Essentials Midterm study guide
Chp. 28-Infection Prevention
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Explain the relationship of the chain of infection to transmission of infection.
Nature of Infection
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An infection is the invasion of a susceptible host by pathogens or microorganisms,
resulting in disease.
 Colonization is the presence and growth of microorganisms within a host but without
tissue invasion or damage (Tweeten, 2009).
 Disease or infection results only if the pathogens multiply and alter normal tissue
function.
 Some infectious diseases such as viral meningitis and pneumonia have a low or no risk for
transmission.
 If an infectious disease can be transmitted directly from one person to another, it is termed
a communicable disease (Tweeten, 2009).
 If the pathogens multiply and cause clinical signs and symptoms, the infection is
symptomatic.
 If clinical signs and symptoms are not present, the illness is termed asymptomatic.
 Hepatitis C is an example of a communicable disease that can be asymptomatic. It is most
efficiently transmitted through the direct passage of blood (hepatitis B too) into the skin
from a percutaneous exposure, even if the source patient is asymptomatic (CDC, 2010c).
Chain of Infection
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Infection occurs in a cycle that depends on the presence of all of the following elements:
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An infectious agent or pathogen
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A reservoir or source for pathogen growth
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A port of exit from the reservoir
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A mode of transmission (handwashing breaks this part of the cycle)
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A port of entry to a host
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A susceptible host
Infection can develop if this chain remains uninterrupted (Fig. 28-1). Preventing
infections involves breaking the chain of infection.
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Infectious Agent: The potential for microorganisms or parasites to cause disease
depends on the number of microorganisms present; their virulence, or ability to produce
disease; their ability to enter and survive in the host; and the susceptibility of the host.
Reservoir: a place where microorganisms survive, multiply, and await transfer to a
susceptible host.
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Common reservoirs are humans and animals (hosts), insects, food, water, and organic
matter on inanimate surfaces (fomites).
Frequent reservoirs for health care–associated infections (HAIs) include health care
workers, especially their hands; patients; equipment; and the environment.
Human reservoirs are divided into two types: those with acute or symptomatic disease
and those who show no signs of disease but are carriers of it.
They like warm, dark, moist environments w/ neutral pH
Port of Exit/ Entry: include sites such as blood, skin and mucous membranes, respiratory
tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
Modes of Transmission:
 Contact
 Direct: Person-to-person (fecal, oral) physical contact between source and
susceptible host (e.g., touching patient feces and then touching your inner mouth
or consuming contaminated food)
 Indirect: Personal contact of susceptible host with contaminated inanimate object
(e.g., needles or sharp objects, dressings, environment)
 Droplet: Large particles that travel up to 3 feet during coughing, sneezing, or
talking and come in contact with susceptible host (i.e. Streptococcal Pharyngitis,
Pertussis)
 Airborne: Droplet nuclei or residue or evaporated droplets suspended in air
during coughing or sneezing or carried on dust particles (i.e. pulmonary TB and
measles)
 Vehicles:
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• Contaminated items
• Water
• Drugs, solutions
• Blood
• Food (improperly handled, stored, or cooked; fresh or thawed meats)
Vector: External mechanical transfer (flies)
Explain conditions that promote the transmission of healthcare associated infections
(HAI's)
Health care–associated infections (HAIs), formerly called nosocomial or health care–
acquired infections, result from the delivery of health services in a health care facility.
They occur as the result of invasive procedures, antibiotic administration, the presence of
multidrug-resistant organisms, and breaks in infection prevention and control activities.
Patients who develop HAIs often have multiple illnesses, are older adults, newborns, and
are poorly nourished; thus they are more susceptible to infections.
In addition, many patients have a lowered resistance to infection because of underlying
medical conditions (e.g., diabetes mellitus or malignancies) that impair or damage the
immune response of the body.
Invasive treatment devices such as intravenous (IV) catheters or indwelling urinary
catheters (most common HAI) impair or bypass the natural defenses of the body against
microorganisms.
Critical illness increases patients’ susceptibility to infections, especially multidrugresistant bacteria.
The number of microorganisms needed to cause a health care–associated infection
depends on the virulence of the organism, the susceptibility of the host, and the body site
affected.
The number of health care employees having direct contact with a patient, the type and
number of invasive procedures, the therapy received, and the length of hospitalization
influence the risk of infection.
Major sites for HAIs include surgical or traumatic wounds, urinary and respiratory tracts,
and the bloodstream (Box 28-3).
Health care–associated infections significantly increase costs of health care. Older adults
(immunosenescence) have increased susceptibility to these infections because of their
affinity to chronic disease and the aging process itself (Box 28-4).
Extended stays in health care institutions, increased disability, increased costs of
antibiotics, and prolonged recovery times add to the expenses both of the patient and the
health care institution and funding bodies (e.g., Medicare).
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Identify clients most at risk for infection.
Age:
Infants has immature defenses against infection.
The young or middle-age adult has refined defenses against infection. Viruses are the
most common cause of communicable illness in young or middle-age adults.
Older Adults
Risks for Infection: Older adults more susceptible because of lower immune system.
Risks associated with the development of health care–associated infections in older
patients include poor nutrition, unintentional weight loss, and low serum albumin levels
undergo alterations in the structure and function of the skin, urinary tract, and lungs. Skin
loses its turgor, and the epithelium thins. As a result it is easier to tear or abrade the skin,
Nutritional Status:
A reduction in the intake of protein and other nutrients such as carbohydrates and fats
reduces body defenses against infection and impairs wound healing.
Patients with illnesses or problems that increase protein requirements, such as extensive
burns and conditions causing fever, are at further risk. Patients who have undergone
surgery, for example, require increased protein.
A thorough diet history is necessary. Determine a patient's normal daily nutrient intake
and whether preexisting problems such as nausea, impaired swallowing, or oral pain alter
food intake. Confer with a dietitian to assist in calculating the calorie count of foods
ingested.
Stress:
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If stress continues or becomes intense it results in decreased resistance to infection.
Continued stress leads to exhaustion, which causes depletion in energy stores, and the
body has no resistance to invading organisms.
Disease Process:
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Patients with diseases of the immune system are at particular risk for infection.
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Differentiate between medical and surgical asepsis
Asepsis is the absence of pathogenic (disease-producing) microorganisms. Aseptic
technique refers to practices/procedures that help reduce the risk for infection. The two
types of aseptic technique are medical and surgical asepsis.
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Medical Asepsis:
Medical asepsis, or clean technique, includes procedures for reducing the number of
organisms present and preventing the transfer of organisms.
Hand hygiene, barrier techniques, and routine environmental cleaning are examples of
medical asepsis.
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Cleaning, Disinfection, and Sterilization
Cleaning
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Cleaning is the removal of all soil (e.g., organic and inorganic material) from objects and
surfaces (Rutala and Weber, 2008, 2009). Generally cleaning involves use of water and
mechanical action with detergents or enzymatic `````````products.
Apply protective eyewear (or a face shield) and utility (dishwashing style) gloves when
cleaning equipment that is soiled by organic material such as blood, fecal matter, mucus,
or pus. Protective barriers provide protection from potentially infectious organisms. A
brush and detergent or soap are necessary for cleaning.
Disinfection and Sterilization:
Disinfection describes a process that eliminates many or all microorganisms, with the
exception of bacterial spores, from inanimate objects (Rutala and Weber, 2008, 2009).
Sterilization is the complete elimination or destruction of all microorganisms, including
spores. Steam under pressure, ethylene oxide (ETO) gas, hydrogen peroxide plasma, and
chemicals are the most common sterilizing agents.
Surgical Asepsis
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Surgical asepsis or sterile technique prevents contamination of an open wound, serves to
isolate the operative area from the unsterile environment, and maintains a sterile field for
surgery.
Surgical asepsis includes procedures used to eliminate all microorganisms, including
pathogens and spores, from an object or area (Rutala and Weber, 2008, 2009).
In surgical asepsis an area or object is considered contaminated if touched by any object
that is not sterile. It demands the highest level of aseptic technique and requires that all
areas be kept free of infectious microorganisms.
Use surgical asepsis in the following situations:
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During procedures that require intentional perforation of the patient's skin such as
insertion of IV catheters or central lines suctioning the tracheobronchial airway, and
reapplying sterile dressings
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When the integrity of the skin is broken as a result of trauma, surgical incision, or
burns
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During procedures that involve insertion of catheters or surgical instruments into
sterile body cavities such as insertion of a urinary catheter
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A nurse in an operating room follows a series of steps to maintain sterile
technique, including applying a mask, protective eyewear, and a cap; performing
a surgical hand scrub; and applying a sterile gown and gloves.
Explain the rationale for standard precautions.
Standard Precautions (Tier One) for Use with All Patients
• Standard precautions apply to blood, blood products, all body fluids,
secretions, excretions (except sweat), nonintact skin, and mucous membranes.
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• Perform hand hygiene before, after, and between direct contact with
patients.
• Perform hand hygiene after contact with blood, body fluids, mucous
membranes, nonintact skin, secretions, excretions or wound dressings; after
contact with inanimate surfaces or articles in a patient room; and immediately
after gloves are removed.
• Wash hands with nonantimicrobial soap and water if contact with spores
(e.g., Clostridium difficile) is likely to have occurred.
• Wear gloves when touching blood, body fluids, secretions, excretions,
nonintact skin, mucous membranes, or contaminated items or surfaces is
likely
• Wear personal protective equipment when the anticipated patient
interaction indicates that contact with blood or body fluids may occur.
• Respiratory hygiene/cough etiquette: sit at least 3 feet away from others if
coughing.
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Identify indications for and interventions associated with the following transmission
based precautions: airborne, contact & droplet
Chp. 27-Safety
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Discuss the purpose of the National Patient Safety Goals and identify 5 initiatives
included within these goals.
National Patient Safety Goals
2012 National Patient Safety Goals
 Established by the Joint Commission to:
 Promote patient/resident safety
 Evaluate the safety and the quality of care provided for patients/residents
Client Safety Goals:
 Decrease the incidence of illness and injury
 Prevent extended lengths of therapy/hospitalizations
 Maintain/improve clients functional ability
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 Increase clients’ well-being
Hospital National Patient Safety Goals
 Identify Patients Correctly
 Improve Staff Communication
 Use Medicines Safely
 Prevent Infection
 Identify Patient Safety Risks
 Prevent Mistakes in Surgery
Long Term Care National Patient Safety Goals
 Identify Patients Correctly
 Use Medicines Safely
 Prevent Infection
 Prevent Residents From Falling
 Prevent Bed Sores
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Describe how unmet basic physiologic needs of oxygen, nutrition, temperature, and
humidity threaten client’s safety.
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Physiological needs, including the need for sufficient oxygen, nutrition, and optimum
temperature, influence a person's safety. According to Maslow's hierarchy of needs,
these basic needs must be met before physical and psychological safety and security
can be addressed (see Chapter 6).
Oxygen
 Supplemental oxygen is sometimes required to meet a person's oxygenation
needs. Oxygen is not flammable, but fire needs oxygen to start and to keep
burning. When more oxygen is in the air, a fire burns hotter and faster.
 Be aware of factors in a patient's environment that decrease the amount of
available oxygen. A common environmental hazard in the home is an
improperly functioning heating system. A furnace, stove, or fireplace that is not
properly vented introduces carbon monoxide into the environment.
 Carbon monoxide affects a person's oxygenation by binding with hemoglobin,
preventing the formation of oxyhemoglobin and thus reducing the supply of
oxygen delivered to tissues (see Chapter 40). Low concentrations cause nausea,
dizziness, headache, and fatigue. Very high concentrations cause death after 1 to
3 minutes of exposure (National Fire Protection Association, 2010a).
Nutrition:
Meeting nutritional needs adequately and safely requires environmental controls and
knowledge (see Chapter 44). Health care facilities and restaurants are required to meet
State Board of Health regulations.
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Food and Drug Administration (FDA) regulates commercially processed and
packaged foods
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o federal agency
o responsible for the enforcement of federal regulations regarding the
manufacture, processing, and distribution of foods, drugs, and cosmetics
to protect consumers against the sale of impure or dangerous substances.
 Foodborne illnesses- each year about 76 million illnesses occur, more than
300,000 persons are hospitalized, and 5,000 die (Centers for Disease Control
and Prevention, 2009).
o Groups at the highest risk are children, pregnant women, older adults,
and people with compromised immune systems.
o Foods that are inadequately prepared or stored or subject to unsanitary
conditions increase the patient's risk for infections and food poisoning.
Temperature
 Comfort zone: between 18.3° and 23.9° C (65° and 75° F).
 Temperature extremes affect comfort, productivity, and safety.
 Frostbite and accidental hypothermia: exposure to severe cold for prolonged
periods
o Frostbite occurs when a surface area of the skin freezes
o Hypothermia occurs when the core body temperature is 35° C (95° F) or
below.
o Who is at greatest risk: Older adults, the young, patients with
cardiovascular conditions, patients who have ingested drugs or alcohol
in excess, and people who are homeless
 Heatstroke or heat exhaustion: from exposure to extreme heat that changes the
electrolyte balance of the body and raises the core body temperature
o Who is at greatest risk: Chronically ill patients, older adults, and infants
These patients need to avoid extremely hot, humid environments (see
Chapter 29).
Physical Hazards
On average 33.5 million injuries take place each year (Mostly inside or outside the home)
 Motor vehicle accidents are the leading cause of death in America
 Followed by poisonings and falls.
 Additional hazards consist of fire and disasters.
 Unintentional injuries are the fifth leading cause of death for Americans of all
ages
 Our role: educate patients about common safety hazards and how to prevent
injury while placing emphasis on hazards to which patients are more vulnerable.
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Discuss the specific risks to safety related to developmental age.
A patient's developmental stage creates threats to safety as a result of lifestyle, cognitive
and mobility status, sensory impairments, and safety awareness. With this information,
you tailor safety prevention programs to the needs, preferences, and life circumstances of
particular age-groups.
1. Infant, Toddler, and Preschooler
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a. Injuries are the leading cause of death in children over age 1 and cause
more death and disabilities than do all diseases combined.
b. The nature of the injury sustained is closely related to normal growth and
development. For example, the incidence of lead poisoning is highest in
late infancy and toddlerhood.
c. Increased level of oral activity, put objects in their mouth.
o This increases risk for poisoning and choking.
d. Fire often results from curiosity with matches.
e. Falls from bicycles and playground equipment due to limited physical
coordination
f. Additional injuries at this age are related to riding unrestrained in a motor
vehicle, drowning, and head trauma from objects.
g. Child accidents are highly preventable, but parents need to be aware of
specific dangers at each stage of growth and development.
h. We need to TEACH!! Accident prevention
School-Age Child
When a child enters school, the environment expands to include the school, transportation
to and from school, school friends, and after-school activities. School-age children are
learning how to perform more complicated motor activities and often are uncoordinated.
o Parents, teachers, and nurses need to instruct children in safe practices to follow at
school or play, including what to do if approached by strangers.
o Teach school-age children involved in team and contact sports the rules for
playing safely and how to use protective safety equipment such as helmets and
other protective gear.
o Head injuries are a major cause of death, with bicycle accidents being one of the
major causes of such injuries (Hockenberry and Wilson, 2009).
o Bikes need to be the proper size for the child, and helmets must be worn (Fig. 272).
o TEACH!! proper use of seat belts and booster seats in motor vehicles and provide
pedestrian safety education.
Adolescent
As children enter adolescence, they develop greater independence and begin to develop a
sense of identity and their own values. The adolescent begins to separate emotionally
from his or her family, and peers generally have a stronger influence. Wide variations
that swing from childlike to mature behavior are characteristic of adolescent behavior
(Hockenberry and Wilson, 2009).
 Engage in risk-taking behaviors such as smoking, drinking alcohol, and using
drugs
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o Increases the incidence of accidents such as drowning and motor vehicle
accidents.
When adolescents learn to drive, their environment expands, and so does their
potential for injury. Fortunately teen motor vehicle crashes are preventable by
avoiding distractions such as using cell phones, texting, eating, and drinking while
driving.
assess for possible substance abuse,
o have parents look for environmental and psychosocial clues from their
children: presence of drug-oriented magazines, beer and liquor bottles,
drug paraphernalia and blood spots on clothing and the continual wearing
of long-sleeved shirts in hot weather and dark glasses indoors.
o Psychosocial clues include failing grades, change in dress, increased
absenteeism from school, isolation, increased aggressiveness, and changes
in interpersonal relationships.
risk of sexually transmitted diseases because mature sexual physical
characteristics begin to develop
Adult
 lifestyle habits
Older Adult
 The physiological changes associated with aging,
 Polypharmacy
 Psychological factors, and acute or chronic disease increase the older adult's risk
for falls and other types of accidents.
 Falls in the bedroom, bathroom, and kitchen.
o Environmental factors such as broken stairs, icy sidewalks, inadequate
lighting, throw rugs, and exposed electrical cords cause many of the
accidents.
o Inside falls most often occur while transferring from beds, chairs, and
toilets; getting into or out of bathtubs; tripping over items such as cords
covered by rugs or carpets, carpet edges, or doorway thresholds; slipping
on wet surfaces; and descending stairs.
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Describe assessment activities designed to identify clients’ physical, psychosocial,
and cognitive status as it pertains to their safety status.
Nursing Assessment Questions
Activity and Exercise
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Do you use any assistive devices such as a wheelchair, walker, or cane to help
you move or get around? Did someone show you how to use them safely?
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Do you have any difficulty bathing? Dressing? Eating? Using the bathroom?
Transferring out of the bed or chair?
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What type of exercise or physical activity do you get? How often?
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How do you handle meal preparation (e.g., use stove and appliances safely)?
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Do you do your own laundry? How do you do this, and where are these
appliances located?
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Do you drive an automobile? When do you normally drive? How far?
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How often do you wear a safety belt when in the car?
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Have you recently been involved in a motor vehicle accident?
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Medication History
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Which medications (prescription, over-the-counter, herbal) do you take?
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Has your doctor or pharmacist reviewed your medicines with you?
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Do any medications make your dizzy or light-headed?
History of Falls
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Have you ever fallen or tripped over anything in your home?
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Have you ever suffered an injury from a fall? What was it and how did it happen?
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Did you have any symptoms right before you fell? What were they?
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Which activity were you performing before the fall?
Home Maintenance and Safety
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Who does your simple home maintenance or minor home repairs?
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Who shovels your snow? Tends to your lawn?
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Do you feel safe in your home? Which things in your environment make you feel
unsafe?
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Do you have someone to call in case of an emergency?
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How do you feel about modifying your home to make it safer? Do you need help
finding resources to help you do this? (al 372)
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Describe the four categories of risks in a health care agency.
 Falls:
 Falls result in minor to severe injuries such as hip fractures or head trauma
that result in reduced mobility and independence and increase the risk for
premature death. Patients who have underlying disease states are more
susceptible to fall-related injuries (Hughes, 2008). The unfamiliar
environment, acute illness, surgery, mobility status, medications,
treatments, and placement of various tubes and catheters are common
challenges that place patients of any age at risk of falling.
 Factors the nurse can influence include assessment and communication
about patient risks, information access, signage, the environment,
teamwork, and involving the patient and family (Dykes et al., 2009).
 Falls that result in injuries often extend a patient's length of stay in the
health care environment, placing them at an even greater risk for other
complications.
Falls
2012 National Patient Safety Goals
Full Side rails
Increased injury and death (only using half side rails)
Measures to Help Prevent Falls
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Stairs
Handrails
Lighting (well lit areas, especially in going to bathroom)
Clutter
Floors
Footwear (make sure clients have non-skid footwear)
Why are the Elderly at
such a High Risk?
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Medications (meds may make them drowsy or blurry)
Poor Vision (possible infectious process going on)
Sudden Mental Status Changes
Untied Shoes/Improper Fitting Footwear
Spills on the Floor (little spills that goes unnoticed)
Too much Furniture
Uneven Terrain
Poor Hydration (elderly is at high risk for dehydration)
Patient-Inherent Accidents:
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accidents (other than falls) in which the patient is the primary reason for the accident.
self-inflicted cuts, injuries, and burns; ingestion or injection of foreign substances;
self-mutilation or fire setting; and pinching fingers in drawers or doors
One of the more common precipitating factors for a patient-inherent accident is a
seizure.
Client Inherent Accidents
 Seizure Precautions
 Client Protection
 Create Safe Environment
Types of Seizures
 Focal
 Tonic-Clonic
 Generalized
 Loss of Consciousness and Fall
 Status-Epilepticus (that is an emergency)
 Prolonged or repeated
During a Seizure (#1 responsibility is client safety)
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Position for adequate ventilation
Side lying
Provide Privacy (if possible)
Protect patient from injury
Do Not Restrain
Do not place anything in the client’s mouth
Time seizure (note how long it lasted)
Documentation (did they recall the event)
Procedure-Related Accidents:
 caused by health care providers
 medication and fluid administration errors
 improper application of external devices
 accidents related to improper performance of procedures such as dressing changes
or urinary catheter insertion
 Nurses are able to prevent many procedure-related accidents by adhering to
organizational policy and procedures and standards of nursing practice.
o proper preparation and administration of medications
o use of patient and medication bar coding, and “Smart” intravenous (IV)
pumps reduce medication errors
o distractions and interruptions contribute to procedure-related accidents and
need to be limited, especially during high-risk procedures such as
medication administration.
o The potential for infection is reduced when surgical asepsis is used for
sterile dressing changes or any invasive procedure such as insertion of a
urinary catheter.
o correct use of safe patient handling techniques and equipment reduces the
risk of injuries when moving and lifting patients (see Chapter 47).
Equipment-Related Accidents:
 malfunction, disrepair, or misuse of equipment or from an electrical hazard.
 To avoid rapid infusion of IV fluids, all general-use and patient-controlled
analgesic pumps need to have free-flow protection devices.
 To avoid accidents, do not operate monitoring or therapy equipment without
adequate instruction.
 If faulty equipment is discovered, place a tag on it to prevent it from being used
on another patient and promptly report any malfunctions.
 Assess potential electrical hazards to reduce the risk of electrical fires,
electrocution, or injury from faulty equipment.
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Facilities must report all suspected medical device—related deaths to both the
FDA and the manufacturer of the product if known (FDA, 2009).
Safety Risks in Health Care Agency
 Procedure related accidents
 Radiation (wrong doses)
 Equipment related accidents (incidents can happen because pts turn off heart
monitor alarms)
 Incident Reporting
 Extinguisher
 Poisoning/Medications (should not always induce vomiting)
 Electrical Hazards
 Radiation
 Bioterroist (there is always drills in ER concerning bioterroism)
 Fire (1st thing is to get your pt to safety)
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Rescue and remove (biggest role as a nurse)
Activate alarm
Confine fire
Extinguish
Identify nursing diagnosis associated with risk to safety specific to client's age.
Nursing diagnoses for patients with safety risk include the following:
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RACE
R
A
C
E
Risk for falls
Impaired home maintenance
Risk for injury
Deficient knowledge
Risk for poisoning
Risk for suffocation
Risk for trauma (al 377)
Develop care plans for clients whose safety is threatened and nursing interventions
specific to clients’ age for reducing risks of falls, fires, poisonings, and electrical
hazards.
Nursing diagnosis:
Gather data from your nursing assessment and analyze clusters of defining characteristics
to identify relevant nursing diagnoses. Include specific related or contributing factors to
individualize your nursing care (Box 27-6).
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For example, the nursing diagnosis risk for injury is sometimes related to altered mobility
or sensory alteration (e.g., visual). Altered mobility leads you to select such nursing
interventions as range-of-motion (ROM) exercises or teaching the proper use of safety
devices such as side rails, canes, or crutches. Visual impairment as the related factor
leads you to select different interventions such as keeping the area well lit; orienting the
patient to the surrounding; or keeping eye glasses clean, handy, and well protected. When
you do not identify the correct related factor, the use of inappropriate interventions
increases a patient's risk for injury. For example, not evaluating the home environment
for hazards possibly results in sending a hospitalized patient home only to return with an
additional injury. (al 374-377)
Planning:
Patients with actual or potential risks to safety require a nursing care plan with
interventions that prevent and minimize threats to their safety. Design your interventions
to help a patient feel safe to move about and interact freely within the environment. The
total plan of care addresses all aspects of patient needs and uses resources of the health
care team and the community when appropriate. Critically synthesize information from
multiple sources (Fig. 27-4). Critical thinking ensures that the patient's plan of care
integrates all that you learned about the patient and the key critical thinking elements. For
example, you reflect on knowledge regarding the services that other disciplines (e.g.,
occupational therapy, case management) provide in helping patients return to their home
environments safely. Also reflect on any previous experience when a patient benefited
from safety interventions. Such experience helps you adapt approaches with each new
patient. Applying critical thinking attitudes such as creativity helps you to collaborate
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with the patient in planning interventions that are relevant and most useful, particularly
when making changes in the home environment. (al 377)
Goals and Outcomes:
You collaborate with the patient, family, and other members of the health care team when
setting goals and expected outcomes during the planning process (see the Nursing Care
Plan). The patient who is an active participant in reducing threats to safety becomes more
alert to potential hazards and is more likely to adhere to the plan. Make sure that goals
and outcomes for each nursing diagnosis are measurable and realistic, with consideration
of the resources available to the patient. For example, in the case of the nursing diagnosis
of impaired physical mobility related to left-sided paralysis, the goal is the patient
“remains free of injury by discharge.” Examples of expected outcomes include: (al 377)
 Patient uses tripod cane correctly within 24 hours.
 Patient describes approach to rise up from bed correctly with assistance by end of
the teaching session today. (al 377)
Setting Priorities:
Prioritize a patient's nursing diagnoses and interventions to provide safe and efficient
care. For example, the patient described in the concept map (Fig. 27-5) has several
nursing diagnoses. The patient's mobility problem is an obvious priority because of its
influence on risk for falls and skin integrity. Plan individualized interventions based on
the severity of risk factors and the patient's developmental stage, level of health, lifestyle,
and cultural needs (Box 27-7). Planning involves an understanding of the patient's need
to maintain independence within physical and cognitive capabilities. Collaborate to
establish ways of maintaining the patient's active involvement within the home and health
care environment. Education of the patient and family is also an important intervention to
plan for reducing safety risks over the long term. (al 377-379)
Teamwork and Collaboration:
Collaboration with the patient, family, and other disciplines such as social work and
occupational and physical therapy become an important part of the patient's plan of care.
Patients need to be able to identify, select, and know how to use resources within their
community (e.g., neighborhood block homes, local police departments, and neighbors
willing to check on their well-being) that enhance safety. Make sure that the patient and
family understand the need for these resources and are willing to make changes that
promote their safety.
Implementation:
The QSEN (2011) project outlines recommended skills to ensure nurse competency in
patient safety. Among these skills are those involving safe nursing practice during direct
care:
18
•
Demonstrate effective use of technology and standardized practices that support
safety and quality.
•
Demonstrate effective use of strategies to reduce risk of harm to self or others.
•
Use appropriate strategies to reduce reliance on memory (such as forcing
functions, checklists).
Direct your nursing interventions toward maintaining the patient's safety in all types of
settings. You implement health promotion and illness prevention measures in the
community setting, whereas prevention is a priority in the acute care setting. (al 379)
Treatment Interventions:
o Prioritize Care (what is most important? Make sure your objective is
measurable to easily evaluate!)
o Set Realistic Goals
o Collaboration
o Client and family members
o Health care providers
o Treatment Interventions
o Evaluate Medication Regimen
o Activity/Exercise program
o Assistive devices (therapists can assist in the home to help set up
independent living)
o Alternatives to Restraint Use (not used as often. Mostly in ER. Not really
used in LTC unless extreme circumstance)
o Evaluate continence needs
o toileting schedule
Characteristics of Safe Environment:
o Physical hazards reduced
o Reduce fall risks
o Ensure lighting
o Reduce obstacles
o Remove bathroom hazards
o Increase security
o Environmental Interventions
o Decrease glare; provide dim light
o Elevated toilet seats; grab bars and handrail in the shower, toilet and sink
o Bedside Commode
o Stabilize furnishings; evaluate footwear
o Use signage (stickers, colored dots, wrist bands)
19
o Bed / chair exit alarm
o Remove clutter

Identify factors to assess when it becomes necessary to physically restrain a client,
elements of a restraint order and follow up care of the client requiring restraints
Types of Restraint:
 Medical Immobilization:
o Pharmacologic
o Temporary (usually is temporary)
o Performance of and recovery from medical surgical treatment
o Surgical positioning
o IV arm boards
o Bulky dressing

Physical Restraint:
o Any manual method, physical or mechanical device, material or equipment
attached or adjacent to the person’s body cannot be removed easily restricts
freedom of movement or normal access to one’s body
o Soft wrist/ankle
o Straps/Belts
o Two-Three-or Four Point
o Wheelchair Safety Bars
o Mitts
o Chairs with Lapboards
o Beds with Full Side rails
o Bedsheets
o Vest/Jacket
o Vest and belt restraints
o Extremity restraints
o Mummy restraint
Reasons for using Restraints:
o Prevent falls and protect the patient from harm
o Prevent interference with medical treatments
o Protect medical devices
o Control disruptive behavior
Reasons for NOT Using Restraints:
o Decrease legal liability
20
o Family pressure
o Convenience
o Under Staffed
Risks Associated with Physical Restraints
o Spiraling immobility
o Risk for strangulation (by trying to escape)
o Hypoxic encephalopathy
o Death from strangulation
o Psychological Effects
o Deconditioning (lose that will to go on. The longer in bed the weaker a
person gets)
Safe Use of Restraints in Healthcare Facilities:
Restraint order requirements
o Method specified
 Should be least restrictive
o Time parameters/limitations
o Physician assessment and indications
o In emergency RN may initiate restraint but client must receive face to face
evaluation by physician within 1 hour
o Nursing care and assessment
 Inspect skin where restraint will be applied and document skin
integrity
 Insure staff safety
 Pad boney prominences (assess if there is any numbness or
capillary bursting)
 Apply appropriate restraint
o Delegation
 Applying restraint
21

Identify interventions to avoid the use of restraints and alternatives to patient
restraint.
•Orient patients and families to environment; explain all procedures and treatments.
•Provide companionship and supervision; use trained sitters; adjust staffing and involve
family.
•Offer diversionary activities such as music or something to hold; enlist support and input
from family.
•Use calm, simple statements and physical cues as needed.
•Use de-escalation, time-out, and other verbal intervention techniques when managing
aggressive behaviors.
•Provide appropriate visual and auditory stimuli (e.g., family pictures, clock, radio).
•Remove cues that promote leaving (e.g., elevators, stairs, or street clothes).
•Promote relaxation techniques and normal sleep patterns.
22
•Institute exercise and ambulation schedules as allowed by patient's condition; consult
physical therapist for mobility and exercise programs.
•Attend frequently to needs for toileting, food, and liquid.
•Camouflage intravenous lines with clothing, stockinette, or Kling dressing.
•Evaluate all medications patient is receiving and ensure effective pain management.
•Reassess physical status and review laboratory findings. (al 385)
Alternative Interventions
 Pharmacologic agents to treat patient’s agitation
o Therapeutic vs. chemical restraint
 Early identification of source of patient’s discomfort and agitation
 Increase patient observations - video cameras, move closer to nurses station
 Music and frequent reorientation
 Allow family greater access
o Video/audiotapes of family
 Consistent Nurse Caregiver
 Alter the environment
o Reduce noise level
o Turn TV off
o Use bed/chair exit alarms
o Relocate patient near the nurse’s station
o Lower nurse-to-patient ratio

Define the knowledge, skills, and attitudes necessary to promote safety in a health
care setting.
Safety in Health Care Organizations:
 Patient-centered safety culture
 Current reliable technology
 Risk management and safety reports
 Evidence-based practice
 Safe work environment
 Continuous improvement goals
Quality and Safety Education for Nurses (QSEN):
 QSEN minimizes risk of harm to patients and providers by
 System effectiveness
 Individual performance
 Use of the nursing process promotes safety.
 Critical thinking is an ongoing process
 Staff education
23
Education Interventions for Nurses:
 Increase awareness
 improve nurses’ attitudes about falls; statistics
 Proper patient transfer technique
 Restraint-free attitudes
 Provide gait training, balance and strength

Describe follow-up nursing care of the client placed in physical restraints.
Ongoing Care When Using Restraints:
o Assess for ongoing need for restraint
 Every 24 hours
o Assess distal to extremity
o Schedule periods of release
o Preventative skin interventions (padding)
o Call light in reach (very important)
o Bed in lowest, locked position
o Mobile chairs locked

Describe the assessment of the client who has recently experienced a seizure.
1. Assess patient's seizure history and knowledge of precipitating factors. Note
frequency of past seizures, presence and type of typical aura (e.g., metallic taste,
perception of breeze blowing on face, or noxious odor), and body parts affected if
known. Use family as resource if necessary. Rationale: Knowledge about seizure
history enables you to anticipate onset of seizure activity and take appropriate safety
measures.
2. Assess for medical and surgical conditions, including electrolyte disturbances such as
hypoglycemia, hyperkalemia; heart disease; excess fatigue; alcohol or caffeine
consumption. Rationale: These are common conditions that lead to seizures or
exacerbate existing seizure condition.
3. Assess medication history and patient's adherence. Assess therapeutic drug levels of
anticonvulsants if test results available. Rationale: Not taking seizure medications as
prescribed and stopping them suddenly often precipitate seizure activity.
4. Inspect patient's environment for potential safety hazards (e.g., extra furniture) if
seizure occurs. Keep bed in low position, side rails up at head of bed, patient in sidelying position when possible. Rationale: Protect patient from injury sustained by
striking head or body on furniture or equipment.
24
5. Assess patient's cultural perspective about the meaning of seizures and their
treatment. Rationale: Some cultures follow different caring practices for a person with
seizures. (al 394)
Chp. 39-Hygiene

Describe factors that influence personal hygiene practices.
 Social patterns: Ethnic, social, and family influences on hygiene patterns
 Personal preferences: Dictate hygiene practices
 Body image: A person’s subjective concept of his or her body appearance
 Socioeconomic status: Influences the type and extent of hygiene practices used
 Health beliefs and motivation: Motivation is the key factor in hygiene.
 Cultural variables: People from diverse cultures practice different hygiene rituals.
 Developmental stage: Affects the patient’s ability to perform hygiene care
 Physical condition: May lack physical energy and dexterity to perform self-care

Discuss the role critical thinking plays in providing hygiene.
Critical Thinking and Hygiene: Safety Guidelines
 Communicate clearly with team members.
 Incorporate patient’s priorities.
 Move from the cleanest to less clean areas.
 Use clean gloves for contact with nonintact skin, mucous membranes, secretions,
excretions, or blood.
 Test the temperature of water or solutions.
 Use principles of body mechanics and safe patient handling.
 Be sensitive to the invasion of privacy.

Discuss conditions that place clients at risk for impaired skin integrity.

Risk Factors for Impaired Hygiene and Skin Integrity
 Immobility
 Sensory Impairment
 Vascular Insufficiency
 Nutrition and hydration
 Secretions and excretion
25


Special considerations
 Immunosuppressed
 Use time spent providing hygiene care to identify abnormalities and
initiate appropriate actions to prevent further injury to sensitive tissues.
Assessment of Integument
 note color, texture, thickness, turgor, temperature, and hydration.
 Pay special attention to the presence and condition of any lesions.
 dryness of the skin indicated by flaking, redness, scaling, and cracking.
 Determine the degree of cleanliness by observing the appearance of the
skin and detecting body odors that possibly indicate inadequate cleansing
or excessive perspiration caused by fever or pain. Inspect less obvious or
difficult-to-reach skin surfaces such as under the breasts or scrotum,
around the female patient's perineum, or in the groin for redness, excessive
moisture, and soiling or debris. Separate skinfolds for observation and
palpation.
26




Be attentive to characteristics of skin problems most influenced by
hygiene measures. Is the skin dry from too much bathing or from use of
hot water or irritating soap? Does the patient have a rash caused by an
allergic reaction to a skin care product?
Patients may be unaware of skin problems because they are unable to feel
pain or pressure or see their skin in some places (e.g., the back or the feet).
Prolonged contact of urine or feces occurs such as with diarrhea or
incontinence, skin breakdown often results.
Examples of diagnoses commonly associated with hygiene problems:
•
Activity intolerance
•
Bathing self-care deficit
•
Dressing self-care deficit
•
Impaired physical mobility
•
Impaired oral mucous membrane
•
Ineffective health maintenance
•
Risk for infection (al 779)
Interventions:
 Hygiene Care Schedule
 Early Morning Care: Nursing personnel on the night shift provide basic
hygiene to patients getting ready for breakfast, scheduled tests, or early
morning surgery. “AM care” includes offering a bedpan or urinal if the
patient is not ambulatory, washing the patient's hands and face, and
assisting with oral care.
 Routine Morning Care: After breakfast assist by offering a bedpan or
urinal to patients confined to bed; provide a bath or shower, including
perineal care and oral, foot, nail, and hair care; give a back rub; change the
patient's gown or pajamas; change the bed linens; and straighten the
patient's bedside unit and room. This is often referred to as “complete AM
care.”
 Afternoon Care: Hospitalized patients often undergo many exhausting
diagnostic tests or procedures in the morning. In rehabilitation centers
patients participate in physical therapy in the morning. Afternoon hygiene
care includes washing the hands and face, assisting with oral care, offering
a bedpan or urinal, and straightening bed linen.
 Evening, or Hour-Before-Sleep, Care: Before bedtime offer personal
hygiene care that helps patients relax and promotes sleep. “PM care” often
includes changing soiled bed linens, gowns, or pajamas; helping patients
wash the face and hands; providing oral hygiene; giving a back massage;
and offering the bedpan or urinal to nonambulatory patients. Some
27






patients enjoy a beverage such as juice; check diet to determine which
beverages are allowed. (al 784)
 Types of Baths
 Complete bed bath
 Partial bed bath
 Sponge bath at sink
 Tub bath/shower
 Perineal Care:
 Most at risk: incontinence
 Back Rub
 Promotes relaxation
Delegation
 UAP
Privacy: Close the door and/or pull room curtains around the bathing area. While
bathing the patient, expose only the areas being bathed by using proper draping.
(al 784)
Safety: Keep side rails up when away from the patient's bedside when patients are
dependent or unconscious. NOTE: When side rails serve as a restraint, you need a
health care provider's order (see agency-specific policy for restraint usage). Place
the call light in the patient's reach if leaving the bedside even temporarily. (al
784)
Clean to dirty/Head to toe
Special considerations:
 Maintain warmth. Keep the room warm because the patient is partially
uncovered and easily chilled. Wet skin causes an excess loss of heat
through evaporation. Control drafts and keep windows closed. Keep
patient covered, only exposing the body part being washed during the
bath.
 Promote independence. Encourage the patient to participate in as much of
the bathing activities as possible. Offer assistance when needed.
 Anticipate needs. Bring a new set of clothing and hygiene products to the
bedside or bathroom. (al 784)
Evaluation and Documentation
28

Discuss factors that influence the condition of the nails and feet.
29

Foot and Nail Care Guidelines:
o Cleaning:
 Lukewarm water temperature
 Clean each day
o Nails:
 Cut straight across and square or file
o Socks:
 No elastic socks
 Change socks 1-2 x/day
o Shoes:
 Shoes with porous uppers
 Room in toe box; lambswool b/t toes that overlap
 Sturdy closed-in, non restrictive; Non-slip sole
 No barefeet
o DM or Neuropathy:
30

Discuss conditions that place clients at risk for impaired oral mucous membranes.
Oral Hygiene:
 Brushing and flossing
 Clients with special needs
o Presence of stomatitis
o Use of oxygen therapy
31

o Unconscious Patient
o Physical Difficulty
Assessment
o Dental caries
o Gingivitis/periodontitis
o Bleeding gums
o Halitosis
o Cheilosis
o Gag reflex, impaired swallowing
32

List common hair and scalp problems and their related interventions.
33

Describe how hygiene care for the older adult client differs from that for the
younger client.
 Skin:
 Neonate's skin is relatively immature at birth. The epidermis and dermis
are loosely bound together, and the skin is very thin. Friction against the
skin layers causes bruising. Handle the neonate carefully during bathing.
Any break in the skin easily results in an infection.
 Toddler's skin layers become more tightly bound together. Thus the child
has a greater resistance to infection and skin irritation. However, because
of his or her more active play and the absence of established hygiene
habits, parents and caregivers need to provide thorough hygiene and teach
good hygiene habits.
 During adolescence the growth and maturation of the integument
increases. More frequent bathing and shampooing become necessary to
reduce body odors and eliminate oily hair.
 The condition of the adult's skin depends on hygiene practices and
exposure to environmental irritants. Normally the skin is elastic, well
hydrated, firm, and smooth. Moisture leaves the skin, increasing the risk
for bruising and other types of injury. These changes warrant caution
when turning and repositioning older adults and when bathing. Toofrequent bathing and bathing with hot water or harsh soap cause the skin
to become excessively dry (American Academy of Dermatology, 2009).
 Feet and Nails: With aging and continued exposure the patient is more likely to
develop chronic foot problems as a result of poor foot care, improper fit of
footwear, and systemic disease. Older adults do not always have the strength,
flexibility, visual acuity, or manual dexterity to care for their feet and nails. Long
or roughened nails lead to traumatic nail avulsions in which the nail plate is torn
from the nail bed (Berridge, 2009).

Older adults often have dry feet Common problems of the feet affecting
older adults include corns, calluses, bunions, hammertoe, and fungal
infections (Wright, 2009). Older adults frequently complain of foot pain
(Meiner, 2011). Painful feet result from a variety of congenital
deformities, weak structure, injuries, and diseases such as diabetes and
rheumatoid arthritis.
The Mouth
 age-related changes of the mouth, chronic disease such as diabetes, physical
disabilities involving hand grasp or strength affecting the ability to perform
oral care
34
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


prescribed medications that have oral side effects(dry mouth).
Gums lose vascularity and tissue elasticity, which causes dentures to fit poorly
causing pain and discomfort, which in turn affect digestive processes,
enjoyment of food, and nutritional status..
If the older adult becomes edentulous (i.e., without teeth) and wears complete
or partial dentures, include assessment of underlying gums and palate.
The periodontal membrane weakens with aging, making it more prone to
infection. Periodontal disease predisposes the older adult to systemic
infection.
Financial limitations and the belief that dentures eliminate the need for routine
dental care are reasons why older adults do not seek dental care
o Hair: With aging, as scalp hair becomes thinner and drier, shampooing is usually
performed less frequently.
o Eyes, Ears, and Nose: Alterations in sensory function often require modifications in
hygiene care.

Discuss the different approaches used in maintaining a client's comfort during
hygiene care.
Chp. 47-Mobility & Immobility

Discuss physiological and pathological influences on body alignment and joint
mobility.
 Body Alignment:
 Correct Body Alignment
 Center of gravity is stable
 Decrease strain on musculoskeletal system
 Maintain muscle tone
 Maintain Balance: Disease, injury, pain, physical development
(e.g., age), and life changes (e.g., pregnancy) compromise the
ability to remain balanced. Impaired balance is a major threat to
35
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




physical safety and contributes to a fear of falling and self-imposed
restrictions on activity. (al 1128)
Alterations in Body Alignment
 Center of gravity displaced
 Fall risk and Injury
Spinal Alignment
 Lordosis
 Kyphosis
 Scoliosis
Hip dislocation
Knees
 Knock-knee
 Bow Leg
Head Alignment
 Torticollis
Postural Abnormalities: Some limit ROM. Nurses intervene to maintain
maximum ROM in unaffected joints and then design interventions to strengthen
affected muscles and joints, improve the patient's posture, and adequately use
affected and unaffected muscle groups. Referral to and/or collaboration with a
physical therapist enhances the nurse's interventions for a patient with a postural
abnormality. (al 1130)
 Club Foot
 Foot Drop
 Pigeon Toe
 Leg Length
Influences on Mobility
 Impaired Muscle Development
 Central Nervous System Damage
 Head Injury
 Stroke
 Direct Trauma: bruises, contusions, sprains, and fractures.
 Sprains and Fractures
o muscle atrophy
36
37

Identify changes in physiological and psychosocial function associated with
immobility and mobility.
Metabolic Changes:
 Changes in mobility alter endocrine metabolism, calcium resorption, and
functioning of the gastrointestinal system.
 When injury or stress occurs, the endocrine system triggers a series of responses
aimed at maintaining blood pressure and preserving life. Thyroid hormone
increases the basal metabolic rate (BMR), and energy becomes available to cells
through the integrated action of gastrointestinal and pancreatic hormones
 Immobility disrupts normal metabolic functioning: decreasing the metabolic rate;
altering the metabolism of carbohydrates, fats, and proteins; causing fluid,
electrolyte, and calcium imbalances; and causing gastrointestinal disturbances
such as decreased appetite and slowing of peristalsis.
 Infection in immobilized patients often results in increased BMR because of fever
or wound healing
 A deficiency in calories and protein is characteristic of patients with a decreased
appetite secondary to immobility.
 calcium resorption (loss) from bones. Immobility causes the release of calcium
into the circulation. Normally the kidneys excrete the excess calcium. However, if
the kidneys are unable to respond appropriately, hypercalcemia results.
Pathological fractures occur if calcium resorption continues as the patient remains
on bed rest or continues to be immobile (Huether and McCance, 2008).
 Impairments of gastrointestinal functioning caused by decreased mobility vary
 Respiratory Changes: Regular aerobic exercise enhances respiratory functioning.
Lack of movement and exercise places patients at higher risk for respiratory
complications. The most common respiratory complications are atelectasis
(collapse of alveoli) and hypostatic pneumonia (inflammation of the lung from
stasis or pooling of secretions).
 Cardiovascular Changes: The three major changes are
 orthostatic hypotension an increase in heart rate of more than 15% and a
drop of 15 mm Hg or more in systolic blood pressure or a drop of 10 mm
Hg or more in diastolic blood pressure when the patient changes from the
supine to standing position (Huether and McCance, 2008).
 increased cardiac workload - heart works harder and less efficiently during
periods of prolonged rest
 thrombus formation- A thrombus is an accumulation of platelets, fibrin,
clotting factors, and the cellular elements of the blood attached to the
interior wall of a vein or artery, which sometimes occludes the lumen of
the vessel (Fig. 47-7).
38
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



Virchow's triad, Three factors contribute to venous thrombus
formation:
1. damage to the vessel wall (e.g., injury during surgical
procedures),
2. alterations of blood flow (e.g., slow blood flow in calf veins
associated with bed rest),
3. alterations in blood constituents (e.g., a change in clotting
factors or increased platelet activity).
Musculoskeletal Changes: sometimes results in loss of endurance, strength, and
muscle mass and decreased stability and balance, impaired calcium metabolism
and joint mobility.
Joint contractures.
 A joint contracture is an abnormal and possibly permanent condition
characterized by fixation of the joint.
 flexor muscles for joints are stronger than extensor muscles and therefore
contribute to the formation of contractures.
 Disuse, atrophy, and shortening of the muscle fibers cause joint
contractures.
 Early prevention of contractures is essential; they can begin to form after
only 8 hours of immobility in the older adult (Fletcher, 2005).
Urinary Elimination Changes:
 urinary stasis- gravity used for urine function and can’t get to bladder
while pt is lying flat and increases the risk of urinary tract infection and
renal calculi (calcium stones) that lodge in the renal pelvis or pass through
the ureters.
Dehydration: fluid intake often diminishes.
Integumentary Changes: The changes in metabolism effect of pressure on the skin
 major risk factor for pressure ulcers.
 Skin breakdown
Psychosocial Effects:
 leads to emotional and behavioral responses, sensory alterations, and
changes in coping.
 Depression: patients often do not want to participate in their own care.
39

Assess for correct and impaired body alignment and mobility.
Mobility Assessment

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
Body alignment: assess center of gravity while pt is sitting, standing, or lying down
Gait: assessing allows you to draw conclusions about balance, posture, safety, and ability
to walk without assistance.
Range of Motion: (ROM) is the maximum amount of movement available at a joint in
one of the three planes of the body: sagittal, transverse, or frontal
 Active ROM-the patient moves all joints through their ROM unassisted
 Passive ROM- the patient is unable to move independently, and the nurse moves
each joint
Joint Contractures
Exercise & Activity Tolerance: used to correct a deformity or restore the overall body to
a maximal state of health. Assessment of activity tolerance is necessary when planning
activity such as walking, ROM exercises, or ADLs.
Activities of Daily Living
Discuss the importance of no-lift policies & safe client handling and body
mechanics.
Prevention of Work-Related Musculoskeletal Injuries: Back injuries due to improper
lifting and bending when lifting, transferring, or positioning immobilized patients
 Be aware of agency policies and protocols that protect staff and patients from
injury.
 When lifting, assess the weight you will lift and determine the assistance you will
need.
 Current evidence supports that using mechanical or other ergonomic assistive
devices is the safest way to reposition and lift patients who are unable to do these
activities themselves (Box 47-4).
 Many agencies have developed special patient lift teams and have instituted a nolift policy.
If providing care (e.g., bathing) to a patient, consider his or her condition and whether or
not he or she can assist you. When you cannot safely complete a task (e.g., moving a bed
from one room to another), assess the number of people you will need to help you and do
not start until the task can be completed safely to prevent injury to you, the other
members of the health care team, and the patient.
Follow these steps to prevent injury:
1. Keep the weight to be lifted as close to the body as possible; this action
places the object in the same plane as the lifter and close to the center of
gravity for balance.
40
2. Bend at the knees; this helps to maintain the center of gravity and uses the
stronger leg muscles to do the lifting (Fig. 47-17).
3. Tighten abdominal muscles and tuck the pelvis; this provides balance and
helps protect the back.
4. Maintain the trunk erect and knees bent so multiple muscle groups work
together in a coordinated manner (see Chapter 38); do not allow the trunk
to twist. (al 1147)


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

Discuss nursing interventions to reduce risks from impaired mobility.
Exercise:
 exercise programs enhance feelings of well-being and improve endurance,
strength, and health.
 Help the chronically ill overcome barriers to physical activity. For example, if a
patient has a below-the-knee amputation, suggest activities such as lifting soup
cans, which capitalize on the patient's strengths and abilities. Encourage
hospitalized patients to perform stretching, ROM exercises, and light walking
within the limits of their condition (see Chapter 38). (al 1147)
 Exercise is a key prescription for health promotion of all patients, regardless of
their age.
Bone Health in Patients with Osteoporosis: Encourage patients at risk to be screened for
osteoporosis and assess their diets for calcium and vitamin D intake. Patients who have
lactose intolerance need dietary teaching about alternative sources of calcium.
 The goal of the patient with osteoporosis is to maintain independence with ADLs.
Assistive ambulatory devices, adaptive clothing, and safety bars help the patient
maintain independence. Patient teaching needs to focus on limiting the severity of
the disease through diet and activity (Box 47-6).
Acute Care: impaired respiratory status, orthostatic hypotension, and impaired skin
integrity. design nursing interventions to reduce the impact of immobility on body
systems and prepare the patient for the restorative phase of care
Metabolic System: give the immobilized patient a high-protein, high-calorie diet. A highcalorie intake provides sufficient fuel to meet metabolic needs and replace subcutaneous
tissue. Also ensure that the patient is taking vitamin B and C supplements: C is needed
for skin integrity and wound healing; vitamin B complex assists in energy metabolism.
Respiratory System: Nursing interventions that support the respiratory system are
important. Patients need to frequently reexpand their lungs to maintain their elastic recoil
property. In addition, secretions accumulate in the dependent areas of the lungs. Cough
reflex gradually becomes inefficient because of weakness. All of these factors put the
patient at risk of developing pneumonia. The stasis of secretions in the lungs is life
threatening for an immobilized patient.
41
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A variety of nursing interventions are available to expand the lungs, dislodge and
mobilize stagnant secretions, and clear the lungs.
Encourage the patient to deep breathe and cough every 1 to 2 hours. Teach alert patients
to deep breathe or yawn every hour or to use an incentive spirometer. Instruct the patient
to take in three deep breaths and cough with the third exhalation.
Chest physiotherapy (CPT) (percussion and positioning) is another effective method for
preventing pneumonia and keeping the airway clear. CPT helps the patient drain
secretions from specific segments of the bronchi and lungs into the trachea so he or she is
able to cough and expel them. Respiratory assessment findings identify areas of the lungs
requiring CPT (see Chapter 40).
Ensure that patients who are immobile take an adequate fluid intake. Unless there is a
medical contraindication, an adult needs to drink at least 1100 to 1400 ml of
noncaffeinated fluids daily. This helps keep mucociliary clearance normal.
Cardiovascular System: TED hose, compression devices
Musculoskeletal System: Exercises to prevent excessive muscle atrophy and joint
contractures help maintain musculoskeletal function.
 Passive ROM exercises for all immobilized joints while bathing the patient and at
least 2 or 3 more times a day. If one extremity is paralyzed, teach the patient to
put each joint independently through its ROM. Patients on bed rest need to have
active ROM exercises incorporated into their daily schedules. Teach patients to
integrate exercises during ADLs.
Integumentary System: Interventions aimed at prevention include positioning every 1-2
hours, skin care, and the use of therapeutic devices to relieve pressure. Teach patients to
shift their weight every 15 minutes if able. Chair-bound patients need to have a device for
the chair that reduces pressure
Compare and contrast active and passive range-of-motion exercises.
Range-of-Motion Exercises:


Passive ROM
 begin as soon as the patient's ability to move the extremity or joint is lost
 Carry out movements slowly and smoothly, just to the point of resistance;
 Each movement needs to be repeated 5 times during the session.
 At bath time and 2-3 times more per day
 Perform passive ROM exercises using a head-to-toe sequence and moving from
larger to smaller joints.
Active ROM
 Client able to perfom
 Instruct client to perform ROM independently
42








 Monitor to be sure patient is performing ROM
Describe interventions for maintaining activity tolerance and mobility across the
lifespan
Restorative and Continuing Care:
 Restore ability to perform ADLs & IADLs
 work collaboratively with patients and their significant others and with other
health care professionals to facilitate the patient's return to maximal functional
ability in both ADLs and IADLs (activities that are necessary to be independent in
society beyond eating, grooming, transferring, and toileting and include such
skills as shopping, preparing meals, banking, and taking medications)
 Intensive specialized therapy such as occupational or physical therapy is common.
Developmental Changes:
 Ideally immobilized patients continue normal development.
 Nursing care needs to provide mental and physical stimulation, particularly for a
young child. Incorporate play activities into the care plan.
Older patients:
 Maintaining a calendar and clock with a large dial, conversing about current
events and family members, and encouraging visits from significant others reduce
the risk of social isolation. Spending time in the room talking and listening to the
patient also helps reduce the risk of social isolation.
 Encourage to perform as many ADLs as independently as possible.
Psychosocial Changes:
 Observe the patient's ability to cope with restricted mobility. If the nursing care
plan is not improving coping patterns, consult a clinical nurse specialist,
counselor, social worker, spiritual adviser, or other health care professional.
Incorporate their recommendations into the care plan.
Nurses provide stimuli to maintain a patient's orientation.
 Interaction with people
 Place around mobile and active people
 Daily newspaper
 Books
 craft activities
 Radio
 Television
Involve patients in their care whenever possible.
Describe essential techniques when helping a client to safely use mobility devices
1. Assess physiological capacity to transfer
a. Muscle strength (legs and upper arms)
b. Joint mobility (range of motion [ROM]) and contracture formation
43
c. Paralysis or paresis (spastic or flaccid)
d. Risk for orthostatic (postural) hypotension (e.g., previously on bed
rest, first time arising from supine position following surgical
procedure, history of dizziness when arising)
e. Activity
f. Level of comfort (pain)
g. Vital signs
2. Assess patient's sensory status:
 Visual field loss
 Hearing loss
 Peripheral sensation loss decreases proprioception.
3. Assess patient's cognitive status (ability to follow directions and learn transfer
techniques)
4. Assess patient's level of motivation
 Canes
 Used on stronger side of body
 Placed 6 to 10 inches in front of body
 Weaker limb advanced
 Stronger limb follows
 Length equal to distance between the greater trochantor and the floor
 2 points of support with ground must be present at all times
o both feet
o cane and one foot
 Walkers
o Waist high
o Walker is advanced, Client follows
o The client should lift feet when using a walker
– Avoid shuffling gait
o Care must be used with rolling walker to avoid excessive propulsion
– Hand brakes
 Crutches
 Measuring for Axillary Crutches
o Client should stand straight with unaffected limb slightly bent
o Should wear shoes which will be worn while walking on crutches
o 2 fingers should fit between top of crutch and axilla
o Handgrip should allow client to flex arm at 30o angle about at level of
greater trochanter
o Weight on hands not axilla

Discuss treatments to prevent thrombus formation including sequential external
compression device and TED hose
Preventing Thrombus Formation
44
Many interventions reduce the risk of thrombus formation in the immobilized patient.
Leg, foot, and ankle exercises; regularly providing fluids; position changes; and patient
teaching need to begin when the patient becomes immobile (see Chapter 50).
SCDs and intermittent pneumatic compression (IPC) Use of SCD/IPC on the legs
decreases venous stasis by increasing venous return through the deep veins of the legs.
Elastic stockings (sometimes called antiembolitic stockings) also aid in maintaining
external pressure on the muscles of the lower extremities and thus promote venous return




Proper positioning reduces the patient's risk of thrombus formation because
compression of the leg veins is minimized. Teach patients to avoid the following:
crossing the legs, sitting for prolonged periods of time, wearing clothing that
constricts the legs or waist, and massaging the legs.
Elevate the leg but avoid pressure on the thrombus. Instruct the family, patient,
and all health care personnel not to massage the area because of the danger of
dislodging the thrombus.
Specific exercises that help prevent thrombophlebitis are ankle pumps, foot
circles, and knee flexion
Discuss nursing implications for heat and cold/or cold applications.
Heat and cold stimuli create different physiological responses. The choice of heat or
cold therapy depends on local responses desired for wound healing (Table 48-10).




Effects of Heat Application: Heat therapy 105o - 113o F
Improves circulation to affected area in short duration when adequate circulation
present
Excessive exposure results in a compensatory vasoconstriction
Intermittent therapy is most effective
Continuous application of heat can damage epithelial cells
Heat generally is quite therapeutic, improving blood flow to an injured part.
However, if heat is applied for 1 hour or more, the body reduces blood flow by a
reflex vasoconstriction to control heat loss from the area. Periodic removal and
reapplication of local heat restores vasodilation. Continuous exposure to heat
damages epithelial cells, causing redness, localized tenderness, and even blistering.
Effects of Cold Application
o Cold compress 15oC (59oF)
45
 Initially diminishes swelling and pain
 Prolonged exposure
o Compensatory vasodilatation
o Ischemia with damage to underlying tissues
Prolonged exposure of the skin to cold results in a reflex vasodilation. The inability of the
cells to receive adequate blood flow and nutrients results in tissue ischemia. The skin
initially takes on a reddened appearance, followed by a bluish-purple mottling, with
numbness and a burning type of pain.
Chp. 31- Medication Administration

Discuss the nurse’s role and responsibilities in medication administration, inclusive
of client education.
• Knowledge of medications
– What medications are prescribed
• Indication
• Correct dose, route, frequency
– Pharmacokinetics
• Absorption
• Distribution
• Metabolism
• Excretion
– Medication Action
Onset
Time it takes to
produce a response
Plateau
Blood serum
concentration is
reached and
maintained
Peak
Blood serum
concentration
reaches highest
effective
concentration
Duration
Time it takes to
produce greatest
result
46
Trough
Minimum blood
serum concentration
before next
scheduled dose
•
•
•
Half-life
Time it takes for
blood serum
concentration to be
halved
– Evaluating effects of medications
• Expected actions/desired effects
• Therapeutic vs. non-therapeutic
– Contraindications/Precautions
– Synergistic Effect
• Combined effect is greater than when drugs are given separately
– Interactions
• One medication may alter action of another
– Side Effects
– Adverse reactions
• Toxicity
• Idiosyncratic Reaction
• Allergic Reaction
• Anaphylactic Reaction
Identification of Clients at Increased Risk for Adverse Reactions:
– Clients taking a medication for the first time
– Very young and/or elderly clients
– Women
– Polypharmacy
– Clients who are extremely underweight or overweight
– Clients with renal and/or hepatic disease
– Clients with altered blood flow
– Clients with a past history of an adverse medication reaction
– Clients with depression and/or anxiety
– Clients who abuse alcohol, nicotine, or street medications
– Clients who self-medicate with over-the-counter medications
RN Responsibilities
Client Education
– Inform Client of Rights
• Information about prescribed medication
• To refuse a medication
• Safe administration
47
–
–
–
–
–
–
–
• Not receive unnecessary medications
• Informed consent
• Qualified assessment of medication history and need
• Inform Client of Rights
• Information about prescribed medication
• To refuse a medication
• Safe administration
• Not receive unnecessary medications
• Informed consent
• Qualified assessment of medication history and need
Assessment
• Medical History
• Allergies
• Diet history
• Medication history
• Over the counter medication use
• Misuse/non-compliance/self-prescribing
• Current condition
• Attitudes concerning medication use
• Cultural considerations
Recognize knowledge and understanding of a prescribed medications influence
compliance with medical regimen
• Explain purpose and actions of medications
• Importance of dose scheduling
• establish a medication routine
• Proper administration
• Evaluate client technique in self-administration
• Assess for perceptual or coordination difficulties
Potential side effects
Safe use and storage
Refer to community resources for “decreased cost/free” medications and
transportation as needed
Nursing Implications
• When a nurse administers a medication, the nurse accepts responsibility
medication and will not harm patient in any way
Nursing Diagnosis:
Medication Administration
• Anxiety
• Ineffective health maintenance
• Deficient knowledge (medications)
48
•
•
•






Noncompliance (medications)
Impaired swallowing
Effective therapeutic regimen management
Discuss nursing actions to prevent medication errors.
 Medication Administration
 Compare for accuracy
 Providers Order
 Medical Administration Record (MAR)
 Triple-check each medication with the MAR:
1. MAR and Label of Medication
2. MAR and amount of medication removed from container
3. MAR and container as you return
 Review 6-rights with patient
 Only administer what you have prepared!
Clarify order- read back
Question amount of medication
Document medication immediately after giving
Learn your medications
Steps to Take to Prevent Medication Errors
 Six Rights
 Compare provider orders with MAR
 2 Patient ID (WHO, 2007)
 FH “Pt ID”
 No interruptions
 Two nurse verification
 Dose calculations
 Anticoagulants
 Insulin
 IV push medications
 Be sure to check Policy and Procedures
 Report all medication errors– even near miss
 Non-punitive reporting system
 Determine how to prevent
 Analysis of cause
o Multiple roles in “medication administration”
49

Discuss the nurse's six rights for safe medication administration.






Six Rights
 Right client
 Right medication
 Right dose
 Right route
 Right time
 Right documentation
Complete, legible written medication order
Access to current, up to date medication information
Written “Facility” policies and procedures regarding medication administration
Safe administration of medications and means to identify problems in the
“system”
Distraction-free Zone



Identify forbidden abbreviations in medication administration.

Discuss factors to include assessing a client’s need for and response to medication
therapy.
Assessment
 During the assessment process, thoroughly assess each patient and critically
analyze findings to ensure that you make patient-centered clinical decisions
required for safe nursing care.

(pg. 581)
Discuss components of medication order and types of medication orders.
Components of Medication Orders
A medication order is incomplete unless it has the following parts:
Patient's full name: (medical record number used if pts have same name
Date and time that the order is written: The day, month, year, and time need to be
included.
Medication name: The health care provider orders a medication by its generic or trade
name. Correct spelling is essential in preventing confusion with medications with similar
spelling.
Dose: The amount or strength of the medication is included.
Route of administration
Time and frequency of administration
Signature of health care provider: The signature makes an order a legal request.
50
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

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
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


Begin your assessment by asking a variety of questions that help you better
understand your patients’ current medication management routine, the ability to
afford medications, and beliefs and expectations about medications (Box 31-8).
History
 Before administering medications, obtain or review the patient's medical history
 Knowledge helps the nurse anticipate the type of medications that a patient
requires.
Allergies
Medications
 Assess information about each medication that the patient takes,
 Length of time the medication has been taken
 Current dosage
 Side effects?
 Review the action, purpose, normal dosage, routes, side effects, and nursing
implications for administering and monitoring each medication.
Diet History
 Teach the patient to avoid foods that interact with medications.
 some medications are more effective when taken with meals
Patient's Perceptual or Coordination Problems
 Assess the patient's ability to prepare doses and take medications correctly.
Patient's Current Condition
 Assess a patient’s physical or mental status carefully before giving any
medication.
 Check the patient's blood pressure before giving an antihypertensive
Patient's Attitude About Medication Use
 Reveals a level of medication dependence or drug avoidance.
 Observe the patient's behavior for evidence of dependence or avoidance.
 Also be aware that his or her cultural beliefs about Western medicine sometimes
interfere with medication compliance
Patient's Understanding of and Adherence to Medication Therapy
 Determine if the patient understands the purpose of the medication, the
importance of regular dosage schedules, proper administration methods, and the
possible side effects.
Patient's Learning Needs
 Serious errors can occur when patients do not understand information about their
medications.
51


 Assess patients’ health literacy
Discuss polypharmacy.
• What is Polypharmacy?
• The practice of administering many different medicines concurrently
• Multiple medications to treat the same illness
• May be necessary to treat multiple chronic conditions at the same time
• Multiple medications to treat side effects of other medications
• Unintended consequences
• Decreased adherence to medical regimen
• Higher risk for adverse reactions
• Increased incidence of drug interactions
• More frequent or longer hospital stays
• Polypharmacy in the Elderly
• Common RX Medications in the Elderly:
• Cardiovascular drugs
• Antihypertensives
• Analgesics
• Antiarthritic drugs
• Sedatives and tranquilizers
• Pain medications
• Anticoagulants/Blood thinners
• Common OTC (Over The Counter) Medications in the Elderly:
• Aspirin
• Laxatives
• Antacids
• Vitamins
• Home Remedies
Discuss various non-parenteral routes of medication administration.
 Distribution Systems
 Stock supply
 Unit dose
 Computer controlled
 Routes of Administration
 Oral: The easiest and most desirable way to administer medications
 Sublingual
 Buccal
o Most given 30 mins-1 hr before meals to speed absorption
o Scatter times of multiple meds may be needed to reduce
interactions
52






Topical: applied locally
 lotions, pastes, and ointments create systemic and local effects,
apply these medications using gloves and applicators.
 transdermal patch
 Document the location on the patient's body where the medication
was placed on the MAR
 Document removal of the patch or medication on the MAR
Inhalation
 Nasal sprays
 Inhalers: dispersed through an aerosol spray, mist, or powder that
penetrates lung airways
o Deliver medications that produce local effects such as
bronchodilation.
 Pressurized metered-dose inhalers (pMDIs)
 Breath-actuated metered dose inhalers (BAI)
release medication when a patient raises a lever and
inhales
 Dry powder inhalers (DPIs): hold dry powdered
medication and create an aerosol when the patient
inhales through a reservoir that contains a dose of
the medication
Intraocular
 eyedrops and ointments
 Avoid instilling any form of eye medications directly onto the
cornea. The cornea of the eye has many pain fibers and thus is very
sensitive to anything applied to it.
 Avoid touching the eyelids or other eye structures with
eyedroppers or ointment tubes. The risk of transmitting infection
from one eye to the other is high.
 Use eye medication only for the patient's affected eye.
 Never allow a patient to use another patient's eye medication
Ear Instillation
 Adult: up and out
 Child (3 and under): down and back
 Instill eardrops at room temperature
 sterile solutions are used in case the eardrum is ruptured
Vaginal Instillation
 suppositories, foam, jellies, or creams
 Patients often prefer administering their own vaginal medications
and need privacy
Rectal Instillation
 thinner and more bullet-shaped
53

often stored in the refrigerator until administered

Identify proper sites for subcutaneous injections.
Sites
 Outer posterior aspect of the upper arms
 Abdomen (recommended for heparin) from below the costal margins to the iliac
crests (2 in away from umbilicus)
 Anterior aspects of the thighs
 Scapular areas of the upper back and the upper ventral or dorsal gluteal areas.
 The injection site chosen needs to be free of skin lesions, bony prominences, and
large underlying muscles or nerves.
 pinch the injection site as you insert the needle.

Calculate an accurate dose of insulin using a sliding scale. (review Insulin in CWC)
54

Identify proper injection sites for an intradermal injection.
 The inner forearm and upper back are ideal locations.



Identify proper injection sites for an intramuscular injection.
Intramuscular Injections—APSPIRATE!!!!!!!!
The IM route provides faster medication absorption than the subcutaneous route because
of the greater vascularity of the muscle.
A very obese patient often requires a needle 3 inches long, whereas a thin patient only
requires a 1/2- to 1-inch needle.
The angle of insertion: 90 degrees
A normal, well-developed adult patient tolerates 2 to 5 mL of medication into a larger
muscle without severe muscle discomfort.
Children, older adults, and thin patients tolerate only 2 mL of an IM injection.
Do not give more than 1 mL to small children and older infants
Do not give more than 0.5 mL to smaller infants
Larger volumes of medication (4 to 5 mL) are unlikely to be absorbed properly.







 Sites

When selecting an IM site, consider the following:
 Is the area free of infection or necrosis?
 Are there local areas of bruising or abrasions?
 What is the location of underlying bones, nerves, and major blood vessels?
 What volume of medication is to be administered?
 Ventrogluteal (ASPIRATE!!!)




The ventrogluteal muscle involves the gluteus medius;
situated deep and away from major nerves and blood vessels
This site is the preferred and safest site for all adults, children, and infants,
especially for medications that have larger volumes and are more viscous and
irritating
 The ventrogluteal site is recommended for volumes greater than 2 mL
 No complications regularly associated with site
Locate the ventrogluteal muscle
 positioning the patient in a supine or lateral position
 Flex the knee and hip helps to relax this muscle
 Place the palm of your hand over the greater trochanter of the patient's hi
 Point the thumb toward the patient's groin
 Index finger toward the anterior superior iliac spine
 Extend the middle finger back along the iliac crest toward the buttock.
 The index finger, the middle finger, and the iliac crest form a V-shaped triangle;
the injection site is the center of the triangle
55
56
Vastus Lateralis (ASPIRATE!!!!)







The vastus lateralis muscle
Adults and children
Muscle is thick and well developed
Located on the anterior lateral aspect of the thigh, and extends in an adult from a hand
breadth above the knee to a hand breadth below the greater trochanter of the femur
Use the middle third of the muscle for injection
midline of the thigh to the midline of the outer side of the thigh.
With young children or cachectic patients, it helps to grasp the body of the muscle during
injection to be sure that the medication is deposited in muscle tissue.
57
 Deltoid (ASPIRATE!!!!)



Although the deltoid site is easily accessible, this muscle is not well developed in many
adults. There is a potential for injury because the axillary, radial, brachial, and ulnar
nerves, as well as the brachial artery, lie within the upper arm under the triceps and along
the humerus.
Use this site for small medication volumes (1 mL or less)
Palpate the lower edge of the acromion process which forms the base of a triangle in line
with the midpoint of the lateral aspect of the upper arm. The injection site is in the center
of the triangle, about 3 to 5 cm (1 to 2 inches) below the acromion process. You can also
locate the site by placing four fingers across the deltoid muscle, with the top finger along
the acromion process. The injection site is then three finger widths below the acromion
process.
58
Use of the Z-Track Method in Intramuscular Injections (ASPIRATE!!)












Used to minimize local skin irritation by sealing the medication in muscle tissue
Put a new needle on the syringe after preparing the medication so no solution remains on
the outside needle shaft.
Select an IM site, preferably in a large, deep muscle such as the ventrogluteal muscle.
Place the ulnar side of the nondominant hand just below the site and pull the overlying
skin and subcutaneous tissues approximately 2.5 to 3.5 cm (1 to 1 ½ inches) laterally or
downward
Hold the skin in this position until you administer the injection.
Slowly inject the medication at a rate of 10 seconds per mL if there is no blood return on
aspiration
The needle remains inserted for 10 seconds to allow the medication to disperse evenly
Release the skin after withdrawing the needle
Injections using this technique result in less discomfort and decrease the occurrence of
lesions at the injection site
Correctly calculate the concentration of the reconstituted medication
Correctly calculate the amount of prescribed reconstituted medication to be
administered.
Discuss indications for use of a filter needle and proper use.
Ampules
 contain single doses of medication in a liquid
 available 1 mL to 10 mL or more
 Carefully aspirate the medication into a syringe with a filter needle
59

Replace the filter needle with an appropriate-size needle or a needleless access
device before administering the injection
Mixing Medications From a Vial and an Ampule








When mixing medication from both a vial and ampule, prepare medication from
the vial first.
Using the same syringe and filter needle, next withdraw medication from the
ampule.
Nurses prepare the combination in this order because it is not necessary to add air
to withdraw medication from an ampule.
After mixing multidose vials, make a label that includes the date and time of
mixing and the concentration of medication per milliliter.

Discuss the rationale for avoiding use of the dorsogluteal muscle for an
intramuscular injection.
Most dangerous
Many major blood vessles
Sciatic nerve!
60

Describe the differences between Type 1 and Type 2 diabetes mellitus.
61

Identify the signs and symptoms of hypoglycemia & hyperglycemia & state
treatment for hypoglycemia & hyperglycemia
62

Identify resources for educating people with diabetes
63
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
Discuss maintenance of intravenous therapy.
After placing an IV line and regulating the flow rate, maintain the IV system. The
frequency and options for maintaining the system are identified in agency policies.
An important component of patient care is maintaining the integrity of an IV line to
prevent infection. Inserting an IV line under appropriate aseptic technique reduces the
chances of contamination from the patient’s skin microflora. After insertion, the
conscientious use of infection control principles, including thorough hand hygiene before
and after handling any part of the IV system, and maintaining sterility of the system
during tubing and fluid container changes, prevents infection.
Always maintain the integrity of an IV system. Never disconnect tubing because it
becomes tangled, or it might seem more convenient for positioning or moving a patient or
applying a gown. If a patient needs more room to maneuver, use aseptic technique to add
extension tubing to an IV line. However, keep the use of extension tubing to a minimum
because each connection of tubing provides an opportunity for contamination. Never let
IV tubing touch the floor.
IV tubing contains needleless injection ports through which syringes or other adaptors
can be inserted for medication administration.
Patients receiving IV therapy over several days require periodic changes of IV fluid
containers. It is important to organize tasks so you can change containers rapidly before a
thrombus forms in the catheter. Recommended frequency of IV tubing change depends
on whether it is used for continuous or intermittent infusion.
To prevent the accidental disruption of an IV system, a patient often needs assistance
with hygiene, comfort measures, meals, and ambulation.
Nurses monitor vigilantly for complications of IV therapy, which include fluid overload,
infiltration, phlebitis, local infection, and bleeding at the infusion site.
The signs and symptoms of complications often arise rapidly; this highlights the
importance of frequent assessment of patients receiving IV therapy. Infiltration occurs
when an IV catheter becomes dislodged, or a vein ruptures, and IV fluids inadvertently
enter subcutaneous tissue around the venipuncture site. When the IV fluid contains
additives that damage tissue, extravasation occurs. Phlebitis (i.e., inflammation of a vein)
results from chemical, mechanical, or bacterial causes. Flood volume excess occurs when
the fluid is administered too rapidly.
Discontinue IV access after infusion of the prescribed amount of fluid; when infiltration,
phlebitis, or local infection occurs; or if the IV catheter develops a thrombus at its tip.
[See also Box 41-7 on text p. 908 Evidence-Based Practice: Preventing Complications at
Peripheral Intravenous Sites; Table 41-12 on text p. 910 Complications of Intravenous
Therapy with Nursing Interventions; Table 41-13 on text p. 911 Infiltration Scale; and
Table 41-14 on text p. 911 Phlebitis Scale.] (from IV powerpoint)
64

Identify common intravenous (IV) solutions and abbreviations.

Types of Solutions:
 Isotonic solutions have the same effective osmolality as body fluids. Sodiumcontaining isotonic solutions such as normal saline are indicated for ECV
(Extracellular Volume) replacement
 Hypotonic solutions have an effective osmolality less than body fluids, thus
decreasing osmolality by diluting body fluids and moving water into cells.
 Hypertonic solutions have an effective osmolality greater than body fluids. If they
are hypertonic sodium-containing solutions, they increase osmolality rapidly and
pull water out of cells, causing them to shrivel (David, 2007). The decision to use
a hypotonic or hypertonic solution is based on the patient's specific fluid and
electrolyte imbalance. For example, a patient with hypernatremia that cannot be
treated with oral water generally receives a hypotonic IV solution to dilute the
ECF (extracellular fluid) and rehydrate cells. Too rapid or excessive infusion of
any IV fluid has the potential to cause serious patient problems.
Additives such as potassium chloride (KCl) are common in IV solutions.
 A health care provider's order is necessary if an IV is to have additives added
 Administer KCl carefully because hyperkalemia can cause fatal cardiac
dysrhythmias.
 Verify that a patient has adequate kidney function and urine output before
administering an IV solution containing potassium.
 Patients with normal renal function who are receiving nothing by mouth should
have potassium added to IV solutions. The body cannot conserve potassium, and
the kidneys continue to excrete potassium even when the plasma level falls.
Without potassium intake, hypokalemia develops quickly. (al 906)
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Define the following terms associated with IV therapy: peripheral line, central line,
primary line, secondary line, saline/heparin locks, IV piggyback (IVPB), and IV
push.
 Peripheral line: a catheter placed into a peripheral vein in order to administer IV
fluids and meds
 Central line: a catheter placed into a large vein in the neck (internal jugular vein),
chest (subclavian vein or axillary vein) or groin (femoral vein) to administer IV
fluids, obtain blood, and directly obtain cardiovascular measurements such as
central venous pressure.
 Primary line: The main IV fluid used in a continuous infusion flows through
tubing called the primary line. The primary line connects to the IV catheter.
 Secondary line/piggy back: Injectable medications such as antibiotics are usually
added to a small IV solution bag and “piggybacked” as a secondary set into the
primary line
 Saline/heparin locks: intravenous access in a patient. The lock consists of a small
plastic piece called a hub that is attached to a catheter that is directly in the
patient’s vein. The plastic has saline in it, which prevents blood from flowing out.
 IV push: The intravenous or IV push or bolus is a means of delivering additional
medication through an intravenous line, administered all at once, over a period of
a minute or two. This contrasts with IV drip techniques where medicine is slowly
delivered from an IV bag. An IV push has the advantage of being able to give
extra medicine, as needed, without having to inject the patient elsewhere, and it
can rapidly get this medicine into the body since it’s injected directly into the
bloodstream.
Calculate an intravenous flow rate. (CWC)
Discuss daily weight and fluid intake and output measurement.
The nurse often converts between systems to calculate a client's intake and output. Intake
and output is abbreviated I&O.
 Intake refers to the monitoring of fluid a client takes orally (p.o.), by feeding tube,
or parenterally. Oral intake includes fluids and solids that become liquid at body
and room temperature, such as gelatin and Popsicles. Intake also includes water,
broth, and juice.
 Liquid output refers to fluids that exit the body, such as diarrhea, vomitus, gastric
suction, and urine. A client's intake and output are usually recorded on a special
form called an intake and output flow sheet (or I&O flow sheet or record) (Figure
8-1), which varies from institution to institution. A variety of clients require I&O
monitoring, such as those whose fluids are restricted and those who are receiving
diuretic or intravenous (IV) therapy. (Morris 86)
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Discuss the complications of intravenous therapy including fluid overload.
Nurses monitor vigilantly for complications of IV therapy, which include fluid overload,
infiltration, phlebitis, local infection, and bleeding at the infusion site. (al 937)
Sterile Technique
Differentiate between medical and surgical asepsis and identify situations where each
method of asepsis is indicated.
Asepsis the absence of pathogenic microorganisms
Medical is clean technique:
Clean technique
Hand hygiene
Re-useable Equipment i.e. I.V. Poles
Standard Precations
Surgical is sterile technique
Eliminate ALL microorganisms (used in surgical setting)
Area/object considered not sterile if touched by anything not sterile
Describe 7 principles of surgical sepsis.
1) Sterile object can only be touched by sterile object/area
2) Only sterile objects can be placed on a sterile field
3) A sterile object/field out of the range of vision (or below your waist) is no longer
sterile
4) Sterile field is contaminated when exposed to environment/air for prolonged
periods of time
5) Moisture on sterile field makes it contaminated
6) Fluids flow down, contaminating the field
7) The edges of a sterile field/container are considered contaminated
Skin cannot be sterilized and is considered unsterile
Conscientiousness, awareness and honesty are essential in maintaining a sterile field
Describe the procedure to open a sterile package with attention to the principles of surgical
asepsis.
Attention:
1) Clean bedside table
2) Check for expiration date
3) Flap “away” (This is how you begin)
4) Keep packaging from reclosing
5) Reaching over a sterile field is NOT recommended reach around it
Prepping a sterile field:
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1) 1” border is contaminated
2) Banana peel package
3) Drop onto sterile field from a distance of 6”
Describe preparation of the sterile field including proper technique for pouring fluids.
1) Palm over label
2) Technique is to “lip” the bottle before pouring
3) “No splash zone”
4) If liquid is left over refer to facility policy
Describe the process of open gloving using surgical asepsis.
Gloves:
1) Ensure no latex allergy
2) Proper size (ensures success)
Caution:
1) Cuffs/Jackets (Roll them up)
2) Watch (Take it off)
3) Thumbs!
Wound Care & Sterile Dressing Change
Describe the differences in wounds healing by primary, secondary and tertiary intention;
and the phases of wound healing.
Wound: Disruption of the integrity and function of tissues in the body
Take a detailed assessment of the wound in order to determine proper course of action
(anything that impedes oxygen will impede wound healing)
Describe complications of wound healing and the usual time of occurrence
Explain the factors that impede or promote wound healing
Identify different types of wound drainage, wound drainage systems and how to empty a
wound drainage device
Identify various types of dressings, their purpose, and how to apply and secure various
types of dressings
Determine what is appropriate and inappropriate to delegate regarding dressing changes
and wound management
Discuss the risks and contributing factors to pressure ulcer formation
List the four stages of pressure ulcers
Identify prevention strategies for pressure ulcers
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