LVN HESI REVIEW ON BASICS

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LVN HESI REVIEW ON BASICS
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  1. T.L. is a relatively healthy 73-year-old female with newly diagnosed postmenopausal osteoporosis. She has been prescribed treatment with alendronate (Fosamax) 10 mg orally every day. Approximately 5 days after initiating treatment, T.L. experiences dysphagia and odynophagia. She is scheduled for an endoscopy in the morning to rule out ulcerative esophagitis.

    • What is alendronate and what are its indications?
    • How could the adverse reaction to this medication administration have been prevented?
    • What drug interactions are significant with alendronate?
    Alendronate (Fosamax) is a bisphosphonate used to treat osteopenia and osteoporosis. It is available in a daily or weekly dose. It must be taken with 8 oz of water, 30 minutes before ingesting any food, liquids, or medication, and the client must remain upright for 30 minutes. Once-a-week dosing has made this a first-line therapy. Common side effects include abdominal pain and acid reflux.
  2. Sodium-Restricted Diets
    • In the presence of cystic fibrosis, the sweat glands produce excessive amounts of sodium and chloride. In this special condition sodium intake is not restricted; indeed, generous amounts of sodium and salt are encouraged to compensate for the large losses of sodium through sweat.
    • Sodium restrictions may be used to treat a number of medical conditions. Hypertension is often responsive to a lowered sodium intake. The Dietary Approaches to Stop
    • Hypertension (DASH) diet has been found to effectively lower blood pressure. It involves limiting sodium intake to either 2400 mg or 1500 mg/day. The DASH diet also emphasizes fruit and vegetable intakes of 8
    • to 12 servings per day and 2 to 4 servings of low- or nonfat milk products. Information on the DASH diet can be obtained from the National Heart, Lung, and Blood Institute (www.nhlbi.nih.gov).Sodium is also restricted when water retention or edema is present. In the presence of congestive heart failure, sodium intake should be decreased to alleviate pulmonary and peripheral edema. Directly after a myocardial
    • infarction, sodium, fluid, kilocalorie, and fat restrictions may be implemented. These restrictions are to minimize the workload on the heart. As recovery progresses, the diet will be liberalized as the individual's condition permits. If cirrhosis is accompanied by ascites, sodium intake should be reduced. In chronic renal failure, sodium restriction is necessary for blood pressure control and to reduce feelings of thirst.Sodium-restricted diets vary in degree of restriction. The no-added-salt (NAS) diet is the least restrictive, allowing 2000 to 3000 mg of sodium per day. This diet allows the use of most foods with the exception of highly salted snack foods and prepared foods. Patients following this diet should read nutrition labels to assess the sodium content of food products and determine which would be appropriate for their diet. Little or no salt should be added in cooking or at the table (Box 21-9). Other sodium-restricted diets range from 2000 mg (2 g) to as little as 500 mg of sodium per day.
  3. What to Limit in Sodium-restricted Diets
  4. Salt in cooking or at the table•
    • Salt-preserved foods, such as smoked or cured meats or pickled foods•
    • Regular canned soups, broths, and bouillon•
    • Spices and condiments that contain sodium, such
    • as soy sauce, barbeque sauce, Worcestershire and steak sauces, meat
    • tenderizers, monosodium glutamate (MSG), spice salts, and salad
    • dressings•
    • Leavening agents such as baking soda and powder•
    • Canned vegetables (fresh and frozen are lower in sodium)•
    • Salty snack foods such as pretzels, popcorn, chips•
    • Processed cheeses•
    • Commercial mixes such as pasta, stuffing, muffins, potatoes
  5. Sodium
    is a mineral essential to health. In the body it functions as an electrolyte (a compound that when dissolved in water or another solvent dissociates into ions and is able to conduct an electrical current). Sodium is needed in very small amounts for good health and is found naturally in almost all foods. Therefore dietary sodium deficiency is virtually unheard of in the United States. Of greater concern is the possibility that excess sodium may be detrimental to health. Salt (sodium chloride) is the largest contributor of sodium to the diet. The major adverse effect of too much sodium chloride is elevated blood pressure. Approximately 65 million, or 31% of American adults, suffer from hypertension. Diets low in salt have been shown to lower blood pressure. Sodium attracts water; because of this, a high-sodium diet consumed by individuals who suffer from edema (fluid retention) may exacerbate the problem. Evidence has linked a high-sodium diet with increased urinary calcium excretion. Dietary reference intakes for sodium suggest an adequate intake (AI) of 1500 mg/day for younger adults, 1300 mg for adults, and 1200 mg for older adults. The upper limit of intake is set at 2300 mg/day. Most adults in the United States consume significantly greater amounts than this. Information concerning the sodium content of various foods and food groups can be found in many nutritional sources and on Nutrition Facts labels.
  6. The DASH diet
    • is the result of a successful landmark study called “Dietary Approaches to Stop Hypertension” that was able to significantly lower blood pressure by diet alone within a short period of time (14 days).[13] The diet recommends eating four to six servings of fruits, four to six servings of vegetables, and two to three servings of low-fat dairy foods per day, in addition to lean meats and high fiber grains. Studies have found that individuals following the diet have an average decrease in systolic
    • blood pressure of 6 to 11 mmHg.[13] When combining the DASH diet with a
    • low sodium diet, the blood pressure–lowering effects are even
    • greater.[14] More recent studies have found that the DASH diet also can produce a slight reduction in LDL cholesterol, an added benefit for preventing heart disease[15] (although findings indicate the diet may cause a slight decrease in HDL cholesterol as well.)The DASH diet is recommended for individuals with high blood pressure, blood pressure in the “high-normal” range, a family history of high blood pressure, or for those who are trying to get off blood pressure medications. The first step in following the DASH diet is to determine the
    • appropriate energy (kcalorie) level based on desired weight and
    • activity level (Chapter 6). Then, the appropriate number of servings per
    • day of each food group should be based on the total energy need. Table
    • 19-6 outlines the DASH diet and serving sizes, whereas Box 19-3 provides
    • a 1-day sample menu based on a 2000-calorie diet.
  7. Transdermal
    • 1.
    • Wash hands and assemble the equipment.2.
    • Use the five RIGHTS of medication preparation and administration throughout the procedure.RIGHT PATIENTRIGHT DRUGRIGHT ROUTE OF ADMINISTRATIONRIGHT DOSERIGHT TIME OF ADMINISTRATION3.
    • Provide for patient privacy and give a thorough explanation of what is to be done.4.
    • Position the patient so that the surface on which
    • the topical materials are to be applied is exposed. Provide for patient
    • comfort. Note: When
    • reapplying a transdermal disk or patch, remove the old disk or patch and
    • cleanse the skin thoroughly. Select a new site for application. It is
    • especially important in the older adult or confused patient to look for
    • the old disk if it is not where the prior application is charted. The
    • confused patient may have moved it elsewhere on the body or removed it.
    • The old disk can be encased in the glove as the nurse removes it and
    • should be disposed of in a receptacle on the medication cart, not in the
    • patient's room.5.
    • Apply the small adhesive topical disk. Figure 8-4FIGURE 8-4
    • Administering nitroglycerin topical disks (Trans-Derm Nitro). A, Carefully pick up the system lengthwise, with the tab up. B, Remove clear plastic backing from system at the tab. Do not touch inside of exposed system. C, Place the exposed adhesive side of the system on the chosen skin site; press firmly with the palm of the hand. D, Circle the outside edge of the system with one or two fingers.
    • illustrates nitroglycerin being applied to one of the sites recommended
    • by the rotation schedule. The frequency of application depends on the
    • specific medication being applied in the transdermal disk and the
    • duration of action of the prescribed medication. Nitroglycerin is
    • applied once daily, whereas fentanyl is reapplied every 3 days, and
    • clonidine and Ortho-Evra are reapplied once every 7 days.6.
    • Wash hands after application.7.
    • Label the disk with the date, time, and nurse's
    • initials. If the dosage of the medication is not printed on the patch
    • applied, it is useful to include the dosage as part of the labeling
    • process.
  8. Transdermal Disk Application
    • The transdermal disk provides a
    • controlled release of nitroglycerin through a semipermeable membrane
    • for 24 hours when applied to intact skin. The dosage released depends on
    • the surface area of the disk. Therapeutic effect can be observed in
    • about 30 minutes after attachment and continues for about 30 minutes
    • after removal.1.
    • The disk should be applied to a clean, dry,
    • hairless area of skin. Do not apply to shaved areas since skin
    • irritation may alter drug absorption. If hair is likely to interfere
    • with patch adhesion or removal, trim the hair but do not shave. Optimal
    • locations for patch placement are the upper chest or side; pelvis; and
    • inner, upper arm. Avoid scars, skinfolds, and wounds. Rotate skin sites
    • daily. (Help the patient develop a rotation chart.)2.
    • Wash hands before applying and after removing the product.3.
    • See individual product information to determine whether a patch can be worn while swimming, bathing, or showering.4.
    • If a disk becomes partially dislodged, discard it and replace with a new disk.5.
    • Sublingual nitroglycerin may be necessary for anginal attacks, especially while the dosage is being adjusted.6.
    • Dispose of used patches out of reach of children.
    • Discarded patches still contain enough active ingredient to be
    • dangerous to children.
  9. Skin Applications
    • Because many locally applied
    • medications, such as lotions, pastes, and ointments, create systemic and
    • local effects, wear gloves and use applicators when administering them.
    • Use sterile technique if the patient has an open wound. Skin
    • encrustation and dead tissues harbor microorganisms and block contact of
    • medications with the tissues to be treated. Therefore clean the skin
    • thoroughly before applying topical medications.Spread
    • the medication evenly over the involved surface when applying ointments
    • or pastes. In some cases you apply a gauze dressing over the medication
    • to prevent soiling of clothes and wiping away of the medication. Apply
    • each type of medication according to directions to ensure proper
    • penetration and absorption. Spread lotions and creams lightly onto the
    • skin's surface, because rubbing causes irritation. Apply a liniment by
    • rubbing it gently but firmly into the skin. You dust a powder lightly to
    • cover the affected area with a thin layer. Before and during any
    • application, assess the skin
    • thoroughly. Note the area applied and condition of skin in the
    • patient's chart, and document the name and administration of the
    • medication on the MAR.
  10. Absorption
    • Absorption is the
    • process by which a drug is transferred from its site of entry into the
    • body to the circulating fluids of the body (i.e., blood and lymph) for
    • distribution. The rate at which this occurs depends on the route of
    • administration, the blood flow through the tissue where the drug is
    • administered, and the solubility of the drug. It is therefore important
    • to (1) administer oral drugs with an adequate amount of fluid, usually a
    • large (8 oz) glass of water; (2) give parenteral forms properly so that
    • they are deposited in the correct tissue for enhanced absorption; and
    • (3) reconstitute and dilute drugs only with the diluent recommended by
    • the manufacturer in the package literature so that drug solubility is
    • not impaired. Equally important are nursing assessments that reveal poor
    • absorption (e.g., if insulin is administered subcutaneously and a lump
    • remains at the site of injection 2 to 3 hours later, absorption from
    • that site may be impaired).The three categories of drug administration are enteral, parenteral, and percutaneous routes. In the enteral route, the drug is administered directly into the gastrointestinal (GI) tract by oral, rectal, or nasogastric routes. The parenteral routes bypass the GI tract by using subcutaneous (SC), intramuscular (IM), or intravenous (IV) injection. Methods of percutaneous administration include inhalation, sublingual (under the tongue), or topical (on the skin) administration.Regardless
    • of the route of administration, a drug must be dissolved in body fluids
    • before it can be absorbed into body tissues. For example, before a
    • solid drug taken orally can be absorbed into the bloodstream for
    • transport to the site of action, it must disintegrate and dissolve in
    • the GI fluids and be transported across the stomach or intestinal lining
    • into the blood. The process of converting the drug into a soluble form
    • can be partially controlled by the pharmaceutical dosage form used
    • (e.g., solution, suspension, capsule, and tablets with various
    • coatings). This conversion process can also be influenced by
    • administering the drug with or without food in the patient's stomach.The
    • rate of absorption when a drug is administered by a parenteral route
    • depends on the rate of blood flow through the tissues. Circulatory
    • insufficiency and respiratory distress may lead to hypoxia and further
    • complicate this situation by resulting in vasoconstriction. For that
    • reason, the nurse should not give an injection where circulation is
    • known to be impaired. Another site on the rotation schedule should be
    • used. SC injections have the slowest absorption rate, especially if
    • peripheral circulation is impaired. IM injections are more rapidly
    • absorbed because of greater blood flow per unit weight of muscle
    • compared with subcutaneous tissue. (Depositing the medication into the
    • muscle belly is important. The nurse must carefully assess the
    • individual patient for the correct length of needle to ensure that this
    • occurs.) Cooling the area of injection slows the rate of absorption,
    • whereas heat or massage hastens the rate of absorption. The drug is
    • dispersed throughout the body most rapidly when administered by IV
    • injection. (The nurse must be thoroughly educated regarding the
    • responsibilities and techniques associated with administering IV
    • medications. Once the drug enters the patient's bloodstream, it cannot
    • be retrieved.)Absorption of topical
    • drugs applied to the skin can be influenced by the drug concentration,
    • length of contact time, size of affected area, thickness of skin
    • surface, hydration of tissue, and degree of skin disruption.
    • Percutaneous absorption is greatly increased in newborns and young
    • infants, who have thin, well-hydrated skin. When drugs are inhaled,
    • their absorption can be influenced by depth of respirations, fineness of
    • the droplet particles, available surface area of mucous membranes,
    • contact time, hydration state, blood supply to the area, and
    • concentration of the drug itself.
  11. Age Consideration for DRUG admin
    • Before a medicine can be
    • absorbed, it must be administered. Pediatric and geriatric patients each
    • require special considerations for medication administration. For
    • example, the absorption of medicines given intramuscularly (IM) may be
    • affected by differences in muscle mass, blood flow to muscles, and
    • muscle inactivity in patients who are bedridden.Life Span IssuesPediatric
    • and geriatric patients each require special considerations for
    • medication administration. Medicines given intramuscularly (IM) are
    • usually erratically absorbed in both neonates and older adults.
    • Differences in muscle mass, blood flow to muscles, and muscle inactivity
    • in patients who are bedridden make absorption unpredictable.Topical
    • administration with percutaneous absorption is usually effective in
    • infants because the outer layer of skin (stratum corneum) is not fully
    • developed. Because the skin is more fully hydrated at this age,
    • water-soluble drugs are absorbed more
    • readily. Infants wearing plastic-coated diapers are also more
    • susceptible to skin absorption because the plastic acts as an occlusive
    • dressing that increases hydration of the skin. Inflammation (e.g.,
    • diaper rash) also increases the amount of drug absorbed.Transdermal
    • administration in geriatric patients is often difficult to predict.
    • Although dermal thickness decreases with aging and may enhance
    • absorption, conversely, factors that may diminish absorption occur, such
    • as drying, wrinkling, and a decrease in hair follicles. With aging,
    • decreased cardiac output and diminishing tissue perfusion may also
    • affect transdermal drug absorption.In
    • most cases, medicines are administered orally. However, tablet and
    • capsule forms are often too large for either pediatric or geriatric
    • patients to swallow. It is often necessary to crush a tablet for
    • administration with food or use a liquid formulation for easier
    • administration. Taste also becomes a factor when administering oral
    • liquids, since the liquid comes in contact with the taste buds.
    • Timed-release tablets (p. 119), enteric-coated tablets (p. 119), and sublingual tablets (p. 107) should not be crushed because of the effect on the absorption rate and the potential for toxicity.Infants
    • and older adults often lack a sufficient number of teeth for chewable
    • medicines. Chewable tablets should not be given to children with loose
    • teeth (p. 27). Geriatric patients often have reduced salivary flow (p. 28), making chewing and swallowing more difficult.Gastrointestinal
    • (GI) absorption of medicines is influenced by a variety of factors,
    • including gastric pH, gastric emptying time, motility of the GI tract,
    • enzymatic activity, blood flow of the mucous lining of the stomach and
    • intestines, permeability and maturation of the mucosal membrane, and
    • concurrent disease processes. Absorption by passive diffusion
    • across the membranes and gastric emptying time both depend on the pH of
    • the environment. Newborns and geriatric patients have reduced gastric
    • acidity and transit time when compared with adults. Premature infants
    • have a high gastric pH (6 to 8) because of immature acid-secreting cells
    • in the stomach. In a full-term newborn, the gastric pH is also 6 to 8,
    • but within 24 hours the pH decreases to 2 to 4 because of gastric acid
    • secretion. At 1 year of age, the child's stomach pH approximates that of
    • an adult (1 to 3). Geriatric patients often have a higher gastric pH
    • because of loss of acid-secreting cells. Drugs destroyed by gastric acid
    • (e.g., ampicillin, penicillin) are more readily absorbed and have
    • higher serum concentrations in older adults because of the lack of acid
    • destruction. In contrast, drugs that depend on an acidic environment for
    • absorption (e.g., phenobarbital, acetaminophen, phenytoin, aspirin) are
    • more poorly absorbed and have lower serum concentrations in older
    • adults. Premature infants and geriatric patients also have a slower
    • gastric emptying time, partly because of the reduced acid secretion. A
    • slower gastric emptying time may allow the drug to stay in contact with
    • the absorptive tissue longer, allowing increased absorption with a
    • higher serum concentration. There is also the potential for toxicity
    • caused by extended contact time in the stomach for ulcerogenic drugs
    • (e.g., nonsteroidal antiinflammatory agents).Another factor affecting drug absorption in the newborn is the absence of enzymes needed for hydrolysis.
    • Infants cannot metabolize palmitic acid from chloramphenicol palmitate
    • (an antibiotic), thus preventing absorption of the chloramphenicol. Oral
    • phenytoin dosages are also greater in infants less than 6 months of age
    • because of poor absorption (neonates: 15 to 20 mg/kg/24 hr as compared
    • with infants and children: 4 to 7 mg/kg/24 hr).The intestinal transit
    • rate also varies with age. As the newborn matures into infancy, the GI
    • transit rate increases, causing some medicines to be poorly absorbed.
    • Sustained-release capsules (e.g., theophylline [Theo-24]) move through
    • the intestines so rapidly at this age that only about 50% of a dose is
    • absorbed, compared with dose absorption in children more than 5 years of
    • age. The elderly develop decreased GI motility and intestinal blood
    • flow. This has the potential for altered absorption of medicines, as
    • well as either constipation or diarrhea, depending on the medicine.
  12. Prescription Verification
    • With the nonautomated order and
    • distribution systems, once a prescription order has been written for a
    • hospitalized patient, the nurse interprets it and makes a professional
    • judgment on its acceptability. Judgments must be made regarding the type
    • of drug, therapeutic intent, usual dose, and mathematical and physical
    • preparation of the dose. The nurse must also evaluate the method of
    • administration in relation to the patient's physical condition, as well
    • as any allergies and the patient's ability to tolerate the dose form. If
    • any part of an order is vague, the physician who wrote the order should
    • be consulted for clarification. Patient safety is of primary importance
    • and the nurse assumes responsibility for verification and safety
    • of the medication order. If, after gathering all possible information,
    • it is concluded that it is inappropriate to administer the medication as
    • ordered, the prescribing physician should be notified immediately. An
    • explanation should be given as to why the order should not be executed.
    • If the physician cannot be contacted or does not change the order, the
    • nurse should notify the director of nurses, the nursing supervisor on
    • duty, or both. The reasons for refusal to administer the drug should be
    • recorded in accordance with the policies of the employing institution.
  13. Correct Transcription and Communication of Orders
    • Once you receive and process a
    • medication, place the physician's or health care provider's complete
    • order on the appropriate medication form, the MAR. The MAR includes the
    • patient's name, room, and bed number, as well as the names, dosages,
    • frequencies, and routes of administration for each medication. As a
    • nurse you complete or update the MAR. Sometimes a computer system
    • generates the MAR. When you use a computer printout, it lists all
    • currently ordered medications with dosage information (Figure 14-9Figure 14-9
    • Example of medication administration record (MAR).).
    • You can use the same printout to record medications given. Each time
    • you prepare a medication dosage, refer to the MAR. When transcribing
    • orders, ensure the names of medications, dosages, routes, and times are
    • legible. Clarify and rewrite any illegible transcriptions, and, whether
    • the MAR is handwritten or computer generated, carefully verify that all
    • information on the MAR is complete and accurate.The
    • nurse checks all medication orders for accuracy and thoroughness. When
    • orders are transcribed, the same information needs to be checked again
    • by the nurse. It is essential that you verify the accuracy of every
    • medication you give to the patient with the patient's orders. The
    • process of verification of medications varies among health care
    • agencies. However, if an order seems incorrect or inappropriate or if
    • there is a discrepancy between the written order and what is on the MAR,
    • you consult the prescriber. When you give the wrong medication or an
    • incorrect dose, you are legally responsible for the error.
  14. Independent Nursing Actions
    • The nurse performs baseline and
    • subsequent assessments that are valuable in establishing therapeutic
    • goals, duration of therapy, detection of drug toxicity, and frequency of
    • reevaluation.The nurse should approach
    • any problems related to the medication prescribed collaboratively with
    • appropriate members of the health care team. Whenever the nurse is in
    • doubt about medication calculations, monitoring for therapeutic efficacy
    • and side effects, or the establishment of nursing interventions or
    • patient education, another qualified professional should be consulted.The
    • pharmacist reviews all aspects of the drug order, then prepares the
    • medications and sends them to the unit for storage in a medication room
    • or a unit dose medication cart. If any portion of the drug order or the
    • rationale for therapy is unclear, the nurse and pharmacist may consult
    • with each other or the health care provider for clarification.The
    • frequency of medication administration is defined by the health care
    • provider in the original order. The nurse and pharmacist establish the
    • schedule of the medication based on the standardized administration
    • times used at the practice setting. The nurse, and occasionally the
    • pharmacist, also coordinates the schedule of the medication
    • administration and the collection of blood samples with the laboratory
    • phlebotomist to monitor drug serum levels.The
    • nurse completes laboratory test requisitions based on the health care
    • provider's orders to monitor drug therapy, establish dosages, and
    • identify the most effective medication for pathogenic microorganisms.As
    • soon as laboratory and diagnostic test results are available, the nurse
    • and pharmacist review them to identify values that could have an
    • influence on drug therapy. The results of the tests are conveyed to the
    • health care provider. The nurse should also have current assessment data
    • available for collaborative discussion of signs and symptoms that may
    • relate to the medications prescribed, dosage, therapeutic efficacy, or
    • adverse effects.Patient education,
    • including discharge medications, requires that an established plan be
    • developed, written in the patient's medical record, implemented,
    • documented, and reinforced by all persons delivering care to the patient
    • (see the sample teaching plan on p. 57).
  15. Legal and Ethical considerations
    • The practice of nursing under a
    • professional license is a privilege, not a right. In accepting the
    • privilege, the nurse must understand that this responsibility includes
    • accountability for one's actions and judgments during the execution of
    • professional duties. An understanding of the nurse practice act
    • and the rules and regulations established by the state boards of nursing
    • for the various levels of entry (practical nurse, registered nurse, and
    • nurse practitioner) is a solid foundation for beginning practice. Many
    • state boards have developed specific guidelines for the registered nurse
    • to use when delegating medication duties to assistive personnel.Standards of care
    • are guidelines developed for the practice of nursing. These guidelines
    • are defined by the Nurse Practice Act of each state, by state and
    • federal laws regulating health care facilities, by The Joint Commission
    • on Accreditation of Healthcare Organizations (JCAHO), as well as by
    • professional organizations such as the American Nurses Association
    • (ANA), and other specialty nursing organizations such as the Intravenous
    • Nurses Society, Inc. Nurses must also be familiar with the established
    • policies of the employing health care agency. Policies developed by the
    • health care agency must adhere to the minimum standards of state
    • regulatory authorities, however, agency policies may be more stringent
    • than those recognized by the state. Employment within the agency implies
    • the willingness of the nurse to adhere to established standards and to
    • work within established guidelines to make necessary changes in the
    • standards. Examples of policy statements relating to medication
    • administration include the following:1.
    • Educational requirements of professionals
    • authorized to administer medications. Many health care facilities
    • require passage of a written test to confirm the knowledge and skills
    • needed for medication calculation, preparation, and administration
    • before granting approval to administer any medications.2.
    • Approved lists of intravenous solutions and medications that the nurse can start or add to an existing infusion.3.
    • Lists of restricted medications (e.g.,
    • antineoplastic agents, magnesium sulfate, allergy extracts, lidocaine,
    • RhoGAM, Imferon, and heparin) that may be administered only by certain
    • staff members.Before
    • administering any medication, the nurse must have a current license to
    • practice, a clear policy statement that authorizes the act, and a
    • medication order signed by a practitioner licensed with prescriptive
    • privileges. The nurse must understand the individual patient's diagnosis
    • and symptoms that correlate with the rationale for drug use. The nurse
    • should also know why a medication is ordered, the expected actions,
    • usual dosing, proper dilution, route and rate of administration, minor
    • side effects to expect, adverse effects to report, and contraindications
    • for the use of a particular drug. If drugs are to be administered using
    • the same syringe or at the same IV site, drug compatibility should be
    • confirmed before administration. If unsure of any of these key
    • medication points, the nurse must consult an authoritative resource or
    • the hospital pharmacist before the administration of a medication. The
    • nurse must be accurate in the calculation, preparation, and
    • administration of medications. The nurse must assess the patient to be
    • certain that both therapeutic and adverse effects associated with the
    • medication regimen are reported. Nurses must be able to collect patient
    • data at regularly scheduled intervals and record observations in the
    • patient's chart for evaluation of the effectiveness of the treatment.
    • Claiming unfamiliarity with any of these nursing responsibilities, when
    • an avoidable complication arises, is unacceptable; in fact, it is
    • considered negligence of nursing responsibility.Nurses
    • must take an active role in the education of the patient, family, and
    • significant others in preparation for discharge from the health care
    • environment. (A person's health will improve only to the extent that the
    • patient understands how to care for himself or herself.) Specific
    • teaching goals should be developed and implemented. Nursing observations
    • and progress toward mastery of skills should be charted to document the
    • learner's degree of understanding.
  16. Medical Management
    • The physician will order bed rest, pain control, physical therapy (aimed at muscle strengthening and
    • comfort), and skin traction (may be pelvic or cervical). If the patient demonstrates neurological deterioration or continued pain, a surgical procedure may be required, such as the following:

    • • Laminectomy: Surgical removal of the bony
    • arches or one or more vertebrae performed to relieve compression of the spinal cord caused by bone displacement from an injury or degeneration of a disk or to remove a displaced vertebral disk.
    • • Spinal fusion (arthrodesis; the surgical immobilization of a joint; artificial ankylosis): Removal of the lamina and several herniated nuclei pulposi. A portion of bone taken from the
    • patient's iliac crest or from a bone bank is used as a bone graft in the vertebral spaces.
    • • Diskectomy: Often done with a microscope.
    • Only the extruded disk material is removed. Percutaneous lateral diskectomy is performed under local anesthesia with the surgeon cutting a window around the anulus fibrosus.
    • • Endoscopic spinal microsurgery: Can be
    • performed under local anesthesia. Special scopes enable the surgeon to successfully remove herniated discs with minimal damage to surrounding
    • tissues.
    • • Chemonucleolysis: Can be done on patients
    • who have no nerve involvement. The procedure involves administering a local anesthetic agent and then guiding a needle into the nucleus pulposus to inject chymopapain (a drug that dissolves the nucleus pulposus).Postoperative
    • laminectomy care includes assessing the incision site for signs of infection such as drainage, edema, odor, and temperature elevation. Use of surgical asepsis when changing dressings and handling drainage will decrease development of infection. After a chemonucleolysis, careful assessment is noted for signs of allergic reactions to chymopapain, such as urticaria and respiratory difficulties.
  17. Pain
    • Pain is expected in the early
    • postoperative phase. Pain receptors are stimulated because tissues are
    • cut and stretched during surgery. Muscle spasms in the area around the
    • incision add to the patient's discomfort. The pain is usually most
    • severe during the first 48 hours after surgery. During that time opioid
    • analgesics such as meperidine or morphine are most appropriate. The
    • physician may order doses to be given at 3- to 4-hour intervals when
    • needed, or patient-controlled analgesia may be used. Patient-controlled
    • analgesia is discussed in Chapter 14.
    • By the third postoperative day most patients need less medication for
    • pain relief. The dosage or frequency may be reduced, or the order may be
    • changed to an oral analgesic such as acetaminophen with codeine.When
    • postoperative patients complain of pain, determine the exact nature of
    • the complaint. Where is the pain located? It is easy to assume that the
    • pain is incisional when in fact the patient may have a headache or a
    • backache. Chest pain, leg pain, or gas pain requires additional
    • assessment and interventions. How severe is the pain? Ask the patient to
    • rate the severity of the pain on a scale of 1 to 10, with 1 being mild
    • pain and 10 being the worst pain imaginable. This provides a system for
    • evaluating response to comfort measures.During
    • the first few days after surgery, promptly medicate the patient for
    • pain. Pain is controlled better if it is treated before it becomes
    • severe. Some physicians will order routine (rather than PRN) analgesics
    • for the first 24 to 36 hours. This maintains consistent therapeutic
    • blood levels of the analgesic and reduces episodes of acute pain. Pain
    • medication can also be given before activities that normally cause pain.
    • Some patients are afraid that they will become addicted to opioids.
    • Assure them that the short-term use of opioids for acute pain relief
    • generally has not been associated with addiction.A
    • patient whose pain is controlled adequately is better able to
    • participate in the exercises necessary to prevent postoperative
    • complications. Schedule turning, coughing, deep breathing, and even
    • walking to take advantage of periods when the patient is most
    • comfortable. Of course, a medicated patient must be closely supervised
    • when out of bed.Although
    • drugs are the mainstay of pain management in the early postoperative
    • phase, other nursing measures can be used to help reduce pain. Position
    • changes and backrubs can be very soothing. Relaxation exercises and
    • mental imagery are often very effective alone or in combination with
    • other nursing measures.One
    • source of discomfort in the postoperative patient is singultus,
    • commonly known as hiccups. Hiccups are caused by intermittent spasms of
    • the diaphragm. They are uncomfortable and may put stress on the
    • incision, disrupt rest, and interfere with the intake of food and
    • fluids. If hiccups persist, notify the physician.Anxiety
    • seems to intensify discomfort. Measures to decrease anxiety may
    • therefore enhance the effects of pain relief measures. Recognize when
    • the patient is tense and try to discover the source of the anxiety.
    • Patients need to feel safe and need reassurance about what is happening
    • to them.Pain
    • management in the elderly can pose special challenges. The older
    • patient may be stoic, reluctant to request analgesics, and fearful of
    • addiction and overdose. Nurses, fearing greater risk of adverse effects
    • or believing that the older person experiences less pain, may fail to
    • treat the older person adequately. Good management of postoperative pain
    • in the older person can often be attained with nonsteroidal
    • anti-inflammatory drugs or acetaminophen in combination with opioids at
    • somewhat reduced dosages. The rule of thumb with opioids is to start
    • with a low dose and gradually increase it. Drugs that are more likely to
    • have adverse effects in the older person are meperidine (Demerol) and
    • long-acting benzodiazepines like diazepam (Valium). Well-prepared
    • patients, regardless of age, can participate in pain management by
    • describing and rating their pain, informing the nurse of the effects of
    • treatment, and using patient-controlled analgesia when appropriate.The
    • management of pain in cognitively impaired elders is especially
    • difficult. You may have to rely on your observations of patient behavior
    • or family perceptions to recognize pain. Inappropriate behaviors such
    • as pulling at tubes, striking out, and yelling may be manifestations of
    • pain. Some impaired elders can use pediatric pain rating scales, which
    • provide you with some measure of pain intensity. After procedures that
    • are known to be painful, pain should be assumed and analgesics given in
    • combination with other comfort measures.
  18. Key Points
    • The skeletal system has five basic functions:
    • support of the body, protection of internal organs, movement of the
    • body, storage of minerals, and blood cell formation.•
    • The skeleton is composed of two main divisions:The axial skeleton, containing the skull, vertebrae, and thoraxThe appendicular skeleton, containing the upper and lower extremities•
    • The skeleton is divided into the axial and the
    • appendicular skeletons. The axial skeleton is composed of the skull,
    • vertebral column, and thorax. The appendicular skeleton is composed of
    • the upper extremities, lower extremities, shoulder girdle, and pelvic
    • girdle.•
    • The three types of joints and their movement are:Synarthrosis: no movementAmphiarthrosis: slight movementDiarthrosis: free movement•
    • Joints hold the bones together and allow movement
    • and flexibility. Differences in the structure determine the amount of
    • flexibility.•
    • Some of the more common movements that the body
    • is capable of producing are flexion, extension, abduction, adduction,
    • rotation, supination, pronation, dorsiflexion, and plantar flexion.•
    • The
    • bones and joints provide the framework of the body, but the muscles are
    • necessary for movement. Movement results from contraction and
    • relaxation of the individual muscles.•
    • An erythrocyte sedimentation rate (ESR) is the
    • most objective laboratory test for determining the severity of
    • rheumatoid arthritis.•
    • Rheumatoid arthritis affects a young population (ages 30 to 55) with crippling changes in the synovial membrane of the joints.•
    • Salicylates and nonsteroidal antiinflammatory drugs (NSAIDs) are used to treat rheumatoid arthritis and osteoarthritis.•
    • Osteoarthritis is a degenerative joint disease
    • (DJD) that affects the population older than 40 years of age and causes
    • articular cartilage degeneration.•
    • Porous and brittle bones caused by a lack of calcium is one of the physiologic changes noted in osteoporosis.•
    • Vertebroplasty and kyphoplasty are surgical
    • procedures used to relieve pain in women with osteoporosis who do not
    • respond to other pain management programs.•
    • Arthroplasty procedures (such as hip and knee arthroplasty) are commonly performed on patients suffering from severe arthritis.•
    • Unicompartmental knee arthroplasty is also
    • referred to as partial knee replacement and is performed on patients who
    • have only one of the compartments of the knee affected by arthritis.•
    • Nursing intervention specific to the care of a
    • patient suffering from a fractured hip involves maintaining abduction of
    • the affected leg.•
    • Fractured hip fixation devices—such as hip
    • prosthetic implant, plate and screw fixation, and telescoping nail
    • fixation—require some degree of non–weight bearing for 6 weeks to 3
    • months.•
    • A significant postoperative nursing intervention
    • for a patient with an amputation is proper care of the stump to
    • facilitate the use of a prosthetic device.•
    • Herniated nucleus pulposus is seen most often in
    • the cervical and lumbar spinal regions and can be treated surgically
    • (laminectomy and spinal fusion) or medically (medication, traction, and
    • physical therapy).•
    • Osteogenic sarcoma is a common primary malignant tumor seen in young people; it can metastasize to the lungs.•
    • Compartment syndrome, shock, fat embolism, gas
    • gangrene, thromboembolus, and osteomyelitis are complications resulting
    • from a fractured bone.•
    • External fixation devices such as casts, braces,
    • metal pins, and skeletal and skin traction are used to hold bone
    • fragments in normal position.•
    • Regardless of whether the casting material is
    • plaster of paris or a synthetic material, proper drying, cleansing,
    • handling, and assessing are required to prevent patient complications.•
    • The nurse caring for a patient in traction is
    • responsible for knowing (1) the purpose of the traction (traction
    • applied for fractures must be continuous); (2) the equipment needed and
    • appropriate safety measures; (3) the amount of weight ordered; and (4)
    • the patient's knowledge regarding the traction.•
    • Crutches, canes, walkers, and the Roll-A-Bout are used as gait enhancers for patients with altered mobility.•
    • Crutch walking involving the three-point gait is most commonly used for patients wearing leg casts.
  19. Nursing Intervention with Blind Patients
    • The nurse might falsely assume
    • that patients should be in the acceptance phase if the blindness has
    • been present for years. This is not necessarily the case. Complications
    • of long-term blindness may result in physical and emotional problems.
    • Physically the patient may be malnourished from diminished self-care
    • cooking skills. The patient may also have secondary infections related
    • to poor hygiene practices. Assistance with activities of daily living
    • (ADLs) is a primary focus of patient care. Adequate time should be
    • provided to allow the patient to assist in self-care. Emotional aspects
    • of nursing interventions include appropriate communication

    (Box 53-1).Box 53-1Guidelines for Communicating with Blind People

    • • Talk in a normal tone of voice.
    • • Do not try to avoid common phrases in speech, such as “See what I mean?”
    • • Introduce yourself with each contact (unless well known to the person).
    • • Explain any activity occurring in the room.
    • • Announce when you are leaving the room so the blind person is not put in the position of talking to someone who is no longer there.
  20. Vision Loss
    Vision loss affects not only the patient but also family, friends, and the community. Coping mechanisms differ between individuals. It is a nursing responsibility to educate, assist, counsel, and prevent complications. A comprehensive approach to patient care is essential with blind individuals. Home health care considerations include education on community resources. When a total approach is taken, the patient's successful adjustment to home, work, and society is possible. Blind individuals are capable of leading a full and active life and need to be treated in such a manner.Nursing diagnoses and interventions for the patient with blindness or near blindness include but are not limited to the following:

    NURSING DIAGNOSESNURSING INTERVENTIONS

    • Fear, related to blindnessDetermine the patient's level of fear.Risk for injury, related to new environmentOrient the patient to use people and the environment.Use therapeutic touch.Avoid loud sounds that may startle the patient.Use protective devices, such as side rails and canes.Alter surroundings to afford safety—clear passageways, nonslip rugs, etc.The patient will require instruction on ambulatory safety. Instructions to include are walking slowly, using verbal clues from the walking companion, and encouraging the patient to touch objects or borders.The walking companion should precede the patient by about 1 foot, and the patient's hand should be on the companion's elbow to provide security (Figure 53-5). For both short-term and long-term blindness, if total vision is affected, a description of the surroundings is appropriate.
    • Sighted-guide technique. The walking companion serves as the sighted guide, walking slightly ahead of the patient with the patient holding the back of the companion's arm.
  21. Risk For Injuries
    • The physician may prescribe
    • limitations on activity or position, or both. The head of the bed is
    • usually elevated. The patient may be wearing a bulky dressing or a small
    • eye patch. Either may be covered with a lightweight metal shield (Fig. 49-10).
    • The dressing absorbs any drainage, and the shield protects the eye from
    • rubbing. Instruct the patient not to rub the eye. Check the physician's
    • orders to determine whether the dressing can be changed. Eye drops or
    • ointments may be ordered. They may be different from those used before
    • surgery. When an eye is patched, take safety precautions to prevent
    • injury.FIGURE 49-10
    • The shield protects the operative eye from pressure or rubbing.An
    • important aspect of the postoperative care of patients having eye
    • surgery is to prevent increased intraocular pressure. Caution the
    • patient against straining, leaning forward, lifting, and lying on the
    • affected side. Because vomiting and retching raise intraocular pressure,
    • treat nausea promptly.Put on your THINKING CAP!!After
    • eye surgery, patients often go home the same day. Considering the usual
    • restrictions imposed to prevent increased intraocular pressure, what
    • are some obstacles the patient might encounter? What strategies might
    • you suggest to the patient?
  22. Application of Elastic Bandage
    • Elasticized bandages are
    • applied to immobilize a joint, or to apply pressure to reduce swelling.
    • They may also be used to provide support to a wound and hold dressings
    • in place. Elastic bandages are made in rolls of varying widths; the
    • heavy stretch material conforms to the body part and provides support.
    • Guidelines for applying an elastic or roller bandage are as follows:•
    • Elevate the limb and support it while applying the bandage.•
    • Face the patient and wrap the bandage from the distal to the proximal area.•
    • Apply even pressure by exerting equal tension throughout the wrapping of the bandage.•
    • Overlap turns of the bandage equally.•
    • Smooth the bandage, removing wrinkles, as you wrap it.•
    • Secure the end of the bandage with self-adherent portion of the bandage, a safety pin, or tape. (Metal clips may come loose and land in the bed, where they can injure the patient.)•
    • Check the color and sensation of the part distal and proximal to the bandage when finished and at frequent intervals thereafter.•
    • Remove the bandage for bathing of the body part;
    • assess the skin for irritation or breaks; rewrap the bandage at least
    • twice a day.Steps 39-2
    • show the technique for application of an elastic bandage. The same
    • technique is used for gauze roller bandages. Different bandaging
    • techniques are applied depending on the part to be bandaged.Steps 39-2Application of an Elastic BandageThe
    • type and size of the bandage used will depend on the area to be
    • bandaged and the purpose of the bandage. The physician usually orders
    • the type of bandage.Review and carry out the Standard Steps in Appendix 2.1.
    • ACTION Wash and dry the area to be bandaged.RATIONALE Helps prevent infection by removing microorganisms.2.
    • ACTION Elevate the extremity to be bandaged; ask an assistant to help if necessary.RATIONALE
    • Elevation encourages venous return and helps prevent swelling. It is
    • easier to wrap the bandage properly if someone else supports the
    • extremity.3.
    • ACTION Stand in front of the
    • patient and unroll the end of the bandage slightly; anchor it in place
    • with the thumb of the nondominant hand on the anterior part of the
    • extremity to be bandaged.RATIONALE Secures the bandage while wrapping is occurring.4.
    • ACTION Make two initial circular turns to anchor the bandage in place.RATIONALE Securing the bandage end prevents it from becoming loose.5.
    • ACTION Use a circular, spiral,
    • spiral reverse, figure-of-8, recurrent turn, or thumb spica bandaging
    • technique as appropriate for the area to be bandaged.RATIONALE The body part to be bandaged will indicate which style of bandaging is best.6.
    • ACTION Apply the bandage smoothly and evenly with light to moderate tension.RATIONALE Smoothness helps prevent pressure areas; adequate tension is necessary for the bandage to stay in place.7.
    • ACTION Secure the bandage with tape, clips, or a safety pin.RATIONALE The bandage must be secured to remain in place.8.
    • ACTION Assess the bandage for fit and circulation distal to the area bandaged.RATIONALE A bandage applied too tightly will impede circulation; a loose bandage will fall off.Circular Turn.Circular
    • turns are used to anchor the bandage and to terminate the wrap. This
    • turn is useful for bandaging the proximal aspect of the finger or wrist.
    • Simply hold the free end of the rolled material in one hand and wrap it about the area, bringing it back to the starting point (Figure 39-10, A).FIGURE 39-10
    • Applying an elastic bandage: A, Starting a bandage with circular turns B, Bandaging with spiral turns C, Bandaging with spiral reverse turns. D, Bandaging a joint with figure-of-8 turns. E, Recurrent turn bandaging. F, Thumb spica bandaging.Spiral Turn.This
    • turn is used to bandage parts of the body that are uniform in
    • circumference, such as the upper arm or upper leg. The spiral turn
    • partly overlaps the previous turn. The amount of overlap varies from one
    • half to three fourths of the width of the bandage (Figure 39-10, B).Spiral Reverse Turn.Spiral
    • reverse turns are employed to bandage body parts that are not uniform
    • in circumference, such as the lower leg or forearm. After securing the
    • bandage with circular turns, the bandage is brought upward at a
    • 30-degree angle. The thumb of the free hand is placed on the upper edge
    • of the bandage to hold it in place while it is reversed upon itself.
    • Unroll the bandage about 6 inches (15 cm) and turn the hand so that the
    • bandage falls over itself. Continue the bandage around the extremity,
    • overlapping each previous turn by two-thirds the width of the bandage.
    • Make each turn at the same position on the extremity so that the turns
    • of the bandage are all aligned (Figure 39-10, C). Care should be taken not to apply undue pressure over a major blood vessel.Figure-of-8 Turn.Figure-of-8
    • turns are used to bandage and stabilize an elbow, knee, or ankle, or to
    • immobilize and hold a fractured clavicle in position. Anchor the
    • bandage with two circular turns. Bring the bandage above the joint,
    • around it, and then below it, making a figure-of-8. Continue bandaging
    • above and below the joint, overlapping the previous turn by one-third to
    • two-thirds the width of the bandage (Figure 39-10, D). Secure the bandage above the joint with two circular turns and fasten it.Recurrent Turn.This
    • turn is used to cover distal parts of the body, such as the end of a
    • finger, the skull, or the stump left by amputation. The bandage is
    • anchored by two circular turns. It is then folded back on itself and
    • brought centrally over the distal end to be covered. Hold it in place
    • with the other hand and bring the bandage back over the end to the right
    • of the center bandage but overlapping it by two-thirds the width of the
    • bandage. Then bring the bandage back on the left side, overlapping the
    • first turn by two-thirds the width of the bandage. Continue alternating
    • bandaging right and left until the area is well covered. Terminate the
    • bandage with two circular turns and secure the end appropriately (Figure 39-10, E).Thumb Spica.This
    • is a variation of the figure-of-8 bandage used to support the thumb in
    • neutral position following a sprain or other injury. The technique can
    • also be used to bandage the hip or shoulder. For the thumb, secure the
    • bandage with two circular turns around the wrist. Bring the bandage down
    • to the distal aspect of the thumb and encircle the thumb. If possible,
    • leave the tip of the thumb exposed. Take the bandage back up and around
    • the wrist, and then back down and around the thumb, overlapping the
    • previous turn by two-thirds the width of the bandage. Repeat the above steps, working up the thumb and hand until the thumb is covered (Figure 39-10, F).
  23. Figure 8 turn
    • Figure-of-8 turns are used to
    • bandage and stabilize an elbow, knee, or ankle, or to immobilize and
    • hold a fractured clavicle in position. Anchor the bandage with two
    • circular turns. Bring the bandage above the joint, around it, and then
    • below it, making a figure-of-8. Continue bandaging above and below the
    • joint, overlapping the previous turn by one-third to two-thirds the
    • width of the bandage (Figure 39-10, D). Secure the bandage above the joint with two circular turns and fasten it.
  24. Thumb Spica
    • This is a variation of the
    • figure-of-8 bandage used to support the thumb in neutral position
    • following a sprain or other injury. The technique can also be used to
    • bandage the hip or shoulder. For the thumb, secure the bandage with two
    • circular turns around the wrist. Bring the bandage down to the distal
    • aspect of the thumb and encircle the thumb. If possible, leave the tip
    • of the thumb exposed. Take the bandage back up and around the wrist, and
    • then back down and around the thumb, overlapping the previous turn by two-thirds the width of the bandage. Repeat the above steps, working up the thumb and hand until the thumb is covered (Figure 39-10, F).
  25. Closed Drainage System
    • After you insert an indwelling
    • catheter it is necessary to maintain a closed urinary drainage system to
    • minimize the risk of infection. Urinary drainage bags are plastic and
    • hold approximately 2000 ml of urine. The bag hangs on the lower bed
    • frame without touching the floor. Some urinary drainage bags have
    • special urometers between the collection tubing and bag. When the
    • patient ambulates, instruct patient or caregiver to carry the bag below
    • the level of the
    • patient's bladder. Never raise a drainage bag and tubing above the
    • level of the patient's bladder. Urine in the bag and tubing is a medium
    • for bacteria, and infection will develop if urine is allowed to reflux
    • (return to the bladder).Most drainage
    • bags contain an antireflux valve to prevent urine from reentering the
    • drainage tubing and contaminating the bladder. A spigot at the base of
    • the bag provides a means to empty the bag. Make sure the spigot is
    • always clamped, except during emptying, and tucked into the protective
    • pouch at the bag's side.To keep the
    • drainage system patent, check for kinks or bends in the tubing, avoid
    • positioning the patient on drainage tubing, prevent tubing from becoming
    • dependent, and observe for clots or sediment that block the tubing.
  26. Routine Cathether Care
    • Patients with indwelling
    • catheters require specific perineal hygiene care to reduce the risk of
    • urinary tract infection. In most institutions, patients receive catheter
    • care every 8 hours as the minimal standard of care. In addition,
    • provide catheter care each time the patient defecates or has bowel
    • incontinence. Proper care involves removal of any secretions or
    • encrustation at the catheter insertion site and cleansing of the first 4
    • inches of the catheter.Provide thorough perineal care (see Chapter 27),
    • and observe the urethral meatus and surrounding tissues for
    • inflammation, swelling, and discharge. Note the amount, color, odor, and
    • consistency of discharge to determine local infection and status of
    • hygiene. Use soap and water to cleanse along the length of the catheter
    • for 4 inches (10 cm) (Figure 32-7Figure 32-7
    • Cleansing the catheter during catheter care.).
    • Hold the catheter firmly as you cleanse from the urethra up toward the
    • end of the catheter. Cleansing away from the urethra reduces
    • microorganisms around the meatus. The use of powders or lotions on the
    • perineum is contraindicated because of the risk of growth of
    • microorganisms, which travel up the urinary tract.Replace,
    • as necessary, the adhesive tape or multipurpose tube holder that
    • anchors the catheter to the patient's leg or abdomen, and remove
    • adhesive residue from the skin. Secure the catheter, thus reducing the
    • risk of the catheter being pulled on and exposing the portion that was
    • in the urethra. This also prevents drag on the catheter and avoids
    • pressure from the balloon on the bladder neck. Replace the urinary
    • tubing and collection bag if necessary, adhering to principles of
    • surgical asepsis. Change the urinary tubing and collection bag if there
    • are signs of leakage, odor, or sediment buildup. Check the drainage
    • tubing and bag to ensure that no tubing loops hang below the level of
    • the bladder. Make sure that the tube is coiled and secured onto the bed
    • linen, the tube is not kinked or clamped, and the drainage bag is
    • positioned on the bed frame.
  27. Urinary Cathether
    • Nursing interventions for the
    • patient with a urinary drainage system include employing a number of
    • principles to prevent and detect infection and trauma:1.
    • Follow aseptic technique to avoid introduction of
    • microorganisms from the environment. Never rest the collecting bag on
    • the floor.2.
    • Record intake and output (I&O). For precision
    • monitoring, such as hourly urine output, add a urometer to the drainage
    • system. If urine output falls to less than 50 mL/hour, first check the
    • drainage system for proper placement and function before contacting the
    • physician.3.
    • Adequately hydrate the patient to flush the urinary tract.4.
    • Do not open the drainage system after it is in
    • place except to irrigate the catheter, and then only with a specific
    • order from the physician. It is important to maintain a closed system to
    • prevent urinary infections.5.
    • Perform catheter care twice daily and as needed,
    • using standard precautions. Each institution has a specific protocol for
    • catheter care. Cleanse perineum with mild soap and warm water, rinse
    • well, and pat dry. At times an antiseptic solution or ointment may be
    • ordered to use at the catheter incision site.6.
    • Check the drainage system daily for leaks.7.
    • Avoid placement of the urinary drainage bag above
    • the level of the catheter insertion, which would cause urine to reenter
    • the drainage system and contaminate the urinary tract.8.
    • Prevent tension on the system or backflow of urine while transferring the patient.9.
    • Ambulate the patient if possible to facilitate
    • urine flow. If the patient's activity must be restricted, turn and
    • reposition every 1½ hours.10.
    • Avoid kinks or compression of the drainage tube
    • that may cause pooling of the urine within the urinary tract. Gently
    • coil excess tubing, secure with a clamp or pin to avoid dislodging the
    • catheter, and release the tubing before transferring or repositioning
    • the patient.11.
    • Gently inspect the entry site of the catheter for
    • blood or exudate that may indicate trauma or infection. Observe the
    • color and composition of the urine to note any blood or sediment. During
    • drainage of the collection bag, note the presence of malodor.12.
    • Collect specimens from the catheter by cleansing
    • the drainage port with alcohol, then withdrawing the urine by using a
    • sterile adapter and a sterile 10-mL syringe, using standard precautions.
    • Send the urine specimen immediately to the laboratory.13.
    • Report and record assessment findings and interventions initiated.After
    • the urinary catheter is removed, the patient may experience difficulty
    • voiding until bladder tone and sensation return. If the patient
    • complains of urinary retention, the nurse should institute the following
    • measures:1.
    • If necessary, urination may be stimulated by
    • running water, placing the patient's hands in water, or pouring water
    • over the perineum. If the last method is attempted, the amount of water
    • used should be subtracted in calculating the correct amount voided.2.
    • If the patient's condition permits, it is
    • preferable for a female to sit on a bathroom stool or commode, and
    • preferable for a male to stand to void.The
    • patient may experience some dribbling of urine after voiding as a
    • result of dilation of the sphincter from the catheter. The time, amount,
    • and color of the urine output should be recorded.
  28. Urinary Cathether Diag.
    • Nursing diagnoses and interventions for the patient with a urinary catheter include but are not limited to the following:NURSING DIAGNOSESNURSING INTERVENTIONSRisk for trauma, related to insertion and maintenance of the catheterMaintain sterile technique during insertion.Use smallest size of catheter possible.Lubricate catheter.Secure catheter to leg, as appropriate.Provide adequate fluids.Administer urinary analgesic as ordered.Allow enough slack in tubing for patient to move about freely while in bed.Evaluation: Patient reports no discomfort from catheter.Inspect insertion site to determine if area is clean and without signs of possible infection or bleeding.Risk for infection, related to invasive use of catheterUse aseptic technique.Complete meticulous catheter care.Maintain closed urinary drainage system.Avoid placement of drainage bag above level of catheter insertion (meatus).Avoid reflux of urine.Encourage adequate fluid intake.Administer antimicrobials as ordered.Evaluation: Temperature remains within normal limits.Patient reports no burning, etc.Color, odor, and clarity of urine normal.The
    • patient should be instructed about proper transfer from bed, chair, or
    • stretcher and taught the principles of catheter care. Fluid intake
    • should be encouraged to flush the urinary system.
  29. Self-Catheterization
  30. may be the intervention of choice for the patient who experiences
    • spinal cord injury or other neurological disorders that interfere with
    • urinary elimination. Intermittent self-catheterization promotes
    • independent function for the patient. At home there is less risk of
    • cross-contamination than in the hospital, so the catheterization
    • procedure can be safely modified as a clean technique, although the
    • nurse will instruct the patient using strict surgical asepsis in the
    • hospital because of the risk of infection there. The need for the
    • patient to be alert for signs and symptoms of infection and to have
    • periodic evaluations by the physician should be emphasized.
    • Institutional guidelines for catheter insertion technique should be
    • followed.
  31. Bladder TrainingBladder
    • Bladder TrainingBladder
    • training involves developing the use of the muscles of the perineum to
    • improve voluntary control over voiding; bladder training may be modified
    • for different problems. In preparation for the removal of a urethral
    • catheter, the physician may order a clamp/unclamp routine to improve
    • bladder tone. For the patient with stress incontinence, the muscles of
    • the perineum are exercised to assist in stopping urine flow. The nurse
    • instructs the patient to perform Kegel, or pubococcygeal, exercises
    • by tightening the muscles of the perineal floor. The patient can
    • perhaps develop awareness of the appropriate muscle group by trying to
    • stop the flow of urine during voiding. Having identified the correct
    • muscles and the feeling of their contraction, the patient can be
    • directed to tighten the muscles of the perineum, holding that tension
    • for 10 seconds, then relaxing for 10 seconds. The exercises should be
    • done initially in groups of 10, building to groups of 20, four times a
    • day. Because muscle control develops gradually, it may take 4 to 6 weeks
    • to develop control of leakage.For
    • habit training, a voiding schedule is established. The nurse monitors
    • the patient's voiding for a few days to identify patterns, or schedules
    • voiding times to correlate with the patient's activities. Typical
    • voiding times are on arising, before each meal, and at bedtime. The
    • patient is assisted to void as scheduled. After a few days, the
    • scheduled voiding pattern is evaluated by identifying its effectiveness
    • in keeping the patient continent. The schedule is modified until
    • continence is established. Fluid intake and medications may influence
    • voiding patterns (i.e., the patient may need to void 30 minutes after
    • the ingestion of coffee or furosemide in response to the diuretic
    • effect). Reduction of fluid intake during the hours preceding bedtime
    • may aid in keeping the patient dry during sleep.
  32. Urinary Cath. Rationale
    • 8.
    • ACTION Wash your hands and don disposable gloves.RATIONALE Reduces transfer of microorganisms.9.
    • ACTION
    • Assist patient to assume the dorsal recumbent position, with thighs
    • relaxed so that hips can externally rotate, and drape with a bath
    • blanket or sheet.RATIONALE Positions patient for ease of viewing the meatus and inserting the catheter into the bladder.10.
    • ACTION
    • With the use of good lighting, inspect the perineum. Wash the area if
    • needed. Spread the labia with your nondominant hand and locate the
    • urinary meatus.RATIONALE
    • An assistant may be needed to hold a flashlight with the beam directed
    • at the perineum. This step ensures greater success in placing the
    • catheter into the bladder on the first attempt.11.
    • ACTION Remove gloves and wash your hands.RATIONALE Reduces transfer of microorganisms.STEP 1012.
    • ACTION
    • Open the plastic covering of the catheter kit by tearing along the
    • lined perforated edge. Use the plastic cover as a discard bag and place
    • it to the side of the field or toward the foot of the bed for waste
    • disposal.RATIONALE Provides a receptacle for used supplies.13.
    • ACTION
    • Remove the paper-wrapped catheter tray and place it on the bed between
    • the patient's legs, near the perineum (8 to 12 inches away).RATIONALE Provides a workspace.14.
    • ACTION
    • Fold back the corner of the bath blanket drape to expose the perineum.
    • With clean hands, using sterile technique, open the wrapper and use it
    • as a sterile field.RATIONALE Provides a sterile field within which to work.15.
    • ACTION
    • Pick up the sterile absorbent underpad by one corner, and while holding
    • two corners turned over your fingers, slip it under the patient's
    • buttocks, plastic side down, while asking her to lift the buttocks.
    • Touch only the corners and underside of the sterile underpad.RATIONALE Keeps solution from soiling the bedding. Keeps the center of the pad sterile.16.
    • ACTION
    • Put on the sterile gloves and separate the two containers in the kit,
    • placing the tray with the cotton balls in front of the box containing
    • the catheter and drainage bag.RATIONALE Catheterization is a sterile procedure. Places supplies in order of use.17.
    • ACTION Place the drape with the opening over the genital area, exposing the labia. Continue reassuring the patient.RATIONALE Sterile drape helps prevent catheter from touching the skin on the thighs as the meatus is approached.18.
    • ACTION
    • Loosen the cotton balls one from another, open the antiseptic solution
    • pack, and drizzle antiseptic solution evenly over the cotton balls.
    • Discard the empty package. Be careful not to splatter the solution.RATIONALE Prepares the cotton balls to be picked up individually with the forceps.19.
    • ACTION
    • Open the package of lubricant, or remove the stopper from the syringe
    • containing it, and squirt it into an open area of the tray.RATIONALE Lubricant may be squirted into the tray and the catheter tip then rotated in it to lubricate.20.
    • ACTION Place the sterile specimen bottle on the side of the tray or discard it.RATIONALE Bottle may be discarded if no specimen is required.21.
    • ACTION
    • Remove the plastic sleeve on the catheter by tearing it down the
    • perforated side while carefully controlling the catheter. Place the
    • catheter within the sterile tray where it can be easily reached.RATIONALE
    • Prepares the catheter for use. An uncontrolled catheter may strike a
    • nonsterile surface, contaminating it. Wrapping the catheter around a
    • gloved hand while tearing the sleeve helps prevent a break in sterile
    • technique.22.
    • ACTION
    • Attach the sterile water-filled syringe to the balloon port on the
    • catheter and gently insert the water to test the patency of the balloon.
    • Omit pretesting if it is a prefilled type of balloon.RATIONALE Ensures balloon patency before the catheter is introduced into the bladder.23.
    • ACTION After the test, draw the water back into the syringe, leaving the syringe attached to the catheter balloon port.RATIONALE Makes it easier to inject the water into the balloon at the right moment.24.
    • ACTION
    • With the forefinger and thumb of the nondominant hand, separate the
    • labia minora, exposing the meatus. Pull slightly upward (see figure with
    • Step 10). Leave this hand in place, holding the labia open until the
    • catheter is inserted.RATIONALE
    • Exposes the urinary meatus so that the catheter can be introduced.
    • Using dry cotton balls or an open 4 × 4 gauze between the fingers and
    • the inner labia helps prevent the fingers from slipping. Remember: The hand holding open the labia is now contaminated and must not be used to handle sterile objects.25.
    • ACTION
    • Using the forceps, pick up one saturated cotton ball at a time and
    • cleanse down one side of the labia majora and then the other, discarding
    • each used cotton ball after one stroke. Cleanse one side of the labia
    • minora and then the other. Cleanse last over the meatus with a slow
    • downward stroke. Do not allow the labia to close over the meatus after cleansing.RATIONALE Removes microorganisms from the perineal area and urinary meatus. Take
    • care not to pass over the sterile field with used cotton balls when
    • discarding them because this contaminates the sterile field.a.
    • ACTION If solution is obscuring the meatus, a dry sterile cotton ball can be used to sponge up the excess solution.RATIONALE This allows better visualization of the meatus.b.
    • ACTION Dispose of the forceps in the discard bag.RATIONALE Contaminated forceps must be discarded.26.
    • ACTION
    • Pick up the catheter about 3 inches from the tip, lubricate it well,
    • and gently insert it into the meatus while pointing the catheter
    • slightly toward the umbilicus. Insert it about 2 to 3 inches or until
    • you visualize urine flow. There may be slight resistance as the catheter
    • passes the internal urethral sphincter. If urine does not flow, rotate
    • the catheter gently and carefully insert it another inch farther. Do not
    • use force. If resistance is encountered, ask the patient to take a deep
    • breath, and twist and advance the catheter as the patient does so; this
    • relaxes the sphincter. If the catheter has been inserted into the
    • vagina by mistake, leave it there as a marker for the vaginal opening,
    • rescrub, and begin the procedure again with a sterile kit.STEP 26RATIONALE
    • Technique eases insertion into the bladder. Leaving marker catheter in
    • place ensures vaginal opening is not mistaken for urinary meatus.27.
    • ACTION
    • Hold the catheter in place with the dominant hand while instilling the
    • water into the balloon with the nondominant hand. Remove the syringe
    • from the port after inflation and discard it. A prefilled balloon is
    • filled by unclamping the port. Gently pull on the catheter to see if it
    • is anchored securely, then gently push it into the bladder about ½ inch.
    • Watch the patient's face for an expression of discomfort while
    • inflating the balloon to be certain that the balloon is not in the
    • urethra.RATIONALE
    • Inflated balloon keeps the catheter from slipping back into the
    • urethra. If the balloon sits at the neck of the bladder after inflation,
    • it causes pressure and a greater urge to urinate.28.
    • ACTION Cleanse the antiseptic solution from the perineum and remove the underdrape.RATIONALE Prevents the antiseptic solution from irritating the skin and makes the patient more comfortable.29.
    • ACTION
    • Attach the drainage bag to the stationary part of the bed frame along
    • the side of the bed close to the middle. Remove the drapes, dry the
    • genital area, dispose of used supplies, remove gloves, and wash hands.STEP 29RATIONALE
    • Attaching bag to bed frame keeps bag from coming into contact with the
    • floor. Use the plastic or metal hook to attach the bag to the bed.30.
    • ACTION Attach the catheter to the thigh with tape or a catheter holder.RATIONALE
    • Secures the catheter so that there is no tension on the internal
    • urinary sphincter. Tension on the catheter causes pressure on the
    • external urethral sphincter and may damage it.STEP 3031.
    • ACTION Coil the excess drainage tubing on the bed so that the last portion hangs straight to the drainage bag and secure it.RATIONALE The catheter will drain better if no tubing is hanging below the level of entry into the drainage bag.32.
    • ACTION Restore the unit, lower the bed, raise the rails if needed, and place the call light within reach.RATIONALE Protects the patient; call light provides a sense of security.
  33. Urinary Cath. Rationale
    • 5.
    • ACTION Wash your hands.RATIONALE Reduces transfer of microorganisms.6.
    • ACTION
    • With the patient supine and knees slightly apart, drape by fan-folding
    • the bedcovers down to cover the lower legs, exposing the perineal area.
    • Use a bath blanket to cover the trunk.RATIONALE Draping keeps the patient warm and reduces embarrassment. Bunching
    • the bath blanket a bit over the abdomen obstructs the patient's view
    • and may decrease his embarrassment. It is not unusual for an erection to
    • occur when the penis is handled.7.
    • a.
    • ACTION Open the catheter tray by tearing open the plastic cover at the perforated line. Place the kit on the bed between the legs.RATIONALE Supplies must be within reach.b.
    • ACTION Use the plastic cover as a discard bag by placing it to the side of the field or toward the foot of the bed.RATIONALE Provides a receptacle for used supplies.8.
    • ACTION
    • Place the absorbent pad under the penis; place the opening of the
    • sterile drape over the penis and onto the perineum touching only the
    • outer corners.RATIONALE Provides a sterile field within which to work.9.
    • ACTION
    • Separate the two parts of the kit and remove the plastic sleeve from
    • the catheter by tearing it down the perforated side while controlling
    • the catheter. Test the balloon unless it is a prefilled type with a
    • clamp.RATIONALE
    • Prepares the catheter for use. Controlling the catheter prevents it
    • from touching contaminated surfaces and ensures sterility. Testing is
    • done to detect leaks in the balloon.10.
    • ACTION Lubricate around the first 3 to 4 inches (5 to 7 cm) of the catheter if the lubricant comes in a foil package. If it is in a syringe, squirt it directly into the urethra.RATIONALE
    • Lubricant prevents undue trauma when inserting the catheter into the
    • urethra. It is recommended practice to place the lubricant into the
    • urethra of the male. When difficulty is encountered with insertion of
    • the catheter, obtain an order for Xylocaine gel. Squirting this into the
    • urethra immediately relaxes muscle spasm and allows easier entry for
    • the catheter.11.
    • a.
    • ACTION Retract the foreskin if necessary to expose the head of the penis.RATIONALE Foreskin interferes with adequate cleansing.b.
    • ACTION
    • Using forceps and a saturated cotton ball, grasp the glans below the
    • tip with the nondominant hand, hold it erect, and cleanse the glans in a
    • circular motion moving outward from the meatus.STEP 11RATIONALE Reduces the number of microorganisms around the meatus.c.
    • ACTION Discard the used cotton ball and cleanse again with two more cotton balls. Continue to hold the shaft of the penis.RATIONALE Be careful not to cross the sterile field when discarding the used cotton ball because this contaminates the field.12.
    • ACTION
    • Pick up the catheter with the dominant hand 3 to 4 inches (8 to 10 cm)
    • below the tip. With the penis perpendicular to the body, pull it
    • slightly upward, ask the patient to bear down as if trying to urinate,
    • and insert the catheter into the meatus about 8 inches (20 cm) using a
    • rotating motion until urine begins to flow.STEP 12RATIONALE
    • Elevating and putting slight traction on the penis straightens the
    • urethra and makes it easier to insert the catheter into the bladder.13.
    • ACTION
    • If resistance is met, twist the catheter and ask the patient to take a
    • deep breath, and or turn feet soles inward and wiggle the toes to relax
    • the muscles. If resistance persists and the catheter will not advance
    • without difficulty, remove it and notify the physician.RATIONALE
    • The internal sphincter relaxes when a deep breath is taken. Forcing the
    • catheter to advance when continued resistance is met may cause trauma.14.
    • ACTION
    • Gently push the catheter in 1 to 2 inches more after urine starts to
    • flow. Hold the catheter in place, inject the contents of the prefilled
    • syringe into the balloon, and detach the syringe while holding the
    • plunger all the way down. If the catheter has a prefilled balloon clamp
    • at the drainage end, release it.RATIONALE
    • Holding the catheter in place guides the balloon away from the
    • sphincter, preventing pressure on the neck of the bladder. Filling the
    • balloon ensures that the catheter will remain in the bladder. Holding
    • down the plunger of the syringe that is used to fill the balloon keeps
    • the water from flowing back into the syringe.15.
    • ACTION Pull gently on the catheter to check that the balloon is inflated. Then push it back in slightly.RATIONALE Ensures that the catheter will not fall out. Relieves pressure on the sphincter.16.
    • a.
    • ACTION Clean the antiseptic solution from the penis and remove the drape by tearing it toward the penis on one side.RATIONALE Prevents irritation of the skin and makes the patient comfortable.b.
    • ACTION Reposition the foreskin if it was retracted.RATIONALE If not repositioned, the foreskin can constrict the penis, causing circulation difficulties and swelling.17.
    • ACTION
    • Tape the catheter to the abdomen if it is to remain in place for an
    • extended period. Alternatively, it may be taped to the top of the thigh
    • for short-term use.RATIONALE
    • Secures the catheter so there is no tension on the internal urinary
    • sphincter. Taping the catheter to the abdomen helps prevent pressure on
    • the penoscrotal angle.18.
    • ACTION Attach the drainage bag to the bed frame (not the side rail). Coil the excess drainage tubing on the mattress and secure it.STEP 17RATIONALE
    • The drainage bag must be kept below the level of the bladder for
    • drainage to occur. Tubing should not hang below the level of entry into
    • the bag.19.
    • ACTION
    • Remove the drape, make the patient comfortable, lower the bed, raise
    • the side rails, and restore the unit, placing the call light within
    • reach.RATIONALE Provides for patient comfort and safety.20.
    • ACTION Dispose of used supplies in the appropriate waste container.RATIONALE Patient's unit wastebasket should not be overfilled with used supplies.21.
    • ACTION Note the initial amount and character of urine in the bag.RATIONALE Provides output data and a baseline for further assessments of urine character and output.22.
    • ACTION Remove gloves and wash hands.RATIONALE Reduces transfer of microorganisms.
  34. IncontinenceCare
    • Incontinence is a very common
    • problem, especially among older adults. Regardless of the cause,
    • incontinence is a psychologically distressing and socially disruptive
    • problem.Urinary incontinence occurs
    • because pressure in the bladder is too great, because the sphincters are
    • weak, or because the innervation has been compromised due to illness or
    • injury. The nurse can collaborate with other members of the health care
    • team to assess the cause and extent of incontinence and to assist in
    • managing the problem. The physical therapist, for example, can assess
    • the extent of musculoskeletal involvement and determine methods of
    • treatment.Incontinence may involve a
    • small leakage of urine when a person laughs, coughs, or lifts something
    • heavy. The patient can be taught exercises to strengthen muscles around
    • the external sphincters to help manage this type of incontinence. Pelvic
    • floor exercises (Kegel exercises) involve tightening the ring of muscle
    • around the vagina and anus and holding it for several seconds. This
    • should be done a minimum of 10 times, three times a day. (See Chapter 52.)Alert
    • patients need an incontinence product that is discreet and promotes
    • self-care. Some incontinence products are designed for small amounts of
    • leakage. Persistent urge, stress, or overflow incontinence may need
    • referral for urologic evaluation.Incontinence
    • characterized by urine or fecal flow at unpredictable times requires
    • the use of disposable adult undergarments or underpads as the primary
    • means of management. Urine and feces are very irritating to the skin.
    • Skin that is continually exposed quickly becomes inflamed and irritated.
    • Cleansing the skin thoroughly after each episode of incontinence with
    • warm soapy water and drying it thoroughly help prevent skin impairment.When
    • urinary incontinence results from decreased perception of bladder
    • fullness or impaired voluntary motor control, bladder training can be
    • helpful.

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