and providing a moist environment without
maceration. They fill in dead spaces and are used for packing cavities as long as sufficient
exudate is being produced. They have autolytic properties. Examples are Sorbisan and
Kaltostat.
Wound management is a recognised specialty. When you are unsure of a cleansing agent or dressing
choice, consult with the specialist in the facility in which you are working.
Unit 2.5 – Evaluation of the patient with a wound
Learning outcomes
• determine criteria for reassessment so goals are evaluated;

• document the effectiveness of nursing care and treatments.
Criteria for reassessment so goals are evaluated
This section is general, because the criteria that you establish for assessment of the goals and the
effectiveness of the interventions depend on your initial assessment.
29
Some of the criteria you might choose to use are:
• intact skin;
• healthy granulating tissue;
• reduction in size and depth of the wound;
• reduction in amount of exudate;
• elimination of symptoms of infection;
• evidence of re-epithelization;
• reduction or elimination of pain;
• increased ability to mobilise;
• ability to view the wound without anxiety.
LEARNING ACTIVITY
After reading all of the material for this module, can you think of other criteria that would indicate that
a wound was healing? Write a list.
Documentation of the effectiveness of nursing interventions
Documentation is necessary to keep the health care team informed of the progress (or not) of the
patient and to justify the nursing time spent. Documentation is, ideally, done immediately following a
treatment or patient interaction. It should include subjective statements from the patient as well as the
objective observations of the nurse, the treatment performed and any actions taken to alter the care
given. Documentation must be clear, concise and accurate. The importance of knowing the medical
terminology cannot be over-emphasised. Facilities differ in their approach to documentation and you
should discuss with your clinical facilitator what is expected in the facility to which you are assigned.
Generally, documentation of wound care would include the assessment findings of size, location,
depth, exudate, sutures (generally stated as sutures or staples intact), condition of the wound and
wound edges and any statement the patient has made about the wound. Further, the treatment
would be stated and the patient’s reaction noted. Examples follow.
For a surgical wound, you might write:
10.01.2011 Abdominal incision cleansed with NS and dressed with Melolin. Wound is 16 cm, midline
0930 abdomen, wound edges well approximated with little induration, a 2 cm haematoma evident
at mid-incision. Minimal serosanguinous exudate. Clips intact. No evidence of inflammatory
Nursing reaction at clip insertion sites. Drain site cleansed. Draining moderate serous fluid. Drain
dressed with Melolin and reinforced with an abdominal pad. Mrs Fatima Rashid states pain is
minimal at rest but rates it at 5/10 with movement. Analgesia given as charted. Patient states
pain is now 3/10. Y.Chu RN (Chu).
30
For a pressure ulcer, you might write:
10.01.2011 Wound on right heel irrigated with NS. Wound remains 4x4.5x1 cm. Slough on medial edge
0945 has been debrided and wound bed has granulating tissue. Exudate is reduced to moderate.
Wound edges intact with no evidence of inflammation or maceration. Wound dressed with
Nursing hydrocolloid dressing and dressing edges reinforced with paper tape. Dressing to remain in
place until 17.10.03. Mrs Skoczylas states the pain is minimal 2/10 and refused offer of an
analgesic. S.Baker RN (Baker).
LEARNING ACTIVITY
Document as if you have just irrigated the stage 3 pressure ulcer pictured on page 483 in your text:
et al. Medical surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol. 1, p.
483). Frenchs Forest: Pearson.
Did you note its location, size, appearance, skin at edges, what you used to irrigate and what you
used to dress it?
Did you comment on pain or the patient’s ability to move? These things should all appear in your
documentation.
31
Module 3
Respiratory Assessment and Obstructive Problems
Unit 3.1 – Review the structure and function of the respiratory
system
Learning outcomes
On completion of the unit you will be able to:
• use the appropriate terminology when discussing respiratory anatomy and physiology;
• explain the processes of ventilation, perfusion and gas exchange;
• describe the process of gas exchange in the alveolar-capillary system;
• describe the mechanical, neural and chemical stimuli that can effect ventilation;
• discuss the defence systems that protect the integrity of the respiratory system.
Terminology used for discussing respiratory anatomy and physiology

Take time to review the material from the science subjects that you have taken, on the structure and
function of the respiratory system.
TEXTBOOK READING
McLean, D. (2011). Assessing clients with respiratory disorders. In P. LeMone, et al. Medical
Use the appropriate terminology when discussing respiratory anatomy and physiology.
TERMINOLOGY
Define the terminology from your laboratory session pages.
The process of ventilation, perfusion, and gas exchange
A solid understanding of these processes is vital to your comprehension of the pathophysiological

changes that occur during respiratory alterations. This knowledge will be used to plan care and
choose interventions.
32
LEARNING ACTIVITY
Outline each of the above processes (ventilation, perfusion & gas exchange) and how they are
integrated. List the factors that alter the oxyhaemoglobin dissociation curve, and how it is altered.
The process of gas exchange in the alveolar-capillary system
Partial pressures of 02 and C02 are important concepts for the safe administration of oxygen therapy.
The interpretation of arterial blood gasses is dependent on a basic understanding of the processes of
diffusion and acid base balance as related to the respiratory system. These concepts are important
when caring for patients who have unstable respiratory status.
LEARNING ACTIVITY
Write down your understanding of the process of diffusion.

How does diffusion affect arterial blood gas readings?
33
The mechanical, neural and chemical stimuli that can effect ventilation
The control of respiration is a complex process. An understanding of the renal-respiratory interaction

of acid/base is essential to nursing care of patients with respiratory disorders. Review the material in
your science courses for a more in depth discussion of acid/base balance. The care of patients who
have developed Chronic Obstructive Pulmonary Disease (COPD) also known as Chronic Airways
Limitation (CAL), is easier to understand if you have a firm grasp of the PaCO2 mechanism for
stimulation of respirations.
TEXTBOOK READING
READING ON CDROM
Kaufman. J. (2008). Nursing assessment: respiratory system. In D. Brown, H. Edwards, S.L. Lewis,
Elsevier Mosby.
LEARNING ACTIVITY
Discuss the defence systems that protect the integrity of the respiratory system.
• Outline the defence mechanisms discussed in the above reading. What is the effect of
smoking on these protective mechanisms?
Learning outcomes
• outline the elements of history taking;

• discuss the requirements of the physical assessment;
• discuss nursing responsibilities associated with various diagnostic procedures used to
evaluate respiratory function.
34
TEXTBOOK READING

• Respiratory assessment – pp. 35-38.
Respiratory history taking
History taking during assessment is vital. The health history will give hints about the physiological
cues that you find. Make sure that if the patient is short of breath (SOB) you ask a minimum of
questions and those should be closed questions to allow the patient to expend the least energy when
answering. Usually, the presenting problem is explored first, and the patient’s context is used to ask
questions. For example, use the activities of daily living – how does this affect your ability to sleep, do
self care, walk, climb stairs and so on to establish the degree of difficulty the patient is experiencing.
LeMone et al. (2011) Vol 3, page 1229 presents a respiratory health pattern Interview using Gordon’s
Functional Health Patterns. Review the questions and leading statements you could use in a
respiratory assessment.
You could also add some extra areas to the health maintenance/health perception pattern – patient’s
occupation (or former occupations) as some (farming, mining, dry cleaning work, working with
asbestos) can cause respiratory difficulties such as fibrosis or mesothelioma. Hobbies can also cause
problems in the respiratory system over a period of years. Use of solvents and glues, paints and
aerosol varnishes, care of birds and some animals will cause lung damage if care is not taken.
If the patient is extremely distressed, the history should be minimal until some degree of comfort has
been established.
READING ON CDROM
Mehta, M. (2003) Assessing respiratory status. Nursing, 33(2), 54-56.
LEARNING ACTIVITY
If you know anyone with an altered respiratory function, ask them if you can do a health history with
them. If not, answer all of the questions posed in the text about yourself. Document what you have
learned.
35
TERMINOLOGY
Define the terminology on your clinical laboratory session pages.
The requirements of the physical assessment
TEXTBOOK READING

• Monitoring with pulse oximetry – p. 231-233.
LEARNING ACTIVITY
You will be practicing physical assessment during residential school and on clinical placement this
study period. In the meantime, you might listen to your own or your family’s chests. This will give
you a chance to practice listening to the very quiet sounds in the respiratory system. Often, initially,
you will not be able to hear the very quiet, normal inspiratory and expiratory sounds. Your ear
becomes able to discern the sounds with practice. Try listening over the right lung fields to avoid
heart sounds, starting near the top of the sternum where the sound is the loudest. Move the
stethoscope diagonally down and out to the mid-axilla line about 5cm below the nipple line to hear
the quiet sounds at the base of the lungs.
LEARNING ACTIVITY
To determine clubbing, ask the patient (or show them) to put the fronts of their index fingers together,
nail to nail and first knuckle to first knuckle. If you look between the nails, on people with no clubbing,
there will be a small, elongated diamond visible between the nails and base of the nails. With
clubbing, the angle flattens and disappears.
Nursing responsibilities associated with various diagnostic

procedures used to evaluate respiratory function
TEXTBOOK READING
When obtaining ABGs an Allen’s test is performed to ensure adequate circulation to the hand before
the radial artery is used.
36
LEARNING ACTIVITY
Outline the nursing responsibilities for pulse oximetry, sputum collection. Find out how to perform an
Allen’s test and conduct one on a colleague.
Endoscopic examinations are done by doctors, but nurses need to understand what will happen to the
patient. To allay anxiety (which increases dyspnoea), careful explanations, including the sensations
the patient will feel must be given. To do this, the prudent nurse is aware of what occurs in such an
examination. You will need to take opportunities presented to attend various diagnostic studies with
your patients (over the clinical placements that remain).
The lung function studies (also called Pulmonary Function Tests in some texts) are interesting and
give an insight into your patient’s abilities to complete various activities of daily living.
Unit 3.2 – Planning with the patient who has alterations in their
respiratory system
Learning Outcomes

Patient problems that are amenable to the interventions of nurses
Much of the care that nurses provide for patients with respiratory difficulties is dependent. That is, the
doctor directs the treatment. Medical care is provided to treat the disorder that is diagnosed. Medical
care ranges from surgical interventions for such problems as tumours, abscesses, empyema and
trauma to the more common treatments of oxygen therapy, drug therapy and chest physiotherapy.
Throughout these medically ordered treatments, the nurse has the responsibility to administer drug
therapy as ordered, perform chest physiotherapy and provide oxygen safely and effectively. There
are many medications used for disorders of the respiratory system. Knowledge of these drugs or drug
classifications is imperative, although a more detailed knowledge will develop with familiarity.
LEARNING ACTIVITY
The following are drugs frequently used in caring for the patient with a respiratory disorder. Look up
these classifications of drugs. Note any special considerations of individual drugs.
37
TERMINOLOGY
• Bronchodilators (Atrovent [Ipratropium], Ventolin [Salbutamol], Theodur [Theophylline])

• Mucolytics (Bromhexine)
• Corticosteroids (Becotide, Pulmacort, Prednisone)
• Antibiotics (Amphotericin, Augmentin Forte, Ciprofloxin)
• Anti-tubercular drugs (Ethambutol, Para-Amino Salicylate [PAS], Rimfampin, Streptomycin,
Isoniazid)
TEXTBOOK READING
Hales, M. (2011). Nursing care of clients with ventilation disorders. In P. LeMone, et al. Medical
READING ON CDROM
Capriotti, T. (2005). Changes in inhaler devices for Asthma and COPD. Medsurg Nursing, 14(3),
185-194.
Although this is a US-based report, you may find the basic explanation and tabulation of inhalers and
their mechanism of action useful.
One responsibility the nurse assumes is the monitoring of the respiratory response to the treatment.
Generally, nurses monitor respiratory rate, depth, rhythm, cough, sputum production, breath sounds
and the patient’s reaction to the treatment. The more unstable the patient is, the more frequently they
require monitoring.
Patient problems frequently encountered in the nursing care of patients who have respiratory
difficulties include:
• ineffective airway clearance related to fatigue, weakness or copious sputum production;

• impaired gas exchange related to hypoxaemia;
• alteration in breathing pattern related to fatigue;
• anxiety related to breathlessness/dyspnoea;
• self care deficit (hygiene) related to hypoxia and fatigue;
• altered nutrition (less than body requirements) related to dyspnoea;
• disturbed sleep pattern related to dyspnoea, orthopnoea;
• altered family relationships related to difficulty coping with severity of the disease process;
• sexual dysfunction related to decreased exercise tolerance.
LEARNING ACTIVITY
During your reading of Chapter 39 Nursing Care of Clients with Gas Exchange Disorders in Volume
3 of LeMone et al. (2011) keep a list of other patient problems or other causative mechanisms (i.e.
the ‘related to’ phrase) for the above patient problems.
38
Goals that are measurable, achievable, time limited and patient oriented
The goals for patient problems will, of course be dependent on the first phrase of the problem
statement. Thus, the patient oriented goals would start with the patient’s name (E.g. Ray) and then
state the desired behaviour. They would be measurable. This means that there has to be a difference
in the patient’s condition that can be seen and measured by you, or felt by the patient. The goal also
has to be achievable. It is not helpful to set a goal in conjunction with a patient that you know is not
attainable by that patient. If, for instance, the patient is suffering from advanced Chronic Obstructive
Pulmonary Disease (COPD), it would be unreasonable and unkind to set a goal of independently
completing all activities of daily living. The time limit is a judgement on your part as to when it is
reasonable to expect change to occur or when you would decide to reassess and change
interventions if there had been no progress. The time limit depends on the severity of the symptom or
problem. If the problem were life threatening, and not resolving in seconds to minutes, reassessment
would have to occur quickly – therefore the time limit would be 2 minutes. In a non-emergent but
unstable situation, 2nd or 4th hourly is a reasonable time for treatments and nursing interventions to
begin to be effective.
Thus, the goals for the above patient problems might read:
• Ray will maintain a clear airway (monitor 2nd hourly) as evidenced by a patent airway, quiet
respirations, effective cough and absence of signs of hypoxaemia.
• Ray’s gas exchange will improve within 5 minutes as evidenced by SaO2 increasing to 95%.
• Ray’s breathing pattern will become regular and even within fifteen minutes as evidenced by
regular, even respiratory rate between 14 and 20 breaths per minute.
• Ray’s anxiety level will be diminished within half an hour as evidenced by statement of same.
• Ray will be able to carry out his normal hygiene routines (shower, shaving, dressing, tooth and
hair care) within 2 days with minimal assistance from nurse.
LEARNING ACTIVITY
For the remaining problem statements, write goals that reflect the above discussions. You will gain
some insight into this as you read the following sections as well.
39
Unit 3.3 –Nursing care of the patient with a respiratory alteration
(selected disorders)
There are so many respiratory disorders that a discussion of all of them is beyond the scope of this
subject – if not the entire course. Several disorders have been chosen to illustrate the care of the
patient with a respiratory disorder; Pneumonia, Asthma and Chronic Obstructive Pulmonary Disease
Please note: When studying remember that some texts, the source is American and thus some drug
names will differ as will the spelling. Statistics are also often for the United States of America.
Look up www.abs.gov.au and go through the ‘Statistical Profile of Australia’ to ‘Health’ to look for
mortality and morbidity statistics. Concentrate on the nursing care, after you have a basic
understanding of the aetiology, pathophysiology and medical care.
Learning outcomes
• discuss the aetiology, incidence, clinical manifestations, complications, and medical care of
patients who have selected respiratory disorders;
• outline nursing interventions and their rationale for each of the patients with each of the above
selected disorders.
Asthma
TEXTBOOK READING
surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol. 3, pp. 1276-1286;
1324-1336; 1336-1347). Frenchs Forest: Pearson.
These readings provides a comprehensive review of the Australian and New Zealand experiences
and management of asthma, COPD & Pneumonia.
Asthma patients are being diagnosed at younger ages. Asthma is one of the diseases that will be
encountered in your practice time and time again – whether in the acute phase or the chronic
remission phase. You will need the knowledge to discuss the disease and help the patient to make
the most of their lives within the constraints of asthma. Treatments are becoming more and more
sophisticated and effective. Hopefully, the effects of asthma will be controlled in the future and its
impact will be less obtrusive.
WEB LINK
Visit the Australian Bureau of Statistics website and determine what the incidence (numbers, gender,
ages) of asthma is in Australia.
■ http://www.abs.gov.au
40
REFLECTIVE THINKING
Asthma has many triggers. Your textbook lists them. Think about how these triggers would affect
your everyday activities if you reacted to them with an asthma attack. What types of lifestyle changes
would have to be made by someone who develops adult onset asthma? How would your lifestyle
change (assuming you do not now suffer from asthma) if you were diagnosed with severe asthma
now? Use the list of triggers as a framework to shape your answer.
LEARNING ACTIVITY
Asthma is generally a patient controlled disease (unless there are acute exacerbations). That means
that patients must have a great deal of knowledge about the disease at their fingertips. Outline some
resources in your area that you could direct a patient to use to increase his knowledge of the
disease. Hint: phonebooks, websites, people, health care personnel.
Again, the detail of drugs used for asthma that is given in LeMone et al. (2011) on p.1331 is greater
than is needed for the purposes of examinations. It is important to remember the general discussion
about drug classifications, rather than individual drug names. Drugs are being introduced to the
market frequently, so information that is presented in a textbook was researched the year previous to
publication, and in the area of drug use, can be outdated in a couple of years. You would have had
some pharmacy work in your PP subjects last year on this as well. There are ‘old standbys’ in the
medical treatment of asthma and these are generally discussed within the classification discussion on
drug therapy in your text.
Read the Asthma self management plan:
READING ON CDROM
Steinman Kaufman, J. (2008). Nursing management: Obstructive pulmonary diseases. In D.

(2nd ed.) (p. 684). Marrickville: Elsevier.
Chronic Obstructive Airways disease (COAD) (Emphysema and Chronic Bronchitis)

LeMone et al. (2011) has a discussion of the aetiology and pathophysiology of COPD on pp. 1336-
1338, Vol. 3
41
TEXTBOOK READING
LEARNING ACTIVITY
Make a list of the symptoms of Emphysema and Chronic Bronchitis. Describe the differences in
presentation of these diseases. Is it possible to determine which disease the patient has? Look
carefully ... and write down the differences.
Much of this chapter will be pertinent to your clinical skills workbook (oxygen therapy, chest
physiotherapy, coughing and deep breathing).
LEARNING ACTIVITY
Oxygen therapy for the patient with COPD has additional nursing considerations. What are they?
How would giving a High FiO2 to a patient with COPD be detrimental or even life threatening? .
Make sure you understand and are able to discuss the problems that can occur from administering
oxygen therapy.
42
Unit 3.4 – Evaluation of the patient with a respiratory disorder
Learning outcomes
• determine criteria for reassessment so that goals are evaluated;

LEARNING ACTIVITY
From the information you have gleaned from the readings, can you list criteria that would indicate
that your interventions had been successful? Use the symptom list from the textbook to write a
patient progress note for a patient with pneumonia and one with emphysema that has responded
well to your interventions.
43
Module 4
Resuscitation
Learning Outcomes
On completion of this module and with further practice you will be able to:
• explain why it is important to initiate CPR without delay.

• explain the assessment of a patient before, during and after cardiac arrest.
• demonstrate competence when performing BLS on a mannequin.
• discuss organisational factors which will help to improve patient care during and following
cardiac arrest.
• outline the benefits of debriefing sessions following a cardiac arrest on the ward.
Introduction
In this module you will be extending the knowledge gained in Foundations of Nursing A. You may
want to refer back to Unit 1.2 in this subject. The focus of this module is to introduce you to the
management of a cardiac or respiratory arrest in the hospital setting. Some concepts of advanced life
support will be discussed. While performing CPR in a hospital is not different to the procedure you
would use in a community setting, you do have access to adjunct equipment in a hospital. Emergency
resuscitation equipment is available within minutes in a hospital, and this will influence the way the
cardiac or respiratory arrest is managed.
Unit 4.1 – Review of the structure and function of the upper and
lower airways and heart
Learning outcomes
Following completion of this unit you will be able to:
• identify the location of normal structures within the upper airway and state how an open airway
can be maintained in an unconscious infant, adult and child;
• identify the location of the heart and the recommended point of compression during cardiac
resuscitation;
• explain how chest compression will cause blood circulation to the body.
In this unit you will review the structures of the upper and lower airways. You will review the
procedure for maintaining an airway in an unconscious person. By reviewing the physical structures
of the thorax, you will have a better understanding of why the lower third of the sternum is the
recommended point for chest compressions. Oxygen requirements are vital for major organ function,
so the time that we have to initiate CPR before organ damage occurs will be reviewed.
TEXTBOOK READING
By clearing and opening the airway you will provide the patient with an immediate opportunity to
inhale. If you are attending a collapsed victim, you may in fact prevent a person from going into
cardiac arrest. For example, if a person has fainted their airway may be obstructed due to poor body
44
posture. You may find that clearing, then opening the upper airway causes the person to re-
commence their breathing – and by taking these initial actions you may have saved their life!
CRITICAL THINKING
State the purpose of lateral chest thrusts.

• Explain the technique for opening an obstructed airway in an infant or child.
• Describe how you would perform the procedure for opening the unconscious patient’s airway
using the head tilt and jaw thrust methods.
Clearing and opening the patient’s airway will allow the entry of air into the lungs, and the continued
circulation of oxygen. Brain cells which are deprived of oxygen will begin to die within a few minutes.
While most texts and readings state that you need to restore oxygenation within four minutes, this
period may be shorter in the person who is already unwell (for example, the patient with congestive
heart disease who already had reduced circulation prior to the cardiac arrest). As a nurse in an acute
care setting, you can increase oxygen by a few methods:
1. Clear and open the airway, (if the patient is able to breathe observe for the rate and depth of
breathing. Commence oxygen via a simple mask).
2. Commence mouth-to mask ventilation if patient is not breathing.
3. When oxygen becomes available attach the oxygen tubing to the mask or insert it under the
mask. You can also place oxygen tubing straight into the patient’s mouth if you are
performing mouth-to-mask resuscitation. By doing this you will increase the oxygen intake to
approximately 50%. The importance of this step cannot be stressed highly enough. Without
the addition of oxygen the patient will only receive the oxygen contained in your exhaled air
(this air contains approximately17% oxygen, while room air contains approximately 21%).
CRITICAL THINKING
Explain the benefits of increasing the oxygen intake of patients during expired air resuscitation.
• State the action you will take if the patient vomits during expired air resuscitation.
45
WEB LINK
Current guidelines have been changed in December 2010. Make sure you are familiar with the
new guidelines for BLS and ALS.
http://www.resus.org.au
Click on →
Guidelines →
Click on “Click here to access ‘read only’ “guidelines”.
Read Sections 4, 5, 6, 7 & 8.
Unit 4.2 – Assessing the patient who requires basic and advanced
life support
Learning outcomes
• state how you will identify cardiac arrest;

• correctly identify the following rhythms on a cardiac monitor: normal sinus rhythm, ventricular
fibrillation, asystole;
• describe how you will determine if cardiopulmonary resuscitation is being performed
effectively.
Assessing the patient before, during and after CPR is an essential skill. You’ll need to be able to
determine if you should commence rescue breathing or CPR. You will also need to identify if CPR is
being performed effectively. Also, ongoing assessment and monitoring of the patient following
cardiac arrest is important – as the person may arrest again!
Basic life support includes three major components:
A Airway Assessment and Management;

B Breathing Assessment and Management;
C Circulation Assessment and Management.
Before commencing any management you should be confident with identifying that an airway,
breathing or circulation problem exists.
WEB LINK
Australian Resuscitation Council (2006). Frequently asked questions (FAQ) following the release of
the “new” ARC guidelines (December 2010).
http://www.resus.org.au/
46
TEXTBOOK READING
Hales, M. (2011). Nursing care of clients with coronary heart disease. In P. LeMone, et al. Medical
LEARNING ACTIVITY
Review the procedure for performing basic life support. This procedure is included in your Clinical Skills
Workbook. Review the readings in your Clinical Skills Workbook.
CRITICAL THINKING
• List the signs of complete and partial airway obstruction.

• Two cardinal signs of cardiac arrest are unconsciousness and absent pulse. If you follow the
basic life support procedure at what point will you determine that a cardiac arrest has
occurred?
• You will have already learned how to assess the respiratory and cardiac systems. State the
assessment findings that you would expect in a patient who has hypoxia.
• State the assessment findings that would demonstrate oxygenation and blood volume
circulation is adequate during cardiopulmonary resuscitation.
47
Cardiac arrest rhythms
TEXTBOOK READING
These tracings and descriptions outline how to identify asystole and ventricular fibrillation (VF).
Familiarise yourself with these rhythms. With both of these rhythms the patient will usually be in
cardiac arrest. Also understand Pulseless ventricular tachycardia (VT) as it often leads to VF.
Following successful cardiac resuscitation the patient will be closely monitored. Consider the following
scenario.
CASE STUDY
Mrs Jane Hill is a 56 year old woman admitted to the medical ward yesterday following an episode of
chest pain. Mrs Hill has a four year history of angina. The latest episode awoke her from sleep at 3
am and did not subside following three anginine tablets. You are rostered to care for Mrs Hill. While
talking to her she suddenly stops speaking and her eyes roll strangely. You call her name, but there
is no response. You note that it is 9.46am when you ring the emergency bell. You commence basic
life support. Mrs Hill is successfully resuscitated. She is to be transferred to the coronary care unit.
CRITICAL THINKING
List the assessment that you think will be necessary while waiting to transfer Mrs Hill to the coronary
care unit.
48
Unit 4.3 – Planning for patients who require cardiopulmonary
resuscitation
Learning outcomes
• discuss the planning strategies used to help reduce delays in treatment during cardiopulmonary
arrest;
• list the equipment which you would expect to be available for efficient management of
cardiopulmonary arrest;
• explain the nursing responsibilities when checking emergency equipment.
Although it isn’t possible to predict and expect all cardiopulmonary arrests, it is possible to have a
plan in place which will help to efficiently manage this emergency. In this unit we will discuss the
roles of the health care professionals attending the cardiac arrest. Being aware of your role is part of
the prior planning needed for cardiac arrest management. Be informed and you won’t feel so lost or
helpless when you arrive at an emergency. Knowledge of equipment and emergency call systems
within the health care setting in which you work is essential. Ensure you know where everything is
kept on your resuscitation trolley in the ward you are working in. Get into the habit of checking the
trolley regularly
Consider the scenario above with Mrs Hill. The nurse in this scenario acted promptly and without
hesitation. Calling a code and commencing CPR immediately gives the patient the best chance to be
revived. Calling a code immediately reduces the response times of the emergency resuscitation
team, and the sooner they arrive and begin ALS the greater the chance of patient survival.
REMEMBER: To improve chances of survival the arrest should be:
• Witnessed;
• CPR commenced immediately;
• If the cardiac rhythm is ventricular fibrillation or pulseless VT, then defibrillation occurs as soon as
possible.
Generally, the roles of those in attendance are clearly defined while managing a cardiac arrest, as this
will help the patient’s chances of survival.
In brief:
• First responder: calls for help, starts CPR;

• Second responder: brings the equipment, clears bed area, helps with airway management / CPR;
• Third responder: assesses patient rhythm, assists with defibrillation, IV access and drug
administration, and documents events as they occur.
Many registered nurses are now accredited to perform Advanced Life Support techniques (including
defibrillation and the administration of resuscitation drugs). Each hospital will have a plan of action
which will clearly state the expected actions of each person during a cardiac arrest. Testing a plan is
integral to its success, so you may be required to participate in mock cardiac arrests. Planning and
practice help to improve the chances of survival for the patient.
In addition, awareness of your role will help you to perform resuscitation techniques in a calm and
assured manner.
49
LEARNING ACTIVITY
During Residential, have a look at our resuscitation trolley. Whilst on clinical placement you should
make yourself familiar with the ward resuscitation trolley and the emergency call bell system.
Not only does planning involve preparing the environment and yourself for an emergency event, it
also involves strategies for managing the rest of the unit. Often staff members will be designated to
look after the other patients on the unit. This means that they need to have at least an idea of the
needs and priorities of all of the patients on the unit.
Unit 4.4 – Nursing care of the patient who requires

cardiopulmonary resuscitation
Learning outcomes
Following this unit, and practice you will be able to:
• Demonstrate effective basic life support technique.

• State the safety precautions required when a cardiac defibrillator is in use.
• State the action and describe the effects and side-effects of Atropine, Adrenaline, Amiodarone
and Lignocaine.
• Describe nursing responsibilities for patient care during a cardiac arrest.
• Outline management practices which will improve patient care during an emergency.
By now you will have reviewed many aspects of basic life support. In this unit on patient care, you will
build on the knowledge from Foundations of Nursing. We will discuss defibrillation and its use, and
also explain the use of some cardiac arrest medications. The Advanced Life Support (ALS) algorithm
will also be explained. During a cardiac arrest other organizational issues will need to be considered,
for example, other patients in the ward and re-allocation of workloads.
The difference between basic and advanced life support is the addition of emergency equipment and
medication. Both algorithms initially follow the same path. However, once a defibrillator arrives the
patient’s cardiac arrest rhythm can be identified and treated.
Many rhythms can cause cardiac arrest. However, there are two key classifications according to the
current (internationally approved) ALS algorithm:
1. ventricular fibrillation / (Pulseless) ventricular tachycardia.

2. non ventricular fibrillation / tachycardia.
From the readings you can see that if the patient has VF they need to be defibrillated, and if the
patient’s rhythm is asystole then CPR and medication are given. The administration of atropine and
adrenaline during asystole may cause ventricular fibrillation. If this occurred the patient would then be
defibrillated. Generally, it is more difficult to resuscitate a person who has asystole.
50
CRITICAL THINKING
List the actions and side effects of atropine, adrenaline, amiodarone and lignocaine. You will need
access to a pharmacology text to complete this exercise.
It is important for you to be aware (and memorise) the BLS & ALS algorithm. This is an internationally
recognised procedure for response to cardiac arrest management. As a nursing student, you may not
be active in performing some of the advanced roles, however you will be required to be an active
participant during cardiac arrest management in an acute care setting.
LEARNING ACTIVITY
Write a list of the interventions which you think you’ll be able to perform or assist with during the
emergency.
Unit 4.5 – Evaluation following cardiopulmonary resuscitation

Learning outcomes
Following completion of this unit, you will be able to:
• Explain the purpose of evaluating the care given to the patient during cardiopulmonary
resuscitation;
• Outline the benefits of a clinical debriefing session.
Following the successful resuscitation of a patient who has had a cardiopulmonary arrest you will be
required to monitor the ongoing health status of the patient. When the patient is stable the evaluation
of this emergency situation will be useful for future planning. As part of the evaluation, a debriefing
51
session with staff involved will be useful. A debriefing session will also benefit staff who may feel
stressed as a result of the emergency situation.
LEARNING ACTIVITY
Consider how you may respond to a cardiac arrest. When you think about being involved in a
cardiac arrest does it make you anxious? Hands clammy, heart racing ... breathing faster??? Do
you feel like running in the opposite direction (you won’t be the first person to do so!).
Talk to other students about your feelings. They may have similar feelings or previous experiences.
Talking about experiences with each other may help you to think about how you would react in the
same situation.
READING ON CDROM
Abella, B., Alvarado, J., Myklebust, H., Edelson, D., Barry, A., O’Hearn, N., Vanden Hock, T, &
Becker, L. (2005). Quality of cardiopulmonary resuscitation during in-hospital cardiac arrest.
American Medical Association, 293(3), 305-310.
Madden, C. (2006). Undergraduate nursing students’ acquisition and retention of CPR knowledge
and skills. Nurse Education Today, 26, 218-227.
Debriefing sessions may be held in the ward following the cardiac arrest. If the ward staff are too busy
to have critical debriefing on the same day, it should be held as soon as possible. However, as a
student nurse it is very important to debrief with your clinical educator, even if the arrest is
successfully reversed or you have been an observer. The debriefing session may help people to
understand their involvement in the emergency. Many nurses and health care workers feel that they
may have done something wrong during the emergency. Getting the full story and being filled in on
the sequence of events may help those who attended to feel that they performed to the best of their
ability. This is an opportunity for those involved to also say ’that was a job well done’ and/or discuss
any aspects that could be improved upon.
LEARNING ACTIVITY
Answer the questions in the CONCEPT CHECK activity in your text:
Hales, M. (2011). Assessing clients with cardiac disorders. In P. LeMone, et al. Medical surgical
Forest: Pearson.
52
Module 5
Ischaemia, Myocardial Infarction (MI) and Heart
Failure
Unit 5.1 – Review the relationship of oxygenation, perfusion and

electrical activity of the heart
Learning outcomes
On completion of this unit and with further study, you will be able to:
• Outline perfusion of the heart;

• Outline the relationship between perfusion blockages, decreased oxygenation, and ischemia
and cell death with resulting electrical conduction changes in the heart.
Ischemia can occur in any artery. For clarity in this module the discussion is limited to its occurrence
in the cardiovascular system as coronary artery disease (CAD) or myocardial infarction (MI).
TERMINOLOGY
Define the terminology in your laboratory session pages.
TEXTBOOK READING
Forest: Pearson.
LEARNING ACTIVITY
From your textbook:

nursing: Critical thinking in client care (1st Australian ed.) (Vol. 2, pp. 957). Frenchs Forest:
Pearson.
Draw a heart and lungs (it does not have to be perfect!). Make sure you can follow the course the
blood flow takes in receiving deoxygenated blood, pumping it through to the lungs, receiving
oxygenated blood and pumping it through the body. Name the valves. In a different colour, draw in
the electrical conduction of the heart. Later in this module, when reading about ECGs, return to your
drawing and isolate and link the conduction pathway to fit the parts of the ECG.
53
Unit 5.2 – Planning with the patient who has alterations in the
cardiovascular system
Learning outcomes
• Identify patient problems that are amenable to nursing interventions;

• Set goals that are measurable, achievable, time limited and patient oriented.
TEXTBOOK READING
Forest: Pearson.
Caring for the patient with cardiovascular problems involves the entire health care team. Much of the
nursing care is dependent – that is, based on the doctor’s orders. Independent nursing interventions
are those the nurse uses on their own initiative.
TEXTBOOK READING
Forest: Pearson.
54
LEARNING ACTIVITY
Using the nursing interventions discussed in this chapter of your text, make two lists. One list will be
independent nursing interventions and the other will be dependent nursing interventions. When you
are documenting (e.g. care plans), how would you distinguish between the two? Is there any other
member of the health team that you know of who might leave ‘orders’ for the nursing staff to carry
out?
Unit 5.3 – Nursing care of the patient with a cardiovascular

system disorder (CAD/MI)
Learning outcomes
patients who have Coronary Artery Disease (CAD) and its complications (Angina, Myocardial
Infarction);
• outline the nursing interventions and their rationales for each of the patients with each of the
above selected disorders.
Aetiology, incidence, clinical manifestations, complications

and medical care of patients with CAD
TEXTBOOK READING
nursing: Critical thinking in client care (1st Australian ed.) (Vol. 2, pp. 987-999; 999-1008).
The development of collateral circulation as the body compensates for the chronic under supply of
blood to the myocardium is interesting. This compensatory mechanism goes some way to explaining
the finding that younger people with CAD often have a more ‘serious’ disease than those in the aged
population.
The risk factors and contributing factors to CAD are numerous and wide reaching. This disease is
one of the most widely studied disease processes because of the morbidity and mortality it causes.
LEARNING ACTIVITY
What do you think will happen to the mortality and morbidity rates as the ‘Baby Boomers’ progress
through their fifties and beyond? Look at the risk factors and think about some of the television
commercials you have seen. Do you think these types of health promotion campaigns will have an
impact on the rates of morbidity and mortality?
55
REFLECTIVE THINKING
How do you and your family ‘rate’ on the CAD risk factors? If necessary, could you or would you
make the necessary lifestyle changes? How would making such changes alter your life?
The discussion of the pathophysiology of CAD is a revision of material covered in the second year
science subject. This explanation of ischaemia is clear. The section on complications outlines the
importance of recognising angina in its many forms of presentation.
The medical management of angina is discussed well in your text. The surgical procedures are all
done at regional cardiac care centres (e.g. Townsville). Many of the patients are managed with drug
therapy or until they can have the needed procedure. You will also care for patients who have stable
angina and are taking the drugs mentioned in your text.
Because of the ubiquitous nature of CAD and the great number of people on some sort of ‘heart pill’,
be sure to know the various classifications of the drugs, an example of each and the side effects or
contraindications (e.g. giving an asthmatic patient propanolol [Inderal] is not a good idea – do you
know why?).
TEXTBOOK READING
56
READING ON CDROM
Morton, P., Tucker, T., & Van Rueden, K. (2005). Patient assessment cardiovascular system.
(pp.240-243). In Morton, P., Fontaine, D., Hudak, C., & Gallo, B. (2005). Critical care
nursing: A holistic approach (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
LEARNING ACTIVITY
List the advantages and disadvantages of post-MI investigations:

• stress testing
• angiograms.
Myocardial infarction
TEXTBOOK READING
Review:
The discussion of the healing process is easier to conceptualise if you imagine a series of concentric
spheres as the zones of injury. The centre zone has been deprived of oxygen for too long, so the
tissue dies and tissue necrosis develops. This is known as an infarct, and because it occurs in the
myocardium (heart muscle), is called a myocardial infarct. The second ring out is inflamed and
ischaemic tissue. This tissue needs 02 and nutrients to survive or it too will become develop into an
area of infarct. Quick treatment by the health care professionals will prevent further injury (rest, 02,
nitroglycerine, thrombolytic therapy, among others). Tissue in the third zone (surrounding the second
zone) is inflamed, but will recover to normal in 48-72 hours assuming adequate treatment. The
collaborative goal amongst all health professionals is to limit the infarct size, as this will help recovery
and lead to a better outcome for the patient.
57
Diagnostic studies
The important ideas in this section are the alterations in the ECG – initially, the serial ECGs which will
eventually show the damage, and then the ST changes as the area of infarction becomes defined.
The cardiac enzymes are an important indicator and are done serially as well since changes are not
immediate.
ECGs are an important diagnostic tool, in cases of acute MI. You may see patients’ management
include what is called an Expanded ECG. This ECG looks at the heart from a different perspective
and is especially useful for looking at the right ventricle and posterior side of the left ventricle. The
following reading discusses this tool and its use. If you see an ECG in a patient chart with V(4) V (5)
V(6) crossed out and V(7) V(8) V(9) written in this section you will know you are looking at an
expanded ECG.
Pre-hospital care
The first priority is to recognise the condition.
LEARNING ACTIVITY
Differentiate between the assessment findings of patients who present with chest pain. Remember
that the pain may not be of cardiac origin, but is always considered cardiac until this is excluded.
As you can see – the differentiations are small and usually subjective. Erring on the side of caution is
the best rule – that is, treat anyone who you cannot decide about as if they had a MI. Whether the
patient is suffering angina or an MI, positioning in a supported upright position, loosening clothing and
talking to them in a calm manner will reduce anxiety and increase comfort (decreasing 02 use). This
can be accomplished in the few seconds during which you are assessing them. Call an ambulance
(000), stay with the person, continuing to observe them and be prepared to initiate CPR if it becomes
necessary.
Take special note of the clinical manifestations and emergency care. If a patient has angina, there
will be no time to review the care in the textbook – it will need to be instituted without delay.
READING ON CDROM
Greenland, P. (2006). Glyceryl trinitrate (Anginine) use in a cardiovascular emergency.

Contemporary Nurse, 22(1), 91-96.
58
LEARNING ACTIVITY
List the steps you would take if a neighbour or family member complained of this kind of pain at
home.
Did you assess the pain? Make the person rest (sitting upright but supported), check if they have
nitroglycerine and give it to them every 5 minutes x 3? Loosen clothing? Monitor their pain levels,
pulse rate and general appearance and sensations? Phone the ambulance if the pain has not abated
within the 15 minutes or if it gets worse? I hope so. If you did these things, you are doing well. If not,
perhaps you should review the chapter.
Acute hospital care

The patient will be brought to the emergency department by the ambulance. The patient is assessed
using 12-Lead ECG analysis, and medications are commenced. The patient should have received a
½ Aspirin (an antiplatelet aggregate), administered by ambulance officers, and this may be repeated
on arrival at hospital. This first line treatment, along with rest and oxygen therapy has been shown to
limit infarct size and enhance survival. Other medications will include: glyceryl trinitrate given
sublingually or by oral spray; β-Adrenergic blockers; and calcium channel blockers. You can read
about these in your text.
If MI is diagnosed, there are a variety of immediate interventions which could be performed. These
are only available in some hospitals, usually larger tertiary referral hospitals (such as the Townsville
Hospital).
The discussion of thrombolytic therapy is interesting and, as you can gather, vital in saving lives.
When you have the opportunity to work in a Cardiac Unit or an Accident and Emergency Unit, take
note of the protocol used there. Note the contraindications for thrombolytic/fibrinolytic therapy
Take particular note of the drugs used in CAD. Where indicated, follow the drug up in your text.
Otherwise, turn to your pharmacology text to ensure that you understand the actions,
contraindications, side effects and interactions.
You will practice ECG interpretation at a basic level when you come for residential school.
Another consideration for patients on enforced bed-rest especially post surgery or diagnostic tests
that require rest is Deep Vein Thrombosis (DVT).
As more and more hospitalised patients are discharged early or indeed, managed at home, the
teaching roles of the Registered Nurse will assume greater importance.
Heart failure
Congestive Heart Failure (CHF), while not actually a disease, is often the outcome of many cardiac
related disease processes and dysfunctions. CHF incidence is not gender specific and increases in
incidence and severity with the increasing ageing population (House-Fancher, Foell, & Soars, 2005).
Causes of heart failure include both chronic and acute issues and can be responsible for significant
decreases in resulting quality of life for affected patients.
59
Although this module does not address the problem of hypertension it underlies many of the specific
problems that you will encounter and is thus an important concept to understand. Hypertension will be
covered in module 6.
TEXTBOOK READING
LEARNING ACTIVITY
List the common acute and chronic causes of heart failure. Try to write a brief explanation of each
cause’s effect on the heart.
Differentiate between systolic and diastolic heart failure and left sided and right sided heart failure.
60
LEARNING ACTIVITY
What type of symptoms may you expect to see in a patient presenting with a diagnosis of CHF? List
these and explain why it is related or linked with CHF.
READING ON CDROM
Nicholas, M. (2004). Heart failure: Pathophysiology, treatment and nursing care. Nursing Standard,
19(11), 46-51.
LEARNING ACTIVITY
Congestive Heart Failure is often seen as an inevitable result for some patients with cardiac
problems and who are often initially admitted with an acute myocardial infarction. Draw up an
education plan to teach a patient about heart failure and how it will be managed.
See:
61
Unit 5.4 – Evaluation of the patient with CAD or MI
Learning outcomes


Recall that the criteria used for evaluation of a problem are the reverse of the cues that shaped the
problem statement. An example might be:
Problem statement:
Pain related to myocardial ischaemia as evidenced by John’s statement that the pain is 8/10,
substernal and radiating to the left arm and jaw, elevated pulse and BP, grimacing and teary facial
expression, guarding of left arm.
The italicised section includes the cues that were in the assessment. Following treatment (02,
nitroglycerine, rest in a semi-Fowler’s position, morphine or whatever), you would expect improvement
in the condition.
The evaluation criteria might be:
Statement that the pain has subsided to 2/10, no longer radiates to left arm and jaw
Pulse has decreased, but is still above normal, BP has decreased
Facial expression is calm, no grimacing
Moving left arm freely
As you see, these criteria say nothing about what you did in the nursing intervention – only about the
outcome – ie how effective the interventions were. It would not matter what you had done if the
patient was still in pain (except that you would know that whatever you did did not work). Now you
know that the interventions were effective and you can document the altered assessment of the
patient.
62
Module 6
(Hypertension, Peripheral Vascular Disease, Deep
Vein Thrombosis & Pulmonary Embolism)
Unit 6.1 – Review the structure and function of the cardiovascular

system
Learning outcomes
• Use the appropriate terminology when discussing the cardiovascular system;

• Explain the structure of the cardiovascular system;
• Describe the process of the cardiovascular system;
• Discuss the physiology of the cardiovascular system.
The terminology used for discussing the cardiovascular system is an extensive area. I would suggest
that you keep track of unfamiliar words and establish your own vocabulary reference. The following
are only suggested.
TERMINOLOGY
Define the terminology on your laboratory session pages.
The section on cardiovascular nursing is vast and there are numerous books and post-graduate
courses available on this type of nursing alone. You are not expected to have memorised the text –
much of the information, while valuable in itself, is not addressed in this subject. Read widely, and
especially what is presented in your textbook for background and to consolidate your understanding
of the material. However, material that is examinable will be specifically addressed in this study
guide. Again this material should be a revision for you. If necessary, review the material from the PP
subjects from last year so you feel comfortable with the anatomy and physiology and can relate it to
the assessment and interventions.
Unit 6.2 – Assessment

Learning outcomes
• outline the elements of the nursing history for a patient with cardiovascular system dysfunction;
• discuss the specific requirements of the physical assessment of the patient with a cardiovascular
system dysfunction;
• discuss the nursing responsibilities associated with the various diagnostic studies and procedures
used to evaluate the alteration of cardiovascular system.
History taking
When asking patients about medications, use ‘lay’ terms. For example ‘heart pill’ instead of the
medical category or ‘water pill’ rather than ‘diuretic’. You will probably gain much more information –
and the patient will not feel unintelligent when they cannot understand your jargon. Nurses also need
to consider herbal medications and remedies for such symptoms as angina (e.g. Angelica, Bilberry,
Evening Primrose), dysrhythmias (e.g. Angelica, Purslane, Ginko, Valarian), elevated blood pressure
63
(e.g. Hawthorne, Evening Primrose, Flaxseed) or those that act as anticoagulants (e.g. Evening
Primrose, Willow). Many patients will take these herbs to address non-cardiac problems (such as
Valarian for sleeplessness, Willow for arthritis) and may then have cardiac symptoms without being
aware of the potential hazard. Always ask about over the counter medications and more specifically,
herbal remedies or those from a naturopath. Document this information.
Ascertain the patient’s vaccination status. Patients, particularly the elderly and those over 55 years
with a chronic disease, should be vaccinated yearly against influenza and pneumococcal pneumonia.
Cardiovascular disease is a chronic condition and as such, requires prevention of these potentially
fatal diseases.
LEARNING ACTIVITY
Ask a friend/neighbour, family member’s permission to do a health history for the cardiovascular
system. After you conduct the interview, organise the material into Gordon’s 11 Functional Health
Patterns.
Physical assessment
• Cardiovascular assessment – pp. 31-33.
NOTE: When palpating the neck pulses, palpate only one side of the neck at a time. For all
peripheral pulses, palpate simultaneously to allow for comparison.
If the pulse is irregular, listen to the apical pulse (5ICS MCL) and palpate the radial pulse at the same
time. If there are fewer radial pulse beats, the patient has a pulse deficit of the number of missing
radial pulse beats. This is recorded as the pulse deficit.
LEARNING ACTIVITY
Listen to your own heart and that of as many friends or family members as you can talk into it. Use
both the bell and the diaphragm sides of your stethoscope. Can you discern any differences? Listen
carefully over the cardiac auscultory areas. Can you distinguish the S1 and S2 sounds? The more
you practice, the easier it is to hear the heart sounds.
HINT: listen selectively – first for the rate and rhythm then to the S1, then to the S2, then to the
‘silence’ between S1 and S2.
The Angle of Louis (Sternal Angle) is easy to locate on some people and extremely difficult on a few.
To find your Angle of Louis, find the sternal notch at the base of your throat. Keep your finger firmly
on the sternum and pull it down until you feel a distinct raise (bump) in the sternum. This is the Angle
of Louis where the manubrium and the gladiolus (body) of the sternum articulate. Just below and to
the right or left, you will find a shallow hollow. This is the 2ICS (L or RSB). This is an important
landmark for finding the cardiac auscultory areas.
You will be able to practice the assessment skills for the cardiovascular system during residential.
However, listening to hearts – normal ones – helps you to develop the ability to listen well and to
distinguish between small variations in sound. If there is someone available on whom to practice
listening to heart sounds, take advantage of the extra practice.
64
There is a great deal of material written about heart sounds. If you can determine the normal sounds
(and thus recognise the abnormal), you will be able to refer your patient for more expert assessment if
abnormal sounds are detected.
• 12-lead electrocardiogram, pp. 153-156.
One important consideration that is not mentioned is to ask the patient if they need to void (and
facilitating that) prior to beginning diagnostic tests (or provide other simple comfort measures such as
support for positioning). These measures can prevent having to reschedule a diagnostic test because
the patient was unable to stay still for the required time.
The diagnostic tests that are particularly pertinent in general medical/surgical nursing include chest x-
ray, electrocardiogram (ECG), ambulatory ECG monitoring, exercise or stress testing,
echocardiogram, blood studies, cardiac catheterisation, coronary angiogram and haemodynamic
monitoring. Nuclear imaging is available only at specialised cardiac units. This type of diagnostic
procedure will not be seen during your student nursing days, unless you are lucky enough to have a
clinical experience in a specialist unit.
Unit 6.3 – Aetiology and management of concomitant problems

such as DVT, PE and care of patients with hypertension and
peripheral vascular disease
Learning outcomes
On completion of this unit and with practice you will be able to:
• Outline the chronic and acute causes of conditions such as DVT, PE, hypertension and PVD;
• Outline specific assessment requirements of patients with these health problems;
• Discuss management and concomitant links between these issues for clients in an acute
setting;
• Discuss nursing responsibilities related to the management of these issues.
Hypertension
TEXTBOOK READING
Disorders of blood pressure regulation;

DVT – The client with venous thrombosis;
PVD - The client with peripheral vascular disease;
PE - The client with pulmonary embolism.
Fagan, A. (2011). Nursing care of clients with peripheral vascular disorders. In P. LeMone, et al.
Medical surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol. 2, pp. 1162-
1181; 1197-1204; 1187-1190, Vol. 3, 1354-1356). Frenchs Forest: Pearson.
65
You can see that hypertension has many effects on the different systems that balance homeostasis.
Sometimes alterations in blood pressure is a necessary measure the body takes to maintain
alterations in perfusion. For most patients a protracted increase of blood pressure can create
concomitant health related problems.
LEARNING ACTIVITY
• Outline the difference between primary (essential hypertension) and secondary hypertension.
• Explain what is meant by the term “concomitant” health problems in this context.
• What specific questions may you need to ask the patient in relation to health history and
hypertension?
READING ON CDROM
Woods, A. (2002). Improving the odds against hypertension. Nursing Management, 33(4), 27-33.
These readings outline overall management strategies for the patient with hypertension. Use these
strategies and write up a correlational map of causes of hypertension and associated management
strategies.
66
READING ON CDROM
Davidhizar, R., & Shearer, R. (2004). Assisting patients to maintain a healthy blood pressure. The
Journal of Practical Nursing, 54(3), 5-8.
Patient education is a large factor in patient care and management of blood pressure. Davidhizar and
Shearer (2004) discuss some very simple but effective interventions for improving management of
healthy blood pressure. Which of these interventions do you feel would be easiest and most difficult to
apply in an acute presentation of a patient in a hypertensive crisis? Why?
Peripheral Vascular Disease (PVD)

Peripheral Vascular Disease (also known as peripheral arterial disease) can cause alterations in
functionality, healing and perfusion of extremities. In most cases the lower extremities are more
adversely affected than the upper extremities.
TEXTBOOK READING
Fagan, A. (2011). Nursing care of clients with peripheral vascular disorders. In P. LeMone, et al.
LEARNING ACTIVITY
One of the most common complications of PVD are foot ulcers, especially in patients with Diabetes
Mellitis. From your textbook Reading, outline the difference between venous and arterial leg ulcers.
What is the reason clients with Diabetes Mellitis have increased management problems and risk of
infection with leg ulcers?
67
READING ON CDROM
Sontheimer, D. (2006). Peripheral vascular disease: Diagnosis and treatment. American Family
Physician, 73(11), 1971-1976.
Although this article is directed at medical staff, Sontheimer (2006) presents a rounded perspective on
PVD assessment and medical management.
Deep Vein Thrombosis (DVT)

Deep Vein Thrombosis is a common venous disorder and requires careful management to avoid
further, sometimes fatal, complications such as pulmonary embolism.
READING ON CDROM
Day, M. (2003). Recognizing and managing DVT – deep vein thrombosis. Nursing, 33(5), 36-41.
LEARNING ACTIVITY
Outline pathophysiology of DVT and map resulting management and nursing interventions to the
causes of DVT.
Pulmonary Embolism (PE)
Pulmonary Embolism (PE) is caused by an emboli of blood clots (thrombus), fat or air collection
blocking the pulmonary blood supply or arteries. PE can, at best, result in a painful protracted
hospitalisation and, at worst, death (Mipke-Tevis, Rich, & Soars, 2005). PE is most commonly caused
by a thrombus, originating as a DVT, where part of the clot (most usually in a leg) breaks off and
68
travels to the pulmonary arteries causing a blockage. Timely assessment and management is vital to
patients’ outcomes.
TEXTBOOK READING
Hales, M. (2011). Nursing care of clients with gas exchange disorders. In P. LeMone, et al. Medical
READING ON CDROM
Sox, H. (2006). Better care for patients with suspected pulmonary embolism. Annals of Internal
Medicine, 144(3), 210-212.
Your text outlines aetiology, pathophysiology and management of PE. Sox (2006), a doctor,
discusses the process taken in assessing and diagnosing PE, and common errors made by doctor’s
in diagnosis of PE. This will be useful to know the process in decision-making to influence the role you
play in assessment and management of the patient’s condition. While nurses do not diagnose medical
problems, we are the ones who are with the patients for the highest percentage of time and so are
better placed to notice changes and cues in patient condition to prompt formal assessment and
collaboration/notification with and for medical staff.
Unit 6.4 – Prophylaxis and prevention of cardiovascular

complications in acute care patients; Outline, plan and manage
disease progression of chronic cardiovascular system disorders
and diseases
Learning outcomes
On completion of this unit and with practice you will be able to:
• Discuss assessment of risk for complications of patients with acute cardiovascular problems.
• Plan care and education designed to prevent complications.
• Assess outcomes of care and education.
Review your notes from the readings you have done on this module. For the following cardiovascular
problems, fill in table on the following page. Once you have completed the table, this will provide you
with an excellent revision source for your exam.
69
Problem Possible Causes Problems/ How can I assess the What interventions can I How can I assess the
Complications this patient’s risk for this? employ to prevent further outcomes of these
problem can lead to problems/complications interventions?
or worsening of
condition?
DEEP VEIN
THROMBOSIS (DVT)
PULMONARY EMBOLISM
(PE)
HYPERTENSION
PERIPHERAL VASCULAR
DISEASE
(PVD)
70
Disease progression and prevention of disease are very similar. Even in patients with chronic health
problems, similar strategies used to prevent the disease altogether can arrest or slow down the
progress of the disease process.
71
Module 7
Fluids/Electrolytes/Acid-Base Imbalances
Unit 7.1 – Review of the physiology of fluid and electrolyte balance
Learning outcomes
On completion of this unit, and with further study, you will be able to:
• use the appropriate terminology when discussing fluid and electrolyte balance;
• discuss the process of fluid and electrolyte balance.
Fluid and electrolyte balance is a process that is necessary for normal functioning of cells. When a
person is healthy, there is a homeostatic balance preserved. Many disease and environmental
stressors can disrupt this balance. Patient care encompasses assisting the patient to maintain their
regulatory processes through their disease or injury state, until their body is able to do so on its own.
Therefore a basic knowledge of these regulatory processes is necessary so the nurse can be alert for
alterations and can intervene appropriately.
Terminology used for discussing fluid and electrolyte balance
TERMINOLOGY
TEXTBOOK READING
Hall, M. (2011). Nursing care of clients with altered fluid, electrolyte and acid-base balance. In P.
LeMone, et al. Medical surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol.
1, pp. 206-214). Frenchs Forest: Pearson.
This material should be a review, since body fluid chemistry will have been covered in your science
subjects. Take a few moments to revise that material.
Insensible water loss is an important concept in ‘Intake and output’ calculations. Although you do not
write down ‘insensible loss’ anywhere, you must be aware that the patient will have this fluid loss.
Thus, even if the recorded intake exceeds his output, some of the discrepancy can be accounted for
by the insensible loss.
LEARNING ACTIVITY
Maintain an intake and output record on yourself for a day (guesstimate the urine output if you do not
wish to catch and measure your urine). In the tropics, it is probably wise to increase your fluid intake
(mostly water as caffeine beverages cause increased water loss) to a minimum of 2 litres, which
would bring your daily intake to approximately 3 litres.
72
REFLECTIVE THINKING
Can you think of times when your urine output increased substantively (without a corresponding
intake increase)? Re-read the section on fluid and electrolytes in your prescribed text and try to
follow what may have been occurring in your body. How might this knowledge be applied in a
nursing situation?
Unit 7.2 – Assessment
Learning outcomes
• outline the elements of the nursing history for a patient with altered fluid and electrolyte
balance;
• discuss the specific requirements of the physical assessment of the patient with altered fluid
and electrolyte balance;
• discuss the nursing responsibilities associated with the various diagnostic studies and
procedures used to evaluate the alteration of fluid and electrolyte balance.
TEXTBOOK READING
1, pp. 214-255; 225-150). Frenchs Forest: Pearson.
This information is concentrated and you should read it in small pieces so that you do not confuse the
various electrolyte excesses and deficiencies.
LEARNING ACTIVITY
To clarify and simplify the understanding of the electrolyte imbalances, it is helpful to organise the
information in a consistent way. For each of the fluid and electrolyte imbalances discussed in your
text, construct a table with hyper and hypo-whatever along the top, and normal range, function, a list
of body systems in which to organise clinical manifestations, intake (i.e. where it comes from), output
(i.e. urine, faeces, perspiration) and regulation (hormonal) along the side. Fill in this table from your
text(s). You may need to refer to the science texts to complete this.
73
History taking
History taking is diverse to determine fluid and electrolyte imbalances. Knowledge of clinical
conditions (e.g. hyperparathyroidism) or medications (e.g. potassium wasting or sparing diuretics) that
predispose the patient to specific fluid or electrolyte imbalances is necessary. Therefore, the patient
should be asked about known conditions, medications (including OTC, antacids, laxatives and
enemata) that are used consistently. The medications for ongoing conditions must be noted so that
therapeutic levels of that medication (e.g. digitalis) are maintained as long as they are not contributing
to the problem. A dietary history is also important in the assessment of the patient with a fluid and
electrolyte imbalance. The following short article highlights how the elderly person can easily develop
a fluid imbalance.
Physical assessment
The physical assessment will encompass most body systems and the findings will be similar to one or
more of the categories in the table you constructed above.
Remember that dehydration is not the only fluid imbalance that needs to be assessed for.
Diagnostic studies for basic fluid and electrolyte imbalances are generally serum electrolyte levels
done on a freshly drawn specimen of blood. The normal ranges for the major electrolytes should be
memorised. You will not be asked to reproduce these in an exam, but you will be expected to apply
your knowledge of normal values. For example, you may be given a question with a case study that
lists the person’s serum electrolyte values, and the answers to the questions that follow will depend
on your knowledge that the values given are excess or deficit.
Haematocrit will give an indication of hypo- or hypervolaemia. An increased haematocrit indicates the
patient has a fluid deficit, and a decreased haematocrit indicates a fluid excess. Recall that
haematocrit is the ratio of red blood cells to plasma.
74
Unit 7.3 – Planning with the patient who has alterations in fluid and
electrolyte balance
Learning outcomes

Patient problems associated with alterations in fluid and electrolyte balance
LEARNING ACTIVITY
Review the nursing care for the patient with electrolyte imbalance:
Goals for patients with alterations in

fluid and electrolyte balance
Case Study:
Henry Woodward, a 38 year old Caucasian male, is admitted via the Accident & Emergency
department of James Cook Hospital following 48 hours of vomiting and diarrhoea. He contracted food
poisoning suspected from eating fried chicken that had been kept warm for several hours. He has no
relevant medical or surgical history. He has no allergies.
LEARNING ACTIVITY
For the case study of Henry Woodward (in Module 7 Clinical Skills Nursing Laboratory Session),
write 2 patient problem statements and appropriate goals. Remember to make the goals patient
specific (i.e. use the patient’s name), achievable, measurable and time limited and directed to the
patient problem (first clause of the problem statement).
75
Unit 7.4 – Nursing care of the patient with a fluid and electrolyte
balance disorder
Most of the nursing care of patients with electrolyte disorders involves care of the patient’s underlying
disorder, PLUS administering and monitoring intravenous fluids and electrolyte and protein and
carbohydrate replacement. This unit will concentrate on the interventions that help to accomplish this
and especially the administration of intravenous fluids and enteral supplements.
Learning outcomes
• outline the nursing interventions for assisting a patient to regain fluid and electrolyte balance;
• discuss hypotonic, isotonic and hypertonic fluids and their use in clinical situations;
• differentiate between colloid and crystalloid solutions and discuss their use;
• describe the complications that may arise in intravenous therapy;
• explain the rationale for enteral feeding;
• describe the types of enteral feeding available;
• discuss the complications of enteral feedings.
TEXTBOOK READING
READING ON CDROM
Spandorfer, P., Allessandrini, E., Joffe, D., Localio, R., & Shaw, K. (2005). Oral versus intravenous
rehydration of moderately dehydrated children: A randomized, controlled trial. Pediatrics,
115(2), 295-301.
Bopp, A., & Yates, P (2008A). Nursing management: Fluid, electrolyte and acid-base imbalances. In
D. Brown, H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher
These are basic discussions of the intravenous fluids. Note: Lactated Ringer’s Solution is known as
Hartmann’s Solution in Australia.
LEARNING ACTIVITY
Write down what you understand about colloid solutions and crystalloid solutions. You should
discuss what they are composed of, when they are used and why, and give a couple of examples.
76
Intravenous therapy is one of the most common of the nursing care interventions that we do to assist
our patients. A basic knowledge, not just of the solutions that are used, but also of the devices used
to administer the fluids is mandatory.
Note that most of the IV devices that you will assist with during your second year of this course will be
peripheral access devices. Central lines are discussed in the third year practice subject.
Enteral feeding
Nasogastric tubes are the most commonly seen enteral feeding device in acute care facilities. These
are generally used if the patient requires supplemental feeding for 6 weeks or less. Your texts
discuss other types of enteral feeding systems.
TEXTBOOK READING
Campbell, S. (2011). Nursing care of clients with nutritional disorders. In P. LeMone, et al. Medical
READING ON CDROM
Bopp, A., & Yates, P. (2008B). Nursing management: nutritional problems. In D. Brown, H.
Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher (Eds.),
(pp.1012 - 1037). Sydney: Elsevier Mosby.
LEARNING ACTIVITY
• List the safety considerations for insertion of and maintenance of a nasogastric tube.
• Make a list of the potential complications of enteral feeding along with their management.
77
Unit 7.5 – Evaluation of the patient with an alteration in fluid and
electrolyte balance
Learning outcomes

Again, these depend of the initial assessment findings. You should be evaluating someone who has
alterations in fluid or electrolyte balance frequently (q1-2hr) and recording the assessments at least
once per shift (more often if the patient is not stable).
LEARNING ACTIVITY
Using the following case study, write nursing notes as you would for an in progress note in a patient’s
chart. Do not forget to time, date and sign it with your designation, year level and university.
CASE STUDY
CASE STUDY – Henry Woodward
Henry Woodward, a 38 year old Caucasian male, is admitted via the Accident & Emergency
department of James Cook Hospital following 48 hours of vomiting and diarrhoea. He contracted
food poisoning suspected from eating fried chicken that had been kept warm for several hours. Mr
Woodward is married with 3 children. He is a high school teacher. He has no relevant medical or
surgical history. He has no allergies.
Neuro:
alert and oriented
pupils 4mm round, briskly reactive bilaterally
spontaneous vigorous movement of all limbs
anxious and restless, complaining of moderate headache - not localised
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CV:
heart rate 108/min, BP (L) 124/78 mmHg, (S) 110/60, T 38°
peripheral pulses - radial 2/3, dorsalis pedis & posterior tibial 1/3 bilaterally
capillary refill 4 sec in all 4 extremities
Respiratory:
respiratory rate 18, lung sounds clear, no associated symptoms
GIT:
nauseated, vomiting small amounts of bile stained fluid
refusing feeds & fluids
bowel sounds hyperactive in all 4 quadrants
frequent bouts of diarrhoea - mucousy liquid stools of 50 to 100ml with tenesmus
no blood apparent, occult blood ++, abdomen tense and tender to touch
states is usually 78-79kg for past 10 years
mucous membranes in mouth are dry and caked, lips dry
GU:
voiding small amounts of dark amber urine
SG 1.035, pH 5, + ketones
Skin/wound:
skin hot and dry, turgor reduced, skin intact
Metabolic:
Na 139 mmol/L; K 3.5 mmol/L.
For IVT, D/Saline 4%/0.18% 250mls 1/24 for 2hrs then 125mls 1/24; antiemetic and antispasmodic
medication.
79
80
JAMES COOK UNIVERSITY Surname ________________________ U.R. No. ________________
School of Nursing Sciences Given Names ____________________________________________
HOSPITAL
Sex ________________ D.O.B. _____________________________
INPATIENT PROGRESS NOTES
(Affix Patient Identification label Here)
DATE AND PROGRESS NOTES
TIME ALL NOTES MUST BE CONCISE RELEVANT AND SIGNED
81
JAMES COOK UNIVERSITY Surname ________________________ U.R. No. ________________
School of Nursing Sciences Given Names ____________________________________________
HOSPITAL
Sex ________________ D.O.B. _____________________________
INPATIENT PROGRESS NOTES
(Affix Patient Identification label Here)
DATE AND PROGRESS NOTES
TIME ALL NOTES MUST BE CONCISE RELEVANT AND SIGNED
82
Module 8
Acute Upper and Lower Respiratory Problems –
Paediatrics
Learning outcomes
At the end of this session, with further practice you will be able to:
• Discuss appropriately the structure and function of the upper respiratory system;
• Discuss what strategies to use to successfully and efficiently assess the client (both adult and
paediatric) in acute respiratory distress;
• Outline emergent management strategies to resolve the client’s respiratory distress;
• Discuss management of non-acute upper and lower respiratory problems;
• Outline evaluation methods to review patient care, goals and respiratory needs.
Introduction
In Module 3 you were introduced to Asthma and CAL. Both of these respiratory disorders can be
chronic or acute. You may see many patients with an acute exacerbation of a chronic disorder.
Because it is a chronic disorder do not mistake an acute exacerbation as being a lower priority.
Respiratory distress, regardless of its origin is still a threat to patients’ breathing. Remember when
assessing a patient in an emergency, the acronym is DRABCD. In a patient with respiratory distress
this is a perfectly reasonable quick assessment to complete before going into more depth, as the
patient who is in respiratory distress may be fighting to keep their airway open (bronchospasm) and
are also experiencing altered breathing patterns. We will also be addressing pneumonia in this
Module as a respiratory disorder of particular interest.
Unit 8.1 – Review the structure of the upper respiratory tract
TERMINOLOGY
Define the terminology for wound care from the laboratory session pages.
TEXTBOOK READING
surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol.3, pp. 1220-1239; 1239-
READING ON CDROM
Nathan, A. (2004). Minor ailments: URTIs. Practice Nurse, 28(4), 59-63.
Kaufman, J., & Kent, B. (2008A). Nursing management: Obstructive pulmonary diseases. In D.
(Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems.
83
The above readings introduce you to the less emergent upper respiratory problems. Do remember
however that a child with a cold (including blocked nose) who also has swollen/infected tonsils may
deteriorate quickly if both mouth and nasal passageways become obstructed. Epiglottitis is also
another upper respiratory paediatric related emergency.
LEARNING ACTIVITY
Outline the education you would give for patients to self care for the more common, less emergent
upper respiratory problems.
Unit 8.2 – Assessment of the adult and paediatric patient

in acute respiratory distress
A patient in acute respiratory distress has one sole focus and that is breathing. Other priorities such
as manners, even answering questions, cannot compete with the patient’s need to drag air into their
lungs. Dyspnoea often triggers panic which, while achieving the end of the patient giving breathing
their full attention, also increases breathing work and ability to get enough oxygen. The way you
conduct yourself when assessing and caring for a patient in respiratory distress can have a large
impact on your patient’s breathing. If you are too panicked by their obvious distress you will only make
their distress worse. However, if you are too relaxed and do not convey that their respiratory effort is
your sole priority, they may panic further or lose trust in you.
READING ON CDROM
Kennedy, S. (2006). Assessment of a patient with an acute exacerbation of asthma. Nursing

Standard, 21(4), 35-38.
LEARNING ACTIVITY
Outline your approach and nursing actions when faced with an adult client in respiratory distress and
a 7 year old in acute respiratory distress.
Point to consider:
• What are your first priorities?
• What immediate treatment can you give?
• Will you need to call for help?
• What equipment will you need?
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• What information do you need to know before administration of medications?
• In what position would you have the patient?
• How will you communicate if the patient cannot speak because they are breathing too hard?
• What communication techniques would you need to use with a child?
• How would you decide what to do first?
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Unit 8.3 – Planning care and management of the client with non-
emergent upper and lower respiratory problems
Pneumonia
TEXTBOOK READING
surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol.3, pp. 1275-1298).

• Oxygen therapy – p. 142.
• Suctioning of oropharynx/nasopharynx – p. 234-237.
READING ON CDROM
Crimlisk, J., & Ward, K. (2008). Nursing management: Lower respiratory tract problems. In D. Brown,
H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L. Bucher (Eds.),
Pneumonia is no longer considered the ‘old man’s friend’ (as it was before widespread use of
antibiotics, when it was often the welcome harbinger of death to someone who was bedridden and
debilitated).
The discussions on aspiration pneumonia and opportunistic pneumonia are pertinent to your careers,
as these are the types of pneumonia often seen in hospital. Read them carefully.
LEARNING ACTIVITY
The Clinical Pathway in the previous reading is an interesting format for plotting patient care. Can
you see the benefits of using such a system? Can you see any reason why nursing would feel less
than comfortable using this? Write a ‘Benefits versus Negatives’ list for using the Critical Pathway. If
you can, discuss this with someone you know who is a nurse.
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LEARNING ACTIVITY
After you have read the Nursing Care Plan, try to think of some other nursing interventions that
would make you feel more comfortable if you were very short of breath and in pain.
Did you think of things like:

• keeping the ambient temperature cool;
• keeping doors and windows open so a breeze is felt;
• using a pulse oximeter to monitor peripheral oxygen;
• cutting up food or providing a dental soft diet so patients do not expend energy on chewing;
• teaching energy conserving tricks like sitting to shower, or prepare food (if at home).
READING ON CDROM
Considine, J. (2005). The reliability of clinical indicators of oxygenation: A literature review.

Contemporary Nurse, 18, 258-267.
LEARNING ACTIVITY
Considine (2005) points out some challenging and provocative points about oxygen use. What did
you find were most interesting? What does this article say about current accepted oxygenation
practices?
Unit 8.4 – Evaluation of the patient in acute respiratory distress

Much of respiratory disorder care for patients is about education to manage the disorder to reduce
acute exacerbations. A common issue is teaching patients how to use their medication devices
properly.
TEXTBOOK READING
surgical nursing: Critical thinking in client care (1st Australian ed.) (Vol.3, pp. 1324-1336).
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READING ON CDROM
Kaufman, J., & Kent, B. (2008B). Nursing management: Obstructive pulmonary diseases. In D.
CASE STUDY
Review the Case Study – Paris Mills in Bed 4 from Module 3 Clinical Session.
Paris Mills is a 16 year old high school student who has presented to the emergency department with
an acute exacerbation of her asthma following a week long history of an upper respiratory tract
infection.
Paris was diagnosed with asthma at the age of 4 and has frequent admissions to hospital with
asthma related illnesses over the last 12 years (last admission was 18 months ago).
The respiratory team have reviewed Paris and have recommenced her on oral prednisone and four
hourly bronchodilator therapy. In addition, a review of her asthma plan is required prior to discharge.
Draw up an education plan for Paris, pre-discharge. Consider how you will assess the effectiveness
of this education and to whom you will direct most of the teaching.
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MODULE 9
Haematological Disorders
As you know, oxygenation is a very important factor in cell life and death cycles. The ability for the
blood to carry and exchange oxygen at a cellular level is a vital function. This unit guides you through
exploring disease processes and disorders that impedes or reduces the bloods ability to fulfil this
need.
Learning outcomes
On completion of this unit and with further study, you will be able to care for patients who have
haematological disorders.
Unit 9.1- Review the process and function of the haematological

system
Learning outcomes
On completion of this unit and with further practice and reading you will be able to:
• Use the appropriate terminology when discussing haematological disorders;

• Outline the structure and function of the haematological system;
• Outline the physiological process of the haematological system.
TERMINOLOGY
Define the following terminology on your laboratory session pages.
Structure and function

In studying haematology you will learn about blood and blood forming tissues. Haematological status
(especially the blood’s ability to be an oxygen vehicle) can impact on every system and health issue
you have learnt about so far. In order to understand the disorders associated with it, review the
structure and functioning of the haematological system.
TEXTBOOK READING
Lea, J., & Sanderson, H. (2011). Nursing care of clients with haematological disorders. In P.
LeMone, et al. Medical surgical nursing: Critical thinking in client care (1st Australian ed.)
(Vol.2, p. 1110). Frenchs Forest: Pearson.
READING ON CDROM
Shelton, B., Rome, S., Lewis, S., & Lee, G. (2008). Nursing assesssment: Haematological system. In
(2nd ed.) (pp.722-741). Sydney: Elsevier Mosby.
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LEARNING ACTIVITY
Outline in simple terms the structures that make up the haematological system and the function they
perform.
Unit 9.2 - Assessment of the haematological system

At the end of this module and with further practice and reading you will be able to:
• Assess the health history of a patient with a haematological disorder;

• Describe associated diagnostic procedures.
READING ON CDROM
Shelton, B., Rome, S., Lewis, S., & Lee, G. (2008). Nursing assesssment: Haematological system.
In D. Brown, H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L.
Bucher (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical
problems (2nd ed.) (pp.729-735). Sydney: Elsevier Mosby.
LEARNING ACTIVITY Case Study
Samantha Jefferies is a 26 year old female auditor who is admitted to the medical ward with lethargy,
malaise, dyspepsia. She has also complained of decreased exercise tolerance including dyspnoea,
palpitations and diaphoresis with light exercise.
Upon examination you note she is pale but her eyes (sclera) are yellow tinged. Samantha reports a
loss of appetite, dizziness on occasion and weight loss of 5kg in the past month. Two months ago
Samantha returned from a hiking holiday in Papua New Guinea for which she took prophylactic
Quinine. Her vital signs are: P: 124, R: 26, BP 100/50 lying, 75/45 standing. Samantha consulted her GP
who upon further investigation found her haemoglobin (Hb) level to be 58 g/L. Her red blood cell
count, haematocrit and serum iron levels were also below normal. Samantha has been diagnosed
with anaemia (severe) and has been admitted for acute management.
Using this case study group the health history information into a system based approach as outlined
in your last reading. Is there any information missing? What would you also ask this patient to find
out that information? Write your questions down under the systems headings that require further
information.
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Unit 9.3 - Planning for the patient with a haematological disorder
At the end of this unit with further reading and practice you will be able to:
• Identify disorders and disease processes of the haematological system;

• Identify patient problems associated with alterations/disorders of the haematological system;
• Set goals for identified patient problems.
Disorders and disease process
There are a number of haematological problems/disorders but in this module you will focus on the
most common issues that you may encounter in an acute health care setting. These include
anaemia, heparin induced thrombocytopaenia (HITTS), thrombosis syndrome and neutropenia.
Anaemia
TEXTBOOK READING
(Vol.2, pp. 1111-1124). Frenchs Forest: Pearson.
As you can see there are many causes for anaemia this is the most common haematological disorder
you will see and treat in an acute care setting. Treatment often depends on the cause of the anaemia,
but usually regardless of the cause if severe enough blood administration may be necessary. As a
result, you will need to know how to administer blood.
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READING ON CDROM
Rome, S., & Lee, G. (2008A). Nursing management: Haematological problems. In D. Brown, H.
(pp.743 - 758). Sydney: Elsevier Mosby.
McCall, J., McMillin, N., & Pielak, K. (2005). Accidental exposure guidelines: What you should
know. Nursing BC, 37(5), 16-20.
Sickle Cell Disease (SCD)
SCD is a hereditary chronic haemolytic anaemia, and is one of the most common inherited conditions
worldwide. In Australia it is most commonly seen in individuals from Middle Eastern and Southern
European origins.
TEXTBOOK READING
(Vol.2, pp. 1115-1118). Frenchs Forest: Pearson.
READING ON CDROM
Rome, S., & Lee, G. (2008B). Nursing management: Haematological problems. In D. Brown, H.
(pp.755-758). Sydney: Elsevier Mosby.
Pinckney, R., & Stuart, G. (2004). Adjustment difficulties of adolescents with sickle cell disease.
Journal of Child and Adolescent Psychiatric Nursing, 16(4), 5-12.
Pinckney and Stuart (2004) discuss psychosocial associated problems in adolescents with SCD.
Nurses need to remember when assessing individuals with SCD the delay in sexual maturation of
adolescents affected by this disorder. This may impact on a number of areas of the health
assessment.
Thrombocytopenia and Neutropenia
TEXTBOOK READING
(Vol.2, p. 1148; pp. 1149-1152). Frenchs Forest: Pearson.
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READING ON CDROM
Rome, S., & Lee, G. (2008C). Nursing management: Haematological problems. In D. Brown, H.
(pp.761 – 767; 773 - 776). Sydney: Elsevier Mosby.
LEARNING ACTIVITY Case Study
Refer to case study Sally Jenkins:

Sally Jenkins is a 42 year old admitted to your unit with an lower respiratory tract infection. Sally has
a history of Rheumatoid Arthritis (RA) for which she has been taking methotrexate for the past six
months. She has also been recently diagnosed as Vit B12 and folic acid deficient. Sally has been
complaining of fatigue, fevers, exacerbation of RA in her knees (which are swollen, reddened and
painful). Sally has been coughing and SOB for two days. She commenced on oral antibiotics at
home, but continued to deteriorate. Sally’s vital signs are all in normal ranges except her
temperature which is 38oC.
Outline the management and care you would expect to see as a result of her neutropenic status.
There are other disorders that you will encounter such as leukaemia, disseminated intravascular
coagulation (DIC), hodgkins disease and non-hodgkins lyniphoma to name a few. These are touched
on in your text and you may see some patients with these problems on your clinical placement.
TEXTBOOK READING
(Vol.2, pp. 1127-1145; 1155-1159). Frenchs Forest: Pearson.
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LEARNING ACTIVITY- Case Study
Mick Williams is a 38 year old man admitted to the ward with a painful, swollen left lower leg,
reddened to the mediolateral aspect of his leg. The area is hot to touch and when measured is 3cm
larger in circumference than his right leg. Mick is a truck driver and has driven the truck for the
previous three days, up to 9 hours per day. He has a history of Transient Ischaemic Attacks (TIA’s)
for the past 2 years and has also been diagnosed with hypertension in the last 12 months. His vital
signs are: BP: 170/90, P: 105, RR: 18, T: 375.C, Sp02 97% on room air. He is given Heparin (25,000
units in 50 ml of NS running at 3 units/kg per hour). He weighs 118 kg. He smokes a pack of
cigarettes a day.
Mr Williams asks you to explain what HITTS is and how it became a complication of his previous
diagnosis of DVT. Develop a patient education plan for Mick.
Nurses and Self Care
You have read about safety and blood products and the need for reverse barrier nursing. What other
strategies may the nurse use to protect the client and themselves in a vulnerable position (eg. patient
load swap if you have a cold and a patient who is immunosuppressed or neutropenic).
Specific Nursing Management
You have been introduced to HITTS, anaemia and neutropenia. Each patient in your laboratory cases
for this unit will need disease process specific care. Outline patient problem goals and nursing
interventions for each case study that are directly a result of the patient’s disease process.
CASE STUDY 1
Samantha Jefferies – Anaemia.
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CASE STUDY 2
Mick Williams – HITTS
CASE STUDY 3
Sally Jenkins – Neutropenia
95
Unit 9.4 - Nursing care for the patient with a haematological
disorder
At the end of this unit, with further practice and reading you will be able to:
• Identify outcomes for patient related problems;

• Identify actions according to management guidelines in the framework of the nursing process;
• Identify indications for practice improvement.
READING ON CDROM
Crisp, J., & Taylor, C. (Eds.) (2009). Planning for nursing care. In Potter & Perry’s fundamentals of
nursing (3rd ed.) (p.293). Marrickville: Mosby.
LEARNING ACTIVITY
In the previous unit you formulated a nursing care plan, patient problems were identified, and goals
and nursing interventions outlined. Return to your goals and make a list of criteria that would indicate
your patient’s problem, if not resolved, has improved.
Map out your care plan to see if your goals show the problem is fixed and interventions have
targeted the cause of the problem. Identify with a different coloured pen which part/parts of the
nursing process you have used in each part of the care plan.
96
Practice Improvement
Caring for patients with haematological disorders can be a challenge for the nurse. Often you will be
caring for the patient with a haematological disorder who has presented with another health problem
or develop a haematological disorder as a complication of an existing health problem.
LEARNING ACTIVITY
For each of the case studies you have planned care for in this unit, identify how you will assess your
own knowledge and practice in order to have a plan to base your practice improvement on. This
relates back to self assessment and critical thinking. How will you know if you are doing what is
needed for the patient?
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Module 10
Special Senses:
Ear, Eye, Nose & Throat (including Paediatrics)
Introduction
The eyes and throat will represent the EENT (Eyes, Ears, Nose and Throat) specialty of nursing in
this subject. We will just skim the surface of this broad topic by looking in some depth at cataracts of
the eyes, vertigo, otitis media and tonsillitis. These conditions were chosen because of the prevalence
of each in the acute care setting. Many EENT problems are diagnosed and cared for in the specialist
rooms and the nurse in the hospital does not see the condition unless the patient is hospitalised for
some other complaint.
Disorders of these organs of perception are usually not life threatening (as some of the previous
disorders studied in this subject have been), but they greatly affect quality of life. In fact, some of the
disorders encountered in this nursing specialty are devastating to the individual and the support
required to adapt to the condition may be just as great as to a cardiac or respiratory problem.
Unit 10.1 – Review of the structure and function of the eyes

Learning outcomes
• use the appropriate terminology when discussing visual disorders;

• explain the structure of the eyes;
• discuss the physiology of the eyes.
TERMINOLOGY
Structure and function of the eyes

William Blake said that “the eye is the window to the soul”. This may be true, but what is known is that
the eye is the only internal organ that can be visualised without invasion of the patient. In fact, when
we visualise the retina using the ophthalmoscope, we are looking at a part of the brain. We can see
blood vessels and the blood coursing through the vessels.
TEXTBOOK READING
Berry, K. (2011). Assessing clients with eye and ear disorders. In P. LeMone, et al. Medical surgical
Forest: Pearson.
98
LEARNING ACTIVITY
If a patient has fixed dilated pupils, which cranial nerve has been inactivated? Can you think of
some causes for this condition?
Understanding the structure of the eyes and the function of the various components will assist you in
visualising the problems to be discussed and in accurately assessing the patient’s eyes and vision.
LEARNING ACTIVITY
In past centuries, amongst the beau monde, women of fashion would put drops of belladonna in their
eyes to dilate the pupils. The effects could be counted on for several hours. This increased their
allure to the gentlemen of the day, but what would it have done to their vision? Describe the effects
of artificially dilated pupils. Would the lady’s age have any effect on these effects? (Hint: think about
the lens’ ability to accommodate in the over-forty age group). How can you use this knowledge in
your practice?
Unit 10.2 – Assessment of the eyes

Learning outcomes
• outline the elements of the nursing history for a patient with visual difficulties;
• discuss the specific requirements of the physical assessment of the patient with a disorder of the
eyes;
• discuss the nursing responsibilities associated with the various diagnostic studies and procedures
used to evaluate the alteration of vision.
Many of the disorders of the eye are asymptomatic or have vague symptoms (e.g. headaches, itchy
eyes, difficulty concentrating on fine work). Many other clinical manifestations are characteristic of
systemic disease (e.g. ptosis may indicate Multiple Sclerosis). This makes careful assessment
mandatory so that all factors are considered.
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TEXTBOOK READING
Forest: Pearson.
Specifics for history taking

Your textbook discusses history taking. Take particular note of the systemic diseases of Diabetes
Mellitus, hypertension, and Multiple Sclerosis. Often, patients are diagnosed with Type II Diabetes
Mellitus when they are admitted to the hospital or medical clinic for something unrelated, and at that
time, examination of the eyes demonstrates lens or retinal changes and diminished vision.
Hypertension can result in embolic strokes, and since the retinal vessels are so tiny, they can be the
first affected and are easily occluded. Tiny ischaemic areas of the retina can be seen on visual
examination in these cases.
Physical assessment
TEXTBOOK READING
Forest: Pearson.
Physical assessment of the external structures of the eye is very straightforward and you will practice
observation of the eyes during Residential School. Brows, lids, lashes, sclera, conjunctiva, cornea,
iris and the puncta are visible and inspection/observation will detect abnormalities.
Pupil size, shape and ability to react to light and accommodation can be practiced at home. Check
pupil size and shape in normal room light before you introduce the penlight to assess pupil reactivity.
Make sure that you do not move the light over the midline (i.e. past the bridge of the nose) when you
are determining pupil reaction to light. Do it twice, once watching the eye you are examining and once
watching the other eye for consensual reaction.
The extraocular movements (EOMs) are determined using nothing more than the end of your penlight
and observation. Make sure the patient keeps their head still and follows the end of the penlight with
their eyes only. Keep the penlight about 40 cm in front of the patient and move it in an “X” shape
followed by a horizontal to assess the muscles and cranial nerves associated with each movement.
Make your movements broad enough that you can see the patient’s eyes follow.
Assessing the internal structures of the eye takes practice. Do not despair if you have trouble
focussing on the retina. If you find the ‘red reflex’ on your first attempts, you will be doing well. It
takes time and lots of practice to visualise the retina, with the optic nerve, macula and vessels.
LEARNING ACTIVITY
Practice physical assessment of the eyes. If the family is tired of being your patient, your pet can be
a substitute in this instance although they get quickly bored and run away! Do practice on a human if
you can.
100
Simple visual acuity (using the Snellen’s Chart [which is measured in meters in Australia – i.e. 6/6]) is
one test that most of you have taken, perhaps in school.
Visual Fields Testing can be done using a darkened room and a black board with lights that come on
in a random order but that cover the entire visual field of a person with normal vision. The patient
focuses on a central point and then indicates when they see a light come on. Scotomas are mapped
from their responses. The face-to-face test can be done to grossly determine the patient’s visual field
(assuming the nurse has a normal visual field!). These two tests are probably the only ones you will
be involved with, unless you work in a specialty unit.
Unit 10.3 – Planning with the patient who has visual alterations
Learning outcomes

READING ON CDROM
Smith, S., Neely, S., & Twyford, K. (2008A). Nursing management: Visual and auditory problems.
In D. Brown, H. Edwards, S.L. Lewis, M.M. Heitkemper, S.R. Dirksen, P.G. O’Brien & L.
Bucher (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical
problems (2nd ed.) (pp.461-463). Sydney: Elsevier Mosby.
LEARNING ACTIVITY
For each of the functional health patterns (or as many as you can) write a nursing diagnosis using
the altered assessment findings in the specific pattern to base the diagnosis on.
Recall that nursing diagnosis lists the patient problem initially, followed by the cause (that nurses
can address) and possibly the list of cues that informed you of the problem from the patient
assessment.
An example might be (for Health Perception-Health Maintenance Pattern) Knowledge deficit (visual
complications of Diabetes Mellitus) related to recent diagnosis of Non Insulin Dependent Diabetes
Mellitus and lack of exposure to the information as evidenced by patient question of “why are you
checking my eyes”?
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Goals for patients with visual alterations
The goal for the above nursing diagnosis would read: Mr Johnston will list the visual complications of
Diabetes Mellitus and outline the prevention of same by the end of this shift.
Outcome criteria will then be related directly to having Mr Johnston list the complications and outline
prevention.
LEARNING ACTIVITY
For each of the nursing diagnosis you created in the learning activity above, write a goal and
associated outcome criteria. Again – be specific, time limited and patient oriented.
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Unit 10.4 – Nursing care of the patient with an EENT disorder
(cataracts)
Learning outcomes
patients who have cataracts;
• outline the nursing interventions and their rationales for patients with cataracts.

and medical care of patients with cataracts
A cataract is an opacity or cloudiness of the normally transparent crystalline lens. The lens opacity
reduces visual acuity. Patients with cataracts are very common in the tropical north of Australia. One
of the risk factors for development of cataracts is living in a warm, sunny climate and exposure to
ultraviolet radiation – which we, in this region, do daily. Add to this the aging of the population, and the
result is increasing incidence of cataracts.
TEXTBOOK READING
Forest: Pearson.
READING ON CDROM
Smith, S., Neely, S., & Twyford, K. (2008B). Nursing management: visual and auditory problems. In
(2nd ed.) (pp.468-472). Sydney: Elsevier Mosby.
The pathophysiology is described in your textbook. The current theory of cataract development
indicates that due to aging and to photochemical changes in the lens itself, the lens has reduced
oxygen uptake. Initially, the lens tissue increases in water content, then dehydrates over time. The
protein matrix of the lens undergoes numerous changes that reduce the transparency of this tissue
and cause the opacity or cloudiness that is seen in the cataract.
LEARNING ACTIVITY
If you do this experiment, you will experience what a patient with cataracts sees. First try a cortical
cataract. Smear vaseline on the lens of your glasses or sunglasses (first cover the lenses with clear
wrap or you will need to do a lot of cleaning) – lightly from the edges inward in a spokelike fashion
and diminishing in thickness to clear in the centre. The cortical cataract affects the periphery of the
person’s vision and does not cause severe vision loss. Then try a nuclear cataract. Smear the
vaseline thickly in the centre of the lens and outward. If you try this in daylight and at night, you will
begin to understand how debilitating the condition can be.
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Most people with cataracts who are over 70 experience the nuclear cataract type, where the centre of
the lens becomes sclerotic and often yellows. A third type, posterior subcapsular cataracts cannot be
simulated. The opacities develop on the visual axis at the back of the lens (ie where the light rays
pass to enable them to be focussed on the retina. They often develop in response to trauma or to
corticosteroid therapy. As you can imagine, visual loss develops rapidly.
The clinical manifestations in your textbook should be supplemented with the following. The blurred
vision is painless. There may be an abnormal colour perception (if present) due to changes in lens
colour to yellow (most common), then to amber and finally progressing to brown.
In the diagnostic studies, add loss of red reflex. In a clear lens, when the ophthalmoscope is used to
focus light on the retina, the light bounces back and gives a red glow to the interior of the eye (this is
the same phenomenon that you see in some photos where the pupil of the eye is red). This is known
as the red reflex. When the lens becomes opaque, the light both going in and bouncing out, is
scattered and does not show the red reflex.
Medical management
Conservative treatment is used until the patient can no longer function to their required level.
Sometimes, this is early in the development of the cataract. For instance, if a person who required
the ability to drive and do close work developed nuclear cataracts, they would have a cataract
removal earlier than someone with the same cataract who did not need to drive and did not require
the ability to do close work. At one time, cataract removal depended on the ‘maturity’ (or the amount
of oedema) of the cataract, and patients waited through years of diminishing vision. This is no longer
the case although you may still hear people using the term.
Surgical treatment is extraction of the cataract, usually with implantation of an intraocular (plastic) lens
(IOL). Surgery is over 95% successful, although it may take a few weeks for the patient to become
accustomed to the use of the intraocular lens, and be able to see well.
Nursing interventions and their rationales for patients with cataracts

Since most cataract extractions with intraocular lens (IOL) implants are done during day surgery, the
nursing interventions are aimed at preparing the patient for surgery and discharge and at teaching
postoperative self-care.
WEB LINK
http://www.health.qld.gov.au/informedconsent/ConsentForms/ophthalmology/ophthalmology_01.pdf
As most clients who have cataract surgery are elderly, there are other considerations that must be
taken into account before a patient is able to undergo surgery that has nothing to do with their eyes.
Think about the types of disease processes you commonly see in elderly people and the risk that is
involved in giving these people a general anaesthetic.
As long as you can help a client control their anxiety and they are able to follow directions, most
cataract surgery is done under topical anaesthetic and sometimes using nerve blocks (eg retrobulbar
block) and the patient is fully alert and awake during the procedure. Think of what this means both for
the client and the nurse post operatively!
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LEARNING ACTIVITY
• For each of the categories of post-operative care (post-op eye care, activity restrictions,
medications, follow-up, complications), describe the specific information you would give a 68
year old woman. Do this exercise without referring to the list below.
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Did your outline contain these instructions?
• Post-op eyecare: appropriate eye hygiene (asepsis, wiping inner to outer canthus, warm
water, no makeup, soap or lotions/cremes near the eye); administration of eye drops or
ointment as prescribed (how to, timing, asepsis); use of an eyepatch for 24 hours or as
prescribed, use of a shield at night for 3 nights or as prescribed; use of dark glasses; do not
rub the eye.
Activity restrictions: no coughing, sneezing, bending, straining at stool for 2 weeks (may need
antiemetics, stool softeners); sleep on back or with operative eye uppermost for 2 weeks or as
prescribed by the surgeon; avoid heavy lifting until cleared by surgeon; no driving until cleared by the
surgeon.
Medications: anti-inflammatories, analgesics, antibiotics, cycloplegics, mydriatics, antiemetics and

stool softeners – patient should know the purpose, how to administer, to stagger administration of eye
drops and ointments and to put the drops in first, use of aseptic technique, and to cleanse the eye
before any drops or ointment is administered.
Follow-up: importance; contact details; contact the surgeon immediately if symptoms of

complications arise; vision usually improves.
Symptoms of complications: pain (severe, sharp or unrelieved by analgesics); blurring of vision,

halos around lights, nausea and vomiting; discharge, redness, itching and pain in the eye.
LEARNING ACTIVITY
For each of the above instructions, give the rationale.
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Evaluation of the patient with an eye disorder
TEXTBOOK READING
Forest: Pearson.
LEARNING ACTIVITY
Rewrite each of the ‘Expected Patient Outcomes’ listed in the Nursing Care Plan so that it would be
an evaluation tool. As an example for the first one: Mr Johnston states that he feels able to care for
his personal safety and he does not injure himself during the convalescent period following surgery.

As always, documentation is individual to the patient. For the patient in the nursing care plan,
documentation may look like this (for the initial nursing diagnosis [pre-op]):
10.02.11 Oriented to environment prior to surgery. States he is familiar with the ‘clock’ method of describing
0800 positions. Does not require assistance with activities of daily living as he has developed coping
methods over the past two years as vision has diminished. Possible sources of injury discussed
Nursing and identified at home. Wife aware and understands the problems. J.Nightingale, RN (Nightingale).
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LEARNING ACTIVITY
For each of the remaining nursing diagnosis, write a short documentation note.
Unit 10.5 – Nursing care of the patient with an EENT disorder

(tonsillitis)
Learning outcomes
• discuss the aetiology, incidence, clinical manifestations, complications and medical care of the
patient who has tonsillitis;
• outline the nursing interventions and their rationales for the care of the patient who has tonsillitis.

and medical care of a patient with tonsillitis
Aetiology
Tonsillitis can be caused by viruses or by bacteria. If the cause is viral, little is done for the patient
other than comfort measures (discussed below), even if the infection becomes exudative, since this
type of tonsillitis is usually self-limiting. Antibiotics are also generally ineffective against a virus. If the
infection is caused bya bacteria – beta-haemolytic streptococci, it is treated vigorously so that
possible complications do not arise. The sequelae of untreated or undertreated beta-haemolytic
streptococci infections include rashes, sinusitis, otitis media, peritonsilar abscess, rheumatic fever and
acute glomerulonephritis.
Incidence
Tonsillitis is generally a childhood disease of the tonsils. It is a relatively uncommon disease in
adults.
108
TEXTBOOK READING
McLean, D. (2011). Nursing care of clients with upper respiratory disorders. In P. LeMone, et al.
LEARNING ACTIVITY
Draw and name the three major sets of tonsils in the oropharynx. Describe their function.
Clinical manifestations
Clinical manifestations of bacterial tonsillitis are described in the readings. Viral tonsillitis presents
more gently with a gradual onset of a sore throat and hoarse voice, a productive cough, low grade
fever (under 38o), a mild headache and loss of appetite.
Complications
Complications of untreated or under-treated tonsillitis include:
• airway and food obstruction from the oedematous and painful tonsils;
• mouth breathing in the child due to enlargement of the adenoid tonsils;
• otitis media from the infection travelling up the eustachian tube due to the proximity to the adenoid
tonsils;
• chronic tonsillitis requiring surgical extraction of the palatine and adenoid tonsils;
• peritonsillar abscess (quinsy).
Medical care
Medical care of patients with tonsillitis is usually conservative. Comfort measures include bed rest,
fluids, paracetamol, warm saline gargles. A swab is taken for C&S and if the cause is bacterial,
appropriate antibiotics are added to the regimen.
Tonsillectomies
Tonsillectomies are not done as frequently now as they were in the past. In fact, every effort is usually
made to avoid this operation.
109
LEARNING ACTIVITY
Why do you think that tonsillectomies are done less frequently in children now than they were years
ago? There are two associated reasons.
The child (usually) has to meet the following criteria:
• recurrent symptomatic hypertrophy of the tonsils with signs and symptoms of obstruction and
chronic infection;
• older than 3-4 years;
• four or more documented episodes of tonsillitis due to beta haemolytic streptococcus infection;
• recurrent otitis media, peritonsillar abscesses, retropharyngeal abscesses;
• tonsillar tumour.
As well, the child or adult must be infection free and not suffering from bleeding or clotting disorders,
or a cleft palate.
Nursing interventions and their rationales for patients with tonsillitis
Pre-operative care
The child who is admitted for tonsillectomy is usually well prepared. Most paediatric surgeons have a
package of information developed to assist the parents to allay fears. Some hospitals ask the child
and parents to come to hospital a week or two before the scheduled surgery to get acquainted with
the hospital unit, staff and even the theatre. Play therapy is an integral part of the preparation. Even
pre-op, the child is told the importance of drinking lots of fluids, even if their throat is sore. Clotting
times are usually checked. Emla crème is available to reduce pain when blood is taken.
LEARNING ACTIVITY
State the reasons why the clotting time is so important for the child with this surgery. When you are
next on Clinical Placement, in conjunction with your clinical educator, call into the paediatric unit and
ask about their protocol for tonsillectomies (be sure that you pick a time that is not inconvenient for
the staff!!).
110
Post-operative care
The child is observed closely for the initial 24 hours (1/4 hourly x 1 hours, 1/2 hourly x 1 hours, hourly
x 4 hours, 2 hourly x 12 hours then 4th hourly. Observe the operative site (use a tongue blade and
torch). Observe the pulse and respiratory rate. Observe for signs of bleeding.
Until the child is fully conscious, they should be in a side lying position. Positioning is then initially
prone to minimise swallowing blood loss (excess swallowed blood = vomiting = strained operative site
= more bleeding). As the child improves, and it is evident that there is minimal bleeding from the
operative site, a low Fowler’s position is useful.
Watch the child closely for swallowing. Vomiting is fairly common – observe the emesis for fresh or
old bleeding and chart your observations. Give antiemetics as ordered – this decreases both pain and
nausea and thus the distress.
Encourage fluids...this needs ingenuity. Icy poles, jelly, other clear fluids (some facilities do not allow
red fluids – can you think why?) are given for the first 24 hours, then full fluids (cream soups, ice
cream) are introduced for 24-48 hours before a dental soft diet is given for about another 3 days. This
last is controversial. Some surgeons allow their young patients to have an unrestricted diet as soon
as day 3. Other surgeons restrict the diet as long as 3 weeks postoperatively.
The dental soft diet supposedly does not interfere as much with the operative site as does a normal
diet with such crunchies as raw vegetables, toast and corn chips, which might damage the freshly
healing site. The surgeons who advocate the regular diet think that the scratchiness will only reveal
problems if they are already there and then something can be done about it quickly. Check the
protocol of the surgeon before you advance the child’s diet. Citrus juices and fruits, hot or spicy foods
are avoided for 7-10 days. Generally, after 7 days, a normal diet can be slowly resumed. You will
need to monitor intake and output – most children are very reluctant to drink early post-op because of
the pain. Check the SG of the urine each time you empty the pan or urinal.
Pain control is by way of Paracetamol (never ASA –why?) and the use of an ice collar. Oral rinses –
not gargles – with warm normal saline reduce the foul taste in the mouth and offer some comfort.
Halitosis is normal, but drinking plenty of fluids and warm gargles help.
For protection, the child is allowed no sharp instruments – forks, straws, etc. that might be harmful.
Discharge instructions include:
• a follow up visit with the surgeon in two weeks;

• the signs and symptoms of bleeding, infection and otitis media to watch for and immediately
report to the surgeon;
• to avoid crowds and ill people for 2 weeks and;
• to return to school in about 2 weeks.
Documentation of the effectiveness of nursing interventions is completed frequently on the paediatric

patient. Each unit will have its own protocol, but generally, the patient’s condition, your pertinent
observations, the interventions and their effect are documented as they happen.
Evaluation of the patient with an ear disorder
TEXTBOOK READING
nursing: Critical thinking in client care (1st Australian ed.) (Vol. 3, pp. 1684-1687; 1687-1693).
111
LEARNING ACTIVITY
The textbook takes you through the assessment for auditory problems. Apply this knowledge to how
you would practically apply assessment techniques to the following clients:
Client 1: Rose Straunn a 13 month old baby.

Client 2: Max Gunawardine a 2½ year old child.
Client 3: Cyril Fine a 96 year old man with hearing and vision loss.
What would you need to do differently in assessing each of these clients?
Otitis Media & Vertigo
TEXTBOOK READING
Forest: Pearson.
READING ON CDROM
Thorne, J. (2004). Middle ear problems in Aboriginal school children cause developmental and
educational concerns. Contemporary Nurse, 16(1-2), 145-150.
LEARNING ACTIVITY
Review the above reading and provide a breakdown of assessment techniques for Otitis Media and
Vertigo as well as specific nursing considerations when caring for patients with these problems.
112
Conclusion
Congratulations. This completes the modules for NS2022. I hope you have enjoyed this introduction
to medical/surgical nursing.
The following section contains the Clinical Sessions

conducted in the simulated nursing laboratories at JCU.
Please ensure you have completed the preparation work prior to labs to
maximise your learning and clinical skills development.
Remember that you must attend all nursing labs in your student nursing
uniform, including appropriate closed-in footwear.
I hope you look forward to and enjoy the challenges ahead!
113
References
Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (ANZCA) (2005).
Acute pain management: Scientific evidence (2nd ed.). Melbourne: Australian and New Zealand
College of Anaesthetists.
Brown, D., Edwards, H., Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., & Bucher, L.
(Eds.) (2008). Lewis’s medical-surgical nursing: Assessment and management of clinical
problems (2nd ed.). Sydney: Elsevier Mosby.
Crisp, J., & Taylor, C. (Eds.). (2001). Potter & Perry’s fundamentals of nursing. Marrickville: Mosby.
Dewar, A. (2006) Assessment and management of chronic pain in the older person living in the
community. Australian Journal of Advanced Nursing, 24(1) 33-39.
Hampton, S. ( 2007). Bacteria and wound healing. Journal of Community Nursing, 21(10) 32-37.
LeMone, P. et al. (2011). Medical surgical nursing: Critical thinking in client care (1st Australian
edition), Frenchs Forest: Pearson.
Lewis, S., Heitkemper, M., & Dirksen, S. (2000). Medical surgical nursing: Assessment and
management of clinical problems (5th ed.). St. Louis: Mosby.
Phipps, W. J., Monahan, F. D., Sands, J. K., Marek, J. F., & Neighbors, M. (2003). Medical-surgical
nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby.
Tollefson, J. (2010). Clinical psychomotor skills: Assessment tools for nursing students (4th ed.). South
Melbourne: Thomson Learning.
Tollefson, J., Piggott, K. & Fitzgerald, M. (2008). Management of chronic pain. Chapter 8. In E.
Change & A. Johnson, Chronic illness and disability: Principles for nursing practice.
Sydney: Elsevier.
Wong, D. L., Hockenberry-Eaton, M., Wilson, D., Winkelstein, M. L., & Schwartz, P. (2001). Wong’s
essentials of pediatric nursing (6th ed.). St. Louis: Mosby.
114

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NS2022:03

Clinical Nursing Practice 3

Overall aims of nursing laboratories and self directed learning

Guidelines for nursing practice

A drug profile includes the following:

• drug name (both generic and trade)

National Competency Standards for the Registered Nurse

Compulsory Blue Card

Define the terminology from your laboratory session pages.

Briefly outline the transmission of pain from the peripheries.

To incorporate this knowledge into your care:

Dangers of Unrelieved Acute Pain

Body System Pathophysiologic Responses to Complications

Cardiovascular Sympathetic over-activity leads to increased Increased cardiac work and

Gastrointestinal Increased sympathetic activity leads to Gastric stasis, paralytic ileus.

Unit 1.2 – Nursing assessment of a patient in pain

Barriers to pain assessment and relief

1. Attitudes (of the nurse, patient and/or care giver);

The following attitudes can contribute to ineffective pain management.

Health Care Providers:

Blackwell Publishing has a range of excellent articles – two of which are:

Children’s Acute Pain Assessment and Management Handbooks

Nursing assessment of pain

Clinical Skills Competency

Q: Quality of pain or discomfort

The Visual Analogue Scale (VAS)

Children’s Acute Pain Assessment and Management Handbooks

Unit 1.3 – Developing a Clinical Pathway for a Patient

PROBLEM RELATED TO/

EXPECTED HEALTH INTERVENTIONS

Clinical Skills Competency

Non-pharmacological measures for pain relief

Clinical Skills Competency

Unit 1.4 – Evaluation and documentation of the nursing

Answer the questions in the CONCEPT CHECK activity in your text:

• presence of infection, foreign bodies, dead space, irradiation;

Physical assessment of a wound (observation, documentation and reporting) are essential

• traumatic (acute, surgical, or chronic, e.g. pressure ulcer);

Unit 2.3 – Treatment goals for wound care

• identify patient problems that are amenable to nursing interventions;

Patient problems associated with wounds

Nursing diagnoses for acute (surgical) wounds include:

For chronic wounds, the nursing diagnoses are more comprehensive:

Goals for patients with wounds

Tissue is held together with a variety of material – as follows:

• Sutures: These may be absorbable or non-absorbable. Absorbable sutures are placed in

TEXTBOOK READING – Clinical Skills Competency

Moore, Z. (2005). Pressure ulcer grading. Nursing Standard 19(52), 56-64.

Mechanical debridement, either in a hydrobath or with forceps and scissors is undertaken by

TEXTBOOK READING – Clinical Skills Competency

The choice of a dressing can be complex. The ideal dressing should:

• maintain a moist environment at the wound/dressing interface;

• Interactive dressings: protect, absorb, maintain or donate moisture, aid in autolytic

• Hydrocolloids are a combination of polymers held in fine suspension in water. They

Unit 2.5 – Evaluation of the patient with a wound

• determine criteria for reassessment so goals are evaluated;

Criteria for reassessment so goals are evaluated

Documentation of the effectiveness of nursing interventions

For a surgical wound, you might write:

Terminology used for discussing respiratory anatomy and physiology

Define the terminology from your laboratory session pages.

The process of ventilation, perfusion, and gas exchange