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Unit 1: Discussion – Myocardial Infarction 1200w.due 1-10-22
Initial Response-800 words
Instructions:
Read the following case study and answer the posed questions:
Mr. T., a 45-year-old black man employed as a midlevel corporate manager, came to the doctor’s office seeking a physical examination. He appeared somewhat overweight. He denied taking any medications or smoking, but admitted drinking alcohol. His father and older brother have hypertension (HTN) and his paternal grandfather experienced a myocardial infarction (MI) and a CVA at a young age. Mr. T. stated, “A year ago at a health fair my cholesterol was tested. I was told later by mail that my cholesterol was 250 and I had to recheck my blood pressure.” His Bp at the time of his examination was 159/94, HR 96, weight 275, height 5’11 in.
1.
200 words
. Using the attached text
(CHAPTER 31 Angina and Myocardial Infarction) and link to Explain the progressive pathophysiologic relationship between an MI and the development of left ventricular (LV) failure.
2.
200 words.
What factors affect the severity of LV failure?
Next, visit
http://www.cdc.gov/ncbddd/dvt/facts.html Links to an external site.
and access resources about deep vein thrombosis.
3.
200 words
. Document the manifestations and management of clients with deep vein thrombosis.
CHAPTER 35 Peripheral Vascular Diseases page 225.
4.
200 words
. Submit a summary of some of the things you learned from this video.
.
Please be sure to validate your opinions and ideas with citations and references in APA format.
Peer Response -400 words
Instructions:
Look at your course colleagues’ responses.
1.
200 words
. From your advanced practice mindset reflect on a discussion you would like to have with two of your course colleagues about their responses.
2.
200 words
. Post a response individually to each of them that expresses your advanced practice nursing role perspective of the data represented in their response.
Use scholarly resources relevant to your advanced practice nursing role to support the key elements of the peer discussions you construct. [For example – if you are a nurse educator (clinical or academic) what are your thoughts about their ability to follow task instructions for constructing the assignment, etc.?; if you a nurse leader what are your thoughts about the success of their application of a process improvement model, etc.?; if you are a nurse practitioner what are your observations about the non-conventional modality presented in the schemata, can you locate any evidence or the foundational basic sciences that support the modality, etc?
Please be sure to validate your opinions and ideas with citations and references in APA format.
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FUNDAMENTALS FOR NURSING I
Fundamentals for Nursing
REVIEW MODULE EDITION 9.0
Contributors
Norma Jean E. Henry, MSN/Ed, RN
Mendy McMichael, DNP, MSN
Janean Johnson, MSN, RN, CNE
Agnes DiStasi, DNP, RN, CNE
Brenda S. Ball, MEd, BSN, RN
Honey C. Holman, MSN, RN
Mary Jane Janowski, RN, MA
Marsha S. Barlow, MSN, RN
Peggy Leehy, MSN, RN
Terri Lemon, DNP, MSN, RN
Consultants
Susan Adcock, RN, MS
Tracey Bousquet, BSN, RN
Lakeisha Wheless, MSN, RN
Pam DeMoss, MSN, RN
Melanie Schrader, MSN, RN
Betty Daniel, MSN Nursing Education, RN
Virginia Tufano, EdD, MSN, RN
Megan Jester, MS, RN
Lisa Kongable, MA, PMH‑CNS, ARNP, CNE
INTELLECTUAL PROPERTY NOTICE
ATI Nursing is a division of Assessment Technologies Institute®, LLC.
Copyright © 2016 Assessment Technologies Institute, LLC. All rights reserved.
The reproduction of this work in any electronic, mechanical or other means, now known or hereafter
invented, is forbidden without the written permission of Assessment Technologies Institute, LLC. All of the
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graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual
property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by
third parties who have licensed their materials to Assessment Technologies Institute, LLC.
II CONTENT MASTERY SERIES
IMPORTANT NOTICE TO THE READER
Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for
informational and educational purposes only and may be modified or updated by the publisher at any time. This
publication is not providing medical advice and is not intended to be a substitute for professional medical advice,
diagnosis, or treatment. The publisher has designed this publication to provide accurate information regarding the
subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to
the use of the contents of this book and makes no guarantee and assumes no responsibility or liability for the use of the
products and procedures described or the correctness, sufficiency, or completeness of stated information, opinions, or
recommendations. The publisher does not recommend or endorse any specific tests, providers, products, procedures,
processes, opinions, or other information that may be mentioned in this publication. Treatments and side effects described
in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect
that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by
the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice,
and government regulations often change the accepted standard in this field. When consideration is being given to use
of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the
drug, reading the package insert, and reviewing prescribing information for the most up‑to‑date recommendations
on dose, precautions, and contraindications and determining the appropriate usage for the product. Any references
in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely
as a general guide. Other or additional safety measures may be required under particular circumstances. This book
is not intended as a statement of the standards of care required in any particular situation, because circumstances
and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book
shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such
specific determination should be made only with the aid of legal counsel. Some images in this book feature models.
These models do not necessarily endorse, represent, or participate in the activities represented in the images. THE
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RESPECT TO THE CONTENT HEREIN. THIS PUBLICATION IS PROVIDED AS‑IS, AND THE PUBLISHER AND ITS AFFILIATES
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DAMAGES RESULTING, IN WHOLE OR IN PART, FROM THE READER’S USE OF, OR RELIANCE UPON, SUCH CONTENT.
Director of content review: Kristen Lawler
Director of development: Derek Prater
Project management: Janet Hines, Nicole Burke
Coordination of content review: Norma Jean E. Henry, Mendy McMichael
Copy editing: Kelly Von Lunen, Derek Prater
Layout: Spring Lenox, Randi Hardy
Illustrations: Randi Hardy
Online media: Morgan Smith, Ron Hanson, Nicole Lobdell, Brant Stacy
Cover design: Jason Buck
Interior book design: Spring Lenox
FUNDAMENTALS FOR NURSING USER’S GUIDE III
User’s Guide
Welcome to the Assessment Technologies Institute®
Fundamentals for Nursing Review Module Edition 9.0. The
mission of ATI’s Content Mastery Series® Review Modules
is to provide user‑friendly compendiums of nursing
knowledge that will:
● Help you locate important information quickly.
● Assist in your learning efforts.
● Provide exercises for applying your nursing knowledge.
● Facilitate your entry into the nursing profession as a
newly licensed nurse.
This newest edition of the Review Modules has been
redesigned to optimize your learning experience. We’ve
fit more content into less space and have done so in a
way that will make it even easier for you to find and
understand the information you need.
ORGANIZATION
This Review Module is organized into units covering the
NCLEX® major client needs categories: Safe, Effective Care
Environment, Health Promotion, Psychosocial Integrity,
and Physiological Integrity. Chapters within these
units conform to one of four organizing principles for
presenting the content.
● Nursing concepts
● Growth and development
● Procedures
● System disorders
Nursing concepts chapters begin with an overview
describing the central concept and its relevance to nursing.
Subordinate themes are covered in outline form to
demonstrate relationships and present the information in
a clear, succinct manner.
Growth and development chapters cover expected growth
and development, including physical and psychosocial
development; age‑appropriate activities; and health
promotion, including immunizations, health screenings,
nutrition, and injury prevention.
Procedures chapters include an overview describing
the procedure(s) covered in the chapter. These
chapters provide nursing knowledge relevant to each
procedure, including indications, nursing considerations,
interpretation of findings, and complications.
ACTIVE LEARNING SCENARIOS
AND APPLICATION EXERCISES
Each chapter includes opportunities for you to test your
knowledge and to practice applying that knowledge. Active
Learning Scenario exercises pose a nursing scenario
and then direct you to use an ATI Active Learning
Template (included at the back of this book) to record
the important knowledge a nurse should apply to the
scenario. An example is then provided to which you can
compare your completed Active Learning Template. The
Application Exercises include NCLEX‑style questions, such
as multiple‑choice and multiple‑select items, providing
you with opportunities to practice answering the kinds of
questions you might expect to see on ATI assessments or
the NCLEX. After the Application Exercises, an answer key
is provided, along with rationales.
NCLEX® CONNECTIONS
To prepare for the NCLEX, it is important to understand
how the content in this Review Module is connected to
the NCLEX test plan. You can find information on the
detailed test plan at the National Council of State Boards
of Nursing’s website, www.ncsbn.org. When reviewing
content in this Review Module, regularly ask yourself,
“How does this content fit into the test plan, and what
types of questions related to this content should I expect?”
To help you in this process, we’ve included NCLEX
Connections at the beginning of each unit and with each
question in the Application Exercises Answer Keys. The
NCLEX Connections at the beginning of each unit point
out areas of the detailed test plan that relate to the content
within that unit. The NCLEX Connections attached to the
Application Exercises Answer Keys demonstrate how each
exercise fits within the detailed content outline.
These NCLEX Connections will help you understand how
the detailed content outline is organized, starting with
major client needs categories and subcategories and
followed by related content areas and tasks. The major
client needs categories are:
● Safe and Effective Care Environment
◯ Management of Care
◯ Safety and Infection Control
● Health Promotion and Maintenance
● Psychosocial Integrity
● Physiological Integrity
◯ Basic Care and Comfort
◯ Pharmacological and Parenteral Therapies
◯ Reduction of Risk Potential
◯ Physiological Adaptation
An NCLEX Connection might, for example, alert you that
content within a unit is related to:
● Basic Care and Comfort
◯ Assistive Devices
■ Assess client use of assistive devices.
IV USER’S GUIDE CONTENT MASTERY SERIES
QSEN COMPETENCIES
As you use the Review Modules, you will note the
integration of the Quality and Safety Education for
Nurses (QSEN) competencies throughout the chapters.
These competencies are integral components of the
curriculum of many nursing programs in the United States
and prepare you to provide safe, high‑quality care as a
newly licensed nurse. Icons appear to draw your attention
to the six QSEN competencies.
Safety: The minimization of risk factors that could
cause injury or harm while promoting quality care
and maintaining a secure environment for clients, self,
and others.
Patient-Centered Care: The provision of caring and
compassionate, culturally sensitive care that addresses
clients’ physiological, psychological, sociological, spiritual,
and cultural needs, preferences, and values.
Evidence-Based Practice: The use of current knowledge
from research and other credible sources, on which to base
clinical judgment and client care.
Informatics: The use of information technology as a
communication and information‑gathering tool that
supports clinical decision-making and scientifically based
nursing practice.
Quality Improvement: Care related and organizational
processes that involve the development and
implementation of a plan to improve health care services
and better meet clients’ needs.
Teamwork and Collaboration: The delivery of client care
in partnership with multidisciplinary members of the
health care team to achieve continuity of care and positive
client outcomes.
ICONS
Icons are used throughout the Review Module to draw
your attention to particular areas. Keep an eye out for
these icons.
This icon is used for NCLEX Connections.
This icon indicates gerontological considerations,
or knowledge specific to the care of older
adult clients.
This icon is used for content related to safety
and is a QSEN competency. When you see this
icon, take note of safety concerns or steps that
nurses can take to ensure client safety and a
safe environment.
This icon is a QSEN competency that indicates
the importance of a holistic approach to
providing care.
This icon, a QSEN competency, points out the
integration of research into clinical practice.
This icon is a QSEN competency and highlights
the use of information technology to support
nursing practice.
This icon is used to focus on the QSEN
competency of integrating planning processes to
meet clients’ needs.
This icon highlights the QSEN competency of care
delivery using an interprofessional approach.
This icon appears at the top‑right of pages
and indicates availability of an online media
supplement, such as a graphic, animation, or
video. If you have an electronic copy of the
Review Module, this icon will appear alongside
clickable links to media supplements. If you have
a hard copy version of the Review Module, visit
www.atitesting.com for details on how to access
these features.
FEEDBACK
ATI welcomes feedback regarding this Review Module.
Please provide comments to comments@atitesting.com.
FUNDAMENTALS FOR NURSING TABLE OF CONTENTS V
Table of Contents
NCLEX® Connections 1
UNIT 1 Safe, Effective Care Environment
SECTION: Management of Care
CHAPTER 1 Health Care Delivery Systems 3
CHAPTER 2 The Interprofessional Team 7
CHAPTER 3 Ethical Responsibilities 11
CHAPTER 4 Legal Responsibilities 15
CHAPTER 5 Information Technology 21
CHAPTER 6 Delegation and Supervision 25
CHAPTER 7 Nursing Process 29
CHAPTER 8 Critical Thinking and Clinical Judgment 33
CHAPTER 9 Admissions, Transfers, and Discharge 37
Admission process 37
Transfer and discharge process 38
NCLEX® Connections 43
SECTION: Safety and Infection Control
CHAPTER 10 Medical and Surgical Asepsis 45
CHAPTER 11 Infection Control 49
Herpes zoster (shingles) 54
CHAPTER 12 Client Safety 57
CHAPTER 13 Home Safety 63
CHAPTER 14 Ergonomic Principles 71
CHAPTER 15 Security and Disaster Plans 75
VI TABLE OF CONTENTS CONTENT MASTERY SERIES
NCLEX® Connections 81
UNIT 2 Health Promotion
SECTION: Nursing Throughout the Lifespan
CHAPTER 16 Health Promotion and Disease Prevention 83
CHAPTER 17 Client Education 87
CHAPTER 18 Infants (2 Days to 1 Year) 91
CHAPTER 19 Toddlers (1 to 3 Years) 97
CHAPTER 20 Preschoolers (3 to 6 Years) 101
CHAPTER 21 School‑Age Children (6 to 12 Years) 105
CHAPTER 22 Adolescents (12 to 20 Years) 109
CHAPTER 23 Young Adults (20 to 35 Years) 113
CHAPTER 24 Middle Adults (35 to 65 Years) 117
CHAPTER 25 Older Adults (65 Years and Older) 121
NCLEX® Connections 125
SECTION: Health Assessment/Data Collection
CHAPTER 26 Data Collection and General Survey 127
CHAPTER 27 Vital Signs 133
Temperature 133
Pulse 135
Respirations 137
Blood pressure 138
CHAPTER 28 Head and Neck 143
Head and neck 143
Eyes 144
Ears, nose, mouth, and throat 146
CHAPTER 29 Thorax, Heart, and Abdomen 151
Breasts 151
Thorax and lungs 152
Heart 154
Abdomen 155
FUNDAMENTALS FOR NURSING TABLE OF CONTENTS VII
CHAPTER 30 Integumentary and Peripheral Vascular Systems 161
CHAPTER 31 Musculoskeletal and Neurosensory Systems 165
Musculoskeletal system 165
Neurosensory system 166
NCLEX® Connections 171
UNIT 3 Psychosocial Integrity
CHAPTER 32 Therapeutic Communication 173
CHAPTER 33 Coping 179
Stress, coping, adaptation, and adherence 179
Family systems and family dynamics 180
Situational role changes 181
CHAPTER 34 Self‑Concept and Sexuality 185
CHAPTER 35 Cultural and Spiritual Nursing Care 189
CHAPTER 36 Grief, Loss, and Palliative Care 195
Palliative care 196
Postmortem care 198
NCLEX® Connections 201
UNIT 4 Physiological Integrity
SECTION: Basic Care and Comfort
CHAPTER 37 Hygiene 203
CHAPTER 38 Rest and Sleep 209
CHAPTER 39 Nutrition and Oral Hydration 213
CHAPTER 40 Mobility and Immobility 219
Mobility and immobility 219
Application of heat and cold 223
Promoting venous return 224
CHAPTER 41 Pain Management 227
CHAPTER 42 Complementary and Alternative Therapies 233
VIII TABLE OF CONTENTS CONTENT MASTERY SERIES
CHAPTER 43 Bowel Elimination 237
Constipation and diarrhea 238
CHAPTER 44 Urinary Elimination 243
Urinary incontinence 246
CHAPTER 45 Sensory Perception 251
Vision loss 253
Hearing loss 254
NCLEX® Connections 259
SECTION: Pharmacological and Parenteral Therapies
CHAPTER 46 Pharmacokinetics and Routes of Administration 261
CHAPTER 47 Safe Medication Administration and Error Reduction 269
CHAPTER 48 Dosage Calculation 277
Solid dosage 277
Liquid dosage 278
Injectable dosage 279
Dosages by weight 280
IV flow rates 282
CHAPTER 49 Intravenous Therapy 289
CHAPTER 50 Adverse Effects, Interactions, and Contraindications 295
CHAPTER 51 Individual Considerations of Medication Administration 301
NCLEX® Connections 305
SECTION: Reduction of Risk Potential
CHAPTER 52 Specimen Collection for Glucose Monitoring 307
Blood glucose testing 307
Urine glucose testing 308
CHAPTER 53 Airway Management 311
Pulse oximetry 311
Oxygen therapy 312
Sputum specimen collection 315
Chest physiotherapy 315
Suctioning 316
Artificial airways and tracheostomy care 317
CHAPTER 54 Nasogastric Intubation and Enteral Feedings 321
Nasogastric intubation 321
Enteral feedings 323
FUNDAMENTALS FOR NURSING TABLE OF CONTENTS IX
NCLEX® Connections 327
SECTION: Physiological Adaptation
CHAPTER 55 Pressure Ulcers, Wounds, and Wound Management 329
General principles of wound management 330
Pressure ulcers 332
CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic Infections 337
Herpes zoster (shingles) 340
CHAPTER 57 Fluid Imbalances 343
Fluid volume deficit 343
Fluid volume excesses 344
CHAPTER 58 Electrolyte Imbalances 347
Hyponatremia 347
Hypernatremia 348
Hypokalemia 349
Hyperkalemia 350
Hypocalcemia 350
Hypercalcemia 351
Hypomagnesemia 352
Hypermagnesemia 352
References 355
Active Learning Templates A1
Basic Concept A1
Diagnostic Procedure A3
Growth and Development A5
Medication A7
Nursing Skill A9
System Disorder A11
Therapeutic Procedure A13
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 1
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Management of Care
CONCEPTS OF MANAGEMENT: Identify roles/
responsibilities of health care team members.
ASSIGNMENT, DELEGATION AND SUPERVISION:
Utilize the five rights of delegation.
CONTINUITY OF CARE: Perform procedures necessary
to safely admit, transfer or discharge a client.
ESTABLISHING PRIORITIES: Prioritize the delivery of client care.
ETHICAL PRACTICE: Recognize ethical
dilemmas and take appropriate action.
INFORMATION TECHNOLOGY: Utilize valid resources
to enhance the care provided to a client.
LEGAL RIGHTS AND RESPONSIBILITIES:
Identify legal issues affecting the client.
FUNDAMENTALS FOR NURSING CHAPTER 1 HealtH Care Delivery SyStemS 3
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 1 Health Care
Delivery Systems
Health care delivery systems incorporate
interactions between health care providers
and clients within the constraints of financing
mechanisms and regulatory agencies.
Health care systems include the clients who
participate, the settings in which health
care takes place, the agencies that regulate
health care, and mechanisms that provide
financial support.
most nurses deliver care within the context of
health care systems. as these systems continue
to become more business‑driven and less
service‑oriented, the challenge to nursing today
is to retain its caring values while practicing
within a cost‑containment structure.
COMPONENTS OF HEALTH
CARE SYSTEMS
PartiCiPaNtS
Consumers (clients)
Providers
● Licensed providers such as:
● Registered nurses
● Licensed practical nurses (also known as licensed
vocational nurses)
● Advanced practice nurses (APN)
● Medical doctors
● Pharmacists
● Dentists
● Dietitians
● Physical, respiratory, and occupational therapists
Unlicensed providers , such as assistive personnel
SettiNGS
● Hospitals
● Homes
● Skilled‑nursing, assisted‑living, and
extended‑care facilities
● Community/health departments
● Adult day care centers
● Schools
● Hospices
● Providers’ offices
● Ambulatory care clinics
● Occupational health clinics
● Stand‑alone surgical centers
● Urgent care centers
● Complementary therapy centers
reGUlatOry aGeNCieS
● U.S. Department of Health and Human Services
● U.S. Food and Drug Administration (FDA)
● State and local public health agencies
● State licensing boards to ensure that health care
providers and agencies comply with state regulations
● The Joint Commission (formerly JCAHO) to set quality
standards for accreditation of health care facilities
● Professional Standards Review Organizations to monitor
health care services provided
● Utilization review committees to monitor
for appropriate diagnosis and treatment of
hospitalized clients
HealtH Care FiNaNCiNG meCHaNiSmS
PUBLIC FEDERALLY FUNDED PROGRAMS
Medicare is for clients greater than 65 years of age or
those with permanent disabilities.
● Part A: hospital insurance
● Part B: medical insurance
● Part C: Medicare advantage plan
● Part D: medications
Medicaid is for clients who have low incomes.
● It is federally and state funded.
● Individual states determine eligibility requirements.
Affordable Care Act of 2010, also known as Obamacare, is
a controversial federal statute aimed at:
● Increasing access to health care for all individuals and
instituting an individual mandate for health insurance
● Deceasing health care costs
● Providing opportunities for uninsured to become
insured at an affordable cost
State Children’s Health Insurance Program: Coverage for
uninsured children up to age 19 at low cost to parents
CHAPTER 1
4 CHAPTER 1 HealtH Care Delivery SyStemS CONTENT MASTERY SERIES
PRIVATE PLANS
● Traditional insurance reimburses for services on a
fee‑for‑service basis.
● Managed care organizations (MCOs): Primary care
providers oversee comprehensive care for enrolled
clients and focus on prevention and health promotion.
● Preferred provider organizations (PPOs): Clients choose
from a list of contracted providers and hospitals.
Using non‑contracted providers increases the
out‑of‑pocket costs.
● Exclusive provider organizations (EPOs): Clients
choose from a list of providers and hospitals
within a contracted organization with no
out‑of‑network coverage.
● Long‑term care insurance: Used as a supplement for
long‑term care expenses Medicare does not cover.
LEVELS OF HEALTH CARE
Preventive health care focuses on educating and
equipping clients to reduce and control risk factors for
disease. Examples include programs that promote
immunization, stress management, occupational health
programs, and seat belt use.
Primary health care emphasizes health promotion and
includes prenatal and well‑baby care, family planning,
nutrition counseling, and disease control. This level
of care is a sustained partnership between clients
and providers. Examples include office or clinic visits,
community health centers, and scheduled school‑ or
work‑centered screenings (vision, hearing, obesity).
Secondary health care includes the diagnosis and
treatment of acute illness and injury. Examples include
care in hospital settings (inpatient and emergency
departments), diagnostic centers, and emergent
care centers.
Tertiary health care , or acute care, involves the provision
of specialized and highly technical care. Examples include
intensive care, oncology centers, and burn centers.
Restorative health care involves intermediate follow‑up
care for restoring health and promoting self‑care.
Examples include home health care, rehabilitation centers,
and skilled nursing facilities.
Continuing health care addresses long‑term or chronic
health care needs over a period of time. Examples include
end‑of‑life care, palliative care, hospice, adult day care,
assisted living, and in‑home respite care.
RELATIONSHIP BETWEEN HEALTH
CARE SYSTEMS AND LEVELS OF CARE
People: The level of care depends on the needs of the
client. Licensed and unlicensed health care personnel
work in every level of care.
Setting: The settings for secondary and tertiary care are
usually within a hospital or specific facility. Settings for
other levels of care vary.
Regulatory agencies help ensure the quality and quantity
of health care and the protection of health care consumers.
Health care finance influences the quality and type of
care by setting parameters for cost containment and
reimbursement.
SAFETY AND QUALITY
In response to concerns about the safety and quality
of client care in the United States, Quality and Safety
Education for Nurses (QSEN) assists nursing programs in
preparing nurses to provide safe, high‑quality care. To
draw attention to the six QSEN competencies, these icons
appear throughout the review modules.
Safety: The minimization of risk factors that could cause
injury or harm while promoting high‑quality care and
maintaining a secure environment for clients, self,
and others.
Patient-Centered Care: The provision of caring and
compassionate, culturally sensitive care that addresses
clients’ physiological, psychological, sociological, spiritual,
and cultural needs, preferences, and values. The client is
included in the decision‑making process.
Evidence Based Practice: The use of current knowledge
from research and other credible sources on which to base
clinical judgment and client care.
Informatics: The use of information technology as a
communication and information‑gathering tool that
supports clinical decision-making and scientifically based
nursing practice.
Quality Improvement: Care‑related and organizational
processes that involve the development and
implementation of a plan to improve health care services
and better meet clients’ needs.
Teamwork and Collaboration: The delivery of client care
in partnership with multidisciplinary members of the
health care team to achieve continuity of care and positive
client outcomes.
THE FUTURE OF HEALTH CARE
The ultimate issue in designing and delivering health care
is ensuring the health and welfare of the population.
FUNDAMENTALS FOR NURSING CHAPTER 1 HealtH Care Delivery SyStemS 5
Application Exercises
1. a nurse is discussing restorative
health care with a newly licensed
nurse. Which of the following
examples should the nurse include in
the teaching? (Select all that apply.)
a. Home health care
B. rehabilitation facilities
C. Diagnostic centers
D. Skilled nursing facilities
e. Oncology centers
2. a nurse is explaining the various
types of health care coverage
clients might have to a group of
nursing students. Which of the
following health care financing
mechanisms are federally
funded? (Select all that apply.)
a. Preferred provider
organization (PPO)
B. medicare
C. long‑term care insurance
D. exclusive provider
organization (ePO)
e. medicaid
3. a nurse manager is developing
strategies to care for the increasing
number of clients who have obesity.
Which of the following actions
should the nurse include as a
primary health care strategy?
a. Collaborating with providers
to perform obesity screenings
during routine office visits
B. ensuring the availability
of specialized beds in
rehabilitation centers for
clients who have obesity
C. Providing specialized
intraoperative training
regarding surgical
treatments for obesity
D. educating acute care nurses on
postoperative complications
related to obesity
4. a nurse is discussing the purpose
of regulatory agencies during
a staff meeting. Which of the
following tasks should the nurse
identify as the responsibility
of state licensing boards?
a. monitoring evidence‑based
practice for clients who
have a specific diagnosis
B. ensuring that health
care providers comply
with regulations
C. Setting quality standards
for accreditation of
health care facilities
D. Determining if
medications are safe for
administration to clients
5. a nurse is explaining the various
levels of health care services to
a group of newly licensed nurses.
Which of the following examples
of care or care settings should
the nurse classify as tertiary
care? (Select all that apply.)
a. intensive care unit
B. Oncology treatment center
C. Burn center
D. Cardiac rehabilitation
e. Home health care
PRACTICE Active Learning Scenario
a nurse on a medical‑surgical unit is acquainting a
group of nurses with the Quality and Safety education
for Nurses (QSeN) initiative. Use the ati active learning
template: Basic Concept to complete this item.
RELATED CONTENT: list the six QSeN competencies,
along with a brief description of each.
6 CHAPTER 1 HealtH Care Delivery SyStemS CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: restorative health care involves intermediate
follow‑up care for restoring health and promoting self‑care.
Home health care is a type of restorative health care.
B. CORRECT: restorative health care involves intermediate
follow‑up care for restoring health and promoting self‑care.
rehabilitation facilities are a type of restorative health care.
C. Secondary health care includes the diagnosis and treatment of acute
injury or illness. Diagnostic centers are a type of secondary health care.
D. CORRECT: restorative health care involves intermediate
follow‑up care for restoring health and promoting self‑care.
Skilled nursing facilities are a type of restorative health care.
e. tertiary health care is specialized and highly technical
care. an oncology center is a type of tertiary health care.
NCLEX® Connection: Management of Care,
Health Promotion/Disease Prevention
2. a. PPOs are privately funded.
B. CORRECT: medicare is federally funded.
C. long‑term care insurance is privately funded.
D. ePOs are privately funded.
e. CORRECT: medicaid is federally funded.
NCLEX® Connection: Management of Care,
Information Technology
3. a. CORRECT: the nurse should identify obesity screenings
at office visits as an example of primary health care. Primary
health care emphasizes health promotion and disease control, is
often delivered during office visits, and includes screenings.
B. the nurse should identify care that is provided in a
rehabilitation center as an example of restorative health care.
C. the nurse should identify specialized and highly
technical care as an example of tertiary health care.
D. the nurse should identify acute care of clients
as an example of secondary health care.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
4. a. the nurse should identify that utilization review committees
have the responsibility of monitoring for appropriate diagnosis
and treatment according to evidence‑based practice
for diagnosis and treatment of hospitalized clients.
B. CORRECT: the nurse should identify that state licensing
boards are responsible for ensuring that health care
providers and agencies comply with state regulations.
C. the nurse should identify that the Joint Commission
has the responsibility of setting quality standards
for accreditation of health care facilities.
D. the nurse should identify that the U.S. Food and Drug
administration has the responsibility of determining if
medications are safe for administration to clients.
NCLEX® Connection: Management of Care,
Information Technology
5. a. CORRECT: tertiary health care involves the provision
of specialized and highly technical care, such as the
care nurses deliver in intensive care units.
B. CORRECT: tertiary health care involves the provision
of specialized and highly technical care, such as the care
nurses deliver in oncology treatment centers.
C. CORRECT: tertiary health care involves the provision of specialized
and highly technical care, such as the care nurses deliver in burn centers.
D. this is an example of restorative care and also of
tertiary prevention, but not of tertiary care.
e. this is an example of restorative care.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● Safety: minimization of risk factors that could cause injury or harm while promoting
quality care and maintaining a secure environment for clients, self, and others.
● Patient‑Centered Care: Provision of caring and compassionate, culturally
sensitive care that addresses clients’ physiological, psychological,
sociological, spiritual, and cultural needs, preferences, and values.
● evidence‑Based Practice: Use of current knowledge from research and other
credible sources, on which to base clinical judgment and client care.
● informatics: Use of information technology as a communication and information‑gathering
tool that supports clinical decision‑making and scientifically based nursing practice.
● Quality improvement: Care‑related and organizational processes that involve the development
and implementation of a plan to improve health care services and better meet clients’ needs.
● teamwork and Collaboration: Delivery of client care in partnership with multidisciplinary
members of the health care team to achieve continuity of care and positive client outcomes.
NCLEX® Connection: Management of Care, Information Technology
FUNDAMENTALS FOR NURSING CHAPTER 2 The InTerprofessIonal Team 7
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 2 The Interprofessional
Team
rns and practical nurses (pns) are integral
members of the interprofessional health care
team. each discipline represented on an
interprofessional team uses a set of skills within
the scope of practice for the specific profession.
In some instances, the scope of practice for one
discipline overlaps with the scope of practice or
set of skills for another profession. for example,
the nurse and the respiratory care therapist both
possess the knowledge and skill to perform
chest physiotherapy (using postural drainage,
percussion, and vibration to promote drainage
of secretions from the lungs).
The interprofessional health care team works
collaboratively to provide holistic care to clients.
The nurse is most often the manager of care and
must understand the roles and responsibilities of
other health care team members to collaborate
and make appropriate referrals.
INTERPROFESSIONAL PERSONNEL
(NON‑NURSING)
Spiritual support staff: Provides spiritual care (pastors,
rabbis, priests).
example of when to refer: a client requests
communion, or the family asks for prayer prior
to the client undergoing a procedure.
Registered dietitian: Assesses, plans for, and educates
regarding nutrition needs. Designs special diets, and
supervises meal preparation.
example of when to refer: a client has a low albumin
level and recently had an unexplained weight loss.
Laboratory technician: Obtains specimens of body fluids,
and performs diagnostic tests.
example of when to refer: a provider
needs to see a client’s complete blood
count (CBC) results immediately.
Occupational therapist: Assesses and plans for clients
to regain activities of daily living (ADL) skills, especially
motor skills of the upper extremities.
example of when to refer: a client has
difficulties using an eating utensil with
her dominant hand following a stroke.
Pharmacist: Provides and monitors medication. Supervises
pharmacy technicians in states that allow this practice.
example of when to refer: a client is concerned
about a new medication’s interactions
with any of his other medications.
Physical therapist: Assesses and plans for clients to
increase musculoskeletal function, especially of the lower
extremities, to maintain mobility.
example of when to refer: following hip
arthroplasty, a client requires assistance
learning to ambulate and regain strength.
Provider: Assesses, diagnoses, and treats disease and
injury. Providers include medical doctors (MDs), doctors
of osteopathy (DOs), advanced practice nurses (APNs),
and physician assistants (PAs). State regulations vary in
their requirements for supervision of APNs and PAs by a
physician (MDs and DOs).
example of when to refer: a client has a
temperature of 39º C (102.2º f), is achy
and shaking, and reports feeling cold.
Radiologic technologist: Positions clients and performs
x‑rays and other imaging procedures for providers to
review for diagnosis of disorders of various body parts.
example of when to refer: a client reports
severe pain in his hip after a fall, and the
provider prescribes an x‑ray of the client’s hip.
Respiratory therapist: Evaluates respiratory status and
provides respiratory treatments including oxygen therapy,
chest physiotherapy, inhalation therapy, and mechanical
ventilation.
example of when to refer: a client who
has respiratory disease is short of breath
and requests a nebulizer treatment.
Social worker: Works with clients and families by
coordinating inpatient and community resources to meet
psychosocial and environmental needs that are necessary
for recovery and discharge.
example of when to refer: a client who has terminal
cancer wishes to go home but is no longer able to
perform many aDls. The client’s partner needs
medical equipment in the home to care for the client.
Speech-language pathologist: Evaluates and makes
recommendations regarding the impact of disorders or
injuries on speech, language, and swallowing. Teaches
techniques and exercises to improve function.
example of when to refer: a client is having difficulty
swallowing a regular diet after trauma to the head
and neck.
CHAPTER 2 Online Video: Interdisciplinary Team
8 CHAPTER 2 The InTerprofessIonal Team CONTENT MASTERY SERIES
NURSING PERSONNEL
The nursing team works together to advocate for and meet
the needs of clients within the health care delivery system.
Registered nurse (RN)
The RN is the lead team member, soliciting input from all
nursing team members, setting priorities, sharing
information with other disciplines, and coordinating
client care.
EDUCATIONAL PREPARATION
● Must meet the state board of nursing’s requirements
for licensure.
● Requires completion of a diploma program, an associate
degree, or a baccalaureate degree in nursing prior to
taking the licensure exam (licensed).
ROLES AND RESPONSIBILITIES
● Function legally under state nurse practice acts.
● Perform assessments; establish nursing diagnoses,
goals, and interventions; and conduct ongoing
client evaluations.
● Participate in developing interprofessional plans for
client care.
● Share appropriate information among team members;
initiate referrals for client assistance, including health
education; and identify community resources.
Practical nurse (PN)
EDUCATIONAL PREPARATION
● Must meet the state board of nursing’s requirements.
● Requires vocational or community college education
prior to taking the licensure exam (licensed).
ROLES AND RESPONSIBILITIES
● Work under the supervision of the RN.
● Collaborate within the nursing process, coordinate the
plan of care, consult with other team members, and
recognize the need for referrals to assist with actual or
potential problems.
● Possess technical knowledge and skills.
● Participate in the delivery of nursing care, using the
nursing process as a framework.
Assistive personnel (AP)
This includes certified nursing assistants (CNAs) and
certified medical assistants (CMAs), and non-nursing
personnel such as dialysis technicians, monitor
technicians, and phlebotomists.
EDUCATIONAL PREPARATION
● Must meet the state’s formal or informal
training requirements.
● Requirement by most states for training and
examination to attain CNA status.
ROLES AND RESPONSIBILITIES
● Work under the direct supervision of an RN or PN.
● Position description in the employing facility outlines
specific tasks.
● Tasks can include feeding clients, preparing nutritional
supplements, lifting, basic care (grooming, bathing,
transferring, toileting, positioning), measuring and
recording vital signs, and ambulating clients.
eXpanDeD nUrsInG roles
Advanced practice nurse (APN): Has a great deal of
autonomy. APNs usually have a minimum of a master’s
degree in nursing (or related field), advanced education in
pharmacology and physical assessment, and certification
in a specialized area of practice. Included in this role are
the following.
● Clinical nurse specialist (CNS): Typically specializes in
a practice setting or a clinical field.
● Nurse practitioner (NP): Collaborates with one or more
providers to deliver nonemergency primary health care
in a variety of settings.
● Certified registered nurse anesthetist (CRNA):
Administers anesthesia and provides care during
procedures under the supervision of an anesthesiologist.
● Certified nurse‑midwife (CNM): Collaborates with one
or more providers to deliver care to maternal‑newborn
clients and their families.
Nurse educator: Teaches in schools of nursing, staff
development departments in health care facilities, or
client education departments.
Nurse administrator: Provides leadership to nursing
departments within a health care facility.
Nurse researcher: Conducts research primarily to improve
the quality of client care.
FUNDAMENTALS FOR NURSING CHAPTER 2 The InTerprofessIonal Team 9
Application Exercises
1. a nurse is caring for a group of clients
on a medical‑surgical unit. for which
of the following client care needs
should the nurse initiate a referral for
a social worker? (select all that apply.)
a. a client who has terminal
cancer requests hospice
care in her home.
B. a client asks about
community resources
available for older adults.
C. a client states that she
wants her child baptized
before surgery.
D. a client requests an
electric wheelchair for
use after discharge.
e. a client states that he
does not understand
how to use a nebulizer.
2. a goal for a client who has difficulty
with self‑feeding due to rheumatoid
arthritis is to use adaptive devices.
The nurse caring for the client
should initiate a referral to which
of the following members of the
interprofessional care team?
a. social worker
B. Certified nursing assistant
C. registered dietitian
D. occupational therapist
3. a client who is postoperative
following knee arthroplasty is
concerned about the adverse
effects of the medication he is
receiving for pain management.
Which of the following members
of the interprofessional care
team can assist the client in
understanding the medication’s
effects? (select all that apply.)
a. provider
B. Certified nursing assistant
C. pharmacist
D. registered nurse
e. respiratory therapist
4. a client who has had a
cerebrovascular accident has
persistent problems with dysphagia
(difficulty swallowing). The nurse
caring for the client should
initiate a referral with which of
the following members of the
interprofessional care team?
a. social worker
B. Certified nursing assistant
C. occupational therapist
D. speech‑language pathologist
5. a nurse is acquainting a group
of newly licensed nurses with the
roles of the various members of the
health care team they will encounter
on a medical‑surgical unit. When
she gives examples of the types
of tasks certified nursing assistants
(Cnas) may perform, which of the
following client activities should
she include? (select all that apply.)
a. Bathing
B. ambulating
C. Toileting
D. Determining pain level
e. measuring vital signs
PRACTICE Active Learning Scenario
a nurse is teaching a group of newly licensed nurses about
the various nursing roles they can aspire to after they
achieve mastery in basic nursing skills. Use the aTI active
learning Template: Basic Concept to complete this item.
RELATED CONTENT: Describe at least five types
of advance practice nursing roles, including a brief
description of their primary responsibilities.
10 CHAPTER 2 The InTerprofessIonal Team CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: The nurse should initiate a referral for a
social worker to provide information and assistance
in coordinating hospice care for a client.
B. CORRECT: The nurse should initiate a referral for a social
worker to provide information and assistance in coordinating
care for community resources available for clients.
C. The nurse should initiate a referral for spiritual support staff
if a client requests specific religious sacraments or prayers.
D. CORRECT: The nurse should initiate a referral for a social worker to
assist the client in obtaining medical equipment for use after discharge.
e. The nurse should provide client teaching for concerns regarding
the use of a nebulizer. If additional information is needed the
nurse should initiate a referral for a respiratory therapist.
NCLEX® Connection: Management of Care, Referrals
2. a. a social worker can coordinate community services to help
the client, but not specifically with self‑feeding devices.
B. a certified nursing assistant can help the client with feeding,
but does not typically procure adaptive devices for the client.
C. a registered dietitian can help with educating the
client about meeting nutritional needs, but cannot
help with the client’s physical limitations.
D. CORRECT: an occupational therapist can assist clients
who have physical challenges to use adaptive devices
and strategies to help with self‑care activities.
NCLEX® Connection: Management of Care, Referrals
3. a. CORRECT: The provider must be knowledgeable
about any medication he prescribes for the client,
including its actions, effects, and interactions.
B. It is not within the scope of a certified nursing assistant’s
duties to counsel a client about medications.
C. CORRECT: a pharmacist must be knowledgeable
about any medication she dispenses for the client,
including its actions, effects, and interactions.
D. CORRECT: a registered nurse must be knowledgeable
about any medication she administers, including
its actions, effects, and interactions.
e. although some analgesics can cause respiratory
depression, requiring assistance from a respiratory therapist,
it is not within this therapist’s scope of practice to counsel
the client about medications his provider prescribes.
NCLEX® Connection: Management of Care, Referrals
4. a. a social worker can coordinate community services to
help the client, but not specifically with dysphagia.
B. a certified nursing assistant can help the client with
feeding, but cannot assess and treat dysphagia.
C. an occupational therapist can assist clients who have
motor challenges to improve abilities with self‑care and
work, but cannot assess and treat dysphagia.
D. CORRECT: a speech‑language pathologist can
initiate specific therapy for clients who have difficulty
with feeding due to swallowing difficulties.
NCLEX® Connection: Management of Care, Referrals
5. a. CORRECT: It is within the scope of a Cna’s duties
to provide basic care to clients, such as bathing.
B. CORRECT: It is within the scope of a Cna’s duties to provide
basic care to clients, such as assisting with ambulation.
C. CORRECT: It is within the scope of a Cna’s duties to provide
basic care to clients, such as assisting with toileting.
D. Determining pain level is a task that requires
the assessment skills of licensed personnel, such as
nurses. It is outside the scope of a Cna’s duties.
e. CORRECT: It is within the scope of a Cna’s duties to provide
basic care to clients, such as measuring and recording vital signs.
NCLEX® Connection: Management of Care, Assignment,
Delegation and Supervision
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● Clinical nurse specialist (Cns): Typically specializes in a practice setting or a clinical field.
● nurse practitioner (np): Collaborates with one or more providers to deliver
nonemergency primary health care in a variety of settings.
● Certified registered nurse anesthetist (Crna): administers anesthesia and provides
care during procedures under the supervision of an anesthesiologist.
● Certified nurse‑midwife (Cnm): Collaborates with one or more providers
to deliver care to maternal‑newborn clients and their families.
● nurse educator: Teaches in schools of nursing, staff development
departments in health care facilities, or client education departments.
● nurse administrator: provides leadership to nursing departments within a health care facility.
● nurse researcher: Conducts research primarily to improve the quality of client care.
NCLEX® Connection: Management of Care, Concepts of Management
FUNDAMENTALS FOR NURSING CHAPTER 3 Ethical REsponsibilitiEs 11
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 3 Ethical
Responsibilities
Ethics is the study of conduct and character, and
a code of ethics is a guide for the expectations
and standards of a profession.
Ethical theories examine principles, ideas,
systems, and philosophies that affect judgments
about what is right and wrong, and good and
bad. common ethical theories are utilitarianism,
deontology, consensus in bioethics, and ethics
of care.
Ethical principles for individuals, groups of
individuals, and societies are standards of what
is right or wrong with regard to important social
values and norms.
Values are personal beliefs about ideas that
determine standards that shape behavior.
Morals are personal values and beliefs about
behavior and decision‑making.
ETHICAL DECISION‑MAKING IN NURSING
Bioethics refers to the application of ethics to health
and life. It addresses dilemmas such as stem cell
research, organ transplantation, gender reassignment,
and reproductive technologies (in vitro fertilization,
surrogate parenting)
basic pRinciplEs oF Ethics
● Advocacy: support of clients’ health, wellness, safety,
and personal rights, including privacy.
● Responsibility: willingness to respect obligations and
follow through on promises.
● Accountability: ability to answer for one’s own actions.
● Confidentiality: protection of privacy without
diminishing access to high‑quality care.
Ethical pRinciplEs FoR cliEnt caRE
● Autonomy: the right to make one’s own personal
decisions, even when those decisions might not be in
that person’s own best interest.
● Beneficence: action that promotes good for others,
without any self‑interest.
● Fidelity: fulfillment of promises.
● Justice: fairness in care delivery and use of resources.
● Nonmaleficence: a commitment to do no harm.
● Veracity: a commitment to tell the truth.
Ethical DilEMMas
● Ethical dilemmas are problems that involve more than
one choice and stem from differences in the values and
beliefs of the decision makers. These are common in
health care, and nurses must apply ethical theory and
decision‑making to ethical problems.
● A problem is an ethical dilemma when:
◯ A review of scientific data is not enough to solve it.
◯ It involves a conflict between two moral imperatives.
◯ The answer will have a profound effect on the
situation and the client.
CHAPTER 3
12 CHAPTER 3 Ethical REsponsibilitiEs CONTENT MASTERY SERIES
Ethical DEcision‑MaKinG
Ethical decision‑making is a process that requires striking
a balance between science and morality.
When making an ethical decision:
● Identify whether the issue is indeed an ethical dilemma.
● Gather as much relevant information as possible about
the dilemma.
● Reflect on your own values as they relate to
the dilemma.
● State the ethical dilemma, including all surrounding
issues and the individuals it involves.
● List and analyze all possible options for resolving the
dilemma, and review the implications of each option.
● Select the option that is in concert with the ethical
principle that applies to this situation, the decision
maker’s values and beliefs, and the profession’s values
for client care. Justify selecting that one option in light
of the relevant variables.
● Apply this decision to the dilemma, and evaluate
the outcomes.
Ethics committees generally address unusual or complex
ethical issues.
Examples of ethical guidelines for nurses are the
American Nurses Association’s Code of Ethics for Nurses With
Interpretive Statements (2015) and the International Council
of Nurses’ The ICN Code of Ethics for Nurses (2012).
3.1 Nursing’s roles in ethical
decision‑making
An agent for clients facing an ethical decision. Examples:
● caring for an adolescent client who has to
decide whether to undergo an abortion even
though her parents believe it is wrong
● Discussing options with a parent who has to decide
whether to consent to a blood transfusion for a
child when his religion prohibits such treatment
A decision maker for health care delivery. Examples:
● assigning staff nurses a higher client load
than previously because administration has
reduced the number of nurses per shift
● Witnessing a surgeon discussing only surgical options with
a client without mentioning more conservative measures
FUNDAMENTALS FOR NURSING CHAPTER 3 Ethical REsponsibilitiEs 13
Application Exercises
1. a nurse is caring for a client who
decides not to have surgery
despite significant blockages in
his coronary arteries. the nurse
understands that this client’s
choice is an example of which of
the following ethical principles?
a. Fidelity
b. autonomy
c. Justice
D. nonmaleficence
2. a nurse offers pain medication
to a client who is postoperative
prior to ambulation. the nurse
understands that this aspect of care
delivery is an example of which of
the following ethical principles?
a. Fidelity
b. autonomy
c. Justice
D. beneficence
3. a nurse is instructing a group
of nursing students about the
responsibilities organ donation and
procurement involve. When the nurse
explains that all clients waiting for a
kidney transplant have to meet the
same qualifications, the students
should understand that this aspect of
care delivery is an example of which
of the following ethical principles?
a. Fidelity
b. autonomy
c. Justice
D. nonmaleficence
4. a nurse questions a medication
prescription as too extreme in
light of the client’s advanced age
and unstable status. the nurse
understands that this action
is an example of which of the
following ethical principles?
a. Fidelity
b. autonomy
c. Justice
D. nonmaleficence
5. a nurse is instructing a group
of nursing students about how
to know and what to expect
when ethical dilemmas arise.
Which of the following situations
should the students identify
as an ethical dilemma?
a. a nurse on a medical‑surgical
unit demonstrates signs
of chemical impairment.
b. a nurse overhears another
nurse telling an older adult
client that if he doesn’t
stay in bed, she will have
to apply restraints.
c. a family has conflicting
feelings about the initiation of
enteral tube feedings for their
father, who is terminally ill.
D. a client who is terminally
ill hesitates to name her
spouse on her durable
power of attorney form.
PRACTICE Active Learning Scenario
a nurse is teaching a group of nursing students about the
process of resolving ethical dilemmas. Use the ati active
learning template: basic concept to complete this item.
UNDERLYING PRINCIPLES: Define the
ethical decision‑making process.
NURSING INTERVENTIONS: list the steps
of making an ethical decision.
14 CHAPTER 3 Ethical REsponsibilitiEs CONTENT MASTERY SERIES
Application Exercises Key
1. a. Fidelity is the fulfillment of promises. the nurse has
not made any promises; this is the client’s decision.
b. CORRECT: in this situation, the client is exercising his right to
make his own personal decision about surgery, regardless of others’
opinions of what is “best” for him. this is an example of autonomy.
c. Justice is fairness in care delivery and in the use of resources. because
the client has chosen not to use them, this principle does not apply.
D. nonmaleficence is a commitment to do no harm. in this situation,
harm can occur whether or not the client has surgery. however,
because he chooses not to, this principle does not apply.
NCLEX® Connection: Management of Care, Ethical Practice
2. a. Fidelity is the fulfillment of promises. Unless the nurse has
specifically promised the client a pain‑free recovery, which
is unlikely, this principle does not apply to this action.
b. autonomy is the right to make personal decisions, even when they
are not necessarily in the person’s best interest. in this situation, the
nurse is delivering responsible client care. this principle does not apply.
c. Justice is fairness in care delivery and in the use of
resources. pain management is available for all clients who
are postoperative, so this principle does not apply.
D. CORRECT: beneficence is action that promotes good for others,
without any self‑interest. by administering pain medication before
the client attempts a potentially painful exercise like ambulation, the
nurse is taking a specific and positive action to help the client.
NCLEX® Connection: Management of Care, Ethical Practice
3. a. Fidelity is the fulfillment of promises. because donor
organs are a scarce resource compared with the numbers
of potential recipients who need them, no one can promise
anyone an organ. thus, this principle does not apply.
b. autonomy is the right to make personal decisions, even when
they are not necessarily in the person’s best interest. no personal
decision is involved with the qualifications for organ recipients.
c. CORRECT: Justice is fairness in care delivery and in the use of
resources. by applying the same qualifications to all potential kidney
transplant recipients, organ procurement organizations demonstrate this
ethical principle in determining the allocation of these scarce resources.
D. nonmaleficence is a commitment to do no harm. in this
situation, harm can occur to organ donors and to recipients. the
requirements of the organ procurement organizations are standard
procedures and do not address avoidance of harm or injury.
NCLEX® Connection: Management of Care, Ethical Practice
4. a. Fidelity is the fulfillment of promises. the nurse is not addressing
a specific promise when she determines the appropriateness of a
prescription for the client. thus, this principle does not apply.
b. autonomy is the right to make personal decisions, even when they
are not necessarily in the person’s best interest. no personal decision
is involved when the nurse questions the client’s prescription.
c. Justice is fairness in care delivery and in the use of resources. in
this situation, the nurse is delivering responsible client care and is
not assessing available resources. this principle does not apply.
D. CORRECT: nonmaleficence is a commitment to do no harm. in
this situation, administering the medication could harm the client. by
questioning it, the nurse is demonstrating this ethical principle.
NCLEX® Connection: Management of Care, Ethical Practice
5. a Delivering client care while showing signs of a substance
use disorder is a legal issue, not an ethical dilemma.
b. a nurse who threatens to restrain a client has committed
assault. this is a legal issue, not an ethical dilemma.
c. CORRECT: Making the decision about initiating enteral tube
feedings is an example of an ethical dilemma. a review of scientific
data cannot resolve the issue, and it is not easy to resolve. the decision
will have a profound effect on the situation and on the client.
D. the selection of a person to make health care decisions on
a client’s behalf is a legal decision, not an ethical dilemma.
NCLEX® Connection: Management of Care, Ethical Practice
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES: Ethical decision‑making is a process that
requires striking a balance between science and morality.
NURSING INTERVENTIONS
● identifying whether the issue is an ethical dilemma
● Gathering as much relevant information as possible about the dilemma
● Reflecting on one’s own values as they relate to the dilemma
● stating the ethical dilemma, including all surrounding issues and individuals it involves
● listing and analyzing all possible options for resolving the
dilemma with implications of each option
● selecting the option that is in concert with the ethical principle that applies to this situation,
the decision maker’s values and beliefs, and the profession’s values for client care
● Justifying the selection of one option in light of relevant variables
NCLEX® Connection: Management of Care, Ethical Practice
FUNDAMENTALS FOR NURSING CHAPTER 4 LegaL ResponsibiLities 15
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 4 Legal
Responsibilities
Understanding the laws governing nursing
practice helps nurses protect clients’ rights and
reduce the risk of nursing liability.
nurses are accountable for practicing nursing
within the confines of the law to shield
themselves from liability; advocate for clients’
rights; provide care that is within the nurse’s
scope of practice; discern the responsibilities
of nursing in relationship to the responsibilities
of other members of the health care team; and
provide safe, proficient care consistent with
standards of care.
SOURCES OF LAW
FeDeRaL RegULations
Federal laws affecting nursing practice
● Health Insurance Portability and
Accountability Act (HIPAA)
● Americans with Disabilities Act (ADA)
● Mental Health Parity Act (MHPA)
● Patient Self‑Determination Act
(PSDA)
CRiMinaL anD CiViL LaWs
● Criminal law is a subsection of public
law and relates to the relationship
between an individual and the
government. A nurse who falsifies
a record to cover up a serious
mistake can be guilty of breaking a
criminal law.
● Civil laws protect individual rights.
One type of civil law that relates
to the provision of nursing care is
tort law. (4.1)
state LaWs
● Each state has enacted statutes that define the
parameters of nursing practice and give the authority
to regulate the practice of nursing to its state board
of nursing.
● In turn, the boards of nursing have the authority to
adopt rules and regulations that further regulate
nursing practice. Although the practice of nursing is
similar among states, it is critical that nurses know the
laws and rules governing nursing in the state in which
they practice.
● Boards of nursing have the authority to issue and revoke
a nursing license.
● Boards also set standards for nursing programs and
further delineate the scope of practice for RNs, practical
nurses (PNs), and advanced practice nurses.
LiCensURe
In general, nurses must have a current license in every
state in which they practice. The states (about half of
them) that have adopted the nurse licensure compact are
exceptions. This model allows licensed nurses who reside
in a compact state to practice in other compact states
under a multistate license. Within the compact, nurses
must practice in accordance with the statues and rules of
the state in which they provide care.
CHAPTER 4
4.1 Types of torts
Unintentional torts
NEGLIGENCE: a nurse fails to implement safety measures for a client at risk for falls.
MALPRACTICE (PROFESSIONAL NEGLIGENCE): a nurse administers a large dose
of medication due to a calculation error. the client has a cardiac arrest and dies.
Quasi‑intentional torts
BREACH OF CONFIDENTIALITY: a nurse releases a client’s
medical diagnosis to a member of the press.
DEFAMATION OF CHARACTER: a nurse tells a coworker that
she believes the client has been unfaithful to her partner.
Intentional torts
ASSAULT
the conduct of one
person makes another
person fearful and
apprehensive
a nurse threatens to place
an ng tube in a client
who is refusing to eat.
BATTERY
intentional and wrongful
physical contact with a
person that involves an
injury or offensive contact
a nurse restrains a
client and administers
an injection against
her wishes.
FALSE IMPRISONMENT
a person is confined or
restrained against his will
a nurse uses restraints
on a competent client
to prevent his leaving
the health care facility.
16 CHAPTER 4 LegaL ResponsibiLities CONTENT MASTERY SERIES
PROFESSIONAL NEGLIGENCE
Professional negligence is the failure of a person who
has professional training to act in a reasonable and
prudent manner. The terms “reasonable” and “prudent”
generally describe a person who has the average judgment,
intelligence, foresight, and skill that a person with similar
training and experience would have.
● Negligence issues that prompt most malpractice suits
include failure to:
◯ Follow professional and facility‑established standards
of care.
◯ Use equipment in a responsible and knowledgeable
manner.
◯ Communicate effectively and thoroughly with clients.
◯ Document care the nurse provided.
◯ Notify the provider of a change in the
client’s condition.
◯ Complete a prescribed procedure.
● Nursing students face liability if they harm clients as
a result of their direct actions or inaction. They should
not perform tasks for which they are not prepared,
and they should have supervision as they learn new
procedures. If a student harms a client, the student,
instructor, educational institution, and facility share
liability for the wrong action or inaction. (4.2)
● Nurses can avoid liability for negligence by:
◯ Following standards of care.
◯ Giving competent care.
◯ Communicating with other health team members
and clients.
◯ Developing a caring rapport with clients.
◯ Fully documenting assessments, interventions,
and evaluations.
◯ Being familiar with and following a facility’s policies
and procedures.
CLIENTS’ RIGHTS
Nurses are accountable for protecting the rights of
clients. Examples include informed consent, refusal
of treatment, advance directives, confidentiality, and
information security.
● Clients’ rights are legal privileges or powers clients have
when they receive health care services.
● Clients using the services of a health care institution
retain their rights as individuals and citizens.
● The American Hospital Association identifies patients’
rights in health care settings. See The Patient Care
Partnership at www.aha.org.
● Nursing facilities that participate in Medicare programs
also follow Resident Rights statutes that govern
their operation.
nURsing RoLe in CLients’ RigHts
● Nurses must ensure that clients understand their rights,
and must protect their clients’ rights.
● Regardless of the client’s age, nursing needs, or health
care setting, the basic tenets are the same. The client
has the right to:
◯ Understand the aspects of care to be active in the
decision‑making process.
◯ Accept, refuse, or request modification of the plan
of care.
◯ Receive care from competent individuals who treat
the client with respect.
4.2 The five elements necessary to prove negligence
ELEMENT OF LIABILITY EXPLANATION EXAMPLE: CLIENT WHO IS A FALL RISK
1. Duty to provide care as
defined by a standard
Care a nurse should give or what a
reasonably prudent nurse would do
the nurse should complete a fall risk assessment
for all clients during admission.
2. breach of duty by failure
to meet standard Failure to give the standard of care the nurse does not perform a fall risk
assessment during admission.
3. Foreseeability of harm Knowledge that failing to give the proper
standard of care could harm the client
the nurse should know that failure to take fall risk
precautions could endanger a client at risk for falls.
4. breach of duty has
potential to cause
harm (combines
elements 2 and 3)
Failure to meet the standard
had potential to cause harm –
relationship must be provable
Without a fall risk assessment, the nurse
does not know the client’s risk for falls and
does not take the proper precautions.
5. Harm occurs actual harm to the client occurs the client falls out of bed and fractures his hip.
FUNDAMENTALS FOR NURSING CHAPTER 4 LegaL ResponsibiLities 17
inFoRMeD Consent
● Informed consent is a legal process by which a client
or the client’s legally appointed designee has given
written permission for a procedure or treatment.
Consent is informed when a provider explains and the
client understands:
◯ The reason the client needs the treatment or procedure.
◯ How the treatment or procedure will benefit the client.
◯ The risks involved if the client chooses to receive the
treatment or procedure.
◯ Other options to treat the problem, including not
treating the problem.
● The nurse’s role in the informed consent process is to
witness the client’s signature on the informed consent
form and to ensure that the provider has obtained the
informed consent responsibly.
INFORMED CONSENT GUIDELINES
Clients must consent to all care they receive in a health
care facility.
● For most aspects of nursing care, implied consent is
adequate. Clients provide implied consent when they
adhere to the instructions the nurse provides. For
example, the nurse is preparing to perform a tuberculosis
skin test, and the client holds out his arm for the nurse.
● For an invasive procedure or surgery, the client must
provide written consent.
● State laws prescribe who is able to give informed
consent. Laws vary regarding age limitations and
emergencies. Nurses are responsible for knowing the
laws in the state(s) in which they practice.
● A competent adult must sign the form for informed
consent. The person who signs the form must be capable
of understanding the information from the health care
professional who will perform the service, such as a
surgical procedure, and the person must be able to
communicate with the health care professional. When
the person giving the informed consent is unable to
communicate due to a language barrier or a hearing
impairment, a trained medical interpreter must
intervene. Many health care facilities contract with
professional interpreters who have additional skills in
medical terminology to assist with providing information.
● Individuals who may grant consent for another person
include the following.
◯ Parent of a minor
◯ Legal guardian
◯ Court-specified representative
◯ An individual who has durable power of attorney
authority for health care
● Emancipated minors (minors who are independent from
their parents, such as a married minor) may consent
for themselves.
● Include a mature adolescent in the informed consent
process by allowing them to sign an assent as a part of
the informed consent document. (4.3)
● The nurse must verify that consent is informed and
witness the client signing the consent form.
ReFUsaL oF tReatMent
● The PSDA stipulates that staff must inform clients they
admit to a health care facility of their right to accept or
refuse care. Competent adults have the right to refuse
treatment, including the right to leave a facility without
a discharge prescription from the provider.
● If the client refuses a treatment or procedure, the client
signs a document indicating that he understands the
risk involved with refusing the treatment or procedure
and that he has chosen to refuse it.
● When a client decides to leave the facility against
medical advice (without a discharge prescription), the
nurse notifies the provider and discusses with the
client the risks to expect when leaving the facility prior
to discharge.
● The nurse asks the client to sign an Against Medical
Advice form and documents the incident.
Online Video: Informed Consent
4.3 Responsibilities for informed consent
Provider
Obtains informed consent. to do so,
the provider must give the client
● the purpose of the procedure.
● a complete description of the procedure.
● a description of the professionals
who will perform and participate
in the procedure.
● a description of the potential harm,
pain, or discomfort that might occur.
● options for other treatments.
● the option to refuse treatment and
the consequences of doing so.
Client
Gives informed consent. to give
informed consent, the client must
● give it voluntarily (no coercion involved).
● be competent and of legal age or be
an emancipated minor. When the client
is unable to provide consent, another
authorized person must give consent.
● Receive enough information to
make a decision based on an
understanding of what to expect.
Nurse
Witnesses informed consent.
this means the nurse must
● ensure that the provider gave the
client the necessary information.
● ensure that the client understood
the information and is competent
to give informed consent.
● Have the client sign the informed
consent document.
● notify the provider if the client has more
questions or appears not to understand
any of the information. the provider is
then responsible for giving clarification.
● Document questions the client has,
notification of the provider, reinforcement
of teaching, and use of an interpreter.
18 CHAPTER 4 LegaL ResponsibiLities CONTENT MASTERY SERIES
stanDaRDs oF CaRe (pRaCtiCe)
● Nurses base practice on established standards of care or
legal guidelines for care, such as the following.
◯ The nurse practice act of each state.
◯ Published standards of nursing practice from
professional organizations and specialty groups,
including the American Nurses Association (ANA), the
American Association of Critical Care Nurses (AACN),
and the American Association of Occupational Health
Nurses (AAOHN).
◯ Health care facilities’ policies and procedures, which
establish the standard of practice for employees of
that facility. They provide detailed information about
how the nurse should respond to or provide care
in specific situations and while performing client
care procedures.
● Standards of care define and direct the level of care
nurses should give, and they implicate nurses who did
not follow these standards in malpractice lawsuits.
● Nurses should refuse to practice beyond the legal scope
of practice or outside of their areas of competence
regardless of reason (staffing shortage, lack of
appropriate personnel).
● Nurses should use the formal chain of command to
verbalize concerns related to assignment in light of
current legal scope of practice, job description, and area
of competence.
iMpaiReD CoWoRKeRs
Impaired health care providers pose a significant risk to
client safety.
● A nurse who suspects a coworker of any behavior that
jeopardizes client care or could indicate a substance
use disorder has a duty to report the coworker to the
appropriate manager.
● Many facilities’ policies provide access to assistance
programs that facilitate entry into a treatment program.
● Each state has laws and regulations that govern the
disposition of nurses who have substance use disorders.
Criminal charges could apply.
aDVanCe DiReCtiVes
The purpose of advance directives is to communicate a
client’s wishes regarding end‑of‑life care should the client
become unable to do so.
● The PSDA requires asking all clients on admission
to a health care facility whether they have
advance directives.
● Staff should give clients who do have advance
directives written information that outlines their rights
related to health care decisions and how to formulate
advance directives.
● A health care representative should be available to help
with this process.
Types of advance directives
Living will
● A living will is a legal document that expresses the
client’s wishes regarding medical treatment in the
event the client becomes incapacitated and is facing
end‑of‑life issues.
● Most state laws include provisions that protect health
care providers who follow a living will from liability.
Durable power of attorney for health care
A durable power of attorney for health care is a document
in which clients designate a health care proxy to make
health care decisions for them if they are unable to do so.
The proxy may be any competent adult the client chooses.
Provider’s orders
Unless a provider writes a “do not resuscitate” (DNR) or
“allow natural death” (AND) prescription in the client’s
medical record, the nurse initiates cardiopulmonary
resuscitation (CPR) when the client has no pulse or
respirations. The provider consults the client and the
family prior to administering a DNR or AND.
NURSING ROLE IN ADVANCE DIRECTIVES
Nursing responsibilities include the following.
● Provide written information about advance directives.
● Document the client’s advance directives status.
● Ensure that the advance directives reflect the client’s
current decisions.
● Inform all members of the health care team of the
client’s advance directives.
ManDatoRY RepoRting
Health care providers have a legal obligation to report
their findings in accordance with state law in the
following situations.
ABUSE
Nurses must report any suspicion of abuse (child or elder
abuse, domestic violence) following facility policy.
COMMUNICABLE DISEASES
Nurses must report communicable disease diagnoses to
the local or state health department. For a complete list
of reportable diseases and a description of the reporting
system, go to the Centers for Disease Control and
Prevention’s website, www.cdc.gov. Each state mandates
which diseases to report in that state.
● Reporting allows officials to:
◯ Ensure appropriate medical treatment of diseases
(tuberculosis).
◯ Monitor for common‑source outbreaks (foodborne,
hepatitis A).
◯ Plan and evaluate control and prevention plans
(immunizations).
◯ Identify outbreaks and epidemics.
◯ Determine public health priorities based on trends.
FUNDAMENTALS FOR NURSING CHAPTER 4 LegaL ResponsibiLities 19
Application Exercises
1. a nurse observes an assistive
personnel (ap) reprimanding a client
for not using the urinal properly. the
ap tells him she will put a diaper on
him if he does not use the urinal more
carefully next time. Which of the
following torts is the ap committing?
a. assault
b. battery
C. False imprisonment
D. invasion of privacy
2. a nurse is caring for a competent
adult client who tells the nurse that he
is thinking about leaving the hospital
against medical advice. the nurse
believes that this is not in the client’s
best interest, so she prepares to
administer a pRn sedative medication
the client has not requested along
with his usual medication. Which
of the following types of tort is
the nurse about to commit?
a. assault
b. False imprisonment
C. negligence
D. breach of confidentiality
3. a nurse in a surgeon’s office is
providing preoperative teaching
for a client who is scheduled for
surgery the following week. the client
tells the nurse that he will prepare
his advance directives before he
goes to the hospital. Which of the
following statements made by the
client should indicate to the nurse an
understanding of advance directives?
a. “i’d rather have my brother
make decisions for me, but i
know it has to be my wife.”
b. “i know they won’t go ahead
with the surgery unless i
prepare these forms.”
C. “i plan to write that i don’t
want them to keep me on
a breathing machine.”
D. “i will get my regular doctor
to approve my plan before i
hand it in at the hospital.”
4. a nurse is caring for a client who
is about to undergo an elective
surgical procedure. the nurse
should take which of the following
actions regarding informed
consent? (select all that apply.)
a. Make sure the surgeon
obtained the client’s consent.
b. Witness the client’s signature
on the consent form.
C. explain the risks and
benefits of the procedure.
D. Describe the consequences
of choosing not to
have the surgery.
e. tell the client about
alternatives to having
the surgery.
5. a nurse has noticed several
occasions in the past week when
another nurse on the unit seemed
drowsy and unable to focus on the
issue at hand. today, she found
the nurse asleep in a chair in the
break room when she was not on
a break. Which of the following
actions should the nurse take?
a. alert the american
nurses association.
b. Fill out an incident report.
C. Report the observations to the
nurse manager on the unit.
D. Leave the nurse alone to sleep.
PRACTICE Active Learning Scenario
a nurse is teaching a group of nursing students about
avoiding liability for negligence. Use the ati active
Learning template: basic Concept to complete this item.
UNDERLYING PRINCIPLES: List the five
elements necessary to prove negligence.
NURSING INTERVENTIONS: List at least four
ways nurses can avoid liability for negligence.
20 CHAPTER 4 LegaL ResponsibiLities CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: by threatening the client, the ap is committing assault.
Her threats could make the client become fearful and apprehensive.
b. battery is actual physical contact without the client’s consent. because
the ap has only verbally threatened the client, battery has not occurred.
C. Unless the ap restrains the client, there is
no false imprisonment involved.
D. invasion of privacy involves disclosing information
about a client to an unauthorized individual.
NCLEX® Connection: Management of Care,
Legal Rights and Responsibilities
2. a. assault is an action that threatens harmful contact without the
client’s consent. the nurse has made no threats in this situation.
b. CORRECT: the nurse gave the medication as a chemical
restraint to keep the client from leaving the facility against
medical advice. this is false imprisonment because the client
neither requested nor consented to receiving the sedative.
C. negligence is a breach of duty that results in harm to the
client. it is unlikely that the medication the nurse administered
without his consent actually harmed the client.
D. the nurse has not disclosed any protected health information, so
there is no breach of confidentiality involved in this situation.
NCLEX® Connection: Management of Care,
Legal Rights and Responsibilities
3. a. the client may designate any competent adult to be his
health care proxy. it does not have to be his spouse.
b. the hospital staff must ask the client whether he has prepared
advance directives and provide written information about them
if he has not. the nurse should document whether the client
has signed the advance directives. the hospital staff cannot
refuse care based on the lack of advance directives.
C. CORRECT: the client has the right to decide and specify which
medical procedures he wants when a life‑threatening situation arises.
D. the client does not need his provider’s approval to submit
his advance directives. However, he should give his primary
care provider a copy of the document for his records.
NCLEX® Connection: Management of Care,
Advance Directives/Self-Determination/Life Planning
4. a. CORRECT: it is the nurse’s responsibility to verify that
the surgeon obtained the client’s consent and that he
understands the information the surgeon gave him.
b. CORRECT: it is the nurse’s responsibility to witness the client’s
signing of the consent form, and to verify that he is consenting
voluntarily and appears to be competent to do so. the nurse also should
verify that he understands the information the surgeon gave him.
C. it is the surgeon’s responsibility to explain the
risks and benefits of the procedure.
D. it is the surgeon’s responsibility to describe the
consequences of choosing not to have the surgery.
e. it is the surgeon’s responsibility to tell the client about
any available alternatives to having the surgery.
NCLEX® Connection: Management of Care, Informed Consent
5. a. the nurse should not alert the american nurses association.
the state’s board of nursing regulates disciplinary action
and can revoke a nurse’s license for substance use.
b. the nurse should not fill out an incident report. incident reports
are filed to document an accident or unusual occurrence.
C. CORRECT: any nurse who notices behavior that could jeopardize
client care or could indicate a substance use disorder has a duty
to report the situation immediately to the nurse manager.
D. the nurse should not leave the nurse alone to sleep. although
the nurse is not responsible for solving the problem, she does
have a duty to take action since she has observed the problem.
NCLEX® Connection: Management of Care,
Legal Rights and Responsibilities
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● Duty to provide care as
defined by a standard
● breach of duty by failure to meet standard
● Foreseeability of harm
● breach of duty has potential to cause harm
● Harm occurs
NURSING INTERVENTIONS
● Following standards of care
● giving competent care
● Communicating with other
health team members
● Developing a caring rapport with clients
● Fully documenting assessments,
interventions, and evaluations
NCLEX® Connection: Management of Care, Legal Rights and Responsibilities
FUNDAMENTALS FOR NURSING CHAPTER 5 InformatIon technology 21
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 5 Information
Technology
the chart or medical record is the legal record
of care.
the medical record is a confidential, permanent,
and legal document that is admissible in court.
nurses are legally and ethically responsible for
ensuring confidentiality. only health care
providers who are involved directly in a client’s
care may access that client’s medical record.
nurses document the care they provide as
documentation or charting, and it should reflect
the nursing process.
there is a rapidly growing trend for maintaining
medical records electronically, which creates
challenges in protecting the privacy and safety
of health information.
Information to document includes assessments,
medication administration, nursing actions,
treatments and responses, and client education.
DOCUMENTATION
Documentation is a standard for many accrediting
agencies, including The Joint Commission (formerly
JCAHO). The Joint Commission mandates the use of
computerized databases to expedite the accreditation
process. Health care facilities use the computerized data
for budget management, quality improvement programs,
research, and many other endeavors.
● Purposes for medical records include communication,
legal documentation, financial billing, education,
research, and auditing.
● The purpose of reporting is to provide continuity of care
and enhance communication among all team members
who provide care to the same clients, thus promoting
client safety.
● Nurses should conduct reporting in a
confidential manner.
elementS of DocUmentatIon
Factual: Subjective and objective data
● Nurses should document subjective data as direct
quotes, within quotation marks, or summarize and
identify the information as the client’s statement.
Subjective data should be supported by objective data so
charting is as descriptive as possible.
● Objective data should be descriptive and should include
what the nurse sees, hears, feels, and smells. Document
without derogatory words, judgments, or opinions.
Document the client’s behavior accurately. Instead of
writing “client is agitated,” write “client pacing back
and forth in his room, yelling loudly.”
Accurate and concise: Document facts and information
precisely (what the nurse sees, hears, feels, smells)
without any interpretations of the situation. Unnecessary
words and irrelevant detail are avoided. Exact
measurements establish accuracy. Only abbreviations
and symbols approved by The Joint Commission and the
facility are acceptable.
Complete and current: Document information that is
comprehensive and timely. Never pre‑chart an assessment,
intervention, or evaluation.
Organized: Communicate information in a logical sequence.
legal gUIDelIneS
● Begin each entry with the date and time.
● Record entries legibly, in nonerasable black ink, and do
not leave blank spaces in the nurses’ notes.
● Do not use correction fluid, erase, scratch out, or
blacken out errors in the medical record. Make
corrections promptly, following the facility’s procedure
for error correction.
● Sign all documentation as the facility requires,
generally with name and title.
● Documentation should reflect assessments,
interventions, and evaluations, not personal opinions
or criticism about client or other health care
professionals’ care.
DOCUMENTATION FORMATS
Flow charts show trends in vital signs, blood glucose
levels, pain level, and other frequent assessments.
Narrative documentation records information as a
sequence of events in a story‑like manner.
Charting by exception uses standardized forms that
identify norms and allows selective documentation of
deviations from those norms.
Problem-oriented medical records are organized by
problem or diagnosis and consist of a database, problem
list, care plan, and progress notes. Examples include SOAP,
PIE, and DAR. (5.1)
CHAPTER 5 Online Video: Confidentiality
22 CHAPTER 5 InformatIon technology CONTENT MASTERY SERIES
Electronic health records are replacing manual formats in
many settings.
● Advantages include standardization, accuracy,
confidentiality, easy access for multiple users, providing
ease in maintaining ongoing health record of client’s
condition, and rapid acquisition and transfer of clients’
information.
● Challenges include learning the system, knowing how
to correct errors, and maintaining security.
● Documentation rules and formats are similar to those
for paper charting.
REPORTING FORMATS
Change‑of‑shift report
Nurses give this report at the conclusion of each shift to
the nurse assuming responsibility for the clients.
● Formats include face to face, audiotaping, or
presentation during walking rounds in each client’s
room (unless the client has a roommate or visitors
are present).
● An effective report should:
◯ Include significant objective information about the
client’s health problems.
◯ Proceed in a logical sequence.
◯ Include no gossip or personal opinion.
◯ Relate recent changes in medications, treatments,
procedures, and the discharge plan.
Telephone reports
Telephone reports are useful when contacting the provider
or other members of the interprofessional team.
● It is important to:
◯ Have all the data ready prior to contacting any
member of the interprofessional team.
◯ Use a professional demeanor.
◯ Use exact, relevant, and accurate information.
◯ Document the name of the person who made the
call and to whom the information was given; the
time, content of the message; and the instructions or
information received during the report.
Telephone or verbal prescriptions
It is best to avoid these, but they are sometimes necessary
during emergencies and at unusual times.
● Have a second nurse listen to a telephone prescription.
● Repeat it back, making sure to include the medication’s
name (spell if necessary), dosage, time, and route.
● Question any prescription that seems inappropriate for
the client.
● Make sure the provider signs the prescription in person
within the time frame the facility specifies, typically
24 hr.
Transfer (hand‑off) reports
These should include demographic information, medical
diagnosis, providers, an overview of health status
(physical, psychosocial), plan of care, recent progress, any
alterations that might become an urgent or emergent
situation, directives for any assessments or client care
essential within the next few hours, most recent vital
signs, medications and last doses, allergies, diet, activity,
specific equipment or adaptive devices (oxygen, suction,
wheelchair), advance directives and resuscitation status,
discharge plan (teaching), and family involvement in care
and health care proxy.
Incident reports (unusual occurrences)
Incident/variance reports are an important part of a
facility’s quality improvement plan.
● An incident is the occurrence of an accident or an
unusual event. Examples of incidents are medication
errors, falls, omission of prescription, and needlesticks.
● Document facts without judgment or opinion.
● Do not refer to an incident report in a client’s
medical record.
● Incident reports contribute to changes that help improve
health care quality.
INFORMATION SECURITY
Mandatory adherence with the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) began
in 2003 to help ensure the confidentiality of health
information.
● A major component of HIPAA, the Privacy Rule,
promotes the use of standard methods of maintaining
the privacy of protected health information (PHI) among
health care agencies.
● It is essential for nurses to be aware of clients’
rights to privacy and confidentiality. Facilities’
policies and procedures help ensure adherence with
HIPAA regulations.
Privacy rule
The Privacy Rule requires that nurses protect all written
and verbal communication about clients. Components of
the Privacy Rule include the following.
● Only health care team members directly responsible for
a client’s care may access that client’s record. Nurses
may not share information with other clients or staff
not caring for the client.
● Clients have a right to read and obtain a copy of their
medical record.
● Nurses may not photocopy any part of a medical record
except for authorized exchange of documents between
facilities and providers.
● Staff must keep medical records in a secure area to prevent
inappropriate access to the information. They may not use
public display boards to list client names and diagnoses.
● Electronic records are password‑protected. The public
may not view them. Staff must use only their own
passwords to access information.
FUNDAMENTALS FOR NURSING CHAPTER 5 InformatIon technology 23
● Nurses must not disclose clients’
information to unauthorized
individuals or family members who
request it in person or by telephone
or email.
◯ Many hospitals use a code system to
identify those individuals who may
receive information about a client.
◯ Nurses should ask any individual
inquiring about a client’s status for
the code and disclose information
only when the individual can give
the code.
● Communication about a client should
only take place in a private setting where unauthorized
individuals cannot overhear it.
● To adhere to HIPAA regulations, each facility has specific
policies and procedures to monitor staff adherence,
technical protocols, computer privacy, and data safety.
Information security protocols
● Log off from the computer before leaving the
workstation to ensure that others cannot view protected
health information on the monitor.
● Never share a user ID or password with anyone.
● Never leave a medical record or other printed or written
PHI where others can access it.
● Shred any printed or written client information for
reporting or client care after use.
Social media precautions
● Know the implications of HIPAA before
using social networking sites for school‑ or
work‑related communication.
● Become familiar with your facility’s policies regarding
the use of social networking.
● Do not use or view social networking media in
clinical settings.
● Do not post information about your facility, clinical
sites, clinical experiences, clients, and other health care
staff on social networking sites
● Do not take pictures that show clients or their
family members.
Application Exercises
1. a nurse is preparing information
for change‑of‑shift report. Which
of the following information should
the nurse include in the report?
a. Input and output for the shift
B. Blood pressure from
the previous day
c. Bone scan scheduled for today
D. medication routine from the
medication administration record
2. a nurse is discussing the hIPaa
Privacy rule with nurses during new
employee orientation. Which of the
following information should the
nurse include? (Select all that apply.)
a. a single electronic records
password is provided for
nurses on the same unit.
B. family members should provide
a code prior to receiving
client health information.
c. communication of client
information can occur at
the nurses’ station.
D. a client can request a copy
of her medical record.
e. a nurse may photocopy a
client’s medical record for
transfer to another facility.
3. a nurse is reviewing documentation
with a group of newly licensed
nurses. Which of the following
legal guidelines should be followed
when documenting in a client’s
record? (Select all that apply.)
a. cover errors with correction
fluid, and write in the
correct information.
B. Put the date and time
on all entries.
c. Document objective data,
leaving out opinions.
D. Use as many abbreviations
as possible.
e. Wait until the end of the
shift to document.
4. a nurse is discussing occurrences that
require completion of an incident report
with a newly licensed nurse. Which of
the following should the nurse include
in the teaching? (Select all that apply).
a. medication error
B. needlesticks
c. conflict with provider
and nursing staff
D. omission of prescription
e. complaint from a client’s
family member
5. a nurse is receiving a provider’s
prescription by telephone for
morphine for a client who is reporting
moderate to severe pain. Which of
the following nursing actions are
appropriate? (Select all that apply.)
a. repeat the details of the
prescription back to the provider.
B. have another nurse listen to
the telephone prescription.
c. obtain the provider’s signature
on the prescription within 24 hr.
D. Decline the verbal
prescription because it is not
an emergency situation.
e. tell the charge nurse that
the provider has prescribed
morphine by telephone.
5.1 Problem‑oriented medical records
SOAP
S Subjective data
O objective data
A assessment
includes a nursing
diagnosis based on
the assessment
P Plan
PIE
P Problem
I Intervention
E evaluation
DAR
focus charting
D Data
A action
R response
24 CHAPTER 5 InformatIon technology CONTENT MASTERY SERIES
Application Exercises Key
1. a. Unless there is a significant change in intake and output, the
oncoming nurse can read that information in the chart.
B. Unless there is a significant change in blood pressure
measurements since the previous day, the oncoming
nurse can read that information in the chart.
c. CORRECT: the bone scan is important because the nurse might
have to modify the client’s care to accommodate leaving the unit.
D. Unless there is a significant change in the medication routine,
the oncoming nurse can read that information in the chart.
NCLEX® Connection: Management of Care, Continuity of Care
2. a. the hIPaa Privacy rule requires the protection of clients’
electronic records. the rule states that electronic records
must be password protected and each staff person should
use an individual password to access information.
B. CORRECT: the hIPaa Privacy rule states that information should only
be disclosed to authorized individuals to whom the client has provided
consent. many hospitals use a code system to identify those individuals
and should only provide information if the individual can give the code.
c. CORRECT: the hIPaa Privacy rule states that communication
about a client should only take place in a private setting
where unauthorized individuals cannot overhear it. a unit
nurses’ station is considered a private and secure location.
D. CORRECT: the hIPaa Privacy rule states that clients have
a right to read and obtain a copy of their medical record.
e. CORRECT: the hIPaa Privacy rule states that nurses
may only photocopy a client’s medical record if it is to
be used for transfer to another facility or provider.
NCLEX® Connection: Safety and Infection Control,
Irregular Occurrence/Variance
3. a. correction fluid implies that the nurse might have tried to hide
the previous documentation or deface the medical record.
B. CORRECT: the day and time confirm the
recording of the correct sequence of events.
c. CORRECT: Documentation must be factual, descriptive,
and objective, without opinions or criticism.
D. too many abbreviations can make the entry difficult to
understand. nurses should minimize use of abbreviations,
and use only those the facility approves.
e. Documentation should be current. Waiting until
the end of the shift can result in data omission.
NCLEX® Connection: Management of Care,
Information Technology
4. a. CORRECT: the nurse should complete an
incident report regarding a medication error.
B. CORRECT: the nurse should complete an
incident report regarding a needlestick.
c. the nurse should report a conflict with a provider and
nursing staff to the charge nurse or nurse manager.,
D. CORRECT: the nurse should complete an incident
report following an omission of a prescription.
e. the nurse should report concerns from a client’s family
member to the charge nurse or nurse manager.
NCLEX® Connection: Safety and Infection Control,
Reporting of Incident/Event/Irregular Occurrence/Variance
5. a. CORRECT: the nurse should repeat the medication’s name,
dosage, time or interval, route, and any other pertinent information
back to the provider and receive and document confirmation.
B. CORRECT: having another nurse listen to the telephone
prescription is a safety precaution that helps prevent
medication errors due to miscommunication.
c. CORRECT: the provider must sign the prescription within the
time frame the facility specifies in its policies (generally 24 hr).
D. Unrelieved pain can become an emergency situation
without the appropriate pain management interventions.
e. there is no need to inform the charge nurse every
time a nurse receives a medication prescription, whether
by telephone, verbally, or in the medical record.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● SoaP
◯ S: Subjective data
◯ o: objective data
◯ a: assessment (includes a
nursing diagnosis based
on the assessment)
◯ P: Plan
● PIe
◯ P: Problem
◯ I: Intervention
◯ e: evaluation
● Dar (focus charting)
◯ D: Data
◯ a: action
◯ r: response
NCLEX® Connection: Management of Care,
Information Technology
PRACTICE Active Learning Scenario
a nurse is introducing a group of newly licensed
nurses to the various approaches to problem‑oriented
documentation. Use the atI active learning
template: Basic concept to complete this item.
UNDERLYING PRINCIPLES: list three common
methods of problem‑oriented charting
with definitions of their acronyms.
FUNDAMENTALS FOR NURSING CHAPTER 6 Delegation anD SuperviSion 25
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 6 Delegation and
Supervision
Delegation is the process of transferring the
performance of a task to another member of the
health care team while retaining accountability
for the outcome.
Supervision is the process of directing,
monitoring, and evaluating the performance
of tasks by another team member. nurses are
responsible for supervising the performance of
client care tasks they delegate to others.
licensed personnel are nurses who have
completed a course of study in nursing and
successfully passed either a pn or rn examination.
unlicensed personnel are individuals who have
had training to function in an assistive role to
licensed nurses in providing client care.
these unlicensed individuals might be nursing
personnel, such as certified nursing assistants
(Cnas) or certified medication assistants (CMas),
or they might be non‑nursing personnel, such
as dialysis technicians, monitor technicians,
or phlebotomists.
Some facilities differentiate between licensed
and unlicensed personnel by using the acronym
nap for nursing assistive personnel or ap for
assistive personnel.
DELEGATION
A licensed nurse is responsible for providing clear
directions when delegating a task initially and for periodic
reassessment and evaluation of the outcome of the task.
● RNs may delegate to other RNs, PNs, and AP.
◯ RNs must be knowledgeable about their state’s nurse
practice act and the regulations that guide the use of
PNs and AP.
◯ RNs must delegate tasks so that they can complete
higher‑level tasks that only RNs can perform. This
allows more efficient use of all team members.
● PNs may delegate to other PNs and to AP.
Delegation FaCtorS
● Nurses may only delegate tasks appropriate for the skill
and education level of the individual who is receiving the
assignment (the delegatee).
● RNs may not delegate the nursing process, client education,
or tasks that require nursing judgment to PNs or to APs.
TASK FACTORS: Prior to delegating client care, nurses
should consider the:
● Predictability of the outcome: Will the completion of
the task have a predictable outcome?
◯ Is it a routine treatment?
◯ Is it a new treatment for that client?
● Potential for harm
◯ Is there a chance that something negative could
happen to the client (bleeding, aspiration)?
◯ Is the client unstable?
● Complexity of care
◯ Does the client’s care require complex tasks?
◯ Does the state’s practice act or the facility’s policy
allow the delegatee to perform the task, and does she
have the necessary skills?
● Need for problem solving and innovation
◯ Is judgment essential while performing the task?
◯ Does it require nursing assessment or
data‑collection skills?
● Level of interaction with the client: Does the delegatee
need psychosocial support or education during the
performance of the task?
Delegatee FaCtorS
● Education, training, and experience
● Knowledge and skill to perform the task
● Level of critical thinking the task requires
● Ability to communicate with others as it pertains to the task
● Demonstration of competence
● The facility’s policies and procedures
● Licensing legislation (state’s nurse practice acts) (6.1)
CHAPTER 6
6.1 Examples of tasks nurses may
delegate to PNs and APs
(provided the facility’s policy and
state’s practice guidelines permit)
TO PNs
● Monitoring findings
(as input to the rn’s
ongoing assessment)
● reinforcing client teaching
from a standard care plan
● performing
tracheostomy care
● Suctioning
● Checking ng
tube patency
● administering
enteral feedings
● inserting a urinary
catheter
● administering medication
(excluding iv medication
in some states)
TO APs
● activities of daily
living (aDls)
◯ Bathing
◯ grooming
◯ Dressing
◯ toileting
◯ ambulating
◯ Feeding (without
swallowing precautions)
◯ positioning
● routine tasks
◯ Bed making
◯ Specimen collection
◯ intake and output
◯ vital signs (for
stable clients)
26 CHAPTER 6 Delegation anD SuperviSion CONTENT MASTERY SERIES
DELEGATION AND
SUPERVISION GUIDELINES
● Use the five rights of delegation to decide. (6.2)
◯ Tasks to delegate (right task)
◯ Under what circumstances (right circumstances, such
as setting and resources)
◯ To whom (right person)
◯ What information to communicate (right direction
and communication)
◯ How to oversee and appraise (right supervision
and evaluation)
● Use professional judgment and critical thinking skills
when delegating.
Right task
● Identify which tasks are appropriate to delegate for each
specific client.
● A right task is repetitive, requires little supervision, and
is relatively noninvasive for the client.
● Delegate activities to appropriate levels of team
members (RN, PN, AP) according to professional
standards of practice, legal and facility guidelines, and
available resources.
RIGHT TASK: Delegate an ap to assist a client
who has pneumonia to use a bedpan.
WRONG TASK: Delegate an ap to administer a
nebulizer treatment to a client who has pneumonia.
Right circumstances
● Determine the health status and complexity of care the
client requires.
● Match the complexity of care demands to the skill level
of the delegatee.
● Consider the workload of the delegatee.
RIGHT CIRCUMSTANCE: Delegate an ap to measure the
vital signs of a client who is postoperative and stable.
WRONG CIRCUMSTANCE: Delegate an ap to measure
the vital signs of a client who is postoperative and
required naloxone to reverse respiratory depression.
Right person
● Determine and verify the competence of the delegatee.
● The task must be within the delegatee’s scope of
practice or job description.
● The delegatee must have the necessary competence and
training.
● Continually review the performance of the delegatee
and determine care competence.
● Evaluate the delegatee’s performance according to
standards, and when necessary, take steps to remediate
any failure to meet standards.
RIGHT PERSON: Delegate an pn to administer
enteral feedings to a client who has a head injury.
WRONG PERSON: Delegate an ap to administer
enteral feedings to a client who has a head injury.
Right direction and communication
in writing, orally, or both
● Communicate what data to collect.
● Provide a method and timeline for reporting, including
when to report concerns and assessment findings.
● Communicate specific task(s) to perform and
client-specific instructions.
● Detail expected results, timelines, and expectations for
follow‑up communication.
RIGHT DIRECTION AND COMMUNICATION:
Delegate an ap to assist Mr. Martin in
room 312 with a shower before 0900.
WRONG DIRECTION AND COMMUNICATION:
Delegate an ap to assist Mr. Martin in
room 312 with morning hygiene.
Right supervision and evaluation
● Provide supervision, either directly or indirectly
(assigning supervision to another licensed nurse).
● Monitor performance.
● Intervene if necessary (for unsafe clinical practice).
● Provide feedback:
◯ Did the delegatee complete the tasks on time?
◯ Was the delegatee’s performance satisfactory?
◯ Did the delegatee document and report
unexpected findings?
◯ Did the delegatee need help completing the tasks
on time?
● Evaluate the client and determine the client’s
outcome status.
● Evaluate task performance and identify needs
for performance‑improvement activities and
additional resources.
RIGHT SUPERVISION: Delegate an ap to
assist with ambulating a client after the rn
completes the admission assessment.
WRONG SUPERVISION: Delegate an ap to assist
with ambulating a client prior to the rn
performing an admission assessment.
Online Video: Delegation
6.2 The five rights of delegation
Right task
Right circumstance
Right person
Right direction and communication
Right supervision and evaluation
FUNDAMENTALS FOR NURSING CHAPTER 6 Delegation anD SuperviSion 27
Application Exercises
1. a nurse on a medical‑surgical
unit has received change‑of‑shift
report and will care for four clients.
Which of the following client’s
needs should the nurse assign
to an assistive personnel (ap)?
a. Feeding a client who was
admitted 24 hr ago with
aspiration pneumonia
B. reinforcing teaching with
a client who is learning to
walk using a quad cane
C. reapplying a condom
catheter for a client who
has urinary incontinence
D. applying a sterile dressing
to a pressure ulcer
2. a nurse manager of a
medical‑surgical unit is assigning
care responsibilities for the oncoming
shift. a client is awaiting transfer
back to the unit from the paCu
following thoracic surgery. to which
of the following staff members
should the nurse assign this client?
a. Charge nurse
B. rn
C. practical nurse (pn)
D. assistive personnel (ap)
3. a nurse is delegating the
ambulation of a client who had
knee arthroplasty 5 days ago to
an ap. Which of the following
information should the nurse share
with the ap? (Select all that apply.)
a. the roommate ambulates
independently.
B. the client ambulates with
his slippers on over his
antiembolic stockings.
C. the client uses a front‑wheeled
walker when ambulating.
D. the client had pain
medication 30 min ago.
e. the client is allergic to codeine.
F. the client ate 50% of his
breakfast this morning.
4. an rn is making assignments for a
practical nurse (pn) at the beginning
of the shift. Which of the following
assignments should the pn question?
a. assisting a client who is
24‑hr postoperative to use
an incentive spirometer
B. Collecting a clean‑catch
urine specimen from a client
who has a wound infection
C. providing nasopharyngeal
suctioning for a client
who has pneumonia
D. teaching a client who
has asthma to use a
metered‑dose inhaler
5. a nurse is preparing an in‑service
program about delegation. Which
of the following elements should
she identify when presenting
the five rights of delegation?
(Select all that apply.)
a. right client
B. right supervision
and evaluation
C. right direction and
communication
D. right time
e. right circumstances
PRACTICE Active Learning Scenario
a nurse manager is reviewing the responsibilities
of delegation with a group of nurses on a medical
unit. use the ati active learning template:
Basic Concept to complete this item.
NURSING INTERVENTIONS: list at least five
tasks the delegating nurse must perform when
supervising and evaluating a delegatee.
28 CHAPTER 6 Delegation anD SuperviSion CONTENT MASTERY SERIES
Application Exercises Key
1. a. it would be inappropriate to delegate the feeding
of a client who has aspiration pneumonia to an ap
because the client is at risk for further aspiration.
B. either an rn or an pn, not an ap, may reinforce teaching.
C. CORRECT: the application of a condom catheter is a noninvasive,
routine procedure that the nurse may delegate to an ap.
D. either an rn or an pn, not an ap, may apply a sterile dressing.
NCLEX® Connection: Management of Care, Assignment,
Delegation and Supervision
2. a. although the charge nurse can provide all the care this client requires
in the immediate postoperative period, administrative responsibilities
might prevent the close monitoring and assessment this client needs.
B. CORRECT: a client returning from surgery requires
an rn’s assessment and establishment of a plan of
care, especially if the client is potentially unstable.
C. although pns can perform some of the tasks crucial in
the immediate postoperative period, they cannot provide
the comprehensive care this client needs at this time.
D. although aps can perform some of the tasks crucial in the immediate
postoperative period, they cannot provide the comprehensive
care this client needs at this time, particularly assessment.
NCLEX® Connection: Management of Care, Assignment,
Delegation and Supervision
3. a. the ap does not need to know the status of the
client’s roommate to complete this assignment.
B. CORRECT: to complete this assignment safely, the ap
should make sure the client wears stockings and slippers.
C. CORRECT: to complete this assignment safely, the ap
should make sure the client uses a front‑wheeled walker.
D. CORRECT: to complete this assignment safely, the ap should know
that the client should be feeling the effects of the pain medication.
e. the ap does not need to know the client’s
allergy status to complete this assignment.
F. the ap does not need to know the client’s
food intake to complete this assignment.
NCLEX® Connection: Management of Care, Continuity of Care
4. a. assisting a client to use an incentive spirometer
is within the scope of practice of the pn.
B. Collecting a clean‑catch urine specimen is
within the scope of practice of the pn.
C. providing nasopharyngeal suctioning is within
the scope of practice of the pn.
D. CORRECT: the rn is responsible for primary
teaching. the pn may only reinforce teaching.
NCLEX® Connection: Management of Care,
Concepts of Management
5. a. the right client is one of the rights of medication
administration, not of delegation.
B. CORRECT: the right supervision and evaluation is one of the five
rights of delegation. they also include the right task and the right person.
C. CORRECT: right direction and communication is one of the five rights
of delegation. they also include the right task and the right person.
D. although the delegatee needs to know whether there is a time frame
or a specific time to perform the task, the right time is not one of the five
rights of delegation. it is one of the rights of medication administration.
e. CORRECT: the right circumstances is one of the five rights of
delegation. they also include the right task and the right person.
NCLEX® Connection: Management of Care, Assignment,
Delegation and Supervision
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
● provide supervision, either directly or indirectly
(assigning supervision to another licensed nurse).
● Monitor performance.
● intervene if necessary (for unsafe clinical practice).
● provide feedback:
◯ Did the delegatee complete the tasks on time?
◯ Was the delegatee’s performance satisfactory?
◯ Did the delegatee document and report unexpected findings?
◯ Did the delegatee need help completing the tasks on time?
● evaluate the client and determine the client’s outcome status.
● evaluate task performance and identify needs for
performance‑improvement activities and additional resources.
NCLEX® Connection: Management of Care, Assignment,
Delegation and Supervision
FUNDAMENTALS FOR NURSING CHAPTER 7 NursiNg Process 29
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 7 Nursing Process
The nursing process is a cyclical, critical thinking
process that consists of five steps to follow in
a purposeful, goal‑directed, systematic way to
achieve optimal client outcomes. it is a variation
of scientific reasoning that helps nurses organize
nursing care and apply the optimal available
evidence to care delivery.
The nursing process is a dynamic, continuous,
client‑centered, problem‑solving, and
decision‑making framework that is foundational
to nursing practice.
The nursing process provides a framework
throughout which nurses can apply knowledge,
experience, judgment, and skills, as well as
established standards of nursing practice to
the formulation of a plan of nursing care. This
plan is applicable to any client system, including
individuals, families, groups, and communities.
The nursing process helps nurses integrate
critical thinking creatively to base nursing
judgments on reason.
The nursing process promotes the professionalism
of nursing while differentiating the practice of
nursing from the practice of medicine and that of
other health care professionals.
ASSESSMENT/DATA COLLECTION
● Assessment/data collection involves the systematic
collection of information about clients’ present health
status to identify needs and additional data to collect
based on findings. Nurses can collect data during an
initial assessment (baseline data), focused assessment,
and ongoing assessments.
● Methods of data collection include observation,
interviews with clients and families, medical history,
comprehensive or focused physical examination,
diagnostic and laboratory reports, and collaboration
with other members of the health care team.
● To collect data effectively, nurses must ask clients
appropriate questions, listen carefully to responses, and
have excellent head‑to‑toe physical assessment skills.
Nurses also must employ clinical judgment and critical
thinking in accurately recognizing when to collect
assessment data. They also must recognize the need to
collect assessment data prior to interventions.
● Nurses collect subjective data (symptoms) during
a nursing history. They include clients’ feelings,
perceptions, and descriptions of health status. Clients
are the only ones who can describe and verify their
own symptoms.
● Nurses observe and measure objective data (signs)
during a physical examination. They feel, see, hear, and
smell objective data through observation or physical
assessment of the client. (7.2)
● During this assessment/data collection, the nurse
validates, interprets, and clusters data.
● Documentation of the assessment data must be
thorough, concise, and accurate.
CHAPTER 7
7.2 Sources of data for collection
and assessment
Primary sources
SUBJECTIVE: What the client tells the nurse
“My shoulder is really, really sore.”
OBJECTIVE: Data the nurse obtains through
observation and examination:
Client grimaces when attempting to
brush her hair with her left arm.
Secondary sources
SUBJECTIVE: What others tell the nurse
based on what the client has told them:
“She told me that her shoulder is sore every morning.”
OBJECTIVE: Data the nurse collects from other
sources (family, friends, caregivers, health care
professionals, literature review, medical records):
Physical therapy note in chart indicates client has
decreased range of motion of left shoulder.
7.1 Nursing process framework
The nursing process
includes sequential but
overlapping steps:
● Assessment/data
collection*
● Analysis/data collection*
● Planning
● implementation
● evaluation
*PNs combine the assessment
and analysis steps into a single
data collection step.
The accuracy and
thoroughness of
assessment/analysis/data
collection and planning
have a direct impact on
implementation and
evaluation. use of the
nursing process results in a
comprehensive,
individualized,
client‑centered plan of
nursing care that nurses can
deliver in a timely and
reasonable manner.
30 CHAPTER 7 NursiNg Process CONTENT MASTERY SERIES
ANALYSIS/DATA COLLECTION
● Nurses use critical thinking skills (a diagnostic
reasoning process) to identify clients’ health status or
problem(s), interpret or monitor the collected database,
reach an appropriate nursing judgment about health
status and coping mechanisms, and provide direction
for nursing care.
● Analysis/data collection requires nurses to look at the
data and
◯ Recognize patterns or trends.
◯ Compare the data with expected standards or
reference ranges.
◯ Arrive at conclusions to guide nursing care.
● RNs make multiple analyses based on their
interpretations of collected data. They decide, using
reasoning and judgment, which data account for clients’
health status or problems. At times, this requires
further data collection and analysis. As nurses again
cluster the collected data, a specific finding might serve
as an alert to a specific problem that requires planning
and intervention.
● As with the assessment/data collection step, complete
and accurate documentation is essential. Documentation
should focus on facts and should be highly descriptive.
PLANNING
● When planning client care (RN) or contributing to
a client’s plan of care (PN), nurses must establish
priorities and optimal outcomes of care they can readily
measure and evaluate. These established priorities and
outcomes of client care then direct nurses in selecting
interventions to include in a plan of care to promote,
maintain, or restore health.
● Nurses do three types of planning. Initially, they
develop a comprehensive plan of care for clients based
on comprehensive assessments they complete, for
example, on admission to a health care facility or to a
home health organization.
● Nurses do ongoing planning throughout the provision of
care. While obtaining new information and evaluating
responses to care, they modify and individualize the
initial plan of care.
● Discharge planning is a process of anticipating
and planning for clients’ needs after discharge.
To be effective, discharge planning must begin
during admission.
● Throughout the planning process, nurses set priorities,
determine client outcomes, and select specific
nursing interventions.
● Nurses participate in priority setting when they
identify a preferential order of problems. This guides
the delivery of nursing care. They can use guidelines
to set priorities, such as Maslow’s hierarchy of basic
needs. (7.3)
● Nurses work with clients to identify goals and outcomes.
◯ Goals identify optimal status, whereas outcomes
identify the observable criterion that will determine
success or failure of the goal.
◯ Often these terms are interchangeable. With any
format, the goal/outcome must be client‑centered,
singular, observable, measurable, time‑limited,
mutually agreeable, and reasonable.
◯ Concise, measurable goals help nurses and clients
evaluate progress:
◯ Nurses use short‑ and long‑term goals to guide the
client toward the planned outcome and determine the
effectiveness of nursing care.
● Nurses identify actions and interventions that help
achieve optimal outcomes. Scientific principles provide
the rationale for nursing interventions.
◯ Nurse-initiated/independent interventions:
Nurses use evidence and scientific rationale to take
autonomous actions to benefit clients. They base
these actions on identified problems and health care
needs, and make sure they are within their scope of
practice. Nurses perform or delegate the interventions
and are accountable for them. An example is
repositioning a client at least every 2 hr to prevent
skin breakdown.
◯ Provider-initiated/dependent interventions:
Interventions nurses initiate as a result of a
provider’s prescription (written, standing, or
verbal) or the facility’s protocol, such as blood
administration procedures.
◯ Collaborative interventions: Interventions nurses
carry out in collaboration with other health care team
professionals, such as ensuring that a client receives
and eats his evening snack.
● The nursing care plan (NCP) is the end product of the
planning step. Nurses organize the NCP for quick
identification of problems, outcomes, and interventions
to implement.
7.3 Maslow’s hierarchy of basic needs
FUNDAMENTALS FOR NURSING CHAPTER 7 NursiNg Process 31
IMPLEMENTATION
● In this step of the nursing process, nurses base the care
they provide on assessment data, analyses, and the plan
of care they developed in the previous steps of the nursing
process. In this step, they must use problem‑solving,
clinical judgment, and critical thinking to select and
implement appropriate therapeutic interventions using
nursing knowledge, priorities of care, and planned
goals or outcomes to promote, maintain, or restore
health. Nurses also use interpersonal skills (therapeutic
communication) and technical skills (psychomotor
performance) when implementing nursing interventions.
● Therapeutic interventions also include measures nurses
take to minimize risk, such as wearing personal protective
equipment. Nurses intervene to respond to unplanned
events, such as an observation of unsafe practice, a change
in a status, or the emergence of a life‑threatening situation.
● Nurses use evidence‑based rationale for the selection and
implementation of all therapeutic interventions.
Additionally, caring and professional behavior should be at
the center of all therapeutic nursing interventions.
● During implementation, nurses perform nursing actions,
delegate tasks, supervise other health care staff, and
document the care and clients’ responses.
EVALUATION
● In this step of the nursing process, nurses evaluate
clients’ responses to nursing interventions and form a
clinical judgment about the extent to which clients have
met the goals and outcomes.
● Nurses continuously evaluate the client’s progress
toward outcomes, and use the client data to determine
whether or not to modify the plan of care.
● Nurses determine the effectiveness of the nursing care
plan. They collect data based on the outcome criteria then
compare what actually happened with the planned outcomes.
This helps determine what further actions to take.
● QUESTIONS TO CONSIDER
◯ “Did the client meet the planned outcomes?”
◯ “Were the nursing interventions appropriate and effective?”
◯ “Should I modify the outcomes or interventions?”
● Client outcomes in specific, measurable terms are easier
to evaluate.
● FACTORS THAT CAN LEAD TO LACK OF
GOAL ACHIEVEMENT
◯ An incomplete database
◯ Unrealistic client outcomes
◯ Nonspecific nursing interventions
◯ Inadequate time for the client to achieve the outcomes
Application Exercises
1. By the second postoperative day, a
client has not achieved satisfactory pain
relief. Based on this evaluation, which of
the following actions should the nurse
take, according to the nursing process?
A. reassess the client to
determine the reasons for
inadequate pain relief.
B. Wait to see whether the pain
lessens during the next 24 hr.
c. change the plan of care
to provide different pain
relief interventions.
D. Teach the client about the plan
of care for managing his pain.
2. A newly licensed nurse is reporting to
the charge nurse about the care she
gave to a client. she states, “The client
said his leg pain was back, so i checked
his medical record, and he last received
his pain medication 6 hours ago. The
prescription reads every 4 hours PrN for
pain, so i decided he needs it. i asked
the unit nurse to observe me preparing
and administering it. i checked with
the client 40 minutes later, and he said
his pain is going away.” The charge
nurse should inform the newly licensed
nurse that she left out which of the
following steps of the nursing process?
A. Assessment
B. Planning
c. intervention
D. evaluation
3. A charge nurse is reviewing the steps
of the nursing process with a group
of nurses. Which of the following data
should the charge nurse identify as
objective data? (select all that apply.)
A. respiratory rate is 22/min with
even, unlabored respirations.
B. The client’s partner states, “He
said he hurts after walking
about 10 minutes.”
c. Pain rating is 3 on a
scale of 0 to 10
D. skin is pink, warm, and dry.
e. The assistive personnel reports
the client walked with a limp.
4. A charge nurse is talking with
a newly licensed nurse and is
reviewing nursing interventions
that do not require a provider’s
prescription. Which of the following
interventions should the charge
nurse include? (select all that apply.)
A. Writing a prescription
for morphine sulfate as
needed for pain.
B. inserting a nasogastric
(Ng) tube to relieve
gastric distention.
c. showing a client how to use
progressive muscle relaxation.
D. Performing a daily bath
after the evening meal.
e. repositioning a client every 2 hr
to reduce pressure ulcer risk.
5. A nurse is discussing the nursing
process with a newly hired nurse.
Which of the following statements
by the newly hired nurse should the
nurse identify as appropriate for the
planning step of the nursing process?
A. “i will determine the most
important client problems
that we should address.”
B. “i will review the past medical
history on the client’s record
to get more information.”
c. “i will go carry out the
new prescriptions
from the provider.”
D. “i will ask the client if his
nausea has resolved.”
32 CHAPTER 7 NursiNg Process CONTENT MASTERY SERIES
Application Exercises Key
1. A. CORRECT: The nurse should collect further data on the client to
determine why he has not achieved satisfactory pain relief, because
various factors might be interfering with his comfort. The nursing
process repeats in an ongoing manner across the span of client care.
B. The nurse should not wait longer to see how the client
would respond, but should to take action to determine why
the client is not reaching achieving satisfactory pain relief.
c. The nurse should not make random changes to the plan
of care without gathering evidence to guide the nurse in
knowing what new interventions can be necessary.
D. The action by the nurse does not acknowledge the
client’s condition or that the current plan is ineffective.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
2. A. CORRECT: The newly licensed nurse should have used the
assessment step of the nursing process by asking the client to
evaluate the severity of his pain on a 0 to 10 scale. she also should
have asked about the characteristics of his pain and assessed for any
changes that might have contributed to worsening of the pain.
B. The newly licensed nurse used the planning step of the nursing
process when she decided that it was appropriate to administer the
medication and, recognizing her level of experience in administering
pain medication, prepared the dose under supervision from the unit staff.
c. The newly licensed nurse used the implementation step of
the nursing process when she administered the medication.
D. The newly licensed nurse used the evaluation step of
the nursing process when she checked the effectiveness
of the pain medication in relieving the client’s pain.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
3. A. CORRECT: objective data includes information
the nurse measures, such as vital signs.
B. subjective data includes a client’s reported
symptoms, even if told by a secondary source.
c. subjective data includes a client’s reported symptoms.
D. CORRECT: objective data includes information
the nurse observes, such as skin appearance.
e. CORRECT: objective data includes information on
observations of others, such as family and staff.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
4. A. The nurse must have a prescription from the provider to administer
a medication. After obtaining the prescription, the nurse has the
flexibility to determine when to administer a PrN medication.
B. The nurse must have a prescription from the provider for the
insertion of an Ng tube. This is a provider‑initiated intervention.
c. CORRECT: showing a client how to use progressive muscle
relaxation is an appropriate nurse‑initiated intervention for stress
relief. unless it is a contraindication for a specific client, the nurse
can use this technique with clients without a provider’s prescription.
D. CORRECT: Performing a bath is a routine nursing care
procedure. unless it is a contraindication for a specific
client, the nurse can determine when bathing is optimal
for a client without a provider’s prescription.
e. CORRECT: repositioning a client every 2 hr is an
appropriate nurse‑initiated intervention for clients. unless
it is a contraindication for a specific client, the nurse can
use this strategy without a provider’s prescription.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
5. A. CORRECT: The nurse should prioritize client problems
during the planning step of the nursing process
B. The nurse should review the client’s history during the
assessment/data collection step of the nursing process
c. The nurse should implement nurse‑ and provider‑initiated
actions during the intervention step of the nursing process.
D. The nurse should gather information about whether
the client’s problems have been resolved during
the evaluation step of the nursing process
NCLEX® Connection: Management of Care,
Legal Rights and Responsibilities
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
Analysis/data collection
● recognize patterns or trends.
● compare the data with expected standards or reference ranges.
● Arrive at conclusions to guide nursing care.
Factors to consider during evaluation for unmet goals
● An incomplete database
● unrealistic client outcomes
● Nonspecific nursing interventions
● inadequate time for the client to achieve the outcomes
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
PRACTICE Active Learning Scenario
A nurse educator is reviewing with a group of nursing
students the actions and thought processes nurses use
during the steps of the nursing process. use the ATi Active
Learning Template: Basic concept to complete this item.
NURSING INTERVENTIONS
● List at three actions to take during the
analysis or data collection step.
● List four factors to consider during the evaluation
step when clients have not achieved their goals.
FUNDAMENTALS FOR NURSING CHAPTER 8 CritiCal thinking and CliniCal Judgment 33
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 8 Critical Thinking and
Clinical Judgment
nursing practice requires the application of
knowledge from biological, social, and physical
sciences; knowledge of pathophysiology;
and knowledge of nursing procedures and
skills. nurses also must use multiple thinking
skills—including critical thinking skills such as
interpretation, analysis, evaluation, inference,
and explanation—to make clinical judgments
about problems in nursing practice. a nursing
knowledge base with foundational thinking
skills, including recall and comprehension, is a
prerequisite to critical thinking in nursing.
in nursing, critical thinking is an active, orderly,
well thought‑out reasoning process that guides
a nurse in various approaches to making a
nursing judgment by applying knowledge and
experience, problem‑solving, logic, reasoning,
and decision‑making. a critical thinker prioritizes,
explores various courses of action, keeps ethics
in mind, and determines appropriate outcomes.
to have a positive effect on a client’s health
status, a nurse must be able to think critically,
correctly identify problems, and both devise
and implement the best solutions (interventions).
Critical thinking discourages quick judgments
that lead to single‑focused solutions.
CRITICAL THINKING
● Critical thinking requires lifelong learning and the
ability to acquire relevant experiences that can be
reflected on continuously to improve nursing judgment.
● The components of critical thinking include knowledge,
experience, critical thinking competencies, attitudes,
and intellectual and professional standards.
● Critical thinking incorporates reflection, language, and
intuition, and it evolves through three distinct levels as
a nurse gains knowledge and experience while maturing
into a competent nursing professional.
Reflection
Purposefully thinking back or recalling a situation to
discover its meaning and gain insight into the event. A
nurse should reflect on the following:
● “Why did I say that or do this?”
● “Did the original plan of care achieve optimal client
outcomes?”
◯ If so: “Which interventions were successful?”
◯ If not: “Which interventions were unsuccessful?”
Language
Precise, clear language demonstrating focused thinking
and communicating unambiguous messages and
expectations to clients and other health care team
members. A nurse should ask the following:
● “Did I use language appropriate for the client?”
● “Did I communicate the message clearly to the provider?”
Intuition
An inner sensing that facts do not currently support
something. Intuition should spark the nurse to search the
data to confirm or disprove the feeling. The nurse should
ask the following:
● “Did the vital signs reflect any changes that account for
the client’s present status?”
● “When the client’s status changed in this way last
month, there was a specific reason for it. Is that what is
happening here?”
LEVELS OF CRITICAL THINKING
Basic critical thinking
● A nurse trusts the experts and thinks concretely based
on the rules.
● Basic critical thinking results from limited nursing
knowledge and experience, as well as inadequate critical
thinking experience.
example: a client reports pain 1 hr after receiving a
pain medication. instead of reassessing the client’s
pain, the nurse tells the client he must wait two
more hours before he can receive another dose.
Complex critical thinking
● The nurse begins to express autonomy by analyzing and
examining data to determine the best alternative.
● Complex critical thinking results from an increase in
nursing knowledge, experience, intuition, and more
flexible attitudes.
example: a nurse realizes that a client is not
ambulating as often as prescribed because of a
fear of missing her daughter’s phone call. the nurse
assures the client that the staff will listen for and
answer her phone when she is out of her room.
CHAPTER 8
34 CHAPTER 8 CritiCal thinking and CliniCal Judgment CONTENT MASTERY SERIES
Commitment
● The nurse expects to make choices without help
from others and fully assumes the responsibility for
those choices.
● Commitment results from an expert level of knowledge,
experience, developed intuition, and reflective,
flexible attitudes.
example: a nurse increases the rate of an iV
fluid infusion when a client’s blood pressure
indicates hypovolemic shock 24 hr after surgery.
COMPONENTS OF CRITICAL THINKING
Knowledge
Information that’s specific to nursing and comes from:
● Basic nursing education
● Use of evidence based practice
● Continuing education courses
● Advanced degrees and certifications
Experience
Decision‑making ability derived from opportunities to
observe, sense, and interact with clients followed by active
reflection. A nurse:
● Demonstrates an understanding of clinical situations.
● Recognizes and analyzes cues for relevance.
● Incorporates experience into intuition.
Competence
Cognitive processes a nurse uses to make nursing judgments.
General critical thinking
● Scientific method
● Problem‑solving
● Decision‑making
● Diagnostic reasoning and inference
● Clinical decision‑making; collaboration
Specific critical thinking in nursing: The nursing
process (8.1)
Attitudes
Mindsets that affect how a nurse approaches a problem.
Attitudes of critical thinkers include:
● Confidence: Feels sure of abilities.
● Independence: Analyzes ideas for logical reasoning.
● Fairness: Is objective, nonjudgmental.
● Responsibility: Adheres to standards of practice.
● Risk taking: Takes calculated chances in finding better
solutions to problems.
● Discipline: Develops a systematic approach to thinking.
● Perseverance: Continues to work at a problem until
there’s a resolution.
● Creativity: Uses imagination to find solutions to unique
client problems.
● Curiosity: Requires more information about clients
and problems.
● Integrity: Practices truthfully and ethically.
● Humility: Acknowledges weaknesses.
Online Video: Priority Setting
8.1 Critical thinking and the nursing process
Assessment/Data collection
Collect information about a client’s
present health status to identify
needs, and to identify additional
data to collect based on findings.
CRITICAL THINKING SKILLS
● Observe.
● use correct techniques
for collecting data.
● differentiate between relevant
and irrelevant data, and between
important and unimportant data.
● Organize, categorize, and validate data.
● interpret assessment data
and draw a conclusion.
Analysis/Data collection
interpret or monitor the collected
database, reach an appropriate nursing
judgment about a client’s health
status and coping mechanisms, and
provide direction for nursing care.
CRITICAL THINKING SKILLS
● identify clusters and cues.
● detect inferences.
● recognize an actual or
potential problem or risk.
● avoid making judgments.
Planning
establish priorities and optimal outcomes
of care to measure and evaluate.
then, select the nursing interventions
to include in a client’s plan of care to
promote, maintain, or restore health.
CRITICAL THINKING SKILLS
● identify goals and outcomes
for client care.
● Set priorities.
● determine appropriate strategies
and interventions for inclusion on a
client’s plan of care or teaching plan.
● take knowledge and apply it to
more than one situation.
● Create outcome criteria.
● theorize.
● Consider the consequences
of implementation.
Implementation
Provide care based on assessment
data, analyses, and the plan of care.
CRITICAL THINKING SKILLS
● use knowledge base.
● use appropriate skills and
teaching strategies.
● test theories.
● delegate and supervise nursing care.
● Communicate appropriately
in response to a situation.
Evaluation
examine a client’s response to nursing
interventions and form a clinical judgment
about meeting goals and outcomes.
CRITICAL THINKING SKILLS
● determine accuracy of theories.
● evaluate outcomes based
on specific criteria.
● determine understanding of teaching.
FUNDAMENTALS FOR NURSING CHAPTER 8 CritiCal thinking and CliniCal Judgment 35
Standards
Model for comparing care to determine acceptability,
excellence, and appropriateness.
● Intellectual standards ensure the thorough application
of critical thinking.
● Professional standards
◯ Nursing judgment based on ethical criteria
◯ Evaluation that relies on evidence based practice
◯ Demonstration of professional responsibility
◯ Promotes maximal level of nursing care
Application Exercises
1. a nurse is caring for a client who
is 24 hr postoperative following
an inguinal hernia repair. the
client is tolerating clear liquids
well, has active bowel sounds, and
is expressing a desire for “real
food.” the nurse tells the client
that she will call the surgeon and
ask. the surgeon hears the nurse’s
report and prescribes a full liquid
diet. the nurse used which of the
following levels of critical thinking?
a. Basic
B. Commitment
C. Complex
d. integrity
2. a nurse receives a prescription for
an antibiotic for a client who has
cellulitis. the nurse checks the client’s
medical record, discovers that she is
allergic to the antibiotic, and calls the
provider to request a prescription for
a different antibiotic. Which of the
following critical thinking attitudes
did the nurse demonstrate?
a. Fairness
B. responsibility
C. risk taking
d. Creativity
3. a nurse is caring for a client
who is 24 hr postoperative
following abdominal surgery. the
nurse suspects the client’s pain
management is inadequate. Which
of the following data reinforce this
suspicion? (Select all that apply.)
a. the client seems
easily agitated.
B. the client is nonadherent
with coughing, deep
breathing, and dangling.
C. the client may have pain
medication every 4 to 6 hr
but accepts it every 6 to 7 hr.
d. the client reports tenderness
in his right lower leg.
e. the client’s vital signs are
heart rate 110/min, respiratory
rate 20/min, temperature
37° C (98.6° F), and blood
pressure 136/80 mm hg.
4. a nurse is caring for a client
who has a new prescription for
antihypertensive medication. Prior
to administering the medication, the
nurse uses an electronic database
to gather information about the
medication and the effects it might
have on this client. Which of the
following components of critical
thinking is the nurse using when he
reviews the medication information?
a. knowledge
B. experience
C. intuition
d. Competence
5. a nurse uses a head‑to‑toe approach
to conduct a physical assessment
of a client who will undergo surgery
the following week. Which of the
following critical thinking attitudes
did the nurse demonstrate?
a. Confidence
B. Perseverance
C. integrity
d. discipline
PRACTICE Active Learning Scenario
a nurse is reviewing with a group of newly licensed
nurses the critical thinking skills nurses used during each
of the steps of the nursing process. use the ati active
learning template: Basic Concept to complete this item.
NURSING INTERVENTIONS: list at three critical thinking
skills for each of the five steps of the nursing process.
36 CHAPTER 8 CritiCal thinking and CliniCal Judgment CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: at the basic level, thinking is concrete and based on a
set of rules, such as obtaining the prescription for diet progression.
B. at the commitment level, the nurse expects to have to
make choices without help from others and fully assumes the
responsibility for those choices. however, postoperative protocols
generally involve obtaining a prescription for diet progression.
C. advanced experience and knowledge at the complex
level will prompt the nurse to request diet progression to
full liquids based on active bowel sounds and the client’s
tolerance of clear liquid, not solely on the client’s request.
d. integrity is a critical thinking attitude that comes into play
when the nurse’s opinion differs from that of the client. the
nurse must then review her own position and decide how to
proceed to help achieve outcomes satisfactory to all parties.
NCLEX® Connection: Management of Care, Advocacy
2. a. Fairness is using a nonjudgmental, objective approach in looking
at clients and situations. this attitude does not apply here.
B. CORRECT: the nurse is responsible for administering
medications in a safe manner and according to standards of practice.
Checking the medical record for allergies helps ensure safety.
C. risk taking is a calculated approach to solving a problem that is not
responding to traditional methods. this attitude does not apply here.
d. Creativity is an approach that uses imagination to find
solutions to unique client problems. this problem is not
unique, and it requires a straightforward solution.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
3. a. Without more data, this finding alone does not suggest that
the client has unrelieved pain. it might be his usual disposition,
a result of hospitalization and surgery, or many other factors.
B. CORRECT: refusal to perform interventions that
could increase his pain level (coughing, deep breathing)
supports that the client has unrelieved pain.
C. CORRECT: acceptance of pain medication only at or beyond the
maximum interval suggests that the client has pain between the time
the effects of the previous dose subside and the new dose takes effect.
d. Sudden tenderness or swelling in a lower extremity is more
likely to suggest a new problem, such as deep‑vein thrombosis.
e. CORRECT: elevated blood pressure and pulse rate
without elevated temperature or other signs of distress
support that the client has unrelieved pain.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
4. a. CORRECT: By using the electronic database, the
nurse takes the initiative to increase his knowledge base,
which is the first component of critical thinking.
B. the nurse has had no prior experience with
administering this medication to this client.
C. intuition requires experience, which the nurse lacks
in administering this medication to this client.
d. Competence involves making judgments, but no one can make a
judgment about how the nurse handles researching and administering
this medication to this client until he performs those tasks.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
5. a. Confidence is feeling sure of one’s own abilities. the nurse
might feel confident of her physical assessment skills, but choosing
a particular method or sequence requires another attitude.
B. Perseverance is continuing to work at a problem until the
nurse resolves it. this attitude does not apply here.
C. integrity is a practicing truthfully and ethically. this
specific attitude does not apply here.
d. CORRECT: discipline is developing a systematic approach
to thinking. Proceeding head to toe is a systematic approach
to collecting the data a physical assessment yields.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
● assessment/data collection
◯ Observe.
◯ use correct techniques for collecting data.
◯ differentiate between relevant
and irrelevant data and between
important and unimportant data.
◯ Organize, categorize, and validate data.
◯ interpret assessment data
and draw a conclusion.
● analysis/data Collection
◯ identify clusters and cues.
◯ detect inferences.
◯ recognize an actual or potential
problem or risk.
◯ avoid making judgments.
● Planning
◯ identify goals and outcomes for client care.
◯ Set priorities.
◯ determine appropriate strategies
and interventions for inclusion on a
plan of care or teaching plan.
◯ take knowledge and apply it to
more than one situation.
◯ Create outcome criteria.
◯ theorize.
◯ Consider the consequences
of implementation.
● implementation
◯ use knowledge base.
◯ use appropriate skills and
teaching strategies.
◯ test theories.
◯ delegate and supervise nursing care.
◯ Communicate appropriately in
response to a situation.
● evaluation
◯ determine accuracy of theories.
◯ evaluate outcomes based on specific criteria.
◯ determine understanding of teaching.
NCLEX® Connection: Management of Care, Legal Rights and Responsibilities
FUNDAMENTALS FOR NURSING CHAPTER 9 Admissions, TrAnsfers, And dischArge 37
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: MANAGEMENT OF CARE
CHAPTER 9 Admissions,
Transfers, and
Discharge
responsibilities of nurses include ensuring
continuity of care and information sharing
throughout the processes of admission,
transfers, and discharge. The admission
assessment provides baseline data to use in
the development of the nursing care plan.
comparisons with future assessments help
monitor client status and response to treatment.
many clients experience anxiety, fear of the
unknown, and loss of independence and
self‑identity at the time of admission to the
hospital or health care facility. children can
experience separation anxiety if parents are
not present during the hospitalization. When
nurses recognize clients’ concerns and provide
respectful, culturally sensitive care, the clients’
experiences will be more positive.
NURSING CONSIDERATIONS
● Discharge planning is an interprofessional process that
starts at admission. Nurses conduct discharge planning
with clients and families for optimal results.
● Nurses establish the ability of clients to participate in
the admission assessment. Clients in distress or who
have mental status changes might need to have a family
member provide necessary information.
● Nurses begin establishing the therapeutic relationship
with clients and families during the admission process.
● Nurses promote professional communication
between providers.
● Nurses use the nursing process as a guide to plan
teaching and interventions for clients during discharge.
● Nurses use standard handoff communication tools, such
as Introduction, Situation, Background, Assessment,
Recommendation (ISBAR) to facilitate transfers
and discharges.
Admission process
EQUIPMENT
Prior to arrival of the client, bring necessary equipment
into the room. This should include appropriate
documentation forms, equipment to measure vital signs, a
pulse oximeter, and hospital attire for the client.
PROCEDURE
● Introduce yourself and identify your role.
● Explain the roles of other care delivery staff.
● If in a semiprivate room, introduce the client to
his roommate.
● Provide hospital attire and assist as necessary.
● Position the client comfortably.
● Apply the identification bracelet and allergy band,
if needed.
● Provide facility-specific brochures and
informational material.
● Provide information about advance directives.
● Document the client’s advance directives status in the
medical record. Place a copy in the medical record if it
is available.
Assess/coLLecT dATA
Baseline data: Vital signs, height, weight, allergy status
Biographical information
Client’s reason for seeking health care
Present illness and symptoms
Health history
● Current illness
● Current medications (prescription and
over‑the‑counter)
● Prior illnesses, chronic diseases
● Surgeries
● Previous hospitalizations
● Other relevant data
Family history (hypertension, cancer, heart disease,
diabetes mellitus)
Psychosocial assessment
● Alcohol, tobacco, drug, and caffeine use
● History of mental illness
● History of abuse or homelessness
● Home situation/significant others
Nutrition
● Current diet, any chewing or swallowing problems
● Recent weight gain/loss
● Use of nutritional or herbal supplements
● Dentures
CHAPTER 9
38 CHAPTER 9 Admissions, TrAnsfers, And dischArge CONTENT MASTERY SERIES
Spiritual health/quality-of-life concerns
● Religion
● Advance directives, living will
Review of systems
Safety assessments
● History of falls
● Sensory deficits (vision, hearing)
● Use of assistive devices (walker, cane, crutches,
wheelchair)
Discharge information
● Family members in the home
● Transportation for discharge
● Relevant phone numbers
● Medical equipment needs at home
● Home health care needs at home
inVenTorY PersonAL iTems
Examples are clothing, jewelry, money, credit cards,
assistive devices (eyeglasses, contacts, hearing aids, cane,
dentures), medications, cell phones and other technology
devices, and religious articles.
● Discourage keeping valuables at the bedside.
● Document communication with client related to items
left within the room, and valuables locked in the
facility’s safe.
orienTATion
Orient the client and family to the room and the facility.
Share information, including the following.
● Call light operation
● Electric bed operation
● Telephone services/television controls
● Overhead lighting operation
● Smoking policy
● Restroom locations
● Waiting areas
● Meal times
● Usual time for providers’ visits
● Dining/vending services
● Visiting policies
Transfer and
discharge process
INDICATIONS FOR TRANSFER
AND DISCHARGE
● The level of care changed (e.g., health status improved
so a client no longer needs intensive care).
● Another setting is required to provide necessary care
(e.g., transfer from medical unit to surgical suite).
● The facility does not offer the type of care a client now
requires (e.g., after the acute phase of a stroke, the
client requires care in a skilled facility).
● The client no longer needs inpatient care and is ready to
return home.
DISCHARGE PLANNING
This should begin on admission for every patient.
● Assess whether the client will be able to return to his
previous residence.
● Determine whether the client needs or has someone to
assist him at home.
● Assess the residence to see if the client needs
adaptations or specific equipment.
● Make a referral to the social worker to arrange for
community services.
● Communicate health status and needs to community
service providers.
● The provider documents that the client may be
discharged. However, a client who is legally competent
has the right to leave the facility at any time. The
nurse notifies the client’s provider, has the client
sign the proper forms if possible, and provides
discharge teaching.
● Involve the client and family as much as possible in the
discharge planning.
DISCHARGE EDUCATION
The nurse discusses the discharge instructions with the
client and provides a printed copy.
● Instructions should use clear, concise language that the
client will understand.
● The nurse should verify understanding of the
instructions by the client.
Standards for discharge education
● Identifying safety concerns at home
● Reviewing symptoms of potential complications and
when to contact emergency care or the provider
● Providing the phone number of the provider
● Providing names and phone numbers of community
resources that give care at the client’s residence
● Step‑by‑step instructions for performing continuing
treatments, such as dressing changes
● Dietary restrictions and guidelines, including those that
pertain to medication administration
● Amount and frequency of therapies to perform to
support continued independence at home
● Directions how to take medications, potential
interactions, and why adherence is important
Online Video: Discharge Teaching
FUNDAMENTALS FOR NURSING CHAPTER 9 Admissions, TrAnsfers, And dischArge 39
EQUIPMENT
Items to transfer/discharge with the client
● Personal belongings at the bedside and from dresser
drawers and closet (flowers, books, clothing, personal
care items)
● Valuables from the safe (if leaving the facility)
● Medications (especially that belong to the client or that
cannot be returned to the pharmacy for credit)
● Assistive devices
● Medical records or a transfer form
PROCEDURE
resPonsiBiLiTies of The nUrse
Transferring/discharging a client
● On the day and time of transfer, confirm that the
receiving facility or unit is expecting the client, and
that the room or bed is available.
● Communicate the time the client will transfer to the
receiving facility or unit.
● Complete documentation (medical records,
transfer form).
● Give a verbal transfer report in person or via telephone.
● Confirm the mode of transportation the client
will use to complete the transfer or discharge (car,
wheelchair, ambulance).
● Make sure the client is dressed appropriately if going
outside the facility.
● Account for all the client’s valuables.
Receiving a transferred client
● Have any specialized equipment ready.
● If appropriate, inform the client’s roommate of the
impending admission or transfer.
● Inform other health care team members of the client’s
arrival and needs.
● Meet with the client and family on arrival to complete
the admission process and orient the client and family
to the new facility or unit.
● Assess how the client tolerates the transfer.
● Review transfer documentation.
● Implement appropriate nursing interventions in a
timely manner.
TrAnsfer docUmenTATion
● Medical diagnosis and care providers
● Demographic information
● Overview of health status, plan of care, and
recent progress
● Alterations that can precipitate an immediate concern
● Notification of assessments or care essential within the
next few hours
● Most recent vital signs and medications, including PRN
● Allergies
● Diet and activity orders
● Specific equipment or adaptive devices (oxygen,
suction, wheelchair)
● Advance directives and emergency code status
● Family involvement in care and health care proxy,
if applicable
dischArge docUmenTATion
● Type of discharge (provider prescription or against
medical advice [AMA])
● Date and time of discharge, who went with the
client, and transportation (wheelchair to car, gurney
to ambulance)
● Where the client went (home, long‑term care facility)
● Summary of the client’s condition at discharge (steady
gait, ambulating independently, in no apparent distress)
● Description of any unresolved difficulties and
procedures for follow up
● Disposition of valuables, medications brought from
home, and prescriptions
dischArge insTrUcTions
Documentation of understanding of instructions by
the client.
● Written instructions in the client’s language
● Diet at home
● Step‑by‑step instructions for procedures at home
● Precautions to take when performing procedures or
administering medications
● Signs and symptoms of complications to report
● Names and numbers of providers and community
services to contact
● Plans for follow‑up care and therapies
40 CHAPTER 9 Admissions, TrAnsfers, And dischArge CONTENT MASTERY SERIES
Application Exercises
1. A nurse is performing an admission
assessment for an older adult client.
After gathering the assessment
data and performing the review
of systems, which of the following
actions is a priority for the nurse?
A. orient the client to his room.
B. conduct a client
care conference.
c. review medical prescriptions.
d. develop a plan of care.
2. A nurse is admitting a client
who has acute cholecystitis to
a medical‑surgical unit. Which
of the following actions are
essential steps of the admission
procedure? (select all that apply.)
A. explain the roles of other
care delivery staff.
B. Begin discharge planning.
c. Provide information about
advance directives.
d. document the client’s wishes
about organ donation.
e. introduce the client
to his roommate.
3. A nurse is caring for a client who
had a stroke and is scheduled
for transfer to a rehabilitation
center. Which of the following
tasks are the responsibility of
the nurse at the transferring
facility? (select all that apply.)
A. ensure that the client has
possession of his valuables.
B. confirm that the rehabilitation
center has a room available
at the time of transfer.
c. Assess how the client
tolerates the transfer.
d. give a verbal transfer
report via telephone.
e. complete a transfer form
for the receiving facility.
4. A nurse is preparing the discharge
summary for a client who has had
knee arthroplasty and is going
home. Which of the following
information about the client should
the nurse include in the discharge
summary? (select all that apply.)
A. Advance directives status
B. follow‑up care
c. instructions for diet
and medications
d. most recent vital sign data
e. contact information for the
home health care agency
5. As part of the admission process, a
nurse at a long‑term care facility
is gathering a nutrition history for
a client who has dementia. Which
of the following components of
the nutrition evaluation is the
priority for the nurse to determine
from the client’s family?
A. Body mass index
B. Usual times for meals
and snacks
c. favorite foods
d. Any difficulty swallowing
PRACTICE Active Learning Scenario
A nurse is reviewing with a group of newly licensed
nurses the essential components of an admission
assessment. Use the ATi Active Learning Template:
Basic concept to complete this item.
NURSING INTERVENTIONS: List at least three aspects of
the health history the nurse must gather and document,
as well as at least three aspects of the psychosocial
evaluation the nurse must gather and document.
FUNDAMENTALS FOR NURSING CHAPTER 9 Admissions, TrAnsfers, And dischArge 41
Application Exercises Key
1. A. CORRECT: The greatest risk to this client is injury from unfamiliar
surroundings. Therefore, the priority action is to orient the client to
the room. Before the nurse leaves the room, the client should know
how to use the call light and other equipment at the bedside.
B. The nurse should conduct a client care conference.
however, another action is the priority.
c. The nurse should review prescriptions in the medical
record. however, another action is the priority.
d. The nurse should develop a plan of care.
however, another action is the priority.
NCLEX® Connection: Management of Care, Continuity of Care
2. A. CORRECT: The client’s hospitalization is likely to be more positive
if the client understands who can perform which care activities.
B. CORRECT: Unless the client is entering a long‑term care
facility, discharge planning should begin on admission.
c. CORRECT: The Patient self‑determination Act requires asking clients
if they have advance directives and providing information about them.
d. Asking about organ donation at the point of
admission could instill fear unnecessarily.
e. CORRECT: Any action that can reduce the stress of hospitalization
is therapeutic. introductions to other clients and staff can
encourage communication and psychological comfort.
NCLEX® Connection: Management of Care, Continuity of Care
3. A. CORRECT: The nurse should account for all of
the client’s valuable at the time of transfer.
B. CORRECT: on the day of the transfer, the nurse should confirm that
the receiving facility is expecting the client and that the room is available.
c. it is the responsibility of the nurse at the receiving facility to assess
the client upon arrival to determine how he tolerated the transfer.
d. CORRECT: The nurse should provide the nurse at the receiving
facility with a verbal transfer report in person or via telephone.
e. CORRECT: The nurse should complete any documentation for the
transfer, including a transfer form and the client’s medical records.
NCLEX® Connection: Management of Care, Continuity of Care
4. A. Advance directives status is important in transfer
documentation, when other care providers will take over a
client’s care. They are not an essential component of a discharge
summary for a client who is returning to his home.
B. CORRECT: it is essential to include the names and
contact information of providers and community resources
the client will need after he returns home.
c. CORRECT: The client will need written information detailing
his medication and dietary therapy at home. A client who
has had knee arthroscopy typically requires analgesics,
possibly anticoagulants, and dietary instructions for avoiding
postoperative complications such as constipation.
d. Vital sign measurements are important in transfer
documentation, when other care providers will take over
a client’s care. They are not an essential component of a
discharge summary for a client who is returning home.
e. CORRECT: it is essential to include the names and contact
information of providers and community resources the client
will need after returning home. for example, a client who had a
knee arthroplasty might require physical therapy at home until
he can travel to a physical therapy department or facility.
NCLEX® Connection: Management of Care, Continuity of Care
5. A. it is important to calculate body mass index to help
determine appropriateness of the client’s weight status
and related risks. however, there is a higher priority.
B. it is important for the nurse to know and try to follow the meal
schedule the client follows at home. however, there is a higher priority.
c. it is important for the nurse to know which foods are the client’s
favorites in case it becomes difficult to get the client to consume
adequate nutrients. however, there is a higher priority.
d. CORRECT: The greatest risk to this client related to a nutrition‑related
evaluation is from difficulty swallowing, or dysphagia. it puts
the client at risk for aspiration, which can be life‑threatening.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
health history
● current illness
● current medications (prescription, herbal
supplements, and over the counter)
● Prior illnesses, chronic diseases
● surgeries
● Previous hospitalizations
Psychosocial assessment
● Alcohol, tobacco, drug, and caffeine use
● history of mental illness
● history of abuse or homelessness
● home situation/significant others
NCLEX® Connection: Management of Care, Continuity of Care
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 43
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Safety and Infection Control
ACCIDENT/ERROR/INJURY PREVENTION: Identify
deficits that may impede client safety.
ERGONOMIC PRINCIPLES: Assess client ability to balance,
transfer, and use assistive devices prior to planning care.
HOME SAFETY: Educate client on home safety issues.
REPORTING OF INCIDENT/EVENT/IRREGULAR OCCURRENCE/
VARIANCE: Acknowledge and document practice error.
SAFE USE OF EQUIPMENT: Teach client about the
safe use of equipment needed for health care.
STANDARD PRECAUTIONS/TRANSMISSION‑BASED PRECAUTIONS/
SURGICAL ASEPSIS: Apply principles of infection control.
FUNDAMENTALS FOR NURSING CHAPTER 10 Medical and Surgical aSepSiS 45
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: SAFETY AND INFECTION CONTROL
CHAPTER 10 Medical and
Surgical Asepsis
asepsis is the absence of illness‑producing
micro‑organisms. Hand hygiene is the
primary behavior.
Medical asepsis refers to the use of precise
practices to reduce the number, growth, and
spread of micro‑organisms (“clean technique”).
it applies to administering oral medication,
managing nasogastric tubes, providing personal
hygiene, and performing many other common
nursing tasks.
Surgical asepsis refers to the use of precise
practices to eliminate all micro‑organisms from
an object or area and prevent contamination
(“sterile technique”). it applies to parenteral
medication administration, insertion of
urinary catheters, surgical procedures, sterile
dressing changes, and many other common
nursing procedures.
Before beginning any task or procedure that
requires aseptic technique, health care team
members must check for latex allergies. if the
client or any member of the team has a latex
allergy, the team must use latex‑free gloves,
equipment, and supplies.
PRACTICES THAT PROMOTE
MEDICAL ASEPSIS
Hand HYgiene
Always use hand hygiene. Handwashing with an
antimicrobial or plain soap and water; using alcohol‑based
products such as gels, foams, and rinses; or performing a
surgical scrub.
● The three essential components of handwashing are
the following:
◯ Soap
◯ Running water
◯ Friction
● All health care personnel must perform hand hygiene,
either with an alcohol‑based product or with soap and
water, before and after every client contact, and after
removing gloves. When hands are visibly soiled, after
contact with body fluids, before eating, and after using
the restroom, wash them with a nonantimicrobial or
antimicrobial soap and water. It is also important for
clients and visitors to practice hand hygiene.
● Perform hand hygiene using recommended
antiseptic solutions when caring for clients who
are immunocompromised or have infections
with multidrug‑resistant or extremely virulent
micro‑organisms.
● Perform hand hygiene after contact with anything in
clients’ rooms and after touching any contaminated
items, whether or not gloves were worn, and
before putting gloves on and after taking them off.
Performing hand hygiene might be necessary between
tasks and procedures on the same client to prevent
cross-contamination of different body sites.
● Wash hands with soap and warm water. Rub hands
together vigorously, and rinse under running water.
Wash for at least 15 seconds to remove transient flora
and up to 2 min when hands are more soiled. After
washing, dry hands with a clean paper towel before
turning off the faucet. If the sink does not have foot or
knee pedals for turning off the water, use a clean, dry
paper towel to turn off the faucet(s).
● For hand hygiene with an alcohol‑based product,
dispense the manufacturer’s recommended amount
(usually 3 to 5 mL) in the palm of the hand. Rub hands
together vigorously, remembering to cover all surfaces
of both hands and fingers. Continue to rub until both
hands are completely dry.
CHAPTER 10
46 CHAPTER 10 Medical and Surgical aSepSiS CONTENT MASTERY SERIES
addiTiOnal perSOnal
HYgiene MeaSureS
● Emphasize the importance of covering the mouth and
nose when coughing or sneezing, using and disposing of
facial tissues, and performing hand hygiene to prevent
spraying and spreading droplet infections. Encourage
clients and visitors to practice respiratory hygiene/
cough etiquette. Ensure spatial separation of 3 ft from
those with a cough, or have them wear a mask.
● Wash hair frequently and keep it short or pulled back to
prevent contamination of the care area or the clients.
● Keep natural nails short and clean and free of nail gels
and acrylic nails. The area around and under the nails
can harbor micro‑organisms.
● Remove jewelry from hands and wrists to facilitate
hand disinfection.
prOTecTiVe clOTHing
Use masks, gloves, gowns, and protective eyewear to help
control the contact and spread of micro-organisms to staff
and clients.
pHYSical enVirOnMenT
Additional examples of practices that reduce the growth
and spread of micro‑organisms are changing linens daily,
cleaning floors and bedside stands, and separating clean
from contaminated materials.
● Do not place items on the floor (even soiled laundry).
The floor is grossly contaminated.
● Do not shake linens because doing so can spread
micro‑organisms in the air. Keep soiled items from
touching clothing.
● Clean the least soiled areas first to prevent moving more
contaminants into the cleaner areas.
● Use plastic bags for moist, soiled items, following
facility protocol for bag selection, to prevent further
contamination of items or of individuals handling
the soiled items. Put all soiled items directly into the
appropriate receptacle to avoid handling soiled items
more than once.
● Place all laboratory specimens in biohazard containers
or bags for transport or disposal.
● Pour any liquids used for client care directly into
the drain and avoid splattering to prevent spreading
droplets. Empty body fluids at water level of toilet to
avoid splashing.
PRACTICES THAT MAINTAIN
A STERILE FIELD
Prolonged exposure to airborne micro-organisms can
make sterile items nonsterile.
● Avoid coughing, sneezing, and talking directly over a
sterile field.
● Advise clients to avoid sudden movements, refrain from
touching supplies, drapes, or the nurse’s gloves and
gown, and avoid coughing, sneezing, or talking over a
sterile field.
Only sterile items may be in a sterile field.
● The outer wrappings and 1‑inch edges of packaging that
contains sterile items are not sterile. The inner surface
of the sterile drape or kit, except for that 1‑inch border
around the edges, is the sterile field to which other
sterile items may be added. To position the field on the
table surface, grasp the 1‑inch border before donning
sterile gloves. Discard any object that comes into
contact with the 1‑inch border.
● Touch sterile materials only with sterile gloves.
● Consider any object held below the waist or above the
chest contaminated.
● Sterile materials may touch other sterile surfaces or
materials; however, contact with nonsterile materials
at any time contaminates a sterile area, no matter how
short the contact.
Microbes can move by gravity from a nonsterile item to a
sterile item.
● Do not reach across or above a sterile field.
● Do not turn your back on a sterile field.
● Hold items to add to a sterile field at a minimum of
6 inches above the field.
Any sterile, non-waterproof wrapper that comes in
contact with moisture becomes nonsterile by a wicking
action that allows microbes to travel rapidly from a
nonsterile surface to the sterile surface.
● Keep all surfaces dry.
● Discard any sterile packages that are torn, punctured,
or wet.
NURSING INTERVENTIONS
eQuipMenT
● Select a clean area above waist level in the client’s
environment (a bedside stand) to set up the sterile field.
● Check that all sterile packages (additional dressings,
sterile bowl, sterile gloves, and solution) are dry and
intact and have a future expiration date. Any chemical
tape must show the appropriate color change.
● Make sure an appropriate waste receptacle is nearby.
prOcedure
Perform hand hygiene.
STERILE FIELD SETUP
● Open the covering of the package per the
manufacturer’s directions, slipping the package onto
the center of the workspace with the top flap of the
wrapper opening away from the body.
● Grasp the tip of the top flap of the package, and with
arm positioned away from the sterile field, unfold the
top flap away from body.
● Next, open the side flaps, using the right hand for the
right flap and the left hand for the left flap.
● Grasp the last flap and turn it down toward the body.
FUNDAMENTALS FOR NURSING CHAPTER 10 Medical and Surgical aSepSiS 47
ADDITIONAL STERILE PACKAGES
● Open next to the sterile field by holding the bottom
edge with one hand and pulling back on the top flap
with the other hand. Place the packages that will be
used last furthest from the sterile field; open these first.
● Add them directly to the sterile field. Lift the package
from the dry surface, holding it 15 cm (6 in) above
the sterile field, pulling the two surfaces apart, and
dropping it onto the sterile field.
POUR STERILE SOLUTIONS
● Removing the bottle cap.
● Placing the bottle cap face up on a clean
(nonsterile) surface.
● Holding the bottle with the label in the palm of the
hand so that the solution does not run down the label.
● First pouring a small amount (1 to 2 mL) of the solution
into an available receptacle.
● Pouring the solution (without splashing) onto the
dressing or site without touching the bottle to the site.
STERILE GLOVES
● Once the sterile field is set up, don sterile gloves.
● Sterile gloving includes opening the wrapper and
handling only the outside of the wrapper. Don gloves by
using the following steps.
● With the cuff side pointing toward the body, use the
nondominant hand and pick up the dominant‑hand
glove by grasping the folded bottom edge of the cuff and
lifting it up and away from the wrapper.
● While picking up the edge of the cuff, pull the dominant
glove onto the hand.
● With the sterile dominant‑gloved hand, place the
fingers of the dominant hand inside the cuff of the
nondominant glove, lifting it off the wrapper and
putting the nondominant hand into it.
● When both hands are gloved, adjust the fingers.
● During that time, only a sterile gloved hand may touch
the other sterile gloved hand.
● At the close of the sterile procedure or if the gloves tear,
remove the gloves. Take them off by grasping the outer
part of one glove at the cuff area, avoiding touching
the wrist and pulling the glove down over the fingers
and into the hand that is still gloved. Then, place the
ungloved hand inside the soiled glove and pull the glove
off so that it is inside out and only the clean inside part
is exposed. Discard into an appropriate receptacle.
Application Exercises
1. When entering a client’s room to
change a surgical dressing, a nurse
notes that the client is coughing and
sneezing. Which of the following
actions should the nurse take
when preparing the sterile field?
a. Keep the sterile field
at least 6 ft away from
the client’s bedside.
B. instruct the client to refrain
from coughing and sneezing
during the dressing change.
c. place a mask on the
client to limit the spread
of micro‑organisms into
the surgical wound.
d. Keep a box of facial tissues
nearby for the client to use
during the dressing change.
2. a nurse has removed a sterile
pack from its outside cover and
placed it on a clean work surface
in preparation for an invasive
procedure. Which of the following
flaps should the nurse unfold first?
a. The flap closest to the body
B. The right side flap
c. The left side flap
d. The flap farthest from the body
3. a nurse is wearing sterile gloves
in preparation for performing a
sterile procedure. Which of the
following objects can the nurse
touch without breaching sterile
technique? (Select all that apply.)
a. a bottle containing
a sterile solution
B. The edge of the sterile drape
at the base of the field
c. The inner wrapping of an
item on the sterile field
d. an irrigation syringe
on the sterile field
e. One gloved hand with
the other gloved hand
4. a nurse is reviewing hand hygiene
techniques with a group of assistive
personnel (ap). Which of the
following instructions should the
nurse include when discussing
handwashing? (Select all that apply.)
a. apply 3 to 5 ml of liquid
soap to dry hands.
B. Wash the hands with soap and
water for at least 15 seconds.
c. rinse the hands with hot water.
d. use a clean paper towel
to turn off hand faucets.
e. allow the hands to air
dry after washing.
5. a nurse has prepared a sterile
field for assisting a provider with a
chest tube insertion. Which of the
following events should the nurse
recognize as contaminating the
sterile field? (Select all that apply.)
a. The provider drops a sterile
instrument onto the near
side of the sterile field.
B. The nurse moistens a
cotton ball with sterile
normal saline and places
it on the sterile field.
c. The procedure is delayed
1 hr because the provider
receives an emergency call.
d. The nurse turns to speak to
someone who enters through
the door behind the nurse.
e. The client’s hand brushes
against the outer edge
of the sterile field.
48 CHAPTER 10 Medical and Surgical aSepSiS CONTENT MASTERY SERIES
Application Exercises Key
1. a. it would be difficult for the nurse to maintain a sterile field
away from the bedside. But more important, this might not have
any effect on the transmission of some micro‑organisms.
B. The client might be unable to refrain from coughing
and sneezing during the dressing change.
c. CORRECT: placing a mask on the client prevents contamination
of the surgical wound during the dressing change.
d. Keeping tissues close by for the client to use still
allows contamination of the surgical wound.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
2. a. The flap closest to the nurse’s body is the
innermost flap and the last one to unfold.
B. The nurse should unfold the side flap that is closest to the
top of the package before the one underneath it; however,
there is another flap the nurse should unfold first.
c. The nurse should unfold the side flap that is closest to the
top of the package before the one underneath it; however,
there is another flap the nurse should unfold first.
d. CORRECT: The priority goal in setting up a sterile field is
to maintain sterility and thus reduce the risk to the client’s
safety. unless the nurse pulls the top flap (the one farthest from
her body) away from her body first, she risks touching part of
the inner surface of the wrap and thus contaminating it.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
3. a. a bottle of sterile solution is sterile on the inside and nonsterile
on the outside. The nurse must prepare the sterile container
of solution on the field before putting on sterile gloves.
B. The 1‑inch border at the outer edge of the sterile field is
not sterile. The nurse may not touch it with sterile gloves.
c. CORRECT: The inner wrappings of any objects the
nurse dropped onto the sterile field are sterile. The
nurse may touch them with sterile gloves.
d. CORRECT: any objects the nurse dropped onto
the sterile field during the setup are sterile. The nurse
may touch the syringe with sterile gloves.
e. CORRECT: One sterile gloved hand may touch the
other sterile gloved hand because both are sterile.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
4. a. The aps should apply alcohol rubs to dry hands, and wet
the hands first before applying soap for handwashing.
B. CORRECT: This is the amount of time it takes to remove transient
flora from the hands. For soiled hands, the recommendation is 2 minutes.
c. The aps should use warm water to minimize
the removal of protective skin oils.
d. CORRECT: if the sink does not have foot or knee
pedals, the aps should turn off the water with a
clean paper towel and not with their hands.
e. The aps should dry their hands with a clean paper
towel. This helps prevent chapped skin.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
5. a. as long as the provider has not reached over the
sterile field, such as by placing the instrument on a
near portion of the field, the field remains sterile.
B. CORRECT: Fluid permeation of the sterile
drape or barrier contaminates the field.
c. CORRECT: prolonged exposure to air contaminates a sterile field.
d. CORRECT: Turning away from a sterile field contaminates
the field because the nurse cannot see if a piece of
clothing or hair made contact with the field.
e. The 1‑inch border at the outer edge of the sterile field is not sterile.
unless the client reached farther into the field, the field remains sterile.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
PRACTICE Answer
Using the ATI Active Learning Template: Nursing Skill
DESCRIPTION OF SKILL
● With the cuff side pointing toward the body, use the
nondominant hand to pick up the dominant‑hand
glove by grasping the folded bottom edge of the cuff
and lifting it up and away from the wrapper.
● While picking up the edge of the cuff, pull
the dominant glove onto the hand.
● With the sterile dominant‑gloved hand, place the fingers of the
dominant hand inside the cuff of the nondominant glove, lifting
it off the wrapper and putting the nondominant hand into it.
● adjust the fingers.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
PRACTICE Active Learning Scenario
a nurse is reviewing with a newly licensed nurse the
procedure for putting on sterile gloves. use the aTi active
learning Template: nursing Skill to complete this item.
DESCRIPTION OF SKILL: list the steps involved
in putting on a pair of sterile gloves.
FUNDAMENTALS FOR NURSING CHAPTER 11 InfectIon control 49
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: SAFETY AND INFECTION CONTROL
CHAPTER 11 Infection Control
An infection occurs when the presence of
a pathogen leads to a chain of events. All
components of the chain must be present and
intact for the infection to occur. A nurse uses
infection control practices (medical asepsis,
surgical asepsis, standard precautions) to break
the chain and thus stop the spread of infection.
tYPeS of PAtHoGen
Pathogens are the micro‑organisms or microbes that
cause infections.
● Bacteria (Staphylococcus aureus, Escherichia coli,
Mycobacterium tuberculosis)
● Viruses: Organisms that use the host’s genetic
machinery to reproduce (HIV, hepatitis, herpes zoster,
herpes simplex)
● Fungi: Molds and yeasts (Candida albicans, Aspergillus)
● Prions: Protein particles (new variant
Creutzfeldt‑Jakob disease)
● Parasites: Protozoa (malaria, toxoplasmosis) and
helminths (worms [flatworms, roundworms], flukes
[Schistosoma])
Virulence is the ability of a pathogen to invade and
injure a host.
Herpes zoster is a common viral infection that erupts
years after exposure to chickenpox and invades a specific
nerve tract.
IMMUne DefenSeS
Nonspecific innate
Native immunity restricts entry or immediately responds
to a foreign organism (antigen) through the activation
of phagocytic cells, complement, and inflammation.
This occurs with all micro‑organisms, regardless of
previous exposure.
Passive: Antibodies are produced by an external source.
● Temporary immunity that does not have memory of
past exposures
● Intact skin, the body’s first line of defense
● Mucous membranes, secretions, enzymes, phagocytic
cells, and protective proteins
● Inflammatory response with phagocytic cells, the
complement system, and interferons localize the
invasion and prevent its spread
Specific adaptive immunity
Specific adaptive immunity allows the body to make
antibodies in response to a foreign organism (antigen).
This reaction directs against an identifiable
micro‑organism.
Active: Antibodies are produced in response to an antigen.
● Requires time to react to antigens
● Provides permanent immunity
● Involves B‑ and T‑lymphocytes
● Produces specific antibodies against specific antigens
(immunoglobulins [IgA, IgD, IgE, IgG, IgM])
InfectIon ProceSS
Chain of infection (11.1)
Causative agent (bacteria, virus, fungus, prion, parasite)
Reservoir (human, animal, food, organic matter on
inanimate surfaces, water, soil, insects)
Portal of exit from (means for leaving) the host
● Respiratory tract (droplet, airborne): Mycobacterium
tuberculosis and Streptococcus pneumoniae
● Gastrointestinal tract: Shigella, Salmonella enteritidis,
Salmonella typhi, hepatitis A
● Genitourinary tract: Escherichia coli, hepatitis A, herpes
simplex virus (type 1), HIV
● Skin/mucous membranes: Herpes simplex virus
and varicella
● Blood/body fluids: HIV and hepatitis B and C
● Transplacental
CHAPTER 11
Online Image: Chain of Infection
11.1 Chain of infection
50 CHAPTER 11 InfectIon control CONTENT MASTERY SERIES
Mode of transmission
● Contact
◯ Direct physical contact: Person to person
◯ Indirect contact with an inanimate object: Object
to person
◯ Fecal‑oral transmission: Handling food after using a
restroom and failing to wash hands
● Droplet: Sneezing, coughing, and talking
● Airborne: Sneezing and coughing
● Vector borne: Animals or insects as intermediaries (ticks
transmit Lyme disease; mosquitoes transmit West Nile
and malaria)
Portal of entry to the host: Might be the same as the
portal of exit
Susceptible host: Compromised defense mechanisms
(immunocompromised, breaks in skin) leave the host more
susceptible to infections.
Stages of an infection
Incubation: interval between the pathogen entering the
body and the presentation of the first symptom.
Prodromal stage: interval from onset of general
symptoms to more distinct symptoms. During this time,
the pathogen is multiplying.
Illness stage: interval when symptoms specific to the
infection occur.
Convalescence: interval when acute symptoms disappear.
Total recovery could take days to months.
ASSESSMENT/DATA COLLECTION
rISK fActorS
A nurse should assess each client for the risks of infection
specific to the client, the disease or injury, and the
environment. The most common risks include:
● Inadequate hand hygiene (client and caregivers).
● Individuals who have compromised health or defenses
against infection, which include:
◯ Those who are immunocompromised.
◯ Those who have had surgery.
◯ Those with indwelling devices.
◯ A break in the skin (the body’s best protection
against infection).
◯ Those with poor oxygenation.
◯ Those with impaired circulation.
◯ Those who have chronic or acute disease, such as
diabetes mellitus, adrenal insufficiency, renal failure,
hepatic failure, or chronic lung disease.
● Caregivers using medical or surgical asepsis that does
not follow the established standards. (11.2)
● Clients who have poor personal hygiene or poor
nutrition, smoke, or consume excessive amounts of
alcohol, and those experiencing stress.
● Clients who live in a very crowded environment.
● OLDER ADULT CLIENTS: Older adults have a slowed
response to antibiotic therapy, slowed immune response,
loss of subcutaneous tissue and thinning of the skin,
decreased vascularity and slowed wound healing,
decreased cough and gag reflexes, chronic illnesses,
decreased gastric acid production, decreased mobility,
bowel and bladder incontinence, dementia, and greater
incidence of invasive devices such as a urinary catheter
or feeding tube.
● Individuals who make poor lifestyle choices that put
them at risk, which include:
◯ Clients who use IV drugs and share needles.
◯ Clients who engage in unprotected sex.
● Clients who have recently been exposed to:
◯ Poor sanitation.
◯ Mosquito‑borne or parasitic diseases.
◯ Diseases endemic to the area visited, but not in the
client’s home country.
eXPecteD fInDInGS
● Findings identifiable in the nursing assessment of
generalized or systemic infection include the following.
◯ Fever
◯ Presence of chills, which occur when temperature
is rising, and diaphoresis, which occurs when
temperature is decreasing
◯ Increased pulse and respiratory rate (in response to
the high fever)
◯ Malaise
◯ Fatigue
◯ Anorexia, nausea, and vomiting
◯ Abdominal cramping and diarrhea
◯ Enlarged lymph nodes (repositories for “waste”)
11.2 Health‑care associated infections
Health‑care associated infections (HAIs) are infections
that a client acquires while receiving care in a health
care setting. formerly called nosocomial infections,
these can come from an exogenous source (from
outside the client) or an endogenous source (inside
the client when part of the client’s flora is altered).
● often occur in the intensive care unit.
● the best way to prevent HAIs is through
frequent and effective hand hygiene.
● A common site of HAIs is the urinary tract and these
are often caused by Escherichia coli, Staphylococcus
aureus, and enterococci. other sites of HAIs are surgical
wounds, the respiratory tract, and the bloodstream.
● An iatrogenic infection is a type of HAI resulting
from a diagnostic or therapeutic procedure.
● HAIs are not always preventable and
are not always iatrogenic.
● Use current evidence‑based practice guidelines to
prevent HAIs due to multidrug‑resistant organisms.
FUNDAMENTALS FOR NURSING CHAPTER 11 InfectIon control 51
● OLDER ADULT CLIENTS
◯ Older adults have a reduced inflammatory and
immune response and thus might have an advanced
infection before it is identified. Atypical findings such
as agitation, confusion, or incontinence can be the
only manifestations.
◯ Other findings can vary depending on the site of
the infection (dyspnea, cough, purulent sputum,
and crackles in lung fields, dysuria, urinary
frequency, hematuria and pyuria, rash, skin
lesions, purulent wound drainage, erythema and
odynophagia, dysphagia, hyperemia, enlarged tonsils,
change in level of consciousness, nuchal rigidity,
photophobia, headache)
● Inflammation is the body’s local response to injury or
infection. The inflammatory response has three stages.
◯ Findings during the first stage of the inflammatory
response (local infection) include the following.
■ Redness (from dilation of arterioles bringing blood
to the area)
■ Warmth of the area on palpation
■ Edema
■ Pain or tenderness
■ Loss of use of the affected part
◯ In the second stage, the micro‑organisms are
killed. Fluid containing dead tissue cells and WBCs
accumulates and exudate appears at the site of the
infection. The exudate leaves the body by draining
into the lymph system. The types of exudate are:
■ Serous (clear).
■ Sanguineous (contains red blood cells).
■ Purulent (contains leukocytes and bacteria).
◯ In the third stage, damaged tissue is replaced by scar
tissue. Gradually, the new cells take on characteristics
that are similar in structure and function to the
old cells.
lABorAtorY teStS
● Leukocytosis (WBCs greater than 10,000/µL)
● Increases in the specific types of WBCs on differential
(left shift = an increase in neutrophils)
● Elevated erythrocyte sedimentation rate (ESR) over
20 mm/hr; an increase indicates an active inflammatory
process or infection
● Presence of micro‑organisms on culture of the
specific fluid/area
DIAGnoStIc ProceDUreS
● Gallium scan: Nuclear scan that uses a radioactive
substance to identify hot spots of WBCs
● Radioactive gallium citrate: Injected by IV and
accumulates in area of inflammation
● X‑rays, CT scan, magnetic resonance imaging (MRI),
and biopsies to determine the presence of infection,
abscesses, and lesions
PATIENT‑CENTERED CARE
nUrSInG cAre
● Use frequent and effective hand hygiene before and
after care.
● Educate the client about the required and recommended
immunizations and where to obtain them. The target
groups include children, older adults, those with chronic
disease, and those who are immunocompromised and
their families and contacts.
● Educate the client and ask for a return demonstration
of good oral hygiene. Good oral hygiene decreases
the protein (which attracts micro‑organisms) in the
oral cavity, which thereby decreases the growth of
micro‑organisms that can migrate through breaks in
the oral mucosa.
● Encourage the client to consume an adequate amount of
fluids. Adequate fluid intake prevents the stasis of urine
by flushing the urinary tract and decreasing the growth
of micro‑organisms. Adequate hydration also keeps
the skin from breaking down. Intact skin prevents
micro‑organisms from entering the body.
● For immobile clients, ensure that pulmonary hygiene
(turning, coughing, deep breathing, incentive
spirometry) is done every 2 hr, or as prescribed.
Good pulmonary hygiene decreases the growth of
micro‑organisms and the development of pneumonia by
preventing stasis of pulmonary excretions, stimulating
ciliary movement and clearance, and expanding
the lungs.
● Use of aseptic technique and proper personal protective
equipment (such as gloves, masks, gowns, and
goggles) in the provision of care to all clients prevents
unnecessary exposure to micro‑organisms.
● Teach and use respiratory hygiene/cough etiquette. It
applies to anyone entering a health care setting (clients,
visitors, staff) with signs or symptoms of illness,
whether diagnosed or undiagnosed. This includes cough,
congestion, rhinorrhea, or an increase in the production
of respiratory secretions. The components of respiratory
hygiene and cough etiquette include:
◯ Covering the mouth and nose when coughing
and sneezing.
◯ Using facial tissues to contain respiratory
secretions and disposing of them promptly into a
hands‑free receptacle.
◯ Wearing a surgical mask when coughing to minimize
contamination of the surrounding environment.
◯ Turning the head when coughing and staying a
minimum of 3 ft away from others, especially in
common waiting areas.
◯ Performing hand hygiene after contact with
respiratory secretions and contaminated
objects/materials.
52 CHAPTER 11 InfectIon control CONTENT MASTERY SERIES
ISolAtIon GUIDelIneS
● Isolation guidelines are a group of actions that include
hand hygiene and the use of barrier precautions,
which intend to reduce the transmission of
infectious organisms.
● The precautions apply to every client, regardless of the
diagnosis, and implementation of them must occur
whenever there’s anticipation of coming into contact
with a potentially infectious material.
● Change personal protective equipment after contact
with each client and between procedures with the same
client if in contact with large amounts of blood and
body fluids.
● Clients in isolation are at a higher risk for depression
and loneliness. Assist the client and their family to
understand the reason for isolation and provide sensory
stimulation.
Standard precautions (tier one)
This tier of standard precautions applies to all body fluids
(except sweat), nonintact skin, and mucous membranes.
A nurse should implement standard precautions for
all clients.
● Hand hygiene using an alcohol‑based waterless product
is recommended after contact with the client when the
hands are not visibly soiled or contaminated with blood
or body fluids and after the removal of gloves.
● Alcohol‑based waterless antiseptic is preferred unless
the hands are visibly dirty, because the alcohol‑based
product is more effective in removing micro‑organisms.
● Use a nonantimicrobial soap if contamination with
spores is suspected.
● Hand hygiene using nonantimicrobial soap or an
antimicrobial soap and water is recommended when
visibly soiled or contaminated with blood or body fluids.
● Remove gloves and complete hand hygiene between
each client.
● Masks, eye protection, and face shields are required
when care might cause splashing or spraying of
body fluids.
● Clean gloves are worn when touching anything that has
the potential to contaminate the hands of the nurse.
This includes body secretions, excretions, blood and
body fluids, nonintact skin, mucous membranes, and
contaminated items.
● Hand hygiene is required after removal of the gown. Use
a sturdy moisture‑resistant bag for soiled items and tie
the bag securely in a knot at the top.
● Properly clean all equipment for client care; dispose of
one‑time use items according to facility policy.
● Bag and handle contaminated laundry to prevent
leaking or contamination of clothing or skin.
● Enable safety devices on all equipment and
supplies after use; dispose of all sharps in a
puncture‑resistant container.
● A client does not need a private room unless he is
unable to maintain appropriate hygienic practices.
Transmission precautions (tier two)
Airborne precautions
Use airborne precautions to protect against droplet
infections smaller than 5 mcg (measles, varicella,
pulmonary or laryngeal tuberculosis).
Airborne precautions require:
● A private room.
● Masks and respiratory protection devices for caregivers
and visitors.
Use an n95 or high‑efficiency particulate
air (HePA) respirator if the client is known
or suspected to have tuberculosis.
● Negative pressure airflow exchange in the room of at
least six to 12 exchanges per hour, depending on the age
of the structure.
● If splashing or spraying is a possibility, wear full face
(eyes, nose, mouth) protection.
Droplet precautions
Droplet precautions protect against droplets larger than
5 mcg and travel 3 to 6 ft from the client (streptococcal
pharyngitis or pneumonia, Haemophilus influenzae type
B, scarlet fever, rubella, pertussis, mumps, mycoplasma
pneumonia, meningococcal pneumonia and sepsis,
pneumonic plague).
Droplet precautions require:
● A private room or a room with other clients who have
the same infectious disease. Ensure that clients have
their own equipment.
● Masks for providers and visitors.
Contact precautions
Contact precautions protect visitors and caregivers
when they are within 3 ft of the client against direct
client and environmental contact infections (respiratory
syncytial virus, shigella, enteric diseases caused by
micro‑organisms, wound infections, herpes simplex,
impetigo, scabies, multidrug‑resistant organisms).
Contact precautions require:
● A private room or a room with other clients who have
the same infection.
● Gloves and gowns worn by the caregivers and visitors.
● Disposal of infectious dressing material into a single,
nonporous bag without touching the outside of the bag.
Protective precautions
Protective environment to protect clients who are
immunocompromised, such as those who have had an
allogeneic hematopoietic stem cell transplant.
A protective environment requires:
◯ Private room.
◯ Positive airflow 12 or more air exchanges/hr.
◯ HEPA filtration for incoming air.
◯ Mask for the client when out of room.
Online Video: Precautions
FUNDAMENTALS FOR NURSING CHAPTER 11 InfectIon control 53
MeDIcAtIonS
Antipyretics
Antipyretics (acetaminophen and aspirin) are used for
fever and discomfort as prescribed.
NURSING CONSIDERATIONS
● Monitor fever to determine effectiveness of medication.
● Document the client’s temperature fluctuations on the
medical record for trending.
Antimicrobial therapy
Antimicrobial therapy kills or inhibits the growth of
micro‑organisms (bacteria, fungi, viruses, protozoans).
Antimicrobial medications either kill pathogens or
prevent their growth. Give anthelmintics for worm
infestations. (11.3)
NURSING CONSIDERATIONS
● Administer antimicrobial therapy as prescribed.
● Monitor for medication effectiveness (reduced fever,
increase in the level of comfort, decreasing WBC count).
● Maintain a medication schedule to ensure consistent
therapeutic blood levels of the antibiotic.
InterProfeSSIonAl cAre
Transporting a client
If movement of the client to another area of the facility is
unavoidable, the nurse takes precautions to ensure that
the environment is not contaminated. For example, a
surgical mask is placed on the client who has an airborne
or droplet infection, and a draining wound is well covered.
Guidelines for cleaning contaminated equipment
● Always wear gloves and protective eyewear.
● Rinse first in running cold water. Hot water coagulates
proteins, making them adhere.
● Wash the article in warm water with soap.
● Use a brush or abrasive to clean corners or
hard‑to‑reach areas.
● Rinse well in warm water.
● Dry the article. It is considered clean at this point.
● Clean the equipment used in cleaning and the sink (still
dirty unless a disinfectant is used).
● If indicated, follow facility policy for recommended
disinfection or sterilization.
● Remove gloves and perform hand hygiene.
Reporting communicable diseases
A complete list of reportable diseases and the reporting
system are available through the Centers for Disease
Control and Prevention’s website (www.cdc.gov). There
are more than 60 communicable diseases that must be
reported to the public health departments to allow for
officials to:
● Ensure appropriate medical treatment of diseases
(tuberculosis).
● Monitor for common‑source outbreaks (foodborne—
hepatitis A).
● Plan and evaluate control and prevention plans
(immunizations for preventable diseases).
● Identify outbreaks and epidemics.
● Determine public health priorities based on trends.
clIent eDUcAtIon
Teach the client about:
● Any infection control measures at home.
● Self‑administration of medication therapy.
● Complications to report immediately.
11.3 Multidrug‑resistant infection
Antimicrobials are becoming less effective for some
strains of pathogens due to the pathogen’s ability to
adapt and become resistant to previously sensitive
antibiotics. this significantly limits the number of
antibiotics that are effective against the pathogen.
Use of antibiotics, especially broad‑spectrum antibiotics,
has significantly decreased to prevent new strains from
evolving. taking the measures below can ensure that
an antimicrobial is necessary and therapy is effective.
Methicillin‑resistant Staphylococcus aureus
(MrSA) is a strain of Staphylococcus aureus that
is resistant to many antibiotics. Vancomycin
and linezolid are used to treat MrSA.
Vancomycin‑resistant Staphylococcus aureus
(VrSA) is a strain of Staphylococcus aureus that is
resistant to vancomycin, but so far is sensitive to
other antibiotics specific to a client’s strain.
NURSING ACTIONS
● obtain specimens for culture and sensitivity
prior to initiation of antimicrobial therapy.
● Monitor antimicrobial levels and ensure that
therapeutic levels are maintained.
CLIENT EDUCATION
● complete the full course of antimicrobial therapy.
● Avoid overuse of antimicrobials.
54 CHAPTER 11 InfectIon control CONTENT MASTERY SERIES
Herpes zoster (shingles)
Herpes zoster is a viral infection. It initially produces
chickenpox, after which the virus lies dormant in the
dorsal root ganglia of the sensory nerves. It is then
reactivated as shingles later in life.
● Shingles is usually preceded by a prodromal period of
several days, during which pain, tingling, or burning
might occur along the involved dermatome.
● Shingles can be very painful and debilitating.
ASSESSMENT/DATA COLLECTION
rISK fActorS
● Concurrent illness
● Stress
● Compromise to the immune system
● Fatigue
● Poor nutritional status
● OLDER ADULT CLIENTS are more susceptible to herpes
zoster infection. The immune function of older adults
might also be compromised, so assess them carefully for
local or systemic signs of infection.
eXPecteD fInDInGS
● Paresthesia
● Pain that is unilateral and extends horizontally along
a dermatome
PHYSICAL ASSESSMENT FINDINGS
● Vesicular, unilateral rash (the rash and lesions occur on
the skin area innervated by the infected nerve)
● Rash that is erythematous, vesicular, pustular, or
crusting (depending on the stage)
● Rash that usually resolves in 14 to 21 days
● Low‑grade fever
lABorAtorY teStS
● Cultures provide a definitive diagnosis. But, the virus
grows so slowly that cultures are often of minimal
diagnostic use.
● Occasionally, an immunofluorescence assay can be done.
PATIENT‑CENTERED CARE
nUrSInG cAre
● Assess/Monitor
◯ Pain
◯ Condition of the lesions
◯ Presence of fever
◯ Neurologic complications
◯ Signs of infection
● Use an air mattress or bed cradle for pain prevention
and control of affected areas.
● Isolate the client until the vesicles have crusted over.
● Maintain strict wound care precautions.
● Avoid exposing the client to infants, pregnant women
who have not had chickenpox, and clients who are
immunocompromised, although anyone who has not
had chickenpox and has not been vaccinated is at risk.
● Use lotions to help relieve itching and discomfort.
● Administer medications as prescribed.
MeDIcAtIonS
Analgesics (NSAIDs, narcotics) enhance client comfort.
Antiviral agents , such as acyclovir, can shorten the
clinical course.
COMPLICATIONS
Postherpetic neuralgia
● Characterized by pain that persists for longer than
1 month following resolution of the vesicular rash
● Tricyclic antidepressants might be prescribed
● Postherpetic neuralgia is common in adults older than
60 years of age.
PREVENTION
● Zoster vaccine reduces the risk of developing shingles
● Do not give to clients who are immunocompromised.
FUNDAMENTALS FOR NURSING CHAPTER 11 InfectIon control 55
Application Exercises
1. A nurse is caring for a client
diagnosed with severe acute
respiratory syndrome (SArS).
the nurse is aware that health
care professionals are required
to report communicable and
infectious diseases. Which of the
following illustrate the rationale for
reporting? (Select all that apply.)
A. Planning and evaluating control
and prevention strategies
B. Determining public
health priorities
c. ensuring proper
medical treatment
D. Identifying endemic disease
e. Monitoring for
common‑source outbreaks
2. A nurse is caring for a client who
presents with linear clusters of
fluid‑containing vesicles with some
crustings. the nurse should identify
the client has manifestations of
which of the following conditions?
A. Allergic reaction
B. ringworm
c. Systemic lupus erythematosus
D. Herpes zoster
3. A nurse is caring for a client
who reports a severe sore throat,
pain when swallowing, and
swollen lymph nodes. the client
is experiencing which of the
following stages of infection?
A. Prodromal
B. Incubation
c. convalescence
D. Illness
4. A nurse educator is reviewing with a
newly hired nurse the difference in
manifestations of a localized versus
a systemic infection. the nurse
indicates understanding when she
states that which of the following
are manifestations of a systemic
infection? (Select all that apply.)
A. fever
B. Malaise
c. edema
D. Pain or tenderness
e. Increase in pulse and
respiratory rate
5. A nurse is contributing to the plan
of care for a client who is being
admitted to the facility with a
suspected diagnosis of pertussis.
Which of the following interventions
should the nurse include in the plan
of care? (Select all that apply.)
A. Place the client in a room that
has negative air pressure of at
least six exchanges per hour.
B. Wear a mask when providing
care within 3 ft of the client.
c. Place a surgical mask on
the client if transportation
to another department
is unavoidable.
D. Use sterile gloves when
handling soiled linens.
e. Wear a gown when performing
care that might result in
contamination from secretions.
PRACTICE Active Learning Scenario
A nurse educator is teaching a module on the chain
of infection during nursing orientation to a group of
newly licensed nurses. Use the AtI Active learning
template: Basic concept to complete this item.
RELATED CONTENT: list the six links in the chain of
infection that must be present for an infection to occur.
56 CHAPTER 11 InfectIon control CONTENT MASTERY SERIES
Application Exercises Key
1. A. CORRECT: reporting of communicable and infectious diseases
assists with planning and evaluating control and prevention strategies.
B. CORRECT: reporting of communicable and infectious
diseases assists with determining public health policies.
c. CORRECT: reporting of communicable and infectious diseases
assists with ensuring proper medical treatment is available.
D. endemic disease is already prevalent within a
population, so reporting is not necessary.
e. CORRECT: reporting of communicable and infectious diseases
assists with monitoring for common‑source outbreaks.
NCLEX® Connection: Physiological Adaptation,
Illness Management
2. A. A pink body rash is a manifestation of an allergic reaction.
B. red circles with white centers is a manifestation of ringworm.
c. A red edematous rash bilaterally on the cheeks is a
manifestation of systemic lupus erythematosus.
D. CORRECT: Vesicles that follow along a unilateral
dermatome is a manifestation of herpes zoster.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. A. the prodromal stage consists of nonspecific
manifestations of the infection.
B. the incubation period consists of the time when
the pathogen first enters the body prior to the
appearance of any manifestations of infection.
c. During convalescence, manifestations of the infection fade.
D. CORRECT: the illness stage is when the client
experiences manifestations specific to the infection.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
4. A. CORRECT: A fever indicates that the infection is
affecting the whole body, and therefore systemic.
B. CORRECT: Malaise indicates that the infection is
affecting the whole body, and therefore systemic.
c. edema is a localized manifestation indicating
a localized, not systemic, infection.
D. Pain and tenderness is a localized manifestation
indicating a localized, not systemic, infection.
e. CORRECT: An increase in pulse and respiratory rate indicates that
the infection is affecting the whole body, and therefore systemic.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
5. A. A nurse should place a client in a private room and initiate
droplet precautions if he has pertussis. negative‑pressure airflow
is required for a client who is on airborne precautions.
B. CORRECT: the nurse should wear a mask
when within 3 ft of the client.
c. CORRECT: the nurse should place a surgical mask on the
client during transport to another area of the facility.
D. the nurse should wear a gown and non‑sterile gloves when
performing care that might result in contamination from body fluids.
e. CORRECT: A gown should be worn if the nurse’s clothing or
skin might be contaminated with body secretions or excretions.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT: the infection process (chain of infection)
● causative agent
● reservoir
● Portal of exit (means of leaving) from the host
● Mode of transmission
● Portal of entry to the host
● Susceptible host
NCLEX® Connection: Safety and Infection Control,
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
FUNDAMENTALS FOR NURSING CHAPTER 12 Client Safety 57
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: SAFETY AND INFECTION CONTROL
CHAPTER 12 Client Safety
Safety is freedom from injury. Providing for
safety and preventing injury are major nursing
responsibilities.
Many factors affect the client’s ability to protect
himself. those factors include the client’s age,
with the young and old at greater risk; mobility;
cognitive and sensory awareness; emotional
state; ability to communicate; and lifestyle and
safety awareness.
it is the provider’s responsibility to assess,
report, and document clients’ allergies and to
provide care that avoids exposure to allergens.
NURSING ACTIONS
● Use risk assessment tools to evaluate clients and their
environment for safety.
● Encourage clients to speak up and take an active role in
their health care and in preventing errors.
● Create a culture of checks and balances to avoid errors
when working in stressful circumstances.
● Communicate risk factors and plans of care to clients,
family, and other staff.
● Use protocols for responding to dangerous situations.
● Adopt quality care priorities from the National Quality
Forum, including “Never Events.”
● Use current evidence to promote a culture of safety,
while using the National Patient Safety Goals as a guide.
● Know the facility’s disaster plan, understand the chain
of command and roles, and use common terminology
when communicating with the team.
● Identify and document incidents and responses
according to the facility’s policy. These reports help
identify trends, patterns, and the root cause of
adverse events.
● Know the location of safety data sheets and hazardous
chemicals in the environment.
● Use equipment only after adequate instruction and
safety inspection.
FALLS
● Older adult clients can be at an increased risk for falls
due to decreased strength, impaired mobility and
balance, improper use of mobility aids, unsafe clothing,
environmental hazards, endurance limitations, and
decreased sensory perception.
● Other clients at increased risk include those with
decreased visual acuity, generalized weakness, urinary
frequency, gait and balance problems (cerebral palsy,
injury, multiple sclerosis), and cognitive dysfunction.
Adverse effects of medications (orthostatic hypotension,
drowsiness) can also increase the risk for falls.
● Clients are at greater risk for falls when they have more
than one risk factor.
● Prevention of client falls is a major nursing priority.
Nurses must evaluate all clients in health care facilities
for risk factors for falls and implement preventative
measures accordingly.
● Programs to prevent falls are essential for settings that
provide services to older adult clients.
● Health care facilities must actively prevent falls,
especially because Medicare and Medicaid no longer
reimburse for treating injuries resulting from falls.
PReVentinG fallS
● Complete a fall‑risk assessment for each client at
admission and at regular intervals. Individualize the
plan for each client according to the results of the
fall‑risk assessment. For example, instruct a client who
has orthostatic hypotension to avoid getting up too
quickly, to sit on the side of the bed for a few seconds
prior to standing, and to stand at the side of the bed for
a few seconds prior to walking.
● Be sure the client knows how to use the call light (by
giving a return demonstration) that it is in reach, and to
encourage its use.
● Respond to call lights in a timely manner.
● Use fall‑risk alerts, such as color‑coded wristbands.
● Provide regular toileting and orientation of clients who
have cognitive impairment.
● Provide adequate lighting.
● Orient clients to the setting to make sure they know
how to use all assistive devices (grab bars) and can
locate necessary items.
● Place clients at risk for falls near the nurses’ station.
● Provide hourly rounding.
● Make sure’ bedside tables, overbed tables, and
frequent‑use items (telephone, water, facial tissues) are
within reach.
● Keep the bed in the low position and lock the brakes.
● For clients who are sedated, unconscious, or otherwise
compromised, keep the side rails up.
● Avoid the use of full side rails for clients who get out of
bed or attempt to get out of bed without assistance.
● Provide nonskid footwear and nonskid bath mats for use
in tubs and showers.
● Use gait belts and additional safety equipment when
moving clients.
● Keep the floor clean, dry, and free from clutter with a clear
path to the bathroom (no scatter rugs, cords, or furniture).
● Keep assistive devices nearby after validation of safe use
(eyeglasses, walkers, transfer devices).
CHAPTER 12
58 CHAPTER 12 Client Safety CONTENT MASTERY SERIES
● Educate the client and family about safety risks and the
plan of care. Clients and family who are aware of risks
are more likely to call for assistance.
● Lock the wheels on beds, wheelchairs, and carts to
prevent them from rolling during transfers or stops.
● Use electronic safety monitoring devices, such as chair
or bed sensors, for clients at risk for getting up without
assistance to alert staff of independent ambulation.
● Report and document all incidents. This provides valuable
information that can help prevent similar incidents.
SEIZURES
A seizure is a sudden surge of electrical activity in the brain.
It can occur at any time due to epilepsy, fever, or a variety
of medical problems. Partial seizures (also called focal
seizures) are due to electrical surges in one part of the brain,
and generalized seizures involve the entire brain. Status
epilepticus (a prolonged seizure) is a medical emergency.
SeiZURe PReCaUtiOnS
Seizure precautions (measures to protect clients from
injury during a seizure) are imperative for clients who
have a history of seizures that involve the entire body
and/or result in unconsciousness.
● Make sure rescue equipment is at the bedside, including
oxygen, an oral airway, suction equipment, and padding
for the side rails. Clients at high risk for generalized
seizures should have a saline lock in place for
immediate IV access.
● Ensure rapid intervention to maintain airway patency.
● Inspect the client’s environment for items that could
cause injury during a seizure, and remove items that are
not necessary for current treatment.
● Assist clients at risk for seizures with ambulation and
transferring to reduce the risk of injury.
● Advise all caregivers and family not to put anything
in the client’s mouth (except an airway for status
epilepticus) during a seizure.
● Advise all caregivers and family not to restrain the
client during a seizure but to lower him to the floor or
bed, protect his head, remove nearby furniture, provide
privacy, put him on his side with his head flexed slightly
forward if possible, and loosen his clothing.
DURinG a SeiZURe
● Stay with the client, and call for help.
● Maintain airway patency and suction PRN.
● Administer medications.
● Note the duration of the seizure and the sequence and
type of movements.
● After a seizure, determine mental status and measure
oxygenation saturation and vital signs. Explain what
happened, and provide comfort, understanding, and a
quiet environment for recovery.
● Document the seizure with any precipitating behavior
and a description of the event (movements, injuries,
duration of seizures, aura, postictal state), and report it
to the provider.
SECLUSION AND RESTRAINT
● Nurses must know and follow federal, state, and facility
policies for the use of restraints.
● Some clients require seclusion rooms and/or restraints.
● In general, use seclusion or restraints for the shortest
duration necessary and only if less restrictive measures
are not sufficient. They are for the physical protection of
the client or the protection of other clients or staff.
● Clients may voluntarily request temporary seclusion if
the environment is disturbing or seems too stimulating.
● Restraints can be either physical (devices that restrict
movement: vest, belt, mitt, limb) or chemical, such as
sedatives and neuroleptic or psychotropic medications
to calm the client.
● Restraints can cause complications, including
pneumonia, incontinence, and pressure ulcers.
● It is inappropriate to use seclusion or restraints for:
◯ Convenience of the staff
◯ Punishment for the client
◯ Clients who are extremely physically or
mentally unstable
◯ Clients who cannot tolerate the decreased stimulation
of a seclusion room
● Restraints should:
◯ Never interfere with treatment
◯ Restrict movement as little as is necessary
◯ Fit properly and be as discreet as possible
◯ Be easy to remove or change
● When all other less restrictive means have failed
to prevent a client from harming himself or others
(orientation to the environment, supervision of a family
member or sitter, diversional activities, electronic
devices), the following must occur before using
seclusion or restraints.
◯ The provider must prescribe seclusion or restraints in
writing, after a face‑to‑face assessment of the client.
in an emergency situation when there is immediate
risk to the client or others, nurses may place
restraints on a client. the nurse must obtain a
prescription from the provider as soon as possible
according to the facility’s policy (usually within 1 hr).
◯ The prescription must include the reason for the
restraints, the type of restraints, the location of the
restraints, how long to use the restraints, and the
type of behavior that warrants using the restraints.
◯ The prescription allows only 4 hr of restraints
for an adult, 2 hr for clients ages 9 to 17, and 1 hr
for clients younger than 9 years of age. Providers
may renew these prescriptions with a maximum of
24 consecutive hours.
◯ Providers cannot write PRN prescriptions
for restraints.
FUNDAMENTALS FOR NURSING CHAPTER 12 Client Safety 59
nURSinG ReSPOnSiBilitieS fOR
ClientS in ReStRaintS
● Explain the need for the restraints to the client and
family, emphasizing that the restraints keep the client
safe and are temporary.
● Ask the client or guardian to sign a consent form.
● Review the manufacturer’s instructions for
correct application.
◯ Assess skin integrity, and provide skin care according
to the facility’s protocol, usually every 2 hr.
◯ Offer food and fluid.
◯ Provide a means for hygiene and elimination.
◯ Monitor vital signs.
◯ Offer range-of-motion exercises of extremities.
● Pad bony prominences to prevent skin breakdown.
● Use a quick‑release knot (loose knot that is easy to
remove) to tie the restraints to the bed frame where
they will not tighten when raising or lowering the bed.
● Make sure the restraints are loose enough for range of
motion and that there is enough room to fit two fingers
between the restraints and the client.
● Remove or replace restraints frequently to ensure good
circulation to the area and allow for full range of motion
to the limbs.
● Conduct an ongoing evaluation of the client.
● Regularly determine the need to continue using
the restraints.
● Never leave the client alone without the restraints.
DOCUMent
● Precipitating events and behavior of the client prior to
seclusion or restraints
● Alternative actions to avoid seclusion or restraints
● Time of application and removal of the restraints
● Type of restraints and location
● The client’s behavior while in restraints
● Type and frequency of care (range of motion,
neurosensory checks, removal, integumentary checks)
● Condition of the body part in restraints
● The client’s response at removal of the restraints
● Medication administration
FIRE SAFETY
Fires in health care facilities are usually due to problems
with electrical or anesthetic equipment, or from smoking.
All staff must:
● Know the location of exits, alarms, fire extinguishers,
and oxygen shut-off valves.
● Make sure equipment does not block fire doors.
● Know the evacuation plan for the unit and the facility.
Fire response follows the RACE sequence
R: Rescue and protect clients in close proximity to the
fire by moving them to a safer location. Clients who are
ambulatory may walk independently to a safe location.
A: Alarm: Activate the facility’s alarm system and then
report the fire’s details and location.
C: Contain/Confine the fire by closing doors and windows
and turning off any sources of oxygen and any electrical
devices. Ventilate clients who are on life support with a
bag‑valve mask.
E: Extinguish the fire if possible using the appropriate fire
extinguisher.
fiRe eXtinGUiSHeRS
To use a fire extinguisher, use the PASS sequence.
P: Pull the pin.
A: Aim at the base of the fire.
S: Squeeze the handle.
S: Sweep the extinguisher from side to side, covering the
area of the fire.
Classes of fire extinguishers
Class A is for combustibles such as paper, wood,
upholstery, rags, and other types of trash fires.
Class B is for flammable liquids and gas fires.
Class C is for electrical fires.
60 CHAPTER 12 Client Safety CONTENT MASTERY SERIES
Application Exercises
1. a nurse is caring for a client who
fell at a nursing home. the client is
oriented to person, place, and time
and can follow directions. Which
of the following actions should the
nurse take to decrease the risk of
another fall? (Select all that apply.)
a. Place a belt restraint on the
client when he is sitting on
the bedside commode.
B. Keep the bed in its lowest
position with all side rails up.
C. Make sure that the client’s
call light is within reach.
D. Provide the client with
nonskid footwear.
e. Complete a fall‑risk
assessment.
2. a nurse manager is reviewing with
nurses on the unit the care of a
client who has had a seizure. Which
of the following statements by a
nurse requires further instruction?
a. “i will place the client
on his side.”
B. “i will go to the nurses’
station for assistance.”
C. “i will administer his
medications.”
D. “i will prepare to
insert an airway.”
3. a nurse observes smoke coming
from under the door of the staff’s
lounge. Which of the following
actions is the nurse’s priority?
a. extinguish the fire.
B. activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors
on the unit.
4. a nurse is caring for a client
who has a history of falls.
Which of the following actions
is the nurse’s priority?
a. Complete a fall‑risk
assessment.
B. educate the client and
family about fall risks.
C. eliminate safety hazards from
the client’s environment.
D. Make sure the client uses
assistive aids in his possession.
5. a charge nurse is assigning rooms
for the clients to be admitted to
the unit. to prevent falls, which
of the following clients should
the nurse assign to the room
closest to the nurses’ station?
a. a middle adult who is
postoperative following a
laparoscopic cholecystectomy
B. a middle adult who requires
telemetry for a possible
myocardial infarction
C. a young adult who is
postoperative following
an open reduction internal
fixation of the ankle
D. an older adult who is
postoperative following a
below‑the‑knee amputation
PRACTICE Active Learning Scenario
a nurse educator is addressing the safe use of seclusion
and restraints with a group of newly licensed nurses. What
information should the nurse include? Use the ati active
learning template: Basic Concept to complete this item.
NURSING INTERVENTIONS: Describe at least
six nursing responsibilities when caring for a
client in either seclusion or restraints.
FUNDAMENTALS FOR NURSING CHAPTER 12 Client Safety 61
Application Exercises Key
1. a. By restraining the client, the nurse risks liability for false imprisonment.
B. full side rails for this client puts the client at risk for a fall because
he might attempt to climb over the rails to get out of bed.
C. CORRECT: Making sure that the call light is within reach enables
the client to contact the nursing staff to ask for assistance and prevents
the client from falling out of bed while reaching for the call light.
D. CORRECT: nonskid footwear keeps the client from slipping.
e. CORRECT: a fall‑risk assessment serves as the basis for a
plan of care the nurse can then individualize for the client.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
2. a. During a seizure, the nurse should place the client in a
side‑lying position to allow for drainage of secretions and
to prevent his tongue from occluding the airway.
B. CORRECT: During a seizure, the nurse should stay with
the client and use the call light to summon assistance.
C. the nurse should administer any medications the provider prescribes.
D. the nurse should place nothing in the client’s
mouth except an oral airway, if he needs it. a tongue
blade can cause injury and airway obstruction.
NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems
3. a. although extinguishing the fire is part of the protocol
for responding to a fire, it is not the priority action.
B. although activating the fire alarm is part of the protocol
for responding to a fire, it is not the priority action.
C. CORRECT: the greatest risk to this client is injury from the fire.
therefore, the priority intervention is to rescue the clients. the nurse
should protect and move clients in close proximity to the fire.
D. although containing the fire by closing doors and windows is part
of the protocol for responding to a fire, it is not the priority action.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
4. a. CORRECT: the first action the nurse should take using the nursing
process is to assess or collect data from the client. therefore, the
priority action is to determine the client’s fall risk. this will guide
the nurse in implementing appropriate safety measures.
B. it is important for family members to be aware of the client’s
risk for falls. Providing instruction to the client and family is an
appropriate nursing action, but this is not the priority action.
C. it is important to eliminate safety hazards from the
client’s environment, but this is not the priority action.
D. it is important for the client to use aids such as eyeglasses, hearing
aids, canes, and walkers. However, this is not the priority action.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
5. a. although this client just had surgery, the client’s age
and type of surgery puts him at low risk for falls.
B. although this client requires telemetry, the client does not
have as many risk factors as another client the nurse will admit.
C. although this client just had surgery, the client’s age
and type of surgery puts him at low risk for falls.
D. CORRECT: the nurse should assign this client to a room
near the nurses’ station due to risk factors that include client’s
age plus the immobility and balance issues that result from this
type of surgery. the client will also receive analgesics, which
increase the risk for drowsiness, dizziness, and confusion.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
● explain the need for the restraints to the client
and family, emphasizing that the restraints
keep the client safe and are temporary.
● ask the client or guardian to
sign a consent form.
● Review the manufacturer’s instructions
for correct application.
● assess skin integrity, and provide
skin care according to the facility’s
protocol, usually every 2 hr.
● Offer food and fluid.
● Provide a means for hygiene and elimination.
● Monitor vital signs.
● Offer range‑of‑motion exercises of extremities.
● Pad bony prominences to
prevent skin breakdown.
● Use a quick‑release knot to tie the restraints
to the bed frame (loose knots that are easy
to remove) where they will not tighten
when raising or lowering the bed.
● Make sure the restraints are loose
enough for range of motion and that
there is enough room to fit two fingers
between the restraints and the client.
● Remove or replace restraints frequently
to ensure good circulation to the area and
allow for full range of motion to the limbs.
● Conduct an ongoing evaluation of the client.
NCLEX® Connection: Safety and Infection Control, Use of Restraints/Safety Devices
FUNDAMENTALS FOR NURSING CHAPTER 13 Home Safety 63
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: SAFETY AND INFECTION CONTROL
CHAPTER 13 Home Safety
In addition to taking measures to prevent injury
of clients in a health care setting, nurses play a
pivotal role in promoting safety in the client’s
home and community. Nurses often collaborate
with the client, family, and members of the
interprofessional team (social workers,
occupational therapists, and physical therapists)
to promote the safety of the client.
to initiate a plan of care, the nurse must identify
risk factors using a risk assessment tool and
complete a nursing history, physical examination,
and home hazard appraisal.
In the plan of care for safety preparedness,
the nurse should include emergency nursing
principles, such as basic first aid and CPR.
RISK faCtoRS foR CLIeNt INJURy
● Age and developmental status
● Mobility and balance
● Knowledge about safety hazards
● Sensory and cognitive awareness
● Communication skills
● Home and work environment
● Community in which the client lives
● Lifestyle choices
SAFETY RISKS BASED ON AGE
AND DEVELOPMENTAL STATUS
● The age and developmental status of the client create
specific safety risks.
● Infants and toddlers are at risk for injury due to a
tendency to put objects in their mouth and from
hazards encountered while exploring their environment.
● Preschool‑ and school‑age children often face injury
from limited or underdeveloped motor coordination.
● Adolescents’ risks for injury can stem from increased
desire to make independent decisions, and relying on
peers for guidance rather than family.
● Some of the accident prevention measures for specific
age groups are found below.
INfaNtS aND toDDLeRS
Aspiration
● Keep all small objects out of reach.
● Check toys and objects for loose or small parts and
sharp edges.
● Do not feed the infant hard candy, peanuts, popcorn, or
whole or sliced pieces of hot dog.
● Do not place the infant in the supine position while
feeding or prop the infant’s bottle.
● A pacifier (if used) should be constructed of one piece
and never placed on string or ribbon around the neck.
Suffocation
● Teach “back to sleep” mnemonic and always place
infants on back to rest.
● Keep plastic bags out of reach.
● Make sure crib mattress fits snugly and that crib slats
are no more than 2 3/8 inches apart.
● Never leave an infant or toddler alone in the bathtub.
● Do not place anything in crib with infant.
● Remove crib toys, such as mobiles, from over the bed as
soon as the infant begins to push up.
● Keep latex balloons away from infants and toddlers.
● Fence swimming pools and use a locked gate.
● Begin swimming lessons when the child’s
developmental status allows for protective responses,
such as closing her mouth under water.
● Teach caregivers CPR and Heimlich maneuver.
● Keep toilet lids down and bathroom doors closed.
Poisoning
● Keep houseplants and cleaning agents out of reach.
● Inspect and remove sources of lead, such as paint chips,
and provide parents with information about prevention
of lead poisoning.
● Place poisons, paint, and gasoline in locked cabinet.
● Keep medications in child‑proof containers and
locked up.
● Dispose of medications that are no longer used or are
out of date.
CHAPTER 13
64 CHAPTER 13 Home Safety CONTENT MASTERY SERIES
Falls
● Keep crib and playpen rails up.
● Never leave the infant unattended on a changing table
or other high surface.
● Use gates on stairs, and ensure windows have screens.
● Restrain according to manufacturer’s recommendations
and supervise when in high chair, swing, stroller, etc.
Discontinue use when the infant or toddler outgrows
size or activity limits.
● Place in a low bed when toddler starts to climb.
Motor vehicle injury
● Place infants and toddlers in a rear‑facing car seat
until 2 years of age or until they exceed the height
and weight limit of the car seat. They can then sit in a
forward‑facing car seat.
● Use a car seat with a five-point harness for infants
and children.
● All car seats should be federally approved and be placed
in the back seat.
Burns
● Test the temperature of formula and bath water.
● Place pots on back burner and turn handle away from
front of stove.
● Supervise the use of faucets.
● Keep matches and lighters out of reach.
● Cover electrical outlets.
PReSCHooLeRS aND
SCHooL‑aGe CHILDReN
Drowning
● Be sure child has learned to swim and knows rules of
water safety.
● Place locked fences around home and
neighborhood pools.
● Provide supervision near pools or water.
Motor vehicle injury
● Use booster seats for children who are less than 4 feet
9 inches tall and weigh less than 40 lb (usually 4 to
8 years old). The child should be able to sit with his back
against the car seat, and his legs should dangle over
the seat.
● If car has a passenger air bag, place children under
12 years in the back seat.
● Use seat belts properly after booster seats are no
longer necessary.
● Use protective equipment when participating in sports,
riding a bike, or riding as a passenger on a bike.
● Supervise and teach safe use of equipment.
● Teach the child to play in safe areas and never to run
after a ball or toy that goes into a road.
● Teach child safety rules of the road.
Begin sex education for school-age child.
Firearms
● Keep firearms unloaded, locked up, and out of reach.
● Teach to never touch a gun or stay at a friend’s house
where a gun is accessible.
● Store bullets in a different location from guns.
Play injury
● Teach to not run with candy or objects in mouth.
● Remove doors from refrigerators or other potentially
confining structures.
● Ensure that bikes are the appropriate size for child.
● Teach playground safety.
● Teach to play in safe areas, and avoid heavy machinery,
railroad tracks, excavation areas, quarries, trunks, and
vacant buildings.
● Teach to never swim alone and to wear a life jacket
in boats.
● Wear protective helmets and knee and elbow pads,
when needed.
● Teach to avoid strangers and keep parents informed
of strangers.
Burns
● Reduce setting on water heater to no higher than 120° F.
● Teach dangers of playing with matches, fireworks,
and firearms.
● Teach school‑age child how to properly use microwave
and other cooking instruments.
Poison
● Teach child about the hazards of alcohol, cigarettes, and
prescription, non‑prescription, and illegal drugs.
● Keep potentially dangerous substances out of reach.
aDoLeSCeNtS
Educate on the hazards of smoking, alcohol, legal and
illegal drugs, and unprotected sex.
Motor vehicle and injury
● Ensure the teen has completed a driver’s
education course.
● Set rules on the number of people allowed to ride in
cars, seat belt use, and to call for a ride home if a driver
is impaired.
● Educate on the hazards of driving while distracted
(eating or drinking, making phone calls or texting).
● Reinforce teaching on proper use of protective
equipment when participating in sports.
● Be alert to signs of depression, anxiety or other
behavioral changes
● Teach about the hazards of firearms and safety
precautions with firearms.
● Teach water safety.
● Teach to check water depth before diving.
Burns
● Teach to use sunblock and protective clothing.
● Teach the dangers of sunbathing and tanning beds.
FUNDAMENTALS FOR NURSING CHAPTER 13 Home Safety 65
yoUNG aND mIDDLe‑aGe aDULtS
Motor vehicle crashes are the most common cause of death
and injury to adults. Occupational injuries contribute to
the injury and death rate of adults. High consumption of
alcohol and suicide are also major concerns for adults.
CLIENT EDUCATION
● Remind clients to drive defensively and to not drive
after drinking alcohol.
● Reinforce teaching about the long-term effects related
to high alcohol consumption.
● Ensure home safety with smoke and carbon monoxide
detectors, fire alarms, well-lit and uncluttered staircases.
● Be attuned to behaviors that suggest the presence of
depression or thoughts of suicide. Referring clients as
appropriate and encourage counseling.
● Teach diving and water safety.
● Encourage clients to become proactive about safety in
the workplace and in the home.
● Discuss dangers of social networking and the Internet.
● Ensure that clients understand the hazards of excessive
sun exposure and the need to protect the skin with the
use of sun‑blocking agents and protective clothing.
oLDeR aDULtS
● The rate at which age‑related changes occur varies
greatly among older adults.
● Many older adults are able to maintain a lifestyle
that promotes independence and the ability to protect
themselves from safety hazards.
● Prevention is important because elderly clients can
have longer recovery times from injuries and the risk
of complications.
● A decrease in tactile sensitivity can place the client at
risk for burns and other types of tissue injury.
● When the client demonstrates factors that increases
the risk for injury (regardless of age), a home hazard
evaluation should be conducted by a nurse, physical
therapist, and/or occupational therapist. The client is
made aware of the environmental factors that can pose
a risk to safety and suggestion modifications to be made.
RISK FACTORS FOR FALLS IN OLDER ADULTS
● Physical, cognitive, and sensory changes
● Changes in the musculoskeletal and neurological systems
● Impaired vision and/or hearing
● Frequent trips to the bathroom at night because of
nocturia and incontinence
MODIFICATIONS TO IMPROVE HOME SAFETY
● Remove items that could cause the client to trip, such as
throw rugs and loose carpets.
● Place electrical cords and extension cords against a wall
behind furniture.
● Monitor gait and balance, and provide aids as needed.
● Make sure that steps and sidewalks are in good repair.
● Place grab bars near the toilet and in the tub or shower,
and install a stool riser.
● Use a nonskid mat in the tub or shower.
● Place a shower chair in the shower and provide a
bedside commode if needed.
● Ensure that lighting is adequate inside and outside
the home.
FIRE SAFETY IN THE HOME
Home fires continue to be a major cause of death and
injury for people of all ages. Nurses should educate clients
about the importance of a home safety plan.
eLemeNtS of a Home Safety PLaN
● Keep emergency numbers near the phone for prompt use
in the event of an emergency of any type.
● Ensure that the number and placement of fire
extinguishers and smoke alarms are adequate, that they
are functional, and that family members understand
how to operate them. Set a time to routinely change
batteries in smoke alarms (e.g., in the fall when the
clocks are set to standard time and spring when set to
Daylight Saving Time).
● Have a family exit plan for fires that is reviewed and
practiced regularly. Be sure to include closing windows
and doors if able and to exit a smoke-filled area by
covering the mouth and nose with a damp cloth, and
getting down as close to the floor as possible.
● Review with clients of all ages that in the event that the
client’s clothing or skin is on fire, the mnemonic “stop,
drop, and roll” should be used to extinguish the fire.
● Review oxygen safety measures. Because oxygen can
cause materials to combust more easily and burn more
rapidly, the client and family must be provided with
information on use of the oxygen delivery equipment
and the dangers of combustion. Include the following
information in the teaching plan:
◯ Use and store oxygen equipment according to the
manufacturer’s recommendations.
◯ Place a “No Smoking” sign in a conspicuous place
near the front door of the home. A sign can also be
placed on the door to the client’s bedroom.
◯ Inform the client and family of the danger of smoking
in the presence of oxygen. Family members and
visitors who smoke should do so outside the home.
◯ Ensure that electrical equipment is in good repair and
well grounded.
◯ Replace bedding that can generate static electricity
(wool, nylon, synthetics) with items made from cotton.
◯ Keep flammable materials, such as heating oil and
nail polish remover, away from the client when
oxygen is in use.
◯ Follow general measures for fire safety in the home,
such as having a fire extinguisher readily available
and an established exit route if a fire occurs.
66 CHAPTER 13 Home Safety CONTENT MASTERY SERIES
ADDITIONAL RISKS IN THE
HOME AND COMMUNITY
Additional risks in the home and community include
passive smoking, carbon monoxide poisoning, and food
poisoning. Bioterrorism also has become a concern,
making disaster plans a mandatory part of community
safety. Nurses should teach clients about the dangers of
these additional risks.
Passive smoking
● Passive smoking is the unintentional inhalation of
tobacco smoke.
● Exposure to nicotine and other toxins places people
at risk for numerous diseases including cancer, heart
disease, and lung infections.
● Low‑birth‑weight infants, prematurity, stillbirths,
and sudden infant death syndrome (SIDS) have been
associated with maternal smoking.
● Smoking in the presence of children is associated with
the development of bronchitis, pneumonia, and middle
ear infections.
● For children who have asthma, exposure to passive
smoke can result in an increase in the frequency and the
severity of asthma attacks.
CLIENT EDUCATION
Inform the client who smokes and his family about:
● The hazards of smoking
● Available resources to stop smoking (smoking cessation
programs, medication support, self‑help groups)
● The effect that visiting individuals who smoke or riding
in the automobile of a smoker has on a nonsmoker
Carbon monoxide
Carbon monoxide is a very dangerous gas because it binds
with hemoglobin and ultimately reduces the oxygen
supplied to the tissues in the body.
● Carbon monoxide cannot be seen, smelled, or tasted.
● Symptoms of carbon monoxide poisoning
include nausea, vomiting, headache, weakness,
and unconsciousness.
● Death can occur with prolonged exposure.
● Measures to prevent carbon monoxide poisoning include
ensuring proper ventilation when using fuel‑burning
devices (lawn mowers, wood-burning and gas fireplaces,
charcoal grills).
● Gas‑burning furnaces, water heaters, and appliances
should be inspected annually.
● Flues and chimneys should be unobstructed.
● Carbon monoxide detectors should be installed and
inspected regularly.
Food poisoning
Food poisoning is a major cause of illness in the United
States. Most food poisoning is caused by bacteria such as
Escherichia coli, Listeria monocytogenes, and Salmonella.
● Healthy individuals usually recover from the illness in a
few days.
● Very young, very old, immunocompromised, and
pregnant individuals are at risk for complications.
● Clients who are especially at risk are instructed to
follow a low‑microbial diet.
● Most food poisoning occurs because of unsanitary
food practice.
● Performing proper hand hygiene, ensuring that
meat and fish are cooked to the correct temperature,
handling raw and fresh food separately to avoid cross
contamination, and refrigerating perishable items are
measures that can prevent food poisoning.
● Check expiration dates, and clean fresh fruits
and vegetables.
Bioterrorism
Bioterrorism is the dissemination of harmful toxins,
bacteria, viruses, and pathogens for the purpose of
causing illness or death.
● Anthrax, variola, Clostridium botulism, and Yersinia pestis
are examples of agents used by terrorists.
● Nurses and other health professionals must be prepared
to respond to an attack by being proficient in early
detection, recognizing the causative agent, identifying
the affected community, and providing early treatment
to affected persons.
FUNDAMENTALS FOR NURSING CHAPTER 13 Home Safety 67
PRIMARY SURVEY
A primary survey is a rapid assessment of life‑threatening
conditions. It should take no longer than 60 seconds
to perform.
● The primary survey should be completed systematically
so conditions are not missed.
● Standard precautions (gloves, gowns, eye protection,
face masks, and shoe covers) must be worn to prevent
contamination with bodily fluids.
aBCDe PRINCIPLe
The ABCDE principle guides the primary survey and
emergency care.
Airway/Cervical Spine: This is the most important step in
performing the primary survey. If a patent airway is not
established, subsequent steps of the primary survey are
futile. Protect the cervical spine if head or neck trauma
is suspected.
Breathing: After achieving a patent airway, assess for the
presence and effectiveness of breathing.
Circulation: After ensuring adequate ventilation, assess
circulation.
Disability: Perform a quick assessment to determine the
client’s level of consciousness.
Exposure: Perform a quick physical assessment to
determine the client’s exposure to adverse elements such
as heat or cold.
See the chapter on Emergency Nursing Principles and
Management in the Adult Medical Surgical Nursing Review
Module for further detail on the primary survey.
BASIC FIRST AID
Complete the primary survey before performing first aid.
Bleeding
● Identify any sources of external bleeding and apply
direct pressure to the wound site.
● DO NOT remove impaling objects. Instead, stabilize
the object.
● Internal bleeding can require intravascular volume
replacement with fluids and/or blood products, or
surgical intervention.
Fractures and splinting
● Assess the site for swelling, deformity, and
skin integrity.
● Assess temperature, distal pulses, and mobility.
● Apply a splint to immobilize the fracture. Cover open
areas with a sterile cloth if available.
● Reassess neurovascular status below the injury site
after splinting.
Sprains
● Use the acronym RICE to manage sprains:
● Refrain from weight‑bearing.
● Apply ice to decrease inflammation.
● Apply a compression dressing to minimize swelling.
● Elevate the affected limb.
Heat stroke
● The nurse should identify heat stroke (body temperature
greater than 40° C [104° F]) quickly and treat
it aggressively.
● Manifestations of heat stroke include hot, dry skin;
hypotension; tachypnea; tachycardia; anxiety;
confusion; unusual behavior; seizures; and coma. The
client does not sweat.
● Intervene to provide rapid cooling.
◯ Remove the client’s clothing.
◯ Place ice packs over the major arteries (axillae, chest,
groin, neck).
◯ Immerse the client in a cold‑water bath.
◯ Wet the client’s body, then fan with rapid movement
of air.
◯ Do not allow client to shiver. If client shivers, cover
her with a sheet.
68 CHAPTER 13 Home Safety CONTENT MASTERY SERIES
Frostnip and frostbite
● Occurs when the body is exposed to freezing
temperatures.
● Common sites include the earlobes, tip of the nose,
fingers, and toes.
● Frostnip does not lead to tissue injury and can be
treated by warming.
● Frostbite presents as white, waxy areas on exposed skin.
Tissue injury occurs.
● Frostbite can be full‑ or partial‑thickness.
● Warm the affected area in a 37° to 42° C (98.6° to 108° F)
water bath.
● Provide pain medication.
● Administer a tetanus vaccination.
Burns
● Burns can result from electrical current, chemicals,
radiation, or flames.
● Home hazards include pot handles that protrude over
the stove, hot bath water, and electrical appliances.
● Remove the agent (electrical current, radiation source,
chemical).
● Smother any flames that are present. Perform a
primary survey.
● Cover the client and maintain NPO status.
● Elevate the client’s extremities if not contraindicated
(presence of a fracture).
● Perform a head‑to‑toe assessment and estimate the
surface area and thickness of burns.
● Administer fluids and a tetanus toxoid.
Altitude‑related illnesses
Clients can become hypoxic in high altitudes. Altitude
sickness can progress to cerebral and pulmonary edema
and requires immediate treatment.
EXPECTED FINDINGS
● Throbbing headache
● Nausea
● Vomiting
● Dyspnea
● Anorexia
NURSING INTERVENTIONS
● Administer oxygen.
● Descend to a lower altitude.
● Provide pharmacological therapy, such as steroids and
diuretics, if indicated.
● Promote rest
CPR
CPR is a combination of basic interventions designed to
sustain oxygen and circulation to vital organs until more
advanced interventions can be initiated to correct the root
cause of the cardiac arrest.
● Efficient CPR improves the client’s chance of survival.
● Trained individuals can deliver basic interventions, but
advanced interventions require training that is more
sophisticated, which requires certification and use of
emergency equipment.
● CPR is directed at artificially providing a client with
circulation (chest compressions) and oxygenation
(ventilations) in the absence of cardiac output.
● CPR is a component of basic life support (BLS).
● The goal of BLS is to provide oxygen to the vital organs
until appropriate advanced resuscitation measures can
be initiated or until resuscitative efforts are ordered to
be stopped.
● BLS involves the CABs (Chest Compression, Airway, and
Breathing) of CPR.
◯ Assess victim for a response and look for breathing.
Do not take time to perform a “look, listen, and feel”
assessment of breathing. If there is no breathing or no
normal breathing (only gasping), call for help.
◯ If alone, activate emergency response system and get
an automated external defibrillator (AED), if available,
and return to the client. If a second person is
available, send her to activate the emergency response
system and get an AED.
◯ Check pulse. Begin CPR compressions alternated with
breaths if a pulse is not detected.
● For further detail on CPR, visit the American Heart
Association website, www.heart.org.
CLIENT EDUCATION
● Encourage family members to take basic first aid and
CPR courses. Refer clients and family members to
a community agency where basic first aid and CPR
are taught.
● Teach clients and family members keep emergency
numbers (poison control, fire/rescue, providers, and
nearest hospitals and urgent care facilities) in the home.
FUNDAMENTALS FOR NURSING CHAPTER 13 Home Safety 69
Application Exercises
1. a nurse is providing discharge
instructions to a client who has a
prescription for oxygen use at home.
Which of the following information
should the nurse include about home
oxygen safety? (Select all that apply.)
a. family members who smoke
must be at least 10 ft from the
client when oxygen is in use.
B. Nail polish should not be
used near a client who
is receiving oxygen.
C. a “No Smoking” sign should
be placed on the front door.
D. Cotton bedding and clothing
should be replaced with
items made from wool.
e. a fire extinguisher should be
readily available in the home.
2. a nurse educator is presenting a
module on basic first aid for newly
licensed home health nurses. the
nurse educator evaluates the
teaching as effective when the
newly licensed nurse states the
client who has heat stroke will
have which of the following?
a. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
3. a nurse educator is conducting
a parenting class for new
parents of infants. Which of
the following statements made
by a participant indicates
understanding of the instructions?
a. “I will set my water
heater at 130° f.”
B. “once my baby can sit up, he
should be safe in the bathtub.”
C. “I will place my baby on
his stomach to sleep.”
D. “once my infant starts to
push up, I will remove the
mobile from over the crib.”
4. a home health nurse is discussing
the dangers of carbon monoxide
poisoning with a client. Which of
the following information should the
nurse include in her counseling?
a. Carbon monoxide has
a distinct odor.
B. Water heaters should be
inspected every 5 years.
C. the lungs are damaged from
carbon monoxide inhalation.
D. Carbon monoxide binds with
hemoglobin in the body.
5. a home health nurse is discussing
the dangers of food poisoning with
a client. Which of the following
information should the nurse
including in her counseling?
(Select all that apply.)
a. most food poisoning
is caused by a virus.
B. Immunocompromised
individuals are at risk
for complications from
food poisoning
C. Clients who are at high risk
should eat or drink only
pasteurized dairy products.
D. Healthy individuals
usually recover from the
illness in a few weeks.
e. Handling raw and fresh
food separately can
prevent food poisoning.
PRACTICE Active Learning Scenario
a nurse educator is teaching a module on the basic
principles of creating a home safety plan during
nursing orientation to a group of newly appointed
home health nurses. Use the atI active Learning
template: Basic Concept to complete this item.
NURSING INTERVENTIONS: List four key elements
that a home safety plan should include.
70 CHAPTER 13 Home Safety CONTENT MASTERY SERIES
Application Exercises Key
1. a. the nurse should remind family members who smoke to do so outside.
B. CORRECT: the nurse should remind the client not to use
nail polish or other flammable materials in the home.
C. CORRECT: the nurse should have the client place a “No Smoking”
sign near the front door, and possibly on the client’s bedroom door.
D. the nurse should tell the client to choose cotton materials
for clothing and bedding. Woolen and synthetic materials
create static electricity and could cause a fire.
e. CORRECT: the nurse should remind all individuals
to have a fire extinguisher at home. this is especially
important for a client who is receiving oxygen.
NCLEX® Connection: Safety and Infection Control,
Safe Use of Equipment
2. a. CORRECT: Hypotension is a manifestation of heat stroke.
B. tachycardia is a manifestation of heat stroke.
C. Hot, dry skin is a manifestation of heat stroke.
D. Dyspnea is a manifestation of heat stroke.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. a. the nurse should instruct the parent to set the home
water heater temperature to 120° f or less.
B. although the baby can hold his head above the water by sitting up,
this does not make the child safe in the bathtub. the nurse should warn
the parent to never leave an infant or toddler alone in the bathtub.
C. the nurse should remind the parent to place the infant on his
back to sleep, and to remove suffocation hazards from the crib.
D. CORRECT: the parent should plan to remove crib toys,
such as mobiles, from over the bed as soon as the infant
begins to push up so the infant is unable to touch them.
NCLEX® Connection: Safety and Infection Control, Home Safety
4. a. the nurse should include that carbon monoxide
cannot be seen, smelled, or tasted.
B. the nurse should tell the client to inspect gas‑burning
furnaces, water heaters, and appliances annually.
C. the nurse should inform the client that carbon monoxide impairs
the body’s ability to use oxygen, but the lungs are not damaged.
D. CORRECT: the nurse should warn the client that carbon
monoxide is very dangerous because it binds with hemoglobin and
ultimately reduces the oxygen supplied to the tissues in the body.
NCLEX® Connection: Safety and Infection Control, Home Safety
5. a. the nurse should include that most food
poisoning is caused by bacteria such as Escherichia
coli, Listeria monocytogenes, and Salmonella.
B. CORRECT: the nurse should warn the client that very young,
very old, immunocompromised, and pregnant individuals
are at risk for complications from food poisoning.
C. CORRECT: the nurse should include that clients who are at high risk
should follow a low‑microbial diet, which includes eating or drinking
only pasteurized milk, yogurt, cheese, and other dairy products.
D. the nurse should inform the client that healthy individuals
usually recover from the illness in a few days.
e. CORRECT: the nurse should include interventions to prevent food
poisoning, such as performing proper hand hygiene, cooking meat and
fish to the correct temperature, handling raw and fresh food separately
to avoid cross‑contamination, and refrigerating perishable items.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
a home safety plan should include the following.
● Keep emergency numbers near the phone for prompt use
in the event of an emergency of any type.
● ensure that the number and placement of fire extinguishers and smoke alarms are
adequate, that they are operable, and that family members know how to operate them.
Set a time to routinely change the batteries in the smoke alarms (for example, in the fall
when the clocks are set to standard time and spring when set to Daylight Saving time).
● Have a family exit plan for fires that the family reviews and practices regularly. Be sure to
include closing windows and doors if able and to exit a smoke filled area by covering the
mouth and nose with a damp cloth and getting down as close to the floor as possible.
● Review with clients of all ages that in the event that the client’s clothing or skin is on
fire, the client should use the mnemonic “stop, drop, and roll” to extinguish the fire.
● Review oxygen safety measures. Because oxygen can cause materials to combust more
easily and burn more rapidly, the client and family must be provided with information
on use of the oxygen delivery equipment and the dangers of combustion.
NCLEX® Connection: Safety and Infection Control, Home Safety
FUNDAMENTALS FOR NURSING CHAPTER 14 Ergonomic PrinciPlEs 71
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: SAFETY AND INFECTION CONTROL
CHAPTER 14 Ergonomic
Principles
Ergonomics is a science that focuses on the
factors or qualities in an object’s design or use
that contribute to comfort, safety, efficiency, and
ease of use.
Using good body mechanics when positioning
and moving clients promotes safety for the client
and the staff.
Before attempting to position or move a
client, perform a mobility assessment. Begin
with the easiest movements (range of motion)
and progress as long as the client tolerates it
(balance, gait, exercise).
ERGONOMIC PRINCIPLES
AND BODY MECHANICS
● Body mechanics is the use of muscles to maintain
balance, posture, and body alignment when performing
a physical task. Nurses use body mechanics when
providing care to clients by lifting, bending, and
assisting clients with the activities of daily living.
● Body alignment keeps the center of gravity stable,
which promotes comfort and reduces strain on
the muscles.
● Good body mechanics reduces the risk of injury.
Whenever possible, use mechanical lift devices to lift
and transfer clients. Many facilities have “no manual
lift” and “no solo lift” policies.
cEnTEr oF grAViTY
● The center of gravity is the center of a mass.
● Weight is a quantity of matter on which the force of
gravity acts.
● To lift an object, it is essential to overcome the weight
of the object and to know the center of gravity of
the object.
● When the human body is in the upright position, the
center of gravity is the pelvis.
● When an individual moves, the center of gravity shifts.
● The closer the line of gravity is to the center of the base
of support, the more stable the individual is.
● To lower the center of gravity, bend the hips and knees.
● Spread your feet apart to lower your center of gravity
and broaden your base of support. This results in greater
stability and balance.
liFTing
● Use the major muscle groups to prevent back strain, and
tighten the abdominal muscles to increase support to
the back muscles.
● Distribute your weight between the large muscles of the
arms and legs to decrease the strain on any one muscle
group and to avoid strain on smaller muscles.
● When lifting an object from the floor, flex your hips,
knees, and back. Bring the object to thigh level, bending
your knees and keeping your back straight. Stand up
while holding the object as close as possible to your
body, bringing the load to the center of gravity to
increase stability and decrease back strain.
● Use assistive devices whenever possible and seek
assistance whenever you need it.
PUsHing or PUlling
When pushing or pulling a load:
● Widen your base of support.
● When opportunity allows, pull objects toward the center
of gravity rather than pushing them away.
● If pushing, move your front foot forward and, if pulling,
move your rear leg back to promote stability.
● Face the direction of movement when moving a client.
● Use your own body as a counterweight when pushing or
pulling to make the movement easier.
● Sliding, rolling, and pushing require less energy than
lifting and offer less risk for injury.
● Avoid twisting your thoracic spine and bending your
back while your hips and knees are straight.
gUiDElinEs For PrEVEnTing inJUrY
● Know your facility’s policies for lifting and safe client
handling.
● Have one or more staff members assist with positioning
clients. Moving them up in bed is a significant cause of
back pain and injury.
● Plan ahead for activities that require lifting, transfer,
and ambulation of a client, and ask others to be
available to assist.
● Prepare the environment by removing obstacles prior to
the procedure.
● Explain the process to the client and assistants to
clarify their roles.
● Be aware that the safest way to lift a client is with
assistive equipment.
● Rest between heavy activities to decrease muscle fatigue.
● Maintain good posture and exercise regularly to
increase the strength of your arms, legs, back, and
abdominal muscles, so these activities will require
less energy.
● Keep your head and neck in a straight line with your
pelvis to avoid neck flexion and hunched shoulders,
which can cause impingement of nerves in your neck.
● Use smooth movements when lifting and moving
clients to prevent injury from sudden or jerky
muscle movements.
CHAPTER 14 Online Video: Ergonomic Principles
72 CHAPTER 14 Ergonomic PrinciPlEs CONTENT MASTERY SERIES
● When standing for long periods of time, flex your hips
and knees by using a footrest. When sitting for long
periods of time, keep your knees slightly higher than
your hips.
● Avoid repetitive movements of the hands, wrists, and
shoulders. Take a break every 15 to 20 min to flex and
stretch joints and muscles.
● Avoid twisting your spine or bending at the waist
(flexion) to minimize the risk for injury.
POSITIONING CLIENTS
● Position clients, especially those who are unable to
move themselves, so that they maintain good body
alignment. Frequent position changes prevent
discomfort, contractures, pressure on tissues, and nerve
and circulatory damage, and they stimulate postural
reflexes and muscle tone.
● Use pillows, bath blankets, hand rolls, boots, splints,
trochanter rolls, ankle support devices, and other aids
to maintain proper body alignment.
TrAnsFErs AnD UsE oF
AssisTiVE DEVicEs
● Evaluate each situation and use an algorithm to
determine the safest method to transfer or move the
client. Answer these questions: Can the client bear
weight? Can she assist? Is she cooperative?
● Determine the client’s ability to help with transfers
(balance, muscle strength, endurance, use of a
trapeze bar).
● Evaluate the need for additional staff or assistive
devices (transfer belt, hydraulic lift, sliding board).
● Assess and monitor the use of mobility aids (canes,
walkers, crutches).
● Include assistance or mobility aids in the plan of care
for safe transfers and ambulation.
BED AND CLIENT POSITIONS
Semi‑Fowler’s
● The client lies supine with the head of the bed elevated
15° to 45° (typically 30°).
● This position prevents regurgitation of enteral feedings
and aspiration by clients who have difficulty swallowing.
● It also promotes lung expansion for clients who have
dyspnea or are receiving mechanical ventilation.
Fowler’s
● The client lies supine with the head of the bed elevated
45° to 60°.
● This position is useful during procedures such as
nasogastric tube insertion and suctioning. It allows
for better chest expansion and ventilation and better
dependent drainage after abdominal surgeries.
High‑Fowler’s
● The client lies supine with the head of the bed elevated
60° to 90°.
● This position promotes lung expansion by lowering the
diaphragm and thus helps relieve severe dyspnea.
● It also helps prevent aspiration during meals.
Supine or dorsal recumbent
● The client lies on his back with his head and shoulders
elevated on a pillow and his forearms on pillows or
at his side. A foot support prevents foot drop and
maintains proper alignment.
Prone
● The client lies flat on his abdomen and chest with his
head to one side and his back in correct alignment.
● This position promotes drainage from the mouth after
throat or oral surgery, but inhibits chest expansion. It is
for short‑term use only.
● This position helps prevent hip flexion contractures
following a lower extremity amputation.
Lateral or side‑lying
● The client lies on his side with most of his weight on
the dependent hip and shoulder and his arms in flexion
in front of his body. He should have a pillow under his
head and neck, his upper arms, and his legs and thighs
to maintain body alignment.
● This is a good sleeping position, but the client needs
turning regularly to prevent the development of
pressure ulcers on the dependent areas. A 30° lateral
position is essential for clients at risk for
pressure ulcers.
Sims’ or semi‑prone
● The client is on his side halfway between lateral and
prone positions, with his weight on his anterior ileum,
humerus, and clavicle. His lower arm is behind him
while his upper arm is in front. Both legs are in flexion
but the upper leg is flexed at a greater angle than the
lower leg at the hip as well as at the knee.
● This is a comfortable sleeping position for many clients,
and it promotes oral drainage.
Orthopneic
● The client sits in the bed or at the bedside with a pillow
on the overbed table, which is across the client’s lap. He
rests his arms on the overbed table.
● This position allows for chest expansion and is
especially beneficial for clients who have COPD.
Trendelenburg
● The entire bed is tilted with the head of the bed lower
than the foot of the bed.
● This position facilitates postural drainage and
venous return.
FUNDAMENTALS FOR NURSING CHAPTER 14 Ergonomic PrinciPlEs 73
Reverse Trendelenburg
● The entire bed is tilted with the foot of the bed lower
than the head of the bed.
● This position promotes gastric emptying and prevents
esophageal reflux.
Modified Trendelenburg
● The client remains flat with his legs above the level of
his heart.
● This position helps prevent and treat hypovolemia and
facilitates venous return.
Application Exercises
1. A nurse is caring for a client who
is receiving enteral tube feedings
due to dysphagia. Which of the
following bed positions should the
nurse use for safe care of this client?
A. supine
B. semi‑Fowler’s
c. semi‑prone
D. Trendelenburg
2. A nurse is caring for a client who is
sitting in a chair and asks to return to
bed. Which of the following actions
is the nurse’s priority at this time?
A. obtain a walker for the client
to use to transfer back to bed.
B. call for additional staff to
assist with the transfer.
c. Use a transfer belt and assist
the client back into bed.
D. Determine the client’s ability
to help with the transfer.
3. A nurse is completing discharge
instructions for a client who has
coPD. The nurse should identify that
the client understands the orthopneic
position when she states that she will
do which of the following when she
has difficulty breathing at night?
A. lie on her back with her head
and shoulders on a pillow.
B. lie flat on her stomach with
her head to one side.
c. sit on the side of her bed and
rest her arms over pillows on
top of her bedside table.
D. lie on her side with her weight
on her hip and shoulder with
her arm flexed in front of her.
4. A nurse manager is reviewing
guidelines for preventing injury with
staff nurses. Which of the following
instructions should the nurse manager
include? (select all that apply.)
A. request assistance when
repositioning a client.
B. Avoid twisting your spine
or bending at the waist.
c. Keep your knees slightly lower
than your hips when sitting
for long periods of time.
D. Use smooth movements when
lifting and moving clients.
E. Take a break from repetitive
movements every 2 to
3 hr to flex and stretch
your joints and muscles.
5. A nurse educator is reviewing
proper body mechanics during
employee orientation. Which of
the following statements should
the nurse identify as an indication
that an attendee understands the
teaching? (select all that apply.)
A. “my line of gravity should fall
outside my base of support.”
B. “The lower my center of gravity,
the more stability i have.”
c. “To broaden my base
of support, i should
spread my feet apart.”
D. “When i lift an object, i
should hold it as close to
my body as possible.”
E. “When pulling an object,
i should move my
front foot forward.”
PRACTICE Active Learning Scenario
A nurse is presenting the basic principles of proper lifting
to a group of assistive personnel. Use the ATi Active
learning Template: Basic concept to complete this item.
UNDERLYING PRINCIPLES: list four key
elements of proper lifting techniques.
74 CHAPTER 14 Ergonomic PrinciPlEs CONTENT MASTERY SERIES
Application Exercises Key
1. A. in the supine position, the client lies on his back with his head and
shoulders elevated on a pillow. This angle will not prevent regurgitation.
B. CORRECT: in the semi‑Fowler’s position, the client lies
supine with the head of the bed elevated 15° to 45° (typically
30°). This position helps prevent regurgitation and aspiration
by clients who have difficulty swallowing. This is the safest
position for clients receiving enteral tube feedings.
c. in the semi‑prone or sims’ position, the client is on his
side halfway between lateral and prone positions. This
position is not safe because it promotes regurgitation.
D. in the Trendelenburg position, the entire bed is tilted with
the head of the bed lower than the foot of the bed. This
position is not safe because it promotes regurgitation.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
2. A. Although this might be a necessary assistive device for this client,
obtaining a walker is not the priority action the nurse should take.
B. Although this might be necessary for a safe transfer, calling for
assistance is the not the priority action the nurse should take.
c. Although this might be a necessary assistive device
for the transfer of this client, using a transfer belt is
not the priority action the nurse should take.
D. CORRECT: The first action the nurse should take using
the nursing process is to assess or collect data from the
client. The nurse should determine the client’s ability to help
with transfers and then proceed with a safe transfer.
NCLEX® Connection: Safety and Infection Control,
Ergonomic Principles
3. A. The client is describing the supine position,
not the orthopneic position.
B. The client is describing the prone position,
not the orthopneic position.
c. CORRECT: The client is describing the orthopneic
position. This position allows for chest expansion and is
especially beneficial for clients who have coPD.
D. The client is describing the lateral or side‑lying
position, not the orthopneic position.
NCLEX® Connection: Safety and Infection Control,
Ergonomic Principles
4. A. CORRECT: To reduce the risk of injury, at least
two staff members should reposition clients.
B. CORRECT: Twisting the spine or bending at the
waist (flexion) increases the risk for injury.
c. When sitting for long periods of time, it is essential
to keep the knees slightly higher, not lower, than the
hips to decrease strain on the lower back.
D. CORRECT: Using smooth movements instead of sudden
or jerky muscle movements helps prevent injury
E. it is important to take a break every 15 to 20 min, not every 2 to
3 hr, from repetitive movements to flex and stretch joints and muscles.
NCLEX® Connection: Safety and Infection Control,
Ergonomic Principles
5. A. To reduce the risk of falling, the line of gravity should
fall within the base of support, not outside it.
B. CORRECT: Being closer to the ground lowers the center
of gravity, which leads to greater stability and balance.
c. CORRECT: spreading the feet apart increases
and widens the base of support.
D. CORRECT: Holding an object as close to the body
as possible helps avoid displacement of the center of
gravity and thus prevent injury and instability.
E. To promote stability, the nurse should move the
rear leg back when pulling on an object.
NCLEX® Connection: Safety and Infection Control,
Ergonomic Principles
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● Use the major muscle groups to prevent back strain, and tighten the
abdominal muscles to increase support to the back muscles.
● Distribute your weight between the large muscles of the arms and legs to decrease
the strain on any one muscle group and to avoid strain on smaller muscles.
● When lifting an object from the floor, flex your hips, knees, and back. Bring the
object to thigh level, bending your knees and keeping your back straight. stand
up while holding the object as close as possible to your body, bringing the load
to the center of gravity to increase stability and decrease back strain.
● Use assistive devices whenever possible, and seek assistance whenever you need it.
NCLEX® Connection: Safety and Infection Control, Ergonomic Principles
FUNDAMENTALS FOR NURSING CHAPTER 15 Security and diSaSter PlanS 75
UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT
SECTION: SAFETY AND INFECTION CONTROL
CHAPTER 15 Security and
Disaster Plans
a disaster is a mass casualty or intra‑facility
event that at least temporarily overwhelms
or interrupts the normal flow of services of a
hospital. disasters that health care facilities face
include internal and external emergencies.
internal emergencies include loss of electric
power or potable water, and severe damage
or casualties within the facility related to fire,
weather (tornado, hurricane), explosion, or a
terrorist act. internal emergency readiness
includes safety and hazardous materials
protocols, and infection control policies
and practices.
external emergencies include hurricanes,
floods, volcano eruptions, earthquakes, disease
epidemics, industrial accidents, chemical plant
explosions, major transportation accidents,
building collapse, and terrorist acts (including
biological and chemical warfare). external
emergency readiness includes a plan for
participation in community‑wide emergencies
and disasters.
THE JOINT COMMISSION AND
EMERGENCY PREPAREDNESS
The Joint Commission established emergency
preparedness management standards for various types of
health care facilities. These standards mandate that an
institutional emergency preparedness plan is developed by
all health care institutions and that these plans include
institution-specific procedures for the following.
● Notifying and assigning personnel.
● Notifying external authorities of emergencies.
● Managing space and supplies and providing security.
● Isolating and decontaminating radioactive or
chemical agents (measures to contain contamination,
decontamination at the scene of exposure).
● Evacuating and setting up an alternative care site when
the environment cannot support adequate client care
and treatment. Critical processes when an alternative
care site is necessary include the following.
◯ Client information/care packaging (medications,
supplies, admissions, medical records, and tracking)
◯ Interfacility communication
◯ Transportation of clients, staff, and equipment
◯ Cross-privileging of medical staff
● Performing triage of incoming clients.
● Managing clients during emergencies, including
scheduling, modification or discontinuation of services,
control of client information, and client discharge
and transportation.
● Interacting with family members and the media and
responding to public reaction.
● Identifying backup resources (electricity, water, fire
protection, fuel sources, medical gas and vacuum) for
utilities and communication.
● Orienting and educating personnel participating in
implementation of the emergency preparedness plan.
● Providing crisis support for health care workers (access
to vaccines, infection control recommendations, mental
health counseling).
● Providing performance monitoring and evaluation
related to emergency preparedness.
● Conducting two emergency preparedness drills
each year.
◯ Drills should include an influx of clients beyond those
being treated by the facility.
◯ Drills should include either an internal or an external
disaster (a situation beyond the normal capacity of
the facility).
● Participating in one community‑wide practice drill
per year.
CHAPTER 15
76 CHAPTER 15 Security and diSaSter PlanS CONTENT MASTERY SERIES
NURSING ROLE IN DISASTER PLANNING
AND EMERGENCY RESPONSE PLANS
Emergency response plans
Each health care institution must have an emergency
preparedness plan developed by a planning committee.
This committee reviews information regarding the
potential for various types of natural and man‑made
emergencies depending on the characteristics of the
community. Resources necessary to meet the potential
emergency are determined and a plan developed that
takes into consideration all of the above factors.
● Nurses, as well as a cross‑section of other members of
the health care team, are involved in the development
of a disaster plan for such emergencies. Criteria under
which the disaster plan is activated must be clear. Roles
for each employee are outlined and administrative
control determined. A designated area for the area
command center is identified as well as a person to
serve as the incident control manager.
● Communication, using common terminology, is
important within any emergency management plan.
● Nurses are expected to set up an emergency action plan
for personal family needs.
triaGe
Principles of triage are followed in health care facilities
involved in a mass casualty event. These differ from the
principles of triage that are typically followed during
provision of day‑to‑day services in an emergency
or urgent care setting. During mass casualty events,
casualties are separated in relation to their potential for
survival, and treatment is allocated accordingly.
Categories of triage during mass casualty events
Emergent Category (Class I): Highest priority is given to
clients who have life‑threatening injuries but also have a
high possibility of survival once they are stabilized.
Urgent Category (Class II):
Second‑highest priority is given
to clients who have major injuries
that are not yet life‑threatening
and can usually wait 45 to 60 min
for treatment.
Nonurgent Category (Class III): The
next highest priority is given to
clients who have minor injuries that
are not life‑threatening and do not
need immediate attention.
Expectant Category (Class IV): The
lowest priority is given to clients
who are not expected to live and are
allowed to die naturally. Comfort
measures can be provided, but
restorative care is not.
diScHarGe/relOcatiOn OF clientS
During an emergency such as a fire or a mass casualty
event, decisions are made regarding discharging clients or
relocating them so their beds can be given to clients who
have higher‑priority needs.
Criteria for identifying when clients can be
safely discharged
● Ambulatory clients requiring minimal care are
discharged or relocated first.
● Clients requiring assistance are next and arrangements
are made for continuation of their care.
● Clients who are unstable and/or require nursing care
are not discharged or relocated unless they are in
imminent danger.
Fire
● If evacuation of the unit is necessary, horizontal
evacuation is done first. Lateral evacuation is done if
client safety cannot be maintained.
● If a nurse discovers a fire that threatens the safety
of a client, the nurse uses the RACE (Rescue, Alarm,
Contain, and Extinguish) mnemonic to guide the order
of actions. (15.1)
SeVere tHunderStOrM/tOrnadO
● Draw shades and close drapes to protect against
shattering glass.
● Lower beds to the lowest position and move away from
the windows.
● Place blankets over all clients who are confined to beds.
● Close all doors.
● Relocate as many ambulatory clients as possible into the
hallways (away from windows) or other secure location
designated by the facility.
● Do not use elevators.
● Monitor for severe weather warnings using television,
radio, or Internet.
15.1 Race mnemonic
R
RESCUE
rescue the client and other individuals from the area.
A
ALARM
Sound the fire alarm, which activates the eMS response system.
Systems that could increase fire spread are automatically
shut down with activation of the alarm.
C
CONTAIN
after clearing the room or area, close the door leading to the
area in which the fire is located as well as the fire doors.
Fire doors are kept closed as much as possible when moving from
area to area within the facility to avoid the spread of smoke and fire.
E
EXTINGUISH
Make an attempt to extinguish small fires using a single fire
extinguisher, smothering them with a blanket, or dousing
with water (except with an electrical or grease fire).
complete evacuation of the area occurs if the nurse
cannot put the fire out with these methods.
attempts at extinguishing the fire are only made when
the employee is properly trained in the safe use of a fire
extinguisher and when only one extinguisher is needed.
FUNDAMENTALS FOR NURSING CHAPTER 15 Security and diSaSter PlanS 77
BiOlOGical PatHOGenS
Be alert to indications of a possible bioterrorism attack,
as early detection and management is key. Often the
manifestations are similar to other illnesses.
● Be alert for the appearance of a disease that does not
normally occur at a specific time or place, has atypical
manifestations, or occurs in a specific community or
people group.
● In most instances, infection from biological agents is
not spread from one client to another. Management
of the incident includes recognition of the occurrence,
directing personnel in the proper use of personal
protective equipment, and, in some situations,
decontamination and isolation.
● Use appropriate isolation measures as indicated.
● Transport or move clients only if needed for treatment
and care.
● Take measures to protect self and others.
● Recognize indications of infection/poisoning and
appropriate treatment. (15.2)
cHeMical incidentS
Chemical incidents can occur as result of an accident or
due to a purposeful action such as terrorism.
● Take measures to protect self and to avoid contact.
● Assess and intervene to maintain the client’s airway,
breathing, and circulation. Administer first aid
as needed.
● Remove the offending chemical by undressing the
client, removing all identifiable particulate matter.
Provide immediate and prolonged irrigations of
contaminated areas. Irrigate skin with running water,
with the exception of dry chemicals such as lye or white
phosphorus. In the case of exposure to a dry chemical,
brush the agent off of the client’s clothing and skin.
● Gather a specific history of the injury, if possible
(name and concentration of the chemical, duration
of exposure).
● In the event of chemical attack, have knowledge of
which facilities are open to exposed clients and which
are only open to unexposed clients.
● Follow the facility’s emergency response plans (personal
protection measures, the handling and disposal of wastes,
use of space and equipment, reporting procedures).
15.2 Biological pathogen manifestations, prevention, and treatment
Inhalational anthrax
MANIFESTATIONS
● Fever
● cough
● Shortness
of breath
● Muscle aches
● Mild chest pain
● Meningitis
● Shock
PREVENTION
● anthrax vaccine for high‑risk
● ciprofloxacin & doxycycline iV/PO
TREATMENT: includes one or two
additional antibiotics such as vancomycin,
penicillin and anthrax antitoxin
Cutaneous anthrax
MANIFESTATIONS
● Starts as a lesion that can be itchy
● develops into a vesicular lesion
that later becomes necrotic with
the formation of black eschar
● Fever, chills
PREVENTION: anthrax
vaccine for high‑risk
TREATMENT: ciprofloxacin, doxycycline
Botulism
MANIFESTATIONS
● difficulty swallowing
● double vision
● Slurred speech
● descending progressive weakness
● nausea, vomiting, abdominal cramps
● difficulty breathing
PREVENTION/TREATMENT
● airway management
● antitoxin
● elimination of toxin
Viral hemorrhagic fevers
(e.g., Ebola, yellow fever)
MANIFESTATIONS
● Fatigue
● Kidney failure
● elevated
temperature
● nausea, vomiting,
diarrhea
● internal and
external bleeding
● Shock
PREVENTION
● Vaccination available for yellow fever,
argentine hemorrhagic fever
● Barrier protection from infected person,
isolation precautions specific to disease
TREATMENT
● no cure, supportive care only
● Minimize invasive procedures
Plague
MANIFESTATIONS
● these forms can occur separately
or in combination:
● Pneumonic plague: fever, headache,
weakness, pneumonia with shortness
of breath, chest pain, cough, and
bloody or watery sputum.
● Bubonic plague: swollen, tender
lymph glands, fever, headache,
chills, and weakness.
● Septicemic plague: fever, chills,
prostration, abdominal pain, shock,
disseminated intravascular coagulation
(dic), gangrene of nose and digits.
PREVENTION: contact precautions
till decontaminated, droplet
precautions till 72 hr after antibiotics
TREATMENT: Streptomycin/gentamicin
or tetracycline/doxycycline.
Smallpox
MANIFESTATIONS
● High fever
● Fatigue
● Severe headache
● rash
● chills
● Vomiting
● delirium
PREVENTION
● Vaccine; can vaccinate within
3 days of exposure
● contact and airborne precautions
TREATMENT
● Supportive care( prevent
dehydration, provide skin care,
medications for pain and fever)
● antibiotics for secondary infections
Tularemia
MANIFESTATIONS
● Sudden fever
● chills
● Headache
● diarrhea
● Muscle aches
● Joint pain
● dry cough
● Progressive
weakness
● if airborne,
life‑threatening
pneumonia and
systemic infection
PREVENTION: vaccine under review by
the Food and drug administration
TREATMENT: streptomycin or gentamicin
are the medications of choice; in mass
causality, use doxycycline or ciprofloxacin
78 CHAPTER 15 Security and diSaSter PlanS CONTENT MASTERY SERIES
HaZardOuS Material incidentS
● Take measures to protect self and to avoid contact.
● Approach the scene with caution.
● Identify the hazardous material with available resources
(emergency response guidebook, poison control centers).
Know the location of the safety data sheets manual.
● Try to contain the material in one place prior to the
arrival of the hazardous materials team.
● If individuals are contaminated, decontaminate them as
much as possible at the scene or as close as possible to
the scene.
◯ Don gloves, gown, mask, and shoe covers to protect
self from contamination.
◯ With few exceptions, water is the universal antidote.
For biological hazardous materials, wash skin with
copious amounts of water and antibacterial soap.
◯ Carefully and slowly remove contaminated clothing
so that deposited material does not become airborne
◯ Place all contaminated material into large plastic bags
and seal them.
radiOlOGical incidentS
● The amount of exposure is related to the duration
of the exposure, distance from source, and amount
of shielding.
● The facility where victims are treated activates
interventions to prevent contamination of treatment
areas (floors and furniture are covered, air vents and
ducts are covered, radiation‑contaminated waste is
disposed of according to procedural guidelines).
● Wear water‑resistant gowns, double glove, and fully
cover their bodies with caps, shoe covers, masks,
and goggles.
● Wear radiation or dosimetry badges to monitor the
amount of their radiation exposure.
● Survey clients initially with a radiation meter to
determine the amount of contamination.
● Decontamination with soap, water, and disposable
towels occurs prior to entering the facility. Water runoff
is contaminated and contained.
● After decontamination, resurvey clients for residual
contamination. Continue irrigation of the skin until the
client is clean of all contamination.
BOMB tHreat
When a phone call is received:
● Extend the conversation as long as possible.
● Listen for distinguishing background noises (music,
voices, traffic, airplanes).
● Note distinguishing voice characteristics of the caller.
● Ask where and when the bomb is set to explode.
● Note whether the caller is familiar with the physical
arrangement of the facility.
● If a bomb‑like device is located, do not touch it. Clear
the area, and isolate the device as much as possible by
closing doors, for example.
● Notify the appropriate authorities and personnel (police,
administrator, director of nursing).
● Cooperate with police and others. Assist to conduct a
search as needed, provide copies of floor plans, have
master keys available, and watch for and isolate
suspicious objects such as packages and boxes.
● Keep elevators available for authorities.
● Remain calm and alert and try not to alarm clients.
SECURITY PLAN
All health care facilities have security plans in place that
include preventive, protective, and response measures
designed for identified security needs.
● Security issues faced by health care facilities include
admission of potentially dangerous individuals,
vandalism, infant abduction, and information theft.
● The International Association for Healthcare Security &
Safety provides recommendations for the development
of security plans.
nurSinG rOle in Security Plan
Nurses should be aware that security measures include:
● An identification system that identifies employees,
volunteers, physicians, students, and regularly
scheduled contract services staff as authorized
personnel of the health care facility.
● Electronic security systems in high‑risk areas (maternal
newborn to prevent infant abductions, the emergency
department to prevent unauthorized entrance).
◯ Key code access into and out of high‑risk areas
◯ Wristbands that electronically link parents and
their infants
◯ Alarms integrated with closed‑circuit
television cameras
Nurses should prepare to take immediate action when
breaches in security occur. Time is of the essence in
preventing or stopping a breach in security.
FUNDAMENTALS FOR NURSING CHAPTER 15 Security and diSaSter PlanS 79
Application Exercises
1. a nurse is caring for multiple clients
during a mass casualty event. Which
of the following clients is the priority?
a. a client who received
crush injuries to the
chest and abdomen and
is expected to die
B. a client who has a 4‑inch
laceration to the head
c. a client who has
partial‑thickness and
full‑thickness burns to his
face, neck, and chest
d. a client who has a
fractured fibula and tibia
2. a nurse educator is discussing the
facility protocol in the event of a
tornado with the staff. Which of the
following should the nurse include in
the instructions? (Select all that apply.)
a. Open doors to client rooms.
B. Place blankets over clients
who are confined to beds.
c. Move beds away from
the windows.
d. draw shades and close drapes.
e. instruct ambulatory
clients in the hallways to
return to their rooms.
3. an occupational health nurse is caring
for an employee who was exposed to
an unknown dry chemical, resulting
in a chemical burn. Which of the
following interventions should the
nurse include in the plan of care?
a. irrigate the affected area
with running water.
B. Wash the affected area
with antibacterial soap.
c. Brush the chemical off
the skin and clothing.
d. leave the clothing in
place until emergency
personnel arrive.
4. a security officer is reviewing
actions to take in the event of a
bomb threat by phone to a group
of nurses. Which of the following
statements by a nurse indicates
understanding of proper procedure?
a. “i will get the caller off the
phone as soon as possible
so i can alert the staff.”
B. “i will begin evacuating
clients using the elevators.”
c. “i will not ask any questions
and just let the caller talk.”
d. “i will listen for
background noises.”
5. a nurse on a medical‑surgical unit is
informed that a mass casualty event
occurred in the community and that
it is necessary to discharge stable
clients to make beds available for
injury victims. Which of the following
clients should the nurse recommend
for discharge? (Select all that apply.)
a. a client who is dehydrated
and receiving iV fluid
and electrolytes
B. a client who has a
nasogastric tube to treat a
small bowel obstruction
c. a client who is scheduled
for elective surgery
d. a client who has chronic
hypertension and blood
pressure 135/85 mm Hg
e. a client who has acute
appendicitis and is scheduled
for an appendectomy
PRACTICE Active Learning Scenario
a nurse educator is teaching a module on biological
pathogens during orientation to a group of newly
hired nurses. What information should the nurse
educator include? use the ati active learning
template: Basic concept to complete this item.
RELATED CONTENT: list four manifestations
and the recommended treatment for anthrax,
botulism, pneumonic plague, and tularemia.
80 CHAPTER 15 Security and diSaSter PlanS CONTENT MASTERY SERIES
Application Exercises Key
1. a. the nurse should give the lowest priority to a client who
is not expected to live. the nurse should provide comfort
measures for this client (expectant category: class iV).
B. the nurse should give third priority to the client who
has minor injury that is not life‑threatening, such as a
laceration to the head (nonurgent category: class iii).
c. CORRECT: the nurse should give first priority to the client who has
the greatest chance of survival with prompt intervention. if not treated
immediately, a client who has burns to his face, neck, and chest is at
risk for airway obstruction, but is otherwise expected to live. therefore,
this client is the highest priority (emergent category: class i).
d. the nurse should give second priority to the client
who has major fractures (urgent category: class ii).
NCLEX® Connection: Management of Care, Establishing Priorities
2. a. the nurse should close all client doors to minimize
the threat of flying glass and debris.
B. CORRECT: the nurse should place blankets over clients
to protect them from shattering glass or flying debris.
c. CORRECT: the nurse should move all beds away from windows
to protect clients from shattering glass or flying debris.
d. CORRECT: the nurse should draw shades and close
drapes to protect clients against shattering glass.
e. the nurse should instruct ambulatory clients to go to the hallways,
away from windows, or other secure location designated by the facility.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
3. a. the nurse should not apply water to a dry chemical exposure
because it could activate the chemical and cause further harm.
B. the nurse should wash the skin with antibacterial
soap in the event of a biological exposure.
c. CORRECT: the nurse should use a brush to remove
the chemical off the skin and clothing.
d. the nurse should plan to remove the client’s clothing
following appropriate decontamination.
NCLEX® Connection: Safety and Infection Control,
Handing Hazardous and Infectious Materials
4. a. in the event of a bomb threat, the nurse should
keep the caller on the line in order to trace the call
and to collect as much information as possible.
B. the nurse should avoid using the elevators so that
they are free for the authorities to use, and should not
evacuate clients unless directed to by facility protocol.
c. the nurse should ask the caller about the location
of the bomb and the time it is set to explode in order
to gather as much information as possible.
d. CORRECT: in order to identify the location of the caller, the
nurse should listen for background noises such as church
bells, train whistles, or other distinguishing noises.
NCLEX® Connection: Safety and Infection Control,
Handing Hazardous and Infectious Materials
5. a. the nurse should recognize that a client who is
receiving iV fluid and electrolytes requires ongoing
nursing care and is therefore unstable for discharge.
B. the nurse should recognize that a client who has a nasogastric tube
requires ongoing nursing care and is therefore unstable for discharge.
c. CORRECT: the nurse should identify a client who
is scheduled elective surgery is stable and is therefore
appropriate to recommend for discharge.
d. CORRECT: a blood pressure 135/85 mm Hg is within the
reference range for prehypertension. the nurse should identify this
client as stable and appropriate to recommend for discharge.
e. the nurse should recognize that a client who has an
acute illness and is scheduled for surgery requires ongoing
nursing care and is therefore unstable for discharge.
NCLEX® Connection: Management of Care, Establishing Priorities
PRACTICE Active Learning Scenario
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
anthrax
● Manifestations
◯ Fever
◯ cough
◯ Shortness of breath
◯ Muscle aches
◯ Meningitis
◯ Shock
● nursing interventions
◯ ciprofloxacin
◯ One or two additional
antibiotics, such as
vancomycin or penicillin
Botulism
● Manifestations
◯ difficulty swallowing
◯ double vision
◯ Slurred speech
◯ descending progressive
weakness
◯ nausea, vomiting,
abdominal cramps
◯ difficulty breathing
● nursing interventions
◯ airway management
◯ antitoxin
◯ elimination of toxin
Pneumonic plague
● Manifestations
◯ Fever
◯ Headache
◯ Weakness
◯ rapidly developing pneumonia
◯ Shortness of breath
◯ chest pain
◯ cough
◯ Bloody or watery sputum.
● nursing interventions
◯ early treatment is essential.
◯ Streptomycin, gentamicin,
the tetracyclines
tularemia
● Manifestations
◯ Sudden fever
◯ chills
◯ Headache
◯ diarrhea
◯ Muscle aches
◯ Joint pain
◯ dry cough
◯ Progressive weakness
◯ if airborne, life‑threatening
pneumonia and
systemic infection
● nursing interventions
◯ Streptomycin iV or gentamicin
iV or iM are the drugs of choice.
◯ in mass casualty, use
doxycycline or ciprofloxacin.
NCLEX® Connection: Safety and Infection Control, Handing Hazardous and Infectious Materials
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 81
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Safety and Infection Control
ACCIDENT/ERROR/INJURY PREVENTION: Identify
factors that influence accident/injury prevention.
HOME SAFETY: Educate the client on home safety issues.
Client Needs: Health Promotion and Maintenance
AGING PROCESS: Provide care and education for the
adult client ages 65 through 85 years and over.
DEVELOPMENTAL STAGES AND TRANSITIONS: Identify expected
physical, cognitive, and psychosocial stages of development.
HEALTH PROMOTION/DISEASE PREVENTION
Assess client’s readiness to learn, learning
preferences and barriers to learning.
Educate the client on actions to promote/
maintain health and prevent disease.
Client Needs: Basic Care and Comfort
MOBILITY/IMMOBILITY: Assess the client for
mobility, gait, strength, and motor skills.
FUNDAMENTALS FOR NURSING CHAPTER 16 HealtH Promotion and disease Prevention 83
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 16 Health Promotion
and Disease
Prevention
nurses use traditional nursing measures and
complementary therapies, such as guided
imagery, massage, relaxation, and music, to help
promote health and prevent disease.
levels of prevention address health‑related
activities that are primary, secondary, and
tertiary. levels of prevention are not the same as
levels of care.
RISK ASSESSMENT
risK FaCtors
Genetics: Heredity creates a predisposition for various
disorders (heart disease, cancers, mental illnesses).
Gender: Some diseases are more common in one gender
than in the other. For example, women have a higher
incidence of autoimmune disorders, while men have a
higher suicide rate.
Physiologic factors: Various physiologic states place
clients at an increased risk for health problems (body
mass index [BMI] above 25, pregnancy).
Environmental factors: Toxic substances and chemicals
can affect health where clients live and work (water
quality, pesticide exposure, air pollution).
Lifestyle-risk behaviors: Clients have control over
how they choose to live, and making positive choices
can reduce risk factors. Risk behaviors to screen for
include stress, substance use disorders, tobacco use, diet
deficiencies, lack of exercise, and sun exposure.
Age: Screening guidelines from the American Diabetes
Association, American Heart Association, and American
Cancer Society promote early detection and intervention.
Ages vary with individual practices (for example, a woman
who is sexually active before the age of 20 should start
screenings when sexual activity begins).
tests
Frequency of some major examinations and screenings are
baseline for clients who are asymptomatic and do not have
risk factors:
Routine physical examination: Generally every 1 to
3 years for women and every 5 years for men from
age 20 to 40, more often after age 40.
Dental assessment: Every 6 months.
Tuberculosis screen: Tuberculosis (TB) skin test every
year. TB tests are generally not needed for people with a
low risk of infection with TB bacteria. Higher risks include
weak immune system and drug use. Health care workers
should be screened annually.
Blood pressure: At least every 2 years; annually if
previously elevated.
Body mass index: At each routine health care visit.
Blood cholesterol: Starting at age 20, a minimum of every
5 years.
Blood glucose: Starting at age 45, a minimum of every
3 years.
Visual acuity: Age 40 and under: every 3 to 5 years. Every
2 years ages 40 and 65. Every year after age 65.
Hearing acuity: Periodic hearing checks as needed; more
frequently if hearing loss is noted.
Skin assessment: Every 3 years by a skin specialist for age
20 to 40; annually over age 40 years.
Digital rectal exam: During routine physical examination
or annually if have at least a 10‑year life expectancy.
Consult with the provider if screen should continue after
age 76.
Colorectal screening: Every year between age 50 and 75
for high-sensitivity fecal occult blood testing, or flexible
sigmoidoscopy every 5 years, or colonoscopy every 10
years. Consult with the provider if screen should continue
after age 76.
Tests specific for women
Cervical cancer screening: Ages 21 to 29: Papanicolaou
test (Pap smear) every 3 years; ages 30 to 65: Pap and
human papilloma virus test every 5 years.
Breast cancer screening: Ages 20 to 39: clinical breast
examination every 3 years, then annually; ages 40 and
older: mammogram annually.
Tests specific for men
Clinical testicular examination: At each routine health
care visit starting at age 20.
Prostate‑specific antigen test, digital rectal examination:
Every year starting at age 50. Consult with the provider if
screen should continue after age 76.
CHAPTER 16
84 CHAPTER 16 HealtH Promotion and disease Prevention CONTENT MASTERY SERIES
PREVENTION
Primary, secondary, and tertiary prevention describe the
focus of activities and the level of prevention.
PrimarY
Primary prevention addresses the needs of healthy clients
to promote health and prevent disease with specific
protections. It decreases the risk of exposure individual/
community to disease.
● Immunization programs
● Child car seat education
● Nutrition, fitness activities
● Health education in schools
seCondarY
Secondary prevention focuses on identifying illness,
providing treatment, and conducting activities that help
prevent a worsening health status.
● Communicable disease screening, case finding
● Early detection, treatment of diabetes mellitus
● Exercise programs for older adults who are frail
tertiarY
Tertiary prevention aims to prevent the long‑term
consequences of a chronic illness or disability and to
support optimal functioning.
● Begins after an injury or illness
● Prevention of pressure ulcers after spinal cord injury
● Promoting independence after traumatic brain injury
● Referrals to support groups
● Rehabilitation center
HEALTHY PEOPLE 2020
The Healthy People 2020 provides a list of national
objectives to promote health and prevent disease among
the national population. The objectives are updated
every 10 years and involve a collaborative effort for
implementation by the local governments, voluntary and
professional organizations, businesses, and individuals.
● Improve health priorities
● Improve awareness and understanding of the progress
involving health, disease, and disability.
● Apply measurable health goals at the local, state, and
national level
● Apply best practice to strengthen polices and improve
health practice
● Identify the need for research, evaluation and data
collection of health disparities
NURSING INTERVENTIONS
Examine risk factors to identify modifications, adopt
mutually agreeable goals, and identify support systems.
● Refer clients to educational/community/support
resources. Help clients recognize benefits (not smoking
reduces the risk of lung cancer) and overcome barriers
(not smoking covers expenses for healthful pursuits).
● Advocate for changes in the community.
Use behavior-change strategies.
● Identify clients’ readiness to receive and apply
health information.
● Identify acceptable interventions.
● Help motivate change by setting realistic timelines.
● Reinforce steps toward change
● Assist the client to recognize his personal perceived
barriers that can hinder commitment to adopting and
maintaining the plan for a healthy lifestyle change.
● Encourage clients to maintain the change.
● Model healthy behaviors.
Promote healthy lifestyle behaviors by instructing clients
to do the following.
● Use stress management strategies.
● Get adequate sleep and rest.
● Eat a nutritious diet to achieve and maintain a
healthy weight.
● Avoid saturated fats.
● Participate in regular physical activity most days.
● While outdoors, wear protective clothing, use sunscreen,
and avoid sun exposure between 10 a.m. and 4 p.m.
● Wear safety gear (bike helmets, knee and elbow pads)
when participating in physical activity.
● Avoid tobacco products, alcohol, and illegal drugs.
● Practice safe sex.
● Seek medical care when necessary, get routine
screenings, and perform recommended
self‑examinations (breast, testicular).
Online Video: Health Screening
FUNDAMENTALS FOR NURSING CHAPTER 16 HealtH Promotion and disease Prevention 85
Application Exercises
1. a nurse is caring for a 20‑year‑old
client who is sexually active and has
come to the college health clinic for
a first‑time checkup. Which of the
following interventions should the
nurse perform first to determine the
client’s need for health promotion
and disease prevention?
a. measure vital signs.
B. encourage Hiv screening.
C. determine risk factors.
d. instruct the client to
use condoms.
2. a nurse in a clinic is planning health
promotion and disease prevention
strategies for a client who has
multiple risk factors for cardiovascular
disease. Which of the following
interventions should the nurse
include? (select all that apply.)
a. Help the client see the
benefits of her actions.
B. identify the client’s
support systems.
C. suggest and recommend
community resources.
d. devise and set goals
for the client.
e. teach stress management
strategies.
3. a nurse in a health clinic is caring
for a 21‑year‑old client who reports
a sore throat. the client tells the
nurse that he has not seen a doctor
since high school. Which of the
following health screenings should
the nurse expect the provider
to perform for this client?
a. testicular examination
B. Blood glucose
C. Fecal occult blood
d. Prostate‑specific antigen
4. a nurse is talking with a client who
recently attended a cholesterol
screening event and a heart‑healthy
nutrition presentation at a
neighborhood center. the client’s
total cholesterol was 248 mg/dl.
after seeing the provider, the client
started taking medication to lower
his cholesterol level. the client was
later hospitalized for severe chest
pain, and subsequently enrolled in a
cardiac rehabilitation program. Which
of the following activities for the client
is an example of primary prevention?
a. Cholesterol screening
B. nutrition presentation
C. medication therapy
d. Cardiac rehabilitation
5. a nurse at a provider’s office is
talking about routine screenings
with a 45‑year‑old female client
who has no specific family history
of cancer or diabetes mellitus.
Which of the following client
statements indicates that the client
understands how to proceed?
a. “so i don’t need the colon
cancer procedure for
another 2 or 3 years.”
B. “For now, i should
continue to have a
mammogram each year.”
C. “Because the doctor just did
a Pap smear, i’ll come back
next year for another one.”
d. “i had my blood glucose test
last year, so i won’t need
it again till next year.”
PRACTICE Active Learning Scenario
a nurse is caring for a client in a spinal cord injury
rehabilitation center following head and neck injuries
sustained while riding a bicycle. the client had
surgery during the acute phase of treatment to relieve
intracranial pressure and to stabilize his cervical spine.
now, the client and his partner are learning essential
self‑management strategies. Use the ati active learning
template: Basic Concept to complete this item.
RELATED CONTENT: list each of the three levels of
prevention with an example of each level from this
client’s history or from what this client might have done
to prevent this injury and its life‑altering consequences.
86 CHAPTER 16 HealtH Promotion and disease Prevention CONTENT MASTERY SERIES
Application Exercises Key
1. a. the nurse should take vital signs when determining the
client’s need for health promotion and disease prevention.
However, there is another action the nurse should take first.
B. the nurse may suggest for the client to have a Hiv screening
when determining health promotion and disease prevention.
However, there is another action the nurse should take first.
C. CORRECT: the first action the nurse should take using the nursing
process is assessment. the nurse should talk with the client first to
determine what risk factors the client might have before initiating the
appropriate health promotion and disease prevention measures.
d. the nurse may provide for the client the use of condoms
to decrease sexual health risk when determining the client’s
need for health promotion and disease prevention. However,
there is another action the nurse should take first.
NCLEX® Connection: Health Promotion and Maintenance,
Health Screening
2. a. CORRECT: the nurse should assist the client to recognize
the benefits of her health‑promoting actions while also
overcoming barriers to implementing actions.
B. CORRECT: the nurse should collect information about who can
help the client change unhealthful behaviors, and then suggest steps
to have friends and family to become involved and supportive.
C. CORRECT: the nurse should promote the client’s use
of any available community or online resources that can
help the client progress toward meeting set goals.
d. the nurse and the client should work together to devise and set
mutually agreeable goals that are also realistic and achievable.
e. CORRECT: the nurse should teach that stress is a
contributing factor to cardiovascular disease, as well
as many other specific and systemic disorders.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
3. a. CORRECT: starting at age 20, the client should have examinations
for testicular cancer, along with blood pressure and body mass
index measurements and cholesterol determinations.
B. Blood glucose testing begins at age 45.
C. testing for fecal occult blood usually begins at age 50.
d. testing for prostate‑specific antigen usually begins at age 50.
NCLEX® Connection: Health Promotion and Maintenance,
Health Screening
4. a. a cholesterol screening is an example of secondary prevention.
B. CORRECT: Primary prevention encompasses strategies
that help prevent illness or injury. this level of prevention
includes health information about nutrition, exercise, stress
management, and protection from injuries and illness.
C. starting medication therapy to lower cholesterol
is an example of secondary prevention.
d. starting cardiac rehabilitation is an example of tertiary prevention.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
5. a. the female client who has no specific family or personal history
of colorectal cancer should begin screening procedures at age 50.
B. CORRECT: the female client who is between the ages
of 40 and 50 should have a mammogram annually.
C. the female client who is between the ages of 30 and 65, with
no family or personal history of cervical cancer, should have a
Pap smear and human papilloma virus test every 5 years.
d. the client who is age 45 should have a blood glucose
test at least every 3 years. Unless there is a specific
family or personal history of diabetes mellitus, annual
blood glucose determinations are not necessary.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● Primary: take various courses, read about bicycle safety (wear a helmet, use reflective
accessories and lights for visibility to drivers, follow the rules of the road for cyclists)
● secondary: emergency care, surgery
● tertiary: rehabilitative care, learning self‑management procedures, strategies
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
FUNDAMENTALS FOR NURSING CHAPTER 17 Client eduCation 87
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 17 Client Education
teaching is goal‑driven and interactive. it
involves purposeful actions to help individuals
acquire knowledge, modify attitudes and
behavior, and learn new skills.
learning is the intentional gain of new
information, attitudes, or skills, and it promotes
behavioral change.
Motivation influences how much and how
quickly a person learns. the desire to learn and
the ability to learn and understand the content
affect motivation.
information technology increases access to and
delivery of knowledge.
NURSING AND CLIENT EDUCATION
● Nurses provide health education to individuals, families,
and communities.
● Some of the most common factors influencing
clients’ educational needs are health, educational
level, socioeconomic status, and cultural and
family influences.
● Emotional status, spiritual factors, health perception,
willingness to participate, and developmental level are
also important to consider when providing
client education.
● Client education provides clients with information and
skills to:
◯ Maintain and promote health and prevent illness
(immunizations, lifestyle changes, prenatal care).
◯ Restore health (self‑administration of insulin).
◯ Adapt to permanent illness or injury (ostomy care,
swallowing techniques, speech therapy).
doMainS oF leaRninG
Cognitive learning requires intellectual behaviors and
focuses on thinking. It involves knowledge (learning the
new information), comprehension (understanding the new
information), application (using the new information in a
concrete way), analysis (organizing the new information),
synthesis (using the knowledge for a new outcome), and
evaluation (determining the effectiveness of learning
the new information). For example, cognitive learning
takes place when clients learn the manifestations of
hypoglycemia and then can verbalize when to notify
the provider.
Affective learning involves feelings, beliefs, and values.
Hearing the instructor’s words, responding verbally and
nonverbally, valuing the content, creating a method
for identifying values and resolving differences, and
employing values consistently in decision‑making are all
characteristics of affective learning. For example, affective
learning takes place when clients learn about the life
changes necessary for managing diabetes mellitus and
then discuss their feelings about having diabetes.
Psychomotor learning is gaining skills that require
mental and physical activity. Psychomotor learning relies
on perception (or sensory awareness), set (readiness
to learn), guided response (task performance with an
instructor), mechanism (increased confidence allowing for
more complex learning), adaptation (the ability to alter
performance when problems arise), and origination (use of
skills to perform complex tasks that require creating new
skills). For example, psychomotor learning takes place
when clients practice preparing insulin injections.
ASSESSMENT/DATA COLLECTION
● Assess/monitor learning needs.
● Evaluate the learning environment.
● Identify learning style (auditory, visual, kinesthetic).
● Identify areas of concern (low literacy levels,
pain, distractions).
● Identify available resources (financial,
social, community).
● Identify developmental level.
● Determine physical and cognitive ability.
● Identify specific needs (visual impairment, decreased
manual dexterity, learning challenges).
● Determine motivation and readiness to learn.
CHAPTER 17 Online Video: Client Education
88 CHAPTER 17 Client eduCation CONTENT MASTERY SERIES
PLANNING
● Identify mutually agreeable outcomes.
● Prioritize the learning objectives with clients’ needs
in mind.
● Use methods that emphasize the learning style.
● Select age‑appropriate teaching methods and materials.
● Speak and provide print materials at or below the
sixth‑grade reading level.
● Avoid nursing terminology (administer, monitor,
implement, assess).
● Speak and write in the second person, not the third
(“your leg,” not “the leg”).
● Avoid using all capital letters, minimal white space, and
small type in print materials.
● Speak and write in active voice (“take the medication,”
not “the medication should be taken”).
● Provide electronic educational resources (CDs, DVDs,
software programs, mobile applications).
● Use reliable Internet sources to access information and
support services.
● Organize learning activities to move from simple to
more complex tasks and known to unknown concepts.
● Incorporate active participation in the learning process.
● Schedule teaching sessions at optimal times for learning
(teaching ostomy care while replacing the pouch).
IMPLEMENTATION
● Create an environment that promotes learning (minimal
distractions and interruptions, privacy).
● Use therapeutic communication (active listening,
empathy) to develop trust and promote sharing
of concerns.
● Review previous knowledge and experiences.
● Explain the therapeutic regimen or procedure.
● Present steps that build toward more complex tasks.
● Demonstrate psychomotor skills.
● Allow time for return demonstrations.
● Provide positive reinforcement.
EVALUATION
● Ask clients to explain the information in their
own words.
● Observe return demonstrations (psychomotor learning).
● Use written tools to measure the accuracy
of information.
● Ask clients to evaluate their own progress.
● Observe nonverbal communication.
● Reevaluate learning during follow‑up telephone calls
or contacts, such as home health visits or appointments
with the provider.
● Revise the care plan accordingly.
FACTORS AFFECTING LEARNING
FACTORS THAT ENHANCE LEARNING
● Perceived benefit
● Cognitive and physical ability
● Health and cultural beliefs
● Active participation
● Age‑ and educational level‑appropriate methods
BARRIERS TO LEARNING
● Fear, anxiety, depression
● Physical discomfort, pain, fatigue
● Environmental distractions
● Health and cultural beliefs
● Sensory and perceptual deficits
● Psychomotor deficits
FUNDAMENTALS FOR NURSING CHAPTER 17 Client eduCation 89
Application Exercises
1. a nurse is observing a client
drawing up and mixing insulin.
Which of the following findings
should the nurse identify as an
indication that psychomotor
learning has taken place?
a. the client is able to discuss
the appropriate technique.
B. the client is able
to demonstrate the
appropriate technique.
C. the client states that
he understands.
d. the client is able to write the
steps on a piece of paper.
2. a nurse in a provider’s office is
collecting data from the mother of
a 12‑month‑old infant. the client
states that her son is old enough
for toilet training. Following an
educational session with the nurse,
the client now states that she will
postpone toilet training until her
son is older. learning has occurred
in which of the following domains?
a. Cognitive
B. affective
C. Psychomotor
d. Kinesthetic
3. a nurse is providing preoperative
education for a client who will
undergo a mastectomy the next
day. Which of the following
statements should the nurse
identify as an indication that
the client is ready to learn?
a. “i don’t want my spouse
to see my incision.”
B. “Will you give me pain
medicine after the surgery?”
C. “Can you tell me about how
long the surgery will take?”
d. “My roommate listens
to everything i say.”
4. a nurse is preparing an instructional
session for an older adult about
managing stress incontinence.
Which of the following actions
should the nurse take first when
meeting with the client?
a. encourage the client to
participate actively in learning.
B. Select instructional materials
appropriate for the older adult.
C. identify goals the nurse and
the client agree are reasonable.
d. determine what the
client knows about
stress incontinence.
5. a nurse is evaluating how well a client
learned the information he presented
in an instructional session about
following a heart‑healthy diet. the
client states that she understands
what to do now. Which of the
following actions should the nurse
take to evaluate the client’s learning?
a. encourage the client
to ask questions.
B. ask the client to explain how
to select or prepare meals.
C. encourage the client to fill
out an evaluation form.
d. ask the client if she has
resources for further
instruction on this topic.
PRACTICE Active Learning Scenario
a nurse is preparing a presentation at a community
center for a group of parents who want to learn how to
prevent childhood obesity. use the ati active learning
template: Basic Concept to complete this item.
RELATED CONTENT
list at least three factors the nurse should consider
when incorporating ways to enhance learning.
list at least three barriers the nurse might
encounter among the attendees.
90 CHAPTER 17 Client eduCation CONTENT MASTERY SERIES
Application Exercises Key
1. a. discussing the appropriate technique demonstrates
learning, but it does not involve the use of motor skills.
B. CORRECT: demonstrating the appropriate technique
indicates that psychomotor learning has taken place.
C. Verbalizing understanding demonstrates learning,
but it does not involve the use of motor skills.
d. Writing steps on paper demonstrates learning, but it does not
involve the motor skills essential for performing the procedure.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
2. a. an example of cognitive learning is stating the behavior
the child will demonstrate when ready to toilet train.
B. CORRECT: affective learning has taken place because
the client’s ideas about toilet training changed.
C. an example of psychomotor learning is performing the
proper techniques for introducing the child to toilet training.
d. Kinesthetic learning is a learning style, not a domain of learning.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
3. a. the client’s concern about her spouse seeing the
incision could indicate anxiety or depression.
B. the client’s request for pain medicine could indicate fear and anxiety.
C. CORRECT: asking a concrete question about the surgery
indicates that the client is ready to discuss the surgery. the
client’s new diagnosis of cancer can cause anxiety, fear, or
depression, all of which can interfere with the learning process.
d. the lack of privacy due to the presence of a
roommate can be a barrier to learning.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
4. a. active participation in the learning process is essential for the
success of the session. However, this is not the priority action.
B. it is essential for the nurse to prepare and select instructional
materials appropriate for the client’s age, developmental level,
and other parameters. However, this is not the priority action.
C. establishing mutually agreeable goals is essential for the
success of the session. However, this is not the priority action.
d. CORRECT: the first action the nurse should take using the
nursing process is to assess or collect data from the client. the
nurse should determine how much the client knows about stress
incontinence, the accuracy of this knowledge, and what the client
needs to learn to manage this problem before instructing the client.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
5. a. the client stated that she understood the content, so she might
not ask any questions that would help the nurse evaluate learning.
B. CORRECT: a useful strategy for evaluating learning is to ask the client
to explain in her own words how she will implement what she learned.
C. an evaluation form usually gives the client a means of evaluating the
teaching. it might not offer clues about what the client has learned.
d. the nurse should identify the client’s resources early in the
instructional process. at this point, the exploration of resources
does not help the nurse evaluate the client’s learning.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
Factors that enhance learning
● Perceived benefit
● Cognitive and physical ability
● Health and cultural beliefs
● active participation
● age
● educational level‑appropriate methods
Barriers to learning
● Fear
● anxiety
● depression
● Physical discomfort
● Pain
● Fatigue
● environmental
distractions
● Health and
cultural beliefs
● Sensory and
perceptual deficits
● Psychomotor deficits
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
FUNDAMENTALS FOR NURSING CHAPTER 18 Infants (2 Days to 1 year) 91
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 18 Infants
(2 Days to 1 Year)
EXPECTED GROWTH AND
DEVELOPMENT FOR NEWBORNS
PHysICaL DeVeLoPMent
● Lose 5% to 10% body birth weight in first few days, but
should regain it by the second week.
● Weight gain is about 150 to 210 g (5 to 7 oz) per week in
the first 6 months
● Measurements of crown‑to‑rump length, head‑to‑heel
length, head circumference and chest circumference are
key indicators of appropriate growth.
● Lanugo (soft hair) present on the back.
● Head molding (overlapping of skull bones) present;
fontanels are palpable.
REFLEXES
● Include startling, sucking, rooting, grasping, yawning,
coughing, plantar and palmar grasp, and Babinski.
● Confirm presence or absence of expected reflexes to
monitor for appropriate neurological development.
BODY POSITION
● Generally flexed at rest.
● Movement should involve all
four extremities equally, but can
be sporadic.
SLEEP
● Sleep patterns may be reversed for
several months (daytime sleeping
and nighttime wakefulness).
● Average 15 hr of sleep time
each day.
CoGnItIVe DeVeLoPMent
● Learn to respond to visual stimuli.
● Use cry as a form
of communication.
● Cry patterns can change to reflect
different needs.
PsyCHosoCIaL
DeVeLoPMent
● Interactions with caregivers affect
psychosocial development. Positive
interactions promote nurturing
and attachment. Negative
experience or lack of interaction
hinders appropriate attachment.
● Most newborns can mimic the
smile of the caregiver by 2 weeks
of life.
EXPECTED GROWTH AND
DEVELOPMENT FOR INFANTS
PHysICaL DeVeLoPMent
● Posterior fontanel closes by 2 to 3 months of age.
● Anterior fontanel closes by 12 to 18 months of age.
Tracking parameters
WEIGHT: Birth weight should double by 4 to 6 months and
triple by the end of the first year.
HEIGHT: Infants grow about 2.5 cm (1 in) per month in the
first 6 months, and then about 1.25 cm (0.5 in) per month
until the end of the first year.
HEAD CIRCUMFERENCE: Head circumference increases
about 1.25 cm (0.5 in) per month in the first 6 months and
then about 0.5 cm (0.2 in) between 6 and 12 months.
DENTITION: Six to eight teeth erupt in the infant’s mouth
by the end of the first year.
● Use cold teething rings, over‑the‑counter teething gels,
and acetaminophen or ibuprofen.
● Use a cool, wet washcloth to clean the teeth.
● Do not give infants a bottle when they are falling asleep.
Prolonged exposure to milk or juice can cause dental
caries (bottle‑mouth caries).
CHAPTER 18
18.1 Motor skill development by age
GROSS MOTOR SKILLS FINE MOTOR SKILLS
1 MONTH Demonstrates head lag Has a strong grasp reflex
2 MONTHS Lifts head off mattress
when prone
Holds hands in an open position
Grasp reflex fading
3 MONTHS
raises head and shoulders
off mattress when prone
only slight head lag
no longer has a grasp reflex
Keeps hands loosely open
4 MONTHS rolls from back to side
Grasps objects with both hands
Places objects in mouth
5 MONTHS rolls from front to back Uses palmar grasp dominantly
6 MONTHS rolls from back to front Holds bottle
7 MONTHS
Bears full weight on feet
sits, leaning forward
on both hands
Moves objects from hand to hand
8 MONTHS sits unsupported Begins using pincer grasp
9 MONTHS Pulls to a standing position
Has a crude pincer grasp
Dominant hand
preference evident
10 MONTHS Changes from a prone
to a sitting position Grasps rattle by its handle
11 MONTHS
Cruises or walks while
holding onto something
Walks with one hand held
Places objects into a container
neat pincer grasp
12 MONTHS sits down from a standing
position without assistance
tries to build a two‑block
tower without success
Can turn pages in a book
92 CHAPTER 18 Infants (2 Days to 1 year) CONTENT MASTERY SERIES
CoGnItIVe DeVeLoPMent
Piaget: Sensorimotor stage (birth to 24 months)
● Separation is the sense of being distinct from other
objects in the environment.
● Object permanence develops at about 9 months. This is
the process of knowing that an object still exists when
it is hidden from view.
● Mental representation is the recognition of symbols.
Language development
● Responds to noises
● Vocalizes with “ooos” and “aahs”
● Laughs and squeals
● Turns head to the sound of a rattle
● Begins to comprehend simple commands
● Pronounces single‑syllable words
● Begins speaking two‑ and then three‑word phrases
PsyCHosoCIaL DeVeLoPMent
Erikson: Trust vs. mistrust (birth to 1 year)
● Infants trust that others will meet their feeding,
comfort, stimulation, and caring needs.
● Infants’ reflexive behavior (attachment, separation
recognition/anxiety, and stranger fear) influences their
social development.
● Attachment, when infants begin to bond with their
parents, develops within the first month, but actually
begins before birth. The process is optimal when the
infant and parents are in good health, have positive
feeding experiences, and receive adequate rest.
● Separation recognition occurs during the first year as
infants recognize the boundaries between themselves
and others. Learning how to respond to people in their
environment is the next phase of development. Positive
interactions with parents, siblings, and other caregivers
help establish trust.
● Separation anxiety develops between 4 and 8 months of
age. Infants protest loudly when separated from parents,
which can cause considerable anxiety for the parents.
● Stranger fear becomes evident between ages
6 to 8 months, when infants are less likely to
accept strangers.
Self‑concept development
By the end of the first year, infants distinguish themselves
as separate from their parents.
Body‑image changes
● Infants discover that the mouth is a pleasure producer.
● Hands and feet are objects of play.
● Smiling makes others react.
aGe‑aPProPrIate aCtIVItIes
● Infants have a short attention span and do not
interact with other children during play (solitary play).
Age‑appropriate activities can promote cognitive, social,
and motor development.
● Appropriate toys and activities that stimulate the senses
and encourage development include rattles, mobiles,
teething toys, nesting toys, playing pat‑a‑cake, playing
with balls, and reading books.
HEALTH PROMOTION FOR
NEWBORNS AND INFANTS
sCreenInGs
● Newborn screenings for metabolism disorders may
be repeated in early weeks of life (phenylketonuria,
galactosemia).
● Developmental milestone screenings occur ongoing
as part of routine well checkups with the provider at
2 weeks, and 2, 4, 6, 9, and 12 months.
IMMUnIZatIons
Follow the latest Centers for Disease Control and
Prevention (CDC) immunization recommendations (see
www.cdc.gov) for healthy infants. During the first year,
these generally include immunizations against hepatitis B,
diphtheria, tetanus, pertussis, rotavirus, polio, influenza,
and pneumococcal pneumonia. The recommendations
change periodically, so check them often.
nUtrItIon
● Breastfeeding provides optimal nutrition during the first
12 months.
● Feeding alternatives
◯ Iron-fortified formula is an acceptable alternative to
breast milk.
◯ Cow’s milk is inadequate and should not be given
before 1 year of age.
● Weaning from the breast or bottle can begin when
infants can drink from a cup (after 6 months).
◯ Replace a single bottle‑ or breast‑feeding with breast
milk or formula in a cup.
◯ Every few days, replace another feeding with a cup.
◯ Replace the bedtime feeding last.
● Solid food is appropriate aound 4 to 6 months.
◯ Indicators for readiness include voluntary control
of the head and trunk and disappearance of the
extrusion reflex (pushing food out of the mouth).
◯ Introduce iron-fortified rice cereal first.
◯ Start new foods one at a time over a 5‑ to 7‑day
period to observe for signs of allergy or intolerance
(fussiness, rash, vomiting, diarrhea, constipation).
Vegetables, fruits, and meats follow, generally in
that order.
FUNDAMENTALS FOR NURSING CHAPTER 18 Infants (2 Days to 1 year) 93
◯ Delay milk, eggs, wheat, citrus fruits, peanuts, and
peanut butter until the second half of the first year of
life, as they can trigger allergies. Do not give honey
to infants until after 12 months of age because it can
cause infant botulism.
◯ Appropriate finger foods to introduce around
9 months include ripe bananas, toast strips, graham
crackers, cheese cubes, noodles, and peeled chunks of
apples, pears, and peaches.
◯ Remind parents that solid food is not a substitute for
breast milk or formula until after 12 months.
◯ Fluoridated water or supplemental fluoride is
recommended after 6 months to protect against
dental caries.
InJUry PreVentIon
Aspiration
● Avoid small objects, such as grapes, coins, and candy,
which can become lodged in the throat.
● Provide age‑appropriate toys.
● Check clothing for safety hazards (loose buttons).
Bodily harm
● Keep sharp objects out of reach.
● Keep infants away from heavy objects they can pull
down.
● Do not leave infants alone with animals.
● Monitor for shaken baby syndrome.
Burns
● Check the temperature of bath water.
● Turn down the thermostat on the hot water heater to
49° C (120° F) or below.
● Have smoke detectors in the home and change their
batteries regularly.
● Turn handles of pots and pans toward the back of
the stove.
● Apply sunscreen when outdoors during daylight hours.
● Cover electrical outlets.
Drowning: Do not leave infants unattended in the bathtub.
Falls
● Keep the crib mattress in the lowest position with the
rails all the way up.
● Use restraints in infant seats.
● Place the infant seat on the ground or floor when
outside of a vehicle, and do not leave it unattended or on
elevated surfaces.
● Use safety gates across stairs.
Poisoning
● Avoid lead paint exposure.
● Keep toxins and plants out of reach.
● Keep safety locks on cabinets that contain cleaners and
other household chemicals.
● Keep a poison control number handy or program it into
the phone.
● Keep medications in childproof containers and out
of reach.
● Have a carbon monoxide detector in the home.
Motor-vehicle injuries: Use an approved rear‑facing car
seat in the back seat, preferably in the middle, (away from
air bags and side impact). Infants should be in rear‑facing
car seats until age 2 or until they reach the maximum
height and weight for the seat (as long as the top of
the head is below the top of the seat back). Convertible
restraints should have a five-point harness or a T-shield.
Suffocation
● Avoid plastic bags.
● Keep balloons away from infants.
● Be sure the crib mattress is firm and fits tightly.
● Ensure crib slats are no farther apart than 6 cm (2.4 in).
● Remove crib mobiles or crib gyms by 4 to 5 months
of age.
● Do not use pillows in the crib.
● Place infants on the back for sleep.
● Keep toys that have small parts out of reach.
● Remove drawstrings from jackets and other clothing.
94 CHAPTER 18 Infants (2 Days to 1 year) CONTENT MASTERY SERIES
Application Exercises
1. a nurse is talking with the parents
of a 6‑month‑old infant about
gross motor development. Which
of the following gross motor skills
are expected findings in the next
3 months? (select all that apply.)
a. rolls from back to front
B. Bears weight on legs
C. Walks holding onto furniture
D. sits unsupported
e. sits down from a
standing position
2. a nurse is cautioning the mother of
an 8‑month‑old infant about safety.
Which of the following statements
by the mother indicates an
understanding of safety for the infant?
a. “My baby loved to play
with his crib gym, but I
took it away from him.”
B. “I just bought a soft mattress
so my baby will sleep better.”
C. “My baby really likes
sleeping on the fluffy pillow
we just got for him.”
D. “I put the baby’s car seat
out of the way on the table
after I put him in it.”
3. a nurse is reviewing car seat safety
with the parents of a 1‑month‑old
infant. When reviewing car seat use,
which of the following instructions
should the nurse include?
a. Use a car seat that has a
three‑point harness system.
B. Position the car seat so that
the infant is rear‑facing.
C. secure the car seat in the front
passenger seat of the vehicle.
D. Convert to a booster
seat after 12 months.
4. a nurse is assessing from a
2‑week‑old newborn during a routine
checkup. Which of the following
findings should the nurse expect?
a. sleeps 14 to 16 hr each day
B. Posterior fontanel closed
C. Pincer grasp present
D. Hands remain in a
closed position
e. Current weight same
as birth weight
5. the mother of a 7‑month‑old infant
tells the nurse at the pediatric
clinic that her baby has been fussy
with occasional loose stools since
she started feeding him fruits
and vegetables. Which of the
following responses should the
nurse make? (select all that apply.)
a. “It might be good to add
bananas, as they can
help with loose stools.”
B. “Let’s make a list of the
foods he is eating so we
can spot any problems.”
C. “Did the changes begin
after you started one
particular food?”
D. “Has he been vomiting since
he started these new foods?”
e. “Most babies react with
a little indigestion when
you start new foods.”
PRACTICE Active Learning Scenario
a nurse is explaining to the parents of a 4‑month‑old infant what infant milestones
to expect during the first year of life, and how to foster infant development. Use the
atI active Learning template: Growth and Development to complete this item.
COGNITIVE DEVELOPMENT
● name the developmental stage Piaget has identified for the first two years of life.
● Identify three essential components that comprise this stage.
AGE‑APPROPRIATE ACTIVITIES: Identify at least two toys and two activities
the nurse should suggest that the parents provide for their infant.
FUNDAMENTALS FOR NURSING CHAPTER 18 Infants (2 Days to 1 year) 95
Application Exercises Key
1. a. CORRECT: the infant should be able to
roll from back to front by 6 months.
B. CORRECT: the infant should be able to
bear weight on legs by 7 months.
C. the infant should be able to walk while holding
furniture until around 11 months.
D. CORRECT: the infant should be able to sit unsupported by 8 months.
e. the infant should be able to sit down from a
standing position until around 12 months.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
2. a. CORRECT: Parents should remove gyms and mobiles at 4 to 5 months
of age to prevent injury can occur from choking or strangulation.
B. the nurse should remind the parents the infant’s crib mattress
should be firm and fit tightly to prevent suffocation.
C. the nurse should remind the parents to remove pillows or
stuffed animals from the crib to prevent possible suffocation.
D. the nurse should remind the parents to place the infant seat
on the ground level when not in a vehicle to prevent falls.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
3. a. the nurse should instruct the parents to provide
a car seat with a five‑point harness system.
B. CORRECT: the nurse should instruct the parents to
position the infant car seat in a rear‑facing position in
the center of the vehicle seat, when possible.
C. the nurse should instruct the parent to place the infant car seat
in the back seat to reduce the risk for injury in the event of a crash.
D. the nurse should instruct the parents to continue
using an infant seat until the child reaches age 2, or
meets the height and weight limits for the seat.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
4. a. CORRECT: the nurse should expect the
newborn to sleep about 15 hr each day.
B. the nurse should expect the posterior fontanel
to close around 2 to 3 months of age.
C. the nurse should expect the pincer grasp
to develop around 8 months of age.
D. CORRECT: the nurse should expect the newborn to keep
hands in a closed position until about 2 months of life.
e. CORRECT: the nurse should expect the newborn to
have lost 5% to 10% of birth weight in the first few days of
life, and to regain the weight by the second week of life.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transistions
5. a. this response by the nurse suggests an intervention without
first determining the cause of the infant’s problem.
B. CORRECT: this response by the nurse is an attempt to assess
about the infant’s diet to help determine whether a food allergy
or intolerance is the cause of the diarrhea and fussiness.
C. CORRECT: this response by the nurse is an attempt to
assess the infant’s diet to help determine which food triggered
the infant’s behavior change. Parents should introduce one
food at a time to help identify allergies or intolerances.
D. CORRECT: this response by the is an attempt to assess for other
changes caused by the infant’s diet which could be linked to a food
allergy or intolerance, such as vomiting, rash, or constipation.
e. this response by the nurse is nontherapeutic because it
involves stereotyping, and offers false reassurance without
any attempt to understand the infant’s problem.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
COGNITIVE DEVELOPMENT
Piaget’s sensorimotor stage (first 2 years)
● separation
● object permanence
● Mental representation
AGE‑APPROPRIATE ACTIVITIES
● toys and activities
● rattles
● Mobiles
● teething toys
● nesting toys
● Playing pat‑a‑cake
● Playing with balls
● reading books
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
FUNDAMENTALS FOR NURSING CHAPTER 19 Toddlers (1 To 3 Years) 97
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 19 Toddlers
(1 to 3 Years)
EXPECTED GROWTH AND
DEVELOPMENT
PHYsICal deVeloPMeNT
The anterior fontanel closes by 18 months.
WEIGHT: At 24 months, toddlers should weigh four times
their birth weight.
HEIGHT: Toddlers grow by 6.2 cm (2.5 in) per year.
CONTRIBUTION TO SELF‑CARE ACTIVITIES: dressing,
feeding, toilet‑training
19.1 Motor skills by age
AGE GROSS MOTOR SKILLS FINE MOTOR SKILLS
15 months
Walks without help
Creeps up stairs
Uses cup well
Builds tower of
two blocks
18 months
assumes standing
position
Jumps in place
with both feet
Manages spoon
without rotation
Turns pages in book
two or three at a time
2 years Walks up and
down stairs
Builds a tower with
six or seven blocks
2.5 years
Jumps with both feet
stands on one foot
momentarily
draws circles
Has good
hand‑finger
coordination
CoGNITIVe deVeloPMeNT
Piaget: Sensorimotor transitions to preoperational
● The concept of object permanence is fully developed.
● Toddlers have and demonstrate memories of events that
relate to them.
● Domestic mimicry is evident (playing house).
● Preoperational thought does not allow toddlers to
understand other viewpoints, but it does allow them
to symbolize objects and people in order to imitate
activities they have seen.
Language development
● Language increases to about 400 words, with toddlers
speaking in two‑ to three‑word phrases.
● Ability to comprehend speech outweighs the number of
words and phrases spoken.
PsYCHosoCIal deVeloPMeNT
Erikson: autonomy vs. shame and doubt
● Independence is paramount as toddlers attempt to do
everything for themselves.
● Separation anxiety continues when parents leave.
● A toddler might show regression (bed‑wetting, thumb
sucking) as a response to anxiety or separation.
● Engages in parallel play, but by age 3 begins to play and
communicate with others.
Moral development
● Moral development parallels cognitive development.
● Egocentric: Toddlers are unable to see another’s
perspective; they can only view things from their point
of view.
● Punishment and obedience orientation begins with a
sense that others reward good behavior and punish
bad behavior.
Self-concept development: Toddlers progressively see
themselves as separate from their parents and increase
their explorations away from them.
Body-image changes: Toddlers appreciate the usefulness
of various body parts.
aGe‑aPProPrIaTe aCTIVITIes
● Solitary play evolves into parallel play where
toddlers observe other children and then engage in
activities nearby.
● Temper tantrums result when toddlers are frustrated
with restrictions on independence. Providing consistent,
age‑appropriate expectations helps them work through
their frustration.
● Offer choices, such as juice or milk, instead of providing
an opportunity for a yes/no response from the toddler.
● Toilet training can begin with awareness of the
sensation of needing to urinate or defecate. The toddler
should show indications of readiness and parents should
demonstrate patience, consistency, and a nonjudgmental
attitude with toilet training. Nighttime control can
develop last.
● Discipline should be consistent with well-defined
boundaries that help develop acceptable social behavior.
Appropriate activities
● Filling and emptying containers
● Playing with blocks
● Looking at books
● Playing with push and pull toys
● Tossing a ball
CHAPTER 19
98 CHAPTER 19 Toddlers (1 To 3 Years) CONTENT MASTERY SERIES
HEALTH PROMOTION
IMMUNIZaTIoNs
Follow the latest Centers for Disease Control and
Prevention immunization recommendations
(see www.cdc.gov) for healthy toddlers 12 months to
3 years of age. These generally include immunizations
against hepatitis A and B, diphtheria, tetanus, pertussis,
measles, mumps, rubella, varicella, polio, influenza,
haemophilus influenza type B, and pneumococcal
pneumonia. Recommendations change periodically, so
check them often.
NUTrITIoN
● Toddlers are picky eaters with repeated requests for
favorite foods.
● Toddlers should consume 2 to 3 cups (16 to 24 oz)
per day and can switch from drinking whole milk to
drinking low‑fat or fat‑free milk at 2 years of age.
● Limit juice to 4 to 6 oz a day.
● Food serving size is 1 tbsp for each year of age.
● Toddlers can be reluctant to try or accept foods new
to them.
● If there is a family history of allergy, introduce cow’s
milk, chocolate, citrus fruits, egg whites, seafood, and
nut butters gradually while monitoring for reactions.
● As toddlers become more autonomous, they tend to
prefer finger foods.
● Regular meal times and nutritious snacks best meet
nutrient needs.
● Avoid snacks and desserts that are high in sugar, fat,
or sodium.
● Avoid foods that pose choking hazards (nuts, grapes, hot
dogs, peanut butter, raw carrots, tough meats, popcorn).
● Supervise toddlers during snacks and mealtimes.
● Cut food into small, bite‑sized pieces to make it easier
to swallow and to prevent choking.
● Do not allow toddlers to eat or drink during play
activities or while lying down.
● Do not use food as a reward or punishment
● Suggest that parents follow U.S. Department
of Agriculture nutrition recommendations
(www.choosemyplate.gov).
● Brush teeth and begin dental visits. Do not allow child
to use a bottle during naps or bedtime to reduce the risk
for dental caries.
INJUrY PreVeNTIoN
Aspiration
● Avoid small objects (grapes, coins, candy) that can lodge
in the throat.
● Keep toys with small parts out of reach.
● Provide age‑appropriate toys.
● Check clothing for safety hazards, such as loose buttons.
● Keep balloons away from toddlers.
Bodily harm
● Keep sharp objects out of reach.
● Keep firearms in a locked box or cabinet.
● Do not leave toddlers unattended with animals present.
● Teach stranger safety.
Burns
● Check the temperature of bath water.
● Turn down the thermostat on the water heater.
● Have smoke detectors in the home and replace their
batteries regularly.
● Turn pot handles toward the back of the stove.
● Cover electrical outlets.
● Use sunscreen when outside.
Drowning
● Do not leave toddlers unattended in the bathtub.
● Keep toilet lids closed.
● Closely supervise toddlers at the pool or any other body
of water.
● Teach toddlers to swim.
Falls
● Keep doors and windows locked.
● Keep the crib mattress in the lowest position with the
rails all the way up.
● Use safety gates across stairs.
Motor-vehicle injuries
● Use an approved car seat in the back seat, away from
air bags.
● Toddlers should be in a rear‑facing car seat until age
2 or until they exceed the height and weight limit
of the car seat. They can then sit in an approved
forward‑facing car seat in the back seat, using a
five-point harness or T-shield until they exceed the
manufacturer’s recommended height and weight for the
car seat.
● Prior to instillation, read all car seat safety guidelines.
● Teach toddler not to run or ride a tricycle into the street.
● Never leave a toddler alone in a car, especially in
warm weather.
Poisoning
● Avoid exposure to lead paint.
● Place safety locks on cabinets that contain cleaners and
other chemicals.
● Keep plants out of reach.
● Keep a poison control number handy or program it into
the phone.
● Keep medications in childproof containers out of the
child’s reach.
● Have a carbon monoxide detector in the home.
Suffocation
● Avoid plastic bags.
● Be sure the crib mattress fits tightly.
● Ensure crib slats are no further apart than 6 cm (2.4 in).
● Keep pillows out of the crib.
● Remove drawstrings from jackets and other clothing.
FUNDAMENTALS FOR NURSING CHAPTER 19 Toddlers (1 To 3 Years) 99
Application Exercises
1. a nurse is giving a presentation
about accident prevention to a group
of parents of toddlers. Which of
the following accident‑prevention
strategies should the nurse
include? (select all that apply.)
a. store toxic agents in
locked cabinets.
B. Keep toilet seats up.
C. Turn pot handles toward
the back of the stove.
d. Place safety gates
across stairways.
e. Make sure balloons
are fully inflated.
2. a nurse is planning diversionary
activities for toddlers on an
inpatient unit. Which of the
following activities should the nurse
include? (select all that apply.)
a. Building models
B. Working with clay
C. Filling and emptying
containers
d. Playing with blocks
e. looking at books
3. a nurse is teaching the parents
of a toddler about discipline.
Which of the following actions
should the nurse suggest?
a. establish consistent
boundaries for the toddler.
B. Place the toddler in a room
with the door closed.
C. Inform the toddler how you
feel when he misbehaves. .
d. Use favorite snacks to
reward the toddler.
4. a mother tells the nurse that her
2‑year‑old toddler has temper
tantrums and says “no” every time
the mother tries to help her get
dressed. The nurse should recognize,
the toddler is manifesting which of
the following stages of development?
a. Trying to increase her
independence
B. developing a sense of trust
C. establishing a new identity
d. attempting to master a skill
5. a nurse is reviewing nutritional
guidelines with the parents of
a 2‑year‑old toddler. Which of
the following parent statements
should indicate to the nurse an
understanding of the teaching?
a. “I should keep feeding
my son whole milk until
he is 3 years old.”
B. “It’s okay for me to give
my son a cup of apple
juice with each meal.”
C. “I’ll give my son about
2 tablespoons of each
food at mealtimes.”
d. “My son loves popcorn,
and I know it is better
for him than sweets.”
PRACTICE Active Learning Scenario
a nurse is explaining to the parents of a 14‑month‑old
toddler what physical and cognitive development
they can expect from now until their child is 3 years
old. Use the aTI active learning Template: Growth
and development to complete this item.
PHYSICAL DEVELOPMENT: Identify at least four gross or
fine motor skills the parents can expect at specific ages.
COGNITIVE DEVELOPMENT: describe at
least three parameters the parents can expect
to observe during the toddler stage.
100 CHAPTER 19 Toddlers (1 To 3 Years) CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: Parents must prevent toddlers
from accessing dangerous substances.
B. easy access to the water in the toilet bowl
could result in aspiration or drowning.
C. CORRECT: Turn pot handles toward the back of the stove to prevent
the toddler from reaching and pulling its contents down on themselves.
d. CORRECT: safety gates at the bottom of a staircase prevent toddlers
from climbing stairs and falling backward. safety gates placed at the
top of a staircase prevent toddlers from falling down the stairs.
e. Toddlers should not have access to balloons. Balloons can
easily burst and toddlers can put fragments of the balloon or
the entire deflated balloon in their mouth and asphyxiate.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
2. a. Toddlers are not cognitively or physically capable of building
models. This play activity is acceptable for school‑age children.
B. Toddlers put small objects into their mouths and can easily
swallow bits of clay. This activity is unacceptable for a toddler.
C. CORRECT: This activity can help a toddler
develop fine motor skills and coordination.
d. CORRECT: This activity can help a toddler develop fine motor skills.
e. CORRECT: This activity can help a toddler prepare to learn to read.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
3. a. CORRECT: Toddlers need consistent
boundaries for discipline to be effective.
B. Placing a toddler in a room with the door
closed can cause anxiety and fear.
C. a toddler is unable to understand how another person is feeling.
d. Using favorite foods as rewards can promote unhealthy eating habits.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
4. a. CORRECT: Toddlers express a drive for independence
by opposing the desires of those in authority and
attempting to do everything themselves.
B. developing trust is a developmental task for infants.
C. establishing a new identity is the developmental task of an adolescent.
d. Mastering a skill is a developmental task of school‑age children.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
5. a. When toddlers turn 2 years old, the parents should give
them low‑fat or fat‑free milk, not whole milk. This reduces fat
and cholesterol intake and helps prevent childhood obesity.
B. Toddlers should have 4 to 6 oz of juice per day. Juices
do not have the whole fiber that fruit has, and they
contain sugar, so parents should limit their use.
C. CORRECT: serving sizes for toddlers should
be about 1 tbsp of solid food per year of age, so
2‑year‑olds should have about 2 tbsp per serving.
d. Popcorn poses a choking hazard to toddlers.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
PHYSICAL DEVELOPMENT
● at 15 months, gross motor skills: walks without help, creeps up stairs
● at 15 months, fine motor skills: uses cup well, builds tower of two blocks
● at 18 months, gross motor skills: assumes standing position, jumps in place with both feet
● at 18 months, fine motor skills: manages spoon without rotation,
turns pages in book two or three at a time
● at 2 years, gross motor skills: walks up and down stairs
● at 2 years, fine motor skills: builds a tower with six or seven blocks
● at 2.5 years, gross motor skills: jumps with both feet, stands on one foot momentarily
● at 2.5 years, fine motor skills: draws circles, has good hand‑finger coordination
COGNITIVE DEVELOPMENT: during toddler stage: object permanence, memories
of events that relate to them, domestic mimicry (playing house), symbolization of
objects and people, use of 400 words, use of two‑ to three‑word phrases
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
FUNDAMENTALS FOR NURSING CHAPTER 20 Preschoolers (3 to 6 Years) 101
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 20 Preschoolers
(3 to 6 Years)
EXPECTED GROWTH AND
DEVELOPMENT
PhYsIcal DeVeloPMeNt
● Occurs at a more gradual rate than cognitive and
psychosocial development.
● Preschoolers evolve from the characteristically unsteady
wide stance and protruding abdomen of toddlers to the
more graceful, posturally erect, and sturdy physicality
of this age group.
● Boys have a tendency to appear larger with more
muscle mass.
WEIGHT: Preschoolers gain about 2.3 kg (5 lb) per year.
HEIGHT: Preschoolers grow about 6.2 to 7.5 cm (2.5 to 3 in)
per year.
FINE AND GROSS MOTOR SKILLS: Preschoolers show an
improvement in fine motor skills, such as copying figures
on paper, scribbling, drawing, and dressing themselves.
20.1 Gross motor skills by age
3‑YEAR‑OLD 4‑YEAR‑OLD 5‑YEAR‑OLD
ride a tricycle
Jump off
bottom step
stand on one foot
for a few seconds
skip and hop
on one foot
throw ball
overhead
Jump rope
Walk backward
with heel to toe
Move up and down
stairs easily
coGNItIVe DeVeloPMeNt
Piaget: preoperational phase
● Preschoolers are still in the preoperational phase
of cognitive development. They participate in
preconceptual thought (from 2 to 4 years of age) and
intuitive thought (from 4 to 7 years of age).
● Preconceptual thought: Preschoolers make judgments
based on visual appearances. Misconceptions in
thinking during this stage include:
◯ Artificialism: Everything is made by humans.
◯ Animism: Inanimate objects are alive.
◯ Imminent justice: A universal code exists that
determines law and order.
● Intuitive thought: Preschoolers can classify and
begin to question information and become aware of
cause-and-effect relationships.
Time concepts: Preschoolers begin to understand the
concepts of past, present, and future. By the end of the
preschool years, they can comprehend days of the week.
Language development: Vocabulary continues to increase,
and by age 6 contains 8,000 to 14,000 words. Desires and
frustrations are more verbally articulated and a need
to learn information is expressed through questioning.
Phonetically similar words (eye and I) are difficult to
comprehend at this age. Preschoolers speak in sentences,
identify colors, and enjoy talking.
PsYchosocIal DeVeloPMeNt
Erikson: Initiative vs. guilt: Preschoolers take on many
new experiences, despite not having all of the physical
abilities necessary to be successful at everything. When
children are unable to accomplish a task, they can
feel guilty and believe they have misbehaved. Guide
preschoolers to attempt activities within their capabilities
while setting limits.
Moral development: Preschoolers continue in the
good‑bad orientation of the toddler years but begin
to understand behavior in terms of what is socially
acceptable.
Self-concept development: Preschoolers feel good
about themselves for mastering skills, such as dressing
and feeding, that allow independence. During stress,
insecurity, or illness, they tend to regress to previous
immature behavior or develop habits such as nose picking,
bed wetting, or thumb sucking.
Body-image changes
● Mistaken perceptions of reality coupled with
misconceptions in thinking lead to active fantasies and
fears. Preschoolers fear bodily harm, the dark, ghosts,
animals, inclement weather, and medical personnel.
● Sex-role identification is typical.
Social development
● During the preschool time period, children generally do
not exhibit stranger anxiety and have less separation
anxiety. This leads to exploring their neighborhood
environment, and making new friends. However,
prolonged separation, such as during hospitalization,
can provoke anxiety. Favorite toys and play help
ease fears.
● Pretend play is healthy and allows children to determine
the difference between reality and fantasy.
● Sleep disturbances are common during early childhood,
and problems range from difficulties going to bed to
night terrors. Advise parents to:
◯ Assess whether the bedtime is too early for children
who still take naps. Preschoolers average about 12 hr
of sleep a day. Some still require a daytime nap.
◯ Keep a consistent bedtime routine, and help children
slow down in preparation for bedtime.
◯ Use a night light.
◯ Reassure children who are frightened.
CHAPTER 20
102 CHAPTER 20 Preschoolers (3 to 6 Years) CONTENT MASTERY SERIES
aGe‑aPProPrIate actIVItIes
Parallel play shifts to associative play during the preschool
years. Play is not highly organized, and preschoolers do
not cooperate during play. Activities include the following.
● Playing ball
● Putting puzzles together
● Riding tricycles
● Pretend and dress‑up activities
● Musical toys
● Painting, drawing, and coloring
● Sewing cards
● Cooking and housekeeping toys
● Looking at illustrated books
● Technology, such as video and computer programs, to
support development and learn new skills
HEALTH PROMOTION
IMMUNIZatIoNs
Follow the latest Centers for Disease Control and
Prevention immunization recommendations
(www.cdc.gov) for healthy preschoolers.
● These generally include immunizations against
diphtheria, tetanus, pertussis, measles, mumps, rubella,
varicella, seasonal influenza, and polio.
● Recommendations change periodically, so check
them often.
health screeNINGs
Vision screening is routine in the preschool population as
part of the prekindergarten physical examination. It is
essential to detect and treat myopia and amblyopia before
poor visual acuity impairs the learning environment.
NUtrItIoN
● Preschoolers consume about half the amount of energy
that adults do (1,800 calories).
● Picky eating remains a problem for some preschoolers,
but often by age 5 they become a bit more willing to
sample different foods.
● Preschoolers need 3 to 5 oz complete protein in addition
to adequate calcium, iron, folate, and vitamins A and C.
● Parents should provide a balance of nutrients. See
www.choosemyplate.gov for nutritional guidelines
for preschoolers.
INJUrY PreVeNtIoN
Bodily harm
● Keep firearms in a locked cabinet or container.
● Teach stranger safety.
● Wear helmets when riding a bicycle or tricycle
and during any other activities that increase
head‑injury risk.
● Wear protective equipment (helmet and pads) during
physical activity.
● Remove doors from unused refrigerators or
other equipment.
● Teach preschoolers not to walk in front of swings.
Burns
● Reduce the temperature setting on the water heater.
● Have smoke detectors in the home and replace the
batteries regularly.
● Use sunscreen while outdoors.
● Teach preschoolers not to play with matches.
Drowning
● Do not leave children unattended in the bathtub.
● Closely supervise children at a pool or any body of water.
● Teach children to swim.
Motor-vehicle injuries
Preschoolers must sit in a forward‑facing car seat with a
harness in the back seat away from airbags for as long as
possible, at least to 4 years of age. Children who outgrow
the seat before age 4 should use a seat with a harness
approved for higher weights and heights. Preschoolers
whose weight or height exceed the forward‑facing limit
for their car seat should use a belt‑positioning booster
seat until the vehicle’s seat belt fits properly, typically
beyond the preschooler stage.
Poisoning
● Avoid exposure to lead paint.
● Keep plants out of reach.
● Place safety locks on cabinets with cleaners and
other chemicals.
● Keep a poison control number handy or program it into
the phone.
● Keep medications in childproof containers out of reach.
● Have a carbon monoxide detector in the home.
FUNDAMENTALS FOR NURSING CHAPTER 20 Preschoolers (3 to 6 Years) 103
Application Exercises
1. a nurse is talking with the parent
of a 4‑year‑old child who states
that his child is waking up at
night with nightmares. Which
of the following interventions
should the nurse suggest?
a. offer the child a large
snack before bedtime.
B. allow the child to watch
an extra 30 min of tV
in the evening.
c. have the child take
an afternoon nap.
D. Increase physical activity
before bedtime.
2. a nurse is planning diversionary
activities for preschoolers on an
inpatient pediatric unit. Which of
the following activities should the
nurse include? (select all that apply.)
a. assembling puzzles
B. Pulling wheeled toys
c. Using musical toys
D. Playing with puppets
e. coloring with crayons
3. a nurse is preparing to administer
medications to a preschooler. Which
of the following strategies should
the nurse implement to increase
the child’s cooperation in taking
medications? (select all that apply.)
a. reassure the child an
injection will not hurt.
B. Mix oral medications in
a large glass of milk.
c. offer the child choices
when possible.
D. have the parents bring in
a favorite toy from home.
e. engage the child in pretend
play with a toy medical kit.
4. a nurse is reviewing the
centers for Disease control and
Prevention’s (cDc) immunization
recommendations with the parents of
preschoolers. Which of the following
vaccines should the nurse include in
this discussion? (select all that apply.)
a. Haemophilus influenzae type B
B. Varicella
c. Polio
D. hepatitis a
e. seasonal influenza
5. a nurse is talking with a parent
who is concerned about several
issues with her preschooler. Which
of the following issues should the
nurse identify as the priority?
a. “My son mimics my husband
getting dressed.”
B. “My son has temper
tantrums every time we
tell him to do something
he doesn’t want to do.”
c. “I think my son truly
believes that his toys have
personalities and talk to him.”
D. “I feel bad when I see
my son trying so hard
to button his shirt.”
PRACTICE Active Learning Scenario
a nurse is making safety recommendations to the parents of
a two preschoolers. Use the atI active learning template:
Growth and Development to complete this item.
INJURY PREVENTION: list at least four key areas of safety
and age‑appropriate instructions for addressing each area.
104 CHAPTER 20 Preschoolers (3 to 6 Years) CONTENT MASTERY SERIES
Application Exercises Key
1. a. eating a large snack, especially one that is heavy or has a high sugar
content, is likely to provide stimulation that will make it more difficult
for the child to fall asleep. this will not alleviate the child’s nightmares.
B. Watching tV is likely to provide stimulation that will
make it more difficult for the child to fall asleep. this
will not alleviate the child’s nightmares.
c. CORRECT: the nurse should encourage the parent to have
the child take an afternoon nap and to empty her bladder
before bedtime to alleviate nightmares and night terrors.
D. Increasing physical activity is likely to provide stimulation
that will make it more difficult for the child to fall asleep.
this will not alleviate the child’s nightmares.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
2. a. CORRECT: Putting puzzles together helps a
preschooler develop fine motor and cognitive skills.
B. Pulling or pushing toys helps toddlers develop
large muscles and coordination.
c. CORRECT: Playing with musical toys helps a preschooler
develop fine motor skills and coordination.
D. CORRECT: Playing with puppets helps a preschooler
develop oral language and actively use his imagination.
e. CORRECT: Using crayons to color on paper or in coloring books
helps a preschooler develop fine motor skills and coordination.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
3. a. telling the preschooler the injection will not hurt
will cause the child to distrust the nurse.
B. oral medications should be mixed in a small amount of fluid
to increase the chance of the child taking the entire dosage.
c. offer the child choices when possible gives the child
some control and helps reduce the child’s fears.
D. CORRECT: having familiar and cherished objects nearby
is therapeutic for children during their hospitalization and is
useful as a distraction during uncomfortable procedures.
e. CORRECT: Pretend play helps children determine the
difference between reality and fantasy (imagined fears), especially
with the assistance of the nurse during hospitalization.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
4. a. the cDc recommends Haemophilus influenzae type B immunizations
during infancy, but not generally beyond 18 months of age.
B. CORRECT: the cDc recommends a varicella (chickenpox)
immunization during the preschool years.
c. CORRECT: the cDc recommends a polio
immunization during the preschool years.
D. the cDc recommends hepatitis a immunizations during
infancy, but not generally beyond 24 months of age.
e. CORRECT: the cDc recommends seasonal influenza
immunizations during the preschool years.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
5. a. the identification of the son with his father through
imitation is nonurgent because it is an expected response for a
preschooler. It is common for preschoolers to identify with the
parent of the same sex and to mimic that parent’s behavior.
B. CORRECT: When using the urgent vs. nonurgent approach to client
care, the priority issue is the problem that reflects a lack of completion
of the previous stage of development and progression to the current
stage of development. according to erikson, it is a task of the toddler
stage to develop autonomy vs. shame and doubt. this preschooler is
still acting out with negativism, which is a persistent negative response
to requests, often manifested in tantrums. he is still struggling with
this task and needs assistance in working through that stage.
c. the strong imagination of a preschooler is nonurgent
because it is expected for preschoolers to have an active
imagination as well as an imaginary friend. It is common for
preschoolers to manifest misperceptions in thinking, such
as animism (the belief that inanimate objects are alive).
D. attempting to master activities such as dressing themselves is
nonurgent because it is an expected activity for a preschooler. It is
common for preschoolers, who are in the stage erikson describes
as initiative vs. guilt, to face the challenge of mastering activities
they can perform independently, such as dressing themselves.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
INJURY PREVENTION
Bodily harm
● Keep firearms in a locked cabinet or container.
● teach stranger safety.
● Wear helmets when riding a bicycle or tricycle and during
any other activities that increase head‑injury risk.
● Wear protective equipment (helmet and pads) during physical activity.
● remove doors from unused refrigerators or other equipment.
● teach preschoolers not to walk in front of swings.
Burns
● reduce the temperature setting on the water heater.
● have smoke detectors in the home and replace the batteries regularly.
● Use sunscreen while outdoors.
● teach preschoolers not to play with matches.
Drowning
● Do not leave children unattended in the bathtub.
● closely supervise children at a pool or any other body of water.
● teach children to swim.
● Motor‑vehicle injuries
● Use a forward‑facing car seat with a harness in the back seat.
● If weight or height exceeds the forward‑facing
limit, use a belt‑positioning booster seat.
Poisoning
● avoid exposure to lead paint.
● Keep plants out of reach.
● Place safety locks on cabinets with cleaners and other chemicals.
● Keep a poison control number handy or program it into the phone.
● Keep medications in childproof containers out of reach.
● have a carbon monoxide detector in the home.
NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
FUNDAMENTALS FOR NURSING CHAPTER 21 School‑Age children (6 to 12 YeArS) 105
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 21 School‑Age Children
(6 to 12 Years)
EXPECTED GROWTH AND
DEVELOPMENT
PhYSicAl deVeloPMent
WEIGHT: Gain about 1.8 to 3.2 kg (4 to 7 lb) per year.
HEIGHT: Grow about 5 cm (2 in) per year.
FINE AND GROSS MOTOR DEVELOPMENT: coordination
continues to improve and movements become
more refined.
● Girls can exceed the height and weight of boys near the
end of school‑age years.
● Permanent teeth erupt.
● Visual acuity improves to 20/20.
● Auditory acuity and sense of touch fully develop.
CHANGES RELATED TO PUBERTY BEGIN:
● Girls
◯ Budding of breasts.
◯ Appearance of pubic hair
◯ Menarche
● Boys
◯ Enlargement of testicles with changes in the scrotum
◯ Appearance of pubic hair
cognitiVe deVeloPMent
Piaget: Concrete Operations
● See weight and volume as unchanging.
● Understand simple analogies and relationships between
things and ideas.
● Understand time (days, seasons).
● Classify more complex information.
● Understand various emotions.
● Become self‑motivated.
● Solve problems and understand cause and effect.
Language development
● Define many words and understands rules of grammar.
● Understand that a word can have multiple meanings.
● Increased ability to connect words into phrases.
● Reason about a word’s meaning rather than the
literal translation.
● Understands jokes and riddles.
PSYchoSociAl deVeloPMent
Erikson: industry vs. inferiority
School‑age children’s stage of psychosocial development,
according to Erikson, is industry vs. inferiority.
● School‑age children develop a sense of industry through
advances in learning.
● Tasks that increase self‑worth motivate them.
● Stress is increasingly common in this age group from
parental and peer expectations, their environment, or
observed violence.
● Fears of ridicule by peers and teachers over
school‑related issues are common. Some children
manifest nervous behavior to deal with stress, such as
nail biting.
Moral development
● Early on, school‑age children might not understand the
reasoning behind many rules and will try to find ways
around them. Instrumental exchange is in place (“I’ll
help you if you help me.”). They want to make the best
deal and do not consider elements of loyalty, gratitude,
or justice when making decisions.
● In the latter part of the school years, they move into
a law‑and‑order orientation, placing more emphasis
on justice.
Self-concept development
● Strive to develop healthy self-respect by finding out in
what areas they excel.
● Need parents to encourage them in educational or
extracurricular successes.
● Self‑esteem develops based on interactions with peers
and perceived self‑concept.
Body-image changes
● Body image solidifies.
● Education should address curiosity about sexuality,
sexual development, and the reproductive process.
● School‑age children are more modest than preschoolers
and place more emphasis on privacy.
● Develop concern about appearance and hygiene
Social development
● Social environment can expand to include school,
community, and church.
● Peer groups play an important part in social
development. However, peer pressure begins to
take effect.
● Friendships begin to form among same‑gender peers.
Clubs and best friends are popular.
● Most relationships come from school associations.
● Children at this age can rival the same‑gender parent.
● Conformity becomes evident.
● Become more independent from parents
CHAPTER 21
106 CHAPTER 21 School‑Age children (6 to 12 YeArS) CONTENT MASTERY SERIES
Age‑APProPriAte ActiVitieS
Competitive and cooperative play predominates.
6‑ TO 9‑YEAR‑OLDS
● Play board, video, and number games.
● Play hopscotch.
● Jump rope.
● Collect rocks, stamps, cards, coins, or stuffed animals.
● Ride bicycles.
● Build simple models.
● Artistic activities such as painting and drawing.
● Play team sports: skill building.
9‑ TO 12‑YEAR‑OLDS
● Make crafts.
● Read books.
● Build models.
● Develop in hobbies.
● Assemble jigsaw puzzles.
● Play video games.
● Play team sports.
● Learn to play musical instruments
HEALTH PROMOTION
iMMUniZAtionS
Follow the latest Centers for Disease Control and
Prevention immunization recommendations
(see www.cdc.gov) for healthy school‑age children. These
generally include immunizations against diphtheria,
tetanus, pertussis, human papillomavirus, hepatitis A and
B, measles, mumps, rubella, varicella, seasonal influenza,
polio, meningococcal infections, and for some high‑risk
individuals, pneumococcal infections. Recommendations
change periodically, so check them often.
heAlth ScreeningS
● Scoliosis: Screening for idiopathic scoliosis, a
lateral curvature of the spine with no apparent
cause, is essential, especially for girls, during the
school‑age stage.
● Health promotion and maintenance education is
essential to promote healthy choices and prevent illness.
nUtrition
● By the end of the school‑age stage, children eat adult
servings of food and also need nutritious snacks.
● Obesity predisposes school‑age children to low
self‑esteem, diabetes mellitus, heart disease, and high
blood pressure. Advise parents to:
◯ Not use food as a reward.
◯ Emphasize physical activity.
◯ Provide a balanced diet. See www.choosemyplate.gov
for nutritional guidelines for school‑age children.
◯ Teach children to make healthy food selections for
meals and snacks.
◯ Avoid eating meals at fast‑food restaurants.
◯ Avoid skipping meals.
dentAl heAlth
● Brush and floss daily.
● Get regular check‑ups.
inJUrY PreVention
Bodily harm
● Keep firearms in a locked cabinet or box.
● Assist with identifying safe play areas.
● Teach stranger safety.
● Teach children to wear helmets and pads when roller
skating, skateboarding, bicycling, riding scooters,
skiing, and during any other activities that increase
injury risk.
● Teach children to wear light reflective clothing at night.
Burns
● Teach fire safety and elimination of potential
burn hazards.
● Have working smoke and carbon monoxide detectors in
the home.
● Promote sunscreen use.
Drowning
● Supervise children when swimming or near a body
of water.
● Teach swimming skills and safety.
Motor-vehicle injuries
● Have children use a car or booster seat until adult seat
belts fit correctly.
● Children younger than 13 years of age are safest in the
back seat.
Substance abuse/poisoning
● Keep cleaners and chemicals in locked cabinets or out
of reach.
● Teach children to say “no” to illegal drugs and alcohol.
● Teach children about the dangers of smoking.
FUNDAMENTALS FOR NURSING CHAPTER 21 School‑Age children (6 to 12 YeArS) 107
Application Exercises
1. A nurse is talking with parents
of a 12‑year‑old child. Which of
the following issues verbalized
by the parents should the nurse
identify as the priority?
A. “We just don’t understand why
our son can’t keep up with the
other kids in simple activities
like running and jumping.”
B. “our son keeps trying to find
ways around our household
rules. he always wants to
make deals with us.”
c. “We think our son is trying too
hard to excel in math just to
get the top grades in his class.”
d. “our son is always afraid the
kids in school will laugh at him
because he likes to sing.”
2. A nurse is planning diversionary
activities for school‑age children on
an inpatient pediatric unit. Which of
the following activities should the
nurse include? (Select all that apply.)
A. Building models
B. Playing video games
c. reading books
d. Using toy carpentry tools
e. Playing board games
3. A nurse is evaluating teaching
about nutrition with the parents
of an 11‑year‑old child. Which
of the following statements
should indicate to the nurse an
understanding of the teaching?
A. “She wants to eat as much
as we do, but we’re afraid
she’ll soon be overweight.”
B. “She skips lunch sometimes,
but we figure it’s okay as
long as she has a healthy
breakfast and dinner.”
c. “We limit fast‑food
restaurant meals to three
times a week now.”
d. “We reward her school
achievements with a
point system instead of
a pizza or ice cream.”
4. A nurse is talking with the parents
of a 10‑year‑old child who is
concerned that their son is
becoming secretive, such as closing
the door when he showers, and
dresses. Which of the following
responses should the nurse make?
A. “Perhaps you should try to
find out what he is doing
behind those closed doors.”
B. “Suggest that he leave the
door ajar for his own safety.”
c. “At this age, children tend
to become modest and
value their privacy.”
d. “You should establish
a disciplinary plan to
stop this behavior.”
5. A nurse is planning a health
promotion and primary prevention
class for the parents of school‑age
children. Which of the following
information should the nurse
include? (Select all that apply.)
A. Provide information about
the risk of childhood obesity.
B. discuss the danger of
substance use disorders.
c. Promote discussion
about sexual issues.
d. recommend the
school‑age child sit in the
front seat of the car.
e. reinforce stranger awareness.
PRACTICE Active Learning Scenario
A nurse is explaining to a group of parents in a
community center what cognitive development
characteristics they should expect of their school‑age
children. Use the Ati Active learning template:
growth and development to complete this item.
COGNITIVE DEVELOPMENT: list at least
eight cognitive and language development
expectations during young adulthood.
108 CHAPTER 21 School‑Age children (6 to 12 YeArS) CONTENT MASTERY SERIES
Application Exercises Key
1. A. CORRECT: When using the urgent vs. nonurgent approach
to client care, the priority issue is the delay in motor skills, which
could indicate an illness and requires further investigation.
B. the failure to understand rules is nonurgent because it is
common for school‑age children to fail to understand the reasoning
behind many rules and to try to find ways around them.
c. the self‑motivation to excel is nonurgent because it is
common for school‑age children, who are in the stage erikson
describes as industry vs. inferiority, to strive to develop
a sense of industry through advances in learning.
d. the fear of disapproval from peers is nonurgent because
it is common for school‑age children, who are in the stage
erikson describes as industry vs. inferiority, to face the challenge
of acquiring new skills and achieving success socially.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
2. A. CORRECT: Building simple models helps the school‑age
child develop fine motor and cognitive skills.
B. CORRECT: Playing video games, especially
educational and nonviolent ones, helps school‑age
children develop fine motor and cognitive skills.
c. CORRECT: reading books helps the school‑age child
develop cognitive and communication skills.
d. Using toy carpentry tools helps preschoolers
develop imagination and fine motor skills.
e. correct: Playing board games builds cognitive
skills and promotes social interaction.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
3. A. By the end of the school‑age stage, parents should
expect children to eat adult‑size portions of food.
B. Skipping meals can lead to unhealthful
snacking and overeating later in the day.
c. Parents should avoid fast‑food restaurants completely to keep
children from eating food high in sugar, fat, and starches.
d. CORRECT: Parents should avoid rewarding children with
food for good behavior or achievements. Associations between
food and feeling good can lead to weight problems.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
4. A. this response implies that the child is doing something wrong.
B. A toddler requires constant supervision. this response
suggests that the school‑age child has something to fear in his
own home, or that the child requires constant supervision.
c. CORRECT: School‑age children develop a need for
privacy. it is important for the parents to show trust in
the child and respect the child’s need for privacy.
d. this suggestion sounds like a punishment, and the parents have
not presented any evidence that the child is doing anything wrong.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
5. A. CORRECT: Parents of school‑age children need to be aware
of nutritional strategies for preventing childhood obesity.
B. CORRECT: Parents of school‑age children need to know
how to teach children to say no to illegal drugs, alcohol,
and all other harmful or addictive substances.
c. CORRECT: Parents should discuss sexual issues with
school‑age children to promote healthy behavior.
d. the nurse should instruct the parents of school‑age
children to keep children under 13 years in the back
seat of the car to reduce the risk of injury. .
e. CORRECT: Parents should reinforce stranger safety
as soon as their children are old enough to understand
it, and throughout all stages of childhood.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
COGNITIVE DEVELOPMENT
● See weight and volume as unchanging.
● Understand simple analogies and relationships
between things and ideas.
● Understand time (days, seasons).
● classify more complex information.
● Understand various emotions people experience.
● Become self‑motivated.
● Solve problems and understand cause and effect.
● define many words and understands rules of grammar.
● Understand that a word can have multiple meanings.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
FUNDAMENTALS FOR NURSING CHAPTER 22 Adolescents (12 to 20 YeArs) 109
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 22 Adolescents
(12 to 20 Years)
EXPECTED GROWTH
AND DEVELOPMENT
PHYsIcAl deVeloPMent
● Adolescents gain the final 20% to 25% of height
during puberty.
● Sleep habits change with puberty due to increased
metabolism and rapid growth during the adolescent
years. Adolescents stay up late, sleep later in the
morning, and perhaps sleep longer than they did during
the school‑age years.
GIRLS
● Grow 5 to 20 cm (2 to 8 in) and gain 7 to 25 kg (15.5 to
55 lb) during the prepuberty growth spurt
● Stop growing around 16 to 17 years of age
● Mature sexually in the following order
◯ Appearance of breast buds
◯ Growth of pubic hair (can have hair growth prior to
breast bud development)
◯ Onset of menstruation
BOYS
● Grow 10 to 30 cm (4 to 12 in) and gain 7 to 29 kg (15 to
65 lb) during the prepuberty growth spurt
● Stop growing at around 18 to 20 years of age
● Mature in the following order
◯ Increase in the size of the testes and scrotum
◯ Appearance of pubic hair
◯ Rapid growth of genitalia
◯ Growth of axillary hair
◯ Appearance of downy hair on upper lip
◯ Change in voice
coGnItIVe deVeloPMent
Piaget: Formal operations
● Think at an adult level.
● Think abstractly and deal with principles and
hypothetical situations.
● Evaluate the quality of their own thinking.
● Have a longer attention span.
● Are highly imaginative and idealistic.
● Make decisions through logical operations.
● Are future‑oriented.
● Are capable of deductive reasoning.
● Understand how actions of an individual
influence others.
Language development
Adolescents communicate one way with the peer group
and another way with adults. Use open‑ended questions to
communicate and discuss sensitive issues.
PsYcHosocIAl deVeloPMent
Erikson: identity vs. role confusion
● They develop a sense of personal identity that family
expectations influence.
● Adolescents strive for independence from parents and
identify with peers.
Group identity: They become part of a peer group that
greatly affects behavior.
Vocationally: Work habits and plans for college and career
begin to solidify.
Sexuality: Sexual identity develops during adolescence,
with increasing interest in the opposite gender, the same
gender, or both genders, according to self-identification
with heterosexuality, homosexuality, or bisexuality.
Self-identification can shift as sexual maturity progresses.
Health perceptions: Adolescents often feel invincible to
bad outcomes of risky behaviors.
Moral development: conventional law and order.
Adolescents do not see rules as absolutes, instead
looking at each situation and adjusting the rules. Not all
adolescents attain this level of moral development during
these years.
Self-concept development: Adolescents develop a
healthy self‑concept by having healthy relationships with
peers, family, and teachers while striving for emotional
independence. Identifying a skill or talent helps them
maintain a healthy self‑concept. Participation in sports,
hobbies, or the community can have a positive outcome.
Body-Image changes: Adolescents seem particularly
concerned with the body images the media portray.
Changes during puberty result in comparisons between
adolescents and peers. Parents also give their input
for hair styles, dress, and activity. Adolescents require
interventions if depression or eating disorders result from
poor body image.
Social development
● Group relationships are important, as they lead to
personal acceptance, approval, and learned behaviors.
● Peer relationships develop as a support system.
● Best‑friend relationships are more stable and
long‑lasting than in previous years.
● Parent‑child relationships change to allow
more independence.
AGe‑APProPrIAte ActIVItIes
● Nonviolent video games, music, movies
● Sports, social events
● Caring for a pet
● Career‑training programs
● Reading
CHAPTER 22
110 CHAPTER 22 Adolescents (12 to 20 YeArs) CONTENT MASTERY SERIES
HEALTH PROMOTION
IMMUnIZAtIons
Follow the latest Centers for Disease Control and
Prevention (CDC) immunization recommendations
(see www.cdc.gov) for healthy adolescents. These
generally include immunizations against diphtheria,
tetanus, pertussis, human papillomavirus, hepatitis
A and B, measles, mumps, rubella, varicella, seasonal
influenza, meningococcal and polio, and for some
high‑risk individuals, pneumococcal infections. The
recommendations change periodically, so check
them often.
HeAltH screenInGs
Provide health promotion and maintenance education
related to illness prevention.
SCOLIOSIS: Screening for idiopathic scoliosis, a lateral
curvature of the spine with no apparent cause, is essential,
especially for girls, during the adolescent growth spurt
because it is most evident at that time.
nUtrItIon
● Rapid growth and high metabolism require increases
in high‑quality nutrients. Nutrients that tend to be
deficient during this stage of life are iron, calcium, and
vitamins A and C.
● Eating disorders commonly develop during adolescence
(more in girls than in boys) due to a fear of being
overweight, fad diets, or as a mechanism of maintaining
control over some aspect of life.
◯ Anorexia nervosa
◯ Bulimia nervosa
◯ Overeating
● Advise parents to:
◯ Not use food as a reward.
◯ Emphasize physical activity.
◯ Provide a balanced diet. See www.choosemyplate.gov
for nutritional guidelines for adolescents.
◯ Teach adolescents to make healthy food selections for
meals and snacks.
dentAl HeAltH
● Brush daily.
● Floss daily.
● Get regular check‑ups.
InJUrY PreVentIon
Bodily harm
● Keep firearms in a locked cabinet or box.
● Teach proper use of sporting equipment prior to use.
● Insist on helmet use and/or pads when roller skating,
skateboarding, bicycling, riding scooters, skiing, and
during any other activities that increase injury risk.
● Avoid trampolines.
● Be aware of changes in mood and monitor for self‑harm
in at‑risk adolescents. Watch for the following.
◯ Poor school performance
◯ Lack of interest in things of previous interest
◯ Social isolation
◯ Disturbances in sleep or appetite
◯ Expression of suicidal thoughts
Burns
● Teach fire safety.
● Promote sunscreen use.
Drowning: Teach swimming skills and safety.
Motor-vehicle injury
● Encourage attendance at drivers’ education courses.
● Emphasize seat belt use.
● Discourage use of cell phones, including texting,
while driving.
● Teach the dangers of combining substance use
with driving.
Substance use
● Monitor at‑risk adolescents.
● Teach adolescents about the dangers of smoking
● Teach adolescents to say “no” to drugs and alcohol.
● Present a no‑tolerance attitude.
Sexually transmitted infections (STIs)
● Identify risk factors through the assessment and
interview process.
● Provide education about prevention of STIs, and
resources for treatment.
Pregnancy prevention
● Provide education.
● For pregnant adolescents, provide resources
for supervision of pregnancy, nutrition, and
psychological support.
FUNDAMENTALS FOR NURSING CHAPTER 22 Adolescents (12 to 20 YeArs) 111
Application Exercises
1. A nurse is teaching the father of a
12‑year‑old boy about manifestations
of puberty. the nurse should
explain that which of the following
physical changes occurs first?
A. Appearance of downy
hair on the upper lip
B. Hair growth in the axillae
c. enlargement of the
testes and scrotum
d. deepening of the voice
2. A nurse on a pediatric unit is
caring for an adolescent who has
multiple fractures. Which of the
following interventions should the
nurse take? (select all that apply.)
A. suggest that his parents bring
in video games for him to play.
B. Provide a television and dVds
for the adolescent to watch.
c. limit visitors to the
adolescent’s immediate family.
d. Involve the adolescent
in treatment decisions
when possible.
e. Allow the adolescent to
perform his own morning care.
3. A nurse is reviewing the cdc’s
immunization recommendations with
the parents of an adolescent. Which
of the following recommendations
should the nurse include in this
discussion? (select all that apply.)
A. rotavirus
B. Varicella
c. Herpes zoster
d. Human papilloma virus
e. seasonal influenza
4. A nurse is talking with an adolescent
who is having difficulty dealing
with several issues. Which of
the following issues should the
nurse identify as the priority?
A. “I kind of like this boy
in my class, but he
doesn’t like me back.”
B. “I want to hang out with the
kids in the science club, but
the jocks pick on them.”
c. “I am so fat, I skip meals
to try to lose weight.”
d. “My dad wants me to be
a lawyer like him, but I
just want to dance.”
5. A nurse is preparing a wellness
presentation for families about health
screening for adolescents. Which of
the following information should the
nurse include? (select all that apply.)
A. obtain a periodic mental
status evaluation.
B. discuss prevention of sexually
transmitted infections.
c. regularly screen for
tuberculosis.
d. Provide education about
drug and alcohol use.
e. teach monthly breast
examinations for girls.
PRACTICE Active Learning Scenario
A nurse on a pediatric unit is reviewing with a group
of newly licensed nurses the cognitive developmental
milestones to expect from adolescent clients.
Use the AtI Active learning template: Growth
and development to complete this item.
COGNITIVE DEVELOPMENT: list at least five cognitive
development expectations during adolescence.
112 CHAPTER 22 Adolescents (12 to 20 YeArs) CONTENT MASTERY SERIES
Application Exercises Key
1. A. the nurse should identify emerging facial hair is a
pubescent change. However, evidence‑based practice
indicates that another change occurs first.
B. the nurse should identify hair growth in nongenital
areas is a pubescent change. However, evidence‑based
practice indicates that another change occurs first.
c. CORRECT: Using evidence‑based practice, the first
prepubescent change in boys is an increase in the size of
the testicles and scrotum, and growth of pubic hair.
d. the nurse should identify changing vocal quality is a
pubescent change. However, evidence‑based practice
indicates that another change occurs first.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
2. A. CORRECT: nonviolent video games are suitable
diversional activities for an adolescent.
B. CORRECT: nonviolent dVds are suitable
diversional activities for an adolescent.
c. An adolescent client forms a strong attachment to peers. Allowing
friends to visit should reduce the adolescent’s feelings of isolation.
d. CORRECT: the adolescent is capable of thinking
through problems. Involving the adolescent in decisions
helps promote independence and control.
e. CORRECT: Allowing the adolescent to perform
his own morning care helps promote a sense of
independence and shows respect for his privacy.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
3. A. the cdc recommends rotavirus immunizations during
infancy and not generally beyond 8 months of age.
B. CORRECT: the cdc recommends varicella
(chickenpox) immunizations during adolescence.
c. the cdc recommends herpes zoster (shingles) immunizations
during middle adulthood, typically one dose at age 60 or beyond.
d. CORRECT: the cdc recommends human papilloma
virus (genital warts) immunizations during adolescence.
e. CORRECT: the cdc recommends seasonal
influenza immunizations during adolescence.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
4. A. the client is at risk for developing an altered self‑esteem
due to rejection from his peers. However, another issue is the
priority. It is common for adolescents, who are in the stage erikson
describes as identity vs. role confusion, to face the challenge
of forming peer relationships and dating relationships.
B. the client is at risk for developing an altered self‑esteem due to
rejection from his peers. However, another issue is the priority. It is
common for adolescents, who are in the stage erikson describes
as identity vs. role confusion, to face the challenge of becoming
part of a peer group and establishing a group identity.
c. CORRECT: the greatest risk to the client is injury due to
an eating disorder. the priority issue is to provide counseling
to promote body image and ensure proper nutrition.
d. the client is at risk for developing an altered self‑identity due to
pressure from a parent;. However, another issue is the priority. It is
common for adolescents, who are in the stage erikson describes
as identity vs. role confusion, to face the challenge of forming
an identity that will lead to higher education and a career.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
5. A. CORRECT: obtain an occasional mental status evaluation
is important for the adolescent to reduce the risk for
suicide, eating disorders, or substance use disorder.
B. CORRECT: discuss prevention of sexually transmitted
infections is important for the adolescent to reduce the
risk for developing a sexually transmitted disease.
c. CORRECT: Periodically screen for tuberculosis is important for the
adolescent to reduce the risk for developing or spreading tuberculosis.
d. CORRECT: Providing education about drug and
alcohol use is important for the adolescent to reduce the
risk for the use of alcohol and recreational drugs.
e. Young adult women should begin monthly breast
examinations to screen for early breast cancer.
NCLEX® Connection: Health Promotion and Maintenance,
Health Screening
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
Cognitive Development
● Think at an adult level
● Think abstractly and deal with principles
● Evaluate the quality of their own thinking
● Have a longer attention span
● Are highly imaginative and idealistic
● Make decisions through logical operations
● Are future‑oriented
● Are capable of deductive reasoning
● Understand how actions of an individual influence others
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
FUNDAMENTALS FOR NURSING CHAPTER 23 Young Adults (20 to 35 YeArs) 113
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 23 Young Adults
(20 to 35 Years)
EXPECTED GROWTH AND
DEVELOPMENT
PHYsICAl deVeloPMent
● Growth has concluded around age 20.
● Physical senses peak.
● Cardiac output and efficiency peak.
● Muscles function optimally at ages 25 to 30.
● Metabolic rate decreases 2% to 4% every decade after
age 20.
● Libido is high for men.
● Libido for women peaks during the latter part of
this stage.
● Time for childbearing is optimal.
● Pregnancy‑related changes occur.
CognItIVe deVeloPMent
Piaget: Formal operations
The young adult years are an optimal time for education,
both formal and informal.
● Critical thinking skills improve.
● Memory peaks in the 20s.
● Ability for creative thought increases.
● Values/norms of friends (social groups) are relevant.
● Decision-making skills are flexible with increased
openness to change.
PsYCHosoCIAl deVeloPMent
According to Erikson, young adults must achieve
intimacy vs. isolation.
● Young adults can take on more adult commitments
and responsibilities.
● Young adults’ occupational choices relate to:
◯ High goals/dreams
◯ Exploration/experimentation
Moral development
● Young adults can personalize values and beliefs.
● They can base reasoning on ethical fairness principles,
such as justice.
Self-concept development: Influences on the formation
of a healthy self‑concept during the young adult
years include:
● Avoidance of substance use disorders
● Formation of a family
● Frequency interactions with family and friends
● Personal choice and response to ethical situations
Body-image changes
● Affected by diet and exercise patterns.
● Pregnancy‑related body image changes can also occur.
Social development
Young adults might:
● Leave home and establish independent living situation.
● Establish close friendships (intimacy).
● Transition from being single to being a member of a
new family.
● Question their ability to parent.
● Experience increased anxiety and/or depression,
especially after the birth of a child.
HEALTH PROMOTION
Young adults are especially at risk for alterations in
health from:
● Substance use disorders
● Periodontal disease due to poor oral hygiene
● Unplanned pregnancies: a source of high stress
● Sexually transmitted infections (STIs)
● Infertility
● Work‑related injuries or exposures
● Violent death and injury
IMMunIZAtIons
Follow the latest Centers for Disease Control and
Prevention (CDC) immunization recommendations (see
www.cdc.gov). Primary vaccinations for young adults
include annual influenza, as well as tetanus, diphtheria,
and pertussis. Other vaccines are given to “catch up” the
young adult for incomplete immunization series, or to
provide additional protection to high‑risk individuals.
These include immunizations against hepatitis A and B,
measles, mumps, rubella, varicella, human papillomavirus,
and pneumococcal and meningococcal infections. The
recommendations change periodically, so check
them often.
HeAltH sCreenIngs
● Young adults should follow age‑related guidelines
for screening.
● Encourage selecting a primary care provider for ongoing,
routine medical care.
● Provide education about contraception and regular
physical activity.
routIne HeAltH CAre VIsIts
Should include obtaining height, weight, vital signs, and
family history; screening for stress; education related to
STIs and substance use disorders; and encouragement of
good nutrition.
CHAPTER 23
114 CHAPTER 23 Young Adults (20 to 35 YeArs) CONTENT MASTERY SERIES
nutrItIon
● Monitor for adequate nutrition and proper
physical activity.
● Monitor calcium intake in women.
● See choosemyplate.gov for nutritional recommendations.
InJurY PreVentIon
● Avoiding drugs, including alcohol, which can lead to
substance use disorders
● Avoiding driving a vehicle during or after drinking
alcohol or taking drugs that impair sensory and
motor functions
● Wearing a seat belt when operating a vehicle
● Wearing a helmet while bike riding, skiing, and other
recreational activities that increase head‑injury risk
● Installing smoke and carbon monoxide detectors in
the home
● Securing firearms in a safe location
FUNDAMENTALS FOR NURSING CHAPTER 23 Young Adults (20 to 35 YeArs) 115
Application Exercises
1. A nurse is teaching a young adult
client about health promotion
and illness prevention. Which
of the following statements
by the client indicates an
understanding of the teaching?
A. “I already had my
immunizations as a child, so
I’m protected in that area.”
B. “It is important to schedule
routine health care visits
even if I am feeling well.”
C. “I will just go to an urgent
care center for my
routine medical care.”
d. “there’s no reason to seek
help if I am feeling stressed
because it’s just part of life.”
2. A nurse is reviewing CdC
immunization recommendations
with a young adult client. Which
of the following vaccines should
the nurse recommend as routine,
rather than catch‑up, during young
adulthood? (select all that apply.)
A. Influenza
B. Measles, mumps, rubella
C. Pertussis
d. tetanus
e. Polio
3. A charge nurse is explaining the
various stages of the lifespan to
a group of newly licensed nurses.
Which of the following examples
should the charge nurse should
include as a developmental
task for a young adult?
A. Becoming actively involved
in providing guidance to
the next generation
B. Adjusting to major changes
in roles and relationships
due to losses
C. devoting a great deal of time
to establishing an occupation
d. Finding oneself
“sandwiched” between
and being responsible
for two generations
4. A nurse is counseling a young adult
who describes having difficulty
dealing with several issues. Which
of the following client statements
should the nurse identify as the
priority to assess further?
A. “I have my own apartment
now, but it’s not easy living
away from my parents.”
B. “It’s been so stressful for
me to even think about
having my own family.”
C. “I don’t even know who I am
yet, and now I’m supposed
to know what to do.”
d. “My girlfriend is pregnant, and
I don’t think I have what it
takes to be a good father.”
5. A nurse is reviewing safety
precautions with a group of
young adults at a community
health fair. Which of the following
recommendations should
the nurse include to address
common health risks for this age
group? (select all that apply.)
A. Install bath rails and grab
bars in bathrooms.
B. Wear a helmet while skiing.
C. Install a carbon
monoxide detector.
d. secure firearms in a
safe location.
e. remove throw rugs
from the home.
PRACTICE Active Learning Scenario
A nurse at a community center is teaching a group of young adults what physical and
cognitive development characteristics they should expect at this stage of life. use
the AtI Active learning template: growth and development to complete this item.
PHYSICAL DEVELOPMENT: list at least five physical development expectations.
COGNITIVE DEVELOPMENT: list at least three cognitive
development expectations during young adulthood.
116 CHAPTER 23 Young Adults (20 to 35 YeArs) CONTENT MASTERY SERIES
Application Exercises Key
1. A. For protection against a wide variety of communicable
illnesses, the nurse should encourage adults to obtain
CdC‑recommended immunizations throughout the lifespan.
B. CORRECT: despite being in relatively good
health, young adult clients should plan to participate
in routine screenings and health care visits.
C. urgent care centers offer limited services, typically for acute injuries
or problems that cannot wait until a primary care provider is available.
the nurse should encourage clients to establish a relationship with
a primary care provider to consult for nonurgent health problems.
d. Although it is true that stress is inevitable, chronic stress can
lead to severe health alterations. Young adults who have stress
that is recurrent or escalating should seek medical care.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
2. A. CORRECT: the CdC recommends annual
influenza immunization during adulthood.
B. the CdC recommends obtaining the measles, mumps, and rubella
vaccines routinely during childhood. the series can be administered
during adulthood for individuals who meet certain criteria.
C. CORRECT: the CdC recommends a booster
dose of pertussis vaccine during adulthood.
d. CORRECT: the CdC recommends ongoing booster doses
of tetanus and diphtheria vaccines during adulthood.
e. the CdC recommends the polio vaccine to be administered
routinely during childhood. the series can be administered
during adulthood for individuals who meet certain criteria.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
3. A. the nurse should identify active involvement in the next
generation as a developmental task for middle adults.
B. the nurse should identify adjusting to major role changes
associated with loss as a developmental task for older adults.
C. CORRECT: the nurse should identify exploring career
options and then establishing oneself in a specific occupation
as a major developmental task for a young adult.
d. the nurse should identify assuming responsibility for the previous as
well as the next generation as a developmental task for middle adults.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
4. A. living away from home and establishing independent
living is nonurgent because it is an expected challenge
during a young adulthood. there is another statement
the nurse should identify as the priority.
B. transitioning from being single to being a member of a new family is
nonurgent because it is an expected challenge during young adulthood.
there is another statement the nurse should identify as the priority.
C. CORRECT: When using the urgent vs. nonurgent approach to
client care, the nurse determines that the counseling priority is the
problem that reflects a lack of completion of the previous stage of
development and progression to the current stage. According to
erikson, it is a task of adolescence to develop identity vs. role confusion.
the nurse should recognize this young adult is still struggling with
this task and needs assistance in working through that dilemma.
d. Considering childbearing and parenting is nonurgent because
it is an expected challenge during young adulthood. there is
another statement the nurse should identify as the priority.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
5. A. Although bath rails and grab bars add a measure of safety to
bathing activities, this recommendation addresses health risks
common to the older adult population due to their risk for falls.
B. CORRECT: the nurse should encourage the client to wear a helmet
while skiing to reduce the risk of head injury. Although it applies to other
age groups, many young adults engage in winter sports. therefore, this
is an age‑appropriate recommendation for this developmental group.
C. CORRECT: the nurse should remind the client to install a carbon
monoxide detector in the home. this is an essential safety precaution
for young adults as well as for all other developmental stages.
d. CORRECT: the nurse should warn the client to secure firearms in a
safe location to reduce the risk of accidental gunshot injuries. Although
it applies to all age groups, many young adults own firearms, so this is
an age‑appropriate recommendation for this developmental group.
e. Although throw rugs can pose a safety hazard, this
recommendation addresses health risks common to the
older adult population due to their risk for falls.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Use the ATI Active Learning Template: Growth and Development
PHYSICAL DEVELOPMENT
● Completion of growth
● Peak in physical senses
● Peak in cardiac
output, efficiency
● optimal muscle function
● gradual decline in
metabolic rate
● High libido (men)
● eventual peak in
libido (women)
● optimal childbearing
● Pregnancy‑related changes
COGNITIVE DEVELOPMENT
● Improvement in
critical thinking
● Peak in memory
● Increased ability for
creative thought
● relevance of values/
norms of friends
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
FUNDAMENTALS FOR NURSING CHAPTER 24 Middle Adults (35 to 65 YeArs) 117
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 24 Middle Adults
(35 to 65 Years)
EXPECTED GROWTH
AND DEVELOPMENT
PHYsiCAl deVeloPMeNt
Decreases in the following:
● Skin turgor and moisture
● Subcutaneous fat
● Melanin in hair (graying)
● Hair
● Visual acuity, especially for near vision
● Auditory acuity, especially for high‑pitched sounds
● Sense of taste
● Skeletal muscle mass
● Height
● Calcium/bone density
● Blood vessel elasticity
● Respiratory vital capacity
● Large intestine muscle tone
● Gastric secretions
● Decreased glomerular filtration rate
● Estrogen/testosterone
● Glucose tolerance
CoGNitiVe deVeloPMeNt
Piaget: Formal operations
● Reaction time and speed of performance slow slightly.
● Memory is intact.
● Crystallized intelligence remains (stored knowledge).
● Fluid intelligence (how to learn and process new
information) declines slightly.
PsYCHosoCiAl deVeloPMeNt
According to Erikson, middle adults must achieve
generativity vs. stagnation.
Middle adults strive for generativity.
● Use life as an opportunity for creativity and productivity.
● Have concern for others.
● Consider parenting an important task.
● Contribute to the well‑being of the next generation.
● Strive to do well in one’s own environment.
● Adjust to changes in physical appearance and abilities.
Moral development
● Religious maturity
● Spiritual beliefs and religion can take on
added importance.
● Middle adults can become more secure in
their convictions.
● Middle adults often have advanced moral development.
Self-concept development: Some middle adults have
issues related to:
● Menopause
● Sexuality
● Depression
● Irritability
● Difficulty with sexual identity
● Job performance and ability to provide support
● Marital changes with the death of a spouse or divorce
Body image changes
● Sex drive can decrease as a result of declining hormones,
chronic disorders, or medications.
● Changes in physical appearance can raise concerns
about desirability.
● WOMEN: Symptoms of menopause can represent as:
◯ Loss of the reproductive role or femininity.
◯ New interest in intimacy.
● MEN: Decreasing strength can be frustrating
or frightening.
Social development
● Need to maintain and strengthen intimacy.
● Empty nest syndrome: experiencing sadness when
children move away from home.
● Provide assistance to aging parents, adult children,
and grandchildren, giving this stage of life the name
“sandwich generation.”
HEALTH PROMOTION
Especially at risk for alterations in health due to:
● Obesity, type 2 diabetes mellitus
● Cardiovascular disease
● Cancer
● Substance use disorders (alcohol use disorder)
● Psychosocial stressors
iMMuNiZAtioNs
Follow the latest Centers for Disease Control and
Prevention (CDC) immunization recommendations
(see www.cdc.gov). Primary vaccinations for young adults
include annual influenza immunization, as well as tetanus,
diphtheria, zoster, pneumococcal, and pertussis. Other
vaccines are given to “catch‑up” the young adult for
incomplete immunization series, or to provide additional
protection to high‑risk individuals. These include
immunizations against hepatitis A and B, measles, mumps,
rubella, varicella, and pneumococcal and meningococcal
infections. The recommendations change periodically, so
check them often.
HeAltH sCreeNiNGs
Middle adults should follow age‑related guidelines
for screening.
● Dual‑energy x‑ray absorptiometry (DXA) screening for
osteoporosis
● Eye examination for glaucoma and other disorders every
2 to 3 years or annually depending on provider.
● Mental health screening for anxiety and depression
CHAPTER 24
118 CHAPTER 24 Middle Adults (35 to 65 YeArs) CONTENT MASTERY SERIES
NutritioN
Nutrition counseling for middle adults generally includes:
● Obtaining adequate protein.
● Increasing the consumption of whole grains and fresh
fruits and vegetables.
● Limiting fat and cholesterol.
● Increasing vitamin D and calcium supplementation
(especially for women).
see www.choosemyplate.gov for
nutritional recommendations.
iNJurY PreVeNtioN
● Avoid drugs, including alcohol, that can lead to
substance use disorders.
● Avoid driving a vehicle during or after drinking
alcohol or taking drugs that impair sensory and
motor functions.
● Wear a seat belt when operating a vehicle.
● Wear a helmet while bike riding, skiing, and other
recreational activities that increase head‑injury risk.
● Install smoke and carbon monoxide detectors in
the home.
● Secure firearms in a safe location.
FUNDAMENTALS FOR NURSING CHAPTER 24 Middle Adults (35 to 65 YeArs) 119
Application Exercises
1. A nursing instructor is explaining the
various stages of the lifespan to a
group of nursing students. Which of
the following examples should the
nurse include as a developmental
task for middle adulthood?
A. the client evaluates
his behavior after a
social interaction.
B. the client states he is
learning to trust others.
C. the client wishes to find
meaningful friendships.
d. the client expresses concerns
about the next generation.
2. A nurse is collecting data to evaluate
a middle adult’s psychosocial
development. the nurse should
expect middle adults to demonstrate
which of the following developmental
tasks? (select all that apply.)
A. develop an acceptance of
diminished strength and
increased dependence
on others.
B. spend time focusing on
improving job performance.
C. Welcome opportunities to
be creative and productive.
d. Commit to finding friendship
and companionship.
e. Become involved with
community issues and activities.
3. A nurse is collecting history and
physical examination data from a
middle adult. the nurse should
expect to find decreases in which
of the following physiologic
functions? (select all that apply.)
A. Metabolism
B. Ability to hear
low‑pitched sounds
C. Gastric secretions
d. Far vision
e. Glomerular filtration
4. A nurse is preparing a health
promotion course for a group
of middle adults. Which of the
following strategies should the nurse
recommend? (select all that apply.)
A. eye examination
every 1 to 3 years
B. decrease intake of
calcium supplements
C. dXA screening for
osteoporosis
d. increase intake of
carbohydrate in the diet
e. screening for depressive
disorders
5. A nurse is counseling a middle
adult client who describes having
difficulty dealing with several
issues. Which of the following client
statements should the nurse identify
as the priority to assess further?
A. “i am struggling to accept
that my parents are aging
and need so much help.”
B. “it’s been so stressful for
me to think about having
intimate relationships.”
C. “i know i should volunteer
my time for a good cause,
but maybe i’m just selfish.”
d. “i love my grandchildren,
but my son expects me to
relive my parenting days.”
PRACTICE Active Learning Scenario
A nurse in a community health center is explaining to a group of
middle adults what moral and cognitive development characteristics
they should expect at this stage of life. use the Ati Active learning
template: Growth and development to complete this item.
COGNITIVE DEVELOPMENT
● list at least two moral development expectations during middle adulthood.
● list at least four cognitive development expectations during middle adulthood.
120 CHAPTER 24 Middle Adults (35 to 65 YeArs) CONTENT MASTERY SERIES
Application Exercises Key
1. A. the nurse should identify evaluating behavior after a social interaction
as a developmental task that begins during the preschool years.
B. the nurse should identify learning to trust others as a developmental
task of infancy during erickson’s trust vs. mistrust stage.
C. the nurse should identify finding meaningful friendships
as a developmental task for school‑aged children.
d. CORRECT: erickson’s task for a middle adult as generativity
vs. stagnation. the nurse should include showing concern for
the next generation as an example for this age group.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
2. A. the nurse should identify acceptance of diminished strength and
increased dependence as a developmental task for older adulthood.
B. CORRECT: Psychosocially healthy middle adults strive
to do well in their environment as part of achieving
erikson’s stage of generativity vs. stagnation.
C. CORRECT: Psychosocially healthy middle adults accept life’s
opportunities for creativity and productivity and use these opportunities
for achieving erikson’s stage of generativity vs. stagnation.
d. the nurse should identify seeking and forming friendships
as a developmental task of young adulthood.
e. CORRECT: Psychosocially healthy middle adults work to contribute
to future generations through community involvement and parenting
as part of achieving erikson’s stage of generativity vs. stagnation.
NCLEX® Connection: Health Promotion and Maintenance,
Health Screening
3. A. CORRECT: the nurse should expect metabolism to
decline, causing weight gain during middle adulthood.
B. the nurse should expect a decline in the ability to hear
high‑pitched sounds during middle adulthood.
C. CORRECT: in middle adulthood, decreases in secretions
of bicarbonate and gastric mucus begin and persist into
older age. this increases the risk of peptic ulcer disease.
d. the nurse should expect a decline in near vision
(presbyopia) during middle adulthood.
e. CORRECT: Middle adults begin to lose nephron units,
which results in a decline in glomerular filtration rates.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
4. A. CORRECT: the nurse should recommend middle
adult clients have an eye examination every 1 to 3 years
to screen for glaucoma and other disorders.
B. the nurse should recommend that middle adult
clients, especially women, increase intake of vitamin
d and calcium to prevent osteoporosis.
C. CORRECT: the nurse should recommend middle adult
client have a dXA scan to screen for osteoporosis.
d. CORRECT: the nurse should recommend middle
adult clients obtain adequate protein, and consume
more fresh fruits, vegetables and whole grains.
e. CORRECT: the nurse should recommend screening
for anxiety and depression during middle adulthood.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
5. A. Adjusting to and caring for aging parents is nonurgent because
it is an expected challenge during middle adulthood. there is
another statement that the nurse should identify as the priority.
B. CORRECT: When using the urgent vs. nonurgent approach to
client care, the counseling priority is the problem that reflects a lack
of completion of the previous stage and progression to the current
stage of development. According to erikson, developing intimacy
vs. isolation is a task of young adulthood. this middle adult is still
struggling with this task and needs assistance in working through
searching for and developing intimate relationships with others.
C. Contributing to the community is nonurgent because it is an
expected challenge during middle adulthood. there is another
statement that the nurse should identify as the priority.
d. Questioning the ability to contribute to future generations is
nonurgent because it is an expected challenge during middle adulthood.
there is another statement that the nurse should identify as the priority.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
COGNITIVE DEVELOPMENT
Moral development
● spiritual beliefs and religion can take on added importance.
● Middle adults can become more secure in their convictions.
● Middle adults often have advanced moral development.
Cognitive development
● reaction time and speed of performance slow slightly.
● Memory is intact.
● Crystallized intelligence remains (stored knowledge).
● Fluid intelligence (how to learn and process
new information) declines slightly.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
FUNDAMENTALS FOR NURSING CHAPTER 25 Older Adults (65 YeArs And Older) 121
UNIT 2 HEALTH PROMOTION
SECTION: NURSING THROUGHOUT THE LIFESPAN
CHAPTER 25 Older Adults
(65 Years and Older)
EXPECTED GROWTH
AND DEVELOPMENT
PHYsICAl deVelOPMent
Integumentary
● Decreased skin turgor, subcutaneous fat, and connective
tissue (dermis), which leads to wrinkles and dry,
transparent skin
● Loss of subcutaneous fat, which makes it more difficult
for older adults to adjust to cold temperatures
● Thinning and graying of hair, as well as a more
sparse distribution
● Thickening of fingernails and toenails
Cardiovascular/pulmonary
● Decreased chest wall movement, vital capacity, and cilia,
which increases the risk for respiratory infections
● Reduced cardiac output
● Decreased peripheral circulation
● Increased blood pressure
Neurosensory
● Slower reaction time
● Decreased touch, smell, and taste sensations
● Decreased production of saliva
● Decline in visual acuity
● Decreased ability for eyes to adjust from light to
dark, leading to night blindness, which is especially
dangerous when driving
● Inability to hear high‑pitched sounds (presbycusis)
● Reduced spatial awareness
Gastrointestinal
● Decreased digestive enzymes
● Decreased intestinal motility, which can lead to
increased risk of constipation
● Increased dental problems
Neuromuscular
● Decreased height due to intervertebral disk changes
● Decreased muscle strength and tone
● Decalcification of bones
● Degeneration of joints
Genitourinary
● Decreased bladder capacity
● Prostate hypertrophy in men
● Decline in estrogen or testosterone production
● Atrophy of breast tissue in women
Endocrine
● Decline in triiodothyronine (T3) production, yet overall
function remains effective
● Decreased sensitivity of tissue cells to insulin
COGnItIVe deVelOPMent
Piaget: Formal operations
● Many older adults maintain their cognitive function.
There is some decline in speed of the cognitive function
versus cognitive ability.
● A number of factors influence older adults’ abilities to
function, such as overall health, the number of stressors,
and lifelong mental well‑being.
● Slowed neurotransmission, vascular circulation
impairment, disease states, poor nutrition, and
structural brain changes can result in the following
cognitive disorders.
◯ Delirium: Acute, temporary, and can have a
physiologic source, such as infection, sleep
deprivation, or pain, or related to a change in
surroundings, such as being in an unfamiliar or new
environment. Delirium is often the first manifestation
of infection (such as urinary tract infection) in
older adults.
◯ Dementia: Chronic, progressive, and possibly
with an unknown cause (Alzheimer’s disease,
vascular dementia).
◯ Depression: Chronic, acute, or gradual onset (present
for at least 6 weeks). Often due to loss of a loved one,
feelings of isolation, or chronic disease.
PsYCHOsOCIAl deVelOPMent
Erikson: Integrity vs. despair
Older adults need to:
● Adjust to lifestyle changes related to retirement
(decrease in income, living situation, loss of work role).
● Adapt to changes in family structure (can be role
reversal in later years).
● Adapt to changes in living environment.
● Deal with multiple losses (death of a spouse,
friends, siblings).
● Face death.
Self-concept development: Older adults face difficulties in
the area of self‑concept.
● Seeing oneself as an aging person
● Finding ways to maintain a good quality of life
● Becoming more dependent on others for activities of
daily living
Body image changes: An adjustment to decreases in
physical strength and endurance is often difficult,
especially for older adults who are cognitively active and
engaged. Many older adults feel frustrated that their
bodies are limiting what they desire to do.
Social development
● Find ways to remain socially active and to
overcome isolation.
● Maintain sexual health.
CHAPTER 25
122 CHAPTER 25 Older Adults (65 YeArs And Older) CONTENT MASTERY SERIES
HEALTH PROMOTION
HeAltH rIsKs
Cardiovascular diseases
● Coronary artery disease
● Hypertension
Factors affecting mobility
● Arthritis
● Osteoporosis
● Falls
Mental health disorders
● Depression
● Dementia
● Suicide
● Alcohol use disorder
● Tobacco use disorder
Other disorders
● Stroke
● Diabetes mellitus
● Cancer
● Incontinence
● Abuse and neglect
● Cataracts
● Chronic pain
● Issues related to poor dental hygiene (gingivitis,
missing teeth, gum disease)
IMMunIZAtIOns
Follow the latest Centers for Disease Control and
Prevention (CDC) immunization recommendations
(www.cdc.gov) for healthy older adults. These
generally include:
● Immunizations against diphtheria, tetanus, pertussis,
varicella, seasonal influenza, herpes zoster, and
pneumococcal infections
● Immunizations against, hepatitis A and B, haemophilus
influenzae type b, and meningococcal infections for
high‑risk individuals
HeAltH sCreenInGs
Older adults should follow age‑related guidelines
for screening.
ANNUAL SCREENINGS
● Hearing
● Fecal occult blood test
● Digital rectal and prostate-specific antigen (men)
● Dual‑energy x‑ray absorptiometry (DXA) scanning
for osteoporosis
● Eye examination for glaucoma and other disorders
PERIODIC SCREENING
● Mental health screening for depression
● Cholesterol and diabetes screening every 3 years
nutrItIOn
● In addition to gastrointestinal alterations, other factors
influence nutrition in older adults.
◯ Difficulty getting to and from the supermarket to
shop for food
◯ Low income
◯ Impaired mobility
◯ Depression or dementia
◯ Social isolation (preparing meals for one person,
eating alone)
◯ Medications that alter taste or appetite
◯ Prescribed diets that are unappealing
◯ Incontinence that can cause the person to limit
fluid intake
◯ Constipation
● Metabolic rates and activity decline as individuals age,
so total caloric intake should decrease to maintain
a healthy weight. With the reduction of total calorie
intake, it becomes even more important that the calories
older adults consume be of good nutritional value.
Go to www.choosemyplate.gov for
nutritional recommendations.
NUTRITIONAL RECOMMENDATIONS
● Increase intake of vitamins D, B12, E, folate, fiber,
and calcium.
● Increase fluid intake to minimize the risk of
dehydration and prevent constipation.
● Take a low‑dose multivitamin along with
mineral supplementation.
● Limit sodium, fat, refined sugar, and alcohol intake.
FUNDAMENTALS FOR NURSING CHAPTER 25 Older Adults (65 YeArs And Older) 123
PsYCHOsOCIAl InterVentIOns
To improve self‑concept and alleviate social isolation
● Therapeutic communication
● Touch
● Reality orientation
● Validation therapy
● Reminiscence therapy
● Attending to physical appearance
● Assistive devices (canes, walkers, hearing aids)
InJurY PreVentIOn
● Install bath rails, grab bars, and handrails on stairways.
● Remove throw rugs.
● Eliminate clutter from walkways and hallways.
● Remove extension and phone cords from walkways
and hallways.
● Instruct clients about how to properly use
ambulation‑assistive devices (walkers, canes).
● Teach clients about safe medication use.
● Ensure adequate lighting.
● Remind clients to wear eyeglasses and hearing aids.
● Prevent substance use disorders.
● Avoid driving a vehicle during or after drinking
alcohol or taking substances that impair sensory and
motor functions.
● Wear a seat belt when operating a vehicle.
● Wear a helmet while bike riding, skiing, and other
recreational activities that increase the risk of
head injury.
● Install smoke and carbon monoxide detectors in
the home.
● Secure firearms in a safe location.
Application Exercises
1. A nurse is counseling an older
adult who describes having
difficulty dealing with several issues.
Which of the following problems
verbalized by the client should the
nurse identify as the priority?
A. “I spent my whole life dreaming
about retirement, and now
I wish I had my job back.”
B. “It’s been so stressful for me
to have to depend on my son
to help around the house.”
C. “I just heard my friend
Al died. that’s the third
one in 3 months.”
d. “I keep forgetting which
medications I have taken
during the day.”
2. A nurse is providing teaching for
an older adult client who has lost
4.5 kg (9.9 lb) since his last admission
6 months ago. Which of the following
instructions should the nurse include
in the teaching? (select all that apply.)
A. “eat three large meals a day.”
B. “eat your meals in front
of the television.”
C. ”eat foods that are easy to
eat, such as finger foods.”
d. ”Invite family members to
eat meals with you.”
e. “exercise every day to
increase appetite.”
3. A nurse is planning a presentation
for a group of older adults about
health promotion and disease
prevention. Which of the following
interventions should the nurse plan to
recommend? (select all that apply.)
A. Human papilloma virus
(HPV) immunization
B. Pneumococcal immunization
C. Yearly eye examination
d. Periodic mental
health screening
e. Annual fecal occult blood test
4. A nurse is talking with an older adult
client about improving her nutritional
status. Which of the following
interventions should the nurse
recommend? (select all that apply.)
A. Increase protein intake to
increase muscle mass.
B. decrease fluid intake to
prevent urinary incontinence.
C. Increase calcium intake to
prevent osteoporosis.
d. limit sodium intake
to prevent edema.
e. Increase fiber intake to
prevent constipation.
5. A nurse is collecting data from
an older adult client as part of a
comprehensive physical examination.
Which of the following findings
should the nurse expect as associated
with aging? (select all that apply.)
A. skin thickening
B. decreased height
C. Increased saliva production
d. nail thickening
e. decreased bladder capacity
PRACTICE Active Learning Scenario
A nurse is reviewing safety precautions for older
adults with a group of home health care assistive
personnel. use the AtI Active learning template:
Growth and development to complete this item.
INJURY PREVENTION: list at least 10 safety
recommendations for older adults.
124 CHAPTER 25 Older Adults (65 YeArs And Older) CONTENT MASTERY SERIES
Application Exercises Key
1. A. the client is at risk for social isolation and loss of independence
because of retirement. However, another issue is the priority.
B. the client is at risk for loss of independence and reduced self‑esteem
due to dependence upon his son. However, another issue is the priority.
C. the client is at risk for social isolation due to the loss
of a friend. However, another issue is the priority.
d. CORRECT: the greatest risk to this client is injury from
overdosing or underdosing medications due to loss of short‑term
memory. the priority issue for the nurse is to assist the client to
implement safe medication strategies. the nurse should assist
the client to use a pill organizer to help him remember to take
his medications and to keep a list of all current medications.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
2. A. the client should eat small frequent meals
to increase nutritional intake.
B. the client should avoid distractions during
meals to increase nutritional intake.
C. CORRECT: the nurse should encourage the client to eat finger
foods because finger foods are easier for the older adult client to eat.
d. CORRECT: the nurse should encourage the client
to involve family members with meals. socialization
during meals promotes nutritional intake.
e. CORRECT: the nurse should encourage the
client to exercise daily to increase appetite.
NCLEX® Connection: Health Promotion and Maintenance,
Health Screening
3. A. the HPV vaccine is recommended for female clients
from age 11 to 26 and male clients from age 9 to 26. It
is not a recommendation for older adults.
B. CORRECT: the pneumococcal vaccine is
recommended for older adult clients.
C. CORRECT: A yearly eye examination to screen for glaucoma
and vision changes is recommended for older adults.
d. CORRECT: Periodic mental health assessments are
recommended for older adult clients to screen for depression.
e. CORRECT: An annual fecal occult blood test
is recommended for older adults.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
4. A. CORRECT: Older adults should increase protein intake
to increase muscle mass and improve would healing.
B. Older adults should increase fluid intake to
prevent dehydration and constipation.
C. CORRECT: Older adults should increase calcium
intake to reduce the risk for osteoporosis.
d. CORRECT: Older adults should limit sodium intake
to reduce the risk for edema and hypertension.
e. CORRECT: Older adults should increase
fiber intake to prevent constipation.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
5. A. Physiological changes that occur with aging can include
decreased skin turgor, subcutaneous fat, and connective tissue
(dermis), which can cause wrinkles and dry, thin, transparent skin.
B. CORRECT: Physiological changes that occur with aging can
include loss in height due to the thinning of intervertebral disks.
C. Physiological changes that occur with aging can include decreased
saliva production, making xerostomia (dry mouth) a common problem.
d. CORRECT: Physiological changes that occur with aging can
include thickening of the nails of the fingers and toes.
e. CORRECT: Physiological changes that occur with aging can include a
reduced bladder capacity. While young adults have a bladder capacity
of about 500 to 600 ml, older adults have a capacity of about 250 ml.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Using the ATI Active Learning Template: Growth and Development
INJURY PREVENTION
● Install bath rails, grab bars, and
handrails on stairways.
● teach clients about safe medication use.
● remove throw rugs.
● eliminate clutter from walkways and hallways.
● remove extension and phone cords
from walkways and hallways.
● Instruct about how to use ambulation‑assistive
devices (walkers, canes).
● ensure adequate lighting.
● remind clients to wear eyeglasses
and hearing aids.
● Prevent substance use disorders.
● Avoid driving a vehicle during or after
drinking alcohol or taking substances that
impair sensory and motor functions.
● Wear a seat belt when operating a vehicle.
● Wear a helmet while bike riding,
skiing, and other recreational activities
that increase head‑injury risk.
● Install smoke and carbon monoxide
detectors in the home.
● secure firearms in a safe location.
NCLEX® Connection: Safety and Infection Control, Accident/Error/Injury Prevention
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 125
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Health Promotion and Maintenance
AGING PROCESS: Provide care and education for
the adult client ages 18 through 64 years.
DEVELOPMENTAL STAGES AND TRANSITIONS:
Compare client development to expected age/
developmental stage and report any deviations.
HEALTH PROMOTION/DISEASE PREVENTION: Assist
the client in maintaining an optimum level of health.
Client Needs: Management of Care
CONFIDENTIALITY/INFORMATION SECURITY:
Maintain client confidentiality and privacy.
Client Needs: Reduction of Risk Potential
CHANGES/ABNORMALITIES IN VITAL SIGNS: Apply
knowledge needed to perform related nursing procedures
and psychomotor skills when assessing vital signs.
SYSTEM SPECIFIC ASSESSMENT: Perform focused assessment.
Client Needs: Health Promotion/Disease Prevention
HEALTH SCREENING: Perform health history/
health and risk assessments.
TECHNIQUES OF PHYSICAL ASSESSMENT: Apply
knowledge of nursing procedures and psychomotor
skills to techniques of physical assessment.
FUNDAMENTALS FOR NURSING CHAPTER 26 Data ColleCtion anD General Survey 127
UNIT 2 HEALTH PROMOTION
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
CHAPTER 26 Data Collection and
General Survey
Data collection includes obtaining subjective
and objective information from clients.
the health history provides subjective data.
the physical examination and diagnostic tests
provide objective data.
INTERVIEWING TECHNIQUES
Standardized formats are a framework for obtaining
information about clients’ physical, developmental,
emotional, intellectual, social, and spiritual dimensions.
Therapeutic techniques for health assessment foster
communication and create an environment that promotes
an optimal health assessment/data collection experience.
tHeraPeutiC CoMMuniCation
Therapeutic communication helps develop rapport with
clients. The techniques encourage a trusting relationship,
whereby clients feel comfortable telling their story. Begin
with the purpose of the interview, gather information,
and then conclude the interview by summarizing
the findings. (26.1)
● Introduce yourself and the various parts of
the assessment.
● Determine what the client wants you to call him.
● Allow more time for responses from older adults.
● Make sure the client is comfortable (room
temperature, chair).
● When possible, start by asking for the health history,
performing the general survey, and measuring vital
signs to build rapport prior to
moving on to more sensitive parts of
the examination.
● Reduce environmental noises
(TV, radio, visitors talking) to
enhance communication and
eliminate distractions.
● Ensure understanding by obtaining
interpretive services for clients
who have language or other
communication barriers.
● Note the client’s nonverbal
communication (body language, eye
contact, tone of voice).
● Avoid using medical or
nursing jargon, giving advice,
ignoring feelings, and offering
false reassurance.
HEALTH HISTORY COMPONENTS
The health history provides subjective data about
health status.
DEMOGRAPHIC INFORMATION: Identifying data include:
● Name, address, contact information
● Birth date, age
● Gender
● Race, ethnicity
● Relationship status
● Occupation, employment status
● Insurance
● Emergency contact information
● Family, others living at home
● Advance directives
SOURCE OF HISTORY
● Client, family members or close friends, other medical
records, other providers
● Reliability of the historian
CHIEF CONCERN: A brief statement in the client’s own
words of why he is seeking care
HISTORY OF PRESENT ILLNESS
● A detailed, chronological description of why the client
seeks care
● Details about the manifestation(s), such as location,
quality, quantity, setting, timing (onset and duration),
precipitating factors, alleviating or aggravating factors,
associated phenomena (concomitant manifestations)
PAST HEALTH HISTORY AND CURRENT HEALTH STATUS
● Childhood illnesses, both communicable and chronic
● Medical, surgical, obstetrical, gynecological,
psychiatric history, including time frames, diagnoses,
hospitalizations, treatments
● Current immunization status, dates and results of any
screening tests
● Allergies to medication, environment, food
● Current medications including prescription,
over‑the‑counter, vitamins, supplements, herbal
remedies, time of last dose(s)
● Habits and lifestyle patterns (alcohol, tobacco, caffeine,
recreational drugs)
CHAPTER 26
26.1 Therapeutic communication techniques
ACTIVE LISTENING: Show clients that they have your undivided attention.
OPEN‑ENDED QUESTIONS: use initially to encourage clients to tell their
story in their own way. use terminology clients can understand.
CLARIFYING: Question clients about specific details in greater
depth or direct them toward relevant parts of their history.
BACK CHANNELING: use active listening phrases such as “Go on” and “tell
me more” to convey interest and to prompt disclosure of the entire story.
PROBING: ask more open‑ended questions such as “What else would
you like to add to that?” to help obtain comprehensive information.
CLOSED‑ENDED QUESTIONS: ask questions that require yes or no answers to
clarify information, such as “Do you have any pain when you cannot sleep?”
SUMMARIZING: validate the accuracy of the story.
128 CHAPTER 26 Data ColleCtion anD General Survey CONTENT MASTERY SERIES
FAMILY HISTORY
● Health information of grandparents, parents, siblings,
children, grandchildren
● Family structure, interaction, support system, function
● Current ages or age at death, acute and chronic
disorders of family members
PSYCHOSOCIAL HISTORY: Relationships, support systems,
concerns about living or work situations, financial status,
ability to perform activities of daily living, spiritual health
HEALTH PROMOTION BEHAVIORS
● Exercise/activity, diet, sun exposure, wearing of safety
equipment, substance use, environmental exposures,
home environment, resources, stress, sleep patterns,
coping measures
● Awareness of risks for heart disease, cancer, diabetes
mellitus, stroke
REVIEW OF SYSTEMS
An extensive review of systems ascertains information
about the functioning of all body systems and
health problems
QueStionS to aSK
Integumentary system
● Do you have any skin diseases?
● Do you have any itching, bruising, lumps, hair loss, nail
changes, or sores?
● Do you have any allergies?
● How do you care for your hair, skin, and nails?
● Do you use lotions, soaps, or sunscreen or wear
protective clothing?
Head and neck
● Do you get headaches? If so, how often? (Ask about and
note onset, precipitating factors, duration, character,
pattern, and concomitant manifestations.)
● What do you do to relieve the pain?
● Have you ever had a head injury?
● Can you move your head and shoulders with ease?
● Are any of your lymph nodes swollen? (If so, ask about
recent colds or viral infections.)
● Have you noticed any unusual facial movements?
● Does anyone in your family have thyroid disease?
Eyes
● How is your vision?
● Have you noticed any changes in your vision?
● Do you ever have any fluid draining from your eyes?
● Do you wear eyeglasses? Contact lenses?
● When was your last eye examination?
● Does anyone in your family have any eye disorders?
● Do you have diabetes?
Ears, nose, mouth, and throat
● How well do you hear?
● Have you noticed any changes in your hearing?
● Have other people commented that you aren’t hearing
what they say?
● Do you wear hearing aids?
● Do you ever have ringing or buzzing in your ears,
drainage, dizziness, or pain?
● Have you had ear infections?
● How do you clean your ears?
● Are you having any pain, stuffiness, or fluid draining
from your nose?
● Do you have nosebleeds?
● Do you have any difficulty breathing through your nose?
● Have you noticed any change in your sense of smell
or taste?
● How often do you go to the dentist?
● Do you have dentures or retainers?
● Do you have any problems with your gums, like bleeding
or soreness?
● Do you have any difficulty swallowing or problems with
hoarseness or a sore throat?
● Do you have allergies?
● Do you use nasal sprays?
● Do you know if you snore?
Breasts
● Do you perform breast self‑examinations? For women:
What time of the month do you perform them?
● Do you have any tenderness, lumps, thickening, pain,
drainage, distortion, or change in breast size, or any
retraction or scaling of the nipples?
● Has anyone in your family had breast cancer?
● Are you aware of breast cancer risks?
● For clients over 40: How often do you get
a mammogram?
Respiratory system
● Do you have any difficulties breathing?
● Do you breathe easier in any particular position?
● Are you ever short of breath?
● Have you recently been around anyone who has a cough,
cold, or influenza?
● Do you receive an influenza vaccine every year?
● Have you had the pneumonia vaccine?
● Do you smoke? If yes, for how long and how much? Are
you interested in quitting?
● Are you around second‑hand smoke?
● Do you have environmental allergies?
● Has anyone in your family had lung cancer
or tuberculosis?
● Have you ever been around anyone who
has tuberculosis?
● Have you had a tuberculosis test?
FUNDAMENTALS FOR NURSING CHAPTER 26 Data ColleCtion anD General Survey 129
Cardiovascular system
● Do you have any problems with your heart?
● Do you take any medications for your heart?
● Do you ever have pain in your chest? Do you also feel it
in your arms, neck, or jaw?
● Do you know if you have high cholesterol or high
blood pressure?
● Do you have any swelling in your feet and ankles?
● Do you cough frequently?
● Are you familiar with the risk factors for heart disease?
Gastrointestinal system
● Do you have any problems with your stomach, such as
nausea, vomiting, heartburn, or pain?
● Do you have any problems with your bowels, such as
diarrhea or constipation?
● When was your last bowel movement?
● Do you ever use laxatives or enemas?
● Have you had any black or tarry stools?
● Do you take aspirin or ibuprofen? If so, how often?
● Do you have any abdominal or lower back pain
or tenderness?
● Have you had any recent weight changes?
● Do you have any swallowing difficulties?
● Do you drink alcohol? If so, how much?
● For clients over 50: Have you had a colonoscopy? If so,
when was your last one?
● Do you know the signs and symptoms of colon cancer?
● What is your typical day’s intake of food and fluid?
● Do you have any dietary restrictions, food intolerances,
or special practices?
Genitourinary system
● Do you have any difficulties with urination, such as
burning, leakage or loss of urine, urgency, frequency,
waking up at night to urinate, or hesitancy?
● Have you noticed any change in the color of your urine?
● For women: Have you noticed any changes in your
menstrual cycle?
● Have you had pain during intercourse?
● Have you had any sexual problems?
● For men: Have you had any pain in your scrotum
or testes?
Musculoskeletal system
● Have you noticed any pain in your joints or muscles?
● Do you have any weakness or twitching?
● Have you had any recent falls?
● Are you able to care for yourself?
● Do you exercise or participate in sports?
● For postmenopausal women: What was your
maximum height?
● For postmenopausal women: Do you take
calcium supplements?
Neurological system
● Have you noticed any change in your vision, speech,
ability to think clearly, or loss of or change in memory?
● Do you have any dizziness or headaches?
● Do you ever have seizures? If so, what triggers them?
● Do you ever have any weakness, tremors, numbness, or
tingling anywhere? If so, where?
Mental health
● Is there anything stressful going on at work or at home?
● Are you having any problems with depression or
changes in mood?
● Have you had any recent losses?
● Are you having any problems concentrating?
Endocrine system
● Have you noticed any change in urination patterns?
● Have you noticed any change in your energy level?
● Have you noticed any change in your ability to
handle stress?
● Have you had any change in weight or appetite?
● Have you had any visual disturbances?
● Have you had any palpitations?
Allergic/immunologic system
● Do you have any allergies to medications, foods, or
environmental substances?
● Have you ever received a blood transfusion? If so, did
you have any adverse reactions?
PHYSICAL ASSESSMENT TECHNIQUES
During a physical examination
● Make sure there is adequate lighting.
● Maintain a quiet and comfortable environment.
● Provide privacy, using a gown or draping the client with
a sheet and visualizing only one section of the body at
a time.
● Explain the various assessment/data collection
techniques you will use.
● Look and observe before touching.
● Keep nails short, and hands and stethoscope warm.
● Do not feel or listen through clothing. (Clothing can
obscure or create sounds.)
● Have necessary equipment ready.
● Use standard precautions when in contact with body
fluids, wound drainage, and open lesions.
ADDITIONAL GUIDELINES FOR OLDER ADULT CLIENTS
● Allow enough time for position changes.
● Perform assessments/data collection in several shorter
segments to avoid overtiring older adults. Organize
the examination, finishing all techniques requiring the
same position before moving on to the next position.
● Make sure older adults who use sensory aids (eyeglasses,
hearing aids) have them available for use.
● Invite the client to use the bathroom before beginning
the physical examination. Collect urine or fecal
specimens at this time.
130 CHAPTER 26 Data ColleCtion anD General Survey CONTENT MASTERY SERIES
inSPeCt, PalPate, PerCuSS, auSCultate
Inspect, palpate, percuss, and auscultate in that order.
the exception is the abdomen; inspect,
auscultate, percuss, and palpate in that
order to avoid altering bowel sounds.
Inspection
Inspection begins with the first interaction and continues
throughout the examination.
● A penlight, an otoscope, an ophthalmoscope, or another
lighted instrument can enhance the process.
● Inspection involves using the senses of vision, smell
(olfaction), and hearing to observe and detect any
expected or unexpected findings. Inspect for size, shape,
color, symmetry (comparing both sides of the body),
and position.
● Validate findings with the client.
Palpation
Palpation is the use of touch to determine the size,
consistency, texture, temperature, location, and
tenderness of the skin, underlying tissues, an organ, or a
body part. Palpate tender areas last.
● Use light palpation (less than 1 cm [0.4 in]) for most
body surfaces. Use deeper palpation (4 cm [1.6 in]) to
evaluate abdominal organs or masses.
● Various parts of your hands detect different sensations.
◯ The dorsal surface is the most sensitive
to temperature.
◯ The palmar surface and base of the fingers are
sensitive to vibration.
◯ Fingertips are sensitive to pulsation, position, texture,
turgor, size, and consistency.
◯ The fingers and thumb are useful for grasping an
organ or mass.
● Starting with light palpation, be systematic, calm, and
gentle. Proceed to deep palpation if necessary.
Percussion
Percussion involves tapping body parts with fingers,
fists, or small instruments to vibrate underlying tissues
and evaluate size, location, tenderness, and presence or
absence of fluid or air in body organs, and to detect any
abnormalities. The denser the tissue, the quieter the
sound. An understanding of the effect of various densities
on sound can help you locate organs or masses, find their
edges, and estimate their size.
TECHNIQUES FOR PERCUSSION
● Direct percussion, which involves striking the body to
elicit sounds.
● Indirect percussion, which involves placing your
hand flatly on the body, as the striking surface, for
sound production.
● Fist percussion, which helps identify tenderness over
the kidneys, liver, and gallbladder.
Auscultation
Auscultation is the process of listening to sounds the
body produces to identify unexpected findings. Some
sounds are loud enough to hear unaided (speech and
coughing), but most sounds require a stethoscope or a
Doppler technique (heart sounds, air moving through
the respiratory tract, blood moving through blood
vessels). Learn to isolate the various sounds to collect
data accurately.
● Evaluate sounds for amplitude or intensity (loud or soft),
pitch or frequency (high or low), duration (time the
sound lasts), and quality (what it sounds like).
● Use the diaphragm of the stethoscope to listen to
high‑pitched sounds (heart sounds, bowel sounds,
lung sounds).
Place the diaphragm firmly on the body part.
● Use the bell of the stethoscope to listen to low‑pitched
sounds (unexpected heart sounds, bruits).
Place the bell lightly on the body part.
EQUIPMENT FOR SCREENING
EXAMINATION
● Gown
● Drapes
● Scale with height measurement
● Thermometer
● Stethoscope with diaphragm and bell
● Sphygmomanometer
● Reading/eye chart
● Otoscope, ophthalmoscope, nasal speculum
● Penlight or ophthalmoscope
● Cotton balls
● Sharp and dull objects
● Tuning fork
● Glass of water
● Items to test smell and taste
● Clean gloves
● Tongue depressor
● Reflex hammer
● Pulse oximeter
● Marking pen
● Measuring tape and clear, flexible ruler with
measurements in centimeters
● Watch or clock to measure time in seconds
26.2 Sample documentation
Client: 16‑year‑old male, alert and oriented x 3. no
distress. Personal hygiene and grooming slightly unkempt
but appropriate for age. Weight appropriate for height,
erect posture, and steady gait. Full range of motion. Does
not maintain eye contact. volunteers no information but
answers questions appropriately. no gross abnormalities.
FUNDAMENTALS FOR NURSING CHAPTER 26 Data ColleCtion anD General Survey 131
GENERAL SURVEY
The general survey is a written summary or appraisal
of overall health. Gather this information from the
first encounter with the client and continue to make
observations throughout the assessment process. (26.2)
Assess/collect data about the following.
PHYSICAL APPEARANCE
● Age
● Gender
● Race and/or ethnicity
● Level of consciousness
● Color of skin
● Facial features
● Signs of distress (pallor, labored breathing,
guarding, anxiety)
● Signs of possible physical abuse or neglect
● Signs of substance use disorders
BODY STRUCTURE
● Body build, stature, height,
and weight
● Nutritional status
● Symmetry of body parts
● Posture and usual position
● Gross abnormalities (skin lesions,
amputations)
MOBILITY
● Gait
● Movements (purposeful, tremulous)
● Range of motion
● Motor activity
BEHAVIOR
● Facial expression and mannerisms
● Mood and affect
● Speech
● Dress, hygiene, grooming, and odors (body, breath)
VITAL SIGNS
● Temperature
● Pulse
● Respirations
● Blood pressure
● Oxygen saturation
Application Exercises
1. a nurse is introducing herself
to a client as the first step of a
comprehensive physical examination.
Which of the following strategies
should the nurse use with this
client? (Select all that apply.)
a. address the client with
the appropriate title
and her last name.
B. use a mix of open‑ and
closed‑ended questions.
C. reduce environmental noise.
D. Have the client complete
a printed history form.
e. Perform the general survey
before the examination.
2. a nurse in a provider’s office is
documenting his findings following
an examination he performed for a
client new to the practice. Which
of the following parameters should
he include as part of the general
survey? (Select all that apply.)
a. Posture
B. Skin lesions
C. Speech
D. allergies
e. immunization status
3. a nurse is collecting data for a client’s
comprehensive physical examination.
after the nurse inspects the client’s
abdomen, which of the following
skills of the physical examination
process should she perform next?
a. olfaction
B. auscultation
C. Palpation
D. Percussion
4. a nurse is performing a
comprehensive physical examination
of an older adult client. Which of
the following interventions should
the nurse use in consideration of the
client’s age? (Select all that apply.)
a. Collect the data in one
continuous session.
B. Plan to allow plenty of time
for position changes.
C. Make sure the client has any
essential sensory aids in place.
D. tell the client to take her
time answering questions.
e. invite the client to use the
bathroom before beginning
the examination.
5. a nurse in a family practice clinic is
performing a physical examination
of an adult client. Which part
of her hands should she use
during palpation for optimal
assessment of skin temperature?
a. Palmar surface
B. Fingertips
C. Dorsal surface
D. Base of the fingers
PRACTICE Active Learning Scenario
a nurse is reviewing the data to collect from a client for a comprehensive
health history prior to the systems review. use the ati active
learning template: Basic Concept to complete this item.
RELATED CONTENT: list at least six general categories to cover
and the essential data to include in each category.
132 CHAPTER 26 Data ColleCtion anD General Survey CONTENT MASTERY SERIES
Application Exercises Key
1. a. the nurse should ask the client what she wants the nurse to call her.
B. CORRECT: open‑ended questions help the client tell her story
in her own way. Closed‑ended questions are useful for clarifying
and verifying information the nurse gathers from the client’s story.
C. CORRECT: a quiet, comfortable environment eliminates distractions
and helps the client focus on the important aspects of the interview.
D. Having the client fill out a printed history form might deter
the establishment of a therapeutic relationship. When the nurse
asks about her history, the client might feel they are wasting time
because she already wrote that information on the form.
e. CORRECT: the general survey is noninvasive and, along with the
health history and vital sign measurement, can help put the client at ease
before the more sensitive parts of the process, such as the examination.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
2. a. CORRECT: Posture is part of the body structure or
general appearance portion of the general survey.
B. CORRECT: Skin lesions are part of the body structure
or general appearance portion of the general survey.
C. CORRECT: Speech is part of the behavior
portion of the general survey.
D. allergies are part of the health history, not the general survey.
e. immunization status is part of the health history, not the general survey.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
3. a. olfaction is the use of the sense of smell to detect any unexpected
findings that the nurse cannot detect via other means, such as a
fruity breath odor. unless there is an open lesion on the client’s
abdomen, this is not the next step in an abdominal examination.
B. CORRECT: Because palpation and percussion can alter the
frequency and intensity of bowel sounds, the nurse should auscultate
the abdomen next and before using those two techniques.
C. Palpation is the next step in examining other
areas of the body, but not the abdomen.
D. Percussion is important for detecting gas, fluid, and solid masses in
the abdomen, but it is not the next step in an abdominal assessment.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
4. a. the nurse should perform the various parts of the assessment
in several shorter segments to avoid overtiring the client.
B. CORRECT: Because many older adults have mobility challenges,
the nurse should plan to allow extra time for position changes.
C. CORRECT: the nurse should make sure clients who use
sensory aids have them available for use. the client has to be
able to hear the nurse and see well enough to avoid injury.
D. CORRECT: Some older clients need more time to collect
their thoughts and answer questions, but most are reliable
historians. Feeling rushed can hinder communication.
e. CORRECT: this is a courtesy for all clients, to avoid discomfort during
palpation of the lower abdomen for example, but this is especially
important for older clients who have a smaller bladder capacity.
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
5. a. the palmar surface of the hands is especially
sensitive to vibration, not temperature.
B. the fingertips are sensitive to pulsation, position,
texture, size, and consistency, not temperature.
C. CORRECT: the dorsal surface of the hand
is the most sensitive to temperature.
D. the base of the fingers is especially sensitive
to vibration, not temperature.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● Demographic information
◯ name, address, contact information
◯ Birth date, age
◯ Gender
◯ race, ethnicity
◯ relationship status
◯ occupation, employment status
◯ insurance
◯ emergency contact information
◯ Family, others living at home
◯ advance directives
● Source of history
◯ Client, family members or close friends,
other medical records, other providers
◯ reliability of the historian
● Chief concern: Brief statement in the client’s
own words of why he is seeking care
● History of present illness
◯ Detailed, chronological description
of why the client seeks care
◯ Details about the manifestation(s), such as
location, quality, quantity, setting, timing
(onset and duration), precipitating factors,
alleviating or aggravating factors, associated
phenomena (concomitant manifestations)
● Past health history and current health status
◯ Childhood illnesses, both
communicable and chronic
◯ Medical, surgical, obstetrical, gynecological,
psychiatric history including time frames,
diagnoses, hospitalizations, treatments
◯ Current immunization status, dates
and results of any screening tests
◯ allergies to medication, environment, food
◯ Current medications including prescription,
over‑the‑counter, vitamins, supplements,
herbal remedies, time of last dose(s)
◯ Habits and lifestyle patterns (alcohol,
tobacco, caffeine, recreational drugs)
● Family history
◯ Health information of grandparents,
parents, siblings, children, grandchildren
◯ Family structure, interaction,
support system, function
◯ Current ages or age at death, acute and
chronic disorders in family members
● Psychosocial history: relationships, support
systems, concerns about living or work
situations, financial status, ability to perform
activities of daily living, spiritual health
● Health promotion behavior
◯ exercise/activity, diet, sun exposure,
wearing of safety equipment,
substance use, environmental
exposures, home environment,
resources, stress, coping measures
◯ awareness of risks for heart disease,
cancer, diabetes mellitus, and
cerebrovascular accident
NCLEX® Connection: Health Promotion and Maintenance, Techniques of Physical Assessment
FUNDAMENTALS FOR NURSING CHAPTER 27 Vital SignS 133
UNIT 2 HEALTH PROMOTION
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
CHAPTER 27 Vital Signs
Vital signs are measurements of the body’s most
basic functions and include temperature, pulse,
respiration, and blood pressure. Many facilities
also consider pain level and oxygen saturation
vital signs. (SEE CHAPTER 41: PAIN MANAGEMENT AND
CHAPTER 53: AIRWAY MANAGEMENT.)
Temperature reflects the balance between
heat the body produces and heat lost to
the environment.
Pulse is the measurement of heart rate and
rhythm. Pulse corresponds to the bounding
of blood flowing through various points in the
circulatory system. it provides information about
circulatory status.
Respiration is the body’s mechanism for
exchanging oxygen and carbon dioxide
between the atmosphere and the blood and
cells of the body, which is accomplished through
breathing and recorded as the number of
breaths per minute.
Blood pressure (BP) reflects the force the blood
exerts against the walls of the arteries during
contraction (systole) and relaxation (diastole) of
the heart. Systolic blood pressure (SBP) occurs
during ventricular systole of the heart, when the
ventricles force blood into the aorta and
pulmonary artery, and it represents the
maximum amount of pressure exerted on the
arteries when ejection occurs. Diastolic blood
pressure (DBP) occurs during ventricular diastole
of the heart, when the ventricles relax and exert
minimal pressure against arterial walls, and
represents the minimum amount of pressure
exerted on the arteries.
Temperature
PHYSiOlOgiC RESPOnSES
● The neurological and cardiovascular systems work
together to regulate body temperature. Disease or
trauma of the hypothalamus or spinal cord will alter
temperature control.
● The rectum, tympanic membrane, temporal artery,
pulmonary artery, esophagus, and urinary bladder are
core temperature measurement sites.
● The skin, mouth, and axillae are surface temperature
measurement sites.
HEat PRODUCtiOn anD lOSS
Heat production results from increases in basal metabolic
rate, muscle activity, thyroxine output, testosterone, and
sympathetic stimulation, which increases heat production.
Heat loss from the body occurs through:
● Conduction: Transfer of heat from the body directly
to another surface (when the body is immersed in
cold water).
● Convection: Dispersion of heat by air currents (wind
blowing across exposed skin).
● Evaporation: Dispersion of heat through water
vapor (perspiration).
● Radiation: Transfer of heat from one object to another
object without contact between them (heat lost from the
body to a cold room).
● Diaphoresis: Visible perspiration on the skin.
ASSESSMENT/DATA COLLECTION
EXPECtED tEMPERatURE RangES
● An oral temperature range of 36° to 38° C (96.8° to
100.4° F) is acceptable. The average is 37° C (98.6° F).
● Rectal temperatures are usually 0.5° C (0.9° F) higher
than oral and tympanic temperatures.
● Axillary temperatures are usually 0.5° C (0.9° F) lower
than oral and tympanic temperatures
● Temporal temperatures are close to rectal, but they
are nearly 0.5° C (1° F) higher than oral, and 1° C (2° F)
higher than axillary temperatures.
● A client’s usual temperature serves as a baseline
for comparison.
CHAPTER 27
134 CHAPTER 27 Vital SignS CONTENT MASTERY SERIES
COnSiDERatiOnS
Newborns have a large surface‑to‑mass ratio, so they lose
heat rapidly to the environment. A newborn’s temperature
should be between 36.5° and 37.5° C (97.7° and 99.5° F).
Older adult clients experience a loss of subcutaneous fat
that results in lower body temperatures and feeling cold.
Their average body temperature is 36° C (96.8° F). Older
adult clients are more likely to develop adverse effects
from extremes in environmental temperatures (heat
stroke, hypothermia). It also takes longer for body
temperature to register on a thermometer due to changes
in temperature regulation.
Hormonal changes can influence temperature. In general,
temperature rises slightly with ovulation and menses.
With menopause, intermittent body temperature can
increase by up to 4° C (7.2° F).
Exercise, activity, and dehydration can contribute to the
development of hyperthermia.
Illness and injury can cause elevations in temperature.
Fever is the body’s response to infectious and
inflammatory processes. Fever causes an increase in the
body’s immune response by:
● Increasing WBC production.
● Decreasing plasma iron concentration to reduce
bacteria growth.
● Stimulating interferon to suppress virus production.
Recent food or fluid intake and smoking can interfere
with accurate oral measurement of body temperature,
so it is best to wait 20 to 30 min before measuring oral
temperature.
Circadian rhythm, stress, and environmental conditions
can also affect body temperature.
NURSING INTERVENTIONS
EQUiPMEnt
Electronic thermometers use a probe to measure oral,
rectal, or axillary temperature. Place a disposable probe
cover on the probe, insert the probe, and when you hear
the signal, note the digital reading then discard the
probe cover. Tympanic temperatures require a device
specifically for measuring temperature at the tympanic
membrane (eardrum).
Disposable, single-use thermometers are for oral or
axillary temperature measurement. They reduce the risk
of cross‑infection.
PROCEDURES FOR taKing tEMPERatURE
Perform hand hygiene, provide privacy, and apply
clean gloves.
Oral
● Gently place the thermometer (with an oral probe) under
the tongue in the posterior sublingual pocket lateral to
the center of the lower jaw.
● Leave it in place until you hear the signal.
AGE‑SPECIFIC: Use this site for clients who are 4 years of
age and older.
note: Do not use this site for clients who breathe
through their mouth or have experienced trauma to
the face or mouth.
Rectal
● Assist the client to Sims’ position with the upper leg
flexed. Wearing gloves, expose the anal area while
keeping other body areas covered. Spread the buttocks
to expose the anal opening.
● Ask the client to breathe slowly and relax when placing
a lubricated thermometer (with a rectal probe) into the
anus in the direction of the umbilicus 2.5 to 3.5 cm (1 to
1.5 in) for an adult. If you encounter resistance, remove
it immediately. Once inserted, hold the thermometer in
place until you hear the signal.
● Clean the anal area to remove feces or lubricant.
● Use the rectal site to obtain a second measurement if
the temperature is above 37.2º C (99º F).
SAFETY MEASURE: Do not use for clients who have
diarrhea, are on bleeding precautions (such as those who
have a low platelet count), or have rectal disorders.
AGE‑SPECIFIC: A rectal measurement of temperature is
more accurate than axillary. However, because of the risk
of rectal perforation, the American Academy of Pediatrics
recommends screening infants 3 months old and younger
by measuring axillary temperature initially.
note: Stool in the rectum can
cause inaccurate readings.
Axillary
● Place the thermometer (with an oral probe) in the center
of the client’s clean, dry axilla. Lower the arm over
the probe.
● Hold the arm down, keeping the thermometer in
position until you hear the signal.
Tympanic
● Pull the ear up and back (for an adult) or down and back
(for a child who is younger than 3 years old).
● Place the thermometer probe snugly into the client’s
outer ear canal and press the scan button.
● Leave it in place until you hear the signal.
● Carefully remove the thermometer from the ear canal
and read the temperature.
● Ambient temperature can affect readings.
FUNDAMENTALS FOR NURSING CHAPTER 27 Vital SignS 135
AGE‑SPECIFIC: The American Academy of Pediatrics advises
against the use of electronic ear thermometers for infants
3 months old and younger due to the inaccuracy of readings.
note: Excess earwax can alter the reading. if
noted, use the other ear or select another
site for temperature assessment.
Temporal
● Remove the protective cap and wipe the lens of the
scanning device with alcohol to make sure it is clean.
● While pressing the scan button, hold the probe flat
against the forehead while moving it gently across the
forehead over the temporal artery, and then touch the
skin behind the earlobe.
● Release the scan button to display the temperature reading.
note: Depending on facility policy, either use
disposable probe covers or clean the probe
with a disinfectant wipe between clients.
COMPLICATIONS
Fever
Usually not harmful unless it exceeds 39° C (102.2° F).
Hyperthermia
Hyperthermia is an abnormally elevated body temperature.
NURSING INTERVENTIONS
● Obtain specimens for blood, urine, sputum, or wound
cultures as needed.
● Assess/monitor white blood cell counts, sedimentation
rates, and electrolytes.
● Administer antibiotics (after obtaining specimens
for culture).
● Provide fluids and rest. Minimize activity. Use a
cooling blanket.
● Children and older adults are at particular risk for fluid
volume deficit.
● Provide antipyretics (aspirin, acetaminophen, ibuprofen).
Do not give aspirin to manage fever for children
and adolescents who have a viral illness (influenza,
chickenpox) due to the risk of Reye syndrome.
● Prevent shivering, as this increases energy demand.
● Offer blankets during chills and remove them when the
client feels warm.
● Provide oral hygiene and dry clothing and linens.
● Keep environmental temperature between 21° and 27° C
(70° to 80° F).
Hypothermia
Hypothermia is a body temperature less than 35º C (95° F).
NURSING INTERVENTIONS
● Provide a warm environmental temperature, heated
humidified oxygen, warming blanket, and/or warmed
oral or IV fluids.
● Keep the head covered.
● Provide continuous cardiac monitoring.
● Have emergency resuscitation equipment on standby.
Pulse
PHYSiOlOgiC RESPOnSES
Autonomic nervous system controls the heart rate.
Parasympathetic nervous system lowers the heart rate.
Sympathetic nervous system raises the heart rate.
ASSESSMENT/DATA COLLECTION
Assess the wave‑like sensations or impulses you feel in a
peripheral arterial vessel or over the apex of the heart as a
gauge of cardiovascular status.
Rate: The number of times per minute you feel or hear
the pulse.
Rhythm: The regularity of impulses. A premature, late
heartbeat or a missed beat can result in an irregular
interval between impulses and can indicate altered
electrical activity of the heart. Typically, you should detect
an impulse at regular intervals.
Strength (amplitude): Reflects the volume of blood ejected
against the arterial wall with each heart contraction and
the condition of the arterial vascular system. The strength
of the impulse should be the same from beat to beat.
Grade strength on a scale of 0 to 4.
● 0 = Absent, unable to palpate
● 1+ = Diminished, weaker than expected
● 2+ = Brisk, expected
● 3+ = Increased, strong
● 4+ = Full volume, bounding
Equality: Peripheral pulse impulses should be
symmetrical in quality and quantity from the right side
of the body to the left. Assess strength and equality
to evaluate the adequacy of the vascular system. An
inequality or absence of pulse on one side of body can
indicate a disease state (e.g., thrombus, aortic dissection).
COnSiDERatiOnS
Dysrhythmia: An irregular heart rhythm, generally with
an irregular radial pulse.
Pulse deficit: The difference between the apical rate and
the radial rate. With dysrhythmias, the heart can contract
ineffectively, resulting in a beat at the apical site with no
pulsation at the radial pulse point. To determine the pulse
deficit accurately, two clinicians should measure the apical
and radial pulse rates simultaneously.
Age: For infants, the expected pulse rate is 120 to 160/min.
The rate gradually decreases as the child grows older. The
average pulse for a 12‑ to 14‑year‑old child is 80 to
90/min. The strength of the pulsation can weaken in older
adult clients due to poor circulation or cardiac dysfunction,
which makes the peripheral pulses more difficult
to palpate.
136 CHAPTER 27 Vital SignS CONTENT MASTERY SERIES
EXPECtED HEaRt RatE RangE
The expected reference range for an adult client’s pulse is
60 to 100/min at rest.
Tachycardia
A rate greater than the expected range or greater
than 100/min.
FACTORS LEADING TO TACHYCARDIA
● Exercise
● Fever, heat exposure
● Medications: epinephrine, levothyroxine
beta2‑adrenergic agonists (albuterol)
● Changing position from lying down to sitting
or standing
● Acute pain
● Hyperthyroidism
● Anemia, hypoxemia
● Stress, anxiety, fear
● Hypovolemia, shock, heart failure, hemorrhage
Bradycardia
A rate less than the expected range or slower than 60/min.
FACTORS LEADING TO BRADYCARDIA
● Long-term physical fitness
● Hypothermia
● Medications: digoxin, beta‑blockers (propranolol),
calcium channel blockers (verapamil)
● Changing position from standing or sitting to
lying down
● Chronic severe pain
● Hypothyroidism
● Relaxation
NURSING INTERVENTIONS
EQUiPMEnt
A watch or clock that allows for counting seconds
Stethoscope
PROCEDURE
● Perform hand hygiene and provide privacy.
● Locate the radial pulse on the radial‑ or thumb‑side of
the forearm at the wrist. (27.1)
◯ Place the index and middle finger of one hand gently
but firmly over the pulse. Assess the pulsation for
rate, rhythm, amplitude, and quality.
◯ If the peripheral pulsation is regular, count the
rate for 30 sec and multiply by 2. If the pulsation is
irregular, count for a full minute and compare the
result to the apical pulse rate.
27.1 Pulse points
27.2 Apical pulse
FUNDAMENTALS FOR NURSING CHAPTER 27 Vital SignS 137
● Locate the apical pulse at the fifth intercostal space at
the left midclavicular line. (27.2)
◯ Use this site for assessing the heart rate of an
infant, rapid rates (faster than 100/min), irregular
rhythms, and rates prior to the administration of
cardiac medications.
◯ Place the stethoscope on the chest at the fifth
intercostal space at the left midclavicular line. If the
rhythm is regular, count for 30 sec and multiply by
2. If the rhythm is irregular or the client is receiving
cardiovascular medications, count for 1 full min.
COMPLICATIONS
Tachycardia
NURSING INTERVENTIONS
● Monitor for pain, anxiety, restlessness, fatigue, low
blood pressure, and low oxygen saturation.
● Monitor for potential adverse effects of medications.
● Prevent injury.
Bradycardia
NURSING INTERVENTIONS
● Monitor for hypotension, chest pain, syncope,
diaphoresis, dyspnea, and altered mental state.
● Monitor for potential adverse effects of medications.
● Prevent injury.
Respirations
PHYSiOlOgiCal RESPOnSES
Chemoreceptors in the carotid arteries and the aorta
primarily monitor carbon dioxide (CO2) levels of the blood.
Rising CO2 levels trigger the respiratory center of the brain
to increase the respiratory rate. The increased respiratory
rate rids the body of excess CO2. For clients who have
chronic obstructive pulmonary disease (COPD), a low
oxygen level becomes the primary respiratory drive.
PROCESSES OF RESPiRatiOn
Ventilation: The exchange of oxygen and carbon dioxide
in the lungs. Measure ventilation with the respiratory rate,
rhythm, and depth.
Diffusion: The exchange of oxygen and carbon dioxide
between the alveoli and the red blood cells. Measure
diffusion with pulse oximetry.
Perfusion: The flow of red blood cells to and from
the pulmonary capillaries. Measure perfusion with
pulse oximetry.
ASSESSMENT/DATA COLLECTION
Accurate assessment of respiration involves observing the
rate, depth, and rhythm of chest‑wall movement during
inspiration and expiration. Do not inform the client that
you are measuring respirations.
Rate: The number of full inspirations and expirations in
1 min. Determine this by observing the number of times
the client’s chest rises and falls. The expected reference
range for adults is 12 to 20/min.
Depth: The amount of chest wall expansion that occurs
with each breath. Altered depths are deep or shallow.
Rhythm: The observation of breathing intervals. For
adults, expect a regular rhythm (eupnea) with an
occasional sigh.
PUlSE OXiMEtRY
This is a noninvasive, indirect measurement of the oxygen
saturation (SaO2) of the blood (the percent of hemoglobin
that is bound with oxygen in the arteries is the percent of
saturation of hemoglobin). The expected reference range is
95% to 100%, although acceptable levels for some clients
range from 91% to 100%. Some illness states can even
allow for an SaO2 of 85% to 89%.
COnSiDERatiOnS
Age: Respiratory rate decreases with age. Newborns have
rates of 35 to 40/min. School‑age children have respiratory
rates of 20 to 30/min.
Sex: Men and children are diaphragmatic breathers, and
abdominal movements are more noticeable. Women use
more thoracic muscles, and chest movements are more
pronounced when they breathe.
Pain in the chest wall area can decrease the depth of
respirations. At the onset of acute pain, the respiration
rate increases but stabilizes over time.
Anxiety increases the rate and depth of respirations.
Smoking causes the resting rate of respirations to
increase.
Body position: Upright positions allow the chest wall to
expand more fully.
Medications such as opioids, sedatives, bronchodilators,
and general anesthetics decrease respiratory rate and
depth. Respiratory depression is a serious adverse effect.
Amphetamines and cocaine increase rate and depth.
Neurological injury to the brainstem decreases respiratory
rate and rhythm.
Illnesses can affect the shape of the chest wall, change
the patency of passages, impair muscle function, and
diminish respiratory effort. With these conditions, the use
of accessory muscles, such as those visible in the neck,
and the respiratory rate increase.
Impaired oxygen-carrying capacity of the blood that
occurs with anemia or at high altitudes results in
increases in the respiratory rate and alterations in rhythm
to compensate.
138 CHAPTER 27 Vital SignS CONTENT MASTERY SERIES
NURSING INTERVENTIONS
Respiratory rate
EQUIPMENT: A watch or clock that allows for
counting seconds.
PROCEDURE
● Perform hand hygiene and provide privacy.
● Place the client in semi‑Fowler’s position, being sure
the chest is visible.
● Have the client rest an arm across the abdomen, or place
a hand directly on the client’s abdomen.
● Observe one full respiratory cycle, look at the timer, and
then begin counting the rate.
● Count a regular rate for 30 seconds and multiply by 2.
Count the rate for 1 min if irregular, faster than 20/min,
or slower than 12/min. Note depth (shallow, normal, or
deep) and rhythm (regular or irregular).
Oxygen saturation
EQUIPMENT: Pulse oximeter with digit probe, earlobe
probe, or disposable sensor pad
PROCEDURE
● Choose an intact, nonedematous site for probe or
sensor placement.
● Place the digit probe on the client’s finger.
● Use earlobe or bridge of nose for clients who have
peripheral vascular disease.
● A disposable sensor pad can be applied to the sole of an
infant’s foot.
● When the readout on the pulse oximeter is stable, record
this value as the oxygen saturation.
Blood pressure
PHYSiOlOgiCal RESPOnSES
The principal determinants of blood pressure are cardiac
output (CO) and systemic (peripheral) vascular
resistance (SVR).
BP = CO × SVR
Cardiac output
● CO is determined by
◯ Heart rate
◯ Contractility
◯ Blood volume
◯ Venous return
● Increases in any of these increase CO and BP
● Decreases in any of these decrease CO and BP
Systemic vascular resistance
● SVR reflects the amount of constriction or dilation of
the arteries, and diameter of blood vessels.
● Increases in SVR increase BP
● Decreases in SVR decrease BP
ASSESSMENT/DATA COLLECTION
ClaSSiFiCatiOnS OF BlOOD PRESSURE
27.3 BP classifications
according to the Seventh Report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure
SYSTOLIC BP
(mm Hg)
DIASTOLIC BP
(mm Hg)
NORMAL less than 120 and less than 80
PREHYPERTENSION 120 to 139 or 80 to 89
STAGE 1 HYPERTENSION 140 to 159 or 90 to 99
STAGE 2 HYPERTENSION greater
than 160 or greater
than 100
● Base the classification on the highest reading. A client
who has a BP of 124/92 mm Hg has stage 1 hypertension
because the DBP places the client in that category.
A client who has a BP of 146/82 mm Hg also has stage 1
hypertension because the SBP places the client in
that category.
● If the client has a SBP greater than 140 mm Hg and a
DBP greater than 90 mm Hg that are averages of two or
more BP measurements, he should return for two or
more visits for additional readings. If the readings are
elevated on at least three separate occasions over
several weeks, the client has hypertension.
Hypotension is a blood pressure below the expected
reference range (systolic less than 90 mm Hg) and can be
a result of fluid depletion, heart failure, or vasodilation.
FUNDAMENTALS FOR NURSING CHAPTER 27 Vital SignS 139
Pulse pressure is the difference between the systolic and
the diastolic pressure readings.
Orthostatic (postural) hypotension is a blood pressure
that decreases when a client changes position from lying
to sitting or standing, and it can result from various
causes (peripheral vasodilation, medication adverse
effects, fluid depletion, anemia, prolonged bed rest).
assess orthostatic changes by taking the client’s
BP and heart rate (HR) in the supine position. next,
have the client change to the sitting or standing
position, wait 1 to 3 min, and reassess BP and
HR. the client has orthostatic hypotension if
the SBP decreases more than 20 mm Hg and/or
the DBP decreases more than 10 mm Hg with
a 10% to 20% increase in HR. Do not delegate
this procedure to an assistive personnel.
COnSiDERatiOnS
Age
● Infants have a low BP that gradually increases with age.
● Older children and adolescents have varying BP based
on body size. Larger children have a higher BP.
● Adults’ BP can increase with age.
● Older adult clients can have a slightly elevated systolic
pressure due to decreased elasticity of blood vessels.
Circadian (diurnal) rhythms affect BP, with BP usually
lowest in the early morning hours and peaking during the
later part of the afternoon or evening.
Stress associated with fear, emotional strain, and acute
pain can increase BP.
Ethnicity: African Americans have a higher incidence of
hypertension in general and at earlier ages.
Sex: Adolescent to middle‑age men have higher blood
pressures than their female counterparts. Postmenopausal
women have higher blood pressures than their male
counterparts.
Medications such as opiates, antihypertensives, and
cardiac medications can lower BP. Cocaine, nicotine,
cold medications, oral contraceptives, alcohol, and
antidepressants can raise BP.
Exercise can cause a decrease in BP for several hours
afterward.
Obesity is a contributing factor to hypertension.
Family history of hypertension, lack of exercise, high
sodium intake, and continuous stress can increase the risk
of hypertension.
NURSING INTERVENTIONS
EQUiPMEnt
Auscultatory method
● Sphygmomanometer with a pressure manometer
(aneroid or mercury) and a correctly sized cuff
◯ The width of the cuff should be 40% of the arm
circumference at the point where the cuff is wrapped.
◯ The bladder (inside the cuff) should surround 80% of
the arm circumference of an adult and the whole arm
for a child.
◯ Cuffs that are too large give a falsely low reading, and
cuffs that are too small give a falsely high reading.
● Stethoscope
Automatic blood pressure devices
Use when available for monitoring clients who require
frequent evaluation. Measure BP first using the
auscultatory method to make sure the automatic device
readings are valid.
PROCEDURE (aUSCUltatORY MEtHOD)
● Perform hand hygiene and provide privacy.
● Initially measure BP in both arms. If the difference
is more than 10 mm Hg, use the arm with the higher
reading for subsequent measurements. This difference
can indicate a vascular problem.
● Apply the BP cuff 2.5 cm (1 in) above the antecubital
space with the brachial artery in line with the marking
on the cuff.
● Use a lower extremity if the brachial artery is
not accessible.
● Estimate systolic pressure by palpating the radial pulse
and inflating the cuff until the pulse disappears. Inflate
the cuff another 30 mm Hg, and slowly release the
pressure to note when the pulse is palpable again (the
estimated systolic pressure).
● Deflate the cuff and wait 1 min.
● Position the stethoscope over the brachial artery.
● Close the pressure bulb by turning the valve clockwise
until tight.
● Quickly inflate the cuff to 30 mm Hg above the palpated
systolic pressure.
● Release the pressure no faster than 2 to 3 mm Hg
per second.
● The level at which you hear the first clear sounds is the
systolic pressure.
● Continue to deflate the cuff until the sounds muffle and
disappear and note the diastolic pressure.
● Record the systolic over the diastolic pressure
(110/70 mm Hg).
140 CHAPTER 27 Vital SignS CONTENT MASTERY SERIES
The client should
● Not use nicotine or drink any caffeine for 30 min prior
to measurement.
● Rest for 5 min before measurement.
● Sit in a chair, with the feet flat on floor, the back and
arm supported, and the arm at heart level.
The nurse should
● Use the auscultatory method with a properly calibrated
and validated instrument.
● Not measure BP in an arm with an IV infusion
in progress or on the side where the client had a
mastectomy or an arteriovenous shunt or fistula.
● Average two or more readings, taken at least 2 min
apart. (If they differ by more than 5 mm Hg, obtain
additional readings and average them.)
● After initial readings, measure BP and pulse with the
client standing.
UNEXPECTED BP READINGS
● It is helpful to measure the BP again near the end of
an encounter with the client. Earlier pressures can be
higher due to the stress of the clinical setting.
● Recheck blood pressures when you use an
automatic device.
● Deflate the cuff completely between attempts. Wait at
least 1 full min before reinflating the cuff. Air trapped in
the bladder can cause a falsely high reading.
COMPLICATIONS
Orthostatic (postural) hypotension
NURSING INTERVENTIONS
● Assess/monitor BP.
● Assess for dizziness, weakness, and fainting.
● Instruct the client to activate the call light and not to
get out of bed without assistance.
● Have the client sit at the edge of the bed for at least
1 min before standing up.
● Assist with ambulation.
HOME CARE INSTRUCTIONS
● Warn the client that lightheadedness and dizziness
can occur.
● Advise the client to sit or lie down if these
manifestations occur.
● Suggest that the client get up slowly when lying or
sitting and avoid sudden changes in position.
Hypertension
NURSING INTERVENTIONS
● Assess/monitor for tachycardia, bradycardia, pain,
and anxiety. Primary hypertension is usually
without manifestations.
● Assess for identifiable causes of hypertension (kidney
disease, thyroid disease, medication).
● Administer pharmacological therapy.
● Assess for risk factors.
● Encourage the client to follow up with the provider.
● Encourage lifestyle modifications.
◯ Cessation of smoking or use of smokeless tobacco
◯ Weight control
◯ Modification of alcohol intake
◯ Physical activity
◯ Stress reduction
◯ Dietary modifications
■ Dietary Approaches to Stop Hypertension (DASH) diet
■ Restrict sodium intake.
■ Consume adequate potassium, calcium, and
magnesium, which help lower BP.
■ Restrict cholesterol and saturated fat intake.
FUNDAMENTALS FOR NURSING CHAPTER 27 Vital SignS 141
Application Exercises
1. a nurse is caring for an 82‑year‑old
client in the emergency department
who has an oral body temperature of
38.3° C (101° F), pulse rate 114/min,
and respiratory rate 22/min. He is
restless and his skin is warm. Which
of the following interventions should
the nurse take? (Select all that apply.)
a. Obtain culture specimens
before initiating antimicrobials.
B. Restrict the client’s
oral fluid intake.
C. Encourage the client to
rest and limit activity.
D. allow the client to shiver
to dispel excess heat.
E. assist the client with oral
hygiene frequently.
2. a nurse is instructing an assistive
personnel (aP) about caring for
a client who has a low platelet
count as a result of chemotherapy.
Which of the following instructions
is the priority for measuring
vital signs for this client?
a. “Do not measure the client’s
temperature rectally.”
B. “Count the client’s radial
pulse for 30 seconds
and multiply it by 2.”
C. “Do not let the client know you
are counting her respirations.”
D. “let the client rest for
5 minutes before you measure
her blood pressure.”
3. a nurse is instructing a group of
nursing students in measuring a
client’s respiratory rate. Which of
the following guidelines should the
nurse include? (Select all that apply.)
a. Place the client in
semi‑Fowler’s position.
B. Have the client rest an arm
across the abdomen.
C. Observe one full respiratory
cycle before counting the rate.
D. Count the rate for 30 sec
if it is irregular.
E. Count and report any sighs
the client demonstrates.
4. a nurse who is admitting a client who
has a fractured femur obtains a blood
pressure reading of 140/94 mm Hg.
the client denies any history of
hypertension. Which of the following
actions should the nurse take first?
a. Request a prescription for an
antihypertensive medication.
B. ask the client if she
is having pain.
C. Request a prescription for
an antianxiety medication.
D. Return in 30 min to recheck
the client’s blood pressure.
5. a nurse is performing an admission
assessment on a client. the nurse
determines the client’s radial pulse
rate is 68/min and the simultaneous
apical pulse rate is 84/min. What
is the client’s pulse deficit?
PRACTICE Active Learning Scenario
a nurse is explaining to a group of nursing
students the various factors that can affect a
client’s heart rate. Use the ati active learning
template: Basic Concept to complete this item.
UNDERLYING PRINCIPLES: list at least five
factors that can cause tachycardia and at least
five factors that can cause bradycardia.
142 CHAPTER 27 Vital SignS CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: the provider can prescribe cultures to identify
any infectious organisms causing the fever. the nurse should
obtain culture specimens before antimicrobial therapy to
prevent interference with the detection of the infection.
B. the nurse should increase oral fluid intake to replace
the loss of body fluids from the diaphoresis and
increased metabolic rate the fever can cause.
C. CORRECT: Rest helps conserve energy and decreases
metabolic rate. activity can increase heat production.
D. the nurse should provide interventions to prevent
shivering, because shivering increases energy demands.
E. CORRECT: Oral hygiene helps prevent cracking of
dry mucous membranes of the mouth and lips.
NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs
2. a. CORRECT: the greatest risk to a client who has a low platelet
count is an injury that results in bleeding. Using a thermometer
rectally poses a risk of injury to the rectal mucosa. the low platelet
count contraindicates the use of the rectal route for this client.
B. the aP should count the radial pulse, unless it is irregular,
for 30 seconds and then multiply by 2 to obtain the number of
pulsations per minute. However, this is not the highest priority.
C. the aP should avoid letting the client know about counting
respirations as this awareness can sometimes alter the
respiratory rate. However, this is not the highest priority.
D. the aP should let the client rest for 5 min before
measuring blood pressure as activity can alter the
reading. However, this is not the highest priority.
NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs
3. a. CORRECT: Having the client sit upright facilitates full ventilation and
gives the students a clear view of chest and abdominal movements.
B. CORRECT: With the client’s arm across the abdomen or lower
chest, it is easier for the students to see respiratory movements.
C. CORRECT: Observing for one full respiratory cycle before starting
to count assists the students in obtaining an accurate count.
D. the students should count the rate for 1 min if it is irregular.
E. an occasional sigh is an expected finding in adults and can
assist to expand airways. Students do not need to count sighs.
NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs
4. a. the nurse should request a prescription for an antihypertensive
medication if the client’s blood pressure remains elevated
after the nurse implements other interventions to reduce it.
However, there is another action the nurse should take first
B. CORRECT: the first action the nurse should take using the
nursing process is to assess the client for pain which can cause
multiple complications, including elevated blood pressure.
therefore, the nurse’s priority is to perform a pain assessment. if
the client’s blood pressure is still elevated after pain interventions,
the nurse should report this finding to the provider.
C. the nurse should request a prescription for an anti‑anxiety
medication if the client’s blood pressure remains elevated
after the nurse implements other interventions to reduce it.
However, there is another action the nurse should take first.
D. the nurse should recheck the client’s blood pressure
in 30 min and periodically thereafter if it remains elevated
after the nurse implements other interventions to reduce it.
However, there is another action the nurse should take first.
NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs
5. 16/min
the pulse deficit is the difference between the apical and radial pulse
rates. it reflects the number of ineffective or nonperfusing heartbeats
that do not transmit pulsations to peripheral pulse points. 84‑68 = 16
NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
tachycardia
● Exercise
● Fever
● Medications: epinephrine,
levothyroxine, beta2 adrenergic
agonists (albuterol )
● Changing position from lying
down to sitting or standing
● acute pain
● Hyperthyroidism
● anemia, hypoxemia
● Stress, anxiety, fear
● Hypovolemia, shock, heart failure
Bradycardia
● long‑term physical fitness
● Hypothermia
● Medications: digoxin, beta‑blockers (propranolol),
calcium channel blockers (verapamil )
● Changing position from standing or sitting to lying down
● Chronic, severe pain
● Hypothyroidism
NCLEX® Connection: Reduction of Risk Potential, Changes/Abnormalities in Vital Signs
FUNDAMENTALS FOR NURSING CHAPTER 28 Head and neck 143
UNIT 2 HEALTH PROMOTION
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
CHAPTER 28 Head and Neck
This examination includes the head, neck, eyes,
nose, mouth, and throat.
Head and neck
● This examination includes the skull, face, hair, neck,
shoulders, lymph nodes, thyroid gland, trachea position,
carotid arteries, and jugular veins.
● Use the techniques of inspection, palpation, and
auscultation to examine the head and neck.
● Unexpected findings include palpation of a mass,
limited range of motion of the neck, and enlarged
lymph nodes.
● Equipment includes a stethoscope.
● Test the following cranial nerves (CN) during the head
and neck examination.
◯ CN V (trigeminal): Assess the face for strength
and sensation.
◯ CN VII (facial): Assess the face for
symmetrical movement.
◯ CN XI (spinal accessory): Assess the head and
shoulders for strength.
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you get headaches? If so, how often? Would you
point to the exact location? Do you have any other
manifestations related to your headaches, such as
nausea and vomiting? What do you do to relieve
the pain?
● Have you ever had a head injury?
● Do you have any pain in your neck?
● Can you move your head and shoulders with ease?
● Have you noticed any unusual facial movements?
● Are any of your lymph nodes swollen?
● Does anyone in your family have thyroid disease?
INSPECTION, PALPATION,
AND AUSCULTATION
Skull
EXPECTED FINDINGS
● Size (normocephalic)
● No depressions, deformities, masses, tenderness
● Overall contour and symmetry
Face
EXPECTED FINDINGS
● Symmetry of facial features (If there is asymmetry, note
if all features on one side of face are affected, or only
some of the features)
● Symmetry of expressions
● No involuntary movements
● Proportionate features (no thickening as with acromegaly)
● CN V
◯ MOTOR: Test the strength of the muscle contraction
by asking the client to clench her teeth while you
palpate the masseter and temporal muscles, and then
the temporomandibular joint. Joint movement should
be smooth.
◯ SENSORY: Test light touch by having the client close
her eyes while you touch her face gently with a wisp
of cotton. Ask her to tell you when she feels the touch.
● CN VII: MOTOR: Test facial movement and symmetry by
having the client smile, frown, puff out her cheeks, raise
her eyebrows, close her eyes tightly, and show her teeth.
Neck
EXPECTED FINDINGS
● Muscles of the neck symmetric.
● Shoulders equal in height and with average muscle mass.
◯ RANGE OF MOTION (ROM): Moving her head smoothly
and without distress in the following directions:
■ Chin to chest (flexion).
■ Ear to shoulder bilaterally (lateral flexion).
■ Chin up (hyperextension).
◯ CN XI: Place your hands on the client’s shoulders and
ask her to shrug her shoulders against resistance;
then turn head against resistance of your hand.
Lymph nodes
● Chains of lymph nodes extend from the lower half of
the head down into the neck. Palpate each node for
enlargement, in the following sequence.
◯ Occipital nodes: Base of the skull
◯ Postauricular nodes: Over the mastoid
◯ Preauricular nodes: In front of the ear
◯ Tonsillar (retropharyngeal) nodes: Angle of
the mandible
◯ Submandibular nodes: Along the base of the mandible
◯ Submental nodes: Midline under the chin
◯ Anterior cervical nodes: Along the
sternocleidomastoid muscle
◯ Posterior cervical nodes: Posterior to the
sternocleidomastoid muscle
◯ Supraclavicular nodes: Above the clavicles
● Lymph nodes are usually difficult to palpate and not
tender or visible.
● Use the pads of the index and middle fingers and move
the skin over the underlying tissue in a circular motion to
try to detect enlarged nodes. Compare from side to side.
● Evaluate any enlarged nodes for location, tenderness,
size, shape, consistency, mobility, and warmth.
CHAPTER 28
144 CHAPTER 28 Head and neck CONTENT MASTERY SERIES
Thyroid gland
The thyroid gland has two lobes and is fixed to the
trachea. It lies in front of the trachea and extends to
both sides.
Examine the gland by
● First, inspecting the lower half of the neck to see any
enlargement of the gland. An average‑size thyroid
gland is not visible. Having the client hyperextend
the neck helps makes the skin taut and allows
better visualization.
● Instructing the client to take a sip of water and feeling
the thyroid gland as it moves up with the trachea.
● Palpating the thyroid gland on both sides of the trachea
for size, masses, and smoothness.
AUSCULTATION: If the thyroid is enlarged, auscultate the
gland using a stethoscope. A bruit indicates an increase in
blood flow to the area, possibly due to hyperthyroidism.
Trachea
Inspect and palpate the trachea for any deviation from
midline above the suprasternal notch. Masses in the
neck or mediastinum and pulmonary abnormalities cause
lateral displacement.
Eyes
● This examination includes the external and internal
anatomy of the eye, visual pathways, fields, visual
acuity, extraocular movements, and reflexes.
● The primary technique for examination of the eyes is
inspection, with a limited amount of palpation that
requires gloves.
● Unexpected findings include loss of visual fields,
asymmetric corneal light reflex, periorbital edema,
conjunctivitis, and corneal abrasion.
● Perform the eye examination in the following sequence,
using the correct equipment.
◯ Visual acuity
■ Distant vision: Snellen and Rosenbaum charts, eye
cover, Ishihara test for color blindness
■ Near vision: hand‑held card
◯ Extraocular movements (EOMs): Penlight or
ophthalmoscope light, eye cover
◯ Visual fields: Eye cover
◯ External structures: Penlight or ophthalmoscope
light, gloves
◯ Internal structures: Ophthalmoscope
● Test cranial nerves during the eye examination.
◯ CN II (optic): visual acuity
◯ CN III (oculomotor), CN IV (trochlear), CN VI
(abducens): extraocular movements
◯ CN II (optic): visual fields
◯ CN II (optic), CN III (oculomotor): corneal light reflex,
pupillary reaction to light
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● How is your vision? Have you noticed any changes?
● Do you ever have blurry or double vision? Do you ever
see spots or halos?
● Do you have any eye pain, sensitivity to light, burning,
itching, dryness, or excessively watery eyes?
● Do you ever have drainage or crusting from your eyes?
● Do you wear eyeglasses? Contact lenses?
● When was your last eye examination?
● Have you ever been diagnosed with an eye disorder?
● Does anyone in your family have any eye disorders?
● Do you have diabetes mellitus?
INSPECTION
Visual acuity: CN II
● Have the client stand 20 feet from the Snellen (E) chart.
● Evaluate both eyes and then each eye separately with
and without correction.
● For each eye, cover the opposite eye.
● Ask the client to read the smallest line of print visible.
● Note the smallest line the client can read correctly.
● The first number is the distance (in feet) the client
stands from the chart. The second number is the
distance at which a visually unimpaired eye can see the
same line clearly.
For example: a 20/30 vision means a client can
read a line from 20 feet away that a person who
has unimpaired vision can read from 30 feet away.
Snellen chart: Use to screen for myopia (impaired
far vision).
Rosenbaum eye chart: Hold 14 inches from the client’s
face to screen for presbyopia (impaired near vision or
farsightedness). Readings correlate with the Snellen chart.
Color vision: Assess using the Ishihara test. The client
should be able to identify the various shaded shapes.
Extraocular movements: CN III, IV, VI
Assess EOMs to determine the coordination of the eye
muscles using three different tests (CN III, CN IV, CN VI).
● Assess for parallel eye movement, the position of
the upper eyelid, and the presence of abnormal eye
movements while the client looks in each direction (28.1).
● Test the corneal light reflex by directing a light onto the
eyes and looking to see if the reflection is symmetric on
the corneas.
● Screen for strabismus with the cover/uncover test.
While covering one eye, ask the client to look in another
direction. Remove the cover and expect both eyes to be
gazing in the same direction.
● The six cardinal positions of gaze require the client to
follow your finger with his eyes without moving his
head. Move your finger in a wide “H” pattern about
20 to 25 cm (7.9 to 9.8 in) to from the client’s eyes.
Expect smooth, symmetric eye movements with no
jerky or tremor‑like movements (nystagmus).
FUNDAMENTALS FOR NURSING CHAPTER 28 Head and neck 145
Visual fields: CN II
Evaluate by facing the client at a distance of 60 cm (2 ft).
The client covers one eye while you cover your direct
opposite eye (client’s right eye and your left eye). Ask
the client to look at you and report when she can see the
fingers on your outstretched arm coming in from four
directions (up, down, temporally, nasally). The expected
finding is that the client sees your fingers at the same
time you do.
External structures
EXPECTED FINDINGS
● Eyes parallel to each other without bulging
(exophthalmos) or crossing (strabismus)
● Eyebrows symmetric from the inner to the outer
canthus: can raise and lower symmetrically
● Eyelids closing completely and opening to show the
lower border and most of the upper portion of the iris
without ptosis (the upper eyelid covering the pupil)
● Eyelashes curving outward with no inflammation
around any of the hair follicles
● No edema or redness in the area of the lacrimal glands.
● Conjunctiva
◯ Palpebral pink
◯ Bulbar transparent
● The sclerae will be white in those who have fair skin
and light yellow in clients who have a dark complexion.
● Corneas clear, shiny, and smooth.
● Lenses clear, cloudy with cataracts
● Irises round and illuminating fully when you shine a
light across from the side. A partially illuminated iris
indicates glaucoma. Note the color of the irises.
PERRLA (CN II, CN III)
● P: Pupils clear
● E: Equal and between 3 to 7 mm
in diameter
● R: Round
● RL: Reactive to light both directly
and consensually when you direct
light into one pupil and then
the other
● A: Accommodation of the pupils
when they dilate to look at
an object far away and then
converge and constrict to focus
on a near object
Internal structures
Examine by
● Darken the room.
● Turn on the ophthalmoscope, and use the lens selector
disc to find the large white disc.
● The diopter is set at 0. You can change the setting to
bring structures into focus during the examination.
● Use your right eye to examine the client’s right eye and
vice versa.
● Instruct the client to stare at a point somewhere
behind you.
● Start slightly lateral and 25 to 30 cm from the client,
finding and following the red reflex, to within a
distance of 2 to 3 cm of the client’s eye.
EXPECTED FINDINGS
● The optic disc is light pink or more yellow than the
surrounding retina.
● The retina is without lesions. The color will be dark pink
in those with a dark complexion and light pink in those
who have fair skin.
● The arteries and veins have a 2:3 ratio with no nicking.
● Without pupil dilation, you might only glimpse the
macula briefly when the client looks directly at the light.
PALPATION
Palpate the lacrimal apparatus to assess for tenderness
and to express any discharge from the lacrimal duct.
Expected findings include no tenderness, no discharge,
and clear fluid (tears).
28.1 Extraocular movements
146 CHAPTER 28 Head and neck CONTENT MASTERY SERIES
Ears, nose, mouth, and throat
This examination includes the external, middle, and
internal ear; evaluation of hearing; the nose and sinuses;
and the mouth and throat.
● Use the techniques of inspection and palpation to
examine the ears, nose (sinuses), mouth, and throat.
● Unexpected findings include otitis externa, osteoma,
polyp, retracted drum, decreased hearing acuity,
and lateralization.
● Test the following cranial nerves during the ears, nose,
mouth, and throat examination.
◯ CN I (olfactory): Assess the nose for smell.
◯ CN VII (facial) and CN IX (glossopharyngeal): Assess
the mouth for taste.
◯ CN VIII (auditory): Assess the ears for hearing.
◯ CN IX (glossopharyngeal) and CN X (vagus): Assess
the mouth for movement of the soft palate and the
gag reflex. Assess swallowing and speech.
◯ CN XII (hypoglossal): Assess the tongue for movement
and strength.
EQUIPMENT
● Otoscope
● Wristwatch or clock to measure time in seconds
● Tuning fork
● Nasal speculum
● Tongue blade
● Penlight
● Gauze square
● Cotton‑tipped applicators
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● How well do you hear?
● Have you noticed any changes in your hearing? Do you
wear hearing aids?
● Have other people commented that you aren’t hearing
what they say?
● Do you ever have ringing or buzzing in your ears,
drainage, dizziness, itching, or pain? Do you have a
history of ear infections?
● Are you routinely exposed to loud noises
(work, recreation)?
● How do you clean your ears?
● Do you ever have pain, stuffiness, or fluid draining from
your nose?
● Have you ever suffered an injury to your nose?
● Do you ever have nosebleeds?
● Have you noticed any change in your senses of smell
or taste?
● Do you use nasal sprays?
● Do you snore or have difficulty breathing through
your nose?
● How often do you go to the dentist? Do you have
dentures? Retainers? Do you have any problems with
your gums?
● Do you have any difficulty swallowing or problems with
hoarseness or sore throat?
INSPECTION AND PALPATION
Ears
EXTERNAL EAR EXPECTED FINDINGS
● Alignment: The top of the auricles meeting an
imaginary horizontal line that extends from the outer
canthus of the eye. The auricles should be of equal size
and level with one another.
● Ear color matching face color
● No lesions, deformities, or tenderness
● No foreign bodies or discharge
● Presence of a small amount of cerumen
INTERNAL EAR
Straighten the ear canal by pulling the auricle up and
back for adults and older children, and down and back for
younger children. Using the otoscope, insert the speculum
slightly down and forward 1 to 1.5 cm (0.4 to 0.6 in)
following, but not touching, the ear canal to visualize:
● Tympanic membranes that are pearly gray and intact,
taut, and free from tears.
● A light reflex that is visible and in a well-defined
cone shape.
● Umbo and manubrium landmarks are readily visible.
● Ear canals are pink with fine hairs.
AUDITORY SCREENING TESTS
● Whisper test (CN VIII)
◯ TECHNIQUE
■ Occlude one ear and test the other to see if the
client can hear whispered sounds without seeing
your mouth move.
■ Repeat with the other ear.
◯ EXPECTED FINDING: The client can hear you whisper
softly from 30 to 60 cm (1 to 2 ft) away.
● Rinne test (28.2)
◯ TECHNIQUE
■ Place a vibrating tuning fork firmly against the
mastoid bone. Have the client state when he can no
longer hear the sound. Note the length of time that
the client heard the sound (bone conduction).
■ Then move the tuning fork in front of the ear canal.
When the client can no longer hear the tuning fork
sound, note the length of time the sound was heard
(air conduction).
◯ EXPECTED FINDING: Air conduction (AC) sound longer
than bone conduction (BC) sound; 2:1 ratio.
● Weber test (28.3)
◯ TECHNIQUE: Place a vibrating tuning fork on top of
the client’s head. Ask whether the client can hear
the sound best in the right ear, the left ear, or both
ears equally.
◯ EXPECTED FINDING: The client hears sound equally in
both ears (negative Weber test).
FUNDAMENTALS FOR NURSING CHAPTER 28 Head and neck 147
Nose
EXPECTED FINDINGS
● The nose is midline, symmetrical, and the same color
as the face. Observe for tenderness, swelling, masses,
or deviations.
● Each naris (nostril) is patent without excessive flaring.
The structure of the nose is firm and stable.
● To examine internal structures, insert a nasal speculum
just barely into each naris as the client tips his head back.
◯ Septum is midline and intact.
◯ Mucous membranes are deep pink and moist with no
discharge or lesions.
● Assess smell (CN I) by asking the client to close his
eyes, occlude one naris at a time, and identify a familiar
smell with the eyes closed.
Mouth and throat
EXPECTED FINDINGS
● Lips: Darker pigmented skin than the face and are moist,
symmetric, smooth, soft with no lesions, and nontender.
● Gums: Coral pink and tight against the teeth with no
bleeding on gloves from palpation.
● Mucous membranes: Pink and moist with no lesions.
● Tongue: Use a gauze pad to hold the tip and move the
tongue from side to side. The dorsal surface is pink,
with the presence of papillae, and symmetric. The
underside of the tongue is smooth with a symmetric
vascular pattern. Assess taste (CN VII, CN IX) by having
the client close his eyes and identify foods you place on
his tongue. Ask the client to move his tongue up, down,
and side to side. Test strength (CN XII) by applying
resistance against each cheek while the client sticks his
tongue into each cheek. The tongue is midline, moist,
free of lesions, and moves freely.
● Teeth: Shiny, white, and smooth. Check for
malocclusions by asking the client to clench his
teeth. Note any missing or loose teeth, as well as any
discoloration. Yellow or darkened teeth are common in
older adults because of long‑term wear.
● Hard palate: Whitish, intact, symmetric, firm,
and concave.
● Soft palate: Light pink, intact, smooth, symmetric, and
moves with vocalization (CN IX, CN X).
● Uvula: Pink, midline, intact, and moves
with vocalization.
● Tonsils: The same color as the surrounding mucosa and
vary in size and visibility.
◯ +1: Barely visible
◯ +2: Halfway to the uvula
◯ +3: Touching the uvula
◯ +4: Touching each other or midline
● Gag reflex: Elicit by using a tongue blade to stimulate
the back of the throat (CN IX, CN X). Explain
the procedure to the client prior to performing
this assessment.
● Speech: Clear and articulate.
Sinuses
TECHNIQUE
● Palpate the frontal sinuses by pressing upward with the
thumbs from just below the eyebrows on either side of
the bridge of the nose.
● Palpate the maxillary sinuses by pressing upward at the
skin crevices that run from the sides of the nose to the
corner of the mouth.
EXPECTED FINDING: Nontender
28.2 Rinne test 28.3 Weber test
148 CHAPTER 28 Head and neck CONTENT MASTERY SERIES
For all systems in this chapter
EXPECTED CHANGES WITH AGING
Eyes: Decreased visual acuity, decreased peripheral vision,
diminishing ability to see close objects or read small print
(presbyopia), decreased ability to accommodate extreme
changes in light (glare, darkness), difficulty distinguishing
colors, intolerance to glare, delayed pupillary reaction
to light, yellowing of the lens, thin gray‑white ring
surrounding the cornea, loss of lateral third of eyebrows
Ears: Hearing loss, loss of acuity for high‑frequency tones
(presbycusis), cerumen accumulation in the ear canal,
thickening of the tympanic membrane
Mouth: Decreased sense of taste due to reduced number
of taste buds, tooth loss, pale gums, gum disease due to
inadequate oral hygiene, darkening of teeth, decreased
salivation
Voice: Rise in pitch, loss of power and range
Nose: Decreased sense of smell
SAMPLE DOCUMENTATION
client reports no pain in head or neck region.
Skull normocephalic, symmetrical, and nontender.
Symmetric facial features, movements. Trachea
midline. Thyroid lobes palpable but not enlarged;
no nodules. neck supple with no palpable lymph
nodes. Full range of motion of the neck.
Visual acuity 20/30 in the left eye, 20/20 in the
right eye, 20/20 in both eyes without correction.
eOMs symmetric with no strabismus or nystagmus.
Peripheral fields full bilaterally. eyebrows evenly
distributed. eyelids close completely with no ptosis.
no discharge. Bulbar conjunctiva clear, palpebral
conjunctiva pink, sclerae white, irises blue bilaterally.
corneas and lenses clear. PeRRLa intact bilaterally.
Red reflex bilaterally. Retinas yellowish orange
with no nicking or hemorrhaging of vessels.
no lesions or tenderness on external ears. Top of
ears align with outer canthus of eyes. Tympanic
membranes pearly gray and translucent with
well‑defined cone of light. Light yellow cerumen
in ear canals bilaterally. auditory acuity intact to
whispered voice bilaterally. negative Weber test
and ac > Bc bilaterally. nose midline, symmetrical.
nares patent. nasal mucosa pink, septum intact
and midline, no discharge. no sinus tenderness.
Lips darker pink and intact, symmetric. Oral
mucosa pink, no dental caries, no missing teeth.
Tongue pink and midline. Papillae on dorsum,
symmetrical vascular pattern on the underside
of the tongue. Gums tight against the teeth with
no bleeding. Hard and soft palates intact with
no lesions. Uvula midline. Gag reflex present.
Tonsils +1 bilaterally. Taste and smell sensations
intact. Speech clear. cn I through XII intact.
FUNDAMENTALS FOR NURSING CHAPTER 28 Head and neck 149
Application Exercises
1. a nurse in a provider’s office
is preparing to test a client’s
cranial nerve function. Which of
the following directions should
she include when testing cranial
nerve V? (Select all that apply.)
a. “close your eyes.”
B. “Tell me what you can taste.”
c. “clench your teeth.”
d. “Raise your eyebrows.”
e. “Tell me when you feel a touch.”
2. a nurse is assessing a client’s thyroid
gland as part of a comprehensive
physical examination. Which of the
following findings should the nurse
expect? (Select all that apply.)
a. Palpating the thyroid in the
lower half of the neck
B. Visualizing the thyroid on
inspection of the neck
c. Hearing a bruit when
auscultating the thyroid
d. Feeling the thyroid ascend
as the client swallows
e. Finding symmetric extension
off the trachea on both
sides of the midline
3. a nurse is assessing an adult
client’s internal ear canals with an
otoscope as part of a head and
neck examination. Which of the
following actions should the nurse
take? (Select all that apply.)
a. Pull the auricle down and back.
B. Insert the speculum slightly
down and forward.
c. Insert the speculum 2 to
2.5 cm (0.8 to 1 in).
d. Make sure the speculum does
not touch the ear canal.
e. Use the light to visualize
the tympanic membrane
in a cone shape.
4. a nurse is caring for a client who
asks what her Snellen eye test results
mean. The client’s visual acuity
is 20/30. Which of the following
responses should the nurse make?
a. “Your eyes see at 20 feet
what visually unimpaired
eyes see at 30 feet.”
B. “Your right eye can see the
chart clearly at 20 feet, and
your left eye can see the
chart clearly at 30 feet.”
c. “Your eyes see at 30 feet
what visually unimpaired
eyes see at 20 feet.”
d. “Your left eye can see the
chart clearly at 20 feet, and
your right eye can see the
chart clearly at 30 feet.”
5. a nurse is performing a head and
neck examination for an older
adult client. Which of the following
age‑related findings should the
nurse expect? (Select all that apply.)
a. Reddened gums
B. Lowered vocal pitch
c. Tooth loss
d. Glare intolerance
e. Thickened eardrums
PRACTICE Active Learning Scenario
a nurse is assessing a client’s lymph nodes as part of a
comprehensive physical examination. Use the aTI active
Learning Template: nursing Skill to complete this item.
DESCRIPTION OF SKILL: List the nine chains
of lymph nodes and the location of each, in the
appropriate sequence for palpating them.
150 CHAPTER 28 Head and neck CONTENT MASTERY SERIES
Application Exercises Key
1. a. The first step of testing cranial nerve I, the olfactory
nerve, is to have the client close his eyes.
B. Testing cranial nerve VII, the facial nerve, involves
testing the mouth for taste sensations.
c. CORRECT: Testing cranial nerve V, the trigeminal nerve, involves
testing the strength of muscle contraction by asking the client
to clench his teeth while the nurse palpates the masseter and
temporal muscles, and then the temporomandibular joint.
d. Testing cranial nerve VII, the facial nerve, involves testing for
a range of facial expressions by having the client smile, raise his
eyebrows, puff out his cheeks, and perform other facial movements.
e. CORRECT: Testing cranial nerve V, the trigeminal nerve, involves
testing light touch by having the client tell the nurse when he
feels a gentle touch on his face from a wisp of cotton.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
2. a. CORRECT: The thyroid gland lies in the anterior portion
of the lower half of the neck, just in front of the trachea.
B. an average‑size thyroid gland is not visible on inspection.
c. a bruit indicates increased blood flow,
possibly due to hyperthyroidism.
d. CORRECT: When the client swallows a sip of water, the nurse
should feel the thyroid move upward with the trachea.
e. CORRECT: The thyroid gland lies in front of the trachea
and extends symmetrically to both sides of the midline.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
3. a. The nurse should pull the auricle up and back for adults
and down and back for children younger than 3 years.
B. CORRECT: Inserting the speculum slightly down and
forward follows the natural shape of the ear canal.
c. The nurse should insert the speculum 1 to 1.5 cm (0.4 to 0.6 in).
d. CORRECT: The lining of the ear canal is sensitive.
Touching it with the speculum could cause pain.
e. CORRECT: due to the angle of the ear canal, the nurse
can only visualize the light reflecting off of the tympanic
membrane as a cone shape rather than a circle.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
4. a. CORRECT: The first number is the distance (in feet) the client
stands from the chart. The second number is the distance at
which a visually unimpaired eye can see the same line clearly.
B. each eye has its own visual acuity, which includes both numbers.
c. The numerator of visual acuity results is a constant. It
does not change with a client’s ability to see clearly.
d. each eye has its own visual acuity, which includes both numbers.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
5. a. The nurse should expect an older adult’s gums to be pale.
B. The nurse should expect an older adult’s vocal pitch to rise.
c. CORRECT: Tooth loss and gum disease are common in older adults.
d. CORRECT: Older adults tend to become intolerant of glaring
lights and also lose some ability to distinguish colors.
e. CORRECT: Tympanic membranes (eardrums) thicken in older
adults, and they tend to accumulate cerumen in their ear canals.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
PRACTICE Answer
Using the ATI Active Learning Template: Nursing Skill
DESCRIPTION OF SKILL
● Occipital nodes: base of the skull
● Postauricular nodes: over the mastoid
● Preauricular nodes: in front of the ear
● Tonsillar (retropharyngeal) nodes: angle of the mandible
● Submandibular nodes: along the base of the mandible
● Submental nodes: midline under the chin
● anterior cervical nodes: along the sternocleidomastoid muscle
● Posterior cervical nodes: posterior to the
sternocleidomastoid muscle
● Supraclavicular nodes: above the clavicles
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
FUNDAMENTALS FOR NURSING CHAPTER 29 Thorax, hearT, and abdomen 151
UNIT 2 HEALTH PROMOTION
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
CHAPTER 29 Thorax, Heart,
and Abdomen
This examination includes the thorax (breast and
lungs), heart, and abdomen.
Breasts
● For clients who have had a mastectomy, breast
augmentation, or reconstruction, palpate the incisional
lines. Look for lymphedema in clients who have
impaired lymphatic drainage on the affected side.
● Instruct clients who do not currently perform monthly
breast self‑examination (BSE) to inspect their breasts in
front of a mirror and palpate them during a shower. The
optimal time is right after menstruation ends. Clients
who are pregnant or postmenopausal should perform
BSE on the same day of each month.
● Perform breast examinations on female and
male clients.
● Use the techniques of inspection and palpation to
examine the breasts.
EQUIPMENT
● Gloves
● Drape
● Small pillow or folded towel
DOCUMENTATION OF NODULES
● Location (quadrant or clock method)
● Size (centimeters)
● Shape
● Consistency (soft, firm, or hard)
● Discreteness (well-defined borders of mass)
● Tenderness
● Erythema
● Dimpling or retraction over the mass
● Lymphadenopathy
● Mobility
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you perform breast self‑examinations? How often?
● Have you noticed any tenderness or lumps? For women:
Does this change with your menstrual cycle?
● Do you have any thickening, pain, drainage, distortion,
or change in breast size, or any retraction or scaling of
the nipples?
● For clients over 40: How often are you
having mammograms?
● Has anyone in your family had breast cancer?
● Are you aware of the risks for breast cancer?
INSPECTION
Position client
● WOMEN: Four positions (sitting or standing)
◯ Arms at the side
◯ Arms above the head
◯ Hands on the hips pressing firmly
◯ Leaning forward (arms out in front or on hips)
● MEN: In sitting or lying position (with arms at the
side only)
Inspect for
● Size, symmetry (One breast is often slightly larger than
the other.)
● Shape (convex, conical, pendulous)
● Symmetric venous patterns and consistency of
skin color
● No lesions, edema, erythema (Rashes and ulcerations
are unexpected findings.)
● Round or oval shape of areola
● Darker‑pigmented areola and nipple
● Direction of nipples (Nipples are usually everted; recent
inversion is unexpected.)
● Bleeding or discharge from the nipples
● For women with large breasts, check for excoriation
under the breasts.
CHAPTER 29
152 CHAPTER 29 Thorax, hearT, and abdomen CONTENT MASTERY SERIES
PALPATION
Palpate axillary and clavicular lymph nodes with the
client sitting with her arms at her sides. Expect them to
be nonpalpable with no tenderness.
Breast examination
● Wear gloves if skin is not intact. Feel for lumps using
the finger pads of your three middle fingers. The best
position is for the client to be lying down with the
arm up by her head and a small pillow or folded towel
under the shoulder of the side you are examining. This
position spreads the breast tissue more evenly over the
chest wall, allowing for easier palpation.
● Palpate each breast from the sternum to the posterior
axillary line, and from the clavicle to the bra line
(including the areola, nipple, and tail of Spence) using
one of three techniques.
◯ Circular pattern
◯ Wedge pattern
◯ Vertical strip pattern
● Compress the nipples carefully between your thumb
and index finger to check for discharge (unexpected in
nonlactating women). Note the color, consistency, and
odor of any discharge.
● For pendulous breasts, use one hand to support the
lower portion of the breast while using your other hand
to palpate breast tissue against the supporting hand.
EXPECTED FINDINGS
● WOMEN
◯ Breasts firm, dense, elastic, and without lesions
or nodules
◯ Breast tissue granular or lumpy bilaterally in
some women
● MEN
◯ No edema, masses, nodules, or tenderness
◯ Areolas round and darker pigmented
UNEXPECTED FINDINGS
● WOMEN: Fibrocystic breast disease: tender cysts often
more prominent during menstruation
● MEN: Unilateral or bilateral (but asymmetrical)
gynecomastia in adolescent boys or
bilateral gynecomastia in older adult males
Thorax and lungs
● This examination includes the anterior and posterior
thorax and lungs.
● Use the techniques of inspection, palpation, percussion,
and auscultation.
EQUIPMENT
● Stethoscope
● Centimeter ruler
● Wristwatch or clock that allows for counting seconds
POSITIONING: Assess the posterior thorax with the client
sitting or standing. Assess the anterior thorax with the
client sitting, lying, or standing.
ANATOMICAL REMINDER: The right lung has three lobes;
the left lung has two lobes. Auscultate the right middle
lobe via the axillae.
VERTICAL CHEST LANDMARKS: Use the following
landmarks to perform assessments and describe findings.
● The midsternal line is through the center of
the sternum.
● The midclavicular line is through the midpoint of
the clavicle.
● The anterior axillary line is through the anterior
axillary folds.
● The midaxillary line is through the apex of the axillae.
● The posterior axillary line is through the posterior
axillary fold.
● The right and left scapular lines are through the
inferior angle of the scapula.
● The vertebral line is along the center of the spine.
PERCUSSION AND AUSCULTATORY SITES are in the
intercostal spaces (ICSs). The number of the ICSs
corresponds to the rib above it.
● Posterior thorax: The sites are between the scapula
and the vertebrae on the upper portion of the back.
Below the scapula, the sites are along the right and left
scapular lines.
● Anterior thorax: The sites are along the midclavicular
lines bilaterally, with several sites at the anterior/
midaxillary lines bilaterally in the lower portions of the
chest wall and on either side of the sternum following
along the rib cage. Observe for accessory muscle use.
● Percussing and auscultating in a systemic pattern
allows side‑to‑side comparisons.
● Maximize sounds by:
◯ Having the client take deep breaths with an open
mouth each time you move the stethoscope.
◯ Placing the diaphragm stethoscope directly on the
skin to prevent muffling or distortion of sounds.
◯ Facilitating breathing by medicating for pain,
giving clear directions, and assisting the client to a
sitting position.
Online Animation: Lung Landmarks
FUNDAMENTALS FOR NURSING CHAPTER 29 Thorax, hearT, and abdomen 153
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you have any chronic lung conditions such as asthma
or emphysema? Do you take any medications for your
respiratory problems?
● Have you ever had pneumonia? If so, when?
● Do you get coughs and colds frequently?
● Do you have environmental allergies?
● Do you ever have shortness of breath or difficulty
breathing with activity?
● Do you have a cough now? Do you cough up sputum? If
so, what does it look like?
● Do you currently or have you ever smoked? If you no
longer smoke, when did you quit? How long did you
smoke? If you do currently smoke, when did you start and
how much do you smoke? Are you interested in quitting?
● Are you exposed to secondhand smoke?
● Are you exposed to environmental pollutants in your
work area or residence?
● Has anyone in your family had lung cancer or
tuberculosis? Have you had any exposure to tuberculosis?
● Do you receive an influenza vaccine every year?
● Have you received a pneumonia vaccine?
● Have you had a TB test?
INSPECTION
SHAPE: The anteroposterior diameter is one third to one
half of the transverse diameter.
SYMMETRY: The chest is symmetric with no deformities
of the ribs, sternum, scapula, or vertebrae, and equal
movements during respiration.
ICS: No excessive retractions.
RESPIRATORY EFFORT
● Rate and pattern: 12 to 20/min and regular
● Character of breathing (diaphragmatic,
abdominal, thoracic)
● Use of accessory muscles
● Chest wall expansion
● Depth of respirations: unlabored, quiet breathing
COUGH: If productive, note the color and consistency
of sputum.
TRACHEA: Midline.
PALPATION
● Surface characteristics include tenderness, lesions,
lumps, and deformities. Tenderness is an unexpected
finding. Avoid deep palpation if the client reports pain
or tenderness.
● Chest excursion or expansion of the posterior thorax:
With thumbs aligned parallel along the spine at the
level of the tenth rib, and the hands flattened around
the client’s back, instruct the client to take a deep
breath. Move your thumbs outward approximately
5 cm (2 in) when the client takes a deep inspiration.
Vocal (tactile) fremitus
● Palpate the chest wall using the palms of both hands,
comparing side to side from top to bottom.
● Ask the client to say “99” each time you move
your hands.
EXPECTED FINDINGS: Vibration is symmetric and more
pronounced at the top, near the level of the tracheal
bifurcation.
PERCUSSION
● Compare sounds from side to side.
● Percussion of the thorax elicits resonance.
UNEXPECTED FINDINGS AND SIGNIFICANCE
● Dullness: In fluid or solid tissue, this can indicate
pneumonia or a tumor.
● Hyperresonance: In the presence of air, this can
indicate pneumothorax or emphysema.
AUSCULTATION
exPeCTed SoUndS
Bronchial: Loud, high‑pitched, hollow quality, expiration
longer than inspiration over the trachea
Bronchovesicular: Medium pitch, blowing sounds and
intensity with equal inspiration and expiration times over
the larger airways
Vesicular: Soft, low‑pitched, breezy sounds, inspiration
three times longer than expiration over most of the
peripheral areas of the lungs
UnexPeCTed or adVenTITIoUS SoUndS
Crackles or rales: Fine to coarse bubbly sounds (not
cleared with coughing) as air passes through fluid or
re‑expands collapsed small airways
Wheezes: High‑pitched whistling, musical sounds as air
passes through narrowed or obstructed airways, usually
louder on expiration
Rhonchi: Coarse, loud, low‑pitched rumbling sounds
during either inspiration or expiration resulting from fluid
or mucus, can clear with coughing
Pleural friction rub: Dry, grating, or rubbing sound as
the inflamed visceral and parietal pleura rub against each
other during inspiration or expiration
Absence of breath sounds: From collapsed or surgically
removed lobes
154 CHAPTER 29 Thorax, hearT, and abdomen CONTENT MASTERY SERIES
Heart
This examination includes measuring heart rate and blood
pressure, examining the jugular veins, and auscultating
heart sounds.
EQUIPMENT
● Stethoscope
● Blood pressure cuff
● Wristwatch or clock that allows for counting seconds
● Two rulers
Cardiac cycle and heart sounds
● Closure of the mitral and tricuspid valves signals the
beginning of ventricular systole (contraction) and
produces the S1 sound (lub). Place the diaphragm of the
stethoscope at the apex.
● Closure of the aortic and pulmonic valves signals the
beginning of ventricular diastole (relaxation) and
produces the S2 sound (dub). Place the diaphragm of the
stethoscope at the aortic area.
● An S3 sound (ventricular gallop) indicates rapid
ventricular filling and can be an expected finding
in children and young adults. Use the bell of
the stethoscope.
● An S4 sound reflects a strong atrial contraction and can
be an expected finding in older and athletic adults and
children. Use the bell of the stethoscope.
● Dysrhythmias occur when the heart fails to beat at
regular successive intervals.
● Gallops are extra heart sounds. Use the bell of
the stethoscope.
◯ Ventricular gallop occurs after S2, sounds like
“Ken‑tuck’‑y”
◯ Atrial gallop occurs before S1, sounds like
“Ten’‑es‑see”
● Murmurs are audible when blood volume in the heart
increased or its flow is impeded or altered. Use the bell
of the stethoscope to hear the characteristic blowing or
swishing sound. Can be asymptomatic or a finding of
heart disease.
◯ Systolic murmurs occur just after S1.
◯ Diastolic murmurs occur just after S2.
● Thrills are a palpable vibration that can accompany
murmurs or cardiac malformation.
● Bruits are blowing or swishing sounds that indicate
obstructed peripheral blood flow. Use the bell of
the stethoscope.
Auscultatory sites for the heart
Aortic: Just right of the sternum at the second ICS
Pulmonic: Just left of the sternum at the second ICS
Erb’s point: Just left of the sternum at the third ICS
Tricuspid: Just left of the sternum at the fourth ICS
Apical/mitral: Left midclavicular line at the fifth ICS
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you have any problems with your heart? Do you take
any medications for your heart?
● Have you had any history of heart trouble, preexisting
diabetes, lung disease, obesity, or hypertension?
● Do you have high blood pressure or high cholesterol?
● Do your feet and ankles ever swell?
● Do you cough frequently?
● Do you have chest pain? When? How long does it last?
How often does it occur? Describe the pain. Do you also
feel it in your arms, neck, or jaw?
● What are you doing before the pain begins?
● Do you have any other symptoms with the pain (nausea,
shortness of breath, sweating, dizziness)?
● What have you tried to relieve the pain? Does it work?
● Describe your energy level. Are you frequently tired? Do
you have unusual fatigue?
● Do you have fainting spells or dizziness? If so, how
often? When was the last time?
● What is your stress level?
● Do currently or have a history of smoking, drinking
alcohol, using caffeine, using prescriptive or
recreational drugs?
● Describe your exercise habits.
● Describe your dietary pattern and intake.
● Are you familiar with the risk factors for heart disease?
● Does anyone in your family have health problems
related to the heart?
INSPECTION AND PALPATION
VITAL SIGNS: Pulse and blood pressure reflect
cardiovascular status.
Peripheral vascular system
Inspect jugular veins with the client in bed with the head
of the bed at a 30° to 45° angle to assess for right‑sided
heart failure.
APPEARANCE: no neck vein distention
JUGULAR VENOUS PRESSURE (JVP): Measure at less than
2.5 cm (1 in) above the sternal angle using the following
technique:
● Place one ruler vertically at the sternal angle.
● Locate the pulsation in the external jugular vein and
place the straight edge of another ruler parallel to the
floor at the level of the pulsation.
● Line up the two rulers as a T square, keeping the
horizontal ruler at the level of pulsation.
● Measure JVP at the level where the horizontal ruler
intersects the vertical ruler.
● Bilateral pressures greater than 2.5 cm (1 in) are
considered elevated, and a finding of right-sided
heart failure. One‑sided pressure elevation
indicates obstruction.
◯ Examine one carotid artery at a time. If you occlude
both arteries simultaneously during palpation, the
client loses consciousness as a result of inadequate
circulation to the brain.
Online Image: Cardiac Landmarks
FUNDAMENTALS FOR NURSING CHAPTER 29 Thorax, hearT, and abdomen 155
Heart
APICAL PULSE OR POINT OF MAXIMAL IMPULSE (PMI)
● Can be visible just medial to the left midclavicular line
at the fourth or fifth ICS. With female clients, displace
the breast tissue.
● Palpate where you visualized it. Otherwise, try to
palpate the location to feel the pulsations.
HEAVES (OR LIFTS) are unexpected, visible elevations of
the chest wall that indicate heart failure, and are often
along the left sternal border or at the PMI.
THRILLS: Use the palm of the hand to feel for vibration
similar to that of a purring kitten. This is an
unexpected finding.
AUSCULTATION
Heart
● Positioning the client in three different ways allows for
optimal assessment of heart sounds, as some positions
amplify extra or abnormal sounds.
◯ Sitting, leaning forward
◯ Lying supine
◯ Turned toward the left side (best position for
auscultating extra heart sounds or murmurs)
● Use both the diaphragm and the bell of the stethoscope
in a systematic manner to listen at all of the
auscultatory sites.
● To measure the heart rate, listen and count for 1 min.
Determine if the rhythm is regular. If a dysrhythmia
exists, check for a pulse deficit (radial pulse slower than
apical pulse). Report a difference in pulse rates to the
provider immediately.
Peripheral vascular system
LOCATIONS TO ASSESS FOR BRUITS
● Carotid arteries: Over the carotid pulses
● Abdominal aorta: Just below the xiphoid process
● Renal arteries: Midclavicular lines above the umbilicus
on the abdomen
● Iliac arteries: Midclavicular lines below the umbilicus
on the abdomen
● Femoral arteries: Over the femoral pulses
Abdomen
● This examination includes observing the shape of the
abdomen, palpating for masses, and auscultating for
vascular sounds.
● Use the techniques of inspection, auscultation,
percussion, and palpation. Note that this changes the
usual order of assessment techniques. Auscultate just
after inspection, because percussion and palpation can
alter bowel sounds.
● EQUIPMENT
◯ Stethoscope
◯ Tape measure or ruler
◯ Marking pen
● Ask the client to urinate before the abdominal
examination. Have the client lie supine with arms at
sides and knees slightly bent.
● Imagine vertical and horizontal lines through the
umbilicus to divide the abdomen into four quadrants
with the xiphoid process as the upper boundary and the
symphysis pubis as the lower boundary.
◯ Right upper quadrant
◯ Left upper quadrant
◯ Right lower quadrant
◯ Left lower quadrant
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you ever have nausea, vomiting, or cramping?
● Have you had any change in your appetite? Do you have
any food intolerances? Any recent weight changes?
● Do you have any difficulty with swallowing, belching
or gas?
● Have you had any vomit containing blood?
● Do you have any problems with your bowels? Do you
get diarrhea? Constipation? When was your last bowel
movement? Do you often use laxatives or enemas?
● Have you had any black or tarry stools?
● Do you take aspirin or ibuprofen? If so, how often?
● Do you ever have heartburn? When? How often?
● Have you had any low abdominal or back pain? Any
tenderness in these areas?
● Have you had any abdominal surgery, injuries, or
diagnostic tests in this area?
● Has anyone in your family had colon cancer?
● For clients over 50: Do you have routine colonoscopies?
● Are you aware of the warning signs of colon cancer?
● Do you drink alcohol? If so, how much?
● What do you eat and drink on a typical day?
● Do you have any dietary restrictions or special practices?
● Do you have any health problems related to the
stomach or bowels? Do you take any medications for
these problems? Do you have any family history of
these conditions?
156 CHAPTER 29 Thorax, hearT, and abdomen CONTENT MASTERY SERIES
INSPECTION
● Note any guarding or splinting of the abdomen.
● Inspect the umbilicus for position, shape, color,
inflammation, discharge, and masses.
ASSESS THE SKIN FOR
● Lesions: Bruising, rashes, or other primary lesions
● Scars: Location and length
● Silver striae or stretch marks (expected findings)
● Dilated veins: An unexpected finding possibly reflecting
cirrhosis or inferior vena cava obstruction
● Jaundice, cyanosis, or ascites: Possibly
reflecting cirrhosis
SHAPE OR CONTOUR
● Flat: In a horizontal line from the xiphoid process to the
symphysis pubis
● Convex: Rounded
● Concave: A sunken appearance
● Distended: A large protrusion of the abdomen due to fat,
fluid, or flatus
◯ Fat: The client has rolls of fat tissue along her sides,
and the skin does not look taut.
◯ Fluid: The flanks also protrude, and when the client
turns onto her side, the protrusion moves to the
dependent side.
◯ Flatus: The protrusion is mainly midline, and there is
no change in the flanks.
◯ Hernias: Protrusions through the abdominal muscle
wall are visible, especially when the client raises
her head.
MOVEMENT OF THE ABDOMINAL WALL
● Peristalsis: Wavelike movements visible in thin adults
or in clients who have intestinal obstructions.
● Pulsations: Regular beats of movement midline above
the umbilicus are expected findings in thin adults, but a
pulsating mass is unexpected.
AUSCULTATION
Bowel sounds result from the movement of air and fluid
in the intestines. The most appropriate time to auscultate
bowel sounds is in between meals.
● TECHNIQUE: Listen with the diaphragm of the
stethoscope in all four quadrants.
● EXPECTED SOUNDS: High‑pitched clicks and gurgles
5 to 35 times/min. To make the determination of absent
bowel sounds, you must hear no sounds after listening
for a full 5 min.
● UNEXPECTED SOUNDS: Loud, growling sounds
(borborygmi) are hyperactive sounds and indicate
increased gastrointestinal motility. Possible causes
include diarrhea, anxiety, bowel inflammation, and
reactions to some foods.
Friction rubs result from the rubbing together of inflamed
layers of the peritoneum.
● Listen with the diaphragm over the liver and spleen.
● Ask the client to take a deep breath while you listen for
any grating sounds (like sandpaper rubbing together).
PERCUSSION
● Expect to hear tympany over most of the abdomen. A
lower‑pitch tympany over the gastric bubble in the left
upper quadrant is common.
● Expect dullness over the liver or a distended bladder.
● The liver span is a measurement of liver size at the right
midclavicular line.
◯ Establish the lower border of the liver by percussing
upward from below the umbilicus at the right
midclavicular line until tympany turns to dullness.
◯ Make a mark.
◯ Establish the upper border by percussing downward,
starting at the right midclavicular line over the lung
until resonance turns to dullness.
◯ Make a mark.
◯ Measure the distance between the two marks for the
size of the liver span.
◯ The expected finding is 6 to 12 cm (2.4 to 4.7 in).
● Assess for kidney tenderness by fist percussion over the
costovertebral angles at the scapular lines on the back.
The expected finding is no tenderness.
PALPATION
Palpate tender areas last.
Light
● Use the finger pads on one hand to palpate to a depth of
1.3 cm (0.5 in) in each quadrant.
● Expect softness, no nodules, and no guarding.
● The bladder is palpable if full; otherwise, it is nonpalpable.
Deep
TWO‑HANDED APPROACH: The top hand depresses the
bottom hand 2.5 to 7.5 cm (1 to 3 in) in depth. The bottom
hand assesses for organ enlargement or masses.
EXPECTED FINDINGS: The stool can be palpable in the
descending colon.
29.1 Abdominal assessment
FUNDAMENTALS FOR NURSING CHAPTER 29 Thorax, hearT, and abdomen 157
Rebound tenderness (Blumberg’s sign)
An indication of irritation or inflammation somewhere in
the abdominal cavity. Use the following technique in all
four quadrants.
● Apply firm pressure for 4 seconds with the hand at a
90° angle and with the fingers extended.
● After releasing the pressure, observe the client’s
response to see if releasing the pressure caused pain.
● Ask about pain and tenderness.
● Never palpate an abdominal mass, tender organs, or
surgical incisions deeply.
For all systems in this chapter
EXPECTED CHANGES WITH AGING
Breasts
● With menopause, glandular tissue atrophies.
Adipose tissue replaces it, making it feel softer and
more pendulous. The atrophied ducts can feel like
thin strands.
● Nipples no longer have erectile ability and can invert.
Lungs
● Chest shape changes so that the AP diameter becomes
similar to the transverse diameter (barrel chest),
resulting in decreased vital capacity.
● Chest excursion or expansion diminishes.
● Cough reflex diminishes.
● Cilia ineffectively removes dust and irritants from
the airways.
● Alveoli dwindle, airway resistance increases, and the
risk of pulmonary infection increases.
● Kyphosis, an increased curvature of the thoracic spine
due to osteoporosis and weakened cartilage, results in
vertebral collapse and impairment of respiratory effort.
Cardiovascular system
● Systolic hypertension (widened pulse pressure) is a
common finding with atherosclerosis.
● The PMI becomes more difficult to palpate because the
AP diameter of the chest widens.
● Coronary blood vessel walls thicken and become more
rigid with a narrowed lumen.
● Cardiac output decreases and strength of contraction
leads to poor activity tolerance.
● Heart values stiffen due to calcification.
● The left ventricle thickens.
● Pulmonary vascular tension increases.
● Systolic blood pressure rises.
● Peripheral circulation diminishes.
Abdomen
● Weaker abdominal muscles declining in tone and
more adipose tissue result in a rounder, more
protruding abdomen.
● Peritoneal inflammation is more difficult to detect due
to less pain, guarding, fever, and rebound tenderness.
● Saliva, gastric secretions, and pancreatic
enzymes decrease.
● Esophageal peristalsis and small‑intestine
motility decrease.
SAMPLE DOCUMENTATION
breasts conical, symmetric in size, and without
masses or lesions. nipples and areolae darker
pigmented and symmetric. everted nipples
without discharge. no palpable axillary or
clavicular lymph nodes. no pain or tenderness.
respiratory rate 16/min and regular. respirations
easy and unlabored. Thorax has a greater transverse
than aP diameter. no chest wall deformities.
Trachea midline. movement symmetric with 5 cm
of expansion. equal tactile fremitus. resonant
sounds throughout. Vesicular sounds primarily over
the bases bilaterally. no adventitious sounds. no
cough, shortness of breath, difficulty breathing.
heart rhythm and rate regular at 72/min. blood
pressure 118/76 mm hg. no thrills or heaves.
PmI approximately 1 cm at the fifth ICS left
midclavicular line. S1 louder at the apex than S2.
S2 loudest in the pulmonary area on inspiration.
no extra heart sounds, murmurs, or bruits. JVP
2 cm bilaterally. no chest pain or discomfort.
abdomen flat with active bowel sounds every
10 to 20 seconds in all four quadrants. no bruits
or friction rubs. abdomen soft, nontender,
and without masses or enlargement of spleen
or liver. Liver span 8 cm. no rebound or
costovertebral tenderness. bladder not palpable.
no pain or discomfort in abdominal region.
158 CHAPTER 29 Thorax, hearT, and abdomen CONTENT MASTERY SERIES
Application Exercises
1. a nurse in a provider’s office is
preparing to perform a breast
examination for an older adult client
who is postmenopausal. Which of
the following findings should the
nurse expect? (Select all that apply.)
a. Smaller nipples
b. Less adipose tissue
C. nipple discharge
d. more pendulous
e. nipple inversion
2. a nurse in a provider’s office
is preparing to auscultate and
percuss a client’s thorax as part
of a comprehensive physical
examination. Which of the
following findings should the nurse
expect? (Select all that apply.)
a. rhonchi
b. Crackles
C. resonance
d. Tactile fremitus
e. bronchovesicular sounds
3. during an abdominal examination,
a nurse in a provider’s office
determines that a client has
abdominal distention. The protrusion
is at midline, the skin over the area
is taut, and the nurse notes no
involvement of the flanks. Which
of the following possible causes of
distention should the nurse suspect?
a. Fat
b. Fluid
C. Flatus
d. hernias
4. during a cardiovascular examination,
a nurse in a provider’s office places
the diaphragm of the stethoscope
on the left midclavicular line at
the fifth intercostal space. Which
of the following heart sounds
is the nurse attempting to
auscultate? (Select all that apply.)
a. Ventricular gallop
b. Closure of the mitral valve
C. Closure of the pulmonic valve
d. Closure of the tricuspid valve
e. murmur
5. a nurse in a provider’s office
is preparing to auscultate and
percuss a client’s abdomen as
part of a comprehensive physical
examination. Which of the
following findings should the nurse
expect? (Select all that apply.)
a. Tympany
b. high‑pitched clicks
C. borborygmi
d. Friction rubs
e. bruits
PRACTICE Active Learning Scenario
a nurse is teaching a group of newly licensed nurses about
identifying chest landmarks to help them find the optimal
locations for auscultation of the thorax. Use the aTI active
Learning Template: basic Concept to complete this item.
UNDERLYING PRINCIPLES: List the seven key chest
landmarks, along with their location on the thorax.
FUNDAMENTALS FOR NURSING CHAPTER 29 Thorax, hearT, and abdomen 159
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● midsternal line: through the center of the sternum
● midclavicular line: through the midpoint of the clavicle
● anterior axillary line: through the anterior axillary folds
● midaxillary line: through the apex of the axillae
● Posterior axillary line: through the posterior axillary fold
● right and left scapular lines: through the
inferior angle of the scapula
● Vertebral line: along the center of the spine
NCLEX® Connection: Health Promotion and Maintenance,
Techniques of Physical Assessment
Application Exercises Key
1. a. CORRECT: In older adulthood, the nipples become smaller and flatter.
b. older adults have more adipose tissue and
less glandular tissue in their breasts.
C. older adults have no nipple discharge, unless
there is some underlying pathophysiology.
d. CORRECT: In older adulthood, breasts
become softer and more pendulous.
e. CORRECT: nipple inversion is common among older
adults, due to fibrotic changes and shrinkage.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
2. a. rhonchi are coarse sounds that result
from fluid or mucus in the airways.
b. Crackles are fine to coarse popping sounds that result from air
passing through fluid or re‑expanding collapsed small airways.
C. CORRECT: resonance is the expected percussion sound over
the thorax. It is a hollow sound that indicates air inside the lungs.
d. Tactile fremitus is an expected vibration the nurse can
expect to feel or palpate as the client vocalizes. Speech
creates sound waves, the vibrations of which travel from the
vocal cords through the lungs and to the chest wall.
e. CORRECT: bronchovesicular sounds are expected breath sounds
of medium pitch and intensity and of equal inspiration and expiration
time. The nurse can expect to hear them over the larger airways.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. a. With fat, there are rolls of adipose tissue along
the sides, and the skin does not look taut.
b. With fluid, the flanks also protrude, and when the client turns
onto one side, the protrusion moves to the dependent side.
C. CORRECT: With flatus, the protrusion is mainly
midline, and there is no change in the flanks.
d. With hernias, protrusions through the abdominal muscle
wall are visible, especially when the client raises her head.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
4. a. To auscultate a ventricular gallop (an S3 sound), the nurse places
the bell of the stethoscope at each of the auscultatory sites.
b. CORRECT: To auscultate the closure of the mitral valve, the nurse
places the diaphragm of the stethoscope over the apex, or apical/mitral
site, which is on the left midclavicular line at the fifth intercostal space.
C. To auscultate the closure of the pulmonic valve, the nurse places
the diaphragm of the stethoscope over the aortic area, which is
just to the right of the sternum at the second intercostal space.
d. CORRECT: To auscultate the closure of the tricuspid valve, the nurse
places the diaphragm of the stethoscope over the apex, or apical/mitral
site, which is on the left midclavicular line at the fifth intercostal space.
e. To auscultate a murmur, the nurse places the bell of
the stethoscope at various auscultatory sites.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
5. a. CORRECT: Tympany is the expected drumlike percussion
sound over the abdomen. It indicates air in the stomach.
b. CORRECT: Typical bowel sounds are high‑pitched
clicks and gurgles occurring about 35 times/min.
C. borborygmi are unexpected loud, growling sounds that indicate
increased gastrointestinal motility. Possible causes include diarrhea,
anxiety, bowel inflammation, and reactions to some foods.
d. Friction rubs result from the rubbing together of inflamed
layers of the peritoneum and are unexpected findings.
e. bruits indicate narrowed blood vessels and are unexpected findings.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
FUNDAMENTALS FOR NURSING CHAPTER 30 Integumentary and PerIPheral Vascular systems 161
UNIT 2 HEALTH PROMOTION
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
CHAPTER 30 Integumentary
and Peripheral
Vascular Systems
assess the integumentary (skin, hair, scalp, and
nails) and peripheral vascular systems at the
same time.
First, examine the upper extremities while the
client is sitting or recumbent. then remove
stockings/socks, and drape the client to expose
the entire lower extremity at once. make
side‑to‑side comparisons to evaluate for
variations of symmetry. examine lesions
individually. use the Braden scale or a similar
assessment tool to predict pressure‑ulcer risk.
Inspect and palpate simultaneously.
equipment includes adequate lighting, gloves
for palpating open or draining lesions, a flexible
ruler or tape measure to measure the size and
depth of lesions in centimeters, and a gown or
drape to cover the client.
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Have you noticed any change in your skin color? If so, is
the change widespread or just in one area?
● Do you have a rash? Where? Does it itch? How long have
you had it? What have you used to treat the rash?
● Is your skin excessively dry or oily? Does this change
with the seasons? Do you use anything to treat it?
● Have you developed any new moles or lesions? Have
any of the moles or lesions changed in any way (color,
borders, size)?
● How often are you out in the sun? Do you use sunscreen
or wear protective clothing and a hat?
● Do you have any swelling? If in your legs, is it in both
legs? Does the swelling cause pain? What do you do to
relieve the swelling? Does it occur at any particular time
of day?
INSPECTION AND PALPATION
Hair, skin, and nails
● Assess the color of the hair, nails, and skin for
uniformity. Hair color can vary due to dyes or from
aging changes. Typically, skin color varies from ivory to
ruddy to deep brown. Color changes are more difficult to
notice in dark‑skinned clients.
◯ Pallor: loss of color
■ LOCATION: face, conjunctivae, nail beds, palms,
lips, buccal mucosa
■ INDICATION: Anemia, shock, or lack of blood flow
◯ Cyanosis: bluish
■ LOCATION: nail beds, lips, mouth mucosa,
skin, palms
■ INDICATION: Hypoxia or impaired venous return
◯ Jaundice: yellow to orange
■ LOCATION: skin, sclera, mucous membranes
■ INDICATION: Liver dysfunction, red blood‑cell
destruction
◯ Erythema: redness
■ LOCATION: face, skin, trauma and pressure
sore areas
■ INDICATION: Inflammation, localized vasodilation,
substance use, sun exposure, rash, elevated
body temperature
● Note cleanliness of the hair, skin, and nails, as well as
any odors.
● Expect firm nail bases and nail angles to be
approximately 160°. Note the curvature of the nail plate
in relationship to the tissue just before the cuticle.
◯ Clubbing, an angle of the nail greater than 160°, can
result from chronic low oxygen saturation related
to heart and lung disease (emphysema, chronic
bronchitis). (The angle of the nail and base can
eventually exceed 180°).
● Expect pink, symmetric nail beds. Capillary refill
assesses circulation to the periphery. Assess capillary
refill by applying firm pressure to the nail bed to blanch
it. Quick release of the pressure should result in a brisk
return of color (within 2 seconds).
● Expect even hair distribution patterns and symmetric
hair loss, as with male pattern baldness. Note any
infestations of the hair or skin. Alopecia can result from
endocrine disorders and poor nutrition.
● Expect skin color of the extremities to be symmetric
and similar to the rest of the body.
◯ Brown pigmentation changes with
venous insufficiency.
◯ Shiny and translucent skin without hair on the toes
and foot indicates arterial insufficiency.
● Palpate the temperature of the skin with the dorsal part
of the hand and assess for symmetry of temperature,
and expect warmth. Note changes reflecting circulation
impairment or environmental temperature. Slightly
cooler temperatures of the hands or feet are acceptable.
● Expect smooth, soft, even skin. Hair can be smooth,
coarse, or fine. Thicker skin of the palms and soles of
the feet is an expected finding.
CHAPTER 30 View Video: Capillary Refill
162 CHAPTER 30 Integumentary and PerIPheral Vascular systems CONTENT MASTERY SERIES
● Assess skin turgor by lifting and releasing a fold of skin
on the forearm or sternum to verify that it returns
quickly into place. Tenting is a delay in the skin
returning to its usual place. Poor turgor indicates
dehydration or aging, increasing the risk for skin
breakdown.
● Moisture in the axillae is an expected finding.
Otherwise, the skin should be dry. Note diaphoresis,
oiliness, or excessive dryness with flaking or scaling.
Peripheral arteries
● Palpate the peripheral pulses for strength (amplitude)
and equality (symmetry).
◯ Strength (amplitude): The same from beat to beat
◯ Grade strength as
■ 0 = Absent, unable to palpate
■ 1+ = Diminished, weaker than expected
■ 2+ = Brisk, expected
■ 3+ = Increased
■ 4+ = Full volume, bounding
◯ Equality: Symmetric in quality and quantity from the
right side of the body to the left
● With the exception of the carotid arteries, palpate pulse
sites bilaterally to make comparisons.
◯ Carotid pulse: On either side of the trachea, just
medial to the sternocleidomastoid muscle on the neck
◯ Radial pulse: On the radial (or thumb) side of
each wrist
◯ Brachial pulse: In the antecubital fossa above
the elbow
◯ Femoral pulse: Midway between the symphysis pubis
and the anterosuperior iliac spine
◯ Popliteal pulse: Behind the knee, deep in the popliteal
fossa, just lateral to midline
◯ Dorsalis pedis pulse: On the top of the foot, along
a line with the groove between the first toe and the
extensor tendons of the great toe
◯ Posterior tibial pulse: Behind and below the medial
malleolus of the ankles
● Inspect peripheral veins for varicosities, redness,
and swelling.
Edema
Edema is an accumulation of fluid in the tissues most
often from direct trauma or impaired venous return.
The presence of edema causes swelling with the skin
appearing shiny and tight.
● Assess the swelling for discoloration, location,
and tenderness. In the extremities, measure the
circumference of the swollen body area and compare
both sides.
● Evaluate pitting by compressing the skin for at least
5 seconds over a bony prominence (behind the medial
malleolus, the dorsum of foot, or over the shin) and
then assess. The depth of pitting reflects the degree
of edema.
◯ 1+ = Trace, 2 mm, rapid skin response
◯ 2+ = Mild, 4 mm, 10‑ to 15‑second skin response
◯ 3+ = Moderate, 6 mm, prolonged skin response
◯ 4+ = Severe, 8 mm, prolonged skin response
Lesions
Examine skin lesions for size, color, shape, consistency,
elevation, location, distribution, configuration, tenderness,
fluid, and drainage. Measure the height, width, and depth
of lesions. Observe a lesion for any odor, exudate, the
amount and consistency of the exudate and document.
Primary lesions arise from healthy skin tissue. Common
examples include the following.
● Macule
◯ Nonpalpable, skin color change, smaller than 1 cm
◯ EXAMPLES: Freckle, petechiae
● Papule
◯ Palpable, circumscribed, solid elevation of skin,
smaller than 1 cm
◯ EXAMPLE: Elevated nevus
● Nodule
◯ Palpable, circumscribed, deep, firm, 1 to 2 cm
◯ EXAMPLE: Wart
● Vesicle
◯ Serous fluid-filled, smaller than 1 cm
◯ EXAMPLES: Blister, herpes simplex, varicella
● Pustule
◯ Pus-filled, varies in size
◯ EXAMPLE: Acne
● Tumor
◯ Solid mass, deep, larger than 1 to 2 cm
◯ EXAMPLE: Epithelioma
● Wheal
◯ Palpable, irregular borders, edematous
◯ EXAMPLE: Insect bite
● Atrophy
◯ Thinning of skin with loss of normal skin furrow.
Skin is shiny and translucent
◯ EXAMPLE: Arterial insufficiency
Secondary lesions result from a change in a primary
lesion. Common examples include the following.
● Erosion
◯ Lost epidermis, moist surface, no bleeding
◯ EXAMPLE: Ruptured vesicle
● Crust
◯ Dried blood, serum, or pus
◯ EXAMPLE: Scab
● Scale
◯ Flakes of skin that exfoliate
◯ EXAMPLES: Dandruff, psoriasis, eczema
● Fissure
◯ Linear crack
◯ EXAMPLE: Tinea pedis
● Ulcer
◯ Loss of epidermis and dermis with possible
bleeding, scarring
◯ EXAMPLES: Venous stasis ulcer, pressure ulcer
View Video: Skin Turgor
FUNDAMENTALS FOR NURSING CHAPTER 30 Integumentary and PerIPheral Vascular systems 163
Common examples of skin lesions in various age groups
include the following.
● CHILDREN
◯ Diaper dermatitis
◯ Intertrigo
◯ Impetigo
◯ Atopic dermatitis (eczema)
● ADULTS
◯ Primary contact dermatitis
◯ Tinea pedis (ringworm of the foot)
◯ Psoriasis
◯ Labial herpes simplex (cold sores)
● OLDER ADULTS
◯ Lentigines (liver spots)
◯ Seborrheic keratosis
◯ Acrochordons (skin tags)
◯ Sebaceous hyperplasia
Vascular lesions result from aging changes or
blood‑vessel damage in or near the skin. Common
examples include the following.
● Spider angioma: Red center with radiating red legs, up
to 2 cm, possibly raised
● Cherry angioma: Red, 1 to 3 cm, round, possibly raised
● Spider vein: Bluish, spider‑shaped or linear, up to
several inches in size
● Petechiae/purpura: Deep reddish purple, flat, petechiae
1 to 3 mm, purpura larger than 3 mm
● Ecchymosis: Purple fading to green or yellow over time,
variable in size, flat
● Hematoma: Raised ecchymosis
EXPECTED CHANGES WITH AGING
Integumentary system
● Skin thin and translucent, dry, flaky, tears easily, loss of
elasticity and wrinkling
● Thinning of hair
● Slow growth of nails with thickening
● Decline in glandular structure and function (less oil,
moisture, sweat)
● Uneven pigmentation
● Slow wound healing
● Little subcutaneous tissue over bony prominences
Peripheral vascular system
● Thicker, more rigid peripheral blood vessel walls with a
narrowed lumen leading to poor peripheral circulation
● Higher systolic blood pressure
SAMPLE DOCUMENTATION
skin pink, warm, and dry. turgor brisk, skin
elastic. rough, thickened skin over heels, elbows,
and knees; otherwise, smooth. a 0.5 cm brown
papule on right forearm and a 2.5 cm scar on left
knee. scalp dry with slight dandruff. hair brown,
clean, smooth, straight, evenly distributed on the
head. axillary and pubic hair evenly distributed
with no infestations. nails short and firm with no
clubbing. capillary refill < 3 seconds. no edema.
Pulses palpable, 2+, and equal bilaterally.
Application Exercises
1. a nurse in a provider’s office is
preparing to assess a client’s
skin as part of a comprehensive
physical examination. Which of the
following findings should the nurse
expect? (select all that apply.)
a. capillary refill less
than 2 seconds
B. 1+ pitting edema in both feet
c. Pale nail beds in both hands
d. thick skin on the
soles of the feet
e. numerous light brown
macules on the face
2. a nurse is assessing an older adult
client who has significant tenting
of the skin over his forearm. Which
of the following factors should the
nurse consider as a cause for this
finding? (select all that apply.)
a. thin, parchment‑like skin
B. loss of adipose tissue
c. dehydration
d. diminished skin elasticity
e. excessive wrinkling
3. a nurse is assessing postoperative
circulation of the lower extremities for
a client who had knee surgery. the
nurse should include which of the
following? (select all that apply.)
a. range of motion
B. skin color
c. edema
d. skin lesions
e. skin temperature
4. a nurse is performing skin
assessments on a group of clients.
Which of the following lesions
should the nurse identify as
vesicles? (select all that apply.)
a. acne
B. Warts
c. Psoriasis
d. herpes simplex
e. Varicella
5. a nurse is performing an
integumentary assessment for
a group of clients. Which of the
following findings should the
nurse recognize as requiring
immediate intervention?
a. Pallor
B. cyanosis
c. Jaundice
d. erythema
164 CHAPTER 30 Integumentary and PerIPheral Vascular systems CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: the nurse should expect capillary refill
in less than 2 seconds as an expected finding.
B. the nurse should not expect pitting edema, which can
reflect excess fluid that has accumulated in body tissues.
c. the nurse should not expect pallor in the nail beds,
which can reflect anemia or impaired circulation.
d. CORRECT: the nurse should expect thicker skin on the
palms of the hands and the soles of the client’s feet.
e. CORRECT: the nurse should expect light brown
macules on the face, such as freckles, .
NCLEX® Connection: Physiological Adaptation, Pathophysiology
2. a. the older adult client as aging occurs will have skin that becomes
thin and translucent and is not a factor for tenting of the skin.
B. CORRECT: tenting is a delay in the skin returning to its normal
place after pinching. tenting is a manifestation of aging skin and
loss of subcutaneous tissue that provides recoil in younger skin.
c. CORRECT: tenting is a delay in the skin returning to its
normal place after pinching. dehydration can cause the skin
to tent, which can easily develop in the older adult client.
d. CORRECT: tenting is a delay in the skin returning to its
normal place after pinching. tenting in the older adult client
is a manifestation of aging skin and loss of elasticity.
e. the older adult client who has aging skin does become
wrinkled, but is not a factor for tenting of the skin
NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. a. determining range of motion helps the nurse
evaluate joint function, not circulation.
B. CORRECT: the nurse should assess the peripheral vascular system
to verify adequate circulation to the client’s legs, which includes
skin color. Pallor and cyanosis reflect inadequate circulation.
c. CORRECT: the nurse should assess the peripheral vascular
system to verify adequate circulation to the client’s legs, which
includes edema. edema reflects inadequate venous circulation.
d. Inspecting for skin lesions is part of an integumentary
assessment, but it does not evaluate circulation. some skin
lesions do reflect inadequate circulation, but they would not
have developed in the immediate postoperative period.
e. CORRECT: the nurse should assess the peripheral vascular
system to verify adequate circulation to the client’s legs, which
includes skin temperature. coolness of the extremity compared
with the nonoperative extremity indicates inadequate circulation.
NCLEX® Connection: Physiological Adaptation,
Illness Management
4. a. acne lesions are pustules, not vesicles.
B. Warts are nodules, not vesicles.
c. Psoriasis lesions are scales, not vesicles.
d. CORRECT: herpes simplex lesions are vesicles, which
are circumscribed fluid‑filled skin elevations. eczema and
impetigo also cause vesicles to appear on the skin.
e. CORRECT: Varicella (chickenpox) lesions are vesicles, which
are circumscribed fluid‑filled skin elevations. eczema and
impetigo also cause vesicles to appear on the skin.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
5. a. the nurse should report pallor, which can indicate anemia or
circulation difficulties. however, another assessment finding is the priority.
B. CORRECT: the priority finding when using the airway,
breathing, circulation (aBc) approach to care is cyanosis, which
an indication of hypoxia (inadequate oxygenation). therefore, the
nurse should immediately report this finding to the provider.
c. the nurse should report jaundice, which can indicate
liver dysfunction or red blood cell destruction. however,
another assessment finding is the priority.
d. the nurse should report erythema, which can indicate
inflammation. however, another assessment finding is the priority.
NCLEX® Connection: Physiological Adaptation,
Illness Management
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
● have you noticed any changes in your skin color? If
so, is the change widespread or just in one area?
● do you have a rash? Where? does it itch? how long have
you had it? What have you used to treat the rash?
● Is your skin excessively dry or oily? does this change
with the seasons? do you use anything to treat it?
● have you developed any new moles or lesions? have any of the
moles or lesions changed in any way (color, borders, size)?
● how often are you out in the sun? do you use
sunscreen or wear protective clothing and a hat?
● do you have any swelling? If in your legs, is it in both legs?
does the swelling cause pain? What do you do to relieve
the swelling? does it occur at any particular time of day?
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
PRACTICE Active Learning Scenario
a nurse is reviewing the questions to ask when interviewing
clients as part of an integumentary and peripheral
vascular assessment. use the atI active learning
template: Basic concept to complete this item.
NURSING INTERVENTIONS: Identify at least five
questions to ask prior to beginning the inspection
and palpation portions of the assessment.
FUNDAMENTALS FOR NURSING CHAPTER 31 Musculoskeletal and neurosensory systeMs 165
UNIT 2 HEALTH PROMOTION
SECTION: HEALTH ASSESSMENT/DATA COLLECTION
CHAPTER 31 Musculoskeletal
and Neurosensory
Systems
this examination includes muscles, joints, range
of motion, mental status, cranial nerves, and
motor and sensory function.
Musculoskeletal system
● Examination of the musculoskeletal system includes
assessing both its structure and function.
● Assessment involves examining each joint, muscle,
and the surrounding tissues bilaterally and comparing
findings for symmetry.
● Use the techniques of inspection and palpation to assess
the musculoskeletal system.
EQUIPMENT
● Tape measure
● Drape or cover for privacy
ASSESS
● Gait: Manner or style of walking
● Alignment: Position of the joints, tendons, muscles, and
ligaments while sitting, standing and lying
● Symmetry, muscle mass
● Muscle tone: Normal state of balanced muscle tension
allowing one to maintain positions such as sitting
or standing
● Range of motion (ROM): Maximum amount of
movement of a joint – sagittal (left or right), transverse
(side to side) and frontal (front to back).
● Any involuntary movements
● Indications of inflammation: Redness, swelling,
warmth, tenderness, loss of function
● Gross deformities
EXPECTED RANGE OF MOTION OF JOINT MOVEMENT
● Flexion: Movement that decreases the angle between
two adjacent bones
● Extension: Movement that increases the angle between
two adjacent bones
● Hyperextension: Movement of a body part beyond its
normal extended position
● Supination: Movement of a body part so the ventral
(front) surface faces up
● Pronation: Movement of a body part so the ventral
(front) surface faces down
● Abduction: Movement of an extremity away from the
midline of the body
● Adduction: Movement of an extremity toward the
midline of the body
● Dorsiflexion: Flexing the foot and toes upward
● Plantar flexion: Bending the foot and toes downward
● Eversion: Turning a body part away from midline
● Inversion: Turning a body part toward the midline
● External rotation: Rotating a joint outward
● Internal rotation: Rotating a joint inward
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you have any pain in your joints or muscles?
● Do you have any stiffness, weakness, or twitching?
● Have you fallen recently?
● Are you able to care for yourself?
● Do you have any physical problems that limit
your activities?
● Do you exercise or participate in sports on a regular basis?
● For postmenopausal women: What was your maximum
height? Do you take calcium supplements?
INSPECTION
SYMMETRY: Observe and compare both sides of the body
for symmetry.
HEIGHT: Measure for comparison over time. Gradual
height loss is a common finding as a person ages.
POSTURE: Observe when the client is unaware. Expected
finding: client standing with head erect with both
shoulders and hips at equal heights bilaterally.
SPINE: Inspect from the side. Note the following curvatures:
Expected curvatures (posteriorly)
● Concave cervical spine
● Convex thoracic spine
● Concave lumbar spine
● Convex sacral spine
UNEXPECTED FINDINGS
● Kyphosis: exaggerated curvature of the thoracic spine
(common among older adults)
● Lordosis: exaggerated curvature of the lumbar spine
(common during the toddler years and pregnancy)
● Scoliosis: exaggerated lateral curvature
CHAPTER 31
166 CHAPTER 31 Musculoskeletal and neurosensory systeMs CONTENT MASTERY SERIES
INSPECTION AND PALPATION
Expect equal range of motion (ROM) in the joints bilaterally.
● Assess passive ROM by moving the client’s joints
through his full range of movements. Do not move a
joint past the point of pain or resistance.
● Assess active ROM by having the client repeat the
movements the nurse demonstrates.
● Assess joints for warmth, inflammation, edema,
stiffness, crepitus, deformities, tenderness, limitations,
and instability. Assess the following joints.
◯ Temporomandibular joint
◯ Shoulders
◯ Elbows
◯ Wrists and hands
◯ Spine (scoliosis)
◯ Hips
◯ Knees
◯ Ankles, feet
Muscles should be firm, symmetric, and have equal
strength bilaterally. The dominant side is usually slightly
larger; less than a 1 cm difference is not significant.
● Size variations
◯ Hypertrophy: Enlargement of muscle due to
strengthening
◯ Atrophy: Decrease in muscle size due to disuse; feels
soft and boggy
● During ROM, assess tone: slight resistance of the
muscles during relaxation.
● Assess the strength of muscle groups by asking the
client to push or pull against resistance. Expected
finding: strength equal, or slightly stronger, on the
dominant side of the body.
● Assess for muscle tremors.
Inspect and palpate the spine from the back for any lateral
deviations or scoliosis.
● Instruct the client to bend at the waist with the arms
reaching for the toes.
● Inspect and palpate down the spine using the thumb
and forefinger.
● Inspect and palpate the spine again with the
client standing.
● Expected finding: No tenderness, with spinal vertebrae
that are midline.
Neurosensory system
● A neurological screening examination can evaluate the
major indicators of neurological function and assist
with recognition of areas of dysfunction.
● Integrate the neurological system with
other assessments.
EXAMINATION COMPONENTS
● Mental status examination to test cerebral function
● Assessment of cranial nerves
● Motor function to test cerebellar function
● Sensory function
● Reflexes
EQUIPMENT
● Snellen and Rosenbaum eye charts
● Aromatic substances
● Tongue blades
● Penlight
● Sugar and salt
● Tuning fork
● Reflex hammer
● Cotton balls
● Two test tubes containing water (one cold, one warm)
● Pencil
● Paper clips
● Key
HEALTH HISTORY: REVIEW OF SYSTEMS
QUESTIONS TO ASK
● Do you have any dizziness or headaches?
● Do you ever have seizures? If so, what triggers them?
● Have you ever had a head injury or any loss
of consciousness?
● Have you noticed any change in your vision, speech,
ability to think clearly, loss of memory, or change in
memory or behavior?
● Do you have any weakness, numbness, tremors, or
tingling? If so, where?
FUNDAMENTALS FOR NURSING CHAPTER 31 Musculoskeletal and neurosensory systeMs 167
INSPECTION
Mental status
● Describe levels of consciousness and observed behavior
with the following terms.
◯ Alert: The client is responsive and able to open
his eyes and answer questions spontaneously
and appropriately.
◯ Lethargic: The client is able to open his eyes and
respond but is drowsy and falls asleep readily.
◯ Obtunded: The client responds to light shaking but
can be confused and slow to respond.
◯ Stuporous: The client requires painful stimuli
(pinching a tendon or rubbing the sternum) to achieve
a brief response. The client might not be able to
respond verbally.
◯ Comatose: There is no response to repeated
painful stimuli. Abnormal posturing in clients who
are comatose:
■ Decorticate rigidity: Flexion and internal rotation
of upper extremity joints and legs
■ Decerebrate rigidity: Neck and elbow extension,
with the wrists and fingers flexed
● Assess appearance by observing hygiene, grooming,
and clothing choice. EXPECTED FINDINGS: client is
clean and dressed appropriately for the environment
or situation.
● Assess mood by inspecting mannerisms and actions
during interactions. EXPECTED FINDINGS: client
makes eye contact, and emotions correspond to the
conversation and situation.
● Assess cognitive and intellectual processes:
◯ Assess memory, both recent and remote.
■ Recent: Ask the client to repeat a series of numbers
or a list of objects.
■ Remote: Ask the client to state his birth date or
mother’s maiden name (verifiable).
◯ Level of knowledge: Ask the client what he knows
about his current hospitalization or illness.
◯ Ability for calculation: Ask the client to count
backward from 100 in serials of 7.
◯ Abstract thinking: Ask the client the interpretation
of a cliché such as, “A bird in the hand is worth two
in the bush.” This demonstrates a higher level of
thought processes.
◯ Insight: Perform an objective assessment of the
client’s perception of illness.
◯ Judgment: Ask the client about the solution to a
specific dilemma. (“What would you do if you locked
your keys in your car?”)
◯ Thought process: Note processing differences, such
as a rapid change of topic (flight of ideas) and use of
nonsense words (“hipsnippity”).
◯ Thought content: Note the presence of delusions,
hallucinations, and other ideas the client presents
during the interview.
● Expect speech and language rate and features, such
as quality, quantity, and volume, to be articulate and
responses meaningful and appropriate.
31.1 Cranial nerve functions
EARS, NOSE,
MOUTH,
AND THROAT EYES
HEAD
AND NECK
NEURO
LOGICAL
✔ I (Olfactory) SENSORY: smell
✔ II (Optic) SENSORY: visual acuity, visual fields
✔
III (Oculomotor),
IV (Trochlear), and
VI (Abducens)
MOTOR: Perrla, six cardinal positions of gaze
✔ V (Trigeminal)
SENSORY: light touch sensation to
the face (forehead, cheek, jaw)
MOTOR: jaw opening, clenching, chewing
✔ VII (Facial)
SENSORY: taste (salt/sweet) on
anterior two thirds of the tongue
MOTOR: facial movements
✔ VIII (Auditory) SENSORY: hearing and balance
✔ ✔ IX (Glossopharyngeal)
SENSORY: taste (sour/bitter) on
posterior third of the tongue
MOTOR: swallowing, speech sounds, gag reflex
✔ X (Vagus) SENSORY: gag reflex
MOTOR: swallowing, speech sounds
✔ XI (Spinal accessory) MOTOR: turning head, shrugging shoulders
✔ XII (Hypoglossal) MOTOR: tongue movement
168 CHAPTER 31 Musculoskeletal and neurosensory systeMs CONTENT MASTERY SERIES
STANDARDIZED SCREENING TOOLS
● Use the Mini‑Mental State Examination to assess
cognitive status objectively. The tool evaluates:
◯ Orientation to time and place
◯ Attention and calculation of counting backward
by sevens
◯ Registration and recalling of objects
◯ Language, including naming of objects, following of
commands, and ability to write
◯ Reading
● Use the Glasgow Coma Scale to obtain a baseline
assessment of the client’s level of consciousness and for
ongoing assessment.
◯ This assessment looks at eye, verbal, and motor
response, and assigns a number value based on the
client’s response.
◯ The highest value possible is 15, indicating
full consciousness.
Motor function
● Assess coordination by asking the client to extend
his arms and rapidly touch his finger to his nose,
alternating hands, and then doing it with his
eyes closed. EXPECTED FINDINGS include smooth,
coordinated movements.
● Assess gait when the client is unaware of the
assessment. EXPECTED FINDING: Gait is steady, smooth,
and coordinated.
● Assess balance using the following tests.
◯ Romberg test: Ask the client to stand with his feet
together, his arms at his sides, and his eyes closed.
EXPECTED FINDING: The client stands with minimal
swaying for at least 5 seconds.
◯ Heel-to-toe walk: Ask the client to place the heel
of one foot in front of the toes of the other foot as
he walks in a straight line. EXPECTED FINDING:
The client walks in a straight line without losing
his balance.
● Muscle strength: Assess the strength of muscle groups
by asking the client to push or pull against resistance.
EXPECTED FINDING: Strength is equal or slightly
stronger on the dominant side of the body.
Sensory function
Perform tests on all four extremities with the client’s
eyes closed.
● Assess pain sensation by alternating sharp and dull objects
on the skin and asking the client to report what he feels.
● Assess temperature by using two test tubes containing
water (one warm and one cold), and ask the client to
identify which he feels.
● Assess light touch by asking the client to report when
and where he feels a cotton ball touching his skin.
● Assess vibration by having the client report when and
where he feels the handle of the vibrating tuning fork
on his skin.
● Assess position by repositioning the client’s appendages
and asking him to report whether each is positioned up
or down.
● Assess discrimination by using one of the following.
◯ Two-point discrimination: Use open paper clips to
determine the smallest distance between the two
points at which the client can still feel the two points
on his skin and not just one. Compare bilaterally.
Minimal distance varies with the body part.
◯ Stereognosis: Place a familiar object (key, cotton ball)
in the client’s hand, and ask him to identify it.
◯ Graphesthesia: Trace a number on the client’s palm
with the blunt end of a pencil and ask him to identify it.
Deep‑tendon reflexes (DTRs)
Using a reflex hammer, assess DTRs bilaterally and
compare results for symmetry.
Biceps
● Flex arm 45°.
● Place the thumb on the tendon in antecubital fossa.
● Strike the thumb with a reflex hammer.
● EXPECTED RESPONSE: Flexion of the elbow
Brachioradialis
● Rest a forearm on the examiner’s forearm with the wrist
slightly pronated.
● Strike the tendon 2.5 to 5 cm above the wrist.
● EXPECTED RESPONSE: Pronation of the forearm and
flexion of the elbow
Triceps
● Support the upper arm with the forearm hanging at a
90° angle.
● Strike the tendon above the elbow.
● EXPECTED RESPONSE: Extension of the elbow
Patellar
● With the upper leg supported and the lower leg dangling
freely, strike the tendon below the knee.
● EXPECTED RESPONSE: Extension of the lower leg
Achilles
● Flex the knee, dorsiflex the foot, and strike the tendon
above the heel.
● EXPECTED RESPONSE: Plantar flexion of the foot
Grade DTR responses as
● 4+ = Very brisk with clonus
● 3+ = More brisk than average
● 2+ = Expected
● 1+ = Diminished
● 0 = No response
FUNDAMENTALS FOR NURSING CHAPTER 31 Musculoskeletal and neurosensory systeMs 169
For all systems in this chapter
EXPECTED CHANGES WITH AGING
Musculoskeletal system
● Reduced muscle mass
● Declines in speed, strength, resistance to fatigue,
reaction time, coordination
● Osteoporosis (fragility of bones, loss of bone mass
and height)
● Greater risk of fractures and vertebral compression
● Degenerative alterations in joints
● Limited range of motion
● Flexed elbows, hips, and knees
● Thinning intervertebral discs, kyphosis (with height
loss), wider stance altering posture
Neurological system
● Some short‑term memory decline
● Diminished/slowed reflex and motor responses, impulse
transmission, and reaction times
● Altered vibration, position, hearing, vision, smell, and
deep pain and temperature sensation
● Slower fine finger movement (no change in superficial
pain and light touch sensation, standing balance)
● Decline in mental function probably related to less
cognitive stimulation and solitude
● Fewer brain cells, smaller brain volume, deteriorating
nerve cells, fewer neurotransmitters
● With infection, delirium more common than fever
● Greater risk of depression
SAMPLE DOCUMENTATION
Full range of motion without pain in all joints and
spine. no joint deformities, warmth, or swelling.
Posture erect. spine midline with expected cervical,
thoracic, and lumbar curvatures. no scoliosis.
Muscle strength equal and strong bilaterally.
Application Exercises
1. a nurse in a provider’s office is
preparing to assess a young adult
male client’s musculoskeletal
system as part of a comprehensive
physical examination. Which of the
following findings should the nurse
expect? (select all that apply.)
a. concave thoracic
spine posteriorly
B. exaggerated lumbar curvature
c. concave lumbar
spine posteriorly
d. exaggerated thoracic curvature
e. Muscles slightly larger
on his dominant side
2. a nurse is assessing a client’s
neurosensory system. to evaluate
stereognosis, the nurse should ask
the client to close his eyes and
identify which of the following items?
a. a word she whispers
30 cm from his ear
B. a number she traces on
the palm of his hand
c. the vibration of a tuning
fork she places on his foot
d. a familiar object she
places in his hand
3. a nurse is caring for a client who
reports pain with internal rotation of
her right shoulder. the nurse should
identify that this discomfort can
affect the client’s ability to perform
which of the following activities?
a. Mopping her floors
B. Brushing the back of her hair
c. Fastening her bra
behind her back
d. reaching into a cabinet
above her sink
4. a nurse is performing a neurosensory
examination for a client. Which of
the following assessments should
the nurse perform to test the client’s
balance? (select all that apply.)
a. romberg test
B. Heel‑to‑toe walk
c. snellen test
d. spinal accessory function
e. rosenbaum test
5. a nurse is collecting data from
an older adult client as part of a
neurosensory examination. Which
of the following findings should the
nurse expect as changes associated
with aging? (select all that apply.)
a. slower light touch sensation
B. some vision and
hearing decline
c. slower fine finger movement
d. some short‑term
memory decline
e. slower superficial
pain sensation
170 CHAPTER 31 Musculoskeletal and neurosensory systeMs CONTENT MASTERY SERIES
Application Exercises Key
1. a. the nurse should expect the client to have
a convex thoracic spine posteriorly.
B. although lordosis (an exaggerated lumbar curvature) is
common among toddlers and pregnant women, the nurse
should not expect this finding in a young adult male client.
c. CORRECT: the nurse should expect the client to
have a concave lumbar spine posteriorly.
d. although kyphosis (an exaggerated lumbar curvature)
is common among older adults, the nurse should
not expect this finding in a young adult client.
e. CORRECT: the nurse should expect the client to have muscle
size equal on both sides or slightly larger on the dominant side.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
2. a. Identifying a whispered word confirms that cranial nerve VIII is intact.
B. Identifying a tracing on the palm confirms the client’s
sense of graphesthesia, which is the ability to use only the
sensation of touch to recognize writing on the skin.
c. Identifying the vibration of a tuning fork
confirms the client’s vibratory sense.
d. CORRECT: Identifying a familiar object in the hand confirms
the client’s sense of stereognosis, which is tactile recognition.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
3. a. the client who is mopping the floor requires
flexion and extension of the shoulder.
B. the client who is brushing the back of the hair
requires external rotation of the shoulder.
c. CORRECT: the client who is fastening a bra from behind requires
internal rotation of the shoulder, so this activity will elicit pain.
d. the client who is reaching for something up high
requires external rotation of the shoulder.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
4. a. CORRECT: For the romberg test, the client stands with his eyes
closed, arms at his side, and feet together. the nurse verifies balance
if the client can stand with minimal swaying for at least 5 seconds.
B. CORRECT: For the heel‑to‑toe walk, the client places the
heel of one foot in front of the toes of the other foot as he
walks in a straight line. the nurse verifies balance if the client
can walk in a straight line without losing his balance.
c. a snellen eye chart tests visual acuity, not balance.
d. testing spinal accessory function verifies that cranial
nerve XI is intact by asking the client to shrug his
shoulders and turn his head against resistance.
e. a rosenbaum eye chart tests visual acuity, not balance.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
5. a. light touch sensation typically remains the
same for the client who is aging.
B. CORRECT: losses in vision, hearing, taste, and
smell decline for the client who is aging.
c. CORRECT: Fine finger movement slows, along with some
reflex and motor responses for the client who is aging.
d. CORRECT: Minimal decline in short‑term memory is
an expected finding for the client who is aging.
e. superficial pain sensation typically remains
the same for the client who is aging.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● Flexion: a movement that decreases
the angle between two adjacent bones
● extension: a movement that increases
the angle between two adjacent bones
● Hyperextension: movement of a body part
beyond its normal extended position
● supination: movement of a body part so the
ventral (or front) surface faces up
● Pronation: movement of a body part so the
ventral surface (or front) faces down
● abduction: the movement of an extremity
away from the midline of the body
● adduction: the movement of an extremity
toward the midline of the body
● dorsiflexion: flexing the foot and toes upward
● Plantar flexion: bending the foot and toes downward
● eversion: turning the body part away from midline
● Inversion: turning the body part toward the midline
● external rotation: rotating a joint outward
● Internal rotating: rotating a joint inward
NCLEX® Connection: Physiological Adaptation, Pathophysiology
PRACTICE Active Learning Scenario
a nurse is reviewing the expected range of motion
of joint movement with a group of nursing students.
What information should the nurse include in the
review? use the atI active learning template:
Basic concept to complete this item.
RELATED CONTENT: list the 13 common types of
motion along with the actions that demonstrate them.
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 171
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Psychosocial Integrity
COPING MECHANISMS: Assess client in coping
with life changes and provide support.
CULTURAL AWARENESS/CULTURAL INFLUENCES
ON HEALTH: Incorporate client cultural practice and
beliefs when planning and providing care.
GRIEF AND LOSS: Assist the client in coping with
suffering, grief, loss, dying, and bereavement.
END OF LIFE CARE: Identify end of life needs of the client.
RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH:
Identify the emotional problems of client or client needs
that are related to religious/spiritual beliefs.
THERAPEUTIC COMMUNICATION
Allow time to communicate with the client.
Use therapeutic communication techniques to provide client support.
FUNDAMENTALS FOR NURSING CHAPTER 32 TherapeuTic communicaTion 173
UNIT 3 PSYCHOSOCIAL INTEGRITY
CHAPTER 32 Therapeutic
Communication
communication is a complex process of sending,
receiving, and comprehending messages
between two or more people. it is a dynamic and
ongoing process that creates a unique experience
for the participants. When communication breaks
down, the result can be workplace errors and the
loss of professional credibility.
communicating effectively is a skill that nurses
must develop. nurses use communication when
providing care to demonstrate caring, establish
therapeutic relationships, obtain and deliver
information, and assist with changing behavior.
Therapeutic communication is foundational to the
nurse‑client relationship. effective communication
is key to ensuring clients’ safety.
BASIC COMMUNICATION
LeVeLS oF BaSic communicaTion
Intrapersonal communication: Communication within
an individual. It is each person’s “self‑talk,” the internal
discussion when thinking but not outwardly verbalizing
thoughts. It helps nurses assess clients and situations and
think critically about them before communicating verbally.
Interpersonal communication: Communication
between two people. This form of communication is
the most common in nursing and requires an exchange
of information with another individual. However,
messages the receiver perceives can differ from what the
sender intended.
Public communication: Communication within groups of
people. Using this type of communication, many nurses
teach, give community presentations, or write about
nursing or health care topics and issues.
Transpersonal communication: Communication that
addresses spiritual needs and provides interventions to
meet these needs, such as prayer and meditation.
Small group communication: Communication within a
group of people, often working toward a mutual goal, such
as in committees, research teams, and support groups.
FuncTionaL componenTS
Referent: The incentive or motivation for communication
between two people
Sender: The person who initiates and transmits
the message
Receiver: The person to whom the sender aims the
message and who interprets the sender’s message
Message: The verbal and nonverbal information the sender
expresses and intends for the receiver
Channel: The method of transmitting and receiving
a message (sight, hearing, touch, facial expression,
body language)
Environment: The emotional and physical climate in
which the communication takes place
Feedback: Can be verbal, nonverbal, positive, negative
● The message the receiver returns to the sender that
indicates the receipt of the message
● An essential component of ongoing communication
Interpersonal variables: Factors that influence
communication between the sender and the receiver, such
as educational and developmental levels
meThoDS oF communicaTion
Verbal communication
Vocabulary
● These are the words that communicate a message the
sender writes or speaks.
● Limited vocabulary or speaking another language can
make it difficult for nurses to communicate with clients.
Using medical or nursing jargon can decrease clients’
understanding. Children and adolescents tend to use
words differently than adults.
Credibility
● Trustworthiness and reliability of the individual. Nurses
must be knowledgeable, consistent, honest, confident,
and dependable.
● Lack of credibility creates a sense of uncertainty
for clients.
Denotative and connotative meaning
● When communicating, participants must
share meanings.
● Words that have multiple meanings can cause
miscommunication if people interpret them differently.
Clarity and brevity
● The shortest, simplest communication is usually
most effective.
● Long and complex communication can be difficult
to understand.
CHAPTER 32
174 CHAPTER 32 TherapeuTic communicaTion CONTENT MASTERY SERIES
Timing and relevance
● Knowing when to communicate makes the receiver
more attentive to the message.
● When clients are uncomfortable or distracted , it can be
difficult to convey the message.
Pacing
● The rate of speech can communicate a meaning the
speaker did not intend.
● Speaking rapidly can suggest not having time for
the clients.
Intonation
● The tone of voice can communicate a variety of feelings.
● Nurses communicate feelings such as acceptance,
judgment, and dislike through their tone of voice.
Nonverbal communication
Nurses should be aware of how they communicate
nonverbally and should determine the meaning of clients’
nonverbal communication as well. Culture also affects
interpretation. Attention to the following in both the
communicator and the receiver is necessary.
Appearance, posture, gait: Physical characteristics can
convey professionalism. Body language and posture can
demonstrate comfort and ease in the situation. The first
impression is very important.
Facial expressions, eye contact, gestures: Facial
expressions can reveal feelings that clients can easily
misinterpret. Eye contact typically conveys interest and
respect but varies with culture and situation. Gestures
can enhance verbal communication or create their
own messages.
Sounds: Crying or moaning can have multiple meanings,
especially when other nonverbal communication
accompanies it.
Territoriality, personal space: Lack of awareness of
territoriality (right to space) and personal space (the area
around an individual) can make clients perceive a threat
and react defensively.
Electronic communication
Some facilities permit nurses to communicate with
clients via email. An email encryption system is essential
for assuring confidentiality. These facilities must also
have guidelines that address when and how to use email
and what information nurses may convey. Many clients
welcome the use of technology in this way; for all clients,
nurses must have their permission to communicate
electronically and must respect their preferences.
Email communication becomes part of the clients’
medical record.
THERAPEUTIC COMMUNICATION
Therapeutic communication is the purposeful use of
communication to build and maintain helping
relationships with clients, families, and significant others.
● Nurses use interactive, purposeful communication
skills to
◯ Elicit and attend to clients’ thoughts, feelings,
concerns, and needs.
◯ Express empathy and genuine concern for clients’ and
families’ issues.
◯ Obtain information and give feedback about
clients’ status.
◯ Intervene to promote functional behavior and
effective interpersonal relationships.
◯ Evaluate clients’ progress toward desired goals
and outcomes.
● Children and older adults often require specific,
age‑appropriate techniques to enhance communication.
● Use of the nursing process depends on therapeutic
communication among the nurse, client, family,
significant other, and the interprofessional health
care team.
CHARACTERISTICS
● Client‑centered: Not social or reciprocal
● Purposeful, planned, and goal‑directed
eSSenTiaL componenTS
Time: Plan for and allow adequate time to communicate
with others.
Attentive behavior or active listening: Use this as a means
of conveying interest, trust, and acceptance.
Caring attitude: Show concern and facilitate an emotional
connection and support among nurses and clients,
families, and significant others.
Honesty: Be open, direct, truthful, and sincere.
Trust: Demonstrate to clients, families, and significant
others that they can rely on nurses without doubt,
question, or judgment.
Empathy: Convey an objective awareness and
understanding of the feelings, emotions, and behavior of
clients, families, and significant others, including trying
to envision what it must be like to be in their position.
Nonjudgmental attitude: A display of acceptance of clients,
families, and significant others encourages open, honest
communication.
View Video: Therapeutic Communication
FUNDAMENTALS FOR NURSING CHAPTER 32 TherapeuTic communicaTion 175
NURSING PROCESS
aSSeSSmenT/DaTa coLLecTion
● Determine verbal and nonverbal communication needs
for client‑centered care.
◯ Clients who have hearing, vision, or cognitive losses,
are unresponsive, are aphasic, or do not speak the
same language as the staff.
● Consider physical status.
● Consider the developmental level, and alter
communication accordingly.
◯ CHILDREN
■ Use simple, straightforward language.
■ Be aware of nonverbal messages because children
are especially sensitive to nonverbal communication.
■ Enhance communication by being at the child’s
eye level.
■ Incorporate play in interactions.
◯ OLDER ADULT CLIENTS
■ Recognize that many older adults require
amplification of sound.
■ Make sure assistive devices such as glasses and
hearing aids are available for clients who need them.
■ Minimize distractions, and face clients
when speaking.
■ Speak in short and simple sentences.
■ Allow plenty of time for clients to respond.
■ Ask for input from caregivers or family to
determine the extent of any communication deficits
and how best to communicate.
● Identify any cultural considerations that
affect communication.
◯ Provide an interpreter.
◯ Address the client directly when the interpreter
is present.
◯ Provide educational materials and instructions in the
client’s language.
pLanninG
● Minimize distractions.
● Provide privacy.
● Identify mutually agreed‑upon outcomes.
● Set priorities according to the clients’ needs.
● Collaborate with other health care professionals
when necessary.
● Plan adequate time for interventions.
impLemenTaTion
● Establish a trusting nurse‑client relationship. Clients
feel more at ease during the implementation phase
when nurses establish a helping relationship.
● Provide empathetic responses and explanations by using
observations, giving information, conveying hope, and
using humor.
● Manipulate the environment to decrease distractions.
EFFECTIVE SKILLS AND TECHNIQUES
Silence: This allows time for meaningful reflection.
Presenting reality: This helps the client distinguish
what is real from what is not and to dispel delusions,
hallucinations, and faulty beliefs.
Active listening: This helps the nurse hear, observe,
and understand what the client communicates and
provide feedback.
Asking questions: This is a way to seek additional
information.
Open-ended questions: This facilitates spontaneous
responses and interactive discussion. It encourages the
client to explore feelings and thoughts and avoids yes or
no answers
Clarifying techniques: This helps the nurse determine
whether the message the client received was accurate:
● Restating: Uses the client’s exact words
● Reflecting: Directs the focus back to the client for him
to examine his feelings
● Paraphrasing: Restates the client’s feelings and
thoughts for him to confirm what he has communicated
● Exploring: Allows the nurse to gather more information
about important topics the client mentioned
Offering general leads, broad opening statements: This
encourages the client to start and to continue talking.
Showing acceptance and recognition: This acknowledges
the nurse’s interest and nonjudgmental attitude.
Focusing: This helps the client concentrate on what
is important.
Giving information: This provides factual details that the
client might need for decision‑making.
Summarizing: This emphasizes important points and
reviews what the nurse and the client have discussed.
Offering self: This demonstrates a willingness to spend
time with the client. The nurse may share limited
personal information, but the focus should return to the
client as soon as possible. Relevant self‑disclosure by the
nurse helps the client see that others share his experience
and understand.
Touch: If appropriate, touch can communicate caring and
provide comfort.
176 CHAPTER 32 TherapeuTic communicaTion CONTENT MASTERY SERIES
BARRIERS TO EFFECTIVE
COMMUNICATION
● Asking irrelevant personal questions
● Offering personal opinions
● Stereotyping
● Giving advice
● Giving false reassurance
● Minimizing feelings
● Changing the topic
● Asking “why” questions or asking for explanations
● Challenging
● Offering value judgments
● Asking questions excessively (probing)
● Responding approvingly or disapprovingly (refusing)
● Being defensive
● Testing
● Judging
● Offering sympathy
● Arguing
COMMUNICATION AMONG
HEALTH PROFESSIONALS
Nurses must communicate clearly, respectfully, and
professionally with all staff members.
Faulty communication among the members of the
health care team can have a negative effect on the work
environment and on clients’ outcomes.
● Incivility: Rude dialogue or actions (sarcasm,
eye rolling)
● Bullying: Repeated words or acts of intimidation
● Lateral violence: Abusive words or actions of peers
(gossiping, exclusion of information, threats of harm,
actual harm)
FUNDAMENTALS FOR NURSING CHAPTER 32 TherapeuTic communicaTion 177
Application Exercises
1. a nurse is caring for a client who
states, “i have to check with my wife
and see if she thinks i am ready to
go home.” The nurse replies, “how
do you feel about going home
today?” Which clarifying technique
is the nurse using to enhance
communication with the client?
a. pacing
B. reflecting
c. paraphrasing
D. restating
2. Which of the following actions
should the nurse take when using the
communication technique of active
listening? (Select all that apply.)
a. use an open posture.
B. Write down what the client
says to avoid forgetting details.
c. establish and maintain
eye contact.
D. nod in agreement with
the client throughout
the conversation.
e. respond positively when
giving feedback.
3. a nurse is caring for a client who
is concerned about his impending
discharge to home with a new
colostomy because he is an avid
swimmer. Which of the following
statements should the nurse
make? (Select all that apply.)
a. “You will do great! You just
have to get used it.”
B. “Why are you worried
about going home?”
c. “Your daily routines will be
different when you get home.”
D. “Tell me about your support
system you’ll have after
you leave the hospital.”
e. “Let me tell you about a friend
of mine with a colostomy
who also enjoys swimming.”
4. Which of the following strategies
should a nurse use to establish a
helping relationship with a client?
a. make sure the communication
is equally reciprocal between
the nurse and the client.
B. encourage the client
to communicate his
thoughts and feelings.
c. Give the nurse‑client
communication no time limits.
D. allow communication to occur
spontaneously throughout
the nurse‑client relationship.
5. a nurse is caring for a school‑age
child who is sitting in a chair. To
facilitate effective communication,
which of the following actions
should the nurse take?
a. Touch the child’s arm.
B. Sit at eye level with the child.
c. Stand facing the child.
D. Stand with a relaxed posture.
PRACTICE Active Learning Scenario
a nurse manager is reviewing nonverbal communication with staff members.
use the aTi active Learning Template: Basic concept to complete this item.
RELATED CONTENT: List at least four examples of nonverbal communication.
UNDERLYING PRINCIPLES: explain their effect on the communication.
178 CHAPTER 32 TherapeuTic communicaTion CONTENT MASTERY SERIES
Application Exercises Key
1. a. pacing is a characteristic of verbal
communication, not a clarifying technique.
B. CORRECT: reflecting directs the focus of the conversation back
to the client so that he can further explore his own feelings.
c. paraphrasing restates the client’s feelings for him to
confirm what he has communicated. in this scenario, the
client did not verbalize his feelings to the nurse.
D. restating uses the client’s exact words. in this scenario,
the nurse did not restate what the client stated.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
2. a. CORRECT: having an open posture, facing the client, and leaning
forward are ways the nurse can demonstrate active listening.
B. Writing down everything the client says can interfere with
the nurse’s ability to convey full attention and interest.
c. CORRECT: establishing and maintaining eye contact
are ways the nurse can demonstrate active listening.
D. if the nurse nods in agreement throughout the conversation,
the client could interpret that as agreement with what the
client is saying when instead the nurse meant to convey
attending to and understanding what he is saying.
e. CORRECT: responding positively when giving feedback
is a way the nurse can demonstrate active listening.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
3. a. Giving false reassurance and minimizing the client’s
feelings are both barriers to effective communication.
B. although this might appear to help the client discuss his feelings,
asking a “why” question is a barrier to effective communication.
c. CORRECT: presenting reality is an effective communication
technique that can help the client focus on what will really
happen after the changes the surgery has made.
D. CORRECT: asking open‑ended questions and offering
general leads and broad opening statements are effective
communication techniques that encourage the client to express
feelings through dialogue and offer additional information.
e. CORRECT: offering self is an effective communication technique
that can convey understanding and share another’s experience
with the client. however, the nurse should return the focus to
the client as soon as she communicates the relevant point.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
4. a. The communication should not be reciprocal but client‑focused.
B. CORRECT: Therapeutic communication facilitates a
helping relationship that maximizes the client’s ability
to express his thoughts and feelings openly.
c. The nurse should limit therapeutic communication to the
boundaries of the therapeutic relationship, including time.
D. The nurse should plan therapeutic communication.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
5. a. Touching can intimidate the child and block communication.
B. CORRECT: The nurse should be at the same eye
level as the child to facilitate communication.
c. Standing can appear domineering and intimidating.
D. Standing can appear domineering and
intimidating, even with a relaxed posture.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
PRACTICE Answer
Using ATI Active Learning Template: Basic Concept
RELATED CONTENT
● appearance, posture, gait
● Facial expressions, eye
contact, gestures
● Sounds
● Territoriality, personal space
UNDERLYING PRINCIPLES
● appearance, posture, gait: physical characteristics convey professionalism
and can demonstrate comfort and ease in the situation.
● Facial expressions: Facial expressions can reveal feelings that clients could misinterpret.
● eye contact: eye contact conveys interest and respect but varies with culture and situation.
● Gestures: Gestures can enhance verbal communication or create their own messages.
● Sounds: crying or moaning can have multiple meanings when clients also convey other nonverbal communication
● Territoriality, personal space: Lack of awareness of territoriality (right to space) and personal space
(the area around an individual) can make clients perceive a threat and react defensively.
NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication
FUNDAMENTALS FOR NURSING CHAPTER 33 Coping 179
UNIT 3 PSYCHOSOCIAL INTEGRITY
CHAPTER 33 Coping
Coping describes how an individual deals with
problems, such as illness and stress. Factors
involved in coping and adaptation include the
client’s family dynamics, adherence to treatment
regimens, and the role an individual can play in
important relationships.
Stress, coping, adaptation,
and adherence
Stress
● Stress describes changes in an individual’s state of
balance in response to stressors, the internal and
external forces that disrupt that state of balance. Any
stressor, whether it is perceived as “good” or “bad,”
produces a similar biological response in the body.
● Stress can be situational (adjusting to a chronic disease
or a stressful job change).
● Stress can be developmental (varying with life stage).
Adult stressors can include losing parents, having a
baby, and getting married.
● Stress can be caused by sociocultural factors, including
substance use, lack of education, and prolonged poverty.
● Research has shown that stress not only impairs and
weakens the immune system but has been identified as
a causal factor in numerous health conditions.
Coping
● Coping describes how an individual deals with problems
and issues.
● Factors influencing an individual’s ability to cope
include the number, duration, and intensity of stressors;
the individual’s past experiences; the current support
system; and available resources (financial).
● Coping strategies are unique to an individual and can
vary greatly with each stressor.
● Caregiver burden results from the accumulated stress
that family members experience after caring for a loved
one over a period of time. Some responses include
fatigue, difficulty sleeping, and illness (increased blood
pressure, mental illness).
● Ego defense mechanisms: assist a person during
a stressful situation or crisis by regulating
emotional distress.
Adaptation
Coping behavior that describes how an individual handles
demands imposed by the environment.
General adaptation syndrome (GAS)
Also known as “stress syndrome.” Hans Selye developed a
theory of adaptation that describes the stress reaction in
three stages.
● Alarm reaction: Body functions are heightened
to respond to stressors. Hormones (epinephrine,
norepinephrine, cortisone) are released, which cause
elevated blood pressure and heart rate, heightened
mental alertness, increased secretion of epinephrine and
norepinephrine, and increased blood flow to muscles.
● Resistance stage: Body functions normalize while
responding to the stressor. The body attempts to
cope with the stressor and return to homeostasis.
Stabilization of BP, heart rate and hormones will occur.
● Exhaustion stage: Body functions are no longer able
to maintain a response to the stressor and the client
cannot adapt. The end of this stage results in recovery
or death.
Adherence
● The commitment and ability of the client and family to
follow a given treatment regimen.
● Commitment to the regimen increases adherence.
● Complicated regimen interferes with adherence.
● Involvement of the client and significant support people
in the planning stage increases adherence.
● Adverse effects of medications diminish adherence.
● Coping mechanisms, such as denial, can cause
non‑adherence.
● Available resources increase adherence.
ASSESSMENT/DATA COLLECTION
● Ask the client questions related to
◯ Current stress, perception of stressors, and ability
to cope
◯ Support systems
◯ Adherence to healthy behaviors and/or the
treatment regimen
◯ Sleep patterns
◯ Altered elimination patterns, changes in appetite, and
weight loss or gain
● Observe the client’s appearance and eye contact, verbal,
motor and cognitive status during the assessment.
● Measure vital signs.
● Observe for irritability, anxiety, and tension.
● Thoroughly assess each client to ensure client centered
clinical decisions required for safe nursing care.
CHAPTER 33
180 CHAPTER 33 Coping CONTENT MASTERY SERIES
PATIENT‑CENTERED CARE
nURSing CARE
Stress
● Encourage health promotion strategies, including
regular exercise, optimal nutrition, and adequate sleep
and rest.
● Assist with time management, and determine
priority tasks.
● Encourage appropriate relaxation techniques,
including breathing exercises, massage, imagery, yoga,
and meditation.
● Listen attentively, and take the time to understand the
client’s perspective.
● Control the environment to reduce the number of
external stressors, including noise and breaks in the
continuity of care.
● Identify available support systems.
● Use effective communication techniques to foster the
expression of feelings.
Coping
● Be empathetic in communication, and encourage the
client to verbalize feelings.
● Identify the client’s and family’s strengths and abilities.
● Encourage client’s autonomy with decision‑making.
● Discuss the client’s and family’s abilities to deal with
the current situation.
● Encourage the client to describe coping skills used
effectively in the past.
● Identify available community resources, and refer the
client for counseling if needed.
Adherence
● Put instructions in writing.
● Allow the client to give input into the
treatment regimen.
● Simplify treatment regimens as much as possible.
● Follow up with the client to address any questions
or problems.
Family systems and
family dynamics
● Family is defined by the client, and it consists of the
individual structures and roles. It is typically two or
more people whose relationships create a bond and
influence their mutual development, support, goals,
and resources.
● Consider five realms of processes involved in family
function during a family assessment: interactive,
developmental, coping, integrity, health.
● Assessment of a family can focus on family as a context,
a client, or a system.
● Families and clients are not mutually exclusive;
family‑centered care creates a holistic approach to
nursing care.
● Family dynamics are constantly evolving due to the
processes of family life and developmental stages of the
family members.
CURRENT TRENDS
FASTEST‑GROWING POPULATION: Those older than
65 years, leading to caregiver issues
DECLINING ECONOMIC STATUS OF FAMILIES (increased
unemployment)
FAMILY VIOLENCE and its endless cycle
ANY ACUTE OR CHRONIC ILLNESS THE DISRUPTS THE
FAMILY UNIT (can include end‑of‑life care issues)
HOMELESSNESS: Lack of stable environment, financial
issues, inadequate access to health care (fastest‑growing
homeless population is families with children).
The homeless population is increasing due to lack of
affordable housing.
ATTRIBUTES OF FAMILIES
● Structure dictates the family’s ability to cope.
◯ Rigid structure is dictatorial and strict.
◯ Open structure includes few or no boundaries,
consistent behavior, or consequences.
◯ Either structure can provide positive or
negative outcomes.
● Function describes the course of action the family uses
to reach its goals, including members’ communication
skills, problem‑solving abilities, and available resources.
FUNDAMENTALS FOR NURSING CHAPTER 33 Coping 181
ASSESSMENT/DATA COLLECTION
● Assess all clients within the context of the family.
● Assess a family by looking at its structure and function.
● Identify who is a family member, what role each family
member plays, and the dynamic interactions within
the family.
● Listen attentively, and use the therapeutic
communication techniques of reflection and restatement
to clarify the family’s concerns.
● Cultural variables: all of which can differ between and
within generations
◯ Perception of events
◯ Rites and rituals
◯ Health beliefs
PATIENT‑CENTERED CARE
nURSing CARE
● Identify and adapt family strengths to
perceived stressor(s).
◯ Communication
◯ Adaptability
◯ Nurturing
◯ Crisis as a growth element
◯ Parenting skills
◯ Resiliency
● Set realistic goals with the family.
● Provide information about support networks and
community resources.
◯ Child and adult day care
◯ Caregiver support groups
● Promote family unity.
● Ensure safety for families at risk for violence.
● Encourage conflict resolution.
● Minimize family process disruption effects.
● Remove barriers to health promotion.
● Increase family members’ abilities to participate.
● Perform interventions that the family cannot perform.
● Evaluate goals within the context of the family by
checking back to ensure that goals were realistic
and achievable.
Situational role changes
● A role is the function a person adopts within their
life. Seldom is it limited to one role, but rather is
multidimensional and is often relative to the role
of others.
◯ Grandparent
◯ Parent
◯ Dependent child
◯ Employee/employer
◯ Committee member
◯ Community activist
● Stress affects roles in many ways.
● The presence of stressors delays a client’s return to
health in the same way that the presence of a foreign
body or infection delays the healing of a wound.
● Illness causes role stress by creating a situation in
which roles can change simply due to the effect and
progression of the illness.
● Nurses must be aware of a client’s roles in life, as well
as how the situation of illness might change these roles,
either temporarily or permanently.
● A basic assumption is that a client can either advance or
regress in the face of a situational role change.
TYPES OF ROLE PROBLEMS
Role conflict: This develops when a person must assume
opposing roles with incompatible expectations. Role
conflicts can be interpersonal (when parents expect
adolescents to participate in sports and perform household
tasks) or inter‑role (when a mother wants to stay at home
with her infant, but family finances require her to work).
Sick role: Expectations of others and society regarding
how one should behave when sick (caring for self while
sick and continuing to provide childcare to grandchildren).
Role ambiguity: Uncertainty about what is expected when
assuming a role; creates confusion.
Role strain: The frustration and anxiety that occurs when
a person feels inadequate for assuming a role (caring for a
parent dementia).
Role overload: More responsibility and roles than are
manageable; very common (assuming the role of student,
employee, and parent).
182 CHAPTER 33 Coping CONTENT MASTERY SERIES
SITUATIONAL ROLE CHANGES
● Caused by situations other than physical growth and
development (marriage, job changes, divorce)
● Can disrupt one or more of the client’s roles in life (with
illness or hospitalization)
● With resolution, can contribute to healing in the
physical, mental, and spiritual realms
TEMPORARY ROLE CHANGES: The client will resume the
role when illness resolves.
PERMANENT ROLE CHANGES: Illness has altered the level
of the client’s health to a point that previous roles are no
longer available.
ASSESSMENT/DATA COLLECTION
● Identify the client’s roles as perceived as owning and by
significant others.
● Validate any discrepancies.
● Identify the effect that the loss or addition of a role is
having on the client (grieving the loss of a role).
● Identify who will now take on the client’s role while the
client cannot and make referrals as appropriate.
PATIENT‑CENTERED CARE
nURSing CARE
● Provide short‑term care to provide relief for the
family caregiver.
● Provide encouragement during times of stress.
● Seek congruence among perceived roles.
● Prepare the client for the anticipated situational crisis.
● Anticipate role conflict or overload on the client’s part.
● Help the client improve relationships by supplementing
specific role behaviors.
● Explore which roles the client can relinquish.
● Help the client improve personal judgment of self‑worth
given the current situational role change.
● Counsel the client about roles that are
permanently altered.
● Refer the client to community services for outpatient
adaptation to lost or new roles.
● Refer the client to social services for assistance in
some roles.
● Evaluate the client after acceptance of the role change(s)
to assess adaptation.
FUNDAMENTALS FOR NURSING CHAPTER 33 Coping 183
Application Exercises
1. A nurse is caring for a client whose
partner passed away 4 months
ago and who has been recently
diagnosed with diabetes mellitus. He
is tearful and states, “How could you
possibly understand what i am going
through?” Which of the following
responses should the nurse make?
A. “it takes time to get over
the loss of a loved one.”
B. “You are right. i cannot really
understand. perhaps you’d
like to tell me more about
what you’re feeling.”
C. “Why don’t you try
something to take your
mind off your troubles, like
watching a funny movie.”
D. “i might not share your exact
situation, but i do know what
people go through when
they deal with a loss.”
2. A nurse is caring for a client awaiting
transport to the surgical suite for a
coronary artery bypass graft. Just
as the transport team arrives, the
nurse takes the client’s vital signs
and notes an elevation in blood
pressure and heart rate. The nurse
should recognize this response
as which part of the general
adaptation syndrome (gAS)?
A. Exhaustion stage
B. Resistance stage
C. Alarm reaction
D. Recovery reaction
3. A nurse is caring for a client who
has left‑sided hemiplegia resulting
from a cerebrovascular accident. The
client works as a carpenter and is
now experiencing a situational role
change based on physical limitations.
The client is the primary wage earner
in the family. Which of the following
describes the client’s role problem?
A. Role conflict
B. Role overload
C. Role ambiguity
D. Role strain
4. A nurse is caring for a client who
has a new diagnosis of type 2
diabetes mellitus. Which of the
following nursing interventions
for stress, coping, and adherence
to the treatment plan should
the nurse initiate at this time?
(Select all that apply.)
A. Suggest coping skills for the
client to use in this situation.
B. Allow the client to provide
input in the treatment plan.
C. Assist the client with time
management, and address
the client’s priorities.
D. provide extensive
instructions on the client’s
treatment regimen.
E. Encourage the client
in the expression of
feelings and concerns.
5. A nurse is caring for a family who
is experiencing a crisis. Which of
the following approaches should
the nurse use when working
with a family using an open
structure for coping with crisis?
A. prescribing tasks unilaterally
B. Delegating care to
one member
C. Speaking to the primary
client privately
D. Convening a family meeting
PRACTICE Active Learning Scenario
A nurse manager is reviewing coping factors with the members of her team.
Use the ATi Active Learning Template: Basic Concept to complete this item.
RELATED CONTENT: List at least four factors that
influence an individual’s ability to cope.
NURSING INTERVENTIONS: List three interventions the nurse can take
to assist the client in coping with a stressful event or situation.
184 CHAPTER 33 Coping CONTENT MASTERY SERIES
Application Exercises Key
1. A. Telling the client it will take more time to heal belittles
the client’s feelings and gives false reassurance.
B. CORRECT: By stating that she is not in his situation, the
nurse is using the therapeutic communication technique of
validation, whereby she shows sensitivity to the meaning behind
his behavior. She is also creating a supportive and nonjudgmental
environment, and inviting him to express his frustrations.
C. Telling the client to try a distraction dismisses the client’s
feelings and gives common advice instead of expert advice.
D. Saying she knows what clients feel is presumptive and inappropriate.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
2. A. Although the exhaustion stage is a component of gAS, body
functions are no longer able to respond to the stressor in this stage.
B. Although the resistance stage is a component of gAS, body functions
normalize in an attempt to cope with the stressor in this stage.
C. CORRECT: As a component of gAS, body functions,
such as blood pressure and heart rate, are heightened in
order to respond to the stressor in the alarm stage.
D. Although not technically a component of gAS, recovery
reaction is an alternative to the exhaustion stage, but it would
not account for an elevation in blood pressure and heart rate.
NCLEX® Connection: Reduction of Risk Potential,
Changes/Abnormalities in Vital Signs
3. A. CORRECT: The client is experiencing role conflict because his
career is extremely physical, and he can no longer perform his job
duties. However, the client is the primary wage earner in the family.
B. Although the client can feel overloaded and overwhelmed, role
overload occurs when the client is trying to juggle too many roles.
C. The client is not experiencing role ambiguity because his
job duties and his physical limitations are quite clear.
D. The client is not experiencing role strain. That occurs
when one feels inadequate for assuming a role.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
4. A. Although it can seem helpful to suggest specific
coping skills for the client, it is best to allow the client to
discuss coping skills that have worked in the past.
B. CORRECT: Allowing the client to contribute to the
treatment plan allows for greater adherence to the plan.
C. CORRECT: Helping the client to prioritize is an intervention
that can reduce levels of stress for the client because many times
time management is extremely difficult in times of stress.
D. Although it is necessary to provide complete information on
treatment plans, simplifying treatment regimens as much as
possible allows for greater adherence to the treatment plan.
E. CORRECT: By using effective communication techniques,
encouraging the client to verbalize feelings is an intervention for
stress, coping, and adherence that allows the client to reduce
stress, validate emotions, and start planning for valid concerns.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
5. A. prescribing tasks is too rigid for acceptance
by a family with an open structure.
B. Delegating care is too rigid for acceptance
by a family with an open structure.
C. Speaking to the primary client privately excludes the family.
D. CORRECT: An open structure is loose, and convening
a family meeting would give all family members input
and an opportunity to express their feelings.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
PRACTICE Answer
Using ATI Active Learning Template: Basic Concept
RELATED CONTENT
● number of stressors
● Duration of the stressors
● intensity of the stressors
● individual’s past
experiences
● Current support system
● Available resources
(financial)
NURSING INTERVENTIONS
● Be empathetic in communication, and
encourage the client to verbalize feelings.
● identify the client’s and family’s strengths and abilities.
● Discuss the client’s and family’s abilities
to deal with the current situation.
● Encourage the client to describe coping
skills used effectively in the past.
● identify available community resources, and
refer the client for counseling if needed.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
FUNDAMENTALS FOR NURSING CHAPTER 34 Self‑ConCept and Sexuality 185
UNIT 3 PSYCHOSOCIAL INTEGRITY
CHAPTER 34 Self‑Concept
and Sexuality
Self‑concept is the way individuals feel and
view themselves. this involves conscious and
unconscious thoughts, attitudes, beliefs, and
perceptions. Body image, a component of
self‑concept, refers to the way individuals
perceive their appearance, size, and body
structure/function.
Sexuality and sexual orientation are integrated
into individuals’ personalities as well as their
general health. Sexuality encompasses their
sense of maleness and/or femaleness and their
physical and emotional connections with others.
individuals’ sexuality and sexual health are
influenced by self‑concept, body image, gender
identity, and sexual orientation.
nurses should assess their own comfort levels
with issues related to sexuality because clients
usually can sense any discomfort nurses have
about these issues. Skills that nurses use in
dealing with clients’ sexuality issues are a
knowledge of sexual growth and development,
and an understanding of how health problems
and treatments affect sexuality.
Self‑concept
● Self‑concept is subjective and includes self‑identity,
body image, role performance, and self‑esteem.
◯ Individuals who have high self‑esteem are better
equipped to cope successfully with life’s stressors.
◯ Stressors that affect self-concept include unrealistic
expectations, surgery, chronic illness, and changes in
role performance.
● Individuals who have positive self‑concepts tend to feel
good about themselves.
● Individuals who have positive self‑esteem feel capable
and competent.
● Individuals’ self-concepts can be adversely affected
by physical, spiritual, emotional, sexual, familial, and
sociocultural stressors.
Body image
● Body image changes with growth and development.
During adolescence, hormonal changes include the
development of secondary sex characteristics that
influence body image. Among older adults, changes in
mobility, thinning and graying of hair, and decreased
visual and hearing acuity are just a few factors that
affect body image.
● Stressors that affect body image include loss of
body parts due to an amputation, mastectomy, or
hysterectomy; loss of body function due to arthritis,
spinal cord injury, or stroke; and an unattainable
body ideal.
● External influences (media, others’ perceptions and
responses, cultural standards) can affect body image.
● Clients who have a negative body image perception tend
to be at risk for suicidal ideations.
Sexuality
● Sexuality and sexual health are vital components of
general health and part of a nursing assessment.
● Sexual health occurs when relationships are safe,
enjoyable, and respected.
● Aspects of sexual health include knowledge of sexual
behavior, understanding of expected growth and
development, and access to appropriate health care
resources for preventing and treating problems related
to sexual health.
● Sexuality is affected by developmental stage. For
example, during adolescence, primary and secondary
sex characteristics develop, menarche occurs,
relationships involving sexual activity can develop, and
masturbation is common.
● Sexuality is influenced by culture. Various
cultures view premarital sex, homosexuality, and
polygamy differently.
● Sexuality affects health status. Certain conditions can
alter sexual expression. For example, the presence
of a sexually transmitted infection can cause fear of
transmission to a partner, leading to a decrease in
sexual desire.
● Some prescription medications affect sexual
functioning. Diuretics decrease vaginal lubrication,
cause erectile dysfunction, and reduce sexual
desire. Erectile dysfunction can also be caused by
antidepressant medications.
● Use the PLISSIT assessment tool for sexuality
◯ P: Permission (obtain permission to discuss this
with client)
◯ LI: Limited information (related to sexual
health patterns)
◯ SS: Specific suggestions (based upon assessment data
make appropriate suggestions)
◯ IT: Intensive therapy (more referral if needed)
CHAPTER 34
186 CHAPTER 34 Self‑ConCept and Sexuality CONTENT MASTERY SERIES
ASSESSMENT/DATA COLLECTION
● Posture
● Appearance
● Demeanor
● Eye contact
● Grooming
● Unusual behavior
EXPECTED FINDINGS
● Cultural background
● Quality of relationships
● Feelings related to recent body image changes,
self‑concept, and issues of sexuality
● Coping mechanisms used in the past
● Evaluation of self‑worth
PATIENT‑CENTERED CARE
Self‑concept
● How one values oneself
● Suggest a healthier lifestyle (exercise, diet,
stress management).
● Encourage the client to verbalize fears or anxieties.
● Use therapeutic communication skills to assist the client
with self‑awareness.
● Encourage the use of effective coping skills.
● Reinforce successes and strengths.
Body image
● Establish a therapeutic relationship with the client. A
caring and nonjudgmental manner puts the client at
ease and fosters meaningful communication.
● Ensure privacy and confidentiality. Let the client know
that sensitive issues are safe to discuss.
● A person’s perception about their appearance
● Identify individuals who can be at risk for body
image disturbances.
● Acknowledge anger, depression, and denial as feelings
to be expected when adjusting to body changes.
● Encourage the client to participate in the plan of care.
● Arrange for a visit from a volunteer who has
experienced a similar body image change.
Sexuality
● Allow the client to discuss issues and concerns related
to sexuality.
● Be straightforward with questions in relaxed manner.
(“Are you, or have you been, concerned about sexual
functioning since your surgery?”)
● Ask client to describe factors that influence
sexual desire.
● Health promotion: Determine the client’s current
knowledge base regarding sexuality, and provide
education as needed based upon developmental level
such as: contraception, sexually transmitted infections
prevention, and immunizations.
● Acute care: Increase awareness by introducing or
clarifying information and referring the client for
counseling if necessary.
● Inform the client of available resources and
support groups.
● Never assume that sexual function is not a concern.
● Discuss alternative means of sexual expression if the
client experiences a change in body functioning or
structure (hugging, cuddling).
FUNDAMENTALS FOR NURSING CHAPTER 34 Self‑ConCept and Sexuality 187
Application Exercises
1. a nurse in an ambulatory care clinic
is caring for a client who had a
mastectomy 6 months ago. the client
tells the nurse that she has not had
much desire for sexual relations since
her surgery, stating, “My body is so
different now.” Which of the following
responses should the nurse make?
a. “Really, you look just fine
to me. there’s no need
to feel undesirable.”
B. “i’m interested in finding
out more about how your
body feels to you.”
C. “Consider an afternoon at
a spa. a facial will make
you feel more attractive.”
d. “it’s still too soon to expect
to feel normal. Give it
a little more time.”
2. a nurse is caring for a group
of clients on a medical‑surgical
unit. Which of the following
clients are at risk for body image
disturbances? (Select all that apply.)
a. 30‑year‑old male client
following laparoscopic
appendectomy
B. 45‑year‑old female client
following mastectomy
C. 20‑year‑old female
client following left
above‑the‑knee amputation
d. 65‑year‑old male client
following cardiac
catheterization
e. 55‑year‑old male client
following stroke with
right‑sided hemiplegia
3. a nurse is caring for a client who
is 3 days postoperative following
a below‑the‑knee amputation as a
result of a motor vehicle crash. Which
of the following client statements
indicates to the nurse that the client
has a distorted body image?
a. “i’ll be able to function exactly
as i did before the accident.”
B. “i just can’t stop crying.”
C. “i am so mad at that guy who
hit us. i wish he lost a leg.”
d. “i don’t even want to
look at my leg. you can
check the dressing.”
4. a nurse is caring for a client who
is recovering from a myocardial
infarction and a cardiac
catheterization. the client states,
“i am concerned that things might
be a little, you know, ‘different’
with my wife when i get home.”
Which of the following statements
should the nurse make?
a. “Sounds like something
you should discuss with
her when you get home.”
B. “it sounds like you are
concerned about sexual
functioning. let’s discuss
your concerns.”
C. “oh, i wouldn’t be too
concerned. things will be fine
as soon as we get you home.”
d. “Just make sure you take
your medication as directed,
and you should be fine.”
5. a nurse is teaching a group
of clients how to care for their
colostomies. Which of the following
statements should alert the nurse
that one of the clients is having
an issue with self‑concept?
a. “i was having difficulty with
attaching the appliance at first,
but my wife was able to help.”
B. “i’ll never be able to care for
this at home. Can’t you just
send a nurse to the house?”
C. “i met a neighbor who also
has a colostomy, and he
taught me a few things.”
d. “it may take me a while to get
the hang of this. i have to
admit, i am pretty nervous.”
PRACTICE Active Learning Scenario
a nurse manager is reviewing self‑concept assessment
findings with her staff. use the ati active learning
template: System disorder to complete this item.
EXPECTED FINDINGS: list at least six.
188 CHAPTER 34 Self‑ConCept and Sexuality CONTENT MASTERY SERIES
Application Exercises Key
1. a. telling the client she looks fine is using the nontherapeutic
communication technique of giving an opinion. assuming
she feels undesirable is using the nontherapeutic
communication technique of interpreting.
B. CORRECT: Showing interest in the client is applying the therapeutic
communication technique of offering self. asking more about
how the client feels is applying the therapeutic communication
technique of encouraging a description of perception.
C. Suggesting a facial is using the nontherapeutic
communication technique of giving advice.
d. telling her it is too soon to feel normal and to give it more time
is belittling the client’s feelings and giving false reassurance.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
2. a. Based on the concept of body image, an appendectomy would
not place a client at high risk for a body image disturbance.
B. CORRECT: Having a mastectomy involves a change in
the physical appearance of a woman and can lead to body
image disturbances related to femininity and sexuality.
C. CORRECT: Having an above‑the‑knee amputation involves
a change in physical appearance and can lead to body image
disturbances related to function, health, and strength.
d. depending on the client’s prognosis postcatheterization,
the client can experience some limitations. However, in
general, a cardiac catheterization would not place a
client at high risk for a body image disturbance.
e. CORRECT: Having right‑sided hemiplegia involves a
change in physical appearance and can lead to body image
disturbances related to function, health, and strength.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
3. a. denial is a normal and expected reaction
when adjusting to body changes.
B. depression and sadness are normal and expected
reactions when adjusting to body changes.
C. anger is a normal and expected reaction
when adjusting to body changes.
d. CORRECT: Refusing to look at the leg or the dressing indicates
that the client is having difficulty acknowledging the fact that the leg
has been amputated. this would imply a distorted body image.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
4. a. the nurse should allow the client to discuss issues and
concerns related to sexuality and not dismiss his concerns.
B. CORRECT: the nurse is acknowledging and allowing the
client to discuss his concerns regarding sexual functioning.
C. false reassurance should not be used. the client has valid
concerns. the nurse also is dismissing the client’s feelings.
d. the nurse is not allowing the client to express his
feelings and is displaying false reassurance, which should
not be used because the client has valid concerns.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
5. a. although the client was having difficulty at first, the client
expressed how he was able to use his resources, resulting in a
positive outcome, and does not show signs of self‑concept issues.
B. CORRECT: this client is displaying a lack of interest in learning how
to care for the colostomy and dependence on others to care for him.
the nurse should suspect issues with self‑concept with this client.
C. this client is displaying a positive self‑concept
by reaching out and using his resources to learn
additional information regarding the colostomy.
d. expression of feelings is a sign of positive self‑concept
even if the client admits being nervous or hesitant
regarding caring for the colostomy on his own.
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
PRACTICE Answer
Using the ATI Active Learning Template: System Disorder
EXPECTED FINDINGS
● Cultural background
● Quality of relationships
● feelings related to
recent body image
changes, self‑concept,
and issues of sexuality
● Coping mechanisms
used in the past
● expectations
● posture
● appearance
● demeanor
● eye contact
● Grooming
● unusual behavior
NCLEX® Connection: Psychosocial Integrity, Coping Mechanisms
FUNDAMENTALS FOR NURSING CHAPTER 35 Cultural and Spiritual nurSing Care 189
UNIT 3 PSYCHOSOCIAL INTEGRITY
CHAPTER 35 Cultural
and Spiritual
Nursing Care
Clients vary widely in their cultural and spiritual
backgrounds and belief systems. nurses must
examine their own beliefs before providing
optimal cultural and spiritual care to their clients.
CULTURE
Culture is a collection of learned, adaptive, and socially
and intergenerationally transmitted behaviors, values,
beliefs, and customs that form the context from which a
group interprets the human experience. Culture includes
language, communication style, traditions, religions, art,
music, dress, health beliefs, and health practices. These
components can be shared by members of an ethnic, racial,
social, or religious group.
● Ethnicity (the shared identity, bond, or kinship people
feel with their country of birth or place of ancestral
origin) affects culture.
● Culture influences health beliefs; health practices;
and manifestations of, responses to, and treatment of
illness or injury. Culture evolves over time and is shared
by members of a group who have similar needs and
life experiences.
● Many cultures consider the mind‑body‑spirit to be a
single entity. Therefore, no distinction is made between
physical and mental illness.
● The predominant culture in the U.S. is anglicized or
English‑based, with a general cultural tendency to do
the following.
◯ Express positive and negative feelings freely.
◯ Prefer direct eye contact when communicating.
◯ Address people in a casual manner.
◯ Prefer a strong handshake as a way of greeting.
● Although everyone within a culture shares cultural
values, diversity exists, forming subcultures based on
age, gender, sexual orientation, marital status, family
structure, income, education level, religious views, and
life experiences.
eVOlutiOn OF Culture
Culture evolves as the following.
● Knowledge
● Values
◯ Values guide decision‑making and behavior. For
example, if health promotion and maintenance are
valued, monthly breast self‑examinations are done.
◯ Values develop unconsciously during childhood.
● Beliefs
● Morals and law
● Customs and habits
CULTURALLY RESPONSIVE NURSING CARE
● Culturally responsive nursing care involves the delivery
of care that transcends cultural boundaries and
considers a client’s culture as it affects health, illness,
and lifestyle. Communication, dietary preferences, and
dress are influenced by culture.
● Within the context of culturally responsive nursing care
is terminology that describes how nurses approach
clients’ culture.
◯ Culturally sensitive means that nurses are
knowledgeable about the cultures prevalent in their
area of practice.
◯ Culturally appropriate means that nurses apply their
knowledge of a client’s culture to their care delivery.
◯ Culturally competent means that nurses understand
and address the entire cultural context of each client
within the realm of the care they deliver.
◯ Culturally responsive nursing care improves
communication, fosters mutual respect, promotes
sensitive and effective care, and increases adherence
with the treatment plan as clients’ and families’ needs
are met. Culturally responsive nursing care should
encourage client decision‑making by introducing
self‑empowerment strategies.
◯ Cultural imposition is a key prerequisite to the delivery
of culturally responsive nursing care is the nurses’
understanding and awareness of their own culture and
any cultural biases that might affect care delivery.
● Nurses should accommodate each client’s cultural beliefs
and values whenever possible, unless they are in direct
conflict with essential health practices. The goal is to
provide culturally competent care.
BarrierS tO CulturallY
reSpOnSiVe nurSing Care
● Language, communication, and perception of
time differences
● Culturally inappropriate tests and tools that lead
to misdiagnosis
● Ethnic variations in drug metabolism related to genetics
● Ethnocentrism is the belief that one’s culture is
superior to others. Ethnocentric ideas interfere with the
provision of cultural nursing care.
CHAPTER 35
190 CHAPTER 35 Cultural and Spiritual nurSing Care CONTENT MASTERY SERIES
SPIRITUALITY
Spirituality can play an important role in clients’ abilities
to achieve balance in life, maintain health, seek health
care, and deal with illness and injury. Hope, faith, and
transcendence are integral components of spirituality.
● Spiritual distress is a challenge to belief systems
or spiritual well‑being. It often arises as a result of
catastrophic events. The client can display hopelessness
and decreased interactions with others.
● When faced with health care issues such as acute,
chronic, or life‑limiting illness, clients often find ways
to cope through the use of spiritual practices. Clients
who begin to question their belief systems and are
unable to find support from those belief systems can
experience spiritual distress.
● Nursing interventions are directed at identification,
restoration, and/or reconnection of clients and families
to spiritual strength.
Spirituality implies connectedness.
◯ Intrapersonal: within one’s self
◯ Interpersonal: with others and the environment
◯ Transpersonal: with an unseen higher power
Faith is a belief in something or a relationship with
a higher power. Faith can be defined by a culture or
a religion.
Hope is a concept that includes anticipation and optimism
and provides comfort during times of crisis.
Religion is a system of beliefs practiced outwardly to
express one’s spirituality.
Spiritual ritualS and OBSerVanCeS
Buddhism
BIRTH RITUALS AND HEALTH CARE DECISIONS
● Can refuse care on holy days.
● Can refuse analgesics or strong sedatives.
DIETARY RITUALS
● Some are vegetarians.
● Can avoid alcohol and tobacco.
● Clients might fast on holy days.
DEATH RITUALS
● Clients can request a priest to deliver last rites.
● Chanting is common.
● Brain death is not considered as a requirement for death.
Christianity
BIRTH RITUALS AND HEALTH CARE DECISIONS: Some
baptize infants at birth.
DIETARY RITUALS
● Some avoid alcohol, tobacco, and caffeine.
● Might fast during Lent.
● Some wish to receive the Holy Communion.
DEATH RITUALS: Some give last rites.
Hinduism
BIRTH RITUALS AND HEALTH CARE DECISIONS
● Those practicing Hinduism do not prolong life.
● Personal hygiene and cleanliness are valued.
DIETARY RITUALS: Some are vegetarians.
DEATH RITUALS
● Clients might want to lie on the floor while dying.
● A thread is placed around the neck/wrist.
● The family pours water into the mouth.
● The family bathes the body.
● Clients might want to be cremated.
Islam
BIRTH RITUALS AND HEALTH CARE DECISIONS
● Women must be cared for by female providers,
especially during childbirth.
● Women often must wear head and/or body covering
when in the presence of males who are not
immediate family.
● Have strict rules regarding hand washing.
● Must pray five times a day facing Mecca.
DIETARY RITUALS
● Clients avoid alcohol and pork.
● Clients can fast during Ramadan.
DEATH RITUALS
● Dying clients confess their sins.
● The body faces Mecca.
● The body is washed and enveloped in a white cloth.
● A prayer is said.
Jehovah’s Witnesses
BIRTH RITUALS AND HEALTH CARE DECISIONS: Might
not accept blood transfusions, even in life‑threatening
situations.
DIETARY RITUALS: Clients avoid foods having or prepared
with blood.
DEATH RITUALS: Clients can choose burial or cremation.
Judaism
BIRTH RITUALS AND HEALTH CARE DECISIONS: On the
eighth day after birth, males are circumcised.
DIETARY RITUALS: Some practice a kosher diet.
DEATH RITUALS
● Someone stays with the body.
● A burial society prepares the body.
Mormonism
BIRTH RITUALS AND HEALTH CARE DECISIONS: Children
are baptized at age 8 by immersion.
DIETARY RITUALS: Clients avoid alcohol, tobacco,
and caffeine.
DEATH RITUALS
● Last rites include wearing temple clothes for burial.
● Burial is preferred.
FUNDAMENTALS FOR NURSING CHAPTER 35 Cultural and Spiritual nurSing Care 191
ASSESSMENT/DATA COLLECTION
To meet a client’s cultural needs, a nurse must first
perform a cultural assessment to identify those needs.
Cultural background and acculturation
example: the client was born in Central america
and has been a resident of new York for 2 years.
Health and wellness beliefs/practices
example: the client relies on folk
medicine to treat or prevent illness.
Family patterns
example: the client is from a patriarchal
culture where the oldest male family member
makes decisions for all family members.
Verbal and nonverbal communication
example: Within the client’s culture, it is
disrespectful to make direct eye contact.
Space and time orientation
example: Within the client’s culture, little importance
is placed on how past behavior affects future health.
Nutritional patterns
example: the client believes that some
foods have healing properties.
Meaning of pain
example: Within the client’s culture, pain is
viewed as a punishment for misbehavior or sin.
Death rituals
example: Within the client’s
culture, suicide is acceptable.
Care of ill family members
example: the client expects the entire family to
remain at the client’s bedside during an illness.
Perform the cultural assessment in a language
that is common to both nurse and client, or use a
facility‑approved medical interpreter. Inform the
interpreter of questions that might be asked.
4 C’S Cultural aSSeSSMent
Nurses may use the 4 C’s of Culture by Slavin, Galanti, and
Kuo (2012).
● What do you call the problem you are having now?
● How do you cope with the problem?
● What are your concerns regarding the problem?
● What do you think caused the problem?
OTHER QUESTIONS
● When did the problem start?
● What does the illness do to you? How does it work?
● What makes it better or worse?
● How severe is the illness?
● What treatments have you tried? How do you think it
should be treated?
● What are the chief problems the illness has caused you?
● What do you fear most about the illness?
nOnVerBal BeHaViOr
● Assess the client’s gestures, vocal tones, and inflections.
● Culturally competent nurses must understand how
nonverbal behaviors vary among cultures.
Tone of voice
ASIAN: Many use a soft tone of voice to convey respect.
ITALIAN AND MIDDLE EASTERN: Many use a loud tone
of voice.
Eye contact
AMERICAN: Use direct eye contact. Lack of direct eye
contact implies deception or embarrassment.
MIDDLE EASTERN: Usually avoid making direct eye
contact with nonrelated members of the opposite
gender. Direct eye contact can be seen as rude, hostile, or
sexually aggressive.
ASIAN: Can believe that direct eye contact is disrespectful.
NATIVE AMERICAN: Can believe that direct eye contact
leads to soul loss or soul theft.
Touch
AMERICAN: Can use touch during conversations between
intimate partners or family members.
ITALIAN AND LATIN AMERICAN: Can view frequent touch
as a sign of concern, interest, and warmth.
NATIVE AMERICANS: View touch as a form of aggression.
Use of space
ANGLO‑AMERICAN/NORTH EUROPEANS (ENGLISH,
SWISS, SCANDINAVIAN, GERMAN): Tend to keep their
distance during communication except in intimate or
family relationships.
ITALIAN, FRENCH, SPANISH, RUSSIAN, LATIN AMERICAN,
MIDDLE EASTERN: Prefer closer personal contact and less
distance between individuals during communication.
MetHOdS FOr aSSeSSing Culture
Observation: Study the client and his environment for
examples of cultural relevance.
Interview
● Establish a therapeutic relationship with the client. This
can be hindered by misinterpretations of
communication. Nurses should develop transcultural
communication skills.
● Use focused, open‑ended, nonjudgmental questions.
● Paraphrasing the client’s communication will
decrease misinterpretations.
192 CHAPTER 35 Cultural and Spiritual nurSing Care CONTENT MASTERY SERIES
Participation
● Become involved in culturally related activities outside
of the health care setting.
● Maintain awareness of population demographics (review
census data).
◯ Number of members in a practice area
◯ Average educational and economic levels
◯ Typical occupations
◯ Commonly practiced religious spiritual beliefs
◯ Prevalence of illnesses/health issues
◯ Most commonly held health, wellness, illness, and
death beliefs
◯ Social organization
Spiritual aSSeSSMent
● A spiritual assessment includes several components.
◯ Primary: self‑reflection (nurses) on personal beliefs
and spirituality
◯ Initial: identifying the client’s religion, if any
◯ Focused: ongoing, as nurses identify the clients at
risk for spiritual distress
● Spirituality is a highly subjective area requiring the
development of rapport and trust among the client,
family, and provider.
ASSESSMENT OF THE CLIENT
● Faith/beliefs
● Perception of life and self‑responsibility
● Satisfaction with life
● Culture
● Fellowship and the client’s perceived place in
the community
● Rituals and practices
● Incorporation of spirituality within profession or workplace
● Client expectations for health care in relation to
spirituality (traditional vs. alternative paths, such as
shamans, priests, prayer)
PATIENT‑CENTERED CARE
Death rituals
Death rituals vary among cultures. Facilitate practices and
offer appropriate spiritual care whenever possible.
Pain
● Recognize that how clients react to, display, and relieve
pain varies by culture.
● Use an alternative to the pain scale (0 to 10) because it
might not appropriately reflect pain for all cultures.
● Explore religious beliefs that influence the meaning
of pain.
Nutrition
● Provide food choices and preparation consistent with
cultural beliefs.
● When possible, allow the client’s family/caregiver to
bring in food (as long as it meets the client’s dietary
restrictions), and allow clients to consume foods that
they view as a treatment for illness.
● Communicate ethnicity‑related food intolerances/
allergies to the dietary staff.
Communication
● Improve nurse‑client communication when cultural
variations exist by establishing rapport with client
and family.
● Use facility‑approved interpreters when the
communication barrier is significant enough to affect
the exchange of information between the nurse and
the client.
● Use nonverbal communication with caution because it can
have a different meaning for the client than for the nurse.
● Apologize if cultural traditions or beliefs are violated.
Family patterns and gender roles
Communicate with and include the person who has the
authority to make decisions in the family.
Culture and life transitions
Assist families as they mark rituals (rites of passage) that
symbolize cultural values. Common events expressed with
cultural rituals are puberty, pregnancy, childbirth, dying,
and death.
Repatterning
Changing one’s lifestyle for a new and beneficial one
● Accommodate clients’ cultural beliefs and values as
much as possible.
● Attempt to repattern that belief to one that is
compatible with health promotion, when a cultural
value or behavior hinders a client’s health and wellness.
● Plan and implement appropriate interventions, with
knowledge of cultural differences and respect for the
client and family.
Using an interpreter
The Joint Commission requires that an interpreter
be available in health care facilities in the client’s
language (2010).
● Use only a facility‑approved medical interpreter. Do not
use the client’s family or friends, or a nondesignated
employee to interpret.
● Inform the interpreter about the reason for and the type
of questions that will be asked, the expected response
(brief or detailed), and with whom to converse.
● Interpreters must recognize their role without being
biased of the client’s response.
● Allow time for the interpreter and the family to be
introduced and become acquainted before starting
the interview.
● Refrain from making comments about the family to the
interpreter because the family might understand some
of the discussion.
● Ask one question at a time.
● Direct the questions to the client, not to the interpreter.
● Use lay terminology if possible, knowing that some words
might not have an equivalent word in the client’s language.
● Do not interrupt the interpreter, the client, or the family
as they talk.
● Do not try to interpret answers.
● Following the interview, ask the interpreter for any
additional thoughts about the interview and the client’s
and family’s responses, both verbal and nonverbal.
FUNDAMENTALS FOR NURSING CHAPTER 35 Cultural and Spiritual nurSing Care 193
Addressing spirituality
● Identify the client’s perception of the existence of a
higher power.
● Facilitate growth in the client’s abilities to connect with
a higher power.
● Look for environmental, behavioral, or verbal cues to
assess a client’s spirituality, such as a Bible at bedside,
praying at bedtime, or talking about God.
● Assist the client to feel connected or reconnected to a
higher power.
◯ Allow time and/or resources for the practice of
religious rituals.
◯ Provide privacy for prayer, meditation, or the reading
of religious materials.
● Use your facility’s pastoral care department
if appropriate.
● Facilitate development of a positive outcome in a
particular situation.
● Provide stability for the person experiencing a
dysfunctional spiritual mood.
● Establish a caring presence in being with the client and
family rather than merely performing tasks for them.
● Support all healing relationships.
◯ Using a holistic approach to care: seeing the large
picture for the client
◯ Using client-identified spiritual resources and needs
● Be aware of diet therapies included in spiritual beliefs.
● Support religious rituals.
◯ Icons
◯ Statues
◯ Prayer rugs
◯ Devotional readings
◯ Music
● Support restorative care.
◯ Prayer
◯ Meditation
◯ Grief work
● Evaluation of care is ongoing and continuous, with a
need for flexibility as the client and family process the
current crisis through their spiritual identity.
Application Exercises
1. a nurse is using an interpreter to
communicate with a client. Which of
the following actions should the nurse
use when communicating with a client
and his family? (Select all that apply.)
a. talk to the interpreter
about the family while the
family is in the room.
B. ask the family one
question at a time.
C. look at the interpreter when
asking the family questions.
d. use lay terms if possible.
e. do not interrupt the interpreter
and the family as they talk.
2. a nurse is caring for a client
who shares the nurse’s religious
background. Which of the
following information should
the nurse anticipate?
a. Members of the same
religion share similar feelings
about their religion.
B. a shared religious background
generates mutual regard
for one another.
C. the same religious beliefs can
influence individuals differently.
d. the nurse and client should
discuss the differences and
commonalities in their beliefs.
3. a nurse is caring for a client
who is crying while reading from
his devotional book. Which
of the following interventions
should the nurse take?
a. Contact the hospital’s
spiritual services.
B. ask him what is making him cry.
C. provide quiet times
for these moments.
d. turn on the television
for a distraction.
4. a nurse is planning care for a
client who is a devout Muslim and
is 3 days postoperative following
a hip arthroplasty. the client
is scheduled for two physical
therapy sessions today. Which
of the following statements by
the nurse indicates culturally
appropriate care to the client?
a. “i will make sure the menu
includes kosher options.”
B. “i will discuss the daily
schedule with the client to
make sure the client will
have time for prayer.”
C. “i will make sure to use
direct eye contact when
speaking with this client.”
d. “i will make sure daily
communion is available
for this client.”
5. a nurse is caring for a client who is a
Jehovah’s Witness and is scheduled
for surgery as a result of a motor
vehicle crash. the surgeon tells the
client that a blood transfusion is
essential. the client tells the nurse
that based on his religious values and
mandates, he cannot receive a blood
transfusion. Which of the following
responses should the nurse make?
a. “i believe in this case you
should really make an
exception and accept the
blood transfusion.”
B. “i know your family would
approve of your decision to
have a blood transfusion.”
C. “Why does your religion
mandate that you
cannot receive any
blood transfusions?”
d. “let’s discuss the necessity
for a blood transfusion with
your religious and spiritual
leaders and come to a
reasonable solution.”
194 CHAPTER 35 Cultural and Spiritual nurSing Care CONTENT MASTERY SERIES
Application Exercises Key
1. a. talking to the interpreter about the family while
the family is in the room would hinder communication
between the family and the nurse/interpreter.
B. CORRECT: asking the family one question at a time will promote
effective communication between the family and the nurse/interpreter.
C. looking at the interpreter instead of the family while
the family is in the room would hinder communication
between the family and the nurse/interpreter.
d. CORRECT: using lay terms will promote effective
communication between the family and the nurse/interpreter.
e. CORRECT: not interrupting will promote effective
communication between the family and the nurse/interpreter.
NCLEX® Connection: Psychosocial Integrity,
Cultural Awareness/Cultural Influences on Health
2. a. it would be stereotyping to assume that all members of a specific
religion had the same beliefs. Feelings and ideas about religion and
spiritual matters can be quite diverse, even within a specific culture.
B. Mutual regard does not necessarily follow
a shared religious background.
C. CORRECT: Members of any particular religion should
be assessed for individual feelings and ideas.
d. due to boundary issues, the nurse’s beliefs are not part of a
therapeutic client relationship. it is the client’s beliefs that are important.
NCLEX® Connection: Psychosocial Integrity,
Religious Influences on Health
3. a. Contacting the hospital’s spiritual services
presumes there is a problem.
B. asking the client about the crying could be interpreted as
discounting or being disrespectful of the client’s beliefs.
C. CORRECT: providing privacy and time for the reading of
religious materials supports the client’s spiritual health.
d. providing a distraction could be interpreted as discounting
or being disrespectful of the client’s beliefs.
NCLEX® Connection: Psychosocial Integrity,
Religious Influences on Health
4. a. Clients of the Jewish culture, not islam, require their food to be kosher.
B. CORRECT: devout Muslims pray five times per day. Without
proper awareness and planning, the client can refuse necessary
treatments, such as physical therapy, if adequate prayer times
are not planned for and incorporated into the client’s day.
C. american culture appreciates direct eye contact. in
Middle eastern cultures, direct eye contact can be
perceived as rude, hostile, or sexually aggressive.
d. daily communion is a ritual to consider for a
Catholic client, not for a Muslim client.
NCLEX® Connection: Psychosocial Integrity,
Cultural Awareness/Cultural Influences on Health
5. a. the nurse should not impose her opinion onto the
client and ask him to go against his religious beliefs.
B. the nurse should not make an assumption
on behalf of the client’s family.
C. asking a “why” question can appear judgmental or accusatory.
d. CORRECT: involving the client’s religious and spiritual leaders is a
culturally responsive action at this point. alternative forms of blood
products can be discussed, and a plan reasonable to all can be reached.
NCLEX® Connection: Psychosocial Integrity,
Cultural Awareness/Cultural Influences on Health
PRACTICE Active Learning Scenario
a nurse educator is conducting a class on culturally
responsive nursing care. use the ati active learning
template: Basic Concept to complete this item.
RELATED CONTENT: list five examples of subculture
categories than can exist within a culture.
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
although everyone within a culture shares cultural values,
diversity exists. Forming subcultures is based on the following.
● age
● gender
● Sexual orientation
● Marital status
● Family structure
● income
● education level
● religious views
● life experiences
NCLEX® Connection: Psychosocial Integrity,
Cultural Awareness/Cultural Influences on Health
FUNDAMENTALS FOR NURSING CHAPTER 36 Grief, Loss, and PaLLiative Care 195
UNIT 3 PSYCHOSOCIAL INTEGRITY
CHAPTER 36 Grief, Loss, and
Palliative Care
Clients experience loss in many aspects of their
lives. Grief is the inner emotional response to
loss and is exhibited through thoughts, feelings,
and behaviors. Bereavement includes both
grief and mourning (the outward display of
loss) as the individual deals with the death of a
significant individual in their life.
Palliative or end‑of‑life care is an important aspect
of nursing care and attempts to meet the client’s
physical, spiritual, emotional, and psychosocial
needs. end‑of‑life issues include decision‑making
in a highly stressful time during which the nurse
must consider the desires of the client and the
family. decisions are shared with other health care
personnel for a smooth transition during this time
of stress, grief, and bereavement.
advanCe direCtives
Advance directives: Legal documents that direct
end‑of‑life issues
● Living will: Directive documents for medical treatment
per the client’s wishes
● Health care proxy (also known as durable power of
attorney for health care): A document that appoints
someone to make medical decisions when the client is
no longer able to do so on his own behalf
TYPES OF LOSS
Necessary loss: A loss related to a change that is part
of the cycle of life that is anticipated but still can be
intensely felt. This type of loss can be replaced by
something different or better.
Actual loss: Any loss of a valued person, item, or status,
such as loss of a job that can be recognized by others
Perceived loss: Any loss defined by the client that is not
obvious or verifiable to others
Maturational or developmental loss: Any loss normally
expected due to the developmental processing of life. These
losses are associated with normal life transitions and help
to develop coping skills (e.g., child leaving home for college).
Situational loss: Any unanticipated loss caused by an
external event (e.g., family loses home during tornado)
Anticipatory loss: Experienced before the loss happens
THEORIES OF GRIEF
KÜBLer‑ross ModeL
Denial: The client has difficulty believing a terminal
diagnosis or loss.
Anger: The client lashes out at other people or things.
Bargaining: The client negotiates for more time or a cure.
Depression: The client is overwhelmingly saddened by the
inability to change the situation.
Acceptance: The client acknowledges what is happening
and plans for the future by moving forward.
stages might not be experienced in order, and the
length of each stage varies from person to person.
FACTORS INFLUENCING LOSS,
GRIEF, AND COPING ABILITY
● Individual’s current stage of development
● Gender
● Interpersonal relationships and social support networks
● Type and significance of the loss
● Culture and ethnicity
● Spiritual and religious beliefs and practices
● Prior experience with loss
● Socioeconomic status
FACTORS THAT CAN INCREASE AN INDIVIDUAL’S RISK FOR
DYSFUNCTIONAL GRIEVING
● Being exceptionally dependent upon the deceased
● A person dying unexpectedly at a young age, through
violence or in a socially unacceptable manner
● Inadequate coping skills or lack of social supports
● Lack of hope or preexisting mental health issues, such
as depression or substance use disorder
ASSESSMENT/DATA COLLECTION
Manifestations of Grief reaCtions
Normal grief
● This grief is considered uncomplicated.
● Emotions can be negative, such as anger, resentment,
withdrawal, hopelessness, and guilt but should change
to acceptance with time.
● Some acceptance should be evident by 6 months after
the loss.
● Somatic complaints can include chest pain, palpitations,
headaches, nausea, changes in sleep patterns,
and fatigue.
Anticipatory grief
● This grief implies the “letting go” of an object or person
before the loss, as in a terminal illness.
● Individuals have the opportunity to start the grieving
process before the actual loss.
CHAPTER 36
196 CHAPTER 36 Grief, Loss, and PaLLiative Care CONTENT MASTERY SERIES
Complicated grief
● Unresolved or chronic grief is a type of
complicated grief.
● This grief involves difficult progression through the
expected stages of grief.
● Usually, the work of grief is prolonged. The
manifestations of grief are more severe, and they can
result in depression or exacerbate a preexisting disorder.
● The client can develop suicidal ideation, intense feelings
of guilt, and lowered self‑esteem.
● Somatic complaints persist for an extended period
of time.
Disenfranchised grief
This grief entails an experienced loss that cannot be
publicly shared or is not socially acceptable, such as
suicide and abortion.
NURSING INTERVENTIONS
faCiLitate MoUrninG
● Grant time for the grieving process.
● Identify expected grieving behaviors, such as crying,
somatic manifestations, and anxiety.
● Use therapeutic communication related to the client’s
stage of grief. Name the emotion the client is feeling.
For example, the nurse can say, “You sound as though
you are angry. Anger is a normal feeling for someone
who has lost a loved one. Tell me about how you
are feeling.”
● Use active listening, open‑ended questions,
paraphrasing, clarifying, and/or summarizing, while
using therapeutic communication.
● Use silence and personal presence to facilitate mourning.
● Avoid communication that inhibits the open expression
of feelings, such as offering false reassurance, giving
advice, changing the subject, and taking the focus away
from the grieving individual.
● Assist the grieving individual to accept the reality of
the loss.
● Support efforts to “move on” in the face of the loss.
● Encourage the building of new relationships.
● Provide continuing support. Encourage the support of
family and friends.
● Assess for evidence of ineffective coping, such as a
client refusing to leave the home months after his
partner died.
● Share information about mourning and grieving with
the client, who might not realize that feelings, such as
anger toward the deceased, are expected.
● Encourage attendance at bereavement or grief
support groups. Provide information about available
community resources.
● Initiate referrals for individual psychotherapy for clients
who have difficulty resolving grief.
● Ask the client whether contacting a spiritual advisor
would be acceptable, or encourage the client to do so.
● Participate in debriefing provided by professional grief
and mental health counselors.
Palliative care
● The nurse serves as an advocate for the client’s sense of
dignity and self‑esteem by providing palliative care at
the end of life.
● Goal is to learn to live fully with an incurable condition.
● Palliative care improves the quality of life of clients and
their families facing end‑of‑life issues.
● Palliative care interventions are primarily used when
caring for clients who are dying and family members
who are grieving. Assessment of the client’s family is
very important as well.
● Palliative care interventions focus on the relief of
physical manifestations (such as pain) as well as
addressing spiritual, emotional, and psychosocial
aspects of the client’s life.
● Palliative care can be provided by an interprofessional
team of physicians, nurses, social workers, physical
therapists, massage therapists, occupational therapists,
music/art therapists, touch/energy therapists, and
chaplains.
● Hospice care is a comprehensive care delivery system,
that can be performed in a variety of settings, and
can be implemented when a client is not expected
to live longer than 6 months. Further medical care
aimed toward a cure is stopped, and the focus becomes
enhancing quality of life and supporting the client
toward a peaceful and dignified death.
ASSESSMENT/DATA COLLECTION
● Determine the client’s sources of strength and hope.
● Identify the desires and expectations of the client and
family for end‑of‑life care.
CHARACTERISTICS OF DISCOMFORT
● Pain
● Anxiety
● Restlessness
● Dyspnea
● Nausea or vomiting
● Dehydration
● Diarrhea or constipation
● Urinary incontinence
● Inability to perform ADLs
MANIFESTATIONS OF APPROACHING DEATH
● Decreased level of consciousness
● Muscle relaxation of the face
● Labored breathing (dyspnea, apnea, Cheyne‑Stokes
respirations), “death rattle”
● Hearing is not diminished
● Touch diminished, but client is able to feel the pressure
of touch
● Mucus collecting in large airways
● Incontinence of bowel and/or bladder
● Mottling (cyanosis) occurring with poor circulation
● Pupils no longer reactive to light
● Pulse slow and weak and blood pressure dropping
● Cool extremities
● Perspiration
● Decreased urine output
● Inability to swallow
FUNDAMENTALS FOR NURSING CHAPTER 36 Grief, Loss, and PaLLiative Care 197
NURSING INTERVENTIONS
● Promote continuity of care and communication by
limiting assigned staff changes.
● Assist the client and family to set priorities for
end‑of‑life care.
PHYsiCaL Care
● Give priority to controlling findings.
● Administer medications (such as morphine) that
manage pain, air hunger, and anxiety.
● Perform ongoing assessment to determine the
effectiveness of treatment and the need for
modifications of the treatment plan, such as lower or
higher doses of medications.
● Manage adverse effects of medications.
● Reposition the client to maintain airway patency
and comfort.
● Maintain the integrity of skin and mucous membranes.
● Provide caring touch (holding the client’s hand).
● Provide an environment that promotes dignity and
self‑esteem.
◯ Remove products of elimination as soon as possible to
maintain a clean and odor‑free environment.
◯ Offer comfortable clothing.
◯ Provide careful grooming for hair, nails, and skin.
◯ Encourage family members to bring in comforting
possessions to make the client feel at home.
● If appropriate, encourage the use of relaxation
techniques, such as guided imagery and music.
● Promote decision‑making in food selection, activities,
and health care to give the client as much control
as possible.
● Encourage the client to perform ADLs as able and
willing to do so.
PsYCHosoCiaL Care
● Use an interprofessional approach.
● Provide care and foster support to the client and family.
● Use volunteers when appropriate to provide
nonmedical care.
● Use therapeutic communication to develop and maintain
and facilitate communication between the client, family,
and the provider.
● Facilitate the understanding of information regarding
disease progression and treatment choices.
● Facilitate communication between the client, the family,
and the provider.
● Encourage the client to participate in religious practices
that bring comfort and strength, if appropriate.
● Assist the client in clarifying personal values in order to
facilitate effective decision-making.
● Encourage the client to use coping mechanisms that
have worked in the past.
● Be sensitive to comments made in the presence of
clients who are unconscious because hearing is the last
sensation lost.
Prevention of aBandonMent
and isoLation
● Prevent the fear of dying alone.
● Make your presence known by answering call lights in a
timely manner and making frequent contact.
● Keep the client informed of procedure and
assessment times.
● Allow family members to stay overnight.
● Determine where the client is most comfortable, such as
in a room close to the nurses’ station.
sUPPort for tHe GrievinG faMiLY
● Suggest that family members plan visits to promote the
client’s rest.
● Ensure that the family receives appropriate information
as the treatment plan changes.
● Provide privacy so family members have the
opportunity to communicate and express feelings
among themselves without including the client.
● Determine family members’ desire to provide physical
care while maintaining awareness of possible caregiver
fatigue. Provide instruction as necessary.
● Educate the family about physical changes to expect as
the client moves closer to death.
● Allow families to express feelings
198 CHAPTER 36 Grief, Loss, and PaLLiative Care CONTENT MASTERY SERIES
Postmortem care
● Nurses are responsible for following federal and state
laws regarding requests for organ or tissue donation,
obtaining permission for autopsy, ensuring the
certification and appropriate documentation of the
death, and providing postmortem (after‑death) care.
● After postmortem care is completed, the client’s family
becomes the nurse’s primary focus.
NURSING INTERVENTIONS
Care of tHe BodY
● Provide care with respect and compassion while
attending to the desires of the client and family per
their cultural, religious, and social practices. Check the
client’s religion and make attempts to comply.
● Recognize that the provider certifies death by
pronouncing the time and documenting therapies used,
and actions taken prior to the death.
PREPARING THE BODY FOR VIEWING
● Maintain privacy.
● Remove all tubes (unless organs are to be donated or
this is a medical examiner’s case).
● Remove all personal belongings to be given to
the family.
● Cleanse and align the body supine with a pillow under
the head, arms with palms of hand down outside the
sheet and blanket, dentures in place, and eyes closed.
● Apply fresh linens with absorbent pads on bed and
a gown.
● Brush/comb the client’s hair. Replace any hairpieces.
● Remove excess supplies, equipment, and soiled linens
from the room.
● Dim the lights and minimize noise to provide a
calm environment.
VIEWING CONSIDERATIONS
● Ask the family whether they would like to visit with the
body, honoring any decision.
● Clarify where the client’s personal belongings should go:
with the body or to a designated person.
● Adhere to the same procedures when the client is an
infant, with the following exceptions.
◯ Swaddle the infant’s body in a clean blanket.
◯ Transport the infant in the nurse’s arms or in an
infant carrier based on facility protocol.
◯ Offer mementos of the infant (identification bracelets,
footprints, the cord clamp, a lock of hair, photos).
POSTVIEWING
● Apply identification tags according to facility policy.
● Complete documentation.
● Remain aware of visitor and staff sensibilities
during transport.
orGan/tissUe donation
● Recognize that requests for tissue and organ donations
must be made by specifically trained personnel.
● Provide support and education to family members as
decisions are being made. Use private areas for any
family discussions concerning donation.
● Be sensitive to cultural and religious influences.
● Maintain ventilatory and cardiovascular support for
vital organ retrieval.
aUtoPsY Considerations
● The provider typically approaches the family about
performing an autopsy.
● The nurse’s role is to answer the family members’
questions and support their choices.
● Autopsies can be conducted to advance scientific
knowledge regarding disease processes, which can lead
to the development of new therapies.
● The law can require an autopsy to be performed if the
death is due to homicide, suicide, or accidental death, or
if death occurs within 24 hr of hospital admission.
● Most facilities require that all tubes remain in place for
an autopsy.
● Documentation and completion of forms following
federal and state laws typically includes the following.
◯ Who pronounced the death and at what time
◯ Consideration of and preparation for organ donation
◯ Description of any tubes or lines left in or on the body
◯ Disposition of personal articles
◯ Who was notified, and any decisions made
◯ Location of identification tags
◯ Time the body left the facility and the destination
Care of nUrses WHo are GrievinG
● Caring long‑term for clients can create personal
attachments for nurses.
● Nurses can use coping strategies.
◯ Going to the client’s funeral
◯ Communicating in writing to the family
◯ Attending debriefing sessions with colleagues
◯ Using stress management techniques
◯ Talking with a professional counselor
Online Video: Postmortem Care
FUNDAMENTALS FOR NURSING CHAPTER 36 Grief, Loss, and PaLLiative Care 199
Application Exercises
1. a nurse is caring for a client who
has terminal lung cancer. the nurse
observes the client’s family assisting
with all adLs. Which of the following
rationales for self‑care should the
nurse communicate to the family?
a. allowing the client to
function independently will
strengthen her muscles
and promote healing.
B. the client needs to be
given privacy at times
for self‑reflecting and
organizing her life.
C. the client’s sense of loss
can be lessened through
retaining control of
certain areas of her life.
d. Performing adLs is required
prior to discharge from
an acute care facility.
2. a nurse is caring for a client who has
stage iv lung cancer and is 3 days
postoperative following a wedge
resection. the client states, “i told
myself that i would go through with
the surgery and quit smoking, if i
could just live long enough to attend
my daughter’s wedding.” Based on
Kübler‑ross’ model, which stage of
grief is the client experiencing?
a. anger
B. denial
C. Bargaining
d. acceptance
3. a nurse is consoling the partner
of a client who just expired after a
long battle with liver cancer. the
partner is displaying grief and
states, “i hate him for leaving
me.” Which of the following
statements by the nurse successfully
facilitate mourning for the grieving
partner? (select all that apply.)
a. “Would you like me to
contact the chaplain to
come speak with you?”
B. “You will feel better soon.
You have been expecting
this for a while now.”
C. “Let’s talk about your
children and how they
are going to react.”
d. “You know, it is quite normal
to feel anger toward your
husband at this time.”
e. “tell me more about
how you are feeling.”
4. a nurse is caring for a client who
has a terminal illness. death is
expected within 24 hr. the client’s
family is at the bedside and asks
the nurse about anticipated
findings at this time. Which of
the following findings should the
nurse include in the discussion?
a. regular breathing patterns
B. Warm extremities
C. increased urine output
d. decreased muscle tone
5. a nurse is assisting a newly licensed
nurse with postmortem care of a
client. the family wishes to view
the body. Which of the following
statements by the newly licensed
nurse indicate an understanding of
the procedure? (select all that apply.)
a. “i will remove the dentures
from the body.”
B. “i will make sure the body
is lying completely flat.”
C. “i will apply fresh linens
and place a clean
gown on the body.”
d. “i will remove all equipment
from the bedside.”
e. “i will dim the lights
in the room.”
PRACTICE Active Learning Scenario
a nurse educator is teaching a module on palliative care
to a group of newly licensed nurses. Use the ati active
Learning template: Basic Concept to complete this item.
NURSING INTERVENTIONS: List five physical care
interventions and five psychological care interventions
appropriate for the care of a client who is dying.
200 CHAPTER 36 Grief, Loss, and PaLLiative Care CONTENT MASTERY SERIES
Application Exercises Key
1. a. strengthening of muscles is not a priority of palliative care.
B. Privacy for periods of self‑reflection can be achieved
at times apart from performance of adLs.
C. CORRECT: allowing the client as much control as
possible maintains dignity and self‑esteem.
d. Performance of adLs is not a criterion for
discharge from an acute care facility.
NCLEX® Connection: Psychosocial Integrity, End of Life Care
2. a. this client statement does not display anger.
B. the client is not denying the severity of the diagnosis and prognosis.
C. CORRECT: the client is displaying bargaining by attempting
to negotiate more time to live to see his daughter get married.
d. although the client might have accepted his diagnosis and prognosis,
this client statement does not convey coming to terms with the situation.
NCLEX® Connection: Psychosocial Integrity, End of Life Care
3. a. CORRECT: asking the grieving individual whether she
would like spiritual support at this time is an acceptable
nursing intervention to facilitate mourning.
B. the nurse should avoid giving false reassurance and offering
assumptions while intervening to facilitate mourning.
C. the nurse should avoid hanging the subject and bringing the focus
away from the grieving individual while intervening to facilitate mourning.
d. CORRECT: the nurse should educate the grieving individual
on the grieving process and expected emotions at this time.
e. CORRECT: the nurse should encouraging the open communication
of feelings by using therapeutic communication to facilitate mourning.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
4. a. Labored breathing and irregular patterns
are indicative of imminent death.
B. Cool extremities would be indicative of imminent death.
C. decreased urine output would be indicative of imminent death.
d. CORRECT: Muscle relaxation is an expected
finding when a client is approaching death.
NCLEX® Connection: Psychosocial Integrity, End of Life Care
5. a. the nurse should insert the client’s dentures so
that the face looks as natural as possible.
B. the body should not be completely flat. one pillow is placed
under the head and shoulders to prevent discoloration of the face.
C. CORRECT: the body and the environment should be
as clean as possible. this includes washing soiled areas of
the body and applying fresh linens and a clean gown.
d. CORRECT: the environment should be as clutter‑free as possible. the
nurse should remove all equipment and supplies from the bedside.
e. CORRECT: dimming the lights helps to provide
a calm environment for the family.
NCLEX® Connection: Basic Care and Comfort, Personal Hygiene
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
NURSING INTERVENTIONS
Physical care
● Give priority to controlling findings.
● administer medications that manage pain, air hunger, and anxiety.
● Perform ongoing assessment to determine the effectiveness
of treatment and the need for modifications of the treatment
plan, such as lower or higher doses of medications.
● Manage adverse effects of medications.
● reposition the client to maintain airway patency and comfort.
● Maintain the integrity of skin and mucous membranes.
● Provide an environment that promotes dignity and self‑esteem.
● remove products of elimination as soon as possible to
maintain a clean and odor‑free environment.
● offer comfortable clothing.
● Provide careful grooming for hair, nails, and skin.
● encourage family members to bring in comforting
possessions to make the client feel at home.
● if appropriate, encourage the use of relaxation
techniques, such as guided imagery and music.
● Promote decision‑making in food selection, activities, and
health care to give the client as much control as possible.
● encourage the client to perform adLs as able and willing to do so.
Psychosocial care
● Use an interprofessional approach.
● Provide care to the client and family.
● Use volunteers when appropriate to provide nonmedical care.
● Use therapeutic communication to develop and
maintain a nurse‑client relationship.
● facilitate the understanding of information regarding
disease progression and treatment choices.
● facilitate communication between the client, family, and provider.
● encourage the client to participate in religious practices
that bring comfort and strength, if appropriate.
● assist the client in clarifying personal values in order
to facilitate effective decision‑making.
● encourage the client to use coping mechanisms
that have worked in the past.
● Be sensitive to comments made in the presence of clients who
are unconscious because hearing is the last sensation lost.
NCLEX® Connection: Basic Care and Comfort, Non-Pharmacological Comfort Interventions
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 201
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Basic Care and Comfort
ASSISTIVE DEVICES
Assess the client’s use of assistive devices.
Assist client to compensate for a physical or sensory impairment.
ELIMINATION: Provide skin care to clients who are incontinent.
MOBILITY/IMMOBILITY: Apply knowledge of nursing procedures and
psychomotor skills when providing care to clients with immobility.
NON-PHARMACOLOGICAL COMFORT INTERVENTIONS
Recognize complementary therapies and
identify potential contraindications.
Plan measures to provide comfort interventions to clients
with anticipated or actual impaired comfort.
NUTRITION AND ORAL HYDRATION: Evaluate client
intake and output and intervene as needed.
PERSONAL HYGIENE: Assess the client for
personal hygiene habits/routine.
REST AND SLEEP: Schedule client care
activities to promote adequate rest.
FUNDAMENTALS FOR NURSING CHAPTER 37 Hygiene 203
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 37 Hygiene
Personal hygiene needs vary with clients’ health
status, social and cultural practices, and the
daily routines they follow at home. For most
clients, personal hygiene includes bathing, oral
care, nail and foot care, perineal care, hair care,
and shaving (especially for men).
Because personal hygiene has a profound effect
on overall health, comfort, and well‑being, it
is an integral component of individualized
nursing care plans. When clients become ill,
have surgery, or are injured and are unable to
manage their own personal hygiene needs, it
becomes the nurse’s responsibility to meet
those needs.
Before beginning any personal care delivery, it
is important to evaluate the client’s ability to
participate in personal hygiene. encourage
clients to participate in any way they can.
integrate assessment, range of motion
exercises, and dressing changes while providing
hygiene care.
HYGIENE CARE
Bathing
● Bathe clients to cleanse the body, stimulate circulation,
provide relaxation, and enhance healing.
● Bathing clients is often delegated to the assistive
personnel. However, the nurse is responsible for data
collection and client care.
● Bathe clients whose health problems have exhausted
them or limited their mobility.
◯ Give a complete bath to clients who can tolerate it and
whose hygiene needs warrant it.
◯ Partial baths are useful when clients cannot tolerate
a complete bath, need particular cleansing of odorous
or uncomfortable areas, or can perform part of the
bath independently.
◯ Therapeutic baths are used to promote comfort and/or
provide treatment, such as soothe itchy skin.
Oral hygiene
Proper oral hygiene helps decrease the risk of infection for
clients living in long‑term care facilities, especially from
the transmission of pathogens that can cause pneumonia.
Foot care
● Foot care prevents skin breakdown, pain, and infection.
● Foot care is extremely important for clients who have
diabetes mellitus, and a qualified professional must
perform it.
Perineal care
Perineal care helps maintain skin integrity, relieve
discomfort, and prevent transmission of micro‑organisms
(catheter care).
CULTURAL AnD SOCiAL PRACTiCeS
● Clients vary in their hygiene preferences and practices.
These include bathing routines, oral care, grooming
preferences, and health beliefs.
● Culture also plays an important role, because some
cultures have unique hygiene practices. Be sure to
be respectful and observant of each client’s specific
cultural needs.
● Consider the client’s personal preference regarding
hygiene practices.
● Socioeconomic status can affect clients’ hygiene status.
If a client is homeless, alter discharge instructions and
follow‑up care accordingly.
● Respect each client’s dignity. Many clients are dealing
with a loss of control when others must provide their
hygiene care. Reassure clients and allow them to have
as much control as possible.
CHAPTER 37
204 CHAPTER 37 Hygiene CONTENT MASTERY SERIES
SAFeTy
● Before starting any care, understand how to complete
each task to avoid injuring the client. This includes
knowing the equipment and what the proper techniques
are for each hygiene procedure.
● Never leave clients in a position where injury could
occur during routine hygiene care. For example, avoid
leaving a client who is at risk for aspiration alone with
oral hygiene supplies.
● Adjust the bed to comfortable working height and lower
the bed upon completion of the task.
COnSiDeRATiOnS FOR OLDeR ADULTS
● Older adults’ skin is drier, thinner, and will not tolerate
as much bathing as younger adults’ skin.
● Older adults have higher incidences of infection and
periodontal disease due to the weakening of the
periodontal membrane.
● Dentures must fit correctly, or they can cause digestive
issues, pain, and discomfort. Dentures are a client’s
personal property. Never leave them on a meal tray or in
a place where they could be damaged or lost.
● Dry mouth is common in older adults due to decreased
saliva production and the use of certain medications
(antihypertensives, diuretics, anti-inflammatory
agents, antidepressants).
● Poor nutritional status is often due to dental problems,
socioeconomic status, or a limited ability to prepare
healthful foods.
ASSESSMENT/DATA COLLECTION
● Inspect the skin for color, hydration, texture, turgor,
and any lesions or other impaired integrity.
● Check the condition of the gums and teeth for dryness
or inflammation of the oral mucosa. Does the client
report any pain?
● Assess the skin surfaces, including the feet and
nails, and note the shape and size of each foot, any
lesions, and areas of dryness or inflammation.
Significant alterations can indicate neuropathy and/or
vascular insufficiency. Are all pulses palpable and
equal bilaterally?
● Identify hygiene preferences to understand how clients
perform hygiene at home and what additional education
and care to provide.
● Monitor for safety issues (altered positioning, decreased
mobility) and the ability to participate in self‑care. Alter
the plan of care according to the client’s capabilities.
PATIENT‑CENTERED CARE
nURSing COnSiDeRATiOnS
Giving a bed bath
● Collect supplies, provide for privacy, and explain the
procedure to the client.
● Apply gloves.
● Lock the wheels on the bed.
● Adjust the bed to a comfortable working position.
● Place a bath blanket over the client, and remove the
client’s gown.
● Obtain warm bath water.
● Wash the client’s face first. Allow the client to perform
this task if able.
● Perform the bath systematically by starting with the
client’s trunk and upper extremities and continuing
to the client’s lower extremities. Keep cleaned areas
covered with a blanket or towel.
● Wash with long, firm strokes from distal to proximal.
Use light strokes over lower extremities for clients who
have a history of deep vein thrombosis.
● Apply lotion and powder (if neither is contraindicated),
and a clean gown.
● Change water if cool or as indicated, and use fresh water
to perform perineal care.
● Document skin assessment, type of bath, and the
client’s response.
TO CHANGE LINENS ON AN OCCUPIED BED
● Adjust the bed to a comfortable working height.
● Don gloves.
● Roll the bottom linens up in the bottom sheet or
mattress pad under the client who is turned on his side,
facing the opposite direction. For safety purposes, adjust
and lower side rails accordingly.
● Apply clean bottom linens to the bed (draw sheets are
optional), and extend them to the middle of the bed
with the remainder of the linen fan‑folded underneath
the client.
● Have the client roll over the linens and face the opposite
direction, then remove the used linens (keep away from
your uniform) and apply the clean linens. Make sure the
linens are free from wrinkles.
● Apply the upper sheet and blanket.
● To remove the pillowcase, insert one hand into the
opening, grab the pillow, and turn the pillowcase
inside‑out.
● Apply the clean pillowcase by grasping the center of
the closed end, turning the case inside-out, fitting the
pillow into the corner of the case, and pulling the case
until it is right‑side out over the pillow.
FUNDAMENTALS FOR NURSING CHAPTER 37 Hygiene 205
Foot care
● It is important to prevent any infection or pain that
can interfere with gait. A qualified professional should
perform foot care for clients who have diabetes mellitus,
peripheral vascular disease, or immunosuppression to
evaluate the feet and prevent injury.
● Instruct clients at risk for injury to do the following.
◯ Inspect the feet daily, paying specific attention to the
area between the toes.
◯ Use lukewarm water, and dry the feet thoroughly.
◯ Apply moisturizer to the feet, but avoid applying it
between the toes.
◯ Avoid over‑the‑counter products that contain alcohol
or other strong chemicals.
◯ Wear clean cotton socks daily.
◯ Check shoes for any objects, rough seams, or edges
that can cause injury.
◯ Cut the nails straight across, and use an emery board
to file nail edges.
◯ Avoid self‑treating corns or calluses.
◯ Wear comfortable shoes that do not
restrict circulation.
◯ Do not apply heat unless prescribed.
◯ Contact the provider if any indications of infection or
inflammation appear.
Perineal care
It is important to maintain skin integrity to relieve
discomfort and prevent transmission of infection
(catheter care).
PRINCIPLES OF PERINEAL CARE
● Provide privacy.
● Maintain a professional demeanor.
● Remove any fecal material from the skin.
● Cleanse the perineal area from front to back (perineum
to rectum).
● Dry thoroughly.
● Retract the foreskin of male clients to wash the tip of
the penis, clean from the meatus outward in a circular
motion, then replace the foreskin.
Oral hygiene
● Check for aspiration risk, impaired swallowing, or
decreased gag reflex.
● Clients who have fragile oral mucosa require gentle
brushing and flossing.
● Have suction apparatus ready at the bedside when
providing oral hygiene to clients who are unconscious to
help prevent aspiration. Do not place fingers into an
unconscious client’s mouth (the client could bite down
on your fingers). Position the client on his side with his
head turned toward you in either a semi‑Fowler’s
position, or with the head of the bed flat. This will allow
fluid and oral secretions to collect in the dependent side
of the client’s mouth and drain out.
● Perform denture care for clients who are unable to do
so themselves. Dentures are very fragile, so handle
with care.
◯ Remove the dentures with a gloved hand, pulling
down and out at the front of the upper denture, and
lifting up and out at the front of the lower denture.
◯ Place the dentures in a denture cup, emesis basin, or
on a washcloth in the sink.
◯ Brush in a horizontal back and forth motion with a
soft brush and denture cleaner.
◯ Rinse dentures in tepid water.
◯ Store the dentures in a denture cup. Label the cup
with the client’s name.
◯ Place the dentures in the cup with water to keep them
moist, or help the client reinsert the dentures.
Nail care
● Observe the size, shape, and condition of the nails and
nail beds.
● Check for cracking, clubbing, and fungus.
● Before cutting any client’s nails, check the facility’s
policy. Some require a prescription from the provider,
while others allow only a podiatrist or other qualified
professional to cut some or all clients’ nails.
● Foot and nail care vary from the standard when caring
for a client who has diabetes mellitus or peripheral
vascular disease. Do not soak the feet due to the risk of
infection, and do not cut the nails. Instead, file nails
using a nail file. Do not apply lotion between the fingers
or toes because the moisture can cause skin irritation
and breakdown.
206 CHAPTER 37 Hygiene CONTENT MASTERY SERIES
Hair care
● Caring for the hair and scalp is important for clients’
appearance and sense of well‑being, and is an essential
component of personal hygiene. Take into consideration
the client’s cultural and personal preferences.
● Brush or comb the hair daily to remove tangles,
massage the scalp, stimulate circulation to the scalp,
and distribute natural oils along the shaft of the hair.
Use a soft‑bristled brush to prevent injury or trauma to
the scalp and a wide‑toothed comb or hair pick to comb
through tightly curled hair.
● For clients who cannot shower but can sit in a chair and
lean back, shampoo the hair at the sink. For clients on
bed rest, use a plastic shampoo trough. Dry or no‑rinse
shampoos and shampoo caps are also options for clients
on bed rest.
● Start shampooing the hair at the hairline and work
toward the neck. To wash the hair on the back of the
head, gently lift the head with one hand and shampoo
with the other.
● Place a folded or rolled towel behind the neck to pad the
edge of the sink. Then rinse, comb, and dry the hair.
Shaving
● Safety is important. Clients who are prone to bleeding,
receiving anticoagulants, or have low platelet counts
should use an electric razor.
● Soften the skin with warm water.
● Apply soap (bar soap not recommended) or
shaving cream.
● Hold the skin taut.
● Move the razor over the skin in the direction of hair
growth using long strokes on large areas of the face and
short strokes around the chin and lips.
● Be sure to communicate with clients about personal
shaving preferences.
FUNDAMENTALS FOR NURSING CHAPTER 37 Hygiene 207
Application Exercises
1. A nurse is performing mouth care
for a client who is unconscious.
Which of the following actions
should the nurse take?
A. Turn the client’s head
to the side.
B. Place two fingers in the
client’s mouth to open.
C. Brush the client’s teeth
once per day.
D. inject a mouth rinse into the
center of the client’s mouth.
2. A nurse is instructing a client
who has diabetes mellitus about
foot care. Which of the following
guidelines should the nurse
include? (Select all that apply.)
A. inspect the feet daily.
B. Use moisturizing
lotion on the feet.
C. Wash the feet with warm
water and let them air dry.
D. Use over‑the‑counter
products to treat abrasions.
e. Wear cotton socks.
3. A nurse is planning care for a
client who develops dyspnea
and feels tired after completing
her morning care. Which of the
following actions should the nurse
include in the client’s plan of care?
A. Schedule rest periods
during morning care.
B. Discontinue morning
care for 2 days.
C. Perform all care as
quickly as possible.
D. Ask a family member to
come in to bathe the client.
4. A nurse is beginning a complete
bed bath for a client. After
removing the client’s gown and
placing a bath blanket over him,
which of the following areas
should the nurse wash first?
A. Face
B. Feet
C. Chest
D. Arms
5. A nurse is preparing to perform
denture care for a client. Which
of the following actions should
the nurse plan to take?
A. Pull down and out at
the back of the upper
denture to remove.
B. Brush the dentures
with a toothbrush and
denture cleaner.
C. Rinse the dentures with hot
water after cleaning them.
D. Place the dentures in a
clean, dry storage container
after cleaning them.
PRACTICE Active Learning Scenario
A nurse is about to perform perineal care for a client whose
ability to assist with care is limited. Use the ATi Active
Learning Template: nursing Skill to complete this item.
DESCRIPTION OF SKILL: List the steps the nurse
should take to perform this procedure.
208 CHAPTER 37 Hygiene CONTENT MASTERY SERIES
Application Exercises Key
1. A. CORRECT: The nurse should position the client’s head on the
side, unless contraindicated, to reduce the risk of aspiration.
B. The nurse should not insert fingers into the client’s mouth
because the client might bite down on the fingers.
C. The nurse should brush the client’s teeth at least twice per day.
D. The nurse should gently inject a mouth rinse into the side
of the client’s mouth to reduce the risk for aspiration.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
2. A. CORRECT: Clients who have diabetes mellitus are
at increased risk for infection and diminished sensitivity
in the feet, so they should inspect them daily.
B. CORRECT: The client should use moisturizing lotions (but not
between the toes) to help keep the skin smooth and supple.
C. The client should wash the feet with lukewarm
water and dry the feet thoroughly.
D. Over‑the‑counter products often contain harmful
chemicals that can cause skin impairment.
e. CORRECT: The client should wear clean cotton socks each day.
NCLEX® Connection: Reduction of Risk Potential,
Potential for Alterations in Body Systems
3. A. CORRECT: Planning for rest periods during morning care will
help prevent fatigue and continue to foster independence.
B. Fatigue and dyspnea do not eliminate the need for morning care.
C. Performing all of the client’s care quickly might affect
the client’s self‑esteem and reduce his independence.
D. Having a family member bathe the client reduces his self‑esteem
and independence, and does not reduce the client’s fatigue.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
4. A. CORRECT: The greatest risk to a client during bathing is the
transmission of pathogens from one area of the body to another. The
nurse should begin with the cleanest area of the body and proceed
to the least clean area. The face is generally the cleanest area, and
washing it first follows a systematic head‑to‑toe approach to client care.
B. The client is at risk for infection from pathogens on the client’s
feet. Therefore, the nurse should wash another area first.
C. The client is at risk for infection from pathogens on the client’s
chest. Therefore, the nurse should wash another area first.
D. The client is at risk for infection from pathogens on the client’s
arms. Therefore, the nurse should wash another area first.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
5. A. The nurse remove the upper dentures with a gloved hand,
pulling down and out at the front of the upper denture.
B. CORRECT: Brushing the dentures thoroughly with
a toothbrush and denture cleaner removes debris
that accumulates on and between the teeth.
C. Using hot water to rinse dentures can damage some denture
materials. The nurse should use tepid water to rinse dentures.
D. Dentures should be moist when not in use to prevent warping
and to facilitate insertion. The nurse should store them in water
in a denture cup with the client’s identification on the cup.
NCLEX® Connection: Basic Care and Comfort, Assistive Devices
PRACTICE Answer
Using the ATI Active Learning Template: Nursing Skill
DESCRIPTION OF SKILL
● Provide privacy.
● Maintain a professional demeanor.
● Remove any fecal material from the skin.
● Cleanse the perineal area from front to back.
● Dry skin thoroughly.
● Retract the foreskin of male clients to wash the tip of the penis, clean from
the meatus outward in a circular motion, then replace the foreskin.
NCLEX® Connection: Safety and Infection Control,
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
FUNDAMENTALS FOR NURSING CHAPTER 38 Rest and sleep 209
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 38 Rest and Sleep
adequate amounts of sleep and rest promote
health. too little sleep leads to inability to
concentrate, poor judgment, moodiness,
irritability, and increased risk for accidents.
Chronic sleep loss can increase risks of obesity,
depression, hypertension, diabetes mellitus,
heart attack, and stroke.
SLEEP CYCLE
The sleep cycle consists of four stages of nonrapid eye
movement (NREM) sleep and a period of rapid eye
movement (REM) sleep. Typically, after Stage 1 of NREM
sleep, people cycle four to six times through the other
stages of sleep per night. With each cycle, the length of
time in REM sleep increases. NREM sleep accounts for
75% to 80% of sleep time.
Stage 1 NREM
● Very light sleep
● Only a few minutes long
● Vital signs and metabolism beginning to decrease
● Awakens easily
● Feels relaxed and drowsy
Stage 2 NREM
● Deeper sleep
● 10 to 20 min long
● Vital signs and metabolism continuing to slow
● Requires slightly more stimulation to awaken
● Increased relaxation
Stage 3 NREM
● Initial stages of deep sleep
● 15 to 30 min long
● Vital signs continuing to decrease but remain regular
● Difficult to awaken
● Relaxation with little movement
Stage 4 NREM
● Called delta sleep
● Deepest sleep
● 15 to 30 min long
● Vital signs low
● Very difficult to awaken
● Physiologic rest and restoration
● Enuresis, sleepwalking, sleeptalking possible
● Repair and renewal of tissue
REM
● Vivid dreaming
● About 90 min after falling asleep
● Longer with each sleep cycle
● Average length 20 min
● Varying vital signs
● Very difficult to awaken
● Cognitive restoration
sleep dURatIOn
Sleep averages vary with the developmental stage, with
infants and toddlers averaging 9 to 15 hr/day. This
declines gradually throughout childhood, with adolescents
averaging 9 to 10 hr/day and adults 7 to 8 hr/day.
COMMOn sleep dIsORdeRs
Insomnia
● The most common sleep disorder, this is the inability
to get an adequate amount of sleep and to feel rested.
It might mean difficulty falling asleep, difficulty
staying asleep, awakening too early, or not getting
refreshing sleep.
● Acute insomnia lasts a few days possibly due to
personal or situational stressors.
● Chronic insomnia lasts a month or more.
● Some people have intermittent insomnia, sleeping well
for a few days and then having insomnia for a few days.
● Women and older adults are more prone to insomnia.
Sleep apnea
● More than five breathing cessations lasting longer than
10 seconds per hour during sleep, resulting in decreased
arterial oxygen saturation levels.
● Sleep apnea can be a single disorder or a mixture of
the following
◯ Central: Central nervous system dysfunction in the
respiratory control center of the brain that fails to
trigger breathing during sleep.
◯ Obstructive: Structures in the mouth and throat relax
during sleep and occlude the upper airway.
Narcolepsy
● Sudden attacks of sleep or excessive sleepiness during
waking hours.
● It often happens at inappropriate times and increases
the risk for injury.
CHAPTER 38
210 CHAPTER 38 Rest and sleep CONTENT MASTERY SERIES
ASSESSMENT/DATA COLLECTION
● Ask about sleep patterns, history, and any
recent changes.
● Identify the usual sleep requirements.
● Ask about sleep problems (type, manifestations, timing,
seriousness, related factors, aftereffects).
● Use a linear or visual scale with “best sleep” on one
end and “worst sleep” on the opposite end and ask for a
sleep rating on a 0 to 10 scale.
● Check for common factors that interfere with sleep.
FaCtORs tHat InteRFeRe WItH sleep
Illness: Can require more sleep or disrupt sleep, such
as nocturia.
Current life events: Traveling more, change in work hours.
Emotional stress or mental illness: Anxiety, fear, grief.
Diet: Caffeine consumption, heavy meals before bedtime.
Exercise: Promotes sleep if at least 2 hr before bedtime.
Otherwise can disrupt sleep.
Fatigue: Exhausting or stressful work makes falling
asleep difficult.
Sleep environment: Too light, the wrong temperature, or
too noisy (children, pets, loud noise, snoring partner).
Medications: Some can induce sleep but interfere
with restorative sleep. Others (bronchodilators,
antihypertensives) cause insomnia.
NURSING CONSIDERATIONS
● Help clients establish and follow a bedtime routine.
● Limit waking clients during the night.
● Promote a quiet hospital environment.
● Help with personal hygiene needs or a back rub prior to
sleep to increase comfort.
● Consider continuous positive airway pressure (CPAP)
devices for clients who have sleep apnea.
● Consult the provider about trying sleep‑promoting
over‑the‑counter products (melatonin, valerian,
chamomile).
● As a last resort, suggest that the provider prescribe
a pharmacological agent. Medications of choice for
insomnia are benzodiazepine‑like medications, which
include the sedative‑hypnotics zolpidem, eszopiclone,
and zaleplon.
ClIent edUCatIOn
● Exercise regularly at least 2 hr before bedtime.
● Establish a bedtime routine and a regular sleep pattern.
● Arrange the sleep environment for comfort.
● Limit alcohol, caffeine, and nicotine at least 4 hr
before bedtime.
● Limit fluids 2 to 4 hr before bedtime.
● Engage in muscle relaxation if anxious or stressed.
ClIent edUCatIOn FOR naRCOlepsY
● Exercise regularly.
● Eat small meals that are high in protein.
● Avoid activities that increase sleepiness (sitting too long,
warm environments, drinking alcohol).
● Avoid activities that could cause injury should the client
fall asleep (driving, heights).
● Take naps when drowsy or when narcoleptic events
are likely.
● Take prescribed stimulants.
FUNDAMENTALS FOR NURSING CHAPTER 38 Rest and sleep 211
Application Exercises
1. a nurse in a provider’s office is caring
for a client who states that, for the
past week, she has felt tired during
the day and cannot sleep at night.
Which of the following responses
should the nurse ask when collecting
data about the client’s difficulty
sleeping? (select all that apply.)
a. “does your lack of sleep
interfere with your ability to
function during the day?”
B. “do you feel confused in
the late afternoon?”
C. “do you drink coffee, tea, or
other caffeinated drinks? If
so, how many cups per day?”
d. “Has anyone ever told you
that you seem to stop
breathing for a few seconds
while you are asleep?”
e. “tell me about any personal
stress you are experiencing.”
2. a nurse is talking with a client
about ways to help him sleep
and rest. Which of the following
recommendations should the nurse
give to the client to promote sleep
and rest? (select all that apply.)
a. practice muscle
relaxation techniques.
B. exercise each morning.
C. take an afternoon nap.
d. alter the sleep environment
for comfort.
e. limit fluid intake at least
2 hr before bedtime.
3. a nurse is caring for an older adult
client who has been following the
facility’s routine and bathing in
the morning. However, at home,
she always takes a warm bath
just before bedtime. now she is
having difficulty sleeping at night.
Which of the following actions
should the nurse take first?
a. Rub the client’s back for
15 min before bedtime.
B. Offer the client warm milk
and crackers at 2100.
C. allow the client to take a
bath in the evening.
d. ask the provider for a
sleeping medication.
4. a nurse is preparing a presentation at
a local community center about sleep
hygiene. When explaining rapid eye
movement (ReM) sleep, which of the
following characteristics should the
nurse include? (select all that apply.)
a. ReM sleep provides
cognitive restoration.
B. ReM sleep lasts about 90 min.
C. It is difficult to awaken a
person in ReM sleep.
d. sleepwalking occurs
during ReM sleep.
e. Vivid dreams are common
during ReM sleep.
5. a nurse is instructing a client who
has a new diagnosis of narcolepsy
about measures that might help
with self‑management. Which of the
following statements should the nurse
identify as an indication that the
client understands the instructions?
a. “I’ll add plenty of
carbohydrates to my meals.”
B. “I’ll take a short nap whenever
I feel a little sleepy.”
C. “I’ll make sure I stay warm when
I am at my desk at work.”
d. “It’s okay to drink alcohol
as long as I limit it to
one drink per day.”
PRACTICE Active Learning Scenario
a nurse on a medical unit is collecting data
from a client who reports a persistent inability
to sleep. Use the atI active learning template:
Basic Concept to complete this item.
UNDERLYING PRINCIPLES: list at least three common
factors that might be interfering with the client’s sleep.
NURSING INTERVENTIONS: list at least three
strategies the nurse can implement to help
the client sleep while in the hospital.
212 CHAPTER 38 Rest and sleep CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: daytime sleepiness, which can interfere with functioning,
is common during the day when people cannot sleep at night.
B. Chronic sleep deprivation or lack of rapid eye
movement sleep can cause confusion, but sleep difficulties
for 1 week should not result in confusion.
C. CORRECT: Caffeinated drinks act as a
stimulant and can interfere with sleep.
d. CORRECT: periods of apnea warrant a prompt
referral for diagnostic sleep studies.
e. CORRECT: emotional stress is the most common
cause of short‑term sleep problems.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
2. a. CORRECT: Relaxation techniques, especially muscle
relaxation, can help promote sleep and rest.
B. CORRECT: Following an exercise routine regularly, at least
2 hr prior to bedtime, can help promote rest and sleep.
C. napping during the day can keep some people from getting
the sleep they need during their usual sleeping hours.
d. CORRECT: For example, rather than trying to sleep with a restless
pet at the foot of the bed, move the pet to another sleep area.
e. CORRECT: limiting fluids for a few hours before
bedtime helps minimize getting up to urinate.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
3. a. Rubbing the client’s back can help promote sleep, but
there is another option the nurse should try first.
B. Offering the client warm milk and crackers can help promote
sleep, but there is another option the nurse should try first.
C. CORRECT: When providing nursing care, the nurse should
first use the least restrictive intervention. Of these options,
allowing the client to follow her usual bedtime routine represents
the least change, so it is the first intervention to try.
d. asking for a prescription for sleep medication can help,
but there is another option the nurse should try first.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
4. a. CORRECT: Cognitive and brain tissue
restoration occur during ReM sleep.
B. ReM sleep lasts an average of 20 min. It typically
begins about 90 min after falling asleep.
C. CORRECT: In this stage, awakening is difficult. awakening
is relatively easy in stages 1 and 2 of non‑ReM sleep.
d. sleepwalking and sleeptalking tend to occur
during stage 4 of non‑ReM sleep.
e. CORRECT: dreaming does occur in other stages,
but it is less vivid and possibly less colorful.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
5. a. Clients who have narcolepsy should eat light, high‑protein meals.
B. CORRECT: Clients who have narcolepsy should take
short naps to reduce feelings of drowsiness.
C. Clients who have narcolepsy should avoid sitting
for prolonged periods in warm environments.
d. Clients who have narcolepsy should avoid ingesting any
substance that could increase drowsiness, such as alcohol.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● Illness
● Current life events (travel,
change in work hours)
● emotional stress or mental
illness (anxiety, fear)
● Caffeine consumption
● Heavy meals before bedtime
● exercise within 2 hr of bedtime
● sleep environment that is noisy, too
light, or the wrong temperature
● Medications that cause insomnia
NURSING INTERVENTIONS
● Help clients establish and
follow a bedtime routine.
● limit waking clients during the night.
● promote a quiet hospital environment.
● assist with personal hygiene needs.
● Offer a back rub.
● Request a prescription for a sleep
medication from the provider.
NCLEX® Connection: Basic Care and Comfort, Rest and Sleep
FUNDAMENTALS FOR NURSING CHAPTER 39 NutritioN aNd oral HydratioN 213
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 39 Nutrition and
Oral Hydration
Nutrients provide energy for cellular metabolism,
tissue maintenance and repair, organ function,
growth and development, and physical activity.
Water, the most basic of all nutrients, is crucial
for all body fluid and cellular functions.
the proper balance of nutrients and fluid
along with consideration of energy intake
and requirements is essential for ensuring
adequate nutritional status. Early recognition
and treatment of clients who are malnourished
or at risk can have a positive influence on
client outcomes.
a nutritional assessment helps identify areas
to modify, either through adding or avoiding
specific nutrients or by increasing or decreasing
caloric intake.
When planning a nutritional or hydration
intervention, it is important to consider beliefs
and culture, the environment, and the
presentation of the food, as well as any illnesses
or allergies clients might have.
BASIC NUTRIENTS THE BODY REQUIRES
Carbohydrates provide most of the body’s energy and
fiber. Each gram produces 4 kcal. They provide glucose,
which burns completely and efficiently without end
products to excrete. Sources include whole grain breads,
baked potatoes, brown rice, and other plant foods.
Fats provide energy and vitamins. No more than 35% of
caloric intake should be from fat. Each gram produces
9 kcal. Sources include olive oil, salmon, and egg yolks.
Proteins contribute to the growth, maintenance, and
repair of body tissues. Each gram produces 4 kcal. Sources
of complete protein include beef, whole milk, and poultry.
Vitamins are necessary for metabolism. The fat‑soluble
vitamins are A, D, E, and K. The water‑soluble vitamins
include C and B complex (eight vitamins).
Minerals complete essential biochemical reactions in the
body (calcium, potassium, sodium, iron).
Water is critical for cell function and replaces fluids
the body loses through perspiration, elimination,
and respiration.
FACTORS AFFECTING NUTRITION
AND METABOLISM
Religious and cultural practices guide food preparation
and choices.
Financial issues prevent some clients from buying foods
that are high in protein, vitamins, and minerals.
Appetite decreases with illness, medications, pain,
depression, and unpleasant environmental stimuli.
Negative experiences with certain foods or familiarity
with foods clients like help determine preferences.
Environmental factors such as sedentary lifestyles, work
schedules, and widespread access to less healthy foods
contribute to obesity.
Disease and illness can affect the functional ability to
prepare and eat food.
Medications can alter taste and appetite and can interfere
with the absorption of certain nutrients.
Age affects nutritional requirements.
CHAPTER 39
214 CHAPTER 39 NutritioN aNd oral HydratioN CONTENT MASTERY SERIES
aGE
Newborns and infants (birth to 1 year)
● High energy requirements
● Breast milk (ideally) or formula to provide
◯ 108 kcal/kg of weight the first 6 months
◯ 98 kcal/kg of weight the second 6 months
● Solid food starting at 4 to 6 months of age
● No cow’s milk or honey for the first year
Toddlers (12 months to 3 years) and preschoolers
(3 to 6 years)
● Toddlers and preschoolers need fewer calories per kg of
weight than infants do.
● Toddlers and preschoolers need increased protein from
sources other than milk.
● Calcium and phosphorus are important for bone health.
● Nutrient density is more important than quantity.
School‑age children (6 to 12 years)
● School‑age children need supervision to consume
adequate protein and vitamins C and A.
● They tend to eat foods high in carbohydrates, fats,
and salt.
● They grow at a slower and steadier rate, with a gradual
decline in energy requirements.
Adolescents (12 to 20 years)
● Metabolic demands are high and require more energy.
● Protein, calcium, iron, iodine, folic acid, and vitamin B
needs are high.
● One‑fourth of dietary intake comes from snacks.
● Increased water consumption is important for
active adolescents.
● Body image and appearance, fast foods, peer pressure,
and fad diets influence adolescents’ diet.
Young adults (20 to 35 years) and
middle adults (35 to 65 years)
● There is a decreased need for most nutrients (except
during pregnancy).
● Calcium and iron are essential minerals for women.
● Good oral health is important.
Older adults (over 65 years)
● A slower metabolic rate requires fewer calories.
● Thirst sensations diminish.
● Older adults need the same amount of most vitamins
and minerals as younger adults.
● Calcium is important for both men and women.
● Many older adults require carbohydrates that provide
fiber and bulk to enhance gastrointestinal function.
EatiNG diSordErS
Anorexia nervosa
● Significantly low body weight for gender, age,
developmental level, and physical health.
● Fear of being fat
● Self‑perception of being fat
● Consistent restriction of food intake or repeated
behavior that prevents weight gain
Bulimia nervosa: a cycle of binge eating followed
by purging (vomiting, using diuretics or laxatives,
exercise, fasting)
● Lack of control during binges
● Average at least one cycle of binge eating and purging
per week for at least 3 months
Binge‑eating disorder: repeated episodes of binge eating
● Feels a loss of control when binge eating, followed by an
emotional response such as guilt, shame, or depression
● Does not use compensatory behaviors, such as purging
● Binge‑eating episodes can range from 1 to more than 14
times per week
● Clients are often overweight or obese.
oBESity
A BMI of 25 is the upper boundary of healthy weight (25 to
29.9 is considered overweight for an adult; 30 or greater is
considered obese).
ASSESSMENT/DATA COLLECTION
Dietary history should include the following.
● Number of meals per day
● Fluid intake
● Food preferences, amounts
● Food preparation, purchasing practices, access
● History of indigestion, heartburn, gas
● Allergies
● Taste
● Chewing and swallowing
● Appetite
● Elimination patterns
● Medication use
● Activity levels
● Religious, cultural food preferences and restrictions
● Nutritional screening tools
CliNiCal MEaSurES
● Height, weight to calculate BMI and ideal body weight
BMi = weight (kg) ÷ height (m2)
Step 1: determine the client’s
weight in kg and height in m
Step 2: Multiply the client’s height by
itself to determine the m2 value
Step 3: divide the weight in kg by the height
value from step 2. the result is the client’s BMi.
● Skinfold measurements
● Laboratory values of cholesterol, triglycerides,
hemoglobin, electrolytes, albumin, prealbumin,
transferrin, lymphocyte count, nitrogen balance
FUNDAMENTALS FOR NURSING CHAPTER 39 NutritioN aNd oral HydratioN 215
iNtaKE aNd outPut
● Record I&O.
● Monitor I&O for clients who have fluid or
electrolyte imbalances.
● Weigh clients each day at the same time, after voiding,
and while wearing the same type of clothes.
● If using bed scales, use the same amount of linen each
day, and reset the scale to zero if possible.
EXPECtEd FiNdiNGS oF
Poor NutritioN
● Nausea, vomiting, diarrhea, constipation
● Flaccid muscles
● Mental status changes
● Loss of appetite
● Change in bowel pattern
● Spleen, liver enlargement
● Dry, brittle hair and nails
● Loss of subcutaneous fat
● Dry, scaly skin
● Inflammation, bleeding of gums
● Poor dental health
● Dry, dull eyes
● Enlarged thyroid
● Prominent protrusions over bony areas
● Weakness, fatigue
● Change in weight
● Poor posture
NURSING INTERVENTIONS
● Assist in advancing the diet as prescribed.
● Instruct clients about the appropriate diet regimen.
● Provide interventions to promote appetite (good oral
hygiene, favorite foods, minimal environmental odors).
● Educate clients about medications that can affect
nutritional intake.
● Assist clients with feeding to promote
optimal independence.
● Individualize menu plans according to clients’
preferences.
● Assist with preventing aspiration.
◯ Position in Fowler’s position or in a chair.
◯ Support the upper back, neck, and head.
◯ Have clients tuck their chin when swallowing to help
propel food down the esophagus.
◯ Avoid the use of a straw.
◯ Observe for aspiration and pocketing of food in the
cheeks or other areas of the mouth.
◯ Observe for indications of dysphagia, such as
coughing, choking, gagging, and drooling of food.
◯ Keep clients in semi‑Fowler’s position for at least 1 hr
after meals.
◯ Provide oral hygiene after meals and snacks.
● Provide therapeutic diets.
◯ Clear liquid: liquids that leave little residue (clear
fruit juices, gelatin, broth)
◯ Full liquid: clear liquids plus liquid dairy products, all
juices, pureed vegetables
◯ Pureed: clear and full liquids plus pureed meats,
fruits, scrambled eggs
◯ Mechanical soft: clear and full liquids plus diced or
ground foods
◯ Soft/low-residue: foods that are low in fiber and easy
to digest
◯ High‑fiber: whole grains, raw and dried fruits
◯ Low sodium: no added salt or 1 to 2 g sodium
◯ Low cholesterol: no more than 300 mg/day of dietary
cholesterol
◯ Diabetic: balanced intake of protein, fats, and
carbohydrates of about 1,800 calories
◯ Dysphagia: pureed food and thickened liquids
◯ Regular: no restrictions
● Administer and monitor enteral feedings via nasogastric,
gastrostomy, or jejunostomy tubes.
● Administer and monitor parenteral nutrition to clients
who are unable to use their gastrointestinal tract
to acquire nutrients. Parenteral nutrients include
lipids, electrolytes, minerals, vitamins, dextrose, and
amino acids.
● Maintain fluid balance.
◯ Administer IV fluids.
◯ Restrict oral fluid intake (maintaining strict I&O).
■ Remove the water pitcher from the bedside.
■ Inform the dietary staff of the amount of fluid to
serve with each meal tray.
■ Inform the staff of each shift of the amount of fluid
clients may have in addition to what they receive
with each meal tray.
■ Record all oral intake, and inform the family of
the restriction.
◯ Encourage oral intake of fluids.
■ Provide fresh drinking water.
■ Remind and encourage a consistent fluid intake.
■ Ask about beverage preferences.
216 CHAPTER 39 NutritioN aNd oral HydratioN CONTENT MASTERY SERIES
Application Exercises
1. a nurse is caring for a client
who is at high risk for aspiration.
Which of the following actions
should the nurse take?
a. Give the client thin liquids.
B. instruct the client to tuck
her chin when swallowing.
C. Have the client use a straw.
d. Encourage the client to lie
down and rest after meals.
2. a nurse is preparing a presentation
about basic nutrients for a group
of high school athletes. She
should explain that which of the
following nutrients provides the
body with the most energy?
a. Fat
B. Protein
C. Glycogen
d. Carbohydrates
3. a nurse is caring for a client who
requires a low‑residue diet. the
nurse should expect to see
which of the following foods
on the client’s meal tray?
a. Cooked barley
B. Pureed broccoli
C. Vanilla custard
d. lentil soup
4. a nurse is caring for a client
who weighs 80 kg (176 lb) and
is 1.6 m (5 ft 3 in) tall. Calculate
her body mass index (BMi) and
determine whether this client’s BMi
indicates that she is of a healthy
weight, overweight, or obese.
5. a nurse in a senior center is
counseling a group of older adults
about their nutritional needs and
considerations. Which of the
following information should the
nurse include? (Select all that apply.)
a. older adults are more
prone to dehydration than
younger adults are.
B. older adults need the same
amount of most vitamins and
minerals as younger adults do.
C. Many older men and women
need calcium supplementation.
d. older adults need more
calories than they did
when they were younger.
E. older adults should consume
a diet low in carbohydrates.
PRACTICE Active Learning Scenario
a nurse is preparing a presentation in a community
center on eating disorders that affect adolescents
and young adults. use the ati active learning
template: Basic Concept to complete this item.
RELATED CONTENT: list two common eating
disorders and their characteristics.
FUNDAMENTALS FOR NURSING CHAPTER 39 NutritioN aNd oral HydratioN 217
Application Exercises Key
1. a. thin liquids increase the client’s risk for aspiration.
B. CORRECT: tucking the chin when swallowing allows
food to pass down the esophagus more easily.
C. using a straw increases the client’s risk for aspiration.
d. Sitting for an hour after meals helps prevent gastroesophageal
reflux and possible aspiration of stomach contents after a meal.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
2. a. although the body gets about half of its energy supply
from fat, it is an inefficient means of obtaining energy. it
produces end products the body has to excrete, and it
requires energy from another source to burn the fat.
B. Protein can supply energy, but it has other very
essential and specific functions that only it can perform.
So it is not the body’s priority energy source.
C. Glycogen, which the body stores in the liver, is a backup
source of energy, not a primary or priority source.
d. CORRECT: Carbohydrates are the body’s greatest energy
source; providing energy for cells is their primary function.
they provide glucose, which burns completely and efficiently
without end products to excrete. they are also a ready source
of energy, and they spare proteins from depletion.
NCLEX® Connection: Health Promotion and Maintenance,
Health Promotion/Disease Prevention
3. a. Whole grains, such as barley and oats, are high in fiber and
thus inappropriate components of a low‑residue diet.
B. raw and gas‑producing vegetables, such as broccoli
and the cabbage in coleslaw, are high in fiber and thus
inappropriate components of a low‑residue diet.
C. CORRECT: a low‑residue diet consists of foods that are low
in fiber and easy to digest. dairy products and eggs, such as
custard and yogurt, are appropriate for a low‑residue diet.
d. legumes, such as lentils and black beans, are high in fiber
and thus inappropriate components of a low‑residue diet.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
4. BMi = weight (kg) ÷ height (m2).
Step 1: Client’s weight (kg) and height (m) = 80 kg and 1.6 m
Step 2: 1.6 × 1.6 = 2.56 m2
Step 3: 80 ÷ 2.56 = 31.25
a BMi greater than 30 is considered obese.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
5. a. CORRECT: Sensations of thirst diminish with age,
leaving older adults more prone to dehydration.
B. CORRECT: these requirements do not change
from middle adulthood to older adulthood.
C. CORRECT: if older adults ingest insufficient calcium in the diet, they
need supplements to help prevent bone demineralization (osteoporosis).
d. older adults have a slower metabolic rate, so they require less
energy (unless they are very active), and therefore need fewer calories.
E. Many older adults need more carbohydrates for the fiber and
bulk they contain. they should, however, reduce their intake of
fats and of “empty” calories, such as pastries and soda pop.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
anorexia nervosa
● Significantly low body weight for gender, age,
developmental level, and physical health.
● Fears being fat
● Self‑perception of being fat
● Consistent restriction of food intake or
repeated behavior that prevents weight gain
Bulimia nervosa
● Cycle of binge eating followed by
purging (vomiting, using diuretics
or laxatives, exercise, fasting)
● lack of control during binges
● average of at least one cycle of binge eating
and purging per week for at least 3 months
Binge‑eating disorder
● repeated episodes of binge eating
● Feels a loss of control when binge eating,
followed by an emotional response
such as guilt, shame, or depression
● does not use compensatory
behaviors, such as purging
● Binge‑eating episodes can range from
1 to more than 14 times per week
● Clients are often overweight or obese.
NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention
FUNDAMENTALS FOR NURSING CHAPTER 40 Mobility and iMMobility 219
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 40 Mobility and
Immobility
Mobility is freedom and independence in
purposeful movement. Mobility refers to
adapting to and having self-awareness of the
environment. Functional musculoskeletal and
nervous systems are essential for mobility.
immobility is the inability to move freely and
independently at will. the risk of complications
increases with the degree of immobility and
the length of time of immobilization. Periods
of immobility or prolonged bed rest can cause
major physiological and psychosocial effects.
Cutaneous stimulation in the form of cold
and heat applications helps relieve pain and
promotes healing. Promoting venous return
is another key component of reducing the
complications of immobility.
Mobility and immobility
Immobility can be the following.
● Temporary, such as following knee arthroplasty
● Permanent, such as paraplegia
● Sudden onset, such as a fractured arm and leg following
a motor‑vehicle crash
● Slow onset, such as multiple sclerosis
Body mechanics involves coordination between the
musculoskeletal and nervous systems, and the use of
alignment, balance, gravity, and friction.
Movement depends on an intact skeletal system, skeletal
muscles, and nervous system.
Assessment focuses on mobility, range of motion
(ROM), gait, exercise status, activity tolerance, and body
alignment while standing, sitting, and lying.
FACTORS AFFECTING MOBILITY
● Alterations in muscles
● Injury to the musculoskeletal system
● Poor posture
● Impaired central nervous system
● Health status and age
body SyStEM CHanGES
Integumentary
● Increased pressure on skin, which is aggravated by
metabolic changes
● Decreased circulation to tissue causing ischemia, which
can lead to pressure ulcers
Respiratory
● Decreased respiratory movement resulting in decreased
oxygenation and carbon dioxide exchange
● Stasis of secretions and decreased and weakened
respiratory muscles, resulting in atelectasis and
hypostatic pneumonia
● Decreased cough response
Cardiovascular
● Orthostatic hypotension
● Less fluid volume in the circulatory system
● Stasis of blood in the legs
● Diminished autonomic response
● Decreased cardiac output leading to poor
cardiac effectiveness, which results in increased
cardiac workload
● Increased oxygenation requirement
● Increased risk of thrombus development
CHAPTER 40
220 CHAPTER 40 Mobility and iMMobility CONTENT MASTERY SERIES
Metabolic
● Altered endocrine system
● Decreased basal metabolic rate
● Changes in protein, carbohydrate, and fat metabolism
● Decreased appetite with altered nutritional intake
● Negative nitrogen balance
● Decreased protein resulting in loss of muscle
● Loss of weight
● Alterations in calcium, fluid, and electrolytes
● Resorption of calcium from bones
● Decreased urinary elimination of calcium resulting
in hypercalcemia
Elimination
GENITOURINARY
● Urinary stasis
● Change in calcium metabolism with hypercalcemia
resulting in renal calculi
● Decreased fluid intake, poor perineal care, and
indwelling urinary catheters resulting in urinary tract
infections
GASTROINTESTINAL
● Decreased peristalsis
● Decreased fluid intake
● Constipation, then fecal impaction, then diarrhea
Musculoskeletal
● Decreased muscle endurance, strength, and mass
● Impaired balance
● Atrophy of muscles
● Decreased stability
● Altered calcium metabolism
● Osteoporosis
● Pathological fractures
● Contractures
● Foot drop
● Altered joint mobility
Neurological/Psychosocial
● Altered sensory perception
● Ineffective coping
CHANGES IN EMOTIONAL STATUS: depression, alteration
in self‑concept, and anxiety
BEHAVIORAL CHANGES: withdrawal, altered sleep/wake
pattern, hostility, inappropriate laughter, and passivity
Developmental
INFANTS, TODDLERS, AND PRESCHOOLERS
● Slower progression in gross motor skills and intellectual
and musculoskeletal development
● Body aligned with line of gravity, resulting in
unbalanced posture
ADOLESCENTS
● Imbalanced growth spurt possibly altered with
immobility
● Delayed development of independence
● Social isolation
ADULTS
● Alterations in every physiological system
● Alterations in family and social systems
● Alterations in job identity and self‑esteem
OLDER ADULTS
● Alterations in balance resulting in a major risk for falls
and injuries
● Steady loss of bone mass resulting in weakened bones
● Decreased coordination
● Slower walk with smaller steps
● Alterations in functional status
● Increased dependence on staff and family
ASSESSMENT/DATA COLLECTION
AND PATIENT-CENTERED CARE
Integumentary
Maintain intact skin.
ASSESSMENT
● Observe the skin for breakdown, warmth, and change
in color.
● Look for pallor or redness in fair‑skinned clients, and
purple or blue discoloration in dark‑skinned clients.
● Observe bony prominences.
● Check skin turgor.
● Use a pressure ulcer risk scale such as Norton or Braden.
● Assess at least every 2 hr.
● Observe for urinary or bowel incontinence.
NURSING INTERVENTIONS
● Identify clients at risk for pressure ulcer development.
● Position using corrective devices such as pillows, foot
boots, trochanter rolls, splints, and wedge pillows.
● Turn every 1 to 2 hr, and use devices for support or
per protocol.
● Teach clients who can move independently to turn at
least every 15 min.
● Provide clients who are sitting in a chair with a device
to decrease pressure.
● Limit sitting in a chair to 1 hr. Instruct clients to shift
their weight every 15 min.
● Use a therapeutic bed or mattress for clients in bed for
an extended time.
● Monitor nutritional intake.
● Provide skin and perineal care.
FUNDAMENTALS FOR NURSING CHAPTER 40 Mobility and iMMobility 221
Respiratory
Maintain airway patency, achieve optimal lung expansion
and gas exchange, and mobilize airway secretions.
ASSESSMENT
Complete every 2 hr.
● Observe chest wall movement for symmetry.
● Auscultate lungs and identify diminished breath sounds,
crackles, or wheezes.
● Observe for productive cough, and note the color,
amount, and consistency of secretions.
NURSING INTERVENTIONS
● Reposition every 1 to 2 hr.
● Instruct clients to turn, cough, and breathe deeply every
1 to 2 hr while awake.
● Instruct clients to yawn every hr while awake.
● Instruct clients to use an incentive spirometer
while awake.
● Remove abdominal binders every 2 hr and
replace correctly.
● Use chest physiotherapy.
● Auscultate the lungs to determine the effectiveness of
chest physiotherapy or other respiratory therapy.
● Instruct clients to consume at least 2,000 mL fluid per
day, unless intake is restricted.
● Monitor the ability to expectorate secretions.
● Use suction if unable to expectorate secretions.
Cardiovascular
Maintain cardiovascular function, increase activity
tolerance, and prevent thrombus formation.
ASSESSMENT
● Measure orthostatic blood pressure and pulse (lying to
sitting to standing), and assess for dizziness.
● Palpate the apical and peripheral pulses.
● Auscultate the heart at the apex for S3 (an early sign of
heart failure). Older adult clients might not adapt well
to immobility.
● Palpate for edema in the sacrum, legs, and feet.
● Palpate the skin for warmth in peripheral areas to
include the nose, ear lobes, hands, and feet.
● Assess for deep‑vein thrombosis by observing the calves
for redness and palpating for warmth and tenderness.
● Measure the circumference of both calves and thighs
and compare in size.
NURSING INTERVENTIONS
● Increase activity as soon as possible by dangling feet on
side of bed or transferring to a chair.
● Instruct clients to perform isometric exercises to
increase activity tolerance.
● Change position as often as possible.
● Move the client gradually during position changes.
● Instruct clients to avoid the Valsalva maneuver.
● Give a stool softener to prevent straining.
● Teach range of motion (ROM) and antiembolic exercises
such as ankle pumps, foot circles, and knee flexion.
● Instruct clients to avoid placing pillows under the knees
or lower extremities, crossing the legs, wearing tight
clothes around the waist or on the legs, sitting for long
periods of time, and massaging the legs.
● Use elastic stockings.
● Use sequential compression devices (SCD) or
intermittent pneumatic compression (IPC).
● Increase fluid intake if no restrictions.
● Administer low‑dose heparin or enoxaparin
subcutaneously prophylactically.
● Contact the provider immediately if there is absence of a
peripheral pulse in the lower extremities or assessment
data that indicates venous thrombosis.
Metabolic
Reduce skin injury and maintain metabolism.
ASSESSMENT
● Record anthropometric measurements of height, weight,
and skinfolds.
● Assess I&O.
● Assess food intake.
● Review urinary and bowel elimination status.
● Assess wound healing.
● Auscultate bowel sounds.
● Check skin turgor.
● Review laboratory values for electrolytes, serum total
protein, and BUN.
NURSING INTERVENTIONS
● Provide a high‑calorie, high‑protein diet with vitamin B
and C supplements.
● Monitor and evaluate oral intake. For clients who
cannot eat or drink, provide enteral or parenteral
nutritional therapy.
Elimination
Maintain urinary and bowel elimination.
ASSESSMENT
● Assess I&O.
● Assess the bladder for distention.
● Observe urine for color, amount, clarity, and frequency.
● Auscultate bowel sounds.
● Observe feces for color, amount, frequency,
and consistency.
NURSING INTERVENTIONS
● Maintain hydration (at least 2,000 mL/day unless fluid
is restricted).
● Instruct clients to consume a diet that includes fruits
and vegetables and is high in fiber.
● Give a stool softener, laxative, or enema as needed.
● Provide perineal care.
● Teach bladder and bowel training.
● Insert a straight or indwelling catheter to relieve or
manage bladder distention.
● Promote urination by pouring warm water over the
perineal area.
222 CHAPTER 40 Mobility and iMMobility CONTENT MASTERY SERIES
Musculoskeletal
Maintain or regain body alignment and stability, decrease
skin and musculoskeletal system changes, achieve full or
optimal ROM, and prevent contractures.
ASSESSMENT
● Assess ROM capability.
● Assess muscle tone and mass.
● Observe for contractures.
● Monitor gait.
● Monitor nutritional intake of calcium.
● Monitor use of assistive devices to assist with ADLs.
NURSING INTERVENTIONS
● Make sure clients change position in bed at least
every 2 hr and perform weight shifts in the wheelchair
every 15 min.
● Encourage active or provide passive ROM two or three
times/day.
● Instruct clients to perform ROM while bathing, eating,
grooming, and dressing.
● A continuous passive motion (CPM) device might be
prescribed. Develop an individualized program for each
client. Older adult clients can require a program that
addresses the aging process.
● Cluster care to promote a proper sleep‑wake cycle.
● Request physical therapy for clients who have
decreased mobility.
● Assist client with ambulation. Use assistive devices such
as gait belts, walkers, canes, or crutches, as needed.
CANE INSTRUCTIONS
● Maintain two points of support on the ground at
all times.
● Keep the cane on the stronger side of the body.
● Support body weight on both legs.
● Move the cane forward 15 to cm (6 to 10 inches).
● Then move the weaker leg forward toward the cane.
● Next, advance the stronger leg past the cane.
CRUTCH INSTRUCTIONS
● Do not alter crutches after fitting.
● Follow the prescribed crutch gait.
● Support body weight at the hand grips with elbows
flexed at 30°.
● Position the crutches on the unaffected side when
sitting or rising from a chair.
Psychosocial
Maintain an acceptable sleep/wake pattern, achieve
socialization, and complete self‑care independently.
ASSESSMENT
● Assess emotional status.
● Assess mental status.
● Assess behavior and decision‑making skills.
● Monitor mobility status.
● Observe for unusual alterations in sleep/wake pattern.
● Assess coping skills, especially for loss.
● Monitor activities of daily living (ADLs).
● Assess for family support and relationships.
● Monitor social activities.
NURSING INTERVENTIONS
● Assist in using usual coping skills or in developing new
coping skills.
● Maintain orientation to time (clock and calendar with
date), person (call by name and introduce self), and
place (talk about treatments, therapy, and length of
stay).
● Develop a schedule of therapies, and place it on a
calendar for clients.
● Arrange for clients who have limited mobility to be in a
semiprivate room with an alert roommate.
● Involve clients in daily care.
● Provide stimuli such as books, crafts, television,
newspapers, and radio.
● Help clients maintain body image by performing or
assisting with hygiene and grooming tasks such as
shaving or applying makeup.
● Have nurses and other staff interact on a routine and
informal social basis.
● Recommend a referral for consultation (psychological,
spiritual, or social worker) for clients who are not
coping well.
Developmental
Continue expected development and achieve physical and
mental stimulation.
Infancy through school age
● ASSESSMENT
◯ Gross motor skills, and intellectual and
musculoskeletal development
◯ Body alignment and posture
◯ Developmental tasks specific to age
● NURSING INTERVENTIONS
◯ Initiate events that stimulate physical and
psychosocial systems. Increase mobility, and involve
play therapists in age‑appropriate activities.
◯ Use measures to prevent falls.
◯ Develop strategies for maintaining or enhancing the
developmental process.
◯ Teach families that their perception of immobility can
affect progress and ability to cope.
◯ Encourage parents to stay with children.
◯ Incorporate children’s involvement, if it is age‑
appropriate, in their treatments.
◯ Place children in a room with others who are age‑
appropriate.
FUNDAMENTALS FOR NURSING CHAPTER 40 Mobility and iMMobility 223
Adolescents
● ASSESSMENT
◯ Growth and development specific to age
◯ Level of independence
◯ Social activities
● NURSING INTERVENTIONS
◯ Initiate care that facilitates independence.
◯ Involve adolescents in decision‑making for ADLs.
◯ Provide stimuli to promote socialization (interaction
with peers, use of adolescents’ activity room).
Adults
● ASSESSMENT
◯ All physical systems
◯ Family relationships
◯ Social status
◯ Meaning of career/job
● NURSING INTERVENTIONS
◯ Provide care that promotes activity in all
physical systems.
◯ Discuss with families the importance of interaction
with clients.
◯ Discuss social involvement.
◯ Discuss the meaning of career/job.
Older adults
● ASSESSMENT
◯ Balance
◯ Coordination
◯ Gait
◯ Functional status
◯ Level of independence
◯ Social isolation
● NURSING INTERVENTIONS
◯ Plan care with clients and families to increase
independence with ADLs and decision‑making skills.
◯ Teach the staff to facilitate clients’ independence in
all activities.
◯ Provide stimuli such as a clock, newspaper, calendar,
and weather status.
◯ Encourage families to visit to maintain socialization.
◯ Plan for staff to spend some time talking and
listening to clients.
Application of heat and cold
tHERaPEUtiC EFFECtS
HEAT
● Increases blood flow
● Increases tissue metabolism
● Relaxes muscles
● Eases joint stiffness and pain
COLD
● Decreases inflammation
● Prevents swelling
● Reduces bleeding
● Reduces fever
● Diminishes muscle spasms
● Decreases pain by decreasing the velocity of
nerve conduction
PATIENT-CENTERED CARE
nURSinG ConSidERationS
FOR CLIENTS AT RISK FOR INJURY FROM HEAT/COLD
● Use extreme caution with clients who are very young or
fair‑skinned, and older adults because they have
fragile skin.
● Clients who are immobile might not be able to move
away from the application if it becomes uncomfortable.
They are at risk for skin injuries.
● Clients who have impaired sensory perception might not
feel numbness, pain, or burning.
● Use minor temperature changes and short‑term
applications of heat or cold for best results.
● Avoid long applications of either heat or cold because
this can result in tissue damage, burns, and reflex
vasodilation (with cold therapy).
● Do not use cold applications for clients who have
cold intolerance, vascular insufficiency, open
wounds, and disorders aggravated by cold, such as
Raynaud’s phenomenon.
● Make sure the provider has written a prescription that
includes the following.
◯ Location
◯ Duration and frequency
◯ Specific type (moist or dry)
◯ Temperature to use
HEAT
● Monitor bony prominences carefully because they are
more sensitive to heat applications.
● Avoid the use of heat applications over metal devices
(pacemakers, prosthetic joints) to prevent deep
tissue burns.
● Do not apply heat to the abdomen of a client who is
pregnant to prevent harm to the fetus.
● Do not place a heat application under a client who is
immobile because this can increase the risk of burns.
● Do not use heat applications during the first 24 hr
after a traumatic injury, for active bleeding, for
noninflammatory edema, or for some skin disorders.
224 CHAPTER 40 Mobility and iMMobility CONTENT MASTERY SERIES
SUPPliES
Heat application
MOIST
● Warm compresses: towel, bath thermometer, hot water,
plastic covering, hot pack or aquathermia pad (with
distilled water), tape
● Warm soaks: water, bath thermometer, basin,
waterproof pads
● Sitz baths: specific chair, tub, or basin (disposable or
built‑in), bath thermometer, bath blanket, towels
DRY
● Hot pack (disposable or reusable) or an aquathermia pad
with distilled water, and a pillowcase
● Warming blanket
Cold application
MOIST
● Cold water compresses
● Cold soaks
DRY
● Ice bag, ice collar, ice glove, or a cold pack
● Cooling blanket
nURSinG aCtionS
● Apply to the area.
● Make sure the call light is within reach, and instruct
clients to report any discomfort.
● Assess the site every 5 to 10 min to check for
the following.
◯ Redness or pallor
◯ Pain or burning
◯ Numbness
◯ Shivering (with cold applications)
◯ Blisters
◯ Decreased sensation
◯ Mottling of the skin
◯ Cyanosis (with cold applications)
● Discontinue the application if any of the above occur,
or remove the application at the predetermined time
(usually 15 to 30 min).
● Document the following.
◯ Location, type, and length of the application
◯ Condition of the skin before and after the application
◯ Client’s tolerance of the application
Promoting venous return
● Elastic (antiembolic) stockings cause external pressure
on the muscles of the lower extremities to promote
blood return to the heart.
● SCDs and IPC have plastic or fabric sleeves that wrap
around the leg and secure with hook‑and‑loop closures.
The sleeves are then attached to an electric pump that
alternately inflates and deflates the sleeve around the leg.
These machines are set to cycle, typically a 10‑ to
15-second inflation and a 45- to 60-second deflation.
● Positioning techniques reduce compression of leg veins.
● ROM exercises cause skeletal muscle contractions,
which promote blood return. Specific exercises that help
prevent thrombophlebitis include ankle pumps, foot
circles, and knee flexion.
● Antiembolic stockings, SCDs, and IPC require
a prescription.
● Clients who are immobile should perform leg
exercises, increase their fluid intake, and change
positions frequently.
● When suspecting poor venous return or possible
thrombus, notify the provider, elevate the leg, and do
not apply pressure or massage the thrombus to avoid
dislodging it.
PATIENT-CENTERED CARE
Antiembolic stockings
EQUIPMENT: Tape measure
PROCEDURE
● Perform hand hygiene.
● Assess skin, circulation, and presence of edema in
the legs.
● Measure the calf and/or thigh circumference and the
length of the leg to select the correct size stocking.
● Turn the stockings inside to the heel.
● Put the stocking on the foot.
● Pull the remainder of the stocking over the heel and
up the leg.
● Smooth any creases or wrinkles.
● Remove the stockings every 8 hr to assess for redness,
warmth, or tenderness.
● Make sure the stockings are not too tight over the toes.
● Keep the stockings clean and dry. Clients who are
postoperative or have specific needs can need a second
pair of hose.
● Document the application and removal of the stockings.
FUNDAMENTALS FOR NURSING CHAPTER 40 Mobility and iMMobility 225
SCD and IPC
EQUIPMENT
● Tape measure
● Sequential stockings
PROCEDURE
● Perform hand hygiene.
● Assess circulation and skin prior to application.
● Measure around the largest part of the thigh to
determine the stocking size.
● Apply the sleeves to each leg. Position the opening at
the client’s knees.
● Attach the sleeves to the inflator.
● Turn on the device.
● Monitor circulation and skin after application.
● Remove every 8 hr for assessment of calves.
● Document the application and removal of the stockings.
Positioning techniques
To reduce compression of leg veins
PROCEDURE
Instruct clients to avoid the following.
● Crossing legs
● Sitting for long periods
● Wearing restrictive clothing on the lower extremities
● Putting pillows behind the knees
● Massaging legs
ROM exercises
Hourly while awake.
PROCEDURE
Instruct clients to perform the following.
● Ankle pumps: Point the toes toward the head and then
away from the head.
● Foot circles: Rotate the feet in circles at the ankles.
● Knee flexion: Flex and extend the legs at the knees.
COMPLICATIONS
Thrombophlebitis, deep‑vein thrombosis
Thrombophlebitis and deep‑vein thrombosis are
inflammation of a vein (usually in the lower extremities)
that result in clot formation.
MANIFESTATIONS: Pain, edema, warmth, and erythema at
the site
ASSESSMENT: Another assessment method for clients
prone to thrombosis is to measure bilateral calf and thigh
circumference daily. Unilateral increase is early indication
of thrombosis.
NURSING ACTIONS
● Notify the provider immediately.
● Position the client in bed with the leg elevated.
● Avoid any pressure at the site of the inflammation.
● Anticipate giving anticoagulants.
Pulmonary embolism
A pulmonary embolism is a potentially life‑threatening
occlusion of blood flow to one or more of the pulmonary
arteries by a clot. The clot or embolus often originates in
the venous system of the lower extremities.
MANIFESTATIONS: Shortness of breath, chest pain,
hemoptysis (coughing up blood), decreased blood pressure,
and rapid pulse
NURSING ACTIONS
● Prepare to give thrombolytics or anticoagulants.
● Position client in a high‑Fowler’s position.
● Obtain pulse oximetry.
● Administer oxygen.
● Prepare to obtain blood gas analysis.
● Monitor frequent vital signs.
PRACTICE Active
Learning Scenario
a nurse is reviewing the effects
of immobility on various body
systems with a group of newly
licensed nurses. Use the ati
active learning template: basic
Concept to complete this item.
RELATED CONTENT: list at least
two effects of immobility on the
cardiovascular system and at least
two on the respiratory system.
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
Cardiovascular system
● orthostatic hypotension
● less fluid volume in the circulatory system
● Stasis of blood in the legs
● diminished autonomic response
● decreased cardiac output leading
to poor cardiac effectiveness, which
results in increased cardiac workload
● increased oxygenation requirement
● increased risk of thrombus development
Respiratory system
● decreased respiratory movement
resulting in decreased oxygenation
and carbon dioxide exchange
● Stasis of secretions and decreased and
weakened respiratory muscles, resulting
in atelectasis and hypostatic pneumonia
● decreased cough response
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
226 CHAPTER 40 Mobility and iMMobility CONTENT MASTERY SERIES
Application Exercises
1. a nurse is caring for a client who
has been sitting in a chair for 1 hr.
Which of the following complications
is the greatest risk to the client?
a. decreased subcutaneous fat
b. Muscle atrophy
C. Pressure ulcer
d. Fecal impaction
2. a nurse is caring for a client who is
postoperative. Which of the following
interventions should the nurse take
to reduce the risk of thrombus
development? (Select all that apply.)
a. instruct the client not to
perform the Valsalva maneuver.
b. apply elastic stockings.
C. Review laboratory values
for total protein level.
d. Place pillows under the client’s
knees and lower extremities.
E. assist the client to
change position often.
3. a nurse is planning care for a client
who is on bed rest. Which of the
following interventions should
the nurse plan to implement??
a. Encourage the client
to perform antiembolic
exercises every 2 hr.
b. instruct the client to cough
and deep breathe every 4 hr.
C. Restrict the client’s fluid intake.
d. Reposition the client every 4 hr.
4. a nurse is evaluating teaching
on a client who has a new
prescription for a sequential
compression device. Which of
the following client statements
should indicate to the nurse the
client understands the teaching?
a. “this device will keep me from
getting sores on my skin.”
b. “this thing will keep the blood
pumping through my leg.”
C. “With this thing on, my leg
muscles won’t get weak.”
d. “this device is going to keep
my joints in good shape.”
5. a nurse is instructing a client, who has
an injury of the left lower extremity,
about the use of a cane. Which of
the following instructions should the
nurse include? (Select all that apply.)
a. Hold the cane on the right side.
b. Keep two points of
support on the floor.
C. Place the cane 38 cm
(15 in) in front of the feet
before advancing.
d. after advancing the cane,
move the weaker leg forward.
E. advance the stronger
leg so that it aligns
evenly with the cane.
Application Exercises Key
1. a. the client is at risk for decreased subcutaneous fat due to
altered mobility. However, there is another risk that is the priority.
b. the client is at risk for muscle atrophy due to altered
mobility. However, there is another risk that is the priority.
C. CORRECT: the greatest risk to this client is injury from
skin breakdown due to unrelieved pressure over a bony prominence
from prolonged sitting in a chair. the nurse should instruct the client
to shift his weight every 15 min and reposition the client after 1 hr.
d. the client is at risk for fecal impaction due to altered
mobility. However, there is another risk that is the priority.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
2. a. the Valsalva maneuver increases the workload of the
heart, but it does not affect peripheral circulation.
b. CORRECT: Elastic stockings promote venous
return and prevent thrombus formation.
C. a review of the client’s total protein level is important for
evaluating his ability to heal and prevent skin breakdown.
d. Placing pillows under the knees and lower extremities
can impair circulation of the lower extremities.
E. CORRECT: Frequent position changes prevents venous stasis.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
3. a. CORRECT: the nurse should encourage the client to
perform antiembolic exercises every 1 to 2 hr to promote
venous return and reduce the risk of thrombus formation.
b. the nurse should instruct the client to cough and deep
breathe every 1 to 2 hr to reduce the risk of atelectasis.
C. the nurse should increase the client’s intake of fluids,
unless contraindicated, to reduce the risk of thrombus
formation, constipation, and urinary dysfunction.
d. the nurse should reposition the client every 1 to
2 hr to reduce the risk for pressure ulcers.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
4. a. the nurse should assess the skin under the sequential pressure device
every 8 hr to check for manifestations of a thrombus and skin breakdown.
b. CORRECT: Sequential pressure devices promote venous return in
the deep veins of the legs and thus help prevent thrombus formation.
C. Continuous passive motion machines, not sequential
pressure devices, provide some muscle movement that
can assist in preserving some muscle strength.
d. Continuous passive motion machines, not sequential
pressure devices, exercise the knee joint after arthroplasty.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
5. a. CORRECT: the client should hold the cane on the
uninjured side to provide support for the injured left leg.
b. CORRECT: the client should keep two points of
support on the ground at all times for stability.
C. the client should place the cane 15 to 25 cm (6
to 10 in) in front of her feet before advancing.
d. CORRECT: the client should advance the weaker
leg first, followed by the stronger leg.
E. the client should advance the stronger leg past the cane.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
FUNDAMENTALS FOR NURSING CHAPTER 41 Pain ManageMent 227
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 41 Pain Management
effective pain management includes the use
of pharmacological and nonpharmacological
pain management therapies. invasive therapies
such as nerve ablation can be appropriate for
intractable cancer‑related pain.
Clients have a right to adequate assessment and
management of pain. nurses are accountable
for the assessment of pain. the nurse’s role is
that of an advocate and educator for effective
pain management.
nurses have a priority responsibility to measure
the client’s pain level on a continual basis
and to provide individualized interventions.
nurses should assess the effectiveness of the
interventions 30 to 60 min after implementation.
assessment challenges can occur with clients
who have cognitively impairment, who speak
a different language than the nurse, or who
receive prescribed mechanical ventilation.
Undertreatment of pain is a serious health care
problem. Consequences of undertreatment of
pain include physiological and psychological
components. acute/chronic pain can cause
anxiety, fear, and depression. Poorly managed
acute pain can lead to chronic pain syndrome.
PHYSIOLOGY OF PAIN
Transduction is the conversion of painful stimuli to
an electrical impulse through peripheral nerve fibers
(nociceptors).
Transmission occurs as the electrical impulse travels
along the nerve fibers, where neurotransmitters
regulate it.
Pain threshold is the point at which a person feels pain.
Pain tolerance is the amount of pain a person is willing
to bear.
Perception or awareness of pain occurs in various
areas of the brain, with influences from thought and
emotional processes.
Modulation occurs in the spinal cord, causing muscles
to contract reflexively, moving the body away from
painful stimuli.
SUBSTANCES THAT INCREASE PAIN TRANSMISSION AND
CAUSE AN INFLAMMATORY RESPONSE
● Substance P
● Prostaglandins
● Bradykinin
● Histamine
SUBSTANCES THAT DECREASE PAIN TRANSMISSION AND
PRODUCE ANALGESIA
● Serotonin
● Endorphins
PAIN CATEGORIES
Pain is categorized by duration (acute or chronic) or by
origin (nociceptive or neuropathic).
Acute pain
● Acute pain is protective, temporary, usually self‑limiting,
has a direct cause, and resolves with tissue healing.
● Physiological responses (sympathetic nervous system)
are fight-or-flight responses (tachycardia, hypertension,
anxiety, diaphoresis, muscle tension).
● Behavioral responses include grimacing, moaning,
flinching, and guarding.
● Interventions include treatment of the
underlying problem.
● Can lead to chronic pain if unrelieved.
Chronic pain
● Chronic pain is not protective. It is ongoing or recurs
frequently, lasting longer than 6 months and persisting
beyond tissue healing.
● Physiological responses do not usually alter vital signs,
but clients can have depression, fatigue, and a decreased
level of functioning. It is not usually life‑threatening.
● Psychosocial implications can lead to disability.
● Management aims at symptomatic relief. Pain does not
always respond to interventions.
● Chronic pain can be malignant or nonmalignant.
● Idiopathic pain is a form of chronic pain without a
known cause, or pain that exceeds typical pain levels
associated with the client’s condition.
Nociceptive pain
● Nociceptive pain arises from damage to or inflammation
of tissue, which is a noxious stimulus that triggers the
pain receptors called nocioceptors and causes pain.
● It is usually throbbing, aching, and localized.
● This pain typically responds to opioids and
nonopioid medications.
TYPES OF NOCICEPTIVE PAIN
● Somatic: In bones, joints, muscles, skin, or
connective tissues.
● Visceral: In internal organs such as the stomach or
intestines. It can cause referred pain in other body
locations separate from the stimulus.
● Cutaneous: In the skin or subcutaneous tissue.
CHAPTER 41
228 CHAPTER 41 Pain ManageMent CONTENT MASTERY SERIES
Neuropathic pain
● Neuropathic pain arises from abnormal or damaged
pain nerves.
● It includes phantom limb pain, pain below the level of a
spinal cord injury, and diabetic neuropathy.
● Neuropathic pain is usually intense, shooting, burning,
or described as “pins and needles.”
● This pain typically responds to adjuvant medications
(antidepressants, antispasmodic agents, skeletal
muscle relaxants).
ASSESSMENT/DATA COLLECTION
● Noted pain experts agree that pain is whatever the
person experiencing it says it is, and it exists whenever
the person says it does. The client’s report of pain is the
most reliable diagnostic measure of pain.
● Self‑report using standardized pain scales is useful
for clients over the age of 7 years. Specialized pain
scales are available for use with younger children or
individuals who have difficulty communicating verbally.
● Assess and document pain (the fifth vital sign)
frequently.
● Use a symptom analysis to obtain subjective data. (41.1)
RiSK FaCtORS
UNDERTREATMENT OF PAIN
● Cultural and societal attitudes
● Lack of knowledge
● Fear of addiction
● Exaggerated fear of respiratory depression
POPULATIONS AT RISK FOR UNDERTREATMENT OF PAIN
● Infants
● Children
● Older adults
● Clients who have substance use disorder
CAUSES OF ACUTE AND CHRONIC PAIN
● Trauma
● Surgery
● Cancer (tumor invasion, nerve compression, bone
metastases, associated infections, immobility)
● Arthritis
● Fibromyalgia
● Neuropathy
● Diagnostic or treatment procedures (injection,
intubation, radiation)
FACTORS THAT AFFECT THE PAIN EXPERIENCE
● Age
◯ Infants cannot verbalize or understand their pain.
◯ Older adult clients can have multiple pathologies that
cause pain and limit function.
● Fatigue: Can increase sensitivity to pain.
● Genetic sensitivity: Can increase or decrease
pain tolerance.
● Cognitive function: Clients who have cognitively
impairment might not be able to report pain or report
it accurately.
● Prior experiences: Can increase or decrease sensitivity
depending on whether clients obtained adequate relief.
● Anxiety and fear: Can increase sensitivity to pain.
● Support systems and coping styles: Presence of these
can decrease sensitivity to pain.
● Culture: Cam influence how clients express pain or the
meaning they give to pain.
Online Video: Pain Assessment
41.1 Symptom analysis
Use anatomical terminology and
landmarks to describe location
(superficial deep, referred, or radiating).
QUESTIONS
“Where is your pain? Does it
radiate anywhere else?”
ask clients to point to the location.
Quality refers to how the pain feels:
sharp, dull, aching, burning, stabbing,
pounding, throbbing, shooting, gnawing,
tender, heavy, tight, tiring, exhausting,
sickening, terrifying, torturing, nagging,
annoying, intense, or unbearable.
QUESTIONS
“What does the pain feel like?”
give more than two choices: “is the pain
throbbing, burning, or stabbing?”
Intensity, strength, and severity are
“measures” of the pain. Use a pain
intensity scale (visual analog, description,
or number rating scales) to measure
pain, monitor pain, and evaluate the
effectiveness of interventions.
QUESTIONS
“How much pain do you have now?”
“What is the worst/best
the pain has been?”
“Rate your pain on a scale of 0 to 10.”
Timing: onset, duration, frequency
QUESTIONS
“When did it start?”
“How long does it last?”
“How often does it occur?”
“is it constant or intermittent?”
Setting: how the pain affects
daily life or how activities of daily
living (aDLs) affect the pain
QUESTIONS
“Where are you when the
symptoms occur?”
“What are you doing when
the symptoms occur?”
“How does the pain affect your sleep?”
“How does the pain affect your ability
to work or interact with others?”
Document associated findings:
fatigue, depression, nausea, anxiety.
QUESTIONS
“What other symptoms do you have
when you are feeling pain?”
Aggravating/relieving factors
QUESTIONS
“What makes the pain better?”
“What makes the pain worse?”
“are you currently taking any prescription,
herbal, or over‑the‑counter medications?”
FUNDAMENTALS FOR NURSING CHAPTER 41 Pain ManageMent 229
eXPeCteD FinDingS
● Behaviors complement self‑report and assist in pain
assessment of nonverbal clients.
◯ Facial expressions (grimacing, wrinkled forehead),
body movements (restlessness, pacing, guarding)
◯ Moaning, crying
◯ Decreased attention span
● Blood pressure, pulse, and respiratory rate increase
temporarily with acute pain. Eventually, increases
in vital signs will stabilize despite the persistence of
pain. Therefore, physiologic indicators might not be an
accurate measure of pain over time.
PATIENT‑CENTERED CARE
nOnPHaRMaCOLOgiCaL Pain
ManageMent StRategieS
Nonpharmacological strategies should not replace
pharmacological pain measures, but can be used along
with them.
Cognitive-behavioral measures: changing the way
a client perceives pain, and physical approaches to
improve comfort
Cutaneous (skin) stimulation: transcutaneous electrical
nerve stimulation (TENS), heat, cold, therapeutic touch,
and massage
● Interruption of pain pathways
● Cold for inflammation
● Heat to increase blood flow and to reduce stiffness
Distraction
● Includes ambulation, deep breathing, visitors, television,
games, prayer, and music
● Decreased attention to the presence of pain can decrease
perceived pain level.
Relaxation: Includes meditation, yoga, and progressive
muscle relaxation
Imagery
● Focusing on a pleasant thought to divert focus
● Requires an ability to concentrate
Acupuncture and acupressure: Stimulating subcutaneous
tissues at specific points using needles (acupuncture) or
the digits (acupressure)
Reduction of pain stimuli in the environment
Elevation of edematous extremities to promote venous
return and decrease swelling
PHaRMaCOLOgiCaL inteRVentiOnS
Analgesics are the mainstay for relieving pain. The
three classes of analgesics are nonopioids, opioids,
and adjuvants.
Nonopioid analgesics
Nonopioid analgesics (acetaminophen, nonsteroidal
anti-inflammatory drugs [NSAIDs], including salicylates)
are appropriate for treating mild to moderate pain.
● Be aware of the hepatotoxic effects of acetaminophen.
Clients who have a healthy liver should take no more
than 4 g/day. Make sure clients are aware of opioids that
contain acetaminophen, such as hydrocodone bitartrate
5 mg/acetaminophen 500 mg.
● Monitor for salicylism (tinnitus, vertigo, decreased
hearing acuity).
● Prevent gastric upset by administering the medication
with food or antacids.
● Monitor for bleeding with long‑term NSAID use.
Opioid analgesics
Opioid analgesics, such as morphine sulfate, fentanyl, and
codeine, are appropriate for treating moderate to severe
pain (postoperative pain, myocardial infarction pain,
cancer pain).
● Managing acute severe pain with short‑term (24 to
48 hr) around‑the‑clock administration of opioids is
preferable to following a PRN schedule.
● The parenteral route is best for immediate, short‑term
relief of acute pain. The oral route is better for chronic,
no fluctuating pain.
● Consistent timing and dosing of opioid administration
provide consistent pain control.
● It is essential to monitor and intervene for adverse
effects of opioid use.
◯ Sedation: Monitor level of consciousness and take
safety precautions. Sedation usually precedes
respiratory depression.
◯ Respiratory depression: Monitor respiratory rate prior
to and following administration of opioids (especially
for clients who have little previous exposure to
opioid medications). Initial treatment of respiratory
depression and sedation is generally a reduction in
opioid dose. If necessary, slowly administer diluted
naloxone to reverse opioid effects until the client can
deep breathe with a respiratory rate of at least 8/min.
◯ Orthostatic hypotension: Advise clients to sit or lie
down if lightheadedness or dizziness occur. Instruct
clients to avoid sudden changes in position by slowly
moving from a lying to a sitting or standing position.
Provide assistance with ambulation.
◯ Urinary retention: Monitor I&O, assess for distention,
administer bethanechol, and catheterize.
◯ Nausea/vomiting: Administer antiemetics,
advise clients to lie still and move slowly, and
eliminate odors.
◯ Constipation: Use a preventative approach
(monitoring of bowel movements, fluids, fiber intake,
exercise, stool softeners, stimulant laxatives, enemas).
230 CHAPTER 41 Pain ManageMent CONTENT MASTERY SERIES
Adjuvant analgesics
Adjuvant analgesics enhance the effects of nonopioids,
help alleviate other manifestations that aggravate pain
(depression, seizures, inflammation), and are useful for
treating neuropathic pain.
Anticonvulsants: carbamazepine, gabapentin
Antianxiety agents: diazepam, lorazepam
Tricyclic antidepressants: amitriptyline, nortriptyline
Anesthetics: infusional lidocaine
Antihistamine: hydroxyzine
Glucocorticoids: dexamethasone
Antiemetics: ondansetron
Bisphosphonates and calcitonin: for bone pain
Patient‑controlled analgesia
Patient‑controlled analgesia (PCA) is a medication delivery
system that allows clients to self‑administer safe doses
of opioids.
● Small, frequent dosing ensures consistent plasma levels.
● Clients have less lag time between identified need and
delivery of medication, which increases their sense
of control and can decrease the amount of medication
they need.
● Morphine, hydromorphone, and fentanyl are typical
opioids for PCA delivery.
● Clients should let the nurse know if using the pump
does not control the pain.
to prevent inadvertent overdosing, the client is the
only person who should push the PCa button.
Other interventions
ADDITIONAL PHARMACOLOGICAL PAIN INTERVENTIONS:
Local and regional anesthesia and topical analgesia
OTHER STRATEGIES FOR EFFECTIVE PAIN MANAGEMENT
● Take a proactive approach by giving analgesics before
pain becomes too severe. It takes less medication to
prevent pain than to treat pain.
● Instruct clients to report developing or recurrent
pain and not wait until pain is severe (for PRN
pain medication).
● Explain misconceptions about pain (medication
dependence, pain measurement and perception).
● Help clients reduce fear and anxiety.
● Create a treatment plan that includes both
nonpharmacological and pharmacological
pain‑relief measures.
Chronic pain relief strategies
Strategies specific for relieving chronic pain include the
above interventions, plus the following.
● Administering long‑acting or controlled‑release opioid
analgesics (including the transdermal route).
● Administering analgesics around the clock rather
than PRN.
COMPLICATIONS AND
NURSING IMPLICATIONS
Undertreatment of pain is a serious complication and can
lead to increased anxiety with acute pain and depression
with chronic pain. Assess clients for pain frequently, and
intervene as appropriate.
Sedation, respiratory depression, and coma can occur as
a result of overdosing. Sedation always precedes
respiratory depression.
● Identify high‑risk clients (older adult clients, clients
who are opioid‑naïve).
● Carefully titrate client dose while closely monitoring
respiratory status.
● Stop the opioid and give the antagonist naloxone if
respiratory rate is below 8/min and shallow, or the
client is difficult to arouse.
● Identify the cause of sedation.
● Use a sedation scale in addition to a pain rating scale to
assess pain, especially when administering opioids.
FUNDAMENTALS FOR NURSING CHAPTER 41 Pain ManageMent 231
Application Exercises
1. a nurse at a clinic is collecting data
about pain from of a client who
reports severe abdominal pain. the
nurse asks the client whether he has
nausea and has been vomiting. Which
of the following pain characteristics is
the nurse attempting to determine?
a. Presence of associated
manifestations
B. Location of the pain
C. Pain quality
D. aggravating and
relieving factors
2. a nurse is collecting data from
a client who is reporting pain
despite taking analgesia. Which
of the following actions should
the nurse take to determine the
intensity of the client’s pain?
a. ask the client what
precipitates the pain.
B. Question the client about
the location of the pain.
C. Offer the client a pain scale
to measure his pain.
D. Use open‑ended questions
to identify the client’s
pain sensations.
3. a nurse is discussing the care of a
group of clients with a newly licensed
nurse. Which of the following clients
should the newly licensed nurse
identify as experiencing chronic pain?
a. a client who has a broken
femur and reports hip pain.
B. a client who has incisional
pain 72 hr following
pacemaker insertion.
C. a client who has food
poisoning and reports
abdominal cramping.
D. a client who has episodic
back pain following a
fall 2 years ago.
4. a nurse is monitoring a client who is
receiving opioid analgesia for adverse
effects of the medication. Which of
the following effects should the nurse
anticipate? (Select all that apply.)
a. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
e. nausea
5. a nurse is caring for a client
who is receiving morphine via a
patient‑controlled analgesia (PCa)
infusion device after abdominal
surgery. Which of the following
statements indicates that the client
knows how to use the device?
a. “i’ll wait to use the device until
it’s absolutely necessary.”
B. “i’ll be careful about pushing
the button too much so i
don’t get an overdose.”
C. “i should tell the nurse if
the pain doesn’t stop while
i am using this device.”
D. “i will ask my adult child
to push the dose button
when i am sleeping.”
PRACTICE Active Learning Scenario
a nurse on a medical‑surgical unit is reviewing with a
group of newly licensed nurses the various types of pain
the clients on the unit have. Use the ati active Learning
template: Basic Concept to complete this item.
UNDERLYING PRINCIPLES: List the four different types
of pain, their definitions, and characteristics.
232 CHAPTER 41 Pain ManageMent CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: the nurse should attempt to identify manifestations that
occur along with the client’s pain, such as nausea, fatigue, or anxiety.
B. the nurse should ask the client to point out where
he feels pain to determine the location.
C. the nurse should ask the client if his pain is throbbing,
dull, or aching to determine the pain quality.
D. the nurse should ask the client what makes the pain better
or worse to determine aggravating and relieving factors.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
2. a. the nurse should ask what precipitates the client’s pain
when collecting data to determine the cause of the pain.
B. the nurse should ask the location of the client’s
pain to help determine the cause or classify the
pain as deep, subcutaneous, or radiating.
C. CORRECT: the nurse should use a pain rating scale to help the client
report the intensity of his pain. the nurse should use a numeric, verbal,
or visual analog scale appropriate to the client’s individual needs.
D. the nurse should ask open‑ended questions about
the client’s pain sensation to help determine the quality
of the pain, such as exhausting, tight, or burning.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
3. a. the newly licensed nurse should identify pain from a
recent, nonhealed bone fracture as acute pain.
B. the newly licensed nurse should identify
postoperative pain as acute pain.
C. the newly licensed nurse should identify pain associated
with a current illness, such as food poisoning, as acute pain.
D. CORRECT: a client who reports pain that lasts more than
6 months and continues beyond the time of tissue healing
is experiencing chronic pain. the nurse should identify this
client’s pain as chronic, and assist with planning interventions
to relieve manifestations associated with the pain.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
4. a. the nurse should identify urinary retention as a
possible adverse effect of opioid analgesia.
B. the nurse should identify constipation as a
possible adverse effect of opioid analgesia.
C. CORRECT: Opioid analgesia can cause respiratory
depression, which causes respiratory rates to drop to
dangerously low levels. the nurse should monitor the client’s
respiratory rate, and administer naloxone if indicated.
D. CORRECT: Opioid analgesia can cause orthostatic
hypotension. the nurse should monitor the client for
dizziness or lightheadedness when changing positions.
e. CORRECT: Opioid analgesia can cause nausea and vomiting. the
nurse should monitor for and treat these complications as needed.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
5. a. the nurse should remind the client to use the PCa when
he begins to feel pain to achieve better pain control.
B. the nurse should remind the client the PCa has a timing
control or lockout mechanism, which enforces a preset
minimum interval between medication doses. the client
cannot self‑administer another dose of medication until that
time interval has passed, even if the button is pressed.
C. CORRECT: PCa allows the client to self‑administer
pain medication on an as‑needed basis. if the client is not
achieving adequate pain control, he should let the nurse
know so that she can initiate a reevaluation of the client’s
pain management plan and possible dosage change.
D. the nurse should warn the client he is the only one
who should operate the PCa pump. in situations where
a client is not able to do so, a provider may authorize a
nurse or a family member to operate the pump.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
acute pain
● Definition: Protective,
temporary, usually self‑limiting,
resolves with tissue healing
● Physiological responses:
tachycardia, hypertension,
anxiety, diaphoresis,
muscle tension
● Behavioral responses: grimacing,
moaning, flinching, guarding
Chronic pain
● Definition: not protective;
ongoing or recurs frequently,
lasts longer than 6 months,
persists beyond tissue
healing, can be malignant
or nonmalignant
● Physiological responses: no
change in vital signs; depression;
fatigue; decreased level of
functioning; disability
nociceptive pain
● Definition: arises from damage
to or inflammation of tissue,
which is a noxious stimulus that
triggers the pain receptors
called nocioceptors and causes
pain, is usually throbbing,
aching, localized; pain typically
responds to opioids and
nonopioid medications
● types of nociceptive pain:
◯ Somatic: in bones,
joints, muscles, skin, or
connective tissues
◯ Visceral: in internal organs such
as the stomach or intestines,
can cause referred pain
◯ Cutaneous: in skin or
subcutaneous tissue
neuropathic pain
● Definition: arises from abnormal
or damaged pain nerves
(phantom limb pain, pain below
the level of a spinal cord injury,
diabetic neuropathy), usually
intense, shooting, burning,
or “pins and needles”
● Physiological responses
to adjuvant medications
(antidepressants, antispasmodic
agents, skeletal muscle relaxants).
NCLEX® Connection: Pharmacological and Parenteral Therapies, Pharmacological Pain Management
FUNDAMENTALS FOR NURSING CHAPTER 42 Complementary and alternative therapies 233
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 42 Complementary
and Alternative
Therapies
in combination with allopathic therapies
(conventional Western medicine),
complementary and alternative therapies
comprise integrative health care, which focuses
on optimal health of the whole person. another
term for these therapies is complementary and
alternative medicine (Cam).
alternative therapies are unconventional
treatment approaches that become the primary
treatment and replace allopathic medical care.
Complementary therapies are unconventional
treatment approaches used in addition to or to
enhance conventional medical care.
many health care entities are developing
programs of integrative medicine or integrative
therapies to provide clients with conventional
and unconventional health care choices,
particularly for chronic health problems.
the number of clients using Cam is considerably
rising. this interest is related to a desire for
more natural treatments to add to or replace
ineffective allopathic treatment, increased
awareness of alternative medicine, and from
clients who desire to take a more active role in
the treatment process.
an important prerequisite for implementing
complementary or alternative therapies is the
client’s acceptance of and involvement in the
therapeutic intervention.
CATEGORIES OF CAM
Alternative medical philosophies: Complete medical
systems outside of allopathic medicinal beliefs (traditional
Chinese medicine, Ayurveda, homeopathy)
Biological and botanical therapies: Involve the use
of natural products to affect health (diets, vitamins,
minerals, herbal preparations, probiotics)
Body-based and manipulative methods: Involve external
touch to affect body systems (massage, touch, chiropractic
therapy, acupressure)
Mind-body therapies: Connect the physiological function
to the mind and emotions (acupuncture, breathwork,
biofeedback, art therapy, meditation, guided imagery,
yoga, psychotherapy, tai chi)
Energy therapies: Involve use of the body’s energy fields
(Reiki, therapeutic touch, magnet therapy)
Movement therapies: Use exercise or activity to promote
physical and emotional well‑being (Pilates, dance therapy)
TYPES OF CAM
Specialized licensed or certified practitioners may provide
complementary or alternative therapies.
Acupuncture/acupressure: Needles or pressure along
meridians to alter body function or produce analgesia
Homeopathic medicine: Administering doses of
substances (remedies) that would produce manifestations
of the disease state in a well person to ill clients to bring
about healing
Naturopathic medicine: Diet, exercise, environment, and
herbal remedies to promote natural healing
Chiropractic medicine: Spinal manipulation for healing
Massage therapy: Stretching and loosening muscles and
connective tissue for relaxation and circulation
Biofeedback: Using technology to increase awareness of
various neurological body responses to minimize extremes
Therapeutic touch: Using hands to help bring energy
fields into balance
CHAPTER 42
234 CHAPTER 42 Complementary and alternative therapies CONTENT MASTERY SERIES
natUral prodUCts and
herBal remedies
● Natural products include herbal medicines, minerals
and vitamins, essential oils, and dietary supplements.
● Clients use nonvitamin, nonmineral natural products to
prevent disease and illness, and to promote health.
● Herbal remedies are derived from plant sources and are
the oldest form of medicine.
● The FDA does not regulate many of these products.
● Some herbal agents have been deemed safe or effective
by nongovernment agencies. However, even safe or
commonly used substances can have adverse effects and
interfere with prescription medication efficacy.
Aloe: Wound healing
Chamomile: Anti-inflammatory, calming
Echinacea: Enhances immunity
Garlic: Inhibits platelet aggregation
Ginger: Antiemetic
Ginkgo biloba: Improves memory
Ginseng: Increases physical endurance
Valerian: Promotes sleep, reduces anxiety
NURSING AND CAM
Nurses should do the following.
● Understand the varieties of therapies available and any
safety precautions associated with their use.
● Be receptive to learning about clients’ alternative health
beliefs and practices (home remedies, cultural practices,
vitamin use, modification of prescriptions).
● Identify clients’ needs for complementary or alternative
therapies, along with the client’s values and treatment
preferences.
● Incorporate complementary or alternative therapies into
clients’ care plans.
● Evaluate client’s responses to CAM interventions.
● Assist with evaluating the safety of herbal and natural
products the client may be using. Provide the client
with reliable information, and determine possible
interactions with prescription medicines and therapies.
therapies
Nursing interventions can provide some aspects
of complementary alternative therapies, including
the following.
Guided imagery/visualization therapy: Encourages
healing and relaxation of the body by having the mind
focus on images
Healing intention: Uses caring, compassion, and empathy
in the context of prayer to facilitate healing
Breathwork: Reduces stress and increases relaxation
through various breathing patterns
Humor: Reduces tension and improves mood to
foster coping
Meditation: Uses rhythmic breathing to calm the mind
and body
Simple touch: Communicates presence, appreciation,
and acceptance
Music or art therapy: Provides distraction from pain
and allows the client to express emotions; earphones
improve concentration
Therapeutic communication: Allows clients to verbalize
and become aware of emotions and fears in a safe,
nonjudgmental environment
Relaxation techniques: Promotes relaxation using
breathing techniques while thinking peaceful thoughts
(passive relaxation) or while tensing and relaxing specific
muscle groups (progressive relaxation)
FUNDAMENTALS FOR NURSING CHAPTER 42 Complementary and alternative therapies 235
Application Exercises
1. a nurse is caring for a client
scheduled for abdominal
surgery. the client reports being
worried. Which of the following
actions should the nurse take?
a. offer information on a
relaxation technique
and ask the client if he is
interested in trying it.
B. request a social worker see
the client to discuss meditation.
C. attempt to use biofeedback
techniques with the client.
d. tell the client many people feel
the same way before surgery
and to think of something else.
2. a nurse is assessing a client as
part of an admission history. the
client reports drinking an herbal
tea every afternoon at work to
relieve stress. the nurse should
suspect the tea includes which
of the following ingredients?
a. Chamomile
B. Ginseng
C. Ginger
d. echinacea
3. a nurse is reviewing complementary
and alternative therapies with a
group of nursing students. the nurse
should classify which of the following
interventions as a mind‑body
therapy? (select all that apply.)
a. art therapy
B. acupressure
C. yoga
d. therapeutic touch
e. Biofeedback
4. a nurse is teaching a group of
nursing students on complementary
and alternative therapies they can
incorporate into their practice
without the need for specialized
licensing or certification. Which
of the following should the
nurse encourage the students
to use? (select all that apply.)
a. Guided imagery
B. massage therapy
C. meditation
d. music therapy
e. therapeutic touch
5. a nurse is planning to use healing
intention with a client who is
recovering from a lengthy illness.
Which of the following is the
priority action the nurse should take
before attempting this particular
mind‑body intervention?
a. tell the client the goal of the
therapy is to promote healing.
B. ask whether the client is
comfortable with using prayer.
C. encourage the client
participate actively
for best results.
d. instruct the client to relax
during the therapy.
PRACTICE Active Learning Scenario
a nurse is reviewing the various categories of
complementary and alternative therapies with a group
of newly licensed nurses. Use the ati active learning
template: Basic Concept to complete this item.
RELATED CONTENT: list at least four different types of
therapies with examples of each.
236 CHAPTER 42 Complementary and alternative therapies CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: it is appropriate for the nurse to recommend a
noninvasive technique to facilitate coping, and to allow the
client to make an informed decision about participating.
B. meditation does not require specialized training. the nurse can use
this therapy and does not need to request a social worker consult.
C. the nurse should recognize that biofeedback requires
specialized training and licensing or certification. it is not
appropriate for the nurse to attempt to use these techniques.
d. this response by the nurse is nontherapeutic because
it uses stereotyping and dismisses the client’s feelings. the
nurse should use therapeutic communication techniques
to allow the client to further verbalize fears.
NCLEX® Connection: Basic Care and Comfort,
Non-Pharmacological Comfort Interventions
2. a. CORRECT: the nurse should suspect the tea might contain
chamomile, which produces a calming effect, or valerian, which reduces
anxiety. the nurse should attempt to gain further information to confirm
the ingredients of any herbal or natural products the client may use.
B. the nurse should expect a client to use ginseng
tea to improve physical endurance.
C. the nurse should expect a client to use ginger
tea to prevent or relieve nausea.
d. the nurse should expect a client to use echinacea
tea to boost the immune system.
NCLEX® Connection: Management of Care,
Concepts of Management
3. a. CORRECT: the nurse should classify art therapy as a
mind‑body therapy because it allows the client to express
unconscious emotions or concerns about their health.
B. the nurse should classify acupressure is a body‑based therapy
because it focuses specifically on body structures and systems.
C. CORRECT: the nurse should classify yoga as a mind‑body
therapy because it focuses on achieving well‑being
through exercise, posture, breathing, and meditation.
d. the nurse should classify therapeutic touch as an energy therapy
because it involves using the hands to balance energy fields.
e. CORRECT: the nurse should classify biofeedback because it
increases mental awareness of the body responses to stress.
NCLEX® Connection: Basic Care and Comfort,
Non-Pharmacological Comfort Interventions
4. a. CORRECT: nurses may use guided imagery with clients once
they understand the general principles of this therapy.
B. the nurse should inform the students that massage therapists
undergo training as well as certification and/or licensure.
C. CORRECT: nurses may use meditation with clients once
they understand the general principles of this therapy.
d. CORRECT: nurses may use music therapy with clients
once they understand the general principles.
e. the nurse should inform the students that therapeutic
touch practitioners undergo specific training.
NCLEX® Connection: Basic Care and Comfort,
Non-Pharmacological Comfort Interventions
5. a. the nurse should tell the client the goals of therapy
to provide information to the client. however, there
is another action the nurse should take first.
B. CORRECT: the first action the nurse should take using the nursing
process is to assess or collect data from the client. Because people
can have personal, cultural, or religious sensitivities or aversions to
religious practices such as prayer, the nurse must first determine
that the client is comfortable with a therapy that involves prayer.
C. the nurse should encourage the client to participate
to improve the effectiveness of the therapy. however,
there is another action the nurse should take first.
d. the nurse should instruct the client relax to promote
the client’s ability to focus during the therapy. however,
there is another action the nurse should take first.
NCLEX® Connection: Basic Care and Comfort,
Non-Pharmacological Comfort Interventions
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● alternative medical philosophy: traditional Chinese
medicine, ayurvedic medicine, homeopathy
● Biological and botanical therapies: diets, vitamins, minerals, herbal preparations
● Body manipulation: massage, touch, chiropractic therapy
● mind‑body therapies: biofeedback, art therapy, meditation, yoga, psychotherapy, tai chi
● energy therapies: reiki, therapeutic touch
NCLEX® Connection: Basic Care and Comfort, Non-Pharmacological Comfort Interventions
FUNDAMENTALS FOR NURSING CHAPTER 43 Bowel elimination 237
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 43 Bowel Elimination
many factors can alter bowel function.
interventions such as surgery, immobility,
medications, and therapeutic diets can affect
bowel elimination. Various disease processes
necessitate the creation of bowel diversions to
allow fecal elimination to continue.
Stool specimens are collected both for
screening and for diagnostic tests, such as
for the detection of occult blood, bacteria,
or parasites.
alterations in bowel pattern include infrequent,
difficult stools (constipation) or an increased
number of loose, liquid stools (diarrhea).
BOWEL ELIMINATION PATTERNS
There are objective ways to assess a client’s bowel pattern,
but individual bowel patterns vary greatly.
FaCtoRS aFFeCtinG
Bowel elimination
Age
INFANTS
● Breast milk stools: watery and yellow brown
● Formula stools: pasty and brown
TODDLERS: Bowel control at 2 to 3 years old
OLDER ADULTS: Decreased peristalsis, relaxation
of sphincters
Diet
Fiber requirement: 25 to 30 g/day
Lactose intolerance: Difficulty digesting milk products
Fluid intake
Fluid requirement: 2,000 to 3,000 mL/day from fluid and
food sources
Physical activity
Stimulates intestinal activity
Psychosocial factors
Emotional distress increasing peristalsis and exacerbating
chronic conditions (colitis, Crohn’s disease, ulcers,
irritable bowel syndrome)
Depression decreases peristalsis and can lead to
constipation.
Personal habits
Willingness to use public toilets, false perception of the
need for “one‑a‑day” bowel movements, lack of privacy
when hospitalized
Positioning
NORMAL: Squatting
IMMOBILIZED CLIENT: Difficulty defecating
Pain
● Normal defecation is painless. Discomfort leads to
suppression of the urge to defecate.
● Opioid use contributes to constipation.
Pregnancy
● Growing fetus compromising intestinal space
● Slower peristalsis
● Straining increasing the risk of hemorrhoids
Surgery and anesthesia
Temporary slowing of intestinal activity (rationale for
auscultating bowel sounds before advancing diet)
Medications
Laxatives: To soften stool
Cathartics: To promote peristalsis
Laxative overuse: Chronic use of laxatives causes a
weakening of the bowel’s expected response to distention
from feces resulting in the development of chronic
constipation.
CHAPTER 43
238 CHAPTER 43 Bowel elimination CONTENT MASTERY SERIES
inContinenCe
Fecal incontinence is the inability to control defecation,
often caused by diarrhea.
● Determine causes, such as medications, infections,
or impaction.
● Provide perineal care after each stool, and apply a
moisture barrier.
● The provider can prescribe an anal bag or other bowel
management system to collect stool and prevent it from
coming into contact with the skin.
FlatUlenCe
Flatulence results from distention of the bowel from gas
accumulation (can cause cramping or a feeling of fullness).
● Check for abdominal distention and the ability to pass
gas through the anus.
● Encourage ambulation to promote the passage of flatus.
HemoRRHoiDS
Hemorrhoids are engorged, dilated blood vessels in the
rectal wall from difficult defecation, pregnancy, liver
disease, and heart failure.
● Hemorrhoids can be itchy, painful, and bloody
after defecation.
● Use moist wipes for cleansing the perianal area, and
apply ointments or creams as prescribed.
● Use a sitz bath or ice pack to promote relief from
hemorrhoid discomfort.
oStomieS
● Some bowel disorders prevent the normal elimination of
stool from the body. Bowel diversions through ostomies
are temporary or permanent openings (stomas)
surgically created in the abdominal wall to allow fecal
matter to pass.
● Ostomies are created in either the large intestine or
the small intestine. Colostomies end in the colon, and
ileostomies end in the ileum.
◯ End stomas are a result of colorectal cancer or some
types of bowel disease.
◯ Loop colostomies help resolve a medical emergency
and are temporary. In a loop colostomy, a loop
of bowel is supported on the abdomen with a
proximal stoma draining stool and a distal stoma
draining mucus. It is usually constructed in the
transverse colon.
◯ Double-barrel colostomies consist of two abdominal
stomas: one proximal and one distal. The proximal
stoma drains stool and the distal stoma leads to
inactive intestine. After the injured area of the
intestine heals, the colostomy is often reversed by
reattaching the two ends.
Constipation and diarrhea
For healthy clients, constipation and diarrhea are not
serious. For older adult clients and clients who have
pre‑existing medical problems, constipation and diarrhea
can have a significant impact on the client’s health.
Constipation
Constipation is a bowel pattern of difficult and infrequent
evacuation of hard, dry feces.
Paralytic ileus is an intestinal obstruction caused by
reduced motility following bowel manipulation during
surgery, electrolyte imbalance, wound infection, or by the
effects of medication.
CAUSES OF CONSTIPATION
● Frequent use of laxatives
● Advanced age
● Inadequate fluid intake
● Inadequate fiber intake
● Immobilization due to injury
● Sedentary lifestyle
● Pregnancy
● Medication effects
Diarrhea
Diarrhea is a bowel pattern of frequent loose or liquid stools.
CAUSES OF DIARRHEA
● Viral gastroenteritis
● Bacterial gastroenteritis
● Antibiotic therapy
● Inflammatory bowel disease
● Irritable bowel syndrome
ASSESSMENT/DATA COLLECTION
● Perform a routine physical examination of the abdomen
(bowel sounds, tenderness).
● Check for fluid deficit.
● Inspect skin integrity around the anal area.
● Collect a detailed history of diet, exercise, and
bowel habits.
● Monitor for constipation.
◯ Abdominal bloating
◯ Abdominal cramping
◯ Straining at defecation
◯ Presence of dry, hard feces at defecation.
◯ Irregular bowel movements, or reduced frequency
from client’s normal pattern.]
● Monitor for diarrhea.
◯ Frequent loose stools
◯ Abdominal cramping
◯ Stool of watery consistency
● Perform specimen collection for diagnostic testing
as indicated.
● Perform a digital rectal examination for impaction.
◯ Position on the left side with the knees flexed.
◯ Monitor vital signs and response.
FUNDAMENTALS FOR NURSING CHAPTER 43 Bowel elimination 239
DiaGnoStiC PRoCeDUReS
Stool samples should come from fresh stools. Avoid
contaminating with water or urine.
Fecal occult blood (guaiac) test: Obtain a fecal sample
using medical asepsis while wearing gloves. Collect stool
specimens for serial guaiac testing three times from three
different defecations. Some foods (red meat, citrus fruit,
raw vegetables) and medications can cause false positive
results. Bleeding can be an indication of cancer.
Specimens for stool cultures: Obtain using medical
asepsis while wearing gloves. Label the specimen, and
promptly send it to the laboratory.
Specimen collection
EQUIPMENT
● Specimen container
● Soap/cleansing solution or wipe
● Clean gloves
● Specimen label
● Fecal occult blood test cards
● Wooden applicator or tongue depressor
● Developer solution
● Stool collection container (bedside commode, bedpan,
receptacle in toilet)
PROCEDURE
● Fecal occult blood testing (guaiac test)
◯ Explain the procedure to the client.
◯ Ask the client to collect a specimen in the toilet
receptacle, bedpan, or bedside commode.
◯ Don gloves.
◯ With a wooden applicator, place small amounts of
stool on the windows of the test card or as directed.
◯ Follow the facility’s procedures for handling.
■ Apply a label to the cards and send them to the
laboratory for processing.
■ Alternatively, if for point‑of‑care testing, place a
couple of drops of developer on the opposite side of
the card. A blue color indicates the stool is positive
for blood.
◯ Remove the gloves and perform hand hygiene.
● Stool for culture, parasites, and ova
◯ Explain the procedure to the client.
◯ Ask the client to collect the specimen in the toilet
receptacle, bedside commode, or bedpan.
◯ Don gloves.
◯ Use a wooden tongue depressor to transfer the stool
to a specimen container.
◯ Label the container with the client’s
identifying information.
◯ Remove the gloves.
◯ Perform hand hygiene.
◯ Transport the specimen to the laboratory.
Colonoscopy
Use of a lighted instrument by the provider to visualize
and collect tissue samples for biopsy or remove polyps
from the colon or lower small bowel
Sigmoidoscopy
Use of a lighted instrument by the provider to visualize
and collect tissue for biopsy or remove polyps from the
sigmoid colon and rectum
CLIENT PREPARATION
● Protocols vary with the provider and the facility, but
generally include clear liquids only and a bowel cleanser.
● Clients receive moderate (conscious) sedation and may
not drive home afterwards.
PATIENT‑CENTERED CARE
nURSinG CaRe
● Closely monitor fluid status and elimination pattern.
● Record food and fluid intake and output. For diarrhea,
measure the volume of the stools.
● Observe and document the character of bowel
movements. Carefully check for blood or pus.
● Promote regular bowel elimination through several
measures.
◯ Adequate fiber in the diet
◯ Adequate fluid intake: Minimum of 1,500 mL/day of
water and/or juices
◯ Adequate activity: Walking 15 to 20 min/day if mobile
and exercises in bed or chair (pelvic tilt, single leg
lifts, lower trunk rotation)
Constipation
● Increase fiber and water consumption (unless
contraindicated) before more invasive interventions.
● Give bulk‑forming products before stool softeners,
stimulants, or suppositories.
● Enemas are a last resort for stimulating defecation.
Diarrhea
● Help determine and treat the cause.
● Administer medications to slow peristalsis.
● Provide perineal care after each stool, and apply a
moisture barrier.
● After diarrhea stops, suggest eating yogurt to help
re‑establish an intestinal balance of beneficial bacteria.
Meeting needs of older adults
● Older adult clients are more susceptible to developing
constipation as bowel tone decreases with age.
Therefore, they are more at risk for developing fecal
impaction. Adequate fluid, fiber intake, and exercise
decrease the likelihood of developing constipation or
fecal impaction.
● Older adult clients are less able to compensate for fluid
lost due to diarrhea. Monitor older adults who have
diarrhea for diarrhea‑associated complications such as
electrolyte imbalances and skin breakdown.
240 CHAPTER 43 Bowel elimination CONTENT MASTERY SERIES
Promoting healthy bowel elimination
EQUIPMENT
● Bedpans
◯ Fracture pan: for supine clients and clients in body
casts or leg casts
◯ Regular pan: for seated clients
● Beside commode
● Toilet
PROCEDURE
● Encourage the client to set aside time to defecate.
Sometimes, after a meal works best.
● If not contraindicated or restricted, encourage the client
to drink plenty of fluids and to consume a diet high in
fiber to prevent constipation.
● Wear gloves when addressing toileting needs.
● Provide privacy.
● Assist the client to a sitting position whether using a
regular bedpan, commode, or toilet.
● For clients using a fracture pan, raise the head of the
bed to 30°.
● If the client cannot lift his hips to get the bedpan under
him, roll him onto one side, position the bedpan over
his buttocks, and roll the client back onto the bedpan.
● Encourage the client to decrease stress when sitting or
rising by using an elevated toilet seat or a footstool.
● Never leave a client lying flat on a regular bedpan.
● After the client defecates, provide skin care to the
perianal area.
Cleansing enema
The height of the bag above the rectum determines the
depth of cleansing.
EQUIPMENT
● Gloves
● Lubricant
● Absorbent, waterproof pads
● Bedpan, beside commode, or toilet
● IV pole
● Enema bag with tubing or prepackaged enema
● Solutions and additives: vary with the type of enema
◯ Tap water or hypotonic solution
■ Stimulates evacuation
■ Never repeated due to potential water toxicity
◯ Soapsuds
■ Pure castile soap in tap water or normal saline
■ Acts as an irritant to promote bowel peristalsis
◯ Normal saline
■ Safest due to equal osmotic pressure
■ Volume stimulates peristalsis
◯ Low‑volume hypertonic
■ Used by clients who cannot tolerate high‑volume
enemas
■ Commercially prepared
◯ Oil retention: Lubricates the rectum and colon for
easier passage of stool
◯ Medicated enema: Contains medications, such as
antibiotics or antihelmintics, to retain for a period of
time (1 to 3 hr).
PROCEDURE
● Perform hand hygiene.
● Prepare and warm the enema solution.
● Pour the solution into the enema bag, allowing it to fill
the tubing, and then close the clamp.
● Explain the procedure to the client.
● Provide privacy.
● Provide quick access to a commode or bedpan.
● Place absorbent pads under the client to protect the
bed linens.
● Position the client on the left side with the right leg
flexed forward.
● Put on gloves.
● Lubricate the rectal tube or nozzle.
● Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). For
a child, insert the tube 5 to 7.5 cm (2 to 3 in).
● With the bag level with the client’s hip, open the clamp.
● Raise the bag 30 to 45 cm (12 to 18 in) above the anus,
depending on the level of cleansing desired.
● Slow the flow of solution by lowering the container if
the client reports cramping, or if fluid leaks around the
tube at the anus.
● If using a prepackaged solution, insert the lubricated tip
into the rectum, and squeeze the container to instill all
of the solution.
● Ask the client to retain the solution for the prescribed
amount of time, or until the client is no longer able to
retain it.
● Discard the enema bag and tubing.
● Assist the client to the appropriate position to defecate.
● Remove the gloves.
● Perform hand hygiene.
● For clients who have little or no sphincter control,
administer the enema on a bedpan.
● Document the results and the client’s tolerance of
the procedure.
Ostomy care
EQUIPMENT
● Pouch system (skin barrier and pouch)
● Pouch closure clamp
● Barrier pastes (optional)
● Gloves
● Washcloths
● Towel
● Warm water
● Scissors
● Pen
PROCEDURE
● If a wound ostomy continence nurse is not available,
educate the client about stoma care.
● Perform hand hygiene.
● Put on gloves.
● Remove the pouch from the stoma.
● Inspect the stoma. It should appear moist, shiny, and
pink. The peristomal area should be intact, and the skin
should appear healthy.
● Use mild soap and water to cleanse the skin, then dry it
gently and completely. Moisturizing soaps can interfere
with adherence of the pouch.
● Apply paste if necessary.
Online Video: Bowel Elimination
FUNDAMENTALS FOR NURSING CHAPTER 43 Bowel elimination 241
● Measure and mark the desired size for the skin barrier.
● Cut the opening 0.15 to 0.3 cm (1⁄18 to 1⁄8 in) larger,
allowing only the stoma to appear through the opening.
● If necessary, apply barrier pastes to creases.
● Apply the skin barrier and pouch.
● Fold the bottom of the pouch and place the closure
clamp on the pouch.
● Dispose of the used pouch. Remove the gloves and
perform hand hygiene.
COMPLICATIONS
Complications of constipation
Fecal impaction: Stool becomes wedged in the rectum,
and can involve diarrhea fluid leaking around the
impacted stool.
● Administer enemas and suppositories or stool softeners
as prescribed to promote relief of fecal impaction. If
necessary, manually remove fecal impactions that do
not respond to other interventions.
● Use a gloved, lubricated finger for digital removal
of stool.
● Loosen the stool around the edges and then remove it in
small pieces, allowing the client to rest as necessary.
● When evacuating the rectum, be careful to avoid
stimulating the vagus nerve.
● Stop the procedure if the heart rate drops significantly
or the heart rhythm changes.
Hemorrhoids and rectal fissures
Bradycardia, hypotension, syncope
● Associated with the Valsalva maneuver (occurs with
straining/bearing down).
● Instruct clients not to strain to have bowel movements.
● Encourage measures to treat and prevent constipation.
Complications of diarrhea
Dehydration
Fluid and electrolyte disturbances: Metabolic acidosis
from excessive loss of bicarbonate
● Monitor for manifestations of dehydration (weak, rapid
pulse, hypotension, poor skin turgor, elevated body
temperature).
● Monitor for manifestations of electrolyte imbalance.
● Replace fluid and electrolytes as prescribed.
Skin breakdown around the anal area: Provide treatment
for skin breakdown as prescribed.
Application Exercises
1. a nurse is caring for a client who
will perform fecal occult blood
testing at home. which of the
following information should the
nurse include when explaining
the procedure to the client?
a. eating more protein is
optimal prior to testing.
B. one stool specimen is
sufficient for testing.
C. a red color change
indicates a positive test.
D. the specimen cannot be
contaminated with urine.
2. a nurse is talking with a client who
reports constipation. when the
nurse discusses dietary changes
that can help prevent constipation,
which of the following foods
should the nurse recommend?
a. macaroni and cheese
B. Fresh fruit and whole
wheat toast
C. Bread pudding and yogurt
D. Roast chicken and white rice
3. a nurse is caring for a client who
has had diarrhea for 4 days. when
assessing the client, the nurse
should expect which of the following
findings? (Select all that apply.)
a. Bradycardia
B. Hypotension
C. elevated temperature
D. Poor skin turgor
e. Peripheral edema
4. while a nurse is administering
a cleansing enema, the client
reports abdominal cramping.
which of the following actions
should the nurse take?
a. Have the client hold his breath
briefly and bear down.
B. Discontinue the
fluid instillation.
C. Remind the client that
cramping is common
at this time.
D. lower the enema
fluid container.
5. a nurse is preparing to administer
a cleansing enema to an adult
client in preparation for a
diagnostic procedure. which of
the following steps should the
nurse take? (Select all that apply.)
a. warm the enema solution
prior to instillation.
B. Position the client on the
left side with the right
leg flexed forward.
C. lubricate the rectal
tube or nozzle.
D. Slowly insert the rectal
tube about 5 cm (2 in).
e. Hang the enema container
61 cm (24 in) above
the client’s anus.
PRACTICE Active Learning Scenario
a nurse is explaining to a group of nursing students
the various factors that alter bowel elimination
patterns. Use the ati active learning template:
Basic Concept to complete this item.
UNDERLYING PRINCIPLES: list at least eight
factors that affect bowel elimination, along with
a brief example or description of each.
242 CHAPTER 43 Bowel elimination CONTENT MASTERY SERIES
Application Exercises Key
1. a. Some proteins can alter the test results. the nurse should instruct
the client not to consume red meat, fish, and poultry prior to testing.
B. the nurse should instruct the client to obtain three
specimens from three different bowel movements.
C. the nurse should inform the client to look for a blue color
on the card to indicate positive blood in the stool.
D. CORRECT: For fecal occult blood testing, the nurse should warn
the client not to contaminate the stool specimens with water or urine.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
2. a. the nurse should identify macaroni and cheese as a
low‑residue option that could actually worsen constipation.
B. CORRECT: a high‑fiber diet promotes normal bowel elimination. the
nurse should recommend the client consume fresh fruits and vegetables
with whole‑grain carbohydrates to provide the highest fiber option.
C. the nurse should identify bread pudding and yogurt as
low‑residue options that could actually worsen constipation.
D. the nurse should identify roast chicken and white rice as
low‑residue options that could actually worsen constipation.
NCLEX® Connection: Basic Care and Comfort, Elimination
3. a. the nurse should expect the client who has
prolonged diarrhea to have tachycardia.
B. CORRECT: Prolonged diarrhea leads to dehydration. the nurse
should expect the client to have a decrease in blood pressure.
C. CORRECT: Prolonged diarrhea leads to dehydration. the nurse
should expect the client to have an increased temperature.
D. CORRECT: Prolonged diarrhea leads to dehydration. the
nurse should expect the client to have poor skin turgor.
e. the nurse should expect the client who has prolonged
diarrhea to possibly have weakened peripheral pulses.
Peripheral edema results from a fluid overload.
NCLEX® Connection: Physiological Adaptation,
Illness Management
4. a. the nurse should have the client take slow, deep
breaths to relax and ease discomfort.
B. the nurse should stop the instillation if the client’s abdomen becomes
rigid and distended or if the nurse notes bleeding from the rectum.
C. this action by the nurse is nontherapeutic because it
implies that the client must tolerate the discomfort and that
the nurse cannot or will not do anything to ease it.
D. CORRECT: to relieve the client’s discomfort, the
nurse should slow the rate of instillation by reducing
the height of the enema solution container.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
5. a. CORRECT: the nurse should warm the enema solution
because cold fluid can cause abdominal cramping, and
hot fluid can injure the intestinal mucosa.
B. CORRECT: the nurse should place the client in this position
to promote a downward flow of solution by gravity along
the natural anatomical curve of the sigmoid colon.
C. CORRECT: the nurse should lubricate the tubing to
prevent trauma or irritation to the rectal mucosa.
D. the correct length of insertion for a child is 5 cm (2 in). For an adult
client, the nurse should insert the tube 7.6 to 10.2 cm (3 to 4 in).
e. the maximum recommended height is 46 cm (18 in). the height
of the fluid container affects the speed of instillation. the nurse
should hang the container within the recommended height range to
prevent rapid instillation and possibly painful distention of the colon.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● age
◯ infants
■ Breast milk stools: watery
and yellow brown
■ Formula stools: Pasty and brown
◯ toddlers: Bowel control at 2 to 3 years old
◯ older adults: Decreased peristalsis,
relaxation of sphincters
● Diet
◯ Fiber requirement: 25 to 30 g/day
◯ lactose intolerance: Difficulty
digesting milk products
◯ Fluid requirement: 2,000 to 3,000 ml/day
from fluid and food sources
● Physical activity: Stimulates intestinal activity
● Psychosocial factors
◯ emotional distress increasing
peristalsis and exacerbating chronic
conditions (colitis, Crohn’s disease,
ulcers, irritable bowel syndrome)
◯ Depression decreasing peristalsis
● Personal habits: Use of public toilets, false
perception of the need for “one‑a‑day” bowel
movements, lack of privacy when hospitalized
● Positioning
◯ normal: Squatting
◯ immobilized client: Difficulty defecating
● Pain
◯ Discomfort leading to suppression
of the urge to defecate
◯ opioid use contributing to constipation
● Pregnancy
◯ Growing fetus compromising intestinal space
◯ Slower peristalsis
◯ Straining increasing the risk of hemorrhoids
● Surgery and anesthesia
◯ temporary slowing of intestinal activity
◯ Paralytic ileus
● medications
◯ laxatives: to soften stool; overuse
leads to chronic constipation
◯ Cathartics: to promote peristalsis
NCLEX® Connection: Physiological Adaptation, Pathophysiology
FUNDAMENTALS FOR NURSING CHAPTER 44 Urinary Elimination 243
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 44 Urinary Elimination
Urinary elimination is a precise system of
filtration, reabsorption, and excretion. these
processes help maintain fluid and electrolyte
balance while filtering and excreting
water‑soluble wastes.
the primary organs of urinary elimination are the
kidneys, with the nephrons performing most of
the functions of filtration and elimination. most
adults produce 1,500 to 2,000 ml/day of urine.
after filtration, the urine passes through the
ureters into the bladder, the storage reservoir
for urine. once an adequate amount of urine
(150 to 200 ml) collects in the bladder, stretch
receptors in the bladder wall send a signal to
the brain to indicate the need to urinate. the
person then relaxes the internal and external
sphincters at the bottom of the bladder and the
urethra. Urine passes from the bladder through
the urethra, from which it exits the body.
interventions such as surgery, immobility,
medications, and therapeutic diets can affect
urinary elimination.
URINARY DIVERSIONS
● Urinary diversions are the surgical creation of a stoma,
either temporary or permanent, for the drainage of
urine. Surgeons create urinary diversions for clients
who have bladder cancer or injury.
● Urinary diversions have many similarities to bowel
diversions. Clients who have urinary diversions often
share similar body image concerns as those who have
bowel diversions.
● Diversions are either continent (with controlled
elimination of urine from the body) or incontinent (with
urine draining continuously without control).
● Continent diversions have a reservoir in the abdomen
that allows clients to control the elimination of urine.
Ureterostomy: An incontinent urinary diversion for which
the surgeon attaches one or both ureters via a stoma to
the surface of the abdominal wall
Nephrostomy: An incontinent urinary diversion for which
the surgeon attaches a tube from the renal pelvis via a
stoma to the surface of the abdominal wall
FACTORS AFFECTING
URINARY ELIMINATION
● Poor abdominal and pelvic muscle tone
● Acute and chronic disorders
● Spinal cord injury
Age
● Children achieve full bladder control by 4 to 5 years
of age.
● The prostate enlarges after 40 years of age, leading to
urinary frequency, hesitancy, retention, incontinence,
and urinary tract infections (UTIs).
● Childbirth and gravity weaken the pelvic floor, putting
clients at risk for prolapse of the bladder, leading to
stress incontinence, which clients can help manage with
pelvic floor (Kegel) exercises.
OLDER ADULT CLIENTS
● Fewer nephrons
● Loss of muscle tone of the bladder leading to frequency
● Inefficient emptying of the bladder: residual urine
increasing the risk for UTIs
● Increase in nocturia
CHAPTER 44
244 CHAPTER 44 Urinary Elimination CONTENT MASTERY SERIES
Pregnancy
● A growing fetus compromises bladder space and
compresses the bladder.
● There is a 30% to 50% increase in circulatory volume,
which increases renal workload and output.
● The hormone relaxin causes relaxation of the sphincter.
Diet
● An increase in sodium leads to decreased urination.
● Caffeine and alcohol intake lead to increased urination.
Immobility
Incontinence is not a result of aging, but of neurological or
mobility impairments.
Psychosocial factors
● Emotional stress and anxiety
● Having to use public toilets
● Lack of privacy during hospital stays
● Not having enough time to urinate (predetermined
bathroom breaks in elementary schools)
Pain
● Suppression of the urge to urinate when there is pain in
the urinary tract
● Obstruction in the ureter leading to renal colic
● Arthritis or painful joints causing immobility and
leading to delayed urination
Surgical procedures
● Alterations in glomerular filtration rate from
anesthesia and opioid analgesics, resulting in decreased
urine output
● Lower abdominal surgery creating obstructive edema
and inflammation
Medications
● Diuretics preventing reabsorption of water
● Antihistamines and anticholinergics causing
urinary retention
● Chemotherapy creating a toxic environment for
the kidneys
MEDICATIONS THAT CHANGE URINE COLOR
● Phenazopyridine: orange, red
● Amitriptyline: green‑blue
● Levodopa: dark
DIAGNOSTIC TESTS
Bedside sonography with a bladder scanner: Noninvasive
portable ultrasound scanner for measuring bladder volume
and residual volume after urination
Kidneys, ureters, bladder: X‑ray to determine size, shape,
and position of these structures
Intravenous pyelogram: Injection of contrast media
(iodine) for viewing of ducts, renal pelvis, ureters, bladder,
and urethra
! allergy to shellfish contraindicates
the use of this contrast medium.
Renal scan: View of renal blood flow and anatomy of the
kidneys without contrast
Renal ultrasound: View of gross renal structures
and structural abnormalities using high‑frequency
sound waves
Cystoscopy: Use of a lighted instrument to visualize, treat,
and obtain specimens from the bladder and urethra
Urodynamic testing: Test for bladder muscle function by
filling the bladder with CO2 or 0.9% sodium chloride and
comparing pressure readings with reported sensations
CONSIDERATIONS
Promoting healthy urinary elimination
EQUIPMENT
● Urinal for men
● Toilet, bedpan, or commode
◯ Fracture pan: For clients who must remain supine and
clients in body or leg casts
◯ Regular pan: For clients who can sit up
PROCEDURE NURSING CONSIDERATIONS
● Have clients sit when possible.
● Provide for privacy needs with adequate time
for urinating.
I&O
EQUIPMENT
● Hard plastic urometer on an indwelling catheter
drainage bag
● Graduated cylinders, urinal, or toilet receptacle
PROCEDURE NURSING CONSIDERATIONS
● Measure output from a bedpan, commode, or collection
bag into a graduated container.
● Use a receptacle to measure urine clients void into
the toilet.
● Use markings on the side of the urinal to measure urine.
! less than 30 ml/hr for more than
2 hr is a cause for concern.
FUNDAMENTALS FOR NURSING CHAPTER 44 Urinary Elimination 245
Bladder retraining for treating urge incontinence
EQUIPMENT: Clock
PROCEDURE NURSING CONSIDERATIONS
● Use timed voiding to increase intervals
between urination.
● Have clients perform pelvic floor (Kegel) exercises.
● Assist clients to perform relaxation techniques.
● Offer undergarments while clients are retraining.
● Teach clients not to ignore the urge to urinate.
● Provide positive reinforcement as clients remain continent.
● Tell clients to eliminate or decrease caffeine drinks.
● Instruct clients to take diuretics in the morning.
Specimen collection
EQUIPMENT
● Specimen container
◯ Nonsterile for urinalysis
◯ Sterile for clean‑catch midstream and specimens
from a catheter
● Soap or cleansing solution and towel
● Gloves (for contact with any body fluids)
● Specimen label
● Urine collection container (catheter, urinal, receptacle in
toilet, commode)
Urinalysis: random nonsterile specimen
NURSING CONSIDERATIONS
● Explain the procedure.
● Label the container with clients’ identifying
information, and follow the facility’s policy for
transporting the specimen to the laboratory.
Clean-catch midstream for culture and sensitivity (C&S)
NURSING CONSIDERATIONS
● Teach the technique for obtaining the specimen.
● After thorough cleansing of the urethral meatus, clients
catch the urine sample midstream.
Catheter urine specimen for C&S
NURSING CONSIDERATIONS: Obtain a sterile specimen
from a straight or indwelling catheter using surgical
asepsis (sterile technique).
Timed urine specimens
NURSING CONSIDERATIONS
● Collect for 24 hr or other duration.
● Discard the first voiding.
● Collect all other urine. Refrigerate, label, and transport
the specimen.
Straight or indwelling catheter insertion
EQUIPMENT
● Usual size and type of catheter
◯ 8 to 10 Fr for children
◯ 14 to 16 Fr for women
◯ 16 to 18 Fr for men
◯ Use silicon or Teflon products for clients who have
latex allergies.
● Catheterization kit with a sterile drainage bag for
indwelling catheter insertion
● Soap and water
● Collection container for straight catheterization
PROCEDURE NURSING CONSIDERATIONS
● Explain the procedure, and provide for privacy.
● Use the correct technique for inserting an indwelling
catheter or for straight catheterization.
Closed intermittent irrigation
Use the correct technique to perform closed intermittent
irrigation.
Routine catheter care
EQUIPMENT
● Soap and water
● Washcloth
● Gloves
PROCEDURE NURSING CONSIDERATIONS
● Use soap and water at the insertion site.
● Cleanse the catheter at least three times a day and
after defecation.
● Monitor the patency of the catheter.
◯ For reports of fullness in the bladder area, check
for kinks in the tubing, and check for sediment in
the tubing.
◯ Make sure the collection bag is at a level below the
bladder to avoid reflux.
Condom catheter application
EQUIPMENT
● Gloves
● Condom catheter
● Elastic tape
● Leg or standard collection bag
PROCEDURE NURSING CONSIDERATIONS
● Explain the procedure.
● Use the correct technique for application of a
condom catheter.
COMPLICATIONS
Urinary tract infections
Most due to Escherichia coli
RISK FACTORS
● In women, close proximity of the urethral meatus to
the anus
● Frequent sexual intercourse
● Menopause: decreasing estrogen levels
● Uncircumcised males
● Use of indwelling catheters
NURSING CONSIDERATIONS
● Cleanse female clients from front to back.
● Cleanse beneath the foreskin in males.
● Provide catheter care regularly.
246 CHAPTER 44 Urinary Elimination CONTENT MASTERY SERIES
Urinary incontinence
Urinary incontinence is a significant contributing factor to
skin breakdown and falls, especially in older adults.
maJor tyPES
Stress: Loss of small amounts of urine from increased
abdominal pressure without bladder muscle contraction
with laughing, sneezing, or lifting
Urge: Inability to stop urine flow long enough to reach
the bathroom due to an overactive detrusor muscle with
increased bladder pressure
Overflow: Urinary retention from bladder overdistention
and frequent loss of small amounts of urine due
to obstruction of the urinary outlet or an impaired
detrusor muscle
Reflex: Involuntary loss of a moderate amount of urine
usually without warning due to hyperreflexia of the
detrusor muscle, usually from spinal cord dysfunction
Functional: Loss of urine due to factors that interfere
with responding to the need to urinate, such as cognitive,
mobility, and environmental barriers
Total: Unpredictable, involuntary loss of urine that
generally does not respond to treatment
ASSESSMENT/DATA COLLECTION
riSK FaCtorS
● Female gender
● History of multiple pregnancies and vaginal births,
aging, chronic urinary retention, urinary bladder spasm,
renal disease, chronic bladder infection (cystitis)
● Neurological disorders: Parkinson’s disease,
cerebrovascular accident, spinal cord injury,
multiple sclerosis
● Medication therapy: Diuretics, opioids, anticholinergics,
calcium channel blockers, sedative/hypnotics,
adrenergic antagonists
● Obesity
● Confusion, dementia, immobility, depression
● Physiological changes of aging
● Decreased estrogen levels and decreased
pelvic‑muscle tone
● Immobility, chronic degenerative diseases, dementia,
diabetes mellitus, cerebrovascular accident
● Urinary incontinence increasing the risk for falls,
fractures, pressure ulcers, and depression
EXPECtED FinDinGS
● Loss of urine when laughing, coughing, sneezing
● Enuresis (bed‑wetting)
● Bladder spasms
● Urinary retention
● Frequency, urgency, nocturia
laBoratory tEStS
Urinalysis and urine culture and sensitivity: To identify
UTI (presence of RBCs, WBCs, micro‑organisms)
Serum creatinine and BUN: To assess renal function
(elevated with renal dysfunction)
DiaGnoStiC ProCEDUrES
Ultrasound: Detects bladder abnormalities and/or
residual urine
Voiding cystourethrography: Identifies the size, shape,
support, and function of the urinary bladder, obstruction
(prostate), residual urine
Urodynamic testing
● Cystourethroscopy: Visualizes the inside of the bladder
● Uroflowmetry: Measures the rate and degree of
bladder emptying
Electromyography: Measures the strength of pelvic
muscle contractions
PATIENT‑CENTERED CARE
nUrSinG CarE
● Establish a toileting schedule.
● Monitor and increase fluid intake during the daytime,
and decrease fluid intake prior to bedtime.
● Remove or control barriers to toileting.
● Provide incontinence garments.
● Apply an external or condom catheter for men.
● Avoid the use of indwelling urinary catheters.
● Provide incontinence care.
● Teach clients the following.
◯ How to keep an incontinence diary.
◯ How to perform Kegel exercises: Tighten pelvic
muscles for a count of 10, relax slowly for a count of
10, and repeat in sequences of 15 in the lying‑down,
sitting, and standing positions.
◯ Bladder compression techniques (Credé, Valsalva,
double voiding, splinting) to help manage
reflex incontinence.
◯ To avoid caffeine and alcohol consumption because
these produce diuresis and the urge to urinate.
◯ Adverse effects of medications that affect urination.
◯ Vaginal cone therapy to strengthen pelvic muscles (for
stress incontinence).
FUNDAMENTALS FOR NURSING CHAPTER 44 Urinary Elimination 247
mEDiCationS
Antibiotics
Gentamicin and cephalexin for infection
NURSING CONSIDERATIONS: Administer medication with
food to decrease gastrointestinal distress.
CLIENT EDUCATION
● Inform clients that antibiotics might change the
urine’s odor.
● Instruct clients to report loose stools.
● Tell clients to complete the full course of therapy even if
symptoms resolve.
Tricyclic antidepressants
Nortriptyline has anticholinergic effects that help relieve
urinary incontinence.
NURSING CONSIDERATIONS
● Monitor for dizziness.
● Evaluate blood pressure for orthostatic hypotension.
● Do not administer to clients taking an MAOI.
CLIENT EDUCATION: Encourage clients to get up slowly.
Urinary antispasmodics or anticholinergic agents
Oxybutynin and dicyclomine decrease urgency and help
alleviate pain from a neurogenic or overactive bladder.
NURSING CONSIDERATIONS
● Ask clients about a history of glaucoma. These
medications increase intraocular pressure.
● Monitor for dizziness, tachycardia, and urinary retention.
CLIENT EDUCATION
● Instruct clients to report dysuria, palpitations,
and constipation.
● Inform clients that dizziness and dry mouth are
common with these medications.
Phenazopyridine
This bladder analgesic treats the symptoms of UTIs.
NURSING CONSIDERATIONS
● This medication will not treat infection but will help
relieve bladder discomfort.
● Monitor for decreases in Hgb and Hct.
● Hepatic disorders and renal insufficiency
are contraindications.
CLIENT EDUCATION
● Encourage clients to take the medication with food.
● Inform clients that the medication turns urine orange.
● Instruct clients to notify the provider immediately if
their skin becomes yellowish.
Hormone replacement therapy
This is controversial, but it increases the blood supply to
the pelvis.
tHEraPEUtiC ProCEDUrES
Bladder‑retraining program
Urinary bladder retraining increases the bladder’s ability
to hold urine and clients’ ability to suppress urination.
NURSING CONSIDERATIONS
● Clients should urinate at scheduled intervals.
● Clients should gradually increase urination intervals
after no incontinence episodes for 3 days, working
toward the optimal 4‑hr intervals.
CLIENT EDUCATION
● Remind clients to hold urine until the scheduled
toileting time.
● Encourage clients to keep track of urination times.
Urinary habit training
Urinary habit training helps clients who have limited
cognitive ability to establish a predictable pattern of
bladder emptying.
NURSING CONSIDERATIONS: Clients should urinate at
scheduled intervals.
CLIENT EDUCATION
● Inform clients that urination patterns determine the
toileting schedule.
● Encourage clients to follow a toileting schedule
according to the pattern with which they have
no incontinence.
Intermittent urinary catheterization
Intermittent urinary catheterization is periodic
catheterization to empty the bladder. It reduces the
risk of infection from indwelling catheterization, which
is a temporary intervention for clients at risk for skin
breakdown, or when other options have failed.
NURSING CONSIDERATIONS
● Adjust the frequency of catheterization to keep output at
300 mL or less.
● Explain the procedure.
CLIENT EDUCATION: Encourage clients to follow a
toileting schedule according to the pattern with which
they have no incontinence.
248 CHAPTER 44 Urinary Elimination CONTENT MASTERY SERIES
Anterior vaginal repair, retropubic suspension,
pubovaginal sling, insertion of an artificial sphincter
● Catheters (suprapubic or urinary) remain until clients
have a post‑void residual of less than 50 mL. Traction
(with tape) helps prevent movement of the bladder.
● Surgeons insert suprapubic catheters into the abdomen
above the pubic bone and in the bladder and suture the
catheter in place. The care for the catheter tubing and
drainage bag is the same as for an indwelling catheter.
NURSING ACTIONS
● Monitor output and for any signs of infection (color of
urine, sediment, level of output).
● Keep the catheter patent at all times.
● Determine clients’ ability to detect the urge to urinate.
CLIENT EDUCATION
● Teach skin care around the insertion site.
● Teach care and emptying of the catheter bag.
Periurethral collagen injections to the bladder neck
CARE AFTER DISCHARGE
● To alleviate stress incontinence, consult nutritional
services for dietary modifications for clients who
are obese.
● Consult home care services to provide intermittent
catheters, portable commodes, or stool risers. Suggest
installing handrails to assist clients who have
bathroom needs.
CliEnt EDUCation
● Instruct clients to drink 2 to 3 L of fluid daily.
● Instruct clients to try to hold urine, and stay on
schedule with bladder retraining.
● Advise clients to drink cranberry juice to decrease the
risk of infection.
● Encourage clients who are obese to participate
in a weight‑reduction program to help resolve
stress incontinence.
● Instruct clients to take medications to help
resolve incontinence.
● Teach intermittent catheterization if necessary.
● Encourage clients to express their feelings
about incontinence.
COMPLICATIONS
Skin breakdown (from chronic exposure to urine)
NURSING ACTIONS
● Keep the skin clean and dry.
● Assess for signs of breakdown.
● Apply protective barrier creams.
● Implement a bladder‑retraining program.
Social isolation
NURSING ACTIONS
● Assist with measures to conceal urinary
leaking (perineal pads, external catheters, adult
incontinence garments).
● Offer emotional support.
FUNDAMENTALS FOR NURSING CHAPTER 44 Urinary Elimination 249
Application Exercises
1. a nurse in a provider’s office is
evaluating a client who reports losing
control of urine whenever she coughs,
laughs, or sneezes. the client relates
a history of three vaginal births, but
no serious accidents or illnesses.
Which of the following interventions
should the nurse suggest for helping
to control or eliminate the client’s
incontinence? (Select all that apply.)
a. limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. take calcium supplements.
D. avoid drinking alcohol.
E. Use the Credé maneuver.
2. a client who has an indwelling
catheter reports a need to
urinate. Which of the following
actions should the nurse take?
a. Check to see whether
the catheter is patent.
B. reassure the client that it is
not possible for her to urinate.
C. recatheterize the bladder
with a larger‑gauge catheter.
D. Collect a urine specimen
for analysis.
3. a nurse is caring for a client who
has a prescription for a 24‑hr urine
collection. Which of the following
actions should the nurse take?
a. Discard the first voiding.
B. Keep the urine in a single
container at room temperature.
C. ask the client to urinate
and pour the urine into
a specimen container.
D. ask the client to urinate into
the toilet, stop midstream,
and finish urinating into
the specimen container.
4. a nurse is reviewing factors
that increase the risk of
urinary tract infections (Utis) with a
client who has recurrent Utis. Which
of the following factors should the
nurse include? (Select all that apply.)
a. Frequent sexual intercourse
B. lowering of testosterone levels
C. Wiping from front to back
D. location of the urethra
in relation to the anus
E. Frequent catheterization
5. a nurse is preparing to initiate a
bladder‑retraining program for
a client who has incontinence. Which
of the following actions should the
nurse take? (Select all that apply.)
a. Establish a schedule of
urinating prior to meal times.
B. Have the client record
urination times.
C. Gradually increase the
urination intervals.
D. remind the client to
hold urine until the next
scheduled urination time.
E. Provide a sterile
container for urine.
PRACTICE Active Learning Scenario
a nurse is teaching a group of nursing students about the
various types of urinary incontinence. Use the ati active
learning template: System Disorder to complete this item.
ALTERATION IN HEALTH (DIAGNOSIS): list at least
four of the six types of urinary incontinence, along
with a brief example or description of each.
RISK FACTORS: list at least 10 common
risk factors for urinary incontinence.
250 CHAPTER 44 Urinary Elimination CONTENT MASTERY SERIES
Application Exercises Key
1. a. Because stress incontinence results from weak pelvic muscles
and other structures, limiting fluids will not resolve the problem.
B. CORRECT: Caffeine is a bladder irritant and
can worsen stress incontinence.
C. Calcium has no effect on stress incontinence.
D. CORRECT: alcohol is a bladder irritant and
can worsen stress incontinence.
E. the Credé maneuver helps manage reflex
incontinence, not stress incontinence.
NCLEX® Connection: Basic Care and Comfort, Elimination
2. a. CORRECT: a clogged or kinked catheter causes the
bladder to fill and stimulates the need to urinate.
B. reassuring the client that it is not possible to urinate is a
nontherapeutic response because it dismisses the client’s concern.
C. there are less invasive approaches the nurse
can try before replacing the catheter.
D. although it might become necessary to collect a urine
specimen, there is a simpler approach the nurse can take
to assess and possibly resolve the client’s problem.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
3. a. CORRECT: the nurse should discard the first voiding
of the 24‑hr urine specimen, and note the time.
B. the nurse should keep the urine in a refrigerated container.
C. For a urinalysis, the nurse should ask the client to
urinate and pour the urine into a specimen container.
D. For a culture specimen, the nurse should ask the
client to urinate first into the toilet, then stop midstream,
and finish urinating in the specimen container.
NCLEX® Connection: Reduction of Risk Potential, Diagnostic Tests
4. a. CORRECT: Having frequent sexual intercourse
increases the risk of Utis in both men and women.
B. the decrease in estrogen levels during menopause
increases a woman’s susceptibility to Utis.
C. Wiping from front to back decreases a woman’s risk of Utis.
D. CORRECT: the close proximity of the female urethra
to the anus is a factor that increases the risk of Utis.
E. CORRECT: Frequent catheterization and the use of
indwelling catheters are risk factors for Utis.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
5. a. Bladder training involves voiding at scheduled frequent intervals
and gradually increasing these intervals to 4 hr. meal times are
not regular, and the intervals can be longer than every 4 hr.
B. CORRECT: the nurse should ask the client to keep
track of urination times as a record of progress toward
the goal of 4‑hr intervals between urination.
C. CORRECT: Gradually increasing the urination intervals helps the
client progress toward the goal of 4‑hr intervals between urination.
D. CORRECT: the nurse should remind the client to hold urine
until the next scheduled urination time as part of progressing
toward the goal of 4‑hr intervals between urination.
E. a bladder‑retraining program does not involve
collecting sterile urine specimens.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
PRACTICE Answer
Using the ATI Active Learning Template: System Disorder
ALTERATION IN HEALTH (DIAGNOSIS)
● Stress: the loss of small amounts of urine from
increased abdominal pressure without bladder muscle
contraction with laughing, sneezing, or lifting
● Urge: the inability to stop urine flow long enough to reach the bathroom
due to an overactive detrusor muscle with increased bladder pressure
● overflow: Urinary retention from bladder overdistention and
frequent loss of small amounts of urine due to obstruction
of the urinary outlet or an impaired detrusor muscle
● reflex: the involuntary loss of a moderate amount of
urine usually without warning due to hyperreflexia of the
detrusor muscle, usually from spinal cord dysfunction
● Functional: the loss of urine due to factors that
interfere with responding to the need to urinate, such as
cognitive, mobility, and environmental barriers
● total: the unpredictable, involuntary loss of urine
that does not generally respond to treatment
RISK FACTORS
● Female gender
● History of multiple pregnancies and vaginal births, aging, chronic urinary
retention, urinary bladder spasm, renal disease, chronic bladder infection
● neurological disorders: Parkinson’s disease, cerebrovascular
accident, spinal cord injury, multiple sclerosis
● medications: diuretics, opioids, anticholinergics, calcium channel
blockers, sedative/hypnotics, adrenergic antagonists
● obesity
● Confusion, dementia, immobility, depression
● Physiological changes of aging
● Decreased estrogen levels, decreased pelvic‑muscle tone
● immobility, chronic degenerative diseases, dementia,
diabetes mellitus, cerebrovascular accident
● Urinary incontinence increasing the risk for falls,
fractures, pressure ulcers, and depression
NCLEX® Connection: Physiological Adaptation, Pathophysiology
FUNDAMENTALS FOR NURSING CHAPTER 45 SenSory PercePtion 251
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: BASIC CARE AND COMFORT
CHAPTER 45 Sensory Perception
Sensory perception is the ability to receive and
interpret sensory impressions through sight
(visual), hearing (auditory), touch (tactile), smell
(olfactory), taste (gustatory), and movement
or position (kinesthetic). Sensory input affects
consciousness, arousal, awareness, memory,
affect, judgment, awareness of reality,
and language.
A sensory deficit is a change in reception and/or
perception. Deficits can affect any of the senses.
When a sensory deficit develops gradually, the
body often compensates for the deficit.
Sensory deprivation is reduced sensory input
from the internal or external environment. it
can result from illness, trauma, or isolation.
Manifestations of sensory deprivation can
be cognitive (decreased ability to learn,
disorientation), affective (restlessness,
anxiousness), or perceptual (decreased
coordination, decreased color perception).
Sensory overload is excessive, sustained, and
unmanageable multisensory stimulation.
Manifestations are similar to those of sensory
deprivation and include racing thoughts,
anxiousness, and restlessness.
CONTRIBUTING FACTORS
Vision loss: Presbyopia, cataracts, glaucoma, diabetic
retinopathy, macular degeneration, infection,
inflammation, injury, brain tumor
Conductive hearing loss: Obstruction, wax accumulation,
tympanic membrane perforation, ear infections,
otosclerosis
Sensorineural hearing loss: Exposure to loud noises,
ototoxic medications, aging, acoustic neuroma
PATIENT‑CENTERED CARE
nUrSinG cAre
● Check for communication deficits, and adjust
care accordingly.
● Collect equipment necessary to care for any assistive
devices clients have (corrective lenses, hearing aids).
Make sure these devices are available for use.
● Make every effort to communicate with clients who
have sensoriperceptual losses because they tend to
withdraw from interactions with others.
EQUIPMENT
● Assistive devices
● Orientation tools (clocks, calendars)
● Radio, television, CD/DVD player, digital audio player
● Large‑print materials
NURSING CONSIDERATIONS
● Keep clients safe and free from injury.
◯ Make sure the call light is easily accessible.
◯ Orient clients to the room.
◯ Keep furniture clear from the path to the bathroom.
◯ Keep personal items within reach.
◯ Place the bed in its lowest position.
◯ Make sure IV poles, drainage tubes, and bags are easy
to maneuver.
● Learn clients’ preferred method of communication, and
make accommodations.
● FOR CLIENTS WHO HAVE HEARING LOSS
◯ Sit and face the clients.
◯ Avoid covering your mouth while speaking.
◯ Encourage the use of hearing devices.
◯ Speak slowly and clearly.
◯ Do not shout.
◯ Try lowering vocal pitch before increasing volume.
◯ Use brief sentences with simple words.
◯ Write down what clients do not understand.
◯ Minimize background noise.
◯ Ask for a sign‑language interpreter if necessary.
◯ Do not shout.
● FOR CLIENTS WHO HAVE VISION LOSS
◯ Call clients by name before approaching to avoid
startling them.
◯ Identify yourself.
◯ Stay within clients’ visual field if they have a
partial loss.
◯ Give specific information about the location of items
or areas of the building.
◯ Explain interventions before touching clients.
◯ Before leaving, inform clients of your departure.
◯ Carefully appraise clients’ clothing, and suggest
changes if soiled or torn.
◯ Make a radio, television, CD player, or digital audio
player available.
◯ Describe the arrangement of the food on the tray
before leaving the room.
CHAPTER 45
252 CHAPTER 45 SenSory PercePtion CONTENT MASTERY SERIES
● FOR CLIENTS WHO HAVE APHASIA
◯ Greet clients, and call them by name.
◯ Make sure only one person speaks at a time.
◯ Speak clearly and slowly using short sentences and
simple words.
◯ Do not shout.
◯ Pause between statements to allow time for clients
to understand.
◯ Check for comprehension.
◯ Tell clients when you do not understand them.
◯ Ask questions that require simple answers.
◯ Reinforce verbal with nonverbal communication
(gestures, body language).
◯ Allow plenty of time for clients to respond.
◯ Use methods speech therapists implement, such as a
picture chart, to improve communication.
◯ Acknowledge any frustration in communicating.
● FOR CLIENTS WHO ARE DISORIENTED
◯ Call clients by name, and identify yourself.
◯ Maintain eye contact at eye level.
◯ Use brief, simple sentences.
◯ Ask only one question at a time.
◯ Allow plenty of time for clients to respond.
◯ Give directions one step at a time.
◯ Avoid lengthy conversations.
◯ Provide for adequate sleep and pain management.
● Encourage clients to verbalize feelings about
sensoriperceptual loss.
● Orient clients to time, person, place, and situation.
◯ Keep a clock in the room.
◯ Post a calendar, or write the date where it is visible.
● Provide and use assistive devices.
● Provide care clients cannot perform (reading menus,
opening containers).
interProFeSSionAL cAre
● Determine which assistive devices clients need, and
plan for their procurement.
● Consult with rehabilitation therapists for
restorative potential.
● Refer clients to community‑based support groups and
organizations for additional resources.
COMPLICATIONS
Risk for injury in the home environment
Teach ways to reduce hazards at home.
VISUAL
● Remove throw rugs to prevent tripping hazards.
● Keep walking pathways clear.
● Ensure that stairways are well lit with secure handrails.
AUDITORY: Use flashing lights vs. a warning sound for
alarms and doorbells.
OLFACTORY: Make sure smoke and carbon monoxide
detectors are functioning to sense odors and odorless
gases (burning food, natural gas, carbon monoxide).
GUSTATORY: Read expiration dates on food packages to
avoid consuming contaminated or spoiled food products.
TACTILE: Protect and inspect body parts that lack
sensation (burns, pressure ulcers, frostbite). Avoid the
use of hot water bottles; label faucets “hot” and “cold”
with words or colors; and set hot water heaters to avoid
excessively hot water. Sources vary, but an upper limit of
48.8° C (120° F) is generally acceptable.
Sensory deprivation and overload
Minimize overall stimuli and provide meaningful
stimulation.
● Provide a private room.
● Minimize glare.
● Manage pain effectively.
● Allow for adequate sleep and rest periods.
● Provide large‑print materials or electronic players for
audio books.
● Amplify phones.
● Season foods.
● Reduce unpleasant odors.
● Provide pleasant aromas.
● Increase touch (if acceptable) with back rubs, hand
holding, range‑of‑motion exercises, and hair care.
● Organize care to minimize the activity surrounding the
bed when possible.
FUNDAMENTALS FOR NURSING CHAPTER 45 SenSory PercePtion 253
Vision loss
● Visual acuity is the degree of detail clients can perceive
in an image.
● Reduced visual acuity can be unilateral (one eye) or
bilateral (both eyes).
HEALTH PROMOTION AND
DISEASE PREVENTION
● Advise clients to wear sunglasses while outside and
protective eyewear while working in areas and at tasks
with a risk for eye injury.
● Instruct clients to avoid rubbing eyes.
● Tell clients to get an eye examination regularly,
especially after age 40.
ASSESSMENT/DATA COLLECTION
riSK FActorS
● Age is the most significant risk factor for visual sensory
alterations.
● Eye infection, inflammation, or injury
● Brain tumor
Presbyopia: Age‑related loss of
the eye’s ability to focus on close
objects due to decreased elasticity
of the lens
Cataracts: Opacity of the lens,
which blocks the entry of light rays
into the eye
Glaucoma: Structural damage
within the eye resulting from
elevated pressure within the eye
leading to blindness
Diabetic retinopathy:
Noninflammatory changes in
the eye’s blood vessels leading
to blindness
Macular degeneration: Loss of
central vision from deterioration of
the center of the retina
eXPecteD FinDinGS
● Frequent headaches
● Frequent eye strain
● Blurred vision
● Poor judgment of depth
● Diplopia: double vision
● Tendency to close or favor one eye
● Poor hand‑eye coordination
DiAGnoStic ProceDUreS
Ophthalmoscopy: Allows visualization of the back part
of the eyeball (fundus), including the retina, optic disc,
macula, and blood vessels
Visual acuity tests: Snellen and Rosenbaum eye charts
Tonometry: Measures intraocular pressure (expected
range 10 to 21 mm Hg), which is elevated with glaucoma,
especially angle‑closure glaucoma
Gonioscopy: Allows visualization of the iridocorneal angle
or anterior chamber of the eyes
Slit lamp examination: Allows visualization of the
anterior portion of the eye, such as the cornea, anterior
chamber, and lens
Online Image: Intraocular Pressure
45.1 Intraocular pressure
254 CHAPTER 45 SenSory PercePtion CONTENT MASTERY SERIES
PATIENT‑CENTERED CARE
nUrSinG cAre
● Monitor the following.
◯ Visual acuity using Snellen and Rosenbaum eye charts.
■ Both measure distance vision.
■ The Snellen method has clients stand 20 ft away.
■ The Rosenbaum method has clients hold the chart
14 inches away from their eyes.
◯ External and internal eye structures
(ophthalmoscope)
◯ Functional ability
● Assess how clients adapt to the environment to
maintain safety.
◯ Increase the amount of light in a room.
◯ Arrange the home to remove hazards, such as
eliminating throw rugs.
◯ Use phones with large numbers and auto dial.
● Suggest adaptive devices that accommodate for
reduced vision.
◯ Magnifying lens and large‑print books and
newspapers
◯ Talking devices, such as clocks and watches
MeDicAtionS
Anticholinergics
Anticholinergics, such as atropine ophthalmic solution,
provide mydriasis (dilation of the pupil) and cycloplegia
(ciliary paralysis) for examinations and surgery.
CLIENT EDUCATION: Adverse effects include reduced
accommodation, blurred vision, and photophobia. With
systemic absorption, there could be anticholinergic effects
(tachycardia, decreased secretions).
cLient eDUcAtion
● Wash hands before and after instilling eye medication.
● Quit smoking.
● Limit alcohol intake.
● Keep blood pressure, blood glucose, and cholesterol
under control.
● Eat foods rich in antioxidants, such as green
leafy vegetables.
CARE AFTER DISCHARGE: Initiate referrals to social
services, support groups, and reduced‑vision resources.
COMPLICATIONS
Risk for injury
Reduced vision increases injury risk, especially for
older adults.
NURSING ACTIONS: Monitor for safety risks, such as the
ability to drive safely, and intervene to reduce risks.
Hearing loss
Hearing loss is difficulty in hearing or interpreting speech
and other sounds due to a problem in the middle or
inner ear.
Conductive hearing loss is an alteration in the middle ear
that blocks sound waves before they reach the cochlea of
the inner ear.
Sensorineural hearing loss is an alteration in the inner
ear, auditory nerve, or hearing center of the brain.
Mixed hearing loss is a combination of conductive and
sensorineural hearing loss.
HEALTH PROMOTION AND
DISEASE PREVENTION
● Advise clients not to place any objects in the ear,
including cotton‑tipped swabs.
● Tell clients to have an otologist remove any object
lodged in the ear. Use a commercial ceruminolytic (ear
drops that soften cerumen) for impactions, and follow
with warm‑water irrigation.
● Instruct clients to wear ear protection during exposure
to high‑intensity noise and risk for ear trauma.
● Tell clients to blow the nose gently and with both
nostrils unobstructed.
● Advise clients to keep the volume as low as possible
when wearing headphones.
ASSESSMENT/DATA COLLECTION
riSK FActorS
● Advancing age
● Use of ototoxic medications (aminoglycosides,
monobactams)
Conductive hearing loss
● History of middle ear infections
● Older age (otosclerosis)
Sensorineural hearing loss
● Prolonged exposure to loud noises
● Ototoxic medications
● Infectious processes
● Older age (presbycusis: decreased ability to hear
high‑pitched sounds)
Online Image: External, Middle, and Internal Ear
FUNDAMENTALS FOR NURSING CHAPTER 45 SenSory PercePtion 255
eXPecteD FinDinGS
Conductive hearing loss
● Hears better in a noisy environment
● Speaks softly
● Obstruction in external canal (packed cerumen)
● Tympanic membrane findings (holes, scarring)
● Rinne test that demonstrates air conduction of sound
less than or equal to bone conduction (AC ≤ BC)
● Weber test that lateralizes to the affected ear
Sensorineural hearing loss
● Tinnitus (ringing, roaring, humming in ears)
● Dizziness
● Hears poorly in a noisy environment
● Speaks loudly
● No otoscopic findings
● Rinne test that demonstrates expected response of air
conduction being greater than bone conduction (AC > BC),
but with length of time decreased for both
● Weber test lateralizing to unaffected ear
● Diagnosis of acoustic neuroma (benign tumor cranial
nerve VIII)
DiAGnoStic ProceDUreS
Audiometry
An audiogram identifies whether hearing loss is
sensorineural and/or conductive.
NURSING CONSIDERATIONS
● Use audiometry when screening
for hearing loss in a school
or older adult setting (after
specific training to perform this
procedure). Results are more
accurate in a quiet room.
● Assess clients’ ability to hear
various frequencies (high vs. low
pitch) at various decibels (soft vs.
loud tones).
● Have clients wear audiometer
headphones and face away from
the examiner.
● Have clients indicate when they
hear a tone and in which ear
by raising their hand on the
corresponding side. Comparing
the responses on a graph with
expected age and other norms
yields information about the type
and degree of hearing loss.
Tympanogram
A tympanogram measures the mobility of the tympanic
membrane and middle ear structures relative to sound to
diagnose disorders of the middle ear.
Otoscopy
An otoscope allows visualization of the external auditory
canal, the tympanic membrane (TM), and malleus bone
visible through the TM.
NURSING CONSIDERATIONS
● Perform an otoscopic examination when audiometry
results indicate a possible impairment or for ear pain.
● Select a speculum according to the size of the ear, then
attach it and insert the otoscope into the external ear.
● If the ear canal curves, pull up and back on the auricle
of adults and down and back on the auricle of children
younger than 3 years to straighten out the canal and
enhance visualization.
● The tympanic membrane should be pearly gray and
intact. It should provide complete structural separation
of the outer and middle ear structures.
● The light reflex should be visible from the center of the
TM anteriorly (5 o’clock right ear; 7 o’clock left ear).
● With fluid or infection in the middle ear, the tympanic
membrane will become inflamed and can bulge from
the pressure of the exudate. This also will displace the
light reflex, a significant finding.
● Avoid touching the lining of the ear canal, which causes
pain due to sensitivity.
Online Videos: Rinne and Weber Tests; Otoscopic Examination
Online Image: Light Reflex
45.2 External, middle, and internal ear
256 CHAPTER 45 SenSory PercePtion CONTENT MASTERY SERIES
PATIENT‑CENTERED CARE
nUrSinG cAre
● Monitor functional ability.
● Check the hearing of clients receiving ototoxic
medications for more than 5 days. Reduced renal
function that occurs with aging increases the risk
for ototoxicity.
Ototoxic medications
● Antibiotics: gentamicin, metronidazole
● Diuretics: furosemide
● NSAIDs: aspirin, ibuprofen
● Chemotherapeutic agents: cisplatin
Communication
● Get clients’ attention before speaking.
● Stand or sit facing clients in a well‑lit, quiet room
without distractions.
● Speak clearly and slowly without shouting and without
hands or other objects covering the mouth.
● Arrange for communication assistance (sign‑language
interpreter, closed-captions, phone amplifiers,
teletypewriter [TTY] capabilities).
interProFeSSionAL cAre
Refer clients who have audiometry findings to an
audiologist for more sensitive testing.
tHerAPeUtic ProceDUreS
Hearing aids
● Hearing aids amplify sounds, but do not help clients
interpret what they hear.
● Amplification of sound in a loud environment can be
distracting and disturbing.
CLIENT EDUCATION
● Use the lowest setting that allows hearing
without feedback.
● To clean the ear mold, use mild soap and water while
keeping the hearing aid dry.
● When the hearing aid is not in use, turn it off or remove
the batteries to conserve battery power. Keep
replacement batteries on hand.
Tympanoplasty and myringoplasty
For conductive hearing loss
● Tympanoplasty is a surgical reconstruction of the
middle ear structures
● Myringoplasty is an eardrum repair.
NURSING ACTIONS
● Place sterile ear packing postoperatively.
● Position clients flat with the operative ear facing
up for 12 hr.
CLIENT EDUCATION
● Tell clients to avoid air travel and forceful straining,
coughing, or sneezing with the mouth closed.
● Teach clients to cover the ear with a dressing before
washing hair and not to allow water to enter the ear.
● Remind clients that they will hear less while packing is
in the ear.
45.3 Light reflex
FUNDAMENTALS FOR NURSING CHAPTER 45 SenSory PercePtion 257
Application Exercises
1. A nurse is caring for a client who
recently had a cerebrovascular
accident and has aphasia. Which of
the following interventions should the
nurse use to promote communication
with this client? (Select all that apply.)
A. increase the volume
of your voice.
B. Make sure only one
person speaks at a time.
c. Avoid discouraging the
client by saying that you
do not understand him.
D. Allow plenty of time for
the client to respond.
e. Use brief sentences
with simple words.
2. A nurse is caring for a client who
had an amphetamine overdose
and has sensory overload. Which
of the following interventions
should the nurse implement?
A. immediately complete a
thorough assessment.
B. Put the client in a room with a
client who has a hearing loss.
c. Provide a private room,
and limit stimulation.
D. Speak at a higher
volume to the client, and
encourage ambulation.
3. A nurse is caring for a client who
reports difficulty hearing. Which of
the following assessment findings
indicate a sensorineural hearing loss
in the left ear? (Select all that apply.)
A. Weber test showing
lateralization to the right ear
B. Light reflex at 10 o’clock
in the left ear
c. indications of obstruction
in the left ear canal
D. rinne test showing less time
for air and bone conduction
e. rinne test showing air
conduction less than bone
conduction in the left ear
4. A nurse is caring for a client who has
several risk factors for hearing loss.
Which of the following medications,
that the client currently takes, should
alert the nurse to a further risk for
ototoxicity? (Select all that apply.)
A. Furosemide
B. ibuprofen
c. cimetidine
D. Simvastatin
e. Amiodarone
5. A nurse is reviewing instructions
with a client who has a hearing
loss and has just started wearing
hearing aids. Which of the following
statements should the nurse identify
as an indication that the client
understands the instructions?
A. “i use a damp cloth to
clean the outside part
of my hearing aids.”
B. “i clean the ear molds
of my hearing aids with
rubbing alcohol.”
c. “i keep the volume of my
hearing aids turned up
so i can hear better.”
D. “i take the batteries out of
my hearing aids when i
take them off at night.”
PRACTICE Active Learning Scenario
A nurse is teaching a group of nursing students how to intervene
for clients who have sensory impairment. Use the Ati Active
Learning template: System Disorder to complete this item.
NURSING CARE
● List at least six interventions for clients who have hearing loss.
● List at least six interventions for clients who have vision loss.
258 CHAPTER 45 SenSory PercePtion CONTENT MASTERY SERIES
Application Exercises Key
1. A. the nurse should speak in a normal tone of voice to a client
who had a stroke and has aphasia to promote communication.
B. CORRECT: trying to understand more than
one voice at a time is challenging.
c. Feigning understanding shows a lack of respect for the
client’s needs and blocks further communication.
D. CORRECT: Allowing ample time for the client to respond
helps enhance communication. rushing ahead to the next
question would be demeaning and could cause frustration.
e. CORRECT: Brief sentences with simple words
are generally easiest to understand.
NCLEX® Connection: Psychosocial Integrity,
Therapeutic Communication
2. A. immediately completing a thorough assessment might overwhelm
the client at this time. Brief assessments throughout the shift are better.
B. rooming with a client who has a hearing loss
would increase environmental stimuli.
c. CORRECT: Minimizing stimuli helps clients who have sensory overload.
D. talking at a higher volume would increase environmental stimuli.
NCLEX® Connection: Basic Care and Comfort, Assistive Devices
3. A. CORRECT: With sensorineural hearing loss, the Weber
test demonstrates lateralization to the unaffected ear.
B. A light reflex at 10 o’clock in the left ear indicates that
air or fluid has displaced the tympanic membrane, but
it does not indicate sensorineural hearing loss.
c. indications of obstruction in the ear canal
would indicate conductive hearing loss.
D. CORRECT: With sensorineural hearing loss in the left ear,
length of time is decreased for both air and bone conduction.
e. With sensorineural hearing loss in the left ear, air conduction
is greater than bone conduction in the left ear.
NCLEX® Connection: Safety and Infection Control,
Accident/Error/Injury Prevention
4. A. CORRECT: Furosemide, a loop diuretic, can
cause hearing loss as well as blurred vision.
B. CORRECT: ibuprofen, a nonsteroidal anti‑inflammatory
agent, can cause hearing loss as well as vision loss.
c. cimetidine, a medication that decreases gastric
acid secretion, is unlikely to cause hearing loss.
D. Simvastatin, a medication that helps lower
cholesterol, is unlikely to cause hearing loss.
e. Amiodarone, an antidysrhythmic medication, is more
likely to cause blurred vision than hearing loss.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
5. A. the client should keep the hearing aids completely dry at all times.
B. the client should clean the ear molds with mild soap and water.
c. to avoid feedback, the client should keep the volume
on the lowest setting that allows her to hear.
D. CORRECT: to conserve battery power, the client should turn
off the hearing aids and remove the batteries when not in use.
NCLEX® Connection: Psychosocial Integrity,
Sensory/Perceptual Alterations
PRACTICE Answer
Using the ATI Active Learning Template: System Disorder
NURSING CARE
Hearing loss
● Sit and face the client.
● Avoid covering your mouth while speaking.
● encourage the use of hearing devices.
● Speak slowly and clearly.
● Do not shout.
● try lowering vocal pitch before increasing volume.
● Use brief sentences with simple words.
● Write down what clients do not understand.
● Minimize background noises.
● Ask for a sign‑language interpreter if necessary.
Vision loss
● call clients by name before approaching to avoid startling them.
● identify yourself.
● Stay within the clients’ visual field if they have a partial loss.
● Give specific information about the location
of items or areas of the building.
● explain interventions before touching clients.
● Before leaving, inform clients of your departure.
● carefully appraise clothing and suggest changes if soiled or torn.
● Make a radio, television, cD player, or digital audio player available.
● Describe the arrangement of the food on
the tray before leaving the room.
NCLEX® Connection: Psychosocial Integrity, Sensory/Perceptual Alterations
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 259
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Management of Care
CLIENT RIGHTS: Recognize the client’s right
to refuse treatment/procedures.
CONTINUITY OF CARE: Use approved abbreviations
and standard terminology when documenting care.
Client Needs: Safety and Infection Control
ACCIDENT/ERROR/INJURY PREVENTION: Ensure
proper identification of client when providing care.
Client Needs: Pharmacological and Parenteral Therapies
DOSAGE CALCULATION: Perform calculations
needed for medication administration.
EXPECTED ACTIONS/OUTCOMES: Obtain
information on a client’s prescribed medications.
MEDICATION ADMINISTRATION: Prepare and administer
medications, using rights of medication administration.
FUNDAMENTALS FOR NURSING CHAPTER 46 Pharmacokinetics and routes of administration 261
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
CHAPTER 46 Pharmacokinetics
and Routes of
Administration
Pharmacokinetics refers to how medications
travel through the body. medications undergo
a variety of biochemical processes that result
in absorption, distribution, metabolism,
and excretion.
PHASES OF PHARMACOKINETICS
Absorption
The transmission of medications from the location of
administration (gastrointestinal [GI] tract, muscle, skin,
or subcutaneous tissue) to the bloodstream. The most
common routes of administration are enteral (through the
GI tract) and parenteral (by injection). Each of these routes
has a unique pattern of absorption.
● The rate of medication absorption determines how soon
the medication takes effect.
● The amount of medication the body absorbs determines
its intensity.
● The route of administration affects the rate and amount
of absorption.
Route: Oral
● BARRIERS TO ABSORPTION: Medications must pass
through the layer of epithelial cells that line the GI tract.
● ABSORPTION PATTERN varies greatly due to
◯ Stability and solubility of the medication
◯ Gastrointestinal pH and emptying time
◯ Presence of food in the stomach or intestines
◯ Concurrent medications
◯ Forms of medications (enteric‑coated pills, liquids)
Route: Subcutaneous and intramuscular
● BARRIERS TO ABSORPTION: The capillary walls have
large spaces between cells. Therefore, there is no
significant barrier.
● ABSORPTION PATTERN factors determining the rate
of absorption
◯ Solubility of the medication in water
■ Highly soluble medications have rapid absorption
(10 to 30 min).
■ Poorly soluble medications have slow absorption.
◯ Blood perfusion at the site of injection
■ Sites with high blood perfusion have rapid absorption.
■ Sites with low blood perfusion have slow absorption.
Route: Intravenous
● BARRIERS TO ABSORPTION: No barriers
● ABSORPTION PATTERN
◯ Immediate: enters directly into the blood
◯ Complete: reaches the blood in its entirety
Distribution
The transportation of medications to sites of action by
bodily fluids.
FACTORS INFLUENCING DISTRIBUTION
● Circulation: Conditions that inhibit blood flow or
perfusion, such as peripheral vascular or cardiac disease,
can delay medication distribution.
● Permeability of the cell membrane: The medication
must be able to pass through tissues and membranes to
reach its target area. Medications that are lipid‑soluble
or have a transport system can cross the blood‑brain
barrier and the placenta.
● Plasma protein binding: Medications compete for
protein binding sites within the bloodstream, primarily
albumin. The ability of a medication to bind to a protein
can affect how much of the medication will leave and
travel to target tissues. Two medications can compete
for the same binding sites, resulting in toxicity.
Metabolism (biotransformation)
Changes medications into less active forms or inactive
forms by the action of enzymes. This occurs primarily
in the liver, but also takes place in the kidneys, lungs,
intestines, and blood.
FACTORS INFLUENCING MEDICATION METABOLISM RATE
● Age: Infants have a limited medication‑metabolizing
capacity. The aging process also can influence
medication metabolism, but varies with the individual.
In general, hepatic medication metabolism tends to
decline with age. Older adults require smaller doses of
medications due to the possibility of accumulation in
the body.
● An increase in some medication-metabolizing
enzymes: This can metabolize a particular medication
sooner, requiring an increase in dosage of that
medication to maintain a therapeutic level. It can
also cause an increase in the metabolism of other
concurrent‑use medications.
● First‑pass effect: The liver inactivates some
medications on their first pass through the liver. Thus,
they require a nonenteral route (sublingual, IV) because
of their high first-pass effect.
● Similar metabolic pathways: When the same
pathway metabolizes two medications, it can alter the
metabolism of one or both of them. In this way, the
rate of metabolism can decrease for one or both of the
medications, leading to medication accumulation.
● Nutritional status: Clients who are malnourished can
be deficient in the factors that are necessary to produce
specific medication-metabolizing enzymes, thus
impairing medication metabolism.
Excretion
The elimination of medications from the body, primarily
through the kidneys. Elimination also takes place through
the liver, lungs, intestines, and exocrine glands (such as in
breast milk). Kidney dysfunction can lead to an increase in
the duration and intensity of a medication’s response.
CHAPTER 46
262 CHAPTER 46 Pharmacokinetics and routes of administration CONTENT MASTERY SERIES
MEDICATION RESPONSES
● Medication dosing attempts to regulate medication
responses to maintain plasma levels between the
minimum effective concentration (MEC) and the
toxic concentration.
● A plasma medication level is in the therapeutic
range when it is effective and not toxic. Nurses use
therapeutic levels of many medications to monitor
clients’ responses.
THERAPEUTIC INDEX (TI)
Medications with a high TI have a wide safety
margin; therefore, there is no need for routine serum
medication‑level monitoring. Medications with a low
TI require close monitoring of serum medication levels.
Nurses should consider the route of administration when
monitoring for peak levels (highest plasma level when
elimination = absorption).
● For example, an oral medication can peak from 1 to 3 hr
after administration.
● If the route is IV, the peak time might occur within
10 min.
● Refer to a medication reference or a pharmacist for
specific medication peak times.
● For trough levels, obtain a blood sample immediately
before the next medication dose, regardless of the route
of administration.
● A plateau is a medication concentration in plasma
during a series of doses.
HALF‑LIFE (t1/2)
The time for the medication in the body to drop by
50%. Liver and kidney function affect half-life. It
usually takes four half‑lives to achieve a steady state of
serum concentration (medication intake = medication
metabolism and excretion).
Short half‑life Long half‑life
medications
leave the body
quickly: 4 to 8 hr.
medications leave the body more slowly:
over more than 24 hr, with a greater risk
for medication accumulation and toxicity.
short‑dosing
interval or
mec drops
between doses.
can give medications at longer intervals
without a loss of therapeutic effects.
medications take a longer time
to reach a steady state.
PHARMACODYNAMICS
(MECHANISM OF ACTION)
The interactions between medications and target cells,
body systems, and organs to produce effects. These
interactions result in functional changes that are the
mechanism of action of the medication.
Agonist: Medication that can mimic the receptor activity
that endogenous compounds regulate. For example,
morphine is an agonist because it activates the receptors
that produce analgesia, sedation, constipation, and other
effects. (Receptors are the medication’s target sites on or
within the cells.)
Antagonist: Medication that can block the usual receptor
activity that endogenous compounds regulate or the
receptor activity of other medications. For example,
losartan, an angiotensin II receptor blocker, is an
antagonist. It works by blocking angiotensin II receptors
on blood vessels, which prevents vasoconstriction.
Partial agonists: Medication that acts as an agonist and
an antagonist, with limited affinity to receptor sites. For
example, nalbuphine acts as an antagonist at mu receptors
and an agonist at kappa receptors, causing analgesia at
low doses with minimal respiratory depression.
ROUTES OF ADMINISTRATION
Oral or enteral
Tablets, capsules, liquids, suspensions, elixirs, lozenges
● Most common route
● Least expensive
● Convenient
NURSING CONSIDERATIONS
● Contraindications for oral medication administration
include vomiting, decreased GI motility, absence of a
gag reflex, difficulty swallowing, and a decreased level
of consciousness.
● Have clients sit upright at a 90° angle to facilitate
swallowing.
● Administer irritating medications, such as analgesics,
with small amounts of food.
● Do not mix with large amounts of food or beverages in
case clients cannot consume the entire quantity.
● Avoid administration with interacting foods or
beverages such as grapefruit juice.
● In general, administer oral medications on an empty
stomach (30 min to 1 hr before meals, 2 hr after meals).
● Follow the manufacturer’s directions for crushing,
cutting, and diluting medications. Break or cut scored
tablets only.
● Make sure clients swallow enteric‑coated or
time‑release medications whole.
● Use a liquid form of the medication to facilitate
swallowing whenever possible.
FUNDAMENTALS FOR NURSING CHAPTER 46 Pharmacokinetics and routes of administration 263
Sublingual and buccal
Directly enters the bloodstream and bypasses the liver
● Sublingual: under the tongue
● Buccal: between the cheek and the gum
NURSING CONSIDERATIONS
● Instruct clients to keep the medication in place until
complete absorption occurs.
● Clients should not eat or drink while the tablet is in
place or until it has completely dissolved.
Liquids, suspensions, and elixirs
NURSING CONSIDERATIONS
● Follow directions for dilution and shaking.
● When administering the medication, pour it into a cup
on flat surface. Make sure the base of the meniscus
(lowest fluid line) is at the level of the dose.
Transdermal
Medication in a skin patch for absorption through the
skin, producing systemic effects
CLIENT EDUCATION
● Apply patches as prescribed to ensure proper dosing.
● Wash the skin with soap and water, and dry it
thoroughly before applying a new patch.
● Place the patch on a hairless area and rotate sites to
prevent skin irritation.
Topical
● Painless
● Limited adverse effects
NURSING CONSIDERATIONS
● Apply with a glove, tongue blade, or
cotton‑tipped applicator.
● Do not apply with a bare hand.
Instillation (drops, ointments, sprays)
Generally used for eyes, ears, and nose
Eyes
NURSING CONSIDERATIONS
● Use medical aseptic technique when instilling
medications in eyes.
● Have clients sit upright or lie supine, tilt their head
slightly, and look up at the ceiling.
● Rest your dominant hand on the clients’ forehead, hold
the dropper above the conjunctival sac about 1 to 2 cm,
drop the medication into the center of the sac, avoid
placing it directly on the cornea, and have them close
the eye gently. If they blink during installation, repeat
the procedure.
● Apply gentle pressure with your finger and a clean facial
tissue on the nasolacrimal duct for 30 to 60 seconds to
prevent systemic absorption of the medication.
● If instilling more than one medication in the same eye,
wait at least 5 minutes between them.
● For eye ointment, apply a thin ribbon to the edge of the
lower eyelid from the inner to the outer canthus.
Ears
NURSING CONSIDERATIONS
● Use medical aseptic technique when administering
medications into the ears.
● Have clients sit upright or lie on their side.
● Straighten the ear canal by pulling the auricle upward
and outward for adults or down and back for children.
Hold the dropper 1 cm above the ear canal, instill the
medication, and then gently apply pressure with your
finger to the tragus of the ear unless it is too painful.
● Do not press a cotton ball deep into the ear canal. If
necessary, gently place it into the outermost part of the
ear canal.
● Have clients remain in the side‑lying position if
possible for 2 to 3 min after installation of ear drops.
Nose
NURSING CONSIDERATIONS
● Use medical aseptic technique when administering
medications into the nose.
● Have clients lie supine with their head positioned to allow
the medication to enter the appropriate nasal passage.
● Use your dominant hand to instill the drops, supporting
the head with your nondominant hand.
● Instruct clients to breathe through the mouth, stay in a
supine position, and not to blow the nose for 5 min after
drop instillation.
Inhalation
Administered through metered‑dose inhalers (MDI) or
dry‑powder inhalers (DPI)
MDI
CLIENT INSTRUCTIONS
● Remove the cap from the inhaler’s mouthpiece.
● Shake the inhaler vigorously five or six times.
● Hold the inhaler with the mouthpiece at the bottom.
● Hold the inhaler with your thumb near the mouthpiece
and your index and middle fingers at the top.
● Hold the inhaler about 2 to 4 cm (1 to 2 in) away from
the front of your mouth or close your mouth around the
mouthpiece of the inhaler with the opening pointing
toward the back of your throat.
● Take a deep breath, and then exhale.
● Tilt your head back slightly, press the inhaler, and, at
the same time, begin a slow, deep inhalation breath.
Continue to breathe slowly and deeply for 3 to 5 seconds
to facilitate delivery to the air passages.
● Hold your breath for 10 seconds to allow the medication
to deposit in your airways.
● Take the inhaler out of your mouth and slowly exhale
through pursed lips.
● Resume normal breathing.
● A spacer keeps the medication in the device longer,
thereby increasing the amount of medication the device
delivers to the lungs and decreasing the amount of
medication in the oropharynx.
● For clients who use a spacer
◯ Remove the covers from the mouthpieces of the
inhaler and of the spacer.
◯ Insert the MDI into the end of the spacer.
◯ Shake the inhaler five or six times.
◯ Exhale completely, and then close your mouth around
the spacer’s mouthpiece. Continue as with an MDI.
264 CHAPTER 46 Pharmacokinetics and routes of administration CONTENT MASTERY SERIES
DPI
CLIENT INSTRUCTIONS
● Do not shake the device.
● Take the cover off the mouthpiece.
● Follow the manufacturer’s directions for preparing the
medication, such as turning the wheel of the inhaler or
loading a medication pellet.
● Exhale completely.
● Place the mouthpiece between your lips and take a deep
inhalation breath through your mouth.
● Hold your breath for 5 to 10 seconds.
● Take the inhaler out of your mouth and slowly exhale
through pursed lips.
● Resume normal breathing.
● Clients who need more than one puff should wait
the length of time the provider specifies before
self-administering the second puff.
● Instruct clients to rinse their mouth out with water or
brush their teeth if using a corticosteroid inhaler to
reduce the risk of fungal infections of the mouth.
● Instruct clients to remove the canister and rinse the
inhaler, cap, and spacer once a day with warm running
water and dry them completely before using the
inhaler again.
Nasogastric and gastrostomy tubes
NURSING CONSIDERATIONS
● Verify proper tube placement.
● Use a syringe and allow the medication to flow in by
gravity or push it in with the plunger of the syringe.
GENERAL GUIDELINES
● Use liquid forms of medications; if not available,
consider crushing medications if appropriate
guidelines allow.
● Do not administer sublingual medications.
● Do not crush specially prepared oral medications
(extended/time-release, fluid-filled, enteric-coated).
● Administer each medication separately.
● Do not mix medications with enteral feedings.
● Completely dissolve crushed tablets and capsule
contents in 15 to 30 mL of sterile water prior
to administration.
● To prevent clogging, flush the tubing before and after
each medication with 15 to 30 mL water.
● Flush with another 15 to 30 mL sterile water after
instilling all the medications.
Suppositories
NURSING CONSIDERATIONS
● Follow the manufacturer’s directions for storage.
● Wear gloves for the procedure.
● Remove the wrapper, and lubricate the suppository
if necessary.
Rectal suppositories (thin, bullet-shaped medication)
NURSING CONSIDERATIONS
● Position clients in the left lateral or Sims’ position.
● Insert the suppository just beyond the internal sphincter.
● Instruct clients to remain flat or in the left lateral
position for at least 5 min after insertion to retain the
suppository. Absorption times vary with the medication.
Vaginal suppositories
NURSING CONSIDERATIONS
● Position clients supine with their knees bent and their
feet flat on the bed and close to their hips (modified
lithotomy or dorsal recumbent position).
● Use the applicator, if available.
● Insert the suppository along the posterior wall of the
vagina 7.5 to 10 cm (3 to 4 in).
● Instruct clients to remain supine for at least 5 min after
insertion to retain the suppository.
● If using an applicator, wash it with soap and water. (If it
is disposable, discard it.)
Parenteral
NURSING CONSIDERATIONS
● The vastus lateralis is best for infants 1 year
and younger.
● The ventrogluteal site is preferable for IM injections and
for injecting volumes exceeding 2 mL.
● The deltoid site has a smaller muscle mass and can only
accommodate up to 1 mL of fluid.
● Use a needle size and length appropriate for the type
of injection and the client’s size. Syringe size should
approximate the volume of medication.
● Use a tuberculin syringe for solution volumes less than
0.5 mL.
● Rotate injection sites to enhance medication absorption,
and document each site.
● Do not use injection sites that are edematous, inflamed,
or have moles, birthmarks, or scars.
● For IV administration, immediately monitor clients for
therapeutic and adverse effects.
● Discard all sharps (broken ampule bottles, needles) in
leak‑ and puncture‑proof containers.
Intradermal
NURSING CONSIDERATIONS
● Use for tuberculin testing or checking for medication or
allergy sensitivities.
● Use small amounts of solution (0.01 to 0.1 mL) in a
tuberculin syringe with a fine-gauge needle (26- to
27‑gauge) in lightly pigmented, thin‑skinned, hairless
sites (the inner surface of the mid‑forearm or scapular
area of the back) at a 10° to 15° angle.
● Insert the needle with the bevel up. A small bleb
should appear.
● Do not massage the site after injection.
Subcutaneous
NURSING CONSIDERATIONS
● Use for small doses of nonirritating, water‑soluble
medications, such as insulin and heparin.
● Use a 3⁄8‑ to 5⁄8‑inch, 25‑ to 27‑gauge needle or a 28‑ to
31‑gauge insulin syringe. Inject no more than 1.5 mL
of solution.
● Select sites that have an adequate fat‑pad size (abdomen,
upper hips, lateral upper arms, thighs).
● For average‑size clients, pinch up the skin and inject at
a 45° to 90° angle. For clients who are obese, use a
90° angle.
FUNDAMENTALS FOR NURSING CHAPTER 46 Pharmacokinetics and routes of administration 265
Intramuscular
NURSING CONSIDERATIONS
● Use for irritating medications, solutions in oils, and
aqueous suspensions.
● The most common sites are ventrogluteal, deltoid, and
vastus lateralis (pediatric). The dorsogluteal is no longer
recommended as a common injection site due to its
close proximity to the sciatic nerve.
● Use a needle size 18‑ to 27‑gauge (usually 22‑ to
25‑gauge), 1‑ to 1.5‑inch long, and inject at a 90° angle.
Solution volume is usually 1 to 3 mL. Divide larger
volumes into two syringes and use two different sites.
Z‑track
NURSING CONSIDERATIONS
Use this technique for all IM injections because it is less
painful, prevents medication from leaking back into
subcutaneous tissue, and prevents skins stains (e.g., iron
preparations).
Intravenous
NURSING CONSIDERATIONS
● Use for administering medications, fluid, and
blood products.
● Vascular access devices can be for short‑term use
(catheters) or long‑term use (infusion ports).
◯ Use 16‑gauge devices for clients who have trauma.
◯ Use 18‑gauge during surgery and
blood administration.
◯ Use 22‑ to 24‑gauge for children, older adults,
and clients who have medical issues or are
stable postoperatively.
● Peripheral veins in the arm or hand are preferable. Ask
clients which site they prefer. For newborns, use veins
in the head, lower legs, and feet. After administration,
immediately monitor for therapeutic and adverse effects.
Epidural
NURSING CONSIDERATIONS
● Use for IV opioid analgesia (morphine or fentanyl).
● The clinician advances the catheter through the needle
into the epidural space at the level of the fourth or
fifth vertebra.
● Use an infusion pump to administer medication.
46.1 Advantages and disadvantages of different routes
ADVANTAGES DISADVANTAGES
Oral
safe
inexpensive
easy and convenient
oral medications have highly variable absorption.
inactivation can occur by the Gi
tract or first‑pass effect.
clients must be cooperative and conscious.
contraindications include nausea and vomiting.
Subcutaneous and
intramuscular (IM)
use for poorly soluble medications.
use for administering medications that
have slow absorption for an extended
period of time (depot preparations).
im injections are more costly.
im injections are inconvenient.
there can be pain with the risk for local
tissue damage and nerve damage.
there is a risk for infection at the injection site.
Intravenous (IV)
onset is rapid, and absorption
into the blood is immediate, which
provides an immediate response.
this route allows control over the precise
amount of medication to administer.
it allows for administration of
large volumes of fluid.
it dilutes irritating medications
in free‑flowing iV fluid.
iV injections are even more costly.
iV injections are inconvenient.
absorption of the medication into the blood is
immediate. this is potentially dangerous if giving
the wrong dosage or the wrong medication.
there is an increased risk for infection
or embolism with iV injections.
Poor circulation can inhibit the
medication’s distribution.
266 CHAPTER 46 Pharmacokinetics and routes of administration CONTENT MASTERY SERIES
Application Exercises
1. a nurse is caring for a client who is
1 day postoperative following a total
knee arthroplasty. the client states
his pain level is 10 on a scale of 0
to 10. after reviewing the client’s
medication administration record,
which of the following medications
should the nurse administer?
a. meperidine 75 mg im
B. fentanyl 50 mcg/hr
transdermal patch
c. morphine 2 mg iV
d. oxycodone 10 mg Po
2. a nurse is teaching a client about
taking multiple oral medications
at home to include time‑release
capsules, liquid medications,
enteric‑coated pills, and opioids.
Which of the following statements
should the nurse identify as
an indication that the client
understands the instructions?
a. “i can open the capsule with
the beads in it and sprinkle
them on my oatmeal.”
B. “if i am having difficulty
swallowing, i will add
the liquid medication to
a batch of pudding.”
c. “i can crush the pills with
the coating on them.”
d. “i will eat two crackers
with the pain pills.”
3. a nurse is teaching a client how
to administer medication through
a jejunostomy tube. Which
of the following instructions
should the nurse include?
a. “flush the tube before and
after each medication.”
B. “mix your medications with
your enteral feeding.”
c. “Push tablets through
the tube slowly.”
d. “mix all the crushed
medications prior to
dissolving them in water.”
4. a nurse is preparing to inject heparin
subcutaneously for a client who is
postoperative. Which of the following
actions should the nurse take?
a. use a 22‑gauge needle.
B. select a site on the
client’s abdomen.
c. spread the skin with the
thumb and index finger.
d. observe for bleb formation
to confirm proper placement.
5. a nurse is teaching an adult
client how to administer ear
drops. Which of the following
statements should the nurse identify
as an indication that the client
understands the proper technique?
a. “i will straighten my ear
canal by pulling my ear
down and back.”
B. “i will gently apply pressure
with my finger to the
front part of my ear after
putting in the drops.”
c. “i will insert the nozzle
of the ear drop bottle
snug into my ear before
squeezing the drops in.”
d. “after the drops are in, i will
place a cotton ball all the
way into my ear canal.”
PRACTICE Active Learning Scenario
a nurse educator is teaching a module on biotransformation
as a phase of pharmacokinetics during nursing orientation
to a group of newly licensed nurses. use the ati active
Learning template: Basic concept to complete this item.
RELATED CONTENT: List four areas of the body
where biotransformation takes place.
UNDERLYING PRINCIPLES: List at least three factors
that influence the rate of biotransformation.
FUNDAMENTALS FOR NURSING CHAPTER 46 Pharmacokinetics and routes of administration 267
Application Exercises Key
1. a. although meperidine is a strong analgesic, the im route of
administration can allow for slow absorption, delaying the onset of pain
relief. the im route also can cause additional pain from the injection.
B. although fentanyl is a strong analgesic, the
transdermal route of administration can allow for slow
absorption, delaying the onset of pain relief.
c. CORRECT: the nurse should administer iV morphine
because the onset is rapid, and absorption of the medication
into the blood is immediate, which provides the optimal
response for a client who is reporting pain at a level of 10.
d. although oxycodone is a strong analgesic, the oral
route of administration of this medication can allow for
onset of pain relief in 10 to 15 min, which can be a long
time for a client who is reporting pain at a level of 10.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
2. a. although this might help a client who has
swallowing issues, it is essential for the client to swallow
enteric‑coated or time‑release medications whole.
B. although adding a liquid medication to food is helpful if
the client is having difficulty swallowing, he should not mix
the medication with large amounts of food or beverages
in case he cannot consume the entire quantity.
c. the client must not crush enteric‑coated or time‑release
preparations. he must swallow them whole.
d. CORRECT: the client should take irritating
medications, such as analgesics, with small amounts of
food. it can help prevent nausea and vomiting.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Pharmacological Pain Management
3. a. CORRECT: the client should flush the tubing before and after each
medication with 15 to 30 mL water to prevent clogging of the tube.
B. to maximize the therapeutic effect of a medication, the client should
not mix medications with enteral formula. in addition, if the client
does not receive the entire feeding, he does not receive the entire
medication. this can also delay the client receiving the medication.
c. the client should not administer tablets or undissolved medications
through a jejunostomy tube because they can clog the tube.
d. the client should self‑administer each medication separately.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
4. a. for a subcutaneous injection, the nurse
should use a 25‑ to 27‑gauge needle.
B. CORRECT: for a subcutaneous injection, the nurse
should select a site that has an adequate fat‑pad size
(abdomen, upper hips, lateral upper arms, thighs).
c. for a subcutaneous injection, the nurse should
pinch the skin with her thumb and index finger.
d. Bleb formation confirms injection into the
dermis, not into subcutaneous tissue.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
5. a. the client should straighten his ear canal by pulling
the auricle upward and outward to open up the ear canal
and allow the medication to reach the eardrum.
B. CORRECT: the client should gently apply pressure
with the finger to the tragus of the ear after administering
the drops to help the drops go into the ear canal.
c. the client should never occlude the ear canal with
the dropper when instilling ear drops because this can
cause pressure that could injure the eardrum.
d. the client should not place a cotton ball past
the outermost part of the ear canal because it could
introduce bacteria to the inner or middle ear.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT: Biotransformation (metabolism) changes medications into
less active forms or inactive forms by the action of enzymes. this occurs primarily
in the liver, but also takes place in the kidneys, lungs, intestines, and blood.
UNDERLYING PRINCIPLES
● age: infants have a limited medication‑metabolizing capacity. the aging process
also can influence medication metabolism, but varies with the individual. in general,
hepatic medication metabolism tends to decline with age. older adults require
smaller doses of medications due to the possibility of accumulation in the body.
● an increase in some medication‑metabolizing enzymes: this can metabolize
a particular medication sooner, requiring an increase in dosage of that
medication to maintain a therapeutic level. it can also cause an increase
in the metabolism of other concurrent‑use medications.
● first‑pass effect: the liver inactivates some medications on their first pass through the liver.
thus, they require a nonenteral route (sublingual, iV) because of their high first‑pass effect.
● similar metabolic pathways: When the same pathway metabolizes two medications, it
can alter the metabolism of one or both of them. in this way, the rate of metabolism can
decrease for one or both of the medications, leading to medication accumulation.
● nutritional status: clients who are malnourished can be deficient in the
factors that are necessary to produce specific medication‑metabolizing
enzymes, thus impairing medication metabolism.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication adMiniStration and error reduction 269
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
CHAPTER 47 Safe Medication
Administration and
Error Reduction
the providers who may legally write
prescriptions in the united States include
physicians, advanced practice nurses, dentists,
and physician assistants.
ProVider reSPonSiBiLitieS
● Obtaining clients’ medical history and performing
a physical examination
● Diagnosing
● Prescribing medications
● Monitoring the response to therapy
● Modifying medication prescriptions as necessary
nurSe reSPonSiBiLitieS
● Having knowledge of federal, state (nurse practice
acts), and local laws, and facilities’ policies that govern
the prescribing, dispensing, and administration
of medications
● Preparing, administering, and evaluating clients’
responses to medications
● Developing and maintaining an up‑to‑date knowledge
base of medications they administer, including uses,
mechanisms of action, routes of administration, safe
dosage range, adverse and side effects, precautions,
contraindications, and interactions
● Maintaining knowledge of acceptable practice and
skills competency
● Determining the accuracy of medication prescriptions
● Reporting all medication errors
● Safeguarding and storing medications
MEDICATION CATEGORY
AND CLASSIFICATION
noMencLature
Chemical name: A medication’s chemical composition
(N‑acetyl‑para‑aminophenol).
Generic name: Official or nonproprietary name the United
States Adopted Names Council gives a medication. Each
medication has only one generic name (acetaminophen).
Trade name: Brand or proprietary name the company that
manufacturers the medication gives it. One medication
can have multiple trade names (Tylenol, Tempra).
PreScriPtion MedicationS
Nurses administer prescription medications under the
supervision of providers. These medications can be
habit-forming, have potential harmful effects, and
require monitoring.
Uncontrolled substances
These medications require monitoring by a provider, but do
not generally pose a risk of abuse or addiction. Antibiotics
are an example of uncontrolled prescription medications.
Controlled substances
Medications that have a potential for abuse and
dependence and have a “schedule” classification. Heroin is
in Schedule I and has no medical use in the United States.
Medications in Schedules II through V have legitimate
applications. Each subsequent level has a decreasing
risk of abuse and dependence. For example, morphine
is a Schedule II medication that has a greater risk for
abuse and dependence than phenobarbital, which is a
Schedule IV medication.
Pregnancy Risk Categories
The U.S. Food and Drug Administration’s (FDA’s)
Pregnancy Risk Categories (A, B, C, D, X) classify
medications according to their potential harm during
pregnancy, with Category A being the safest and
Category X the most dangerous. Teratogenesis from
unsafe medications is most likely to occur during the
first trimester. Before administering any medication to a
woman who is pregnant or could be pregnant, determine
whether it is safe for administration during pregnancy.
CHAPTER 47
270 CHAPTER 47 Safe Medication adMiniStration and error reduction CONTENT MASTERY SERIES
KnoWLedGe reQuired Prior to
Medication adMiniStration
Medication category
Medications have a pharmacological action, therapeutic
use, body system target, chemical makeup, and
classification for use during pregnancy. For example,
lisinopril is an angiotensin‑converting enzyme inhibitor
(pharmacological action) and an antihypertensive
(therapeutic use).
Mechanism of action
This is how the medication produces its therapeutic effect.
For example, glipizide is an oral hypoglycemic agent
that lowers blood glucose levels primarily by stimulating
pancreatic islet cells to release insulin.
Therapeutic effect
This is the expected effect for which the nurse administers
the medication to a specific client. One medication can
have more than one therapeutic effect. For example, one
client receives acetaminophen to lower fever, whereas
another receives it to relieve pain.
Side effects
These are expected and predictable effects that result at
a therapeutic dose. For example, morphine for pain relief
usually results in constipation.
Adverse effects
These are undesirable, inadvertent, and unexpected
dangerous effects of the medication. Some are immediate,
whereas others take weeks or months to develop.
Toxic effects
Medications can have specific risks and manifestations
of toxicity. For example, nurses monitor clients
taking digoxin for dysrhythmias, a manifestation of
cardiotoxicity. Hypokalemia places these clients at greater
risk for digoxin toxicity.
Interactions
Medications can interact with each other, resulting in
beneficial or harmful effects. For example, giving the
beta‑blocker atenolol concurrently with the calcium
channel blocker nifedipine helps prevent reflex
tachycardia. Medications can also increase or decrease
the actions of other medications, and food can interact
beneficially or harmfully with medications.
Precautions, contraindications
These are conditions (diseases, age, pregnancy, lactation)
that make it risky or completely unsafe for clients to take
specific medications. For example, tetracyclines can stain
developing teeth; therefore, children younger than 8 years
should not take these medications. Another example is
that heart failure is a contraindication for labetalol, an
antihypertensive medication.
Preparation, dosage, administration
It is important to know any specific considerations for
preparation, safe dosages, and how to administer the
medication. For example, morphine is available in many
different formulations. Oral doses of morphine are
generally higher than parenteral doses due to extensive
first-pass effect. Clients who have chronic severe pain,
such as with cancer, generally take oral doses of morphine.
MEDICATION PRESCRIPTIONS
Each facility has written policies for medication
prescriptions, including which providers may write,
receive, and transcribe medication prescriptions.
tYPeS of Medication PreScriPtionS
Routine or standard prescriptions
● A routine or standard prescription identifies medications
nurses give on a regular schedule with or without a
termination date. Without a termination date, the
prescription will be in effect until the provider
discontinues it or discharges the client.
● Providers must re‑prescribe some medications, such as
opioids and antibiotics, within a specific amount of time
or they will automatically discontinue.
Single or one‑time prescriptions
A single or one‑time prescription is for administration
once at a specific time or as soon as possible. These
prescriptions are common for preoperative or
preprocedural medications. For example, a one‑time
prescription instructs the nurse to administer warfarin
5 mg PO at 1700.
Stat prescriptions
A stat prescription is only for administration once and
immediately. For example, a stat prescription instructs the
nurse to administer digoxin 0.125 mg IV bolus stat.
FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication adMiniStration and error reduction 271
Now prescriptions
A now prescription is only for administration once, but up
to 90 min from when the nurse received the prescription.
For example, a now prescription instructs the nurse to
administer vancomycin 1 g intermittent IV bolus now.
PRN prescriptions
A PRN (pro re nata) prescription specifies at what
dosage, what frequency, and under what conditions a
nurse may administer the medication. The nurse uses
clinical judgment to determine the client’s need for the
medication. For example, a PRN prescription instructs the
nurse to administer morphine 2 mg IV bolus every hour
PRN for chest pain.
Standing prescriptions
Providers write standing prescriptions for specific
circumstances or for specific units. For example, a critical
care unit has standing prescriptions for treating clients
who have asystole.
coMPonentS of a
Medication PreScriPtion
● The client’s full name
● The date and time of the prescription
● The name of the medication (generic or brand)
● The strength and dosage of the medication
● The route of administration
● The time and frequency of administration: exact times
or number of times per day (according to the facility’s
policy or the specific qualities of the medication)
● The quantity to dispense and the number of refills
● The signature of the prescribing provider
coMMunicatinG
Medication PreScriPtionS
Origin of medication prescriptions
Providers or nurses who take verbal or telephone
prescriptions from a provider write medication
prescriptions on the client’s medical record. If the
nurse writes a medication prescription on the client’s
medical record, the facility’s policy specifies how much
time the provider has to sign the prescription. Nurses
transcribe medication prescriptions onto the medication
administration record (MAR).
Taking a telephone prescription
Only when absolutely necessary
● Ensure that the prescription is complete and correct by
reading it back to the provider: the client’s name, the
name of the medication, the dosage, the time to give it,
the frequency, and the route.
● To ensure correct spelling, use aids such as “b as in boy.”
State numbers separately, such as “one, seven” for 17.
● Remind the provider to verify the prescription and
sign it within the amount of time the facility’s
policy specifies.
● Write or enter the prescription in the client’s
medical record.
Medication reconciLiation
The Joint Commission requires policies and procedures for
medication reconciliation. Nurses compile a list of each
client’s current medications, including all medications
with correct dosages and frequency. They compare the
list with new medication prescriptions and reconcile it
to resolve any discrepancies. This process takes place at
admission, when transferring clients between units or
facilities, and at discharge.
PREASSESSMENT FOR
MEDICATION THERAPY
Nurses obtain the following information before initiating
medication therapy, and update it as necessary.
Health history
● Age
● Health problems and the current reason for seeking care
● All medications clients currently take (prescription and
nonprescription): the name, dose, route, and frequency
of each
● Any unexpected findings possibly from medication
therapy
● Use of herbal or “natural” products for
medicinal purposes
● Use of caffeine, tobacco, alcohol, or illicit drugs
● Clients’ understanding of the purpose of
the medications
● All medication and food allergies
Physical examination
A systematic physical examination provides a baseline for
evaluating the therapeutic effects of medication therapy
and for detecting possible side and adverse effects.
272 CHAPTER 47 Safe Medication adMiniStration and error reduction CONTENT MASTERY SERIES
RIGHTS OF SAFE
MEDICATION ADMINISTRATION
Right client
Verify clients’ identification before each medication
administration. The Joint Commission requires two client
identifiers. Acceptable identifiers include the client’s name,
an assigned identification number, telephone number,
birth date, or other person-specific identifier, such as
a photo identification card. Nurses also use bar-code
scanners to identify clients. Check for allergies by asking
clients, checking for an allergy bracelet or medal, and
checking the MAR.
Right medication
Correctly interpret medication prescriptions, verifying
completeness and clarity. Read medication labels and
compare them with the MAR three times: before removing
the container, when removing the amount of medication
from the container, and in the presence of the client
before administering the medication. Leave unit‑dose
medication in its package until administration.
Right dose
Use a unit‑dose system to decrease errors. If not available,
calculate the correct medication dose; check a drug
reference to make sure the dose is within the usual range.
Ask another nurse to verify the dose if uncertain of the
calculation. Prepare medication dosages using standard
measurement devices, such as graduated cups or syringes.
Some medication dosages require a second verifier or
witness, such as some cytotoxic medications. Automated
medication dispensing systems use a machine to control
the dispensing of medications.
Right time
Administer medication on time to maintain a consistent
therapeutic blood level. It is generally acceptable to
administer the medication 30 min before or after the
scheduled time. Refer to the drug reference or the
facility’s policy for exceptions.
Right route
The most common routes of administration are
oral, topical, subcutaneous, intramuscular (IM), and
intravenous (IV). Additional administration routes include
sublingual, buccal, intradermal, transdermal, epidural,
inhalation, nasal, ophthalmic, otic, rectal, vaginal,
intraosseous, and via enteral tubes. Select the correct
preparation for the route the provider prescribed (otic vs.
ophthalmic topical ointment or drops).
Right documentation
Immediately record pertinent information, including
the client’s response to the medication. Document the
medication after administration, not before.
Right client education
Inform clients about the medication: its purpose,
what to expect, how to take it, and what to report. To
individualize the teaching, determine what the clients
already know about the medication, need to know about
the medication, and want to know about the medication.
Right to refuse
Respect clients’ right to refuse any medication. Explain
the consequences, inform the provider, and document
the refusal.
47.1 Error‑prone abbreviation list
Some abbreviations cause a high number of medication errors.
DO NOT USE USE
MS, MSo4 morphine
MgSo4 magnesium sulfate
abbreviated medication
names (aZt, Kcl,
Hct, Ptu, HctZ)
full name of medication
nitro nitroglycerin
decimal points without
a leading zero (.5 mg)
smaller units (500 mcg) or
a leading zero (0.5 mg)
trailing zero (1.0 mg,
100.0 g)
without a trailing
zero (1 mg, 100 g)
u, u, iu units
μ, μg mcg or microgram
x3d times 3 days
cc mL
apothecary units metric units
od, o.d., od daily or intended time
of administration
q.d, qd, Q.d, Qd, q1d, i/d daily
DO NOT USE USE
q.o.d., Qod every other day
Q6PM, etc. 6 p.m. daily or
daily at 6 p.m.
tiW, tiw 3 times weekly
mg., mL. mg, mL (no period)
HS half‑strength, bedtime
(hour of sleep)
Bt, hs, HS, qhs, qn bedtime or hour of sleep
Sc, SQ, sub q subcutaneously
in intranasal
iJ injection
oJ orange juice
> or < greater than or less than
@ at
&, + and
/ per
ad, aS, au right ear, left ear, both ears
od, oS, ou right eye, left eye, both eyes
d/c, dc, d/c discharge or discontinue
FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication adMiniStration and error reduction 273
Right assessment
Collect any essential data before and after administering
any medication. For example, measure apical heart rate
before giving digoxin.
Right evaluation
Follow up with clients to verify therapeutic effects as well
as side and adverse effects.
RESOURCES FOR
MEDICATION INFORMATION
● Nursing drug handbooks
● Pharmacology textbooks
● Professional journals
● Physicians’ Desk Reference (PDR)
● Professional websites
● Pharmacists
MEDICATION ERROR PREVENTION
coMMon Medication errorS
● Wrong medication or IV fluid
● Incorrect dose or IV infusion rate
● Wrong client, route, or time
● Administration of a medication to which the client
is allergic
● Omission of a dose or extra doses
● Incorrect discontinuation of medication or IV fluid
● Inaccurate prescribing
the institute for Safe Medication Practices (iSMP) is a
nonprofit organization working to educate health
care providers and consumers about safe
medication practices. the iSMP and the fda
identify the most common medical abbreviations
that result in misinterpretation, mistakes, and injury.
for a complete list, go to w w w.ismp. o rg.
nurSinG ProceSS
Use the nursing process to prevent medication errors.
Assessment/data collection
● Ensure knowledge of medication to administer and why.
● Obtain information about the clients’ medical diagnoses
and conditions that relate to medication administration,
such as the ability to swallow, diet, allergies, and heart,
liver, and kidney disorders.
◯ Identify allergies.
◯ Obtain necessary preadministration data (heart rate,
blood pressure) to assess the appropriateness of the
medication and to obtain baseline data for evaluating
the effectiveness of medications.
◯ Omit or delay doses according to findings, and notify
the provider.
● Determine if the medication prescription is complete:
with the client’s name, date and time, name of
medication, dosage, route of administration, time and
frequency, and signature of the prescribing provider.
● Interpret the medication prescription accurately. Refer
to the ISMP lists.
Online Video: Look‑Alike, Sound‑Alike Medications
47.2 Confused medication name list
Sound‑alike and look‑alike medication names
ESTABLISHED NAME RECOMMENDED NAME
acetohexamide
acetazolamide
acetoHeXaMide
acetaZoLaMide
bupropion
buspirone
buProPion
busPirone
chlorpromazine
chlorpropamide
chlorproMaZine
chlorproPaMide
clomiphene
clomipramine
clomiPHene
clomiPraMine
cyclosporine
cycloserine
cycloSPorine
cycloSerine
daunorubicin
doxorubicin
daunorubicin
doXorubicin
dimenhydrinate
diphenhydramine
dimenhydrinate
diphenhydraMine
dobutamine
dopamine
doButamine
doPamine
glipizide
glyburide
glipiZide
glyBuride
ESTABLISHED NAME RECOMMENDED NAME
hydralazine
hydromorphone
hydroxyzine
hydraLaZine
hYdromorphone
hydroXYzine
medroxyprogesterone
methylprednisolone
methyltestosterone
mitoxantrone
medroxyProGeSterone
methylPredniSolone
methylteStoSterone
mitoXantrone
nicardipine
nifedipine
nicardipine
nifedipine
prednisone
prednisolone
predniSone
prednisoLone
risperidone
ropinirole
risperidone
roPinirole
sulfadiazine
sulfisoxazole
sulfadiaZine
sulfiSoXaZoLe
tolazamide
tolbutamide
toLaZamide
toLButamide
vinblastine
vincristine
vinBLaStine
vincriStine
274 CHAPTER 47 Safe Medication adMiniStration and error reduction CONTENT MASTERY SERIES
● Question the provider if the prescription is unclear or
seems inappropriate for the client’s condition. Refuse to
administer a medication if it seems unsafe, and notify
the charge nurse or supervisor.
● Providers usually make dosage changes
gradually. Question the provider about abrupt and
excessive changes.
● Determine clients’ learning needs.
Planning
● Identify clients’ outcomes for medication administration.
● Set priorities.
Implementation
● Avoid distractions during medication preparation
(poor lighting, phones). Interruptions increase the risk
of error.
● Prepare medications for one client at a time.
● Check the labels for the medication’s name and
concentration. Read labels carefully. Measure doses
accurately, and double‑check dosages of high‑alert
medications, such as insulin and heparin, with a
colleague. Check the medication’s expiration date.
● Doses are usually one to two tablets or one single‑dose
vial. Question multiple tablets or vials for a single dose.
● Follow the rights of medication administration
consistently. Take the MAR to the bedside.
● Only give medications that you have prepared.
● Encourage clients to become part of the safety net,
teaching them about medications and the importance of
proper identification before medication administration.
Omit or delay a dose when clients question the size of
the dose or the appearance of the medication.
● Follow correct procedures for all routes of administration.
● Communicate clearly both in writing and speaking.
● Use verbal prescriptions only for emergencies, and follow
the facility’s protocol for telephone prescriptions. Nursing
students may not accept verbal or telephone orders.
● Follow all laws and regulations for preparing and
administering controlled substances. Keep them in a
secure area. Have another nurse witness the discarding
of controlled substances.
● Do not leave medications at the bedside. Some
facilities’ policies allow exceptions, such as for
topical medications.
Evaluation
● Evaluate clients’ responses to medications, and
document and report them.
● Recognize side and adverse effects, and document and
report them.
● Report all errors, and implement corrective
measures immediately.
◯ Complete an incident report within the specified
time frame, usually 24 hr. Include the client’s
identification, the time and place of the incident, an
accurate account of the event, who you notified, what
actions you took, and your signature. Do not reference
or include this report in the client’s medical record.
◯ Medication errors relate to systems, procedures,
product design, or practice patterns. Report all errors
to assist the facility’s risk managers to learn how
errors occur and what changes to make to avoid
similar errors in the future.
47.3 High‑alert medication list
the following medications and medication categories from the iSMP’s list require specific safeguards to reduce
the risk of errors. Strategies include limiting access; using auxiliary labels and automated alerts; standardizing
the prescription, preparation, and administration; and using automated or independent double checks.
Class or category of medications
● adrenergic agonists, iV (epinephrine)
● adrenergic antagonists, iV (propranolol)
● anesthetic agents, general, inhaled and iV (propofol)
● cardioplegic solutions
● chemotherapeutic agents, parenteral and oral
● dextrose, hypertonic, 20% or greater
● dialysis solutions, peritoneal and hemodialysis
● epidural or intrathecal medications
● Glycoprotein iib/iiia inhibitors (eptifibatide)
● Hypoglycemics, oral
● inotropic medications, iV (digoxin, milrinone)
● Liposomal forms of drugs (liposomal amphotericin B)
● Moderate sedation agents, iV (midazolam)
● Moderate sedation agents, oral, for children (chloral hydrate)
● narcotics/opiates, iV and oral (including liquid
concentrates, immediate‑ and sustained‑release)
● neuromuscular blocking agents (succinylcholine)
● radiocontrast agents, iV
● Sodium chloride injection, hypertonic,
more than 0.9% concentration
● thrombolytics/fibrinolytics, iV (tenecteplase)
● total parenteral nutrition solutions
Specific medications
● epinephrine, subcutaneous
● epoprostenol, iV
● Heparin, low molecular weight, injection
● Heparin, unfractionated, iV
● insulin, subcutaneous and iV
● Lidocaine, iV
● Magnesium sulfate injection
● Methotrexate, oral, nononcologic use
● opium tincture
● oxytocin, iV
● nitroprusside for injection
● Potassium chloride for injection concentrate
● Potassium phosphates injection
● Promethazine, iV
● Vasopressin, iV or intraosseous
● Warfarin
FUNDAMENTALS FOR NURSING CHAPTER 47 Safe Medication adMiniStration and error reduction 275
Application Exercises
1. a nurse prepares an injection
of morphine to administer to a
client who reports pain. Prior to
administering the medication, the
nurse assists another client onto
a bedpan. She asks a second
nurse to give the injection. Which
of the following actions should
the second nurse take?
a. offer to assist the client
who needs the bedpan.
B. administer the injection
the other nurse prepared.
c. Prepare another syringe and
administer the injection.
d. tell the client who needs
the bedpan she will have
to wait for her nurse.
2. a nurse is preparing to administer a
0900 medication to a client. Which
of the following are acceptable
administration times for this
medication? (Select all that apply.)
a. 0905
B. 0825
c. 1000
d. 0840
e. 0935
3. a nurse is working with a newly
licensed nurse who is administering
medications to clients. Which of
the following actions should the
nurse identify as an indication that
the newly hired nurse understands
medication error prevention?
a. taking all medications out of
the unit‑dose wrappers before
entering the client’s room
B. checking with the provider
when a single dose
requires administration
of multiple tablets
c. administering a medication,
then looking up the
usual dosage range
d. relying on another nurse
to clarify a medication
prescription
4. a nurse educator is teaching a
module about safe medication
administration to newly licensed
nurses. Which of the following
statements should the nurse
identify as an indication that
one of the group understands
how to implement medication
therapy? (Select all that apply.)
a. “i will observe for side effects.”
B. “i will monitor for
therapeutic effects.”
c. “i will prescribe the
appropriate dose.”
d. “i will change the dose if
adverse effects occur.”
e. “i will refuse to give a
medication if i believe
it is unsafe.”
5. a nurse is preparing to administer
digoxin to a client who states,
“i don’t want to take that medication.
i do not want one more pill.”
Which of the following responses
should the nurse make?
a. “Your physician prescribed
it for you, so you really
should take it.”
B. “Well, let’s just get it
over quickly then.”
c. “okay, i’ll just give you
your other medications.”
d. “tell me your concerns about
taking this medication.”
PRACTICE Active Learning Scenario
a nurse educator is teaching a module about the
rights of safe medication administration to a group
of newly licensed nurses. use the ati active Learning
template: Basic concept to complete this item.
RELATED CONTENT: List the rights of
safe medication administration.
UNDERLYING PRINCIPLES: List at least three acceptable
identifiers to use to verify the client’s identity.
276 CHAPTER 47 Safe Medication adMiniStration and error reduction CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: the second nurse should offer to assist
the client who needs the bedpan. this will allow the
nurse who prepared the injection to administer it.
B. a nurse should only administer medications that she prepared.
c. Preparing another syringe will delay the
administration of the pain medication.
d. telling the client to wait is not an acceptable
option for a client who needs a bedpan.
NCLEX® Connection: Management of Care,
Legal Rights and Responsibilities
2. a. CORRECT: the nurse should administer medications within 30 min of
the time it is due. 0905 is within 30 min of the time the medication is due.
B. 0825 is not within 30 min of the time the medication is due.
c. 1000 is not within 30 min of the time the medication is due.
d. CORRECT: 0840 is within 30 min of the time the medication is due.
e. 0935 is not within 30 min of the time the medication is due.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
3. a. to prevent errors, the nurse should not take unit‑dose medications
out of wrappers until at the bedside when performing the third
check of medication administration. the nurse can encourage
clients’ involvement and provide teaching at this time.
B. CORRECT: if a single dose requires multiple tablets, it is possible
that an error has occurred in the prescription or transcription of
the medication. this action could prevent a medication error.
c. reviewing the usual dosage range prior to administration
can help the nurse identify an inaccurate dosage.
d. if the prescription is unclear, the nurse should contact
the provider, not another nurse, for clarification.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
4. a. CORRECT: the nurse is responsible for observing for
side effects. this is within a nurse’s scope of practice.
B. CORRECT: the nurse is responsible for monitoring
therapeutic effects. this is within a nurse’s scope of practice.
c. the provider is responsible for prescribing the appropriate
dose. this is outside of the nurse’s scope of practice.
d. the provider is responsible for changing the dose if adverse
effects occur. this is outside of the nurse’s scope of practice.
e. CORRECT: the nurse is responsible for identifying when a
medication could harm a client. it is within the nurse’s scope of practice
to refuse to administer the medication and contact the provider.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Expected Actions/Outcomes
5. a. this response dismisses the client’s concerns.
B. the nurse is dismissing the client’s concerns about taking the
medication by continuing with medication administration.
c. although clients have the right to refuse a medication, the
nurse should provide information about the risk of refusal
instead of proceeding with medication administration.
d. CORRECT: although clients have the right to refuse a medication, the
nurse is correct in determining the reason for refusal by asking the client
his concerns. then the nurse can provide information about the risk of
refusal and facilitate an informed decision. at that point, if the client still
exercises his right to refuse a medication, the nurse should notify and
the provider and document the refusal and the actions the nurse took.
NCLEX® Connection: Management of Care, Client Rights
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT: rights of Safe Medication administration
● right client: Verify clients’ identification before each medication
administration. the Joint commission requires two client
identifiers. acceptable identifiers include the client’s name,
an assigned identification number, telephone number, birth
date, or other person‑specific identifier, such as a photo
identification card. nurses also use bar‑code scanners to
identify clients. check for allergies by asking clients, checking
for an allergy bracelet or medal, and checking the Mar.
● right medication: correctly interpret medication prescriptions,
verifying completeness and clarity. read medication labels
and compare them with the Mar three times: before
removing the container, when removing the amount of
medication from the container, and in the presence of
the client before administering the medication. Leave
unit‑dose medication in its package until administration.
● right dose: use a unit‑dose system to decrease errors. if not
available, calculate the correct medication dose; check a drug
reference to make sure the dose is within the usual range. ask
another nurse to verify the dose if uncertain of the calculation.
Prepare medication dosages using standard measurement
devices, such as graduated cups or syringes. Some medication
dosages, such as some cytotoxic medications, require a second
verifier or witness. automated medication dispensing systems
use a machine to control the dispensing of medications.
● right time: administer medication on time to maintain a consistent
therapeutic blood level. it is generally acceptable to administer
the medication 30 min before or after the scheduled time. refer
to the drug reference or the facility’s policy for exceptions.
● right route: the most common routes of administration are
oral, topical, subcutaneous, intramuscular, and intravenous.
additional administration routes include sublingual, buccal,
intradermal, transdermal, epidural, inhalation, nasal, ophthalmic,
otic, rectal, vaginal, intraosseous, and via enteral tubes.
Select the correct preparation for the route the provider
prescribed (otic vs. ophthalmic topical ointment or drops).
● right documentation: immediately record pertinent
information, including the client’s response to the medication.
document the medication after administration, not before.
● right client education: inform clients about the medication: its
purpose, what to expect, how to take it, and what to report. to
individualize the teaching, determine what the clients already
know, need to know, and want to know about the medication.
● right to refuse: respect clients’ right to refuse any
medication. explain the consequences, inform
the provider, and document the refusal.
● right assessment: collect any essential data before
and after administering any medication. for example,
measure apical heart rate before giving digoxin.
UNDERLYING PRINCIPLES
● acceptable identifiers include the client’s name, an
assigned identification number, telephone number,
birth date, or other person‑specific identifier.
● the nurse can use bar‑code scanners to identify clients.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
FUNDAMENTALS FOR NURSING CHAPTER 48 Dosage CalCulation 277
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
CHAPTER 48 Dosage Calculation
Basic medication dose conversion and
calculation skills are essential for providing safe
nursing care.
nurses are responsible for administering the
correct amount of medication by calculating the
precise amount of medication to give. nurses
can use three different methods for dosage
calculation: ratio and proportion, formula
(desired over have), and dimensional analysis.
tYPes oF CalCulations
● Solid oral medication
● Liquid oral medication
● Injectable medication
● Correct doses by weight
● IV infusion rates
stanDaRD ConVeRsion FaCtoRs
● 1 mg = 1,000 mcg
● 1 g = 1,000 mg
● 1 kg = 1,000 g
● 1 oz = 30 mL
● 1 L = 1,000 mL
● 1 tsp = 5 mL
● 1 tbsp = 15 mL
● 1 tbsp = 3 tsp
● 1 kg = 2.2 lb
● 1 gr = 60 mg
geneRal RounDing guiDelines
ROUNDING UP: If the number to the right is equal to or
greater than 5, round up by adding 1 to the number on
the left.
ROUNDING DOWN: If the number to the right is less
than 5, round down by dropping the number, leaving the
number to the left as is.
For dosages less than 1.0: Round to the nearest hundredth.
● For example (rounding up): 0.746 mL = 0.75 mL. The
calculated dose is 0.746 mL. Look at the number in the
thousandths place (6). Six is greater than 5. To round to
hundredths, add 1 to the 4 in the hundredths place and
drop the 6. The rounded dose is 0.75 mL.
● Or (rounding down): 0.743 mL = 0.74 mL. The
calculated dose is 0.743 mL. Look at the number in the
thousandths place (3). Three is less than 5. To round
to the hundredth, drop the 3 and leave the 4 as is. The
rounded dose is 0.74 mL.
For dosages greater than 1.0: Round to the nearest tenth.
● For example (rounding up): 1.38 = 1.4. The calculated
dose is 1.38 mg. Look at the number in the hundredths
place (8). Eight is greater than 5. To round to the tenth,
add 1 to the 3 in the tenth place and drop the 8. The
rounded dose is 1.4 mg.
● Or (rounding down): 1.34 mL = 1.3 mL. The calculated
dose is 1.34 mL. Look at the number in the hundredths
place (4). Four is less than 5. To round to the tenth, drop
the 4 and leave the 3 as is. The rounded dose is 1.3 mL.
Solid dosage
example: a nurse is preparing to administer
phenytoin 0.2 g Po every 8 hr. the amount available
is phenytoin 100 mg/capsule. How many capsules
should the nurse administer per dose? (Round the
answer to the nearest whole number. use a leading
zero if it applies. Do not use a trailing zero.)
using Ratio anD PRoPoRtion
STEP 1: What is the unit of measurement the nurse
should calculate?
capsules
STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
0.2 g
STEP 3: What is the dose available? Dose available = Have
100 mg
STEP 4: Should the nurse convert the units of
measurement? Yes (g ≠ mg)
1 g = 1,000 mg (1 × 1,000)
0.2 g = 200 mg (0.2 × 1,000)
STEP 5: What is the quantity of the dose available? = Quantity
1 capsule
STEP 6: Set up the equation and solve for X.
Have = Desired
Quantity X
100 mg = 200 mg
1 cap X cap
X = 2
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 100 mg/capsule and
the prescription reads 0.2 g (200 mg), it makes sense
to administer 2 capsules. The nurse should administer
phenytoin 2 capsules PO.
CHAPTER 48
278 CHAPTER 48 Dosage CalCulation CONTENT MASTERY SERIES
using DesiReD oVeR HaVe
STEP 1: What is the unit of measurement the nurse
should calculate?
capsules
STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
0.2 g
STEP 3: What is the dose available? Dose available = Have
100 mg
STEP 4: Should the nurse convert the units of
measurement? Yes (g ≠ mg)
1 g = 1,000 mg (1 × 1,000)
0.2 g = 200 mg (0.2 × 1,000)
STEP 5: What is the quantity of the dose available? = Quantity
1 capsule
STEP 6: Set up the equation and solve for X.
Desired × Quantity = XHave
200 mg × 1 cap = X cap100 mg
X = 2
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 100 mg/capsule and
the prescription reads 0.2 g (200 mg), it makes sense
to administer 2 capsules. The nurse should administer
phenytoin 2 capsules PO.
using DiMensional analYsis
STEP 1: What is the unit of measurement the nurse
should calculate?
capsules
STEP 2: What is the quantity of the dose available? = Quantity
1 capsule
STEP 3: What is the dose available? Dose available = Have
100 mg
STEP 4: What is the dose the nurse should administer?
Dose to administer = Desired
0.2 g
STEP 5: Should the nurse convert the units of
measurement? Yes (g ≠ mg)
1,000 mg = 1 g
0.2 g = 200 mg (0.2 × 100)
STEP 6: Set up the equation and solve for X.
X = Quantity × Conversion (Have) × DesiredHave Conversion (Desired)
X cap = 1 cap × 1,000 mg × 0.2 g100 mg 1 g
X = 2
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 100 mg/capsule and
the prescription reads 0.2 g (200 mg), it makes sense
to administer 2 capsules. The nurse should administer
phenytoin 2 capsules PO.
Liquid dosage
example: a nurse is preparing to administer
amoxicillin 0.25 g Po every 8 hr. the amount
available is amoxicillin oral suspension 250 mg/5 ml.
How many ml should the nurse administer per
dose? (Round the answer to the nearest tenth. use a
leading zero if it applies. Do not use a trailing zero.)
using Ratio anD PRoPoRtion
STEP 1: What is the unit of measurement the nurse
should calculate?
ml
STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
0.25 g
STEP 3: What is the dose available? Dose available = Have
250 mg
STEP 4: Should the nurse convert the units of
measurement? Yes (g ≠ mg)
1 g = 1,000 mg (1 × 1,000)
0.25 g = 250 mg (0.25 × 1,000)
STEP 5: What is the quantity of the dose available? = Quantity
5 ml
STEP 6: Set up the equation and solve for X.
Have = Desired
Quantity X
250 mg = 250 mg
5 ml X ml
X = 5
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 250 mg/5 mL and
the prescription reads 0.25 g (250 mg), it makes sense to
administer 5 mL. The nurse should administer amoxicillin
5 mL PO every 8 hr.
FUNDAMENTALS FOR NURSING CHAPTER 48 Dosage CalCulation 279
using DesiReD oVeR HaVe
STEP 1: What is the unit of measurement the nurse
should calculate?
ml
STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
0.25 g
STEP 3: What is the dose available? Dose available = Have
250 mg
STEP 4: Should the nurse convert the units of
measurement? Yes (g ≠ mg)
1 g = 1,000 mg (1 × 1,000)
0.25 g = 250 mg (0.25 × 1,000)
STEP 5: What is the quantity of the dose available? = Quantity
5 ml
STEP 6: Set up the equation and solve for X.
Desired × Quantity = XHave
250 mg × 5 ml = X ml250 mg
5 = X
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 250 mg/5 mL and
the prescription reads 0.25 g (250 mg), it makes sense to
administer 5 mL. The nurse should administer amoxicillin
5 mL PO every 8 hr.
using DiMensional analYsis
STEP 1: What is the unit of measurement the nurse
should calculate?
ml
STEP 2: What is the quantity of the dose available? = Quantity
5 ml
STEP 3: What is the dose available? Dose available = Have
250 mg
STEP 4: What is the dose the nurse should administer?
Dose to administer = Desired
0.25 g
STEP 5: Should the nurse convert the units of
measurement? Yes (g ≠ mg)
1,000 mg = 1 g
0.25 g = 250 mg (0.25 × 1,000)
STEP 6: Set up the equation and solve for X.
X = Quantity × Conversion (Have) × DesiredHave Conversion (Desired)
X ml = 5 ml × 1,000 mg × 0.25 g250 mg 1 g
X = 5
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 250 mg/5 mL and
the prescription reads 0.25 g (250 mg), it makes sense to
administer 5 mL. The nurse should administer amoxicillin
5 mL PO every 8 hr.
Injectable dosage
example: a nurse is preparing to administer heparin
8,000 units subcutaneously every 12 hr. available
is heparin injection 10,000 units/ml. How many
ml should the nurse administer per dose? (Round
the answer to the nearest tenth. use a leading
zero if it applies. Do not use a trailing zero.)
using Ratio anD PRoPoRtion
STEP 1: What is the unit of measurement the nurse
should calculate?
ml
STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
8,000 units
STEP 3: What is the dose available? Dose available = Have
10,000 units
STEP 4: Should the nurse convert the units of
measurement? No
STEP 5: What is the quantity of the dose available? = Quantity
1 ml
STEP 6: Set up the equation and solve for X.
Have = Desired
Quantity X
10,000 units = 8,000 units
1 ml X ml
X = 0.8
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 10,000 units/mL
and the prescription reads 8,000 units, it makes sense to
administer 0.8 mL. The nurse should administer heparin
injection 0.8 mL subcutaneously every 12 hr.
280 CHAPTER 48 Dosage CalCulation CONTENT MASTERY SERIES
using DesiReD oVeR HaVe
STEP 1: What is the unit of measurement the nurse
should calculate?
ml
STEP 2: What is the dose the nurse should administer?
Dose to administer = Desired
8,000 units
STEP 3: What is the dose available? Dose available = Have
10,000 units
STEP 4: Should the nurse convert the units of
measurement? No
STEP 5: What is the quantity of the dose available? = Quantity
1 ml
STEP 6: Set up an equation and solve for X.
Desired × Quantity = XHave
8,000 units × 1 ml = X ml10,000 units
0.8 = X
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 10,000 units/mL
and the prescription reads 8,000 units, it makes sense to
administer 0.8 mL. The nurse should administer heparin
injection 0.8 mL subcutaneously every 12 hr.
using DiMensional analYsis
STEP 1: What is the unit of measurement the nurse
should calculate?
ml
STEP 2: What is the quantity of the dose available? = Quantity
1 ml
STEP 3: What is the dose available? Dose available = Have
10,000 units
STEP 4: What is the dose the nurse should administer?
Dose to administer = Desired
8,000 units
STEP 5: Should the nurse convert the units of
measurement? No
STEP 6: Set up an equation and solve for X.
X = Quantity × Conversion (Have) × DesiredHave Conversion (Desired)
X ml = 1 ml × 8,000 units10,000 units
X = 0.8
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount to
administer makes sense. If there are 10,000 units/mL
and the prescription reads 8,000 units, it makes sense to
administer 0.8 mL. The nurse should administer heparin
injection 0.8 mL subcutaneously every 12 hr.
Dosages by weight
example: a nurse is preparing to administer
cefixime 8 mg/kg/day Po to divide equally every
12 hr to a toddler who weighs 22 lb. available is
cefixime suspension 100 mg/5 ml. How many
ml should the nurse administer per dose? (Round
the answer to the nearest tenth. use a leading
zero if it applies. Do not use a trailing zero.)
STEP 1: What is the unit of measurement the nurse
should calculate?
kg
STEP 2: Set up an equation and solve for X.
2.2 lb = client’s desired weight in lb
1 kg X kg
2.2 lb = 22 lb
1 kg X kg
X = 10
STEP 3: Round, if necessary.
STEP 4: Reassess to determine whether the equivalent
makes sense. If 1 kg = 2.2 lb, it makes sense that
22 lb = 10 kg.
STEP 5: What is the unit of measurement the nurse
should calculate?
mg
STEP 6: Set up an equation and solve for X.
mg × kg/day = X
8 mg × 10 kg = 80 mg1 day
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount makes
sense. If the prescription reads 8 mg/kg/day to divide
equally every 12 hr and the toddler weighs 10 kg, it makes
sense to give 80 mg/day, or 40 mg every 12 hr.
FUNDAMENTALS FOR NURSING CHAPTER 48 Dosage CalCulation 281
using Ratio anD PRoPoRtion
STEP 9: What is the unit of measurement the nurse
should calculate?
ml
STEP 10: What is the dose the nurse should administer?
Dose to administer = Desired
40 mg
STEP 11: What is the dose available? Dose available = Have
100 mg
STEP 12: Should the nurse convert the units of
measurement? No
STEP 13: What is the quantity of the dose available? = Quantity
5 ml
STEP 14: Set up the equation and solve for X.
Have = Desired
Quantity X
100 mg = 40 mg
5 ml X ml
X = 2
STEP 15: Round, if necessary.
STEP 16: Reassess to determine whether the amount
to give makes sense. If there are 100 mg/5 mL and the
prescription reads 40 mg, it makes sense to give 2 mL.
The nurse should administer cefixime suspension 2 mL PO
every 12 hr.
using DesiReD oVeR HaVe
STEP 9: What is the unit of measurement the nurse
should calculate?
ml
STEP 10: What is the dose the nurse should administer?
Dose to administer = Desired
40 mg
STEP 11: What is the dose available? Dose available = Have
100 mg
STEP 12: Should the nurse convert the units of
measurement? No
STEP 13: What is the quantity of the dose available? = Quantity
5 ml
STEP 14: Set up an equation and solve for X.
Desired × Quantity = XHave
40 mg × 5 ml = X ml100 mg
2 = X
STEP 15: Round, if necessary.
STEP 16: Reassess to determine whether the amount
to give makes sense. If there are 100 mg/5 mL and the
prescription reads 40 mg, it makes sense to give 2 mL.
The nurse should administer cefixime suspension 2 mL PO
every 12 hr.
using DiMensional analYsis
STEP 9: What is the unit of measurement the nurse
should calculate?
ml
STEP 10: What is the quantity of the dose available? = Quantity
5 ml
STEP 11: What is the dose available? Dose available = Have
100 mg
STEP 12: What is the dose the nurse should administer?
Dose to administer = Desired
40 mg
STEP 13: Should the nurse convert the units of
measurement? No
STEP 14: Set up an equation and solve for X.
X = Quantity × Conversion (Have) × DesiredHave Conversion (Desired)
X ml = 5 ml × 40 mg100 mg
X = 2
STEP 15: Round, if necessary.
STEP 16: Reassess to determine whether the amount
to give makes sense. If there are 100 mg/5 mL and the
prescription reads 40 mg, it makes sense to give 2 mL.
The nurse should administer cefixime suspension 2 mL PO
every 12 hr.
282 CHAPTER 48 Dosage CalCulation CONTENT MASTERY SERIES
IV flow rates
Nurses calculate IV flow rates for large-volume continuous
IV infusions and intermittent IV bolus infusions
using electronic infusion pumps (mL/hr) and manual
IV tubing (gtt/min).
IV INFUSIONS WITH ELECTRONIC
INFUSION PUMPS
Infusion pumps control an accurate rate of fluid infusion.
Infusion pumps deliver a specific amount of fluid during
a specific amount of time. For example, an infusion pump
can deliver 150 mL in 1 hr or 50 mL in 20 min.
example: a nurse is preparing to administer
dextrose 5% in water (D5W) 500 ml iV to infuse
over 4 hr. the nurse should set the iV infusion
pump to deliver how many ml/hr? (Round the
answer to the nearest whole number. use a leading
zero if it applies. Do not use a trailing zero.)
STEP 1: What is the unit of measurement the nurse
should calculate?
ml/hr
STEP 2: What is the volume the nurse should infuse?
500 ml
STEP 3: What is the total infusion time?
4 hr
STEP 4: Should the nurse convert the units of
measurement? No
STEP 5: Set up the equation and solve for X.
Volume (ml) = X ml/hrTime (hr)
500 ml = X ml/hr4 hr
125 = X
STEP 6: Round, if necessary.
STEP 7: Reassess to determine whether the IV flow rate
makes sense. If the prescription reads 500 mL to infuse
over 4 hr, it makes sense to administer 125 mL/hr. The
nurse should set the IV pump to deliver D5W 500 mL IV at
125 mL/hr.
example: a nurse is preparing to administer
cefotaxime 1 g intermittent iV bolus over 45 min.
available is cefotaxime 1 g in 100 ml 0.9% sodium
chloride (0.9% naCl). the nurse should set the
iV infusion pump to deliver how many ml/hr?
(Round the answer to the nearest whole number.)
STEP 1: What is the unit of measurement the nurse
should calculate?
ml/hr
STEP 2: Should the nurse convert the units of
measurement? Yes (min ≠ hr) Yes (g ≠ mL)
60 min = 1 hr 100 ml = X ml
45 min X hr 1 g 1 g
X = 0.75 X = 100
STEP 3: What is the total infusion time?
45 min
STEP 4: What is the volume the nurse should infuse?
100 ml
STEP 5: Set up an equation and solve for X.
Volume (ml) = X ml/hrTime (hr)
100 ml = X ml/hr0.75 hr
133.3333 = X
STEP 6: Round, if necessary.
133.3333 = 133
STEP 7: Reassess to determine whether the IV flow rate
makes sense. If the prescription reads 100 mL to infuse
over 45 min (0.75 hr), it makes sense to administer
133 mL/hr. The nurse should set the IV pump to deliver
cefotaxime 1 g in 100 mL of 0.9% NaCl IV at 133 mL/hr.
FUNDAMENTALS FOR NURSING CHAPTER 48 Dosage CalCulation 283
MANUAL IV INFUSIONS
If an electronic infusion pump is not available, regulate
the IV flow rate using the roller clamp on the IV tubing.
When setting the flow rate, count the number of drops
that fall into the drip chamber over 1 min. Then calculate
the flow rate using the drop factor on the manufacturer’s
package containing the administration set. The drop
factor is the number of drops per milliliter of solution.
example: a nurse is preparing to administer
lactated Ringer’s (lR) 1,500 ml iV to infuse over
10 hr. the drop factor of the manual iV tubing is
15 gtt/ml. the nurse should adjust the manual iV
infusion to deliver how many gtt/min? (Round the
answer to the nearest whole number. use a leading
zero if it applies. Do not use a trailing zero.)
using Ratio anD PRoPoRtion
anD DesiReD oVeR HaVe
STEP 1: What is the unit of measurement the nurse
should calculate?
gtt/min
STEP 2: What is the quantity of the drop factor that
is available?
15 gtt/ml
STEP 3: What is the volume the nurse should infuse?
1,500 ml
STEP 4: What is the total infusion time?
10 hr
STEP 5: Should the nurse convert the units of
measurement? No (mL = mL) Yes (hr ≠ min)
1 hr = 10 hr
60 min X min
X = 600 min
STEP 6: Set up the equation and solve for X.
Volume (ml) × Drop factor (gtt/ml) = XTime (min)
1,500 ml × 15 gtt/ml = X gtt/min600 min
37.5 = X
STEP 7: Round, if necessary.
37.5 = 38
STEP 8: Reassess to determine whether the IV flow
rate makes sense. If the prescription reads 1,500 mL to
infuse over 10 hr (600 min), it makes sense to administer
38 gtt/min. The nurse should adjust the manual IV
infusion to deliver LR 1,500 mL IV at 38 gtt/min.
using DiMensional analYsis
STEP 1: What is the unit of measurement the nurse
should calculate?
gtt/min
STEP 2: What is the quantity of the drop factor that
is available?
15 gtt/ml
STEP 3: What is the total infusion time?
10 hr
STEP 4: What is the volume the nurse should infuse?
1,500 ml
STEP 5: Should the nurse convert the units of
measurement? No (mL = mL) Yes (hr ≠ min)
1 hr = 10 hr
60 min X min
X = 600 min
STEP 6: Set up the equation and solve for X.
X = Quantity × Conversion (Have) × Volume
1 ml Conversion (Desired) Time
X gtt/min = 15 gtt × 1 hr × 1,500 ml
1 ml 60 min 10 hr
X = 37.5
STEP 7: Round, if necessary.
37.5 = 38
STEP 8: Reassess to determine whether the IV flow
rate makes sense. If the prescription reads 1,500 mL to
infuse over 10 hr (600 min), it makes sense to administer
38 gtt/min. The nurse should adjust the manual IV
infusion to deliver LR 1,500 mL IV at 38 gtt/min.
284 CHAPTER 48 Dosage CalCulation CONTENT MASTERY SERIES
example: a nurse is preparing to administer
ranitidine 150 mg by intermittent iV bolus. available
is ranitidine 150 mg in 100 ml of 0.9% sodium
chloride (0.9% naCl) to infuse over 30 min. the
drop factor of the manual iV tubing is 10 gtt/ml.
the nurse should adjust the manual iV infusion
to deliver how many gtt/min? (Round the answer
to the nearest whole number. use a leading
zero if it applies. Do not use a trailing zero.)
using Ratio anD PRoPoRtion
anD DesiReD oVeR HaVe
STEP 1: What is the unit of measurement the nurse
should calculate?
gtt/min
STEP 2: Should the nurse convert the units of
measurement? Yes (mg ≠ mL)
150 mg = 150 mg
100 ml X ml
X = 100
STEP 3: What is the total infusion time?
30 min
STEP 4: What is the quantity of the drop factor that
is available?
10 gtt/ml
STEP 5: What is the volume the nurse should infuse?
100 ml
STEP 6: Set up an equation and solve for X.
Volume (ml) × Drop factor (gtt/ml) = XTime (min)
100 ml × 10 gtt/ml = X gtt/min30 min
33.3333 = X
STEP 7: Round, if necessary.
33.3333 = 33
STEP 8: Reassess to determine whether the IV flow rate
makes sense. If the amount prescribed is 100 mL to infuse
over 30 min, it makes sense to administer 33 gtt/min.
The nurse should adjust the manual IV infusion to deliver
ranitidine 150 mg in 100 mL of 0.9% NaCl IV at 33 gtt/min.
using DiMensional analYsis
STEP 1: What is the unit of measurement to calculate?
gtt/min
STEP 2: What is the quantity of the drop factor that
is available?
10 gtt/ml
STEP 3: What is the total infusion time?
30 min
STEP 4: Should the nurse convert the units of
measurement? Yes (mg ≠ mL)
150 mg = 150 mg
100 ml X ml
X = 100
STEP 5: What is the volume the nurse should infuse?
100 ml
STEP 6: Set up an equation and solve for X.
X = Quantity × Conversion (Have) × Volume
1 ml Conversion (Desired) Time
X gtt/min = 10 gtt × 100 ml
1 ml 30 min
X = 33.3333
STEP 7: Round, if necessary.
33.3333 = 33
STEP 8: Reassess to determine whether the IV flow rate
makes sense. If the amount prescribed is 100 mL to infuse
over 30 min, it makes sense to administer 33 gtt/min.
The nurse should adjust the manual IV infusion to deliver
ranitidine 150 mg in 100 mL of 0.9% NaCl IV at 33 gtt/min.
FUNDAMENTALS FOR NURSING CHAPTER 48 Dosage CalCulation 285
Application Exercises
1. a nurse is preparing to administer
methylprednisolone 10 mg by
iV bolus. the amount available
is methylprednisolone injection
40 mg/ml. How many ml should
the nurse administer? (Round
the answer to the nearest tenth.
Do not use a trailing zero.)
2. a nurse is preparing to administer
lactated Ringer’s (lR) iV 100 ml
over 15 min. the nurse should set
the iV infusion pump to deliver how
many ml/hr? (Round the answer
to the nearest whole number.
Do not use a trailing zero.)
3. a nurse is preparing to administer
0.9% sodium chloride (0.9% naCl)
250 ml iV to infuse over 30 min. the
drop factor of the manual iV tubing
is 10 gtt/ml. the nurse should
adjust the manual iV infusion to
deliver how many gtt/min? (Round
the answer to the nearest whole
number. Do not use a trailing zero.)
4. a nurse is preparing to administer
metoprolol 200 mg Po daily. the
amount available is metoprolol
100 mg/tablet. How many tablets
should the nurse administer? (Round
the answer to the nearest whole
number. Do not use a trailing zero.)
5. a nurse is preparing to administer
ketorolac 0.5 mg/kg iV bolus every
6 hr to a school‑age child who
weighs 66 lb. the amount available
is ketorolac injection 30 mg/ml. How
many ml should the nurse administer
per dose? (Round the answer to the
nearest tenth. use a leading zero if it
applies. Do not use a trailing zero.)
6. a nurse is preparing to administer
dextrose 5% in water (D5W) 1,000 ml
iV to infuse over 10 hr. the nurse
should set the iV infusion pump to
deliver how many ml/hr? (Round
the answer to the nearest whole
number. Do not use a trailing zero.)
7. a nurse is preparing to administer
acetaminophen 320 mg Po every 4 hr
PRn for pain. the amount available is
acetaminophen liquid 160 mg/5 ml.
How many ml should the nurse
administer per dose? (Round
the answer to the nearest whole
number. Do not use a trailing zero.)
8. a nurse is preparing to administer
dextrose 5% in lactated Ringer’s
(D5lR) 1,000 ml to infuse over 6 hr.
the drop factor of the manual iV
tubing is 15 gtt/ml. the nurse should
adjust the manual iV infusion to
deliver how many gtt/min? (Round
the answer to the nearest whole
number. Do not use a trailing zero.)
286 CHAPTER 48 Dosage CalCulation CONTENT MASTERY SERIES
Application Exercises Key
1. 0.3 ml
Using Ratio and Proportion
STEP 1: What is the unit of measurement
the nurse should calculate? ml
STEP 2: What is the dose the
nurse should administer? Dose to
administer = Desired = 10 mg
STEP 3: What is the dose available?
Dose available = Have = 40 mg
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: What is the quantity of the
dose available? = Quantity = 1 ml
STEP 6: set up the equation and solve for X.
Have = Desired
Quantity X
40 mg
×
10 mg
1 ml X ml
X = 0.25
STEP 7: Round, if necessary. 0.25 = 0.3
STEP 8: Reassess to determine whether
the amount to administer makes sense. if
there are 40 mg/ml and the prescription
reads 10 mg, it makes sense to administer
0.3 ml. the nurse should administer
methylprednisolone injection 0.3 ml by iV bolus.
Using Desired Over Have
STEP 1: What is the unit of measurement
the nurse should calculate? ml
STEP 2: What is the dose the
nurse should administer? Dose to
administer = Desired = 10 mg
STEP 3: What is the dose available?
Dose available = Have = 40 mg
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: What is the quantity of the
dose available? = Quantity = 1 ml
STEP 6: set up an equation and solve for X.
Desired × Quantity =
10 mg × 1 ml
= X ml
Have 40 mg
0.25 = X
STEP 7: Round, if necessary. 0.25 = 0.3
STEP 8: Reassess to determine whether
the amount to administer makes sense. if
there are 40 mg/ml and the prescription
reads 10 mg, it makes sense to administer
0.3 ml. the nurse should administer
methylprednisolone injection 0.3 ml by iV bolus.
Using Dimensional Analysis
STEP 1: What is the unit of measurement
the nurse should calculate? ml
STEP 2: What is the quantity of the
dose available? = Quantity = 1 ml
STEP 3: What is the dose available?
Dose available = Have = 40 mg
STEP 4: What is the dose the
nurse should administer? Dose to
administer = Desired = 10 mg
STEP 5: should the nurse convert
the units of measurement? no
STEP 6: set up an equation and solve for X.
X = Quantity × Conversion (Have) × Desired
Have Conversion (Desired)
X ml =
1 ml
× 10 mg
40 mg
X = 0.25
STEP 7: Round, if necessary. 0.25 = 0.3
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there
are 40 mg/ml and the prescription reads 10
mg, it makes sense to administer 0.3 ml. the
nurse should administer methylprednisolone
injection 0.3 ml by iV bolus.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
2. 400 ml/hr
STEP 1: What is the unit
of measurement the nurse
should calculate? ml/hr
STEP 2: What is the volume the
nurse should infuse? 100 ml
STEP 3: What is the total
infusion time? 15 min
STEP 4: should the nurse convert
the units of measurement?
no (ml = ml)
Yes (min ≠ hr)
60 min
=
1 hr
15 min X hr
X = 0.25
STEP 5: set up an equation
and solve for X.
Volume (ml) = X ml/hr
Time (hr)
100 ml
= X ml/hr0.25 hr
400 = X
STEP 6: Round, if necessary.
STEP 7: Reassess to determine
whether the iV flow rate makes
sense. if the prescription reads
100 ml to infuse over 15 min
(0.25 hr), it makes sense to
administer 400 ml/hr. the nurse
should set the iV pump to deliver
lR 100 ml iV at 400 ml/hr.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
3. 83 gtt/min
Using Ratio and Proportion and Desired Over Have
STEP 1: What is the unit of measurement the
nurse should calculate? gtt/min
STEP 2: What is the quantity of the drop factor that is available? 10 gtt/ml
STEP 3: What is the volume the nurse should infuse? 250 ml
STEP 4: What is the total infusion time? 30 min
STEP 5: should the nurse convert the units of measurement? no
STEP 6: set up an equation and solve for X.
Volume (ml) × Drop factor (gtt/ml) = X
Time (min)
250 ml
× 10 gtt/ml = X gtt/ml30 min
83.3333 = X
STEP 7: Round, if necessary. 83.3333 = 83
STEP 8: Reassess to determine whether the iV flow rate makes
sense. if the amount prescribed is 250 ml to infuse over 30 min, it
makes sense to administer 83 gtt/min. the nurse should adjust the
manual iV infusion to deliver 0.9% naCl 250 ml at 83 gtt/min.
Using Dimensional Analysis
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the quantity of the drop factor that is available? 10 gtt/ml
STEP 3: What is the total infusion time? 30 min
STEP 4: What is the volume the nurse should infuse? 250 ml
STEP 5: should the nurse convert the units of measurement? no
STEP 6: set up an equation and solve for X.
X = Quantity × Conversion (Have) × Volume
1 ml Conversion (Desired) Time
X gtt/min =
10 gtt
×
250 ml
1 ml 30 min
X = 83.3333
STEP 7: Round, if necessary. 83.3333 = 83
STEP 8: Reassess to determine whether the iV flow rate makes
sense. if the amount prescribed is 250 ml to infuse over 30 min, it
makes sense to administer 83 gtt/min. the nurse should adjust the
manual iV infusion to deliver 0.9% naCl 250 ml at 83 gtt/min.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
FUNDAMENTALS FOR NURSING CHAPTER 48 Dosage CalCulation 287
4. 2 tablets
Using Ratio and Proportion
STEP 1: What is the unit of measurement
the nurse should calculate? tablets
STEP 2: What is the dose the
nurse should administer? Dose to
administer = Desired = 200 mg
STEP 3: What is the dose available?
Dose available = Have = 100 mg
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: What is the quantity of the dose
available? = Quantity = 1 tablet
STEP 6: set up the equation and solve for X.
Have = Desired
Quantity X
100 mg
×
200 mg
1 tablet X tablets
X = 2
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there are
100 mg/tablet and the prescription reads 200 mg,
it makes sense to administer 2 tablets. the nurse
should administer metoprolol 2 tablets daily.
Using Desired Over Have
STEP 1: What is the unit of measurement
the nurse should calculate? tablets
STEP 2: What is the dose the nurse should
administer? Dose to administer = Desired = 200 mg
STEP 3: What is the dose available?
Dose available = Have = 100 mg
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: What is the quantity of the dose
available? = Quantity = 1 tablet
STEP 6: set up the equation and solve for X.
Desired × Quantity = X
Have
200 mg × 1 tablet
= X tablets100 mg
2 = X
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there are
100 mg/tablet and the prescription reads 200 mg,
it makes sense to administer 2 tablets. the nurse
should administer metoprolol 2 tablets daily.
Using Dimensional Analysis
STEP 1: What is the unit of measurement
the nurse should calculate? tablets
STEP 2: What is the quantity of the dose
available? = Quantity = 1 tablet
STEP 3: What is the dose available?
Dose available = Have = 100 mg
STEP 4: What is the dose the nurse should
administer? Dose to administer = Desired = 200 mg
STEP 5: should the nurse convert the
units of measurement? no
STEP 6: set up the equation and solve for X.
X = Quantity × Conversion (Have) × Desired
Have Conversion (Desired)
X tablets =
1 tablet
× 200 mg
100 mg
X = 2
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there are
100 mg/tablet and the prescription reads 200 mg,
it makes sense to administer 2 tablets. the nurse
should administer metoprolol 2 tablets daily.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
5. 0.5 ml
STEP 1: What is the unit of measurement the nurse should calculate? kg
STEP 2: set up an equation and solve for X.
2.2 lb
= client’s weight in lb
1 kg X kg
2.2 lb
×
66 lb
1 kg X kg
X = 30
STEP 3: Round, if necessary.
STEP 4: Reassess to determine whether the equivalent makes
sense. if 1 kg = 2.2 lb, it makes sense that 66 lb = 30 kg.
STEP 5: What is the unit of measurement the nurse should calculate? mg
STEP 6: set up an equation and solve for X.
mg × kg = X
0.5 mg × 30 kg = 15 mg
15 = X
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the amount makes
sense. if the prescription reads 0.5 mg/kg every 6 hr and the
school‑age child weighs 30 kg, it makes sense to give 15 mg.
Using Ratio and Proportion
STEP 9: What is the unit of measurement the nurse should calculate? ml
STEP 10: What is the dose the nurse should administer?
Dose to administer = Desired = 15 mg
STEP 11: What is the dose available? Dose available = Have = 30 mg
STEP 12: should the nurse convert the units of measurement? no
STEP 13: What is the quantity of the dose available? = Quantity = 1 ml
STEP 14: set up the equation and solve for X.
Have = Desired
Quantity X
30 mg
×
15 mg
1 ml X ml
X = 0.5
STEP 15: Round, if necessary.
STEP 16: Reassess to determine whether the amount makes sense. if the
prescription reads 0.5 mg/kg every 6 hr and the school‑age child weighs
30 kg, it makes sense to give 15 mg. if there are 30 mg in 1 ml, it makes sense
to give 0.5 ml. the nurse should give ketorolac 0.5 ml iV bolus every 6 hr.
Using Desired Over Have
STEP 9: What is the unit of measurement the nurse should calculate? ml
STEP 10: What is the dose the nurse should administer?
Dose to administer = Desired = 15 mg
STEP 11: What is the dose available? Dose available = Have = 30 mg
STEP 12: should the nurse convert the units of measurement? no
STEP 13: What is the quantity of the dose available? = Quantity = 1 ml
STEP 14: set up an equation and solve for X.
Desired × Quantity = X
Have
15 mg × 1 ml
= X ml30 mg
0.5 = X
STEP 15: Round, if necessary.
STEP 16: Reassess to determine whether the amount makes sense. if the
prescription reads 0.5 mg/kg every 6 hr and the school‑age child weighs
30 kg, it makes sense to give 15 mg. if there are 30 mg in 1 ml, it makes sense
to give 0.5 ml. the nurse should give ketorolac 0.5 ml iV bolus every 6 hr.
Using Dimensional Analysis
STEP 9: What is the unit of measurement the nurse should calculate? ml
STEP 10: What is the quantity of the dose available? = Quantity = 1 ml
STEP 11: What is the dose available? Dose available = Have = 30 mg
STEP 12: What is the dose the nurse should administer?
Dose to administer = Desired = 15 mg
STEP 13: should the nurse convert the units of measurement? no
STEP 14: set up an equation and solve for X.
X = Quantity × Conversion (Have) × Desired
Have Conversion (Desired)
X ml =
1 ml
× 15 mg
30 mg
X = 0.5
STEP 15: Round, if necessary.
STEP 16: Reassess to determine whether the amount makes sense. if the
prescription reads 0.5 mg/kg every 6 hr and the school‑age child weighs
30 kg, it makes sense to give 15 mg. if there are 30 mg in 1 ml, it makes sense
to give 0.5 ml. the nurse should give ketorolac 0.5 ml iV bolus every 6 hr.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
288 CHAPTER 48 Dosage CalCulation CONTENT MASTERY SERIES
6. 100 ml/hr
STEP 1: What is the unit of measurement
the nurse should calculate? ml/hr
STEP 2: What is the volume the nurse
should infuse? 1,000 ml
STEP 3: What is the total infusion time? 10 hr
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: set up an equation and solve for X.
Volume (ml) = X ml/hr
Time (hr)
1,000 ml
= X ml/hr10 hr
100 = X
STEP 6: Round, if necessary.
STEP 7: Reassess to determine whether the iV
flow rate makes sense. if the prescription reads
1,000 ml to infuse over 10 hr, it makes sense to
administer 100 ml/hr. the nurse should set the iV
pump to deliver D5W 1,000 ml iV at 100 ml/hr.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
7. 10 ml
Using Ratio and Proportion
STEP 1: What is the unit of measurement
the nurse should calculate? ml
STEP 2: What is the dose the
nurse should administer? Dose to
administer = Desired = 320 mg
STEP 3: What is the dose available?
Dose available = Have = 160 mg
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: What is the quantity of the
dose available? = Quantity = 5 ml
STEP 6: set up the equation and solve for X.
Have = Desired
Quantity X
160 mg
×
320 mg
5 ml X ml
X = 10
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there
are 160 mg/5 ml and the prescription reads
320 mg, it makes sense to administer 10 ml.
the nurse should administer acetaminophen
liquid 10 ml Po every 4 hr PRn for pain.
Using Desired Over Have
STEP 1: What is the unit of measurement
the nurse should calculate? ml
STEP 2: What is the dose the
nurse should administer? Dose to
administer = Desired = 320 mg
STEP 3: What is the dose available?
Dose available = Have = 160 mg
STEP 4: should the nurse convert the
units of measurement? no
STEP 5: What is the quantity of the
dose available? = Quantity = 5 ml
STEP 6: set up the equation and solve for X.
Desired × Quantity = X
Have
320 mg × 5 ml
= X ml160 mg
10 = X
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there
are 160 mg/5 ml and the prescription reads
320 mg, it makes sense to administer 10 ml.
the nurse should administer acetaminophen
liquid 10 ml Po every 4 hr PRn for pain.
Using Dimensional Analysis
STEP 1: What is the unit of measurement
the nurse should calculate? ml
STEP 2: What is the quantity of the
dose available? = Quantity = 5 ml
STEP 3: What is the dose available?
Dose available = Have = 160 mg
STEP 4: What is the dose the
nurse should administer? Dose to
administer = Desired = 320 mg
STEP 5: should the nurse convert the
units of measurement? no
STEP 6: set up the equation and solve for X.
X = Quantity × Conversion (Have) × Desired
Have Conversion (Desired)
X ml =
5 ml
× 320 mg
160 mg
X = 10
STEP 7: Round, if necessary.
STEP 8: Reassess to determine whether the
amount to administer makes sense. if there
are 160 mg/5 ml and the prescription reads
320 mg, it makes sense to administer 10 ml.
the nurse should administer acetaminophen
liquid 10 ml Po every 4 hr PRn for pain.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
8. 42 gtt/min
Using Ratio and Proportion and Desired Over Have
STEP 1: What is the unit of measurement the
nurse should calculate? gtt/min
STEP 2: What is the quantity of the drop factor that is available? 15 gtt/ml
STEP 3: What is the volume the nurse should infuse? 1,000 ml
STEP 4: What is the total infusion time? 6 hr
STEP 5: should the nurse convert the units of
measurement? no (ml = ml) Yes (hr ≠ min)
1 hr
=
6 hr
60 min X hr
X = 360 min
STEP 6: set up an equation and solve for X.
Volume (ml) × Drop factor (gtt/ml) = X
Time (min)
1,000 ml
× 15 gtt/ml = X gtt/ml360 min
41.6666 = X
STEP 7: Round, if necessary. 41.6666 = 42
STEP 8: Reassess to determine whether the iV flow rate makes sense.
if the amount prescribed is 1,000 ml to infuse over 6 hr (360 min),
it makes sense to administer 42 gtt/min. the nurse should adjust
the manual iV infusion to deliver D5lR 1,000 ml at 42 gtt/min.
Using Dimensional Analysis
STEP 1: What is the unit of measurement to calculate? gtt/min
STEP 2: What is the quantity of the drop factor that is available? 15 gtt/ml
STEP 3: What is the total infusion time? 6 hr
STEP 4: What is the volume the nurse should infuse? 1,000 ml
STEP 5: should the nurse convert the units of
measurement? no (ml = ml) Yes (hr ≠ min)
1 hr
=
6 hr
60 min X hr
X = 360 min
STEP 6: set up an equation and solve for X.
X = Quantity × Conversion (Have) × Volume
1 ml Conversion (Desired) Time
X gtt/min =
15 gtt
×
1 hr
×
1,000 ml
1 ml 60 min 6 hr
X = 41.6666
STEP 7: Round, if necessary. 41.6666 = 42
STEP 8: Reassess to determine whether the iV flow rate makes sense.
if the amount prescribed is 1,000 ml to infuse over 6 hr (360 min),
it makes sense to administer 42 gtt/min. the nurse should adjust
the manual iV infusion to deliver D5lR 1,000 ml at 42 gtt/min.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Dosage Calculation
FUNDAMENTALS FOR NURSING CHAPTER 49 Intravenous therapy 289
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
CHAPTER 49 Intravenous Therapy
Intravenous (Iv) therapy involves infusing fluids
via an Iv catheter to administer medications,
supplement fluid intake, or provide fluid
replacement, electrolytes, or nutrients.
nurses administer large‑volume Iv infusions, as
well as Iv boluses, usually in a small amount of
fluid. nurses or pharmacists mix Iv medication in
a large volume of fluid to give as a continuous Iv
infusion or intermittently in a small amount of fluid.
proCeDure
● The provider prescribes the type of IV fluid, the volume
to infuse, and either the rate at which to infuse the IV
fluid or the total amount of time it should take to infuse
the fluid. The nurse regulates the IV infusion, either
with an IV pump or manually, to be sure to deliver the
right amount.
● Nurses administer large‑volume IV infusions on a
continuous basis, such as 0.9% sodium chloride IV to
infuse at 100 mL/hr or 0.9% sodium chloride 500 mL to
give IV over 3 hr.
● A fluid bolus is a large amount of IV fluid to give in a
short time, usually less than 1 hr. A fluid bolus rapidly
replaces fluid loss from dehydration, shock, hemorrhage,
burns, or trauma. A large‑gauge catheter (18‑gauge
or larger) is essential for maintaining the rapid rate
necessary to give a fluid bolus to an adult.
● Nurses administer medications as an IV bolus,
giving the medication in a small amount of solution,
concentrated or diluted, and injecting it over a short
time (1 to 2 min).
ADVANTAGES
● Rapid absorption and onset of action
● Constant therapeutic blood levels
● Less irritation to subcutaneous and muscle tissue
DISADVANTAGES
● Circulatory fluid overload is possible if the volume of
solution is large or the infusion rate is rapid.
● Immediate absorption leaves little time to correct errors.
● Solutions and IV catheters can irritate the lining of
the vein.
● Failure to maintain surgical asepsis can lead to local
and systemic infection.
CONSIDERATIONS
nursInG aCtIons
Nurses administer IV medication infusions in the
following ways.
● Giving the medication the pharmacist mixed in a large
volume of fluid (500 to 1,000 mL) as a continuous IV
infusion, such as potassium chloride and vitamins
● Delivering the medication in premixed solution bags
from the medication’s manufacturer
Administering volume-controlled infusions
● Giving some medications, such as antibiotics,
intermittently in a small amount of solution (25 to
250 mL) through a continuous IV fluid system or with
saline or heparin lock systems
● Infusing the medications for short periods of time and
on a schedule
● Using a secondary (“piggyback”) IV bag or bottle or
tandem setup, a volume‑control administration set, or a
mini‑infusion pump
Giving an IV bolus dose
● Injecting the medications in small amounts of solution,
concentrated or diluted, over a short time (1 to 2 min)
● Administering medications directly into the peripheral
IV or access port to achieve an immediate medication
level in the bloodstream, such as with pain medication
● Preparing medications in the correct concentration and
at a safe rate (amount of medication per minute)
● Using extreme caution and observing for adverse
reactions or complications such as redness, burning, or
increasing pain
Older adult clients, clients taking anticoagulants,
or clients who have fragile veins
● Avoid tourniquets.
● Use a blood pressure cuff instead.
● Do not slap the extremity to visualize veins.
● Avoid rigorous friction while cleaning the site.
Edema in extremities
● Apply digital pressure over the selected vein to
displace edema.
● Apply pressure with a swab of cleaning solution.
● Cannulate the vein quickly.
Clients who are obese
Use anatomical landmarks to find veins.
CHAPTER 49
290 CHAPTER 49 Intravenous therapy CONTENT MASTERY SERIES
preproCeDure
EQUIPMENT
● IV start kit if available: Tourniquet, sterile drape,
antiseptic swabs, transparent dressing, small roll of
sterile tape, 2x2 or 4x4 gauze sponges, and safety
positioning device.
● Correct size catheter
◯ 16‑gauge for clients who have trauma, rapid fluid volume
◯ 18‑ to 20‑gauge for clients who are having surgery,
rapid blood administration
◯ 22‑ to 24‑gauge for other clients (children, adults)
● Tubing
● Prefilled syringe containing 1 to 3 mL of 0.9% sodium
chloride solution
● Infusion pump
● Clean gloves
● Scissors or electric shaver for hair removal
NURSING ACTIONS
● Check the prescription (solution, rate).
● Identify allergies to latex or tape.
● Follow the rights of medication administration.
● Check compatibilities of IV solutions and medications.
● Perform hand hygiene.
● Examine the IV solution for clarity, leaks, and
expiration date.
● Don clean gloves.
● Evaluate extremities and veins. Clip hair at and around
the insertion site with scissors. Do not shave the area
because an abrasion can occur, increasing the risk
of infection.
CLIENT EDUCATION
● Identify the client and explain the procedure.
● Place the client in a comfortable position.
IntraproCeDure
NURSING ACTIONS
● Apply a clean tourniquet or blood pressure cuff
(especially for older adults) 10 to 15 cm (4 to 6 in) above
the insertion site to compress only venous blood flow.
● Select the vein by using visualization, gravity, fist
clenching, friction with the cleaning solution, or heat
and choose
◯ Distal veins first on the nondominant hand
◯ A site that is not painful or bruised and will not
interfere with activity
◯ A vein that is resilient with a soft, bouncy sensation
on palpation
◯ Avoid the following.
■ Varicose veins that are permanently dilated
and tortuous
■ Veins in the inner wrist with bifurcations, in flexion
areas, near valves (appearing as bumps), in lower
extremities, and in the antecubital fossa (except for
emergency access)
■ Veins in the back of the hand
■ Veins that are sclerosed or hard
■ Veins in an extremity with impaired sensitivity
(scar tissue, paralysis), lymph nodes removed,
recent infiltration, a PICC line, or an arteriovenous
fistula or graft
■ Veins that had previous venipunctures
● Untie the tourniquet or deflate the blood pressure cuff.
● Cleanse the area at the site using friction in a
circular motion from the middle and outwardly with
chlorhexidine or the cleaning agent the facility’s
protocol specifies. Allow it to air dry for 1 to 2 min.
● Remove the cover from the catheter, grasp the plastic
hub, and examine the device for smooth edges.
● Retie the tourniquet or reinflate the blood pressure cuff.
● Anchor the vein below the site of insertion.
● Pull the skin taut and hold it.
● Warn the client of a sharp, quick stick.
● Use a steady, smooth motion to insert the catheter into
the skin at an angle of 10° to 30° with the bevel up.
● Advance the catheter through the skin and into the vein,
maintaining a 10° to 30° angle. A flashback of blood will
confirm placement in the vein.
● Lower the hub of the catheter close to the skin to
prepare for threading it into the vein approximately
0.6 cm (0.24 in).
● Loosen the needle from the catheter and pull back
slightly on the needle so that it no longer extends past
the tip of the catheter.
● Use the thumb and index finger to advance the
catheter into the vein until the hub rests against the
insertion site.
● Stabilize the IV catheter with one hand and release the
tourniquet or blood pressure cuff with the other.
● Apply pressure approximately 3 cm (1.2 in) above the
insertion site with the middle finger and stabilize the
catheter with the index finger.
● Remove the needle and activate the safety device.
● Maintain pressure above the IV site and connect the
appropriate equipment to the hub of the IV catheter.
● Apply a dressing and leave it in place until catheter
removal, unless it becomes damp, loose, or soiled.
● Avoid encircling the entire extremity with tape and
taping under the sterile dressing.
● For a continuous IV infusion, regulate the infusion rate
according to the prescription.
● Dispose of used equipment and supplies.
● Document the following in the medical record.
◯ The date and time of insertion
◯ The insertion site and appearance
◯ The catheter’s size
◯ The type of dressing
◯ The IV fluid and rate
◯ The number, locations, and conditions of previously
attempted catheterizations
◯ The client’s response
sample documentation: 6/1/20XX, 1635,
Inserted #22‑gauge Iv catheter into left wrist
cephalic vein (one attempt); applied sterile
occlusive dressing. Iv dextrose 5% in lactated
ringer’s infusing at 100 mL/hr per infusion
pump without redness or edema at the site.
tolerated without complications. s. velez, rn
FUNDAMENTALS FOR NURSING CHAPTER 49 Intravenous therapy 291
postproCeDure
NURSING ACTIONS
● Maintaining the patency of
IV access
◯ Do not stop a continuous
infusion or allow blood to back
up into the catheter for any
length of time. Clots can form at
the tip of the needle or catheter
and lodge against the vein’s
wall, blocking the flow of fluid.
◯ Instruct clients not to
manipulate the flow rate device,
change the settings on the IV
pump, or lie on the tubing.
◯ Make sure the IV insertion site’s
dressing is not too tight.
◯ Flush intermittent IV catheters
with the appropriate solution
after every medication
administration or every 8 to
12 hr when not in use, according
to the facility’s policy.
◯ Monitor the site and infusion
rate at least every hour.
● Discontinuing IV therapy
◯ Check the prescription.
◯ Prepare the equipment.
◯ Perform hand hygiene.
◯ Don clean gloves.
◯ Clamp the IV tubing.
◯ Remove the tape and dressing, stabilizing the
IV catheter.
◯ Apply a sterile gauze pad over the site without putting
pressure on the vein. Do not use alcohol.
◯ Using the other hand, withdraw the catheter by
pulling it straight back from the site, keeping the hub
parallel to the skin.
◯ Elevate the extremity and apply pressure for 2 to
3 min and until bleeding stops.
◯ Examine the site.
◯ Apply tape over the gauze.
◯ Use a pressure dressing, if necessary.
◯ Check the catheter for intactness.
◯ Dispose of the catheter in the designated
puncture‑resistant receptacle, and the IV solution and
equipment in the appropriate location.
◯ Document.
types oF Iv aCCess
● Peripheral vein via a catheter
● Jugular or subclavian vein via a central venous
access device
GUIDELINES FOR SAFE
IV MEDICATION ADMINISTRATION
● Use an infusion pump to administer medications that
can cause serious adverse reactions, such as potassium
chloride. Never administer them by IV bolus.
● Never administer IV medications through tubing
that is infusing blood, blood products, or parenteral
nutrition solutions.
● Verify the compatibility of medications with IV solutions
before infusing a medication through tubing that is
infusing another medication or IV fluid.
neeDLestICK preventIon
● Be familiar with IV insertion equipment.
● Do not use needles when needleless systems are
available. (49.1)
● Use protective safety devices when available.
● Dispose of needles immediately in designated
puncture‑resistant receptacles.
● Do not break, bend, or recap needles.
Online Image: Needleless Injection System
49.1 Needleless injection system
292 CHAPTER 49 Intravenous therapy CONTENT MASTERY SERIES
preventInG Iv InFeCtIons
● Perform hand hygiene before and after handling
IV systems.
● Use standard precautions.
● Change IV sites according to the facility’s policy (usually
every 72 hr).
● Replace continuous and intermittent infusion tubing
according to the facility’s policy (usually every 24 or
48 hr).
● Remove catheters as soon as there is no clinical need
for them.
● Replace catheters when suspecting any break in surgical
aseptic technique, such as during emergency insertions.
● Use a sterile needle or catheter for each
insertion attempt.
● Avoid writing on IV bags with pens or markers, because
ink can contaminate the solution.
● Change tubing immediately for potential contamination.
● Do not allow fluids to hang for more than 24 hr unless
it is a closed system (pressure bags for hemodynamic
monitoring).
● Wipe all ports with alcohol or an antiseptic swab before
connecting IV lines or inserting a syringe to prevent the
introduction of micro‑organisms into the system.
● Never disconnect tubing for convenience or to reposition
the client.
COMPLICATIONS
Complications require notification of the provider
and documentation. Use new tubing and catheters for
restarting IV infusions after detecting complications.
Infiltration or extravasation
Pallor, local swelling at the site, decreased skin
temperature around the site, damp dressing, slowed rate
of infusion
TREATMENT
● Stop the infusion and remove the catheter.
● Elevate the extremity.
● Encourage active range of motion.
● Apply a warm or cold compress depending on the
solution infusing.
● Restart the infusion proximal to the site or in
another extremity.
PREVENTION
● Carefully select the site and catheter.
● Secure the catheter.
Phlebitis or thrombophlebitis
Edema; throbbing, burning, or pain at the site; increased
skin temperature; erythema; a red line up the arm with a
palpable band at the vein site; slowed rate of infusion
TREATMENT
● Promptly discontinue the infusion and remove
the catheter.
● Elevate the extremity.
● Apply warm compresses three to four times/day.
● Restart the infusion in a different vein proximal to the
site or in another extremity.
● Obtain a specimen for culture at the site and prepare the
catheter for culture if drainage is present.
PREVENTION
● Rotate sites at least every 72 hr or sooner according to
the facility’s policy.
● Avoid the lower extremities.
● Use hand hygiene.
● Use surgical aseptic technique.
Hematoma
Ecchymosis at the site
TREATMENT
● Do not apply alcohol.
● Apply pressure after IV catheter removal.
● Use a warm compress and elevation after the
bleeding stops.
PREVENTION
● Minimize tourniquet time.
● Remove the tourniquet before starting the IV infusion.
● Maintain pressure after IV catheter removal.
Fluid overload
Distended neck veins, increased blood pressure,
tachycardia, shortness of breath, crackles in the lungs,
edema, additional findings varying with the IV solution
TREATMENT
● Stop the infusion.
● Raise the head of the bed.
● Measure vital signs and oxygen saturation.
● Adjust the rate after correcting fluid overload.
● Administer diuretics.
PREVENTION
● Use an infusion pump.
● Monitor I&O.
FUNDAMENTALS FOR NURSING CHAPTER 49 Intravenous therapy 293
Cellulitis
Pain, warmth, edema, induration, red streaking, fever,
chills, malaise
TREATMENT
● Discontinue the infusion and remove the catheter.
● Elevate the extremity.
● Apply warm compresses three to four times/day.
● Obtain a specimen for culture at the site and prepare the
catheter for culture if drainage is present.
● Administer the following.
◯ Antibiotics
◯ Analgesics
◯ Antipyretics
PREVENTION
● Rotate sites at least every 72 hr.
● Avoid the lower extremities.
● Use hand hygiene.
● Use surgical aseptic technique.
Catheter embolus
Missing catheter tip on removal, severe pain at the site
with migration, absence of findings if no migration
TREATMENT
● Place a tourniquet high on the extremity to limit
venous flow.
● Prepare for removal under x‑ray or via surgery.
● Save the catheter after removal to determine the cause.
PREVENTION: Do not reinsert the stylet into the catheter.
Application Exercises
1. a nurse is demonstrating how to
insert an Iv catheter. Which of the
following statements by a nurse
viewing the demonstration indicates
understanding of the procedure?
a. “I will thread the needle all
the way into the vein until
the hub rests against the
insertion site after I see
a flashback of blood.”
B. “I will insert the needle into the
client’s skin at an angle of 10 to
30 degrees with the bevel up.”
C. “I will apply pressure
approximately 1.2 inches
below the insertion site prior
to removing the needle.”
D. “I will choose a vein in the
antecubital fossa for Iv
insertion due to its size and
easily accessible location.”
2. a nurse is collecting data from a
client who is receiving Iv therapy
and reports pain in his arm, chills,
and “not feeling well.” the nurse
notes warmth, edema, induration,
and red streaking on the client’s
arm close to the Iv insertion site.
Which of the following actions
should the nurse plan to take first?
a. obtain a specimen for culture.
B. apply a warm compress.
C. administer analgesics.
D. Discontinue the infusion.
3. During new employee orientation,
a nurse is explaining how to
prevent Iv infections. Which of
the following statements by an
orientee indicates understanding
of the preventive strategies?
a. “I will leave the Iv catheter
in place after the client
completes the course
of Iv antibiotics.”
B. “as long as I am working with
the same client, I can use
the same Iv catheter for my
second insertion attempt.”
C. “If my client needs to use
the rest room, it would be
safer to disconnect his Iv
infusion as long as I clean
the injection port thoroughly
with an antiseptic swab.”
D. “I will replace any Iv catheter
when I suspect contamination
during insertion.”
4. a nurse on the Iv team is conducting
an in‑service education program
about the complications of Iv therapy.
Which of the following statements
by an attendee indicates an
understanding of the manifestations
of infiltration? (select all that apply.)
a. “the temperature around
the Iv site is cooler.”
B. “the rate of the
infusion increases.”
C. “the skin at the Iv site is red.”
D. “the Iv dressing is damp.”
e. “the tissue around the
venipuncture site is swollen.”
5. a nurse is caring for a client receiving
dextrose 5% in 0.9% sodium chloride
Iv at 120 mL/hr. Which of the
following statements by the client
should alert the nurse to suspect fluid
overload? (select all that apply.)
a. “I feel lightheaded.”
B. “I feel as though my
heart is racing.”
C. “I feel a little short of breath.”
D. “the nurse technician told
me that my blood pressure
was 150 over 90.”
e. “I think my ankles are
less swollen.”
PRACTICE Active Learning Scenario
a nurse has inserted an Iv catheter for a client who requires Iv rehydration.
What information should the nurse document in the client’s medical record?
use the atI active Learning template: Basic Concept to complete this item.
RELATED CONTENT: List the seven components of
documentation following insertion of an Iv catheter.
294 CHAPTER 49 Intravenous therapy CONTENT MASTERY SERIES
Application Exercises Key
1. a. after seeing a flashback of blood, the nurse should lower the hub
close to the skin to prepare for threading the needle into the vein,
then loosen the needle from the catheter and pull back slightly on the
needle so that it no longer extends past the tip of the catheter. the
nurse should use the thumb and index finger to advance the catheter
into the vein until the hub rests against the insertion site. Inserting
the needle all the way into the vein could puncture the vein.
B. CORRECT: the nurse should use a smooth, steady
motion to insert the catheter through the skin at an angle
of 10° to 30° with the bevel up. this is the optimal angle for
preventing the puncture of the posterior wall of the vein.
C. the nurse should apply pressure approximately
3 cm (1.2 in) above the insertion site to reduce the backflow
of blood into the vein prior to removing the needle.
D. the nurse should not use a vein in the antecubital
fossa for Iv insertion, except for emergency access,
because it will limit the mobility of the client’s arm.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Parenteral/Intravenous Therapies
2. a. the nurse should obtain a specimen for culture to identify
pathogens causing infection. however, another action is the priority.
B. the nurse should apply a warm compress to promote
healing and comfort. however, another action is the priority.
C. the nurse should administer analgesics to promote
comfort. however, another action is the priority.
D. CORRECT: the greatest risk to this client is injury from infection. the
first action the nurse should take is to stop the infusion and remove
the catheter because the catheter might be the source of infection.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
3. a. nurses should remove catheters as soon as they are no longer
clinically necessary to eliminate a portal of entry for pathogens.
B. nurses should use a sterile needle or catheter for each
insertion attempt for safety and prevention of infection.
C. nurses should not disconnect tubing for convenience, because
this increases the risk of bacteria entering the system.
D. CORRECT: nurses should replace Iv catheters when suspecting any
break in surgical aseptic technique, such as in emergency insertions.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
4. a. CORRECT: a decrease in skin temperature around the site
is a manifestation of infiltration due to the Iv solution entering
the subcutaneous tissue around the venipuncture site.
B. When infiltration occurs, the rate of infusion can slow or stop, not
increase, as the solution is no longer infusing directly into the vein. this
occurs due to dislodgement of the catheter or rupture of the vein.
C. When infiltration occurs, the skin around the Iv site is pale, not
red, because the solution is no longer infusing directly into the vein
and enters the subcutaneous tissue around the venipuncture site.
D. CORRECT: a damp Iv dressing is a common finding with
infiltration due to the Iv solution entering the subcutaneous
tissue and leaking out through the venipuncture site.
e. CORRECT: swollen tissue around the venipuncture
site is a manifestation of infiltration due to the Iv solution
entering the subcutaneous tissue and causing swelling,
as the fluid is no longer infusing into the vein.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
5. a. a manifestation of fluid overload is hypertension.
Lightheadedness is a manifestation of hypotension.
B. CORRECT: a manifestation of fluid overload is tachycardia due to
the increased blood volume, which causes the heart rate to increase.
C. CORRECT: a manifestation of fluid overload is shortness of breath
or dyspnea due to the increased amount of fluid entering the air
spaces in the lungs, which reduces the amount of circulating oxygen.
D. CORRECT: a manifestation of fluid overload is
hypertension due to the increased blood volume,
which causes the blood pressure to increase.
e. a manifestation of fluid overload is edema. If the
client’s ankles are less swollen, this is an indication that
the edema and the fluid overload are resolving.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● Date and time of insertion
● Insertion site and appearance
● Catheter’s size
● type of dressing
● Iv fluid and rate
● the number, locations, and
conditions of previously
attempted catheterizations
● Client’s response
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Parenteral/Intravenous Therapies
FUNDAMENTALS FOR NURSING CHAPTER 50 Adverse effects, InterActIons, And contrAIndIcAtIons 295
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
CHAPTER 50 Adverse Effects,
Interactions, and
Contraindications
to ensure safe medication administration
and prevent errors, nurses must know the
therapeutic effect, potential adverse effects,
interactions, contraindications, and precautions
for each medication they administer.
every medication has the potential to
cause adverse effects. these are undesired,
inadvertent, and harmful effects of the
medication. Adverse effects can range from
mild to severe, and some can be life‑threatening.
Medications are chemicals that affect the body.
With concurrent use of medications, there is a
potential for an interaction. Medications can also
interact with foods and dietary supplements.
contraindications and precautions for specific
medications are conditions (diseases, age,
pregnancy, lactation) that make it risky or
completely unsafe for clients to take them.
Anticipation of adverse effects, interactions,
contraindications, and precautions is an
important component of client education. Both
the nurse and the client should know the major
adverse effects a medication can cause. early
identification of adverse effects allows for timely
intervention to minimize harm.
ADVERSE EFFECTS
Central nervous system effects
From either central nervous system (CNS) stimulation
(excitement) or CNS depression
NURSING CONSIDERATIONS
● Implement seizure precautions for CNS stimulation.
● For CNS depression, advise clients not to drive or
participate in other dangerous activities.
Extrapyramidal symptoms
● Abnormal body movements: tremors, rigidity,
restlessness, acute dystonia (spastic movements of
the back, neck, tongue, and face), drooling, agitation,
shuffling gait
● These can take a few hours or months to develop.
NURSING CONSIDERATIONS
● More common with medications affecting the CNS, such
as those that treat mental health disorders.
● Keep clients safe when movements and balance
are uncontrollable.
Anticholinergic effects
Result from muscarinic receptor blockade and affect the
eye, smooth muscle tone, exocrine glands, and heart
NURSING CONSIDERATIONS
● Have clients sip fluids to relieve dry mouth.
● Tell clients to wear sunglasses outdoors to
prevent photophobia.
● Suggest that clients urinate before taking the
medication to lessen urinary retention.
● To prevent constipation, instruct clients to increase
dietary fiber and fluids and to increase exercise.
● Remind clients to avoid activities that could lead to
overheating, because adverse effects include a decrease
in sweat.
Cardiovascular effects
● Involve blood vessels and the heart
● Antihypertensives can cause orthostatic hypotension.
NURSING CONSIDERATIONS: To relieve and prevent
postural hypotension (lightheadedness, dizziness),
instruct clients to sit or lie down and to get up and change
positions slowly.
CHAPTER 50
296 CHAPTER 50 Adverse effects, InterActIons, And contrAIndIcAtIons CONTENT MASTERY SERIES
Gastrointestinal effects
From local irritation of the gastrointestinal (GI) tract,
stimulation of the vomiting center, or stimulation or
slowing of bowel motility
NURSING CONSIDERATIONS
● Many medications, such as NSAIDs, cause GI distress.
● Tell clients to try taking the medication with food and
to notify the provider about consistent GI effects.
Hematologic effects
Relatively common and potentially life‑threatening
NURSING CONSIDERATIONS
● Bone marrow depression can result from anticancer
medications and hemorrhagic disorders from
anticoagulants and thrombolytics.
● Instruct clients taking an anticoagulant to report
bruising, discolored urine or stool, petechiae, and
bleeding gums to the provider immediately.
Hepatotoxicity
Because metabolism of most medications takes place
in the liver, the liver is particularly vulnerable to
medication‑induced injury. Damage to liver cells can
impair medication metabolism and cause accumulation
in the body or alter results of liver function tests with no
obvious manifestations of liver dysfunction.
NURSING CONSIDERATIONS
● When combining two or more medications that are
hepatotoxic, the risk for liver damage increases.
● Liver function tests are essential when a client
starts taking a hepatotoxic medication and
periodically thereafter.
Nephrotoxicity
● Primarily the result of antimicrobial agents and NSAIDs
● Impaired kidney function can interfere with medication
excretion, leading to accumulation and adverse effects.
NURSING CONSIDERATIONS
● Aminoglycosides can cause kidney damage.
● Monitor serum creatinine and BUN levels of clients
taking nephrotoxic medications.
Toxicity
Severe and potentially life-threatening effects from
excessive dosing, but can also occur at therapeutic
dose levels.
NURSING CONSIDERATIONS
● An overdose of acetaminophen can result in
hepatotoxicity, which can lead to liver damage.
● The antidote acetylcysteine minimizes liver damage due
to acetaminophen toxicity.
● There is a greater risk of toxicity and liver damage with
chronic alcohol use.
● Liver damage from disease states can delay or prevent
medication metabolism.
Allergic reaction
An immune response to a medication after previous
exposure, causing antibody formation
NURSING CONSIDERATIONS
● Allergic reactions range from minor to serious.
Diphenhydramine treats mild rashes and hives.
● Before administering any medications, obtain a
complete medication and allergy history.
Anaphylactic reaction
A life‑threatening immediate allergic reaction that
causes respiratory distress, severe bronchospasm, and
cardiovascular collapse
NURSING CONSIDERATIONS
● Treat anaphylaxis with epinephrine, bronchodilators,
and antihistamines.
● Provide respiratory support and notify the provider.
Immunosuppression
A decreased or absent immune response
NURSING CONSIDERATIONS
● Glucocorticoids depress the immune response and
increase the risk for infection.
● Monitor for indications of infection.
50.1 Over‑the‑counter medication interactions
Interactions Interactions
Ingredients in otc medications
can interact with other otc or
prescription medications.
Inactive ingredients such as
dyes, alcohol, and preservatives
can cause adverse reactions.
the potential for overdose exists
with the use of several preparations
(including prescription medications)
that have similar ingredients.
NURSING INTERVENTIONS Interactions of some
prescription and
otc medications
can interfere with
therapeutic effects.
NURSING INTERVENTIONS
obtain a complete
medication history that
includes both prescription
and otc medications.
Instruct clients to follow
the manufacturer’s
recommendations for dosage.
obtain a history of herbal and
other dietary supplements.
Advise clients to use caution
and to check with their provider
before using any otc preparations
such as antacids, laxatives,
decongestants, and cough syrups.
for example, antacids can interfere
with the absorption of ranitidine
and other medications. tell clients
to take antacids at least 1 hr
apart from other medications
FUNDAMENTALS FOR NURSING CHAPTER 50 Adverse effects, InterActIons, And contrAIndIcAtIons 297
MEDICATION‑MEDICATION
INTERACTIONS
Increased therapeutic effects
NURSING CONSIDERATIONS: Taking some medications
together can increase their therapeutic effect. For
example, clients who have asthma inhale albuterol, a beta2
adrenergic agonist, 5 min prior to inhaling fluticasone, a
glucocorticoid, to increase the absorption of fluticasone.
Increased adverse effects
NURSING CONSIDERATIONS: Taking two medications
that have the same adverse effects together increases
the risk of or worsens these adverse effects. Diazepam
and hydrocodone with acetaminophen both have CNS
depressant effects. The risk increases when clients take
both concurrently.
Decreased therapeutic effects
NURSING CONSIDERATIONS: One medication can
increase the metabolism of another medication and
therefore decrease the serum level and effectiveness
of that medication. Phenytoin increases hepatic
medication-metabolizing enzymes that affect warfarin
and thereby decreases the serum level and the therapeutic
effect of warfarin.
Decreased adverse effects
NURSING CONSIDERATIONS: One medication can
counteract the adverse effects of another medication.
Ondansetron, an antiemetic, counteracts the adverse
effects of nausea and vomiting that result from
chemotherapy.
Increased serum levels, leading to toxicity
NURSING CONSIDERATIONS: One medication can decrease
the metabolism of a second medication and therefore
increase the serum level of the second medication and
lead to toxicity. Fluconazole, an antifungal, inhibits
hepatic medication-metabolizing enzymes that affect
aripiprazole, an antipsychotic, and thereby increases
serum levels of aripiprazole.
MEDICATION‑FOOD INTERACTIONS
Food can alter medication absorption and can contain
substances that react with some medications.
Tyramine
Consuming foods that contain tyramine (avocados, figs,
aged cheese, yeast extracts, beer, smoked meats) while
taking monoamine oxidase inhibitors (MAOIs) can lead to
hypertensive crisis.
NURSING CONSIDERATIONS: Tell clients taking an MAOI
to avoid these foods.
Vitamin K
Vitamin K can decrease the therapeutic effects of warfarin
and put clients at risk for developing blood clots.
NURSING CONSIDERATIONS: Clients taking warfarin
should maintain a consistent intake of dietary vitamin K
to avoid sudden fluctuations that could affect the action
of warfarin.
Dairy
Tetracycline can interact with a chelating agent such as
milk to form an insoluble, unabsorbable compound.
NURSING CONSIDERATIONS: Instruct clients not to take
tetracycline within 2 hr of consuming any dairy products.
Grapefruit juice
Grapefruit juice seems to act by inhibiting presystemic
medication metabolism in the small bowel, thus
increasing the absorption of some oral medications such
as nifedipine, a calcium channel blocker. This combination
can result in increased effects or intensified adverse
reactions.
NURSING CONSIDERATIONS: Instruct clients not to drink
grapefruit juice if they are taking a medication it affects.
Caffeine
Theophylline, a methylxanthine for asthma control, and
caffeine can result in excessive CNS excitation.
NURSING CONSIDERATIONS: Instruct clients taking this
medication to avoid beverages containing caffeine.
Antacids, vitamin C
Taking aluminum‑containing antacids with citrus
beverages can result in excessive absorption of aluminum.
NURSING CONSIDERATIONS: Tell clients taking antacids
to avoid taking vitamin C supplements or drinking
citrus juices.
298 CHAPTER 50 Adverse effects, InterActIons, And contrAIndIcAtIons CONTENT MASTERY SERIES
CONTRAINDICATIONS
AND PRECAUTIONS
● Take extra precautions for clients who are at greater
risk for developing an adverse reaction to a medication.
For example, morphine depresses respiratory function,
so asthma and respiratory dysfunction require
precautions with the use of morphine.
● Contraindications for specific medications relate to
clients’ physical status, health, and allergy history.
For example, an allergy to any medication is a
contraindication for taking that medication. Pregnancy
or health conditions such as kidney disease are also
contraindications for many medications.
PreGnAncY rIsK cAteGorIes
The U.S. Food and Drug Administration (FDA) places
medications in categories according to the risks they pose
to a fetus.
Category A: There is no evidence of risk to a fetus from
taking the medication during pregnancy, according to
adequate and well‑controlled studies. Ferrous sulfate, an
iron supplement, is a Category A medication.
Category B: There is no evidence of risk to an animal
fetus according to studies, but there are no adequate and
well‑controlled studies of pregnant women. Or, there is
evidence of risk to an animal fetus, but controlled studies
of pregnant women show no evidence of risk to the fetus.
Esomeprazole, an antiulcer medication, is in Category B.
Category C: Studies have demonstrated adverse effects
on animal fetuses, but there are no adequate and
well‑controlled studies of pregnant women. Or, there
have not been any studies of animals or pregnant women.
Glipizide, an antidiabetic medication, is in Category C.
Category D: Studies have demonstrated adverse effects on
human fetuses according to data from investigational or
marketing experience, but potential benefits from the use
of the medication during pregnancy might warrant its use.
Sorafenib, an antineoplastic medication, is in Category D.
Category X: Studies have demonstrated adverse effects on
animal and human fetuses, according to studies and data
from investigational or marketing experience. Pregnancy
is a contraindication for the use of the medication because
the risks outweigh the potential benefits. Estradiol, an
estrogen replacement, is a Category X medication.
FUNDAMENTALS FOR NURSING CHAPTER 50 Adverse effects, InterActIons, And contrAIndIcAtIons 299
Application Exercises
1. A nurse is collecting data from a
client who takes haloperidol to treat
schizophrenia. Which of the following
findings should the nurse document
as extrapyramidal symptoms
(ePss)? (select all that apply.)
A. orthostatic hypotension
B. tremors
c. Acute dystonia
d. decreased level of
consciousness
e. restlessness
2. A nurse is teaching a client who has
a new prescription for oxybutynin
about managing the medication’s
anticholinergic effects. Which of the
following instructions should the
nurse include? (select all that apply.)
A. take sips of water frequently.
B. Wear sunglasses when
outdoors in sunlight.
c. Use a soft toothbrush
when brushing teeth.
d. take the medication
with an antacid.
e. Urinate prior to taking
the medication.
3. A nurse is reviewing a client’s
medications. they include cimetidine
and imipramine. Knowing that
cimetidine decreases the metabolism
of imipramine, the nurse should
identify that this combination is likely to
result in which of the following effects?
A. decreased therapeutic
effects of cimetidine
B. Increased risk of
imipramine toxicity
c. decreased risk of adverse
effects of cimetidine
d. Increased therapeutic
effects of imipramine
4. A nurse in an outpatient clinic
is caring for a client who has
a new prescription for an
antihypertensive medication.
Which of the following instructions
should the nurse give the client?
A. “Get up and change
positions slowly.”
B. “Avoid eating aged cheese
and smoked meat.”
c. “report any usual bruising
or bleeding to the
doctor immediately.”
d. “eat the same amount of foods
that contain vitamin K every day.”
5. A nurse in an outpatient surgical
center is admitting a client for a
laparoscopic procedure. the client
has a prescription for preoperative
diazepam. Prior to administering the
medication, which of the following
actions is the nurse’s priority?
A. teaching the client about the
purpose of the medication
B. Giving the medication at
the administration time
the provider prescribed
c. Identifying the client’s
medication allergies
d. documenting the
client’s anxiety level
PRACTICE Active Learning Scenario
A nurse is reviewing the fdA’s pregnancy risk categories
in an in‑service presentation. Use the AtI Active Learning
template: Basic concept to complete this item.
RELATED CONTENT: Include the definition and an
example of each of the five pregnancy risk categories.
300 CHAPTER 50 Adverse effects, InterActIons, And contrAIndIcAtIons CONTENT MASTERY SERIES
Application Exercises Key
1. A. orthostatic hypotension is an adverse effect, but it is not an ePs.
B. CORRECT: tremors are an ePs. others are rigidity,
drooling, agitation, and a shuffling gait.
c. CORRECT: Acute dystonia is an ePs. It includes spastic
movements of the back, neck, tongue, and face.
d. decreased level of consciousness is an
adverse effect, but it is not an ePs.
e. CORRECT: restlessness is an ePs. others are
rigidity, drooling, agitation, and a shuffling gait.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions
2. A. CORRECT: taking sips of water frequently will help
relieve the anticholinergic effect of dry mouth.
B. CORRECT: Wearing sunglasses will help relieve
the anticholinergic effect of photophobia.
c. Anticholinergic effects do not increase the client’s risk for
bleeding. constipation is an example of an anticholinergic effect.
d. taking the medication with an antacid will not
decrease anticholinergic effects. constipation is
an example of an anticholinergic effect.
e. CORRECT: Urinating prior to taking the medication will
help relieve the anticholinergic effect of urinary retention.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
3. A. A medication that increases the metabolism of another
medication can decrease the effectiveness of that medication.
B. CORRECT: A medication that decreases the metabolism
of another medication increases the serum level of
that medication, increasing the risk for toxicity.
c. A medication that decreases the metabolism of another
medication does not decrease the risk for adverse effects.
d. A medication that decreases the metabolism of another
medication does not increase that medication’s therapeutic effects.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
4. A. CORRECT: Antihypertensive medications can cause
orthostatic hypotension. the nurse should instruct the
client to change positions slowly and to sit or lie down
when feeling dizzy or lightheaded to prevent injury.
B. consuming foods that contain tyramine (avocados, figs, aged cheese,
yeast extracts, beer, smoked meats) while taking monoamine oxidase
inhibitors, not antihypertensives, can lead to hypertensive crisis.
c. clients taking an anticoagulant, not an antihypertensive, should
report bruising, discolored urine or stool, petechiae, bleeding gums,
and any other manifestations of bleeding to the provider immediately.
d. clients taking anticoagulants, not antihypertensives, should
maintain a consistent intake of dietary vitamin K to avoid sudden
fluctuations that could affect the action of the anticoagulant.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
5. A. the nurse should teach the client about the purpose of
the medication to make sure the client understands why the
provider prescribed it. However, another action is the priority.
B. the nurse should administer the medication at the time the
provider prescribed that the client receive it to help prepare the client
for the surgical procedure. However, another action is the priority.
c. CORRECT: the greatest risk to this client is injury from
an allergic reaction. the priority action is to identify the
client’s allergies prior to medication administration.
d. the nurse should document the client’s anxiety level to
have a baseline against which to measure the effectiveness of
the medication. However, another action is the priority.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● category A: there is no evidence of risk to
a fetus from taking the medication during
pregnancy, according to adequate and
well‑controlled studies. ferrous sulfate, an
iron supplement, is a category A medication.
● category B: there is no evidence of risk to
an animal fetus according to studies, but
there are no adequate and well‑controlled
studies of pregnant women. or, there is
evidence of risk to an animal fetus, but
controlled studies of pregnant women show
no evidence of risk to the fetus. esomeprazole,
an antiulcer medication, is in category B.
● category c: studies have demonstrated
adverse effects on animal fetuses, but
there are no adequate and well‑controlled
studies of pregnant women. or, there
have not been any studies of animals or
pregnant women. Glipizide, an antidiabetes
medication, is in category c.
● category d: studies have demonstrated
adverse effects on human fetuses according
to data from investigational or marketing
experience, but potential benefits from the
use of the medication during pregnancy
might warrant its use. sorafenib, an
antineoplastic medication, is in category d.
● category X: studies have demonstrated
adverse effects on animal and human
fetuses, according to studies and data from
investigational or marketing experience.
Pregnancy is a contraindication for the use of
the medication because the risks outweigh
the potential benefits. estradiol, an estrogen
replacement, is a category X medication.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Medication Administration
FUNDAMENTALS FOR NURSING CHAPTER 51 IndIvIdual ConsIderatIons of MedICatIon adMInIstratIon 301
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHARMACOLOGICAL AND PARENTERAL THERAPIES
CHAPTER 51 Individual
Considerations
of Medication
Administration
various factors affect how clients respond to
medications. It is important for nurses to identify
these factors to help them individualize nursing
care when administering medications.
FACTORS AFFECTING MEDICATION
DOSAGES AND RESPONSES
Body weight: Because body tissues absorb medications,
individuals with a greater body mass require larger doses.
Because the percentage of body fat an individual has can
alter the distribution of a medication, basing dosages on
body surface area (BSA) can be a more precise method of
regulating an individual’s response to a medication.
Age: Liver and kidney function are immature in young
children and often decreased in older adults, which can
cause heightened sensitivities to medications and thus
necessitate proportionately smaller medication doses.
Gender: Women respond differently to medications than
men due to a higher proportion of body fat and the effects
of female hormones.
Genetics: Genetic factors such as missing enzymes
can alter the metabolism of certain medications, thus
enhancing or reducing a medication’s action. The usual
effect is either fewer benefits from the medication or
greater medication toxicity.
Biorhythmic cycles: Responses to some medications
vary with the biologic rhythms of the body. For example,
hypnotic medications work better when clients take them
at their usual sleep time than at other times.
Tolerance: Reduced responsiveness to a medication clients
take over time, such as morphine, is pharmacodynamic
tolerance. Other medications, such as barbiturates, cause
metabolic tolerance as metabolism of the medication
increases over time and the effectiveness of the
medication declines. Cross‑tolerance can occur with other
chemically similar medications.
Accumulation: Medication concentration in the body
increases due to the inability to metabolize or excrete a
medication rapidly enough, resulting in a toxic medication
effect. For older adults, decreased kidney and liver
function are the major causes of medication accumulation
leading to toxicity.
Psychological factors: Emotional state and expectations
can influence the effects of a medication. The placebo
effect describes positive medication effects that
psychological factors, not biochemical properties of the
medication, influence.
Diet: Inadequate nutrition, such as starvation, can
affect the protein-binding response of medications.
It increases their response and thus increases the risk for
medication toxicity.
Medical problems
● Inadequate gastric acid inhibits the absorption of
medications that require an acid medium to dissolve.
● Diarrhea causes oral medications to pass through the
gastrointestinal tract too quickly for adequate absorption.
● Vascular insufficiency prevents the distribution of a
medication to affected tissue.
● Liver disease or failure impairs medication metabolism,
which can cause toxicity.
● Kidney disease or failure prevents or delays medication
excretion, which can cause toxicity.
● Prolonged gastric emptying time delays the absorption
of medications in the intestines.
PHARMACOLOGY AND CHILDREN
Although most medications adults take are useful for
children, the dosages are different. Providers base
pediatric dosages on body weight or BSA.
● Newborns (younger than 1 month old) and infants
(1 month to 1 year old) have immature liver and kidney
function, alkaline gastric juices, and an immature
blood‑brain barrier, making them especially sensitive
to medications that affect the CNS. Providers base some
medication dosages on age due to a greater risk for
decreased skeletal bone growth, acute cardiopulmonary
failure, and hepatic toxicity.
● Be particularly alert when administering medications to
children due to the risk for medication errors.
◯ Check that dosages are accurate for weight or BSA.
◯ Initial pediatric dosages are an approximation.
◯ Be aware that most medications do not undergo
testing on children.
◯ Some adult medication forms and concentrations
require dilution, calculation, preparation, and
administration of very small doses for children.
◯ Limited sites exist for IV medication administration.
◯ Give written and verbal instructions to parents to
promote adherence to medication regimens.
Additional pharmacokinetic factors specific to children
● Decreased gastric acid production and slower gastric
emptying time
● Decreased first-pass medication metabolism
● Increased absorption of topical medications (greater
blood flow to the skin and thinner skin)
● Lower blood pressure (more blood flow to the liver and
brain and less to the kidneys)
● Higher body water content (dilutes
water‑soluble medications)
● Decreased serum protein‑binding sites (until age 1 year).
This can result in an increase in the serum level of
protein‑binding medications.
CHAPTER 51
302 CHAPTER 51 IndIvIdual ConsIderatIons of MedICatIon adMInIstratIon CONTENT MASTERY SERIES
PHARMACOLOGY AND
OLDER ADULTS (65+ YEARS)
PHYsIoloGIC CHanGes WItH aGInG
tHat affeCt PHarMaCoKInetICs
● Increased gastric pH (alkaline)
● Decreased gastrointestinal motility and gastric
emptying time, resulting in a slower rate of absorption
● Decreased blood flow through the cardiovascular system,
liver, and kidneys
● Decreased hepatic enzyme function
● Decreased kidney function and glomerular filtration rate
● Decreased protein‑binding sites, resulting in lower
serum albumin levels
● Decreased body water, increased body fat, and decreased
lean body mass
otHer faCtors affeCtInG
MedICatIon tHeraPY
● Impaired memory or altered mental state
● Multiple or severe illnesses
● Changes in vision and hearing
● Decreased mobility and dexterity
● Poor adherence
● Inadequate supervision of long‑term therapy
● Limited financial resources
● Polypharmacy: The practice of taking several
medications simultaneously (prescription and
over‑the‑counter [OTC]) with diminished bodily
functions and some medical problems can contribute to
the potential for medication toxicity.
nursInG InterventIons
Decreasing the risk of adverse medication effects
● Obtain a complete medication history and include all
OTC medications.
● Make sure medication therapy starts at the lowest
possible dose.
● Assess and monitor for therapeutic and adverse effects.
● Monitor plasma medication levels to provide a rational
basis for dosage adjustment.
● Assess and monitor for medication‑medication and
medication‑food interactions.
● Document findings.
● Notify the provider of adverse effects.
Promoting adherence
● Give clear and concise instructions, verbally and
in writing.
● Ensure that the dosage form is appropriate.
Administer liquid forms to clients who have
difficulty swallowing.
● Provide clearly marked containers that are easy to open.
● Assist the client with setting up a daily calendar with
the use of pill containers.
● Discuss the availability of and access to local resources
for obtaining and paying for medications.
● Suggest that the client obtain assistance from a friend,
neighbor, or relative.
PHARMACOLOGY:
PREGNANCY AND LACTATION
PreGnanCY
● Any medication women who are pregnant ingest will
affect the fetus. The U.S. Food and Drug Administration
(FDA) classifies medications in five categories that range
from remote risk to proven risk of fetal harm.
● Most medications are potentially harmful to the
fetus. Prescribers must weigh the benefits of maternal
medication administration against possible fetal risk.
● Medications women take during pregnancy include
nutritional supplements (iron, vitamins, minerals) and
medications that treat nausea, vomiting, gastric acidity,
and mild discomforts.
● Providers manage chronic medical disorders such as
diabetes mellitus and hypertension in conjunction with
careful maternal‑fetal monitoring.
● Pregnancy is a contraindication for live‑virus vaccines
(measles, mumps, polio, rubella, yellow fever) due to
possible teratogenic effects.
laCtatIon
● Most medications women take during lactation enter
breast milk. Women who are lactating should avoid
medications that have an extended half‑life, are
sustained‑released, or are harmful to infants.
● For medications that are safe, administer them
immediately after breastfeeding to minimize the
medication’s concentration in the next feeding. Use the
lowest effective dosage for the shortest possible time.
FUNDAMENTALS FOR NURSING CHAPTER 51 IndIvIdual ConsIderatIons of MedICatIon adMInIstratIon 303
Application Exercises
1. to promote adherence with
medication self‑administration, a
nurse is making recommendations
for an older adult client. Which of
the following instructions should the
nurse include? (select all that apply.)
a. adjust dosages according
to daily weight.
B. Place pills in daily pill holders.
C. ask for liquid forms if the client
has difficulty swallowing pills.
d. ask a relative to assist
periodically.
e. request child‑resistant caps
on medication containers.
2. a young adult client in a provider’s
office tells the nurse that she uses
fasting for several days each week
to help control her weight. the
client takes several medications for
various chronic issues. the nurse
should explain to the client that
which of the following mechanisms
that results from fasting puts her
at risk for medication toxicity?
a. Increasing the metabolism of
the medications over time
B. Increasing the
protein‑binding response
C. Increasing medications’ transit
time through the intestines
d. decreasing the excretion
of medications
3. a nurse is preparing medications for
a preschooler. Which of the following
factors should the nurse identify as
altering how a medication affects
children? (select all that apply.)
a. Increased gastric
acid production
B. lower blood pressure
C. Higher body water content
d. Increased absorption of
topical medications
e. Increased gastric
emptying time
4. a nurse is teaching a client who is
lactating about taking medications.
Which of the following actions
should the nurse recommend
to minimize in the entry of
medication into breast milk?
a. drink 8 oz milk with each
dose of medication.
B. use medications that have
an extended half‑life.
C. take each dose right
after breastfeeding.
d. Pump breast milk and
freeze it prior to feeding
to the newborn.
5. a nurse in an outpatient clinic is
teaching a client who is in her first
trimester of pregnancy. Which
of the following statements
should the nurse make?
a. “You will need to get a rubella
immunization if you haven’t
had one prior to pregnancy.”
B. “You can safely take
over‑the‑counter medications.”
C. “You should avoid any vitamin
preparations containing iron.”
d. “Your provider can
prescribe medication for
nausea if you need it.”
PRACTICE Active Learning Scenario
a nurse is preparing to administer medications to an
older adult client who has vascular insufficiency and
impaired kidney function. use the atI active learning
template: Basic Concept to complete this item.
UNDERLYING PRINCIPLES
● discuss medication considerations
with vascular insufficiency.
● discuss medication considerations
with impaired kidney function.
● Identify at least four physiologic changes with
aging that affect pharmacokinetics.
NURSING INTERVENTIONS: Identify at least three
interventions for reducing the risk for adverse effects.
304 CHAPTER 51 IndIvIdual ConsIderatIons of MedICatIon adMInIstratIon CONTENT MASTERY SERIES
Application Exercises Key
1. a. the provider adjusts the client’s dosages. Instructing
the client to base dosages on daily weight increases the
risk for error in medication self‑administration.
B. CORRECT: organizing medications in daily pill
holders promotes medication adherence.
C. CORRECT: Providing a form of medication that is easier for
the client to swallow promotes medication adherence.
d. CORRECT: Including the client’s support
system promotes medication adherence.
e. some older adult clients have difficulty opening child‑resistant
caps. request easy‑open containers from the pharmacy.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
2. a. some medications, not fasting, cause metabolic tolerance
as metabolism of the medication increases over time
and the effectiveness of the medication declines.
B. CORRECT: Inadequate nutrition, such as starvation, can affect
the protein‑binding response of medications. It increases their
response and thus increases the risk for medication toxicity.
C. disorders that cause diarrhea, not fasting, cause oral medications
to pass through the gastrointestinal tract too quickly for adequate
absorption. this mechanism does not cause toxicity.
d. Kidney disease or failure, not fasting, prevents or delays
medication excretion, which can cause toxicity.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
3. a. Children have decreased gastric acid production.
B. CORRECT: Children have a lower blood pressure.
C. CORRECT: Children have a higher body water content.
d. CORRECT: Children have increased absorption of topical medications.
e. Children have a slower gastric emptying time.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
4. a. the intake of food or fluid with medication does
not affect entry of medications into breast milk.
B. the client should avoid medications that have an extended
half‑life due to their increased entry into breast milk.
C. CORRECT: taking medication immediately after breastfeeding
helps minimize medication concentration in the next feeding.
d. Pumping and freezing breast milk does not
affect entry of medications into breast milk.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
5. a. Pregnancy is a contraindication for live‑virus vaccines,
including rubella, due to possible teratogenic effects.
B. Most medications, including over‑the‑counter, are
potentially harmful to the fetus. the client should avoid
any medications unless her provider prescribes them.
C. nutritional supplements that include iron are
common recommendations during pregnancy to
support the health of the mother and fetus.
d. CORRECT: Providers can prescribe medications to
treat nausea and other discomforts of pregnancy.
NCLEX® Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
UNDERLYING PRINCIPLES
● vascular insufficiency prevents distribution of a medication to affected tissue. the nurse should
document and monitor for the medication’s effectiveness and report concerns to the provider.
● Impaired kidney function prevents or delays medication excretion, which increases the risk for
toxicity. decreased kidney function is a major cause of medication accumulation leading to toxicity.
● Physiologic changes
◯ Increased gastric pH (alkaline)
◯ decreased gastrointestinal motility and gastric emptying time, resulting in a slower rate of absorption
◯ decreased blood flow through the cardiovascular system, liver, and kidneys
◯ decreased hepatic enzyme function
◯ decreased kidney function and glomerular filtration rate
◯ decreased protein‑binding sites, resulting in lower serum albumin levels
◯ decreased body water, increased body fat, and decreased lean body mass
◯ Impaired memory or altered mental state
◯ Multiple or severe illnesses
◯ Changes in vision and hearing
◯ decreased mobility and dexterity
NURSING INTERVENTIONS
● obtain a complete medication history,
and include all otC medications.
● Make sure medication therapy starts
at the lowest possible dose.
● assess and monitor for therapeutic
and adverse effects.
● Monitor plasma medication levels to provide
a rational basis for dosage adjustment.
● assess and monitor for medication‑medication
and medication‑food interactions.
● document findings.
● notify the provider of adverse effects.
NCLEX® Connection: Physiological Adaptation, Illness Management
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 305
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Basic Care and Comfort
NUTRITION AND ORAL HYDRATION: Provide client
nutrition through continuous or intermittent tube feedings.
Client Needs: Reduction of Risk Potential
DIAGNOSTIC TESTS: Perform diagnostic testing.
LABORATORY VALUES: Obtain specimens
other than blood for diagnostic testing.
POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS:
Identify client potential for skin breakdown.
POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/
TREATMENTS/PROCEDURES: Position the client to prevent
complications following tests/treatments/procedures.
THERAPEUTIC PROCEDURES: Educate client
about home management of care.
Client Needs: Physiological Adaptation
FLUID AND ELECTROLYTE IMBALANCES: Identify signs
and symptoms of client fluid and/or electrolyte imbalance.
ILLNESS MANAGEMENT: Manage the care of a
client with impaired ventilation/oxygenation.
FUNDAMENTALS FOR NURSING CHAPTER 52 Specimen collection for GlucoSe monitorinG 307
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: REDUCTION OF RISK POTENTIAL
CHAPTER 52 Specimen Collection
for Glucose
Monitoring
monitoring blood glucose levels is an essential
component in the care of clients who have
diabetes mellitus. Blood glucose testing is the
preferred method of monitoring blood
glucose levels.
urine testing is not an effective measure of
glucose level because glucose levels must be
greater than 220 mg/dl before glucose appears
in the urine.
clients who are able and willing to monitor
independently can learn how to self‑monitor
blood glucose levels. required abilities include
alertness, the ability to comprehend and give a
return demonstration of the process, adequate
finger dexterity, and adequate visual acuity.
Blood glucose testing
For blood glucose testing, clients who have diabetes
mellitus use a glucometer or a blood glucose meter with
small test strips to “read” the blood sample. These
systems require proper calibration, storage of supplies,
and matching of lot numbers.
INDICATIONS
Regular testing is necessary for clients who have diabetes
mellitus to manage the disease by maintaining safe blood
glucose levels.
CONSIDERATIONS
preproceDure
NURSING ACTIONS
● Check the client’s record and prescription.
◯ Frequency and type of test: Testing times vary based
on the goals of management and the complexity of
the client’s hypoglycemic medication schedule.
◯ Results from previous tests: norms and ranges
◯ Actions according to results
● Review the client’s medication profile.
◯ Note anticoagulant usage, history of bleeding
disorders, and low platelet count.
◯ Note the times and dose of hypoglycemic agents.
◯ Note the use of corticosteroids, oral contraceptives,
beta blockers, antipsychotics, and other medications
that can elevate blood glucose levels.
● Gather materials, and prepare the equipment.
◯ Blood glucose meter
◯ Reagent strip compatible with the meter
◯ Washcloth and soap or antiseptic swab
◯ Clean gloves
◯ Sterile lancet
◯ Cotton ball
● Review the meter and the manufacturer’s instructions.
● Check the strip solution’s expiration date.
● Some meters require calibration; others require zeroing
of the timer. No‑code models require no calibration
because the calibration is integrated into the test strips.
Follow the manufacturer’s directions.
● Explain the procedure to the client.
● Evaluate the selected puncture site.
◯ Integrity of the skin (to avoid areas of bruising,
open lesions)
◯ Compromised circulation
● Perform hand hygiene and put on gloves.
CHAPTER 52
308 CHAPTER 52 Specimen collection for GlucoSe monitorinG CONTENT MASTERY SERIES
intrAproceDure
NURSING ACTIONS
● Select a site from which to collect the blood sample.
◯ Outer edge of a fingertip (most common site)
◯ Alternate site (earlobe, heel, palm, arm, thigh)
● Rotate sites to avoid ongoing tenderness.
● Wrap the site in a warm, moist towel to enhance
circulation, especially when it has been difficult to
obtain an adequate sample.
● Cleanse the site with warm water and soap or an
antiseptic swab (not alcohol), and allow it to dry.
Alcohol can interfere with results.
● Hold the finger in a dependent position before
puncturing to improve blood flow.
● Pierce the skin using a sterile lancet (or a lancet injector
device) and holding it perpendicular to the skin.
● Wipe away the first drop of blood with a cotton ball.
● Place a drop of blood on the test strip.
◯ Follow the manufacturer’s procedure for applying
blood to the strip.
◯ If necessary, gently milk the finger to obtain a
drop. (Forceful milking or squeezing can cause pain,
bruising, and scarring.) Do not touch the site directly
to stimulate bleeding.
◯ Hold the test strip next to the blood on the fingertip.
◯ Do not smear blood onto the strip because this can
cause an inaccurate reading.
◯ Allow the meter to process the reading. (Time varies
with the meter.)
◯ Apply a cotton ball over the puncture site.
◯ Note the reading; turn off the meter; and dispose
of the cotton ball, test strip, lancet, and gloves in
proper receptacles.
poStproceDure
NURSING ACTIONS
● Perform hand hygiene.
● Document the meter’s reading.
● Check the prescription for medication or treatment
actions, and implement them.
INTERPRETATION OF FINDINGS
● Usually, a random blood glucose level greater than
200 mg/dL indicates hyperglycemia.
● Usually, a blood glucose level less than 70 mg/dL
indicates hypoglycemia.
● Poor storage of glucose test strips can lead to falsely
high or low readings. Typically, these test strips
come in a vial to store at room temperature or as the
manufacturer directs.
Urine glucose testing
INDICATIONS
Clients who have diabetes mellitus perform urine glucose
testing at home at times of acute illness, stress, or a blood
glucose greater than 240 mg/dL to identify the presence
of ketones.
CONSIDERATIONS
preproceDure
NURSING ACTIONS
● Evaluate the client’s ability to urinate.
● Verify the prescription for frequency and actions to take
based on the results.
● Gather materials, and prepare the equipment.
◯ Clean urine specimen cup
◯ Chemical reagent strips, container with glucose
reading scale
◯ Clean gloves
◯ Towelette or soap and washcloth
● Check the strip’s expiration date.
● Explain the procedure.
● Perform hand hygiene, and put on clean gloves.
intrAproceDure
NURSING ACTIONS
● Assist the client with urine sample collection.
● Dip the reagent strip into the urine sample and gently
shake off excess urine.
● Compare the strip’s color change with the ranges on
the container within the instructed time (usually 1 to
5 seconds).
poStproceDure
NURSING ACTIONS
● Dispose of the remaining urine sample, test strip,
and gloves.
● Perform hand hygiene.
● Check the prescription for medication or treatment
actions, and implement.
INTERPRETATION OF FINDINGS
If the test is positive for ketones, it indicates uncontrolled
blood glucose.
FUNDAMENTALS FOR NURSING CHAPTER 52 Specimen collection for GlucoSe monitorinG 309
Application Exercises
1. A nurse is determining a client’s
ability to learn self‑monitoring of
blood glucose using a glucometer.
Which of the following abilities
should the nurse confirm that the
client has before proceeding with
instruction? (Select all that apply.)
A. finger dexterity
B. Visual acuity
c. color vision
D. Basic literacy
e. Demonstration ability
2. A nurse is reviewing a client’s
medication history. the client has
an admission blood glucose of
260 mg/dl and no documented
history of diabetes mellitus.
Which of the following types
of medications should alert the
nurse to the possibility that the
client has developed an adverse
effect of pharmacological
therapy? (Select all that apply.)
A. Diuretics
B. corticosteroids
c. oral anticoagulants
D. opioid analgesics
e. Antipsychotics
3. A nurse is providing education
on how to check blood glucose
levels to a client who has a new
diagnosis of type 1 diabetes
mellitus. the nurse should include
which of the following instructions
about transferring blood onto the
reagent portion of the test strip?
A. Smear the blood onto the strip.
B. Squeeze the blood
onto the strip.
c. touch the puncture to
stimulate bleeding.
D. Hold the test strip next to
the blood on the fingertip.
4. A nurse attempts to collect a capillary
blood specimen via finger stick for
a blood glucose monitoring from
a client who has diabetes mellitus.
the nurse is unable to obtain an
adequate drop of blood for the
reagent strip. Which of the following
actions should the nurse take first?
A. puncture another finger to
obtain a capillary specimen.
B. test the urine with a
urine reagent strip.
c. Wrap the hand in a
warm, moist cloth.
D. perform a venipuncture to
obtain a venous sample.
5. A nurse is teaching self‑monitoring
of blood glucose (SmBG) to a client
who has diabetes mellitus. Which of
the following instructions should the
nurse include? (Select all that apply.)
A. perform SmBG once
daily at bedtime.
B. Wipe the hand with
an alcohol swab.
c. Hold the hand in a dependent
position prior to the puncture.
D. place the puncturing device
perpendicular to the site.
e. prick the outer edge of the
fingertip for the blood sample.
PRACTICE Active Learning Scenario
A nurse is teaching a group of nursing students how to
perform urine glucose testing. use the Ati Active learning
template: Diagnostic procedure to complete this item.
NURSING INTERVENTIONS: list the steps of the
procedure in the three phases (pre‑, intra‑, post‑procedure).
310 CHAPTER 52 Specimen collection for GlucoSe monitorinG CONTENT MASTERY SERIES
Application Exercises Key
1. A. CORRECT: the client should have the manual dexterity to cleanse
and puncture his finger, collect the blood, and insert the strip into
the meter, in order to use a glucometer to monitor blood glucose
B. CORRECT: the client should have the visual acuity
to see the digital reading of the results, in order to
use a glucometer to monitor blood glucose.
c. the client who has color blindness can have difficulty interpreting
the colors on a reagent strip for urine glucose testing. However, the
client should be able to perform blood glucose testing accurately.
D. the client needs only to recognize numerals for basic use of a
glucometer to monitor blood glucose. reading skills are not necessary.
e. CORRECT: the client should learn to use a glucometer accurately
and safely, and therefore must perform for the nurse a return
demonstration of the procedure in order to verify understanding.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
2. A. CORRECT: Diuretics can cause hyperglycemia,
especially in clients who have diabetes mellitus, and
also can cause many electrolyte imbalances.
B. CORRECT: corticosteroids can cause hyperglycemia and glycosuria.
c. Anticoagulants can cause excessive bleeding
during blood sampling for glucose testing.
D. opioid analgesics cause many adverse effects, including respiratory
depression, but they are unlikely to raise blood glucose levels.
e. CORRECT: Antipsychotics, particularly atypical
antipsychotics, can cause new‑onset diabetes mellitus.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions
3. A. Smearing the blood on the test strip can cause inaccurate results.
B. the client should milk her finger gently to obtain a drop of blood.
forceful milking or squeezing can cause pain, bruising, and scarring.
c. touching the puncture site can cause transfer
of micro‑organisms to the site.
D. CORRECT: Holding the pad of the strip next to the puncture
allows the blood to flow until the amount on the strip is
adequate. too little blood can result in falsely low readings.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
4. A. the nurse can puncture another finger to obtain a capillary specimen.
However, the nurse should use a less restrictive intervention first.
B. the nurse can obtain a urine glucose. However, the client’s blood
glucose level should be significantly elevated in order to detect glucose
in the urine. the nurse should use a less restrictive intervention first.
c. CORRECT: When providing client care, the nurse should
first use the least restrictive intervention. the nurse should
warm the client’s finger with a warm, moist cloth to promote
blood flow in preparation for the next finger stick.
D. the nurse might need to request a venipuncture for
checking the blood glucose level. However, the nurse
should use a less restrictive intervention first.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
5. A. the client can perform SmBG as often as before each
meal and at bedtime. Generally, the timing and frequency of
SmBG testing correlates with the client’s medication schedule.
monitoring once a day at bedtime does not provide enough
information to monitor blood glucose control effectively.
B. the client should wash his hand with warm water and
soap. Alcohol can alter the blood glucose reading.
c. CORRECT: the client should hold the hand in a dependent
position to increase blood flow to the fingers.
D. CORRECT: the client should hold the lancet perpendicular
to the skin to ensure the correct piercing depth.
e. CORRECT: the client should use the outer edge of the fingertip for
blood sampling. the client can also use a heel, palm, arm, or thigh.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
PRACTICE Answer
Using ATI Active Learning Template: Diagnostic Procedure
NURSING INTERVENTIONS
preprocedure
● evaluate the client’s ability to urinate.
● Verify the prescription for frequency and
actions to take based on the results.
● Gather materials and prepare
equipment: urine specimen cup,
chemical reagent strips, container with
the glucose reading scale, clean gloves,
towelette or soap and washcloth.
● check the strip’s expiration date.
● explain the procedure.
● perform hand hygiene, and
put on clean gloves.
intraprocedure
● Assist the client with urine sample collection.
● Dip the reagent strip into the urine sample.
● compare the strip’s color change with
the ranges on the container within the
instructed time (usually 1 to 5 seconds).
postprocedure
● Dispose of the remaining urine
sample, test strip, and gloves.
● perform hand hygiene.
● check the prescription for medication
or treatment actions, and implement.
NCLEX® Connection: Reduction of Risk Potential, Therapeutic Procedures
FUNDAMENTALS FOR NURSING CHAPTER 53 AirwAy MAnAgeMent 311
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: REDUCTION OF RISK POTENTIAL
CHAPTER 53 Airway Management
Managing airway compromise includes
respiratory assessment and measuring vital
signs, including oxygen saturation via pulse
oximetry and administration of oxygen.
Oxygen helps maintain adequate cellular
oxygenation for clients who have many
acute and chronic respiratory problems
(hypoxemia, cystic fibrosis, asthma) or are at
risk for developing hypoxia (respiratory illness,
circulatory impairment).
Maintaining a patent airway is a nursing priority.
it involves mobilizing secretions, suctioning
the airway, and managing artificial airways
(endotracheal tubes, tracheostomy tubes)
to promote adequate gas exchange and
lung expansion.
Pulse oximetry and
oxygen therapy
● A pulse oximeter is a device with a sensor probe that
attaches securely to the fingertip, toe, bridge of nose,
earlobe, or forehead with a clip or band.
● A pulse oximeter measures pulse saturation (SpO2) via
a wave of infrared light that measures light absorption
by oxygenated and deoxygenated hemoglobin in arterial
blood. SpO2 reliably reflects the percent of saturation of
hemoglobin (SaO2) when the SaO2 is greater than 70%.
● Oxygen is a tasteless and colorless gas that accounts for
21% of atmospheric air.
● Oxygen flow rates vary to maintain an SpO2 of 95% to
100% using the lowest amount of oxygen to achieve the
goal without risking complications.
● The fraction of inspired oxygen (FiO2) is the percentage
of oxygen the client receives.
Pulse oximetry
Noninvasive measurement of the oxygen saturation of the
blood for monitoring respiratory status when assessment
findings include any of the following.
● Increased work of breathing
● Wheezing
● Coughing
● Cyanosis
● Changes in respiratory rate or rhythm
● Adventitious breath sounds
● Restlessness, irritability, confusion
CONSIDERATIONS
INTERVENTIONS FOR READINGS LESS THAN 90%
(INDICATING HYPOXEMIA)
● Confirm probe placement.
● Confirm that the oxygen delivery system is functioning
and that the client is receiving the prescribed
oxygen levels.
● Place the client in semi‑Fowler’s or Fowler’s position
promote chest expansion and to maximize
ventilation.
● Encourage deep breathing.
● Remain with the client and provide emotional support
to decrease anxiety.
INTERPRETATION OF FINDINGS
● The expected reference range is 95% to 100%.
Acceptable levels range from 91% to 100%. Some illness
states can allow for 85% to 89%. Readings less than
90% reflect hypoxemia.
● Values can be slightly lower for older adult clients and
clients who have dark skin.
● Additional reasons for low readings include
hypothermia, poor peripheral blood flow, too much light
(sun, infrared lamps), low hemoglobin levels, jaundice,
movement, edema, and nail polish.
CHAPTER 53
312 CHAPTER 53 AirwAy MAnAgeMent CONTENT MASTERY SERIES
Oxygen therapy
Oxygen is a therapeutic gas that treats hypoxemia (low
levels of arterial oxygen). Administering and adjusting it
requires a prescription.
INDICATIONS
MAniFeStAtiOnS OF HyPOXeMiA
EARLY
● Tachypnea
● Tachycardia
● Restlessness, anxiety, confusion
● Pale skin, mucous membranes
● Elevated blood pressure
● Use of accessory muscles, nasal flaring, tracheal
tugging, adventitious lung sounds
LATE
● Stupor
● Cyanotic skin, mucous membranes
● Bradypnea
● Bradycardia
● Hypotension
● Cardiac dysrhythmias
CONSIDERATIONS
NURSING ACTIONS
● Monitor respiratory rate and pattern, level of
consciousness, SpO2, and arterial blood gases.
● Provide oxygen therapy at the lowest liter flow that will
correct hypoxemia.
● Make sure the mask creates a secure seal over the nose
and mouth.
● Assess/monitor hypoxemia and hypercarbia (elevated
levels of CO2): restlessness, hypertension, and headache.
● Auscultate the lungs for breath sounds and adventitious
sounds, such as crackles and wheezes.
● Assess/monitor oxygenation status with pulse oximetry
and arterial blood gases (ABGs).
● Promote oral hygiene.
● Encourage turning, coughing, deep breathing, and the
use of incentive spirometry and suctioning.
● Promote rest and decrease environmental stimuli.
● Provide emotional support.
● Assess nutritional status. Provide supplements.
● Assess skin integrity. Provide moisture and
pressure‑relief devices.
● Assess and document the response to oxygen therapy.
● Titrate oxygen to maintain the recommended
oxygen saturation.
● Discontinue supplemental oxygen gradually.
● Monitor for respiratory depression (decreased
respiratory rate and level of consciousness).
● Low-flow oxygen delivery systems deliver varying
amounts of oxygen based on the delivery method and
the client’s breathing pattern.
LOw‑FLOw OXygen DeLiVery SySteMS
Nasal cannula
Tubing with two small prongs for insertion into the nares
FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of 24%
to 44% at a flow rate of 1 to 6 L/min
ADVANTAGES
● Cannula is a safe, simple, and easy‑to‑apply method.
● Cannula is comfortable and well‑tolerated.
● The client is able to eat, talk, and ambulate.
DISADVANTAGES
● The FiO2 varies with the flow rate, and rate and depth of
the client’s breathing.
● Extended use can lead to skin breakdown and dry
mucous membranes.
● Tubing is easily dislodged.
NURSING ACTIONS
● Assess the patency of the nares.
● Ensure that the prongs fit in the nares properly.
● Use water‑soluble gel to prevent dry nares.
● Provide humidification for flow rates of 4 L/min
and greater.
Simple face mask
Covers the client’s nose and mouth
FRACTION OF INSPIRED OXYGEN
● It delivers an FiO2 of 40% to 60% at flow rates of 5 to
8 L/min.
● The minimum flow rate is 5 L/min to ensure flushing of
CO2 from the mask.
ADVANTAGES
● A face mask is easy to apply and can be more
comfortable than a nasal cannula.
● It is a simple delivery method.
● It is more comfortable than a nasal cannula.
● It provides humidified oxygen.
DISADVANTAGES
● Flow rates less than 5 L/min can result in rebreathing
of CO2.
● Clients who have anxiety or claustrophobia do not
tolerate it well.
● Eating, drinking, and talking are impaired.
● Moisture and pressure can collect under the mask and
cause skin breakdown.
NURSING ACTIONS
● Assess proper fit to ensure a secure seal over the nose
and mouth.
● Make sure the client wears a nasal cannula
during meals.
● Use with caution for clients who have a high risk of
aspiration or airway obstruction.
● Monitor for skin breakdown.
Online Images: Nasal Cannula, Simple Mask, Venturi Mask, Nonrebreather Mask, Face Tent
FUNDAMENTALS FOR NURSING CHAPTER 53 AirwAy MAnAgeMent 313
Partial rebreather mask
Covers the client’s nose and mouth
FRACTION OF INSPIRED OXYGEN:
Delivers an FiO2 of 40% to 70% at flow
rates of 6 to 10 L/min.
ADVANTAGES: The mask has a reservoir
bag attached with no valve, which
allows the client to rebreathe up to ⅓
of exhaled air together with room air.
DISADVANTAGES
● Complete deflation of the reservoir
bag during inspiration causes
CO2 buildup.
● The FiO2 varies with the client’s
breathing pattern.
● Clients who have anxiety or
claustrophobia do not tolerate it well.
● Eating, drinking, and talking
are impaired.
NURSING ACTIONS
● Keep the reservoir bag from deflating
by adjusting the oxygen flow rate to
keep the reservoir bag ⅓ to ½ full
on inspiration.
● Assess proper fit to ensure a secure seal over nose and
mouth. Assess for skin breakdown beneath the edges of
the mask and bridge of the nose.
● Make sure the client uses a nasal cannula during meals.
● Use with caution for clients who have a high risk of
aspiration or airway obstruction.
Nonrebreather mask
Covers the client’s nose and mouth
FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of
60% to 100% at flow rates of 10 to 15 L/min to keep the
reservoir bag ⅔ full during inspiration and expiration.
ADVANTAGES
● It delivers the highest O2 concentration possible (except
for intubation).
● A one‑way valve situated between the mask and
reservoir allows the client to inhale maximum O2 from
the reservoir bag. The two exhalation ports have flaps
covering them that prevent room air from entering
the mask.
DISADVANTAGES
● The valve and flap on the mask must be intact and
functional during each breath.
● It is poorly tolerated by clients who have anxiety
or claustrophobia.
● Eating, drinking, and talking are impaired.
● Use with caution for clients who have a high risk of
aspiration or airway obstruction.
NURSING ACTIONS
● Perform an hourly assessment of the valve and flap.
● Assess proper fit to ensure a secure seal over the nose
and mouth. Assess for skin breakdown beneath the
edges of the mask and bridge of nose.
● Make sure the client uses a nasal cannula during meals.
HigH‑FLOw OXygen DeLiVery SySteMS
Venturi mask
Covers the client’s nose and mouth
FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of 24%
to 60% at flow rates of 4 to 12 L/min via different size
adapters, which allows specific amounts of air to mix
with oxygen.
ADVANTAGES
● It delivers the most precise oxygen concentration.
● Humidification is not required.
● Best for clients who have chronic lung disease.
DISADVANTAGES
● Use is expensive.
● Eating, drinking, and talking are impaired.
NURSING ACTIONS
● Assess frequently to ensure an accurate flow rate.
● Assess proper fit to ensure a secure seal over the nose
and mouth. Assess for skin breakdown beneath the
edges of the mask particularly on the nares.
● Make sure the tubing is free of kinks.
● Ensure that the client wears a nasal cannula
during meals.
Aerosol mask
Face tent: fits loosely around the face and neck
Tracheostomy collar: a small mask that covers the
surgically created opening of the trachea
FRACTION OF INSPIRED OXYGEN
● Delivers an FiO2 of 24% to 100% at flow rates of at least
10 L/min.
● Provides high humidification with oxygen delivery.
53.2 Simple face mask53.1 Nasal cannula
314 CHAPTER 53 AirwAy MAnAgeMent CONTENT MASTERY SERIES
ADVANTAGES
● Use with clients who do not tolerate masks well.
● Useful for clients who have facial trauma, burns, and
thick secretions.
DISADVANTAGES: High humidification requires
frequent monitoring.
NURSING ACTIONS
● Empty condensation from the tubing often.
● Ensure adequate water in the humidification canister.
● Ensure that the aerosol mist leaves from the vents
during inspiration and expiration
● Make sure the tubing does not pull on the tracheostomy.
COMPLICATIONS
Oxygen toxicity
Oxygen toxicity can result from high concentrations of
oxygen (typically greater than 50%), long durations of
oxygen therapy (typically more than 24 to 48 hr), and the
severity of lung disease.
MANIFESTATIONS: Nonproductive cough, substernal pain,
nasal stuffiness, nausea, vomiting, fatigue, headache, sore
throat, and hypoventilation
NURSING ACTIONS
● Use the lowest level of oxygen necessary to maintain an
adequate SpO2.
● Monitor ABGs and notify the provider if SpO2 levels are
outside the expected reference range.
● Decrease the FiO2 as the client’s SpO2 improves.
Oxygen‑induced hypoventilation
Clients who have conditions that cause alveolar
hypoventilation can be sensitive to the administration of
oxygen.
NURSING ACTIONS
● Monitor respiratory rate and pattern, level of
consciousness, and SpO2.
● Provide oxygen therapy at the lowest liter flow rate that
manages hypoxemia.
● If the client tolerates it, use a Venturi mask to deliver
precise oxygen levels.
● Notify the provider of impending respiratory depression
such as a decreased respiratory rate and a decreased
level of consciousness.
Combustion
Oxygen is combustible.
NURSING ACTIONS
● Post “No Smoking” or “Oxygen in Use” signs to alert
others of the fire hazard.
● Know where to find the closest fire extinguisher.
● Educate about the fire hazard of smoking with
oxygen use.
● Have clients wear a cotton gown because synthetic or
wool fabrics can generate static electricity.
● Ensure that all electric devices (razors, hearing aids,
radios) are working well.
● Make sure all electric machinery (monitors, suction
machines) is grounded.
● Do not use volatile, flammable materials (alcohol,
acetone) near clients receiving oxygen.
53.4 Venturi mask53.3 Nonrebreather mask 53.5 Face tent
FUNDAMENTALS FOR NURSING CHAPTER 53 AirwAy MAnAgeMent 315
Specimen collection
and airway clearance
Mucosal secretion buildup or aspiration of emesis can
obstruct a client’s airway.
● Adequate hydration and coughing help the client
maintain airway patency.
● Nursing interventions that mobilize secretions and
maintain airway patency include assistance with
coughing, hydration, positioning, humidification,
nebulizer therapy, chest physiotherapy, and suctioning.
● These interventions promote adequate gas exchange and
lung expansion.
INDICATIONS
CLIENTS AT RISK FOR DEVELOPING AIRWAY
COMPROMISE: infants, clients who have neuromuscular
disorders, clients who are quadriplegic, clients who have
cystic fibrosis
INDICATIONS THAT CLIENTS NEED HELP MAINTAINING
AIRWAY CLEARANCE: hypoxemia (restlessness, irritability,
tachypnea, tachycardia, cyanosis, decreased level of
consciousness, decreased SpO2 levels), adventitious breath
sounds, visible secretions, absence of spontaneous cough
CONSIDERATIONS
● Humidification of oxygen moistens the airways, which
loosens and mobilizes pulmonary secretions.
● Nebulization breaks up medications (bronchodilators,
mucolytic agents) into minute particles that disperse
throughout the respiratory tract and improves clearance
of pulmonary secretions.
● Chest physiotherapy involves the use of chest
percussion, vibration, and postural drainage to help
mobilize secretions. Chest percussion and vibration
facilitate movement of secretions into the central
airways. For postural drainage, one or more positions
allow gravity to assist with the removal of secretions
from specific areas of the lung.
● Early‑morning postural drainage mobilizes secretions
that have accumulated through the night.
NURSING ACTIONS
● Collect sputum specimens by suctioning
during coughing.
● Whenever possible, encourage coughing. Coughing is
more effective than artificial suctioning at moving
secretions into the upper trachea and laryngopharynx.
● Suction orally, nasally, or endotracheally, not routinely
but only when clients need it.
● Maintain surgical asepsis when performing any form of
tracheal suctioning to avoid bacterial contamination of
the airway.
Sputum specimen collection
Collection of sputum for analysis
INDICATIONS
● For cytology to identify aberrant cells or cancer
● For culture and sensitivity to grow and identify
micro-organisms and the antibiotics effective
against them
● To identify acid‑fast bacillus (AFB) to diagnose
tuberculosis (requires three consecutive
morning samples)
CONSIDERATIONS
NURSING ACTIONS
● Obtain specimens early in the morning.
● Wait 1 to 2 hr after the client eats to obtain a specimen
to decrease the likelihood of emesis or aspiration.
● Perform chest physiotherapy to help mobilize secretions.
● Use a sterile specimen container, a label, a laboratory
requisition slip, a biohazard bag for delivery of the
specimen to the laboratory, clean gloves, and a mask
and goggles if necessary.
● Use a container with a preservative to obtain a specimen
for cytology.
● Use a sterile container for routine cultures and
AFB testing.
● If a client cannot cough effectively and expectorate
sputum into the container, collect the specimen by
endotracheal suctioning.
● Older adult clients have a weak cough reflex and
decreased muscle strength, making it difficult for them
to expectorate. They can require suctioning for sputum
specimen collection.
INTERPRETATION OF FINDINGS
● Presence of micro‑organisms indicating infection
● Presence of cancer cells
Chest physiotherapy
● The use of a set of techniques that loosen respiratory
secretions and move them into the central airways
where coughing or suctioning can remove them
● For clients who have thick secretions and are unable to
clear their airways
● Contraindicated for clients who are pregnant; have a rib,
chest, head, or neck injury; have increased intracranial
pressure; have had recent abdominal surgery; have
a pulmonary embolism; or have bleeding disorders
or osteoporosis
Percussion: the use of cupped hands to clap rhythmically
on the chest to break up secretions
Vibration: the use of a shaking movement during
exhalation to help remove secretions
Postural drainage: the use of various positions to allow
secretions to drain by gravity
316 CHAPTER 53 AirwAy MAnAgeMent CONTENT MASTERY SERIES
CONSIDERATIONS
nUrSing ACtiOnS
● Schedule treatments 1 hr before or 2 hr after meals,
and at bedtime to decrease the likelihood of vomiting
or aspirating.
● Administer a bronchodilator medication or nebulizer
treatment 30 min to 1 hr prior to postural drainage.
● Offer the client an emesis basin and facial tissues.
● Apply manual percussion to the chest wall using cupped
hands or a specific device.
● Place hands on the affected area, tense hand and arm
muscles, and move the heel of the hands to create
vibrations as the client exhales. Have the client cough
after each set of vibrations.
● Have the client remain in each position for 10 to
15 min to allow time for percussion, vibration, and
postural drainage.
● Discontinue the procedure if the client reports faintness
or dizziness.
● Note that older adult clients have decreased respiratory
muscle strength and chest wall compliance, which puts
them at risk for aspiration. They require more frequent
position changes and other interventions to promote
mobility of secretions.
Positioning: Ensure proper positioning to promote
drainage of specific areas of the lungs.
● Both lobes in general: high Fowler’s
● Apical segments of both lobes: sitting on the side of
the bed
● Right upper lobe, anterior segment: supine with
head elevation
● Right upper lobe, posterior segment: on the left side
with a pillow under the right side of the chest
● Right middle lobe, anterior segment: three‑quarters
supine with dependent lung in Trendelenburg
● Right middle lobe, posterior segment: prone with thorax
and abdomen elevation
● Right lower lobe, lateral segment: on the left side
in Trendelenburg
● Left upper lobe, anterior segment: supine with
head elevation
● Left upper lobe, posterior segment: on the right side
with a pillow under the left side of the chest
● Left lower lobe, lateral segment: on the right side
in Trendelenburg
● Both lower lobes, anterior segments: supine
in Trendelenburg
● Both lower lobes, posterior segments: prone
in Trendelenburg
Suctioning
Suction orally, nasally, or endotracheally when clients
have early signs of hypoxemia, such as restlessness,
confusion, tachypnea, tachycardia, decreased SpO2 levels,
adventitious breath sounds, audible or visible secretions,
cyanosis, and absence of spontaneous cough.
CONSIDERATIONS
nUrSing ACtiOnS
● Don the required personal protective equipment.
● Assist the client to high‑Fowler’s or Fowler’s position for
suctioning if possible.
● Encourage the client to breathe deeply and cough in an
attempt to clear the secretions without artificial suction.
● Obtain baseline breath sounds and vital signs, including
SaO2 by pulse oximeter. Can monitor SaO2 continually
during the procedure.
● For oropharyngeal suctioning, use a Yankauer or
tonsil‑tipped rigid suction catheter and move the
catheter around the mouth, gum line, and pharynx.
● For nasopharyngeal and nasotracheal suctioning, use
a flexible catheter and lubricate the distal 6 to 8 cm
(2 to 3 in) with water‑soluble lubricant.
● For endotracheal suctioning, use a suction catheter.
The catheter should not exceed one half of the internal
diameter of the endotracheal tube to prevent hypoxia.
The nurse should use no larger than a 16 French suction
catheter when suctioning an 8 mm endotracheal tube
or tracheostomy tube. Hyperoxygenate the client using
a bag‑valve‑mask (BVM) or specialized ventilator
function with an FiO2 of 100%.
● Use medical asepsis for suctioning the mouth.
● Use surgical asepsis for all other types of suctioning.
● Use suction pressure no higher than 120 to 150 mm Hg.
● Limit each suction attempt to no longer than 10 to
15 seconds to avoid hypoxemia and the vagal response.
Repeat suctioning if needed. Limit total suctioning time
to 5 minutes.
Online Image: Tracheal Suctioning
FUNDAMENTALS FOR NURSING CHAPTER 53 AirwAy MAnAgeMent 317
Additional guidelines for nasopharyngeal and
nasotracheal suctioning
● Insert the catheter into the naris during inhalation.
● Do not apply suction while inserting the catheter.
● Follow the natural course of the naris and slightly slant
the catheter downward while advancing it.
● Advance the catheter the approximate distance from the
tip of the nose to the base of the earlobe.
● Apply suction intermittently by covering and releasing
the suction port with the thumb for 10 to 15 seconds.
● Apply suction only while withdrawing the catheter and
rotating it with the thumb and forefinger.
● Do not perform more than two passes with the catheter.
Allow at least 1 min between passes for ventilation
and oxygenation.
Additional guidelines for endotracheal suctioning
● Remove the bag or ventilator from the tracheostomy
or endotracheal tube and insert the catheter into
the lumen of the airway. Advance the catheter until
resistance is met. The catheter should reach the
level of the carina (location of bifurcation into the
mainstem bronchi).
● Pull the catheter back 1 cm (0.4 in) prior to applying
suction to prevent mucosal damage.
● Apply suction intermittently by covering and releasing
the suction port with the thumb for 10 to 15 seconds.
● Apply suction only while withdrawing the catheter and
rotating it with the thumb and forefinger.
● Reattach the BVM or ventilator and administer
100% oxygen.
● Rinse catheter and suction tubing with sterile saline
until clear.
● Do not reuse the suction catheter for subsequent
suctioning sessions.
Artificial airways and
tracheostomy care
A tracheotomy is a sterile surgical incision into the
trachea through the skin and muscles for the purpose of
establishing an airway.
● A tracheotomy can be an emergency or a scheduled
surgical procedure; it can be temporary or permanent.
● A tracheostomy is the stoma/opening that results from a
tracheotomy to provide and secure a patent airway.
● Artificial airways can be placed orotracheally,
nasotracheally, or through a tracheostomy to assist
with respiration.
● Tracheostomy tubes vary in their composition (plastic,
steel, silicone), number of parts, size (long vs. short), and
shape (50° to 90° angles).
● There is no standard tracheostomy sizing system.
However, the diameter of the tracheostomy tube must be
smaller than the trachea.
● The outside cannula has a flange or neck plate that
sits against the skin of the neck and has holes on each
side for attaching ties around the neck to stabilize the
tracheostomy tube.
● Airflow in and out of a tracheostomy without air leakage
(a cuffed tracheostomy tube) bypasses the vocal cords,
resulting in an inability to produce sound or speech.
● Uncuffed tubes and fenestrated tubes, in place or capped,
allow speech. Clients who have a cuffed tube can be off
mechanical ventilation, can breathe around the tube, and
can use a specific valve to allow for speech. The cuff is
deflated and the valve occludes the opening.
● Indications for a tracheostomy include acute or chronic
upper airway obstruction, edema, anaphylaxis, burns,
trauma, head/neck surgery, copious secretions, obstructive
sleep apnea refractory to conventional therapy, and the need
for long‑term mechanical ventilation or reconstruction
after laryngeal trauma or laryngeal cancer surgery.
ArtiFiCiAL AirwAy tUBe tyPeS
Single‑lumen (cannula)
● Long, single‑cannula tube
● For clients who have long or thick necks
NURSING CONSIDERATIONS: Do not use with clients who
have excessive secretions.
Double‑lumen (cannula)
● An outer cannula fits into the stoma and keeps the
airway open.
● An inner cannula fits snugly into the outer cannula and
locks into place.
● An obturator is a thin, solid tube the provider places
inside the tracheostomy and uses as a guide for
inserting the outer cannula, and removes immediately
after outer cannula insertion.
NURSING CONSIDERATIONS
● This device allows removing, cleaning, reusing,
discarding, and replacing the inner cannula with a
disposable inner cannula.
● It is useful for clients who have excessive secretions.
318 CHAPTER 53 AirwAy MAnAgeMent CONTENT MASTERY SERIES
Cuffed tube
It has a balloon that inflates around the outside of the
distal segment of the tube to protect the lower airway by
producing a seal between the upper and lower airway.
NURSING CONSIDERATIONS
● A cuffed tube permits mechanical ventilation.
● A cuffed tube prevents aspiration of
oropharyngeal secretions.
● Cuffs do not hold the tube in place.
● Cuff pressures must be monitored to prevent tracheal
tissue necrosis.
● The client is unable to speak.
● Children do not require a cuffed tube.
Cuffless tube
It has no balloon and is for clients who have long‑term
airway‑management needs.
NURSING CONSIDERATIONS
● The client must be at low risk for aspiration.
● Cuffless tubes are not for clients on mechanical ventilation.
● This device allows the client to speak.
Fenestrated tube with cuff
● It has one large or multiple openings (fenestrations) in
the posterior wall of the outer cannula with a balloon
around the outside of the distal segment of the tube.
● It also has an inner cannula.
NURSING CONSIDERATIONS
● This device allows for mechanical ventilation.
● Removing the inner cannula allows the fenestrations to
permit air to flow through the openings.
● This device allows the client to speak.
Fenestrated tube without cuff
● It has one larger or multiple openings (fenestrations) in
the posterior wall of the outer cannula with no balloon.
● It also has an inner cannula.
NURSING CONSIDERATIONS
● The holes in the tube help wean the client from
the tracheostomy.
● Removing the inner cannula allows the fenestrations to
permit air to flow through the openings.
● This device allows the client to speak.
CONSIDERATIONS
NURSING ACTIONS
● Keep the following at the bedside: two extra
tracheostomy tubes (one the client’s size and one
size smaller, in case of accidental decannulation), the
obturator for the existing tube, an oxygen source,
suction catheters and a suction source, and a BVM.
● Provide methods to communicate with staff (paper and
pen, dry‑erase board).
● Provide an emergency call system and a call light.
● Provide adequate humidification and hydration to thin
secretions and reduce the risk of mucous plugs.
● Give oral care every 2 hr.
● Provide tracheostomy care every 8 hr to reduce the risk
of infection and skin breakdown.
◯ Suction the tracheostomy tube, if necessary, using
sterile suctioning supplies.
◯ Remove soiled dressings and excess secretions.
◯ Apply the oxygen source loosely if the client’s SpO2
decreases during the procedure.
◯ Use cotton‑tipped applicators and gauze pads to
clean exposed outer cannula surfaces. Use the
facility‑approved solution. Clean in a circular motion
from the stoma site outward.
◯ Use surgical asepsis to remove and clean the inner
cannula (with the facility‑approved solution). Use a
new inner cannula if it is disposable.
◯ Clean the stoma site and then the tracheostomy plate.
◯ Place a fresh split‑gauze tracheostomy dressing
of nonraveling material under and around the
tracheostomy holder and plate.
◯ Replace tracheostomy ties if they are wet or soiled.
Secure the new ties before removing the soiled ones
to prevent accidental decannulation.
◯ If a knot is needed, tie a square knot that is visible on
the side of the neck. Check that one or two fingers fit
between the tie and the neck.
● Change nondisposable tracheostomy tubes every 6 to
8 weeks or per protocol.
● Reposition the client every 2 hr to prevent atelectasis
and pneumonia.
● Minimize dust in the room. Do not shake bedding.
● If the client is permitted to eat, position him upright
and tip his chin to his chest to enable swallowing.
Assess for aspiration.
53.6 Tracheal suctioning
FUNDAMENTALS FOR NURSING CHAPTER 53 AirwAy MAnAgeMent 319
COMPLICATIONS
Accidental decannulation
Accidental decannulation in the first 72 hr after surgery
is an emergency because the tracheostomy tract has not
matured, and replacement can be difficult.
! Ventilate the client with a BVM. Call for assistance.
NURSING ACTIONS
● Always keep the tracheostomy obturator and two spare
tracheostomy tubes at the bedside.
● If unable to replace the tracheostomy tube, administer
oxygen through the stoma. If unable to administer
oxygen through the stoma, occlude the stoma and
administer oxygen through the nose and mouth.
If accidental decannulation occurs after the first 72 hr
● Immediately hyperextend the neck and with the obturator
inserted into the tracheostomy tube, quickly and gently
replace the tube and remove the obturator.
● Secure the tube.
● Assess tube placement by auscultating for bilateral
breath sounds.
Damage to the trachea
Tracheal stenosis: Narrowing of the tracheal lumen due
to scar formation resulting from irritation of the tracheal
mucosa from the tracheal tube cuff.
NURSING CONSIDERATIONS
● Keep the cuff pressure between 14 and 20 mm Hg.
● Check the cuff pressure at least once every 8 hr.
● Keep the tube in the midline position and prevent
pulling or traction on the tracheostomy tube.
Tracheal wall necrosis: Tissue damage that results when
the pressure of the inflated cuff impairs blood flow to the
tracheal wall.
Application Exercises
1. A nurse is assessing a client who
has an acute respiratory infection
that puts her at risk for hypoxemia.
which of the following findings are
early indications that should alert the
nurse that the client is developing
hypoxemia? (Select all that apply.)
A. restlessness
B. tachypnea
C. Bradycardia
D. Confusion
e. Pallor
2. A provider is discharging a client who
has a prescription for home oxygen
therapy via nasal cannula. Client
and family teaching by the nurse
should include which of the following
instructions? (Select all that apply.)
A. Apply petroleum jelly around
and inside the nares.
B. remove the nasal cannula
during mealtimes.
C. Check the position of
the cannula frequently.
D. report any nasal stuffiness,
nausea, or fatigue.
e. Post “no Smoking” signs
in a prominent location.
3. A nurse is caring for a client who
is having difficulty breathing. the
client is lying in bed and is already
receiving oxygen therapy via nasal
cannula. which of the following
interventions is the nurse’s priority?
A. increase the oxygen flow.
B. Assist the client to
Fowler’s position.
C. Promote removal of
pulmonary secretions.
D. Obtain a specimen for
arterial blood gases.
4. A nurse is preparing to perform
endotracheal suctioning for a
client. the nurse should follow
which of the following guidelines?
(Select all that apply.)
A. Apply suction while
withdrawing the catheter.
B. Perform suctioning on a
routine basis, every 2 to 3 hr.
C. Maintain medical asepsis
during suctioning.
D. Use a new catheter for
each suctioning attempt.
e. Limit total suctioning
time to 5 minutes.
5. A nurse is caring for a client who
has a tracheostomy. which of the
following actions should the nurse
take when providing tracheostomy
care? (Select all that apply.)
A. Apply the oxygen source
loosely if the SpO2 decreases
during the procedure.
B. Use surgical asepsis to remove
and clean the inner cannula.
C. Clean the outer surfaces
in a circular motion from
the stoma site outward.
D. replace the tracheostomy
ties with new ties.
e. Cut a slit in gauze squares to
place beneath the tube holder.
PRACTICE Active Learning Scenario
A nurse is reviewing with a group of nursing students
how to perform postural drainage. Use the Ati Active
Learning template: nursing Skill to complete this item.
DESCRIPTION OF SKILL: List the specific
positions that facilitate secretion drainage
from at least eight specific lung areas.
320 CHAPTER 53 AirwAy MAnAgeMent CONTENT MASTERY SERIES
Application Exercises Key
1. A. CORRECT: the nurse should monitor for restlessness, which
is an early manifestation of hypoxemia, along with tachycardia,
elevated blood pressure, use of accessory muscles, nasal
flaring, tracheal tugging, and adventitious lung sounds.
B. CORRECT: the nurse should monitor for tachypnea,
which is an early manifestation of hypoxemia.
C. Bradycardia is a late manifestation of hypoxemia, along
with stupor, cyanotic skin and mucous membranes,
bradypnea, hypotension, and cardiac dysrhythmias.
D. CORRECT: the nurse should monitor for confusion,
which is an early manifestation of hypoxemia.
e. CORRECT: the nurse should monitor for pallor,
which is an early manifestation of hypoxemia.
NCLEX® Connection: Physiological Adaptation,
Illness Management
2. A. the nurse should teach the client to apply a water‑based
lubricant to protect the nares from drying during oxygen therapy.
B. the nurse should teach the client to leave the nasal cannula
on while eating because it does not interfere with eating.
C. CORRECT: the nurse should teach the client that a disadvantage of
the nasal cannula is that it dislodges easily. the client should form the
habit of checking its position periodically and readjusting it as necessary.
D. CORRECT: the nurse should teach the client about oxygen
toxicity, which is a complication of oxygen therapy, usually
from high concentrations or long durations. Manifestations
include a nonproductive cough, substernal pain, nasal
stuffiness, nausea, vomiting, fatigue, headache, sore throat, and
hypoventilation. the client should report any of these promptly.
e. CORRECT: the nurse should teach the client that oxygen
is combustible and thus increases the risk of fire injuries. no
one in the house should smoke or use any device that might
generate sparks in the area where the oxygen is in use.
NCLEX® Connection: Reduction of Risk Potential,
Therapeutic Procedures
3. A. the nurse might need to increase the client’s oxygen
flow, as hypoxemia can be the cause of his difficulty
breathing. However, another action is the priority.
B. CORRECT: the priority action the nurse should take when
using the airway, breathing, circulation (ABC) approach to care
delivery is to relieve dyspnea (difficulty breathing). Fowler’s
position facilitates maximal lung expansion and thus optimizes
breathing. with the client in this position, the nurse can better
assess and determine the cause of the client’s dyspnea.
C. the nurse might need to suction the client or
encourage expectoration of pulmonary secretions.
However, another action is the priority,
D. the nurse should check the client’s oxygenation
status. However, another action is the priority.
NCLEX® Connection: Physiological Adaptation,
Illness Management
4. A. CORRECT: the nurse should apply suction pressure only while
withdrawing the catheter to prevent damaging the tracheal tissue.
B. the nurse should suction the client only as needed,
because suctioning is not without risk. it can cause
mucosal damage, bleeding, and bronchospasm.
C. the nurse should use surgical asepsis when performing
endotracheal suctioning to prevent contamination with
microorganism that can cause an infection.
D. CORRECT: the nurse should use a new suction catheter,
unless an in‑line suctioning system is in place, to prevent
contamination with microorganism that can cause an infection.
e. CORRECT: to prevent hypoxemia, the nurse should limit
total suctioning time to 5 minutes and allow at least 1 min
between passes for ventilation and oxygenation.
NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems
5. A. CORRECT: the nurse should provide supplemental
oxygen in response to any decline in oxygen saturation
while performing tracheostomy care.
B. CORRECT: the nurse should use a sterile disposable
tracheostomy cleaning kit or sterile supplies and maintain
surgical asepsis throughout this part of the procedure.
C. CORRECT: the nurse should cleanse the surface around
the stoma in a circular motion from the stoma site outward.
Cleansing in this manner helps move mucus and contaminated
material away from the stoma for easy removal.
D. the nurse should replace the tracheostomy ties if they
are wet or soiled. there is a risk of tube dislodgement with
replacing the ties, so he should not replace them routinely.
e. the nurse should use a commercially prepared
tracheostomy dressing with a slit in it. Cutting gauze squares
can loosen lint or gauze fibers the client could aspirate.
NCLEX Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
PRACTICE Answer
Using the ATI Active Learning Template: Nursing Skill
DESCRIPTION OF SKILL
● Both lobes in general: high‑Fowler’s
● Apical segments of both lobes:
sitting on the side of the bed
● right upper lobe, anterior segment:
supine with head elevation
● right upper lobe, posterior segment:
on the left side with a pillow under
the right side of the chest
● right middle lobe, anterior segment:
three‑quarters supine with dependent
lung in trendelenburg
● right middle lobe, posterior segment:
prone with thorax and abdomen elevation
● right lower lobe, lateral segment: on
the left side in trendelenburg
● Left upper lobe, anterior segment:
supine with head elevation
● Left upper lobe, posterior segment: on the right
side with a pillow under the left side of the chest
● Left lower lobe, lateral segment: on
the right side in trendelenburg
● Both lower lobes, anterior segments:
supine in trendelenburg
● Both lower lobes, posterior segments:
prone in trendelenburg
NCLEX® Connection: Physiological Adaptation, Alterations in Body Systems
FUNDAMENTALS FOR NURSING CHAPTER 54 Nasogastric iNtubatioN aNd ENtEral FEEdiNgs 321
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: REDUCTION OF RISK POTENTIAL
CHAPTER 54 Nasogastric
Intubation and
Enteral Feedings
Nasogastric intubation is the insertion
of a nasogastric (Ng) tube to manage
gastrointestinal (gi) dysfunction and provide
enteral nutrition via Ng. Nurses also give enteral
feedings through jejunal and gastric tubes.
Nasogastric intubation
An NG tube is a hollow, flexible, cylindrical device the
nurse inserts through the nasopharynx into the stomach.
INDICATIONS
Decompression
● Removal of gases or stomach contents to relieve
distention, nausea, or vomiting
● Tube types: Salem sump, Miller‑Abbott, Levin
Feeding
● Alternative to the oral route for administering
nutritional supplements
● Tube types: Duo, Levin, Dobhoff
Lavage
● Washing out the stomach to treat active bleeding,
ingestion of poison, or for gastric dilation
● Tube types: Ewald, Levin, Salem sump
Compression
● Using an internal balloon to apply pressure for
preventing hemorrhage
● Tube type: Sengstaken‑Blakemore
CHAPTER 54
Online Images: Enteral Feeding Tube, Sengstaken‑Blakemore Tube
54.1 Enteral feeding tube
54.2 Sengstaken‑Blakemore tube
322 CHAPTER 54 Nasogastric iNtubatioN aNd ENtEral FEEdiNgs CONTENT MASTERY SERIES
CONSIDERATIONS
PrEProcEdurE
NURSING ACTIONS
● Review the prescription and purpose, plan for drainage
or suction, and understand the need for placement for
diagnostic purposes.
● Identify the client, and explain the procedure.
● Review the client’s history (nasal problems,
anticoagulants, previous trauma, past history
of aspiration).
● Evaluate the client’s ability to assist and cooperate.
● Establish a means of communication to signal distress,
such as the client raising a hand.
● Perform hand hygiene.
● Set up the equipment.
◯ NG tube: selected according to the indication
◯ Tape or use a commercial fixation device to secure
the dressing
◯ Clean gloves
◯ Water‑soluble lubricant
◯ Topical anesthetic
◯ Cup of water and straw
◯ Catheter‑tipped syringe, usually 30 to 60 mL
◯ Basin to prepare for gag‑induced nausea
◯ pH test strip or meter to measure gastric secretions
for acidity
◯ Stethoscope
◯ Disposable towel to maintain a clean environment
◯ Clamp or plug to close the tubing after insertion
◯ Suction apparatus if attaching the tube to continuous
or intermittent suction
◯ Gauze square to cleanse the outside of the tubing
after insertion
◯ Safety pin and elastic band or commercial device to
secure the tubing and prevent accidental removal
● Position a disposable towel and basin.
● Provide privacy.
iNtraProcEdurE
NURSING ACTIONS
● Auscultate for bowel sounds, and palpate the abdomen
for distention, pain, and rigidity.
● Raise the bed to a level comfortable for the nurse.
● Assist the client to high‑Fowler’s position (if possible).
● Assess the nares for the best route to determine how to
avoid a septal deviation or other obstruction during the
insertion process.
● Use the correct procedure for tube insertion, wearing
clean gloves, and evaluate the outcome.
● If the client vomits, clear the airway, and provide
comfort prior to continuing.
● Check placement. Aspirate gently to collect gastric
contents, testing pH (4 or less is expected), and assess
odor, color, and consistency.
● After placement verification, secure the NG tube on the
nose, avoiding pressure on the nares.
◯ Confirm placement with an x-ray.
◯ Injecting air into the tube and then listening over the
abdomen is not an acceptable practice.
● If the tube is not in the stomach, advance it 5 cm (2 in),
and repeat the placement check.
● Clamp the NG tube, or connect it to the suction device.
● Salem sump tubing has a blue pigtail for negative air
release. Do not insert any substance into the blue pigtail
because it will break the seal and the tubing will leak.
PostProcEdurE
NURSING ACTIONS
● The insertion and maintenance of an NG tube is
a nursing responsibility, but nurses may delegate
measuring output, providing comfort, and giving
oral care.
● For removal, wear clean gloves.
◯ Inform the client of the prescription and process,
emphasizing that removal is less stressful
than placement.
◯ Measure and record any drainage, assessing it for
color, consistency, and odor.
◯ Ensure comfort.
◯ Document all relevant information.
■ Tubing removal and condition of the tube
■ Volume and description of the drainage
■ Abdominal assessment, including inspection,
auscultation, percussion, and palpation
■ Last and next bowel movement and urine output
COMPLICATIONS
Excoriation of nares and stomach
● Apply water‑soluble lubricant to the nares as necessary.
● Assess the color of the drainage. Report dark,
coffee-ground, or blood-streaked drainage immediately.
● Consider switching the tube to the other naris.
Discomfort
● Rinse the mouth with water for dryness.
● Throat lozenges can help.
● Provide oral hygiene frequently.
Occlusion of the NG tube leading to distention
● Irrigate the tube per the facility’s protocol to unclog
blockages. Use tap water with enteral feedings. Have
the client change position in case the tip of the tube is
against the stomach wall.
● Verify that suction equipment functions properly.
FUNDAMENTALS FOR NURSING CHAPTER 54 Nasogastric iNtubatioN aNd ENtEral FEEdiNgs 323
Enteral feedings
Enteral feeding is a method of providing nutrients to
clients who cannot consume foods orally.
ENtEral ForMulas
Polymeric: 1 to 2 kcal/mL
● Milk‑based, blenderized foods
● Whole‑nutrient formulas, either commercial or from the
dietary department
● Only for clients whose GI tract can absorb whole
nutrients
Modular formulas: 3.8 to 4 kcal/mL
● Single‑macronutrient preparation
● Not nutritionally complete
● Supplement to other foods
Elemental formulas: 1 to 3 kcal/mL
● Predigested nutrients
● Not nutritionally complete
● Easier for a partially dysfunctional GI tract to absorb
Specialty formulas: 1 to 2 kcal/mL
● For meeting specific nutritional needs
● Not nutritionally complete
● Primarily for clients who have hepatic failure,
respiratory disease, or HIV infection
ENtEral accEss tubEs
Gastroparesis, esophageal reflux, or a history of aspiration
pneumonia generally requires intestinal placement.
Nasogastric or nasointestinal
● Therapy duration less than 4 weeks
● Inserted via the nose
Gastrostomy or jejunostomy
● Therapy duration longer than 4 weeks
● Inserted surgically
Percutaneous endoscopic gastrostomy or jejunostomy
● Therapy duration longer than 4 weeks
● Inserted endoscopically
INDICATIONS
● Critical illness/trauma
● Neurological and muscular disorders: brain neoplasm,
stroke, dementia, myopathy, Parkinson’s disease
● Cancer that affects the head and neck, upper GI tract
● GI disorders: enterocutaneous fistula, inflammatory
bowel disease, mild pancreatitis
● Respiratory failure with prolonged intubation
● Inadequate oral intake
CONSIDERATIONS
PrEParatioN oF tHE cliENt
NURSING ACTIONS
● Review the prescription. Generally, the provider and
dietary staff consult to determine the type of tube
feeding formula.
● Set up the equipment.
◯ Feeding bag
◯ Tubing
◯ 30‑ to 60‑mL syringe (compatible with the tubing)
◯ Stethoscope
◯ pH indicator strip
◯ Infusion pump (if not a gravity drip)
◯ Appropriate enteral formula
◯ Irrigant solution: sterile or tap water, according to the
facility’s policy
◯ Clean gloves
◯ Supplies for blood glucose (if protocol or
prescription indicates)
◯ Suction equipment to use in case of aspiration
oNgoiNg carE
NURSING ACTIONS
● Prepare the formula, tubing, and infusion device.
◯ Check expiration dates, and note the content of
the formula.
◯ Ensure that the formula is at room temperature.
◯ Set up the feeding system via gravity or pump.
◯ Mix or shake the formula, fill the container, prime the
tubing, and clamp it.
● Assist the client to Fowler’s position, or elevate the head
of the bed to a minimum of 30°.
● Auscultate for bowel sounds.
● Monitor tube placement.
◯ Check gastric contents for pH. A good indication of
appropriate placement is obtaining gastric contents
with a pH between 0 and 4.
◯ Aspirate for residual volume.
◯ Note the appearance of the aspirate.
◯ Return aspirated contents, or follow the
facility’s protocol.
● Flush the tubing with at least 30 mL tap water.
● Administer the formula.
◯ Intermittent feeding
■ Prepare the formula and a 60‑mL syringe.
■ Remove the plunger from the syringe.
■ Hold the tubing above the instillation site.
■ Open the stopcock on the tubing, and insert the
barrel of the syringe with the end up.
■ Fill the syringe with 40 to 50 mL formula.
■ If using a feeding bag, fill the bag with the total
amount of formula for one feeding, and hang it to
drain via gravity until empty (about 30 to 45 min).
■ If using a syringe, hold it high enough for the
formula to empty gradually via gravity.
■ Continue to refill the syringe until the amount for
the feeding is instilled. Follow with at least 30 mL
tap water to flush the tube and prevent clogging.
324 CHAPTER 54 Nasogastric iNtubatioN aNd ENtEral FEEdiNgs CONTENT MASTERY SERIES
◯ Continuous-drip feeding
■ Connect the feeding bag system to the feeding tube.
■ If using a pump, program the instillation rate, and
set the total volume to instill.
■ Start the pump.
■ Flush the enteral tubing with at least 30 mL
irrigant, usually tap water, every 4 to 6 hr, and
check tube placement again.
■ Monitor intake and output, and include 24‑hr totals.
■ Monitor capillary blood glucose every 6 hr until the
client tolerates the maximum administration rate
for 24 hr.
■ Use an infusion pump for intestinal tube feedings.
■ Follow the manufacturer’s recommendations for
formula hang time. Refrigerate unused formula,
and discard after 24 hr.
■ Check gastric residual every 4 to 8 hr. Each
facility’s protocol specifies the actions to take for
the amount of residual.
■ Do not delegate this skill to assistive personnel.
COMPLICATIONS
Gastric residual exceeds 250 mL for each
of two consecutive assessments
NURSING ACTIONS
● Withhold the feeding.
● Notify the provider.
● Keep the client in semi‑Fowler’s position.
● Recheck residual in 1 hr.
Diarrhea three times or more in a 24‑hr period
NURSING ACTIONS
● Slow the instillation rate.
● Notify the provider.
● Confer with the dietitian.
● Provide skin care and protection.
Nausea or vomiting
NURSING ACTIONS
● Slow the instillation rate.
● Keep the head of the bed at 30°.
● Make sure the formula is at room temperature.
● Turn the client to the side.
● Notify the provider.
● Check the tube’s patency.
● Aspirate for residual.
● Auscultate for bowel sounds.
● Obtain a chest x‑ray.
Aspiration of formula
NURSING ACTIONS
● Withhold the feeding.
● Turn the client to the side.
● Suction the airway.
● Provide oxygen if indicated.
● Monitor vital signs for elevated temperature.
● Monitor for decreased oxygen saturation or increased
respiratory rate.
● Auscultate breath sounds for increased congestion.
● Notify the provider.
● Obtain a chest x‑ray.
Skin irritation around the tubing site
NURSING ACTIONS
● Provide a skin barrier for any drainage at the site.
● Monitor the tube’s placement.
FUNDAMENTALS FOR NURSING CHAPTER 54 Nasogastric iNtubatioN aNd ENtEral FEEdiNgs 325
Application Exercises
1. a nurse is delivering an enteral
feeding to a client who has an
Ng tube in place for intermittent
feedings. When the nurse pours
water into the syringe after the
formula drains from the syringe, the
client asks the nurse why the water
is necessary. Which of the following
responses should the nurse make?
a. “Water helps clear the tube
so it doesn’t get clogged.”
b. “Flushing helps make sure
the tube stays in place.”
c. “this will help you get
enough fluids.”
d. “adding water makes the
formula less concentrated.”
2. a nurse is caring for a client who
is receiving continuous enteral
feedings. Which of the following
nursing interventions is the highest
priority when the nurse suspects
aspiration of the feeding?
a. auscultate breath sounds.
b. stop the feeding.
c. obtain a chest x‑ray.
d. initiate oxygen therapy.
3. a nurse is preparing to instill an
enteral feeding for a client who
has an Ng tube in place. Which of
the following actions is the nurse’s
highest assessment priority before
performing this procedure?
a. check how long the feeding
container has been open.
b. Verify the placement
of the Ng tube.
c. confirm that the client
does not have diarrhea.
d. Make sure the client is
alert and oriented.
4. a nurse is caring for a client in
a long‑term care facility who is
receiving enteral feedings via an
Ng tube. Which of the following
actions should the nurse complete
prior to administering the tube
feeding? (select all that apply.)
a. auscultate bowel sounds.
b. assist the client to an
upright position.
c. test the pH of gastric aspirate.
d. Warm the formula to
body temperature.
E. discard any residual
gastric contents.
5. a nurse is preparing to insert an
Ng tube for a client who requires
gastric decompression. Which of
the following actions should the
nurse perform before beginning the
procedure? (select all that apply.)
a. review a signal the client can
use if feeling any distress.
b. lay a towel across
the client’s chest.
c. administer oral pain
medication.
d. obtain a dobhoff
tube for insertion.
E. Have a petroleum‑based
lubricant available.
PRACTICE Active Learning Scenario
a nurse is teaching a group of nursing students about
administering enteral feedings. use the ati active
learning template: Nursing skill to complete this item.
INDICATIONS: list at least four
indications for enteral feedings.
NURSING INTERVENTIONS (INTRAPROCEDURE):
list the steps of administering an enteral feeding.
326 CHAPTER 54 Nasogastric iNtubatioN aNd ENtEral FEEdiNgs CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: the nurse should flush the tube after instilling the
feeding to help keep the Ng tube patent by clearing any excess
formula from the tube so that it doesn’t clump and clog the tube.
b. the nurse should tape a securing device, not flush the tube
with water, to help maintain the position of the Ng tube.
c. the nurse should administer additional fluids. the small
amount used for flushing the Ng tube will not be adequate.
d. the nurse should contact the dietary staff to prepare formula
according to the prescription before the nurse instills it.
NCLEX® Connection: Reduction of Risk Potential,
Potential for Alterations in Body Systems
2. a. the nurse should listen to breath sounds whenever there is suspicion
of the client aspirating. However, another assessment is the priority.
b. CORRECT: the greatest risk to the client is aspiration
pneumonia. the first action the nurse should take is to stop
the feeding so that no more formula can enter the lungs.
c. the nurse should obtain a chest x‑ray whenever there is suspicion
of the client aspirating. However, another assessment is the priority.
d. the nurse should initiate oxygen therapy whenever there is suspicion
of the client aspirating. However, another assessment is the priority.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
3. a. checking that the container has not exceeded its expiration date,
either for having it open or for opening it, is important. However,
there is a higher assessment priority among these options.
b. CORRECT: the greatest risk to the client receiving enteral feedings is
injury from aspiration. the priority nursing assessment before initiating
an enteral feeding is to verify proper placement of the Ng tube.
c. the nurse should assess the client for any possible
complications of enteral feedings, such as diarrhea. However,
there is another assessment that is the priority.
d. the nurse should determine the client’s level of consciousness
as an assessment parameter that is ongoing and should precede
any procedure. However, another assessment is the priority.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
4. a. CORRECT: the nurse should auscultate for bowel sounds, because
the client’s gastrointestinal tract might not be able to absorb nutrients.
the nurse should then withhold feedings and notify the provider.
b. CORRECT: the nurse should place the client in an upright
position, with at least a 30° elevation of the head of the
bed. upright positioning helps prevent aspiration.
c. CORRECT: before administering enteral feedings, the nurse should
verify the placement of the Ng tube. the only reliable method is x‑ray
confirmation, which is impractical prior to every feeding. testing the pH
of gastric aspirate is an acceptable method between x‑ray confirmations.
d. the nurse should have the enteral formula at room
temperature before administering the enteral feeding.
E. the nurse should return the residual to the client’s
stomach, unless the volume of gastric contents is more than
250 ml or the facility has other guidelines in place.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
5. a. CORRECT: the nurse should establish a means
for the client to communicate that she wants to stop
the procedure, before inserting an Ng tube.
b. CORRECT: the nurse should place a disposable towel
across the client’s chest to provide for a clean environment
and protect the client’s gown from becoming soiled.
c. because the purpose of the procedure is to remove stomach
contents, the procedure would also remove the oral pain medication.
d. the nurse should plan to use the prescribed type of
tube for gastric decompression, which is a salem sump,
Miller‑abbott, or levin. a dobhoff tube is for feeding.
E. the nurse should plan to use a water‑based lubricant
to reduce complications from aspiration.
NCLEX® Connection: Reduction of Risk Potential, Potential for
Complications of Diagnostic Tests/Treatments/Procedures
PRACTICE Answer
Using the ATI Active Learning Template: Nursing Skill
INDICATIONS
● critical illness, trauma
● Neurological and muscular disorders:
brain neoplasm, cerebrovascular accident,
dementia, myopathy, Parkinson’s disease
● gi disorders: enterocutaneous fistula,
inflammatory bowel disease, mild pancreatitis
● respiratory failure with prolonged intubation
● inadequate oral intake
NURSING INTERVENTIONS (INTRAPROCEDURE)
● Prepare the formula and a 60 ml syringe.
● remove the plunger from the syringe.
● Hold the tubing above the instillation site.
● open the stopcock on the tubing, and insert the barrel of the syringe with the end up.
● Fill the syringe with 40 to 50 ml formula.
● if using a feeding bag, fill the bag with the total amount of formula for one
feeding, and hang it to drain via gravity until empty (about 30 to 45 min).
● if using a syringe, hold it high enough for the formula to empty gradually via gravity.
● continue to refill the syringe until the amount for the feeding is instilled.
● Follow with at least 30 ml tap water to flush the tube and prevent clogging.
NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures
FUNDAMENTALS FOR NURSING NCLEX® CONNECTIONS 327
NCLEX® Connections
When reviewing the following chapters, keep in mind the
relevant topics and tasks of the NCLEX outline, in particular:
Client Needs: Reduction of Risk Potential
CHANGES/ABNORMALITIES IN VITAL SIGNS: Assess
and respond to changes in client vital signs.
POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/
TREATMENTS/PROCEDURES: Apply knowledge of
nursing procedures and psychomotor skills when caring
for a client with potential for complications.
SYSTEM SPECIFIC ASSESSMENTS
Assess the client for peripheral edema.
Identify factors that result in delayed wound healing.
Client Needs: Physiological Adaptation
ALTERATIONS IN BODY SYSTEMS
Monitor wounds for signs and symptoms of infection.
Perform wound care or dressing change.
FLUID AND ELECTROLYTE IMBALANCES: Identify signs
and symptoms of client fluid and/or electrolyte imbalance.
MEDICAL EMERGENCIES: Perform emergency care procedures.
PATHOPHYSIOLOGY: Understand general principles of pathophysiology.
Client Needs: Basic Care and Comfort
MOBILITY/IMMOBILITY: Perform skin assessment and implement
measures to maintain skin integrity and prevent skin breakdown.
FUNDAMENTALS FOR NURSING CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent 329
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHYSIOLOGICAL ADAPTATION
CHAPTER 55 Pressure Ulcers,
Wounds, and Wound
Management
Wounds are a result of injury to the skin.
although there are many different methods and
degrees of injury, the basic phases of healing
are essentially the same for most wounds.
a pressure ulcer (formerly called a decubitus
ulcer) is a specific type of tissue injury from
unrelieved pressure or friction over bony
prominences that results in ischemia and
damage to the underlying tissue.
WOUND HEALING AND MANAGEMENT
stages oF Wound HealIng
Inflammatory stage
Begins with the injury and lasts 3 to 6 days.
EFFECTS TO THE WOUND
● Controlling bleeding with vasoconstriction and
retraction of blood vessels, and with clot formation.
● Delivering oxygen, white blood cells, and nutrients
to the area via the blood supply. Hemostasis occurs
along with fibrin formation. Macrophages engulf
microorganisms and cellular debris (phagocytosis).
Proliferative stage
Lasts the next 3 to 24 days.
EFFECTS TO THE WOUND
● Replacing lost tissue with connective or granulated
tissue or collagen.
● Contracting the wound’s edges.
● Resurfacing of new epithelial cells.
Maturation or remodeling stage
Occurs after day 21 and involves the strengthening of
the collagen scar and the restoration of a more normal
appearance. It can take more than 1 year to complete,
depending on the extent of the original wound.
HealIng Processes
Primary intention
● Little or no tissue loss
● Edges approximated, as with a surgical incision
● Heals rapidly
● Low risk of infection
● No or minimal scarring
example: closed surgical incision with staples
or sutures or liquid glue to seal laceration
Secondary intention
● Loss of tissue
● Wound edges widely separated, unapproximated
(pressure ulcers, open burn areas)
● Longer healing time
● Increase for risk of infection
● Scarring
● Heals by granulation
example: Pressure ulcer left open to heal
Tertiary intention
● Widely separated
● Deep
● Spontaneous opening of a previously closed wound
● Closure of wound occurs when free of infection
● Risk of infection
● Extensive drainage and tissue debris
● Closed later
● Long healing time
example: abdominal wound initially left open
until infection is resolved and then closed
Factors aFFectIng Wound HealIng
Age: Increased age delays healing.
● Loss of skin turgor
● Skin fragility
● Decrease in peripheral circulation and oxygenation
● Slower tissue regeneration
● Decrease in absorption of nutrients
● Decrease in collagen
● Impaired immune system function
● Dehydration due to decreased thirst sensation
Overall wellness: A wound in a young, healthy client
will heal faster than a wound in an older adult who has a
chronic illness.
Decreased leukocyte count: Delays wound healing because
the immune system function is to fight infection by
destroying invading pathogens.
Some medications (anti-inflammatory and antineoplastic)
interfere with the body’s ability to respond to and
prevent infection.
Malnourished clients: Nutrition provides energy and
elements for wound healing.
CHAPTER 55
330 CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent CONTENT MASTERY SERIES
Tissue perfusion provides circulation that delivers
nutrients for tissue repair and infection control.
Low Hgb levels: Hgb is essential for oxygen delivery to
healing tissues.
Obesity: Fatty tissue lacks blood supply.
Chronic diseases , such as diabetes mellitus and
cardiovascular disorders, place additional stress on the
body’s healing mechanisms.
Smoking impairs oxygenation and clotting.
Wound stress, such as from vomiting or coughing, puts
pressure on the suture line and disrupts the wound
healing process.
General principles of
wound management
● Wounds impair skin integrity.
● Inflammation is a localized protective response to injury
or destruction of tissue.
● Wounds heal by various processes and in stages.
● Wound infections result from the invasion of pathogenic
micro‑organisms.
● Principles of wound care include assessment, cleansing,
and protection.
ASSESSMENT/DATA COLLECTION
APPEARANCE
● Note the color of open wounds.
◯ Red: Healthy regeneration of tissue
◯ Yellow: Presence of purulent drainage and slough
◯ Black: Presence of eschar that hinders healing and
requires removal
● Assess the length, width, and depth, and any
undermining, sinus tracts or tunnels, and redness or
swelling. Use a clock face with 12:00 toward the client’s
head to document the location of sinus tracts.
● Use the RYB color code guide for wound care:
red (cover), yellow (clean), black (debride, removal
of necrotic tissue).
● Closed wounds: Skin edges should be
well‑approximated.
DRAINAGE (EXUDATE) is a result of the healing process
and occurs during the inflammatory and proliferative
phases of healing.
● Note the amount, odor, consistency and color of
drainage from a drain or on a dressing.
● Note the integrity of the surrounding skin.
● With each cleansing, observe the skin around a drain for
irritation and breakdown.
● For accurate measurement of drainage, weigh dressing.
1 g = 1 ml drainage
● Note and document the number of dressings and
frequency of dressing changes.
◯ Serous drainage: The portion of the blood (serum)
that is watery and clear or slightly yellow in
appearance (e.g., fluid in blisters).
◯ Sanguineous drainage: Contains serum and red
blood cells. It is thick and appears reddish. Brighter
drainage indicates fresh bleeding; darker drainage
indicates older bleeding/drainage.
◯ Serosanguineous drainage: Contains both serum
and blood. It is watery and appears blood‑streaked or
blood‑tinged.
◯ Purulent drainage: The result of infection. It is thick
and contains white blood cells, tissue debris, and
bacteria. It may have a foul odor, and its color such
as yellow, tan, brown reflects the type of organism
present (green for a Pseudomonas aeruginosa infection).
◯ Purosanguineous: A mixed drainage of pus and blood
(e.g., newly infected wound).
WOUND CLOSURE: Staples, sutures, wound‑closure strips
STATUS of any drains or tubes
PAIN: Note the location, quality, intensity, timing, setting,
associated manifestations, and aggravating/relieving factors.
NURSING INTERVENTIONS
● Provide adequate hydration and meet protein and
calorie needs.
◯ Encourage an intake of 2,000 to 3,000 mL of fluid/day,
from food and beverage sources if not contraindicated
(heart and chronic kidney disease).
◯ Provide education about good sources of protein
(meat, fish, poultry, eggs, dairy products, beans, nuts,
whole grains).
◯ Note if serum albumin levels are low (below 3.5 g/dL),
because a lack of protein increases the risk for a delay
in wound healing and infection.
◯ Provide nutritional support (vitamin and mineral
supplements, nutritional supplements, and enteral
and parenteral nutrition). Most adult clients need at
least 1,500 kcal/day for nutritional support.
● Perform wound cleansing.
◯ For clean wounds, such as a surgical incision, cleanse
from the least contaminated (the incision) toward the
most contaminated (the surrounding skin).
◯ Use gentle friction when cleansing or applying
solutions to the skin to avoid bleeding or further
injury to the wound.
◯ Although the provider might prescribe other mild
cleansing agents, isotonic solutions remain the
preferred cleansing agents.
◯ Never use the same gauze to cleanse across an
incision or wound more than once.
◯ Do not use cotton balls and other products that
shed fibers.
◯ If irrigating, use a piston syringe or a sterile straight
catheter for deep wounds with small openings. Apply
5 to 8 psi of pressure. A 30 to 60 mL syringe with a
19‑gauge needle provides approximately 8 psi. Use
normal saline, lactated Ringer’s, or an antibiotic/
antimicrobial solution.
FUNDAMENTALS FOR NURSING CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent 331
● Remove sutures and staples.
● Administer analgesics and monitor for effective
pain management.
● Administer antimicrobials (topical, systemic) and
monitor for effectiveness (reduced fever, increase in
comfort, decreasing WBC count).
● Document the location and type of wound and incision,
the status of the wound and type of drainage, the type
of dressing and materials, client teaching, and how the
client tolerated the procedure.
Wound dressIngs
Protects the wound from microbes
Woven gauze (sponges): Absorbs exudate from the wound
Nonadherent material: Does not stick to the wound bed
Damp to damp 4-inch by 4-inch dressings: Used to
mechanically debride a wound until granulation tissue
starts to form in the wound bed. Must keep moist at all
times to prevent pain and disruption of wound healing.
Self‑adhesive, transparent film: A temporary “second
skin” ideal for small, superficial wounds
Hydrocolloid: An occlusive dressing that swells in the
presence of exudate; composed of gelatin and pectin, it
forms a seal at the wound’s surface to prevent evaporation
of moisture from the skin.
● Maintains a granulating wound bed
● Can stay in place up to 7 days
Hydrogel: Composition is mostly water. Gels after contact
with exudate, promoting autolytic debridement and
cooling. Rehydrates and fills dead space.
● For infected, deep wounds, or necrotic tissue
● Not for moderately to heavily draining wounds
● Provides a moist wound bed
● Can stay in place for 3 days
VacuuM‑assIsted closure sYsteM
● Use of foam strips laid into the wound bed with an
occlusive sealed drape applied and suction tubing is
placed for negative pressure (suction) to occur once the
tubing is connected to the systems therapy unit.
◯ Speed tissue generation
◯ Decrease swelling
◯ Enhance healing in a moist protected environment
COMPLICATIONS AND
NURSING IMPLICATIONS
Dehiscence and evisceration
Dehiscence: A partial or total rupture (separation) of a
sutured wound, usually with separation of underlying
skin layers.
Evisceration: A dehiscence that involves the protrusion of
visceral organs through a wound opening.
MANIFESTATIONS
● A significant increase in the flow of serosanguineous
fluid on the wound dressings
● Immediate history of sudden straining (coughing,
sneezing, vomiting)
● Client report of a change or “popping” or “giving way”
in the wound area
● Visualization of viscera
PREVENTION: Thin, folded blanket or small pillow over
surgical wounds when client coughs in order to support
the wound
RISK FACTORS
● Chronic disease
● Advanced age
● Obesity
● Invasive abdominal cancer
● Vomiting
● Excessive straining, coughing, sneezing
● Dehydration, malnutrition
● Ineffective suturing
● Abdominal surgery
● Infection
NURSING INTERVENTIONS
evisceration and dehiscence require
emergency treatment.
● Call for help. Notify the provider immediately due to the
need for surgical intervention.
● Stay with the client.
● Cover the wound and any protruding organs with sterile
towels or dressings soaked with sterile normal saline
solution to decrease the chance of bacteria invasion and
drying of the tissues. Do not attempt to reinsert the
organs.
● Position the client supine with the hips and knees bent.
● Observe for indications of shock.
● Maintain a calm environment.
● Keep the client NPO in preparation for returning
to surgery.
332 CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent CONTENT MASTERY SERIES
Hemorrhage
● Can be caused by clot dislodgement, broken stitch, or
blood vessel damage.
● Internal bleeding will present with swelling or
distension in the area and sanguineous drainage.
● Hematoma is a local area of blood that appears as a
red/blue bruise.
● Wound hemorrhage is an emergency. Pressure dressing
should be applied, with notification of the provider and
monitoring of vital signs.
Infection
RISK FACTORS
● Extremes in age (immature immune system, decrease in
immune function)
● Impaired circulation and oxygenation (COPD, peripheral
vascular disease)
● Wound condition and nature (gunshot wound vs.
surgical incision)
● Impaired or suppressed immune system
● Malnutrition, such as with alcohol use disorder
● Chronic disease, such as diabetes mellitus or
hypertension
● Poor wound care, such as breaches in aseptic technique
MANIFESTATIONS: 3 to 11 days after injury or surgery
● Purulent drainage
● Pain
● Redness, edema (in and around the wound)
● Fever
● Chills
● Odor
● Increased pulse, respiratory rate
● Increase in WBC count
NURSING INTERVENTIONS
● Prevent infection by using aseptic technique when
performing dressing changes.
● Provide optimal nutrition to promote the
immune response.
● Provide for adequate rest to promote healing.
● Administer antibiotic therapy after collecting specimens
for culture and sensitivity testing.
Pressure ulcers
The National Pressure Ulcer Advisory Panel (NPUAP)
classifies pressure ulcers in six stages/categories (visit
www . npuap . org for additional information). (55.1)
Suspected deep tissue injury, depth unknown:
Discoloration but intact skin from damage to
underlying tissue.
Stage I, nonblanchable erythema: Intact skin with an
area of persistent, nonblanchable redness, typically over a
bony prominence, that can feel warmer or cooler than the
adjacent tissue. The tissue is swollen and has congestion,
with possible discomfort at the site. With darker skin
tones, the ulcer can appear blue or purple.
Stage II, partial thickness: Involves the epidermis and
the dermis. The ulcer is visible with reddish‑pinkish bed
without slough or bruising, superficial, and can appear
as an abrasion, blister, or shallow crater. Edema persists.
The ulcer can become infected, possibly with pain and
scant drainage.
Stage III, full-thickness skin loss: Damage to or necrosis
of subcutaneous tissue. The ulcer can extend down to,
but not through, underlying fascia. The ulcer appears as
a deep crater with or without undermining or tunneling
of adjacent tissue and without exposed muscle or bone.
Drainage and infection are common.
Stage IV, full-thickness tissue loss: Destruction, tissue
necrosis, or damage to muscle, bone, or supporting
structures. There can be sinus tracts, deep pockets
of infection, tunneling, undermining, eschar (black
scab‑like material), or slough (tan, yellow, or green
scab‑like material).
Unstageable/unclassified, full‑thickness skin or tissue
loss, depth unknown: No determination of stage because
eschar or slough obscures the wound. The actual depth of
injury is unknown.
ASSESSMENT/DATA COLLECTION
The primary focus of prevention and treatment of pressure
ulcers is to relieve the pressure and provide optimal
nutrition and hydration.
● Monitor all clients regularly for skin‑integrity status
and for risk factors that contribute to impaired
skin integrity.
● Use a risk assessment tool (Braden, Norton scales) for
periodic systemic monitoring for skin breakdown risk.
● Pressure ulcers are a significant source of morbidity and
mortality among older adults and those who have
limited mobility.
FUNDAMENTALS FOR NURSING CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent 333
rIsK Factors
● Aging skin (older adult clients)
● Immobility
● Incontinence, excessive moisture
● Skin friction, shearing
● Vascular disorders
● Obesity
● Inadequate nutrition, hydration
● Anemia
● Fever, dehydration
● Impaired circulation
● Edema
● Sensory deficits
● Impaired cognitive functioning, neurological disorders
● Chronic diseases (diabetes mellitus, chronic kidney
disease, heart failure, chronic lung disease)
● Sedation that impairs spontaneous repositioning
NURSING INTERVENTIONS
PreVentIon
Avoid skin trauma.
● Keep skin clean, dry, and intact. Provide a firm,
wrinkle‑free foundation with wrinkle‑free linens.
● Reposition the client in bed at least every 2 hr and every
1 hr in a chair. Document position changes.
● Keep the head of the bed at or below a 30° angle (or flat),
unless contraindicated, to relieve pressure on the
sacrum, buttocks, and heels.
● Raise heels off of the bed to prevent pressure.
● Ambulate clients as soon and as often as possible.
● Instruct clients who are mobile to shift their weight
every 15 min when sitting.
● Keep clients from sliding down in bed, as this increases
shearing forces that pull tissue layers apart and cause
damage. Lift, rather than pull, clients up in bed or in a
chair, because pulling creates friction that can damage
the outer layer of skin (epidermis).
Provide supportive devices.
● Use pressure‑reducing surfaces and devices (overlays;
replacement mattresses; specialty beds; kinetic therapy;
foam, gel, or air cushions).
55.1 Stages of pressure ulcers
334 CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent CONTENT MASTERY SERIES
Maintain skin hygiene.
● Inspect the skin frequently and document the client’s
risk using a tool such as the Braden scale.
● Clean the skin with a mild cleansing agent, and pat it
dry immediately following urine or stool incontinence.
● Bathe with tepid (not hot) water and avoid scrubbing.
● Apply dimethicone‑based moisture barrier creams or
alcohol-free barrier films to the skin of clients who
have incontinence.
● Do not use powder or cornstarch to prevent friction
or repel moisture due to their abrasive grit and
aspiration potential.
● Implement active and passive exercises for clients who
are immobile.
● Do not massage bony prominences.
Encourage proper nutrition.
● Provide adequate hydration (2,000 to 3,000 mL/day) and
meet protein and calorie needs.
● Note if serum albumin levels are low (less than 3.5 g/dL),
because a lack of protein puts the client at greater risk
for skin breakdown, slowed healing, and infection.
● Provide nutritional support as indicated, such as
vitamin and mineral supplements (especially A, C,
zinc, copper), nutritional supplements, and enteral and
parenteral nutrition.
● Monitor lymphocyte count.
● Lift, rather than pull, clients up in bed or in a chair,
because pulling creates friction that can damage the
outer layer of skin (epidermis).
treatMent
SUSPECTED DEEP TISSUE INJURY AND STAGE I
● Relieve pressure.
● Encourage frequent turning and repositioning.
● Use pressure‑relieving devices, such as an
air-fluidized bed.
● Implement pressure‑reduction surfaces (air mattress,
foam mattress). (55.2)
● Keep the client dry, clean, well‑nourished, and hydrated.
STAGE II
● Maintain a moist healing environment (saline or
occlusive dressing). Apply hydrocolloid dressing
● Promote natural healing while preventing the formation
of scar tissue.
● Provide nutritional supplements.
● Administer analgesics.
STAGE III
● Clean and/or debride the following.
◯ Prescribed dressing
◯ Surgical intervention
◯ Proteolytic enzymes
● Provide nutritional supplements.
● Administer analgesics.
● Administer antimicrobials (topical and/or systemic).
STAGE IV
● Clean and/or debride the following.
◯ Prescribed dressing
◯ Surgical intervention
◯ Proteolytic enzymes
● Perform nonadherent dressing changes every 12 hr.
● Treatment can include skin grafts or specialized therapy
such as hyperbaric oxygen.
● Provide nutritional supplements.
● Administer analgesics.
● Administer antimicrobials (topical and/or systemic).
UNSTAGEABLE: Debride until staging is possible.
note: do not use alcohol, dakin’s solution, acetic
acid, povidone‑iodine, hydrogen peroxide, or any
other cytotoxic cleansers on a pressure ulcer wound.
COMPLICATIONS AND
NURSING IMPLICATIONS
Deterioration to higher‑stage ulceration or infection
● Check the ulcer frequently and report an increase in
the size or depth of the lesion, changes in granulation
tissue (color, texture), and changes in exudates (color,
quantity, odor).
● Follow the facility’s protocol for ulcer treatment.
● Might need to confer with wound care specialist.
Systemic infection
● Monitor for indications of sepsis (changes in level of
consciousness, persistent recurrent fever, tachycardia,
tachypnea, hypotension, oliguria, or an increase in
WBC count).
● Prevent infection by using asepsis when performing
ulcer treatment and dressing changes.
● Provide optimal nutrition to promote the
immune response.
● Provide for adequate rest to promote healing.
● Administer antibiotic therapy after collecting specimens
for culture and sensitivity testing.
55.2 Pressure-relieving device
FUNDAMENTALS FOR NURSING CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent 335
Application Exercises
1. a nurse is caring for an adolescent
client who is 2 days postoperative
following an appendectomy and has
type I diabetes mellitus. the client
is tolerating a regular diet. He has
ambulated successfully around the
unit with assistance. He requests
pain medication every 6 to 8 hr while
reporting pain at a 2 on a scale of 0
to 10 after receiving the medication.
His incision is approximated and free
of redness, with scant serous drainage
on the dressing. the nurse should
recognize that the client has which of
the following risk factors for impaired
wound healing? (select all that apply.)
a. extremes in age
B. Impaired circulation
c. Impaired/suppressed
immune system
d. Malnutrition
e. Poor wound care
2. a nurse is collecting data from a
client who is 5 days postoperative
following abdominal surgery. the
surgeon suspects an incisional
wound infection and has prescribed
antibiotic therapy for the nurse
to initiate after collecting wound
and blood specimens for culture
and sensitivity. Which of the
following findings should the nurse
expect? (select all that apply.)
a. Increase in incisional pain
B. Fever and chills
c. reddened wound edges
d. Increase in serosanguineous
drainage
e. decrease in thirst
3. a nurse educator is reviewing the
wound healing process with a
group of nurses. the nurse educator
should include in the information
which of the following alterations
for wound healing by secondary
intention? (select all that apply.)
a. stage III pressure ulcer
B. sutured surgical incision
c. casted bone fracture
d. laceration sealed
with adhesive
e. open burn area
4. a client who had abdominal surgery
24 hr ago suddenly reports a pulling
sensation and pain in his surgical
incision. the nurse checks the
surgical wound and finds it separated
with viscera protruding. Which of
the following actions should the
nurse take? (select all that apply.)
a. cover the area with
saline‑soaked sterile dressings.
B. apply an abdominal binder
snugly around the abdomen.
c. use sterile gauze to
apply gentle pressure to
the exposed tissues.
d. Position the client supine with
his hips and knees bent.
e. offer the client a warm
beverage, such as herbal tea.
5. a nurse is caring for an older
adult client who is at risk for
developing pressure ulcers. Which
of the following interventions
should the nurse use to help
maintain the integrity of the client’s
skin? (select all that apply.)
a. Keep the head of the
bed elevated 30°.
B. Massage the client’s bony
prominences frequently.
c. apply cornstarch liberally
to the skin after bathing.
d. Have the client sit on a gel
cushion when in a chair.
e. reposition the client at least
every 3 hr while in bed.
PRACTICE Active Learning Scenario
a nurse is teaching a group of nursing students about
the national Pressure ulcer advisory Panel’s classification
system for pressure ulcers. use the atI active learning
template: Basic concept to complete this item.
RELATED CONTENT: list the six pressure ulcer stages
along with a brief description of the assessment
findings typical for ulcers at each stage.
336 CHAPTER 55 Pressure ulcers, Wounds, and Wound ManageMent CONTENT MASTERY SERIES
Application Exercises Key
1. a. the client is not at either extreme of the age spectrum.
B. CORRECT: the client who has type I diabetes
mellitus is at risk for impaired circulation.
c. CORRECT: the client who has type I diabetes mellitus
is at risk for impaired immune system function.
d. there is no indication that the client is malnourished.
e. that there is no indication that there have been any
breaches in aseptic technique during wound care.
NCLEX® Connection: Health Promotion and Maintenance,
Health Screening
2. a. CORRECT: the nurse should expect the client to have pain
and tenderness at the wound site with an incisional infection.
B. CORRECT: the nurse should expect the client to
have fever and chills with an incisional infection.
c. CORRECT: the nurse should expect the client to have
reddened or inflamed wound edges with an incisional infection.
d. the nurse should expect the client to have
purulent drainage with an incisional infection.
e. the nurse should not expect changes in thirst
as an indication of an incisional infection.
NCLEX® Connection: Physiological Adaptation,
Alterations in Body Systems
3. a. CORRECT: open pressure ulcers heal by secondary intention, which is
the process for wounds that have tissue loss and widely separated edges.
B. sutured surgical incisions heal by primary intention,
which is the process for wounds that have little or no
tissue loss and well‑approximated edges.
c. unless the bone edges have pierced the skin, a
casted bone fracture is an injury to underlying structures
and does not require healing of the skin.
d. lacerations sealed with tissue adhesive heal by primary
intention, which is the process for wounds that have little
or no tissue loss and well‑approximated edges.
e. CORRECT: open burn areas heal by secondary intention, which is the
process for wounds that have tissue loss and widely separated edges.
NCLEX® Connection: Reduction of Risk Potential,
System Specific Assessments
4. a. CORRECT: the nurse should cover the wound with a sterile dressing
soaked with sterile normal saline solution to keep the exposed organs
and tissues moist until the surgeon can assess and intervene.
B. an abdominal binder can help prevent, not
treat, a wound evisceration.
c. the nurse should not handle or apply pressure to
any exposed organs or tissues because these actions
increase the risks of trauma and perforation.
d. CORRECT: this position minimizes pressure on the abdominal area.
e. the nurse must keep the client nPo in anticipation of the surgical
team taking him back to the surgical suite for repair of the evisceration.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
5. a. CORRECT: the nurse should slightly elevate the
client head of bed reduce shearing forces that could tear
sensitive skin on the sacrum, buttocks, and heels.
B. the nurse can traumatize deep tissues if she
massages the skin over bony prominences.
c. the nurse can abrade the client’s sensitive skin and increase
the risk for aspiration if cornstarch or powders are used.
d. CORRECT: the nurse should have the client sit on a gel, air, or
foam cushion to redistribute weight away from ischial areas.
e. the nurse should reposition the client at least every 2 hr.
Frequent position changes are important for preventing skin
breakdown, but every 3 hr is not frequent enough.
NCLEX® Connection: Basic Care and Comfort, Mobility/Immobility
PRACTICE Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
● suspected deep tissue injury, depth
unknown: discoloration but intact skin
from damage to underlying tissue.
● stage I, nonblanchable erythema: Intact skin
with an area of persistent, nonblanchable
redness, typically over a bony prominence,
that can feel warmer or cooler than the
adjacent tissue. the tissue is swollen and
has congestion, with possible discomfort
at the site. With darker skin tones, the
ulcer can appear blue or purple.
● stage II, partial thickness: Involves the
epidermis and the dermis. the ulcer is visible
with reddish‑pinkish bed without slough or
bruising, superficial, and can appear as an
abrasion, blister, or shallow crater. edema
persists. the ulcer can become infected,
possibly with pain and scant drainage.
● stage III, full‑thickness skin loss: damage to or
necrosis of subcutaneous tissue. the ulcer can
extend down to, but not through, underlying
fascia. the ulcer appears as a deep crater
with or without undermining or tunneling of
adjacent tissue and without exposed muscle
or bone. drainage and infection are common.
● stage IV, full‑thickness tissue loss:
destruction, tissue necrosis, or damage
to muscle, bone, or supporting structures.
there can be sinus tracts, deep pockets of
infection, tunneling, undermining, eschar
(black scab‑like material), or slough (tan,
yellow, or green scab‑like material).
● unstageable/unclassified, full‑thickness
skin or tissue loss, depth unknown: no
determination of stage because eschar
or slough obscures the wound. the
actual depth of injury is unknown.
NCLEX® Connection: Physiological Adaptation, Pathophysiology
FUNDAMENTALS FOR NURSING CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic inFections 337
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHYSIOLOGICAL ADAPTATION
CHAPTER 56 Bacterial, Viral,
Fungal, and
Parasitic Infections
Pathogens are the micro‑organisms or microbes
that cause infections. Virulence is the ability of a
pathogen to invade the host and cause disease.
Herpes zoster is a common viral infection that
erupts years after exposure to chickenpox and
invades a specific nerve tract.
PatHogens
Bacteria: Most common type of pathogen (Staphylococcus
aureus, Escherichia coli, Mycobacterium tuberculosis)
Viruses: Organisms that use the host’s genetic machinery
to reproduce (rhinovirus, HIV, hepatitis, herpes zoster,
herpes simplex)
Fungi: Molds and yeasts (Candida albicans, Aspergillus)
Prions: Protein particles that have the ability to cause
infections (Creutzfeldt‑Jakob disease)
Parasites: Organisms that live on and often cause harm to
a host organism
● Protozoa (malaria, toxoplasmosis)
● Helminths (worms: flatworms, roundworms)
● Flukes (schistosomes)
● Arthropods (lice, mites, ticks)
INFECTION PROCESS
The infection process (chain of infection) includes
the following.
Causative agent
Bacteria, virus, fungus, prion, parasite
Reservoir
Human, animal, food, water, soil, insects, fomites
Portal of exit from (means for leaving) the host
Respiratory tract (droplet, airborne): Mycobacterium
tuberculosis and Parainfluenza virus
Gastrointestinal tract: Shigella, Salmonella enteritidis,
Salmonella typhi, hepatitis A, Clostridium difficile
Genitourinary tract: Escherichia coli, herpes simplex virus
(type 1), HIV
Skin/mucous membranes: Herpes simplex virus and varicella
Blood/body fluids: HIV and hepatitis B and C
Mode of transmission
CONTACT
● Direct physical contact: Person to person
● Indirect contact with a vehicle of transmission:
Inanimate object, water, food, blood
● Fecal-oral transmission: Handling food after using a
restroom and failing to wash hands
DROPLET: Large droplets travel through the air up to 3 to
6 feet (sneezing, coughing, and talking)
AIRBORNE: Small droplets remain in the air and can
travel extended distances depending on airflow (sneezing
and coughing)
VECTOR‑BORNE: Animals or insects as intermediaries
(ticks transmit Lyme disease; mosquitoes transmit
West Nile virus and malaria)
Portal of entry to the host
Often the same as the portal of exit
Susceptible host
Compromised defense mechanisms (immunosuppression,
breaks in skin) leave the host more susceptible
to infections.
CHAPTER 56
Online Image: Chain of Infection
56.1 Chain of infection
338 CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic inFections CONTENT MASTERY SERIES
IMMUNE DEFENSES
Nonspecific innate‑native immunity
Allows the body to restrict entry or immediately respond
to a foreign organism (antigen) through the activation of
phagocytic cells, complement, and inflammation
● Nonspecific innate-native immunity provides temporary
immunity but does not have memory of past exposures.
● Intact skin is the body’s first line of defense against
microbial invasion.
● The skin, mucous membranes, secretions, enzymes,
phagocytic cells, and protective proteins work in concert
to prevent infections.
Inflammatory response
● Phagocytic cells (neutrophils, eosinophils, macrophages),
the complement system, and interferons are involved.
● An inflammatory response localizes the area of
microbial invasion and prevents its spread.
Specific adaptive immunity
Allows the body to make antibodies in response to a
foreign organism (antigen)
● Requires time to react to antigens
● Provides permanent immunity due to memory of
past exposures
● Involves B and T lymphocytes
● Produces specific antibodies against specific antigens
(immunoglobulins: IgA, IgD, IgE, IgG, IgM).
ASSESSMENT/DATA COLLECTION
risK Factors
ENVIRONMENTAL FACTORS
● Excessive alcohol consumption
● Nicotine use: smoking, smokeless tobacco
● Malnutrition
MEDICATION THERAPY (IMMUNOSUPPRESSIVE AGENTS)
● Glucocorticosteroids
● Antineoplastics
CHRONIC DISEASES
● Diabetes mellitus
● Cancer
● HIV, AIDS
● Peripheral vascular disease
● Chronic pulmonary disease
● Heart failure
AGE
Older adults are at increased risk for infections due to
the following.
● Slowed response to antibiotic therapy
● Slowed immune response: indicators of infection more
difficult to identify, resulting in possible delays in
diagnosis and treatment
● Loss of subcutaneous tissue and thinning of the skin
● Decreased vascularity and slowed wound healing
● Decreased cough and gag reflexes
● Chronic illnesses (diabetes mellitus, COPD, neurological
or musculoskeletal impairments)
● Decreased gastric acid production
● Decreased mobility
● Bowel/bladder incontinence
● Dementia
● Greater incidence of invasive devices (urinary catheters,
feeding tubes, tracheostomies, intravenous lines)
common indications of infection are not always
present in the older adult client. altered mental
status, agitation, or incontinence can be
present instead.
eXPected Findings
● Chills
● Sore throat
● Fatigue and malaise
● Change in level of consciousness, nuchal rigidity,
photophobia, headache
● Nausea, vomiting, anorexia, abdominal cramping,
and diarrhea
● Localized pain or discomfort
PHYSICAL ASSESSMENT FINDINGS
● Fever
● Increased pulse and respiratory rate,
decreased blood pressure
● Localized redness and edema
● Enlarged lymph nodes
● Dyspnea, cough, purulent sputum, and crackles in
lung fields
● Dysuria, urinary frequency, hematuria, and pyuria
● Rash, skin lesions, purulent wound drainage,
and erythema
● Dysphagia, hyperemia, and enlarged tonsils
laBoratorY tests
White blood cell (WBC) count with differential
● An elevated WBC count is an indicator of infection
(expected reference range is 5,000 to 10,000/mm3).
● The differential identifies specific types of WBCs that
can assist in diagnosis of the severity of infection or the
specific type of pathogen.
Erythrocyte sedimentation rate (ESR)
● The rate at which red blood cells settle out of plasma
● An elevated ESR is an indicator of an active
inflammatory process or infection (expected reference
range is 15 to 20 mm/hr).
● An increase indicates an active inflammatory process
or infection.
FUNDAMENTALS FOR NURSING CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic inFections 339
Immunoglobulin electrophoresis
● Determines the presence and quantity of specific
immunoglobulins (IgG, IgA, IgM).
● Used to detect hypersensitivity disorders, autoimmune
disorders, chronic viral infections, immunodeficiency,
multiple myeloma, and intrauterine infections.
Antibody screening tests
● Detect the presence of antibodies against specific
causative agents (bacteria, fungi, viruses, parasites).
● A positive antibody test indicates that the client
has been exposed to and developed antibodies to a
specific pathogen, but it does not provide information
about whether or not the client is currently infected
(HIV antibodies).
Auto-antibody screening tests
● Detect the presence of antibodies against a person’s
own DNA (self‑cells).
● The presence of antibodies against self cells is
associated with autoimmune conditions (systemic lupus
erythematosus, rheumatoid arthritis).
Antigen tests
● Detect the presence of a specific pathogen (HIV).
● Used to identify certain infections or disorders.
Stool for ova and parasites
● Detects presence of ova and parasites, such as
hookworm ova in stool.
● Three separate stool specimens usually collected.
● Each specimen must be transported to the laboratory
while it is still warm.
Culture and sensitivity
● A culture is a microscopic examination to identify an
infecting organism.
● Cultures can be obtained from blood, sputum, urine,
wound, and soft tissue.
● Cultures should be obtained before any antibiotic
therapy is initiated.
● The sensitivity report indicates which antibiotics are
effective against the identified organism.
diagnostic Procedures
X-rays, computed tomography (CT) scan, magnetic
resonance imaging (MRI), and biopsies are used
to determine the presence of infection, abscesses,
and lesions.
Gallium scan
● A nuclear scan that uses a radioactive substance to
identify hot spots of WBCs within the client’s body.
● Radioactive gallium citrate is injected intravenously and
accumulates in areas where inflammation is present.
PATIENT‑CENTERED CARE
nursing care
● Assess the following.
◯ Presence of risk factors for infection
◯ Recent travel or exposure to an infectious disease
◯ Behaviors that can put the client at increased risk
◯ Increased temperature, heart and respiratory rate,
thirst, anorexia
◯ Presence of chills, which occur when temperature
is rising, and diaphoresis, which occurs when
temperature is decreasing
◯ Presence of hyperpyrexia (greater than 105.8° F),
which can cause brain and organ damage
● Implement infection control measures.
◯ Perform frequent hand hygiene to prevent
transmission of infection to other clients.
◯ Maintain a clean environment.
◯ Perform wound care measures, such as sterile
dressing changes.
◯ Use personal protective equipment/barriers
(gloves, masks, gowns, goggles).
◯ Encourage recommended immunizations.
◯ Implement protective precautions as needed.
■ Standard: Implemented for all clients
■ Contact: Clostridium difficile, herpes simplex virus,
impetigo, methicillin‑resistant Staphylococcus
aureus (MRSA), vancomycin‑resistant
Staphylococcus aureus (VRSA)
■ Droplet: Haemophilus influenzae type B (Hib),
pertussis, mumps, rubella, plague, streptococcal
pneumonia, meningococcal pneumonia
■ Airborne: Measles, varicella, tuberculosis
● Encourage adequate rest and nutrition.
● Provide diversional activities if needed.
● Encourage increased fluid intake or maintain
intravenous fluid replacement to prevent dehydration.
● Protect and maintain the client’s protective barriers
(skin, mucous membranes).
Medications
Antipyretics
Acetaminophen and aspirin are used for fever and
discomfort as prescribed.
NURSING CONSIDERATIONS
● Monitor fever to determine effectiveness of medication.
● Document temperature fluctuations on the medical
record for trending.
Antimicrobial therapy
Antimicrobial medications kill pathogens or prevent their
growth. Anthelmintics are given for worm infestations.
There are currently no treatments for prions.
NURSING CONSIDERATIONS
● Administer antimicrobial therapy as prescribed.
● Monitor for medication effectiveness (reduced fever,
increased level of comfort, decreasing WBC count).
● Maintain a medication schedule to assure consistent
therapeutic blood levels of the antibiotic.
340 CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic inFections CONTENT MASTERY SERIES
client education
● Teach the client regarding the following.
◯ Any infection control measures needed at home
◯ Self‑administration of medication therapy
◯ Complications that need to be reported immediately
● Infants should receive the H. influenzae type b (Hib) vaccine.
● Adults and older adults at risk should receive the
pneumococcal polysaccharide vaccine (PPSV).
● Adolescents should receive the meningococcal vaccine
on schedule and prior to living in a residential or
communal setting.
COMPLICATIONS
Medication‑resistant infections
Antimicrobials are becoming less effective for some
strains of pathogens, due to the pathogen’s ability to adapt
and become resistant to previously sensitive antibiotics.
This significantly limits the number of antibiotics that
are effective against the pathogen. Use of antibiotics,
especially broad-spectrum antibiotics, has significantly
decreased to prevent new strains from evolving. Taking
the measures below can ensure an antimicrobial is
warranted and increase the effectiveness of treatment.
● MRSA is a strain of S. aureus that is resistant to all
antibiotics, except vancomycin
● VRSA is a strain of S. aureus that is resistant to
vancomycin but so far is sensitive to other antibiotics
specific to the strain.
NURSING ACTIONS
● Obtain specimens for culture and sensitivity prior to
initiation of antimicrobial therapy.
● Monitor antimicrobial levels and ensure that therapeutic
levels are maintained.
● Implement precautions to prevent the spread of
the infection.
CLIENT EDUCATION
● Complete the full course of antimicrobial therapy.
● Avoid overuse of antimicrobials.
Sepsis
A systemic inflammatory response syndrome resulting
from the body’s response to a serious infection, usually
bacterial (peritonitis, meningitis, pneumonia, wound
infections, urinary tract infections)
● Sepsis is a potentially life‑threatening complication that
can lead to widespread inflammation, blood clotting,
organ failure, and shock.
● Blood cultures definitively diagnose sepsis. Systemic
antimicrobials are prescribed accordingly. Vasopressors
and anticoagulants may be prescribed for shock and
blood clotting manifestations. Mechanical ventilation,
dialysis, and other interventions can be needed for
treatment of specific organ failure.
RISK FACTORS: Very young age, very old age, weakened
immune system, and severe injuries (trauma).
Herpes zoster (shingles)
Herpes zoster is a viral infection. It initially produces
chickenpox, after which the virus lies dormant in the
dorsal root ganglia of the sensory cranial and spinal
nerves. It is then reactivated as shingles later in life.
● Shingles is usually preceded by a prodromal period of
several days, during which pain, itching, tingling, or
burning can occur along the involved dermatome.
● Shingles can be very painful and debilitating.
ASSESSMENT/DATA COLLECTION
risK Factors
● Concurrent illness
● Stress
● Compromise to the immune system
● Fatigue
● Poor nutritional status
Possible immunocompromise makes older adult
clients more susceptible to herpes zoster infection.
assess the client carefully for typical and atypical
indications of infection.
eXPected Findings
● Paresthesia
● Pain that is unilateral and extends horizontally along
a dermatome
PHYSICAL ASSESSMENT FINDINGS
● Vesicular, unilateral rash (the rash and lesions occur on
the skin area innervated by the infected nerve)
● Changes in or loss of vision if the eye is affected
● Rash that is erythematous, vesicular, pustular, or
crusting (depending on the stage)
● Rash that usually lasts several weeks
● Low‑grade fever
laBoratorY tests
● Cultures provide a definitive diagnosis (but the virus
grows so slowly that cultures are often of minimal
diagnostic use).
● Occasionally, an immunofluorescence assay can be done.
FUNDAMENTALS FOR NURSING CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic inFections 341
PATIENT‑CENTERED CARE
nursing care
● Assess/monitor the following.
◯ Pain
◯ Condition of lesions
◯ Presence of fever
◯ Neurologic complications
◯ Indications of infection
● Use an air mattress or bed cradle for pain prevention/
control of affected areas.
● Isolate the client until the vesicles have crusted over.
● Maintain strict wound care precautions.
● The virus can be transmitted through direct contact,
causing chickenpox. Avoid exposing the client to infants,
pregnant women who have not had chickenpox, and
clients who are immunocompromised.
● Moisten dressings with cool tap water or 5% aluminum
acetate (Burow’s solution) and apply to the affected skin
for 30 to 60 min, four to six times per day as prescribed.
● Use lotions, such as calamine lotion, or recommend
oatmeal baths to help relieve itching and discomfort.
● Administer medications as prescribed.
Medications
● Analgesics (NSAIDs, narcotics) enhance client comfort.
● If started soon after the rash appears, antiviral agents,
such as acyclovir, can decrease the severity of the
infection and shorten the clinical course.
● Recommend zoster vaccine live for clients 60 and older
to prevent shingles. This vaccine does not treat active
shingles infections.
COMPLICATIONS
Postherpetic neuralgia
● Characterized by pain that persists for longer than
1 month following resolution of the vesicular rash.
● Tricyclic antidepressants may be prescribed.
● Postherpetic neuralgia is common in adults older than
60 years of age.
Application Exercises
1. a nurse is discussing direct
and indirect contact modes of
transmission of infection at a staff
education session. Which of the
following incidents are examples
of direct mode of transmission?
(select all that apply.)
a. a client vomits on a
nurse’s uniform.
B. a nurse has a needle
stick injury.
c. a mosquito bites a
hiker in the woods.
d. a nurse finds a hole in
his glove while handling
a soiled dressing.
e. a person fails to wash
her hands after using
the bathroom.
2. a nurse in a residential care facility is
assessing an older adult client. Which
of the following findings should the
nurse identify as atypical indications
of infection? (select all that apply.)
a. urinary incontinence
B. Malaise
c. acute confusion
d. Fever
e. agitation
3. a nurse is preparing to admit a
client who is suspected to have
pulmonary tuberculosis. Which
of the following actions should
the nurse plan to perform first?
a. implement airborne
precautions.
B. obtain a sputum culture.
c. administer prescribed
antituberculosis medications.
d. recommend a screening
test for family members.
4. a nurse in a primary care clinic is
assessing a client who has a history of
herpes zoster. Which of the following
findings suggests the client is
experiencing postherpetic neuralgia?
a. linear clusters of vesicles
present on the right shoulder
B. Purulent drainage
from both eyes
c. decreased white
blood cell count
d. report of continued pain
following resolution of rash
5. a charge nurse is teaching about
the care of a client who has
methicillin‑resistant Staphylococcus
aureus (Mrsa) with a newly
licensed nurse. Which of the
following statements by the
newly licensed nurse indicates an
understanding of the teaching?
a. “i should obtain a specimen for
culture and sensitivity after the
first dose of an antimicrobial.”
B. “Mrsa is usually resistant
to vancomycin, so
another antimicrobial
will be prescribed.”
c. “i will need to monitor
the client’s serum
antimicrobial levels during
the course of therapy.”
d. “to decrease resistance,
antimicrobial therapy is
discontinued when the
client is no longer febrile.”
342 CHAPTER 56 Bacterial, Viral, Fungal, and Parasitic inFections CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: transmission from emesis is
person‑to‑person or direct contact.
B. transmission from a needle or other
inanimate object is indirect contact.
c. transmission from an insect is vector‑borne.
d. transmission from a soiled dressing or other
inanimate object is indirect contact.
e. CORRECT: transmission from contaminated
hands is person‑to‑person or direct contact.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
2. a. CORRECT: urinary incontinence is an atypical
indication of infection in an older adult client.
B. Malaise is a typical indication of infection.
c. CORRECT: acute confusion is an atypical
indication of infection in an older adult client.
d. Fever is a typical indication of infection.
e. CORRECT: agitation is an atypical indication
of infection in an older adult client.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
3. a. CORRECT: the greatest safety risk to the nurse and others
is transmission of the infection from airborne exposure to
tuberculosis. the priority intervention the nurse should
take is to place the client on airborne precautions.
B. the nurse should obtain a sputum culture,
but another action is the priority.
c. the nurse should administer prescribed medications to
treat tuberculosis, but another action is the priority.
d. the nurse should recommend screening tests for those
in close contact with the client to determine if antibiotic
therapy is needed, but another action is the priority.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
4. a. localized linear clusters of vesicles are an expected finding
of herpes zoster rather than postherpetic neuralgia.
B. eye infection is a potential complication of herpes
zoster but does not suggest postherpetic neuralgia.
c. immunosuppression increases the risk for herpes zoster
but does not suggest postherpetic neuralgia.
d. CORRECT: Pain that persists following resolution of the
vesicular rash is an indication of postherpetic neuralgia.
NCLEX® Connection: Physiological Adaptation,
Illness Management
5. a. the nurse should obtain a specimen for culture and
sensitivity prior to the initiation of antimicrobial therapy.
B. Mrsa is resistant to all antibiotics except vancomycin.
c. CORRECT: the nurse should monitor antimicrobial levels
to ensure that therapeutic levels are maintained.
d. discontinuing antimicrobial therapy prior to completing a full course
of treatment increases the risk of producing resistant pathogens.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
PRACTICE Answer
Using the ATI Active Learning Template: System Disorder
PATHOPHYSIOLOGY RELATED TO CLIENT
PROBLEM: contact transmission
RISK FACTORS
● concurrent illness
● stress
● compromise to the immune system
● Fatigue
● Poor nutritional status
EXPECTED FINDINGS
● Paresthesia
● Pain that is unilateral and extends horizontally along a dermatome
● Vesicular, unilateral rash (the rash and lesions occur on
the skin area innervated by the infected nerve)
● changes in or loss of vision if the eye is affected
● rash that is erythematous, vesicular, pustular,
or crusting (depending on the stage)
● rash that usually lasts several weeks
● low‑grade fever
NURSING CARE
● assess/monitor the following.
◯ Pain
◯ condition of lesions
◯ Presence of fever
◯ neurologic complications
◯ indications of infection
● use an air mattress or bed cradle for pain
prevention/control of affected areas.
● isolate the client until the vesicles have crusted over.
● Maintain strict wound care precautions.
● Moisten dressings with cool tap water or 5% aluminum
acetate (Burow’s solution) and apply to the affected skin
for 30 to 60 min, four to six times per day as prescribed.
● use lotions, such as calamine lotion, or recommend
oatmeal baths to help relieve itching and discomfort.
● administer medications as prescribed
CLIENT EDUCATION
● the virus can be transmitted through direct contact,
causing chickenpox. avoid exposing the client to
infants, pregnant women who have not had chickenpox,
and clients who are immunocompromised.
● recommend zoster vaccine live for clients 60 and over to prevent
shingles. this vaccine does not treat active shingles infections.
NCLEX® Connection: Safety and Infection Control, Standard
Precautions/Transmission-Based Precautions/Surgical Asepsis
PRACTICE Active Learning Scenario
a nurse is admitting a client who has a new diagnosis
of herpes zoster. use the ati active learning
template: system disorder and the Medical‑surgical
nursing review Module to complete this item.
PATHOPHYSIOLOGY RELATED TO CLIENT
PROBLEM: identify the mode of transmission.
RISK FACTORS: identify at least three risk
factors for acquiring herpes zoster.
EXPECTED FINDINGS: identify at least three
indications of infection with herpes zoster
NURSING CARE: identify information the nurse
should provide the client and family about
acquiring adaptive immunity for herpes zoster.
CLIENT EDUCATION: identify one preventative
measure to prevent the transmission of herpes zoster.
FUNDAMENTALS FOR NURSING CHAPTER 57 Fluid imbalances 343
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHYSIOLOGICAL ADAPTATION
CHAPTER 57 Fluid Imbalances
body fluids are distributed between
intracellular fluid (icF) and extracellular fluid
(ecF) compartments. ecF is comprised of
intravascular (plasma), interstitial (fluid that
surrounds the cells), lymph, and transcellular
fluids (cerebrospinal, pericardial, pancreatic,
pleural, intraocular, biliary, peritoneal, and
synovial fluids).
Fluid can move between compartments
(through selectively permeable membranes)
by a variety of methods (diffusion, active
transport, filtration, osmosis) in order to maintain
homeostasis. Fluid imbalances that the nurse
should be familiar with are fluid volume deficit
and fluid volume excess.
Fluid volume deficit
● Fluid volume deficit (FVD) includes the following.
◯ Isotonic FVD is the loss of water and electrolytes
from the ECF. Isotonic FVD is often referred to as
hypovolemia because intravascular fluid is also lost.
◯ Dehydration is the loss of water from the
body without the loss of electrolytes. This
hemoconcentration results in increases in Hct, serum
electrolytes, and urine specific gravity.
● Compensatory mechanisms include sympathetic
nervous system responses of increased thirst,
antidiuretic hormone (ADH) release, and
aldosterone release.
● FVD can lead to hypovolemic shock.
● Older adults have an increased risk for dehydration due
to multiple physiological factors including a decrease in
total body mass, which includes total body water
content, and a decrease in the ability to detect thirst.
ASSESSMENT/DATA COLLECTION
RisK FacTORs
CAUSES OF ISOTONIC FVD (HYPOVOLEMIA)
● Excessive gastrointestinal (GI) loss:
vomiting, nasogastric suctioning, diarrhea
● Excessive skin loss: diaphoresis
● Excessive renal system losses: diuretic therapy, diabetes
insipidus, kidney disease, adrenal insufficiency,
osmotic diuresis
● Third spacing: peritonitis, intestinal obstruction,
ascites, burns
● Excessive loss of fluids from a wound
● Hemorrhage
● Altered intake: anorexia, nausea, impaired swallowing,
confusion, nothing by mouth (NPO)
CAUSES OF DEHYDRATION
● Hyperventilation
● Prolonged fever
● Diabetic ketoacidosis
● Enteral feeding without sufficient water intake
eXPecTed FindinGs
VITAL SIGNS: Hypothermia, tachycardia, thready
pulse, hypotension, orthostatic hypotension, decreased
central venous pressure, tachypnea (increased
respirations), hypoxia
NEUROMUSCULOSKELETAL: Dizziness, syncope, confusion,
weakness, fatigue
GI: Thirst, dry mucous membranes, dry furrowed tongue,
nausea, vomiting, anorexia, acute weight loss
RENAL: Oliguria (decreased production of urine)
OTHER FINDINGS: Diminished capillary refill, cool
clammy skin, diaphoresis, sunken eyeballs, flattened neck
veins, absence of tears, decreased skin turgor
assessment of skin turgor in the older adult might
not provide reliable findings due to a natural loss of
skin elasticity.
CHAPTER 57
344 CHAPTER 57 Fluid imbalances CONTENT MASTERY SERIES
labORaTORY TesTs
Hct: Increased in both hypovolemia and dehydration
unless the fluid volume deficit is due to hemorrhage
Serum osmolarity
Dehydration: Increased hemoconcentration osmolarity
(greater than 295 mOsm/kg); increased protein, BUN,
electrolytes, glucose
Urine specific gravity
Dehydration: Increased concentration (urine specific
gravity greater than 1.030)
Serum sodium
Dehydration: Increased hemoconcentration (greater than
145 mEq/L)
PATIENT‑CENTERED CARE
nuRsinG caRe
● Observe respiratory rate, symmetry, and effort.
● Monitor for shortness of breath and dyspnea.
● Check urinalysis, oxygen saturation (SaO2), CBC,
and electrolytes.
● Administer supplemental oxygen as prescribed.
● Measure the client’s weight daily at same time of day
using the same scale.
● Observe for nausea and vomiting.
● Monitor vital signs. (Check for hypotension and
orthostatic hypotension.)
● Check neurological status to determine level of
consciousness.
● Assess heart rhythm (can be irregular or tachycardic).
● Initiate and maintain IV access.
● For fluid replacement, administer IV fluids as prescribed
(isotonic solutions such as lactated Ringer’s or
0.9% sodium chloride; blood transfusions).
● Monitor I&O. Encourage fluids as tolerated. Alert the
provider to a urine output less than 30 mL/hr.
● Monitor level of consciousness and ensure client safety.
● Observe level of gait stability.
● Encourage the client to use the call light and ask
for assistance.
● Encourage the client to change positions slowly (rolling
from side to side or standing up).
● Check capillary refill (expected reference range less
than 2 seconds).
● Provide frequent oral care.
● Prevent skin breakdown.
Fluid volume excesses
● Fluid volume excesses include the following.
◯ Fluid volume excess (FVE) is the isotonic retention of
water and sodium in high proportions. FVE is often
referred to as hypervolemia because of the resulting
increased blood volume.
◯ Overhydration, or hypoosmolar fluid imbalance, is
the retention of more water than electrolytes. This
hemodilution results in decreases in Hct, serum
electrolytes, and protein.
● Severe FVE can lead to pulmonary edema and
heart failure.
● Compensatory mechanisms include an increased release
of natriuretic peptides, resulting in increased excretion
of sodium and water by the kidneys, and a decreased
release of aldosterone.
ASSESSMENT/DATA COLLECTION
RisK FacTORs
CAUSES OF HYPERVOLEMIA
● Chronic stimulus to the kidney to conserve
sodium and water (heart failure, cirrhosis,
increased glucocorticosteroids)
● Altered kidney function with reduced excretion of
sodium and water (kidney failure)
● Interstitial to plasma fluid shifts (hypertonic
fluids, burns)
● Age‑related changes in cardiovascular and kidney
function
● Excessive sodium intake from IV fluids, diet, or
medications (sodium bicarbonate antacids, hypertonic
enema solutions)
CAUSES OF OVERHYDRATION
● Water replacement without electrolyte replacement
(strenuous exercise with profuse diaphoresis)
● Syndrome of inappropriate antidiuretic hormone
(SIADH), which is the excess secretion of ADH
● Head injuries
● Barbiturates
● Anesthetics
eXPecTed FindinGs
VITAL SIGNS: Tachycardia, bounding pulse, hypertension,
tachypnea, increased central venous pressure
NEUROMUSCULOSKELETAL: Confusion, muscle weakness
GI: Weight gain, ascites
RESPIRATORY: Dyspnea, orthopnea, crackles
OTHER FINDINGS: Edema, distended neck veins
FUNDAMENTALS FOR NURSING CHAPTER 57 Fluid imbalances 345
labORaTORY TesTs
Hct
● Hypervolemia: Decreased Hct
● Overhydration: Decreased Hct = hemodilution
Serum osmolarity
Overhydration: Osmolarity less than 280 mOsm/kg
Serum sodium
Hypervolemia: Sodium within expected reference range
Electrolytes, BUN, and creatinine
Overhydration/hypervolemia: Decreased electrolytes, BUN,
and creatinine
Arterial blood gases
● Respiratory alkalosis: Decreased PaCO2 (less than
35 mm Hg), increased pH (greater than 7.45)
● Urine specific gravity: Less than 1.010 (if not due
to SIADH)
diaGnOsTic PROceduRes
Chest x‑rays can indicate pulmonary congestion.
PATIENT‑CENTERED CARE
nuRsinG caRe
● Observe respiratory rate, symmetry, and effort.
● Auscultate breath sounds in all lung fields. Lung sounds
can be diminished with crackles.
● Monitor for shortness of breath and dyspnea.
● Check ABGs, SaO2, CBC, and chest x‑ray results.
● Position the client in semi‑Fowler’s position.
● Measure the client’s weight daily at same time of day
using the same scale.
● Monitor and document edema (pretibial,
sacral, periorbital).
● Monitor I&O.
● Implement prescribed restrictions for fluid and
sodium intake.
◯ Provide fluids in small glass to promote the
perception of a full glass of fluid.
◯ Set 1- to 2-hr short-term goals for the fluid
restriction to promote client control and
understanding.
● Administer supplemental oxygen as needed. Reduce
IV flow rates.
● Administer diuretics (osmotic, loop) as prescribed.
● Monitor and document circulation to the extremities.
● Reposition the client at least every 2 hr.
● Support arms and legs to decrease dependent edema.
Application Exercises
1. a nurse is performing an admission
assessment on a client who has
hypovolemia due to vomiting
and diarrhea. The nurse should
expect which of the following
findings? (select all that apply.)
a. distended neck veins
b. Hyperthermia
c. Tachycardia
d. syncope
e. decreased skin turgor
2. a nurse on a medical‑surgical unit
is caring for a group of clients.
The nurse should identify that
which of the following clients
is at risk for hypovolemia?
a. a client who has
nasogastric suctioning.
b. a client who has chronic
constipation.
c. a client who has
syndrome of inappropriate
antidiuretic hormone
d. a client who took an
overdose of sodium
bicarbonate antacids
3. a nurse is reviewing the laboratory
test results for a client who has an
elevated temperature. The nurse
should recognize which of the
following findings is a manifestation
of dehydration? (select all that apply.)
a. Hct 55%
b. serum osmolarity
260 mOsm/kg
c. serum sodium 150 meq/l
d. urine specific gravity 1.035
e. serum creatinine 0.6 mg/dl
4. a nurse on a medical‑surgical unit
is caring for a group of clients.
For which of the following clients
should the nurse anticipate a
prescription for fluid restriction?
a. a client who has a new
diagnosis of adrenal
insufficiency
b. a client who has heart failure
c. a client who is receiving
treatment for diabetic
ketoacidosis
d. a client who has
abdominal ascites
5. a nurse is planning care for a
client who has dehydration.
Which of the following actions
should the nurse include?
a. administer antihypertensive
on schedule.
b. check the client’s weight
each morning.
c. notify the provider of a urine
output greater than 30 ml/hr.
d. encourage independent
ambulation four times a day.
346 CHAPTER 57 Fluid imbalances CONTENT MASTERY SERIES
Application Exercises Key
1. a. distended neck veins is an expected finding of hypervolemia.
b. Hypothermia is an expected finding of hypovolemia.
c. CORRECT: Tachycardia is an expected finding of hypovolemia.
d. CORRECT: syncope is an expected finding of hypovolemia.
e. CORRECT: decreased skin turgor is an
expected finding of hypovolemia.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
2. a. CORRECT: The nurse should identify that a client who
has nasogastric suctioning is at risk for hypovolemia
due to excessive gastrointestinal losses.
b. diarrhea, rather than constipation, places the client at risk
for hypovolemia due to excessive gastrointestinal losses.
c. syndrome of inappropriate antidiuretic hormone places
the client at risk for hypervolemia due to overhydration.
d. an overdose of sodium bicarbonate antacids places the client
at risk for hypervolemia due to excessive sodium intake.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
3. a. CORRECT: This Hct is greater than the expected reference
range of 42‑52% for men and 37‑47% for women and is an
indication of dehydration due to hemoconcentration.
b. This serum osmolarity is within the expected reference
range of 285‑295 mOsm/kg. a serum osmolarity greater
than 295 mOsm/kg is an indication of dehydration.
c. CORRECT: This serum sodium level is greater than the
expected reference range of 136‑145 meq/l and is an
indication of dehydration due to hemoconcentration.
d. CORRECT: This urine specific gravity is greater than the
expected reference range of 1.005‑1.030. an increased
urine specific gravity is an indication of dehydration.
e. This serum creatinine is within the expected
reference range of 0.6 to 1.3 mg/dl. an elevated serum
creatinine level is an indication of dehydration.
NCLEX® Connection: Basic Care and Comfort,
Nutrition and Oral Hydration
4. a. a client who has adrenal insufficiency is at risk for isotonic fluid
volume deficit (hypovolemia) because of a decrease in aldosterone
secretion and an increase in sodium and water excretion .
b. CORRECT: The nurse should anticipate a client
who has heart failure to require fluid and sodium
restriction to reduce the workload on the heart.
c. a client who has diabetic ketoacidosis is at risk for
dehydration because hyperglycemia can cause osmotic
dieresis which leads to dehydration and electrolyte loss.
d. a client who has ascites is at risk for hypovolemia because
of a fluid shift from the intravascular space to the abdomen.
NCLEX® Connection: Physiological Adaptation,
Illness Management
5. a. Hypotension is a manifestation of dehydration therefore the
administration of antihypertensive medication would further lower
the client’s blood pressure and increase the risk for injury.
b. CORRECT: The nurse should include obtaining the client’s
weight each day in the plan of care. To ensure accuracy the client’s
weight should be obtained at the same time each day using the
same scale. by determining the client’s weight gain or loss each
day the nurse can evaluate the client’s response to treatment.
c. a urine output greater than 30 ml/hr is an expected finding and is an
indicator of adequate fluid balance. The nurse should plan to monitor
the client’s urine output and notify the provider if it is less than 30 ml/hr.
d. The client who has dehydration is at risk for falls due to orthostatic
hypotension, possible decrease in level of consciousness, and possible
gait instability. The nurse should encourage the client to use the call
light and ask for assistance when getting out of bed or ambulating.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
PRACTICE Answer
Using the ATI Active Learning Template: System Disorder
DESCRIPTION OF DISORDER/DISEASE PROCESS:
Fluid volume excess (FVe) is the isotonic retention
of water and sodium in high proportions.
COMPLICATIONS
● FVe is often referred to as hypervolemia because
of the resulting increased blood volume.
● severe FVe can lead to pulmonary edema and heart failure.
EXPECTED FINDINGS
assessment findings
● Vital signs: Tachycardia, bounding pulse, hypertension,
tachypnea, increased central venous pressure
● neuromusculoskeletal: confusion, muscle weakness
● Gi: Weight gain, ascites
● Respiratory: dyspnea, orthopnea, crackles
● Other findings: edema, distended neck veins
laboratory findings
● decreased Hct
● serum sodium within the expected reference range
● decreased electrolytes
● decreased bun, and creatinine
● arterial blood gases
● Respiratory alkalosis: decreased PacO2 (less than
35 mm Hg), increased pH (greater than 7.45)
● urine specific gravity less than 1.010
PATIENT‑CENTERED CARE
● Observe respiratory rate, symmetry, and effort.
● auscultate breath sounds in all lung fields. lung
sounds can be diminished with crackles.
● monitor for shortness of breath and dyspnea.
● check abGs, saO2, cbc, and chest x‑ray results.
● Position the client in semi‑Fowler’s position.
● measure the client’s weight daily at same
time of day using the same scale.
● monitor and document edema (pretibial, sacral, periorbital).
● monitor i&O.
● implement prescribed restrictions for fluid and sodium intake.
● Provide fluids in a small glass to promote the
perception of a full glass of fluid.
● set 1‑ to 2‑hr short‑term goals for the fluid restriction
to promote client control and understanding.
● administer supplemental oxygen as needed. Reduce iV flow rates.
● administer diuretics (osmotic, loop) as prescribed.
● monitor and document circulation to the extremities.
● Reposition the client at least every 2 hr.
● support arms and legs to decrease dependent edema.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
PRACTICE Active Learning Scenario
a nurse is caring for a client who has fluid volume
excess due to cirrhosis of the liver. use the aTi active
learning Template: system disorder to complete
this item to include the following sections.
ALTERATION IN HEALTH (DIAGNOSIS): describe
the diagnosis of fluid volume excess.
COMPLICATIONS: identify two complications
that can result from this disorder.
EXPECTED FINDINGS: identify at least five expected
assessment findings and three expected laboratory findings.
NURSING CARE: identify at least five interventions
the nurse should include in the plan of care.
FUNDAMENTALS FOR NURSING CHAPTER 58 ElEctrolytE ImbalancEs 347
UNIT 4 PHYSIOLOGICAL INTEGRITY
SECTION: PHYSIOLOGICAL ADAPTATION
CHAPTER 58 Electrolyte
Imbalances
Electrolytes are minerals (sometimes called
salts) that are present in all body fluids. they
regulate fluid balance and hormone production,
strengthen skeletal structures, and act as
catalysts in nerve response, muscle contraction,
and the metabolism of nutrients.
When dissolved in water or another solvent,
electrolytes separate into ions and then conduct
either a positive (cations: magnesium, potassium,
sodium, calcium) or negative (anions: phosphate,
sulfate, chloride, bicarbonate) electrical current.
major electrolytes in the body include sodium,
potassium, chloride, magnesium, phosphorus,
and calcium. nurses monitor laboratory
values to identify any electrolyte imbalances.
Electrolytes are distributed between intracellular
fluid (IcF) and extracellular fluid (EcF)
compartments. While laboratory tests can
accurately reflect the electrolyte concentrations
in plasma, it is not possible to directly measure
electrolyte concentrations within cells.
It is important to recognize the manifestations of
electrolyte imbalance. clients at greatest risk for
electrolyte imbalance are infants, children, older
adults, clients who have cognitive disorders, and
clients who have chronic illnesses.
Sodium imbalances
● Sodium (Na+) is the major electrolyte found in ECF and
is present in most body fluids or secretions.
● Sodium is essential for maintenance of acid‑base
and fluid balance, active and passive transport
mechanisms, and irritability and conduction of nerve
and muscle tissue.
● Expected serum sodium levels are between
136 and 145 mEq/L.
Hyponatremia
● Hyponatremia is a serum sodium level less than
136 mEq/L.
● Hyponatremia results from an excess of water in the
plasma or loss of sodium-rich fluids.
● Hyponatremia delays and slows the depolarization
of membranes.
● Water moves from the ECF into the ICF, which causes
cells to swell (cerebral edema).
● Serious complications can result from untreated acute
hyponatremia (coma, seizures, respiratory arrest).
ASSESSMENT/DATA COLLECTION
rIsK Factors
● Deficient ECF volume
● Excessive GI losses: vomiting, nasogastric suctioning,
diarrhea, tap water enemas
● Renal losses: diuretics, kidney disease, adrenal
insufficiency, excessive sweating
● Skin losses: burns, wound drainage, gastrointestinal
obstruction, peripheral edema, ascites
● Increased or normal ECF volume: excessive oral water
intake, syndrome of inappropriate antidiuretic hormone
secretion (SIADH)
● Edematous states: heart failure, cirrhosis, nephrotic
syndrome
● Excessive hypotonic IV fluids
● Inadequate sodium intake (NPO status)
● Hyperglycemia
● Age‑related risk factors: Older adult clients are at
greater risk due to an increased incidence of chronic
illnesses, use of diuretic medications, and risk for
insufficient sodium intake.
EXPEctED FInDInGs
PHYSICAL ASSESSMENT FINDINGS: Vary with a normal,
decreased, or increased ECF volume
VITAL SIGNS: Hypothermia, tachycardia, rapid thready
pulse, hypotension, orthostatic hypotension
NEUROMUSCULOSKELETAL: Headache, confusion,
lethargy, muscle weakness with possible respiratory
compromise, fatigue, decreased deep tendon reflexes
(DTRs), seizures, coma
GI: Increased motility, hyperactive bowel sounds,
abdominal cramping, anorexia, nausea, vomiting
CHAPTER 58
348 CHAPTER 58 ElEctrolytE ImbalancEs CONTENT MASTERY SERIES
laboratory tEsts
Serum sodium
Decreased: Less than 136 mEq/L
Serum osmolarity
● Decreased: Less than 280 mOsm/kg
● Urine specific gravity: Less than 1.010 (if not due
to SIADH)
PATIENT‑CENTERED CARE
nUrsInG carE
● Report irregular laboratory findings to the provider.
● Monitor I&O, and weigh the client daily at same time of
day using the same scale.
● Monitor vital signs and level of consciousness, reporting
irregular findings.
● Encourage the client to change positions slowly.
● Follow any prescribed fluid restrictions.
● Monitor respiratory status if muscle weakness
is present.
FLUID OVERLOAD: Restrict water intake as prescribed.
RESTORATION OF NORMAL ECF VOLUME: Administer
hypertonic IV therapy (3% sodium chloride).
ACUTE HYPONATREMIA
● Administer hypertonic oral and IV fluids as prescribed.
● Encourage foods and fluids high in sodium (cheese,
milk, condiments).
Hypernatremia
● Hypernatremia is a serum sodium level greater than
145 mEq/L.
● Hypernatremia is a serious electrolyte imbalance. It
can cause significant neurological, endocrine, and
cardiac disturbances.
● Increased sodium causes hypertonicity of the serum.
This causes a shift of water out of the cells, making the
cells dehydrated.
ASSESSMENT/DATA COLLECTION
rIsK Factors
● Water deprivation (NPO)
● Heat stroke
● Excessive sodium intake: dietary sodium intake,
hypertonic IV fluids, hypertonic tube feedings,
bicarbonate intake
● Excessive sodium retention: kidney failure, Cushing’s
syndrome, aldosteronism, some medications
(glucocorticosteroids)
● Fluid losses: fever, diaphoresis, burns, respiratory
infection, diabetes insipidus, hyperglycemia,
watery diarrhea
● Age-related changes, specifically decreased total body
water content and inadequate fluid intake related to an
altered thirst mechanism
● Compensatory mechanisms: increased thirst and
increased production of ADH
EXPEctED FInDInGs
VITAL SIGNS: Hyperthermia, tachycardia,
orthostatic hypotension
NEUROMUSCULOSKELETAL: Restlessness, disorientation,
irritability, muscle twitching, muscle weakness, seizures,
decreased level of consciousness, reduced to absent DTRs
GI: Thirst, dry mucous membranes, dry and swollen
tongue that is red in color, increased motility, hyperactive
bowel sounds, abdominal cramping, nausea
OTHER FINDINGS: Edema, warm flushed skin, oliguria
laboratory tEsts
Serum sodium
Increased: Greater than 145 mEq/L
Serum osmolarity
● Increased: Greater than 295 mOsm/kg
● Urine specific gravity: Greater than 1.030
PATIENT‑CENTERED CARE
nUrsInG carE
● Report laboratory findings outside of the expected
reference range to the provider.
● Monitor level of consciousness and ensure safety.
● Provide oral hygiene and other comfort measures to
decrease thirst.
● Monitor I&O, and alert the provider if urinary output
is inadequate.
FLUID LOSS: Based on serum osmolarity
Administer hypotonic IV fluids (0.225% sodium chloride).
EXCESS SODIUM
● Encourage water intake and discourage sodium intake.
● Administer diuretics (loop diuretics).
FUNDAMENTALS FOR NURSING CHAPTER 58 ElEctrolytE ImbalancEs 349
Potassium imbalances
● Potassium (K+) is the major cation in ICF.
● Potassium plays a vital role in cell metabolism;
transmission of nerve impulses; functioning of cardiac,
lung, and muscle tissues; and acid‑base balance.
● Potassium has reciprocal action with sodium.
● Expected serum potassium levels are 3.5 to 5 mEq/L.
Hypokalemia
● Hypokalemia is a serum potassium level less than
3.5 mEq/L.
● Hypokalemia is the result of an increased loss of
potassium from the body, decreased intake and
absorption of potassium, or movement of potassium
into the cells.
ASSESSMENT/DATA COLLECTION
rIsK Factors
● Hyperaldosteronism
● Inadequate dietary intake (rare)
● Prolonged administration of non‑electrolyte‑containing
IV solutions such as 5% dextrose in water
EXCESSIVE GI LOSSES: Vomiting, nasogastric suctioning,
diarrhea, excessive laxative use
RENAL LOSSES: Excessive use of potassium‑excreting
diuretics, such as furosemide, corticosteroids
SKIN LOSSES: Diaphoresis, wound losses
ICF: Metabolic alkalosis, after correction of acidosis
(treatment of diabetic ketoacidosis), during periods
of tissue repair (burns, trauma, starvation),
total parenteral nutrition
EXPEctED FInDInGs
VITAL SIGNS: Hyperthermia, weak irregular pulse,
hypotension, orthostatic hypotension, respiratory distress
NEUROMUSCULOSKELETAL: Ascending bilateral muscle
weakness with respiratory collapse and paralysis, muscle
cramping, decreased muscle tone and hypoactive reflexes,
paresthesias, mental confusion
ELECTROCARDIOGRAM (ECG): Premature ventricular
contractions (PVCs), bradycardia, blocks, ventricular
tachycardia, flattening T waves, and ST depression
GI: Decreased motility, hypoactive bowel sounds,
abdominal distention, constipation, ileus, nausea,
vomiting, anorexia
OTHER CLINICAL FINDINGS: Anxiety, which can progress
to lethargy
laboratory tEsts
Serum potassium
Decreased: Less than 3.5 mEq/L
Arterial blood gases
Metabolic alkalosis: pH greater than 7.45
DIaGnostIc ProcEDUrEs
Electrocardiogram
NURSING CONSIDERATIONS: Monitor for dysrhythmias,
such as PVCs, ventricular tachycardia, flattening T waves,
and ST depression.
PATIENT‑CENTERED CARE
nUrsInG carE
● Report findings outside of the expected reference range
to the provider.
● Treat the underlying cause.
● Replace potassium.
◯ Provide dietary education and encourage foods high
in potassium (avocados, dried fruit, cantaloupe,
bananas, potatoes, spinach).
◯ Provide oral potassium supplementation.
● Monitor for and maintain an adequate urine output.
● Monitor for shallow, ineffective respirations and
diminished breath sounds.
● Monitor cardiac rhythm, and intervene promptly
as needed.
● Monitor clients receiving digoxin. Hypokalemia
increases the risk for digoxin toxicity.
● Monitor level of consciousness and ensure safety.
● Monitor bowel sounds and abdominal distention and
intervene as needed.
IV POTASSIUM SUPPLEMENTATION
● Mixed by a pharmacist and double‑checked by two
nurses prior to administration.
● Dilute potassium to a concentration of no more than
1 mEq potassium to 10 mL solution and infuse slowly,
no faster than 10 mEq/hr.
● Monitor for phlebitis (tissue irritant). Discontinue the IV,
and notify the provider for infiltration of potassium.
! never IV bolus (high risk of cardiac arrest)
350 CHAPTER 58 ElEctrolytE ImbalancEs CONTENT MASTERY SERIES
Hyperkalemia
● Hyperkalemia is a serum potassium level greater than
5.0 mEq/L.
● Hyperkalemia is the result of an increased intake of
potassium, movement of potassium out of the cells, or
inadequate renal excretion.
● Hyperkalemia uncommon in clients who have adequate
kidney function.
● Hyperkalemia is potentially life‑threatening due to the
risk of cardiac arrhythmias and cardiac arrest.
ASSESSMENT/DATA COLLECTION
rIsK Factors
INCREASED TOTAL BODY POTASSIUM: IV potassium
administration, salt substitutes, blood transfusion
ECF SHIFT: Insufficient insulin, acidosis
(diabetic ketoacidosis), tissue catabolism (sepsis, trauma,
surgery, fever, myocardial infarction)
HYPERTONIC STATES: Uncontrolled diabetes mellitus
DECREASED EXCRETION OF POTASSIUM: Kidney
failure, severe dehydration, potassium‑sparing diuretics,
ACE inhibitors, adrenal insufficiency
AGE: Older adult clients are at greater risk due to
decreased kidney function and medical conditions
resulting in the use of salt substitutes,
angiotensin‑converting enzyme inhibitors, and
potassium‑sparing diuretics.
EXPEctED FInDInGs
VITAL SIGNS: Slow, irregular pulse; hypotension
NEUROMUSCULOSKELETAL: Irritability, confusion,
weakness with ascending flaccid paralysis, paresthesias,
lack of reflexes
ECG: Ventricular fibrillation, peaked T waves,
widened QRS, cardiac arrest
GI: Increased motility, diarrhea, abdominal cramps,
hyperactive bowel sounds
laboratory tEsts
Serum potassium
Increased: Greater than 5 mEq/L
Arterial blood gases
Metabolic acidosis: pH less than 7.35
DIaGnostIc ProcEDUrEs
ECG will show dysrhythmias (ventricular fibrillation,
peaked T waves, widened QRS).
PATIENT‑CENTERED CARE
nUrsInG carE
● Report findings outside of the expected reference range
to the provider.
● Decrease potassium intake.
◯ Stop infusion of IV potassium.
◯ Withhold oral potassium.
◯ Provide a potassium‑restricted diet.
◯ If potassium levels are extremely high, dialysis might
be required.
● Promote the movement of potassium from ECF to ICF.
Administer IV fluids with dextrose and regular insulin.
● Monitor cardiac rhythm, and intervene promptly
as needed.
● Maintain IV access.
● Prepare the client for dialysis if prescribed.
mEDIcatIons
TO INCREASE POTASSIUM EXCRETION
● Administer loop diuretics, such as furosemide, if kidney
function is adequate. Loop diuretics increase the
excretion of potassium from the renal system.
● Sodium polystyrene sulfonate is given orally or as an
enema. Sodium polystyrene sulfonate increases the
excretion of potassium from the gastrointestinal system.
Calcium imbalances
● Calcium is found in the body’s cells, bones, and teeth.
The expected total calcium level is 9 to 10.5 mg/dL.
● Calcium balance is essential for proper functioning
of the cardiovascular, neuromuscular, and endocrine
systems, as well as blood clotting and bone and
teeth formation.
Hypocalcemia
Hypocalcemia is a total serum calcium level less than
9 mg/dL.
ASSESSMENT/DATA COLLECTION
rIsK Factors
Increased calcium output
● Chronic diarrhea
● Steatorrhea as with pancreatitis (binding of calcium to
undigested fat)
Inadequate calcium intake or absorption
● Malabsorption syndromes, such as Crohn’s disease
● Vitamin D deficiency (alcohol use disorder, chronic
kidney disease)
FUNDAMENTALS FOR NURSING CHAPTER 58 ElEctrolytE ImbalancEs 351
Calcium shift from ECF into bone or to an inactive form
● Rapid infusion of blood transfusion
● Post‑thyroidectomy
● Hypoparathyroidism
EXPEctED FInDInGs
MUSCLE TWITCHES/TETANY
● Numbness and tingling (fingers and around mouth)
● Frequent, painful muscle spasms at rest that can
progress to tetany
● Hyperactive DTRs
● Positive Chvostek’s sign (tapping on the facial nerve
triggering facial twitching)
● Positive Trousseau’s sign (hand/finger spasms with
sustained blood pressure cuff inflation)
● Laryngospasms
CARDIOVASCULAR
● Weak, thready pulse, tachycardia or bradycardia
● Cardiac dysrhythmias: prolonged QT interval and
ST segments
GI: Hyperactive bowel sounds, diarrhea,
abdominal cramping
CENTRAL NERVOUS SYSTEM: Seizures due to
overstimulation of the CNS
laboratory tEsts
Calcium level less than 9 mg/dL
DIaGnostIc ProcEDUrEs
ECG
PATIENT‑CENTERED CARE
nUrsInG carE
● Administer oral or IV calcium supplements. (Carefully
monitor respiratory and cardiovascular status.)
● Initiate seizure precautions.
● Keep emergency equipment on standby.
● Encourage foods high in calcium, including dairy
products and dark green vegetables.
Hypercalcemia
Hypercalcemia is a total serum calcium level greater than
10.5 mg/dL.
ASSESSMENT/DATA COLLECTION
rIsK Factors
Decreased calcium output: Thiazide diuretics
Increased calcium intake and absorption
Calcium shift from bone to ECF
● Hyperparathyroidism
● Bone cancer
● Paget’s disease
● Chronic immobility
● Long‑term glucocorticoid use
● Hyperthyroidism
EXPEctED FInDInGs
NEUROMUSCULAR
● Decreased reflexes
● Bone pain
● Flank pain if renal calculi develop
CARDIOVASCULAR
● Dysrhythmias
● Increased risk for blood clot
GI: Anorexia, nausea, vomiting, constipation
CENTRAL NERVOUS SYSTEM
● Weakness, lethargy
● Confusion, decreased level of consciousness
laboratory tEsts
Total serum calcium level greater than 10.5 mg/dL
DIaGnostIc ProcEDUrEs
ECG: Shortened QT interval
PATIENT‑CENTERED CARE
nUrsInG carE
● Increase the client’s activity level.
● Limit dietary calcium.
● Encourage fluids to promote urinary excretion.
● Encourage fiber to promote bowel elimination.
● Implement safety precautions if client is confused.
● Monitor for pathologic fractures.
● Encourage fluid intake to decrease the risk for renal
calcium stone formation.
● Monitor for blood clots; measure calf circumference.
352 CHAPTER 58 ElEctrolytE ImbalancEs CONTENT MASTERY SERIES
Magnesium imbalances
Most of the body’s magnesium is found in the bones.
Magnesium in smaller amounts is found within the body
cells. A very small amount is found in ECF. The expected
magnesium level is 1.3 to 2.1 mEq/L.
Hypomagnesemia
Hypomagnesemia is a serum magnesium level less than
1.3 mEq/L.
ASSESSMENT/DATA COLLECTION
rIsK Factors
INCREASED MAGNESIUM OUTPUT
● GI losses (diarrhea, nasogastric suction)
● Thiazide or loop diuretics
● Often associated with hypocalcemia
INADEQUATE MAGNESIUM INTAKE OR ABSORPTION
● Malnutrition
● Alcohol use disorder
● Laxative use
EXPEctED FInDInGs
NEUROMUSCULAR: Increased nerve impulse transmission
(hyperactive DTRs, paresthesias, muscle tetany),
positive Chvostek’s and Trousseau’s signs, tetany, seizures
GI: Hypoactive bowel sounds, constipation,
abdominal distention, paralytic ileus
CARDIOVASCULAR: Dysrhythmias, tachycardia, hypertension
PATIENT‑CENTERED CARE
nUrsInG carE
● Discontinue magnesium‑losing medications.
● Administer oral or IV magnesium sulfate following
safety protocols. IV route is used because IM can cause
pain and tissue damage. Oral magnesium can cause
diarrhea and increase magnesium depletion.
● Monitor DTRs during infusion to
prevent hypermagnesemia.
● Encourage foods high in magnesium, including whole
grains and dark green vegetables.
● Implement seizure precautions.
Hypermagnesemia
Hypermagnesemia is a serum magnesium level greater
than 2.1 mEq/L.
ASSESSMENT/DATA COLLECTION
rIsK Factors
Decreased magnesium output
● Chronic kidney disease or acute kidney injury
● Adrenal insufficiency
Increased magnesium intake and absorption:
Laxatives or antacids containing magnesium
EXPEctED FInDInGs
NEUROMUSCULAR
● Diminished DTRs
● Muscle paralysis
● Shallow respirations, decreased respiratory rate
CARDIOVASCULAR
● Bradycardia, hypotension
● Dysrhythmias, cardiac arrest
CENTRAL NERVOUS SYSTEM: Lethargy
laboratory tEsts
Serum magnesium level greater than 2.1 mEq/L
DIaGnostIc ProcEDUrEs
ECG: Prolonged PR interval, widened QRS
PATIENT‑CENTERED CARE
nUrsInG carE
● Perform frequent focused assessments (vital signs,
level of consciousness, reflexes). Notify the provider of
changes or absent reflexes.
● Monitor respiratory and cardiac status.
● Administer loop diuretics and magnesium free IV fluids
if kidney function is adequate.
● Administer calcium for severe cardiac changes.
FUNDAMENTALS FOR NURSING CHAPTER 58 ElEctrolytE ImbalancEs 353
Application Exercises
1. a nurse is planning care for a
client who has hypernatremia.
Which of the following actions
should the nurse anticipate
including in the plan of care?
a. Infuse hypotonic IV fluids.
b. Implement a fluid restriction.
c. Increase sodium intake.
D. administer sodium
polystyrene sulfonate.
2. a nurse is reviewing the
medical record of a client who
has hypocalcemia. the nurse
should identify which of the
following findings as risk factors
for the development of this
electrolyte imbalance?
a. crohn’s disease
b. Postoperative following
appendectomy
c. History of bone cancer
D. Hyperthyroidism
3. a nurse receives a laboratory
report for a client indicating a
potassium level of 5.2 mEq/l.
When notifying the provider, the
nurse should anticipate which
of the following actions?
a. starting an IV infusion of
0.9% sodium chloride
b. consulting with dietitian to
increase intake of potassium
c. Initiating continuous
cardiac monitoring
D. Preparing the client
for gastric lavage
4. a nurse is collecting data from
a client who has hypercalcemia
as a result of long‑term use of
glucocorticoids. Which of the
following findings should the nurse
expect? (select all that apply.)
a. Hyperreflexia
b. confusion
c. Positive chvostek’s sign
D. bone pain
E. nausea and vomiting
5. a nurse is providing education
for a client who has severe
hypomagnesemia due to alcohol
use disorder. the client is to receive
magnesium sulfate. Which of the
following information should the
nurse include in the teaching?
a. “you will receive
magnesium in a series of
intramuscular injections.”
b. “you should receive a
prescription for a thiazide
diuretic to take with
the magnesium.”
c. “you should eliminate whole
grains from your diet until your
magnesium level increases.”
D. “you will have your
deep‑tendon reflexes
monitored while you are
receiving magnesium.”
PRACTICE Active Learning Scenario
a nurse is caring for a client who has hypokalemia as
an adverse effect of furosemide. Use the atI active
learning template: system Disorder to complete
this item to include the following sections.
ALTERATION IN HEALTH (DIAGNOSIS)
EXPECTED FINDINGS: Identify at
least five expected findings.
NURSING CARE: Identify two safety actions for the
administration of IV potassium supplementation.
354 CHAPTER 58 ElEctrolytE ImbalancEs CONTENT MASTERY SERIES
Application Exercises Key
1. a. CORRECT: Hypotonic IV fluids, such as 0.225% sodium chloride,
are indicated for the treatment of hypernatremia related to fluid
loss to expand the EcF volume and rehydrate the cells.
b. Increased fluid intake is indicated for the treatment of hypernatremia.
c. Decreased sodium intake is indicated for
the treatment of hypernatremia.
D. administration of sodium polystyrene sulfonate is
indicated for the treatment of hyperkalemia.
NCLEX® Connection: Physiological Adaptation,
Unexpected Response to Therapies
2. a. CORRECT: crohn’s disease is a risk factor for hypocalcemia.
this malabsorption disorder places the client at risk for
hypocalcemia due to inadequate calcium absorption.
b. a thyroidectomy places the client at risk for hypocalcemia due
to the possible removal of or injury to the parathyroid glands.
c. a history of bone cancer increases the client’s risk of
hypercalcemia due to the shift of calcium from bone to EcF.
D. Hyperthyroidism places the client at risk for hypercalcemia
due to the shift of calcium from bone to EcF.
NCLEX® Connection: Physiological Adaptation,
Fluid and Electrolyte Imbalances
3. a. the nurse should initiate an IV infusion of a fluid containing
dextrose to promote the movement of potassium from EcF to IcF.
b. the nurse should withhold oral potassium and provide
the client with a potassium‑restricted diet.
c. CORRECT: a potassium level of 5.2 mEq/l indicates
hyperkalemia. the nurse should anticipate the initiation
of continuous cardiac monitoring due to the client’s risk
for dysrhythmias such as ventricular fibrillation.
D. Gastric lavage is not indicated for the treatment of
hyperkalemia. However, the nurse should prepare the
client for dialysis if hyperkalemia becomes severe.
NCLEX® Connection: Physiological Adaptation,
Illness Management
4. a. the nurse should expect the client who has
hypercalcemia to have decreased reflexes.
b. CORRECT: the nurse should expect the client who has hypercalcemia
to have confusion and a possible decreased level of consciousness.
c. the nurse should expect the client who has
hypocalcemia to have a positive chvostek’s sign.
D. CORRECT: the nurse should expect the client
who has hypercalcemia to have bone pain.
E. CORRECT: the nurse should expect the client who has
hypercalcemia to have nausea and vomiting along with anorexia.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Adverse Effects/Contraindications/Side Effects/Interactions
5. a. magnesium sulfate is administered either orally or
IV. Im administration of magnesium is avoided due
to pain and the potential for tissue damage.
b. thiazide diuretics increase magnesium output, thereby
worsening the client’s hypomagnesemia.
c. the nurse should encourage the client’s intake of foods that are
high in magnesium, such as whole grains and dark green vegetables.
D. CORRECT: the nurse should instruct the client on the need
to monitor deep‑tendon reflexes during administration of
magnesium. this assessment helps identify hypermagnesemia
that can occur during IV administration of magnesium sulfate.
NCLEX® Connection: Pharmacological and Parenteral Therapies,
Medication Administration
PRACTICE Answer
Using the ATI Active Learning Template: System Disorder
ALTERATION IN HEALTH (DIAGNOSIS):
Hypokalemia is a serum potassium level
less than 3.5 mEq/l that can result from
the increased loss of potassium from the
body due to the use of potassium‑excreting
diuretics, such as furosemide.
EXPECTED FINDINGS
● Vital signs: Weak irregular pulse,
hypotension, respiratory distress
● neuromusculoskeletal: ascending bilateral
muscle weakness, muscle cramping,
decreased muscle tone, hypoactive
reflexes, paresthesias, mental confusion
● GI: Decreased motility, hypoactive
bowel sounds, abdominal distention,
constipation, nausea, vomiting, anorexia
● Dysrhythmias: PVcs, bradycardia,
blocks, ventricular tachycardia,
flattening t waves, st depression
NURSING CARE
● Ensure all infusions containing potassium
are mixed by the pharmacist.
● Double‑check all infusions containing
potassium with another nurse
prior to administration.
● Dilute potassium to a concentration of no
more than 1 mEq potassium to 10 ml solution
and infuse slowly, no faster than 10 mEq/hr.
● never administer potassium as an IV bolus.
● monitor vital signs and cardiac and respiratory
status closely during administration
of IV potassium supplementation.
NCLEX® Connection: Pharmacological and Parenteral Therapies, Expected Actions/Outcomes
FUNDAMENTALS FOR NURSING REFERENCES 355
References
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb’s
fundamentals of nursing: Concepts, process, and practice
(10th ed.). Upper Saddle River, NJ: Prentice‑Hall.
Burchum, J. R., & Rosenthal, L. D. (2016). Lehne’s pharmacology
for nursing care (9th ed.). St. Louis: Elsevier.
Dudek, S. G. (2014). Nutrition essentials for nursing practice
(7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Eliopoulos, C. (2014). Gerontological nursing (8th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Grodner, M., Escott‑Stump, S., & Dorner, S. (2016).
Nutritional foundations and clinical applications of nutrition:
A nursing approach (6th ed.). St. Louis, MO: Mosby.
Pagana, K. D. & Pagana, T. J. (2014). Mosby’s manual of diagnostic
and laboratory tests (5th ed.). St. Louis, MO: Elsevier.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013).
Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby.
Touhy, T. A., & Jett, K. F. (2012) Ebersole & Hess’ toward healthy aging:
Human needs and nursing response (8th ed.). St. Lois, MO: Mosby.
ACTIVE LEARNING TEMPLATES therapeutic proceDure A1
Basic Concept
STUDENT NAME _____________________________________
CONCEPT ______________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Related Content
(E.G., DELEGATION,
LEVELS OF PREVENTION,
ADVANCE DIRECTIVES)
Underlying Principles Nursing Interventions
WHO? WHEN? WHY? HOW?
ACTIVE LEARNING TEMPLATES therapeutic proceDure A3
Diagnostic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Procedure
Indications
Interpretation of Findings
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
ACTIVE LEARNING TEMPLATE:
ACTIVE LEARNING TEMPLATES therapeutic proceDure A5
EXPECTED GROWTH AND DEVELOPMENT
Growth and Development
STUDENT NAME _____________________________________
DEVELOPMENTAL STAGE _______________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Health Promotion
Physical
Development
Immunizations
Cognitive
Development
Health Screening
Psychosocial
Development
Nutrition
Age-Appropriate
Activities
Injury Prevention
ACTIVE LEARNING TEMPLATES therapeutic proceDure A7
Medication
STUDENT NAME _____________________________________
MEDICATION __________________________________________________________________________ REVIEW MODULE CHAPTER ___________
CATEGORY CLASS ______________________________________________________________________
ACTIVE LEARNING TEMPLATE:
PURPOSE OF MEDICATION
Expected Pharmacological Action
Complications
Contraindications/Precautions
Interactions
Medication Administration
Evaluation of Medication Effectiveness
Therapeutic Use
Nursing Interventions
Client Education
ACTIVE LEARNING TEMPLATES therapeutic proceDure A9
Nursing Skill
STUDENT NAME _____________________________________
SKILL NAME ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Skill
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
ACTIVE LEARNING TEMPLATES therapeutic proceDure A11
System Disorder
STUDENT NAME _____________________________________
DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
ASSESSMENT SAFETY
CONSIDERATIONS
PATIENT-CENTERED CARE
Alterations in
Health (Diagnosis)
Pathophysiology Related
to Client Problem
Health Promotion and
Disease Prevention
Risk Factors Expected Findings
Laboratory Tests Diagnostic Procedures
Complications
Therapeutic Procedures Interprofessional Care
Nursing Care Client EducationMedications
ACTIVE LEARNING TEMPLATES therapeutic proceDure A13
Therapeutic Procedure
STUDENT NAME _____________________________________
PROCEDURE NAME ____________________________________________________________________ REVIEW MODULE CHAPTER ___________
ACTIVE LEARNING TEMPLATE:
Description of Procedure
Indications
Outcomes/Evaluation
CONSIDERATIONS
Nursing Interventions (pre, intra, post)
Potential Complications
Client Education
Nursing Interventions
