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# 153613 Cust: Pearson Au: Berman Pg. No. e Title: Kozier & Erb’s Fundamentals of Nursing 10e
C/M/Y/K Short / Normal
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# 153613 Cust: Pearson Au: Berman Pg. No. d Title: Kozier & Erb’s Fundamentals of Nursing 10e
C/M/Y/K Short / Normal
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Brief Contents UNIT 1 The Nature of Nursing 1 Chapter 1 Historical and Contemporary Nursing
Practice 2
Chapter 2 Evidence-Based Practice and Research in Nursing 26
Chapter 3 Nursing Theories and Conceptual Frameworks 37 Chapter 4 Legal Aspects of Nursing 47 Chapter 5 Values, Ethics, and Advocacy 73
UNIT 2 Contemporary Health Care 88 Chapter 6 Health Care Delivery Systems 89 Chapter 7 Community Nursing and Care Continuity 105 Chapter 8 Home Care 118 Chapter 9 Electronic Health Records and Information
Technology 129
UNIT 3 The Nursing Process 143 Chapter 10 Critical Thinking and Clinical Reasoning 144 Chapter 11 Assessing 155 Chapter 12 Diagnosing 175 Chapter 13 Planning 189 Chapter 14 Implementing and Evaluating 208 Chapter 15 Documenting and Reporting 221
UNIT 4 Health Beliefs and Practices 243 Chapter 16 Health Promotion 244 Chapter 17 Health, Wellness, and Illness 262 Chapter 18 Culturally Responsive Nursing Care 276 Chapter 19 Complementary and Alternative Healing
Modalities 295
UNIT 5 Life Span Development 311 Chapter 20 Concepts of Growth and Development 312 Chapter 21 Promoting Health from Conception Through
Adolescence 328
Chapter 22 Promoting Health in Young and Middle-Aged Adults 353 Chapter 23 Promoting Health in Older Adults 364 Chapter 24 Promoting Family Health 386
UNIT 6 Integral Aspects of Nursing 397 Chapter 25 Caring 398 Chapter 26 Communicating 411 Chapter 27 Teaching 438 Chapter 28 Leading, Managing, and Delegating 462
UNIT 7 Assessing Health 476 Chapter 29 Vital Signs 477 Chapter 30 Health Assessment 513
UNIT 8 Integral Components of Client Care 601 Chapter 31 Asepsis 602 Chapter 32 Safety 640 Chapter 33 Hygiene 669 Chapter 34 Diagnostic Testing 718 Chapter 35 Medications 750 Chapter 36 Skin Integrity and Wound Care 828 Chapter 37 Perioperative Nursing 865
UNIT 9 Promoting Psychosocial Health 903 Chapter 38 Sensory Perception 904 Chapter 39 Self-Concept 922 Chapter 40 Sexuality 934 Chapter 41 Spirituality 954 Chapter 42 Stress and Coping 972 Chapter 43 Loss, Grieving, and Death 989
UNIT 10 Promoting Physiological Health 1009 Chapter 44 Activity and Exercise 1010 Chapter 45 Sleep 1066 Chapter 46 Pain Management 1086 Chapter 47 Nutrition 1127 Chapter 48 Urinary Elimination 1174 Chapter 49 Fecal Elimination 1210 Chapter 50 Oxygenation 1241 Chapter 51 Circulation 1287 Chapter 52 Fluid, Electrolyte, and Acid–Base Balance 1308
Further enhance your Clinical Reasoning with the additional resources below. For more information and purchasing options visit www.mypearsonstore.com.
Break Through to improving results
MyNursingLab provides a guided learning path that is proven to help students synthesize vast amounts of information, guiding them from memorization to true understanding through application.
Thinking Like a Nurse in Clinical Thinking Like a Nurse for NCLEX-RN® Success
Align ed to
the
2013 NCL
EX-R N®
Test Plan
Clinical references across the nursing curriculum available.
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eText
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Kozier and Erb’s Fundamentals of Nursing 10e
1 Historic and Contemporary Nursing Practice
2 Evidence-Based Practice and Research in Nursing
3 Nursing Theories and Conceptual Frameworks
4 Legal Aspects of Nursing
5 Values, Ethics, and Advocacy
6 Health Care Delivery Systems
7 The Nurse-Patient Relationship and Therapeutic Communication
8 Home Care
9 Electronic Health Records and Information Technology
10 Critical Thinking and Clinical Reasoning
11 Assessing
12 Diagnosing
13 Planning
14 Implementing and Evaluating
15 Documenting and Reporting
16 Health Promotion
Available for your favorite
electronic device!
NURSE’S DRUG GUIDE Wilson • Shannon • Shields
2016
NURSE’S DRUG GUIDE
Wilson • Shannon • Shields
• Thousands of drugs organized alphabetically
• Indexed by generic and trade drug names
• Complete IV drug information
PEARSON
PEARSON
www.pearsonhighered.com
PEARSON NURSE’S DRUG GUIDE 2016 NURSES AGREE: Pearson Nurse’s Drug Guide provides all the information you need for safe, effective drug administration in any setting!
• Organized alphabetically and indexed by generic and trade drug names
• Dosages across the lifespan from neonate to older adults
• Dosage with adjustments for clinically relevant conditions
• Complete IV preparation and administration information
• Clinically relevant drug interactions with food, herbals, and other drugs
• Pharmacologic and therapeutic classifications for every drug
• Unique glossary of clinical conditions and their related signs and symptoms
• Prototype drugs for each drug classification
• NEW! Black box warnings throughout
Comprehensive Current Clinically Relevant
Available for your favorite
electronic device!
2016
Simplify your study time by using the resources included with this textbook at http://www.nursing.pearsonhighered.com
using your
Begin Thinking LIKE A NURSE
PEARSON RESOURCES
A00_BERM4362_10_SE_FEP.indd 4-5 04/12/14 8:14 PM
# 153613 Cust: Pearson Au: Berman Pg. No. e Title: Kozier & Erb’s Fundamentals of Nursing 10e
C/M/Y/K Short / Normal
DESIGN SERVICES OF
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# 153613 Cust: Pearson Au: Berman Pg. No. d Title: Kozier & Erb’s Fundamentals of Nursing 10e
C/M/Y/K Short / Normal
DESIGN SERVICES OF
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Brief Contents UNIT 1 The Nature of Nursing 1 Chapter 1 Historical and Contemporary Nursing
Practice 2
Chapter 2 Evidence-Based Practice and Research in Nursing 26
Chapter 3 Nursing Theories and Conceptual Frameworks 37 Chapter 4 Legal Aspects of Nursing 47 Chapter 5 Values, Ethics, and Advocacy 73
UNIT 2 Contemporary Health Care 88 Chapter 6 Health Care Delivery Systems 89 Chapter 7 Community Nursing and Care Continuity 105 Chapter 8 Home Care 118 Chapter 9 Electronic Health Records and Information
Technology 129
UNIT 3 The Nursing Process 143 Chapter 10 Critical Thinking and Clinical Reasoning 144 Chapter 11 Assessing 155 Chapter 12 Diagnosing 175 Chapter 13 Planning 189 Chapter 14 Implementing and Evaluating 208 Chapter 15 Documenting and Reporting 221
UNIT 4 Health Beliefs and Practices 243 Chapter 16 Health Promotion 244 Chapter 17 Health, Wellness, and Illness 262 Chapter 18 Culturally Responsive Nursing Care 276 Chapter 19 Complementary and Alternative Healing
Modalities 295
UNIT 5 Life Span Development 311 Chapter 20 Concepts of Growth and Development 312 Chapter 21 Promoting Health from Conception Through
Adolescence 328
Chapter 22 Promoting Health in Young and Middle-Aged Adults 353 Chapter 23 Promoting Health in Older Adults 364 Chapter 24 Promoting Family Health 386
UNIT 6 Integral Aspects of Nursing 397 Chapter 25 Caring 398 Chapter 26 Communicating 411 Chapter 27 Teaching 438 Chapter 28 Leading, Managing, and Delegating 462
UNIT 7 Assessing Health 476 Chapter 29 Vital Signs 477 Chapter 30 Health Assessment 513
UNIT 8 Integral Components of Client Care 601 Chapter 31 Asepsis 602 Chapter 32 Safety 640 Chapter 33 Hygiene 669 Chapter 34 Diagnostic Testing 718 Chapter 35 Medications 750 Chapter 36 Skin Integrity and Wound Care 828 Chapter 37 Perioperative Nursing 865
UNIT 9 Promoting Psychosocial Health 903 Chapter 38 Sensory Perception 904 Chapter 39 Self-Concept 922 Chapter 40 Sexuality 934 Chapter 41 Spirituality 954 Chapter 42 Stress and Coping 972 Chapter 43 Loss, Grieving, and Death 989
UNIT 10 Promoting Physiological Health 1009 Chapter 44 Activity and Exercise 1010 Chapter 45 Sleep 1066 Chapter 46 Pain Management 1086 Chapter 47 Nutrition 1127 Chapter 48 Urinary Elimination 1174 Chapter 49 Fecal Elimination 1210 Chapter 50 Oxygenation 1241 Chapter 51 Circulation 1287 Chapter 52 Fluid, Electrolyte, and Acid–Base Balance 1308
Further enhance your Clinical Reasoning with the additional resources below. For more information and purchasing options visit www.mypearsonstore.com.
Break Through to improving results
MyNursingLab provides a guided learning path that is proven to help students synthesize vast amounts of information, guiding them from memorization to true understanding through application.
Thinking Like a Nurse in Clinical Thinking Like a Nurse for NCLEX-RN® Success
Align ed to
the
2013 NCL
EX-R N®
Test Plan
Clinical references across the nursing curriculum available.
Courses | Hello Instructors | Account | Help & Support
Course Home
Syllabus
Assignment Calendar
Course Content
eText
Class Preparation
Class Master
Submissions
Kozier and Erb’s Fundamentals of Nursing 10e
1 Historic and Contemporary Nursing Practice
2 Evidence-Based Practice and Research in Nursing
3 Nursing Theories and Conceptual Frameworks
4 Legal Aspects of Nursing
5 Values, Ethics, and Advocacy
6 Health Care Delivery Systems
7 The Nurse-Patient Relationship and Therapeutic Communication
8 Home Care
9 Electronic Health Records and Information Technology
10 Critical Thinking and Clinical Reasoning
11 Assessing
12 Diagnosing
13 Planning
14 Implementing and Evaluating
15 Documenting and Reporting
16 Health Promotion
Available for your favorite
electronic device!
NURSE’S DRUG GUIDE Wilson • Shannon • Shields
2016
NURSE’S DRUG GUIDE
Wilson • Shannon • Shields
• Thousands of drugs organized alphabetically
• Indexed by generic and trade drug names
• Complete IV drug information
PEARSON
PEARSON
www.pearsonhighered.com
PEARSON NURSE’S DRUG GUIDE 2016 NURSES AGREE: Pearson Nurse’s Drug Guide provides all the information you need for safe, effective drug administration in any setting!
• Organized alphabetically and indexed by generic and trade drug names
• Dosages across the lifespan from neonate to older adults
• Dosage with adjustments for clinically relevant conditions
• Complete IV preparation and administration information
• Clinically relevant drug interactions with food, herbals, and other drugs
• Pharmacologic and therapeutic classifications for every drug
• Unique glossary of clinical conditions and their related signs and symptoms
• Prototype drugs for each drug classification
• NEW! Black box warnings throughout
Comprehensive Current Clinically Relevant
Available for your favorite
electronic device!
2016
Simplify your study time by using the resources included with this textbook at http://www.nursing.pearsonhighered.com
using your
Begin Thinking LIKE A NURSE
PEARSON RESOURCES
A00_BERM4362_10_SE_FEP.indd 4-5 04/12/14 8:14 PM
# 153613 Cust: Pearson Au: Berman Pg. No. i Title: Kozier & Erb’s Fundamentals of Nursing 10e
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Audrey Berman, PhD, RN Professor
Dean, Nursing Samuel Merritt University
Oakland, California
Shirlee J. Snyder, EdD, RN Former Dean and Professor, Nursing
Nevada State College Henderson, Nevada
Geralyn Frandsen, EdD, RN Professor of Nursing Maryville University St. Louis, Missouri
TENTH EDITION
FUNDAMENTALS OF NURSING
KOZIER & ERB’S
Concepts, Process, and Practice
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# 153613 Cust: Pearson Au: Berman Pg. No. ii Title: Kozier & Erb’s Fundamentals of Nursing 10e
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Publisher: Julie Levin Alexander Executive Product Manager: Katrin Beacom Program Manager: Melissa Bashe Editorial Assistant: Kevin Wilson Development Editor: Teri Zak Project Manager: Michael Giacobbe Production Editor: Roxanne Klaas, S4Carlisle Publishing Services Manufacturing Buyer: Maura Zaldivar-Garcia Art Director/Cover and Interior Design: Maria Guglielmo Director of Marketing: David Gesell
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Copyright © 2016, 2012, 2008 by Pearson Education, Inc. All rights reserved. Manufactured in the United States of America. This publication is protected by Copyright and permission should be obtained from the publisher prior to any prohibited reproduction, stor- age in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, recording, or likewise. For information regarding permission(s), write to: Rights and Permissions Department, 221 River Street, Hoboken, New Jersey 07030.
Notice: Care has been taken to confirm the accuracy of information presented in this book. The authors, editors, and the publisher, how- ever, cannot accept any responsibility for errors or omissions or for consequences from application of the information in this book and make no warranty, express or implied, with respect to its contents.
The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with cur- rent recommendations and practice at time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Library of Congress Cataloging-in-Publication Data Berman, Audrey, author. Kozier & Erb’s fundamentals of nursing : concepts, practice, and process / Audrey Berman, Shirlee Snyder, and Geralyn Frandsen.—Tenth edition. p. ; cm. Kozier and Erb’s fundamentals of nursing Fundamentals of nursing Includes bibliographical references and index. ISBN 978-0-13-397436-2—ISBN 0-13-397436-7 I. Snyder, Shirlee, author. II. Frandsen, Geralyn, author. III. Title. IV. Title: Kozier and Erb’s fundamentals of nursing. V. Title: Fundamentals of nursing. [DNLM: 1. Nursing Process. 2. Nursing Care. 3. Nursing Theory. WY 100] RT41 610.73—dc23 2014018545 10 9 8 7 6 5 4 3 2 1
ISBN-13: 978-0-13-397436-2 ISBN-10: 0-13-397436-7
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Dedication Audrey Berman dedicates this tenth edition to everyone who ever played a part in its creation: to Barbara Kozier and Glenora Erb who started it all and taught me the ropes; to the publishers, editors, faculty authors, contributors, reviewers, and adopters who improved every edition; to the students and their clients who made all the hard work worthwhile; and to all my family and colleagues who allowed me the time and space to make these books my scholarly contribution to the profession.
Shirlee Snyder dedicates this edition to her husband, Terry J. Schnitter, for his unconditional love and support; and to all of the nursing students and nurse educators she has worked with and learned from during her nursing career.
Geralyn Frandsen dedicates this edition to her husband and fellow nursing colleague Gary. He is always willing to answer questions and provide editorial support. She also dedicates this edition to her children Claire and Joe and future son-in-law, John Conroy.
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About the Authors Audrey Berman, PhD, RN A San Francisco Bay Area native, Audrey Berman received her BSN from the University of California–San Francisco and later returned to that campus to obtain her MS in physiological nursing and her PhD in nursing. Her dissertation was entitled Sailing a Course Through Chemotherapy: The Experience of Women with Breast Cancer. She worked in oncol- ogy at Samuel Merritt Hospital prior to
beginning her teaching career in the diploma program at Samuel Merritt Hospital School of Nursing in 1976. As a faculty member, she participated in the transition of that program into a baccalaureate degree and in the development of the master of science and doctor of nursing practice programs. Over the years, she has taught a variety of medical–surgical nursing courses in the prelicensure programs. She currently serves as the dean of nursing at Samuel Merritt University and is the 2014–2016 president of the California Association of Colleges of Nursing.
Dr. Berman has traveled extensively, visiting nursing and health care institutions in Australia, Botswana, Brazil, Germany, Israel, Japan, Korea, the Philippines, the Soviet Union, and Spain. She serves on the board of directors for the Bay Area Tumor Institute and the East Bay American Heart Association. She is a member of the American Nurses Association and Sigma Theta Tau and is a site visitor for the Commission on Collegiate Nursing Education. She has twice par- ticipated as an NCLEX-RN item writer for the National Council of State Boards of Nursing. She has presented locally, nationally, and internationally on topics related to nursing education, breast cancer, and technology in health care.
Dr. Berman authored the scripts for more than 35 nursing skills videotapes in the 1990s. She was a coauthor of the sixth, seventh, eighth, ninth, and tenth editions of Fundamentals of Nursing and the fifth, sixth, seventh, and eighth editions of Skills in Clinical Nursing.
Shirlee J. Snyder, EdD, RN Shirlee J. Snyder graduated from Columbia Hospital School of Nursing in Milwaukee, Wisconsin, and sub- sequently received a bachelor of sci- ence in nursing from the University of Wisconsin–Milwaukee. Because of an interest in cardiac nursing and teach- ing, she earned a master of science in nursing with a minor in cardiovascular
clinical specialist and teaching from the University of Alabama in Birmingham. A move to California resulted in becoming a faculty member at Samuel Merritt Hospital School of Nursing in Oakland, California. Shirlee was fortunate to be involved in the phasing out of the diploma and ADN programs and development of a baccalaureate
intercollegiate nursing program. She held numerous positions dur- ing her 15-year tenure at Samuel Merritt College, including curricu- lum coordinator, assistant director–instruction, dean of instruction, and associate dean of the Intercollegiate Nursing Program. She is an associate professor alumnus at Samuel Merritt College. Her interest and experiences in nursing education resulted in Shirlee obtaining a doctorate of education focused on curriculum and instruction from the University of San Francisco.
Dr. Snyder moved to Portland, Oregon, in 1990 and taught in the ADN program at Portland Community College for 8 years. During this teaching experience she presented locally and nationally on top- ics related to using multimedia in the classroom and promoting eth- nic and minority student success.
Another career opportunity in 1998 led her to the Community College of Southern Nevada in Las Vegas, Nevada, where Dr. Snyder was the nursing program director with responsibilities for the associ- ate degree and practical nursing programs for 5 years. During this time she coauthored the fifth edition of Kozier & Erb’sTechniques in Clinical Nursing with Audrey Berman.
In 2003, Dr. Snyder returned to baccalaureate nursing educa- tion. She embraced the opportunity to be one of the nursing faculty teaching the first nursing class in the baccalaureate nursing program at the first state college in Nevada, which opened in 2002. From 2008 to 2012, she was the dean of the School of Nursing at Nevada State College in Henderson, Nevada. She is currently retired.
Dr. Snyder enjoyed traveling to the Philippines (Manila and Cebu) in 2009 to present all-day seminars to approximately 5,000 nursing students and 200 nursing faculty. She is a member of the American Nurses Association and Sigma Theta Tau. She has been a site visitor for the National League for Nursing Accrediting Commission and the Northwest Association of Schools and Colleges.
Geralyn Frandsen, EdD, RN Geralyn Frandsen graduated in the last class from DePaul Hospital School of Nursing in St. Louis, Missouri. She earned a bachelor of science in nursing from Maryville College. She attended Southern Illinois University at Edwardsville, earn- ing a master of science degree in nursing with specializations in community health and nursing education. Upon completion,
she accepted a faculty position at her alma mater Maryville College, which has since been renamed Maryville University. In 2003 she com- pleted her doctorate in higher education and leadership at Saint Louis University. Her dissertation was Mentoring Nursing Faculty in Higher Education. Her review of literature was incorporated in the Maryville University Guide to Promotion and Tenure.
In service to the university, she has been a member and chair of the promotion and tenure committee for the past 10 years. She is a tenured full professor and currently serves as assistant director
iv
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Point and My Nursing Lab. This is an online resource to assist stu- dents in reviewing content in their nursing fundamentals course. She has authored both the Nursing Fundamentals: Pearson Reviews and Rationales and, in 2007, Pharmacology Reviews and Rationales.
Dr. Frandsen has completed the End-of-Life Nursing Education Consortium train-the-trainer courses for advanced practice nurses and the doctorate of nursing practice. She is passionate about end-of- life care and teaches a course to her undergraduate students. She also teaches undergraduate pharmacology and advanced pharmacothera- peutics. Her advanced pharmacotherapeutics class is taught at the university and online. Dr. Frandsen is a member of Sigma Theta Tau International, the American Nurses’ Association, and serves as a site visitor for the Commission on Collegiate Nursing Education.
of the Catherine McCauley School of Nursing at Maryville. When educating undergraduate and graduate students, she utilizes a variety of teaching strategies to engage her students. When teaching under- graduate pharmacology she utilizes a team teaching approach, plac- ing students in groups to review content. Each student is also required to bring a completed ticket to class covering the content to be taught. The practice of bringing a ticket to class was introduced to her by Dr. Em Bevis, who is famous for the Toward a Caring Curriculum.
Dr. Frandsen has authored textbooks in pharmacology and nursing fundamentals. In the ninth edition of Kozier & Erb’s Fundamentals of Nursing she contributed the chapters on Safety, Diagnostic Testing, Medications, Perioperative Nursing, and Fecal Elimination. In 2013 she was the fundamentals contributor for Ready
About the Authors v
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We wish to extend a sincere thank you to the talented team involved in the tenth edition of this book: the contributors and reviewers who provide content and very helpful feedback; the nursing students, for their questioning minds and motivation; and the nursing instructors, who provided many valuable suggestions for this edition.
We would like to thank the editorial team, especially Kelly Trakalo, executive acquisitions editor, for her continual support, Melissa Bashe, Program Manager, Pearson Nursing, and most of all Teri Zak, development editor, for keeping our noses to the grind-
stone and especially for her dedication and attention to detail that promoted an excellent outcome once again. Many thanks to the pro- duction team of Michael Giaccobe, production liaison, and Roxanne Klaas, production editor, for producing this book with precision, and to the design team led by Maria Siener and Maria Guglielmo, art directors, for providing a truly beautiful design for this textbook.
Audrey Berman Shirlee Snyder
Geralyn Frandsen
Acknowledgments
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vii
Thank You
vii
We would like to extend our heartfelt thanks to our colleagues from schools of nursing across the country who have given their time generously to help us create this learning package. These individuals helped us develop this textbook and supplements by reviewing chapters, art, and media, and by answering a myriad of questions right up until the time of publication. Kozier & Erb’s Fundamentals of Nursing, Tenth Edition, has benefited immeasurably from their efforts, insights, suggestions, objections, encouragement, and inspiration, as well as from their vast experience as teachers and nurses. Thank you again for helping us set the foundation for nursing excellence.
Contributors to the Tenth Edition Sherrilyn Coffman, PhD, RN Professor, Associate Dean Nevada State College Chapter 25: Caring
Elizabeth Johnston Taylor, PhD, RN Associate Professor, Loma Linda University Research Director, Mary Potter Hospice Wellington South, New Zealand Chapter 41: Spirituality
Reviewers of the Tenth Edition Mary Anderson, RN, MSN Chicago State University Chicago, IL
Kathy Anglin, MSN, RN Texarkana College Texarkana, TX
Barbara Celia, EdD, RN Drexel University Philadelphia, PA
Sarah Dempsey, MSN, RN Maryville University St. Louis, MO
Mary Ann Gaster, MEd, MSN Central Carolina Community College Pittsboro, NC
Susan Growe, MSN, RN, OCN Nevada State College Henderson, NV
Helena Gunnell, MEd, BSN, RN Jones County Community College Ellisville, MS
Sandy Gustafson, MA, RN Hibbing Community College Hibbing, MN
Elizabeth Long, DNP, APRN, GNP-BC Lamar University Beaumont, TX
Colleen Marzilli, DNP, MBA, RN University of Texas at Tyler Tyler, TX
Florence Miller, MSN, MPH Chicago State University Chicago, IL
Sharon M. Nowak, MSN Jackson College Jackson, MI
Martha Olson MSN, MS, RN Iowa Lakes Community College Emmetsburg, Iowa
Laura Warner, MSN, RN Ivy Tech Community College Greenfield, IN
Cindy Zeller, MSN, CPNP Frederick Community College Frederick, MD
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viii
The practice of nursing continues to evolve . . . the practice of caring is timeless.
Nurses today must grow and evolve to meet the demands of a dramatically changing health care system. They need skills in sci- ence, technology, communication, and interpersonal relations to be effective members of the collaborative health care team. They need to think critically and be creative in implementing nursing strate- gies to provide safe and competent nursing care for clients of diverse cultural backgrounds in increasingly varied settings. They need skills in teaching, leading, managing, and the process of change. They need to be prepared to provide home- and community-based nursing care to clients across the life span—especially to the increasing numbers of older adults. They need to understand legal and ethical principles, holistic healing modalities, and complementary therapies. And, they need to continue their unique client advocacy role, which demands a blend of nurturance, sensitivity, caring, empathy, commitment, and skill founded on a broad base of knowledge.
Kozier & Erb’s Fundamentals of Nursing, Tenth Edition, addresses the concepts of contemporary professional nursing. These concepts include but are not limited to caring, wellness, health promotion, dis- ease prevention, holistic care, critical thinking and clinical reason- ing, multiculturalism, nursing theories, nursing informatics, nursing research, ethics, and advocacy. In this edition, every chapter has been reviewed and revised. The content has been updated to reflect the latest nursing evidence and the increasing emphasis on aging, wellness, safety, interprofessional practice, and home- and community-based care.
ORGANIZATION The detailed table of contents at the beginning of the book makes its clear organization easy to follow. Continuing with a strong focus on nursing care, the tenth edition of this book is divided into 10 units.
Unit 1, The Nature of Nursing, clusters five chapters that provide comprehensive coverage of introductory concepts of nursing.
In Unit 2, Contemporary Health Care, four chapters cover con- temporary health care topics such as health care delivery systems, community-based care, home care, and informatics.
In Unit 3, The Nursing Process, six chapters introduce students to this important framework with each chapter dedicated to a spe- cific step of the nursing process. Chapter 10 applies critical thinking, clinical reasoning, and the nursing process. A Nursing in Action case study is used as the frame of reference for applying content in all phases of the nursing process in Chapter 11, Assessing; Chapter 12, Diagnosing; Chapter 13, Planning; and Chapter 14, Implementing and Evaluating. Chapter 15 covers documenting and reporting. Starting in this unit and incorporated throughout the book, we refer to the NANDA International diagnoses.
In Unit 4, Health Beliefs and Practices, four chapters cover health- related beliefs and practices for individuals and families from a variety of cultural backgrounds.
Unit 5, Lifespan Development, consists of five chapters that dis- cuss life span and development from conception to older adults.
Unit 6, Integral Aspects of Nursing, discusses topics such as caring; communicating; teaching; and leading, managing, and delegating. These topics are all crucial elements for providing safe, competent nursing care.
Unit 7, Assessing Health, addresses vital signs and health assess- ment skills in two separate chapters, so beginning students can under- stand normal assessment techniques and findings. Chapter 29, Vital Signs, begins to introduce students to the clinical procedures that they need to learn to perform.
In Unit 8, Integral Components of Client Care, the focus shifts to those components of client care that are universal to all clients, including asepsis, safety, hygiene, diagnostic testing, medications, wound care, and perioperative care.
Unit 9, Promoting Psychosocial Health, includes six chapters that cover a wide range of areas that affect one’s health. Sensory percep- tion, self-concept, sexuality, spirituality, stress, and loss are all things that a nurse needs to consider to properly care for a client.
Unit 10, Promoting Physiological Health, discusses a variety of physiological concepts that provide the foundations for nursing care. These include activity and exercise; sleep; pain; nutrition; elimina- tion; oxygenation; circulation; and fluid, electrolyte, and acid–base balance.
WHAT’S NEW TO THE TENTH EDITION • QSEN linkages. The delivery of high-quality and safe nursing
practice is imperative for every nurse. The QSEN competencies were developed to address the gap between nursing education and practice. There are expectations for each of the six QSEN com- petencies and these expectations relate to knowledge, skills, and attitudes. Nursing students are expected to achieve these compe- tencies during nursing school and use them in their professional role as RNs. This edition has incorporated QSEN competencies and specified expectations in QSEN features. The content in these QSEN features will guide students to learn and maintain safety and quality in their provision of nursing care.
• Culturally Responsive Care highlights diversity and special con- siderations in nursing care.
• Evidence-Based Practice focuses on evidence-informed prac- tice to highlight relevant research and its implications for nurs- ing care.
• Home Care Assessment focuses on educating the client, family, and community to recognize what is needed for care in the home.
• Home Care Considerations focus on teaching the client and care giver the proper care at home.
• Safety Alerts correlate to the National Patient Safety Goals and identify other crucial safety issues.
• Updated photo program with more than 150 new photos
Preface
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book the number-one choice of nursing students and faculty. The walk-through at the beginning of the textbook illustrates these fea- tures. A significant addition to this edition is the inclusion of QSEN features that address the competencies and expectations for quality nursing care. Another important feature is the inclusion of a sec- tion on Interprofessional Practice within specific skills. In addition, Evidence-Based Practices boxes replace the Research Notes in rec- ognition that research is not the only way in which nurses determine best practices.
Supplements That Inspire Success for the Student and the Instructor Pearson is pleased to offer a complete suite of resources to support teaching and learning, including:
• TestGen Test Bank • Lecture Note PowerPoints • Classroom Response System PowerPoints • New! Annotated Instructor’s eText—This version of the eText is
designed to help instructors maximize their time and resources in preparing for class. The AIE contains suggestions for class- room and clinical activities and key concepts to integrate into the classroom in any way imaginable. Additionally, each chapter has recommendations for integrating other digital Pearson Nursing resources, including The Neighborhood 2.0, Skills videos, and MyNursingLab.
• Clinical reasoning. The practice of nursing requires critical thought and clinical reasoning. Clinical reasoning is the cognitive processes a nurse utilizes to gather and analyze client data, evalu- ate the relevance of the information, and implement nursing in- terventions to improve the client’s well being.
• Interprofessional practice. The concept of interprofessional practice is identified in specific skills. It reinforces to the student that other members of the health care team may also be perform- ing the specified skill.
• Men in nursing. This edition has increased information about men in nursing from a historical and current perspective in Chapter 1.
• Standards of care. This edition continues to value and update standards of care as evidenced by the latest National Patient Safety Goals, Infusion Nursing Society Standards of Practice, ANA Scope and Standards of Practice, 2014 Hypertension Guidelines; IHI Pressure Ulcer Prevention Guidelines, ANA Safe Patient Han- dling and Mobility Interprofessional National Standards, OSHA/ CDC BBP and Infection Prevention Standards, and Cancer Screening Guidelines.
FEATURES For years, Kozier & Erb’s Fundamentals of Nursing has been a gold standard that helps students embark on their careers in nursing. This new edition retains many of the features that have made this text-
Preface ix
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Chapter 11 • Assessing 157
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DIAGNOSING After analysis, Nurse Medina formulates a nursing diagnosis: Ineffective Airway Clearance related to accumulated mucus obstructing airways.
PLANNING Nurse Medina and Margaret collaborate to establish goals (e.g., restore effective breathing pattern and lung ventilation); set outcome criteria (e.g., have a symmetrical respiratory excursion of at least 4 cm, and so on); and develop a care plan that includes, but is not limited to, coughing and deep-breathing exercises q3h, fluid intake of 3,000 mL daily, and daily postural drainage.
EVALUATING Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Margaret reevaluate the care plan and modify it to increase coughing and deep-breathing exercises to q2h.
Margaret O’Brien is a 33-year-old nursing student. She is married and has a 13-year-old daughter and 5-year-old son. She is admitted to the hospital with an elevated temperature, a productive cough, and rapid, labored respirations. While taking a nursing history, Mary Medina, RN, finds that Margaret has had a “chest cold” for 2 weeks, and has been experiencing shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to experience “pain” in her “lungs”.
ASSESSING Nurse Medina’s physical assessment reveals that Margaret’s vital signs are temperature, 39.4°C (103°F); pulse 92 beats/min; respirations 28/min; and blood pressure, 122/80 mmHg. Nurse Medina observes that Mrs. O’Brien’s skin is dry, her cheeks are flushed, and she is experiencing chills. Auscultation reveals inspiratory crackles with diminished breath sounds in the right lung.
IMPLEMENTING Margaret agrees to practice the deep-breathing exercises q3h during the day. In addition, she verbalizes awareness of the need to increase her fluid intake and to plan her morning activities to accommodate postural drainage.
Figure 11–1 • Continued
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Features of the Tenth Edition
SPECIAL FEATURES provide the opportunity to link QSEN competencies and to think critically to make a connection to nursing practice. These features provide guidance on maintaining safety and quality of nursing care.
508 Unit 7 ● Assessing Health
PURPOSES • To estimate the arterial blood oxygen saturation • To detect the presence of hypoxemia before visible signs
develop
ASSESSMENT Assess • The best location for a pulse oximeter sensor based on the
client’s age and physical condition. Unless contraindicated, the � nger is usually selected for adults.
• The client’s overall condition including risk factors for development of hypoxemia (e.g., respiratory or cardiac disease) and hemoglobin level
• Vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities as baseline data
• Adhesive allergy
PLANNING Many hospitals and clinics have pulse oximeters readily available for use with other vital signs equipment (or even as an integrated part of the electronic blood pressure device). Other facilities may have a limited supply of oximeters, and the nurse may need to request it from the central supply department.
DELEGATION
Application of the pulse oximeter sensor and recording of the SpO 2 value may be delegated to UAP. The interpretation of the oxygen saturation value and determination of appropriate responses are done by the nurse.
INTERPROFESSIONAL PRACTICE
Measuring oxygen saturation may be within the scope of practice for many health care providers. For example, in addition to nurses, respiratory therapists may check the client’s oxygen saturation before, during, and after treatment. Although these therapists may verbally communicate their � ndings and plan to the health care team members, the nurse must also know where to locate their documen- tation in the client’s medical record.
IMPLEMENTATION Preparation Check that the oximeter equipment is functioning normally.
Performance 1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection prevention procedures.
3. Provide for client privacy. 4. Choose a sensor appropriate for the client’s weight, size, and
desired location. Because weight limits of sensors overlap, a pediatric sensor could be used for a small adult. • If the client is allergic to adhesive, use a clip or sensor
without adhesive.
• If using an extremity, apply the sensor only if the proximal pulse and capillary re� ll at the point closest to the site are present. If the client has low tissue perfusion due to periph- eral vascular disease or therapy using vasoconstrictive medications, use a nasal sensor or a re� ectance sensor on the forehead. Avoid using lower extremities that have a compromised circulation and extremities that are used for infusions or other invasive monitoring.
5. Prepare the site. • Clean the site with an alcohol wipe before applying the sensor. • It may be necessary to remove a female client’s dark nail
polish. Rationale: Nail polish may interfere with accurate measure- ments although the data about this are inconsistent.
• Alternatively, position the sensor on the side of the � nger rather than perpendicular to the nail bed.
Equipment • Nail polish remover as needed • Alcohol wipe • Sheet or towel • Pulse oximeter
The aim of this study by Korhan, Yönt, and Khorshid (2011) was to compare the pulse oximetry values obtained from a finger on re- strained or unrestrained sides of the body. In clinical settings such as intensive care, physical restraints may be indicated to lessen the chances that clients will displace tubes and monitors. However, the most important complication in using physical restraints is impaired circulation. Thus, oxygen saturation from body parts in which cir- culation is impaired can be inaccurate. The research sample con- sisted of 30 hospitalized clients. A significant difference was found between the oxygen saturation values obtained from a finger of an arm that had been physically restrained and a finger of an arm that had not been physically restrained. The mean oxygen saturation
value measured from a finger of an arm that had been physically restrained was found to be 93.40 and the mean oxygen saturation value measured from a finger of an arm that had not been physically restrained was found to be 95.53.
IMPLICATIONS The results of this study indicate that nurses should use a finger of an arm that is not physically restrained when evaluating oxygen sat- uration values. The use of physical restraints is carefully evaluated because there are many possible adverse effects of their use. This study provides one additional physiological consideration: that as- sessment data gathered from a restrained limb may not be accurate.
Evidence-Based Practice Are Pulse Oximeter Readings Accurate If Measured on a Restrained Arm? EVIDENCE-BASED PRACTICE
Measuring Oxygen Saturation S
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Chapter 16 ● Health Promotion 255
This assessment allows the nurse and client to discuss and evaluate the adequacy of the client’s support system together and, if necessary, plan options for enhancing the support system.
Health Risk Assessment A health risk assessment (HRA) is an assessment and educa- tional tool that indicates a client’s risk for disease or injury during the next 10 years by comparing the client’s risk with the mortality risk of the corresponding age, gender, and racial group. The client’s general health, lifestyle behaviors, and demographic data are compared to data from a large national sample. Individual risk reports are based on statistics for the population group that match the individual’s sur- veyed characteristics. The HRA includes a summary of the person’s health risks and lifestyle behaviors with educational suggestions on how to reduce the risk.
Many HRA instruments are available today in paper-and- pencil formats or as computerized forms. Recently, HRAs have be- gun to reflect a broader approach to health as companies use the HRA as a means to begin a health promotion and risk reduction program. Occupational health nurses can identify risk factors and subsequently plan interventions aimed at decreasing illness, absen- teeism, and disability.
HRAs are helpful for assessing individual and group health risks. They are not, however, substitutes for medical care and are not appro- priate for all individuals. For example, people with chronic illnesses such as cancer or heart disease may not obtain accurate risk assess- ments. Certain populations (e.g., very young, older adults, some so- ciocultural groups) may not be fully represented in the population databases and, therefore, the HRA may not project an accurate risk assessment.
Health Beliefs Review Clients’ health beliefs need to be clarified, particularly those beliefs that determine how they perceive control of their own health care status. Locus of control is a measurable concept that can be used to predict which people are most likely to change their behavior (see Chapter 17 ) . Several instruments are available that assess a per- son’s health-belief measures. Assessment of clients’ health beliefs pro- vides the nurse with an indication of how much the clients believe they can influence or control health through personal behaviors. Sev- eral cultures have a strong belief in fate: “Whatever will be, will be.” If people hold this belief, they do not feel that they can do anything
SELF-CARE ALERT
Is exercise a negative term for you? Does it imply something that is boring, routine, and a “must-do”? Instead, think of “physical activity,” which can be a variety of things that increase your activity level (e.g., dancing, tennis, golf, walking the dog).
Lifestyle Assessment Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health. Categories of lifestyle generally as- sessed are physical activity, nutritional practices, stress management, and such habits as smoking, alcohol consumption, and drug use. Other categories may be included. Several tools are available to as- sess lifestyle. The goals of lifestyle assessment tools are to provide the following:
1. An opportunity for clients to assess the impact of their present lifestyle on their health
2. A basis for decisions related to desired behavior and lifestyle changes.
Spiritual Health Assessment Spiritual health is the ability to develop one’s inner nature to its fullest potential, including the ability to discover and articulate one’s basic purpose in life; to learn how to experience love, joy, peace, and ful- fillment; and to learn how to help ourselves and others achieve their fullest potential ( Pender et al., 2011 , p. 104). Spiritual beliefs can affect a person’s interpretation of events in his or her life and, therefore, an assessment of spiritual well-being is a part of evaluating the person’s overall health. See Chapter 41 for more information.
SELF-CARE ALERT
There are two physical arts that blend spirituality and health: t’ai chi and yoga. T’ai chi promotes muscle relaxation through movement. Yoga promotes mobility and flexibility.
Social Support Systems Review Understanding the social context in which a person lives and works is important in health promotion. Individuals and groups, through interpersonal relationships, can provide comfort, assistance, encour- agement, and information. Social support fosters successful coping and promotes satisfying and effective living.
Social support systems contribute to health by creating an en- vironment that encourages healthy behaviors, promotes self-esteem and wellness, and provides feedback that the person’s actions will lead to desirable outcomes. Examples of social support systems in- clude family, peer support groups (including computer-based sup- port groups), community-organized religious support systems (e.g., churches), and self-help groups (e.g., Mended Hearts, Weight Watch- ers). Culturally Responsive Care addresses aspects of social support within the context of culture.
The nurse can begin a social support system review by asking the client to do the following:
• List individuals who provide personal support. • Indicate the relationship of each person (e.g., family member, fel-
low worker or colleague, social acquaintance). • Identify which individuals have been a source of support for 5 or
more years.
Cultural Aspects of Social Support
It is important to understand how various subgroups of U.S. society may define social support. • In the African American community, the family and church
have been major providers of social support. • Hispanic/Latino Americans and Asian Americans view the
family as being a major social support system. • Asian Americans respect older adults and use shame and
harmony in giving and receiving support. • Native Americans live in social networks that foster mutual
assistance and support.
From Health Promotion in Nursing Practice , 6th ed. (p. 220), by N. J. Pender, C. L. Murdaugh, and M. A. Parsons, 2011, Upper Saddle River, NJ: Prentice Hall.
PATIENT-CENTERED CARE Culturally Responsive Care
222 Unit 3 ● The Nursing Process
Communication The record serves as the vehicle by which different health profession- als who interact with a client communicate with each other. This pre- vents fragmentation, repetition, and delays in client care.
Planning Client Care Each health professional uses data from the client’s record to plan care for that client. A primary care provider, for example, may order a specific antibiotic after establishing that the client’s temperature is steadily rising and that laboratory tests reveal the presence of a cer- tain microorganism. Nurses use baseline and ongoing data to evalu- ate the effectiveness of the nursing care plan.
Auditing Health Agencies An audit is a review of client records for quality assurance purposes (see Chapter 14 ) . Accrediting agencies such as The Joint Com- mission may review client records to determine if a particular health agency is meeting its stated standards.
Research The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients.
Education Students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.
Reimbursement Documentation also helps a facility receive reimbursement from the federal government. For a facility to obtain payment through Medi- care, the client’s clinical record must contain the correct diagnosis- related group (DRG) codes and reveal that the appropriate care has been given.
Codable diagnoses, such as DRGs, are supported by accu- rate, thorough recording by nurses. This not only facilitates re- imbursement from the federal government, but also facilitates reimbursement from insurance companies and other third-party payers. If additional care, treatment, or length of stay becomes necessary for the client’s welfare, thorough charting will help jus- tify these needs.
Legal Documentation The client’s record is a legal document and is usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, be- cause information the client gives to the primary care provider is confidential.
Health Care Analysis Information from records may assist health care planners to identify agency needs, such as overutilized and underutilized hospital ser- vices. Records can be used to establish the costs of various services
SAFETY ALERT!
Take safety measures before faxing confidential information. A fax cover sheet should contain instructions that the faxed material is to be given only to the named recipient. Consent is needed from the client to fax information. Make sure that personally identifiable information (e.g., client name, Social Security number) has been removed. Finally, check that the fax number is correct, check the number on the display of the machine after dialing, and check the number a third time before pressing the “send” button.
For purposes of education and research, most agencies allow student and graduate health professionals access to client records. The records are used in client conferences, clinics, rounds, client studies, and written papers. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health profes- sional to protect the client’s privacy by not using a name or any state- ments in the notations that would identify the client.
Ensuring Confidentiality of Computer Records Because of the increased use of EHRs (see Chapter 9 ) , health care agencies have developed policies and procedures to ensure the privacy and confidentiality of client information stored in comput- ers. In addition, the Security Rule of HIPAA became mandatory in 2005. This rule governs the security of electronic PHI. The following are some suggestions for ensuring the confidentiality and security of computerized records:
1. A personal password is required to enter and sign off computer files. Do not share this password with anyone, including other health team members.
2. After logging on, never leave a computer terminal unattended. 3. Do not leave client information displayed on the monitor where
others may see it. 4. Shred all unneeded computer-generated worksheets. 5. Know the facility’s policy and procedure for correcting an entry
error. 6. Follow agency procedures for documenting sensitive material,
such as a diagnosis of AIDS. 7. Information technology (IT) personnel must install a firewall to
protect the server from unauthorized access.
PURPOSES OF CLIENT RECORDS Client records are kept for a number of purposes including communi- cation, planning client care, auditing health agencies, research, educa- tion, reimbursement, legal documentation, and health care analysis.
CLINICAL ALERT!
An accurate client health record provides details about the care a cli- ent has received and the client’s overall response to care. Accurate documentation provides the staff with a means for accountability and reflection on the delivery of client care ( Prideaux, 2011 ). To enhance the accuracy in documenting care, Paans, Sermeus, Nieweg, and van der Schans (2010) identified the PES structure as a guideline for nurs- ing care. The letter P represents the client’s problem or diagnosis. The etiology or cause of the problem is represented by E, and S represents the signs and symptoms the nurse should be assessing. The use of this structure enhances nurses’ ability to exercise clinical reasoning.
SAFETY
INTERPROFESSIONAL PRACTICE reinforces interactions with other members of the health care team.
ENHANCED PHOTO PROGRAM shows procedural steps and the latest equipment.
486 Unit 7 ● Assessing Health
LIFESPAN CONSIDERATIONS Temperature
INFANTS • The body temperature of newborns is extremely labile, and
newborns must be kept warm and dry to prevent hypothermia. • Using the axillary site, you need to hold the infant’s arm against
the chest ( Figure 29–10 ■ ). • The axillary route may not be as accurate as other routes for
detecting fevers in children. • The tympanic route is fast and convenient. Place the infant
supine and stabilize the head. Pull the pinna straight back and slightly downward. Remember that the pinna is pulled upward for children over 3 years of age and adults, but downward for children younger than age 3. Direct the probe tip anteriorly and insert far enough to seal the canal. The tip will not touch the tympanic membrane.
• Avoid the tympanic route in a child with active ear infections or tympanic membrane drainage tubes.
• The tympanic membrane route may be more accurate in determining temperature in febrile infants.
• When using a temporal artery thermometer, touching only the forehead or behind the ear is needed.
• The rectal route is least desirable in infants.
CHILDREN • Tympanic or temporal artery sites are preferred. • For the tympanic route, have the child held on an adult’s lap
with the child’s head held gently against the adult for support. Pull the pinna straight back and upward for children over age 3 ( Figure 29–11 ■ ).
• Avoid the tympanic route in a child with active ear infections or tympanic membrane drainage tubes.
• The oral route may be used for children over age 3, but nonbreakable, electronic thermometers are recommended.
• For a rectal temperature, place the child prone across your lap or in a side-lying position with the knees flexed. Insert the thermometer 2.5 cm (1 in.) into the rectum.
OLDER ADULTS • Older adults’ temperatures tend to be lower than those of
middle-aged adults. • Older adults’ temperatures are strongly influenced by both environ-
mental and internal temperature changes. Their thermoregulation control processes are not as efficient as when they were younger, and they are at higher risk for both hypothermia and hyperthermia.
• Older adults can develop significant buildup of ear cerumen (earwax) that may interfere with tympanic thermometer readings.
• Older adults are more likely to have hemorrhoids. Inspect the anus before taking a rectal temperature.
• Older adults’ temperatures may not be a valid indication of the seriousness of the pathology of a disease. They may have pneumonia or a urinary tract infection and have only a slight temperature elevation. Other symptoms, such as confusion and restlessness, may be displayed and need follow-up to determine if there is an underlying process.
Figure 29–10 ■ Axillary thermometer placement for a child.
Figure 29–11 ■ Pull the pinna of the ear back and up for placement of a tympanic thermometer in a child over 3 years of age; back and down for children under age 3.
Figure 29–12 ■ A pacifier thermometer.
Home Care Considerations Temperature
• Teach the client accurate use and reading of the type of ther- mometer to be used. Examine the thermometer used by the client in the home for safety and proper functioning. Facilitate the replacement of mercury thermometers with nonmercury ones. See page 482 for instructions regarding management of a broken mercury thermometer.
• Observe the client/caregiver taking and reading a temperature. Reinforce the importance of reporting the site and type of ther- mometer used and the value of using the same site and ther- mometer consistently.
• Discuss means of keeping the thermometer clean, such as warm water and soap, and avoiding cross contamination.
• Ensure that the client has water-soluble lubricant if using a rectal thermometer.
• Instruct the client or family member to notify the health care provider if the temperature is 38.5°C (101.3°F) or higher.
• When making a home visit, take a thermometer with you in case the clients do not have a functional thermometer of their own.
• Check that the client knows how to record the temperature. Provide a recording chart/table if indicated.
• Discuss environmental control modifications that should be made during illness or extreme climate conditions (e.g., heating, air conditioning, appropriate clothing and bedding).
• Pacifier thermometers ( Figure 29–12 ■ ) may be used in the home setting for children under 2 years old. The manufacturer’s instructions must be followed carefully since many require adding 0.5°F in order to estimate rectal temperature.
PATIENT-CENTERED CARE
492 Unit 7 ● Assessing Health
Assessing an Apical Pulse
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PURPOSES • To obtain the heart rate of an adult with an irregular
peripheral pulse • To establish baseline data for subsequent evaluation
• To determine whether the cardiac rate is within normal range and the rhythm is regular
• To monitor clients with cardiac, pulmonary, or renal disease and those receiving medications to improve heart action
ASSESSMENT Assess • Clinical signs of cardiovascular alterations such as dyspnea
(dif� cult respirations), fatigue/weakness, pallor, cyanosis (bluish discoloration of skin and mucous membranes), palpitations, syncope (fainting), or impaired peripheral tissue perfusion as evidenced by skin discoloration and cool temperature
• Factors that may alter pulse rate (e.g., emotional status, activity level, and medications that affect heart rate such as digoxin, beta-blockers, or calcium channel blockers)
PLANNING DELEGATION
Due to the degree of skill and knowledge required, UAP are generally not responsible for assessing apical pulses.
Equipment • Clock or watch with a sweep second hand or digital seconds
indicator • Stethoscope • Antiseptic wipes • If using a DUS: the transducer probe, the stethoscope headset,
transmission gel, and tissues/wipes
INTERPROFESSIONAL PRACTICE
Assessing an apical pulse may be within the scope of practice for many health care providers. For example, in addition to nurses, respiratory therapists may check the client’s apical pulse before, during, and after treatment, and physicians often check the api- cal pulse when assessing the chest during examinations. Although these providers may verbally communicate their � ndings and plan to other health care team members, the nurse must also know where to locate their documentation in the client’s medical record.
❶ Second intercostal space. Shirlee Snyder.
IMPLEMENTATION Preparation If using a DUS, check that the equipment is functioning normally.
Performance 1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.
2. Perform hand hygiene and observe appropriate infection pre- vention procedures.
3. Provide for client privacy. 4. Position the client appropriately in a comfortable supine posi-
tion or in a sitting position. Expose the area of the chest over the apex of the heart.
5. Locate the apical impulse. This is the point over the apex of the heart where the apical pulse can be most clearly heard. • Palpate the angle of Louis (the angle between the manu-
brium, the top of the sternum, and the body of the ster- num). It is palpated just below the suprasternal notch and is felt as a prominence (see Figure 29–14 ).
• Slide your index � nger just to the left of the sternum, and palpate the second intercostal space. ❶
CLINICAL ALERT!
When “left” and “right” are used to describe the nurse’s hand place- ment on the client, the terms refer to the client’s right or left side, not the nurse’s.
• Place your middle or next � nger in the third intercostal space, and continue palpating downward until you locate the � fth intercostal space. ❷
• Move your index � nger laterally along the � fth intercostal space toward the MCL. ❸ Normally, the apical impulse is palpable at or just medial to the MCL (see Figure 29–14 ).
6. Auscultate and count heartbeats. • Use antiseptic wipes to clean the earpieces and diaphragm
of the stethoscope. Rationale: The diaphragm needs to be cleaned and disinfected if soiled with body substances. Both earpieces and diaphragms have been shown to harbor pathogenic bacteria ( Muniz, Sethi, Zaghi, Ziniel, & Sandora, 2012 ).
NEW AND ENHANCED FEATURES
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HALLMARK FEATURES
This tenth edition maintains the best aspects of previous editions to provide the most valuable learning experience.
LEARNING OUTCOMES help identify critical concepts.
KEY TERMS provide a study tool for learning new vocabulary. Page numbers are included for easy reference.
MEETING THE STANDARDS end of unit activities provide the opportunity to think through themes and competencies presented across chapters in a unit and think critically to link theory to nursing practice.
NURSING CARE PLANS help you approach care from the nursing perspective.
APPLYING CRITICAL THINKING questions come at the end of select sample Nursing Care Plans to encourage further reflection and analysis.
INTRODUCTION Western medicine is an approach to health that focuses on the use of science in the diagnosis and treatment of health problems. This is in contrast to Eastern medicine , which places greater emphasis on prevention and natural healing. The differences between Western and Eastern medicine are not about geographic location since both Eastern and Western health practitioners exist in almost every part of the world. Most of nursing education in the United States, Canada, Europe, and Australia has been under the umbrella of Western medi- cine. Thus, nurses from these parts of the world are familiar and comfortable with biomedical beliefs, theories, practices, strengths, and limitations. In this chapter the terms conventional medicine , biomedicine , and allopathic medicine are used to describe West- ern medical practices. Fewer nurses have studied Eastern medicine and as a result may lack information or even harbor misinformation about these healing practices.
The term complementary and alternative medicine (CAM) includes as many as 1,800 other therapies practiced all over the world. Many of these have been handed down over thousands of years, both orally and as written records. They are based on the Eastern medical
systems of ancient people, including Egyptians, Chinese, Asian Indi- ans, Greeks, and Native Americans. Other therapies, such as bioelec- tromagnetics and chiropractic, evolved in the United States during the past two centuries. Still others, such as some of the mind–body approaches, are on the frontier of scientific knowledge and under- standing. The CAM therapies described in this chapter are only some of the many used by clients. Nurses must learn about the ones being used by the clients in their specific practice settings.
Complementary medicine refers to the use of CAM together with conventional medicine. Most use of CAM by Americans is complementary. Alternative medicine refers to use of CAM in place of conventional medicine. Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness. It is also called integrated medicine .
The public interest in complementary and alternative therapies is extensive and growing. One has only to look at the proliferation of popular health books, health food stores, and clinics offering heal- ing therapies to realize this. In 1998, the National Institutes of Health established the National Center for Complementary and Alternative
acupressure , 301 acupuncture , 301 allopathic medicine , 295 alternative medicine , 295 animal-assisted therapy , 306 aromatherapy , 299 Ayurveda , 297 balance , 296 bioelectromagnetics , 306 biofeedback , 304 biomedicine , 295 chiropractic , 300
complementary medicine , 295 conventional medicine , 295 curanderismo , 298 detoxification , 306 Eastern medicine , 295 energy , 296 faith , 304 guided imagery , 303 hand-mediated biofield
therapies , 301 herbal medicine , 298 holism , 296
homeopathy , 299 horticultural therapy , 306 humanist , 296 hypnotherapy , 303 imagery , 303 integrative medicine , 295 massage therapy , 301 meditation , 303 music therapy , 305 naturopathic medicine , 300 pilates , 304 prayer , 304
qi , 297 qi gong , 304 reflexology , 301 spirituality , 296 t’ai chi , 304 traditional Chinese medicine
(TCM) , 297 Western medicine , 295 yoga , 302
KEY TERMS
After completing this chapter, you will be able to: 1. Describe the basic concepts of alternative practices. 2. Give examples of healing environments. 3. Describe the basic principles of health care practices such
as Ayurveda, traditional Chinese medicine, Native American healing, and curanderismo.
4. Explain how herbs are similar to many prescription drugs. 5. Discuss the principles of naturopathic medicine. 6. Identify the role of manual healing methods in health and
illness.
LEARNING OUTCOMES
19 Complementary and Alternative Healing Modalities
7. Describe the goals that yoga, meditation, hypnotherapy, guided imagery, qi gong, and t’ai chi have in common.
8. Identify types of detoxification therapies. 9. Discuss uses of animals, prayer, and humor as treatment
modalities. 10. Teach clients the uses of and safety precautions regarding
complementary and alternative therapies.
295
CLIENT: Manuela AGE: 55 CURRENT MEDICAL DIAGNOSIS: Still’s Disease Medical History: Manuela has experienced some type of health challenge for most of her adult life. She was diagnosed with adult- onset Still’s disease (AOSD) at about age 35 after several years of tests to try to determine exactly what syndrome her symptoms re- flected. She complained of joint pain, rash, and fevers, which came and went, and she had an enlarged spleen and liver. This disease has many similarities with rheumatoid and autoimmune diseases, but those conditions were all removed from consideration because the tests were negative. AOSD is a chronic condition for which there is no known cure. In addition to joint deterioration, it can progress to affect the lungs and heart. Initial treatment consists of steroids and nonsteroidal anti-inflammatory drugs (NSAIDS). If those are ineffec- tive, other medications such as gold and chemotherapeutics are used; however, they have severe side effects such as kidney damage and bone marrow suppression. The condition worsens when the person is under physical or emotional stress. Manuela
underwent a hip replacement about 4 years ago and recently has had several hospitalizations for respiratory failure. Personal and Social History: Manuela has never married and has lived near or with her parents or siblings for all her life. She has many friends, drives, and has an active social life when she is feeling well. She uses the computer extensively for communication, especially when having visitors or talking by phone is too exhausting. She must follow a strict diet of food and liquids that are easy to swallow and digest. She is a spiritual person but not overly religious. She is quick to laugh and generally has an optimistic outlook, but expresses awareness that her life could end at any time—certainly long before her full life expectancy.
Manuela is a college graduate but has been able to work only part time for most of her life. Recently, she was declared permanently disabled, which allows her access to financial and other support sys- tems. She is creative in adapting her living situation to her disabilities and unwilling to give up her beloved pet dog.
Questions American Nurses Association Standard of Practice #3 is Outcomes Identification: The nurse consults with the client and family in formulating measureable goals consistent with the client’s culture, values, and environment. As you learned in Chapter 16 , Manuela’s needs fall into the category of tertiary prevention in which rehabilitation and movement toward optimal levels of functionality within the individual’s constraints are the focus. 1. What are some outcomes for Manuela that would reflect
this focus? 2. Do you need to know her personal definitions of health and
health beliefs ( Chapter 17 ) before you can work with her to set expected outcomes?
American Nurses Association Standard of Practice #5b is Health Teaching and Health Promotion: The nurse customizes the client’s teaching to promote a healthy environment. 3. What are some aspects of Manuela’s situation that you would
consider incorporating into a teaching plan to maximize a safe environment for her?
American Nurses Association Standard of Professional Performance #13 is Collaboration: Nurses work with the client, family, and other health care providers in planning, implementing, and evaluating care. 4. Which health care team members other than physicians
and nurses would likely be important to include in Manuela’s care plan?
American Nurses Association Standard of Professional Performance #9 is Research . 5. What evidence might you have or seek to support the use
of alternative or complementary treatment modalities in Manuela’s care?
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.
UNIT
4 Meeting the Standards In this unit, we have explored concepts related to health, health promotion, wellness, illness, culture and heritage, and complementary and alternative healing modalities. These topics heighten awareness of the individualistic nature of the relationship between the nurse and the client and the importance of assessing the breadth of factors that affect health decisions and behaviors. In the case described below, you will see how one person demonstrates complicated, interrelated, personal definitions of health and illness influenced by her medical condition, her heritage, and her demographic character- istics (e.g., age and family structure). These definitions and perspectives in turn influence her choices for care and support—including the role of her nurses.
310
Chapter 13 ● Planning 203
BOX 13–2 Benefits of Standardized Interventions
• Enhances communication among nurses and among nurses and nonnurses.
• Makes it possible for researchers to determine the effectiveness and cost of nursing treatments.
• Helps communicate the nature of nursing to the public. • Helps demonstrate the impact that nurses have on health care. • Makes it easier for nurses to select appropriate interventions by
reducing the need for memorization and recall. • Facilitates the teaching of clinical decision making.
• Contributes to the development and use of computerized clinical records.
• Assists in effective planning for staff and equipment needs. • Aids in development of a system of payment for nursing
services. • Promotes full and meaningful participation of nurses in the
multidisciplinary team.
From Nursing Process & Critical Thinking, 5th ed. (p. 253), by J. M. Wilkinson, 2012, Upper Saddle River, NJ: Prentice Hall. Adapted with permission.
LIFESPAN CONSIDERATIONS Nursing Care Plan
OLDER ADULTS When a client is in an extended care facility or a long-term care facility, interventions and medications often remain the same day after day. It is important to review the care plan on a regular basis, because changes in the condition of older adults may be subtle and go unnoticed. This applies to both changes of improvement or deterioration. Either one should receive attention so that appropri- ate revisions can be made in expected outcomes and interventions. Outcomes need to be realistic with consideration given to the cli- ent’s physical condition, emotional condition, support systems, and
mental status. Outcomes often have to be stated and expected to be completed in very small steps. For instance, clients who have had a cerebrovascular accident may spend weeks learning to brush their own teeth or dress themselves. When these small steps are successfully completed, it gives the client a sense of accomplish- ment and motivation to continue working toward increasing self- care. This particular example also demonstrates the need to work collaboratively with other departments, such as physical and occu- pational therapy, to develop the nursing care plan.
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/Indicators Nursing Interventions Rationale
Respiratory Status: Gas Exchange [0402], as evidenced by • Absence of pallor and cyanosis (skin
and mucous membranes) • Use of correct breathing/coughing
technique after instruction
Monitor respiratory status q4h: rate, depth, effort, skin color, mucous membranes, amount and color of sputum. Monitor results of blood gases, chest x-ray studies, and incentive spirometer volume as available. Monitor level of consciousness.
To identify progress toward or deviations from goal. Ineffective Airway Clearance leads to poor oxygenation, as evidenced by pallor, cyanosis, lethargy, and drowsiness.
• Productive cough • Symmetric chest excursion of
at least 4 cm
Auscultate lungs q4h. Vital signs q4h (TPR, BP, pulse oximetry, pain).
Inadequate oxygenation and pain cause increased pulse rate. Respiratory rate may be decreased by narcotic analgesics. Shallow breathing further compromises oxygenation.
Within 48–72 hours: • Lungs clear to auscultation • Respirations 12–22/min; pulse, less
than 100 beats/min
Instruct in breathing and coughing techniques. Remind to perform, and assist q3h.
To enable client to cough up secretions. May need encouragement and support because of fatigue and pain.
• Inhales normal volume of air on incentive spirometer
Administer prescribed expectorant; schedule for maximum effectiveness. Maintain Fowler’s or semi-Fowler’s position. Administer prescribed analgesics. Notify primary care provider if pain not relieved.
Helps loosen secretions so they can be coughed up and expelled. Gravity allows for fuller lung expansion by decreasing pressure of abdomen on diaphragm. Controls pleuritic pain by blocking pain pathways and altering perception of pain, enabling client to increase thoracic expansion. Unrelieved pain may signal impending complication.
NURSING CARE PLAN Margaret O’Brien
Continued on page 204
218 Unit 3 ● The Nursing Process
Nursing Diagnosis: Ineffective Airway Clearance related to viscous secretions and shallow chest expansion secondary to deficient fluid volume, pain, and fatigue
Desired Outcomes*/ Indicators Evaluation Statements Nursing Interventions**
Explanation for Continuing or Modifying Nursing Interventions
• Freely expresses concerns and possible solutions about work and parenting roles
Partially met. Discussed only briefly on 3–11 shift. Not done on 11–7 shift because of client’s need to rest. (Evaluated 8/27/14, JW)
As client can tolerate, encourage to express and expand on her concerns about her child and her work. Explore alternatives as needed.
It is important that this assessment be made right away, so child care can be arranged if needed.
Note whether husband returns as scheduled. If he does not, institute care plan for actual Interrupted Family Process. (Do on 8/27, day shift) (8/27/14, JW)
*The NOC # for desired outcomes is listed in brackets following the appropriate outcome.
**In this care plan, a line has been drawn through portions the nurse wished to delete; additions to the care plan are shown in italics.
NURSING CARE PLAN For Margaret O’Brien Modified Following Implementation and Evaluation—continued
Applying Critical Thinking 1. From reviewing Margaret O’Brien’s nursing care plan, what general conclusions can you make about the desired outcomes for
Ineffective Airway Clearance and Anxiety? 2. Despite some of the outcomes being only partially met or not met, no new interventions were written for several outcomes. What
reasons might there be for this? 3. For the nursing diagnosis of Anxiety, most of the outcomes are fully met. Would you delete this diagnosis from the care plan at this
time? Why or why not? 4. Since the Evaluation Statements column is generally not used on written care plans, where would auditors or individuals
conducting quality assessments find these data? See Critical Thinking Possibilities on student resource website.
• Implementing is putting planned nursing interventions into action. • Successful implementing and evaluating depend in part on the
quality of the preceding phases of assessing, diagnosing, and planning.
• Reassessing occurs simultaneously with the implementing phase of the nursing process.
• Cognitive, interpersonal, and technical skills are used to implement nursing strategies.
• Before implementing an order, the nurse reassesses the client to be sure that the order is still appropriate.
• The nurse must determine whether assistance is needed to per- form a nursing intervention knowledgeably, safely, and comfortably for the client.
• The implementing phase terminates with the documentation of the nursing activities and client responses.
• After the care plan has been implemented, the nurse evaluates the client’s health status and the effectiveness of the care plan in achieving client goals.
• The desired outcomes formulated during the planning phase serve as criteria for evaluating client progress and improved health status.
• The desired outcomes determine the data that must be collected to evaluate the client’s health status.
• Reexamining the client care plan is a process of making decisions about problem status and critiquing each phase of the nursing process.
• Professional standards of care hold that nurses are responsible and accountable for implementing and evaluating the plan of care.
• Quality assurance evaluation includes consideration of the struc- tures, processes, and outcomes of nursing care.
• Quality improvement is a philosophy and process internal to the institution, and does not rely on inspections by an external agency.
CHAPTER HIGHLIGHTS
Chapter 14 Review
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SETTING THE FOUNDATION FOR CLINICAL COMPETENCE!
STEP-BY-STEP SKILLS An easy-to-follow format helps students understand techniques and practice sequences.
• Includes a complete Equipment list for easy preparation.
• Clearly labeled Delegation boxes assist you in assigning tasks appropriately.
• Easy-to-find rationales give you a better understanding of why things are done.
• Critical steps are visually represented with full-color photos and illustrations.
CONCEPT MAPS provide visual representations of the nursing process, nursing care plans, and the relationships between difficult concepts.
318 Unit 5 ● Life Span Development
CONCEPT MAP Overview of Growth and Development Psychosocial Theories and Theorists
Theories
Freud
personality develops
in five overlapping stages from
birth to adulthood
5 stages: • Oral • Anal • Phallic • Latency • Genital
theorist theorist theorist theoristtheorist
Erikson
stages reflect
positive and
negative aspects of the critical
life periods
8 stages: • Trust vs. Mistrust • Autonomy vs. Shame & Doubt • Initiative vs. Guilt • Industry vs. Inferiority • Identity vs. Role Confusion • Intimacy vs. Isolation • Generativity vs. Stagnation • Integrity vs. Despair
Havighurst
believed
• Growth & development occurs during 6 age periods (infancy to later maturity) • Each age period has developmental tasks • Achieving the developmental tasks helps the individual transition to the next developmental period
Peck
adult development
• Three developmental tasks during old age: • Ego differentiation vs. work-role • Body transcendence vs. body preoccupation • Ego transcendence vs. ego preoccupation
Gould
adult development
7 stages: • 1: 16–18 years • 2: 18–22 years • 3: 22–28 years • 4: 28–34 years • 5: 34–43 years • 6: 43–50 years • 7: 50–60 years
Growth and Development
Psychosocial Development
• Stage 6 (ages 43–50). Personalities are seen as set. Time is accepted
as finite. Individuals are interested in social activities with friends and spouse and desire both sympathy and affection from spouse.
• Stage 7 (ages 50–60). This is a period of transformation, with a real- ization of mortality and a concern for health. There is an increase in warmth and a decrease in negativism. The spouse is seen as a valuable companion ( Gould, 1972 , pp. 525–527).
Temperament Theories Early research on temperament, conducted in the 1950s by Stella Chess and Alexander Thomas, identified nine temperamental qualities seen in children’s behavior ( Table 20–3 ). Temperament is multidimensional leading to the development of a child’s person- ality traits. Temperament has a role in the development of anxiety, depression, attention deficit disorder, and other types of behavior
632 Unit 8 • Integral Components of Client Care
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Sterile gloves are available to protect the nurse from contact with blood and body fluids. Latex and nitrile gloves are more flexible than vinyl, mold to the wearer’s hands, and allow freedom of movement. Since latex should be avoided due to possible allergies, wear nitrile gloves when performing tasks (a) that demand flexibility, (b) that place stress on the material (e.g., turning stopcocks, handling sharp instruments or tape), and (c) that involve a high risk of exposure to pathogens. Vinyl gloves should be chosen for tasks unlikely to stress the glove material, requiring minimal precision, and with minimal risk of exposure to pathogens.
Skill 31–4 describes how to apply and remove sterile gloves by the open method.
Sterile Gloves Sterile gloves may be applied by the open method or the closed method. The open method is most frequently used outside the oper- ating room because the closed method requires that the nurse wear a sterile gown. Gloves are worn during many procedures to enable the nurse to handle sterile items freely and to prevent clients at risk (e.g., those with open wounds) from becoming infected by microorgan- isms on unsterile gloves or the nurse’s hands.
Sterile gloves are packaged with a cuff of about 5 cm (2 in.) and with the palms facing upward when the package is opened. The pack- age usually indicates the size of the glove (e.g., size 6 or 7 1/2 or small, medium, large).
❶ Picking up the first sterile glove.
PURPOSES • To enable the nurse to handle or touch sterile objects freely with-
out contaminating them • To prevent transmission of potentially infective organisms from
the nurse’s hands to clients at high risk for infection
Applying and Removing Sterile Gloves (Open Method)
S K
IL L 3
1 –4
ASSESSMENT Review the client’s record and orders to determine exactly what procedure will be performed that requires sterile gloves. Check the client record and ask about latex allergies. Use nonlatex gloves whenever possible.
INTERPROFESSIONAL PRACTICE
Sterile gloves are used many health care providers. All providers should be comfortable pointing out to each other when any break in sterile technique is detected.
Equipment • Packages of sterile gloves
PLANNING Think through the procedure, planning which steps need to be com- pleted before the gloves can be applied. Determine what additional supplies are needed to perform the procedure for this client. Always have an extra pair of sterile gloves available.
DELEGATION
Sterile procedures are not delegated to UAP.
edge (on the palmar side) with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff. ❶ Rationale: The hands are not sterile. By touching only the inside of the glove, the nurse avoids contaminating the outside.
or • If the gloves are packaged one on top of the other, grasp
the cuff of the top glove as above, using the opposite hand. • Insert the dominant hand into the glove and pull the glove
on. Keep the thumb of the inserted hand against the palm of the hand during insertion. ❷ Rationale: If the thumb is kept
IMPLEMENTATION Preparation Ensure the sterility of the package of gloves.
Performance 1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary.
2. Perform hand hygiene and observe other appropriate infection prevention procedures (see Skills 31–1, 31–2, and 31–3).
3. Provide for client privacy. 4. Open the package of sterile gloves.
• Place the package of gloves on a clean, dry surface. Rationale: Any moisture on the surface could contaminate the gloves.
• Some gloves are packed in an inner as well as an outer package. Open the outer package without contaminating the gloves or the inner package. See Skill 31–3.
• Remove the inner package from the outer package. • Open the inner package as in step 4 of Skill 31–3 or accord-
ing to the manufacturer’s directions. Some manufacturers provide a numbered sequence for opening the flaps and folded tabs to grasp for opening the flaps. If no tabs are provided, pluck the flap so that the fingers do not touch the inner surfaces. Rationale: The inner surfaces, which are next to the sterile gloves, will remain sterile.
5. Put the first glove on the dominant hand. • If the gloves are packaged so that they lie side by side,
grasp the glove for the dominant hand by its folded cuff
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Chapter 15 ● Documenting and Reporting 233
agency’s policies about the type of pen and ink used for recording. In regards to EHRs, changes are made in accordance with the software guidelines. It is important for the nurse to understand the policies and procedures of the health care institution regarding documentation.
Date and Time Document the date and time of each recording. This is essential not only for legal reasons but also for client safety. Record the time in the conventional manner (e.g., 9:00 am or 3:15 pm ) or according to the 24-hour clock (military clock), which avoids confusion about whether a time was am or pm ( Figure 15–9 ■ ).
Timing Follow the agency’s policy about the frequency of documenting, and adjust the frequency as a client’s condition indicates; for example, a client whose blood pressure is changing requires more frequent documentation than a client whose blood pressure is constant. As a rule, documenting should be done as soon as possible after an assessment or intervention. No recording should be done before providing nursing care.
Legibility All entries must be legible and easy to read to prevent interpreta- tion errors. Hand printing or easily understood handwriting is usually permissible. Follow the agency’s policies about handwritten recording.
Permanence All entries on the client’s record are made in dark ink so that the re- cord is permanent and changes can be identified. Dark ink repro- duces well on microfilm and in duplication processes. Follow the
PRACTICE GUIDELINES
Long-Term Care Documentation
• Complete the assessment and screening forms (MDS) and plan of care within the time period specified by regulatory bodies.
• Keep a record of any visits and of phone calls from family, friends, and others regarding the client.
• Write nursing summaries and progress notes that comply with the frequency and standards required by regulatory bodies.
• Review and revise the plan of care every 3 months or whenever the client’s health status changes.
• Document and report any change in the client’s condition to the primary care provider and the client’s family within 24 hours.
• Document all measures implemented in response to a change in the client’s condition.
• Make sure that progress notes address the client’s progress in relation to the goals or outcomes defined in the plan of care.
Figure 15–9 ■ The 24-hour clock.
PM
AM
2400
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300 12 1
2
3
4
5 6
7
8
9
10
11 0100
0200
0300
0400
0500 0600
0700
0800
0900
1000
1100
PRACTICE GUIDELINES
Home Health Care Documentation
• Complete a comprehensive nursing assessment and develop a plan of care to meet Medicare and other third-party payer requirements. Some agencies use the certification and plan of treatment form as the client’s official plan of care.
• Write a progress note at each client visit, noting any changes in the client’s condition, nursing interventions performed (including education and instructional brochures and materials provided to the client and home caregiver), client responses to nursing care, and vital signs as indicated.
• Provide a monthly progress nursing summary to the attending primary care provider and to the reimburser to confirm the need to continue services.
• Keep a copy of the care plan in the client’s home and update it as the client’s condition changes.
• Report changes in the plan of care to the primary care provider and document that these were reported. Medicare and Medicaid will reimburse only for the skilled services provided that are reported to the primary care provider.
• Encourage the client or home caregiver to record data when appropriate.
• Write a discharge summary for the primary care provider to approve the discharge and to notify the reimbursers that services have been discontinued. Include all services provided, the client’s health status at discharge, outcomes achieved, and recommendations for further care.
Chapter 29 ● Vital Signs 481
with severe hypothermia, a hyperthermia blanket (an electronically controlled blanket that provides a specified temperature) is applied, and warm intravenous fluids are given. Wet clothing, which increases heat loss because of the high conductivity of water, should be replaced with dry clothing. See Box 29–3 for nursing interventions for clients who have hypothermia.
Assessing Body Temperature The most common sites for measuring body temperature are oral, rectal, axillary, tympanic membrane, and skin/temporal artery. Each of the sites has advantages and disadvantages ( Table 29–1 ).
The body temperature may be measured orally . If a client has been taking cold or hot food or fluids or smoking, the nurse should wait 30 minutes before taking the temperature orally to ensure that the temperature of the mouth is not affected by the temperature of the food, fluid, or warm smoke.
Rectal temperature readings are considered to be very accurate. Rectal temperatures are contraindicated for clients who are undergo- ing rectal surgery, have diarrhea or diseases of the rectum, are immuno- suppressed, have a clotting disorder, or have significant hemorrhoids.
The axilla is often the preferred site for measuring temperature in newborns because it is accessible and safe. Axillary temperatures are lower than rectal temperatures. Some clinicians recommend re- checking an elevated axillary temperature with one taken from an- other site to confirm the degree of elevation. Nurses should check agency protocol when taking the temperature of newborns, infants, toddlers, and children. Adult clients for whom the axillary method of temperature assessment is appropriate include those for whom other temperature sites are contraindicated.
Nursing Interventions for Clients with Fever BOX 29–2
• Monitor vital signs. • Assess skin color and temperature. • Monitor white blood cell count, hematocrit value, and other
pertinent laboratory reports for indications of infection or dehydration.
• Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled.
• Provide adequate nutrition and fluids (e.g., 2,500–3,000 mL/ day) to meet the increased metabolic demands and prevent dehydration.
• Measure intake and output. • Reduce physical activity to limit heat production, especially
during the flush stage. • Administer antipyretics (drugs that reduce the level of fever) as
ordered. • Provide oral hygiene to keep the mucous membranes moist. • Provide a tepid sponge bath to increase heat loss through
conduction. • Provide dry clothing and bed linens.
CLINICAL MANIFESTATIONS
Hypothermia • Decreased body temperature, pulse, and respirations • Severe shivering (initially) • Feelings of cold and chills • Pale, cool, waxy skin • Frostbite (discolored, blistered nose, fingers, toes) • Hypotension • Decreased urinary output • Lack of muscle coordination • Disorientation • Drowsiness progressing to coma
Nursing Interventions for Clients with Hypothermia BOX 29–3
• Provide a warm environment. • Provide dry clothing. • Apply warm blankets. • Keep limbs close to body. • Cover the client’s scalp with a cap or turban. • Supply warm oral or intravenous fluids. • Apply warming pads.
this results in frostbite. Frostbite most commonly occurs in hands, feet, nose, and ears.
Managing hypothermia involves removing the client from the cold and rewarming the client’s body. For the client with mild hypo- thermia, the body is rewarmed by applying blankets; for the client
Site Advantages Disadvantages
Oral Accessible and convenient Thermometers can break if bitten. Inaccurate if client has just ingested hot or cold food or fluid or smoked. Could injure the mouth following oral surgery.
Rectal Reliable measurement Inconvenient and more unpleasant for clients; difficult for client who cannot turn to the side. Could injure the rectum. Presence of stool may interfere with thermometer placement.
Axillary Safe and noninvasive The thermometer may need to be left in place a long time to obtain an accurate measurement.
Tympanic membrane Readily accessible; reflects the core temperature; very fast
Can be uncomfortable and involves risk of injuring the membrane if the probe is inserted too far. Repeated measurements may vary. Right and left measurements can differ. Presence of cerumen can affect the reading.
Temporal artery Safe and noninvasive; very fast Requires electronic equipment that may be expensive or unavailable. Variation in technique needed if the client has perspiration on the forehead.
TABLE 29–1 Advantages and Disadvantages of Sites Used for Body Temperature Measurements
496 Unit 7 ● Assessing Health
DRUG CAPSULE
CLIENT WITH CARDIAC MEDICATIONS THAT AFFECT HEART RATE Cardiac glycosides increase cardiac contractility, which increases car- diac output. As a result, perfusion to the kidneys is increased, which increases the production of urine. Cardiac glycosides also decrease heart rate by prolonging cardiac conduction, especially at the AV node.
Digoxin is commonly used for the clinical management of heart failure, atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia.
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