Category 4: Physiological Integrity

In the Physiological Integrity part of your examination, you will be expected to demonstrate the
knowledge and skills necessary to promote physical health and wellness by providing care and
comfort, reducing client risk potential and managing health alterations.
The four subsections under Physiological Integrity are Basic Care and Comfort, Pharmacological
Therapies, the Reduction of Risk Potential and Physiological Adaptation.

I) Basic Care and Comfort

In the Basic Care and Comfort questions, the nurse will be required to demonstrate that they can
provide comfort and assistance in the performance of activities of daily living.
The nurse must be competent to:

 Assist client to compensate for a physical or sensory impairment (e.g., assistive devices,
positioning, compensatory techniques)
 Assess and manage a client with an alteration in elimination (e.g., bowel, urinary)
 Perform irrigations (e.g., of the bladder, ear, eye)
 Perform skin assessment and implement measures to maintain skin integrity and prevent skin
breakdown (e.g., turning, repositioning, pressure-relieving support surfaces)
 Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts)
 Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings,
sequential compression devices)
 Implement measures to promote circulation (e.g., active or passive range of motion, positioning,
and mobilization)
 Assess client need for pain management
 Provide non-pharmacological comfort measures
 Manage the client's nutritional intake (e.g., adjust diet, monitor height, and weight)
 Provide client nutrition through continuous or intermittent tube feedings
 Evaluate client intake and output and intervene as needed
 Assess and intervene in client performance of activities of daily living
 Perform post-mortem care
 Assess client need for sleep/rest and intervene as needed

Related content includes but is not limited to:

 Assistive Devices
 Elimination
 Mobility/Immobility
 Non-Pharmacological Comfort Interventions
 Nutrition and Oral Hydration
 Personal Hygiene
 Rest and Sleep

Assistive Devices: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of assistive devices in order to:

 Assess the client for actual/potential difficulty with communication and speech/vision/hearing
problems
 Assess the client's use of assistive devices (e.g., prosthetic limbs, hearing aid)
 Assist client to compensate for a physical or sensory impairment (e.g., assistive devices,
positioning, compensatory techniques)
 Manage the client who uses assistive devices or prostheses (e.g., eating utensils,
telecommunication devices, dentures)
 Evaluate the correct use of assistive devices by the client

Assessing the Client for

Actual/Potential Difficulty with
Communication and a Speech, Vision
and/or Hearing Problem
As previously mentioned and fully explored with the section entitled "The Techniques of Physical
Assessment", nurses assess their clients in terms of any actual and potential difficulties and deficits
in terms of speech, hearing and vision.
Clients are further evaluated and assessed by other members of the health care team when a need to
do so arises. For example, the nurse may refer the client to an ophthalmologist or optician when an
actual or potential visual deficit is present; an audiologist or hearing aid professional may be referred
for the client when they have an actual or potential auditory deficit; and a speech and language
therapist may be contacted in order to evaluate and assess clients with a speech and oral
communication deficit.
Many clients may already have an assistive device to accommodate for their assessed speech, hearing
and/or visual deficit; when this is the case, the nurse and other members of the health care team
must provide these assistive devices to the client.
Some clients may be permanently visually impaired with complete blindness, some may have low
vision and still others may have a temporary visual change. For example, a client may be completely
blind at birth because of some genetic disorder, an elderly client may have low vision as the result of
aging related macular degeneration, and a client can have blindness as the result of some trauma;
some visual disturbances can result of taking a medication such as an antihistamine that can lead to
glaucoma, antipsychotic medications like thorazine and antimalarial medications which can affect the
retina, and corticosteroids which can lead to eye swelling and cataracts.
Clients who are blind use a number of assistive devices such as a walking cane, a service dog, and a
Braille note taker like Vario Ultra for written communication. People with significant low vision may
also use these same assistive devices and others may use communication assistive devices such a low
vision reader and magnifier such as the Merlin, the Amigo and the Pebble and other devices such as
corrective lenses and magnifying glasses. Nurses must accommodate for these deficits and losses.
Similar to blindness and low vision, some clients may be permanently impaired with complete
auditory losses and others may have temporary auditory changes. For example, a client may be
completely deaf at birth because of some genetic disorder, an elderly client may have a hearing loss
as the result of the aging process, and a client can have a hearing loss as the result of some trauma,
and some medication such as loop diuretics like furosemide, cancer chemotherapy agents like
cisplatin, aspirin, nonsteroidal anti-inflammatory medications like ibuprofen, and some
aminoglycoside antimicrobial medications like neomycin, gentamicin and streptomycin.
Drug related hearing losses have a typically abrupt and sudden onset when the medication is begun.
The first signs of possible auditory impairments secondary to medication are usually tinnitus and
vertigo as the result of cochlea damage. At times this damage is permanent and, at other times, the
damage will be corrected when the medication is discontinued.
Clients who are deaf use a number of assistive devices such as sound amplifiers, alerting devices,
closed captioned television, electronic communication devices such as a teletypewriter and other
more advanced devices like a terminal emulator and Unix.
People with a partial hearing loss may also use these same assistive devices and others may simply
use a hearing aid and take advantage of closed captioned television shows and an American Sign
Language interpreter.
Speech deficits are quite common among our client's particularly when they have had a trauma like a
cerebrovascular accident. Some of the assistive devices that can be used for this population in order
to facilitate oral communication can include things like word boards, picture boards, and handheld
speech generating electronic devices as well as the professional services of a speech and language
therapist.

Assessing the Client's Use of Assistive

Devices
Assistive devices facilitate the clients' communication abilities, their performance of the activities of
daily living, their highest possible level of independence, the prevention of the complications
associated with immobility, and it also enhances the patient's feelings of self-esteem and self-worth.
Nurses must assess and reassess the client's safe and appropriate use of all assistive devices, as
discussed above and immediately below.
Some of the commonly used assistive devices relating to mobility and ambulation include canes,
walkers, wheelchairs, crutches, and prosthetic limbs. In most health care facilities, a physical
therapist, in collaboration with nurses and other health care professionals, assess the client for these
assistive devices and the physical therapist and/or the nurse instructs the client about their proper
use and maintenance.
Canes are typically used to facilitate the client's balance and to facilitate ambulation when the client
is physically and cognitively able to use it rather than a walker. There are a variety of different canes
including a standard one foot cane, a tripod cane with three feet, and the quad cane which has four
feet. Some canes like a wooden cane are not adjustable to the client's height and others can be
adjusted to meet the height needs of the client.
The proper length of the cane should be the length that only permits the client's elbow to be slightly
flexed. The cane is held by the client in the hand opposite of where support is needed. For example,
the client will hold the cane with their right hand when the left leg is weak and the client will hold
and use the cane with their left and when the client is affected with weakness on their right leg.
Canes support the affected limb, not the unaffected limb, when the client is ambulating.
Walkers are indicated when the patient needs more support with ambulation than a cane can safely
offer them. Walkers can be with or without wheels, with or without brakes, and with or without a
seat that the client can use when they need to rest during a long walk.
Walkers that do not have wheels require that the client is able to pick the walker up and then
advance it forward at the appropriate distance so the client can proceed to that point; some clients
may lack the coordination and strength to do this, so they may then get a walker with two or four
wheels. Walkers with wheels, however, may not be suitable for a client who is not able to control it
from inadvertently rolling forward which could lead to a client fall. Walkers should be fitted and
adjusted to a height that is at the level of the client's wrist cease when they are standing upright and
erect without any hunching over or leaning forward.
Battery powered and manual wheelchairs offer the client the most assistance in terms of their
mobility and locomotion needs. Manual, mechanical wheelchairs require that the client has upper
arm strength to propel the wheelchair forward or the client must have the assistance of another to
push them in the chair. Battery powered wheelchairs and scooters require some manual dexterity
and close attention to safety. Some facilities prohibit the use of these battery powered chairs because
some clients have the tendency to go too fast in these chairs and they may, as a result, injure
themselves and others. Regardless of the type of wheelchair that is used, the client should always
keep their feet on the foot rests to prevent injury and also lock the brakes prior to getting into and
out of the wheelchair.
Crutches are used most often for younger clients who have good upper arm strength who have been
affected with an acute musculoskeletal injury such as a sprain, strain or fracture. A specific method
of using crutches, referred to as gait, is ordered for a patient as based on their physical support
needs. These gaits include the two point gait, the three point gait, the four point gait, the swing
through gait, and the swing to gait. Properly fitting crutches should have the client's hands firmly
placed on the grips. The client's elbows should be slightly bent when holding the handgrips and the
handgrips should be even with the hip line.
The client's weight is sustained by the hands; there should not be any weight or pressure on the arm
pits when the person is walking with their crutches. All the weight is on the hands which are on the
hand grips.
As with all patient care equipment, assistive devices must be safe, maintained and not broken. For
example, wheelchairs without good brakes and without foot rests must be immediately taken out of
service and not used for the client. Additionally, the rubber tips on a walker, cane and crutches
should be inspected often and immediately replaced if there is any sign of wear or bareness.
Some clients also have artificial limbs which are referred to as a prosthetic device. The need for an
artificial limb can occur as the result of some congenital anomaly, as the result of an accidental
traumatic amputation of a limb, and also as a planned process when the client has a limb that has to
be amputated, as often occurs among clients with diabetes.
A prosthetist assesses the client for prostheses and they also measure, custom design and supply the
client with any necessary prostheses. The client will usually get a trial temporary prosthesis before
they are fitted with a permanent one. Once the client is educated about the use and care of their
permanent prosthesis, the client should be educated about the need to have the prosthetic device
checked by a prosthetist on at least an annual basis.

Assisting the Client to Compensate for

a Physical or Sensory Impairment
Assistive devices for physical impairments affecting mobility and ambulation were previously
discussed under the section immediately above and assistive devices for sensory impairments in
terms of speech, vision and hearing was also previously discussed under the section entitled
"Assessing the Client for Actual/Potential Difficulty with Communication and a Speech, Vision
and/or Hearing Problem".
In addition to these assistive devices, there are also assistive devices such as pillows, bolsters and
wedges that are used to position clients into positions that promote and maintain correct bodily
alignment. Alert, orientated, and physically able clients with full range of motion should be
encouraged to frequently change their position in bed; and, those who are not able to do so, need
the help of the nursing staff to turn and position them at least every two hours to minimize the risks
of pressure ulcers and contractures, which are two of the many hazards associated with immobility.
Other assistive devices to compensate for physical impairments include braces and splints. Braces
and splints are also fitted and customized for the client by a prosthetist. When used, the nurse must
insure that it is applied correctly and they must also assess the skin and its temperature and color
under these assistive devices on a regular basis to insure skin integrity and adequate circulation,
respectively.

Managing the Client Who Uses

Assistive Devices and Prostheses
In addition to the assistive devices and prostheses discussed above, there are assistive devices to aid
the client in terms of their communication, eating, dressing, grooming, dentition and many of the
activities of daily living.
The section above entitled "Assessing the Client for Actual/Potential Difficulty with
Communication and a Speech, Vision and/or Hearing Problem" explored a large number of
assistive devices, including telecommunication devices that facilitate the client's ability to
communicate despite a sensory impairment.
Some of the assistive devices that are used to promote and facilitate the client's independent self-
care including those to promote and facilitate the client's independent activities of daily living are
listed below:

 Grooming self care: Adaptive hair brushes and combs and special nail clippers

 Dressing self care: Long shoe horns, button hooks, oversized buttons, sock pulls, oversized
loops, zipper pulls and Velcro closures for clothing

 Hygiene and bathing self care: Shower chairs, grab bars, nonskid tub and shower floors,
spray nozzles, and long handled back brushes

 Eating self care: Weighted plates, scoop dishes, food guards around the plate, assistive utensils,
weighted and tip proof drinking glasses and cups

 Oral self care: Special tooth paste holders, special tooth brushes and easy to use and manipulate
dental floss.

Dentures, another prosthetic and assistive device, are cleaned with a soft tooth brush and a denture
cleaner. When these dentures are removed they are then placed in a safe place, like a labeled denture
cup, with an overnight denture cleaner. Despite the client's use of dentures, the gums and cheeks
should be gently brushed and a mouth wash should be used in the same manner that other clients
do.

Evaluating the Client's Correct Use of

Assistive Devices
The client's correct use of assistive devices is evaluated and monitored by observing the client using
these devices and evaluating whether or not the client has remained without injury secondary to the
improper use of these devices.

Elimination: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of elimination in order to:

 Assess and manage client with an alteration in elimination (e.g., bowel, urinary)
 Perform irrigations (e.g., of bladder, ear, eye)
 Provide skin care to clients who are incontinent (e.g., wash frequently, barrier
creams/ointments)
 Use alternative methods to promote voiding
 Evaluate whether the client's ability to eliminate is restored/maintained

Some of the commonly used terms relating to urinary elimination, also referred to as micturition,
are:

Polyuria
Polyuria is an excessive amount of urine production in excess of 2.5 liters over a 24 hour period of
time. Some clients may be affected with nocturnal polyuria only during the night time hours and
others may be affected with polyuria throughout the course of the entire day.
Some frequently occurring causes of polyuria are the consumption of large amounts of fluids, the
use of diuretic medications, renal disease, psychogenic polydipsia which is a psychiatric mental
disorder causing excessive thirst, sickle cell, anemia diabetes mellitus and diabetes insipidus.
Excessive and prolonged polyuria can lead to dehydration which can cause fluid and electrolyte
imbalances in the client. The normal urinary output is about 2 liters per day.

Oliguria
Oliguria is a less than the normal amount of urinary output at less than 400 mLs over the course of
24 hours. The most commonly occurring causes of oliguria are impaired renal blood flow, renal
disease, decreased fluid intake and dehydration, hypovolemic shock and other diseases and disorders
associated with excessive bodily fluid losses, and an anatomical urinary stricture.

Anuria
Anuria is a lack of the production of urine or a severely scant amount of urine less than 50 mLs in a
24-hour period of time.

Dysuria
Dysuria is painful burning upon urination. It often occurs as the result of a urinary tract infection
and trauma.

Urinary Incontinence
Urinary incontinence is the involuntary leakage of urine and a loss of bladder control. The types of
urinary incontinence include functional urinary incontinence, reflex urinary incontinence, stress
urinary incontinence, urge urinary incontinence, and total urinary incontinence. The causes of
urinary incontinence are numerous and they can include a neurological deficit, a lack of sphincter
control musculature, and an overactive bladder.

Urinary Retention
Urinary retention is the accumulation of urine in the bladder because, for one reason or another, the
patient is not able to effectively empty their bladder.

Urgency
Urgency is defined as strong, sudden and relentless need to immediately urinate without delay.
Some of the commonly used terms relating to bowel elimination are:

Constipation
Constipation is defined as less than three bowel movements per week. Under normal circumstances,
clients should typically defecate from once a day to every 3 to 5 days. Some of the commonly
occurring causes of constipation are immobility, a lack of fluid intake, some medications like opioid
drugs, and impaired neurological functioning.

Diarrhea
Diarrhea is a watery loose stool. Some of the causes of diarrhea are a gastrointestinal infection, some
foods, stress, anxiety, some medications, malabsorption syndrome and a parasite infection.
Technically, diarrhea is defined as three or more loose stools over a 24 hour period of time.

Fecal Impaction
Fecal impaction is a collection of hardened stool in the rectum. Fecal impaction can occur from
some medications and also secondary to constipation, among other causes.

Flatulence
Flatulence is the expulsion of often odorous gastrointestinal gas. Flatulence can result from some
foods and medications.

Assessing and Managing the Client

with an Alteration in Elimination
Some of the factors that impact on urinary and fecal elimination and place patients at risk for
impaired elimination include, in addition to the ones discussed immediately above, an altered level of
hydration, advanced age, weak muscular tone, the age of the client, the presence of some physical
disorders including anatomical structural disorders, and psychological factors.
For example, some medications can lead to the retention of fluids, increased urinary elimination,
constipation and diarrhea; foods high in sodium can decrease urinary output and increase fluid
retention; and excessive hydration can lead to polyuria.
Both genders can be adversely affected bowel and/or bladder incontinence secondary to impaired
sphincter control; middle aged and older male adults can have urinary retention and urinary
incontinence because of an enlarged prostate gland; and elderly females can have urinary stress
incontinence as the result of their loss of pelvic muscle tone secondary to having vaginal deliveries
of babies.
Age also impacts on bowel and bladder elimination and alterations. For example, urinary tract
infections are the second most common infection among young children; neonates and infant male
babies are the most commonly affected group along the life span with bowel and urinary tract
obstructions and malformations; and older children who are females become more prone to urinary
tract infections because of poor wiping techniques.
Bowel function and bowel elimination can also be affected by a variety of disorders including a
paralytic ileus, an anatomical defect, infectious diarrhea, and other disorders such as ulcerative colitis
and Crohn's disease. Urinary function and urinary excretion can be adversely impacted with a
number of disorders such as an anatomical stricture defect, renal failure, hypertension, shock,
vomiting, diarrhea, and other disorders.
The lack of privacy, the lack of sufficient time to void or defecate, the lack of psychological comfort,
and the need to use unusual devices such as a bed pan and/or urinal can also impair normal urinary
and bowel elimination for many people who are hospitalized.
After a complete client assessment of the client's bladder and bowel functioning, a number of
interventions can be done, according to the client's identified needs.
Some of these interventions can include:
 Positioning
 Exercising to promote bowel function
 The elimination or addition of some foods and fluids. For example, a high fiber diet can
promote normal bowel functioning without constipation.
 The elimination of a medication which is problematic
 Timing
 Privacy
 Medications to promote urinary and/or bowel elimination
 Suppositories to promote bowel function
 Enemas to promote bowel function
 A fecal or urinary diversion such as a colostomy
 Urinary catheters for urinary retention
 Bowel and bladder training and management

Enemas
The four types of enemas are a:

 Carminative Enema: Carminative enemas are used to relieve flatus or flatulence and to
simulate peristalsis.

 Cleansing Enema: Cleansing enemas remove feces. These types of enemas are used to relieve
constipation and also to cleanse the bowel of fecal material prior to some surgical procedures
and to prep the bowel prior to some diagnostic tests like a screening and diagnostic colonoscopy
examination when the visualization of the bowel without fecal contents is necessary.

 Retention Enema: This type of enema consists of an oil solution or a medication added
solution that is administered and then retained and held by the client for an hour or more. A
retention enema is used to administer a medication, to soften stool and to lubricate the rectum
so that it is easier and more comfortable for the client to defecate.

 Return-Flow Enema: Return-flow enemas, similar to a carminative enema, are used to relieve
flatus and stimulate peristalsis which is frequently a problem after a client has received
anesthesia. The fluid is instilled into the rectum and sigmoid colon and, then, the enema bag is
lowered so that the flatus and fluid returns back into the enema bag. The instillation and
removal of this fluid is typically done five to six times and more often if necessary.

Urinary and Fecal Diversion

Fecal diversion colostomies can be either permanent or temporary. Colostomies are done to
promote the healing of anastomoses, to relieve a bowel obstruction caused by a tumor, and to
enable the elimination of fecal contents when the distal colon and rectum are removed.
There are different types of colostomies which are an ascending colostomy, a transverse colostomy,
a descending colostomy and a sigmoid colostomy. The location of the stoma depends on the type of
colostomy. For example, a sigmoid colostomy stoma is usually located on the lower left quadrant of
the abdomen.
Some of the complications associated with a colostomy include infection, dehiscence, an ischemic
ileostomy, a peristomal hernia, stoma stenosis, stomal retraction, a prolapsed stoma, necrosis,
mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage and
parastomal hernias.
A urostomy is a urinary diversion; the types of urostomy are the ileal conduit, the neobladder, the
Miami pouch, the Indiana pouch, and a nephrostomy.
Some complications of urinary diversion surgery include:

 Renal infections
 A urinary tract infection
 Urinary stones
 A vitamin B12 deficiency
 Nocturnal enuresis
 A distended bladder
 Changes in urinary pH
 Mucous plugs and ostomy clogs which can be corrected with Marlen MucoSperse

Urinary pH changes, the formation of salts and stones, and infections can be prevented with ample
oral intake of fluids. Patients should also be instructed to dissolve mucous plugs that are clogging
the pouch by using Marlen MucoSperse.

Urinary Catheterization
In addition to keeping the incontinent client clean and dry, there are a number of topical agents used
for the protection of the skin, including skin sealants that protect the skin from urine, stool, exudate,
chemicals, dirt, and debris, zinc oxide based moisture barrier ointments that also protect the area,
thick moisture barrier pastes that seal the area off and protect it from any moisture, solid skin
barriers in the form of rings, strips or wafers that protect the skin and wounds, and skin barrier
powders that are sprinkled lightly on denuded skin to increase the sticking power of ointments,
pastes and solid skin adhesive barriers.

Bowel and Bladder Management

In terms of generalities, bowel and bladder management are used for bowel and bladder
incontinence and retention. Bowel retention is constipation in terms of bowel functioning and
urinary retention in terms of bladder functioning.
Constipation is treated with interventions such as the promotion of exercise, a high fiber diet, ample
fluids, suppositories and enemas.
Urinary retention can be prevented and managed with ample fluids, assistance with toileting, the
administration of a cholinergic medication to stimulate bladder contractions and bladder emptying,
Crede massage which is the application of manual pressure and a kneading kind of massage of the
area over the bladder, and the use of an intermittent or continuous urinary catheterization to fully
empty the bladder.
The use of a urinary catheter is the last resort because these catheters can relatively easily lead to a
urinary tract infection which is a major infection concern in health care facilities. These and other
infections such as one affecting a client who is intubated, are referred to as health care acquired
infections, formerly known as nosocomial infections. When a urinary catheter is necessary as the last
resort, this catheter should remain in place for the briefest period of time possible and scrupulous
catheter care must be given to the catheter to prevent catheter associated urinary tract infections,
referred to as CAUTI (Catheter associated urinary tract infections).
Urinary and bowel incontinence is managed, whenever possible, with an incontinence management
program which is sometimes referred to as bladder or bowel training, prompted and timed voiding
and evacuation and other techniques such as muscular exercises to strengthen the muscles on the
floor of the pelvis as well as those for the urinary and bowel sphincters. For example, Kegel
exercises, which are also done after a vaginal delivery of a baby, are often done to strengthen the
muscles of the pelvic floor and the sphincter muscles to correct some causes of incontinence.
Clients who remain incontinent, despite preventive measures, can use protective briefs, and fecal
incontinence pouches which are placed externally over the anus. Males, with urinary incontinence
can also use a condom catheter, also referred to as a Texas catheter. Clients who are incontinent
required scrupulous skin care to prevent complications associated with incontinence such as skin
breakdown. Briefs and other devices are used to preserve the dignity of the client, particularly when
the client is in a public space, and NOT a mechanism to save nursing staff's time. No client should
ever be left in a condition with excrement or urine in their briefs. These clients must be promptly
washed and dried to preserve the client's skin integrity and dignity.
Some of the nursing diagnoses appropriate for clients affected with, or potentially at risk for, a
urinary and bowel dysfunction include:

 Bowel incontinence related to rectal urgency

 Bowel incontinence related to a neurological deficit that disables the client's ability to feel the
urge to defecate
 Potential bowel and/or bladder incontinence related to poor pelvic floor muscle strength
 Impaired urinary elimination related to functional urinary incontinence
 Impaired urinary elimination related to reflex urinary incontinence
 Impaired urinary elimination related to stress urinary incontinence
 Impaired urinary elimination related to urge urinary incontinence
 At risk for an alteration in skin integrity related to bowel and/or bladder incontinence
 At risk for infection related to the presence of a urinary catheter
 Readiness for enhance urinary and/or bowel elimination
 Urinary retention related to benign prostatic hyperplasia (BPH)
 Urinary retention related to impaired detrusor musculature and the ability to contract
 Urinary retention related to cauda equine syndrome
 Urinary retention related to the side effect of a medication
 Urinary retention related to peripheral neuropathy

Performing Irrigations
Nurses irrigate bodily orifices and therapeutic interventions such as the irrigation of the bladder, the
ear, the eye and an ostomy. All of these irrigations are done using sterile technique, with the
exception of a fecal diversion irrigation which uses clean technique. Additionally, a gown is donned
to protect the nurse from sprays and splashes; protective masks or goggles when a spray or splash
can be reasonably possible and gloves are used during these doctor ordered irrigations.

Bladder Irrigations
Bladder irrigations are done when a client has an indwelling urinary catheter that is blocked and not
patent.
The procedure for bladder irrigation is as follows:

1. Empty and measure the contents of the existing urinary drainage bag.
2. Hang the irrigation solution on an IV pole above the level of the client to facilitate the flow of
the irrigation solution using gravity.
3. Prime the irrigating solution.
4. Swab the irrigation port on the three way catheter and then connect the irrigation solution to
this port.
5. Open the clamp on the irrigation solution and allow the fluid to flow into the bladder at the
ordered rate which is typically about 40 to 60 gtts per minute.
6. The irrigation solution is allowed to remain in the bladder when the doctor has ordered a closed
intermittent bladder irrigation.
7. The irrigation solution is allowed to flow out of the bladder with a closed intermittent bladder
irrigation by opening the urinary catheter clamp to allow the contents of the bladder to empty
into the urinary drainage bag.
8. Measure and document the volume of the irrigation solution that was used for the irrigation and
also the volume of urinary catheter collection bag. The amount of urine produced as the result
of the irrigation is calculated by subtracting the amount of irrigation solution instilled during the
irrigation from the total volume that was collected in the urinary catheter drainage bag. For
example, if the nurse instills 1200 mLs of irrigating solution into the bladder and the volume in
the urinary drainage bag after this instillation of irrigating solution is 1400 mLs, the urinary
output is 1400 – 1200 = 200 mLs in terms of urinary output.

Urinary Catheter Irrigations

Urinary catheter irrigations are done when a client has an indwelling urinary catheter that is blocked
and not patent.
The procedure for bladder irrigation is as follows:

 Clamp the catheter between the injection port and the extension tubing.
 Clean the port with antiseptic wipes.
 Insert a syringe and slowly inject the irrigation solution.
 Remove the syringe and then finally
 Remove the clamp and permit the irrigation solution to drain into drainage bag.

Ear Irrigations
Ear irrigations are done to cleanse the ears and also to irrigate the ears with an otic medication,
according to the doctor's order. Ear irrigations and instillations are done with slightly warm solutions
and these instillations and irrigations, including medications, are a little different for children less
than three years of age and children and adults over three years of age because of anatomical
differences.
The nurse will gently pull the pinna, or ear lobe, downwards and backwards for children less than
three years of age because the ear canal is still directed upward, and the nurse will gently pull the
pinna upwards and backwards for children older than three years of age and for adults.
The procedure for ear irrigation is as follows:

1. Place the client on their side with the affected ear up in a comfortable position.
2. Cleanse the pinna and the external ear canal with a cotton tipped applicator to remove
extraneous debris and to prevent this debris from entering the inner ear during an instillation or
irrigation.
3. Pull the pinna downwards and backwards for children less than three years of age and upwards
and backwards for clients over three years of age.
4. Insert the syringe with the irrigation solution into the ear.
5. Direct the flow of the solution towards the top of the ear and with gentle pressure.
6. Place the client on their treated ear downward and over a basin to allow the irrigation solution to
freely flow out of the ear.

Eye Irrigations
Ear irrigations are done to cleanse the eyes, to remove debris and to instill optic medications and
solutions.
The procedure for eye irrigations and instillations is as follows:

1. Place the client in an upright and supine position or in a chair.

2. Cleanse the eye lashes and the eye lids with a cotton ball.
3. Advise the client to not blink during the process.
4. While the client is looking upward towards the ceiling, gently apply or instill the ordered optic
solution on to the lower conjunctival sac from the inner canthus of the eye to the outer canthus
of the eye.
5. Apply gently pressure to the client's closed eye for a minimum of 30 seconds to prevent the
outward flow of the solution or medication.

Sigmoid and Descending Colostomy Irrigations

The purposes of a sigmoid and descending colostomy irrigation is to stimulate peristalsis and fecal
emptying by introducing a fluid of about 300 to 1000 mLs into the ostomy using an irrigating cone
or catheter.
These irrigations and instillation cannot be delegated to the unlicensed assistive personnel; these
procedures are restricted to the scope of practice for only the licensed practical nurse or the
registered nurse.

Providing Skin Care to the Client Who

is Incontinent
All incontinent clients must be continuously clean and dry. The use of briefs is done to maintain the
client's dignity in social situations and to allow the staff to be able to clean and dry the client without
having soiled bed linens; however, briefs are not used to allow the client to lie in their urine and
feces without being care for by the nursing staff.
In addition to the frequent washing and drying of all skin exposed to feces and/or urine, there are
some topical skin preparations that are helpful to the prevention of skin breakdown. These topical
agents include:
 Solid Skin Barriers: Solid skin barriers are moldable skin barriers which can be shaped as a disk
or strips; and they can consist of hydrocolloids, carboxymenthyl cellulose, gelatine, karaya,
pectin, and a combination of one or more of these components. Some examples include
Hollister's Flextend, and Premium Skin Barrier. Solid skin barriers are longer lasting but more
expensive than the moisture barrier ointments and pastes described below.

 Moisture Barrier Ointments: Moisture barrier ointments like Lantiseptic Skin Protectant,
Caloseptine Ointment, and Proshield Plus Skin are zinc oxide containing products that are used
to prevent incontinence dermatitis. These products are reapplied after all episodes of
incontinence and the washing of the affected areas.

 Moisture Barrier Pastes: Moisture barrier pastes like Remedy Calazime Protectant Paste and
Ilex Skin Protectant Paste are thick topical skin preparations that permit the nurses' assessment
of the underlying skin while protecting the skin from impaired skin integrity secondary to
incontinence.

 Skin Sealants: Skin sealants, in contrast to moisture barrier pastes and ointments, last up to
about 14 days after application. These products, including Film Wipe, Shield Skin, Bard
Protective Barrier, and Convatec's Allkare, consist of a fast drying polymer transparent film that
can be applied relatively simply with a wipe or a spray.

Using Alternative Methods to Promote

Voiding
Urinary catheters are used to promote urinary elimination. These catheters come in various sizes
which are referred to as French and the abbreviation "Fr". Children will have an 8 to 10 Fr., adult
males will typically have a size 16 to 18 Fr, and adult females will typically use a 14 to 16 Fr. Latex
urinary catheters are contraindicated when the client has a latex sensitivity or allergy. The insertion
of a urinary catheter is a sterile procedure and one that CANNOT be delegated to an unlicensed
assistive staff member. Only registered nurses and licensed practical nurses can insert a sterile
urinary catheter.
The procedure for inserting a urinary catheter is as follows:

 Provide the client with privacy and explain the insertion procedure to the client to alleviate any
anxiety and discomfort which is something that is frequently encountered because this
procedure invades the client's intimate space.
 Position the client in a supine position with the thighs separated so that they do not interfere
with this sterile procedure.
 Lubricate the lower section of the catheter with a sterile water soluble lubricant.
 Cover the surrounding area with a sterile drape.
 Clean the urinary meatus with an antiseptic solution using sterile technique. The male urinary
meatus is cleansed using a circular pattern from the meatus and then outwards. The female
urinary meatus is cleansed with an antiseptic solution beginning with the labia from the front to
the back while holding the area open.
 Insert the urinary catheter into the urinary meatus.
 Advance the catheter about 3 cms past the point when urine appears in the urinary catheter
tubing.
 Inflate the balloon for an indwelling catheter.
 Secure the catheter to the client's leg.
 Connect the urinary drainage bag to the tubing and maintain the level of the urinary drainage
bag below the level of the client's abdomen to prevent any back flow of urine.

After placement, the urinary catheter needs care and maintenance. For example, the insertion site is
washed with soap and water at least on a daily basis and every time the area becomes soiled with
feces. The drainage bag must be maintained below the client's abdominal level, the urinary drainage
bag should be emptied each shift and more often when necessary, and the tubing should be
inspected to make sure that there is no kinking or twisting of the tubing because this will obstruct
the free flow of urinary output that could back up into the bladder.

Evaluating Whether the Client's

Ability to Eliminate is Restored and
Maintained
The interventions and treatments for urinary and bowel elimination problems are evaluated in terms
of whether or not the client has maintained or restored elimination functioning. Some of the
expected outcomes, or client goals, that are evaluated in terms of whether or not the client has
achieved them can include:

 The client will be able to perceive and attend to voiding cues.

 The client will be free of any urgency, frequency and pain associated with voiding
 The client will have no more than 200 mLs of residual urine after voiding
 The client will free of any urinary tract infection secondary to the placement of an indwelling
urinary catheter
 The client will be free of urinary incontinence after a prompted voiding and exercise program
 The client will demonstrate the correct procedure and technique for self intermittent
catheterization
 The client will demonstrate the correct technique and procedure for colostomy irrigation
 The client will be free of fecal incontinence after a bowel training program
 The client will have normal bowel functioning
 The client will be free of diarrhea

Mobility and Immobility:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of mobility and immobility in order to:

 Identify complications of immobility (e.g., skin breakdown, contractures)

 Assess the client for mobility, gait, strength and motor skills
 Perform skin assessment and implement measures to maintain skin integrity and prevent skin
breakdown (e.g., turning, repositioning, pressure-relieving support surfaces)
 Apply knowledge of nursing procedures and psychomotor skills when providing care to clients
with immobility
 Apply, maintain or remove orthopedic devices (e.g., traction, splints, braces, casts)
 Apply and maintain devices used to promote venous return (e.g., anti-embolic stockings,
sequential compression devices)
 Educate the client regarding proper methods used when repositioning an immobilized client
 Maintain the client's correct body alignment
 Maintain/correct the adjustment of client's traction device (e.g., external fixation device, halo
traction, skeletal traction)
 Implement measures to promote circulation (e.g., active or passive range of motion, positioning
and mobilization)
 Evaluate the client's response to interventions to prevent complications from immobility

Identifying the Complications of

Immobility
The hazards or complications of immobility, such as skin breakdown, pressure ulcers, contractures,
muscular weakness, muscular atrophy, disuse osteoporosis, renal calculi, urinary stasis, urinary
retention, urinary incontinence, urinary tract infections, atelectasis, pneumonia, decreased respiratory
vital capacity, venous stasis, venous insufficiency, orthostatic hypotension, decreased cardiac reserve,
edema, emboli, thrombophlebitis, constipation and the loss of calcium from the bones, are highly
costly in terms of health care dollars and in terms of client suffering. Many of these costly
complications of immobility can, and should be, prevented whenever possible.
Immobility and complete bed rest can lead to life threatening physical and psychological
complications and consequences. Members of the nursing care team and other health care
professionals like physical therapists must, therefore, promote client mobility and prevent
immobility whenever possible. Immobility can adversely affect all physiological bodily systems.
The complications and hazards associated with immobility and according to bodily system are
described below:

Urinary System
As the result of immobility, the urinary system can be adversely affected with urinary retention,
urinary stasis, renal calculi, urinary incontinence and urinary tract infections.

Gastrointestinal System
Constipation, impaction and difficult to evacuate feces can occur as the result of immobility and the
lack of exercise that is needed to promote normal bowel functioning. These bowel alterations are
further confounded when the client is not getting adequate fluid intake.

Musculoskeletal System
The muscles, joints and bones are adversely affected by immobility.
The bones lose calcium as a result of the lack of weight bearing activity and this can lead to disuse
osteoporosis, hypercalcemia, and fractures. At times a tilt table can be used to prevent this damage
by placing the client in a position of weight bearing to avoid these complications.
The joints are affected with stiffness, pain, impaired range of motion and contractures including foot
drop which is a plantar flexion contracture. Some of these joint disorders can be prevented with
frequent and proper positioning of the client in correct bodily alignment, the provision of range of
motion exercises to all joints several times a day, and the use of devices like a hand roll and a bed
board to prevent contractures of the hands and feet, respectively.
Muscles are adversely affected with weakness and atrophy as the result of immobility. These hazards
of immobility can be prevented with range of motion exercises and in bed exercises such as isotonic,
isometric and isokinetic muscular exercises.

Respiratory System
Some adverse respiratory system effects relating to immobility include the thickening of respiratory
secretions, the pooling of respiratory secretions and an increased inability of the client to mobilize
and expectorate these secretions, all of which can lead to atelectasis, hypostatic pneumonia, and
respiratory tract infections. Immobility can also lead to shallow, ineffective respirations, decreased
respiratory movement, and a decrease in terms of the client's vital capacity.
Some of these complications of immobility can be prevented with respiratory hygiene measures such
as deep breathing, coughing, postural drainage, percussion and vibration. These techniques will be
discussed below immediately after this section.

Circulatory System
The circulatory system is jeopardized by immobility; some of these respiratory complications and
risks include venous stasis, venous dilation, decreased blood pressure, edema, embolus formation,
thrombophlebitis and orthostatic hypotension which is a risk factor that is often associated with
client falls.
Some of these complications can be prevented with leg exercises, the use of sequential compression
devices or antiembolism stockings, and the initiation of falls risk prevention measures when an
immobilized client is adversely affected with orthostatic hypotension.

Metabolic System
The metabolic system alterations associated with immobility are a decreased rate of metabolism
which can lead to unintended weight gain, a negative calcium balance secondary to the loss of
calcium from the bones during immobilization, a negative nitrogen balance secondary to an increase
in terms of catabolic protein breakdown, and anorexia.

Integumentary System
Immobility places clients at risk for skin breakdown, pressure ulcers, and poor skin turgor.
Preventive measures and the treatments of these skin integrity disorders will be discussed below in
the section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin
Integrity and Prevent Skin Breakdown".

Psychological Alterations
Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered
mood, and depression.
Some nursing diagnoses related to immobility can include:

 At risk for pressure ulcers related to immobility

 Muscular weakness and muscular atrophy related to immobility
 At risk for venous stasis and emboli related to immobility
 At risk for altered and impaired respiratory functioning related to immobility
 At risk for falls related to orthostatic hypotension secondary to immobility
 At risk for osteoporosis and fractures related to the loss of calcium from the bones secondary to
the lack of weight bearing activity
 Plantar flexion contracture related to immobility
 Apathy related to immobility
 Loss of complete range of motion related to immobility

Assessing the Client for Mobility, Gait,

Strength and Motor Skills
Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the
environment. It is an essential part of living. People must be able to move to protect themselves
from trauma and to meet their basic needs. Mobility is vital to independence; a fully immobilized
person is as vulnerable and dependent as an infant" (Berman and Synder, 2012).
The risk factors associated with immobility are client deconditioning, a cognitive impairment,
spasticity, poor cardiac functioning and poor tolerance for activity, inadequate muscular strength,
impaired balance, improper bodily posture and alignment, an impaired gait, pain, the use of sedating
medications, joint pain and stiffness in addition to other skeletal problems, obesity, and neurological
impairments in addition to a physiological health problem that mandates that the client be on
complete bed rest.
These risk factors are assessed by the nurse to determine the etiology of an identified deficit and to
recognize that, because of one or more risk factors, a client is at risk for impairments in terms of
their mobility, gait, strength and motor skills.
Mobility can be assessed by using direct observation of the client's movements and mobility and
using some standardized tests such as the Timed Get Up and Go Test with which the nurse assesses
the client's ability to rise from a chair, walk, and then return to the chair and sit, the Assessment
Tool for Safe Patient Handling and Movement, the Egress test which the nurse uses to assess the
client's ability to sit and then stand, march in place and advance forward with each foot and return
to the same position. These and even more complex and advanced standardized tests and tools are
also used during a physical therapist's assessment of the client.
Mobility abilities and impairments can be also assessed by observing the client while they:

 Move about in bed

 Are sitting to determine whether or not they need support while sitting
 Change from a sitting position to standing, transferring from the bed to the chair, and sitting
down on a chair or bed
 Stand and walk

Simply defined, gait is the way the person walks, or ambulates. Gait is a function of a number of
different things including balance, coordination, muscular strength, and joint mobility.
Balance and equilibrium can be impaired when the client is affected with a middle ear disorder that
affects the vestibule and/or the semicircular canal of the ear's cochlea, poor posture, and a
musculoskeletal or neurological disorder; muscular coordination is the ability of the person to
smoothly and safely use gross motor and fine motor coordination. Coordination can be adversely
affected with a neurological disorder of the cerebellum, cerebral cortex and basal ganglia; muscular
strength can be impaired with things like muscular atrophy, spasticity, nutritional deficits, paresis,
flaccidity and other causes; and joint mobility can be impaired disuse, arthritis and other disorders of
the bone.
Muscular strength is classified on a scale of zero to five, as below.

 Zero: No muscular contraction

 One: No muscular movement, only a quiver is noted

 Two: Muscular movement but only when assisted with gravity

 Three: Muscular movement against gravity but not against resistance

 Four: Muscular movement against resistance

 Five: Full muscular movement and strength

Joint mobility and range of motion are assessed for the client. Simply defined, full range of motion is
defined as the maximum movement of a joint specific to that joint. For example, the elbow should
normally be able to perform extension, flexion, rotation for supination and notation for pronation
and the neck should be fully able to perform extension, flexion, lateral flexion, hyperextension and
rotation.
After the client is assessed, the mobility of the client, in addition to other functional activities, can be
graded and classified as follows in terms of this level of functional ability:

 Level 0: The client is completely independent in terms of mobility

 Level 1: The client needs an assistive device

 Level 2: The client needs an assistive device and the coaching and supervision of another
person

 Level 3: The client needs an assistive device and the direct assistance of another person

 Level 4: The client is totally dependent on others for their mobility needs
Performing a Skin Assessment and
Implementing Measures to Maintain
Skin Integrity and Prevent Skin
Breakdown
Skin Assessment
The skin, which is the first line of defense against infection, should be intact and not broken, it
should be warm and without any excessive moisture, and the skin should also have good elasticity,
which is referred to as good skin turgor.
Some of the factors that impact on the skin and its integrity include intrinsic and extrinsic factors
and forces. Some of these intrinsic factors include the client's urinary and/or fecal incontinence,
poor nutritional and fluid intake, diabetes, hyperthermia, hypothermia, hypotension, a decreased
cardiac output, obesity, an altered sensory perception, some medications, an alteration in terms of
the client's perfusion and peripheral circulation, some of the normal changes of the aging process,
cachexia and emaciation, an alteration in terms of the client's metabolic status, and the client's body
build as well as the size of their boney prominences.
Some of the extrinsic factors that impact on the skin and its integrity are environmental humidity,
chemical irritants, extremes in terms of hot and cold weather, radiation, and mechanical forces such
as pressure, shearing and friction.
Some of the nursing diagnoses related to skin and skin integrity can include:

 At risk for impaired skin integrity related to immobility

 At risk for impaired skin integrity related to poor skin turgor
 Impaired skin integrity related to impaired tissue perfusion
 At risk for impaired skin integrity related to boney prominences
 Impaired skin integrity related to pressure, shearing and friction
 Impaired skin integrity related to poor nutritional status

All skin areas that are not within normal limits and indicate any signs of skin breakdown are assessed
and described according to its color, size, location, odor, drainage, margins, texture, distribution and
underlying bed tissue.

Color
The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched
and reddened, for example.
Size
The area of an abnormality is measured with a disposable rule in terms of centimeters. The length
and width of all areas are measured and the depth of wounds is also measured. The depth of a
wound is measured using a sterile cotton applicator which is then compared to the disposable rule
for an accurate measurement. After the wound is assessed and measured, the wound dimension is
calculated by multiplying the length by the width by the depth of the wound. For example when the
length of the sound is 4 cm and the width of the wound is 3 cm and the depth of the wound is 1 cm,
the wound dimension is 12 cm because 4 x 3 x 1 = 12 cm.

Location
The skin area that has impaired skin integrity is also described according to its exact location and in
reference to its anatomical location. For example, an area of skin breakdown can be described as on
the posterior of the arm just inferior to the elbow or over the sacrum and coccyx. Some assessment
forms allow the nurse to draw the area of concern on it to graphically show both the location and
the relative size of the skin area that is affected with impaired skin integrity.

Odor
Some wounds and wound drainage have odors and others do not. Odors can be described as
malodorous, pungent, foul, or musty; and some pathogens like pseudomonas have a characteristic
odor.

Drainage or Exudate
Wound discharge, which is also referred to as wound exudate, is assessed and described as the lack
of any drainage or the presence of some drainage which be described in terms of color, amount and
characteristics.
The quantity or amount of drainage can be described as minimal, moderate or excessive and copious
when a wound drain is not being used to measure drainage precisely. Wound drainage is also
described in terms of its color and characteristics. For example, serous drainage is clear or a slight
yellowish color because it consists of serum which is the clear portion of the blood; sanguineous
drainage is bloody and red because it consists of red blood cells; serosanguinous drainage is pinkish
in color because it is a combination of serum and red blood cells; and purulent drainage can be
yellow, green, rust color or brown and this drainage indicates the presence of infection and thick
pus.

Texture
Affected skin areas can be assessed and described as macerated, edematous, swollen, indurated or
normal.

Distribution
The distribution of impaired skin integrity can be described as generalized and across many areas of
the body, localized to one area of the body, asymmetrical and on only one side of the body and also
symmetrical which affects both sides of the body bilaterally.

Margins
The margins around the wound are also assessed and described in terms of their color, their
characteristics and their texture which can be classified and documented as macerated, edematous,
swollen, indurated or normal. Wound margins can be described as open, attached, unattached, well
defined and with a healing ridge.

Underlying Bed Tissue:

Underlying bed tissue reflects the extent to which the wound is healing, regenerating and renewing.
The stages of wound healing are the homeostasis phase, the inflammation phase which is also
referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation
phase.
The homeostasis phase is marked with vasoconstriction, platelet formation, thrombin formation and
the formation of a fibrin mesh for healing; the inflammation phase is characterized with the signs
and symptoms of inflammation including edema, swelling, pain, in addition to the beginning of
debris removal to prevent infection through the process of phagocytosis; the proliferative and
granulation phase is marked with the fibroblastic production of collagen and granulation tissue; and,
lastly, the maturation phase of wound healing is characterized with the still fragile skin after the
wound healing process that can last up to two years after a wound. The wound remains vulnerable
to injury until full healing is completed with good tensile strength.
Some wounds, like surgical incisions, are planned wounds and others such as those occurring
secondary to a trauma or a pressure ulcer are considered unplanned wounds. Nurses assess wounds
in respect to their type of wound as well as the other factors discussed above.
The three types of wound healing are primary intention healing, secondary intention healing and
tertiary intention healing.

Primary Intention Healing

Primary intention healing is facilitated with wounds without infection. The wound edges are
approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues.
An example of primary intention healing is the suturing of an abdominal surgical wound after an
appendectomy or the suturing of a traumatic laceration with Steri Strips or sutures when this
traumatic wound is free of any contamination and infection.

Secondary Intension Healing

Secondary intention healing, also referred to as healing by second intention, is done for
contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to
promote healing from the bottom up to the outer surface of the skin so that any potential infection
is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution
and then packed to keep them open and, over time, they will heal on their own. The resulting scar is
more obvious than those scars that result from primary intention healing.

Tertiary Intension Healing

Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of
secondary and primary healing. Tertiary intention healing begins with several days of open wound
irrigations and packing, which is secondary healing, followed by the closure of the wound edges with
approximation and suturing which is primary healing. Some traumatic wounds are healed with
tertiary intention.

Implementing Measures to Maintain

Skin Integrity and Prevent Skin
Breakdown
Nurses maintain skin integrity and prevent skin breakdown in a number of different ways. These
efforts are even more intense and comprehensive when the client has one or more risk factors
associated with impaired skin integrity, as discussed previously in this section.
The best way to maintain skin integrity and to prevent skin breakdown is to prevent them from
occurring in the first place. Some of these preventive techniques include:

 The screening of all clients for their potential for skin breakdown and then initiating special
preventive measures
 Performing skin assessments and reassessments on a regular basis
 Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as
debris
 Turning and positioning clients at least every two hours when the client is unable to move about
in bed to turn and position on their own
 Maintaining the client's nutritional and fluid needs
 The utilization of supportive and assistive devices such as a wedge, pillow, and a pressure
relieving mattress
 The elimination of pressure, friction, shearing and moisture on the client's body and bodily parts

The Braden Scale for Predicting Pressure Ulcers and the Norton Pressure Ulcer Scale are two of the
most popular standardized screening tools that are used to screen and assess clients in order to
determine if they are at risk for skin breakdown. Both of these standardized screening tools are
deemed valid and reliable for identifying those at risk.
Pressure ulcers are also referred to as stasis ulcers, trophic ulcers, and ischemic ulcers; they can result
from the mechanic forces of pressure, friction and shearing, all of which can, and should, be
prevented.

Pressure
Pressure, particularly over boney prominences, areas of poor tissue perfusion, and areas affected
with poor circulation, is a physical force associated with the development of pressure ulcers and skin
breakdown. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage
because harmful substances, such as toxins, accumulate in the area where the pressure is exerted.
Pressure can be eliminated and reduced with out of bed activity, pressure relieving surfaces, the
provision of sitting and lying surfaces free of any objects and wrinkles, and by turning and
repositioning clients frequently to prevent this damaging mechanic force.

Friction
Friction occurs when a person's body is being rubbed against a surface such as a bed.
Shearing is a combination of both pressure and friction that can cause some distortion of the client's
skin and its underlying tissues. Shearing can be prevented by elevating the head of the bed no more
than 30 degrees unless contraindicated, using a lift or a lifting team, if you have one, by transferring
clients carefully, getting help when turning and positioning a client, getting as much client
cooperation as possible during turning, positioning and transfers, using a pressure relieving bed, and
lubricating the skin with a lubricating moisturizer to prevent the damaging skin effects associated
with pressure, friction and shearing. Corn starch is NOT used.
Pressure ulcers are costly both in terms of health care costs and the human costs that the client
suffers as the result of a pressure ulcer including, but not limited to, pain, sepsis, cellulitis, and
osteomyelitis. When pressure ulcers are not prevented, the nurse must assess and care for it.
Pressure ulcers are staged from the least severe to the most severe from Stage 1 to Stage 5. These
stages are:

 Stage I: The skin remains unbroken and intact. The skin among those with a light skin tone may
have some redness or blanching of the affected area; and those with darker skin tones may have
a blue, purple or ashen tinge to the affected area. Additionally, all clients may have some
sensitivity and burning, coolness or increased warmth to the affected area.

 Stage II: The closed and intact skin is now open. The epidermis and the dermis are damaged.
The wound may appear as a blister, crack or a wound that is pink in color.

 Stage III: The wound is now considered a deep wound; the subcutaneous tissue and all the
layers of the skin, including the epidermis and dermis and even adipose tissue may be exposed
and affected. The wound has a blood tinged drainage as well as dark areas and yellow colored
area of dead and necrotic tissue, referred to as eschar and slough, respectively, appear.
 Stage IV: The deep pressure ulcer extends to underlying areas including the muscle, fascia,
connective tissue, tendons, and even the bone under the skin and subcutaneous tissue. Signs of
necrotic tissue including eschar and slough are evident.

The treatment of pressure ulcers is complex and it often includes a combination of treatments and
therapies. The RYB Color Code of Wounds is sometimes used by nurses to guide the treatment
options. RYB stands for the colors of red, yellow and black. The rules of treatment for these three
colors are:

 Red: Protect the area. A new reddened area is protected from further harm and damage with
interventions such as turning and positioning the client, keeping the client's skin clean and dry,
keeping bed linens wrinkle and object free and avoiding all pressure, friction and shearing. When
the wound is red as the result of healing of a previous pressure, the healing of this pressure ulcer
is in the stage of granulation with renewal tissue that remains fragile and prone to another
breakdown so it has to be protected with a barrier film, covering with a dressing such as a
hydrocolloid film, turning and positioning the client and avoiding pressure, friction and shearing;
and the healing of this wound is maintained and promoted with gentle cleansing of this area
using a solution that is not cytotoxic.

 Yellow: Cleanse the area. This wound needs cleansing using an alginate dressing, a hydrogel
dressing or damp normal saline dressings to remove the slough and purulent wound drainage.

 Black: Debridement of the area to remove the black necrotic eschar. There are several methods
of debridement including surgical laser debridement, mechanical debridement, autolytic
debridement, enzymatic debridement and sharp instrument debridement.

Surgical Debridement
Surgical debridement using a laser is perhaps the fastest of all methods of debridement and it is the
method that is least likely to damage the healthy tissue surrounding the necrotic area. One of its
disadvantages, when compared to some other method of debridement, is the need to anesthetize the
client which, in itself, has some risks.

Mechanical Debridement
Mechanical debridement is often the preferred form of treatment for pressure ulcers that only have a
moderate amount of necrotic tissue that has to be removed. This relatively inexpensive type of
debridement can be done with a damp dressing, hydrotherapy, and manually scrubbing the affected
area to remove the debris. This method is not used as much today as it was previously used. Some of
the disadvantages of mechanical debridement include the fact that it nonselective and, as such can
damage healthy tissue, it can cause pain, it is more subject to an infection than other forms of
debridement, and it is more time consuming on the part of the person performing this procedure,
when compared to other methods of debridement.
Autolytic Debridement
Autolytic debridement promotes the body's use of its own enzymes to debride the wound. This
process is referred to as autolysis. Autolytic debridement is most often used to treat Stage 3 and
Stage 4 pressure ulcers.
The procedure for autolytic debridement entails the use of a semi-occlusive, occlusive, hydrocolloid,
alginate, or hydrogel treatment and a transparent dressing to keep the area moist while the body uses
its own enzymes like its fibrinolytic, proteolytic, and collagenolytic enzymes, as well as its on white
blood cells to debride a wound and remove its eschar and slough.
The advantages of this kind of wound debridement include its effectiveness, its ease in terms of
performing it, its relative safety, and lack of pain for the client. Some of its disadvantages, however,
include the fact that autolytic debridement is not as rapid as a surgical debridement in terms of its
effectiveness and the fact that anerobic microbes may thrive under the dressing that is used for this
type of debridement.

Enzymatic Chemical Debridement

Enzymatic chemical debridement can be used on wounds with at least moderate amounts of
necrosis and eschar, including pressure ulcers and burns.
The enzymes introduced for this type of debridement are maintained within a moist environment so
that they can destroy cellular debris, slough and eschar. The eschar is gently crosshatched with a
scalpel so that the introduced enzymes can penetrate all layers of it.
Some of the advantages associated with chemical debridement include its relatively rapid, action and
its ability to be selective and not damage healthy surrounding tissue. Some of its disadvantages
include local irritation, its relatively high cost, and the need for frequent dressing changes once or
twice a day.

Sharp Instrument Debridement

This method of debridement entails the removal of necrotic tissue using a scalpel, forceps and
scissors by the doctor. This method is the most rapid of all debridement methods but it can lead to
client pain and discomfort.
Topical antibiotics that are often used to treat wounds, as based on the identified offending
microorganism, include, among others:

 Cadexomer iodine
 Gentamicin
 Metroidazole
 Mupirocin
 Polymyxin B sulphate
 Silver sulfadiazine
Applying a Knowledge of Nursing
Procedures and Psychomotor Skills
When Providing Care to Clients with
Immobility
Nursing care consists of all of the phases of the nursing process including assessment, nursing
diagnosis, planning implementation and evaluation.
In terms of assessment, the nurse assesses and reassess the client for actual and potential
complications of immobility as fully discussed above under the section entitled "Identifying the
Complications of Immobility" and the clients' needs in reference to mobility, gait, strength and
motor skills as fully discussed in the section entitled "Assessing the Client for Mobility, Gait,
Strength and Motor Skills"
Nursing diagnoses for the hazards of immobility and the client's mobility were also discussed above
in these same sections.
Planning is done according to the actual and potential health problems that were assessed and then
expected client outcomes or goals and interventions are planned to meet these needs. Some of the
expected client outcomes relating to immobility and mobility can include specific goals such as:

 The client will perform active range of motion to all joints two times a day

 The client will safely transfer from the bed to the chair with assistance

 The client will be free of venous stasis

 The client will demonstrate proper deep breathing and coughing

 The client will ambulate 30 feet three times a day with a walker and the assistance of another

 The client will increase their level of exercise and physical activity

 The client will demonstrate the proper use of their assistive device

 The client will maintain skin integrity

 The client will maintain adequate respiratory functioning

The interventions for immobility according to system that can be adversely affected with immobility,
in addition to the constant monitoring of the client, assessments and reassessments for these
hazards, include:

 Urinary System: Maintain adequate fluid intake, measure, document and monitor the client's
intake and output to insure an adequate fluid balance status.

 Gastrointestinal System: Maintain an adequate fluid intake, encourage a high fiber diet,
encourage out of bed activity including ambulation unless it is contraindicated, and the
administration of treatments such as stool softeners, fiber additives, enemas, and laxatives, as
ordered.

 Musculoskeletal System: Range of motion exercises to all bodily parts, muscle strengthening
exercises including isotonic, isometric and isokinetic exercises, aids to assist in positioning the
client in correct bodily alignment, and early weight bearing activity

 Respiratory System: Encouraging the client to perform deep breathing and coughing, and the
provision of postural drainage, percussion, inspiratory respiratory exercises and vibration.
Coughing, deep breathing, postural drainage, percussion, vibration and inspiratory respiratory
exercises will be detailed in the section immediately following this one.

 Circulatory System: Active or passive range of motion, positioning, mobilization, leg exercises,
the use of sequential compression devices or antiembolism stockings, and the initiation of falls
risk prevention measures when an immobilized client is adversely affected with orthostatic
hypotension.

 Metabolic System: The encouragement and provision of a healthy diet with ample protein

 Integumentary System: Maintain good nutrition, encourage fluids, turn and position every two
hours and maintain clean and dry skin without any pressure, friction or shearing.

 Psychological Alterations: Providing an adequate amount of stimulation, encourage visits and

other diversions

Coughing, Deep Breathing, Incentive

Spirometry, Postural Drainage,
Percussion, Vibration and Inspiratory
Respiratory Exercises
Clients are encouraged to cough, deep breathe, use an incentive spirometer, and perform inspiratory
respiratory exercises, and the nurse, or the certified respiratory therapist, will also perform postural
drainage, percussion, and vibration to correct and prevent the collection of respiratory secretions in
the client's airway which can result from immobility and some respiratory diseases and disorders.
Postural drainage, percussion and vibration are often referred to as pulmonary hygiene measures and
pulmonary physiotherapy measures. Coughing, deep breathing and the use of an incentive
spirometer are described as hyperinflation exercises because, when done properly, these respiratory
techniques hyper inflate the lung to facilitate the loosening and mobilization of respiratory
secretions. All of these measures are used not only for immobilized clients but also for many post-
operative clients.
The procedure for deep breathing and coughing is as below. The client should be coached and
taught to:

 Splint any painful or tender abdominal areas with a pillow or the client's hand
 Take the deepest possible diaphragmatic breath through the nose
 Exhale through the mouth
 Do this deep breathing three times
 Cough after the third breath
 Repeat this coughing and deep breathing as often as necessary to clear the airways

An incentive spirometer is used to coach the client in terms of deep breathing and coughing. An
incentive spirometer consists of a plastic chamber with a ball, a mouthpiece and tubing. While the
client is in an upright semi-Fowler's position or sitting in the chair, the client is instructed to put the
mouth piece tightly into their mouth and to take the deepest possible diaphragmatic breath while
observing the ball rise to the level of their goal. The client should be reminded and encourage to
take at least 10 breaths using the incentive spirometer at least every 2 hours while they are awake.
Postural drainage is done by the nurse or the certified respiratory therapist. This technique entails
the positioning of the client in different positions so that all areas of the lungs and airways are able
to be drained of respiratory secretions using the force of gravity. For example, the client is
positioned prone and in a 45 degree Trendelenburg position to drain the posterior bronchus, a 45
degree Trendelenburg position to drain the posterior bronchus and on the left side to drain the
lateral bronchus.
Percussion is also performed by the nurse or the certified respiratory therapist. This technique
entails the placing a cupped hand over the lung areas and doing gentle tapping on the area for about
one minute while the client is hyper inflating their lungs and holding the breath as long as possible.
The client is placed in the same positions that are used for postural drainage, as discussed
immediately above. In fact, percussion is most often done in combination with postural drainage.
Vibration is highly similar to percussion except vibration is done by placing the palm of the hand on
the lung area and doing rapid vibrating movements on the area while the client is positioned for
postural drainage.
Inspiratory muscle training techniques entail instructing the client to lie in a comfortable supine
position, to relax, and then to take deep breaths with a mouth piece with an increasingly smaller
lumen so that the client has to progressively take deeper and deeper breaths using their diaphragm
while overcoming the resistance of the obstructive mouth piece.

Applying, Maintaining and Removing

Orthopedic Devices
Some of the orthopedic devices that nurses apply, maintain and remove include traction devices,
splints, braces and casts:

Traction
Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Traction is
used for the external fixation of a fracture, it is used to maintain anatomically correct alignment, it is
used to reduce pain and it is used to decrease muscle spasms.
Traction forces are classified and categorized as Inline or running traction and balanced traction.
Balanced traction utilizes the weight of the client's bodily part, rather than externally placed weights,
to exert the traction force to the body. Hamilton Russell traction is an example of balanced traction.
Inline traction, also referred to as running traction and Buck's skin traction, exerts the traction force
along the long axis of the bone and along one plane.
The three basic traction techniques can also be classified as manual traction, skeletal traction and
skin traction. Manual traction, which is applied with the hands, is done to properly align a bone after
a fracture so that a cast can be applied to the bone while it is in correct anatomical alignment.
Skeletal traction is applied directly to an affected bone with a continuous traction force and with the
use of a surgically inserted Steinman pin that is placed into the distal end of the affected bone.
Lastly, skin traction applies the traction force to the skin overlying the affected bone. The purpose
of skin traction is to decrease pain and muscular spasms after a fracture has been surgically repaired
with internal fixation. Skin traction is the most commonly used type of traction.
The externally placed skin traction must be applied firmly but without any potentially damaging
pressure and in a smooth manner without any creases. The weights are gently applied, as ordered,
and left to hang freely and without any interference. The skin underneath skin traction must be
inspected on a regular and ongoing basis to prevent some of the possible complications associated
with this type of traction including blistering, skin breakdown, compartment syndrome, circulatory
impairment, neurological impairment, and areas of necrosis. Also, the skin around the surgical site
for skeletal traction must also be inspected for any signs of infection.
Splints
The primary purposes of splinting for limb fractures are to protect soft tissue from further damage,
to reduce the client's pain, to reduce the possibility of a fat embolism, and to minimize painful
muscular spasms. Some splints, like an inflatable arm splint, a Downey splint and a Sager splint, are
temporarily placed on clients by paramedics in the field prior to their arrival at the emergency
department of a hospital. Splints are also used the immobilization of the spine, to support a
weakened area of articulation such as a knee from damage and to support it after a knee
replacement, for example.

Braces
Braces are applied to various parts of the body to provide support and alignment of the part. Some
commonly used braces are neck braces, back braces, and elbow braces.

Casts
Skeletal fractures are classified and described in several ways, many of which are not mutually
exclusive.
A complete fracture involves the entire cross section of the fractured bone; an incomplete fracture
affects only part of the bone and not the entire cross section; stable fractures are defined as fractures
that are not likely to be displaced, therefore, reduction is not indicated; an unstable fracture, unlike a
stable fracture, necessitates reduction because it is likely that this fracture is displaced; a closed
fracture is defined as one that does not break through the surface of the skin and this type of
fracture and this type of fracture is also referred to as a simple fracture; an opened fracture, on the
other hand, breaks through the skin surface to the exterior of the body and, as such, an opened
fracture is prone to infection because the skin lacks integrity; and a pathological fracture is one that
results from a disease process rather than undue stress or trauma as other fractures do.
Fractures can also be categorized and categorized according to it pattern.
These patterns include:

 A greenstick fracture occurs when only one side of the bone is fractured.
 An avulsion fracture occurs when a fragment of the fractured bone is pulled off the bone at its
tendon or ligamentous attachment.
 A comminuted fracture is one that splinters the fractured bone into small fragments as a result
of a traumatic force.
 A transverse fracture is one that occurs straight across the fractured bone.
 An oblique fracture is one that occurs at an angle across the fractured bone.
 A spiral fracture occurs when the pattern twists around the fractured bone.
 An impacted fracture is one that occurs when a bone fragment of the fractured bone is pushed
and wedged into another bone fragment of the fractured bone.
 Compression fractures occur when the fractured bone collapses as occurs with vertebral spinal
fractures.
 A depressed fracture occurs when bone fragments of the fractured bone is pushed in beyond the
surrounding skin. This type of fracture occurs with depressed skull fractures.

Fractures are treated to prevent deformity. In addition to traction and splints, many fractures are
also casted. Casts can be made with plaster or fiberglass. Some casts are solid and others are what
are referred to as a bivalve cast which has two pieces. Fiberglass casts are lighter in terms of weight
than plaster casts; and bivalve casts, unlike solid casts, permit some swelling after the traumatic
fracture and, as such, prevent compartment syndrome, a complication associated with casting.
Casts must be applied in a smooth manner and they should also be allowed to dry without any
external pressure applied to them. External pressure can cause creases and denting which can impair
the skin below in terms of its neurological and circulatory status.
The signs and symptoms of compartment syndrome include intense pain that cannot be relieved
with raising the affected limb and/or the client's ordered analgesic medications. The later signs of
compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to
neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool
and pale skin.
Compartment syndrome is a medical emergency which, left untreated, can lead to the loss of the
affected limb. The treatment plan includes the removal of the cast and, at times, a fasciotomy or
epimysiotomy are indicated.

Applying and Maintaining Devices

That are Used to Promote Venous
Return
Compression stockings, or antiembolism stockings or hose, and automatic sequential compression
devices are used to promote venous return and prevent emboli, both of which can occur as the
result of patient immobilization and other causes such as deep vein thrombosis. At times, these
devices are routinely ordered for post-operative clients to promote venous return. These devices are
ordered by the doctor in terms of millimeters of mercury that they will apply to the lower
extremities.
At the current time, automatic sequential compression devices are used in health care facilities and
they have virtually replaced the use of compression hose; however, compression stockings continue
to be used in other areas including the client's home, for example.
The correct application of antiembolism stockings entails the application of these stockings while
the client is lying in bed and before rising. Like automatic sequential compression, compression
stockings are fitted for the specific client after measuring the client's legs and checking the doctor's
order for the amount of pressure that these stockings should exert on the client's leg. Some of these
compression stockings are knee high and others are thigh high. These stockings are gently and
smoothly pulled over the client's legs without any wrinkles or uneven pressure. Wrinkles and uneven
pressure can cause venous stasis. After they are applied, they should be regularly checked to insure
that they remain in place and without any wrinkling and they should also be removed at least one
time a day so that the nurse can inspect the skin underneath it and also to check the skin for its color
and warmth which can, at times, indicate a circulatory impairment.
Automatic sequential compression devices consist of a pump, a one time single patient use sleeve,
and hosing that connects the sleeve to the pump. Automatic sequential compression devices can
have sleeves to accommodate for pressure on the legs as well as the foot. Similar to compression
hose, sequential compression sleeves are also fitted according to the client's measurements and they
come in both thigh high and knee high sleeves. Unlike compression hose that exerts continuous
pressure on the lower extremities, automatic sequential compression devices deliver intermittent
pressure at the ordered pressure and as set on the pump.
These sleeves, like compression hose, require that the nurse regularly check them to insure that they
remain in place and they, too, should also be removed at least one time a day so that the nurse can
inspect the skin underneath it and also to check the skin for its color and warmth.

Educating the Client Regarding the

Proper Methods Used When
Repositioning an Immobilized Client
Clients should be educated about the proper methods that will be used to position and reposition
them in bed while they are immobilized. Some of the elements of this teaching should include:

 The rationale for the need for frequent position changes

 The different positions that they will be used
 The devices, such as pillows and bolsters, that will be used to maintain the position and proper
bodily alignment
 Ways that the client can assist with position changes. For example, the client may be encouraged
to bend their knees and then exert pressure on their heels as they are being moved up in bed.
 The rationale for maintaining an angle of no more than 30 degrees to prevent skin breakdown
 Signs and symptoms like a burning or sore feeling on a bodily part that must be reported to the
nurse
 The purpose of and the procedure for a mechanical lift if the client will be using one
 The purpose of the lifting team if the facility has one
Maintaining the Client's Correct Body
Alignment
The client positions that are used for maintaining good bodily alignment and optimal physiological
functioning include the Sims or the semi prone position, the Fowler's position, the dorsal recumbent
position, the prone position and the lateral position.
The lateral position is a side lying position with the upper most knee bent and often maintained in
that position with a pillow; the Fowler's position is a sitting position with the head of the bed up and
elevated; the dorsal recumbent position and supine position are lying on the back with or without a
pillow for the head; the prone position is lying on the stomach; and the Sim's position is a semi
prone position.
These positions are supported and maintained with pillow, bolsters and wedges when necessary to
maintain anatomically correct bodily alignment.

Maintaining and Correcting the

Adjustment of the Client's Traction
Device
External fixation devices, halo traction, skeletal traction, and Crutchfield or Vinke cervical tongs are
immobilization techniques that are used for fractures and other serious disorders. These devices are
connected to traction.
Traction is often set up by the nurse and, at times, a traction team may be used for the setup of the
doctor's ordered traction. When applying traction, the client should be placed in the supine position
and boney prominences should be protected from friction and shearing. Traction, when ordered,
should be continuous and not interrupted.
The procedure for setting up traction is as follows:

 Lubricate the pulleys with a silicone spray

 Add the precise weight that was ordered by the doctor
 Apply and maintain the weights so that they hang freely. They should never touch the floor or
any other surface such as a part of the bed because this will interfere with the traction's ordered
weight.
 Insure that the counter traction force is less than the pulling traction force. When the pulling
traction force is greater than the counter traction force of the client's body, the client will slide to
 the source of the traction. The nurse should tilt the bed when this occurs and this can be
prevented by keeping the client's head of the bed up at the maximum of less than a 20 degree
angle.

The neurological condition of the areas of traction must be frequently assessed and inspected, the
skin should be assessed and cared for, and the client should be repositioned as much as possible in a
frequent manner, typically every 2 to 4 hours.

Implementing Measures to Promote

Circulation
In addition to anti embolism stockings and sequential compression devices, as previously discussed,
active or passive range of motion, positioning and mobilization are also measures that promote
circulation.

Range of Motion
Range of motion exercises can be active, active assisted and passive. Patients able to perform full
joint movement on their own and without the assistance of another should be encouraged to do so
several times a day to promote circulatory functioning and also to maintain full joint mobility. The
nurse should monitor these clients to insure that they are performing these active range of motion
exercises in the correct manner and to the greatest possible extent of movement for all of the joints
of the body.
Nurses assist patients with range of motion exercises several times a day when patients are not
completely independent in terms of their own performance of range of motion exercises. Passive
range of motion is done by the nurse when the client is not able to even assist with range of motion
exercise. Patients in a coma, for example, should be given complete passive range of motion to all
joints several times a day.

Positioning and Repositioning

Positioning and repositioning were fully discussed previously in the section entitled "Maintaining the
Client's Correct Body Alignment". Positioning and repositioning in correct bodily alignment
enhances circulation, musculoskeletal integrity and skin integrity.

Routine Exercising and Mobilization

Routine exercising and mobilization also enhance the client's circulatory function in addition to
preventing complications of immobility such as muscular weakness and venous stasis. When
mobilization and ambulation are impaired as the result of muscular weakness and/or impairments of
their gait, balance and coordination, the client should be provided with rehabilitation and restorative
care to facilitate this mobilization and ambulation.
Implementing Measures to Maintain
Skin Integrity and Prevent Skin
Breakdown
As previously discussed skin integrity can be maintained and skin breakdown can be prevented with
a number of different interventions such as turning and repositioning the client at least every two
hours, special pressure relieving mattresses, and the avoidance of all pressure, friction and shearing.

Evaluating the Client's Responses to

Interventions to Prevent the
Complications From Immobility
The nurse determines whether or not the client's expected outcomes were accomplished after
preventive measures were implemented to prevent the complications associated with immobility.
For example, the nurse will determine whether or the client is able to:

 Perform active range of motion to all joints two times a day

 Safely transfer from the bed to the chair with assistance
 Be free of venous stasis
 Demonstrate proper deep breathing and coughing
 Ambulate 30 feet three times a day with a walker and the assistance of another
 Increase their level of exercise and physical activity
 Demonstrate the proper use of their assistive device while ambulating
 Maintain their skin integrity and not have any signs of skin breakdown
 Maintain adequate respiratory functioning
Non Pharmacological
Comfort Interventions:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of non pharmacological comfort interventions in order to:

 Assess the client's need for alternative and/or complementary therapy

 Assess the client's need for palliative care
 Assess client need for pain management
 Recognize differences in client perception and response to pain
 Apply knowledge of pathophysiology to non-pharmacological comfort/palliative care
interventions
 Incorporate alternative/complementary therapies into client plan of care (e.g., music therapy,
relaxation therapy)
 Counsel client regarding palliative care
 Respect client palliative care choices
 Assist client in receiving appropriate end of life physical symptom management
 Plan measures to provide comfort interventions to clients with anticipated or actual impaired
comfort
 Provide non-pharmacological comfort measures
 Evaluate the client's response to non-pharmacological interventions (e.g., pain rating scale,
verbal reports)
 Evaluate the outcomes of alternative and/or complementary therapy practices
 Evaluate outcome of palliative care interventions

Assessing the Client's Need for

Alternative and/or Complementary
Therapy
The number and variety of nonpharmacological interventions including complementary, alternative
and integrative modalities, are numerous and varied. Some of these techniques and interventions are
more successful for some clients than for others so, in addition to assessing the client's need for
these therapies, nurses assess the client's preferences in terms of the therapies that they wish to do.
Some examples of alternative and complementary therapies that can provide the patient with
comfort are:

 Meditation
 Prayer
 Magnets
 Chiropractic services
 Homeopathy
 Reiki
 Music therapy
 Acupuncture
 Acupressure
 Massage
 Deep breathing
 Progressive muscular relaxation
 Distraction
 Guided imagery
 Biofeedback
 Hypnosis and self hypnosis
 Mind Body Exercises and
 Herbs and Dietary Supplements

All of the above alternative and complementary comfort measures were fully discussed previously in
the section entitled "Evaluating the Client on Alternative or Homeopathic Health Care Practices".

Assessing the Client's Need for

Palliative Care
As previously stated, according to the National Board for Certification of Hospice and Palliative
Nurses, "Hospice and palliative care is the provision of care for the patient with life-limiting illness
and their family with the emphasis on their physical, psychosocial, emotional and spiritual needs.
This is accomplished in collaboration with an interdisciplinary team in a variety of settings which
provide 24-hour nursing availability, pain and symptom management, and family support. The
advanced practice registered nurse, registered nurse, pediatric registered nurse, licensed
practical/vocational nurse, nursing assistant and administrator are integral to achieve a high standard
of hospice and palliative care as members of this team."
Many clients choose palliative care, in contrast to curative care, at the end of life. These clients are
educated about hospice and palliative care and how this care differs from curative care. The benefits
of this care, for both the client and their family members, include the relief of pain and discomfort
at the end of life and the psychosocial and spiritual support of the client and their family members.
Some of the interventions that were discussed above in the section entitled "Assessing the Client's
Ability to Cope with End-of-Life Interventions" are done for and with clients when they elect to
have palliative care.

Assessing the Client's Need for Pain

Management
Pain is a highly complex phenomenon. Plato described pain as an emotion and not a sensation;
Hippocrates believed that pain was the result of a lack of balance in terms of the body's fluids.
Neither Hippocrates nor Plato believes that the brain played any role in terms of pain. Other
thinkers and philosophers prior to the Renaissance believed that pain was a punishment from god. It
was Descartes who introduced the notion that pain is transmitted along the nerves to the brain
where the pain is perceived by the person.
Some of the more current theories relating to pain and the evolution of thought relating to pain, the
nature of pain, and the client's response to pain are described below.

 The Specificity Theory of Pain: The Specificity Theory of Moritz Schiff in the 1850s
described pain as a sensation that was different from all the other senses in that pain had its own
specific nervous system pathways from the spinal cord that traveled to the brain. According to
this theory, there are no psychological responses to pain.

 Intensive Theory: This theory of pain debunked the Specificity Theory and it is based on the
belief that pain is an emotional state, rather than a sensory phenomenon. Pain occurs with an
intense stimulus such as intense heat and pressure.

 The Peripheral Pattern Theory: The Peripheral Pattern Theory of pain, which is often
referred to simply as the Pattern Theory of pain, was proposed by Sinclair and Weddell during
the 1950s. Pain, according to this theory, is transmitted by nerve endings in the skin when an
intense stimulus is applied. This theory also does not recognize the psychological aspects of pain
as we know it today.

 The Neuromatrix Theory of Pain: This theory of pain supports the fact that pain is a dynamic
and multidimensional process with physical, behavioral, perceptual, psychological and social
 responses and one that can only be described by the person who is experiencing it. The four
parts of the nervous system according to the Neuromatrix Theory of pain components of the
nervous system, according to this theory, consist of the body self neuromatrix, cyclical
processing, the sentient neural hub which produces the client's awareness, and the patterns of
movement.

 Gate Control Theory: Melzack and Wall are credited with the Gate Control Theory of pain.
Pain, according to this theory, is a combination of sensory, cognitive, affective and psychological
responses to a painful stimulus. Pain is transmitted by rapidly transmitting nerve fibers, slowly
transmitting nerve fibers, small and large nerve fibers along the dorsal horn of the spinal cord
and its substantia gelatinosa. The substantia gelatinosa is the "gate" that facilitates or blocks the
transmission of pain. Some of the factors that open this "gate" and create pain include the
person's level of anxiety and their paucity of endorphins. Some of the factors that close this
"gate" are the lack of anxiety, adequate levels of endorphins and the person's belief that the pain
can be managed and controlled.

The pain process consists of four phases which, in correct sequential order are transduction,
transmission, modulation and perception.
Pain can be described in a number of different ways. Pain can be acute and chronic; it can also be
described as nociceptive, neuropathic, superficial, deep, somatic, radicular, referred, visceral,
localized, diffuse, and mild, moderate, and severe.

 Acute Pain: Simply defined, acute pain is pain that lasts less than 3 months; it has a rapid onset,
it is typically localized, it is accompanied with sympathetic nervous system responses such as
pupil dilation, diaphoresis, and increases in terms of the client's blood pressure, pulse rate and
adrenal hormone secretion as well as other signs and symptoms such as anxiety, muscular
tension and tightness, all of which can increase the severity and the duration of the pain.Acute
pain is most often self-limiting and manageable with sound pain management interventions.
Acute pain is a predictable, physiological warning that something is wrong.

 Chronic Pain: In contrast to acute pain, chronic pain is long lasting pain that can continue for
extended periods of time, it is more difficult for the client to describe, it is less definable than
acute pain, it is more difficult for the nurse to assess, it can be continuous or intermittent and it
is also often difficult to treat than acute pain. For example, some pain, like malignant pain, is
sometimes intractable. Chronic pain is typically not associated with vital sign changes as they are
associated with acute pain because the body has somewhat adjusted to it; but, chronic pain is
associated with physical, emotional, psychological and behavioral changes such as distress,
depression, anorexia, insomnia, fatigue, and withdrawal.
 Neuropathic Pain: This pain is typically described by the client as a burning and sharp
pain.Neuropathic pain can occur as the result of damage to the nervous system; central
neuropathic pain occurs as the result of damage to the central nervous system; and peripheral
neuropathic pain occurs as the result of damage to the peripheral nervous system. Spinal cord
injury pain is an example of central neuropathic pain and examples of peripheral neuropathic
pain include the pain associated with phantom pain and peripheral neuropathy secondary to
diabetes.

 Nocicetive Pain: Nocicetive pain includes both somatic pain and radicular pain which include
deep abdominal pain and the pain resulting from a herniated spinal disk, respectively.

 Superficial Pain: Superficial pain is body surface pain.

 Deep Pain: Deep pain is pain that it is deep inside of the body.

 Somatic Pain: Somatic pain, which is a type of nocicetive pain, occurs as the result of injuries
to the skin, bone, muscle, connective tissues and joints.

 Visceral Pain: Visceral pain, which is also a type of nocicetive pain, is pain that originates in
and around the organs of the body.

 Radicular Pain: Radicular pain is pain that radiates to the lower extremities with transmission
that occurs along the spinal nerve.

 Referred Pain: Referred pain spreads to an area of the body which is not the source of the pain.

 Diffused Pain: Diffuse pain is widespread pain.

 Localized Pain: Localized pain is pain that is restricted to one identifiable area.

Pain is assessed by the nurse by collecting and analyzing subjective and objective data. Pain is a
subjective experience that cannot be scientifically proven to be or not be present. Current research
clearly supports the fact that the client's subjective complaints of pain are far more accurate than
other indicators of pain, such as the client's vital signs and behavioral changes such as crying and
guarding the area of the body affected by the pain.
The PQRST method is a useful way for nurses to assess pain. The PQRST method consists of:

 P: Precipitation: What precipitated the pain symptoms? What things precipitate an increase in
the amount of pain and what things precipitate a relief from the pain?
 Q: Quality: What is the quality of the pain? Is it dull, sharp, deep, superficial, burning, aching, or
stabbing?

 R: Region: Where is the pain? What region or area is painful? Does the pain travel and radiate to
another area of the body like the jaw and your leg?

 S: Severity and Symptoms: What is the intensity of the pain on a scale of 1 to 10 with 1 being
minimal pain and 10 as the most intense pain? What other symptoms are you experiencing in
addition to the pain?
 T: Triggers and Timing: What triggers and starts your pain? What triggers make the pain worse
and more severe? When did the pain begin? Tell me about the timing of the pain. How long
does the pain last? How often does the pain appear?

The quality of pain as sharp, burning, etc. is also described by the client as the nurse is assessing the
client's pain. At times, the quality of the pain can suggest its cause. For example, cramping may
indicate that the source of the pain is musculoskeletal in terms of its origin. The standardized McGill
Pain Questionnaire has a large number of these quality of pain descriptors including descriptors like
unbearable, hot, and pricking needle like pain.
Behavioral signs and symptoms associated with pain can include insomnia, anorexia, muscular
tension, rigidity, a narrow focus of attention and crying. Some of the objective physiological signs
and symptoms of pain include like increased blood pressure, diaphoresis, tachycardia, adrenal
hormone secretion and dilation of the pupils. The signs and symptoms are assessed for by the nurse,
particularly when the client, such as an infant, is not able to provide the nurse with full subjective
data which describes their pain.
Observational behavioral pain assessment scales for the pediatric population are used among
children less than three years of age. Some of these standardized pediatric pain scales include the
FACES Pain Scale, the neonatal CRIES Pain Scale, Toddler Preschooler Postoperative Pain Scale
(TPPPS), the Neonatal Infant Pain Scale (NIPS), the Children's Hospital of Eastern Ontario Pain
Scale (CHEOPS), the Faces Legs Activity Cry Consolability Pain Scale (FLACC), the Visual Analog
Scale (VASobs) the Observation Scale of Behavioral Distress (OSBD), the COMFORT Pain Scale
and the Pre-Verbal Early Verbal Pediatric Pain Scale (PEPPS) that is used with toddlers.
At the current time, most nurses use a pain scale from 0 to 10 along the scale with 0 being the
absence of pain and 10 being the worst possible level of pain for adults who are cognitively aware
and other tools like faces pain assessment scale with adult clients who are affected with the lack of
cognitive abilities, such as those who are demented or in a lethargic state of consciousness..
The consequences of uncontrolled pain are severe and they adversely affect the client's quality of
life. Many clients, like the population at large, have misconceptions about pain and pain
management. Some of these misconceptions include:

 The belief that pain is inevitable and a normal part of illness.

 Addiction occurs when a client takes narcotic analgesics.
 Neonates and infants do not feel pain.
 Clients who have a past personal history of a substance related abuse should not be given any
narcotic analgesics

None of the above statements are true.

Recognizing Differences in the

Clients' Perceptions and Responses to
Pain
Like all other things, clients vary in terms of their perceptions of pain and their responses to pain.
Some of the factors that impact on the clients' perceptions of and responses to pain include:

 Social factors including one's support systems

 Ethnic factors and values
 Cultural factors and values
 Level of development
 Economic factors
 The individual client's personal definition of pain and its meaning
 The client's past experiences with pain
 Level of fatigue
 Genetic factors
 Levels of fear and anxiety
 Level of cognitive functioning

Applying a Knowledge of
Pathophysiology to Non-
Pharmacological Comfort/Palliative
Care Interventions
As previously listed in the Introduction to "End of Life Care", some of the signs and symptoms
associated with the end of life include those below. These signs and symptoms and some possible
non-pharmacological comfort and palliative care interventions are discussed below.
 Excessive sleeping: Excessive sleeping is more of a concern for the family members than it is
for the client. Family members should be instructed about the fact that excessive sleeping is a
commonly occurring occurrence at the end of life. They should also be taught about the
importance of their mere presence and gentle touches are comforting to the client even when
they are sleeping.

 A decreased desire for food and fluids: Anorexia and a lack for fluid and food intake are
common at the end of life. Many clients elect to forgo tube feedings and intravenous fluids for
fluid rehydration in their advance directive so these choices must be supported.

 Incontinence of the bowels and bladder: The end of life is probably not the time to do bowel
and bladder training so the nurse must, instead, insure that the client is always clean and dry.

 Respiratory secretions congestion: Respiratory congestion results from the accumulation of

respiratory secretions in the airways. The pulmonary hygiene procedures discussed above such
as coughing, deep breathing, incentive spirometry, postural drainage, percussion, vibration and
inspiratory respiratory exercises, in addition to suctioning may be indicated for the relief of the
respiratory congestion.

 Changes in respiratory patterns, including Cheyne-Stokes respirations: Cheyne-Stokes

respirations are characterized with deep and rapid breathing that is then followed with periods
of apnea. Apnea is often disturbing and upsetting to the client's family members, therefore, the
nurse should explain the fact that Cheyne-Stokes respirations are normal during the perideath
period and that clients with Cheyne-Stokes respirations report that these episodes did not cause
them to experience any distress.

 Restlessness and agitation: Some clients at the end of life may experience agitation and
restlessness. In addition to insuring the safety of the client, the underlying cause of this agitation
and restlessness must be identified and treated if possible. For example, restlessness can occur as
the result of hypernatremia, renal impairment, poor hepatic function, blood pH changes and
other causes. When the underlying cause cannot be determined and treated, the client may be
given an antipsychotic medication like haloperidol or an antianxiety agent like lorazepam to
correct restlessness and agitation.

 A lack of orientation: Nurses assess the clients' level of orientation to person, time and place.
When a lack of orientation occurs as the result of an identifiable and treatable cause like
delirium, the underlying cause should be treated and corrected. When the cause of the lack of
 orientation is not identifiable and/or not treatable, the client should be frequently oriented by
the nurse and other members of the health care team.

 Body pallor and coolness: Pallor can result from a number of causes including anemia, a low
blood glucose level and exposure to cold. When correctable, treatable causes of this body pallor
are identified, and then they should be treated when the client at the end of life chooses to have
these treatments.

 Social withdrawal: Many clients want to be alone at the end of life. Again, this choice should
be supported and upheld by the members of the health care team and the family.

 Vision like experiences: It appears that many clients at the end of life have vision like
experiences of relatives and friends that have predeceased the client. According to clients who
have experienced these visions, they find them comforting and with a lot of meaning. If, and
when, clients and family members express concerns about these visions and appearances, they
should be told that these things commonly occur at the end of life for some clients.

 Saying goodbyes to loved ones: Although saying goodbye to a loved one is a sad experience
and often associated with grief, saying goodbye allows the client and their loved ones to express
their love, to ask for forgiveness and, for family members, it is a time to tell the loved one that
they have your permission to let go and leave when the client is ready.

 Letting go: Letting go, ideally, occurs when the client has reached a level of acceptance about
their own death. This letting go facilitates the client to reconcile with others and tap into the
spiritual dimension when this is something that the client is connected to.

Nurses monitor the client's responses to non-pharmacological interventions in terms of the client's
level of comfort. As with pharmacological interventions, nonpharmacological interventions have
expected outcomes like a reported or observed decrease in the levels of pain and discomfort and
increased levels of comfort as reported by the patient or observed by the nurse.
In essence, the outcomes of palliative care interventions are evaluated in terms of whether or not the
client and family members have had their physical, psychological, emotional, religious, social and
spiritual needs effectively met, including the client's freedom from pain.
Incorporating Alternative and
Complementary Therapies Into the
Client's Plan of Care
As fully described above in the section entitled "Evaluating the Client on Alternative or
Homeopathic Health Care Practices", nurses assess the clients' needs for alternative and
complementary therapies such as progressive relaxation and music therapy and then incorporate
these therapies into the client's plan of care.

Counseling the Client Regarding

Palliative Care
Clients have the innate right to self-determination and to make their own decisions about care
without any coercion from members of the health care team. Many clients at the end of life may not
be knowledgeable about palliative care and hospice care. They may be exhibiting some of the signs
and symptoms that they may potentially want met with a palliative care philosophy and palliative
care interventions. For this reason, the nurse, in collaboration with other members of the health care
team, educates the client about palliative care and how this care differs from curative care.
After this education and counseling, the client should be encouraged to make a decision about
whether or not they want palliative care after they have become knowledgeable about it and what it
has to offer to clients at the end of life. Again, this informed consent, and decision, is the decision of
the client and it must be supported and respected by the nurse and other members of the health care
team and family members.

Respecting the Client's Palliative Care

Choices
Clients should be provided with complete information about palliative care and they should also
have the opportunity to discuss all of their alternatives and options. This education should also
include the benefits and risks associated with alternative choices and their choices in the same
manner that is done with all informed consents.
Assisting the Client in Receiving
Appropriate End of Life Physical
Symptom Management
Some of the intervention for hypovolemic shock, in addition to correcting an underlying cause such
as bleeding and dehydration, are intravenous fluid replacements with fluids like lactated Ringers, the
administration of blood, blood components and plasma expanders, and placing the client in the
Trendelenburg position.
Some of the non-pharmacological interventions for symptom management at the end of life were
previously discussed in the section entitled "Applying a Knowledge of Pathophysiology to Non-
Pharmacological Comfort/Palliative Care Interventions".
Some of the other physical symptom management intervention will be discussed now, according to
body system. Many of these physical disorders and related symptoms occur most often among
clients at the end of life who have terminal cancer.

Dehydration
Fluid and electrolyte imbalances may occur at the end of life as a result of the client's loss of appetite
and their refusal of food and fluids as the end of lie is near. The signs and symptoms of moderate
dehydration include dry skin, thirst, oral dryness, constipation, headache, a diminished urinary
output, orthostatic hypotension, and dizziness; the signs of severe dehydration have the signs and
symptoms of moderate dehydration in addition to possible anuria and renal failure, hypotension,
poor skin turgor, tachycardia, delirium, tachypnea, sunken eyes, confusion, a high fever, and
electrolyte imbalances.
Some clients at the end of life may elect to have fluid rehydration and other things like total
parenteral nutrition and tube feedings to correct dehydration and, others choose to not have these
interventions at the end of life. Some of the interventions that should be rendered to clients with
dehydration for symptom relief include things like ice chips or an ice pop for oral dryness,
antipyretic medication for a high temperature, and the maintenance of safety when the client is
adversely affect with dizziness, orthostatic hypotension, confusion and/or hypotension.
More information about fluids and electrolytes, and fluid and electrolyte imbalances will be fully
described in detail later in this NCLEX-RN review with the section entitled "Fluid and Electrolyte
Imbalances".

Superior Vena Cava Syndrome

Superior vena cava syndrome is characterized with the compression of the vena cava of the heart to
the extent that this compression decreases and prevents the return of blood to the heart. A tumor in
the mediastinal area is the most common risk factor associated with superior vena cava syndrome.
Some of the signs and symptoms associated with superior vena cava syndrome are a rapid
respiratory rate, cyanosis, dyspnea, edema, a decreased level of consciousness, seizures, venous
stasis, respiratory distress, and respiratory arrest
The treatment of superior vena cava syndrome, depending on the severity of it and the client's
choices at the end of life, can include respiratory support with oxygen supplementation and
mechanical ventilation, dexamethasone or another corticosteroid medication to decrease the edema,
and seizure precautions.

Cardiac Tamponade
Cardiac tamponade results from the collection of fluid in the pericardial sac around the heart which
impedes the compression, filling and pumping actions of this vital organ. Oncology clients who are
affected with tumors near or invading the pericardial sac, those who had therapeutic radiation to this
area, and clients who have had a traumatic chest puncture wound are at risk for cardiac tamponade.
Oliguria, a narrow pulse pressure, tachycardia, diminished peripheral pulses, jugular vein distention,
high central venous pressure and hypotension are some of the signs and symptoms of cardiac
tamponade. Treatments for this life threatening disorder can include medication to correct
hypotension, oxygen supplementation, intravenous fluids and, at times a pericardicentesis may be
indicated for the client affected with cardiac tamponade.

Septic Shock
Septic shock at the end of life is a risk for clients at the end of life particularly if they are
immunosuppressed and not able to combat infections as the result of the client's disease process
such as can occur with HIV/AIDS, leukemia, and lymphoma. Some of the signs and symptoms of
septic shock include a high temperature, confusion, pulmonary edema, massive vasodilation, lethargy
and hypoxia.
Some of the treatments used for septic shock, should the client want these treatments, are
intravenous fluid replacements, antibiotics, oxygen supplementation, mechanical ventilation, dialysis,
and medications to increase the blood pressure.

Hypovolemic Shock
Hypovolemic shock can occur at the end of life and at other times as the result of severe and
prolonged dehydration, hemorrhage, and other causes of bodily fluid losses such as vomiting and
diarrhea. In addition to death from hypovolemic shock, the client can be affected with progressive
and severe dehydration, metabolic acidosis, decreased cardiac output, and multisystem failure and
shutdown.
Some of the intervention for hypovolemic shock, in addition to correcting an underlying cause such
as bleeding and dehydration, are intravenous fluid replacements with fluids like lactated Ringers, the
administration of blood, blood components and plasma expanders, and placing the client in the
Trendelenburg position.

Hypercalcemia
Hypercalcemia, which is elevated calcium in the blood, occurs at the end of life especially among
clients who are affected with bone cancer, multiple myeloma, and breast cancer. Some of the signs
and symptoms of hypercalcemia include anorexia, nausea, vomiting, paresthesia, muscular weakness,
and pain.
The symptomatic relief of hypercalcemia at the end of life, in addition to intensive intravenous fluid
replacement therapy, are increasing oral fluid intake, vitamins D and A, pain medications to relieve
the pain, and medications such as diuretics to increase urinary output and clear the body of the
calcium, and other medications like pamidronate and alendronate. Client safety is also important
because the client with hypercalcemia is at risk for pathological bone fractures secondary to bone
decalcification. Again, some clients may elect to have one or more of these interventions and other
clients may not elect to have one or more of these interventions.

Tumor Lysis Syndrome

Tumor lysis syndrome is an oncological emergency that is most often found among clients who are
affected with group of metabolic complications, which can occur as the result of cancer treatments.
Tumor lysis syndrome produces the release of phosphates, nucleic acids and potassium into the
client's blood. Risk factors for tumor lysis syndrome include tumors that are large and aggressive and
clients affected with dehydration, lymphoma, leukemia and also when clients have had
chemotherapy for cancer.
Some of the signs and symptoms associated with tumor lysis syndrome include lethargy, pain,
muscular weakness secondary to hyperkalemia, renal failure, and sudden death. Some of the
treatments for tumor lysis syndrome include dialysis, intravenous fluid hydration, and medications
like allopurinol and rasburicase.

Increased Intracranial Pressure

Increased intracranial pressure can occur secondary to a traumatic closed head injury, a subdural
hematoma, an epidural hematoma, brain tumors, and structural deficits such as occurs when a
neonate is born with spina bifida, for example. The signs and symptoms of increased intracranial
pressure are Cheyne-Stokes respirations, a widened pulse pressure, bradycardia and Cushing's signs
and symptoms.
Treatments include medications such as mannitol which is a cerebral osmotic diuretic that decreases
the fluid buildup, anticonvulsant medications to decrease the risk of seizure activity, the relief of
edema using corticosteroids, and the correction of any hypertension. When this disorder is profound
and severe, mechanical ventilation can be initiated and a barbiturate coma may be induced.

Syndrome of Inappropriate Antidiuretic Hormone

Secretion (SIADH)
The syndrome of inappropriate antidiuretic hormone secretion most often affects clients who have
cerebral tumors, leukemia, lung cancer, pancreatic cancer, and brain tumors. Physiologically, the
syndrome of inappropriate antidiuretic hormone is the result of the hypersecretion of antidiuretic
hormone from the pituitary endocrine gland.
Some of the signs and symptoms of signs and symptoms associated with the syndrome of
inappropriate antidiuretic hormone include irritability and other mood changes, alterations in the
client's mental status, lethargy, the retention of fluids, and hyponatremia. The symptoms of this
disorder can be corrected and treated, at times, with the permission and consent of the client, with
the symptomatic relief of pulmonary and cerebral edema, as discussed above, increased fluid intake
and the administration of hypertonic intravenous fluids, lithium carbonate that minimizes the
adverse effects of excessive antidiuretic hormone, and demeclocycline to promote urinary
elimination and diuresis.

Planning Measures to Provide

Comfort Interventions to Clients with
Anticipated or Actual Impaired
Comfort
Measures and interventions to provide comfort to the client with potential and anticipated as well as
actual alterations of comfort can include both dependent and independent nursing interventions.
Some of these interventions are pharmacological and others are non-pharmacological, and some of
these interventions are consented to by the client and other clients may refuse these interventions.
Independent nursing functions include those things such as the initiation of coughing and deep
breathing exercises and back massage, and dependent nursing functions, which are interventions that
the nurse can only perform with a doctor's order, include things like the administration of analgesic
medications and intravenous fluid replacements.
Non-pharmacologic comfort measures, of which there are many to select from, have been
previously listed and discussed in the section above entitled "Introduction to End of Life Care".
Pharmacological pain management will be fully discussed below in the section entitled
"Pharmacological Pain Management" and the assessment of clients in reference to pain and their
level of pain was fully discussed above in the section entitled "Assessing the Client's Need for Pain
Management".

Providing Non-Pharmacological
Comfort Measures
Non-pharmacologic comfort measures have been previously listed and discussed in the section
above entitled "Introduction to End of Life Care".
Evaluating the Client's Response to
Non-Pharmacological Interventions
In actuality, this topic heading is somewhat misleading because both the non-pharmacologic
comfort measures and the pharmacologic comfort measures are evaluated in the same manner. Both
are evaluated in terms of the expected outcomes that were established for the client in terms of their
level of comfort and their freedom from pain and discomfort.
Some of these expected outcomes that are considered in terms of whether or not the client has
achieved them include, for example:

 The client will express relief of pain after performing progressive relaxation techniques
 The client will decrease their level by 4 on a scale from 1 to 10 with a numeric pain assessment
scale
 The client will demonstrate the procedure for meditation
 The infant will demonstrate a decreased level of pain according to the CRIES pain scale
 The preschool age client will demonstrate a decreased level of pain according to the FACES
pain scale
 The cognitively impaired client will demonstrate a relief from pain with better periods of rest
and sleep
 The client will have an expressed decreased level of pain after the administration of the ordered
narcotic analgesic
 The client will have an expressed decreased level of pain after the administration of the ordered
NSAID for the relief of pain
 The client will list and describe five non-pharmacological pain control methods that they can use
for the relief of pain

Evaluating the Outcomes of

Alternative and/or Complementary
Therapy Practices
As stated immediately above, both the non-pharmacologic comfort measures which include
alternative and complementary therapy practices, and the pharmacologic comfort measures are
evaluated in the same manner. Both are evaluated in terms of the expected outcomes that were
established for the client in terms of their level of comfort and their freedom from pain and
discomfort.
Evaluating the Outcome of Palliative
Care Interventions
Evaluating the outcomes of palliative care interventions are determined and measured by comparing
and contrasting the client's physical, psychological, social and spiritual/religious current status to the
pre-established client goals or expected outcomes. For example:

 Have the client and family members verbalized a knowledge of palliative care?
 Have the client and family members demonstrated an understanding of the end of life signs and
symptoms?
 Have the client and family members demonstrated a lack of depression and a level of acceptance
in terms of the imminent death?
 Is the client without any signs of respiratory distress?
 Is the client without any signs of pain or discomfort?
 Is the client without any signs of skin breakdown?
 Are the family members participating in the end of life care for the client?
 Are the client and family members free of psychological and emotional distress?
 Are the client and family members free of anger and hostility?
 Are the client and family members free of guilt?
 Are the client and family members effectively coping with grief and loss?
 Is the client meeting their spiritual and/or religious needs?
 Does the client have a sense of meaning and connectedness?
 Is the client free of any spiritual and religious distress?
 Are the client and family members free of depression?
 Are the client and family members free of fear and anxiety?
 Are the client's choices at the end of life supported and accepted by family members?
 Is the client free of any agitation and restlessness?
 Have the client's last wishes been expressed to others and accepted by others?

Nutrition and Oral

Hydration: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of nutrition and oral hydration in order to:
 Assess client ability to eat (e.g., chew, swallow)
 Assess client for actual/potential specific food and medication interactions
 Consider client choices regarding meeting nutritional requirements and/or maintaining dietary
restrictions, including mention of specific food items
 Monitor client hydration status (e.g., edema, signs and symptoms of dehydration)
 Initiate calorie counts for clients
 Apply knowledge of mathematics to client nutrition (e.g., body mass index [BMI])
 Manage the client's nutritional intake (e.g., adjust diet, monitor height and weight)
 Promote the client's independence in eating
 Provide/maintain special diets based on the client diagnosis/nutritional needs and cultural
considerations (e.g., low sodium, high protein, calorie restrictions)
 Provide nutritional supplements as needed (e.g., high protein drinks)
 Provide client nutrition through continuous or intermittent tube feedings
 Evaluate side effects of client tube feedings and intervene, as needed (e.g., diarrhea, dehydration)
 Evaluate client intake and output and intervene as needed
 Evaluate the impact of disease/illness on nutritional status of a client

Adequate nutrition consists of the ingestion and utilization of water, essential nutrients, vitamins and
minerals to maintain and sustain health and wellness.
A normal diet should consist of all of the food groups including fruits, vegetables, dairy foods,
protein and grains according to the United States Department of Agriculture.
Like other basic human needs such as elimination, nutrition can be negatively impacted by a number
of factors and forces such as diseases and disorders like anorexia, nausea, vomiting, anorexia,
dysphagia and malabsorption, cultural and ethnical beliefs about nutrition and foods, personal
preferences, level of development, lifestyle choices, economic restraints, psychological factors and
disorders such as eating disorders, medications, and some treatments like radiation therapy and
chemotherapy.
Some of the terms and terminology relating to nutrition and hydration that you should be familiar
with include those below.

 Anabolism: Anabolism is one of the three things that occur with protein metabolism.
Anabolism occurs when these cells utilize amino acids to build tissue up. The other two
mechanisms of protein metabolism are catabolism and a nitrogen balance.

 Catabolism: Catabolism, which also occurs with protein metabolism, occurs when excessive
amino acids are broken down in the tissue and the liver.

 Nitrogen balance: Nitrogen balance occurs as the result of the client's level of protein
nutrition. It reflects protein metabolism and the gains and losses of nitrogen.
 Basal metabolism rate: The basal metabolism rate reflects the extent to which the body meets
the energy demands of the body with the metabolism of food.

 Body mass index: Body mass index is an indication of how much fat there is in the body. Body
mass index is used as a measurement that is useful in determining whether or not the client is
overweight and/or retaining fluids or if their body mass index is acceptable for the client's
height and weight.

 Calorie: A calorie is a measure of heat. The number of calories varies among the food groups.
For example, there are 9 calories per gram of fat and there are 4 calories per gram of protein and
carbohydrates.

 Complete protein: A complete protein is a protein that consists of all of the essential amino
acids in addition to some non-essential ones. Examples of complete proteins include poultry,
meats, fish and eggs.

 Incomplete protein: An incomplete protein is a protein that is without one or more of the
essential amino acids. Vegetables of all kinds are considered an incomplete protein.

 Essential amino acids: Essential amino acids are those amino acids that cannot be made by
the body. The nine essential amino acids include tryptophan, valine, methionine, phenylalanine,
histidine, leucine, threoline, isoleucine, and lysine.

 Nonessential amino acids: Nonessential amino acids are those amino acids that can be made
by the body. Examples of nonessential amino acids are cystine, glutamic acid, alanine, aspartic
acid, proline, serine, hydroxyproline and tyrosine.

 Dysphagia: Dysphagia is difficulty swallowing. Dysphagia can occur as the result of an

anatomical stricture and from other causes, including those that are neurological in nature.

 Fat soluble vitamins: Fat soluble vitamins are vitamins that cannot be produced by the body
and those that can be stored in the body. A client can also overdose on fat soluble vitamins
because they can accumulate these kinds of vitamins with this storage. Examples of fat soluble
vitamins are vitamins A, D, E and K.

 Water soluble vitamins: Water soluble vitamins are vitamins that cannot be produced by the
body and those that cannot be stored in the body. These vitamins are not stored in the body.
Examples of water soluble vitamins are vitamins B and C.
Assessing the Client's Ability to Eat
Adequate nutrition is dependent on the client's ability to eat, chew and swallow.
In addition to a complete assessment of the client's current nutritional status, nurses also collect data
that can suggest that the client is, or possibly is, at risk for nutritional deficits. The assessment of the
client's nutritional status is done with a number of subjective and objective data that is collected and
analyzed. For example, the client is assessed using the A, B, C and Ds of a nutritional assessment in
addition to the use of some standardized tools such as the Patient Generated Subjective Global
Assessment and the Nutrition Screening Inventory. The A, B, C and Ds of nutritional assessment
include:

 A: Anthropometric Data: This data includes variables such as height, weight, body mass index
and arm measurements such as the mid arm circumference and the triceps skin fold.

 B: Biochemical Data: Laboratory testing data like serum albumin, hemoglobin, urinary
creatinine, and serum transferrin.

 C: Clinical Data: The client's skin condition, level of activity and status of the client's mucous
membranes.

 D: Dietary Data: This data includes the client's subjective reports of their food and fluid intake
over the last 24 hours and the types of foods that are typically eating.

Some of the factors that impact on the client's nutrition, their nutritional status and their ability to
eat include:

 Level of health
 Psychological influences and disorders
 Ethnicity
 Culture
 Personal preferences
 Religious practices and rituals
 Gender
 Level of development
 Lifestyle choices
 Personal beliefs about food and food intake
 Medications
 Therapeutic treatments
 Level of health
 Psychological influences and disorders
 Economic status
 Swallowing disorders
 Chewing disorders
 Dentition

Swallowing disorders, chewing disorders and poor dentition are factors that can impede the client's
mechanical ability to eat. For example, a client with a chewing disorder, such as may occur secondary
to damage to the trigeminal nerve which is the cranial nerve that controls the muscle of chewing,
may have impaired nutrition in the same manner that these clients are at risk:

 A client with poor dentition and misfitting dentures

 A client who does not have the ability to swallow as the result of dysphagia which is a
swallowing disorder that sometimes occurs among clients who are adversely affected from a
cerebrovascular accident
 A client with an anatomical stricture that can be present at birth
 The client with side effects to cancer therapeutic radiation therapy
 A client with a neurological deficit that affects the client's vagus nerve and/or the hypoglossal
cranial nerve which are essential for swallowing and the prevention of dangerous and life
threatening aspiration

Clients with a swallowing disorder are often assessed and treated for this disorder with the
collaborative efforts of the speech and language therapist, the dietitian, the nurse and other members
of the health care team. Clients with poor dentition and missing teeth can be assisted by a dental
professional, the nurse and the dietitian in terms of properly fitting dentures and, perhaps, a special
diet that includes pureed foods and liquids that are thickened to the consistency of honey so that
they can be swallowed safely and without aspiration when the client is adversely affected with a
swallowing disorder.

Assessing the Client for

Actual/Potential Specific Food and
Medication Interactions
Medications have a great impact on the client's nutritional status. Some medications interfere with
the digestive process and others interact with some foods.
Some of the medications that impact on the client's nutrition status include thiazide diuretic
medications which can decrease the body's ability to absorb vitamin B12 and acetylsalicylic acid
which can decrease the amounts of vitamin C, potassium, amino acids, and glucose available to the
body because acetylsalicylic acid can lead to the excessive excretion of these substances.
Medications, including over the counter medications, interact with foods, herbs and supplements.
Some of these interactions are synergistic and others are antagonistic, that is these interactions can
increase and potentiate the effects of the medication(s) and others neutralize and inhibit the
therapeutic effects of the medication. For example, clients who are taking an anticoagulant such as
warfarin are advised to avoid vegetables that contain vitamin K because vitamin K is the antagonist
of warfarin.
Food – drug interactions will be more fully discussed in the "Pharmacological" and "Parenteral
Therapies" sections in the subtitled topic "Providing Information to the Client on Common Side
Effects/Adverse Effects/Potential Interactions of Medications and Informing the Client When to
Notify the Primary Health Care Provider".

Considering Client Choices Regarding

Meeting Nutritional Requirements
and/or Maintaining Dietary
Restrictions
As previously mentioned, a number of factors impact on the client, their preferences and their
choices in terms of the kinds of foods that they want to eat and in terms of the quantity of food that
they want to consume.
Some of these factors, as previously discussed, include gender, cultural practices and preferences,
ethnic practices and preferences, spiritual and religious practices and preferences and, simply,
personal preferences that have no basis in the client's spiritual, religious, cultural, or gender practices
and preferences. The client may simply ask the nurse for a turkey sandwich, something that can be
given to the client when it is available and it is not contraindicated according to the client's
therapeutic diet.
These client choices and preferences become quite challenging indeed when the client has a dietary
restriction. For example, Americans in the southern area of the United States may prefer fried foods
like fried chicken instead of a healthier piece of broiled or baked chicken, however, when they are
affected with high cholesterol levels, modifications in this diet must be made; similarly, when a
member of the Hindu religion is a vegetarian and they lack protein, the diet of this person must also
be modified. These modifications must be explored and discussed with the client; alternatives should
be offered and discussed and the closer these alternative options are to the client's preferences, the
greater the client's adherence to their dietary plan will be. Educating the client and family members
about the modified diet and the need for this new diet in terms of the client's health status is also
highly important and critical to the success of the client's dietary plan and their improved state of
health and wellness.
Monitoring the Client's Hydration
Status
Some of the terms and terminology relating to hydration and the client's hydration status that you
should be familiar with for your NCLEX-RN examination include these below.

 Intracellular fluids: Intracellular fluids are those fluids that are within the cells of the body.
Most of the bodily fluids, that is about two thirds of the total bodily fluids, are intracellular
fluids.

 Extracellular fluids: Extracellular fluids are those fluids that are found outside of the cells of
the body. About one third of the total bodily fluids are extracellular fluids and extracellular fluids
include both intravascular fluids which are fluids contained in the vessels of the body and
interstitial fluids which are fluids around the cells but neither in the vascular system or within the
cells.

 Electrolytes: Electrolytes are electrically charged salts in the body. Electrolytes consist of both
cations and anions.

 Cations: Cations are electrically charged electrolytes with a positive charge. Examples of cations
are sodium, calcium, magnesium and potassium.

 Anions: Anions are electrically charged electrolytes with a negative charge. Examples of anions
include phosphate, bicarbonate, sulfate and chloride.

 Diffusion: Diffusion is the principle of physics that establishes the fact that molecules will
move, or diffuse, from an area that is more concentrated than the area that these molecules
move to. Molecules will diffuse from an area of high concentration to an area of low
concentration across a semipermeable membrane. Diffusion is a mechanism that attempts to
create a balance on both sides of the semipermeable membrane.

 Osmosis: Osmosis is the principle of physics which states that water will move across the
membrane from areas of high concentration to an area of low concentration. Osmosis is similar
to diffusion but diffusion is the movement of molecules and osmosis is the movement of water
from the area of high concentration to the area of lower concentration.
 Filtration: Filtration is the principle of physics that states that solutes, in combination with
fluids, move across the membrane from areas of high concentration to an area of low
concentration.

Fluid imbalances can be broadly categorized a fluid deficits and fluid excesses. Generally speaking
fluid balance and fluid imbalances can be impacted by the client's age, body type, gender, some
medications like steroids which can increase bodily fluids and diuretics which can deplete bodily
fluids, some illnesses such as renal disease and diabetes mellitus, extremes in terms of environmental
temperature, an increased bodily temperature, and some life style choices including those in
relationship to diet and fluid intake.
The aging population as well as Infants and young children are at greatest risk for fluid imbalances
and the results of these imbalances. For example, the elderly is at risk for alterations in terms of fluid
imbalances because of some of the normal changes of the aging process and some of the
medications that they take when they are affected with a chronic disorder such as heart failure. Some
of the normal changes of the aging process that can lead to an imbalance of fluid include the aging
person's loss of the thirst which, under normal circumstances, would encourage the client to drink
oral fluids, decreased renal function, and the altered responses that they have in terms of fluid and
electrolyte imbalances during the aging process
Infants and young children at risk for alterations in terms of fluid imbalances because of their
relatively rapid respiratory rate which increases inpercernible fluid losses through the lungs, the
child's relatively immature renal system, and a greater sensitivity to fluid losses such as those that
occur with vomiting and diarrhea.
Women, in contrast to male clients, are at greater risk for alterations in terms of bodily fluids
because they tend to have more fat, which contains less fluid, than muscle which contains more
bodily fluid. Lastly, clients who are febrile and clients who are exposed to prolonged hot
environmental temperatures will lose bodily fluids as the result of sweating and these unpercernable
fluid losses. Sweating is a cooling off response to intrapersonal and extrapersonal hot temperatures.

Fluid Excesses
Fluid excesses, also referred to as hypervolemia, is an excessive amount of fluid and sodium in the
body. Fluid excesses are the net result of fluid gains minus fluid losses. When fluid gains, and fluid
retention, is greater than fluid losses, fluid excesses occur.
Specific risk factors associated with fluid excesses include poor renal functioning, medications like
corticosteroids, Cushing's syndrome, excessive sodium intake, heart failure, hepatic failure and
excessive oral and/or intravenous fluids. Fluid excesses are characterized with unintended and
sudden gain in terms of the client's weight, adventitious breath sounds such as crackles, tachycardia,
bulging neck veins, occasional confusion, hypertension, an increase in terms of the client's central
venous pressure and edema.
Edema is an abnormal collection of excessive fluids in the interstitial and/or intravascular spaces.
Edema is a sign of fluid excesses because edema occurs as the result of increases in terms of
capillary permeability, decreases in terms of the osmotic pressure of the serum and increased
capillary pressure. In combination, these forces push fluids into the interstitial spaces.
Edema is most often identified in the dependent extremities such as the feet and the legs; however,
it can also become obvious with unusual abdominal distention and swelling. Nurses assess edema in
terms of its location and severity.
Pitting edema is assessed and classified as:

 1+ Pitting Edema: The edematous area is depressed or indented 1 cm or less

 2+ Pitting Edema: The edematous area is depressed or indented 2 cm or less
 3+ Pitting Edema: The edematous area is depressed or indented 3 cm or less
 4+ Pitting Edema: The edematous area is depressed or indented 4 cm or less
 5+ Pitting Edema: The edematous area is depressed or indented 5 cm or less

Some professional literature classifies pitting edema on a scale of 1+ to 4+ with:

 1+ Pitting Edema: The edematous area is hardly detectable

 2+ Pitting Edema: The edematous area is depressed or indented 2 cm to 4 cm
 3+ Pitting Edema: The edematous area is depressed or indented 5 cm to 7 cm
 4+ Pitting Edema: The edematous area is depressed or indented > 7 cm

Fluid Deficits
Dehydration occurs when fluid loses are greater than fluid gains. Fluid losses occur as the result of
vomiting, diarrhea, a high temperature, the presence of ketoacidosis, diuretic medications and other
causes.
The signs and symptoms of mild to moderate dehydration include, among others, orthostatic
hypotension, dizziness, constipation, headache, thirst, dry skin, dry mouth and oral membranes, and
decreased urinary output. The signs and symptoms of severe dehydration include, among others,
oliguria, anuria, renal failure, hypotension, tachycardia, tachypnea, sunken eyes, poor skin turgor,
confusion, fluid and electrolyte imbalances, fever, delirium, confusion, and unconsciousness.
Significant fluid losses can result from diarrhea, vomiting and nasogastric suctioning; and abnormal
losses of electrolytes and fluid and retention can result from medications, such as diuretics or
corticosteroids. Clients at risk for inadequate fluid intake include those who are confused and unable
to communicate their needs.
Dehydration occurs when one loses more fluid than is taken in. Fluid losses occur with normal
bodily functions like urination, defecation, and perspiration and with abnormal physiological
functions such as vomiting and diarrhea.

Initiating Calorie Counts for Clients

Many people on a weight reduction diet or a diet to increase their weight are based on calories
counts. The number of calories per gram of protein is 4 calories, the number of calories per gram of
fat is 9 calories and the number of calories per gram of carbohydrates is 4 calories.
Clients can be instructed to count calories by weighing the food that will be eaten and then multiply
this weight in grams by the number of calories per gram. For example, if the client will be eating a 14
grams of plain tuna fish, the number of calories can be calculated by multiplying 14 by 4 which
would be 56 calories. Similarly, a client who will be eating 100 grams of a carbohydrate could
calculate the number of calories by multiplying 100 by 4 which is 400 calories.
The method above is quite cumbersome because it entails weighing the food and then calculating
the number of calories. A simpler method is to read food labels. For example, if a package of frozen
food like chicken nuggets states that there are 2500 calories per package and there are 3 servings in
each package, each serving will have about 833 calories when a person eats 1/3 of the package of
chicken nuggets.

Applying a Knowledge of
Mathematics to the Client's Nutrition
Similar to the calculation of calories, as above, mathematics is also used to calculate other indicators
about the client's nutritional status. For example, the client's body mass index (BMI) and the "ideal"
bodily weight can be calculated using relatively simple mathematics.
The body mass index is calculated using the client's bodily weight in kg and the height of the client
in terms of meters. The mathematical rule for calculating the client's BMI is:
BMI = kg of body weight divided by height in meters squared
So, the BMI for a client weighing 75 kg who is 1.72 meters tall is calculated as follows:
BMI = 75 kg / 2.96 = 28.8 BMI
The ideal body weight is calculated using the client's height, weight and body frame size as classified
as small, medium and large. The mathematical rule for calculating this ideal weight for males and
females of small, medium and large body build are:

 Ideal body weight for females with a medium body build = 100 pounds per 5 feet of height
+ 5 pounds for every inch over 5 feet tall for females with a medium body build

 Ideal body weight for females with a small body build = 100 pounds per 5 feet of height +
5 pounds for every inch over 5 feet tall – 10% of the client's weight for females with a small
body build
 Ideal body weight for females with a large body build = 100 pounds per 5 feet of height +
5 pounds for every inch over 5 feet tall + 10% of the client's weight for females with a large
body build

 Ideal body weight for males with a medium body build = 106 pounds per 5 feet of height
+ 6 pounds for every inch over 5 feet tall for males with a medium body build

 Ideal body weight for males with a small body build = 106 pounds per 5 feet of height + 6
pounds for every inch over 5 feet tall – 10% of the client's weight for males with a small body
build

 Ideal body weight for males with a large body build = 106 pounds per 5 feet of height + 6
pounds for every inch over 5 feet tall + 10% of the client's weight for males with a large body
build

Managing the Client's Nutritional

Intake
Some clients need management in terms of weight reduction and others may need the assistance of
the nurse and other health care providers, such as a registered dietitian, in order to gain weight. All
clients, however, must have a balanced and healthy diet with all of the food groups. Fad diets and
drastic weight reduction diets are not a successful way to lose and maintain a healthy weight; learning
new eating habits is a successful plan for losing and maintaining a lower and healthier body weight
for those clients who are overweight.
Although more clients should reduce their weight, there are some clients that have to be encouraged
to gain weight. This is often the case when a client is recovering from a physical disease and
disorder, particularly when this disease or disorder is accompanied with nausea, vomiting, and/or
anorexia. These clients should have attractive and preferred food preferences and, at times, they may
need dietary supplements and medications to stimulate their appetite.
In addition to planning a diet with the client to increase or decrease their body weight, the client's
weight and body mass index should be monitored on a regular basis. The calculations for both of
these variables were discussed above. In addition to these calculations, the nurse must also be
knowledgeable about what is and what is not a good body mass index or BMI.
According to the U.S. Department of Health and Human Services, a body mass index of:

 < 18.5 is considered underweight

 18.5 to 24.9 is considered a normal body weight
 25 to 29.9 is considered overweight
 30 to 39.9 is considered obese
 40 is considered extremely obese

Promoting the Client's Independence

in Eating
As with all activities of daily living, nurses and other members of the health care team must promote
and facilitate the client's highest degree of independence that is possible in terms of their eating, as
based on the client, their abilities and their weaknesses.
Some of the assistive devices that can be used to accommodate for clients' weaknesses and to
promote their independent eating include items like weighted plates, scoop dishes, food guards
around the plate, assistive utensils, weighted and tip proof drinking glasses and cups.

Providing and Maintaining Special

Diets Based on the Client's
Diagnosis/Nutritional Needs and
Cultural Considerations
There are a number of therapeutic special diets that are for clients as based on their health care
problem and diagnosis. All diets, including these special diets, must be modified according to the
client's cultural preferences, religious beliefs and personal preferences to the greatest extent possible.
These special diets, some of the indications for them, and the components of each are discussed
below.

Clear Fluid Diet

 Indications: Post-operative diet, prior to some diagnostic tests like a colonoscopy, bowel rest
and during acute illness

 Components: Clear fluids including clear broth, juices like apple juice, water, tea, ginger ale,
clear Italian ice, and Jell-O

Full Fluid Diet

 Indications: Advancement from a clear diet post operatively, and for clients with
gastrointestinal disorders like gastritis

 Components: All clear fluids in addition to vegetable juice, milk, all fruit juices, yogurt and
pudding

Soft Bland Low Fiber Low Residue Diet

 Indications: Advancement from a full fluids diet, problems with chewing and gastrointestinal
disorders

 Components: Soft foods except those with fiber like fruits and vegetables

Mechanical Soft Diet

 Indications: Poor dentition, swallowing disorders, intestinal tract strictures and post operatively
after face or neck surgery

 Components: Ground meats, mashed potatoes, clear and full fluids, and soft vegetables and
fruits

Low Sodium Diet

 Indications: Renal, cardiac and liver disease

 Components: All foods with the exception of frozen and canned foods, cold cuts, smoked
meats like bacon and sausage

Low Cholesterol Diet

 Indications: Cardiac disease

 Components: All food that are low in cholesterol; limited in terms of fats and meats

High Fiber Diet

 Indications: Constipation and other gastrointestinal disorders
 Components: High fiber foods like fruits, vegetables and whole grains

Dysphagia Diet
 Indications: Swallowing disorders

 Components: Honey consistency thickened fluids and easy to swallow ground and pureed
foods

High Protein Diet

 Indications: Cachexia, wasting and during renal dialysis

 Components: Meats, eggs, fish and dairy products in addition to protein supplements

Diabetic Diet
 Indications: Diabetes

 Components: Carbohydrate restrictions

Calorie Restricted Diet

 Indications: Weight reduction

 Components: A balance diet without sugars and low in terms of carbohydrates

Providing Nutritional Supplements as

Needed
Many clients have orders for dietary supplements including high protein drinks like Boost and
Ensure. These drinks come in a variety of flavors including chocolate, vanilla and strawberry. The
doctor's order for these nutritional supplements states the name of the specific nutritional
supplement and the number of cans per day. Clients must be encouraged to drink these supplements
as ordered and the client's flavor preference should also be considered and provided to the client
whenever possible.
Providing Client Nutrition Through
Continuous or Intermittent Tube
Feedings
Enteral nutrition is given to clients when, for one reason or another, the client is not getting
sufficient calories and/or nutrients with oral meals and eating. Enteral nutrition is most often used
among clients who are affected with a gastrointestinal disorder, a chewing and/or swallowing
disorder, or another illness or disorder such as inflammatory bowel disorder, a severe burn and
anorexia as often occurs as the result of an acute illness, chemotherapy and radiation therapy.
Enteral nutrition can be given on a continuous basis, on an intermittent basis, as a bolus, and also as
supplementation in addition to oral feedings when the client is not getting enough oral feedings.
Enteral feedings can consist of commercially prepared formulas that vary in terms of their calories,
fat content, osmolality, carbohydrates and protein as well as given with regular pureed foods.
Enteral tube feedings are delivered with a number of different tubes such as a nasointestinal tube
that goes to the intestine through the nose, a nasogastric tube which is placed in the stomach
through the nose, a nasojejunal tube that enters the jejunum of the small intestine through the nose,
a nasoduodenal tube that enters the duodenum through the nose, a jejunostomy tube that is
surgically placed directly into the jejunum of the small intestine, a gastrostomy tube that is surgically
placed into the stomach directly and a percutaneous endoscopic gastrostomy (PEG) tube. Naso
tubes, like the nasogastric and nasoduodenal tubes, are the preferred tube because their placement is
noninvasive, however, naso tubes are contraindicated when the client has a poor gag reflex and
when they have a swallowing disorder because any reflux can lead to aspiration. Clients receiving
these feedings should be placed in a 30 degree upright position to prevent aspiration at all times
during continuous tube feedings and at this same angle for at least one hour after an intermittent
tube feeding.
In addition to aspiration, some of the other complications associated with tube feedings include tube
leakage, diarrhea, dehydration, nausea, vomiting, inadvertent improper placement or tube
dislodgment, nasal irritation when a naso tube is used and infection at the insertion site when an
ostomy tube is used for the enteral nutrition. At times, abdominal cramping and diarrhea can be
prevented by slowing down the rate of the feeding. The doctor is notified when the residual volume
is excessive and when the tube is not patent or properly placed.
Continuous tube feedings are typically given throughout the course of the 24 hour day. A pump,
similar in terms to an intravenous infusion pump, controls the rate of the tube feeding infusion at
the ordered rate. The residual volume of these feedings is aspirated, measured and recorded at least
every 6 hours and the tube is flushed every 4 hours to maintain its patency.
Intermittent tube feedings are typically given every 4 to 6 hours, as ordered, and the volume of each
of these intermittent feedings typically ranges from 200 to 300 mLs of the formula that is given over
a brief period of time for up to one hour. The residual volume of these feedings is aspirated,
measured and recorded prior to each feeding and the tube is flushed before and after each
intermittent feeding with about 30 mLs of water and before and after each medication
administration to insure and maintain its patency.
Bolus enteral feedings are given using a large syringe and they are typically given up to 6 times a day
over the course of about 15 minutes. The volume of bolus enteral feedings is usually about 200 to
400 mLs but not over 500 mLs per feeding. Bolus tube feedings are associated with dumping
syndrome which is a complication of these feedings.
Tube placement is determined by aspirating the residual and checking the pH of the aspirate and
also with a radiography, and/or by auscultating the epigastric area with the stethoscope to hear air
sounds when about 30 mLs of air are injected into the feeding tube. A pH > 6 indicates that the
tube is improperly placed in the respiratory tract rather than the gastrointestinal tract.
In addition to measuring the client's intake and output, the nurse monitors the client for any
complications, checks the incisional site relating to any signs and symptoms of irritation or infection
for internally placed tubes, secures the tube to prevent inadvertent dislodgement or malpositioning,
cleans the nostril and tube using a benzoin swab stick, applies a water soluble jelly just inside the
nostril to prevent dryness and soreness, provides frequent mouth care, and replaces the securing
tape as often as necessary.

Evaluating the Side Effects of Client

Tube Feedings and Intervening, as
Needed
Some of the side effects and complications associated with tube feedings, their prevention and their
interventions are discussed below.

Aspiration
 Prevention: Maintaining the head of the bed up at 30 degrees
 Interventions: Emergency suctioning, placing the client on their side and addressing any
respiratory distress

Diarrhea

 Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate
and formula when necessary
 Interventions: Slowing the rate down, changing the formula and medications to stop the
diarrhea
Abdominal Pain
 Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate
and formula when necessary
 Interventions: Slowing the rate down, changing the formula and analgesics as indicated

Dehydration
 Prevention: Monitor the client for any signs and symptoms of dehydration, measure intake and
output and notify the doctor of any abnormalities
 Interventions: Provide any ordered oral and/or intravenous fluids

Nausea and Vomiting

 Prevention: Maintaining a slow rate of infusion whenever possible, changing the ordered rate
and formula when necessary
 Interventions: Slowing the rate down, changing the formula and antiemetic medications to stop
the vomiting and to prevent any aspiration

Tube Dislodgment
 Prevention: Secure and monitor the tube
 Interventions: Notify the doctor and discontinue the tube feeding

Evaluating the Client's Intake and

Output and Intervening As Needed
Intake includes all foods and fluids that are consumed by the client with oral eating, intravenous
fluids, and tube feedings; output is the elimination of food and fluids from the body. Some
measurable outputs are urinary elimination, residual that is aspirated when the client is getting a tube
feeding, wound drainage, ostomy output, and vomitus. Some outputs that are not measurable
include respiratory vapors that are exhaled during the respiratory cycle and fluid losses from
sweating.
Solid intake is monitored and measured in terms of ounces; liquid intake is monitored and measured
in terms of mLs or ccs. Solid output is measured in terms of the number of bowel movements per
day; liquid stools and diarrhea are measured in terms of mLs or ccs. Urinary output is monitored and
measured in terms of mLs or ccs for toilet trained children and adults, and, in terms of diaper
weights or diaper counts for neonates and infants. Emesis is monitored and measured in terms of
mLs or ccs. A urinary output of less than 30 mLs or ccs per hour is considered abnormal.
Indirect evidence of intake and output, which includes losses that are not measurable, can be
determined with the patient's vital signs, the signs and symptoms of fluid excesses and fluid deficits,
weight gain and losses that occur in the short term, laboratory blood values and other signs and
symptoms such as poor skin turgor, sunken eyeballs and orthostatic hypotension.

Evaluating the Impact of Diseases and

Illnesses on the Nutritional Status of a
Client
Virtually all acute and chronic illnesses, diseases, and disorders impact on the nutritional status of a
client. For example, clients who are affected with cancer may have an impaired nutritional status as
the result of anorexia related to the disease process and as the result therapeutic chemotherapy
and/or radiation therapy; other clients can have an acute or permanent neurological deficit that
impairs their nutritional status because they are not able to chew and/or safely swallow foods and
still more may have had surgery to their face and neck, including a laryngectomy for example, or a
mechanical fixation of a fractured jaw, all of which place the client at risk for nutritional status
deficiencies.
The relative severity of these nutritional status deficits must be assessed and all appropriate
interventions must be incorporated into the client's plan of care, in collaboration with the client,
family members, the dietitian and other members of the health care team.

Personal Hygiene: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of personal hygiene in order to:

 Assess the client for personal hygiene habits/routine

 Assess and intervene in client performance of activities of daily living
 Provide information to the client on required adaptations for performing activities of daily living
(e.g., shower chair, hand rails)
 Perform post-mortem care

Personal hygiene, which is one of the basic activities of daily living, includes:
 Bathing, showering and washing
 Foot care
 Hair care
 Nail care
 Perineal care
 Shaving
 Mouth and oral care
 Denture care

Assessing the Client for Their

Personal Hygiene Habits and
Routines
There are a wide variety of different factors that influence and impact on our clients' hygiene habits
and routines. For example, cultural practices and beliefs, religious practices and beliefs, the client's
level of growth and development, economic factors and economic constraints, the client's level of
energy, the client's level of cognition, environmental factors including things like the environmental
temperature and the client's state of homelessness, the client's overall state of health and their own
particular personal preferences in terms of their personal hygiene habits and routines impact on
client choices, their preferences and practices relating to hygiene and hygiene practices.
Cultures and cultural practices relating to hygiene vary around the globe. In North America, for
example, there is a high cultural value on cleanliness, daily bathing, an odor free body and the
absence of leg hair on females. Other cultures, however, may only bathe once a week or less and
they are not offended with bodily odors or the presence of underarm and leg hair among females.
Some cultures bathe communally, whereas other cultures value privacy when bathing. There are also
some biocultural differences in terms of hygiene. For example, bodily odors tend to be more
prevalent and stronger among African Americans and Caucasians than they are among Native
Americans and those from Asian cultures.
Some of the religions practices and beliefs that may impact on our clients include those relating to
religious ceremonious bathings and washings; the client's age and level development impacts on how
and how often an infant will be washed and bathed and the client's age and developmental status
may also restrict the client from independent self care in terms of their personal hygiene, for
example; and economics and economic constraints may alter hygiene processes when, for example,
when the client lacks the funds for basic hygiene needs like soap, shampoo, lotions, and even hot
water. The client's level of energy, the client's level of cognition, and the client's overall level of
health are also factors that can both positively and negatively impact on the client's hygiene practices
and routines. For example, clients with impaired cognition, with poor overall health and with a low
level of energy may not be able to perform hygiene self care and they may not even tolerate
someone providing hygiene measures to them. Environmental factors including things like the
environmental temperature of the room in which the client is bathing or showering and the
provision of privacy can also impact on the client's hygiene practices. Lastly, the client's personal
preferences in terms of their personal hygiene habits and routines also vary. For example, some
clients may prefer to bathe in the morning and others may prefer to bathe in the evening before bed,
some male clients may shave daily and other male clients may only shave twice a week, and some
females may shave their legs and underarms on a daily basis, others may shave once a week or less
often, and still more may not shave their legs and underarms at all. Despite all of these factors, all
care, including hygiene care, must be tailored to meet the client's unique needs, preferences,
practices and routines.

Assessing and Intervening in the

Client's Performance of their Activities
of Daily Living
Nurses assess the client's ability to perform their activities such as personal hygiene, mobility,
ambulation, toileting, personal care and hygiene, grooming, dressing, and eating. Some clients are
wholly compensatory in terms of their self care activities. These clients need the nurse and other
members of the nursing team to provide this care to them; other clients are partly compensatory and
they can perform their activities of daily living with the help and assistance of another, and still more
are considered independent in terms of performing the activities of daily living and these clients may
only need the support of others in terms of their activities of daily living including hygiene,
according to Dorothea Orem's Self Care Theory.
As the nurse is assessing the client's ability to perform hygiene measures, they compare the client's
actual performance with established standards relating to these tasks and, then, they may educate the
client about the proper methods of performing the particular task, including safety measures and the
use of assistive devices to facilitate their self care hygiene.

Bathing Standards
The primary purpose of bathing is to cleanse the body of all dirt, sweat, germs, exfoliated skin, and
other things. This cleansing protects our first level defense against infection, and it also promotes
good circulation and client comfort.
In the health care setting, there are three different types of baths. They are a complete bed bath, a
partial bath, and a tub or shower bath.

 A compete bed bath is one that is given in the bed to the client by a nurse or another member of
the health care team like an unlicensed assistive staff member such as a nursing assistant or a
patient care technician.
 A partial bed bath is one that is given in the bed, like the complete bed bath, but the client only
needs the assistance of the nurse or another member of the health care team. The client
themselves is able to perform some or most of the bathing tasks. For example, the nursing staff
member may only have to collect and present the client with the necessary supplies and
equipment or wash the client's back.

 A tub bath is a bath that the clients are usually able to take themselves, but they may still need
assistance, such as getting in or out of the tub or shower, so it is important for the nursing staff
member to be available and present to help the client as needed.

With all types of baths, the water temperature must be checked to insure that it is safe and < 110
degrees. A shower chair, tub chair, grab bars, a nonskid bath or shower mat are also highly
important to prevent accidents. When clients prefer to shower or tub bathe rather than take a bed
bath, they will often need assistance getting in and out of the shower or tub to prevent a fall and
injury.
The following are the steps for a complete bath and a partial bath.

 Identify the client, introduce yourself and explain the bathing procedure to the client.

 Provide privacy.

 Raise the client's bed to a height that is the most comfortable and safe, in terms of body
mechanics, for you to work at. Make sure that the side rail on the side of the bed opposite to
you is up and locked in place. Raise the head of the bed to a height that is comfortable for the
client.

 Remove the client's blankets.

 Place towels under the areas that are being washed to protect the fitted bottom sheet from
moisture and only uncover the areas that are being washed rather than the entire area to
maintain client warmness.

 If a bath mitt is not available, a washcloth should be wrapped around your hand in a mitt like
fashion.

 Each part of the client's body is washed, rinsed, dried and then covered with a bath towel or a
blanket.

 Rinse the wash mitt or washcloth after each part of the body is washed.
 Change the bath water in the basin when it cools off or becomes too soapy.

 Make sure that every area, including the face, behind the ears, chest, back, arms, legs, hands,
fingernails, perineal area, and feet are thoroughly washed, rinsed and dried thoroughly.

 Like physical assessment, the bath is given from head to toe. The first area to be washed is the
inner canthus of each eye; the neck area is the face and neck, after which the bath is given
downwards towards the toes.

After the bath is complete, the height of the bed to lowered to its lowest position to insure client
safety.

Perineal Care
Perineal care, like bathing of the skin, prevents infections, odors and irritation in that area. Perineal
care is done with the bed bath, shower or tub bath and it is done more often for patients affected
with incontinence and diaphoresis, for example. Special perineal care is given to patients with an
indwelling urinary catheter.

Shaving
Male clients often want a facial shave once a day or once every couple of days; female patients
usually want their underarms and legs about once a week. Shaving for patients is often not risky
except when the patient is taking an anticoagulant blood thinner which places them at risk for nicks
and bleeding.

Oral Hygiene
Oral hygiene is done at least twice a day and more often as needed. Oral hygiene consists of
brushing the teeth, flossing the teeth, and rinsing the mouth. Partial and full dentures are also
brushed and rinsed.

Foot Care
Feet are washed with the bath and more often as needed. Diabetics and other patients at risk for
infections should get special foot and toe nail care and monitoring. For example, the feet must be
completely cleaned and dried and examined daily for any signs of skin breakdown, corns, bleeding,
broken, chipped or absent nails, as well as blue or pale nail beds.

Hair Care
Patient's hair can be washed with shampoo and conditioner in the shower, bathtub and in bed with a
special bed tray or dry shampoo. Patients should also be encouraged to comb or brush their hair a
couple of times a day.
Nail Care
Client nail care is another important area of hygiene and client's nails need to be checked daily, to
observe them for any irregularities. The client's nails should appear clean, because dirt can cause
infection, trimmed short, and smooth, as jagged nails have the ability of causing injuries to the client
or to the staff attending to them.

Providing Information to the Client on

Required Adaptations for Performing
Activities of Daily Living
Clients in need of assistive devices and other adaptations to insure safety and/or maximum
independence should be instructed on their proper use and reminded to use them consistently.
Some of these devices and adaptations include shower chairs, grab rails, hand rails, back sponges
and special tools for nail care.

Performing Post-Mortem Care

Postmortem care consists of washing and drying the patient's entire body and removing all medical
equipment such as indwelling urinary catheters and intravenous lines. The deceased patient's hands
and legs are gently placed in good alignment, the eyes and the jaw are held closed and the body is
then wrapped in a shroud after an identification tag has been placed on the client's greater toe and
on the outside of the shroud prior to transfer to the morgue.
Standard precautions are maintained after a patient's death when providing postmortem care.

Rest and Sleep: NCLEX-RN

In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills pf rest and sleep in order to:

 Assess client need for sleep/rest and intervene as needed

 Apply knowledge of client pathophysiology to rest and sleep interventions
 Schedule client care activities to promote adequate rest

Some of the terms and terminology that you should be familiar with in terms of rest and sleep are
described below.
Insomnia
Insomnia, simply defined, is the absence of sleep. The two basic types of insomnia are inducement
insomnia and maintenance insomnia. Clients affected with inducement insomnia have difficulty
falling asleep and clients with maintenance insomnia have difficulty maintaining sleep and staying
asleep once they have fallen asleep. Some clients are affected with both inducement insomnia and
maintenance insomnia. Additionally, some clients may have an acute, short lived episode of
insomnia, and other clients may have chronic insomnia. Both types of insomnia are caused by a
number of different physical and psychological factors such as pain and anxiety. Insomnia, which is
the most commonly occurring sleep disorder, can also be classified as chronic-intermittent which is a
combination of periods of insomnia interspersed with period of restful sleep. The two populations
that are at greatest risk for insomnia are females and members of the aging population.
Insomnia causes the affected person to wake up without feeling that they are rested as well as day
time sleepiness, irritability and problems in terms of cognitive functioning such as decreased levels
of mental concentration and poor problem solving.

Non REM Sleep

The sleep cycle consists of both non REM sleep and REM sleep. Non REM sleep is sleep that is not
accompanied with rapid eye movements (REM). Non REM sleep has four phases which include the
stage of very light sleep, the stage of very light sleep with the non movement of the eyes, the stage of
deep sleep with delta waves and finally, the last stage with is deep sleep and increased delta brain
waves. The vast majority of sleep is non REM sleep and this part of the sleep cycle can occur during
about 80% of the time that the person is sleeping in a cyclical manner.
Some of the physiological changes that occur during non REM sleep include decreases in terms of
the person's basal metabolic rate, intracranial pressure, blood pressure, cardiac rate and cardiac
output in addition to the relaxation of the person's muscles and their peripheral circulatory
vasculature.

REM Sleep
Rapid eye movement sleep is a state of deep sleep that is accompanied with rapid eye movements
and dreams. Some of the physiological changes that occur during REM sleep include increased brain
activity dreams, and a decrease in terms of muscular and reflex activity.

Narcolepsy
Narcolepsy is defined as excessive day time sleepiness that a person can be affected with secondary
to the paucity of hypocretin within the area of the central nervous system that controls sleep.

Hypersomnia
Hypersomnia, which can also be caused by a number of different factors and forces, is defined as
the client's failure to stay awake during day time hours even when they have had enough sleep the
night before. Some of the risk factors associated with hypersomnia, all of which are physical in
nature, include disorders such as hypothyroidism, central nervous system dysfunction, and
alterations of the client's metabolism including diabetic ketoacidosis.

Parasomnia
Parasomnia is defined as a sleep disorder that interferes with sleep. There are a number of
parasomnias including sleep walking, sleep talking, grinding of the teeth that is referred to as
bruxism, nocturnal enuresis and restless leg syndrome.

Sleep Apnea
Simply stated, sleep apnea is apnea that occurs during sleep. There are a couple of types of sleep
apnea including obstructive sleep apnea that is typically caused by large anatomical structures such as
the tongue and the collapse of the oropharynx when the client is sleeping, central sleep apnea which
results from some deficit of the central nervous system such as an insult to the brain stem, and
mixed sleep apnea, which occurs as the result of the combination of both central and obstructive
sleep apnea, and results from multiple related disorders and diseases.

Circadian Rhythm
Circadian rhythm is the human's natural and innate 24 hour a day clock. Circadian rhythms are
sometimes referred to as our body clock. In essence, humans take on cyclical 24 hour periods of
time that are associated not only with sleep, but also in terms of their hormone secretion, their
bodily temperature and other physiological and other psychological variations.
Good sleep habits and rest promote better health and well-being in people. A lack of sleep and rest
do not. Poor sleep habits can lead to inability to mentally focus, adversely affect moods, and increase
the risk of depression, heart attack, high blood pressure, obesity, and other health problems.

Assessing the Client's Need for Sleep

and Rest and Intervening As Needed
How much sleep is needed depends upon the individual, their age and their level of wellness. For
example, some individuals just simply require and need more or less sleep than others do even when
the person is not affected with a health related problem or disorder and it varies according to age
and well-being. Clients who are ill and who are experiencing signs and symptoms related to the
illness will need more sleep than they did prior to the illness. The amount of sleep that is needed also
varies among the age groups. Below are some guidelines that you can use to determine whether or
not a client is getting enough sleep and rest for physiological and psychological health.

 Neonates through 3 months of age typically sleep 14 to 17 hours a day

 Infants from 4 months of age to 11 months of age should normally sleep about 12 to 15 hours a
day
 Older infants and toddlers up to 3 years of age should sleep 11 to 14 hours a day

 Preschool children from 3 to 5 years of age should sleep 10 to 13 years of age

 School age children from 6 to 12 years of age need 9 to 11 hours of sleep each day

 Adolescents from 13 to 17 years of age should sleep about 8 to 10 hours of sleep

 Young adults and middle aged adults need about 7 to 9 hours of sleep

 Older adults over 65 years of age tend to require slightly less sleep than the middle age adults
and only 7 to 8 hours of sleep per night

The factors that impact on sleep, its duration and its quality are described below.

 Illnesses: Despite the fact that clients with physical diseases and disorders require more sleep
than normal for recovery, they tend to get less because of some of the signs and symptoms of
the illness or disorder that they are affected with. For example, pain, respiratory, genitourinary
and gastrointestinal system disorders often interfere with the client's getting enough sleep,
hypothyroidism can decrease stage IV sleep, and pyrexia can impair and reduce the amount of
REM and delta sleep that the client gets.

 Medications: Some medications increase the client's sleepiness and the duration of sleep and
other medications impair and impede the quality and quantity of the sleep that the client gets
while they are on a particular medication. For example, beta blockers used for hypertension can
lead to insomnia and a decrease in the amount of REM sleep that the client gets; and, narcotic
medications, steroid medications, antidepressant medications, and bronchodilating medications
can decrease the duration of sleep and also impair the onset of sleep and the quality of the
person's REM sleep.

 Environment: The environmental factors and forces that can interfere with sleep include things
like an uncomfortable environmental temperature, noise, sleeping in a strange bed, an
uncomfortable mattress and/or pillows, the presence or absence of light, and a snoring partner,
for example.

 Emotional and Psychological Distress and Stress: The National Sleep Foundation, states
that stress is the number one cause of insomnia. Stress makes it more difficult to relax and,
therefore, it can easily lead to sleep induction and sleep maintenance disorders.
 Lifestyle Choices: Consumption patterns such as cigarette smoking and alcohol use interfere
with sleep and other life style choices such as those related to exercise also impact on sleep, the
duration of sleep and the quality of sleep. Daily exercise facilitates sleep; however, exercise
immediately before bed time may interfere with the client's sleep.

 Work Schedules: Long work hours and working night time hours interfere with sleep. For
example, humans, including nurses, who work the night tour of duty, are often unable to go to
sleep and stay asleep during day time hours when they are off from work. Night time work and
activity disrupts the person's normal circadian rhythms in a similar manner that people suffer
from jet lag when they travel across time zones.

Clients are assessed by the nurse for their sleep and rest patterns and any sleep disturbances. After a
complete physical assessment of the client is assessed using other subjective and objective data, as
discussed immediately below.
The physical assessment may reveal some data that can suggest a sleep disorder. Some of this data
can include a deviated nasal septum, enlarged tonsils and obesity, all of which can lead to a sleep
disorder or disturbance.
Other assessments can include:
The review of the client's reports about their sleep: The nurse may ask a client to record their sleep
patterns and record it in a sleep log or diary for a week or more, after which, the nurse will assess
and analyze this data to determine any sleep disturbances. Some of the data that is recorded in this
sleep log can include:

 The extent of and time of exercise before sleep hours

 Consumption patterns like alcohol and cigarette smoking before sleep hours
 A list of all prescribed and over the counter drugs, herbs and supplements to determine if any of
these substances has the potential to interfere with the client's sleep
 A daily recording of any sleepiness during the day time hours
 A daily recording of any stressors that are impacting on the client
 The time the person went to bed for sleep, how long it took to fall asleep, the duration of the
sleep each night, and the duration and frequency of night time awakenings
 Reports by the sleep partner about any irregularities in terms of sleep such as snoring, periods of
apnea, and restless leg movements which the client is most likely to be unaware of

Diagnostic studies, such as a polysomnography which is done in a sleep center by a respiratory

therapist, is used to diagnose sleep disturbances. A polysomnography is done in the sleep laboratory
by placing electrodes on the client's head is a combination of three diagnostic studies which are an
electrocephalogram, an electro-oculogram and an electromyogram.
An electrocephalogram measures and displays the brain waves while the client is sleeping; an electro-
oculogram measures and displays eye movements during sleep; and an electromyogram to measure
muscular movements during sleep. These diagnostic tests, in combination with pulse oximetry and
an electrocardiogram, are used to assess clients for sleep disorders such as sleep apnea, restless leg
syndrome and bruxism.
Some of the nursing diagnoses that the nurse can arrive at after a complete and thorough assessment
of the client are:

 Readiness for enhanced sleep

 Insomnia related to anxiety
 Insomnia related to the disruption in the amount and quality of sleep
 Sleep deprivation related to jet lag
 Sleep deprivation related to nocturnal work hours
 Sleep deprivation related to prolonged periods of time without sleep
 Impaired sleep related to obstructive sleep apnea
 Impaired sleep related to central sleep apnea
 At risk for injury and accidents relating to somnambulism
 Impaired gas exchange related to central or obstructive sleep apnea
 At risk for disturbed sleep secondary to alcohol use
 Insomnia related to unrelenting pain and the lack of comfort

Interventions for sleep disturbances are described below. These interventions are often referred to
as sleep hygiene measures.

 Insomnia: The establishment of and adherence to a regular to bed routine, the avoidance of
alcohol and exercise prior to sleep, using the bed for sleep only and not for watching television
or doing work, the use of stress and relaxation techniques, arising from bed if sleep induction
does not occur within a reasonable amount of time, pain management, the correction of any
assessed sleep disorders, the avoidance of caffeine and heavy meals prior to bed time, cognitive
behavioural therapy, and medications to promote sleep as the last resort, and then, only on a
temporary basis.

 Hypersomnia: Since hypersomnia occurs as the result of a physical rather than a psychological
cause, the underlying physical cause, such as hypothyroidism, should be corrected.

 Narcolepsy: Narcolepsy, which is caused by the lack of the chemical hypocretin in the area of
the CNS that regulates sleep, leads to day time sleepiness and sleep attacks that cause the person
to fall asleep at unpredictable times, such as when driving an automobile. The client who is
assessed as having narcolepsy should be educated about the dangers of using heavy equipment
 and motor vehicles and they can also be treated with central nervous system stimulant
medications like an amphetamine or an antidepressant to control this sleep disorder and its
effects.

 Sleep Apnea: The treatment for sleep apnea depends on the cause. For example if the apnea is
related to enlarged oropharyngeal anatomy such as the tongue, tonsils and pharynx, laser
reduction may be indicated, if the cause of the sleep apnea is obesity, the client should be on a
weight reduction diet, and if the cause is not treatable, the client will be given a CPAP machine
for daily use while the client is sleeping. CPAP, which is continuous positive airway pressure, is
delivered to the client with a CPAP machine, tubing and a full face mask, a nasal prong or a
partial face mask. Full face masks are recommended for clients who are mouth breathers,
however, some clients may reject a full face mask because they feel somewhat claustrophobic
when they are in place. The treatment and correction of sleep apnea is necessary because, left
untreated, sleep apnea can lead to complications such as pulmonary hypertension, hypertension
and cardiac arrhythmias.

 Parasomnias: Parasomnias like bruxism can be treated with dental correction, stress
management techniques, muscle relaxants, or a botulinum toxin A, which is Botox, in severe
cases, and the use of a splint or mouth guard that is a dental appliance that prevents damage to
the teeth as the result of bruxism.

 Nocturnal Enuresis: Nocturnal enuresis can be treated with a bed wetting alarm, positive
reinforcement and medications such as imipramine and desmopressin.

 Sleepwalking: Sleepwalking can be treated with a sleep hygiene program to decrease sleep
deprivation, the elimination of problematic medications, the avoidance of alcohol and the
correction of any causal underlying illnesses, all of which can lead to sleep walking.

 Periodic Limb Movement and Restless Leg Syndrome: These sleep disrupting disorders can
be treated with the correction of an underlying disorder, such as peripheral neuropathy, the
avoidance of alcohol and tobacco, the use of some medications such as those that increase
dopamine, benzodiazepines and anticonvulsant medications, when indicated.
Applying a Knowledge of the Client's
Pathophysiology to Rest and Sleep
Interventions
As mentioned immediately above and in other sections of "Rest and Sleep", many interventions for
sleep disorders and disturbances are based on the needs of the specific client as specific to their
physiological and psychological pathologies. For example, stress and relaxation, in addition to other
complementary and non pharmacological interventions are used when the client is adversely affected
with anxiety that disrupts sleep, continuous positive airway pressure (CPAP) is used when the
client's anatomical structures are abnormally large or they abnormally relax and collapse during sleep,
and analgesics are administered to relieve pain as the result of an acute or chronic physical disorder
or disease.

Scheduling Client Care Activities to

Promote Adequate Rest
The promotion of sleep and adequate rest depends on correcting any underlying problems, including
pain and alcohol use, and then planning activities and routines that will enhance the duration and the
quality of sleep.
Some of these sleep promotion interventions and schedules include:

 Establishing and adhering to a regular sleep time and wake time for the client based on their
patterns and needs
 Limiting the duration and frequency of day time naps
 The promotion of daily exercise
 The avoidance of alcohol, caffeine, heavy meals and exercise at least a couple of hours before
bedtime
 The promotion of comfort using techniques such as white noise, dim lighting, pain
management, stress reduction techniques, massage and the elimination of environmental noise

Many hospitals and nursing homes have established policies and procedures to promote sleep by
decreasing the noisiness of client care areas. For example, the hospital may stop over head paging
after a certain hour; they may turn down the telephone ringer volume after a certain hour and turn
down the lights in the hallways.
 II) Pharmacological and Parenteral
Therapies
The registered nurse provides care related to the administration of medications and parenteral
therapies.
Registered nurses must be able to:

 Administer blood products and evaluate client response

 Access venous access devices, including tunneled, implanted and central lines
 Perform calculations needed for medication administration
 Evaluate client response to medication (e.g., therapeutic effects, side effects, adverse reactions)
 Educate the client about medications
 Prepare and administer medications, using rights of medication administration
 Review pertinent data prior to medication administration (e.g., contraindications, lab results,
allergies, potential interactions)
 Participate in the medication reconciliation process
 Titrate the dosage of medication based on assessment and ordered parameters (e.g., giving
insulin according to blood glucose levels, titrating medication to maintain specific blood
pressure)
 Evaluate appropriateness and accuracy of medication order for the client
 Monitor intravenous infusion and maintain the site (e.g., central, PICC, epidural and venous
access devices)
 Administer pharmacological measures for pain management
 Administer controlled substances within regulatory guidelines (e.g., witness, waste)
 Administer parenteral nutrition and evaluate client response (e.g., TPN)

Some of the commonly used terms and terminology relating to pharmacological and parenteral
treatments that you must be aware of and knowledgeable about include those briefly described
below:

 Pharmacokinetics: Pharmacokinetics is the absorption, distribution, metabolism, and excretion

of drugs.
 Pharmacodynamics: Pharmacodynamics refers to the actions of medications in the body. Drug
concentrations, receptor and binding activities, antagonistic actions and agonist actions are
pharmacodynamic principles.
 Drug absorption: Drug absorption is the pharmacokinetic process with which the medication
moves through the body to the bloodstream. Because intravenous medications are delivered
directly into the bloodstream, they are not absorbed. The rates of absorption for oral
medications vary according to the acidity of the stomach's fluids, the presence of food, and
other factors.
 Drug distribution: Drug distribution, the second phase of the pharmacokinetic process, is the
movement of the medication through the bloodstream to its target. Fat-soluble medications are
attracted to fatty tissue targets.
 Drug metabolism or biotransformation: Drug metabolism, also referred to as
biotransformation, is the third phase of the pharmacokinetic process. Drug metabolism is
defined as the detoxification and breaking down of drugs in the liver.
 Excretion: Excretion, the final stage of pharmacokinetics, is defined as the elimination of active
and inactive drug metabolites from the body. The vast majority of medications are excreted by
the kidney and the urinary tract but some may be excreted via the respiratory and
gastrointestinal tract.
 Indications for medications: The indications for medications are those diseases, disorders,
illnesses, and conditions that are appropriate uses for a particular medication. For example, the
indications for the use of phenobarbital include the control of seizures, the prevention of
seizures, decrease anxiety and withdrawal from a barbiturate. The indications for medications are
established by the United States Food and Drug Administration. When a medication is used for
any other than these established and approved uses, this usage is referred to as an "off label
use".
 Contraindications of medications: Virtually all medications are not indicated for, and thus,
contraindicated for certain clients, as based on one or more conditions. For example,
medications classified as Categories C, D and X are contraindicated for women who are
pregnant. Many drugs are contraindicated during pregnancy, during lactation, and when the
client has a history of renal or hepatic disease, for example.
 The cautious use of medications: Like contraindications, many medications have published
precautions that indicate the cautious use of a medication as based on the status of the client;
although the cautious use of a medication is often done, it is done when there are no suitable
alternatives to it with the provision that the client will be closely monitored and assessed for any
adverse effects.
 Therapeutic effects of medication: A therapeutic effect is the desired effect of the specific
medication. For example, the therapeutic and desired effects of anti-anxiety medications are to
decrease the client's level of anxiety and the therapeutic effects of anti-hypertensive medications
are to decrease the client's blood pressure.
 Side effects of medication: A side effect of a medication is any effect(s) other than the
therapeutic and intended effect(s) of a medication. Some side effects adversely affect a client,
other side effects can be harmless to the client, and still, more may be a desirable side effect that
is therapeutic for the client. These kinds of side effects can include damage to the 8th cranial
nerve, minor oral dryness, and sleepiness after taking an antihistamine such as diphenhydramine
which is taken by many people, particularly the elderly, to induce sleep rather than for its
antihistamine actions.
 Idiosyncratic effects of medication: Idiosyncratic effects ofmedication include those side
effects that are rare, unusual and unexpected. These effects can include things like a client
experiencing hyperactivity after having taken a sedating medication. These effects tend to be
individual rather than common to a group or population of clients affected with a certain risk
factor of disorder, for example.
 Cumulative effects of medication: The cumulative effects of a medication are those effects
that result from the accumulation of a medication. Cumulative effects of medications can occur
as the result of several impaired pharmacokinetic processes including the impaired
biotransformation and excretion of drugs, as often occurs among elderly clients because of some
of the normal changes of the aging process. At times, the cumulative effects of a medication can
be a life-threatening overdose of the medication; therefore, caution must be exercised when a
client is at risk for the accumulation of a medication and its cumulative effects.
 Adverse effects of medication: The adverse effect of a medication is highly serious and far
more than troublesome than the side effects of medications. For example, an anaphylactic
response to an antibiotic is an adverse effect of that medication. Except under highly unusual
circumstances, medications that lead to adverse effects are immediately discontinued.
 Drug interactions: Drug interactions occur when drugs and foods interact, when drugs and
herbs or supplements interact, and when drugs and other drugs interact. Some of these drug
interactions are synergistic and potentiating and others may be inhibiting.
 Potentiating effects of medication: A potentiating effect of a medication is the synergistic,
additive effect that occurs when drugs and foods interact, when drugs and herbs or supplements
interact, and when drugs and other drugs interact. The former two interactions will make the
medication more powerful in its effects, and the later will have an increased effect by one or
more of the medications that are interacting.
 Inhibiting effects of medication: An inhibiting effect of a medication is a decreased effect that
occurs when drugs and foods interact, when drugs and herbs or supplements interact, and when
drugs and other drugs interact. The former two interactions will weaken the effects of the
medication, and the later will have a decreased and inhibiting effect on one or more of the
medications that are interacting.
 Drug toxicity: Drug toxicity is defined as an overdosage of a medication that occurs when the
dose that is administered exceeds the client's ability to metabolize and/or excrete the
medication.
 Drug allergy: A drug allergy is the result of an antigen-antibody immunologic response to a
medication. All clients must be assessed for any drug sensitivities and allergies.
 Drug tolerance: Drug tolerance occurs when a client has been receiving a particular medication,
such as an opioid drug, for a prolonged period of time and, as a result of this prolonged
administration, the client needs increasing doses of the medication to produce the therapeutic
effect.
 The chemical name of a drug: The chemical name of a drug is the chemical composition of the
drug.
 The trade or brand name of a drug: The trade or brand name of a drug is the manufacturer's
name for the drug. Trade name drugs are more expensive than generic drugs.
 The generic name of a drug: The generic name of a drug is the name of a drug that is given to it
by the United States Adopted Names Council. This name remains the same over time. A generic
medication can have a number of different trade names, but a trade name is the exclusive
property of the drug manufacturer, therefore, there is no more than one trade name. For
example, the generic name of metoprolol can have multiple trade names such as Metoprolol
Succinate and Lopressor, both of which are capitalized, unlike generic names.

Related content includes but is not limited to:

 Adverse Effects/Contraindications/Side Effects/Interactions

 Blood and Blood Products
 Central Venous Access Devices
 Dosage Calculations
 Expected Actions/Outcomes
 Medication Administration
 Parenteral/Intravenous Therapies
 Pharmacological Pain Management
 Total Parenteral Nutrition (TPN)
Adverse Effects,
Contradictions, Side Effects
and Interactions of
Medications: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of adverse effects, contradictions, side effects and interactions of
medications in order to:

 Identify a contraindication to the administration of a medication to the client

 Identify actual and potential incompatibilities of prescribed client medications
 Identify symptoms/evidence of an allergic reaction (e.g., to medications)
 Assess the client for actual or potential side effects and adverse effects of medications (e.g.,
prescribed, over-the-counter, herbal supplements, preexisting condition)
 Provide information to the client on common side effects/adverse effects/potential interactions
of medications and inform the client when to notify the primary health care provider
 Notify the primary health care provider of side effects, adverse effects and contraindications of
medications and parenteral therapy
 Document side effects and adverse effects of medications and parenteral therapy
 Monitor for anticipated interactions among the client prescribed medications and fluids (e.g.,
oral, IV, subcutaneous, IM, topical prescriptions)
 Evaluate and document the client's response to actions taken to counteract side effects and
adverse effects of medications and parenteral therapy

The administration of medications involves far more than handing an ordered medication to a client.
The administration of medications entails the nurse's application of critical thinking skills, their
professional judgment, their application of pathophysiology, and a thorough knowledge of the client
and their condition.
When medications are ordered, the nurse must be knowledgeable about the indications,
contraindication, side effects, adverse effects and the interactions associated with the medication, as
found in a reliable resource such as the Physician's Desk Reference. If, and when, the nurse's
knowledge of these things and the nurse's knowledge about the client and their condition are not
consistent and congruent with each other, the nurse must question the order and discuss their
concerns with the ordering physician or licensed independent practitioner such as a physician's
assistant or nurse practitioner.
After a medication has been administered, the nurse is also responsible and accountable for closely
monitoring the client for any side effects and adverse actions.

Identifying a Contraindication to the

Administration of a Medication to the
Client
Like indications, virtually all medications have contraindications against their use. Some of the most
commonly occurring contraindications for medications include:

 Sensitivity or allergy to the medication

 Pregnancy
 Lactation
 Renal disease
 Hepatic disease

Prior to the administration of medications, the nurse must be fully knowledgeable about the
contraindications of the medications, the client's condition and determine whether or not the
ordered medication is contraindicated for this client. When a nurse identifies that fact that a
medication is contraindicated for a client, the nurse must communicate with the ordering physician
in order to clarify this medication order.

Identifying Actual and Potential

Incompatibilities of Prescribed Client
Medications
Some medications are compatible with other medications and others are not; and some intravenous
fluids and medications are compatible with each other, and others are not. Compatible medications
can be safely administered in one syringe for an intramuscular medication and non compatible
medications cannot be given in the same syringe. At times incompatibility is evidenced with changes
such as those related to color changes and the formation of a cloudy solution or obvious precipitate,
and at other times incompatibility may not be noticeable. For this reason, nurses must refer to a
compatibility or incompatibility chart before they mix medications or medications and solutions.
Identifying Symptoms and Evidence
of an Allergic Reaction
Allergic reactions to medications can be minor and they can also be very serious and life threatening,
Nurses, therefore, must assess clients and identify any possible allergies to the medications. These
allergies can be assessed with the client's medical history and they can also be assessed when a client
is getting a medication to which they have never had a prior allergic response to.
All allergies are documented in the nursing assessment and also on the medication administration
record in addition to other areas in the medical record, according to the facility's policy and
procedure. Many healthcare agencies also use allergy bands and/or bar codes with embedded allergy
information to enable nurses to readily identify any allergies to medications.
Commonly occurring medication allergies include allergies to penicillin which can be particularly
dangerous and life threatening, allergies to sulfonamides, and allergic reactions to cephalosporin
medications. It is estimated that about ten percent of people have had a reaction to penicillin. Some
of these reactions are an allergic response to the penicillin, and others are simply a side effect of the
penicillin.
The first exposure to penicillin, referred to as the "sensitizing dose", sensitizes and prepares the
body to respond to a second exposure or dose. The signs and symptoms of this allergic "sensitizing
dose" response include a body wide rash and itching. When this is observed, the nurse must
discontinue the medication, notify the physician and document this reaction thoroughly and
completely in the medical record.
If a medication is administered after a "sensitizing dose", this second exposure or dose can lead to
anaphylaxis, or anaphylactic shock which is a form of distributive shock. The signs and symptoms of
anaphylaxis and anaphylactic shock are decreased cardiac output, a drastic and dramatic drop in the
client's blood pressure, tachycardia with a bounding pulse, the massive collapse of venules and
arterioles in the body's circulatory system, histamine release, the pooling of venous blood, laryngeal
edema, respiratory distress, and death unless it is immediately treated.
All allergic responses, including those secondary to medications, must be immediately documented
and reported to the doctor and other members of the healthcare team, as indicated and according to
the facility's specific policies and procedures. Additionally, the client and family members must be
advised of all allergic reactions and adverse reactions to medications so that this information can be
passed on to other health care providers during the client's lifetime.

Assessing the Client for Actual or

Potential Side Effects and Adverse
Effects of Medications
Nurses collect, analyze and document objective and subjective data from clients in reference to any
actual or potential side effects and adverse reactions, in addition to the allergies as discussed
immediately above, relating to prescribed medications, over the counter preparations, and herbal
supplements as part of the client's medical history.
There are times when a client may state that they are allergic to something, including foods and
medications, when indeed, they may not be. For this reason, nurses will, therefore, record the client's
subjective comments about this "allergy" and also how they know or believe that they are allergic to
something or that they have had an adverse reaction to a medication, an herbal supplement.
Whenever a questionable allergy is identified by the client, this "allergy" must be further explored
before it is given.

Providing Information to the Client on

Common Side Effects/Adverse
Effects/Potential Interactions of
Medications and Informing the Client
When to Notify the Primary Health
Care Provider
In addition to other patient and family education, clients and family members should be given
complete information about all the drugs that they are or will be taking. The contents of this
education should minimally include:

 The name and purpose of the medication

 The dosage of the medication
 When and how often the medication should be given
 The contraindications of the medication
 The possible side effects of the medication and the signs and symptoms of these side effects
 The possible adverse effects of the medication and the signs and symptoms of these side effects
 How the medication can interact with other medications, including prescription and over the
counter medications, foods, and supplements
 Special instructions including things like taking the medication with a meal or taking the
medication between meals
 When to notify the primary health care provider including when a possible allergic response, an
adverse action, or a side effect has occurred
Notifying the Primary Health Care
Provider of Side Effects, Adverse
Effects and Contraindications of
Medications and Parenteral Therapy
Nurses who assess that the client has been affected with a side effect or adverse effect to mediations
and parenteral therapy must report and record this data immediately and they should hold the
medication until a response from the ordering physician gives the nurse further instructions. At
times, the medication may be continued and, at other times, the medication may be discontinued
and replaced with another medication.

Documenting the Side Effects and

Adverse Effects of Medications and
Parenteral Therapy
As stated immediately above, nurses who assess that the client has been affected with a side effect or
adverse effect to mediations and parenteral therapy must report and record this data immediately.

Monitoring for Anticipated

Interactions Among the Client's
Prescribed Medications and Fluids
In addition to the nurse's awareness of and knowledge about the interactions that can occur among
medications in all routes and forms, the nurse must also be knowledgeable the interactions of
medications and fluids. Based on this knowledge, the nurse monitors and assesses clients for all
anticipated interactions and intervenes accordingly.
Evaluating and Documenting the
Client's Response to Actions Taken to
Counteract the Side Effects and
Adverse Effects of Medications and
Parenteral Therapy
In addition to all the other roles and responsibilities of the nurse in reference to medication and
fluid administration, the nurse must evaluate and document all client responses to interventions that
were implemented to counteract any side effects and adverse reactions to medications and parenteral
therapy. For example, a client who is given a new medication that leads to nausea and vomiting may
get an antiemetic medication to counteract these side effects; and a client who has anaphylactic
shock to a medication and is given epinephrine and a bronchodilator to preserve life during this life
threatening emergency as they are closely reassessed and monitored for their responses to these
emergency interventions.

Blood and Blood Products:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of blood and blood products in order to:

 Identify the client according to facility/agency policy prior to administration of red blood cells/
blood products (e.g., prescription for administration, correct type, correct client, cross matching
complete, consent obtained)
 Check the client for appropriate venous access for red blood cell/blood product administration
(e.g., correct gauge needle, integrity of access site)
 Document necessary information on the administration of red blood cells/blood products
 Administer blood products and evaluate client response

Blood transfusions are indicated for the client who has hypovolemia secondary to hemorrhage,
anemia or another disease process that is associated with a deficiency in terms the client's clotting or
another component of blood, for example. Although hypovolemia can be treated with fluid
replacement, this fluid does not provide the client with the oxygen carrying components that only
blood has. In addition to blood's components in terms of oxygen transporting red blood cells, blood
also transports carbon dioxide, and it contains white blood cells to combat infection, clotting factors
and essential blood proteins.
There are four blood types each of which has its antigen in its red blood cells. These blood types are
A with A antigens, B with B antigens, AB with both A and B antigens, and O which has neither A
nor B antigens. People with O type blood are universal donors but they are universal suckers
because type O blood can be given to clients with A, B, AB and O blood type clients but the type O
blood type client can only receive type O blood. Each blood type also has antibodies, which are
referred to as agglutinins. Type A blood has B agglutinins; type B blood has A agglutinins, type AB
blood has no antibodies, or agglutinins, and type O blood has both A and B agglutinins.
People also have a rhesus, or Rh, factor antigen or the lack of it. Clients with an Rh positive blood,
which is the vast majority of people, have Rh positive blood and people without the Rh factor
antigen have Rh negative blood.
Members of the Christian Science religion do not typically accept blood transfusions and members
of Jehovah's Witness religion are prohibited from receiving blood. Plasma expanders without any
blood or blood products, however, are acceptable to members of both of these religions.
Most clients get blood and blood products that are donate by others through the blood bank,
however, some clients can choose to donate their own blood prior to an elective surgery, for
example, and then use this blood rather than the blood of a blood donor. This type of blood
transfusion is referred to as an autologous blood donation.
Blood and blood components are selected and given as based on the client's specific needs. The
different blood products and their components are described below.

 Packed red blood cells: Packed red blood cells are used when the client is in need of increased
oxygen transporting red blood cells as may occur post operatively and with an acute
hemorrhage.

 Platelets: Platelets are administered to clients who are adversely affected with a platelet
deficiency or a serious bleeding disorder, such as thrombocytopenia or platelet dysfunction that
requires the clotting factors that are in platelets.

 Fresh frozen plasma: Fresh frozen plasma, which does not contain any red blood cells, is
administered to clients who are in need of clotting factors or are in need of increased blood
volume as occurs with hypovolemia and hypovolemic shock. Fresh frozen plasma does not have
to be typed and cross matched to the client's blood type because plasma does not contain
antigen carrying red blood cells.

 Albumin: Albumin is administered to clients who need expanded blood volume and/or plasma
proteins.
 Clotting factors and cryoprecipitate: Clotting factors and cryoprecipitate are administered to
clients affected with a clotting disorder including the lack of fibrinogen.

 Whole blood: Whole blood is typically reserved for only cases of severe hemorrhage. Whole
blood contains clotting factors, red blood cells, white blood cells, plasma, platelets, and plasma
proteins.

Identifying the Client According to the

Facility or Agency Policy Prior to the
Administration of Red Blood Cells and
Blood Products
Some blood transfusion reactions and blood transfusion errors occur as the result of inaccurate
client identification. Simply stated, client misidentification can be prevented by matching the client
to the order, insuring that the blood is accurately matched to the client and the order and by using
the two person verification technique that involves two nurses checking the blood, the order and the
client's identity using at least two unique identifiers.
The two nurses will check the blood against the order, check the client's identity, check the client's
blood type against the type of blood that will be infused, check the expiration of the blood or blood
component, and check the client's number against the blood product number. The nurses will also
visually inspect the blood for any unusual color, precipitate, clumping and any other unusual signs.
The order for the blood or blood component must be a complete order that specifies exactly what
will be administered. The client will also give consent for the transfusion.
The gauge of the intravenous catheter should be 18 gauge and the blood should be administered
with normal saline using a Y infusion set that is specifically used for the administration of blood and
blood products. Normal saline is compatible with blood; ringer's lactate, dextrose, hyperalimentation
and other intravenous solutions with incompatible medications are not compatible with blood and
blood products. If a blood filter is used, the filter must be inspected to insure that it is suitable for
the specific blood product that the client will be getting.
Blood should not remain in the client care area for more than 30 minutes so it is important that the
nurse is prepared to begin the transfusion shortly after the blood is delivered to the patient care area.
The nurse must take baseline vital signs just prior to the infusion of blood or a blood product and
then the nurse should remain with and monitor the client for at least 15 minutes after the
transfusion begins at a slow rate since most serious blood reactions and complications occur shortly
after the transfusion begins. All blood and blood products must be administered completely in less
than 4 hours.
Only registered nurses and licensed practical nurses can initiate, monitor and maintain blood
transfusions. These aspects of care can NOT be delegated to an unlicensed assistive nursing staff
member. Additionally, some facilities restrict blood transfusions to only registered nurses, so it is
important to check the facility specific policies and procedures relating to the administration of
blood and blood products.

Checking the Client for Appropriate

Venous Access for Red Blood Cells
and Blood Product Administration
The nurse must insure that the intravenous line is patent and they must insure that a 18 or 20 gauge
catheter is being used and patent.

Documenting the Necessary

Information on the Administration of
Red Blood Cells and Blood Products
All aspects of the administration of red blood cells and blood products are documented. This
documentation must minimally include:

 The date and time that the blood transfusion began

 The name of the second nurse who did the two person verification process
 The name and amount of the specific type of transfusion such as 1 unit of packed red cells
 The number of the blood product
 Where the IV site was
 Size of the angiocath that was used
 The duration of the transfusion
 The vital signs that were taken and when they were taken
 The fact that the client was informed about when and why to contact the nurse after the initial
15 minute monitoring period
Administering Blood Products and
Evaluating the Client's Responses
Whenever blood or a blood product is being administered, the nurse must closely monitor the client
for the signs and symptoms of a possible complication. The first thing that the nurse must do when
a reaction or a complication is possible is to discontinue the administration of the blood or blood
product.
The complications associated with the administration of blood and blood components are discussed
below:

Febrile Reactions
Febrile reactions are the most commonly occurring reaction to blood and blood products
administration. Although a febrile reaction can occur with all blood transfusions, it is most
frequently associated with packed red blood cells and this reaction is not accompanied with
hemolysis. The signs and symptoms of this transfusion reaction include fever, nausea, anxiety,
chilling and warm flushed skin.

Hemolysis
Hemolysis occurs as the result of an incompatibility of the donor's and recipient's blood which is
referred to as an ABO incompatibility. This incompatibility can occur as the result of a laboratory
error in terms of typing and cross matching and a practitioner error in terms of checking the blood
and matching it to the client's blood type. This complication is signaled when the client has flank
pain, chest pain, restlessness, oliguria or anuria, respiratory distress, brown urinary output,
hypotension, fever, low blood pressure and tachycardia. The treatment of hemolysis includes the
administration of normal saline after the transfusion is stopped and all the tubing is changed to
prevent kidney failure and circulatory collapse. Although rare, a delayed, rather than an acute and
immediate, hemolytic reaction can occur up to about 4 weeks after the transfusion. This delayed
reaction is not as severe as an acute hemolytic reaction and it is characterized with jaundice,
discolored urine and anemia.
The intravenous tubing, the blood filter, the blood bag with its remaining contents are retained and
sent to the laboratory. A sample of the client's blood and urine are also taken and sent for diagnostic
testing.

Allergic Reactions
Allergic reactions to a blood transfusion can range from mild to severe. A mild allergic reaction
typically occurs as the result of an allergy to the plasma proteins in the blood, and severe allergic
reactions occur from a severe antibody - antigen reaction. Mild allergic reactions are accompanied
with possible itching, pruritic erythema, swelling of the lips, tongue or pharynx and eyelids, and
flushing of the skin; severe allergic reactions can manifest with chest pain, decreased oxygen
saturation, loss of consciousness, flushing, shortness of breath and respiratory stridor. Mild allergic
responses are treated with the administration of a corticosteroid and/or antihistamine medication;
severe allergic reactions are treated with the administration of supplemental oxygen and medications.
At times, a serious allergic reaction can be life threatening.

Sepsis
Sepsis is characterized with fever, hypotension, oliguria, chilling, nausea and vomiting This
transfusion reaction occurs as the result of some contaminate in the blood. This complication is
treated with intravenous fluids and antibiotics. The intravenous tubing, the blood filter, the blood
bag with its remaining contents are retained and sent to the laboratory. A sample of the client's
blood and urine are also taken and sent for diagnostic testing as is also done when the client has a
hemolytic reaction.

Central Venous Access

Devices: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of central venous access devices in order to:

 Educate the client on the reason for and care of a venous access device
 Access venous access devices, including tunneled, implanted and central lines
 Provide care for client with a central venous access device (e.g., port-a-cath, Hickman)

Educating the Client on the Reason

For and Care of a Venous Access
Device
There are several types of venous access. Venous access can be done with a peripheral intravenous
device and a central venous access device. Peripheral intravenous devices are used for short term
intravenous therapy including fluids, electrolytes, medications and chemotherapy when the client has
accessible and usable veins. Generally speaking peripheral intravenous catheters should be the
shortest possible in terms of their length which is usually about 3 inches for the adult client and, as
with other invasive therapies, peripheral intravenous devices should be left in place for the shortest
possible period of time in order to prevent catheter related infections. Short peripheral catheters can
typically stay in place for 72 hours; and a longer peripherally inserted midline catheters can remain in
place for a longer period of time up to about 4 weeks in duration. These peripherally inserted
midline catheters are longer than 3 inches and they range up to 8 inches in length and they are
advanced into the brachial, basilic or cephalic veins.
The intravenous catheter size depends on the patient's condition and their anticipated needs. For
example, an 18 gauge catheter is used when the administration of a blood transfusion is anticipated;
a larger gauge catheter, typically a 16 gauge catheter is used for a major trauma client with often
unpredictable needs; and a smaller 22 or 24 gauge intravenous catheter is used when a client only
needs intravenous fluids and medication with their peripheral venous catheter. A butterfly can be
used for short term peripheral intravenous access of less than 24 hours and an Angiocatheter is used
for peripheral intravenous therapy of more than 24 hours.
Vein selection for a peripheral intravenous device should be based on a number of considerations.
The best veins to select are the distal veins on the nondominant hand so that the client is able to
fully use their dominant hand. The side of a client's mastectomy, paralysis and a dialysis access
device are not used. Additionally, areas distal to a previous phlebitis or infiltration site should also
not be used. The veins in the hand are not the veins of choice. Whenever possible, the upper
extremities, rather than the legs, are used to prevent lower extremity phlebitis and emboli.
The procedure for inserting a peripheral intravenous catheter is:

 Explain the procedure to the client and use sterile supplies and sterile technique to start an
intravenous line.
 Choose a suitable vein.
 Place the tourniquet on the client's arm about 3 to 4 inches above the selected site.
 Palpate the vein.
 Clean the site with an alcohol prep pad with a circular pattern from the site of the venipuncture
to the area surrounding the site of the venipuncture Permit the area to dry.
 Ask the patient to make a fist. Warm compresses and moving the limb to a dependent position
can also be used to dilate the vein. The client should not pump the limb.
 Pull the skin taunt so the vein is accessible.
 Insert the catheter needle into the vein at a 15 to 30 degree angle with the bevel up.
 Look for the flashback of blood into the catheter.
 Lower the angle of the catheter needle.
 Gently advance the catheter so it is at the same level as the surrounding skin.
 Remove the tourniquet and connect the intravenous tubing to the hub of the catheter.
 Secure and stabilize the catheter with a manufactured catheter stabilization device to prevent
vein irritation and an inadvertent dislodgment.
 Adjust the infusion rate according to the doctor's order.

After the intravenous catheter is successful inserted, the intravenous line and the insertion site is
monitored and maintained by the nurse. The intravenous line is monitored to insure that the line is
patent and that the rate of flow is as ordered. The intravenous site is inspected for any signs of
infiltration and infection. The dressing is changed and dated according to the particular healthcare
facility's policy and procedure which is typically every 24 hours.
Central venous catheters are inserted into the right atrium of the heart through the central venous
superior vena cava. Central venous catheters can be advanced into the superior vena cava through a
peripheral vein, as is the case with a peripherally inserted central venous catheter, or PICC, and also
into the central venous system through the subclavian or jugular vein. Some of these catheters have
multiple lumens, up to 3, and they vary in terms of how long they can remain in place. For example,
a percutaneous, non tunneled subclavian catheter is used when immediate and short term treatments
are anticipated, and other central venous catheters are tunneled and cuffed. For example, an
implanted tunneled and cuffed central venous catheter can have a port that is subcutaneously placed
and accessed with a non coring needle into the port's reservoir.
Central venous catheters are a preferred method of venous access when the client is getting
intravenous fluids or therapies in the home and also when the client:

 Does not have suitable peripheral veins for necessary therapies.

 Is receiving continuous or intermittent multiple therapies such as chemotherapy, blood,
medications and total parenteral nutrition.
 Has a long term chronic disease or condition, such as cancer for example.

Strict sterile technique is used for maintain and caring for a central venous catheter. Central venous
catheter dressings are changed at least every forty eight hours unless it is an occlusive transparent
dressing. These occlusive transparent dressings can be changed every 7 days unless they are wet,
soiled or loosened.
Some central venous catheters have a couple or several lumens. Each lumen must be flushed with a
heparin solution on a daily basis in order to maintain patency. The injection cap on each lumen
should be changed every 7 days or any time that the cap is leaking.
Some of the complications associated with central venous catheters include infection,
pneumothorax, hemothorax, thrombosis, emboli and an accidental cardiac perforation during the
insertion procedure.
Patient and family education about venous access devices begins with the informed consent
procedure and it continues throughout the client's use of these devices. Some of the components of
this education should include:

 The purpose of the venous access device

 The risks associated with these devices
 Alternatives to the venous access device
 How the venous access device will be maintained and care for
 Things that the client should report to their doctor or nurse such as burning or redness at the
site
Accessing Venous Access Devices,
Including Tunneled, Implanted and
Central Lines
All venous access devices are accessed and maintained using sterile technique, therefore, nurses and
not unlicensed assistive personnel insert, maintain and manage venous access devices. Additionally,
some health care facilities limit the insertion, maintenance and care of all IVs to only registered
nurses.
Peripheral venous access devices are accessed by disinfecting all hubs prior to administering a piggy
back or an Intravenous push bolus medication.
For example, the procedure for an intravenous secondary piggy back line is as follows.

 The nurse identifies the patient and informs the patient about the medication that will be
administered
 Insure that the intravenous solution is compatible with the piggyback medication
 The piggyback is hung
 The primary intravenous site is cleansed with alcohol
 The piggyback is inserted into the primary intravenous line
 The primary intravenous and the piggyback are then allowed to run together until the piggyback
administration is completed

Providing Care for the Client with a

Central Venous Access Device
Although both peripheral and central venous access devices are managed and maintained with sterile
technique, additional measures such as wearing sterile gloves and masks are needed with central
venous lines because their risk for infection is much greater than that of a peripheral intravenous
line. Both the nurse and the client wear a mask when a central venous access device is being
accessed and cared for.
A chlorhexidine solution is used to cleanse the insertion site and a chlorhexidine solution
impregnated dressing is used to cover the site. The caps are changed and the flushing of the line is
done before and after each access, such as when a medication or chemotherapeutic agent is
administered.
Central venous catheter dressings are changed at least every 48 hours unless it is an occlusive
transparent dressing. These occlusive transparent dressings can be changed every 7 days unless they
are wet, soiled or loosened. Some central venous catheters have a couple or several lumens. Each
lumen must be flushed with a heparin solution on a daily basis in order to maintain patency.
The injection cap on each lumen should be changed every 7 days and any time that the cap is
leaking.
Blood pressure readings and invasive procedures such as laboratory specimens are not done on the
side of the central venous access device.

Dosage Calculations:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of dosage calculations in order to:

 Perform calculations needed for medication administration

 Use clinical decision making/critical thinking when calculating dosages

Performing the Calculations Needed

for Medication Administration
Safe nursing care mandates accuracy in the calculation of dosages and solution rates. In this section
you will get a brief review of basic arithmetic calculations and a review of the ratio and proportion
method that is used for the calculation of dosages and solutions.
The three measurement systems that are used in pharmacology are the household measurement
system, the metric system and the apothecary system.
The household measurement system is typically only used for patients who are in the home and not
in a hospital or another healthcare facility. Measurements used in the household measurement
system include teaspoons, tablespoons, drops, ounces, cups, pints, quart, gallons, and pounds:

UNIT OF MEASUREMENT APPROXIMATE EQUIVALENT(S)

UNIT OF MEASUREMENT APPROXIMATE EQUIVALENT(S)

1 teaspoon 1 teaspoon = 60 drops

1 teaspoon = 5 mL

1 tablespoon 1 tablespoon = 3 teaspoons

1 tablespoon = 15 mL

1 fluid ounce 1 fluid ounce = 2 tablespoons

1 fluid ounce = 30 mL

1 ounce (weight) 16 ounces = 1 pound

1 ounce 30 g

1 cup 1 cup = 8 ounces

1 cup = 16 tablespoons
1 cup = 240 mL

1 pint 1 pint = 2 cups

1 pint = 480 mL
UNIT OF MEASUREMENT APPROXIMATE EQUIVALENT(S)

1 quart 1 quart = 2 pints

1 quart = 4 cups

1 gallon 1 gallon = 4 quarts

1 gallon = 8 pints
1 gallon = 3,785 mL

1 pound 1 pound = 16 ounces

1 pound = 480 g

The apothecary measurement system has weight measurements like dram, ounce, grain (gr), scruple,
and pound. The volume units of measurement in the apothecary measurement system are a fluid
ounce, a pint, a minim, a fluid dram, a quart and a gallon.
Lower case Roman numerals are used in this system of measurement and these Roman numerals
follow the unit of measurement. For example, 4 grains is written as gr iv.
Below is a table showing the weight and volume apothecary system measures and their approximate
equivalents:

WEIGHT APPROXIMATE EQUIVALENT (S) VOLUME APPROXIMATE EQUIV

1 grain (gr) Weight of a grain of wheat 60 mg 1 minim Quantity of water in a drop 1

WEIGHT APPROXIMATE EQUIVALENT (S) VOLUME APPROXIMATE EQUIV

1 scruple 20 grains (gr xx) 1 fluid dram 60 minims

1 dram 3 scruples 1 fluid ounce 8 fluid drams

1 ounce 8 drams 1 pint 16 fluid ounces

1 pound 12 ounces 1 quart 2 pints

1 gallon 4 quarts

The metric measurement system has volume measurements including liters (L), cubic milliliters (ml)
and cubic centimeter (cc); its units of weight are (kg), grams (g), milligrams (mg) and micrograms
(mcg).
Below is a table displaying the metric length, volume and weight measurements and their
equivalents:

LENGTH EQUIVALENT VOLUME EQUIVALENT WEIGHT EQU

LENGTH EQUIVALENT VOLUME EQUIVALENT WEIGHT EQU

1 millimeter (mm) 0.001 meter 1 milliliter (mL) 0.001 liter 1 milligram 0.001
(mg)

1 centimeter (cm) 0.01 meter 1 centiliter (cl) 0.01 liter 1 centigram (cg) 0.001

1 decimeter (dm) 0.1meter 1 deciliter (dl) 0.1 liter 1 decigram 0.1 gr

(dm)

1 kilometer (km) 1000 meters 1 kiloliter (kl) 1000 liters 1 kilogram (kg) 1000

1000 milliliters 1 liter 1 kilogram (kg) 2.2 po

(mL)

1 milliliter (mL) cubic centimeter 1 pound (lb) 43,59

(cc)

10 millimeters (mm) 1 centimeter (cm) 10 milliliters (mL) 1 centiliter (cl) 1 pound (lb) 45,35
LENGTH EQUIVALENT VOLUME EQUIVALENT WEIGHT EQU

(cm)

10 centimeters (cm) 1 decimeter (dm) 10 centiliters (cl) 1 deciliter (dl) 1 pound (lb) 4,535

10,000 decimeters 1 kilometer (km) 10,000 deciliters 1 kiloliter (kl)

(dm) (dc)

Fractions
The two types of fractions are proper fractions and improper fractions. Proper fractions are less
than 1 and improper fractions are more than one 1.
Fractions are written as:
1/2, 6/8 and 12/4, for example; the numerators for each of these fractions are 1, 6 and 12,
respectively; and the denominators for each of these fractions are 2, 8 and 4, respectively.
Both proper and improper fractions can be reduced to their lowest common denominator. Reducing
fractions make them more understandable and easier to work with. You have to determine which
number can be divided evenly into both the numerator and the denominator to reduce fractions. A
fraction cannot be reduced when there is no number that can be divided evenly into both.
For example, 24 / 56 has a numerator and denominator that can be equally divided by 8. To reduce
this fraction you would divide 24 by 8 which is 3 and you would then divide the 56 by 8 which is
which is 7. This calculation is performed as seen below.
24/56 = 3/7

Mixed Numbers
Mixed numbers are a combination of a whole number greater than one and a fraction. Some
examples of mixed numbers are 4 1/4, 3 5/6 and 24 6/7.
You have to convert all mixed numbers into improper fractions before you can perform calculations
using them.
The procedure for converting mixed numbers into improper fractions is:

1. Multiple the denominator of the fraction by the whole number

2. Add the numerator of the fraction to this number
3. Place this number over the denominator of the fraction

The calculation below shows how you how you convert a mixed number into a fraction.
3 2/8 = (8 x 3 + 2) / 8 = (24 + 2 = 26) / 8

Decimals
Decimals express numbers more or less than one in combination with a decimal number of less than
one like a mixed number is.
All decimals are based on our system of tens; in fact the "dec" of the word decimal means 10.
For example, 0.7 is 7 tenths; 8.13 is 8 and 13 hundredths; and likewise, 9.546 is 9 and 546
thousandths. The first place after the decimal point is tenths; the second place after the decimal
point is hundredths; the third place after the decimal point is referred to as thousandths; the fourth
place after the decimal point is ten thousandths, and so on.
When the decimal point is preceded with a 0, the number is less than 1; and when there is a whole
number before the decimal point, the decimal number is more than 1.
For example:
2.7 = Two and 7 tenths or 2 7/10
21.98 = 21 and 98 hundredths or 21 98/100
Decimal numbers are often rounded off when pharmacology calculations are done. For example, if
your answer to an intravenous flow rate is 67.8 drops per minutes, you would round the number off
to the nearest whole drop because you cannot count parts of a drop. When you have to round off a
number like 67.8 o the nearest whole number, you must look at the number in the tenths place
which is 8. If the number in the tenths place is 5 or more, you would round up the 67 to 68 drops.
Similarly, if you have to round off the number 23.54 to the nearest tenth place, you would look at
the number in the hundredths place and if this number is 5 or more, you would round up the
number in the tenths place, but if the number is less than 5, you would leave the number in the
tenths place as it is.
Here are some decimal numbers rounded off to the nearest whole:

 23.8 = 24

 65.4 = 65
Here are some decimal numbers rounded off to the nearest tenth:

 23.84 = 23.8

 67.47 = 67.5

And here are some decimal numbers rounded off to the nearest hundredth:

 23.847 = 23.85

 67.472 = 67.47

Converting From One Measurement System to

Another
You will have to convert from one measurement system to another when the doctor's order, for
example, orders a medication in terms of grains (gr) and you have the medication but it is measured
in terms of milligrams (mg). In this case, you will have to mathematically convert the gr into mg.
The table below shows conversion equivalents among the metric, apothecary and household
measurement systems.

Conversions Among the Systems of Measurement

METRIC APOTHECARY HOUSEHOLD

1 milliliter 15-16 minims 15-16 drops

4-5 milliliters 1 fluid dram 1 teaspoon or 60 drops

15-16 milliliters 4 fluid drams 1 tablespoon or 3-4 teaspoon

METRIC APOTHECARY HOUSEHOLD

30 milliliters 8 fluid drams or 1 fluid ounce 2 tablespoons

240-250 milliliters 8 fluid ounces or ½ pint 1 glass or cup

500 milliliters 1 pint 2 glasses or 2 cups

1 liter 32 fluid ounces or 1 quart 4 glasses, 4 cups or 1 quart

1 milligram 1/60 grain

60 milligrams 1 grain

300-325 milligrams 5 grains

1 gram 15-16 grains

METRIC APOTHECARY HOUSEHOLD

1 kilogram 2.2 pounds

The most frequently used conversions are shown below. It is suggested that you memorize these. If
at any point you are not sure of a conversion factor, look it up. Do NOT under any circumstances
prepare and/or administer a medication that you are not certain about. Accuracy is of paramount
importance.

 1 Kg = 1,000 g
 1 Kg = 2.2 lbs
 1 L = 1,000 mL
 1 g = 1,000 mg
 1 mg = 1,000 mcg
 1 gr = 60 mg
 1 oz. = 30 g or 30 mL
 1 tsp = 5 mL
 1 lb = 454 g
 1 tbsp = 15 mL

Ratio and Proportion for Calculating Doses

The ratio and proportion method is the most popular methods for calculating dosages and solutions.
Although there are other methods, like dimensional analysis for example, that can also be used, only
ratio and proportion will be used in this NCLEX-RN review for brevity sake.
A ratio is two or more pairs of numbers that are compared in terms of size; weight or volume. For
example, the ratio of women less than 18 years of age compared to those over 18 years of age, who
attend a specific college, can be 6 to 1. This means that there are 6 times as many women less than
18 years old as there are women over 18 years of age.
There are a couple of different ways that ratios can be written. These different ways are listed below.

 1/6
 1:6
 1 to 6
When comparing ratios, they should be written as fractions. The fractions must be equal. If they are
not equal they are NOT considered a ratio. For example, the ratios 2 : 8 and 4 : 16 are equal and
equivalent.
In order to prove that they are equal, simply write down the ratios and simply criss cross multiply
both the numerators and the denominators, as below.
2 x 16 = 32 and 8 x 4 = 32.
Because both multiplication calculations are equal and 32, this is a ratio.
On the other hand, 2/5 and 8/11 are not proportions because 8 x 5 which is 40 is not equal to 11 x
2 which is 22.

Calculating Proportions
Proportions are used to calculate how one part is equal to another part or to the whole. For these
calculations, you criss cross multiply the known numbers and then divide this product of the
multiplication by the remaining number to get the unknown or the unknown number.
For example:
2/4 = x/12
12 x 2 = 24
4 x = 24
x = 24/4 so x = 6

Calculating Oral Medication Dosages Using Ratio

and Proportion
Here is an example of how to calculate oral medication dosage using ratio and proportion:
Doctor's order: 125 mg of medication once a day
Medication label: 1 tablet = 250 mg
How many tablets should be administered daily?
In this problem you have to determine how many tablets the patient will take if the doctor order is
125 mg a day and the tablets are manufactured in tablets and each tablet has 250 mg.
This problem can be set up and calculated as shown below.
250 mg: x tablets = 125 mg
250mg x = 125 mg
x = 125/250 = 1/2 tablet
Here is another example of calculating an oral dosage with a liquid oral medication:
Doctor's order: Tetracycline syrup 150 mg po once daily
Medication label: Tetracycline syrup 50 mg/mL
How many mL should be administered per day?
For this oral dosage problem, you have to find out how many mL of tetracycline the patient will get
when the doctor has ordered 150 mg and the syrup has 50 mg/ml.
This problem is set up and calculated as shown below.
150 mg: x mL = 50 mg: 1 mL
50 x = 150
X = 150/50 = 3 mL

Calculating Intramuscular and Subcutaneous

Medication Dosages Using Ratio and Proportion
The process for calculating intramuscular and subcutaneous dosages is practically identical to that of
calculating oral dosages using ratio and proportion. Here is an example:
Doctor's order: Meperidine 20 mg IM q4h prn for pain
Medication label: Meperidine 40 mg/mL
How many mL or cc will you give for each prn dose?
Using ratio and proportion, this problem is set up and solved as shown below.
20 mg / x mL = 40 mg/1mL
40mg * x = 20mg * 1mL
x = 20mg/40mg * 1mL = 0.5 mL
Now, let's do this one:
Doctor's order: Heparin 3,000 units subcutaneously
Medication label: 5,000 units/mL
How many milliliters will be administered for this patient?
5,000 * X = 3,000
3,000/5,000 = 0.6 mL
Answer: 0.6 mL
Calculating Intravenous Flow Rates Using Ratio
and Proportion
The rule for intravenous flow rates is:
gtts/min = (Number of mLs to be delivered)/(The Number of Minutes) x Drip or drop factor for
the IV tubing
Doctor's order: 0.9% NaCl solution at 50 mL per hour
How many gtts per minute should be administered if the tube delivers 20 gtt/mL?
X gtts per min = (50 x 20)/60 = 1000/60 = 16.6 gtts which rounded off to the closest drop is 17
gtts
Rounded off to: 17 gtt/min
Here's another example:
Doctor's order: 500 mL of 5% D 0.45 normal saline solution to infuse over 2 hours
How many gtt per minute should be given if the tubing delivers 10 gtt/mL?
X gtts per min = (500 x 10)/120 = 5000 / 120 = 41.66 gtts which is 42 gtts when it is rounded off

Using Clinical Decision Making When

Calculating Doses
Nurses apply clinical decision making and professional thinking skills to the calculations of dosages
and solution rates. There are times that nurses make an error in terms of their calculations and these
error can be absolutely ridiculous and, at other times, these calculations can appear to be correct.
Although there is no room for errors, a nurse should be able to immediately recognize that a
calculation is wrong and incorrect. For example, if the nurse calculates an intravenous flow rate and
the answer is that the rate of the flow should be 250 gtts per minute, the nurse should immediately
recognize that this answer is ridiculous because it is not possible to accurately count this number of
drops per minute. The nurse should recalculate the flow rate in this instance. If you are calculated
the number of tablets that you should administer to the client according to the doctor's order and
your mathematics indicates that you should give 1/8th of a tablet or 12 tablets, for example, you
should immediately know that your calculations are inaccurate because these answers are ridiculous.
You can also apply clinical decision making and professional thinking skills to the calculations of
dosages and solution rates based on your knowledge of pharmacology and the usual pediatric and
adults dosages for all medications. When, for example, you are calculating a dosage for a medication
like digoxin and your calculation indicates that you should administer 2 1/2 milligrams, you should
immediately know that this dosage is far beyond the usual dosage for digoxin. Again, you should do
your calculations over again and check them to insure that you are accurate.
Expected Actions and
Outcomes: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of expected actions and outcomes in order to:

 Obtain information on a client's prescribed medications (e.g., review formulary, consult

pharmacist)
 Use clinical decision making/critical thinking when addressing expected effects/outcomes of
medications (e.g., oral, intradermal, subcutaneous, IM, topical)
 Evaluate the client's use of medications over time (e.g., prescription, over-the-counter, home
remedies)
 Evaluate client response to medication (e.g., therapeutic effects, side effects, adverse reactions)

Obtaining Information on a Client's

Prescribed Medications
Some of the reliable resources that nurses can use to access and obtain information about a
client's medications are the Physician's Desk Reference (PDR), a nurses' drug handbook published
by a reputable publishing company, a nursing textbook, a formulary, a pharmacist and a reliable
internet resource.

Using Clinical Decision Making and

Critical Thinking When Addressing
the Expected Effects and Outcomes of
Medications
Critical thinking is an essential skill for registered nurses; nursing care and many other things are
much more complex than they have been in the past. Nurses provide care in a time continuous
change occurs. Things are not as simple and clear as they used to be. Patient care problems are
highly complex and more ambiguous than ever before. For example, in years past the Physician
Desk Reference which included all medications that are approved for use was only an inch or so in
height; now it is over five inches thick. New medications, and new side effects and outcomes, are
now too numerous to immediately recall, therefore, the nurse administering medications must know
about their clients and their health care concerns and integrate this knowledge into the complexities
of the medications that they are administering to the client by using problem solving, clinical
decision making and critical thinking skills. The essential components of critical thinking entail deep
thought and deep repeated questioning. When nurses ask themselves questions like "how", "what
if", "why" and "what else", they are using critical thinking to explore things that are affecting or
possibly affecting the client and they can also discover some innovative solutions and alternatives.
It is essential that all nurses are aware of the possible therapeutic effects, side effects and adverse
reactions of medications. Any medication can result in an adverse effects, which can range from
mild to severe, therefore observation and evaluation of the patient after administration of
medication is vital.
Therapeutic effects are the expected results of medications. The nurse, therefore, must monitor the
client to determine the effects of a medication on the client and their physical or psychological
status.

Evaluating the Client's Use of

Medications Over Time
Some clients take or are given medications for an acute illness and for a brief period of time; while
other clients may take or are given medications for a chronic health disorder for an extended period
of time. These medications can include prescription medications, over the counter medications,
vitamins, supplements, and alternative medications and treatments like a home remedy, an herb or a
naturopathic remedy.
Nurses caring for clients who are taking one or more medications for an extended period of time
must:

 Monitor the client's adherence to and compliance with their medication regimen

 Assess and reassess the client in terms of the achievement of the expected outcomes of the
medication(s) over time

 Monitor the client for any side effects, interactions and adverse effects

 Monitor and assess the client for any signs of toxicity

 Monitor and assess the client for the presence of any cumulative effects of their medication that
has been taken over a period of time
Additionally, the nurse caring for the client over time will periodically perform the medication
reconciliation process to insure that the nurse is aware of all medications that the client is taking,
some of which may have been ordered by a physician other than the client's primary care doctor and
some of which are over the counter or alternative therapies that the client has added. The complete
and current list of medications is then reviewed by the nurse and possible interactions are identified
and addressed with the client.

Evaluating the Client's Responses to

Medications
Nurses evaluate the client's responses to all of their medications. These responses can include the
therapeutic effects, side effects, adverse reactions, and interactions.
Therapeutic effects of a medication include the expected and desired effect of a medication; the side
effects of a medication include all the effects of the medication other than the expected and desired
therapeutic effect of the medication, some of which can be serious and others of which can be not
serious and just an annoyance to the client; an adverse effect to a medication is a serious side effect
of the medication that can, at times, be life threatening, as is the case with an anaphylactic response
to a medication; and drug interactions can increase or decrease the effects of one or more
medication when they are taken together and/or with another substance such as an over the counter
medication.

Medication Administration:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of medication administration in order to:

 Educate client about medications

 Educate client on medication self-administration procedures
 Prepare and administer medications, using rights of medication administration
 Review pertinent data prior to medication administration (e.g., contraindications, lab results,
allergies, potential interactions)
 Mix medications from two vials when necessary (e.g., insulin)
 Administer and document medications given by common routes (e.g., oral, topical)
 Administer and document medications given by parenteral routes (e.g., intravenous,
intramuscular, subcutaneous)
 Participate in medication reconciliation process
 Titrate dosage of medication based on assessment and ordered parameters (e.g., giving insulin
according to blood glucose levels, titrating medication to maintain a specific blood pressure)
 Dispose of unused medications according to facility/agency policy
 Evaluate appropriateness and accuracy of medication order for client

Educating the Client About

Medications
Clients and significant others should be taught about all aspects of the medications that they are
taking. The content of this teaching and education should minimally include:

 The purpose of the medication

 The dosage of the medication
 The side effects of the medication
 The possible adverse effects of the medication
 How and where the medication should be safely stored, such as in the refrigerator or in a dark
place, for example
 The importance of and the method for checking the medication's label for the name, dose, and
expiration date
 Special instructions such as shaking the medication, taking the medication with meals or
between meals and on an empty stomach, for example
 When to call the doctor about any side effects
 The importance of taking the medication as instructed
 The need to continue the medication unless the doctor discontinues it
 Information about foods, supplements and other medications, including over the counter
medications and preparations, that can interact with the ordered medication
 The safe disposal of unused and expired medications
 The importance of keeping medications in a secure place that would not place a curious child or
a cognitively impaired adult at risk for taking medications not intended for them
 The proper and safe disposal of any biohazardous equipment such as used needles that the client
uses for insulin and other medications
Educating the Client about the
Medications Self-Administration
Procedures
The client should be educated about the safe and correct method of self administration of
medications. In addition to the education discussed immediately above, some clients may also have
to be instructed about special procedures like the proper use of an inhaler, taking insulin, mixing
insulins, giving oneself an intramuscular injection or self-administering tube feedings.
All of these procedures are fully discussed below in the sections entitled "Preparing and
Administering Medications and Using the Rights of Medication Administration" and "Mixing
Medications From Two Vials When Necessary".

Preparing and Administering

Medications and Using the Rights of
Medication Administration
The "Ten Rights of Medication Administration" are the right, or correct:

1. Medication
2. Dose
3. Time or frequency
4. Patient
5. Route
6. Client education
7. Documentation
8. Right to refuse
9. Assessment and
10. Evaluation

In addition to the Ten Rights of Medication Administration and identifying the patient using at least
two unique identifiers, nurses must also insure medication safety in respect to the storage of
medications, the checking for expiration dates, checking for any patient allergies, and checking for
any incompatibilities.
Nurses must use at least two (2) unique identifiers, other than room number, prior to all procedures
including the administration of medications. Some examples of unique identifiers include the client's
first, middle and last name, a unique password or code number assigned to that person upon
admission, the client's complete birthday in terms of the month, the day and the year, a photograph,
and an encoded bar code containing two (2) or more unique identifiers.
Narcotics must be in a locked and secured in a safe place; other medications must be stored in a
place that is secure and one that prevents accidental poisonings among the pediatric population and
also among those who are confused and/or cognitively impaired. Additionally, medications that
need refrigeration must be refrigerated.

Clients at Risk for Medication Errors and Other

Medical Errors
The risk factors associated with medication errors and other medical errors such as wrong patient or
wrong site surgery are discussed below:
Developmental disorders: The same concerns and interventions described above for infants and
children apply to those with developmental disorders, as specific to the degree of their
developmental delay.
Psychiatric disorders: Patients/residents/clients with a psychiatric disorder are at risk for
medications as based on their psychiatric mental health disorder and the medications that they may
be taking. Some psychotropic medications have sedating effects and the client may be delusional and
out of touch with reality.
Infants and children: These young children are at risk for medication errors because they are not
able to ask questions about medications and procedures; they may not even be able to state their
name. The support and presence of the family is one way to prevent medication errors among this
high risk population.
Language barriers: People with language barriers may not understand what you are saying or
asking and, you may not know what they are saying or asking you in another language, therefore, the
use of interpreters, family or friends, pictures and drawings should be used to overcome a language
barrier.
Cognitive impairments: Clients who are confused, disoriented, demented or with delirium are at
risk for all types of errors because of the challenges associated with accurate patient identification
and the hazards of impaired cognition. Again, patient identification is highly important, and it is also
beneficial to communicate with the client in a way that is understandable to them using pictures and
drawings and to encourage the participation of the significant other(s) in all aspects of care.
Decreased levels of consciousness: Patients who are not alert, awake and oriented to time, place
and person are also at high risk. At times, a family member or friend who is visiting this
patient/resident/client can assist with the two unique identifier processes and also serve as a person
to question you about questionable medications and to ask questions of you.
Sensory disorders: Assistive devices, such as eyeglasses and hearing aids, must be consistently
provided to the sensory impaired person in order to protect their safety. Additionally, the use of
large print or Braille reading materials and magnifying glasses may be helpful for the visually
impaired; and speaking loudly while facing the patient with an auditory impairment may offer some
protection against medication errors.

Routes and Forms of Medications

Medications are manufactured for various routes of administration and in different forms. These
forms are:

 Tablets
 Capsules (regular and sustained release)
 Ointments
 Pastes
 Creams
 Oral suspensions
 Syrups
 Tinctures
 Elixirs
 Ear and eye drops
 Suppositories
 IV suspensions and solutions
 Inhalers

The routes of administration include the following routes:

 Oral
 Subcutaneous
 Intramuscular
 Intravenous or parenteral
 Buccal
 Sublingual
 Topical
 Ophthalmic
 Otic
 Vaginal
 Rectal
 Nasal
 With a nasogastric or gastrostomy tube
 Inhalation
 Intradermal
 Transdermal
 Intracardial
 Intra-articular
 Intrathecal

The oral route of administration is the preferred route of administration for all clients but the oral
route is contraindicated for clients adversely affected with a swallowing disorder or a decreased level
of consciousness. Oral medications can, at times, be crushed and put into something like apple
sauce, for example, for some clients who have difficulty swallowing pills and tablets, but, time
release capsules, enteric coated tablets, effervescent tablets, medications irritating to the stomach,
foul tasting medications and sublingual medications should not be crushed. An alternative route for
some clients is a liquid form of the medication.

Age Specific Route, Form and Dosage

Considerations
 Infants: Use a syringe, dropper or nipple for oral liquid medications, use the vastus lateralis,
rectus femoris and ventrogluteal muscle sites for intramuscular injections and not the deltoid or
the gluteus maximus muscles because these muscles have not yet developed in the infant and
dosages are based on the infant's weight in kilograms (kg).

 Toddlers: Liquid oral medications are given with a spoon or a cup, the vastus lateralis, rectus
femoris and ventrogluteal sites are used for intramuscular injections, the gluteus maximus
muscle can be used after the toddler has been walking for at least a year, flavors can be used to
improve the taste of oral medications, and the dosages continue to be based on kilograms of
weight.

 Preschool and school age children: These children are usually able to take capsules and
tablets, the gluteus maximus muscle and the deltoid muscle can now be used for intramuscular
injections, in addition to the vastus lateralis, rectus femoris and ventrogluteal intramuscular
injection sites, and dosages continue to be based on kilograms of weight.

 Adolescents: Adolescents get adult dosages, routes and forms of medications.

 The Elderly: Adult dosages may be decreased because the normal physiological changes of the
aging process make this age group more susceptible to side effects, adverse drug reactions, and
toxicity and over dosages. Renal function is decreased which can impair the elimination and
clearance of medications, the liver function can be decreased, absorption in the gastrointestinal
tract may be decrease, and the distribution of medications can be decreased because the elderly
 client may have decreased serum albumin, for example. All of these factors increase the elderly
client's risk for side effects, adverse drug reactions, and toxicity and over dosages. For example,
the risk of toxicity is increase when the elderly client is taking aminoglycosides, thiazides, a
nonsteroidal anti-inflammatory medication, heparin, long acting benzodiazepines, warfarin,
isoniazid and many antiarrhythmics.

Nurses must, therefore, begin a new medication with the lowest possible dosage and then increase
the dosage slowly over time until the therapeutic effect is achieved. The initial dosage may be as low
as ½ of the recommended adult dosage.

Reviewing Pertinent Data Prior to

Medication Administration
Prior to the administration of medications, the nurse must check and validate the medication order,
and also apply their critical thinking skills to the ordered medication and the status and condition of
the client in respect to the contraindications, pertinent lab results, pertinent data like vital signs,
client allergies, and potential interactions of the medication that is to be given.
A complete medication order must include the client's full name, the date and the time of the order,
the name of the medication, the ordered dosage, and the form of the medication, the route of
administration, the time or frequency of administration, and the signature of the ordering physician
or licensed independent practitioner's signature.
The four general types of medication orders are stat orders, single orders, standing orders and prn
orders. Stat medication orders are administered immediately and only once; single orders are also
given only once but not necessarily immediately; a standing order is an order for a medication that
will be given at specific times until it is discontinued by a doctor's order or by default when a
facility's policy states that all standing orders are automatically discontinued after 7 days unless the
physician has reordered the medication. A prn order indicates that the ordered medication is only
given when a specified condition, like pain or nausea, is present.
All incomplete, questionable and/or illegible orders must be questioned and validated by the nurse
transcribing the order before it is administered to the client. This questioning and validation requires
that the registered nurse use, integrate and apply their critical thinking and professional judgment
skills. Automated order entry using a computer eliminates some medication order errors including
those that result from illegibility of handwriting and ordering a medication with which the client is
allergic to, however, nurses should never assume that this is the case. For example, medications that
have sound alike names and medications that are similar in terms of their correct spelling can remain
at risk even when computerized, automatic order entry is used.
Medication orders are often transcribed by hand onto a medication administration record (MAR) or
Medex, when the facility is not using computerized order entry.
The client's allergies are determined, all contraindications for the medication as based on the client's
health problems and disease conditions are determined, pertinent diagnostic laboratory results such
as checking the client's prothrombin time and partial thromboplastin time prior to the
administration of heparin, client data like a blood pressure and a pulse rate prior to the
administration of an antihypertensive medication and digoxin, for example, are assessed and any
possible interactions with other medications, foods and alternative and over the counter
preparations are assessed in order to determine whether or not the medication should be
administered. The doctor must be notified whenever the nurse has any concerns or problems with
these things.

Mixing Medications From Two Vials

When Necessary
Medications can only be mixed together when they are compatible with each other. Many diabetic
clients who take two forms of insulin can mix these medications from two vials so that they will only
have to use one, rather than two, subcutaneous injection sites. For example, a client who takes NPH
insulin in the morning and also takes regular insulin prior to breakfast for the coverage of
hyperglycemia can mix the NPH insulin and the regular insulin in the same syringe. The procedure
for this mixing insulins is as below.

1. Prep the top of the longer acting insulin vial with an alcohol swab.
2. Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe.
Do NOT withdraw the longer acting insulin yet.
3. Prep the top of the shorter acting insulin with an alcohol swab
4. Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin
syringe.
5. Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe.
6. And, then lastly, withdraw the ordered dosage of the longer acting insulin using the same insulin
syringe.

For example, if the client has an order for 10 units of NPH insulin in the morning and they also
need 3 units of regular insulin according to their sliding scale for coverage, the client will draw up
both insulins according to the above procedure and then inject 13 units total for the NPH and the
regular insulins.
Administering and Documenting
Medications Given by a Common
Route
The procedures for the administration of medications using different routes are briefly described
below. Note that the verification of the order, its appropriateness for the client, client identification
using at least two unique identifiers, and explaining the medication and the procedure for it
administration is done BEFORE any medication is given to a client.

Oral Route Administration

Give the patient the medication.
Remain with the patient until the medication is swallowed; some clients may pocket and store
medications in their cheeks rather than swallow them.

Buccal and Sublingual Route of Administration

Buccal medications are placed between the teeth and the inner aspect of the client's cheek.
Sublingual medications are administered under the back of the tongue:

1. Don gloves.
2. Place the buccal medication in the buccal pouch and the sublingual medication under the client's
tongue.
3. Instruct the client to not chew or swallow the medication but, instead, to leave the drug in its
position until it is completely dissolved.

Topical Route Administration

Some topical medications are only suitable on intact skin and others that contain a medication are
used for the treatment of broken skin or a wound.

1. Open the tube or container.

2. Place the top upside down on a table top to prevent contamination to the inner aspect of the
cap.
3. Don gloves.
4. Apply the topical medication onto the ordered area(s) using the gloved hand, a tongue
depressor, a cotton tipped applicator or sterile gauze.
5. Apply the topical medication in long and even strokes following the direction of hair growth
when the ordered bodily area has hair.
Transdermal Route Administration
Transdermal medications are absorbed from the surface of the skin. The site should be without hair
so it may be necessary to shave the area and these medications are applied on the client's upper arm
or chest. Some transdermal medications are commercially prepared with the ordered dosage and
others require the nurse to measure and apply the ordered dosage on a transdermal patch. This
procedure is described below.

1. Remove the old transdermal patch if there is one.

2. Wash the site with soap and water. Dry the site.
3. Don gloves.
4. Measure the ordered dose onto the patch or strip without letting the medication to touch your
own skin because this medication can also be absorbed by the nurse's skin.
5. With the medication against the skin gently move the strip over a 3 inch area to spread it out.
Do not rub the medication into the skin.
6. Secure the site with a plastic wrap or another semipermeable membrane specifically made for
this use.
7. Tape the patch in place if it is not surrounded with an adhesive.
8. Write the date, time and your initials on the dressing.

Ophthalmic Route Medication Administration

Ophthalmic eye medications are applied using sterile technique which is one of the few routes that
require more than medical asepsis or clean technique.

1. Don gloves.
2. Position the patient in a sitting position or in a supine position.
3. Have the patient tilt their head back and toward the eye getting the drops or ointment in order
to prevent the medication from entering and collecting in the client's tear duct.
4. Have the patient look up and away to prevent the tip of the tube or dropper from touching the
client's eye. .
5. Rest your hand against the client's forehead to steady it.
6. To administer drops, pull down the lower lid and instill the ordered number of drops into the
conjunctival space.
7. To administer an ointment, pull down the lower lid and squeeze the ointment into the
conjunctival space from the inner to the outer canthus of the eye without letting the tip of the
tube or dropper from touch the client's eye.
8. Instruct the client to close their eyes, roll their eyes and blink. Blinking will spread the drops and
rolling the closed eyes will spread the ointment over the eye.
9. Clean off any excess drops or ointment gently using a facial tissue from the inner to the outer
canthus of the client's eye(s).

Otic Route Administration

1. Warm the ear drops to body temperature.
2. Instruct the person to lie on their side so that the ear to receive the medication is upright.
3. Straighten out the ear canal by pulling the auricle up and back for the adult and down and back
for the infant and young child less than 3 years of age.
4. Administered the ordered number of drops against the side of the inner ear and hold the auricle
in place until the medication is no longer visible.
5. Release the auricle of the ear.
6. Instruct the client to remain in the side lying position with the treated ear up for at least 10
minutes so that the medication gets a chance to enter the ear.

Inhalation Route Administration

The two different types of inhalers that administer medications via the inhalation route are a
metered-dose inhalers and a turbo inhaler.
The procedure for using a metered dose inhaler is:

1. Shake the bottle and remove the cap.

2. Instruct the client to exhale as fully as possible.
3. Have the client then firmly place their lips around the mouthpiece immediately after the strong
exhalation.
4. Press the bottle against the mouthpiece to release the medication while the person is taking in a
long, slow inhalation.
5. Instruct the client to hold their breath for a couple of seconds and then slowly exhale.
6. Have the client rinse their mouth with water and then spit it out to prevent a fungal infection of
the mouth.

The procedure for using a turbo inhaler is:

1. Slide the sleeve away from the mouthpiece.

2. Turn the mouthpiece counter-clockwise to open it.
3. Place the colored part of the medication into the stem of the mouthpiece.
4. Rescrew the inhaler.
5. Slide the sleeve all the way down to puncture the capsule.
6. Instruct the client to fully exhale and then to deeply inhale and hold their breath for several
seconds.
7. Repeat inhalations until all of the medication has been used.
8. The patient can then gargle and rinse their mouth.

Nasogastric Tube Route Bolus Administration

Using Gravity
1. Position the patient in a Fowler's position and up at least at a 30 degree angle.
2. Insure proper tube placement by aspirating the residual and checking the pH of the aspirate or
by auscultating the epigastric area with the stethoscope to hear air sounds when about 30 mLs of
air are injected into the feeding tube. A pH > 6 indicates that the tube is improperly placed in
the respiratory tract rather than the gastrointestinal tract.
3. Prepare the medication(s) to be administered.
4. Insert the syringe without the piston into the end of the nasogastric tube.
5. Pour the medications into the syringe and allow them to flow with gravity.
6. Follow the administration with about 30 to 50 ml of water for an adult and 15 to 30 ml for
children to clear the tube and to maintain its patency.
7. Leave the person in a Fowler's position for at least 30 minutes after instillation. If the person
cannot remain in a Fowler's position, place the patient on the right side with the head elevated.

Vaginal Route Administration

1. Assist the client into the lithotomy position.
2. Drape the patient exposing only the perineum.
3. Remove the suppository from the wrapper and lubricate it with a water soluble jelly.
4. Don gloves.
5. Spread the labia and insert the suppository about 3 to 4 inches into the vagina.
6. If an applicator was used, wash it or discard it if the applicator is for a single use.

Rectal Route Suppository Administration

1. Position the patient on their left side in the Sim's position.
2. Drape the patient exposing only the buttocks.
3. Remove the suppository from the wrapper and lubricate it with a water soluble jelly.
4. Don gloves.
5. Lift the person's upper buttock with the nondominant hand and insert the suppository with the
tapered end first into the rectum for about 3 inches beyond the rectal sphincter while the patient
is taking deep breaths to relax the sphincter.
6. Instruct the person to lie still so the suppository can be retained. If the person has the urge to
defecate, place a gauze pad over the rectum and gently press the area until the urge to defecate
passes.

Rectal Ointment Administration

1. Drape the patient exposing only the buttocks.
2. Don gloves.
3. Place the ointment on a gauze pad and apply to the rectum.

Subcutaneous Route Injections

Subcutaneous injections can be given in the abdomen, upper arms and the front of the thighs.
Subcutaneous injections are used for the administration of insulin, heparin and other medications.
The sites for these injections should be rotated.

1. Select the site.

2. Don gloves.
3. Clean the injection site with an alcohol swab in an outward circular pattern of about 2 inches
around the selected site.
4. Gently pinch the site so a 1 inch fat fold appears.
5. Position the needle with the bevel up and insert at a 45 degree angle unless you CANNOT
pinch an inch or more. In this case, use a 90 degree angle with the exception of heparin. Heparin
is always injected at a 90 degree angle.
6. Release the skin pinch.
7. Pull the plunger back to check for blood. If blood appears withdraw the needle and start again.
8. Slowly inject the medication.
9. Withdraw the needle and cover the site with an alcohol swab.
10. Gently massage the site, except if you are injecting heparin.
11. Discard the needle and syringe in the proper container.

Intramuscular Route Administration

The sites for intramuscular medications are the gluteus maximus, the deltoid muscle, the vastus
lateralis, the rectus femoris muscle, and the ventrogluteal muscle. The gluteus maximus muscle and
the deltoid muscle are NOT used for infants or young children who are less than 3 years of age.
1. Select the appropriate intramuscular injection site using bony landmarks.
2. Position the client as indicated.
3. Don gloves.
4. Clean the injection site with an alcohol swab in an outward circular pattern of about 2 inches
around the selected site.
5. Position the needle with the bevel up and insert at a 90 degree angle.
6. Pull the plunger back to check for blood. If blood appears withdraw the needle and start again.
7. Slowly inject the medication.
8. Withdraw the needle and cover the site with an alcohol swab.
9. Gently massage the site.
10. Discard the needle and syringe in the proper container.

Z Track Intramuscular Injections

Z tract injections are a special type of an intramuscular injection that is used for iron administration,
for example, to avoid any staining of the skin as the result of the medication. This route is also
advantageous to insure that the injected medication is completely injected into the muscle and not
into the subcutaneous tissue.

1. Select the appropriate intramuscular injection site using bony landmarks.

2. Position the client as indicated.
3. Don gloves.
4. Pull the skin over the selected site to the side.
5. Inject the medication into the selected muscle.
6. Release the skin.
7. Do NOT massage the site if a dark solution like iron was administered.

Intravenous Route Bolus Administration (IV Push)

The procedure for IV push without an existing IV line is as follows:

1. Select the largest vein suitable for the medication.

2. Don gloves.
3. Apply a tourniquet, locate the vein, prep the skin and insert the needle at a 30 degree angle with
the bevel up.
4. Lower the angle when you are in the vein.
5. Check for blood backflow.
6. Remove the tourniquet and slowly inject the medication at the ordered or recommended rate.
7. Withdraw the needle, cover the site with a gauze pad and pressure for 3 minutes.
8. Place a bandage over the site.
The procedure for an IV push bolus with an existing IV line is as follows:

1. Make sure that the medication is compatible with the IV solution and any additives.
2. Don gloves.
3. Close the flow clamp on the IV tubing or pinch the tubing just above the injection port.
4. Prep the injection port with alcohol.
5. Inject the medication slowly over several minutes.
6. Open the flow clamp and readjust the flow rate to the ordered rate.

Intravenous Piggy Back or Secondary Line

Administration
This procedure is as follows:

1. Make sure that the medication is compatible with the IV solution and any additives.
2. Hang the secondary IV set (piggy back).
3. Clean the injection port on the primary intravenous line with alcohol.
4. Insert the secondary set needle or needless system into the injection port of the primary IV
tubing.
5. Lower the primary IV using an extension hook to run only the piggy back medication. This
allows the higher piggy back to run until it is finished, after which the primary intravenous will
automatically run at the established rate. If you want to run the primary intravenous solution at
the same time as the piggy back, keep the primary and the secondary containers at the same
height.
6. Remove the secondary set when the medication is completely administered.

More information about intravenous fluid and medication administration and how to start an
intravenous line was discussed in the section entitled "Educating the Client on the Reason For and
Care of a Venous Access Device" of this NCLEX-RN review guide.

Documenting Medications Given

Using All Routes
Nurses are legally and ethically responsible and accountable for accurate and complete medication
administration, observation, and documentation.
Some health care facilities use double locked cabinets to secure controlled substances and others use
more sophisticated bar coded entry systems to access controlled substances. When the older model
double locked narcotics cabinet is used, the contents are counted and checked by the nurse at the
beginning of the shift; this count is then compared to the documented count that was done by the
nurse from the prior shift. If there are any discrepancies, these are immediately addressed, explored
and corrected if it was a simple oversight or mathematical error. When the narcotics count cannot
be corrected, a report must be filed according to the facility's policies and procedures. At times
illegal drug diversion may be the reason for inconsistent narcotics counts.
When a bar coded entry system for narcotics and controlled substances are used, each nurse can
access these medications because the nurse's identification is automatically processed and the
controlled substances are also automatically processed and recorded. When this automated system is
not used, the "narcotic keys" are retained by one nurse and, if another nurse has to administer a
controlled substances, this nurse will enter the narcotics cabinet with the nurse who is holding the
keys.
All controlled substances are documented on the narcotics record as soon as they are removed, and
all controlled substances, like all other medications, are documented on the client's medication
record as soon as they are administered. If a controlled substance is wasted for any reason, either in
its entirety or only partially, this waste must be witnessed or documented by the wasting nurse and
another nurse. Both nurses document this wasting.
All medications that are given, omitted, held or refused by the patient must be documented in the
patient's medication record in addition to other data like vital signs, apical rate, PT and/or PTT as
indicated by the actions of the medication and/or the doctor's order.
Additional professional responsibilities, in terms of medication administration, include the
observation and assessment of the patient prior to the administration of a medication and the
observation and evaluation of the patient's responses to the medication including the therapeutic
effects, any side effects and adverse drug reactions to the medication.

Participating in the Medication

Reconciliation Process
According to the Institute of Medicine's Preventing Medication Errors report, more 40% of
medication errors are the result of a lack of communication related to the client's medications; these
errors can be prevented by performing the medication reconciliation process for all clients,
particularly those clients who are newly admitted, transferred or discharged to another facility or
health care setting.
All medications including all prescription medications, vitamins, over the counter medications,
herbal remedies, nutritional and dietary supplements, vaccinations, blood derivatives, diagnostic and
contrast agents, and radioactive medications are included in the compilation of the list which
contains all current medications and treatments.
The procedure for this medication reconciliation process are:

1. Compile a list of current medications

2. Compile a list of newly prescribed medications
3. Compare the two lists and make note of any discrepancies and inconsistencies
4. Employ critical thinking and professional judgments during the comparisons of the two lists
5. Communicate and document the new list of medications to the appropriate healthcare providers

Titrating the Dosage of a Medication

Based on the Assessment and Ordered
Parameters
Titration is defined as adjusting the dosage of a medication according to some ordered and specified
parameters or criteria. The most commonly occurring example of a titrated medication is insulin
coverage with regular insulin that is based on the client's blood glucose levels. For example, the
client's order for regular insulin before a meal may specify that the client take 2 units of regular
insulin for blood glucose levels from 200 to 260.
Some intravenous medications are also titrated. For example, an intravenous antihypertensive drug
like Hyperstat will be titrated and adjusted according to the client's blood pressure.

Disposing of Unused Medications

According to the Facility/Agency
Policy
Agencies vary in terms of how they dispose of unused medications after the client has been
discharged and/or no longer in need of a specific medication. Refer to your facility's policies and
procedures relating to the disposal of unused medications.
Clients in the home environment must also be instructed about the proper and safe disposal of
unused and expired medications in order to prevent use by others and to protect the environment.
The U.S. Drug Enforcement Administration (DEA) periodically hosts National Prescription Drug
Take-Back days for the disposal of prescription drugs, some local law enforcement departments may
have a local take back program, and some local health care agencies and pharmacies may also take
back unwanted medication. When these resources are not available in the community, the home care
client should be instructed to contract their local solid waste department to find out how these
medications should be discarded.
If a controlled substance is wasted, this waste must be witnessed by and documented by the wasting
nurse and another nurse.
Controlled substances and narcotics are immediately documented on the narcotic record when they
are taken from their secure and double locked cabinet. This documentation is NOT done after the
medication is administered. Narcotics and controlled substances are then documented in the
patient's medication record as soon as they are administered. During the change of shift, two nurses
perform a complete count of all narcotics and controlled substances. If a discrepancy occurs, it is
immediately reported for further investigation.

Evaluating the Appropriateness and

Accuracy of Medication Orders for the
Client
All medication orders are evaluated by the nurse in terms of their accuracy and appropriateness of
the order. Some of the things that are considered and evaluated include:

 The completeness of the medication order

 The accuracy of the medication order
 The appropriateness of the medication order
 Client allergies
 The client's health condition
 The client's pertinent laboratory findings
 Other client data like vital signs, for example

The doctor must be notified whenever the nurse has any concerns or problems with these things.

Parenteral and Intravenous

Therapies: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of parenteral and intravenous therapies in order to:

 Identify appropriate veins that should be accessed for various therapies

 Educate client on the need for intermittent parenteral fluid therapy
 Apply knowledge and concepts of mathematics/nursing procedures/psychomotor skills when
caring for a client receiving intravenous and parenteral therapy
 Prepare the client for intravenous catheter insertion
 Monitor the use of an infusion pump (e.g., IV, patient-controlled analgesia (PCA) device)
 Monitor intravenous infusion and maintain site (e.g., central, PICC, epidural and venous access
devices)
 Evaluate the client's response to intermittent parenteral fluid therapy

Identifying Appropriate Veins that

Should be Accessed for Various
Therapies
The identification and selection of appropriate vein for various intravenous therapies are done by
the nurse after considering a number of factors. Whenever possible, the best veins for the nurse to
assess and then use are the distal veins on the nondominant hand so that the client is able to fully
use their dominant hand. Additionally, whenever possible, the upper extremities, rather than the
legs, are used to prevent lower extremity phlebitis and emboli. The veins in the hand are not the
veins of choice.
The side of a client's mastectomy, paralysis and a dialysis access side are not used. Additionally, areas
distal to a previous phlebitis or infiltration site should also not be used.
The appropriateness of the vein selected should also be based on the therapy that is anticipated for
the client. Some clients may require small intravenous catheters and others, such as those clients
who may or will be getting a blood transfusion, will require a larger intravenous catheter and the
selection of a larger vein. For example, an 18 gauge intravenous catheter is needed for the
administration of a blood transfusion; an even larger 16 gauge intravenous catheter is used for the
many and often unanticipated needs when a major trauma client enters the emergency department;
and a smaller 22 or 24 gauge intravenous catheter is used when a client only needs intravenous fluids
and medication with their peripheral venous catheter.

Educating the Client on the Need for

Intermittent Parenteral Fluid Therapy
As with all treatments and interventions, nurses must educate the client about the need for their
intermittent parenteral fluid therapy. They should also be educated about when to call for the nurse,
such as when they are experiencing pain or swelling at the insertion site or the flow stops or the
alarm rings.
Applying a Knowledge and Concepts
of Mathematics, Nursing Procedures
and Psychomotor Skills
Nurses apply their critical thinking and professional judgment skills as well as their knowledge of
mathematics, nursing procedures and psychomotor skills when they monitor and care for a client
who is receiving intravenous and parenteral therapy.

The Concepts of Mathematics

The rule for intravenous flow rates is:
gtts/min = Number of mLs to be delivered x Drip or drop factor for the IV tubing
The number of minutes
For example, if the doctor's order: 0.9% NaCl solution at 100 mL per hour, how many gtts per
minute should be administered if the tube delivers 20 gtt/mL?
X gtts per min = (100 x 20)/60 = 2000/60 = 33.3 gtts which rounded off to the closest drop is 33
gtts per minute
Rounded off to: 33 gtt/min

Nursing Procedures
The intravenous line and the insertion site are monitored and maintained by the nurse. The
intravenous line is monitored to insure that the line is patent and that the rate of flow is as ordered.
The intravenous site is routinely assessed and inspected for any signs of infiltration and infection.
The dressing is changed and dated according to the particular healthcare facility's policy and
procedure which is typically every 24 hours.
All of these nursing procedures can only be done by licensed nurses, and not unlicensed assistive
staff.

Psychomotor Skills
The psychomotor skills associated with venipuncture and starting an intravenous line was fully
discussed step by step in the section entitled "Educating the Client on the Reason For and Care of a
Venous Access Device".

Preparing the Client for an Intravenous Catheter

Insertion
Preparing the client for an intravenous catheter insertion should minimally include patient education
and information about:

 The purpose of the intravenous catheter

 The procedure for inserting the intravenous catheter
 How the intravenous catheter will be cared for and maintained
 When to notify the nurse of any possible complications or malfunctioning of the intravenous
therapy

Monitoring the Use of An Infusion

Pump
Infusion pumps are not a substitute for the monitoring and maintenance of intravenous infusion
pumps. Infusion pumps can, and do, malfunction and break down so it is imperative that the nurse
monitor them for accuracy and proper functioning.
There are a couple of simple ways to monitor these pumps. One way is to mathematically calculate
the number of drops of minute that should be infusing and then checking the rate of the infusion
pump by visually counting the number of drops that are actually being delivered. Another method,
in addition to the check just discussed, is to return to the client's bedside and determine how many
mLs or cc s should have been administered during the period of time that the nurse was not at the
bedside. For example, if the client is supposed to receive 125 cc of fluid per hour and when you
monitored the client 2 1/2 hours ago there were 650 cc remaining in the IV bag of fluid, and, now,
there are 550 cc remaining in the IV bag, you should know immediately that there should only be
312 cc remaining, therefore the intravenous flow is not infusing as ordered. When more or less
intravenous fluid is being delivered by the infusion pump, the nurse must correct and rectify the
situation and return the pump and take it out of service when necessary.
Patient controlled analgesia pumps are also monitored for their functioning and accuracy.

Monitoring the Intravenous Infusion

and Maintaining the Site
All intravenous lines, including central lines, PICC lines, and venous access devices are invasive lines
that can lead to catheter associated health care related infections unless they are cared for in the
proper manner. As with all aspects of intravenous therapy, only the nurse is permitted to monitor,
maintain and care for these lines and sites. This care cannot, under any circumstances, be delegated
to an unlicensed assistive staff member like a nursing assistant or a patient care technician.
The care and the maintenance of these sites is stated in the facility's policies and procedures and this
care typically includes the use of sterile technique and the following.

Peripheral Intravenous Lines

The intravenous line and the insertion site are monitored and maintained by the nurse. The
intravenous line is monitored to insure that the line is patent and that the rate of flow is as ordered.
The intravenous site is routinely assessed and inspected for any signs of infiltration and infection.
The dressing is changed and dated according to the particular healthcare facility's policy and
procedure which is typically every 24 hours.

Central Venous Access Devices

In addition to sterile technique, central venous access devices are managed and maintained with
additional measures including the donning of sterile gloves and a personal protective face mask for
both the client and the nurse. Chlorhexidine is used to cleanse the insertion site, a sterile dressing
sometimes impregnated with chlorhexidine covers the site and is often changed every 48 hours
except if it is an occlusive transparent dressing, the caps are changed and the line is flushed after
every access. Occlusive transparent dressings can remain in place for up to 72 hours. Blood pressure
readings and invasive procedures such as laboratory specimens are not done on the side of the
central venous access device.

Evaluating the Client's Responses to

Intermittent Parenteral Fluid Therapy
Intermittent parenteral fluid therapy can be used to administer intravenous medications and also for
intravenous fluid replacements. Intravenous medication administration rapidly enters the client's
circulatory system and, for this reason, adverse effects including allergic responses can also occur
rapidly and place the client at risk for even life endangering complications such as anaphylaxis. The
nurse, must, therefore evaluate and monitor the client's responses to these intermittent medication
administrations. Clients receiving intermittent fluid replacements should be monitored in terms of
their responses to it as well. The client's laboratory data, their fluid intake and output, and any signs
and symptoms of fluid overload must be closely monitored when the client is receiving intermittent
fluid replacement therapy.
All clients receiving intravenous therapy, both intermittent and continuous, must also be evaluated
and monitored in terms of the presence of any complications associated with intravenous lines.
These complications include:

 Infection
 Infiltration
 Extravasation with vesicant medications
 Hematoma
 Phlebitis
 Embolus formation
 Fluid overload

Infection
The signs and symptoms of intravenous therapy infection include the classic signs of infection such
as swelling, soreness, redness at the site, pain, and fever. This complication can be prevented by only
using intravenous therapy when necessary, by discontinuing the intravenous therapy and catheters as
soon as possible and by maintaining strict sterile asepsis when care for and dressing the site of the
intravenous therapy. In addition to documenting this complication and notifying the doctor, the
nurse should also discontinue the intravenous flow and catheter, elevate the client's affected limb,
apply warm compresses, and administer any ordered antipyretic and/or antibiotic medications.

Infiltration
Infiltration occurs when intravenous fluid is infused into the subcutaneous tissues instead of the
vein. When the client is adversely affected with an infiltration, the nurse should be able to identify its
signs and symptoms which can include site pain, swelling in the area of the catheter insertion site,
coolness of the skin near the site, slowing down of the intravenous fluid rate, and paleness of the
skin around the insertion site. Nurse should, again, stop the infusion, remove the intravenous
catheter, elevate the affected limb and apply warm compresses to the area.

Extravasation
Extravasation is a serious form of infiltration that occurs when a caustic medication, like some
chemotherapeutic medications, infiltrates into the tissue. In severe cases, extravasation can lead to
necrosis and the loss of an affected limb. The signs and symptoms in the early stage of extravasation
are the lack of blood return, a lowered rate of infusion, burning, tingling, severe pain in the limb,
erythema, swelling, redness, and blistering; and the signs and symptoms during the later stages of
extravasation include the worst possible unrelenting pain, ulceration, blistering, and severe necrosis
secondary to extravasation.
The interventions for extravasation include the immediate cessation of the infusion, the placement
of a syringe after the removal of the intravenous line near the site, aspirating as much blood and
infused fluid as possible, elevating the limb, applying warm compresses initially to rid the area of any
remaining drug that is in the tissues which is then followed by cool compresses to reduce any
swelling, and the administration of an ordered substance specific medication such as dexrazoxane.

Hematoma
Hematomas secondary to intravenous therapy and other injuries present with ecchymosis. The
treatment of an intravenous therapy related hematoma includes the cessation of the intravenous
therapy, the removal of the intravenous catheter, the application of pressure and a pressure dressing
over the site, the elevation of the limb and the application of warm compresses. This complication
does not typically lead to a serious condition other than minor bruising.
Phlebitis
The signs and symptoms of intravenous therapy related phlebitis include redness, swelling, pain,
fever, the slowering of the intravenous flow, and the possible appearance of a palpable red streak at
the intravenous insertion site and beyond. Phlebitis is treated with the cessation of the intravenous
therapy, the elevation of the limb, the application of warm compresses and the possible
administration of analgesics for the pain and/or antipyretics for the client's fever.

Embolus Formation
The signs and symptoms of an embolus can include shortness of breath and chest pain. In addition
to notifying the doctor, the nurse should monitor the client for life threatening complications, and
place a tourniquet above the site to prevent further migration of broken catheter pieces.

Fluid Overload
Fluid overload can occur when the flow rate of the intravenous fluids exceed the client's capacity to
cope with this volume. The signs and symptoms of fluid overload include hypertension, adventitious
breath sounds such as rales and crackles, tachycardia, shortness of breath, distended neck veins and
edema. Fluid overload is a high risk for elderly clients and those affected with heart failure. The
nurse monitoring the client who suspects fluid overload will notify the doctor and decrease the rate
of the intravenous fluids to prevent further overload.

Pharmacological Pain
Management: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of pharmacological pain management in order to:

 Assess client need for administration of a PRN pain medication (e.g., oral, topical, subcutaneous,
IM, IV)
 Administer and document pharmacological pain management appropriate for client age and
diagnoses (e.g., pregnancy, children, older adults)
 Administer pharmacological measures for pain management
 Administer controlled substances within regulatory guidelines (e.g., witness, waste)
 Evaluate and document the client's use and response to pain medications
Assessing the Client's Need for the
Administration of a PRN Pain
Medication
Some orders for pain medications are PRN which means that the client will only receive the pain
medication when there is pain or discomfort that can be assessed and documented by the nurse.
PRN pain medications can be given using a number of routes including the intramuscular,
intravenous, oral, subcutaneous, and topical route as is used for skin irritation and itchiness, for
example.
RELATED: Pain Management Nursing Careers
As more fully discussed earlier in the section entitled "Assessing the Client's Need for Pain
Management", pain can be classified as acute and chronic, nociceptive and neuropathic, superficial,
somatic, radicular, referred or visceral pain, localized or diffuse, and as mild, moderate, or severe.
As also detailed in this same section, pain that is not controlled and managed can lead to severe
consequences for the client. For example, the client's psychological and emotional state can be
adversely affected with depression, a poor quality of life, and anxiety, and the client's physical status
and hemostasis is also affected with things like alterations in terms of their vital signs and perhaps
even neurogenic shock.
Despite all the misinformation about pain and pain management, pain must be managed according
the external regulatory bodies like the Joint Commission on the Accreditation of Healthcare
Organizations, and the American Nurses Association.
There are several ways of assessing pain. These pain assessment methods include:

 The PQRST method of pain assessment which includes precipitating events, the quality of pain
(dull, sharp, deep, superficial, burning, aching, or stabbing?), region and location of the pain, the
severity of the pain, and the triggers and timing of the pain.

 Using a standardized pain assessment scale specifically for adults, children and infants, such as
the CRIES and McGill Pain Assessment tools

 Using a graphic or numerical pain rating scale with faces and on a scale from 0 to 10, for
example

 The assessment of behavioral signs and symptoms of pain such as tachycardia, hypertension and
diaphoresis
Administering and Documenting
Pharmacological Pain Management
That is Appropriate for the Client's
Age and Diagnoses
Pharmacological pain management medications have some age specific implications along the
lifespan and for some diagnoses, conditions and diseases. For example, infants, children, the elderly
and clients affected with a normal and expected developmental change, such as pregnancy, have
special needs that the nurse must be knowledgeable about before administering a pharmacological
pain medication.
Neonates and infants are given dosages of medications based on their weight in terms of kilograms
or based on their body surface area. Oral pain medications are given as a liquid using a dropper or a
nipple.
Young children are also given pain medications with a dosage as based on their kilograms of body
weight or based on their body surface area. Young children may be able to take some oral pills and
tablets. The vastus lateralis, rectus femoris and ventrogluteal sites are used for intramuscular
injections until the young toddler has been walking for at least one year to develop the gluteus
maximus muscle which can now be used for intramuscular injections.
The elderly population and the normal changes of the aging process also have implications in terms
of pharmacological pain management medications. The normal changes of the aging process such as
decreased renal, hepatic and gastrointestinal functioning place the client at risk for side effects,
adverse drug reactions, toxicity and over dosages. Nurses must, therefore, begin a new medication
with the lowest possible dosage and then increase the dosage slowly over time until the therapeutic
effect is achieved. The initial dosage may be as low as ½ of the recommended adult dosage.
Many pain management medications are contraindicated during pregnancy and lactation. For
example, opioids used during pregnancy can lead to premature births, miscarriages, and other
complications of pregnancy. The fetus may also have withdrawal symptoms from this medication.

Administering Pharmacological
Measures for Pain Management
Analgesic pharmacological medications are broadly categorized as opioid analgesics and non-opioid
analgesics. They can also be categorized as adjuvant medications and primary analgesic medications.
Opioids are narcotics; they are used for moderate to severe pain; non-opioids are non-narcotic
analgesics that are used to treat mild pain and they also to serve as adjuvant medication for the relief
of pain.
The non-narcotic, non opioid medications that are used for pain management include those listed
below along with their examples and possible side effects.

 Tylenol: The side effects can include hepatotoxicity, renal damage and, in very severe cases,
hepatic failure

 NSAIDS: Ibuprofen and Ibuprofen like drugs such as Advil, Motrin, Naprosyn, Naproxen and
Clinoril are associated with side effects such as nausea, indigestion, a headache, fecal occult
blood and anorexia. Although not that common, some of the severe side effects and adverse
effects of these drugs can include aplastic anemia, gastrointestinal tract bleeding, edema, and
renal failure.Selective COX-2 (cyclooxygenase 2 ) inhibitors like Celebrex are also associated
with both mild and very severe side effects. Some of the commonly occur side effects include
abdominal pain, gastrointestinal gas, headache, insomnia, nausea and bloating. Some of the most
serious and life threatening side effects of these medications are gastrointestinal hemorrhage, a
cerebrovascular accident and a myocardial infarction.

 Salicylate NSAIDS: Salicylate NSAIDS include aspirin and disalcid, for example. Some of the
mild side effects include abdominal pain, ulcers and heartburn; more serious side effects and
adverse reactions include hemolytic anemia, bronchospasm and anaphylactic shock.

 Centrally Acting Non Opioid Analgesics: Centrally acting non opioid analgesics such as
Clonidine are associated with side effects such as oral dryness, drowsiness, sedation,
constipation, hypotension and fatigue.The narcotic, opioid medications that are used for pain
management include those listed below along with their examples and possible side effects.

 Opioid Agonists: Opioid agonists such as codeine, OxyContin, Darvon, Dilaudid, Demerol
and Percocet have the side effects of constipation, sedation, nausea, dizziness, pruritus, and
sedation. Some of the more severe side effects and adverse effects of the opioid agonists include
respiratory depression and arrest, hepatic damage, an anaphylactic reaction, circulatory collapse
and cardiac arrest.

 Opioid Antagonists: Opioid antagonists, also referred to as opioid receptor antagonists, such
as naloxone and naltrexone, can have side effects such as hepatic damage, joint pain, insomnia,
vomiting, anxiety, headaches and nervousness.
 Opioids with Mixed Agonist - Antagonist effects: Opioids with mixed agonist- antagonist
effects include analgesics like Talwin and Stadol can have side effects such as nausea,
drowsiness, dizziness, diaphoresis and clammy skin.

RELATED: How Can Pain Management Nurses Help to Identify and Manage Addictions?

Administering Controlled Substances

Within Regulatory Guidelines
Because of the sad realities revolving around the diversion of narcotic drugs by health care
professionals, these substances have legal requirements. Some of these requirements when non
automated systems are used include:

 The signature of the nurse picking up the narcotics from the pharmacy to confirm that this
nurse picked up the medications
 A narcotics sheet which is delivered to the nursing care unit together with the narcotics that
were picked up by the nurse at the pharmacy
 Locking and securing controlled substances in a secure manner to prevent diversion and/or
theft
 The assignment of the accountable nurse who will count and verify the narcotics count at the
beginning and the end of each shift
 The removal of narcotics from the locked cabinet by this accountable nurse and the immediate
signature of the nurse removing it for administration to the client
 The witnessing and signatures of two nurses for any wasting and discarding of controlled
substances

Evaluating and Documenting the

Client's Use and Response to Pain
Medications
Nurses assess, evaluate and document all client responses to pain interventions and also their use of
pain medications. The responses to pain medications can be evaluated in a number of different ways
including the use of pain rating scales, verbal reports of pain, and an objective determination and
evaluation of any physical and/or behavioral cues that can be associated with the patient's pain.
The level of pain should be determined prior to the administration of a pain drug and the level of
pain must also be determined after the medication was administered in order to determine whether
or not it was effective in terms of a decrease in the patient's level of pain.
Some of the expected outcomes and client responses to pain medications can include:

 The client will state that their level of pain has decreased by at least 3 after the administration of
a pain medication
 The infant will be free of any behavioral or physiological signs and symptoms of pain
 The client is able to transfer and ambulate without pain after the administration of their pain
medication
 The client states that they are able to sleep after they have received their ordered pain
medication

Total Parenteral Nutrition

(TPN): NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of total parenteral nutrition in order to:

 Identify side effects/adverse events related to TPN and intervene as appropriate (e.g.,
hyperglycemia, fluid imbalance, infection)
 Educate client on the need for and use of TPN
 Apply knowledge of nursing procedures and psychomotor skills when caring for a client
receiving TPN
 Apply knowledge of client pathophysiology and mathematics to TPN interventions
 Administer parenteral nutrition and evaluate client response (e.g., TPN)

As discussed previously in the section "Providing Client Nutrition Through Continuous or

Intermittent Tube Feedings", clients who are not able to get sufficient calories and nutrition are
given enteral nutrition through a nasointestinal tube, a nasojejunal tube, a nasoduodenal tube, a
jejunostomy tube, a gastrostomy tube, or a percutaneous endoscopic gastrostomy (PEG) tube.
Although parenteral nutrition is more costly than enteral nutrition and it also poses a greater risk in
terms of infection, it is sometimes indicated when enteral nutrition is contraindicated for the client,
when the client is at high risk for aspiration, when the client has a gastrointestinal tract obstruction
that would interfere with an enteral tube feeding, and when the client's gastrointestinal tract is not
functioning in a manner that can accommodate a less costly and lower risk enteral feeding rather
than total parenteral nutrition, which is often referred to as hyperalimentation.
Hyperalimentation places the client at high risk for infection for two major reasons;
hyperalimentation is an invasive procedure and the hyperalimentation solution contains a high
percentage and amount of dextrose.

Identifying the Side Effects and

Adverse Events Related to TPN and
Intervening as Appropriate
The side effects and adverse events related to TPN include those described below.

 Complications associated with the insertion of the TPN catheter: Some of the
complications associated with the insertion of the TPN catheter include an accidental and
inadvertent pneumothorax, hemothorax or hydrothorax when the TPN catheter perforates the
vein and fluid enters the pleural space. The signs and symptoms of these insertion complications
include chest pain, shortness of breath and pain.

 Infection: Infection is probably the most commonly occurring complication associated with
total parenteral nutrition. This complication can be prevented and minimized by using total
parenteral nutrition only when necessary, by discontinuing the total parenteral nutrition as soon
as possible, and by using strict sterile technique during its insertion, care, and maintenance. Most
sources of infectious pathogens enter this closed system during insertion, tubing changes,
dressing changes, and when total parenteral nutrition solutions are mixed. The signs and
symptoms of these infections include the classical signs of infection including a fever, malaise,
swelling and redness at the insertion site, diaphoresis, chilling and pain in the area of the TPN
catheter insertion site.

 Fluid overload: Fluid overload can occur for the same reasons that fluid overload can occur
with a regular peripheral intravenous flow. The rate is too fast and rapid for the client. The signs
and symptoms of fluid overload include hypertension, edema, adventitious breath sounds like
crackles and rales, shortness of breath, and bulging neck veins. This complication can be
prevented by monitoring the client and adjusting the rate of the total parenteral nutrition to
prevent fluid overload.

 Hyperglycemia: Hyperglycemia can occur as the result of the high dextrose content of the total
parenteral nutrition solution as well as the lack of a sufficient amount of administered insulin.
The signs and symptoms of hyperglycemia secondary to total parenteral nutrition are the same
 as those associated with poorly managed diabetes and they include a high blood glucose level,
thirst, excessive urinary output, headache, nausea and fatigue. This total parenteral nutrition
complication can be prevented with the continuous monitoring of the client's blood glucose
levels and the titration of insulin administration as based on these levels.

 Hypoglycemia: Hypoglycemia secondary to total parenteral nutrition are the same as those
associated with poorly managed diabetes and they include a headache, a low blood glucose level,
shakiness, clammy and cool skin, blurry vision, diaphoresis and unconsciousness and seizures.
This complication of total parenteral nutrition, like hyperglycemia, can be prevented with the
close monitoring of the client's blood glucose levels and an adequate dosage of insulin as based
on these levels.

 Embolism: Embolism can occur when air is permitted to enter this closed system during tubing
changes and when a new bottle or bag of hyperalimentation is hung. This complication can be
prevented by instructing the client to perform the Valsalva maneuver and the nurse's rapid
changing of tubings and solutions when the closed system is opened to the air. The signs and
symptoms of an embolism include dyspnea, shortness of breath, coughing, chest pain and
respiratory distress.

Educating the Client On the Need for

and Use of TPN
Clients should be educated and instructed about the purpose of TPN, their need for TPN, the
procedure that will be used to insert the TPN catheter, how the total parenteral nutrition feedings
will be delivered, how the nurse will care for and maintain these feedings, the necessity to use sterile
technique, and the risks, including the complications, of total parenteral nutrition, as discussed
immediately above .
Total parenteral nutrition, or hyperalimentation, is delivered through one of the body's larger veins
such as the subclavian vein. Hyperalimentation can provide for all of the nutritional needs and these
feedings contain minerals, electrolytes, vitamins, hyperosmolar glucose, amino acids, and trace
elements which are administered through the hyperalimentation catheter which was surgically placed
by the physician.
Total parenteral nutrition is most often used for clients who are in need of complete bowel rest,
those who are in a negative nitrogen balance as the result of a severe burn or another cause, among
clients who have a severe medical illness or disease such as cancer or AIDS/HIV, when the client
chooses to have this treatment.
Applying a Knowledge of Nursing
Procedures and Psychomotor Skills
When Caring for a Client
Receiving TPN
The nursing process as applied to the nursing procedures and the psychomotor includes assessment,
nursing diagnoses, planning, establishing expected outcomes and evaluating the client's responses to
this care and treatment.
Assessment: The nurse assesses the client, they assess and validate the client's need for
hyperalimentation including laboratory diagnostic test results, and they also establish baselines prior
to the total parenteral nutrition feedings which include baseline bodily weight, baseline vital signs,
baseline levels of glucose, protein and electrolytes, and baselines in terms of the client's intake and
output.
After the complete assessment of the client, the nurse will establish actual and potential nursing
diagnoses for the client such as:

 Imbalanced nutrition less than the body requirements related to advanced debilitating disease
 Imbalanced nutrition less than the body requirements related to a negative nitrogen balance
secondary to a severe burn
 Imbalanced nutrition less than the body requirements related to an impairment of
gastrointestinal tract functioning
 At risk for hypoglycemia related to total parenteral nutrition
 At risk for hyperglycemia related to total parenteral nutrition
 At risk for sepsis related to total parenteral nutrition
 At risk for sepsis related to total parenteral nutrition

The planning phase of the nursing process in respect to total parenteral nutrition includes the
establishment of client goals or expected outcomes and planning interventions. Some appropriate
expected outcomes can include:

 The client will be free of any complications associated total parenteral nutrition
 The client will have adequate nutrition
 The client will maintain normal blood glucose levels during treatment with total parenteral
nutrition
 The client will be able to verbalize an understanding of total parenteral nutrition and the need
for sterile asepsis
The evaluation of the total parenteral nutrition for the client is based on comparing the client's
baseline data and information to the data and information that is collected during these treatments
and after the total parenteral nutrition feedings are completed, as will be discussed just below in the
section entitled "Administering Parenteral Nutrition and Evaluating the Client Responses".
Some of the psychomotor skills that nurses used when caring for a client receiving TPN include the
nurse's application of sterile asepsis techniques, changing the tubings and the total parenteral
nutrition feeding bags and bottles, the maintenance of the site of insertion of the total parenteral
nutrition catheter, and manipulating and controlling the rate of the infusion of the total parenteral
nutrition. More information about these psychomotor procedures will be discussed just below in the
section entitled "Administering Parenteral Nutrition and Evaluating the Client Responses."

Applying a Knowledge of Client

Physiology and Mathematics to TPN
Interventions
Nurses caring for clients who are receiving TPN must apply their knowledge of the client's
physiology into their care of the client. For example, they must apply sterile technique to avoid
infection, they must closely monitor the client's blood glucose levels on a continuous basis because
the contents of these total parenteral nutrition feedings are high in terms of dextrose content which
can lead to hyperglycemia, they must also monitor these levels to determine if the client is being
affected by hypoglycemia as a result of the insulin that is administered with these total parenteral
nutrition feedings in order to prevent hyperglycemia, and, for example the nurse must monitor the
client's intake and output knowing that, physiologically, the high osmolarity of the TPN can lead to
osmotic diuresis and fluid imbalances.
Mathematic principles are also applied to TPN interventions in terms of flow rate of the solution
which is essentially the same as calculating intravenous flow rates which was fully discussed and
described in the section entitled "Dosage Calculations: Performing Calculations Needed for
Medication Administration".

Administering Parenteral Nutrition

and Evaluating the Client Responses
Total parenteral nutrition is administered in a similar manner to that which is done with intravenous
infusions with a few points of emphasis and differences as listed below.

 Total parenteral nutrition feedings are refrigerated until they are ready to hang
 Strict sterile asepsis is used.
 Regular insulin can be added to the TPN solution to prevent hyperglycemia
 Any time that this closed system is opened, as occurs with a tubing or solution bag change, the
client must perform the Valsalva maneuver to prevent an embolus and the nurse must perform
these tasks as quickly as possible.
 The total parenteral nutrition tubing should be changed every 24 hours and the dressing should
be changed at least every 24 hours for the first several days of treatment. These changes can vary
from facility to facility, so nurses must refer to their facility specific policies and procedures
 III) Reduction of Risk Potential
The Reduction of Risk Potential questions will test the ability of the nurse to reduce the likelihood
that clients will develop complications or health problems related to existing conditions, treatments
or procedures.
The nurse must be able to:

 Assess and respond to changes in client vital signs

 Perform diagnostic testing (e.g., electrocardiogram, oxygen saturation, glucose monitoring)
 Monitor the results of diagnostic testing and intervene as needed
 Obtain blood specimens peripherally or through the central line
 Obtain specimens other than blood for diagnostic testing (e.g., wound, stool, urine)
 Insert, maintain and remove a gastric tube
 Insert, maintain and remove a urinary catheter
 Insert, maintain and remove a peripheral intravenous line
 Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
 Evaluate responses to procedures and treatments
 Recognize trends and changes in client condition and intervene as needed
 Perform focused assessment
 Educate the client about treatments and procedures
 Provide preoperative and postoperative education
 Provide preoperative care
 Provide intraoperative care
 Manage client during and following a procedure with moderate sedation

Related content includes but is not limited to:

 Changes/Abnormalities in Vital Signs

 Diagnostic Tests
 Laboratory Values
 Potential For Alterations in Body Systems
 Potential for Complications of Diagnostic Tests/Treatments/ Procedures
 Potential for Complications from Surgical Procedures and Health Alterations
 System Specific Assessments
 Therapeutic Procedures
Changes and Abnormalities
in Vital Signs: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of the changes and abnormailities in vital signs in order to:

 Assess and respond to changes in client vital signs

 Apply knowledge needed to perform related nursing procedures and psychomotor skills when
assessing vital signs
 Apply knowledge of client pathophysiology when measuring vital signs
 Evaluate invasive monitoring data (e.g., pulmonary artery pressure, intracranial pressure)

Assessing and Responding to

Changes/Abnormalities in Vital Signs
The vital signs include the assessment of the pulse, body temperature, respirations, blood pressure
and oxygen saturation, which is the newest of all the vital signs.
Vital signs are considered vital to the rapid assessment of the client when it is necessary to determine
major changes in the client's basic physiological functioning. Baseline vital signs are taken prior to
many procedures and treatments including upon admission to an acute care facility, prior to the
administration of medications, prior to the administration of a blood transfusion, and prior to
surgery and other invasive procedures These baseline vital signs are taken because they are vitally
important for comparison to those vital signs that are taken during and after a treatment, a
procedure or a significant change in the client. Vital signs are highly responsive to client
abnormalities and changes. For example, a significant drop in blood pressure may indicate the
presence of hemorrhage and bleeding, a drop in terms of a client's oxygen saturation can indicate the
early stages of hypoxia, and a rise in the client's temperature can indicate the presence of infection.
The sensitivity of vital signs to even subtle changes in the client's condition is so effective that vital
signs are routinely taken for all acute care clients on a regular and ongoing basis.
Physiologically, the vital signs reflect the adequacy or inadequacy of basic bodily functions. For
example, the blood pressure reflects the cardiac output and the systemic vascular resistance.
Respirations and the respiratory rate are reflective of a number of factors including the functioning
of the chemoreceptors or baroreceptors in the brain stem, the aorta and the carotid arteries; and the
bodily pulses are the physiological functioning of the parasympathetic nervous system, the
autonomic nervous system and the cardiovascular system functioning.
All significant changes in terms of vital signs must be reported and documented. Many facilities use
a graphic flow chart for their patients' vital signs.

Applying the Knowledge Needed to

Perform Related Nursing Procedures
and Psychomotor Skills
When Assessing Vital Signs
Temperature
Bodily temperature results from the differences between heat production and heat losses. The
normal bodily temperature is 98.6 degrees F, or 36.7 to 37 degrees centigrade, with some small,
minor and normal variations among children, and also as impacted by stress, one's circadian rhythm,
female hormonal changes and the external environment.
Temperature can be taken at a number of sites including the mouth, rectum, ear, axillae, the
temporal area and the forehead depending on the type of thermometer that is used. Oral
temperatures are contraindicated among neonates, infants, young children and those adult clients
adversely affected with confusion, agitation and a decreased level of consciousness; and rectal
temperatures are contraindicated when a client is has a seizure disorder, heart disease or a rectal
disorder.

Respirations
Respirations are assessed and monitored using inspection for the rise and fall of the chest or
abdomen or by gently placing your hand on the chest or abdomen to monitor and assess the rate,
regularity, depth and quality of the client's respirations.
A decreased respiratory rate can indicate and signal a number of disorders such as central nervous
system depression secondary to opioids or central nervous system damage, a coma, planned sedation
and sedation as a side effect to a medication and alkalosis; increased respiratory rates can occur
secondary to a fever, pain, acidosis and anxiety.
The normal respiratory rates along the life span are as follows:

 Neonate: From 30 to 60 per minute

 Infant: From 30 to 60 per minute
 Toddler: From 20 to 40 per minute
 Pre School Child: From 22 to 30 per minute
 School Age Child: From 20 to 26 per minute
 Adolescent: The same as the adult from 16 to 22 per minute
 Adult: From 16 to 22 per minute

Pulses
Pulses are assessed with both palpation and auscultation. Peripheral pulses are assessed with
palpation, often bilaterally. These peripheral pulses include the radial pulse, the femoral pulse, the
brachial pulse, the popliteal pulse, the dorsalis pedis pulse of the foot and the posterior tibial pulse
near the ankle. During the palpation of the pulse the index finger and/or the middle finger is used to
count the number of beats and to assess other characteristics of the pulse such as its regularity,
fullness or volume, and other characteristics. At times, a Doppler is used for difficult to palpate and
assess peripheral pulses.
The apical pulse is assessed with auscultation and the point of maximum intensity for the adult is on
the left side of the chest at the fifth intercostal space. This point differs somewhat along the lifespan
until adolescence and during later years secondary to an enlarged heart.
The normal parameters for pulse rates along the life span are:

 Neonate: From 80 to 180 beats per minute

 Infant: From 100 to 160 beats per minute
 Toddler: From 90 to 140 beats per minute
 Pre School Child: From 80 to 110 beats per minute
 School Age Child: From 70 to 100 beats per minute
 Adolescent: From 60 to 100 beats per minute
 Adult: From 60 to 100 beats per minute

Blood Pressure
Blood pressure results from the pressure of the blood flow as it moves through the arteries. The
blood pressure is what it is as the result of a combination of the blood volume, the peripheral
vascular resistance, the pumping action of the heart and the thickness, or viscosity, of the blood.
Systolic blood pressures reflect the pressure that occurs with the heart's contraction and diastolic
blood pressure reflects the pressure that is exerted when the heart is at rest. Blood pressures are
measured most commonly over the brachial artery just above the client's antecubital space.
The normal blood pressures along the life span are:

 Neonate: Diastolic from 40 to 50 mm Hg and systolic from 60 to 80 mm Hg

 Infant: Diastolic from 50 to 70 mm Hg and systolic from 74 to 100 mm Hg
 Toddler: Diastolic from 50 to 80 mm Hg and systolic from 80 to 112 mm Hg
 Preschool child: Diastolic from 50 to 78 mm Hg and systolic from 82 to 110 mm Hg
 School age child: Diastolic from 54 to 80 mm Hg and systolic from 84 to 120 mm Hg
 Adolescent: < 120/80
 Adult: < 120/80

Applying a Knowledge of Client

Pathophysiology When Measuring
Vital Signs
Nurses apply a knowledge of the client's pathophysiology when they are assessing vital signs.
As stated above, temperatures are a function of bodily heat losses and bodily heat production.
Among other things, bodily temperatures gains and abnormal body temperatures can result from
pathophysiological changes of the brain, the central nervous system, pathologies of the
hypothalamus, the inflammatory process, endocrine hormones, and external environmental
temperatures such as extremes of hot or cold which can cause hyperthermia and hypothermia,
respectively.
Pathophysiologically, alterations and abnormalities of the cardiovascular system, the parasympathetic
nervous system and the autonomic nervous system can lead to an abnormal pulse in terms of
number of beats per minute, the regularity of the pulse, the volume of the pulse, and other
characteristics of the pulse.
Pathophysiological alterations affecting the brain stem and the baroreceptors in the carotid arteries,
and the aorta, as well as pathophysiology of the respiratory system can lead to alterations in terms of
the client's respirations.
Similarly, pathophysiological changes in terms of cardiac rate, systemic vascular resistance, and
venous return can lead to alterations in terms of the client's blood pressure.

Evaluating Invasive Monitoring Data

In addition to monitoring noninvasive data like vital signs, registered nurses also monitor and
evaluate invasive monitoring data such as increased intracranial pressure, pulmonary artery pressure
and other hemodynamic monitoring data.

Increased Intracranial Pressure

The pressure within the cranial cavity or skull is known as intracranial pressure (ICP). The normal
contents of the skull include the brain, cerebrospinal fluid and blood. Because the skull, after
infancy, is a boney and rigid structure without any ability to expand and contract when necessary,
increased intracranial pressure in the skull will lead to impaired cerebral perfusion, hypoxia, and the
compression of the cerebral arteries. Increased intracranial pressure can be a life threatening
situation when it is not treated and reversed.
Increased intracranial pressure can increase when many neurological insults including a closed head
injury, a cerebral tumor, an epidural hematoma, a subdural hematoma, a subarachnoid hematoma,
spina bifida, infections and abscesses, hydrocephalus, a cerebral infarct, and status epilepticus.
The normal range for intracranial pressure ranges from 5 to 15 mmHg. Increased ICP occurs when
the volume of the cranial cavity increases. Under normal circumstances, the pressure that is
necessary to adequately perfuse the brain is known as cerebral perfusion pressure which can be
mathematically calculated by subtracting the actual intracranial pressure from the mean arterial blood
pressure, as shown below.
Cerebral perfusion pressure = The mean arterial pressure – The intracranial pressure
The normal cerebral perfusion pressure, under normal circumstances, should range from 60 to 100
mm Hg.
Brain herniation occurs when intracranial pressure increases to the point where the boney, rigid skull
can no longer accommodate for this increased pressure without successful treatment. The types of
brain herniation that can occur are a downward, lateral, and medial displacements, which are
referred to as central transtentorial, transtentorial, and cingulated herniation, respectively.
Some of the signs and symptoms of increased intracranial pressure include:

 A widening pulse pressure

 Decreased level of consciousness
 A headache
 Vomiting
 Seizures
 Decorticate or decerebrate posturing
 Dilated and sluggish pupils
 Neurological sensory and motor losses
 Visual disturbances
 Cheyne-Stokes respirations: Cheyne-Stokes respirations are signaled with the classical signs of
rapid, deep breathing with periods of apnea and abnormal posturing.
 Cushing's reflex: Cushing's reflex is a late sign of increased intracranial pressure. It is
characterized with bradycardia, hypertension and a widening pulse pressure, which is the
mathematical difference between the systolic and diastolic blood pressure. For example, the
pulse pressure is 40 when a client's blood pressure is 120/80 (120-80= 40) and the pulse
pressure will rise to 90 when the client's blood pressure changes to 160/70 (160-70=90). This
rise is referred to as a widening pulse pressure.

Intracranial pressure is assessed and monitored with invasive and noninvasive tests. A CT scan can
diagnose and monitor intracranial pressure and invasive direct monitoring of the intracranial
pressure can be done with a intraventricular catheter, also referred to as a ventriculostomy, which is
placed into the lateral ventricle of the brain, a subarachnoid bolt and an epidural bolt. Some of these
devices also drain excess intracranial fluid to relieve the pressure.
The treatments of increased intracranial pressure are often dependent on the cause of the increase
and the severity of the increased intracranial pressure. In addition to the identification and treatment
of an underlying disorder when possible, some of the medications that are used include intravenous
osmotic diuretics, like mannitol, to remove fluid, corticosteroids to reduce edema, and
anticonvulsant medications to prevent seizures. At times, a barbiturate coma may be induced to
preserve brain functioning by decreasing the metabolic demands of the brain. Life saving measures,
including cardiopulmonary resuscitation and mechanical ventilation may be indicated.
Decorticate posturing is abnormal rigid bodily posturing that is characterized with the tight
clenching of the fists on the chest while the arms are turned inward; and decerebrate posturing is
rigid and abnormal bodily posturing that is characterized with the extension and arching backward
of the client's head while the arms and the legs are extended and the toes are point upward. These
abnormal posturings can be unilateral or bilateral.

Hemodynamic Monitoring
Hemodynamic monitoring provides health care providers with current data and information relating
to the client's blood pressure, pulmonary artery pressures, pulmonary artery wedge pressure, central
venous pressure, cardiac output, intra-arterial pressure, mixed venous oxygen saturation and other
data.
The normal values for hemodynamic monitoring measurements are as below:

 Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg

 Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg
 Pulmonary Artery Wedge Pressure: 4 to 12 mm Hg
 Central Venous Pressure: 1 to 8 mm Hg
 Cardiac Output: 4 to 7 L/min
 Mixed Venous Oxygen Saturation: 60% to 80%
 Right Atrium Pressure: 0 to 8 mm Hg
 Right Ventricle Peak Systolic: 15 to 30 mm Hg
 Right Ventricle End Diastolic: 0 to 8 mm Hg
 Pulmonary Artery Mean: 9 to 16 mm Hg
 Pulmonary Artery Peak Systolic: 15 to 30 mm Hg
 Pulmonary Artery End Diastolic: 4 to 14 mm Hg
 Pulmonary Artery Occlusion Mean: 2 to 12 mm Hg
 Left Atrium Mean: 2 to 12 mm Hg
 Left Atrium A Wave: 4 to 16 mm Hg
 Left Atrium V Wave: 6 to 12 mm Hg
 Left Ventricle Peak Systolic: 90 to 140 mm Hg
 Left Ventricle End Diastolic: 5 to 12 mm Hg
 Brachial Artery Mean: 70 to 150 mm Hg
 Brachial Artery Peak Systolic: 90 to 140 mm Hg
 Brachial Artery End Diastolic: 60 to 90 mm Hg

Invasive hemodynamic monitoring systems include a pressure transducer, a monitor, pressure

tubing, a pressure bag and a flush device. Some even permit access to draw arterial blood gases. For
example, a pulmonary artery catheter consists of a proximal lumen which measures the central
venous pressure and it can also be used for the administration of intravenous fluids and to draw
venous blood samples, a distal lumen that measures the pulmonary wedge, the pulmonary artery
systolic, and the pulmonary artery diastolic pressures, a thermistor that measures the cardiac output,
and a balloon inflation port that measures the pulmonary artery wedge pressure when it is briefly
inflated.

Diagnostic Tests: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of diagnostic tests in order to:

 Apply knowledge of related nursing procedures and psychomotor skills when caring for clients
undergoing diagnostic testing
 Compare client diagnostic findings with pre-test results
 Perform diagnostic testing (e.g., electrocardiogram, oxygen saturation, glucose monitoring)
 Perform fetal heart monitoring
 Monitor results of maternal and fetal diagnostic tests (e.g., non-stress test, amniocentesis,
ultrasound)
 Monitor the results of diagnostic testing and intervene as needed

Applying a Knowledge of Related

Nursing Procedures and Psychomotor
Skills When Caring for
Clients Undergoing Diagnostic
Testing
Diagnostic tests can be invasive and noninvasive. Registered nurses perform some aspects of both
noninvasive and invasive diagnostic tests such as an ECG and a blood sample for blood glucose
testing, for example.
Regardless of the nature of the diagnostic test, some of the general rule and procedures relating to all
client diagnostic tests include:

 The verification of the doctor's order for the particular diagnostic test

 The verification and validation of the client's identity using at least two unique identifiers

 Providing the client and/or significant others with an explanation of the diagnostic test, the
purpose of the diagnostic tests and the procedure that will be followed for the specific
diagnostic test, in addition to any specific preparation such as NPO after midnight, as indicated
for the particular diagnostic test

 The verification of the client's consent to the diagnostic test, as indicated

 The proper adherence to universal precautions, medical or surgical asepsis as indicated by the
type of the diagnostic test

 Proper handwashing before and after each specimen collection and/or bedside diagnostic
testing

 The proper, complete and accurate labeling of all specimens that are obtained by the nurse at the
bedside that minimally includes the client's full name, the date and time of the specimen
collection

 The proper preservation and transportation of the specimen to the laboratory in a timely
manner along with the proper laboratory requisition slip

 The use of the proper receptacle or container for the specific specimen that contains any
necessary preservatives, chemical or anticoagulants

 The proper disposal of all supplies and equipment that was used for the diagnostic test
Performing an Electrocardiogram (EKG/ECG)
An electrocardiogram traces the electrical activity of the heart over a period to time with an
electrocardiograph which is connected to the patient with the external application of
electrocardiogram leads. The procedure for performing a 12 lead electrocardiogram is:

 Assist the client into a comfortable supine position

 Ask the client to remain as still as possible while the ECG is being done
 Expose the client's chest, lower legs and lower arms
 Cleanse the skin and allow it to dry in the areas that the leads will be placed

The chest or precordial leads are placed as show below:

The limb leads are placed as shown below:

 Secure the electrodes to flat areas on each of the patient's extremities above wrists and ankles
 Place the other six electrodes on the chest in the correct areas.
 Run the ECG strip
 Print the electrocardiogram data off and then place it into the client's medical record, according
to the particular facility's policy or procedure
 Notify the doctor of any unexpected or abnormal findings

Oxygen Saturation
Oxygen saturation reflects the amount of oxygen saturation in arterial blood. It is measured and
monitored by placing a sensor on a client's finger or, when necessary, on their forehead, nose, or ear.
Oxygen saturation levels are often checked with the same frequency as the patient's vital signs using
a pulse oximeter and this noninvasive procedure can be done by trained and competent certified
nursing assistants in the same manner that they can take and record patients' vital signs.

Fecal Occult Blood

Fecal occult blood testing, also referred to as guaiac screening, is a screening tool for colon cancer
and it is also used as part of the diagnostic tests used to determine the source of anemia that can be
related to a gastrointestinal bleed.
Fecal occult blood testing is done by collecting two small portions of the patient's stool and placing
them on a commercially prepared slide. A drop of reagent liquid is then placed on the slide. The test
is positive for occult hidden blood when the slide turns blue within 60 seconds.

Blood Glucose Monitoring

The procedure for checking the client's blood glucose levels is as follows:

 Verify and confirm that the code strip corresponds to the meter code.
 Disinfect the client's finger with an alcohol swab.
 Prick the side of the finger using the lancet.
 Turn the finger down so the blood will drop with gravity.
 Wipe off the first drop of blood using sterile gauze.
 Collect the next drop on the test strip.
 Hold the gauze on the client's finger after the specimen has been obtained.
 Read the client's blood glucose level on the monitor.

Routine Stool Specimens

The procedure for collecting routine stool specimens is as follows.

 Get the proper container for the stool specimen.

 Ask the patient to void before the stool specimen is collected so that the stool is not mixed with
any urine.
 Ask the patient to eliminate their stool in a clean bedpan, bedside commode, or in the toilet
using a high hat.
 Collect the specimen.
 Tighten the lid on stool specimen container.
 Label the specimen with the data that is required according to your facility's policy and
procedure.
 Transport the specimen to the laboratory as quickly as possible.

Routine Urine Specimens

The procedure for collecting a routine urine specimen is to:

 Get the proper container for the urine specimen.

 Ask the patient to void into a clean bedpan, a bedside commode, or on the toilet using a high
hat.
 Tighten the lid on the receptacle after the specimen is obtained.
 Label the specimen with the data that is required according to your facility's policy and
procedure.
 Transport the specimen to the laboratory as quickly as possible.

Obtaining a Clean Catch or Midstream Urine

Specimen
Collecting a clean catch or midstream urine specimen varies among the genders. Males should
cleanse the penis from the urinary meatus to the peripheral area using a circular pattern and using
only one disposable antiseptic wipe for each swipe. Females should use one antiseptic wipe for each
swipe from the front to the back and from the inner labia to the outer labia. Then,

 Ask the patient to void a small amount of urine into the toilet without collecting it.
 Then ask the patient to void into the laboratory collection bottle.
 Tighten the lid on the receptacle and use a disinfectant to clean the outside of container.
 Transport the specimen to the laboratory as quickly as possible.

Obtaining a Timed Urine Specimen Such as a 24

Hour Urine
Timed urine specimens are collected during a specified period of time, as indicated in the doctor's
order. For example, urine is collected for a full day when a twenty 24 hour urine specimen is
ordered. Nurses will then collect all urine passed during this period of time or they will ask the
patient to collect all voided urine so that the nurse can place it into the correct urine collection
container. When the duration of collection has been reached, all the collected urine is then labeled
and delivered to the diagnostic laboratory for testing.

Obtaining a Sputum Specimen

Sputum specimens are collected by providing the patient with a specimen collection container and
asking the client to deep breath, cough and expel sputum into the container. They should also be
instructed to not allow saliva into the container. Once the specimen is collected, it is then labeled
and delivered to the diagnostic laboratory for testing.

Collecting a Throat Culture

 Instruct the client to open mouth widely and then stick their tongue out.
 Insert the sterile swab into the back and wipe across tonsil area, pharynx, or any other region
that is red, swollen, or contains exudate.
 Place the swab into the specimen container, tighten the lid and send it to the laboratory.
Nurses educate clients about the purposes, required preparation, procedures, results and the
implications of abnormal and normal diagnostic tests including the results of all laboratory tests and
testing.

Performing Fetal Heart Monitoring

Fetal heart monitoring was fully discussed previously under "Checking and Monitoring the Fetal
Heart during Routine Prenatal Exams and During Labor".

Monitoring the Results of Maternal

and Fetal Diagnostic Tests
The results of maternal and fetal diagnostic tests such as a non-stress test, amniocentesis and
ultrasound was fully discussed previously under "Providing Prenatal Care and Education".

Monitoring the Results of Diagnostic

Testing and Intervening as Needed
Throughout the course of care, nurses monitor the results of diagnostic tests and modify the plan of
care, as indicated. They also notify the physician when laboratory results are outside of normal limits
and/or a significant change for the client.

Laboratory Values: NCLEX-

RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of laboratory values in order to:

 Identify laboratory values for ABGs (pH, PO2, PCO2, SaO2, HCO3), BUN, cholesterol (total)
glucose, hematocrit, hemoglobin, glycosylated hemoglobin (HgbA1C), platelets, potassium,
sodium, WBC, creatinine, PT, PTT & APTT, INR
 Compare client laboratory values to normal laboratory values
 Educate client about the purpose and procedure of prescribed laboratory tests
 Obtain blood specimens peripherally or through central line
 Obtain specimens other than blood for diagnostic testing (e.g., wound, stool, urine)
 Monitor client laboratory values (e.g., glucose testing results for the client with diabetes)
 Notify primary health care provider about laboratory test results

Identifying Laboratory Values

Arterial Blood Gases
 Partial pressure of oxygen (PaO2): 75 - 100 mmHg
 Partial pressure of carbon dioxide (PaCO2): 38 - 42 mmHg
 Arterial blood pH: 7.38 - 7.42
 Oxygen saturation (SaO2): 94 - 100%
 Bicarbonate - (HCO3): 22 - 28 mEq/L

The oxygen value is lower with an altitude of > 3,000 feet.

Electrolytes
 Ammonia: 15-50 µmol/L
 Ceruloplasmin: 15-60 mg/dL
 Chloride: 95-105 mmol/L
 Copper: 70-150 µg/dL
 Creatinine: 0.8-1.3 mg/dL
 Blood urea nitrogen: 8-21 mg/dL
 Ferritin: 12-300 ng/mL (men), 12-150 ng/mL (women)
 Glucose: 65-110 mg/dL
 Inorganic phosphorous: 1-1.5 mmol/L
 Ionized calcium: 1.03-1.23 mmol/L
 Magnesium: 1.5-2 mEq/L
 Phosphate: 0.8-1.5 mmol/L
 Potassium: 3.5-5 mmol/L
 Pyruvate: 300-900 µg/dL
 Sodium: 135-145 mmol/L
 Total calcium: 2-2.6 mmol/L
 Total iron-binding capacity: 45-85 µmol/L
 Total serum iron: 65-180 µg/dL (men), 30-170 µg/dL (women)
 Transferrin: 200-350 mg/dL
 Urea: 1.2-3 mmol/L
 Uric acid: 0.18-0.48 mmol/L
 Zinc: 70-100 µmol/L

Hematology
 Hemoglobin: 13-17 g/dL (men), 12-15 g/dL (women)
 Hematocrit 40%-52% (men), 36%-47%
 Glycosylated hemoglobin 4%-6%
 Mean corpuscular volume (MCV): 80-100 fL
 Red blood cell distribution width (RDW): 11.5%-14.5%
 Mean corpuscular hemoglobin (MCH): 0.4-0.5 fmol/cell
 Mean corpuscular hemoglobin concentration (MCHC): 30-35 g/dL
 Reticulocytes 0.5%-1.5%
 White blood cells (WBC) 4-10 x 10^9/L
 Neutrophils: 2-8 x 10^9/L
 Bands: < 1 x 10^9/L
 Lymphocytes: 1-4 x 10^9/L
 Monocytes: 0.2-0.8 x 10^9/L
 Eosinophils: < 0.5 x 10^9/L
 Platelets: 150-400 x 10^9/L
 Prothrombin time: 11-14 sec
 International normalized ratio (INR): 0.9-1.2
 Activated partial thromboplastin time (aPTT): 20-40 sec
 Fibrinogen: 1.8-4 g/L
 Bleeding time: 2-9 min

Lipids
 Triglycerides: 50-150 mg/dL
 Total cholesterol: 3-5.5 mmol/L
 High-density lipoprotein (HDL): 40-80 mg/dL
 Low-density lipoprotein (LDL): 85-125 mg/dL

Acid Base Values

 pH: 7.35-7.45
 Base excess: (-3)-(+3)
 H+: 36-44 nmol/L
 Partial pressure of oxygen (pO2): 75-100 mm Hg
 Oxygen saturation: 96%-100%
 Partial pressure of carbon dioxide (pCO2): 35-45 mm Hg
 Bicarbonate (HCO3): 18-22 mmol/L

Gastrointestinal Tests
 Albumin: 35-50 g/L
 Alkaline phosphatase: 50-100 U/L
 Alanine aminotransferase (ALT): 5-30 U/L
 Amylase: 30-125 U/L
 Aspartate aminotransferase (AST): 5-30 U/L
 Direct bilirubin: 0-6 µmol/L
 Gamma glutamyl transferase: 6-50 U/L
 Lipase: 10-150 U/L
 Total bilirubin: 2-20 µmol/L
 Total protein: 60-80 g/L

Cardiac Enzymes
 Creatine kinase: 25-200 U/L
 Creatine kinase MB (CKMB): 0-4 ng/mL
 Troponin: 0-0.4 ng/mL

Hormones
 17 hydroxyprogesterone (female, follicular): 0.2-1 mg/L
 Adrenocorticotropic hormone (ACTH): 4.5-20 pmol/L
 Estradiol: 1.5-5 ng/dL (male), 2-14 ng/dL (female, follicular), 2-16 ng/dL (female, luteal), < 3.5
ng/dL (postmenopausal)
 Free T3: 0.2-0.5 ng/dL
 Free T4: 10-20 pmol/L
 Follicle-stimulating hormone (FSH): 1-10 IU/L (male), 1-10 IU/L (female, follicular/luteal), 5-
25 IU/L (female, ovulation), 30-110 IU/L (postmenopause)
 Growth hormone (fasting) : 0-5 ng/mL
 Progesterone: 70-280 (ovulation), ng/dL
 Prolactin: < 14 ng/mL
 Testosterone (male): 10-25 nmol/L
 Thyroxine-binding globulin: 12-30 mg/L
 Thyroid-stimulating hormone (TSH): 0.5-5 mIU/L
 Total T4: 4.9-11.7 mg/dL
 Total T3: 0.7-1.5 ng/dL
 Free T3: 0.6-1.6 ng/mL

Vitamins
 Folate (serum) : 7-36 nmol/L
 Vitamin A: 30-65 µg/dL
 Vitamin B12: 130-700 ng/L
 Vitamin C: 0.4-1.5 mg/dL
 Vitamin D: 5-75 ng/mL

Tumor Markers
 Alpha fetoprotein: 0-44 ng/mL
 Beta human chorionic gonadotropin (HCG): < 5 IU/I
 CA19.9: < 40 U/mL
 Carcinoembryonic antigen (CEA): < 4 ug/L
 Prostatic acid phosphatase (PAP): 0-3 U/dL
 Prostate-specific antigen (PSA): < 4 ug/L

Miscellaneous
 Alpha 1-antitrypsin: 20-50 µmol/L
 Angiotensin-converting enzyme: 23-57 U/L
 C-reactive protein: < 5 mg/L
 D-dimer: < 500 ng/mL
 Erythrocyte sedimentation rate (ESR): Less than age/2 mm/hour
 Lactate dehydrogenase (LDH): 50-150 U/L
 Lead: < 40 µg/dL
 Rheumatoid factor: < 25 IU/ml
Comparing the Client's Laboratory
Values to Normal Laboratory Values
The client's current laboratory values are compared to the normal laboratory values, as above, in
order to determine the physiological status of the client and to compare the current values during
treatment to the laboratory values taken prior to a treatment.

Educating the Client About the

Purpose and Procedure of Prescribed
Laboratory Tests
As previously discussed, clients must be educated about the purpose of the prescribed laboratory
test, the procedure for the laboratory test and any preparation the laboratory tests that is indicated.
For example, a client in the community may be instructed to remain NPO after midnight. More
information about this client education was previously discussed in the section entitled "Applying a
Knowledge of Related Nursing Procedures and Psychomotor Skills When Caring for Clients
Undergoing Diagnostic Testing".

Obtaining Blood Specimens

Peripherally and Through a Central
Line
Peripheral Venous Blood Samples
Drawing a peripheral venous blood sample is done in this manner:

 Gather and organize the correct laboratory tubes for the specimens that you will be collecting.
 Choose a suitable site for the venipuncture.
 Place the tourniquet on the client's arm about 3 to 4 inches above the selected site.
 Palpate the vein.
 Clean the site with an alcohol prep pad with a circular pattern from the site of the venipuncture
to the area surrounding the site of the venipuncture.
 Allow the area to air dry.
 Ask the patient to make a fist.
 Pull the skin taunt so that the desired and suitable vein is accessible.
 Insert the sterile needle into the vein at a 15 to 30 degree angle.
 Pop the tube onto the tubing.
 Take the tourniquet off when the last tube is filled.
 Take the needle out.
 Place sterile gauze on the site using sufficient pressure to prevent bleeding for about 1 or 2
minutes.
 Remove the gauze.
 Place an adhesive bandage over the site.
 Label the specimen with the data that is required according to your facility's policy and
procedure for laboratory blood samples.

Central Line Blood Samples

Some central venous catheters have a couple or several lumens, one of may be used to withdraw a
blood sample. The port that can be used to draw a blood sample is cleansed with alcohol. Then a
small amount of blood is drawn out and discarded, after which the intended blood sample is drawn.
After the sample is taken, the central line is then flushed with 20 mL of sterile saline.

Obtaining Specimens Other Than

Blood for Diagnostic Testing
Other than blood, other specimens that are collected include urine, stool and wound specimens.
Urine and stool specimens were discussed earlier in this NCLEX-RN review in the section entitled
"Applying a Knowledge of Related Nursing Procedures and Psychomotor Skills When Caring for
Clients Undergoing Diagnostic Testing"
Wound specimens are obtained in the following manner:

 Gently irrigate the wound with sterile normal saline to remove any debris and extraneous matter.
 Remove the swab from the Culturette tube.
 Gently place the swab and rotate the swab on the wound's granulating tissue.
 Place the swab into the Culturette tube.
 Crack the Culturette tube so the culture medium soaks into the swab
Monitoring the Client's Laboratory
Values
Client's laboratory values are monitored prior to, during and after therapeutic interventions and
treatments. For example, diabetic clients should have their blood glucose levels are taken and
monitored by the nurse and they are also monitored by the client in their home. This monitoring
permits the nurse and the client the opportunity to evaluate how well the diabetes is being managed.

Notifying the Primary Health Care

Provider About Laboratory Test
Results
The primary health care provider is immediately informed about all abnormal laboratory test results.

Potential for Alterations in

Body Systems: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of potential for alterations in body systems in order to:

 Identify client potential for aspiration (e.g., feeding tube, sedation, swallowing difficulties)
 Identify client potential for skin breakdown (e.g., immobility, nutritional status, incontinence)
 Identify client with increased risk for insufficient vascular perfusion (e.g., immobilized limb,
post-surgery, diabetes)
 Educate client on methods to prevent complications associated with activity level/diagnosed
illness/disease (e.g., contractures, foot care for client with diabetes mellitus)
 Compare current client data to baseline client data (e.g., symptoms of illness/disease)
 Monitor client output for changes from baseline (e.g., nasogastric [NG] tube, emesis, stools,
urine)
Identifying the Client's Potential for
Aspiration
The risk for aspiration, as defined by the North American Nursing Diagnosis Association
(NANDA), is "At risk for the entry of gastrointestinal secretions, oropharyngeal secretions, solids,
or fluids into the tracheobronchial passages".
The risk factors associated with the risk for aspiration include:

 An impaired cough and/or gag reflex

 Gastrointestinal feeding tubes particularly when there is residual
 An impaired esophageal sphincter
 Impaired gastrointestinal tract emptying and motility
 Dysphagia
 Decreased level of consciousness
 Oral or facial surgery or trauma
 An endotracheal tube or a tracheostomy tube
 An inability to clear airway secretions
 Sedation

Identifying the Client's Potential for

Skin Breakdown
The risk factors associated with skin breakdown include both internal, intrinsic patient related risks
and external, extrinsic risk factors.
Some of the internal, intrinsic patient related risk factors include:

 Poor nutritional status

 Immobility
 A decreased level of consciousness including that which occurs with sedating medications
 Fecal and/or urinary incontinence
 Impaired circulation and tissue perfusion
 Alterations in terms of the fluid balance
 Altered neurological sensory functioning
 Changes in terms of skin turgor
 Boney prominences

Some of the external, extrinsic risk factors associated with impaired skin integrity include:

 Mechanical forces like pressure, friction and shearing

 Moisture including environmental humidity and bodily fluids including urine and diaphoresis
 Radiation
 Hypothermia
 Hyperthermia

The Norton Scale and the Braden Scale are two standardized scales that are used to identify clients
at risk for skin breakdown.

Identifying the Client with Increased

Risk for Insufficient Vascular
Perfusion
Ineffective tissue perfusion, as defined by the North American Nursing Diagnosis Association
(NANDA), is "a decrease in oxygen resulting in a failure to nourish tissues at the capillary level."
Ineffective tissue perfusion can occur in terms of the renal system, the brain, the heart, the
gastrointestinal tract and the peripheral vascular system.
Some of the risk factors associated with impaired vascular perfusion include:

 Hypervolemia
 Hypovolemia
 Low hemoglobin
 An immobilized limb
 Hypotension
 Hypoxia
 Decreased cardiac output
 Diabetes
 Impaired oxygen transportation
 Hypoventilation
Identifying the Client with Increased
Risk for Cancer
The following are the most common risk factors for cancer:

 Tobacco Use and Second Hand Smoke Including Smokeless Tobacco: Cancers of the lung,
bladder, mouth, esophagus, pancreas and larynx.

 Age: Clients over 65 years of age are at greatest risk.

 Family History: Genetics and Familial Tendency: Cancers of the colon, breast, ovaries, and
uterus.

 Chemicals and Other Substances: Asbestos, benzene, benzidine, cadmium, nickel, and vinyl
chloride may cause cancer.

 Ionizing Radiation and Radon Gas: Radioactive fallout, radon gas, which is an odor less gas
found in many buildings, x-rays, therapeutic radiation for cancer, and other sources.

 Sunlight and Ultraviolet Radiation (UV): Skin cancer.

 Viruses and Bacteria: Human papillomaviruses (HPV) (Cancer of the cervix, vagina, penis, anus
and mouth), Hepatitis B and C (Liver cancer), Helicobacter pylori ((Cancer of the stomach) and
the Epstein-Barr virus (Burkitt's lymphoma).

 Hormones: Cancer of the prostate, breast, and uterine cancer.

 Alcohol: Cancer of the liver

 Poor Diet, Lack of Physical Activity, Being Overweight: Cancer of the colon, rectum, pancreas,
kidney, prostate, gall bladder, ovary, uterus, breast, esophagus

Educating the Client on Methods to

Prevent Complications Associated
with Activity
Level/Diagnosed Illness/Disease
Client and family education should address all "At risk" potential nursing diagnoses. For example,
clients at risk for impaired skin integrity should be instructed to move and turn in bed, clients at risk
for contractures secondary to immobility should be instructed and coached on full range of motion
exercises, and diabetic clients must be educated about the needs for daily foot care and foot
inspections to prevent peripheral skin breakdown and infections.

Comparing Current Client Data to

Baseline Client Data
Nurses compare current client data to baseline client data in order to monitor and evaluate the
client's therapeutic plan of care and also to determine and identify any new health care problems
including those that can occur as the result of a complication associated with their risk factors.

Monitoring the Client's Output for

Changes from the Baseline
Changes in the client's output in relationship to nasogastric tube drainage, emesis, stools and urinary
output can also indicate the presence of a disease, illness or disorder. For example, increases in terms
of emesis can indicate the presence of a side effect of a medication or an impairment of the
gastrointestinal tract functioning; decreased urinary output can indicate dehydration or renal disease;
and excessive fecal waste can indicate diarrhea or a gastrointestinal tract infection.
Potential for Complications
of Diagnostic Tests,
Treatments, and Procedures:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of the potential for complications of diagnostic tests, treatments, and
procedures in order to:

 Assess client for an abnormal response following a diagnostic test/procedure (e.g., dysrhythmia
following cardiac catheterization)
 Apply knowledge of nursing procedures and psychomotor skills when caring for a client with
potential for complications
 Monitor the client for signs of bleeding
 Position the client to prevent complications following tests/treatments/procedures (e.g., elevate
head of bed, immobilize extremity)
 Insert, maintain and remove a gastric tube
 Insert, maintain and remove a urinary catheter
 Insert, maintain and remove a peripheral intravenous line
 Maintain tube patency (e.g., NG tube for decompression, chest tubes)
 Use precautions to prevent injury and/or complications associated with a procedure or diagnosis
 Provide care for client undergoing electroconvulsive therapy (e.g., monitor airway, assess for
side effects, teach client about procedure)
 Intervene to manage potential circulatory complications (e.g., hemorrhage, embolus, shock)
 Intervene to prevent aspiration (e.g., check NG tube placement)
 Intervene to prevent potential neurological complications (e.g., foot drop, numbness, tingling)
 Evaluate responses to procedures and treatments
Assessing the Client for an Abnormal
Response Following a Diagnostic
Test/Procedure
Practically all diagnostic tests and procedures can lead to complications, particularly when these tests
and procedures are invasive.
Cardiac dysrhythmias can result from a cardiac catheterization; therapeutic radiation for cancer
treatment can lead to radiation pneumonitis and multiple systems fibrosis, skin erythema and skin
sloughing; cancer chemotherapy can lead to alopecia, ulcerations of the oral mucous membranes,
and an increased risk of infection.

Applying a Knowledge of Nursing

Procedures and Psychomotor Skills
When Caring for a Client
with Potential for Complications
Nurses apply their knowledge of nursing procedures and psychomotor skills when caring for a client
with the potential for complications. For example, a client undergoing a cardiac catheterization will
be closely monitored for any cardiac arrhythmias; a client with a casted extremity may develop limb
threatening compartment syndrome; the nurse will maintain asepsis for all care including the care of
the client who is at risk for infection related to chemotherapy; and the nurse will keep the client up
at least 30 degrees when they are getting a tube feeding to prevent aspiration.

Monitoring the Client for Signs of

Bleeding
Hemorrhage and bleeding are risk factors associated with all invasive surgical procedures and
treatments as well as diseases and disorders such as leukemia, cirrhosis, gastrointestinal tract ulcers,
disseminated intravascular coagulation, hemophilia, inflammatory bowel disease, esophageal varices,
and stress ulcers.
When severe, hemorrhage and excessive bleeding can lead to hypovolemic shock. The stages of
hypovolemic shock are the initial stage, the compensatory stage, the progressive stage and the
refractory and irreversible stage.
The signs and symptoms of hypovolemic shock vary according to the stage of the shock; some of
the signs and symptoms include hypotension, tachycardia, a lack of tissue perfusion,
hyperventilation, decreased cardiac output, decreased urinary output, oliguria, anuria, metabolic
acidosis, increased blood viscosity, and multisystem failure.
The goal of treatments for hypovolemic shock include the correction of the underlying cause, fluid
replacements including lactated Ringer's solution, blood and blood products as indicated, placing the
client into the Trendelenburg position, and plasma expanders. The lack of effective treatment can
lead to death.
Nurse must perform ongoing assessments and reassessments including the monitoring of diagnostic
laboratory data, the client's intake and output, vital signs, central venous pressure, arterial blood
gases, renal functioning and hemodynamic monitoring.

Positioning the Client to Prevent

Complications Following Tests,
Treatments, and Procedures
Clients are positioned during and after many diagnostic tests, treatments and procedures. For
example the head of the bed is elevated when the client has a tube feeding, the client remains flat
and in the supine position after a spinal tap, the client will be protected from any pressure after an
extremity is immobilized with a cast until it is completely dried.

Inserting, Maintaining and Removing

a Gastric Tube
The insertion, maintenance and removal of a gastric tube are discussed below:

Inserting a Nasogastric Tube

As with all procedures, the nurse must verify the order, accurately identify the client using two
unique identifiers, and explain the procedure to the client.
The supplies and equipment that will be needed to insert a nasogastric tube include globes, the
nasogastric tube, a water soluble jelly, a topical anesthetic, tape to secure the tube, a small cup of
water, a drinking straw, a 60 mL catheter tipped syringe, and a suction machine and tubing when
ordered.
 Place the client in a high Fowler's position and inspect the nares.
 Select the best nare.
 Measure the nasogastric tube from the nose to the earlobe to tip of xiphoid. Mark the
nasogastric tube with the tape.
 Apply the topical anesthetic and the water soluble lubricant to the tip of the nasogastric tube.
 Give the client the small cup of water and the straw if they are safe to drink it when you ask
them to.
 Have the client to look up so that their neck is hyperextended upward.
 Advance the nasogastric tube until you meet some resistance at the nasopharynx.
 Continue to advance the tube below the curve of the nasopharynx as the client now takes small
sips of water while they are leaning forward.
 Check for the correct placement of the nasogastric tube.
 Secure the nasogastric tube to the nose with tape.
 Secure the tubing to the client's gown with a safety pin.
 Clamp the tube or connect it to the suction device if ordered.

Removing the Nasogastric Tube

Again, the nurse must verify the order, accurately identify the client using two unique identifiers, and
explain the procedure to the client.

 Remove the securing tape anchor from the nose.

 Remove the safety pin from the client's
 Disconnect the tubing from suction and/or clamp it.
 Ask the client to take a deep breath as you pull the tube out.
 Clean the client's nares and provide oral hygiene to the client.

Maintaining a Nasogastric Tube

Maintenance of a nasogastric tube consists of daily nare care, mouth care, and monitoring the tube
patency. All nasogastric drainage is measured and documented in terms of amount, color and other
characteristics. If the nasogastric tube is used for feedings or medication administration, it must be
irrigated before and after each feeding or medication.

Inserting, Maintaining and Removing

a Urinary Catheter
The insertion, maintenance and removal of a urinary catheter were previously discussed under the
section entitled "Using Alternative Methods to Promote Voiding".
Inserting, Maintaining and Removing
a Peripheral Intravenous Line
The procedures for inserting and maintaining peripheral intravenous lines were previously discussed
in the sections entitled "Educating the Client on the Reason For and Care of a Venous Access
Device" and "Monitoring the Intravenous Infusion and Maintaining the Site", respectively.
The removal of a peripheral intravenous line is done with these steps:

 Turn off and disconnect any intravenous fluids.

 Remove the site dressing.
 Gently withdraw the peripheral intravenous catheter and check it for any breakage or
deterioration.
 Inspect the site and cover it with an adhesive bandage.
 Document the removal of the peripheral intravenous line.

Maintaining Tube Patency

Nurses monitor and maintain the patency of a wide variety of tubes and catheters including
nasogastric tubes, chest tubes. The simplest way to prevent an inpatent tube or line is to insure that
it is not kinked or obstructed in any way.

Nasogastric Tube Patency

Nasogastric tubes should be irrigated before and after each medication administration and each
intermittent tube feeding. These tubes are also irrigated according to the particular facility's policy
and procedure when a continuous tube feeding is being given.

Chest Tube Patency

After the first 24 hours after placement, chest tubes are assessed and monitored in terms of their
functioning, patency, the fluid levels and the characteristics of drainage at least every hour; and then
at least every eight hours after the initial first 24 hours.

Artificial Airway Tube Patency

Endotracheal and Tracheostomy Tubes
Generally speaking, airway tubes such as endotracheal and tracheostomy tubes are monitored and
maintain to insure proper placement and patency. Patency is maintained with the validation that the
tube is correctly placed and the provision of humidity and suctioning, as indicated.
Suctioning is done with a suctioning vacuum source that can be part of the facility's central
suctioning system or a portable suctioning machine that is used in the home, for example.
Suctioning catheters come in different sizes. The largest possible suctioning catheter should be used
whenever possible. Suctioning catheters range in size from 5 Fr, which is the smallest suctioning
catheter, and up to 16 Fr, which is the largest suctioning catheter in terms of diameter.
The typical sizes of suctioning catheters for the different age groups along the life span are:

 Adults: 10 to 16 Fr
 Pediatric Clients From 1 ½ Years of Age Through Adolescence: 10 to 16 Fr
 Neonates and Infants Less Than 1 ½ Years of Age; 5 to 8 Fr

Suctioning is a sterile procedure. Artificial airway suctioning can be done with open airway
suctioning and closed airway suctioning. Open airway suctioning is done while the client is breathing
room air without oxygen; and closed airway suctioning is done when the client is receiving
supplemental oxygen. The latter is the preferred method because pre procedure oxygenation and the
administration of oxygen during suctioning prevents hypoxia during the suctioning episode.
Suctioning episodes should be done as rapidly as possible because it can cause client anxiety as well
as hypoxia.
The correct placement of an endotracheal tubes can be determined and validated in a number of
different ways including:

 Diagnostic capnography to detect for carbon dioxide when the client exhales
 Diagnostic chest x-ray to validate the artificial airway's proper placement
 Auscultating for the presence of breath sounds in both lung areas and NOT in the area of the
stomach
 Using an esophageal detection device to confirm proper placement
 Inspecting the chest rise and fall in a symmetrical manner

The nurse will do the following things when a client with a tracheostomy tube has a partial or
complete airway obstruction:

 If the nurse cannot pass the suction catheter into the airway, the nurse should deflate the cuff
 Attempt to advance the suction catheter with the cuff deflated. It the catheter is still meeting
with resistance, it is highly possible that a mucous plug is obstructing the airway and interfering
with the patency of the artificial airway
 Remove the inner cannula of the tube and remove the mucous plug
Using Precautions to Prevent Injury
and/or Complications Associated with
a Procedure or Diagnosis
At times, special precautions are implemented to prevent injuries and complications associated with
a procedure or diagnosis. As previously discussed, clients who are receiving continuous tube
feedings are placed in a semi Fowler's position of at least 30 degrees to prevent aspiration, clients
who have just had a cast applied to an extremity fracture will be monitored for compartment
syndrome and they will be advised to NOT exert any pressure on the cast until it is completely dried
to prevent denting which could lead to circulatory and neurological impairment; all preoperative
clients are NPO prior to surgery to prevent aspiration, seizure precautions are initiated and
maintained when the client has a seizure disorder, suctioning equipment and supplies are readily
accessible and available at the bedside when the client is at risk for aspiration, special screenings and
assessments are done to identify clients who are at risk for skin breakdown and/or falls, and nurses
implement a wide variety of preventive measures and special precautions to prevent the many
complications of immobility and inactivity, including contractures, urinary stasis and venous
thrombosis.

Providing Care for a Client

Undergoing Electroconvulsive
Therapy
As somewhat discussed in the previous section entitled "Applying a Knowledge of Client
Psychopathology to Mental Health Concepts Applied in Individual, Group and Family Therapy"
nurses maintain client safety by maintaining the client as NPO at least for 6 hours prior to the
electroconvulsant therapy procedure, they remove all items on or around the body like jewelry prior
to the treatment, they initiate and/or maintain an open and patent intravenous line which can be
used in an emergency, they administer pre therapy medications as ordered, they continuously
monitor and assess the client, their vital signs, the induced seizure activity and they insure the client's
safety during and after the electroconvulsant therapy procedure.
Additional nursing responsibilities before and after the electroconvulsant therapy procedure include
client teaching related to the treatment, the purpose of the treatment, some of the side effects of the
treatment, and what to expect before and after the procedure. Care after the electroconvulsant
therapy procedure includes monitoring the client's physical status and reorienting the client because
some confusion and amnesia can occur after the treatment. The nurse assesses the client's level of
confusion and/or amnesia, they initiate and implement special precautions to maintain the client's
safety and to protect them from accidents and injuries, and they also monitor and assess the client
from some of the commonly occurring physiological side effects of the treatment including
muscular soreness, changes in term of the client's cardiovascular status, a headache and
hypertension.

Intervening to Manage Potential

Circulatory Complications
Some of the circulatory complications associated with some tests, treatments and diagnostic tests
include things such as thrombosis, hemorrhage and hypovolemic shock, cardiogenic shock,
anaphylactic shock,.

Interventions for Thrombosis

The treatment for superficial cases of thrombosis includes bed rest, elevation of the extremity, local
heat, and NSAIDs to prevent emboli and deep vein thrombosis. Deep vein thrombosis is treated
with medications, such as anticoagulants, thrombin inhibitors, and thrombolytics. Other types of
treatment include a vena cava filter, when indicated, and graduated compression stockings to
increase peripheral venous return.

Interventions For Hypovolemic Shock and

Hemorrhage
As previously stated in the sections entitled "Monitoring the Client for Signs of Bleeding" and
"Assisting the Client in Receiving Appropriate End of Life Physical Symptom Management", the
treatment of hypovolemic shock include the correction of the underlying disorder and:

 The administration of blood and blood products and plasma expanders

 The administration of fluid replacements including lactated Ringer's solution
 Placing the client into the Trendelenburg position

Interventions For Cardiogenic Shock

Cardiogenic shock can occur secondary to a cardiac arrhythmia, as can occur after a diagnostic
cardiac catheterization, a myocardial infarction, cardiomyopathy, cardiac valve disease and
myocarditis. Cardiogenic shock leads to peripheral vasoconstriction to the vital organs of the body,
hypotension, and tachycardia.
The treatment of cardiogenic shock aims to preserve life and to maintain adequate oxygen to the
vital organs of the body including the brain and the heart muscle itself. These treatments and
interventions can include:

 Emergency cardiopulmonary resuscitation when indicated

 Oxygen supplementation
 Mechanical ventilation as indicated
 The administration of aspirin or super aspirins, such as clopidogrel or a platelet glycoprotein
IIb/IIIa receptor blockers
 The administration of thrombolytics and anticoagulants like heparin
 The administration of inotropic drugs
 Angioplasty and stenting
 The insertion of a balloon pump
 Coronary artery bypass surgery
 A ventricular assist heart pump
 A heart transplant

Interventions For Anaphylactic Shock

Anaphylactic shock most frequently follows an allergic response to a medication such as penicillin,
but it also can occur as the result of an insect bite, some foods like peanuts and shell fish, latex and
some anesthetic drugs.
The signs and symptoms associated with anaphylactic shock include hypotension, massive
circulatory relaxation, decreased cardiac output, laryngeal edema, respiratory distress and tachycardia.
The treatment for anaphylaxis is the immediate cessation of the offending medication and:

 Emergency cardiopulmonary resuscitation when indicated

 The administration of adrenaline or noradrenaline
 Supplemental oxygen
 The administration of cortisone and/or antihistamines
 The administration of a beta agonist such as albuterol

Interventions For Neurogenic Shock

Neurogenic shock can occur as a result when the sympathetic nervous system shuts down. It is most
often associated with a traumatic spinal cord injury but it can also occur as the result of treatment
with a spinal anesthetic.
Neurogenic shock leads to the relaxation of the body's arterioles and venules; and it is characterized
with fainting, syncope, hypotension and bradycardia which is a unique sign of neurogenic shock
when compared to other types of shock.
The treatment of neurogenic shock includes fluid replacement, the administration of vasopressor
drugs, such as dopamine, norepinephrine or phenylephrine.

Interventions For Septic Shock

Septic shock is associated with a high level of morbidity and mortality; this type of shock occurs as
the result of a serious infection, most often the result of gram positive bacteria like streptococcus
pneumoniae and staphylococcus aureus, although it can also be secondary to a gram negative
bacterial like Escherichia coli, some viruses, and some fungus infections. All invasive procedures and
treatments, including surgery, place the client at risk for infection and septic shock.
The signs and symptoms of septic shock include the classical signs of infection in addition to:

 Hypotension secondary to massive vasodilation

 Hypotension
 Confusion
 Metabolic acidosis
 Respiratory alkalosis
 Abnormal breath sounds like crackles and rales
 A widened pulse pressure
 Cardiac depression and decreased cardiac output
 Peripheral vasoconstriction which can lead to microemboli
 Muti-system failure and shut down

The treatments include:

 Fluid replacements
 Oxygen supplementation therapy
 Mechanical ventilation and intubation, as indicated
 The correction of the underlying disorder like the infection
 The symptomatic treatment of the signs and symptoms of septic shock including the metabolic
acidosis and respiratory alkalosis
 Dialysis as indicated

Interventions For Obstructive Shock

A major embolus in a major circulatory vessel, a tension pneumothorax, aortic stenosis, and cardiac
tamponade can lead to obstructive shock. Obstructive shock, left untreated, can lead to organ failure
and death.
The treatment of obstructive shock includes the correction of any underlying condition like treating
a pneumothorax with chest tube drainage and treating cardiac tamponade with a pericardiocentesis,
in addition to fluid replacement therapy.

Intervening to Prevent Aspiration

Aspiration is a risk among clients of all age groups along the life span. For example, a neonate and
an infant may aspirate vomitus and bottle feedings when a baby bottle is propped up and the infant
is not attended to. Aspiration can occur among toddlers and young children when they place a
foreign body or object into their mouth, and it can occur among adolescents and adults when they
are eating solid foods, particularly when alcohol is being consumed during the meal. Older adults are
also at risk because they may have a swallowing disorder. Aspiration can also occur as the result of
therapeutic interventions such as tube feedings.
The prevention of aspiration among infants and children include NOT propping up baby bottles
and turning infants and young children on their side when they are vomiting. Additionally, all
parents must maintain a baby proof and child proof home that does not allow a young toddler or
child to put small foreign bodies, line pieces of a toy into their mouth.
Aspiration secondary to tube feedings can be prevented by keeping the head of the client's bed up to
30 degrees, checking and monitoring residual before administering a tube feeding, and assessing the
abdomen for any distention which can indicate the retention of nasogastric feeding contents.

Intervening to Prevent Potential

Neurological Complications
Many treatments and procedures place a client at neurological complications. For example,
dressings, casts, bandages, restraints, and other medical devices and equipment can cause
neurological damage when they are applied too tightly.
Nurses, therefore, must monitor all constrictive medical equipment and devices to insure that they
are not too tight and constrictive during their application and during the duration of time that they
remain in place, particularly if there is any danger of swelling in the area. The nurse should be able to
put 2 or 3 fingers under these constrictive devices to insure that they are not too tight. At times, the
client may report numbness and tingling to the affected area and, at other times, the nurse may
assess a change in the color of the skin and weak or absent pulses to the area that may indicate a
complication associated with this complication.
Foot drop is a complication of immobility. This complication can be prevented with full range of
motion exercises and the use of a foot boot to prevent this complication. Again, foot boots should
be applied snuggly but not too tight.

Evaluating Responses to Procedures

and Treatments
As discussed throughout this NCLEX-RN review book, nurses evaluate the outcomes of all care,
treatments and procedures to determine whether or not they have been effective and whether or not
the client goals and expected outcomes have been met.
The data collected during this evaluation includes subjective, objective, primary and secondary data
including diagnostic test results, client's subjective comments, and other data collected by the nurse
during their ongoing reassessments of the client and the comparison of this data to baseline data
that were collected prior to care, a treatment or a procedure.

Potential for Complications

from Surgical Procedures and
Health Alterations: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of the potential for complications from surgical procedures and health
alterations in order to:

 Apply knowledge of pathophysiology to monitoring for complications (e.g., recognize signs of

thrombocytopenia)
 Evaluate the client's response to post-operative interventions to prevent complications (e.g.,
prevent aspiration, promote venous return, promote mobility)

Applying a Knowledge of
Pathophysiology to the Monitoring for
Complications
Nurses apply their knowledge of pathophysiology to their monitoring of complications. For
example, nurses apply their knowledge of the etiology, risk factors, signs and symptoms and the
complications of various health related diseases and disorders. As these basic principles are applied
to the care of the client, the nurse also is cognizant of the many complications that may occur as
well as their risk factors, signs and symptoms to prevent these complications. For example, the nurse
will integrate a knowledge of the risk factors, signs and symptoms of complications such as
infection, impaired wound healing, an inadvertent puncture of a major vessel, a pneumothorax,
hemorrhage and thrombocytopenia, for example.
Thrombocytopenia
Thrombocytopenia, a decreased level of platelets in the blood can be caused by a number of physical
diseases and disorders as well as from a number of therapeutic treatments and interventions. For
example, thrombocytopenia can result from aplastic anemia, HIV infection, Immune
thrombocytopenic purpura, as a prenatal complication, a genetic disorder, cancer, particularly cancer
that affects the bones, some viral pathogens like those that cause mononucleosis, as well as from
therapeutic radiation therapy, chemotherapy and some medications such as Depakote.
The signs and symptoms of thrombocytopenia include indirect evidence with vital signs, for
example, that detect bleeding and other data. Thrombocytopenia is often asymptomatic, and it is
often diagnosed with a thorough medical history, including a history of bleeding problems, renal and
liver disease, and a physical examination which should include an inspection of the body for any
evidence of purpura or petechiae and laboratory diagnostic tests such as a complete blood count, a
platelet count, liver function tests, electrolytes and a complete coagulation panel.

Infection
The signs of infection include the local signs of inflammation including swelling heat, swelling, pain,
redness, and at times, a lack of local function like not being able to use an affected limb. The
systemic signs of infection are feelings of malaise, a fever, tachycardia, anorexia, diarrhea, nausea,
cramping, chilling and feelings of fatigue.
Diagnostic laboratory data that can be used to identify the possible presence of infection include:-

 White blood cell count: A complete white blood cell count includes data relating to all of the
major types of white blood cells including lymphocytes, monocytes, eosinophils, basophils and
neutrophils. White blood cells increase with infection, leukemia, and the inflammatory process;
and white blood cell counts decrease with leukopenia. The normal white blood cell count is
from 4,500 to 11,000 white blood cells per mcL.

 Erythrocyte Eedimentation Rate (ESR): The erythrocyte sedimentation rate increases with
infection. The normal erythrocyte sedimentation rate is 0 to 20 mLs per hour for females and 0
to 15 millimeters per hour for males, however, at times, the normal erythrocyte sedimentation
rate can be higher among members of the elderly population.

 C-reactive protein: The normal C reactive protein is < 1.0 mg/dL or less than 10 mg/L. C
reactive protein can increase 1,000 times the normal level with infection as well as with massive
burns.

 Plasma viscosity: Plasma or blood viscosity is the thickness of the blood that is affected with a
number of factors including the client's temperature, the hematocrit and the red blood cell
aggregation. High temperatures, when the client has a fever from an infection, will lower the
 viscosity of the blood in the same manner that Jell-O will thin with heat; and blood viscosity will
increase when the temperature is lower.

Other laboratory diagnostic tests such as urine testing and spinal fluid testing are also done to assess,
monitor and follow up on system specific infections:

Inadvertent Puncture of a Major Vessel

Inadvertent punctures of major vessels can occur during a number of surgical interventions, invasive
procedures and some invasive diagnostic tests. For example, the descending aorta can be punctured
during major abdominal surgery, during the placement of an epidural catheter for anesthesia and
during a lung biopsy or the placement of a chest tube.
The signs and symptoms of a puncture of a major vessel other than obvious signs of hemorrhage
include all the signs and symptoms of hypovolemic shock such as hypotension, tachycardia, a lack of
tissue perfusion, hyperventilation, decreased cardiac output, decreased urinary output, oliguria,
anuria, metabolic acidosis, increased blood viscosity, and multisystem failure.
More information about hypovolemic shock was previously detailed in the section entitled
"Monitoring the Client for Signs of Bleeding".

Pneumothorax
Pneumothorax can occur secondary to the placement of a central venous catheter, the placement of
a total parenteral nutrition catheter, during a thoracentesis, spontaneously, with a penetrating gun
shot or knife wound, a fractured rib and for other reasons such as the presence of lung pathology
like chronic obstructive pulmonary disease and cystic fibrosis when these disorders, traumatic
injuries and diseases for one reason or another create positive pressure with the collection of air or
blood in the plural space.
The signs and symptoms of pneumothorax and hemothorax include dyspnea, chest pain, shortness
of breath and pain. The treatment of a pneumothorax includes the correction of the underlying
cause whenever possible and the placement of a chest tube to remove the blood and/or air in the
pleural space which will re-expand the affected lung and recreate the negative pressure of the pleural
space.

Hemorrhage
Hemorrhage and excessive bleeding can occur as the result of all invasive procedures, particularly
when the procedure is extensive in nature, when the procedure is of extensive duration, when the
client has a clotting disorder, and when the client has been taking anticoagulation medications.
As previously discussed in the section entitled "Monitoring the Client for Signs of Bleeding", the
signs of bleeding, hemorrhage and hypovolemic shock include alterations in terms of diagnostic
laboratory data, the client's intake and output, vital signs, central venous pressure, arterial blood
gases, renal functioning and hemodynamic monitoring in addition to decreased urinary output,
metabolic acidosis, and increased blood viscosity.
The goal of treatments for hypovolemic shock include the correction of any underlying cause, fluid
replacements, blood and blood products plasma expanders, and maintaining the client in a
Trendelenburg position, as indicated.

Evaluating the Client's Response to

Post-Operative Interventions to
Prevent Complications
Post-operative nursing care and patient education begins prior to the surgical procedure during the
preoperative phase of the perioperative process. This education focuses on the interventions that
will be done for the client post operatively to prevent the commonly occurring complications
associated with surgery and surgical procedures. Clients with surgical risks are more apt than other
populations to be adversely affected with a post-operative complication.
Some of these risk factors include age, the client's current nutritional status, the client's state of
overall health, the client's state of mental health and the medications that the client has been taking.
For example, a lack of vitamin A may interfere with good wound healing, corticosteroids can
interfere with wound healing, anticoagulant medications can lead to post-operative bleeding and
hemorrhage, and malnutrition can lead to post-operative complications.
Some of these complications include wound disruptions such as evisceration and dehiscence, airway
obstructions and respiratory alterations including aspiration and hypoxia, impaired venous return,
complications of immobility, a paralytic ileus and infection.
Some of the preventive interventions and the client expected responses to these interventions
include:

Wound Disruptions such as Evisceration and

Dehiscence
Dehiscence occurs when an incisional wound separates after surgery; evisceration occurs when an
internal bodily organ protrudes through the incision. Dehiscence and evisceration can be a life
threatening emergency; do not leave the client immediately call for help and, using a clean, sterile
towel or sterile saline dampened dressing, cover the wound. Under no circumstance should
reinserting the organs be attempted. Maintain light pressure on the wound and monitor client for
shock until help arrives.
Some of the risk factors for wound disruption include obesity, diabetes, vomiting, sneezing,
coughing and a failure to splint the wound. Preventive measures to avoid wound dehiscence and
wound evisceration include client coaching and teaching the client how to splint their incisional area
when coughing, sneezing, vomiting and when doing planned, routine coughing and deep breathing
exercises post operatively.
The expected outcomes of these preventive measures include the lack of a wound disruption and the
client correctly demonstrating the splinting of the surgical wound.

Airway Obstruction, Aspiration and Hypoxia

The prevention of these complications include positioning the client on their side with the chin
slightly downward until the client is fully conscious, placing pillows under the arms to increase chest
expansion, suctioning and the maintenance of the artificial airway until the client is conscious and
able to cough and swallow and the gag reflex has returned, the coaching and reminding the client to
cough, deep breathe and use their incentive spirometer, advancing the client from NPO status to
clear fluids and so on, and the close monitoring of the client in terms of client's respiratory rate,
depth and rhythm, their blood gases and their breath sounds.
With these preventive interventions, the client should be free of any airway obstruction, aspiration
and hypoxia.

Impaired Venous Return

Impaired venous return occurs during the postoperative period of time, particularly when the client
is on complete bed rest and immobility. Some of the preventive interventions that can and should be
done include the application and use of anti embolism or compression devices to promote venous
return, out of bed activity as soon as possible after the surgical procedure, active or passive range of
motion exercises, frequent client positioning and repositioning, leg exercises in and out of bed, and
the assessment of the client's extremities for their warmth and color, and any signs of pain, swelling,
or edema of the lower extremities.
These interventions should leave the client free of impaired venous return, venous blood pooling
and thrombophlebitis and emboli.

Immobility
As detailed in the previous section entitled "Identifying the Complications of Immobility",
immobility can adversely affect virtually all bodily systems. For example some of the hazards of and
complications of immobility include venous and urinary stasis, renal calculi, urinary retention,
atelectasis, the loss of calcium from the bones, respiratory secretion accumulation and pneumonia,
decreased pulmonary vital capacity, orthostatic hypotension, a decrease in terms of cardiac reserve,
edema, emboli, thrombophlebitis, and constipation, among other complications.
The prevention of the complications associated with immobility include early out of bed activity as
soon as possible after surgery and complication related preventive interventions, such as weight
bearing activity to prevent the loss of calcium from the bones and a high fiber diet and plenty of
fluids to prevent constipation.
The client should be free of all complications associate4d with immobility during the post-operative
phase of the perioperative time period.

Paralytic Ileus
A paralytic ileus is a complication of anesthesia used during surgery. The client should be
encouraged to get out of bed as soon as possible and to delay food and fluids until the normal bowel
sounds have returned. The nurse should monitor the client's bowel sounds and assess the client for
any signs abdominal pain and distention.
The expected outcomes related to the prevention of a paralytic ileus should be that the client has
resumed peristalsis and is free of any abdominal distention and pain.

Infection
Infection is probably the most commonly occurring post-operative complication. The local and
systemic signs and symptoms of infection as well as diagnostic laboratory data that are indicative of
infection were previously discussed in the section entitled "Standard Precautions/Transmission-
Based Precautions/Surgical Asepsis". Examples of these local and systemic signs of infection
include wound redness and an elevated body temperature, respectively.

System Specific Assessments:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of system specific assessments in order to:

 Assess the client for abnormal peripheral pulses after a procedure or treatment
 Assess the client for abnormal neurological status (e.g., level of consciousness, muscle strength,
and mobility)
 Assess the client for peripheral edema
 Assess the client for signs of hypoglycemia or hyperglycemia
 Identify factors that result in delayed wound healing
 Recognize trends and changes in client condition and intervene as needed
 Perform a risk assessment (e.g., sensory impairment, potential for falls, level of mobility, skin
integrity)
 Perform focused assessment

Assessing the Client for Abnormal

Peripheral Pulses after a Procedure or
Treatment
Many procedures and treatments place the client at risk for an alteration in terms of their peripheral
pulses. These peripheral pulses include the radial pulse, the femoral pulse, the brachial pulse, the
popliteal pulse, the dorsalis pedis pulse of the foot and the posterior tibial pulse near the ankle.
These pulses are assessed in terms of their rate, volume, and regularity bilaterally. A Doppler can be
used when the peripheral pulses are difficult to palpate.
The strength, volume and fullness of the peripheral pulses are categorized and documented as
follows:

 0: Absent pulses
 1: Weak pulse
 2: Normal pulse
 3: Increased volume
 4: A bounding pulse

Assessing the Client for An Abnormal

Neurological Status
Nurses assess the client's neurological status in terms of the client's level of consciousness, muscle
strength, mobility and the functioning of the cranial nerves and neurological reflexes.
The client's level of consciousness is assessed as oriented to time, person and place, also referred to
as oriented x 3, fully awake but not fully oriented, arousable with some stimuli, and not responsive.
They can also be assessed as alert, confused, lethargic, obtunded, stuporous, or comatose as well as
having a persistent vegetative state, locked in syndrome or brain death, as discussed previously in the
section entitled "Assessing the Client's Appearance, Mood and Psychomotor Behavior and
Identifying and Responding to Inappropriate and Abnormal Behavior".
Muscular strength, like peripheral pulses, are assessed bilaterally for equality and the strength of the
muscles are assessed and documented from 0 to 5 as shown below.
Muscular strength is assessed with manual muscle testing and using a dynamometer. Muscular
strength is also assessed in terms of bilateral equality and other characteristics.
The strength of muscles is classified and documented as follows:

 0: The lack of visible muscle contraction

 1: Visible muscle contraction with the absence of any movement
 2: Muscular contraction coupled with an inability to move against the force of gravity
 3: Full muscle contraction and movement without the ability to move against resistance
 4: Full muscular contraction and movement coupled with some limitation with resistance
 5: Full muscular contraction and movement against high levels of resistance
or

 0: Muscle contraction is not visible

 1: The presence of a contraction and the absence of movement
 2: Muscular contraction and the inability to move the bodily part against the force of gravity
 3: Full contraction and movement
 4: Full contraction and movement but with some limitation when resistance is applied
 5: Full contraction against high levels of resistance and full movement

Mobility
The needs of the client in terms of their mobility, movement, activity and exercise are impacted by a
number of different factors including neurological function, joint mobility, bodily alignment,
coordination, balance and gait. Many of these factors are neurological in nature. For example, joint
mobility can be impaired as the result of paralysis secondary to a cerebrovascular accident, bodily
alignment can be negatively impacted when the client has a lack of balance as the result of altered
visual ability, impaired neurological stretch receptors, and the nerves within labyrinth of the ear; and
impaired coordination can occur as the result of cerebral cortex, basal ganglia and cerebellum
abnormalities.
The cranial nerves are assessed in terms of their sensory and motor functioning. As previously
discussed in the section entitled "The Assessment of the Neurological System", the twelve unique
cranial nerves include:

1. Olfactory cranial nerve

2. Optic cranial nerve
3. Oculomotor cranial nerve
4. Trochlear cranial nerve
5. Trigeminal cranial nerve
6. Abducens cranial nerve
7. Facial cranial nerve
8. Acoustic cranial nerve
9. Glossopharyngeal
10. Vagus cranial nerve
11. Spinal accessory cranial nerve
12. Hypoglossal cranial nerve

Reflexes, including the primitive reflexes are assessed as previously detailed and described in the
section entitled "The Assessment of the Neurological System". For example the primitive Moro or
startle reflex, the primitive step reflex, the reflexes of the pupils are assessed for dilation and pupil
accommodation, and the plantar reflex is assessed by stroking the soles of the client's foot.
Assessing the Client for Peripheral
Edema
Peripheral edema, sometimes referred to as dependent edema, can be present with a number of
physiological disorders such as fluid overload, infection, poor venous circulation, and some cardiac
disorders. Edema results when fluids collect and accumulate in the interstitial and/or intravascular
spaces.
Nurses assess edema in terms of its location and severity. Pitting edema is classified as 1+ to 4+
edema with 1+ pitting edema as edema that remains indented 1 cm or less and 5+ as pitting edema
that remains indented 5 cm; and it can also be described and documented as 1+ to 4+ with 1+
pitting edema as edema that is difficult to detect and 4+as pitting edema that remains indented > 75
cm.

Assessing the Client for Signs of

Hypoglycemia or Hyperglycemia
The most commonly occurring signs and symptoms of diabetes mellitus result from hyperglycemia.
Nurses assess clients for these signs of hyperglycemia:

 High blood glucose levels

 Blurred vision
 Nausea and vomiting
 Polyuria
 Urinary frequency
 Polydipsia
 Dehydration
 Fatigue
 Alterations in terms of mental status like confusion
 Weakness
 Orthostatic hypotension

Hypoglycemia also has a number of signs and symptoms including a headache, anxiety, slurred
speech, dizziness, lightheadedness, a headache, diaphoresis, irritability and hunger which are the
early signs of hypoglycemia. The later signs of hypoglycemia include:

 Low blood glucose levels

 Alterations in terms of consciousness including confusion and the state of unconsciousness
 Lethargy
 Convulsions
 Seizures
 Unconsciousness
 Clumsiness and a lack of coordination
 Muscular weakness
 Agitation
 Coma
 Death

The signs and symptoms of diabetic ketoacidosis are:

 Ketones in the urine

 A very high blood glucose level
 Breath with a fruity odor
 Fatigue
 Respiratory shortness of breath
 Nausea and vomiting
 Abdominal pain
 Confusion
 Excessive thirstiness
 Frequent urination

Initial signs and symptoms of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) include:

 Excessive thirst
 A fever
 Muscular weakness
 Convulsions
 Seizures
 Increased urination
 Lethargy
 Nausea
 Confusion
 Coma
Identifying Factors That Result in
Delayed Wound Healing
Some of the factors that can result in delayed and other wise impaired wound healing include:

 Age: Advancing age is a risk factor associated with delayed and impaired wound healing because
of some of the normal and expected changes related to the aging process and also because aging
clients are more likely to be affected with chronic and long term diseases and disorders, such as
diabetes, that can delay wound healing.Some of the normal and expected changes related to the
aging process that impact on poor wound healing include slower cell renewal, a decreased
immune system which impedes the production of monocytes and antibodies that are necessary
for wound healing, vascular changes that interfere with the blood flow to and the oxygenation of
the wound area, and less elastic collagen and scar tissue which could make the wound more
fragile and more easily disrupted.

 Nutritional Status: Obesity and poor nutrition in terms of the inadequate intake of protein,
lipids, carbohydrates, vitamins like vitamins C and A, copper, zinc, iron and minerals can lead to
delayed and impaired wound healing.

 Lifestyle Choices: Lifestyle choices including poor dietary habits and cigarette smoking which
reduces the oxygenation of the healing tissue can impede optimal wound healing.

 Some Medications: Some medications that can delay and disrupt optimal wound healing
include antineoplastic medications, steroids, and other anti-inflammatory medications including
aspirin.

 Some Diseases and Disorders: Diabetes, cardiovascular, circulatory and respiratory disorders
are examples of diseases and disorders that can impair wound healing.

The different types of wound healing including primary secondary and tertiary healing, the phases of
the wound healing process and other aspects of wound healing were previously discussed in the
section entitled "Performing a Skin Assessment and Implementing Measures to Maintain Skin
Integrity and Prevent Skin Breakdown".
Recognizing Trends and Changes in
Client Condition and Intervening as
Needed
Nurses recognize and monitor trends and changes in the client's condition and, after this
assessment, they intervene as needed.
Many of these interventions include notifying the doctor of these significant changes, performing
further assessments to refine the nurse's decision making, and performing independent nursing
functions that are within the nurse's scope of practice as indicated by these client changes and
trends.

Performing Risk Assessments

Nursing assessments and nursing diagnoses address not only actual health problems but also the risk
factors that place a client in a position that makes them more prone to a disease or disorder than
other clients. For example, the client with diabetes is at risk for a number of different short term and
long term complications such as hyperglycemia, hypoglycemia and peripheral neuropathy; the client
with poor nutrition as a risk factor is more apt to be adversely affected with poor wound healing and
cardiac disease; clients with a sensory impairment are at greater risk for medical errors and accidents;
clients with a neurological deficit and muscular weakness have a greater potential for falls when
compared to other clients; and, immobile clients are at greater risk for all the complications of and
the hazards related to immobility.
Nurses perform these risk assessments to prevent the occurrence of a disorder or illness. For
example, clients who are assessed as a high risk for skin breakdown or falls must have special
preventive measures put into place to avoid an actual health problem such as skin breakdown and
falls, respectively.

Performing a Focused Assessment

Although registered nurses perform a complete health history and a comprehensive head to toe
assessment, there are many occasions when a focused assessment is done. For example, clients at
risk for or affected with a chronic or acute respiratory disorder will be assessed by the nurse in terms
of their respiratory status including the assessment of the client's breath sounds and arterial blood
gases, and clients with a cardiac disorder will be assessed with a focused assessment of their ECG
and heart sounds.
Therapeutic Procedures:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of therapeutic procedures in order to:

 Assess the client response to recovery from local, regional or general anesthesia
 Apply knowledge of related nursing procedures and psychomotor skills when caring for clients
undergoing therapeutic procedures
 Educate client about treatments and procedures
 Educate client about home management of care (tracheostomy and ostomy)
 Use precautions to prevent further injury when moving a client with a musculoskeletal condition
(e.g., log-rolling, abduction pillow)
 Monitor the client before, during, and after a procedure/surgery (e.g., casted extremity)
 Monitor effective functioning of therapeutic devices (e.g., chest tube, drainage tubes, wound
drainage devices, continuous bladder irrigation)
 Provide preoperative and postoperative education
 Provide preoperative care
 Provide intraoperative care
 Manage client during and following a procedure with moderate sedation

Assessing the Client's Responses to

Recovery From Local, Regional and
General Anesthesia
Anesthesia is categorized as local, regional, conscious sedation, and general anesthesia. Whenever
possible local and regional anesthesia are used rather than general anesthesia because general
anesthesia places the client at greater risk for complications.
The types of local and regional anesthesia include:

 A topical anesthesia such as lidocaine or benzocaine is used for less invasive procedures as well
as prior to the administration of a local anesthetic for procedures such as the removal of a skin
 lesion. These same topical agents are used to decrease localized pain such as the pain associated
with a burn.

 A local anesthetic such as lidocaine or tetracaine is injected into the affected area for minor
surgical procedures such as suturing a clean, open wound.

 A nerve block entails the injection of an anesthetic into the area around nerves and groups of
nerves. Some nerve blocks are referred to as minor nerve blocks when they are only introduced
to anesthetize to a single nerve; others are referred to as a major nerve block when they are
introduced into a plexus or groups of nerves; and still more are referred to as a field block which
is a subcutaneous injection of local anesthesia into the area around the intended area to be
anesthetized.

 A Beir's block is the administration of an intravenous regional anesthetic into a limb vein that
has subjected to the temporary interruption of circulation to the area with a tourniquet to
localize the intended effect of the anesthetic to the tissues and nerves in the area that is getting
the procedure or surgical intervention.

 Spinal anesthesia, also referred to as subarachnoid anesthesia, is the injection of a local

anesthetic into the subarachnoid area around the spinal cord after the performance of a lumbar
puncture. The sites for the administration of this anesthesia range from L2 to S1. A low spinal
anesthesia, also referred to a saddle block or a caudal block, is typically used for rectal surgeries
and this anesthesia is delivered above T9, a mid spinal anesthetic is administered above the level
of the naval to T10 and this type of spinal anesthesia can be used for procedures such as the
removal of an infected appendix, and a high spinal anesthetic is done between T4 and the level
of the nipples. This type of spinal anesthesia is often used for a C section.

 Transwound anesthesia, also referred to as transincision anesthesia, entails the administration of

a local anesthetic using a multilumen catheter that is surgically placed into the area that will be
treated.

 Epidural anesthesia, also referred to as peridural anesthesia, entails the administration of a local
anesthetic is into the epidural space outside of the dura mater of the spinal cord. This type of
anesthesia is used for chest and abdominal surgeries.

 Conscious sedation, which is often used for endoscopic examinations and procedures, involves
the intravenous administration of a narcotic such as midazolam, diazepam or morphine which
are intended to decrease the client's awareness, to increase pain tolerance and to induce amnesia.
 Although this type of anesthesia has more complications and risks than local anesthesia, it is less
problematic than general anesthesia.

 General anesthesia produces analgesia, amnesia, sleep and muscular relaxation, but it also
produces unconsciousness, and the lack of life protective reflexes such as the gag and cough
reflexes. This lose places the client at risk for respiratory problems, therefore, continuous
monitoring of the client is necessary. General anesthesia can be administered with a medical gas
or an intravenous transfusion of an anesthetizing agent.

The stages of general anesthesia are:

 Stage 1 - The Induction Stage: During this stage the client begins to lose consciousness and
feel the analgesic effects of the general anesthesia, however, the client is not yet affected with
amnesia.

 Stage 2 - The Excitement Stage: This stage is characterized with irregular respirations, an
irregular cardiac rhythm, uncontrollable muscular activity, and, at times, vomiting. Because of
these risks, the duration of this stage of general anesthesia is minimized to the greatest extent
possible.

 Stage 3 - The Surgical Anesthesia Stage: The client is totally unconscious, the pupils are
dilated, the client is in the maximum state of analgesia and amnesia; they are experiencing a deep
yet artificial sleep; there is total muscular relaxation, and the client is vulnerable because they are
without any protective gag, laryngeal or cough reflexes.

 Stage 4 - The Emergence Stage: During this stage of anesthesia the client begins to return to
their preanesthesia state. Prior to the client's full return to their preanesthesia state, the client
may be agitated, confused, tachycardic, and experience some shivering and changes in terms of
their blood pressure. The client is still at risk for complications during this stage.

For this reason, the client is continuously monitored in terms of their blood pressure, pulse
oximetry, cardiac rhythm, and temperature in order to determine whether or not the client is
affected with malignant hyperthermia which can occur when some medical gases are used. The
artificial airway remains in place and managed by the nurse until the client is able to spontaneously
and safely breathe on their own with the return of the gag, cough and laryngeal reflexes.
All forms and types of anesthesia have risks. As stated previously, local and regional anesthesia have
less risks than conscious sedation and conscious sedation has less risks and complications than
general anesthesia.
The expected outcomes post anesthesia include the client's return to their preanesthesia state and
without any complications.
The complications of local anesthesia, such as that done by a dentist, are typically associated with an
over dosage or too rapid administration of the anesthetizing medication. Mild and moderate
complications can include excitability, seizures, central nervous system depression, respiratory
and/or cardiac distress and collapse.
Regional anesthesia can include complications such a headache, injection site soreness, infection,
bleeding, hematoma, decreased urination, hypotension, nausea, vomiting and nerve damage as well
as complications which may or may not vary in terms of the site that was used. For example, a
pneumothorax, hoarseness of the voice, ptosis, temporary or permanent weakness or paralysis can
occur.
Conscious sedation is associated with complications such as agitation, uncontrollable muscular
activity, respiratory distress, respiratory arrest, unstable vital signs, cerebral hypoxia. The nurse must
insure that the crash cart and other resuscitative equipment is readily available for use when
indicated.
Conscious sedative is rapid in terms of its actions and it is relatively rapid in terms of the client's
return to their preanesthesia state, however, the client remains a risk for complications and at risk
for falls and other accidents until they have fully recovered.
General anesthesia can lead to mild and very serious complications such as a sore throat from the
artificial airway, fatigue, dizziness, damage to dentition as the result of the placement of an artificial
airway, myocardial infarction, serious malignant hyperthermia, a cerebrovascular accident,
respiratory depression, hypoxia, cardiac arrest, respiratory arrest, coma and death.

Applying a Knowledge of Related

Nursing Procedures and Psychomotor
Skills When Caring for
Clients Undergoing Therapeutic
Procedures and Educating the Client
about Treatments and Procedures
Nurses apply their knowledge of nursing procedures and psychomotor skills and abilities as they
care for clients who are undergoing therapeutic procedures, including surgical procedures. Each of
these procedures can be found in the facility specific policies and procedures as well as in standards
of care and reliable, current and accurate nursing textbooks. The details about these psychomotor
procedures are well beyond the scope of this NCLEX RN review, so we suggest that you review and
reference nursing procedures in your current nursing textbooks.
Other than mentioning the necessity for nurses to follow established standards of care and facility
policies and procedures relating to the many nursing procedures, nurses must perform procedures
with physical and emotional jeopardy in mind. Clients must be properly identified using two unique
identifiers, the orders for the procedure must be complete and appropriate, the client must have a
complete informed consent, and the preparation of the client must be completed prior to the
procedure to prevent physical jeopardy. The nurse must explain the procedure to the client and
maintain the client's psychological and emotional safety.

Educating the Client About

Treatments and Procedures
As fully discussed and detailed in the section entitled "Discussing Treatment Options and Decisions
with the Client: Informed Consent", all clients have the legal and ethical right to accept or reject all
treatments and procedures as based on their full understanding of the treatment or procedure, its
benefits, its risks, and any alternatives to the particular treatment or procedure. Except with extreme
emergencies, education and informed consent are mandatory. Consents can be an implicit consent,
an explicit consent and an opt out consent.
Complete education about treatments and procedures should minimally include the purpose of the
procedure, who will be performing the procedure, the benefits of the procedure or treatment, the
risks and complications associated with it, and alternative options to the procedure or treatment that
the client may want to consider.
When client education cannot be provided to the client because they are not competent enough to
understand it because they are a minor, unconscious, developmentally incapacitated, or not mentally
competent, this education is provided to the parent, spouse, legal guardian, the legal durable power
of attorney for healthcare decisions, or the healthcare surrogate or proxy.

Educating the Client About the Home

Management of Care
Many clients are discharged from an acute care facility to the home. Some of these clients may have
the assistance of a home care agency when they meet the criteria for home care and others do not.
As the lengths of stay in acute care facilities decrease, the client and/or family may have to manage
their care of their own. For example, a client may have to manage an ostomy, take care of and dress
a surgical wound, and also care for and suction a tracheostomy tube and even a mechanical
ventilator.
As previously mentioned, discharge planning should begin no later than the day of the admission so
that the client can get all the community resources and all the teaching that they need to successfully
manage their care in the home.
In addition to teaching the client information within the cognitive domain of learning, they are also
taught the psychomotor aspects of their self care. For example, the client will be taught about
medical asepsis and surgical techniques and they will also be taught to properly suction themselves
and change a surgical wound dressing, which are cognitive and psychomotor domains of learning,
respectively.
Cognitive domain learning needs can be met with a discussion and written material that the client
can take home with them and psychomotor domain learning needs should be met with step by step
demonstration, practice and return demonstration. Pictures and videos of these steps should be
provided to the client for their further review and reference when they leave the facility to return
home. Additionally, the spouse or other care givers should also be taught as indicated.

Using Precautions to Prevent Further

Injury When Moving a Client with a
Musculoskeletal Condition
Some musculoskeletal injuries, such as a spinal fracture or possible spinal fracture or injury and a
fracture of the hip, require that the nurse provide special measures to prevent further injury when
moving these clients. For example, log rolling is used for clients who have a spinal fracture and an
abduction pillow is used for clients who have a fractured hip.

Monitoring the Client Before, During,

and After a Procedure/Surgery
Nurses assess and monitor the client before, during, and after a procedure or a surgery.
The assessment and monitoring of the client prior to a procedure and surgery is necessary in order
to insure that the procedure or surgery is appropriate for the client and also to substantiate that the
client is physically and psychologically ready, prepared and safe for the specific treatment or
procedure.
For example, a client who is scheduled for a bronchoscopy must be monitored and assessed in terms
of their maintenance of their NPO status for a minimum of 6 hours prior to the procedure, their
vital signs, their respiratory status, their pulse oximetry, and the client responses to the intramuscular
or intravenous administration of atropine that is given to the client prior to the procedure in order
to decrease the amount of respiratory secretions.
During the procedure, such as a diagnostic bronchoscopy, the client is continuously monitored in
terms of their vital signs, and they are placed on continuous cardiac monitoring, blood pressure
monitoring, and pulse oximetry monitoring.
After the procedure, the client is monitored in terms of their physical status including their vital
signs, pulse oximetry, and respiratory system functioning in addition to the assessment and
monitoring of the vocal cords functioning since the pharynx and vocal cords are anesthetized with
nebulized or aerosol lidocaine prior to the passing of the bronchoscope.
Similarly, the client with a fracture must also be monitored and assessed prior to, during and after
the application of a cast.
Prior to the casting of the extremity, the client is assessed and monitored in terms of their vital signs,
level of pain, the proper alignment of the limb, the peripheral pulses of the limb and the color and
warmth of the affected limb.
During the procedure, the client continues to be monitored for the limb's proper alignment and the
adequacy of the peripheral circulation. After the procedure, the client is monitored and assessed in
terms of their level of pain, vital signs, swelling, and the lack of an external pressure on the limb as
the result of the cast which can lead to a serious limb losing complication of casting that is referred
to as compartment syndrome.
Information about the monitoring and assessment of clients prior to, during and after surgical
procedures will be discussed below in the sections entitled "Providing Preoperative Care",
"Providing Intraoperative Care" and "Managing the Client During and Following a Procedure with
Moderate Sedation".

Monitoring the Effective Functioning

of Therapeutic Devices
Medical devices such as chest tubes, drainage tubes, wound drainage devices and continuous bladder
irrigation systems must be monitored in a continuous manner to insure that they are functioning
correctly. When it appears that a therapeutic device is not functioning properly, the nurse will apply
trouble shooting measures and when these corrective measures and interventions are not successful,
the nurse will remove the device and replace it with a device that is functioning correctly and
effectively.
Nurses monitor for tube and catheter kinks, other obstructions and accidental disconnections and
then intervene appropriately; and they will monitor a chest tube for bubbling and intervene
appropriately when it appears that the chest tube is not functioning effectively.

Providing Preoperative and

Postoperative Education
Preoperative and postoperative education ultimately focuses on the assurance of a safe and effective
surgery and the prevention of any complications and poor sequelae.
Preoperative patient and family education should include complete information about all of the
preoperative procedures and interventions that will be done prior to their surgery.
The elements of these preoperative procedures and interventions that the client should be
knowledgeable about minimally include the purpose of and the procedures relating to:

 The complete physical assessment and medical history that are done prior to the surgery
 The laboratory and other diagnostic tests what will be done prior to the surgery
 Medications and anesthesia that will be administered prior to the surgery
 The medical markings of the surgical site that must be done prior to the surgery
 The informed consent and the elements of the informed consent including the benefits, risks
and alternatives related to the planned surgical procedure
 Special preoperative preparation including shaving and an enema, for example
 The preoperative checklist and its components
 The removal of valuables and prosthetics, including dentures, and their safe keeping
 How pain will be managed

During the preoperative period of time, the client is also taught about the various exercises and
routines that they should practice during the preoperative period of time so that the client is able to
effectively perform these exercises and routines after surgery when they may be in pain and still
under the effects of their general anesthesia.
The components of this preoperative education should include:

 Splinting the incisional site

 Coughing and deep breathing exercises
 The use of the incentive spirometer
 Performing stress and relaxation techniques
 The use of patient controlled analgesia devices (PCA)
 The use of compression hose and sequential compression devices
 In and out of bed exercises including active leg exercises

Postoperative education should include the reinforcement of and coaching the client in terms of all
of the components of preoperative exercises and routines as listed above in addition to how to care
for the surgical wound and any alterations of the normal bodily anatomy such as caring for an
ostomy, for example.

Providing Preoperative Care

In addition to the extensive client and family education components described immediately above in
the section entitled "Providing Preoperative and Postoperative Education", the following roles and
responsibilities are done by the registered nurse during the preoperative period of time. Many of
these roles and procedures are documented on the facility specific Preoperative Checklist to insure
that no elements of this preoperative care are overlooked and not done. Some of the components of
the Preoperative Checklist include things that are done by the registered nurse and others are done
by other members of the health care team but all are validated by the registered nurse as done and
complete.
Preoperative care can include:

 A complete physical assessment and medical history

 Obtaining and assessing laboratory diagnostic test data
 Preparing the client for other diagnostic tests, such as a chest +x-ray, and assessing the results of
these other diagnostic tests
 The administration of ordered preoperative medications
 The nursing role in terms of the informed consent and the validation of the informed consent
 Special preoperative preparation including shaving and an enema, for example
 The removal of valuables and prosthetics, including dentures, and their safe keeping

Providing Intraoperative Care

Registered nurses assume different roles and responsibilities during the intraoperative phase of the
perioperative process. For example, a registered nurse may be assigned to fulfill the role of the scrub
nurse, the circulating nurse or the registered nurse first assistant.
The scrub nurse assists the surgeon during the operative procedure; the circulating nurse assesses
the client, maintains aseptic technique and also maintains the safety of the client and the comfort of
the environment. The registered nurse as the first assistant assists the surgeon in terms of advanced
skills such as cutting tissue and controlling bleeding, as stated by the Association of Perioperative
Nurses (AORN).
The role of the circulating nurse cannot be delegated to an unlicensed assistive person or the
licensed practical nurse. As stated by the Association of Perioperative Nurses (AORN), the role of
the circulating nurse is within the exclusive scope of practice for the registered nurse. The role of the
scrub person, however, can be delegated to the licensed practical nurse and an unlicensed assistive
staff person such as a surgical technologist under the supervision of the registered nurse. Lastly, the
role of the first assistant is assumed only by a registered nurse with the advanced training and
education necessary to perform competently in this capacity.
Some of the elements of nursing care during the intraoperative phase of the perioperative process
include:

 Positioning of the client: The correct positioning of the client is based on the need for the
surgeon to be able to fully visualize the operative area and the need to prevent the complications
that can result from client positioning including skin breakdown and/or damage as the result of
 pressure, friction and shearing, nerve damage, and postoperative joint pain. The most common
position that is used for surgical procedures is the supine position; for this position, the nurse
will pad and protect pressure points such as the head, sacrum, coccyx, olecranon and scapula.

 Preparing and maintaining the sterile field: As fully discussed and detailed in the section
entitled "Using Appropriate Technique to Set up a Sterile Field and Maintaining Asepsis", nurses
set up, maintain and add to the sterile field during the intraoperative phase. Whenever the sterile
field becomes contaminated with an inadvertent action, the entire sterile field and its contents
are promptly discarded because the sterile field is no longer sterile. The entire set up must be
redone from the very beginning. Nurses also add to the sterile fields during surgery when they
open and place the needed supplies for the particular surgical procedure.

 Counting and rectifying sponges, sharps and other instruments: Nurses count sponges,
sharps and other instruments used during the surgical procedure in order to insure that no
foreign bodies are inadvertently left within the client's bodily cavities. The scrub nurse, or tech,
in addition to the circulating registered nurse are responsible and accountable for the final
sponge and instrument counts at the end of the surgical procedure.

 Continuously assessing and monitoring the client: Nurses are also responsible for
continuously assessing and monitoring the client in terms of their vital signs, responses to
anesthesia, their ECG readings, their pulse oximetry, their loss of blood, their intravenous fluid
intake and their output, their laboratory values and their pulmonary artery, arterial and venous
pressures.

 Managing and maintaining the client's drains, catheters and tubes: Nurses manage and
maintain the client's lines, drains, tubes and catheters such as their intravenous catheters, urinary
drainage catheters and nasogastric tubes to suction, as indicated.

All members of the surgical team also participate in a mandatory "time out" before surgery that aims
to prevent surgical medical errors such as wrong patient surgery, wrong procedure, and wrong site
surgery.
According to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO),
time outs are done after surgical site marking is done, after all verification procedures are complete
and all questions and concerns have been addressed and resolved. Time outs are done immediately
prior to the beginning of the invasive procedure and:

 "A designated member of the team starts the time-out.

 The time-out is standardized.

 The time-out involves the immediate members of the procedure team: the individual performing
the procedure, anesthesia providers, circulating nurse, operating room technician, and other
active participants who will be participating in the procedure from the beginning.

 All relevant members of the procedure team actively communicate during the time-out.

 During the time- time-out, the team members agree, at a minimum, on the following:
o correct patient identity
o procedure to be done
o correct site

 When the same patient has two or more procedures: If the person performing the procedure
changes, another time-out needs to be performed before starting each procedure.

 Document the completion of the time-out. The organization determines the amount and type of
documentation." (JCAHO, 2016)

Managing the Client During and

Following a Procedure with Moderate
Sedation
The American Association of Moderate Sedation Nurses (AAMSN) Position Statement on the Role
of the Registered Nurse in the Management of Patients Receiving Conscious Sedation for Short-
Term Therapeutic, Diagnostic, or Surgical Procedures states:
"AAMSN teaches the position that registered nurses trained and experienced in critical care,
emergency and/or peri-anesthesia specialty areas may be given the responsibility of administration
and maintenance of moderate or conscious sedation in the presence, and by the order, of a
physician. The registered nurse has the knowledge and experience with medications used and skills
to assess, interpret and intervene in the event of complications. This registered nurse is an asset to
the physician and enhances the quality of care provided to the patient.
Because of the importance assigned to the task of monitoring the patient who is receiving conscious
sedation, a second nurse or associate is required to assist the physician with those procedures that
are complicated either by the severity of the patient's illness and/or the complex technical
requirements associated with advanced diagnostic and therapeutic procedures.
The registered nurse will be knowledgeable and familiar with their institution's guidelines as well as
the Joint Commission for Accreditation of Health Care Organizations (JCAHO), American
Association of Nurse Anesthetists and the American Society of Anesthesiologists for patient
monitoring, drug administration, and protocols for dealing with potential complications or
emergency situations during and after sedation."
Learn more about a career as a nurse anesthetist.
The procedure for moderate sedation, according to the Policy and Procedure on Conscious
Sedation/Analgesia for Adults is as follows:

The Administration Phase

1. Administer pharmacological agents under direct supervision of responsible physician. Begin
administration of sedative or analgesic drugs only when responsible physician is present.
2. Continuously observe and document patient responses to conscious sedation/analgesia:
o ECG, BP, and oxygen saturation every five minutes
o Auscultation of breath sounds and observation of respiratory depth and rate every five
minutes
o Level of sedation and mental status every five minutes
o Skin color and condition every 10 minutes
o Pain rating every 10 minutes

3. Provide reassurance and emotional support throughout the procedure.

4. Inform the physician immediately of adverse response or any significant changes in baseline
parameters.
5. Maintain continuous IV access.
6. Perform emergency management procedures if necessary.

Note: Determining some of the monitoring parameters as frequently as outlined above may not be
possible during some procedures. For example, if the purpose of conscious sedation/analgesia is to
help the patient remain as still as possible, frequent inflation of the BP cuff may stimulate the patient
and prove to be counterproductive. In these cases, close observation and monitoring of other
parameters is invaluable.

The Recovery Phase

1. Continue mechanical monitoring: ECG, BP, oxygen saturation.
2. Assess and document vital signs, skin condition, level of sedation and mental status, and pain
every 15 minutes for at least 60 minutes after the last sedative or analgesic drug dose is given and
until discharge criteria is met.
3. Maintain IV access for at least 60 minutes after last sedative and analgesic drug dose is given and
until discharge criteria are met.
4. Review discharge instructions - http://prc.coh.org/html/Paserosedation.htm
Alterations in Body Systems:
NCLEX-RN
 IV) Physiological Adaptation
The Physiological Adaptation questions will test the ability of the nurse to manage and provide care
for clients with acute, chronic or life-threatening physical health conditions.
The nurse is expected to be able to:

 Assist with invasive procedures (e.g., central line, thoracentesis, bronchoscopy)

 Implement and monitor phototherapy
 Maintain an optimal temperature of the client (e.g., cooling and/or warming blanket)
 Monitor and care for clients on a ventilator
 Monitor and maintain devices and equipment used for drainage (e.g., surgical wound drains,
chest tube suction, negative pressure wound therapy)
 Perform and manage the care of client receiving peritoneal dialysis
 Perform suctioning (e.g. oral, nasopharyngeal, endotracheal, tracheal)
 Provide wound care or dressing change
 Provide ostomy care and education (e.g. tracheal, enteral)
 Provide pulmonary hygiene (e.g., chest physiotherapy, incentive spirometry)
 Provide postoperative care
 Manage the care of the client with a fluid and electrolyte imbalance
 Monitor and maintain arterial lines
 Manage the care of a client with a pacing device (e.g., pacemaker)
 Manage the care of a client on telemetry
 Manage the care of a client receiving hemodialysis
 Manage the care of a client with alteration in hemodynamics, tissue perfusion and hemostasis
(e.g., cerebral, cardiac, peripheral)
 Educate client regarding an acute or chronic condition
 Manage the care of a client with impaired ventilation/oxygenation
 Evaluate the effectiveness of the treatment regimen for a client with an acute or chronic
diagnosis
 Perform emergency care procedures (e.g., cardio-pulmonary resuscitation, respiratory support,
automated external defibrillator)
 Identify pathophysiology related to an acute or chronic condition (e.g., signs and symptoms)
 Recognize the signs and symptoms of complications and intervene appropriately when
providing client care

Related content includes, but is not limited to:

 Alterations in Body Systems

 Fluid and Electrolyte Imbalances
 Hemodynamics
 Illness Management
 Medical Emergencies
 Pathophysiology
 Unexpected Responses to Therapies

Alterations in Body Systems:

NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of alterations in body systems in order to:

 Assess adaptation of a client to health alteration, illness and/or disease

 Assess tube drainage during the time the client has an alteration in body systems (e.g., amount, color)
 Assess client for signs and symptoms of adverse effects of radiation therapy
 Identify signs of potential prenatal complications
 Identify signs, symptoms and incubation periods of infectious diseases
 Apply knowledge of nursing procedures, pathophysiology and psychomotor skills when caring for a
client with an alteration in body systems
 Educate client about managing health problems (e.g., chronic illness)
 Assist with invasive procedures (e.g., central line, thoracentesis, bronchoscopy)
 Implement and monitor phototherapy
 Implement interventions to address side/adverse effects of radiation therapy (e.g., dietary modifications,
avoid sunlight)
 Maintain optimal temperature of client (e.g., cooling and/or warming blanket)
 Monitor and care for clients on a ventilator
 Monitor wounds for signs and symptoms of infection
 Monitor and maintain devices and equipment used for drainage (e.g., surgical wound drains, chest tube
suction, negative pressure wound therapy)
 Perform and manage care of client receiving peritoneal dialysis
 Perform suctioning (e.g. oral, nasopharyngeal, endotracheal, tracheal)
 Perform wound care or dressing change
 Promote client progress toward recovery from an alteration in body systems
 Provide ostomy care and education (e.g. tracheal, enteral)
 Provide care to client who has experienced a seizure
 Provide care to a client with an infectious disease
 Provide pulmonary hygiene (e.g., chest physiotherapy, incentive spirometry)
 Provide care for client experiencing complications of pregnancy/labor and/or delivery (e.g., eclampsia,
precipitous labor, hemorrhage)
 Provide care for client experiencing increased intracranial pressure
 Provide postoperative care
 Remove sutures or staples
 Evaluate client response to surgery
 Evaluate achievement of client treatment goals
 Evaluate client response to treatment for an infectious disease (e.g., acquired immune deficiency
syndrome [AIDS], tuberculosis [TB])
 Evaluate and monitor client response to radiation therapy

Assessing the Adaptation of a Client to

a Health Alteration, Illness and/or
Disease
Nurses, as discussed throughout this NCLEX RN review, assess the physical and psychological
adaptation of the client to health alterations, illnesses and diseases after which appropriate
interventions are incorporated into the client's plan of care.
Nurses assess the psychological adaptation and coping of the client and the family members to
health alterations, illnesses and diseases as fully discussed and detailed in the previous major section
"Psychosocial Integrity" under its subsections of:

 Coping Mechanisms
 Crisis Intervention
 End of Life Care
 Support Systems
 Grief and Loss
 Family Dynamics

Some of these interventions include patient education, behavioral cognitive therapy and the
adoption of more effective coping mechanisms after which the outcomes of these interventions are
evaluated in terms of how well the client and family members are able to psychologically adapt to
any acute, chronic, temporary and permanent health alterations, illnesses and diseases.
Nurses also assess the physiological adaptation of the client and the family members to health
alterations, illnesses and diseases. For example, registered nurses assess the physical adaptation of
the client in terms of all interventions and therapeutic procedures including medications,
chemotherapy, therapeutic radiation therapy, total parenteral nutrition, artificial ventilation and
many, many other medical and nursing therapeutic interventions.

Assessing Tube Drainage During the

Time the Client Has an Alteration in
Body Systems
All drainage including wound drainage, respiratory secretion drainage, chest tube drainage are
assessed and documented in an ongoing manner in terms of the quantity, color, consistency and
other characteristics of the drainage.
The nurse will intervene in the appropriate manner when the drainage is not considered normal in
any of its aspects. Often, the first intervention is notifying the client's doctor of any abnormality in
terms of this drainage.

Assessing the Client for the Signs and

Symptoms of the Adverse Effects of
Radiation Therapy
As discussed in the previous section entitled "Ensuring the Safe Implementation of Internal and
External Radiation Therapy" there are two basic types of radiation therapy namely external and
internal radiation therapies; and, the three principles of radiation safety include time distance and
shielding; therapeutic internal radiation, or brachytherapy, is a therapeutic procedure that entails the
internal placement of high doses of radioactive material into or near the client's tumor; external
radiation, or teletherapy is applied to the affected bodily area with a linear accelerator that delivers
electron and gamma ionizing radiation; the side effects of radiation therapy can be localized or
systemic, acute and long term; some of the short term effects include alopecia, damage to the skin
and mucosa and bone marrow suppression; some of the long term affects are ulcerations, dental
caries, fatigue, immunosuppression, radiation pneumonia, pulmonary fibrosis, cataracts, atrophy and
strictures depending on the area(s) treated.
All of the signs and symptoms related to the adverse effects of radiation were fully described in the
section entitled ""Ensuring the Safe Implementation of Internal and External Radiation Therapy".
Identifying the Signs of Potential
Prenatal Complications
The signs, symptoms, risk factors and treatments for a wide variety of prenatal complications were
fully discussed above under the section entitled "Assessing the Maternal Client For Antepartal
Complications" and they include:

 Cardiac Disease
 Infections of all types both sexually transmitted and otherwise
 Diabetes
 Hypertension
 Preeclampsia
 Eclampsia
 Preterm Labor
 Post term Pregnancy
 Subchorionic Hematoma
 Hydatidform Moles
 Hyperemesis Gravidarum
 The Effects of Drugs and Substances
 An Incompetent Cervix
 Anemias
 Cardiopulmonary Maternal Collapse
 Disseminated Intravascular Coagulation
 Ectopic Pregnancy
 Substance Use and Abuse
 Spontaneous Abortions
 Premature Rupture of the Membranes
 Multiple Gestations
 Fetal Growth Restriction
 Oligohydramnios
 Polyhydramnios
Identifying the Signs, Symptoms and
Incubation Periods of Infectious
Diseases
The local signs and symptoms, in addition to the visual signs such as a skin pustule, include pain at
the site of the infection, redness, heat, swelling and some bodily part dysfunction. The systemic signs
and symptoms of infection include a fever, fatigue, prodromal malaise, chills, tachycardia, nausea,
vomiting, anorexia, and confusion, in addition to infection specific signs and symptoms such as
dysuria, hematuria, and urinary frequency when the client has a urinary tract infection; and
respiratory infections lead to coughing, dyspnea and adventitious breath sounds.
As more fully described in the section entitled "Understanding Infections and Communicable
Diseases and the Modes of Organism Transmission", incubation periods are simply defined as the
durations of time between the entry of the pathogenic organism into the body upon initial exposure
until the signs and symptoms of the infection begin; and periods of communicability, simply
defined, is the duration of time that a pathogen can indirectly or directly transmit an infection to
another. This period of time varies according to the microorganism.
Some pathogens are associated with brief periods of communicability, others are characterized with
longer periods of communicability; and some pathogens are associated with short periods of
incubation and others are associated with longer periods of incubation.

Applying a Knowledge of Nursing

Procedures, Pathophysiology and
Psychomotor Skills When Caring for a
Client with an Alteration in Body
Systems
All care of the client with an alteration in their body systems requires the registered nurse to apply a
knowledge of nursing procedures, pathophysiology and psychomotor skills.
The knowledge of nursing procedures includes the application of the phases of the nursing process,
and procedures related to each of these phases as well as the procedures for teaching,
communication, informed consent, admission to a facility or service, discharges from a facility or
service, transfers within a facility or service, preoperative care and monitoring medical devices; these
procedures are established in nursing standards of care, nursing standards of practice, and the
policies and procedures within a particular health care facility.
As stated in several previous sections of this NCLEX RN review, nurses must apply their knowledge
of and principles relating to the pathophysiology of the client. For example, the nurse know and
apply the pathophysiology associated with diabetes, heart failure, chronic obstructive pulmonary
disease, increased intracranial pressure, venous stasis, and a pneumothorax to the care of the client
with these disorders and alterations of bodily systems.
Psychomotor skills are also applied in the care of many clients as well. For example, the nurse uses
and applies psychomotor skills when inserting an intravenous line, when irrigating a surgical wound,
when moving a client up in bed using good body mechanics, and when performing complete,
passive range of motion to a client.

Educating the Client about Managing

Health Problems
Nurses educate clients, significant others and caregivers about how a health problem can and should
be managed. These health problems can be acute or chronic.
Some of the acute health problems that the nurse teaches the client about include managing and
caring for a traumatic or surgical wound, managing medications that are used for an acute infectious
disease such as pneumonia, and managing dependent edema, for example.
Some of the commonly occurring chronic health problems that the client is educated about include
diseases and disorders such as chronic heart disease, chronic respiratory diseases like chronic asthma
and amyotrophic lateral sclerosis or Lou Gehrig's disease, chronic and progressive neurological
disorders such as Alzheimer's disease and Parkinson's disease, and diabetes.
The teaching about these chronic health problems should include initial and ongoing education and
reinforcement about the:

 Nature of the health problem

 Risk factors associated with it
 Factors that promote effective management
 Factors that impede effective management
 Medications and other treatments such as a nebulizer for example
 The side effects, adverse effects and complications associated with ordered medications and treatments
 When to call the physician
 The need for follow up care in the community setting
 The community resources , including self help peer support groups, that can assist the client and family
members to manage their chronic disorder and prevent any complications associated with it
Assisting with Invasive Procedures
Nurses assist physicians and other licensed independent practitioners with invasive procedures.
Some of this assistance can be done by either a licensed practical nurse or a registered nurse, and
others may be restricted to only the registered nurse according to the legal state scope of practice
and/or the specific policies and procedures of the particular health care facility.
Many of these invasive procedures are done at the bedside so nurses working outside of special care
areas and special invasive procedure units must be knowledgeable about their role and ready to
perform when asked to do so.
Some of these invasive procedures include things like the placement of a central line, a needle
biopsy, a spinal tap, the placement of chest tubes, a thoracentesis, and a bronchoscopy or intubation.
The general guidelines for these invasive procedures include:

 The verification of the doctor's order

 The accurate identification of the client using two unique identifiers
 The gathering of the necessary equipment and supplies
 Setting up the sterile field if indicated
 Maintaining sterile technique before, during and after the procedure, as indicated
 Taking and documenting the client's vital signs and other assessments, as indicated
 Caring for the client during the invasive procedure
 Monitoring and reassessing the client after the invasive procedure
 Complete, timely and accurate documentation of all aspects of the invasive procedure including
documentation of data pre intervention, during the procedure and after the procedure

The procedure specific procedures for intubation to connect to a mechanical ventilator

include the elements of the MSMAID mnemonic. MSMAID is:

 M: Monitors like blood pressure, pulse oximetry, and ECG monitors or telemetry
 S: Suctioning equipment and supplies
 M: Machines like a mechanical ventilator
 A: Airway supplies like artificial airways and a laryngoscope
 I: Intravenous supplies, equipment and intravenous access
 D: Drugs for emergencies and anesthetics

The procedure specific procedures for a diagnostic bronchoscopy, in addition to the general
guidelines listed above, include:

 Maintaining the client's NPO status for at least 6 hours prior to the procedure whenever possible
 The administration of atropine to decrease respiratory secretions
 The administration of moderate conscious sedation or general anesthesia
 The administration of nebulized lidocaine to numb the patient's pharynx and vocal cords
 The lubrication of the bronchoscope
 Passing the bronchoscope into the bronchi of the lungs

The procedure specific procedures for a needle biopsy are:

 Positioning and maintaining the client's position so that the site of the needle biopsy is exposed
 Prepping the site with betadine
 Covering the surrounding site with a sterile fenestrated drape
 The administration of a topical local lidocaine if ordered
 The administration of a local anesthetic
 Obtaining the specimen using the needle
 Labelling and transporting the specimen to the diagnostic laboratory for processing
 Covering the site with a sterile dressing

The procedure specific procedures for a thoracentesis are:

 Positioning the client in a sitting and leaning forward position over a bedside table to expose the area that
will be used for the withdrawal of excessive fluids
 Prepping the site with betadine
 Covering the surrounding site with a sterile fenestrated drape
 The administration of a topical local lidocaine if ordered
 The administration of a local anesthetic
 The withdrawal of the fluid with a 16 gauge needle attached to a 50 cc syringe
 Labelling and transporting the specimen to the diagnostic laboratory for processing
 Covering the site with a sterile dressing

The procedure specific procedures for the placement of a central line are:

 Positioning the client in a position to expose the entry site

 Prepping the site with betadine
 Covering the surrounding site with a sterile fenestrated drape
 The administration of a local anesthetic to the entry site area
 Positioning the head in the opposite direction of the entry site
 Using ultrasound, the needle is advanced until blood return is seen
 Insertion of the guide wire and placement of the catheter over the guide wire
 Flushing the catheter
 Suturing the catheter in place
 Confirmation of proper insertion and placement with a chest x-ray
 Covering the site with a sterile dressing

The procedure specific procedures for chest tube insertion are:

 Positioning the client in a supine position

 Prepping the site with betadine
 Covering the surrounding site with a sterile fenestrated drape
 The administration of a local anesthetic to the entry site area
 A small incision and the placement of the chest tube
 Connecting the chest tube to the pleural drainage system
 Covering the site with a sterile dressing

The procedure specific procedures for a spinal tap, also referred to as a lumbar puncture,
are:

 Positioning and maintaining the position of the client on their side with their back arched so that the
client's knees are up to their chest OR sitting and leaning over a bedside table
 Prepping the site with betadine
 Covering the surrounding site with a sterile fenestrated drape
 The administration of a local anesthetic to the entry site area
 The insertion of the needle into the two lowest vertebrae
 Withdrawing the cerebrospinal fluid, measuring its pressure and assessing the color and amount
 Placing and maintaining the client in a flat position to avoid post procedure headaches
 Labelling and transporting the specimen to the diagnostic laboratory for processing
 Covering the site with a sterile dressing

Implementing and Monitoring

Phototherapy
Phototherapy is used to treat psoriasis, but it is most commonly employed for the treatment of
neonatal hyperbilirubinemia and jaundice which can occur among both full term and pre term
infants.
The complications of neonatal hyperbilirubinemia can include the depositing of bilirubin in the fatty
tissues, so when the levels of bilirubin are high, phototherapy with the use of direct light or a
bilirubin blanket is used to facilitate and promote the breakdown and excretion of excessive bilirubin
from the neonate.
Although newer and improved methods to deliver phototherapy are safer and less prone to the
complications associated with older methods. For example, older methods of phototherapy employ
the use of direct light onto the infant's skin when the infant is only clothed in a diaper; this method
of phototherapy requires the placement of eye patches and lubricating eye drops to protect the
infant from ocular damage as the result of this direct light, the avoidance of photosensitizing
medications like furosemide and tetracycline, and the monitoring of the client's temperature to
assess for any hypothermia which can result from the absence of clothing and a blanket over the
infant.
Newer methods of phototherapy, using a bilirubin blanket, are less prone to complications and risks
of complications. Bilirubin blankets use light with filtered out harmful infrared and ultraviolet light.
This blanket, which is as effective as the older methods of phototherapy, can be used 24 hours a day
and it is rather simple to use so it can be used in the new mother's home as well as in the acute care
setting or the birthing center.
When a client is getting phototherapy, the nurse delivers the treatment according to the doctor's
order in terms of hours per day and they also monitor and document the client's:

 Skin for changes in color that may indicate an increase or decrease in the amount of bilirubin in the
client's blood
 Laboratory bilirubin levels to determine whether or not the client's bilirubin levels are decreasing as the
result of the phototherapy
 Volume, color and characteristics of the stool because phototherapy can lead to frequent, loose stools as
well as a color change to green colored stools

Implementing Interventions to
Address Side/Adverse Effects of
Radiation Therapy and Radiation
As discussed in the section entitled "Identifying the Client with Increased Risk for Cancer", one of
the risk factors associated with cancer is exposure to sunlight and external ultraviolet radiation and
another is exposure to the ionizing radiation that is in diagnostic x-rays and therapeutic radiation
therapy for cancer.
Nurse address the adverse effects of radiation from sunlight and external ultraviolet radiation by
educating the client relating to the risks of tanning beds and sun bathing as well as the use of
preventive measures such as the use of sun screen lotions, the use of protective clothing such as a
hat, and avoiding the worst times of the day to be in the sun. They also educate clients about the
signs of skin cancer including changes of the skin and the signs of a possible precancerous lesion, a
basil cell carcinoma, a squamous cell carcinoma and multiple myeloma.
As previously discussed in the above section entitled "Assessing the Client for the Signs and
Symptoms of the Adverse Effects of Radiation Therapy", the short term effects of therapeutic
radiation therapy include alopecia, damage to the skin and mucosa, dry mouth and bone marrow
suppression; and some of the long term affects are ulcerations, dental caries, fatigue,
immunosuppression, radiation pneumonia, pulmonary fibrosis, cataracts, atrophy and strictures
depending on the area(s) treated. Other commonly occurring side effects and adverse effects include
nausea, vomiting, diarrhea, and anorexia, all of which can jeopardize the client's nutritional status.
Some of the interventions to address the side effects and adverse effects of radiation therapy and
chemotherapy include:

 Alopecia: Psychological support for this alteration in terms of body image, adopting a shorter hair style
until the hair begins to regrow, wearing a wig or a hair piece, wearing a cold cap to protect the hair, and
gently caring for the hair with a mild shampoo, a soft brush, and protecting the head from the sun with a
hat.

 Damage to the skin: Blanching, ulcerations, cracking, erythema, sloughing and desquamation of the
skin can occur. Topical skin lubricants and lidocaine may be helpful. More severe skin damage must be
assessed and treated according to the nature and extent of the skin damage.

 Xerostomia or dry mouth: Xerostomia, or dry mouth, can lead to damage to the mucosa of the mouth
and dental caries. Dry mouth is a complication of both therapeutic radiation and chemotherapy; it occurs
because these treatments decrease the production of saliva from the salivary glands. The treatment of
xerostomia can consist of a preventive medication such as amifostine, salivary gland stimulating
medications such as pilocarpine or cevimeline, sucking on sugar free hard candies or chewing gum,
mouth rinses with carmellose, hyprolose or hyetellose, using a cool mist humidifier, sucking on ice chips,
and using fluoride mouth rinses and small sips of water throughout the day to relieve this oral dryness
and to prevent the complications associated with it.

 Damage to the mucosa: Severe pain can result from ulcerations of mucous membranes, and the patient
can be more susceptible to infection as the result of this damage and mouth sores. In addition to the
interventions discussed above for dry mouth, other interventions for oral sores and lesions can include a
mouth wash that contains lidocaine for relief from the pain, rinsing the mouth with a baking soda and
salt mixture, the administration of a mild over the counter analgesic such as acetaminophen, a bland food
diet and minimizing the use of dentures.

 Dental caries and oral infections: Regular professional dental examinations and care, brush, flossing
and oral mouth rinsing at least 3 times per day, and the administration of antibiotics, antiviral drugs,
and/or antifungal drugs to treat any oral infections.

 Fatigue: Fatigue can be alleviated with a number of different interventions including the correction of
any and all underlying causes of sleep deprivation such as pain, anemia, depression and anxiety, the
promotion of stress and relaxation techniques, and the promotion of exercise and a healthy diet,
 Nausea and vomiting: Nausea and vomiting can be controlled by treating any underlying cause such as
changing a medication that can be leading to the nausea and vomiting, in addition to stress, relaxation
and distraction techniques, herbs like ginger, medications such as metoclopramide to prevent vomiting,
and antiemetics as ordered.

 Anorexia: Anorexia can sometimes be successfully treated with appetite stimulants such as megestrol
acetate, steroid medications, metoclopramide, dronabinol, the guidance of a dietitian, eating smaller more
frequent meals, dietary supplements like Ensure and, when necessary and elected to by the client, enteral
or parenteral nutrition to maintain the client's nutritional status and fluid balances.

 Diarrhea: Diarrhea can be controlled by treating any underlying cause such as changing a medication
that can be leading to it, in addition to the avoidance of spicy and troublesome foods, the consumption
of foods such as rice and bananas, consuming a low fiber, low residue diet, and medications such as
dipenoxylate in combination with atropine (Lomotil) and loperamide (Imodium).

 Bone marrow suppression and immunosuppression: Bone marrow suppression and

immunosuppression place the client at risk for infections. The client must be monitored for the signs and
symptoms of infection and infections should be treated when they occur and according to the cultures
and sensitivities.

 Radiation pneumonia, radiation pneumonitis and radiation pulmonary fibrosis: These respiratory
complications result from the destruction of normal, healthy cells with radiotherapy, particularly when
the chest area is treated. Radiation pneumonitis typically occurs during a long duration of radiation
therapy and up to even 6 months after the therapeutic radiation therapy has been completed. Radiation
pneumonitis, an inflammation of lung tissue, can be asymptomatic and it can also lead to a fever,
coughing and shortness of breath. It can also be characterized with an elevated sedimentation rate and
abnormal white blood cell counts. When it is not treated with anti-inflammatory medications such as
steroid medications, it can lead to often irreversible pulmonary radiation fibrosis that can occur a year
after the completion of the radiotherapy because the tissue continues to be altered after the course of
radiotherapy has been completed.

 Other fibrosis: Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons,
and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein
accumulation within normal irradiated tissue. It can be treated according to the symptoms and the
severity of this disorder. For example, physical and occupational restorative and rehabilitation therapy
may be indicated when the neuromuscular system is adversely affected with this complication of
therapeutic radiation therapy and it leads to treatable atrophy and strictures, for example.
 Cataracts: Cataracts, which is the clouding of the lens of the eye, can also be a complication of radiation
therapy as well as other causes. Cataracts can be treated with ocular surgery, including laser surgery.

Maintaining the Optimal Temperature

of the Client
The range for normal bodily temperature has a very small range for individual variations except for
some small dip in temperature as the result of the normal bodily physiological changes as the result
of the circadian rhythm.
Hypothermia, a less than normal bodily temperature, occurs when the heat production of the body
is less than heat losses; and hyperthermia, a more than normal bodily temperature, occurs when the
heat production of the body is more than the bodily heat losses. Hypothermia is simply defined as a
core bodily temperature of less than 95 degrees; and hyperthermia is simply defined as a core bodily
temperature of more than 99.5 degrees.
The risk factors associated with hyperthermia include infection, strenuous exercise, damage to the
hypothalamus, some medications like monoamine oxidase inhibiting psychotropic medications,
hyperthyroidism, and exposures to extremely hot and humid environmental temperatures.
The risk factors associated with hypothermia include a normal change associated with the aging
process, diabetes, trauma, are aging, hypothyroidism, diabetes, trauma, and exposures to extremely
cold environmental temperatures.
The signs and symptoms of hyperthermia are a fever, nausea, vomiting, hypotension, seizures, hot
skin, dehydration, confusion, dizziness, tachycardia, rapid respirations, coma, and even death when
the hyperthermia is not treated; the treatments for hyperthermia include the correction of any
underlying disorders, fluid hydration to make up for the patient's fluid losses, and the provision of
coolness with wet packs or a hypothermia warming blanket to decrease the client's temperature to its
normal level.
Hypothermia, on the other hand, presents with signs and symptoms such as confusion, shallow,
slow respirations, shivering, lethargy, slurred speech, a loss of consciousness, coma and death when
left untreated; the treatment of hypothermia includes the use of a warming blanket, the application
of warm packs and the encouragement of warm oral fluids to increase the client's temperature to its
normal level.

Monitoring and Caring for Clients on

a Ventilator
Mechanical ventilation delivers air under pressure that keeps the alveoli open during inspiration and
it prevents alveolar collapse during expiration; this respiratory intervention improves the client's
oxygenation, it enhances the client's gas exchanges, it increases lung capacity, and it decreases the
client's work of breathing. Many facilities have registered certified respiratory therapists who work in
collaboration with nurses to monitor and care for clients who are on a ventilator. Mechanical
ventilators are found in special intensive care units, on regular medical and surgical care units in an
acute care facility, in long term care facilities and even in the home.
Despite the great benefits of mechanical ventilation, nurses must be aware that there are some
complications associated with the use of mechanical ventilation. Nurses, therefore, must monitor the
client in terms of the therapeutic effects of the mechanical ventilation in terms of improved
respiratory function and blood gases as well as for the complications associated with this therapeutic
intervention.
Some of the complications associated with mechanical ventilation include:

 Alveolar Over Distention: Alveolar over distention is the most frequently occurring complication
associated with mechanical ventilation. This complication occurs as the result of causes such as high tidal
volume, high ventilating pressures and atelectrauma as a result of the rapid opening and closing of the
alveoli accompanied with low lung volume. Alveolar over distention can lead to increased work of
breathing, subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, a
decrease in lung compliance and leaking around the client's endotracheal tube. The correction and
treatment of alveolar over distention include decreasing PEEP and the tidal volume, high frequency
oscillatory ventilation or high frequency jet ventilation and extracorporeal membrane oxygenation.

 Cardiovascular Complications Such as Decreased Cardiac Output, Decreased Venous Return,

and Decreased Myocardial Blood Flow: These cardiovascular complications can be prevented with
increasing the circulating volume and when they do occur, they can be treated with the administration of
a nitrogen oxygen mixture of medical gases with low oxygen content or the administration of carbon
dioxide.

 Oxygen Toxicity: Oxygen toxicity can result from oxygen supplementation therapy when the level of
oxygen concentration is too high; and this complication can be identified by closely monitoring the
client's arterial oxygen and carbon dioxide blood gases and insuring that the PaO2 level is maintained
between 50 and 60.

 Denitrogenation Absorption Atelectasis: Denitrogenation absorption atelectasis is defined as the

elimination of nitrogen from the client's bodily tissues and lungs; this complication can occur when the
client is receiving more than 80% oxygen.

 Hypoventilation: Hypoventilation and under inflation of the lungs can occur as the result of an
inadvertent extubation or disconnection from the mechanical ventilator. This complication can be
prevented with the use of and prompt attention to low pressure and disconnect safety alarms and the
 careful handling of the tubings and artificial airways, particularly when the client is being moved about in
bed, when the client is being transferred from the bed to a chair, and also during transport to another
area of the health care facility. These complications are monitored for in terms of the client's flow
volumes, pressure volumes and resistance.

 Hyperventilation: Hyperventilation can also occur as a complication of mechanical ventilation.

Hyperventilation can result from a defective sensitivity setting, the presence of respiratory secretions in
the client's airway, ventilator autocycling because there is a leak in the system, and when the neonatal
client is given surfactant. Hyperventilation can be prevented with the close monitoring of the client's
minute volume, tidal volume, sensitivity levels and levels of carbon dioxide.

 Hospital Acquired Ventilator Infections: The most commonly occurring ventilator related infections
include pneumonia and other pathogens that can lead to respiratory distress syndrome. These infections
can be prevented with basic infection control procedures and techniques such as handwashing, standard
precautions and the adherence to the principles and procedures relating to asepsis. For example,
suctioning of the client is a sterile procedure. In addition to following infection control procedures,
nurses also monitor the client for the signs of infection and any respiratory complications.

 Ventilator Related Airway Complications: Examples of ventilator related air way complications
include vocal cord trauma, airway obstructions secondary to mucus plugs and the kinking of any tubings,
tracheal trauma, glottis injuries and trauma,

 Other Complications: Other possible ventilator related complications are renal impairment, fluid
retention, increased intracranial pressure, periventricular leukomalacia, and interventricular hemorrhage.

Monitoring Wounds for the Signs and

Symptoms of Infection
The local signs of infection are site pain, redness, heat, swelling and some bodily part dysfunction;
and the systemic signs and symptoms of infection include a fever, fatigue, chills which produces
bodily heat, diaphoresis, prodromal malaise, tachypnea, tachycardia, nausea, vomiting, anorexia,
confusion, incontinence, abdominal cramping and diarrhea, among other signs and symptoms as
based on the type of infection.
Nurses monitor for these signs and symptoms of infection in addition to the monitoring of the
client's diagnostic laboratory results such as an increased sedimentation rate, an increased white
blood cell count, and increased C reactive protein, and a lower blood viscosity, for example.
Monitoring and Maintaining Devices
and Equipment Used for Drainage
As previously discussed, surgical wound drains, chest tube suctioning devices and negative pressure
wound therapy devices are monitored and maintained to insure proper drainage and safe operation.
The nurse also monitors the drainage from these closed systems in terms of quantity, color, and
other characteristics.

Performing and Managing the Care of

the Client Receiving Dialysis
Renal dialysis filters wastes and excessive fluids from the body and it also corrects and maintains the
client's normal pH balance. Dialysis replaces the normal diffusion, osmosis and ultrafiltration of the
kidney and it is most often used as a permanent and ongoing treatment for end stage renal failure,
although, it can be used on a temporary basis such as when a client is adversely affected with a
serious disorder such as oseptic shock tumor and tumor lysis syndrome. Nurses care for clients
before, during and after dialysis treatments, often in collaboration with certified dialysis technicians.
The two types of dialysis are hemodialysis and peritoneal dialysis; both of these types of dialysis can
be done in a dialysis center in the community, in some acute care facilities, and in the home when it
can be managed by the client and their care giver in the home environment.

Hemodialysis
Hemodialysis treatments are typically given to long term renal failure clients 3 times per week and
each session can last for three to five hours in duration. Hemodialysis is given through an AV fistula,
an AV graft, or a vascular access central line. The vascular access central line is typically reserved for
clients who will only be getting short term dialysis and also for those clients who cannot get an AV
fistula or graft because the risk of an infection with a vascular access central line is the greatest when
compared to the other hemodialysis access lines.
AV fistulas are surgically placed by a vascular surgeon into the client's upper arm of their lower
forearm. This is the access of choice for dialysis because it can remain usable for a longer period of
time than other devices, and it is less prone to infection and clotting than other hemodialysis
accesses.
Prior to the surgical placement of an AV fistula, the vascular surgeon does vascular mapping using a
Doppler ultrasound to evaluate the adequacy of the blood vessels that may be used and to determine
which vessel is the best. After the AV fistula is done it takes about two or three months for it to
mature to the point that it can be used for the client's dialysis treatments.
When the AV fistula is matured, an arterial needle is inserted into the fistula to transport the client's
blood from their body to the hemodialysis machine; and a venous needle is inserted to transport the
blood back to the client's body after processing,
AV grafts are done when an AV fistula placement is not possible because the client's veins are not
adequate enough to support it or a placed AV fistula does not mature that way it should to
accommodate for hemodialysis.
AV grafts are more prone to clotting off and infection when compared to AV fistulas.
An AV graft, like an AV fistula, is surgically placed by a vascular surgeon using a local anesthetic.
AV grafts also take time to develop and mature before they can be used for hemodialysis treatments.
Using an AV graft or fistula prior to this complete maturation process can lead to blood clotting and
low blood flow through it.
A venous catheter can also surgically placed by a vascular surgeon into the groin area, the chest or
the neck. These catheters split into two tubes at the exterior to the body; these two tubes are
covered with caps and sterile technique is used when taking off and replacing these caps.
Additionally, the client should wear a mask and turn their head to the opposite direction when the
caps are removed and replaced and these two tubes are clamped off during cap changes and
whenever a cap is removed and not immediately replaced. One of these tubes is connected to the
dialyzing machine to carry and transport blood from the client to the dialyzing machine and the
other transports blood back to the client after it has passed through the hemodialysis machine.
The complications associated with venous dialysis include infection, blood clots, and the narrowing
of the vein as the result of scar tissue formation. Except under unusual circumstances, therefore,
venous access devices are used only when the anticipated course of the dialysis is less than three
weeks in duration.
Prior to the hemodialysis treatment, the nurse collects pre-procedure data such as the client's vital
signs, weight, and blood glucose levels; they also assess the access site and patency. For example,
graph patency is assessed and deemed as patent when a thrill or bruit is present.
During the hemodialysis treatment, the nurse monitors, provides care and reassesses the client and
the dialysis treatment. For example, the nurse can administer any ordered anticoagulants; the nurse
will measure and document the client's intake and output in terms of the amount of dialysate that
was instilled and the amount of fluid that was drained off the client during this treatment. They will
monitor the hemodialyzer for proper functioning and trouble shoot problems when they arise, they
will assess and document the color of the drainage, and they will monitor and assess the client for
any complications that can arise from this renal treatment such as disequilibrium syndrome, extreme
fatigue, infection, clotting, hypotension and hypovolemia.
After the hemodialysis session is completed the nurse will then monitor and document the duration
of the session, the client's weight, their post treatment vital signs, blood glucose levels and any
laboratory values.

Peritoneal Dialysis
Peritoneal dialysis is done through a catheter that is placed in the peritoneal space; this type of
dialysis is indicated for clients at risk for complications associated with the anticoagulant medications
that are necessary for hemodialysis and when the client has poor venous access. Like hemodialysis,
peritoneal dialysis can also be done in the home, but unlike hemodialysis, peritoneal dialysis is done
on a daily basis and most often during the night time hours when the client is sleeping. This renal
treatment consists of a fill, a dwell and a drain cycle using the ordered dialysate.
Prior to the hemodialysis treatment, the nurse collects pre-procedure data such as the client's vital
signs, weight, and blood glucose levels; they also assess the access site and patency.
During the peritoneal dialysis treatment, the nurse monitors, provides care and reassesses the client
and the dialysis treatment. For example, the nurse will measure and document the client's intake and
output in terms of the amount of dialysate that was instilled and the amount and color of fluid that
was drained off the client during this treatment. This drainage should be clear, light yellow and
without any clots. They will monitor the dialyzer for proper functioning and trouble shoot problems
when they arise, and they will monitor and assess the client for any complications that can arise from
this renal treatment such as peritonitis, tube insertion site infections, respiratory distress, protein
depletion, hyperglycemia and mechanical problems such as an obstruction of the periotoneal dialysis
catheter.
When the flow is obstructed, the nurse will insure that the drainage bag is kept below the level of the
abdomen and they can also milk the tube to release any fibrin clots and reposition to client to
promote better inflow and outflow.
After the peritoneal dialysis session is completed the nurse will again assess, monitor and document
the duration of the session, the client's weight, their post treatment vital signs, blood glucose levels
and any laboratory values.

Performing Suctioning
Oral, nasopharyngeal, endotracheal, and tracheal airways, including artificial airways, must be
maintained with suctioning. In addition to the content that was more fully discussed in the previous
section entitled "Maintaining Tube Patency: Artificial Airway Tube Patency: Endotracheal and
Tracheostomy Tubes", the procedure for suctioning the client is as follows.

1. Identify the client

2. Instruct the client about the procedure and the purpose of the procedure
3. Pre oxygenate the client
4. Open the suctioning catheter wrapper
5. Don a sterile glove on the dominant hand
6. Lubricate the tip of the suctioning catheter with a water soluble jelly while maintaining strict sterile
technique with the dominant hand
7. Insert and rotate the suction catheter in the client's natural or artificial airway to remove respiratory
secretions
8. Repeat the procedure as necessary but only after the client has rested and been pre oxygenated between
suctioning sessions
Performing Wound Care and Dressing
Changes
Wound care, cleansing of a wound, and dressing changes are sterile procedures that require surgical
asepsis. For this reason, these sterile procedures cannot be delegated to an unlicensed nursing staff
member like a nursing assistant.
Wound care consists of cleaning the wound and dressing the wound. The cleansing solutions that
are used for wounds include sterile normal saline and other solutions such as those that contain an
antiseptic to prevent wound infection; the wound and its surrounding area are cleansed starting at
the cleanest part of the wound and then outward to the most contaminated areas of the wound.
Gauze is carefully used to remove exudate and debris. A fresh sterile gauze is used for each gentle
wipe of the wound in a manner that does not disrupt the newly forming granulating tissue.
Wounds can also be irrigated with sterile solutions to cleanse them, to prevent infection and to
promote good healing.
As discussed previously in the section "Performing a Skin Assessment and Implementing Measures
to Maintain Skin Integrity and Prevent Skin Breakdown", nurses assess the wound and the
surrounding area on a frequent basis, they assess wounds for color, size, location, odor, the
underlying tissue, and drainage or exudate in terms of amount, color and other characteristics. This
wound drainage can be serous, sanguineous, serosanguinous or purulent. They also inspect and
assess the surrounding areas. As also discussed in this same section, the three types of wound
healing are primary intention healing, secondary intention healing and tertiary intention healing and
the treatment of pressure ulcer wounds is based on the RYB Color Code of Wounds which are the
colors of red, yellow and black and, at times, wounds like pressure ulcers and other wounds, need
surgical, mechanical, enzymatic, and autolytic debridement.
Other less commonly employed types of wound care and wound cleansing include those described
below.

Hydrotherapy
Hydrotherapy is sometimes indicated when the client has a severe wound such as a severe burn, or
the wound has otherwise untreatable necrosis and when the wound is very large in size.
Hydrotherapy is done with a therapeutic whirlpool at about 37 degrees centigrade and, at times, an
ordered antiseptic solution can be added to the water. Hydrotherapy is not indicated for client's
affected with arterial insufficiency or venous ulcer wounds. Some of the complications of
hydrotherapy include the cross contamination of infections because these whirlpools are used by
multiple clients; this complication can sometimes be prevented with scrupulous disinfection of the
whirlpool after each client use and rinsing the client's wound area after exposure to the water in the
therapeutic whirlpool.

Pulsed Lavage
Pulsed lavage is employed by using saline and a pulsatile high pressure lavage device to irrigate a
wound and remove exudate. The complications associated with pulsed lavage include wound
disruption when the pressure of the pulsed lavage is too great and occupational related infection
when impervious personal protective equipment such as googles, face masks, gowns and gloves is
not used to protect the staff members from sprays and splashes.
Sterile wound dressings are selected as based on its stage of healing and other characteristics. Some
of these wound dressings include traditional gauze dressings, interactive and transparent dressings
which contain polymeric, and bioactive dressings that contain alginate, collagen and hydrocolloids.

Promoting Client Progress Toward

Recovery From an Alteration in Body
Systems
Like all other health related disorders, clients' progress toward recovery from an alteration in body
systems can be promoted as well as negatively affected with and impacted by intrinsic and extrinsic
factors. For example, diabetes is an intrinsic factor that can negatively impact on a client's recovery
from a physical alteration in the client's body system and the presence and involvement of a solid
social support systems can positively impact on a client's recovery from an acute psychiatric mental
health problem such as substance abuse. Conversely, the lack of affordable and accessible
community resources, social stigma, impaired family dynamics, stress, and the lack of culturally
competent care can negatively impact on the client's physical and psychological recovery.
The Dimensions of Health model is helpful to remembering and understanding the factors that
impact on the patient's recovery, as follows:

 The Biological Dimension of Health: Favorable genetics, full term pregnancies, and protective
immunizations enhance recovery; and comorbid diseases like heart disease and diabetes prevent optimal
recovery.

 The Psychological Dimension of Health: An internal locus of control, high levels of cognition, the
effective use of stress management techniques, and the client's orientation x 3 enhance recovery; and
psychiatric mental diseases, high levels of incapacitating stress, and an external locus of control prevent
optimal recovery.

 The Environmental Dimension of Health: Fluorinated water, clean air without toxins, and clean
drinking water and food enhance recovery; and contaminated water and contaminated food sources
prevent optimal recovery.
 The Behavioral Dimension of Health: Active participation in the treatment plan and adherence to the
medication and other treatment regimens enhance recovery; and a lack of adherence to the treatment
regimen and depression prevent optimal recovery.

 The Sociocultural Dimension of Health: Available resources in the community and the presence of a
good social support system enhance recovery; and the lack of economic resources and follow up care
prevent optimal recovery.

 The Health Systems Dimension of Health: Culturally competent care and the accessibility of
community health care resources enhance recovery; and the lack of affordable and accessible heath care
systems and resources in the community prevent optimal recovery.

Providing Ostomy Care and

Education
Nurses provide ostomy care and ostomy education to clients with bowel diversion ostomies as well
as ostomies of the trachea and enteral ostomies.
The education related to these ostomies include the purpose of the ostomy, care of the ostomy, the
risks associated with and the possible side effects of the ostomy, the care of the ostomy, and things
that should be reported to the doctor when the ostomy is being managed by the client and/or family
member.
Care of the client with an ostomy, in addition to the specific interventions related to a particular type
of ostomy, other interventions include monitoring the site of the ostomy, maintaining the patency of
the ostomy and the prevention of any complications and side effects of the ostomy.
As discussed in the sections entitled "Providing Client Nutrition Through Continuous or
Intermittent Tube Feedings" and "Evaluating the Side Effects of Client Tube Feedings and
Intervening, as Needed", enteral tube feeds can be are given with a nasointestinal tube, a nasogastric
tube, a nasojejunal tube, a nasoduodenal tube, a jejunostomy tube, a gastrostomy tube, and a
percutaneous endoscopic gastrostomy (PEG) tube, with the latter three tubes, that is the
jejunostomy, a gastrostomy and percutaneous endoscopic gastrostomy (PEG) tube, creating
ostomies that are monitored and care for by the nurse. For example, the nurse monitors and assesses
the surgical entry site, they maintain the patency of these tubes, they determine and validate the
proper placement of these tubes, they measure and monitor the client's intake and output, they
administer feedings and they evaluate the client's responses to these feedings, including the
measurement of residual and the presence of any complications.
As discussed in the previous sections entitled "Assessing and Managing the Client with an Alteration
in Elimination", and "Urinary and Fecal Diversion", the different types of colostomies include a
transverse colostomy, a descending colostomy, an ascending colostomy, and a sigmoid colostomy,
and the different urinary diversion ostomies include an ileal conduit, the neobladder, the Miami
pouch, the Indiana pouch, and a nephrostomy; again, the nurse monitors and cares for these
ostomies in terms of the surgical entry site, they maintain the patency of these ostomies, they
measure and monitor the client's intake and output, and they evaluate the client's responses to these
urinary and fecal diversion ostomies in terms of the presence of any complications such as necrosis,
stomal retraction, stomal stenosis, stomal infection, urinary tract infections, renal calculi and any
other complications.
Also, as previously discussed in the section entitled "Artificial Airway Tube Patency: Endotracheal
and Tracheostomy Tubes", the nurse monitors and cares for these tracheostomies in terms of the
surgical entry site, they maintain the patency of these ostomies, they measure and monitor the
client's respiratory secretions output, they validate the correct placement of this ostomy, and they
evaluate the client's responses to the presence of this artificial airway and they provide the necessary
humidity and suctioning.

Providing Care to the Client Who Has

Experienced a Seizure
Seizures can occur as a primary disorder, which is referred to as a seizure disorder like epilepsy, and
also as a secondary disorder such as can result from and as a complication of another disorder such
as hypoglycemia, a traumatic closed head injury, illicit drug over dosages, increased intracranial
pressure and a high fever.
As discussed in the previous section entitled "Implementing Seizure Precautions for At-Risk
Clients", nurses implement seizure precautions for clients at risk for seizures, they remain with the
client, they call for the help of others, they protect the client from injury, and they initiate emergency
medical measures, as indicated by the client's status during the seizure.
Seizures vary in terms of their signs and symptoms according to the type of seizure. These seizure
types and symptoms are:

 A generalized tonic-clonic or grand mal seizures: Convulsions, muscular rigidity and a state of
unconsciousness

 An absence seizure: This type of seizure is characterized with simply a short lived and brief state of
unconsciousness.

 A clonic seizure: A clonic seizure presents with ongoing and repetitive muscular jerking.

 A myoclonic seizure: A myoclonic seizure presents with intermittent and sporadic muscular jerking.

 An atonic seizure: This seizure entails the loss of muscular tone and muscular movement.

 A tonic seizure: This seizure entails muscular rigidity and stiffness.

The care of the client after a seizure includes the assessment of the client, notifying the physician
and the documentation of all events, interventions and patient responses prior to, during and after
the seizure.
Some of the elements of this care and documentation include:

 Events prior to the seizure such as the presence of any aura

 The nature, type and duration of the seizure activity
 Vital signs, pulse oximetry and blood glucose levels
 The client's level of consciousness
 The client's respiratory status
 The client's cardiovascular status
 The emergency interventions that were provided to the client and the client's responses to these
interventions

Providing Care to a Client with an

Infectious Disease
The care of a client with an infectious disease, simply stated, entails the assessment and reassessment
of the client, the provision of interventions to treat the infectious disease, the provision of
interventions including medications to treat the symptoms of the infectious disease, the prevention
of complications, the protection of others against the transmission of the client's infectious disease,
the evaluation of the client's recovery from the infectious disease, follow up care in the community
as indicated and client and family education.
Some of the assessments and reassessments of the client include the identification of the local and
systemic signs and symptoms of infectious diseases including inflammation and an elevated
temperature, respectively, in addition to the many others, the assessment of laboratory data during
the course of treatment including the client's erythrocyte sedimentation rate, the white blood cell
count, the plasma viscosity and the levels of C reactive protein, as more fully discussed in the section
entitled "Applying a Knowledge of Pathophysiology to the Monitoring for Complications:
Infections".
Some infectious diseases such as can be treated with medications such as a broad scope antibiotic
and other infectious diseases simply have symptomatic relief because the offending microorganism
cannot be treated with an antimicrobial medication. Some examples of symptomatic relief
medications include the application of Calamine lotion to chicken pox lesions, the administration of
an antipyretic medication such as Tylenol when a client is adversely affected with an infectious
disease such as Rubella that leads to a high temperature, and the administration of an analgesic
medication when the infection is accompanied with pain.
Some of the most commonly occurring infectious diseases, their signs and symptoms over and
above the typical malaise, fever, and chills, as well as their common treatments in addition to the
necessary transmission based precautions including contact transmission precautions, droplet
transmission precautions and airborne transmission precautions, are shown in the table below:

Signs and Symptoms Treatments

Infectious Disease

Diphtheria Respiratory symptoms such as dyspnea, coughing and a Symptomatic relief of the respirato
sore throat. cardiovascular symptoms; mechan
indicated and the correction of res
Myocarditis, cardiac arrhythmias, and a
with diphtheria toxin.
pseudomembrane on the nasal passages, pharynx, and
tonsils.

Cytomegalovirus A rash, sore throat, oral lesions, fever and enlarged Symptomatic relief of the symptom
infections lymph nodes, headache, chest pain, jaundice, analgesic and mouth rinses.
splenomegaly, and photosensitivity.

Supportive and symptomatic relie

drugs, rest, a dark room to relieve
Measles (Rubeola) Photophobia, a cough, conjunctivitis, Koplik spots, and
cool mist for the cough.
a maculopapular, erythematous rash that starts on the
face and spreads to the body followed by
desquamation.

Supportive and symptomatic relie

drugs and analgesia.
Mumps Anorexia, headache, an ear ache and parotid gland
swelling.
 A pink skin rash that begins on the center of the body Supportive and symptomatic relie
and spreads outward to the face, peripheral limbs, and drugs and analgesia.
Roseola
neck.

Rubella (German Fetal abnormalities when the woman is pregnant, a sore Supportive and symptomatic care
measles) throat, lymphadenopathy, cough, coryza, and a classical the affected client from all woman
rash that begins on the face and spreads in a downward to protect a developing fetus.
manner to the neck, shoulders, trunk and legs. Later,
this rash disappears in an upward manner.

Varicella A very pruritic rash on the trunk and scalp, oral and Skin care with topical calamine lot
(Chickenpox) perineal area lesions, vesicles that change to pustules fingernails short or mittened if the
and then develop a crust which disappears over time. and teaching the child to put press
rather than scratching.
Skin scars can result when the affected client scratches
the itchy areas.

Influenza A productive or dry cough, overall aches and pains, Supportive and symptomatic relie
hoarseness, photophobia, fever, nasal congestion, chills, rest, and analgesics other than Asp
diaphoresis and myalgia to Reyes syndrome. Antiviral med
Tamiflu or Relenza, may be given
duration of the flu and to prevent
complications.

Pertussis A whooping cough, respiratory changes including in Supportive and symptomatic relie
(Whooping cough) terms of the depth of the respirations, cyanosis and rest, analgesics, respiratory care an
respiratory exhaustion, increased lacrimation, the care and treatment of any serio
rhinorrhea, conjunctivitis, and vomiting. with suctioning, mechanical ventil
supplementation, as indicated.
 The administration of erythromyc
azithromycin, or clarithromycin m

Thick mucus that occludes the bronchioles, wheezing, Treatment includes supportive car
respiratory stridor, dyspnea, respiratory distress, management and antibiotics if a se
Respiratory
tachynpea, cyanosis, respiratory hypercapnia and apnea infection is suspected. Hydration s
Syncytial Virus
in severe cases. and other respiratory intervention
(RSV)

Chills, dyspnea, dyspnea, muscular aches, fatigue, The treatment of pneumonia can
enlarged lymph nodes, a sore throat and chest pain. for bacterial pneumonia, fluids an
Pneumonia
supplementation, as indicated.

Providing Pulmonary Hygiene

Pulmonary hygiene consists of a number of different procedures and techniques including relatively
simple and easy techniques such as coughing and deep breathing and more advanced techniques
such as vibration and percussion are used for the removal of respiratory secretions.
Coughing, deep breathing, incentive spirometry, postural drainage, percussion, vibration and
Inspiratory respiratory exercises and the techniques for each were previously discussed and
described in the section entitled "Applying a Knowledge of Nursing Procedures and Psychomotor
Skills When Providing Care to Clients with Immobility".
The correct client positioning for postural drainage is shown in the table below:

Lobe of the Lung

Section of the Client Positioning

Lobe

The Upper Lobe Anterior bronchus Supine with a pillow under the knees

Apical bronchus Semi-Fowler's position and then leaning to the righ

then forward
Posterior
Up at a 45 degree angle and up against a pillow at 4
 bronchus side and then on the right side

The Middle Lobe A 30 degree Trendelenburg position and turned sli

14 to 16 inch elevation of the foot of the bed and t
Medial and lateral
left
bronchus

The Lingula (The small projection Apical bronchus: Prone position and a pillow under the client's
from the lower portion of the upper
Medial bronchus: A 45 degree Trendelenburg position and turned on
lobe)
18 to 20 inch elevation of the foot of the bed and t
Lateral bronchus:
side
Posterior
A 45 degree Trendelenburg position and turned on
bronchus:
18 to 20 inch elevation of the foot of the bed and t
Superior and side
inferior bronchus
A 45 degree prone Trendelenburg position and a p
client's hip

A 30 degree Trendelenburg position and turned sli

14 to 16 inch elevation of the foot of the bed and t
right

Percussion is performed by placing a cupped over the area and doing percussion to remove
secretions. Each area is percussed for at least one minute while the client is holding his or her
breath. Vibration is performed by laying the hand on the area and applying rapid vibrating
movements while the client is deeply exhaling.
The correct hand placement for percussion and vibration is shown in the table below:

Section of the Lobe Client Positioning

Lobe of the
Lung
 The anterior bronchus

The Upper The apical bronchus The area immediately under the clavicles over the anterior chest
Lobe
The posterior The area over the shoulder blades to the clavicle
bronchus
The area over the shoulder blades and on both sides

The medial and lateral

bronchii
The Middle The area from the axillary fold across to the mid anterior chest in
Lobe the lateral right chest and the anterior right chest

The apical bronchus The bilateral area over the lower third of the posterior rib cage

The Lingula The medial bronchus The area over the lower third of the left posterior rib cage

The lateral bronchus The area over the lower third of the right posterior rib cage

The posterior bronchus The lower third of the posterior rib cage bilaterally

The superior and inferior The area extending from the left axillary fold to the midanterior chest
bronchus

Providing Care for the Client

Experiencing Complications of
Pregnancy/Labor and/or Delivery
The maternal, fetal and neonate complications during pregnancy, labor, delivery and during the
postpartum period were fully discussed with "Assessing the Maternal Client For Antepartal
Complications" and "Assessing the Client For the Symptoms of Postpartum Complications",
"Providing Care to the Client in Labor", "Providing Prenatal Care and Education", and "Checking
and Monitoring the Fetal Heart during Routine Prenatal Exams and During Labor".
Providing Care for Clients
Experiencing Increased Intracranial
Pressure
The diagnosis, etiology, signs and symptoms, and the care and treatment of clients experiencing
increased intracranial pressure were fully detailed and discussed in the previous section entitled
"Evaluating Invasive Monitoring Data: Increased Intracranial Pressure".

Providing Postoperative Care

Preoperative, intraoperative and postoperative education and care were previously discussed and
detailed under the sections entitled "Providing Preoperative Care", "Providing Intraoperative Care"
and "Managing the Client During and Following a Procedure with Moderate Sedation".

Removing Sutures and Staples

The process for removing surgical sutures and staples after the validation of the order to remove
these surgical closures and the proper identification of the client using two unique identifiers is
below.

 Cleanse and disinfect the surgical wound with a topical antiseptic

 Carefully lift each knot up with a sterile forceps
 Clip the suture with sterile scissors
 Cleanse the surgical wound again with an antiseptic when all the sutures are removed
 Place steri strips over the incision for additional healing and closure

Staples are removed using the same procedure without the use of sterile forceps and scissors, but
instead, by using a special surgical staple remover.

Evaluating the Client Response to

Surgery
Client responses to surgery were previously discussed and detailed under the section entitled
"Evaluating the Client's Response to Post-Operative Interventions to Prevent Complications".
Evaluating the Achievement of Client
Treatment Goals
As discussed with the section entitled "Integrated Process: The Nursing Process", the evaluation of
the achievement of client treatment goals reflects the client's current condition and status, as
compared and contrasted to the client's baseline data and the established expected outcomes of care,
which were established during the planning phase of the nursing process.
The five steps of the evaluation process are:

 Collecting data related to client's current condition and the established expected outcome
 The analysis of this data
 Comparing this analyzed data to the expected outcomes
 Connecting the interventions to the data and the expected outcomes
 Drawing conclusions about the success of the interventions and treatments using critical thinking and
professional judgment skills
 Making a decision about whether to continue the plan of care, or to modify it or to discontinue it all
together

Evaluating the Client's Responses to

the Treatment For An Infectious
Disease
With the exception of acquired immune deficiency syndrome (AIDS) and tuberculosis (TB), a wide
variety of infectious diseases, including a large number of infectious childhood diseases, was
previously discussed in the section entitled "Providing Care to a Client with an Infectious Disease".
This discussion covered each infectious disease in terms of its signs, symptoms, and treatments.
Some of the assessments and reassessments of the client including the signs and symptoms of
infection and laboratory data that indicate the presence or absence of infection during the recovery
stage of the infection was fully previously discussed in the section entitled ""Applying a Knowledge
of Pathophysiology to the Monitoring for Complications: Infections". This data is used to evaluate
the client's responses to the treatment for an infectious disease.
Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) are blood
borne pathogens that can affect humans of all ages around the globe.
HIV infections can range from an asymptomatic state to overt AIDS which, without effective
treatment, can lead to opportunistic infections and death. Some of these opportunistic infections
include Kaposi's sarcoma, herpes simplex, histoplasmosis, salmonella, toxoplasma gondii,
tuberculosis, cytomegalovirus, mycobacterium avium infections, candidiasis, and Pneumocystis
jirovecii pneumonia, which was formerly known as pneumocystis carinii pneumonia. Other
disorders associated with HIV/AIDS include arthralgia, bodily wasting, blindness, peripheral
neuropathy, acid-base imbalances and fluid and electrolyte disorders.
In addition to the presence of an opportunistic infection and other HIV/AIDS related disorders,
some of the signs and symptoms associated with this infection include headaches, lymphadenopathy,
edema, stiff neck, confusion chills, diarrhea, oral lesions, abdominal discomfort, weight loss, fever,
night sweats, dry cough, dyspnea, lethargy, malaise, skin rash, and seizures.
The treatment of this sexually transmitted and blood borne infectious disease, which is transported
and transmitted among humans with blood and all other bodily fluids, consists of highly active
combination antiretroviral therapy (HAART). The goal of HAART is to prevent the occurrence of
opportunistic infections, to decrease the viral load and to increase the client's CD4 T cells.
HAART consists of lifelong treatments with reverse transcriptase inhibitors, like Zidovudine,
nonnucleoside reverse transcriptase inhibitors like Efavirenz, fusion inhibitors and a combination of
antiretroviral agents like Combivir and Trizivir. The evaluation of the client's responses to the
treatment for AID/HIV, therefore, is based on the outcomes of these medications and other
treatments in terms of the client's ongoing physical status.

Tuberculosis (TB)
Tuberculosis is an airborne transmitted infection that is caused by the tubercle bacilli.
The signs and symptoms of tuberculosis include pallor, fever, chills, night sweats, anorexia, a
productive purulent cough that can sometimes contain blood, dyspnea, chest pain and extreme
fatigue. The most serious complication of TB is the emergence of an untreatable drug resistant strain
of tuberculosis.
Some of the medications that are used to treat TB include rifampin, rifabutin, rifapentine, INH,
pyrazinamide, ethambutol, streptomycin, capreomycin, aminosalicylate sodium, cycloserine and
ethionamide. Combination therapy, rather than a single medication, is the most effective form of
treatment.
Like AIDS/HIV and other diseases and disorders, the outcomes of these medications and other
treatments for TB are evaluated in terms of the client's ongoing physical status from diagnosis
through recovery.
Evaluating and Monitoring the
Client's Responses to Radiation
Therapy
The client responses to radiation therapy, like their responses to other therapies and treatments
including side effects, adverse side effects, and therapeutic effects are evaluated and monitored by
the nurse.
The responses to radiation therapy were previously detailed and discussed under the sections entitled
"Implementing Interventions to Address Side/Adverse Effects of Radiation Therapy and Radiation"
and "Assessing the Client for the Signs and Symptoms of the Adverse Effects of Radiation Therapy
and Chemotherapy".

Fluid and Electrolyte

Imbalances: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills for fluis and electrolyte imbalances in order to:

 Identify signs and symptoms of client fluid and/or electrolyte imbalance

 Apply knowledge of pathophysiology when caring for the client with fluid and electrolyte
imbalances
 Manage the care of the client with a fluid and electrolyte imbalance
 Evaluate the client's response to interventions to correct fluid or electrolyte imbalance

Electrolytes are ions that can have either a negative or positive charge. Electrolytes and the levels of
electrolytes play roles that are essential to life. For example, these electrically charged ions contract
muscles, move fluids about within the body, they produce energy and they perform many other roles
in the body and its physiology.
Electrolytes, similar to endocrine hormones, are produced and controlled with feedback
mechanisms when the kidneys or adrenal gland sense a deficit of the particular electrolyte and an
imbalance in terms of the client's electrolyte balance.
The body's electrolytes are positively or negatively charged as shown below:

 Sodium which is abbreviated as Na+

 Potassium which is abbreviated as K+
 Calcium which is abbreviated as Ca+
 Magnesium which is abbreviated as Mg+
 Chloride which is abbreviated as Cl –
 Hydrogen phosphate which is abbreviated as HPO4–
 Bicarbonate which is abbreviated as HCO3–
 Sulfate which is abbreviated as SO4–

Identifying the Signs and Symptoms

of the Client's Fluid and/or
Electrolyte Imbalances
The functions of the major bodily electrolytes, imbalances of these electrolytes in terms of deficits
and excesses and their signs and symptoms as well as the treatments for these imbalances are
discussed below.

Sodium
The normal range for sodium is 135 to 145 milliequivalents per liter (mEq/L).
Sodium plays a primary role in terms of the body's fluid balance and it also impacts on the
functioning of the bodily muscles and the central nervous system. This electrolyte is most abundant
in the blood plasma; and bodily water goes where sodium is. For example, high levels of fluid in the
plasma will occur when the plasma has high sodium content and the converse is also true.
Hypernatremia, that is a sodium level higher than 145, can result from a number of different factors
and forces such as diabetes insipidus, dehydration, as the result of a fever, vomiting, diarrhea,
diaphoresis, extensive exercise, exposures of long duration to environmental heat, and Cushing's
Syndrome.
The signs and symptoms of hypernatremia, among others, include agitation, thirst, restlessness, dry
mucous membranes, edema, confusion and, in more severe cases, seizures and coma.
The treatment of hypernatremia, like other electrolyte disorders includes the correction and
management of any underlying causes and dietary sodium restrictions. It must be noted, however,
that a rapid reduction of sodium in the body can lead to the rapid flow of water which can result in
cerebral edema, permanent brain damage which is often referred to as central pontinemyolysis, and
even death.
Hyponatremia, that is a sodium level of less than 135, can result from the syndrome of inappropriate
antidiuretic hormone, some medications like diuretics, some antidepressants, water intoxication and
as the result of diseases and disorders such as a disorder of the thyroid gland, cirrhosis, renal failure,
heart failure, pneumonia, diabetes insipidus, Addison's disease, hypothyroidism, primary polydipsia,
severe diarrhea or vomiting, cancer, and cerebral disorders.
RELATED: What is Type 1.5 Diabetes
The signs and symptoms associated with hyponatremia include confusion, vomiting, seizures,
muscle weakness, nausea, headaches, loss of energy, fatigue, and restlessness and irritability.
The treatments of hyponatremia include the correction and management of any underlying causes,
diuretic medications, fluid restrictions, intravenous sodium, and, if Addison's disease is the cause
then hormone replacement may be necessary.

Potassium
The normal potassium level is 3.7 to 5.2 mEq/L.
Unlike sodium that is an extracellular electrolyte that is found in the blood plasma, potassium is
most abundant in the cells of the body; it is primarily an intracellular electrolyte. This electrolyte
promotes and facilitates electrical impulses that are necessary for muscular contractions and also for
the normal functioning of the brain.
Hyperkalemia, which is a potassium level greater than 5.2 mEq/L, can be life threatening; the signs
and symptoms associated with hyperkalemia include muscular weakness, paralysis, weakness, nausea
and possible life threatening cardiac dysrhythmias. Hyperkalemia is most frequently associated with
renal disease, but it can also occur as the result of some medications.
Life threatening hyperkalemia is treated with renal dialysis and potassium lowering medications.
Lower less threatening levels of hyperkalemia can sometimes be treated with the restriction of
dietary potassium containing foods.
Hypokalemia, which is a potassium level less than 3.7 mEq/L, most often as the result of bodily
fluid losses that occur as the result of diarrhea, vomiting, and diaphoresis as well as some
medications like diuretics and laxatives, and with other disorders and diseases such as ketoacidosis.
Mild cases of hypokalemia can be asymptomatic but moderate and severe hypokalemia can be
characterized with muscular weakness, muscular spasms, tingling, numbness, fatigue, light
headedness, palpitations, constipation, bradycardia, and, in severe cases, cardiac arrest can occur.
In addition to treating the underlying cause of this electrolyte imbalance, supplemental potassium is
typically administered.

Calcium
The normal level of calcium is between 8.5 - 10.6 mg/dL.
The levels of calcium in the body are managed by calcitonin which decreases calcium levels and
parathyroid hormone which increases the calcium levels. Calcium is essential for bone health and
other functions.
Hypercalcemia, which is a calcium level of more than 10.6 mg/dL, is most often associated with the
endocrine disorder of hyperparathyroidism, but it is also associated with some medications such as
thiazide diuretics and lithium, some forms of cancer such as breast cancer and cancer of the lungs,
with multiple myeloma, Paget's disease, non weight bearing activity and elevated levels of calcitriol as
can occur with sarcoidosis and tuberculosis.
Hypercalcemia is characterized with thirst, renal stones, anorexia, paresthesia, urinary frequency,
bone pain, muscular weakness, confusion, abdominal pain, depression, fatigue, lethargy,
constipation, nausea and vomiting.
The treatment of hypercalcemia can include intravenous fluid hydration and medications like
prednisone, diuretics, and bisphosphonates. Symptomatic relief measures and interventions can
include analgesia to decrease the client's level of pain, vitamins D and A, and the protection of the
client against injuries and accidents, such as falls, because pathological bone fractures can occur
secondary to the bone decalcification that occurs in many cases of hypercalcemia.
Because magnesium levels are highly associated with calcium levels, it is often necessary to also
correct and treat the magnesium levels before the calcium levels can be corrected.
Hypocalcemia, which is a calcium level less than 8.5 mg/dL, can occur as the result of renal disease,
inadequate dietary calcium, a vitamin D deficiency because vitamin D is essential for the absorption
of calcium, a low level of magnesium, pancreatitis, hypoparathyroidism, an eating disorder, and
certain medications such as anticonvulsants, alendronate, ibandronate bisphosphonates, rifampin,
phenytoin, phenobarbitol, corticosteroids, plicamycin and others.
Symptoms can range from mild and barely noticeable to severe and life threatening. Some of these
signs and symptoms include muscular aches and pain, bronchospasm which can cause respiratory
problems, seizures, tetany, life threatening cardiac arrhythmias, and tingling of the feet, fingers,
tongue and lips.
The treatment of hypocalcemia includes the monitoring of the client's respiratory and cardiac status
in addition to providing the client with calcium supplements coupled with vitamin D because
vitamin D is necessary for the absorption of calcium.

Magnesium
The normal level of magnesium in the blood is 1.7 to 2.2 mg/dL.
Magnesium plays an important role in the body in terms of enzyme activities, brain neuron activities,
the contraction of skeletal muscles and the relaxation of respiratory smooth muscles. Magnesium
also plays a role in terms of the metabolism of calcium, potassium and sodium.
Hypermagnesemia, which is a blood magnesium level of more than 2.2 mg/dL, is most frequently
found secondary to renal failure, dehydration, diabetic acidosis, hyperparathyroidism,
hypothyroidism, Addison's disease, and with the excessive and prolonged use of magnesium
containing laxatives or antacids.
The signs and symptoms associated with hypermagnesemia include nausea, vomiting, respiratory
disturbances, overall and muscular weakness, cardiac arrhythmias, respiratory paralysis, central
nervous system depression and hypotension.
The treatment for hypermagnesemia typically includes the cessation of causative medications like
magnesium containing laxatives, renal dialysis, and the administration of calcium gluconate, calcium
chloride and/or intravenous dextrose and insulin.
Hypomagnesemia, on the other hand, is a blood magnesium level less than 1.7 mg/dL.
Hypomagnesemia often occurs as the result of the prolonged use of diuretics, uncontrolled diabetes,
hypoparathyroidism, diarrhea and gastrointestinal disorders such as Chron's disease, severe burns,
malnutrition, alcoholism and medications such as cisplatin, cyclosporine, amphotericin, proton
pump inhibitors and aminoglycoside antimicrobial drugs.
The signs and symptoms of hypomagnesemia are numbness and tingling, muscular weakness,
convulsions, muscle spasms, cramps, fatigue, and nystagmus.
The treatment of hypomagnesemia can include medications to decrease pain and discomfort as well
as the administration of intravenous fluids and magnesium.

Phosphate
The normal level of serum phosphate is from 0.81 to 1.45 mmol/L.
Hyperphosphatemia is defined as a phosphate level greater than 1.45 mmol/L. The greatest risk
factor for hyperphosphatemia is severe and advanced renal disease, but other risk factors can include
hypoparathyroidism, diabetic ketoacidosis, serious systemic infections, and rhabdomyoysis which is
the destruction of muscular tissue.
Hyperphosphatemia can be asymptomatic but when it is pronounced the client may have signs and
symptoms of muscular spasms and cramping, weakness of the bones, tetany, and crystal
accumulations in the circulatory system and in the body's tissue that can lead to sometimes severe
itchiness and palpable calcifications in the subcutaneous tissue. This electrolyte disorder also has
complications such as impaired circulation, cerebrovascular accidents, myocardial infarctions and
atherosclerosis.
The treatment of hyperphosphatemia includes the restriction of dietary food products containing
phosphates including foods like milk and egg yolks, and phosphate binders such as lanthanum and
sevelamer which make it hard for the client's body to absorb phosphates. These medications are
taken with meals.
Hypophosphatemia, which is defined as a phosphate level less than 0.81 mmol/L, is associated with
risk factors such as chronic diarrhea, severe burns, hyperparathyroidism, severe malnutrition,
pronounced alcoholism, lymphoma, leukemia, hepatic failure, osteomalacia, genetics, the long term
use of some diuretics and aluminium antacids, and the long term use of theophylline.
This sometimes life threatening electrolyte disorder can be accompanied with cardiac dysrhythmias,
death, respiratory alterations including respiratory alkalosis, irritability, confusion, coma and death.
Treatments for hypophosphatemia include cardiac monitoring, oral and intravenous potassium
phosphate, and the encouragement of high phosphorous foods like milk and eggs.

Chloride
The normal level of chloride is from 97 to107 mEq/L.
Hyperchloremia, which is a chloride level greater than 107 mEq/L can adversely affect the oxygen
transportation in the body. Hyperchloremia can occur as the result of dehydration, some
medications, renal disease, diabetes, diarrhea, hyperparathyroidism, hyponatremia, and some
medications such as supplemental hormones and some diuretics.
The client affected with hyperchloremia may be asymptomatic or symptomatic. Some of the signs
and symptoms of hyperchloremia are similar to those signs and symptoms associated with
hypernatremia, and they include extreme thirst, pitting edema, dehydration, diarrhea, vomiting,
Kussmaul's breathing, dyspnea, tachypnea, hypertension, decreased cognition, and coma.
The treatments, in addition to identifying and treating an underlying disorder, include the cautious
administration of fluids because too rapid rehydration efforts can lead to cerebral edema and other
complications, the elimination of problematic medications, and the correction of any renal disease
and hyperglycemia.
Hypochloremia, which is a low chloride level of less than 97 mEq/L, can occur as the result of
vomiting, hypoventilation, cystic fibrosis, metabolic alkalosis, respiratory acidosis, high bicarbonate
levels and hyponatremia.
The signs and symptoms of hypochloremia may include dehydration, hyponatremia, nausea,
vomiting, muscular spasticity, tetany, respiratory depression, muscular weakness and/or muscular
twitching, diaphoresis and a high temperature.
Treatments for this electrolyte imbalance can include the administration of chloride replacements,
and, at times, the administration of hydrochloric acid and a carbonic anhydrase inhibitor like
acetazolamide for an acute episode of hypochloremic alkalosis.

Fluids and Fluid Imbalances

Hypervolemia is an abnormal increase in the volume of fluid in the blood, particularly the blood
plasma and hypovolemia is a deficit of bodily fluids.
Hypervolemia, which is often referred to as fluid overload, can occur as the result of increased
sodium in the body which is hypernatremia, excessive fluid supplementation that cannot be
managed effectively by the body, and other disorders and diseases such as hepatic failure, renal
failure and heart failure.
The signs and symptoms of hypervolemia include hypertension, dyspnea, shortness of breath,
adventitious breath sounds such as rales and crackles, abdominal ascites, bulging and distended
jugular veins with pulsations, peripheral edema in hands, feet and/or ankles, tachycardia, and a
bounding and strong pulse.
In addition to treating the underlying cause whenever possible other treatments for hypervolemia
include fluid and sodium restrictions and diuretics.
Hypovolemia, on the other hand, is a deficit of bodily fluids. Hypovolemia can occur secondary to
bleeding and hemorrhage, severe dehydration, vomiting, and diarrhea. This fluid deficit can lead to
complications such as decreased cardiac output, hypovolemic shock, metabolic acidosis, multisystem
failure, coma and death.
Again, in addition to the treatment of an underlying disorder, some of the interventions for
hypovolemia can include intravenous rehydration with fluids such as lactated Ringers, the placement
of the client in the Trendelenburg position, and the administration of plasma expanders, blood and
blood products as indicated by the nature of the client's status and the severity of the hypovolemia.

Applying a Knowledge of
Pathophysiology When Caring for the
Client with Fluid and Electrolyte
Imbalances
The pathological etiology, risk factors and the signs and symptoms related to fluid and electrolyte
imbalances were fully discussed immediately above in the section entitled "Identifying the Signs and
Symptoms of the Client's Fluid and/or Electrolyte Imbalances".

Managing the Care of the Client with

a Fluid and Electrolyte Imbalance
The care and management of the client with fluid and electrolyte imbalances were also discussed in
the section entitled "Identifying the Signs and Symptoms of the Client's Fluid and/or Electrolyte
Imbalances" which is immediately above.

Evaluating the Client's Responses to

Interventions to Correct Fluid and
Electrolyte Imbalances
Nurses evaluate the client's responses to interventions that were used to correct fluid and electrolyte
imbalances by comparing the client's baseline data, including diagnostic laboratory data and the
client's signs and symptoms, to the outcome data after treatments and interventions. For example,
pretreatment and post treatment laboratory potassium levels or magnesium levels are compared to
determine whether or not the client's electrolyte level is again normal and/or improving towards the
achievement of the client's expected outcomes.
Hemodynamics: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of hemodynamics in order to:

 Assess client for decreased cardiac output (e.g., diminished peripheral pulses, hypotension)
 Identify cardiac rhythm strip abnormalities (e.g., sinus bradycardia, premature ventricular
contractions [PVCs], ventricular tachycardia, fibrillation)
 Apply knowledge of pathophysiology to interventions in response to client abnormal
hemodynamics
 Provide client with strategies to manage decreased cardiac output (e.g., frequent rest periods,
limit activities)
 Intervene to improve client cardiovascular status (e.g., initiate protocol to manage cardiac
arrhythmias, monitor pacemaker functions)
 Monitor and maintain arterial lines
 Manage the care of a client with a pacing device (e.g., pacemaker)
 Manage the care of a client on telemetry
 Manage the care of a client receiving hemodialysis
 Manage the care of a client with alteration in hemodynamics, tissue perfusion and hemostasis
(e.g., cerebral, cardiac, peripheral)

Assessing the Client for Decreased

Cardiac Output
Simply defined, decreased cardiac output is the inability of the heart to meet the bodily demands.
The normal cardiac output is about 4 to 8 L per minute and it can be calculated as:

Cardiac Output = Stroke Volume x Pulse Rate

Decreased cardiac output adversely affects the cardiac rate, rhythm, preload, afterload and
contractibility, all of which can have serious complications and side effects.
The signs and symptoms of decreased cardiac output include the abnormal presence of S3 and S4
heart sounds, hypotension, bradycardia, tachycardia, weak and diminished peripheral pulses,
hypoxia, cardiac dysrhythmias, palpitations, decreased central venous pressure, decreased pulmonary
artery pressure, dyspnea, fatigue, oliguria and possible anuria, decreased organ and tissue perfusion,
and adventitious breath sounds like crackles, and orthopnea.

Identifying Cardiac Rhythm Strip

Abnormalities
Of all the cardiac rhythms, only the normal sinus rhythm is considered normal. All other rhythm
strips are abnormal and some of these abnormal rhythms are relatively harmless and often
immediately correctable and others can be life threatening when they are not treated promptly and
effectively.
The steps for identifying cardiac rhythms are as follows:

1. Determine the pulse or heart rate

2. Determine the cardiac rhythm
3. Assess the P wave
4. Assess the PR interval
5. Assess the QRS complex
6. Make a conclusion about the cardiac rhythm on the rhythm strip

Sinus Rhythms
Sinus cardiac rhythms begin in the sintoatrial (SA) node of the heart. The five types of sinus rhythms
are:

 The normal sinus rhythm which has a cardiac rate of 60 to 100 beats per minute
 Sinus bradycardia which has a cardiac rate of less than 60 beats per minute
 Sinus tachycardia which has a cardiac rate of more than 100 beats per minute
 A sinus arrhythmia which is an irregular heart rate that can range from 60 to 100 beats per
minute
 Sinus arrest

Normal Sinus Rhythm

Normal sinus rhythms have a rate of 60 to 100 beats per minute, the atrial and the ventricular
rhythms are regular, the P wave occurs prior to each and every QRS complex, the P waves are
uniform in shape, the length of the PR interval is form 0.12 to 0.20 seconds, the QRS complexes are
uniform and the length of these QRS complexes are from 0.06 to 0.12 seconds.
As previously stated, the normal sinus rhythm is the only normal cardiac rhythm in terms of the
cardiac rate, cardiac rhythm, its P waves, its PR intervals AND its QRS complexes.
Sinus Tachycardia
Sinus tachycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the
number of beats per minute. Sinus tachycardia is characterized with a cardiac rate of more than 100
beats per minute, the atrial and the ventricular rhythms are regular, the P wave occurs prior to each
and every QRS complex, the P waves are uniform in shape, the length of the PR interval is from
0.12 to 0.20 seconds, the QRS complexes are uniform and the length of these QRS complexes are
from 0.06 to 0.12 seconds.

This abnormal sinus rhythm can occur secondary to hyperthyroidism, some medications,
hypertension, hyperpyrexia, extreme stress and anxiety, the presence of pain, some electrolyte
imbalances, preexisting heart disease and the intake of illicit substances like cocaine and the
excessive intake of nicotine, alcohol and caffeine.
Some of the signs and symptoms of sinus tachycardia include:


o Chest pain
o Dizziness
o Shortness of breath
o Lightheadedness
o Palpitations
o Syncope

Some of the treatments for sinus tachycardia include the treatment of an underlying disorder or a
problematic medication and no treatments when the client is asymptomatic. When the client is,
however, symptomatic, the client can be treated symptomatically with supplemental oxygen because
this rhythm increases the heart's muscle need for increased oxygenation. Some of the complications
associated with sinus tachycardia include a decrease in terms of the client's cardiac output and a
myocardial infarction.

Sinus Bradycardia
Sinus bradycardia is a sinus rhythm that is like the normal sinus rhythm with the exception of the
number of beats per minute. Sinus bradycardia has a cardiac rate less than 60 beats per minute, the
atrial and the ventricular rhythms are regular, the P wave occurs prior to each and every QRS
complex, the P waves are uniform in shape, the length of the PR interval is form 0.12 to 0.20
seconds, the QRS complexes are uniform and the length of these QRS complexes are from 0.06 to
0.12 seconds.
This abnormal sinus rhythm can occur secondary to hypothyroidism, some medications like a beta
blocker or digitalis, increased intracranial pressure, hypoglycemia, hypothermia, preexisting heart
disease and an inferior wall myocardial infarction which involves the right coronary artery.
Some of the signs and symptoms of sinus bradycardia include:


o Chest pain
o Cool, clammy skin
o Weakness
o Fatigue
o Confusion
o Syncope
o An intolerance for exercise
o Shortness of breath

Some of the treatments for sinus bradycardia include the treatment of an underlying disorder or a
problematic medication and no treatments when the client is asymptomatic. When the client is,
however, symptomatic, the client can be treated with atropine and cardiac pacing when the client is
compromised and at risk for reduced cardiac output.

Atrial Arrhythmias
Atrial arrhythmias occur when the heart's natural pacemaker, the sinoatrial node does not generate
the necessary impulses that are required for the normalfunctioning of the heart. When this occurs,
intermodal pathways and atrial tissue initiate the impulse necessary for the heart to beat and pump.
The four types of atrial arrhythmias include atrial flutter, atrial fibrillation, supraventricular
tachycardia and premature atrial contractions or complexes (PAC).

Atrial Flutter
Atrial flutter, which is a relatively frequently occurring tachyarrhymia, is characterized with a rapid
atrial rate of 250 to 400 beats per minute, a variable ventricular rate, a regular atrial rhythm, a
possibly irregular ventricular rhythm. The P waves are not normal, the flutter wave has a saw tooth
looking appearance, the PR interval is not measurable, QRS complexes are uniform and the length
of these QRS complexes are from 0.06 to 0.12 seconds.
Atrial flutter is associated with the aging process, chronic obstructive pulmonary disease, a mitral
valve defect, cardiomyopathy, ischemia; and the possible signs and symptoms of atrial flutter include
weakness, shortness of breath, chest palpitations, angina pain, syncope and anxiety.
The risks and complications of atrial flutter include atrial clot formation, a pulmonary embolus, a
cerebrovascular accident, and a drop in cardiac output.
Atrial flutter can be treated with anticoagulant therapy to prevent clot formation, cardioversion, and
medications like the antiarrhymic medications of procainamide to correct the flutter and a beta
blocker or digitalis to slow down the rate of the ventricles.

Atrial Fibrillation
Atrial fibrillation is characterized with an rapid atrial rate of 350-400 beats per minute, a variable
ventricular rate, an irregular rhythm, the P waves are nonexistent and they are replaced with f waves,
the PR interval is not present, the QRS complexes are uniform and they look alike, and the length of
these QRS complexes are from 0.06 to 0.12 seconds.

Some of the diseases and disorders associated with this cardiac arrhythmia include hypertension,
heart failure, impaired sinus node functioning, hypoxia, a mitral valve defect, pericarditis, rheumatic
heart disease, coronary artery disease, hyperthyroidism, the aging process and the presence of a
pulmonary embolus.
Some of the signs and symptoms of atrial fibrillation include chest tightness, palpitations, shortness
of breath, dyspnea, fluttering in the chest, dizziness, confusion, fainting, and fatigue.
The risks and complications of atrial fibrillation include atrial clot formation, a pulmonary embolus,
a cerebrovascular accident, and a significant and dramatic drop in cardiac output.
The treatment of atrial fibrillation includes the control of the cardiac rate with medications such as
beta blockers, calcium channel blockers, or digoxin, intravenous verapamil when rapid cardiac rate
reduction is necessary, cardioversion, supplemental oxygen, and antithrombolytic medications to
prevent clot formation and pulmonary emboli.

Premature Atrial Contractions (PACs)

Premature atrial contractions occur when the p wave occurs prematurely. After this premature p
wave, there is a compensatory pause.
The cardiac rate is typically normal, the cardiac rhythm is irregular because of this compensatory
pause, the p wave occurs prior to each QRS complex and it is typically upright but not always with
its normal shape, the PR interval is from 0.12 to0.20 seconds, the QRS complexes look alike, and
the length of the QRS complexes ranges from 0.06 to 0.12 seconds.

Premature atrial contractions, which result from the atrial cells taking over the SA impulses, is
associated with a number of different diseases and disorders such as hypertension, ischemia,
hypoxia, some electrolyte disorders, digitalis use, stress, fatigue, the use of stimulants such as
caffeine and nicotine products, some valve abnormalities, some infectious diseases, and also among
clients without any cardiac disease or other disorder.
The signs and symptoms of premature atrial contractions include palpitations and client reports that
they feel a "missed beat" which results from the compensatory pause.
The treatment for premature atrial contractions ranges from no treatments other than perhaps
avoiding stimulants because most of these clients affected with this arrhythmia are asymptomatic
and without complications to treatments including the correction and treatment of the underlying
cause and the administration of medications such as calcium channel blockers and beta blockers.

Supraventricular Tachycardia
Supraventricular tachycardia, simply defined is all tachyarrhythmias with a heart rate of more than
150 beats per minute.
The atrial and ventricular cardiac rates are from 150 to 250 beats per minute, the cardiac rhythm is
regular, the p wave may not be visible because it is behind the QRS complex, the PR interval is not
discernable, the QRS complexes look alike, and the length of the QRS complexes ranges from 0.06
to 0.12 seconds.

The risk factors associated with supraventricular tachycardia include atherosclerosis, hypokalemia,
hypoxia, stress, and stimulants; and some of the signs and symptoms include polyuria, palpitations,
syncope, dizziness, chest tightness, diaphoresis, fatigue, and shortness of breath.
The treatments for supraventricular tachycardia include the performance of the vagal maneuvers
such as the Valsalva maneuver and coughing, as well as oxygen supplementation when the client is
asymptomatic; and medications such as adenosine and cardioversion when the client is symptomatic.
A complication of this cardiac arrhythmia is heart failure.
Ventricular Arrhythmias
Ventricular arrhythmias occur when the AV junction and the sinoatrial node fail to send their
electrical impulses. As a result of this failure, the ventricles take over the role of the heart's
pacemaker. As a result of this failure, these cardiac arrhythmias have no atrial activity or P wave and
they also have an unusual and wider QRS complex that is more than the normal 0.12 seconds.
Ventricular arrhythmias include:

 An idioventricular rhythm, also referred to as a ventricular escape rhythm, has a rate of less than
20 to 40 beats per minute
 An accelerated idioventricular rhythm with more than 40 beats per minute
 An agonal rhythm with less than 20 beats per minute
 Ventricular tachycardia with more than 150 beats per minute
 Ventricular fibrillation
 Asystole or cardiac standstill
 Torsades de Pointes

Idioventricular Rhythm
An idioventricular rhythm is characterized with a ventricular rate of 20 to 40 beats per minute, a
regular rhythm, the absence of a P wave, a PR interval that cannot be measured, a deflection of the
T wave, and a wide QRS complex that is greater than 0.12 seconds.

Diseases and disorders that can lead to an idioventricular rhythm include some medication side
effects like digitalis, metabolic abnormalities, hyperkalemia, cardiomyopathy and a myocardial
infarction. The client with an idioventricular rhythm may present with mottled, cool and pale skin,
dizziness, hypotension, weakness, and changes in terms of the client's mental status and level of
consciousness.
The treatments for an idioventricular rhythm include a cardiac pacemaker, the administration of
atropine, the administration of dopamine when the client is adversely affected with hypotension, and
cardiopulmonary resuscitation when this cardiac arrhythmia leads to cardiac stand still and asystole.

Accelerated Idioventricular Arrhythmia

An accelerated idioventricular arrhythmia occurs when both the SA node and the AV node have
failed to function. The cardiac rate runs from 40 to 100 beats per minute, the rhythm is usually
regular, the P wave is absent, the PR interval is not able to be measured, the QRS complexes are
wide and more than 0.12 seconds in duration, the T wave is detected and the cardiac output is
decreased.
An accelerated idioventricular arrhythmia can be caused by a myocardial infarction, hyperkalemia,
drugs like digitalis, cardiomyopathy, metabolic imbalances, and other causes; and the signs and
symptoms of this arrhythmia is the same as that for an idioventricular rhythm and these include
mottled, cool and pale skin, dizziness, hypotension, weakness, and changes in terms of the client's
mental status and level of consciousness.
This arrhythmia is a serious one that, when left untreated, can lead to cardiac arrest and standstill,
therefore, immediate treatments with a cardiac pacemaker, the administration of atropine, the
administration of dopamine when the client is adversely affected with hypotension, and
cardiopulmonary resuscitation may be indicated.

Agonal Rhythm
An agonal rhythm, simply defined, is a type of an idioventricular rhythm with a cardiac rate of less
than 20 beats per minute. Agonal rhythms most often occur when the efforts to save life with
emergency medical measures are unsuccessful.
The rate is slow and less than 20 beats per minute, the rhythm is typically regular, the P wave is
absent, the PR interval is not measurable, and the QRS interval is abnormally wide and more than
0.12 seconds with an abnormal T wave deflection.
Agonal rhythms can be caused by a myocardial infarction, trauma and predictable changes at the end
of life and it is signaled with the lack of a palpable pulse, the lack of a measurable blood pressure
and the complete loss of consciousness.
The treatment of this serious and highly life threatening dysrhythmia includes the initiation of CPR
and the advanced cardiac life support (ACLS) protocols, if the client has chosen these life saving
treatments.

Ventricular Tachycardia
Ventricular tachycardia occurs when no impulses come from the atria; this life threatening
arrhythmia will progress to ventricular fibrillation and then cardiac arrest and cardiac asystole unless
emergency medical care is immediately rendered.
The cardiac rate can range from 101 to 250 beats per minute, the ventricular rhythm is regular but
the atrial rhythm cannot be distinguished, there are no P waves, the PR interval is not measurable,
and the QRS complex is greater than 0.12 seconds.
The risk factors associated with ventricular tachycardia include severe cardiac disease, myocardial
ischemia, a myocardial infarction, digitalis toxicity, some electrolyte imbalances, heart failure and
some medications.
Some of the signs and symptoms include hemodynamic compromise, unconsciousness, angina chest
pain, palpitations, shortness of breath, dizziness, syncope, hypotension, and the absence of a pulse
or a rapid pulse rate. Additionally, the client may not have any signs or symptoms when there are
less than 30 seconds of ventricular tachycardia.
The complications can include ventricular fibrillation which can lead to cardiac arrest. Immediate
CPR and ACLS protocols, cardioversion, the placement of an internal pacemaker, amiodarone,
lidocaine and antiarrhythmic medications may be used for the treatment of ventricular fibrillation
according to the client's condition and their choices.

Ventricular Fibrillation
The two types of ventricular fibrillation that can be seen on an ECG strip are fine ventricular
fibrillation and coarse ventricular fibrillation; ventricular fibrillation occurs when there are multiple
electrical impulses from several ventricular sites. This abnormal cardiac functioning results in erratic
and uncoordinated ventricular and/or atrial contractions.
The rate of contraction cannot be determined, the rhythm is not detectable because it is highly
erratic and disorganized, there are no P waves, no PR interval and no QRS complexes.
Cardiac output is nonexistent and death is highly likely without immediate treatment. The risk
factors associated with ventricular fibrillation include non treated ventricular tachycardia, illicit drug
overdoses, a myocardial infarction, severe trauma, some electrolyte imbalances, and severe
hypothermia.

The client loses consciousness and there is an absent pulse during ventricular fibrillation; emergency
measures include CPR, ACLS protocols including defibrillation, and other life saving measures are
indicated for the client with this highly serious life threatening cardiac arrythmia.
Asystole
Asystole is a flat line. There is no cardiac rate, no rhythm, no P waves, no PR interval and no QRS
complex.

Asystole occurs most frequently when ventricular fibrillation is not corrected, but it can also occur
suddenly as the result of a myocardial infarction, an artificial pacemaker failure, a pulmonary
embolus and cardiac tamponade.
Immediate BLS and advanced life support is necessary. Intravenous adrenaline, sodium bicarbonate
and atropine, as well as 100% oxygen are done in hopes of saving the person's life.

Torsades de Pointes
The classical features of torsades de pointes are a long QT interval in addition to a downward and
upward deflection of the QRS complexes that are seen on the cardiac strip. The cardiac rate can
range from 150 to 250 beats per minute, the rhythm can be irregular or regular, the PR interval is
not measurable, and the QRS complex is widened with upward and downward deflections.

Torsades de pointes can occur as the result of an over dosage of a tricyclic antidepressant drug of
phenothiazine, hypomagnesemia and hypokalemia. It can be short lived and self-limiting without any
treatment but it can also lead to ventricular fibrillation when it is not corrected and treated.
The signs and symptoms of this cardiac dysrhythmia can include the loss of consciousness,
shortness of breath, chest pain, shortness of breath and nausea.
The treatment of torsades de pointes, which can be life threatening, includes the initiation of CPR
and ACLS protocols, the bolus administration of magnesium sulfate, cardioversion, and the
correction of any underlying and causal factor or condition.

Heart Block
There are several types of heart block including:

 First-Degree Atrioventricular Block

 Second-Degree Atrioventricular Block, Type I
 Second-Degree Atrioventricular Block, Type II
 Complete Heart Block

First Degree Atrioventricular Heart Block

First degree atrioventricular heart block occurs when the AV node impulse is delayed, thus leading
to a prolonged PR interval. The P wave is present before each QRS complex, the PR interval is
more than 0.20 seconds.

The most common causes of first degree heart block are an AV node deficit, a myocardial infarction
particularly an inferior wall myocardial infarction, myocarditis, some electrolyte disorders, and
medications like beta blockers, cardiac glycoside medications, calcium channel blockers and
cholinesterase inhibitors.
Most episodes of transient first degree heart block are benign and asymptomatic, but at times, it can
lead to atrial fibrillation and other cardiac irregularities of varying severity according to the length of
the PR interval prolongation.
The treatment of first degree heart block includes the correction of the underlying disorder, the
elimination of problematic medications, and routine follow up and care.

Second Degree Atrioventricular Block, Type I

Second degree atrioventricular block Type I, which is also referred to as Wenckebach and Mobitz
type I, has progressively longer impulse delays through the AV node. This increasing prolongation
leads to the progressive lengthening of the PR interval until is leads to a non conducted P wave and
the absence of a QRS complex.
A second degree atrioventricular block Type I that has four P waves and three QRS complexes is
referred to as a 4:3 Mobitz Type I block and a second degree atrioventricular block Type I that has
three P waves and two QRS complexes is referred to as a 3:2 Mobitz Type I block. A similar ratio
designation is used for second degree atrioventricular block Type II, as you will learn in the next
section.
Most clients affected with Wenckebach or Type I Mobitz heart block are asymptomatic but others
may experience syncope, dizziness, fainting and feeling somewhat light headed.
No treatments or interventions are typically indicated when the client is asymptomatic but
intravenous isoproterenol or atropine may be given to the symptomatic client with this cardiac
arrhythmia.

Second-Degree Atrioventricular Block, Type II

Second degree AV block type II, also known as Mobitz type II, occurs when the AV node impulses
are intermittently blocked and do not reach the heart's ventricles. This cardiac arrhythmia most
frequently occurs as the result of afailure of the His Purkinje conduction system of the heart.
Second degree AV block type II is identified with the blocking of the P waves without any
subsequent PR shortening and without any preceding PR interval lengthening or prolongation. A 2:1
second degree AV block type II has two P waves for every QRS complex and a 3:1 second degree
AV block type II has three P waves for every QRS complex.

Treatments for this heart block can include intravenous atropine, supplemental oxygen, and, in some
cases, a temporary or permanent pacemaker, as indicated.

Third Degree Heart Block

Third degree atrioventricular block (AV block), also known as complete heart block, is a cardiac
arrhythmia that occurs when the SA node impulses are completely blocked by the ventricles of the
heart which leads to the lack of synchrony, coordination and a relationship between the atria and the
ventricles. This lack of relationship is sometimes referred to as AV disassociation.
The cardiac rates for the atria and the ventricles are different and the QRS complexes are wide and
prolonged. The first rhythm consists of the P wave to P wave interval; and the second rhythm is the
R to R interval as seen in the QRS complex.

Some of the conditions and disorders that can lead to complete heart blood include rheumatic fever,
coronary ischemia, an inferior wall myocardial infarction, the presence of an atrial septal defect, and
some medications including digoxin and beta blockers, for example.
The signs and symptoms of this cardiac arrhythmia can include syncope, dizziness, fainting, chest
pain and a loss of consciousness.
Third-degree AV block is treated with a pacemaker, medications to control atrial fibrillation and the
client's blood pressure, as well as the treatment of any identifiable causes including life style choices
and other modifiable risk factors.

Bundle Branch Block

A bundle branch block occurs when there is a conduction defect from the Purkinje fibers which
coordinate the cardiac myocytes so that the ventricles depolarize in the normal and coordinated
manner. This defect occurs as the result of a myocardial infarction, heart disease, and at times, as a
complication of cardiac surgery.
Bundle branch block has wide QRS complexes and the delayed depolarization travels to either the
right ventricle in an anterior manner or the left ventricle in a lateral manner, which are referred to as
right bundle branch block and left bundle branch block, respectively.
Left bundle branch block is categorized as either a left posterior fascicular block or a left anterior
fascicular block; and other categories of bundle branch block include a trifascicular block and a
bifascicular block. A trifascicular block is a right bundle branch block in combination with a left
posterior fascicular block or a left anterior fascicular block in addition to first degree heart block. A
bifascicular block. is a right bundle branch block in combination with a left anterior fascicular block
or a left posterior fascicular block
Clients affected with bundle branch block may be symptomatic and asymptomatic. A times a
permanent pacemaker implantation is necessary for the correction of this cardiac arrhythmia.

Applying a Knowledge of
Pathophysiology to Interventions in
Response to Client Abnormal
Hemodynamics
As consistent with other abnormal client changes, nurses apply a knowledge of pathophysiology in
terms of the interventions that are employed in response to the client's abnormal hemodynamics.
Some of the knowledge of pathophysiology that is essential to this nursing responsibility includes
both cognitive and psychomotor knowledge.
The cognitive domain knowledge includes:

 The definition of hemodynamics as the flow of blood as ejected from the heart to circulate
throughout the body in order to effectively oxygenate the tissues of the body.
 The physiology and pathophysiology related to cardiac flow rate and cardiac output
 Cardiac output as the function of the volume of pumped blood by the heart and the factors and
forces that alter normal cardiac output
 The blood pressure and the mean arterial pressure which is a function of the blood pressure and
the resistance to the flow of blood within the body's circulatory system
 The resistance to blood flow as a function of the blood's thickness or viscosity, the width of the
vessel that the blood is flowing through and the length of the vessel that the blood is flowing
through, as mathematically calculated with the Hagen Poiseuille equation. For example,
narrowing of the vessels as the result of atherosclerosis and plaque buildup will impede the flow
of blood in the body.
 The normal parameters for hemodynamic monitoring values, as shown below.

The normal values for hemodynamic values are as follows:

 Cardiac Output: 4 to 7 L/min
 Central Venous Pressure: 1 to 8 mm Hg
 Pulmonary Artery Systolic Pressure: 15 to 26 mm Hg
 Pulmonary Artery Diastolic Pressure: 5 to 15 mm Hg
 Pulmonary Artery Wedge Pressure: 4 to 12 mm Hg
 Pulmonary Artery Mean: 9 to 16 mm Hg
 Pulmonary Artery End Diastolic: 4 to 14 mm Hg
 Pulmonary Artery Occlusion Mean: 2 to 12 mm Hg
 Pulmonary Artery Peak Systolic: 15 to 30 mm Hg
 Right Ventricle Peak Systolic: 15 to 30 mm Hg
 Right Ventricle End Diastolic: 0 to 8 mm Hg
 Left Ventricle Peak Systolic: 90 to 140 mm Hg
 Left Ventricle End Diastolic: 5 to 12 mm Hg
 Left Atrium Mean: 2 to 12 mm Hg
 Left Atrium A Wave: 4 to 16 mm Hg
 Left Atrium V Wave: 6 to 12 mm Hg
 Right Atrium Pressure: 0 to 8 mm Hg
 Brachial Artery Mean: 70 to 150 mm Hg
 Brachial Artery Peak Systolic: 90 to 140 mm Hg
 Brachial Artery End Diastolic: 60 to 90 mm Hg
 Mixed Venous Oxygen Saturation: 60% to 80%

The psychomotor domain knowledge includes the nurse's ability to set up, maintain and collect data
from a wide variety of invasive and noninvasive hemodynamic monitoring devices such as:

 Hemodynamic monitoring arterial lines

 Pulmonary artery catheters and their distal lumen, their proximal lumen, their balloon inflation
port
 Pulse oximeters

Providing the Client with Strategies to

Manage Decreased Cardiac Output
Decreased cardiac output can lead to a number of physical, psychological and life style alterations,
signs and symptoms.
The physical alterations, signs and symptoms associated with decreased cardiac output include:
 Hypotension
 Hypercapnea
 Cardiac arrhythmias
 Chest pain
 Diminished peripheral pulses and poor perfusion tissue and organ perfusion
 Clammy and cool skin
 Deteriorating arterial blood gases
 Fainting
 Fatigue
 Weakness
 Edema
 Decreased urinary output
 Dizziness

The psychological alterations, signs and symptoms associated with decreased cardiac output include:

 Restlessness
 Anxiety
 Changes in terms of mental status and level of consciousness
 Confusion

Life style alterations may interfere with the client's activity level because the client with decreased
cardiac output has a decrease in terms of their tolerance to exercise, fatigue, and weakness. They
may also be at risk for accidents such as falls when the client with decreased cardiac output is
affected with weakness, fatigue, confusion and other changes in terms of their level of consciousness
and mental status.
Based on these signs and symptoms of decreased cardiac output, some of the interventions and
strategies for clients with decreased cardiac output include can include rest interspersed with light
exercise, frequent rest periods, pain management, supplemental oxygen as indicated by the client's
doctor's orders, mild analgesia if chest pain occurs, the maintenance of a restful sleep environment
and when to call the doctor as new signs and symptoms arise.

Intervening to Improve the Client's

Cardiovascular Status
In addition to the management of cardiac arrhythmias, as previously discussed in the section above
that was entitled " Identifying Cardiac Rhythm Strip Abnormalities" including the signs, symptoms,
ECG rhythm strips, medical and nursing interventions and emergency care using CPR and ACLS
protocols, nurses also monitor and maintain cardiac pacemakers.
Temporary and permanent pacemakers are indicated for clients affected with a number of different
cardiac conditions and arrhythmias. At times these pacemakers are placed and implanted at the
bedside and at other times they are placed in a special care area like a cardiac invasive laboratory or
the operative suite. When the registered nurse is assisting with the placement of these pacemakers,
the nurse must be knowledgeable about the placement procedure, asepsis, and the care and
monitoring of the client undergoing this invasive procedure.
After the implantation of a pacemaker, the nurse must be fully aware of the possible complications
associated with pacemakers which include bleeding, inadvertent punctures of major vessels,
infection, and mechanical failures, including battery failures, of the pacemaker.
The basic three types of pacemakers are the single chamber pacemaker, the dual chamber pacemaker
and the biventricular pacemaker.

Monitoring and Maintaining Arterial

Lines
Arterial lines, which can be surgically placed in a number of arteries including the femoral, brachial,
radial, ulnar, axillary, posterior tibial, and dorsalis pedis arteries, are used for the continuous
monitoring of the client's blood pressure and other hemodynamic measurements in addition to
drawing frequent blood samples, such as drawing frequent arterial blood gases which could lead to
repeated trauma, hematomas and scar tissue formation.
Some of contraindications for the use of an arterial line include severe burns near the desired site,
impaired circulation to the site, pulselessness, Buerger's disease, and Raynaud syndrome; and arterial
lines are cautiously implanted and used when the client is affected with atherosclerosis, a clotting
disorder, impaired circulation, scar tissue near the desired site, and the presence of a synthetic graft.
Nurse caring for clients with an arterial line must not only monitor the client in terms of their
hemodynamic monitoring but also in terms of the possible complications that can arise as the result
of arterial lines which can include the inadvertent and accidental puncture of a vessel during
placement, catheter breakage and migration, arterial hemorrhage and infection.

Managing the Care of a Client on

Telemetry
Clients on telemetry, which is continuous monitoring and recording of the client's ECG strips, can
be done by a telemetry technician who is an unlicensed staff member who is specially educated and
trained to read and record telemetry and also to alert the nurse when an alarm occurs and/or when
an abnormal rhythm is noticed on the telemetry monitor. Telemetry monitoring is also done by
nurses. Regardless of who is monitoring the telemetry, it is the nurse caring for the client on the
telemetry that is responsible and accountable for the accurate interpretation of the rhythm and the
initiation of any and all interventions when interventions are indicated. For example, a telemetry
technician may hear an alarm that alerts them to the fact that the client may be having an arrhythmia.
This telemetry technician will immediately run and print out the rhythm strip and notify the nurse of
this occurrence. The nurse will then apply their knowledge of pathophysiology, their critical thinking
skills and their professional judgment skills in terms of their interpretation of the rhythm strip, they
will perform a simple system specific assessment of the client, and then they will initiate and
document the appropriate interventions based on their assessment of the client and their
interpretation of the abnormal rhythm strip.
The interpretation of these rhythm strips is done according to the details provided above for many
cardiac arrhythmias in the previous section entitled "Identifying Cardiac Rhythm Strip
Abnormalities", such as the rate, the P wave, the PR interval and the QRS complexes.

Managing the Care of a Client

Receiving Hemodialysis
The purpose, the procedure and the management of care for the client before, during and after
hemodialysis and peritoneal dialysis were previously fully discussed and described in the section
entitled "Performing and Managing the Care of the Client Receiving Dialysis".

Managing the Care of a Client With an

Alteration in Hemodynamics, Tissue
Perfusion and Hemostasis
The management of the care for a client with an alteration in hemodynamics such as decreased
cardiac output in terms of the assessment for and recognition of the signs and symptoms and
interventions was previously discussed above under the section entitled "Providing the Client with
Strategies to Manage Decreased Cardiac Output".
The North American Nursing Diagnosis Association (NANDA) defines altered and ineffective
tissue perfusion as "a decrease in oxygen resulting in a failure to nourish tissues at the capillary
level." Ineffective tissue perfusion can occur and adversely affect the brain, the renal system, the
heart and the heart muscle, the gastrointestinal tract and the peripheral vascular system.
As more fully detailed and discussed previously in the section entitled "Identifying the Client with
Increased Risk for Insufficient Vascular Perfusion", some of the risk factors associated with
impaired tissue perfusion are hypovolemia, hypoxia, hypotension and impaired circulatory oxygen
transport, among other causes.
As discussed in the previous section entitled "Evaluating Invasive Monitoring Data", intracranial
pressure has an impact on the perfusion of the brain. The normal cerebral perfusion pressure, under
normal circumstances, should range from 60 to 100 mm Hg. Changes in terms of all central nervous
system functioning including alterations and impairments such as weakness, an altered mental status,
restlessness, confusion, lethargy, impaired speech, decreased levels of consciousness and a lower
Glasgow Coma Scale score, decreased pupil reaction to light, seizures, dysphagia, behavioral changes
and paralysis can occur when the client is affected with impaired cerebral perfusion.
The renal system also depends on perfusion and a good flow to maintain its functioning. When the
client has impaired perfusion of the renal system, the client may be impacted with Increased blood
urea nitrogen, oliguria, anuria, changes in the blood pressure, elevated BUN/Creatinine ratio, and
hematuria.
Poor tissue perfusion to the heart and the cardiac system can present with signs and symptoms such
as angina, abnormal arterial blood gases, hypotension, tachycardia, tachypnea, and a feeling of
impending doom.
The client with poor perfusion to the gastrointestinal system may have signs and symptoms such as
nausea, decreased motility, absent bowel sounds, abdominal distention and abdominal pain
The signs and symptoms related to the hypoperfusion of the peripheral vascular system include
intermittent claudication, weak or absent peripheral pulses, aches, pain, coolness and numbness of
the extremities, clammy and mottled skin, the lack of the same blood pressure on both limbs, edema
and slow capillary refill times.
Hemostasis can be categorized as cerebral, cardiac and peripheral hemostasis and it occurs as the
result of vascular constriction and spasm, the clotting of blood and the formation of a platelet plug,
all of which impede the free flow of blood throughout the body. For example, venous stasis or
hemostasis is a commonly occurring complication of immobility and during the post-operative
period of time. Hemostasis can occur as the result of the HELLP syndrome during the prenatal
period of time, with congenital clotting disorders, with increased blood viscosity, and with impaired
platelets; and hemostasis is also the desired outcome of good wound healing when a scab forms and
when surgical procedures need hemostasis to prevent a hemorrhage.
Hemostasis can lead to poor tissue perfusion and the formation of emboli.
The goals of treatment in terms of the management of care for a client with an alteration in terms of
their hemodynamics, tissue perfusion and hemostasis include the correction and treatment of any
treatable underlying causes, and the promotion of improved tissue perfusion.

Illness Management:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills illness management in order to:

 Identify client data that needs to be reported immediately

 Apply knowledge of client pathophysiology to illness management
 Educate client regarding an acute or chronic condition
 Educate client about managing illness (e.g., acquired immune deficiency syndrome [AIDS],
chronic illnesses)
 Implement interventions to manage the client's recovery from an illness
 Perform gastric lavage
 Promote and provide continuity of care in illness management activities (e.g., cast placement)
 Manage the care of a client with impaired ventilation/oxygenation
 Evaluate the effectiveness of the treatment regimen for a client with an acute or chronic
diagnosis

Identifying Client Data that Needs to

be Reported Immediately
Client data that must be immediately reported to the nursing supervisor and/or the physician, stated
simply, include data that indicates that one or more of the basic and essential problems and needs,
significant and substantial changes in the client's status, and all unexpected outcomes and responses,
including adverse events and adverse reactions to the care and treatments that were rendered to the
client.
As previously detailed in the section entitled "Setting and Establishing Client Priorities", the most
basic and essential problems and needs of our clients include those in the ABCs, that is the airway,
breathing and cardiovascular status, the priority needs as described by Maslow which are the
physiological needs, the needs of the clients in terms of safety and the psychological needs, the need
for belonging and love, the needs for esteem by others and self-esteem, and the need of the clients
for self-actualization, in terms of descending order of priority, and lastly, the elements of MAUUAR
which are the ABCs and then the mental status, the presence of acute pain, acute urinary elimination
problem, untreated problems, abnormal diagnostic data including laboratory data, and client risks
including the risk for skin breakdown and the risk for infection or falls.
Significant changes, simply defined, are client changes that are significantly different from the client's
baseline and/or are not normal and not consistent with the client's pattern. For example, a
significant change in the client's vital signs after an invasive procedure as compared and contrasted
to the pre procedure vital signs requires that the nurse report this significant change and other
pertinent data to the physician.
Simply defined, unexpected responses to care and treatments include all outcomes that are
unexpected and not therapeutic. For example, a client who experiences an idiosyncratic response or
an adverse reaction to a medication is having an unexpected response to a treatment; and a client
who does not have a therapeutic response to chest tube drainage or mechanical ventilation is also
having an unexpected response to these treatments and care. As stated, these unexpected responses,
in addition to significant client changes, must be reported immediately, particularly when these
events affect a priority client need like oxygenation and cardiovascular status.

Applying a Knowledge of Client

Pathophysiology to Illness
Management
Nurses apply their indepth knowledge of client pathophysiology to illness management as they care
for groups of clients. Examples of this application of this knowledge of client pathophysiology
include the risk factors, etiology, signs, symptoms, complications and how to prevent them using the
principles of pathophysiology, side effects and adverse reactions to illness management.
Examples of this application of knowledge were previously discussed in these previous sections of
this NCLEX RN review entitled:

 Applying a Knowledge of Pathophysiology to the Monitoring for Complications

 Applying a Knowledge of Pathophysiology When Establishing Priorities for Interventions with
Multiple Clients
 Applying a Knowledge of Client Pathophysiology to Home Safety Interventions
 Applying a Knowledge of Pathophysiology to Health Screening
 Applying a Knowledge of Pathophysiology to Non-Pharmacological Comfort/Palliative Care
Interventions
 Applying a Knowledge of the Client's Pathophysiology to Rest and Sleep Interventions
 Applying a Knowledge of Client Pathophysiology When Measuring Vital Signs
 Applying a Knowledge of Nursing Procedures, Pathophysiology and Psychomotor Skills When
Caring for a Client with an Alteration in Body Systems
 Applying a Knowledge of Client Pathophysiology to Illness Management

Educating the Client Regarding an

Acute or Chronic Condition and
Illnesses
As stated previously, the ultimate and primary goal of client education is to enable the client to
change in some aspect of their health wellness and illness. Education promotes the client's ability to
make knowledgeable decisions about the care, treatments and interventions that they choose to have
and choose to not have.
Nurses assess the educational needs of their clients, they analyze this assessment data, they diagnose
the learning needs of their clients in terms of their knowledge or skills deficits, and then they plan
educational activities that meet their knowledge and skills needs that are consistent with the client's
level of understanding and other factors such as their level of motivation, their level of cognition
and their learning style preferences.
Educational activities are then implemented for the client and family members or groups of clients
that are tailored to meet the client's pre-established learning goals.
Some of the content that is typically included in the patient teaching plan relating to both acute and
chronic health concerns and disorders include information about:

 The pathophysiology of the health related concern, disease, condition, and/or illness
 The risk factors associated with the health related concern, disease, condition, and/or illness
 The modifiable risk factors, such as dietary modifications, medication adherence and exercise,
that can be changed to improve one's state of heath and to decrease the risks associated with the
disease and its possible complications
 The non modifiable risk factors that cannot be changed, but however, may be able to be
compensated for with some client actions and changes in term of their behavior
 The procedures, such as diagnostic tests, that will be used to diagnose and also be used for the
ongoing monitoring of the client with an acute or chronic disease
 The signs and symptoms of the acute or chronic disorder, ways to symptomatically treat
treatable signs and symptoms and what signs and symptoms should be reported to the client's
doctor
 All of the treatments and interventions, including medications, that the client will and may
receive. This information should include all of the educational components necessary for
informed consent including the benefits and risks associated with these interventions, possible
alternatives to the intervention or procedure, and the risks and benefits associated with these
alternative interventions.
 Self care strategies for the client
 The available community resources, including financial resources, that can assist the client with
coping with and recovering from a chronic or acute condition or disorder
 The frequency of follow up care in the community and the need for follow up care

Educating the Client about Managing

Illnesses
In addition to all of the education that should be provided to clients with an acute or chronic as
discussed immediately above in the section entitled "Educating the Client Regarding an Acute or
Chronic Condition and Illnesses", some illnesses, diseases and disorders such as serious, chronic and
terminal Illnesses such as cancer and Lou Gehrig's disease as well as those that require life long
treatment like acquired immune deficiency syndrome (AIDS) require special educational
considerations and interventions.
For example, clients affected with AIDS need special education in terms of the importance of
continuing medications on a consistent basis every day without fail; and they also need special
education on how to prevent the spread of their infection to others in the home and with sexual
partners.
Clients with terminal diseases not only need education as discussed above in the section entitled
"Educating the Client Regarding an Acute or Chronic Condition and Illnesses", they also need
education related to end of life choices in terms of hospice and palliative care, advance directives,
post death planning, living wills, durable powers of attorney and other issues.

Implementing Interventions to
Manage the Client's Recovery from an
Illness
As discussed in the previous section entitled "Promoting Client Progress Toward Recovery From an
Alteration in Body Systems", recovery from an illness is a function of both intrinsic and extrinsic
factors and forces.
These factors and forces were organized into the framework associated with the Dimensions of
Health model which is helpful to apply to the client's recovery. Examples of these dimensions and
their applications to the client's recovery from an illness were discussed in this same section of this
review and these dimensions include:

 The Biological Dimension of Health

 The Psychological Dimension of Health
 The Environmental Dimension of Health
 The Behavioral Dimension of Health
 The Sociocultural Dimension of Health
 The Health Systems Dimension of Health

Performing Gastric Lavage

Gastric lavage is indicated for a number of disorders including poisonings, drug overdoses and
gastrointestinal bleeding which is often controlled with iced lavage.
This medically aseptic procedure is done in the following manner for inserting a gastrointestinal tube
that will be done for the insertion of this tube after checking the doctor's order, validating the
identification of the client and explaining the procedure to the client is:

 Place the client in a high Fowler's position whenever possible

 Inspect the nares and select the best one to use that is not obstructed with a deviated septum or
another narrowing
 Measure the length of the nasogastric tube from the nose to the ear lobe to the tip of the
xiphoid. This point should be the length that is needed to enter the stomach Mark this point
with tape on the nasogastric tube.
 Apply a bit of water soluble jelly and a local anesthetic to the tip of the tube.
 Have the client to look up so that their neck is hyperextended upward.
 Advance the nasogastric tube until you get some resistance at the nasopharynx.
 Continue to advance the tube below the curve of the nasopharynx as the client now takes small
sips of water if they are able to do so while they are leaning forward.
 Check for the correct placement of the nasogastric tube.
 Secure the nasogastric tube to the nose with tape.
 Secure the tubing to the client's gown with a safety pin.
 Clamp the tube or connect it to the suction device if ordered.

Lavage is then done according to the doctor's order after the correct placement of the
gastrointestinal tube in the stomach is confirmed. This procedure is somewhat similar to that of
irrigating a nasogastric tube with the exception of connecting the tube to suction and the type of
solution that is used.
The procedure for gastric lavage is listed below:

 Instill the ordered solution

 Clamp the tube off to retain the ordered solution(s).

Promoting and Providing the

Continuity of Care in Illness
Management Activities
As previously discussed immediately above in the sections entitled "Educating the Client about
Managing Illnesses" and "Educating the Client Regarding an Acute or Chronic Condition and
Illnesses", as well as the section entitled "Continuity of Care" much earlier in this NCLEX RN
review, nurses facilitate, manage and coordinate the care of the client along the continuum of care in
a seamless, unfragmented, effective and efficient manner according to the client's ongoing and
changing needs.
Many continuity of care activities include the provision of patient and family education, follow up
care with the client's primary care doctor and any specialists that they may need, and other
community resources in terms of restorative and rehabilitation care such as a physical therapist, an
occupational therapist and/or a speech therapist, assistance such as Meals on Wheels, transportation
to and from medical care settings, and ongoing reassessments of the client to determine whether or
not the treatment goals and the client expected outcomes have been met.
Emergency care clients also need the support of the nurse in terms of promoting and providing the
continuity of care for relatively simple procedures such as casting a fractured extremity. The client
must be educated about the signs and symptoms of compartment syndrome which include intense
pain that cannot be relieved with raising the affected limb and/or the client's ordered analgesic
medications, burning pain, paresthesia, hypoesthesia, pulselessness, and cool and pale skin; and they
must also be educated about how to prevent compartment syndrome, how to identify the signs and
symptoms of compartment syndrome, and when to call their doctor in the community with these
and other symptoms.

Managing the Care of a Client with

Impaired Ventilation/Oxygenation
In addition to assessing the client's arterial blood gases and the client's symptoms of impaired
ventilation and oxygenation, there are other tests such as pulmonary function tests that provide data
related to the client's respiratory functioning.
The normal arterial blood gases are:

 Oxygen saturation (SaO2): 94 - 100%

 Partial pressure of oxygen (PaO2): 75 - 100 mmHg
 Partial pressure of carbon dioxide (PaCO2): 38 - 42 mmHg
 Bicarbonate - (HCO3): 22 - 28 mEq/L
 Arterial blood pH: 7.38 - 7.42

Pulmonary function tests, often done by a certified respiratory therapists or pulmonologist, consist
of an array of diagnostic tests and measurements including:

 Pulse oximetry: Pulse oximetery measures the oxygen saturation of arterial blood by using a
sensor on a client's finger or, when necessary, on their forehead, nose, or ear. In addition to the
 certified respiratory therapist's measuring pulse oximetry, this measurement is and can be
measured by nurses and specially trained unlicensed assistive personnel such as nursing
assistants at the bedside. The normal value for the oxygen saturation of arterial blood should be
from 94 to 100%.

 Spirometry: Some of the data that can be obtained with diagnostic spirometry testing include
tidal volume, forced vital capacity, non forced vital capacity, maximum inspiratory pressure,
maximum expiratory pressure, lung capacity, lung volumes other than residual lung volumes and
other measures of pulmonary functioning.

 Tidal Volume: Tidal volume is the volume of air in terms of mLs that is normally inhaled and
exhaled during the client's normal respiratory cycle including their inhalation and exhalation
without the any exertion on the part of the client and without any obstructive force. The normal
tidal volume of adults is typically about 500 mL and, mathematically, the normal can be
determined mathematically for non-adult clients by knowing that the normal tidal volume
should be 7 mLs per kilogram of body weight.

 Maximum Expiratory Pressure: Maximal expiratory pressure, or MEP, is impacted by the

client's strength of their accessory muscles of breathing during expiration, the strength of the
client's diaphragmatic muscles, the client's lung volume during occlusion, the length of time that
the airway is occluded, and the client's ventilatory drive and efforts. The MEP, like the
maximum inspiratory pressure, can normally decrease as the result of the aging process and it
can also vary according to gender. The normal maximum expiratory pressure is more than 95 cm
H2O among the members of the female population and more than 140 cm H2O for males.

 Maximum Inspiratory Pressure: Maximal inspiratory pressure, or MIP, which is also referred
to as negative inspiratory force, is similar to the MEP and it is the amout of pressure that the
client can exert against an occlusion. Again, the MIP can vary with age and gender. Those with
an MIP of less than – 20 cm H2O have moderate to severe respiratory problems. The lowest
acceptable limit for males is – 75 cm H2O and the lowest acceptable limit for females is – 50 cm
H2O. The client's maximal inspiratory pressure is a function of the client's strength of their
accessory muscles of respiration during inspiration, the strength of the client's diaphragmatic
muscles, the client's lung volume during occlusion, the length of time that the airway is
occluded, and the client's ventilatory drive and efforts.

 Lung Compliance: Pulmonary compliance or lung compliance is a function of the lung's

elasticity and the pulmonary volume. Pulmonary compliance is low when the lungs are stiff,
without their normal degree of elasticity and without good recoil; the lungs are somewhat stiff.
 Low lung compliance can affect clients of all ages with different respiratory disorders and
diseases. For example, the neonate may have low lung compliance because they do not have
sufficient lung surfactant or atelectasis, and pediatric as well as adult clients can have low lung
compliance because they are adversely affected with asthma, a pneumothorax, pulmonary
fibrosis, pneumonia, and edema, among other disorders. The normal lung compliance among
adults is approximately from 100 to 200 mL/c of water.

 Airway Resistance: Airway resistance measurements reflect the airways' resistance to and
opposition to the normal flow of air through the bronchopulmonary system.

 Forced Vital Capacity: Forced vital capacity reflects the measurement of the client's volume of
air that they can expel against resistance. Forced vital capacity reflects the strength of the client's
muscles of respiration.

 Forced Expiratory Volume: Also measured with spirometry, forced expiratory volume consists
of lung's ability to exhale forcibly for a one second.

 Diffusion Capacity: The normal level of DLCO, or diffusion capacity, is about 25

mL/min/mm Hg. The diffusion capacity is altered and decreased when the client is adversely
affected with chronic obstructive pulmonary disease and respiratory fibrosis and, in rare
situations, it can be increased with polycythemia and its abnormally high level of body
oxygenating red blood cells.

 I:E Ratio: The I:E ratio is the ratio of the client's duration of inspiration and the client's
duration of expiration. The normal I:E ratio is 1:2; this ratio becomes greater, such as 1:3, when
the client is affected with an air flow that is not sufficient or it is obstructed as is the case with
respiratory disorders such as asthma, chronic bronchitis, and emphysema. At times the client can
be symptomatic as the result of an abnormal I:E ratio and at other times the client can present
with Kussmaul's, Biot's and/or Cheyne-Stokes respiratory patterns.

 Minute Volume: Minute volume is the amount of air that the client exhales or inhales in one
minute, which is referred to as the expired minute volume and inhaled minute volume,
respectively.

 Expiratory Reserve Volume: Expiratory reserve volume is the greatest volume of air that can
be exhaled after the end expiratory phase of the client's respiratory cycle.

 Inspiratory Reserve Volume: Inspiratory reserve volume is the greatest volume of air that can
be inhaled at the end of the inspiratory phase of the client's respiratory cycle.
 Residual Volume: Residual volume is the volume of air that is left as residual in the lungs after
the client has exercised a forceful and maximal exhalation.

 Exercise Testing: The Exercise Induced Bronchoconstriction Test: The most commonly
employed forms of diagnostic cardiopulmonary exercise testing Include exercise induced
bronchoconstriction testing, full cardiopulmonary exercise testing and the Six Minute Walk test .
Exercise induced bronchoconstriction tests consist of measuring the forced expiratory volume
in one second (FEV1) and the forced vital capacity (FVC) prior to exercise, 5 minutes after the
client began to exercise and ½ hour after exercise on a treadmill while the pulse rate is 80% of
its predicted maximum rate. Bronchoconstriction is suspected when the results show a drop in
the FEV1 or the FVC of more than 15% during this test.

 Exercise Testing: Full Cardiopulmonary Exercise Testing: Full and complete cardiopulmonary
exercise testing is done to collect assessment data related to the person's air flow, cardiac rate,
arterial blood gases, oxygen consumption, and carbon dioxide production when the client is
resting as well as when they are exercising on a treadmill, as discussed immediately above. The
aim of this test is to determine and differentiate between the client's maximal exercise capacity
and their reduced exercise cardiopulmonary status.

 Exercise Testing: The Six-Minute Walk Test: This diagnostic test measures the ability of the
client to walk at their own rate for six minutes in terms of their respiratory data.

In addition to the nurse assessing the client's signs and symptoms of respiratory disorders, the nurse
also considers all of the pertinent respiratory data that are collected by others, as described above,
and then the nurse plans care and monitoring accordingly.
Depending on the medical diagnoses, the medical doctors' orders and the nursing diagnoses in
addition to the scopes of practice, roles and responsibilities of the other members of the health care
team such as the physicians, the physician assistants, the nurse practitioner, the certified respiratory
therapist and the nurse, complete care and follow up care of the client is provided by the health care
team.

Evaluating the Effectiveness of the

Treatment Regimen for a Client with
an Acute or Chronic Diagnosis
As with all other nursing care, nurses evaluate the effectiveness of the client's treatment regimen
when they have an acute or chronic diagnosis and health care problem. This evaluation, a phase of
the nursing process, measures whether or not the client is meeting the expected outcomes of the
care provided in terms of the client's achievement of their planned goals.

Medical Emergencies:
NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of medical emergencies in order to:

 Apply knowledge of pathophysiology when caring for a client experiencing a medical emergency
 Apply knowledge of nursing procedures and psychomotor skills when caring for a client
experiencing a medical emergency
 Explain emergency interventions to a client
 Notify primary health care provider about client unexpected response/emergency situation
 Perform emergency care procedures (e.g., cardio-pulmonary resuscitation, respiratory support,
automated external defibrillator)
 Provide emergency care for wound disruption (e.g., evisceration, dehiscence)
 Evaluate and document the client's response to emergency interventions (e.g., restoration of
breathing, pulse)

Applying a Knowledge of Client

Pathophysiology When Caring for a
Client Experiencing a Medical
Emergency
One of the most challenging things that nurses do is applying a knowledge of client pathophysiology
when a medical emergency occurs.
Life threatening emergencies focus on the here and now as the client's condition often changes in a
rapid and sometimes unpredictable manner. Of the many ways that nurses can somewhat predict the
possibility of a medical emergency is knowing all they can know about the client, their medical
history and their current physical status, understanding the pathophysiology of their current
condition or situation and applying this knowledge to the possible complications and adverse
responses to not only their health related problem but also to the treatments and procedures that
may be currently placing them in jeopardy for a medical emergency.
The nurse must readily identify and respond to all medical emergencies when they occur and they
must also be able to rapidly and knowledgably apply priority setting and critical thinking skills during
a time when needs, priorities and the client condition are rapidly changing. This is the time for short
term minute to minute simultaneous client care planning and interventions.
As previously discussed in the "Integrated Process: The Nursing Process" and the section entitled
"Setting and Establishing Client Priorities", priorities of care are established using a number of
methods and frameworks including the ABCs, Maslow's Hierarchy of Needs, and the ABCs
combined with the MAAUAR method of priority setting. The ABCs method of priority setting
identifies the airway, breathing and cardiovascular status of the patient as the highest of all priorities
in that sequential order; Maslow's Hierarchy of Needs identifies the physiological or biological
needs, including the ABCs, the safety/psychological/emotional needs, the need for love and
belonging, the needs for self-esteem and the esteem by others, and the self-actualization needs in
that order of priority from the highest priority to the lowest priority; and the ABCs / MAAUAR
method of priority setting places the ABCs, again, as the highest and greatest priorities which is then
followed with the 2nd and 3rd priority level needs of the MAAUAR method of priority setting, as
previously detailed in the previous section of this NCLEX RN review.

Applying a Knowledge of Nursing

Procedures and Psychomotor Skills
When Caring for a Client
Experiencing a Medical Emergency
Cardiopulmonary arrest is the sudden loss of cardiac function, the cessation of breathing and the
client's complete loss of consciousness, as the result of a significant disturbance of the heart'
electrical impulses, such as ventricular tachycardia and asystole, as discussed previously in the
sections entitled "Hemodynamics: Identifying Cardiac Rhythm Abnormalities" and "Intervening to
Improve the Client's Cardiovascular Status".
The immediate treatment for sudden cardiac arrest is cardiopulmonary resuscitation (CPR) and
defibrillation, as indicated by the client's condition.
Airway obstructions can be partial or complete. A complete airway obstruction is signalled with the
lack of any cough or other noises from the patient. The airway must be opened using the techniques
you have learned when you took your Basic Life Support course. Intubation, when necessary, is also
done.
A partial airway obstruction can be determined by listening to the patient's cough and other
respiratory noises. A cough that is not efficient indicates a more severe airway obstruction than a
cough that is effective in terms of clearing the airway of secretions and/or foreign bodies. The
patient who is coughing should be encouraged and prompted to continue to cough. Visible foreign
bodies that can be removed and should only be removed if there is no chance of pushing the foreign
body further into the airway.
The look, listen and feel assessment for breathing to determine whether or not the patient is
spontaneously breathing on their own includes looking at the chest to see if it rises and falls,
listening for any breath sounds from the nose or mouth, and feeling the chest and upper abdomen
to see if there is any movement present. Rescue breathing is done when the patient is not breathing
and the airway is open.
Chest compressions are done, as you learned in your Basic Life Support course, on all patients who
are unconscious, unresponsive, not breathing and pulse less.
Defibrillation gives an electric shock to the heart. There are standard external defibrillators which are
typically found in hospitals and other healthcare facilities and used by nurses, transvenous
defibrillators, implantable cardioverter defibrillators, and automated external defibrillators.
Automated external defibrillations are most often found in the community and outside of healthcare
facilities. Automated external defibrillations are simple to use and there is no need to be able to
recognize cardiac arrhythmias or interpret cardiac rhythm strips. Automated external defibrillations
are intended to be used by the general public without any healthcare or nursing knowledge of
experience.
The steps for using an automated external defibrillation is turn the machine on, put the pads on the
patient's chest as shown on the machine, and then listen to and follow the automated instructions of
the automated external defibrillation.
In addition to the most severe of all medical emergencies, there are many other conditions that can
lead to a life threatening medical emergency and these conditions can be classified as:

 Cardiovascular system medical emergencies

 Gastrointestinal medical emergencies
 Respiratory medical emergencies
 Renal medical emergencies
 Central and peripheral nervous system medical emergencies
 Musculoskeletal system medical emergencies
 Obstetrical and gynecological medical emergencies
 Medical emergencies affecting the ear, nose and eyes
 Medical emergencies affecting the mouth and dental structures

The immediate medical care and interventions, in addition to the correction of any underlying
disorder or condition and emergency cardiopulmonary resuscitation, for a number of cardiovascular
emergencies, in addition to the previously discussed cardiac arrest, include the following:

Heart Failure
Brief Description: Heart failure occurs when the heart can no longer pump the ample amount of
oxygenated blood that the body needs and demands to sustain life and to maintain the necessary
bodily functions. Although left sided heart failure and left ventricular malfunctioning is more
common than right sided heart failure and right ventricular malfunctioning, heart failure can be both
right sided and left sided.
Signs and Symptoms: The signs and symptoms associated with heart failure include tachycardia,
hypotension, lethargy, an intolerance of activity, dyspnea, related anxiety, the retention of excessive
bodily fluid and skin pallor.
Interventions and Treatments: ACE inhibitors, angiotensin II receptor antagonists, beta blockers,
diuretics, a sodium restricted diet, an implanted cardioverter and or pacemaker and a physician
approved exercise regimen may be indicated for the client, as based on their current cardiac status.
Complications: Virtually, all bodily systems and tissues can be jeopardized and compromised with
heart failure; these systems and tissues can include the renal system, the client's hemodynamic
stability, and the pulmonary system. Respiratory and cardiac arrest can occur when treatment is not
successfully rendered to the affected client.

Cardiac Tamponade
Brief Description: Cardiac tamponade causes the heart to not fill, contract and pump in the normal
manner because an abnormal accumulation of fluid is present in the pericardial sac around the heart.
Signs and Symptoms: The signs and symptoms of cardiac tamponade include high central venous
pressure, scant urinary output, severe hypotension, impaired peripheral perfusion, impaired
peripheral pulses, narrowing of the pulse pressure, tachycardia, tachypnea, dyspnea, a loss of
consciousness, and jugular vein distention.
Interventions and Treatments: Emergency measures to correct hypotension, oxygen
supplementation, and a pericardiocentesis may be indicated for the client.
Complications: Cardiac arrest.

Hypertensive Crisis
Brief Description: Hypertensive crisis is a sudden, significant rise in the client's blood pressure that
typically occurs unpredictably and without warning.
Signs and Symptoms: The signs and symptoms can include chest pain, the signs and symptoms of
heart failure and/or a myocardial infarction, an altered level of consciousness, headache,
cardiovascular compromise, oliguria, renal compromise, and renal failure.
Interventions and Treatments: Immediate treatment with emergency intravenous antihypertensive
medications such as nitroprusside in combination with an ACE inhibitor or a beta blocker which
should decrease the blood pressure by about 30 percent in one half an hour.
Complications: Renal failure, myocardial infarction, heart failure, and cardiac arrest.

Superior Vena Cava Syndrome

Brief Description: Superior vena cava syndrome is the compression of the vena cava which prevents
the normal return of the body's circulating blood to the heart.
Signs and Symptoms: Tachypnea, dyspnea, venous stasis, a loss of consciousness, edema, seizures,
respiratory and/or cardiac arrest.
Interventions and Treatments: Mechanical ventilation, oxygen supplementation, and seizure
precautions.
Complications: Respiratory arrest and cardiac arrest

Septic Shock
Brief Description: Massive systemic infection that leads to massive vasodilation throughout the
entire body
Signs and Symptoms: Massive hypotension, adventitious breath sounds, decrease cardiac output,
microemboli, peripheral vasoconstriction, a widened pulse pressure, metabolic acidosis and
respiratory alkalosis
Interventions and Treatments: Fluid replacement, mechanical ventilation, oxygen supplementation,
treatment of the underlying cause, the correction of metabolic acidosis and respiratory alkalosis, and
at times, dialysis
Complications: Multisystem failure and death.

Hypovolemic Shock
Brief Description: The depletion of bodily fluids secondary to a number of different causes such as
hemorrhage and severe dehydration
Signs and Symptoms: Decreased cardiac output, progressive and severe dehydration, and metabolic
acidosis
Interventions and Treatments: Fluid replacement with lactated Ringers, blood, blood components
and plasma expanders, and placing the client in the Trendelenburg position.
Complications: Multisystem failure and shutdown.

Acute Coronary Syndrome

Brief Description: A sudden, abrupt and serious reduction of the circulation to the heart
Signs and Symptoms: The signs and symptoms of acute coronary syndrome are similar to those of a
myocardial infarction and they can include referred pain, chest pain, angina pain, dyspnea,
diaphoresis, and nausea and vomiting.
Interventions and Treatments: The administration of nitroglycerin, angiotensin-converting enzymes,
(ACE) inhibitors, angiotensin receptor blockers beta-blockers, calcium channel blockers, aspirin,
thrombolytics, statin therapy drugs, and anticoagulant medications, surgical interventions such as a
stent, coronary bypass surgery or angioplasty, particularly when the client has an acute ST-segment
elevation MI (STEMI), may be indicated as based on the client's physical staus and compromise.
Complications: Myocardial infarction and death

Myocardial Infarction
Brief Description: Ischemia of the heart muscle secondary to the lack of oxygenated blood flow
through the coronary arteries.
Signs and Symptoms: Some are "silent" and asymptomatic; others can present intermittent or
constant diaphoresis, severe chest pain, shortness of breath, nausea and vomiting.
Interventions and Treatments: Oxygen supplementation, unfractionated heparin, intravenous fluids,
nitroglycerin, pain management, aspirin, clopidogrel, anticoagulant therapy; and, at times, a
percutaneous coronary intervention or a coronary artery bypass graft is indicated.
Complications: Life threatening cardiac arrhythmias, cerebrovascular accidents, emboli formation,
and a weakened heart muscle.

Aneurysm Dissection and Rupture

Brief Description: Bulging of an artery that can lead to rupture and hemorrhage, particularly those
aneurysms that are affecting the aorta which is the major artery in the body.
Signs and Symptoms: Asymptomatic until it dissects or ruptures and then it leads to massive
hemorrhage and hypovolemic shock with the signs and symptoms described above for hypovolemic
shock in addition to abdominal pain, tachycardia, clammy skin, nausea and vomiting when the
abdominal aorta is affected. Thoracic aorta rupture and dissections can present with symptoms that
can include shortness of breath, dysphagia, dyspnea, coughing, and pain in the chest, arms, jaw,
neck, and/or back.
Interventions and Treatments: Endovascular repair of the aneurysm or an open abdominal repair,
antihypertensive medications when there is a rupture and antihypertensive medications to prevent a
rupture from occurring.

Deep Vein Thrombosis

Brief Description: Embolus formation
Signs and Symptoms: Can be asymptomatic or symptomatic. Some of the symptoms can include
redness and discoloration of the skin proximate to the site of the thrombosis, pain, tenderness,
swelling and warm skin at the site.
Interventions and Treatments: Interventions vary from the application of heat, the application of
compression hose or a sequential compression device, the elevation of the affected extremity, the
administration of anti-inflammatory NSAIDs, anticoagulants, thrombin inhibitors, and
thrombolytics. At times a vena cava filter is surgically implanted.
Complications: Pulmonary embolus and death.
Cardiogenic Shock
Brief Description: The lack of adequate cardiac functioning that impedes sufficient cardiac output
and systemic circulation as the result of some major ventricular malfunctioning and myocardial
muscle damage
Signs and Symptoms: The signs and symptoms of cerebral and/or cardiac perfusion, tachycardia, a
thready pulse, hypotension, tacypnea, chest pain, diaphoresis, cool and/or pale skin, confusion,
agitation, shortness of breath, oliguria, anuria, and changes in the client's level of consciousness.
Interventions and Treatments: Medications such as dopamine, epinephrine, norepinephrine, and
dobutamine can be administered to increase the client's blood pressure and cardiac output, oxygen
supplementation, a temporary emergency pacemaker, pain relief, defibrillation, cardioversion and
surgical procedures such as angioplasty, a coronary artery bypass, the implantation of a permanent
pacemaker, as well as cardiopulmonary resuscitation and ACLS protocols as indicated.
Complications: Cardiac arrest, renal, cerebral and/or hepatic damage and failure, deadly cardiac
arrhythmias and death.

Anaphylactic Shock
Brief Description: Massive, systemic circulation collapse and relaxation secondary to the body's
impaired immune response to an allergen such as occurs with an allergic response to a drug such as
penicillin, a food or an insect bite, for example
Signs and Symptoms: Severe and significant hypotension, laryngeal edema, respiratory distress, a
lowered cardiac output, venous pooling and venous stasis, tachycardia, and a bounding pulse
Interventions and Treatments: If the cause of the anaphylaxis is an IV antibiotic the IV must be
immediately removed. The immediate injection of epinephrine, rRespiratory support,
cardiopulmonary resuscitation, and ACLS protocols as indicated.
Complications: Respiratory and cardiac arrest

Neurogenic Shock
Brief Description: The massive relaxation and collapse of the venules and arterioles of the
circulatory system which most often occurs as the result of a spinal cord injury, including but not
limited to, a traumatic spinal injury or one that results from the administration of spinal anesthesia
Signs and Symptoms: Fainting, syncope, hypotension and bradycardia
Interventions and Treatments: Medications to stimulate the sympathetic nervous system such as
metarminol or atropine
Complications: Massive circulatory collapse and death

Obstructive Shock
Brief Description: A sudden obstruction of circulatory flow to the heart that occurs with the
obstruction of a major vessel which can occur secondary to such disorders as cardiac tamponade, an
embolus, aortic stenosis, and a pneumothorax
Signs and Symptoms: Hypotension, clammy, cool and pale skin, tachycardia, a thready pulse,
hypothermia, distended neck veins, a change in the level of consciousness, shallow respirations, oral
dryness, confusion, restlessness, anxiety, and cyanosis
Interventions and Treatments: The treatment of the underlying cause with a pericardiocentesis for
cardiac tamponade or chest tube insertion and drainage for a pneumothorax, for example, in
addition to fluid replacements and the management of the complications, signs and symptoms such
as hypothermia and respiratory support for respiratory compromise.
Complications: Multisystem organ failure and death

Disseminated Intravascular Coagulation

Brief Description: Disseminated intravascular coagulation (DIC) is an acquired clotting factor
abnormality that always occurs as the result of an underlying disorder or disease and not as a primary
disorder
Signs and Symptoms: Blood clotting, hemorrhage, peripheral thrombosis, peripheral cyanosis,
hypotension, hypothermia, tachycardia, hypoxia, cyanosis, acidosis, changes in terms of the client's
level of consciousness, headaches, and affective behavioral changes
Interventions and Treatments: Fluid replacement, the administration of human activated protein C,
blood and blood products such as fresh frozen plasma, packed red blood cells, and clotting factors
and intravenous fluids.
Complications: Severely impaired organ perfusion, multisystem failure and death.
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of gastrointestinal medical emergencies include the
following.

Intussusception
Brief Description: The loss of perfusion to an area of the intestine because the affected part of the
intestine slides into another part of the intestine near the affected area
Signs and Symptoms: Knee to chest posturing, abdominal pain, bloody stool, fever, constipation,
vomiting and diarrhea.
Interventions and Treatments: Decompression of the bowel with a nasogastric tube to suction,
intravenous fluid replacements, and a surgical repair of the affected part of the intestine
Complications: Peritonitis, sepsis, shock and death when left untreated

Appendicitis
Brief Description: An acute infection and inflammation of the appendix which is attached to the
cecum of the gastrointestinal tract.
Signs and Symptoms: Constant or intermittent classical McBurney's point pain in the lower right
quadrant of the abdomen, a tense and rigid abdomen, rebound tenderness, a temperature, projectile
vomiting, anorexia, malaise, lethargy and nausea
Interventions and Treatments: Antibiotics and an emergency appendectomy
Complications: A ruptured appendix, gangrene, peritonitis, sepsis, and death

Peritonitis
Brief Description: A massive inflammation and infection of the peritoneum which can result from a
number of causes such as a perforated gastrointestinal ulcer and a ruptured appendix when the
gastrointestinal contents, including E coli, enter the peritoneal space
Signs and Symptoms: The presence of severe and the abrupt onset of abdominal pain accompanied
with abdominal guarding, rebound tenderness, decreased or absent bowel sounds, nausea and
vomiting, abdominal distention, a fever, malaise, tachypnea, tachycardia, oliguria, anuria, and the
other signs and symptoms of shock.
Interventions and Treatments: Pain management, the administration of antibiotics, intestinal
decompression, and emergency surgical interventions to correct the underlying cause
Complications: Massive sepsis, shock and death

Gastrointestinal Hemorrhage
Brief Description: Massive bleeding in the gastrointestinal tract; this bleeding can originate at any
point of the upper gastrointestinal tract and the lower gastrointestinal tract.
Signs and Symptoms: Changes in the color of the stools that can vary from a black and tarry looking
stool, to a burgundy color stool, to a coffee grounds color stool, to a bright red stool with or
without evidence of blood clots depending on the section of the gastrointestinal tract that is
adversely affected. Some of the other signs and symptoms can be vomiting, hypotension, vomiting
blood, skin pallor, weakness, shortness of breath and the signs and symptoms of hypovolemic
shock, as previously discussed in this section of the NCLEX RN review.
Interventions and Treatments: Gastric lavage and suctioning, the administration of blood and blood
products, intravenous fluid replacement and medications to support the client's cardiovascular
functioning
Complications: Hypovolemic shock and death

Esophageal Varices
Brief Description: The pathophysiological enlargement of the veins of the lower esophagus that
most often result from hepatic failure and portal hypertension
Signs and Symptoms: They are asymptomatic until they rupture and lead to hemorrhage, shock,
vomiting of bright red blood and black stools
Interventions and Treatments: The administration of medications to decrease the portal
hypertension, surgical interventions such as banding off the bleeding vessels, and measures to
correct the hypovolemic shock if it has occurred as the result of this medical emergency.
Complications: Hypovolemic shock and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of respiratory medical emergencies include the following:

Obstructions of the Respiratory Tract

Brief Description: A partial or complete obstruction and closure of the respiratory tract can occur
secondary to a number of different causes including aspiration of a foreign body or a bodily
substance such as respiratory secretions and vomitus, chemical inhalation and ingestion, anaphylactic
reactions, pneumonia, croup, an abscess, a tumor and epiglottitis, among other causes
Signs and Symptoms: A partial airway or respiratory tract obstruction is accompanied with coughing,
panic, restlessness, anxiety, air hunger, wheezing and other unusual respiratory sounds; and complete
airway obstructions are characterized with apnea, cyanosis, the loss of consciousness, and cyanosis in
addition to the other signs and symptoms associated with hypoxia.
Interventions and Treatments: The Heimlich maneuver, the removal of the source of the
obstruction, oxygen administration, the placement of an endotracheal or nasotracheal tube and
mechanical ventilation when the condition is severe and otherwise not corrected.
Complications: Aspiration pneumonia, respiratory distress and respiratory arrest and death.

Chronic Obstructive Pulmonary Disease

Brief Description: Chronic obstructive pulmonary disease, which consists of chronic bronchitis and
emphysema, entails the thickening of the mucus production and the lung lining, and the loss of
elasticity and thickening of the alveoli, respectively.
Signs and Symptoms: These physiological changes lead to respiratory difficulty, hypoxia, cyanosis
and other symptoms associated with impaired oxygen and gas exchanges in the lungs.
Interventions and Treatments: Emergency treatments and interventions include oxygen
supplementation, corticosteroid administration, the administration of an anticholinergic drug and a
B2 agonist medication, intubation and mechanical ventilation when indicated
Complications: Hypoxia, respiratory arrest and death.

Aspiration
Brief Description: The abnormal entry of bodily fluids, food or another foreign body into the
respiratory tract.
Signs and Symptoms: Coughing, chocking, and the signs and symptoms of a respiratory obstruction,
as discussed above.
Interventions and Treatments: Correction of the obstruction, prophylactic antibiotic therapy to
prevent aspiration pneumonia, oxygen supplementation, intubation and mechanical ventilation
Complications: Aspiration pneumonia, airway obstruction, respiratory distress, respiratory arrest and
death

Inhalation Lung Injuries

Brief Description: Injuries that occur from the inhalation of toxic substances as occurs from
household cleaning products and dangerous combinations of the same, ammonia, smoke, chlorine
and acts of terror.
Signs and Symptoms: The signs and symptoms differ according to the substance and they can
include respiratory distress, dyspnea, airway obstruction, bronchospasm, pulmonary edema, and
hemorrhage when the inhaled agent is corrosive.
Interventions and Treatments: Oxygen supplementation, corticosteroids, bronchodilators, and
mechanical ventilator support when indicated
Complications: Lung scar tissue formation, respiratory arrest and death

Pleural Effusion
Brief Description: The abnormal collection of fluid around the lung(s) in the pleural space as the
result of an abnormal decrease in the absorption of this fluid and/or the overproduction of this fluid
Signs and Symptoms: Shortness of breath, dyspnea, coughing, chest pain and a possible fever
Interventions and Treatments: In addition to treating any underlying causes, the emergency
interventions for this potentially life threatening disorder include supplemental oxygen, a
thoracentesis, chest tube placement and drainage, and other measures to correct any of the signs and
symptoms
Complications: Respiratory distress, respiratory failure and respiratory arrest which can lead to death
when this medical emergency is not promptly and effectively treated.

Pneumothorax
Brief Description: The complete or partial collapse of the lung because air has entered the pleural
space and created positive pressure on the lung and eliminated the normal negative pressure of the
pleural space which is necessary for the expansion of the lung during the respiratory cycle.
Signs and Symptoms: An increase in the work of breathing, shortness of breath, dyspnea, the use of
the accessory muscles of breathing, hypoxia, tachycardia, tachypnea, hypotension, chest pain, the
shifting of the trachea and the mediastinum to the side opposite of the tension pneumothorax,
hyperextension of the chest, and circulatory collapse
Interventions and Treatments: The insertion of and maintenance of a chest tube to drainage, the
aspiration of the abnormal air collection in the pleural space, a surgical repair of the injured lung
area, and respiratory support such as oxygen supplementation
Complications: Respiratory distress, hypoxia and respiratory arrest

Acute Respiratory Distress Syndrome

Brief Description: The sudden onset of life threatening respiratory distress and hypoxia that can
result from a number of causes such as sepsis, trauma, chemical inhalation, aspiration and
pneumonia.
Signs and Symptoms: An increase in the work of breathing, dyspnea, shortness of breath,
adventitious breath sounds, fatigue, cyanosis, tachypnea, hypotension, hypoxia, and hypotension.
Interventions and Treatments: Intubation, mechanical ventilation, oxygen supplementation, and the
treatment of the underlying cause
Complications: Respiratory distress, hypoxia, multisystem failure and respiratory arrest

Atelectasis
Brief Description: The collapse of the lung as the result of one of many causes such as aspiration,
the poor placement of an endotracheal tube, pleural effusion and a pneumothorax
Signs and Symptoms: Decreased lung volumes, chest pain, dyspnea and the signs and symptoms of
hypoxia when severe
Interventions and Treatments: Coughing, deep breathing and any respiratory support that is
indicated by the severity of the atelectasis
Complications: Respiratory distress, hypoxia, multisystem failure and respiratory arrest

Flail Chest
Brief Description: An instability of the chest wall and a decrease in the expansion of the chest wall
as the result of some trauma such as fractured ribs
Signs and Symptoms: Evidence of chest trauma, palpable rib fractures, the presence of subcutaneous
air at the site of the injury, inspiratory chest wall retraction, and paradoxical chest wall movement.
Interventions and Treatments: Pain management, gentle pressure over the affected area, fixation of
the fractured ribs, oxygen supplementation, chest tube insertion to prevent a pneumothorax, and
mechanical ventilation when indicated
Complications: Pneumothorax, pneumonia, respiratory distress, respiratory failure, hypoxia and
death

Hemothorax
Brief Description: The complete or partial collapse of the lung because blood has entered the pleural
space and created positive pressure on the lung and eliminated the normal negative pressure of the
pleural space which is necessary for the expansion of the lung during the respiratory cycle
Signs and Symptoms: The same signs and symptoms as discussed immediately above under
"Pneumothorax"
Interventions and Treatments: The interventions and treatments as discussed immediately above
under "Pneumothorax"
Complications: The same complications as discussed immediately above under "Pneumothorax"

Respiratory Syncytial Virus (RSV)

Brief Description: A highly infectious communicable upper respiratory infection that commonly
causes bronchiolitis
Signs and Symptoms: Thick mucus production, the accumulation of excessive respiratory secretions
in the bronchioles, wheezing, tachypnea, cyanosis, coughing, respiratory stridor, listlessness,
pharyngitis, hypercapnia and episodes of apnea
Interventions and Treatments: Symptomatic and supportive care, intravenous fluid replacements,
supplemental oxygen administration, and other respiratory interventions, such as intubation and
mechanical ventilation, when it is indicated
Complications: Respiratory failure and respiratory arrest

Fat Emboli
Brief Description: The entry and presence of fat globule emboli from the marrow of the bone into
the circulatory system. This life threatening emergency can occur as the result of a skeletal fracture,
severe burns, blunt trauma to the liver and some severe infections.
Signs and Symptoms: Restlessness, a headache, a decreased level of consciousness and/or cognition,
seizures, dilation of the pupils, pulmonary infiltration, hypoxia, right sided heart failure, a petechial
rash, venous and capillary stasis, a low hematocrit level, fever, tachycardia, diminished urinary
output, anuria, and evidence of fat globules in the urine.
Interventions and Treatments: Symptomatic and supportive care including supplemental oxygen
administration, and other respiratory interventions, such as intubation and mechanical ventilation,
when it is indicated

Pulmonary Emboli
Brief Description: The formation of and the travelling of an embolus into the lungs.
Signs and Symptoms: Increased work of breathing, shortness of breath, tachypnea, tachycardia,
hypoxia, cyanosis, dyspnea, chest pain, coughing, anxiety and panic.
Interventions and Treatments: Respiratory support, the administration of streptokinase or a tissue
plasminogen activator, anticoagulation therapy and oxygen supplementation are often indicated
Complications: Respiratory distress, respiratory arrest and death

Pulmonary Edema
Brief Description: The filling of the alveoli with fluid that leads to the poor gas exchanges of oxygen
and carbon dioxide
Signs and Symptoms: Adventitious breath sounds, fatigue, cyanosis, dyspnea, shortness of breath,
tachypnea and hypoxia
Interventions and Treatments: The administration of diuretics, suctioning, intubation, oxygen
supplementation and mechanical ventilation as indicated by the client's respiratory status
Complications: Respiratory distress, severe hypoxia, respiratory arrest and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of renal medical emergencies include the following:

Renal Calculi
Brief Description: Renal calculi, often referred to as kidney stones, are small, hard mineral and acidic
salt deposits that abnormally form in the kidney
Signs and Symptoms: Asymptomatic until these calculi begin to move into the ureter at which time
the presenting signs and symptoms can include intermittent or constant and severe pain located in
the side and back below their ribs, pain spreading to the lower abdomen and groin, dysuria, pink,
red, or brown urine, cloudy, foul smelling urine, urinary frequency, urinary urgency, nausea,
vomiting and the signs of infection such as a temperature and chills when this medical emergency is
accompanied with an infection.
Interventions and Treatments: Increased oral fluid intake, pain management, the administration of
an alpha blocker, extracorporeal shock wave lithotripsy, and a surgical percutaneous
nephrolithotomy
Complications: Hemorrhage, chronic urinary tract infections, renal damage and renal failure

Pyelonephritis
Brief Description: Pyelonephritis is a kidney infection that originates in the urethra or bladder and
then spreads to the kidneys. Immediate medical attention is required, and if not treated or not
treated effectively, this infection can permanently damage renal function and sepsis can occur.
Signs and Symptoms: Upper back and flank pain, a high fever, urinary frequency, urinary urgency,
chills, nausea, vomiting, pus in the urine, hematuria, and burning while urinating.
Interventions and Treatments: The administration of antimicrobial therapy, often coupled with the
need for hospitalization and intravenous antibiotic therapy
Complications: Renal damage, massive sepsis, shock and renal failure
Renal Failure: Acute and Chronic
Brief Description: Renal failure can be acute or chronic. Acute renal failure can be possibly result
from a number of different causes including poor renal perfusion, infection, poisoning, hemorrhage,
dehydration, obstructions, hypertension, and some medications like gentamicin, streptomycin,
naproxen and ACE inhibitors
Signs and Symptoms: Nausea, vomiting, confusion, oliguria, anuria, edema, anorexia, anxiety and
flank pain
Interventions and Treatments: Hemodialysis, peritoneal dialysis, kidney transplantation, fluid
restrictions, and the administration of medication such as phosphate binders, ferrous sulfate for the
treatment of anemia, erythropoietin, and blood transfusions when indicated.
Complications: Renal shutdown and death

Sickle Cell Anemia Crisis

Brief Description: Sickle cell anemia, an autosomal recessive genetic disorder, can lead to the
hemolysis and rupture of the abnormally sickled red blood cells which in turn adversely affects the
haemoglobin and all bodily systems during sickle cell anemia crisis.
Signs and Symptoms: Splenic sequestration, anemia, cardiac and pulmonary system damage, pain,
extreme fatigue, leg ulcerations, ocular damage, bone infarcts and aseptic necrosis, hand and feet
swelling which is referred to as dactylitis
Interventions and Treatments: Symptomatic treatment with analgesics, fluids, rest, oxygen
supplementation, the administration of hyroxyurea to stimulate the production of haemoglobin and
the administration of blood and blood components.
Complications: Multisystem failure and shutdown which can lead to death with inadequate treatment
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of central and peripheral nervous system medical
emergencies include the following.

Cerebrovascular Accidents
Brief Description: An insult to the brain that can lead to permanent disability and even death.
Cerebrovascular accidents, also referred to as strokes, can result from ischemia secondary to
atherosclerosis, vasculitis, emboli, cerebral hypoperfusion and also as the result of a cerebral
hemorrhage secondary to hypertension, a brain tumor, a ruptured cerebral aneurysm, and cerebral
vascular abnormalities.
Signs and Symptoms: The signs and symptoms of a cerebrovascular accident vary according to the
severity of the cerebrovascular accident and the region of the brain that is adversely affected with
the cerebrovascular accident. Dysphagia, impaired vision, personality changes, unilateral neglect and
impaired urinary elimination can occur as the result of a cerebrovascular accident that adversely
affects the anterior region of the brain; and ataxia, vertigo, nystagmus, diplopia, visual disturbances,
and bilateral or unilateral sensory and motor deficits can occur as the result of a cerebrovascular
accidents that adversely affect the anterior region of the brain; and, brain stem cerebrovascular
accidents are usually accompanied with altered level of consciousness, severe respiratory
compromise, hypoxia, and respiratory arrest.
Interventions and Treatments: Complications are prevented with the administration of thrombolytic
medications within 3 or 4 hours after the symptoms appear when the client has had a thrombolytic
stroke, oxygen supplementation, the control of hypertension with antihypertensive drugs,
anticonvulsant medications such as phenytoin, intubation, and possible mechanical ventilation when
the client indicates the need for these treatments
Complications: Seizures, increased intracranial pressure, post ischemic inflammatory encephalitis and
death.

Guillain Barré Syndrome

Brief Description: Guillain Barré syndrome is an acquired inflammatory condition which most often
occurs as the result of campylobacter jejuni infection; this life threatening disorder leads to
peripheral nerve demyelination.
Signs and Symptoms: The signs and symptoms of Guillain Barré syndrome are pain, paresthesia,
numbness, diaphoresis, the lack of the autonomic nervous system's sweating reflex, bilateral and
ascending paralysis, absent deep tendon reflexes, high levels of protein in the cerebrospinal fluid, as
well as blood pressure and heart rate changes.
Interventions and Treatments: The prevention of respiratory failure and respiratory arrest, the
ABCs, ACLS protocols, intubation, oxygen supplementation, mechanical ventilation and long term
restorative and rehabilitative care are often indicated.
Complications: Respiratory distress, respiratory arrest, coma and death.

Meningitis
Brief Description: This life threatening infection leads to the inflammation of the pia layers of the
meninges and the cerebrospinal fluid. There are a number of pathogens that can cause meningitis
including viruses, fungi and bacteria such as neisseria meningitis, haemophilius influenzae,
streptococcus pneumoniae, group B streptococcus, and gram negative pathogens such as
Escherichia coli, serratia and enterobacter
Signs and Symptoms: Classical nuchal rigidity, a decrease in terms of the clients mental status, a
positive Brudzinski sign, a positive Kernig's sign, a fever, headache, a purpural or petechial skin rash,
arching of the back and neck, seizures, photophobia, and bulging fontanels when an infant is
affected with meningitis prior to the closing of these fontanels.
Interventions and Treatments: Seizure precautions, the frequent monitoring of the client's
neurological signs, maintaining a quiet environment, medications such as antipyretics, antibiotics and
intravenous fluids as ordered and the close monitoring of the client's neurological and vital signs.
Complications: Permanent and irreversible cerebral damage and death
Encephalitis
Brief Description: Encephalitis, which is somewhat similar to meningitis, is an inflammation of
cerebral tissue as the result of a virus such as the West Nile virus, herpes simplex, and toxoplasma
and, at times, as the result of post ischemic inflammatory encephalitis after a cerebrovascular
accident.
Signs and Symptoms: Nausea, vomiting, fever, headache, altered neurological functioning, motor
weakness, disorientation, seizures and unusual behavioral changes.
Interventions and Treatments: Seizure precautions, the frequent monitoring of the client's
neurological signs, maintaining a quiet environment, bed rest, increased fluid intake, medications
such as antipyretics and antiviral drugs such as ganciclovir, foscarnet and acyclovir, intravenous fluid
replacements as ordered and monitoring of the client's vital signs.
Complications: Long lasting or permanent changes in terms of the client's personality, muscular
weakness, a lack of fine and/or gross motor coordination, paralysis, fatigue, impaired memory,
impaired hearing, visual deficits, impaired speech, coma and death.

Brain Herniation
Brief Description: The abnormal protrusion and herniation of the brain stem through the foramen
magnum at the base of the skull; this life threatening emergency is typically the result of increased
intracranial pressure which was fully described and discussed in the previous section entitled
"Assisting the Client in Receiving Appropriate End of Life Physical Symptom Management".
Signs and Symptoms: Cushing's reflex, Cheyne Stokes respirations, decorticate or decerebrate
posturing, hypoxia, apnea, and respiratory failure.
Interventions and Treatments: The preservation of life if this is possible, the administration of
anticonvulsant medications to prevent seizure activity, intravenous osmotic diuretics, like mannitol,
to decrease the increased intracranial pressure, corticosteroids to decrease cerebral edema,
anticonvulsant medications to prevent seizures, a planned barbiturate come to decrease the client's
metabolic demands, intubation and mechanical ventilation as indicated
Complications: Permanent brain damage, seizures, coma, respiratory arrest and death.

Traumatic Head Injury

Brief Description: A traumatic injury to the skull and brain. A primary brain injury is one that occurs
immediately after a trauma; the physical movement and displacement of the anatomical structures of
the brain, contusions, vascular damage and widespread axonal shearing and tearing of the axons of
the cerebral neurons occur and the damage is done immediately upon impact. Secondary traumatic
brain injuries, unlike primary brain injuries, is not due to any type of traumatic physical or
mechanical force, but instead, it occurs gradually and progressively over a period of time and not
immediately after a trauma.
Signs and Symptoms: The signs and symptoms of a traumatic closed head injury include increased
intracranial pressure, cerebral swelling and movement, cerebral ischemia, cerebral hypoxia, and
impaired respiratory functioning in addition to hypotension, acidosis, hypocapnea, pupil dilation,
decerebrate or decorticate posturing, seizures, and major changes in terms of the client's level of
consciousness and awareness.
Interventions and Treatments: Treatments include medications such as mannitol which is a cerebral
osmotic diuretic that decreases the fluid buildup, anticonvulsant medications to decrease the risk of
seizure activity, the relief of cerebral edema using corticosteroids, oxygenation, mechanical
ventilation, intravenous fluid replacement, blood pressure maintenance and the correction of any
accompanying signs and symptoms in order to sustain life.
Complications: Increased intracranial pressure, permanent life altering brain damage, seizures, coma
and death

Subarachnoid Hemorrhage
Brief Description: Hemorrhage and bleeding in the subarachnoid space which is the space between
the brain and the meninges which are the thin tissues surrounding and covering the brain. This
medical emergency occurs as the result of head trauma, a serious bleeding disorder and a bleeding
cerebral aneurysm.
Signs and Symptoms: This medical emergency can be asymptomatic as well as symptomatic and
presenting with signs and symptoms such as a severe, crushing headache which is often referred to
as a thunder clap headache, a sensation of popping in the head, a decreased level of consciousness,
nausea, vomiting, photophobia, a postcoital headache, confusion, irritability, numbness, a stiff neck
and/or back, visual changes such as the development of blind spots, double vision and/or the loss
of vision in one eye, seizures, muscular pain, unequal pupils, and drooped eyelids.
Interventions and Treatments: Bed rest, constipation prevention, the control of hypertension, the
administration of nimodipine to prevent vasospasm, and the correction of the underlying cause such
as the treatment of an aneurysm with a bypass, clip or endovascular coils.
Complications: Chemical meningitis, hydrocephalus, brain edema, vasospasm, coma and death.

Epidural Hematoma
Brief Description: A hematoma and bleeding into the region of the skull between the skull and the
brain and into the dura mater. This emergency medical crisis is usually caused by head trauma and
skull fractures.
Signs and Symptoms: Loss of consciousness, confusion, unilateral pupil dilation, a severe and
crushing headache, nausea, vomiting, seizures, and lethargy
Interventions and Treatments: All interventions to preserve life, to prevent possible complications
and to control the symptoms. Some interventions can include Burr holes in the skull to decrease the
intracranial pressure, a craniotomy, the administration of anticonvulsant medications such as
phenytoin and the administration of hyperosmotic agents such as hypertonic saline, mannitol and
glycerol to reduce the brain swelling.
Complications: Permanent brain damage, brain herniation, paralysis, coma and death
Spinal Cord Injuries
Brief Description: A traumatic injury of the spinal cord which is part of the central nervous system.
The American Spinal Injury Association (ASIA) classifies these injuries from A to E, as based on the
severity of the sensory and motor losses that are sustained by the client.
A grade A spinal cord injury is the most severe of all; all sensory and motor function is lost. In
contrast to the A grade spinal cord injury, grades B, C and D are incomplete injuries. Grade B spinal
cord injuries consists of the loss of motor function at and below the level of the injury but some
sensory functioning, including anal sensation, is preserved; a grade C spinal cord injury reflects the
preservation of some muscular function below the level of the spinal cord injury; a grade D spinal
cord injury is characterized with the preservation of more than 50% of muscular movement at and
below the level of the injury; and a grade E spinal cord injury preserves normal sensory and motor
function.
Spinal cord injuries can also categorized as tetraplegia and paraplegia injuries, which are the loss of
or the impairment of the client's sensory and/or motor function originating at the cervical portion
of the spinal cord which leads to poor or absent functioning of the legs, pelvic organs, arms and
trunk and the pelvic organs and legs and the loss or impairment of, sensory and/or motor function
originating at the thoracic, sacral or lumbar region of the spinal cord.
Lastly, spinal cord injuries are also categorized according to the type of force that was exerted to
produce it and as penetrating and non penetrating. These forces include flexion, extension,
compression and rotation. Penetrating spinal cord injuries, such as those that occur as the result of a
gun shot wound, are serious and unstable because the cerebral neural tissue is lacerated and torn.
Signs and Symptoms: This medical emergency, in addition to the sensory and motor losses discussed
immediately above, these injuries present with different signs and symptoms depending on the level
of the injury and the completeness of the injury; the diaphragm, intercostal muscles and accessory
breathing muscles may be impaired, the arterial blood gases are impaired, respiratory secretions can
accumulate, aspiration, pain, nausea, vomiting, impaired urinary function, paralytic ileus, and
hypothermia can also occur.
Interventions and Treatments: All interventions to preserve life and to prevent any possible
complications such as further spinal cord damage are done. The ABCs, ACLS protocols, intubation,
mechanical ventilation, immobilization and stabilization of the spinal cord using sand bags, head
restraints and a Kendrick Extrication Device (KED) in the field, pain management, a nasogastric
tube to suction and/or antiemetic medication can be used for nausea and vomiting and to avoid
distention and aspiration, the administration of stool softeners and laxatives to prevent autonomic
dysreflexia secondary to constipation and the correction of any hypothermia.
Complications: Spinal neurogenic shock, respiratory distress, respiratory arrest, poikilothermia which
is the body's loss of ability to control and regulate the body temperature, autonomic dysreflexia
which is a life threatening disorder that occurs most often with an over distention of the bowel or
bladder, life threatening hypertension, compensatory bradycardia, all the hazards of immobility, fear
and anxiety, permanent brain damage, seizures, coma and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of musculoskeletal system medical emergencies include
the following.

Skeletal Fractures
Brief Description: The breakage of a bone as the result of some trauma. As discussed in the previous
section entitled "Applying, Maintaining and Removing Orthopedic Devices", some of the several
types of fractures are a greenstick fracture, an avulsion fracture, a comminuted fracture, a transverse
fracture, an oblique fracture, a spiral fracture, an impacted fracture, a compression fracture, an open
fracture and a depressed fracture such as that which may occur when the skull bones are pushed into
the cranial space. Other types of fractures include a stress fracture which occurs among athletes,
stable fractures, unstable fracture which are displaced thereby necessitating reduction, a closed
fracture which is not accompanied with a breakage of the skin at the site, an incomplete fracture
which affects only part of the bone, a complete fracture which adversely affects the entire cross
section of the bone, and a pathological fracture which can occur as the result of a pre existing
disease or disorder such as cancer.
Signs and Symptoms: Abnormal rotation such as occurs when the hip is fractured and the leg on the
affected side externally rotates, shortening of the limb, muscular spasms, crepitus at the site,
deforming angulation, pain, impaired neurological functioning such as cool skin proximate to the
affected area, swelling, ecchymosis at the site, limited or absent muscular movement, impaired skin
integrity and bleeding as may occur with an open fracture, impaired circulation, skin cyanosis and
skin pallor such as occurs when the venous and/or arterial blood flow to the site is impaired and the
area is deprived of adequate perfusion, distal ischemia which is assessed with the 5 Ps of pallor,
paresthesia, pain, polar skin coolness and paralysis, impaired distal pulses, swelling, edema, thrills,
bruits, and poor capillary refill times.
Interventions and Treatments: Pain management, immobilization of the affected limb, elevation of
the affected limb, the application of cold to decrease the swelling, edema, and associated pain,
internal or external fixation, casting, splinting and traction.
Complications: Deformity, compartment syndrome after a casting of a limb, a fat embolism,
neurological and vascular impairments, osteomyelitis with an open compound fracture, and, at times,
lifelong deformity and disability.

Dislocations and Subluxations

Brief Description: Dislocations and subluxations occur as the result of a traumatic injury; a
dislocation occurs when the joints, or their articular surfaces of the bones are completely separated
and are no longer articulated and connected with each other; and a subluxation is only a partial,
rather than a complete, displacement and separation of the joints or articular surfaces.
Signs and Symptoms: Intense and severe pain, limitations in terms of the movement and mobility of
the affected joint, changes in terms of the alignment and length of the affected limb, possible
neurological and circulatory impairments, swelling, and abnormal limb rotation
Interventions and Treatments: Reduction with, for example, the Kocher method, the traction-
counter traction and the Stimson method, or hanging arm technique, for a shoulder dislocation,
immobilization after reduction, and analgesia
Complications: Fractures like a Bankart lesion or a Hill-Sachs lesion, neurological impairment,
vascular impairments, circulatory and perfusion impairments, recurrent dislocations and residual
joint stiffness.

Traumatic Amputation
Brief Description: The traumatic loss of a limb or a part of it. Traumatic amputations are classified
as avulsion amputations, crush amputations, and guillotine amputations.
Signs and Symptoms: Pain, bleeding, haemorrhage, and the signs and symptoms of hypovolemic
shock
Interventions and Treatments: The ABCs, ACLS protocols, the maintenance of the client's
hemodynamics, the preservation and care of the amputated body part by keeping it dry and cool
after it is cleaned with sterile saline and placed in a sealed plastic bag in the field and in the
emergency department until surgical interventions are planned and done, the administration of
broad scope antibiotics, surgical reattachment when possible,
Complications: The permanent loss of the limb, infection, neurological and circulatory compromise,
disability, hypovolemic shock, and death

Mangled Limb
Brief Description: The traumatic mangling of an extremity that is classified according to a scale such
as the Mangled Extremity Severity Score (MESS), the Mangled Extremity Syndrome Index (MESI),
the Hannover Fracture Scale, the Predictive Salvage Index, and/or the Limb Salvage Index. These
scoring scales guide decision making in terms of whether or not the limb can be saved or the need to
amputate the affected limb is necessary.
Signs and Symptoms: Pain, fear, anxiety, and altered neurological and circulatory perfusion to the
affected limb
Interventions and Treatments: The salvage, reconstruction and restoration of the limb when
possible, pain management, the prevention of infection, measures to correct any hemorrhage and
hypovolemic shock, immobilization, and the administration of broad scope antibiotics and the
tetanus vaccine.
Complications: The loss of the mangled limb because restoration and reconstruction were not
possible, infections, a planned surgical amputation, disability and possible impaired neurological and
circulatory perfusion to the affected limb

Traumatic Blast Injuries

Brief Description: An explosion that leads to Injuries to the musculoskeletal and internal organs and
one that can occur with an act of terrorism as occurred with the Boston Marathon massacre or an
accident such as an explosion of a gas or a mining accident. Traumatic blasts carry debris, nails,
glass, rocks and other projectiles in addition to the external application of undue pressure on the
body and bodily parts.
Traumatic blasts can be primary, secondary and tertiary in terms of their classification. Primary
traumatic blast injuries occur as the direct result of a blast and the amount of pressure it exerts on
the body; secondary traumatic blast injuries occur as the result of flying debris and other projectiles
that originated with the blast; and tertiary traumatic blast injuries occur as the result of blunt force
trauma from the blast.
Signs and Symptoms: The stretching, shearing, tearing, and/or lacerations, a possible traumatic limb
amputation, rupture damage and pressure to internal organs, particularly those like the colon and
lungs that contain air or another gas, tissue and organ ischemia and necrosis, hemorrhage, ischemia
and impaired perfusion, and a peppered appearance of the skin as the result of fragments and
projectiles.
Interventions and Treatments: Some treatments, according to the nature and severity of this
traumatic injury, can include a colon repair, an ostomy, a splenectomy, colon repair, a temporary or
permanent colostomy, a nephrectomy, prophylactic antibiotics, the administration of the tetanus
vaccine, wound care, the surgical removal of fragments and debris, incision and drainage, the ligation
and clamping of major vessels that have been adversely affected, and possible amputations.
Complications: Infection, sepsis, hemorrhage, hypovolemic shock, failures of bodily organs that
were affected, disability, limb loss, coma and death

Obstetrical and Gynecological Conditions

In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of different obstetrical and gynecological medical
emergencies include the following.
Some of the obstetrical medical emergencies that can adversely affect the pregnant woman and/or
the developing fetus are:

 Maternal collapse and cardiopulmonary arrest which was previously discussed and detailed in the
section entitled "Assessing the Maternal Client For Antepartal Complications"
 Pulmonary embolus which was previously discussed and detailed in this section
 Ectopic pregnancy which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
 Preeclampsia and eclampsia which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
 Toxic shock syndrome which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
 Endometritis which was previously discussed and detailed in the section entitled "Assessing the
Maternal Client For Antepartal Complications"
 Salpingitis which was previously discussed and detailed in the section entitled "Assessing the
Maternal Client For Antepartal Complications"
 Tubo-Ovarian abscesses which was previously discussed and detailed in the section entitled
"Assessing the Maternal Client For Antepartal Complications"
 Amniotic fluid embolism which is discussed below
 Vaginal bleeding which is discussed below
 Pelvic inflammatory disease which is discussed below
 Ovarian hyperstimulation syndrome which is discussed below

Amniotic Fluid Embolism

Brief Description: This obstetrical disorder, although rare in terms of incidence, is a leading cause of
death among pregnant women. This disorder occurs when amniotic fluid enters into the maternal
circulatory system and it usually occurs as the result of the labor process and some invasive
procedures during pregnancy.
Signs and Symptoms: The onset of the signs and symptoms of an amniotic fluid embolus is rapid
and abrupt and these signs and symptoms can include pulmonary hypertension, hypoxia, and
respiratory distress during the first phase of this disorder; and hemorrhage and uterine atony in
addition the onset of some of the complications of this disorder during the second phase of this life
threatening obstetrical medical emergency. Other signs and symptoms include finger numbness and
tingling, panic, hypotension, coagulopathy, nausea, vomiting, and chest pain.
Treatments and Interventions: The goal of treatment is to sustain the life of the mother and that of
the fetus. Interventions can include oxygen supplementation, intravenous fluids, intubation,
mechanical ventilation, the treatment of the hypotension and hypovolemia, the treatment of
coagulopathy with fresh frozen plasma, cryoprecipitate, platelets, or a whole-blood, the
administration of corticosteroids, continuous fetal monitoring, and an emergency caesarean section
including a post maternal mortem caesarean section when indicated for the preservation of life.
Complications: Myocardial damage, left sided heart failure, disseminated intravascular coagulation
(DIC), consumptive coagulopathy, cardiopulmonary arrest, fetal demise and maternal death.

Vaginal Bleeding
Brief Description: Abnormal vaginal bleeding can affect women of all ages. The types of vaginal
bleeding include primary dysmenorrhagia, dysfunctional uterine bleeding, and abnormal uterine
bleeding
Signs and Symptoms: The signs and symptoms of primary dysmenorrhagia are cramping and pain
during menstruation; the signs and symptoms of dysfunctional uterine bleeding are an irregular
menstrual cycle and heavy bleeding during menstruation; and the sign and symptom of abnormal
uterine bleeding is vaginal bleeding that occurs at times other than that which is expected during the
normal menstrual cycle such as after sexual intercourse.
Interventions and Treatments: Primary dysmenorrhagia is treated with an oral contraceptive, a non-
steroidal anti-inflammatory drugs, the application of a heating pad, exercise, acupuncture, hypnosis,
message and/or using transcutaneous electrical nerve stimulation (TENS); dysfunctional uterine
bleeding can be treated, according to its cause, with the administration of oral contraceptives,
estrogen, progestins and desmopressin when the client has a coagulation disorder, a hysterectomy,
and an endometrial ablation.
Complications: Sterility with a hysterectomy, hemorrhage, and hypovolemic shock

Pelvic Inflammatory Disease

Brief Description: Pelvic inflammatory disease includes the presence of salpingitis, pelvic peritonitis,
a tubo ovarian abscess and/or endometritis caused mostly by the Neisseria gonorrhoeae and
Chlamydia trachomatis pathogens.
Signs and Symptoms: Acute pelvic pain, a fever, abdominal pain, guarding and/or rebound
tenderness, abnormal vaginal bleeding and an elevated white blood cell count.
Interventions and Treatments: Hospitalization for pregnant women and those affected with a tubo
ovarian abscess, the administration of an appropriate antimicrobial drug such as ceftriaxone,
azithromycin, metronidazole and doxycycline.
Complications: Pelvic inflammatory disease can lead to serious and permanent scarring of the
fallopian tubes and infertility, proneness for future ectopic pregnancies, sepsis, septic shock and
death when left untreated.

Ovarian Hyperstimulation Syndrome

Brief Description: Ovarian hyperstimulation syndrome, which is another life threatening medical
emergency, typically follows in vitro fertilization.
Signs and Symptoms: Decreased urinary output, anuria, intense abdominal pain, shortness of breath,
diarrhea, and thirstiness
Interventions and Treatments: Depending on the severity of this disorder, the treatments and
interventions can include hospitalization, the administration of anticoagulating medications, the
administration of intravenous fluids, a paracentesis for ascites, respiratory support, analgesia, and
increasing the daily fluid intake to about 3 liters per day
Complications: Respiratory distress, pleural effusion, ascites, pericardial effusion, coagulopathy,
edema, hemoconcentration, and death
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of ear, nose and eye medical emergencies include the
following:

Mastoiditis
Brief Description: A serious middle ear infection that adversely affects the mastoid bone
Signs and Symptoms: Tenderness, swelling and redness around the mastoid bone which lies behind
the ear, irritability, severe ear pain, a temperature, pus and other ear drainage, and a displaced pinna
which has been pushed away from the side of the head
Interventions and Treatments: Intravenous antibiotics, a myringotomy, and a mastoidectomy
Complications: The spread of this infection to the brain which can, like meningitis, can be life
threatening, abscess formation, necrosis and permanent hearing loss

Ruptured Tympanic Membrane

Brief Description: A ruptured tympanic membrane occurs as the result of some middle ear pressure
that can result from trauma, an infection, being slapped over the ear, using a Q tip to clean the ear,
an explosive blast, in addition to a non penetrating trauma to the ear such as a significant change in
altitude, sky diving and scuba diving.
Signs and Symptoms: Ear drainage which may be bloody, ear pain that may decrease when the
pressure within the ear is relieved with the tympanic membrane rupture, and hearing loss
Interventions and Treatments: Antibiotics to treat an ear infection, the removal of a foreign body in
the ear when that is the cause of the ruptured tympanic membrane, and pain management
Complications: Hearing loss which can be permanent and debilitating

Foreign Bodies in the Ear

Brief Description: The placement of a foreign body in the ear such as a piece of a broken toy or a
bead. Children are at greatest risk for this ear injury and trauma.
Signs and Symptoms: Itching, ear discharge, the signs and symptoms of a ruptured tympanic
membrane when the foreign body has affected this membrane, and visualization of the foreign body
using an auroscope
Interventions and Treatments: Removal of the foreign body using an auroscope or, when necessary,
using crocodile forceps when the foreign body is too large to remove with the auroscope as often
occurs when organic matter such as a vegetable swells and expands after being placed in the ear
Complications: Ruptured tympanic membrane and hearing loss

Epistaxis
Brief Description: Epistaxis is a nasal hemorrhage that can occur as the result of picking the nose,
trauma, the insertion of a foreign body into the nose, multiple traumas, nasal dryness and the use of
anticoagulant medications.
Signs and Symptoms: Hemodynamic instability and hypovolemia when the hemorrhage is severe,
panic, and fear
Interventions and Treatments: The application of continuous and firm pressure at Little's area just
below the nasal bone for about 15 seconds or more while the client is sitting up with their head
forward, blood vessel cauterization, nasal packing, the placement of a large bore cannula or a
balloon catheter when pressure does not successfully stop the epistaxis
Complications: Infections such as sinusitis and aspiration of and airway obstruction secondary to the
dislodgement and displacement of any nasal packing or catheter
Foreign Bodies in the Nose
Brief Description: A foreign body like a piece of food, a button or a bead that is placed in the nose.
Again, children are at risk for this trauma and other traumas associated with foreign objects being
placed in bodily orifices.
Signs and Symptoms: Unilateral nose drainage which can be bloody and nasal pain
Interventions and Treatments: Having the client blow out the affected nostril while pinching off and
occluding the unaffected nostril, and the careful removal of the foreign body using forceps while
insuring that the foreign body does not get pushed into the nostril any further during this effort, a
Complications: Nasal trauma and bleeding

Air Bag Injuries

Brief Description: This trauma occurs when an automobile air bag is deployed. These injuries can
affect the eyes, nose, face, ears and other bodily structures.
Signs and Symptoms: Contusions, lacerations, retinal tears, retinal detachment, hemorrhage, thermal
burns, abrasions and pain
Interventions and Treatments: The treatment of the injuries according to their severity and location
Complications: Blindness, hemorrhage, hypovolemia, enucleation, corneal alkaline burns, permanent
deformity

Orbital Blow Out Fractures

Brief Description: The boney structures of the eye's orbit are fractured and, when this occurs,
intraorbital tissue is pushed out into one of the paranasal sinuses.
Signs and Symptoms: Impaired eye movement, swelling, pain, crepitus, retinal bruising, diplopia,
corneal abrasions and a detached retina
Interventions and Treatments: The application of cold, and client education that underscores the
client's need to protect the eye and to avoid sneezing and blowing the nose
Complications: Retinal detachment and enucleation

Corneal Foreign Body Trauma

Brief Description: Corneal foreign body trauma can occur as the result of many forces and causes
such as an explosion, chiselling and using power tools without the use of safety goggles
Signs and Symptoms: Pain, ocular redness, a rust color appearance of the eye when a piece of metal
has entered it and impaled itself in the eye, and a loss of vision if the foreign body is impaled in the
eye
Interventions and Treatments: Fluorescein staining followed by an ophthalmologist's removal of the
foreign body using a slit lamp, a moistened cotton bud, and a steady hand, and the application of
antiseptic ocular drops to prevent secondary eye infections
Complications: Infection, visual losses, eye ulceration, corneal perforation and scarring

Globe Rupture
Brief Description: Globe rupture is a highly serious ocular emergency that results from a blunt or
penetrating trauma such as occurs with the entry of a projectile or a knife into the globe. These
traumatic injuries are classified and described as posterior and anterior globe ruptures. Posterior
globe injuries affect the retina, sclera, and vitreous; and anterior globe injuries adversely affect the
cornea, anterior chamber, iris and lens.
Signs and Symptoms: Chemosis, decreased intraocular pressure, pain, conjunctival pigmentation,
impaired eye movement, nausea, diplopia and other visual impairments, a tear drop shaped pupil,
and vitreous hemorrhage
Interventions and Treatments: Patching the unaffected eye is patched to decrease eye movement,
pain management, corticosteroid drugs to decrease the risk of sympathetic ophthalmia, the
avoidance of activities that can dangerously increase intraocular pressure such as heavy lifting,
straining while moving the bowels, coughing, and bending over, and surgical interventions, as
indicated and based on the location and the severity of the trauma, including the surgical enucleation
of the affected eye to prevent sympathetic ophthalmia.
Complications: Enucleation and blindness

Hyphemia
Brief Description: Hyphemia is bleeding into the anterior chamber of the eye between the cornea
and the iris. Hyphemia can occur as the result of external compression of the eye, a blunt trauma,
falls and fist fights as well as from spontaneous, nontraumatic disorder related causes such as
retinoblastoma, neurovascularization, xanthogranuloma which is a pediatric vascular abnormality,
myotonic dystrophy, uveitis, Von Willebrand disease, rubeosis iridis, leukemia, hemophilia, and the
use of anticoagulating medications.
Hyphemia is categorized and classified from a grade of 1 to 4. A grade 1 hyphemia is characterized
with less than one third of the anterior chamber filled with blood; a grade 2 hyphemia is
characterized with the anterior chamber's filling with more than one third but less than two thirds of
the chamber; a grade 3 hyphemia is characterized with more than two thirds of the anterior chamber
filled with blood but not with complete filling; and a grade 4 hyphemia is characterized with the
complete filling of the eye's anterior chamber with blood.
Signs and Symptoms: Light sensitivity, pain, blurry vision, a small pool of blood in the cornea or at
the bottom of the iris, a reddish colored tinge to the eye, and the loss of vision.
Interventions and Treatments: The goals of treatments and interventions include the prevention of
secondary corneal blood staining, decreasing the possibility of any rebleeding within the eye, the
elimination of risks associated with atrophy of the optic nerve and increased intraocular pressure.
Interventions to achieve these goals include pharmacologic interventions to reduce intraocular
pressure, pain management, patching the affected eye, surgical procedures to empty the anterior
chamber of the eye of pooled blood and also prevent possible corneal blood staining.
Complications: Increased intraocular pressure and blindness

Retinal Detachment
Brief Description: Retinal detachments occur when the retina of the eye peels away from its
underlying layer of support tissue. This serious disorder is a medical emergency; irreversible and
permanent vision loss can occur when it evolves and progresses to a complete detachment without
immediate and effective treatment. Retinal detachments are typically unilateral.
Signs and Symptoms: Client complaints of flashing lights, floaters and veiling or curtain effects in
their visual field, photopsia, heaviness in the eye, the loss of central vision, and straight lines
suddenly appear as though they are curved
Interventions and Treatments: Laser surgery or cryotherapy, vitrectomy and the placement of a
scleral buckle to move the wall of the eye against the detached retina.
Complications: Permanent, complete and total blindness
In addition to the correction of any underlying disorder or condition and emergency
cardiopulmonary resuscitation, the descriptions, the signs and symptoms, complications, and
interventions and treatments for a number of oral medical emergencies include the following:

Dental Avulsions
Brief Description: The traumatic loss of a tooth or teeth
Signs and Symptoms: Pain, bleeding and the loss of a tooth or multiple teeth
Interventions and Treatments: Reimplantation of the tooth, immersion of the lost tooth in milk or
normal saline to preserve its viability for reimplantation, and splinting of the oral area around the
reimplantation after the reimplantation of the tooth is successfully accomplished
Complications: The permanent loss of the tooth or teeth

Dental Luxations
Brief Description: Dental luxation injuries are injuries that result in the partial displacement of a
tooth or teeth from its socket.
Signs and Symptoms: Pain, bleeding and the partial loss of a tooth or multiple teeth
Interventions and Treatments: Like dental avulsions, there is no attempt to reposition the deciduous
teeth so these affected deciduous teeth are typically extracted, permanent teeth are treated with
repositioning of the teeth under local anesthesia while using the adjacent teeth as a guide and firm
digital pressure is used for this repositioning and later splinting with glass ionomer cement powder
alone or a combination of glass ionomer cement powder and a fine stabilizing wire.
Complications: The permanent loss of the tooth or teeth
Explaining Emergency Interventions
to the Client
All emergency treatments and interventions should be explained to the client and informed consent
should be obtained except under special circumstances such as when an emergency is occurring and
the client is not mentally competent, alert and conscious enough to do so. Healthcare surrogates and
proxies often make decisions for the client when they are not able to do so. However, when the
client and/or the family are able to receive complete information, at a later time, this complete
information must be given in the same manner that is done with clients who are competent enough
to understand this information and to give informed consent.

Notifying the Primary Health Care

Provider About the Client's
Unexpected Responses and
Emergency Situations
As with all other aspects of nursing care, nurses notify the client's health care provider about all
unexpected responses, the rise of an emergency situation and all significant changes in the client's
status in a timely, complete and accurate manner.

Performing Emergency Care

Procedures
Basic emergency care procedures include cardio-pulmonary resuscitation, respiratory support, and
defibrillation. More advance emergency care procedures include those measures that are done by
registered nurses who have been ACLS (Advanced Cardiac Life Support) certified.
Learn more about a career as a Cardiac Care Nurse, Cardiac Catheterization Laboratory
Nurse or Cardiovascular Operating Room Nurse.

Providing Emergency Care for Wound

Disruption
Evisceration and dehiscence are two types of wound disruption. Dehiscence is the separation of a
surgical incision and evisceration is the separation of a surgical incision in addition to the protrusion
of an internal bodily organ through the separated surgical incision to the exterior environment.
Both dehiscence and evisceration can be a life threatening emergencies. The nurse provides
emergency care by not leaving the client unattended, calling for the help of others, and, using a
clean, sterile towel or sterile saline dampened dressing to cover the open wound. No attempts to
reinsert the protruding organs should be done by the nurse; the nurse should simply apply and
maintain light pressure on the wound until the medical doctor is present.

Evaluating and Documenting the

Client's Response to Emergency
Interventions
All aspects of care including the evaluation of the client's responses to emergency interventions,
such as the restoration of spontaneous breathing and cardiac function, are done and documented. At
times, the nurse may recommend changes in emergency treatments as based an unfavourable client
response to emergency interventions. Some of the client responses to emergency interventions
include things like the opening and maintenance of an open airway, the restoration of breathing, the
restoration of the client's pulses including peripheral pulses, the restoration of the client's
hemodynamics and the overall establishment and maintenance of the client's physical stability and
normal functioning.

Pathophysiology: NCLEX-
RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of pathophysiology in order to:

 Identify pathophysiology related to an acute or chronic condition (e.g., signs and symptoms)
 Understand general principles of pathophysiology (e.g., injury and repair, immunity, cellular
structure)
Identifying Pathophysiology Related
to an Acute or Chronic Condition
The pathophysiology of many acute, chronic and emergency disorders and conditions, including
etiologies, risk factors, signs, symptoms, diagnostic findings, complications, and expected outcomes
were discussed throughout this NCLEX RN review.

Understanding the General Principles

of Pathophysiology
Some of the general principles of pathophysiology include the stages of infection, the phases of the
inflammatory process, the stages of wound healing, immunological bodily responses, and the role of
cellular structures.
The stages of infection and a brief description of each of these four stages are discussed below:

 The incubation stage: The incubation stage begins with the entry of the pathogen into the
host and this stage ends when the signs and symptoms of the infection begin to appear.

 The prodromal stage: The prodromal stage begins with the onset of symptoms and this stage
is characterized with the replication and reproduction of the pathogen; and the signs and
symptoms of the prodromal stage include generalized malaise, joint and muscular aches and
pains, anorexia, and the presence of a headache.

 The illness stage: The illness stage is the period of time that begins with continuation of the
signs and symptoms and it continues until the symptoms are no longer as serious as they were
before.

 The convalescence stage: The convalescence stage is the period of recovery during which time
the symptoms completely disappear. .

The inflammatory process is the naturally occurring protective response of the body to a threat in
terms of tissue damage; this process defends the body against harm, it aims to rid the body of
damaged tissue and it promotes the restoration of normal tissue.
The five classic signs and symptoms of inflammation are:

 Pain: Pain occurs with the release of chemicals secondary to the damage of cells and tissues
 Redness: Redness results from the vasodilation of blood vessels that occurs in response to the
injury.
 Swelling: Swelling occurs as the body's fluids enter the area of the injury and tissue damage.
 Heat and warmth: Heat and warmth occur as the result of the vasodilation and the increased
blood flow to the affected area.
 Dysfunction of the area: Local dysfunction occurs as the result of the swelling and pain
associated with the inflammatory process.

The four phases of bacterial growth are in this sequential order.

 The lag phase of bacterial growth: The lag phase of bacterial growth consists of the bacteria's
slow growth as it adjusts to its new environment in the human body. The rate of biosynthesis is
high because the bacteria need these proteins for their future period of rapid growth and
replication.

 The lag phase of bacterial growth: The lag phase of bacterial growth, which is sometimes
referred to as the exponential phase of bacterial growth, is characterized with a period of rapid
and continuous growth until one or more of the nutrients necessary for this rapid growth is no
longer available to the pathogen.

 The stationary stage of bacterial growth: The stationary stage of bacterial growth marks the
end of the bacteria's growth and metabolic activity because all the nutrients for these activities
have been exhausted and depleted.

 The death stage of bacterial growth: This stage is characterized with the end of the bacteria's
life because there are no nutrients to sustain it and no metabolic activity.

Similarly, the six stages of a virus growth include:

 The attachment stage: The attachment stage consists of the virus' attachment to a receptor on
the host's cellular surface. A limited or low host range in terms of attachment means that some
of these attachments are relatively limited and highly specific to only some receptors; and the
converse is also true, there are pathogens with a wide host range in terms of attachment which
means that the attachments are greater in terms of possibility and not highly specific.

 The penetration stage: The penetration stage is marked with the entry of the virus into the
host's cell.
 The uncoating stage: The uncoating stage entails the shedding of the virus coating, or its viral
capsid, which now allows the virus to deposit its own nucleic material into the human's host
cells.

 The replication stage: The replication stage consists of the duration of time during which the
virus is able to replicate and multiple.

 The self-assembly stage: During the self-assembly stage, the virus matures and makes
modifications to its proteins.

 The release and lysis stage: During the release and lysis stage the virus is released from the
host cells with lysis and the resulting death of the virus.

The phases of the inflammatory process include:

 Tissue injury as the result of the injury

 The release of chemicals, such as kinins, histamine and prostaglandins from the damaged cells
and tissues. These chemicals are vasodilators that increase the blood supply to the damaged cells
and tissues.
 The natural, defensive movement and migration of leukocytes, including macrophages and
neutrophils, to the areas where cellular and tissue damage has occurred

Some professional resources refer to the stages of the inflammatory process as the vascular and
cellular response stage, the exudate stage, and the reparative phase of the inflammation process
instead of tissue injury phase, the release of chemicals stage and the final stage of the inflammatory
process, respectively.
The stages of wound healing are the:

 The homeostasis phase: The homeostasis phase is accompanied with vasoconstriction,

thrombin formation, platelet formation, and the formation of a fibrin mesh for healing that
begins the healing process.

 The inflammation phase: The inflammation phase, which is also referred to as the lag or
exudate phase, is accompanied with pain, swelling , edema, and the beginning of wound debris
removal with phagocytosis to prevent infection.

 The proliferative and granulation phase: The proliferative and granulation phase is
accompanied with the fibroblastic production of granulation tissue and collagen.
 The maturation phase: The maturation phase of wound healing is characterized with the
continued development and maturation of the fragile skin over the wound. This phase can last
up to two years during which time the wound remains at risk and vulnerable for injury until full
healing and good tensile strength is complete.

Immunological bodily responses are both innate and adaptive. Innate immunity is the natural,
intrinsic nonspecific immunity mechanisms that protects the body and resists infection with its
physical, cellular, and chemical mechanisms and means. For example, when a pathogen breaks
through the skin or mucus membranes, our first lines of defense, chemical cytokines and other
antimicrobial substances and phagocytic activity prepare the host cells to prevent the pathogen's
entry, colonization, spread and replication.
Adaptive immunity is categorized as active and passive immunity which, simply stated, are the
deliberate or undeliberate exposure to a pathogen and the acquisition of antibodies or activated T
cells in the body, respectively.
Active immunity occurs as the result of our bodily response to the presence of an antigen, with the
development of antibodies. Active immunity can be both natural and artificial. Natural active
immunity occurs when the body produces antibodies after the client is infected with a pathogen; and
artificial active immunity occurs when the body produces antibodies to an immunization vaccine
such as those for pneumonia and a wide variety of childhood infectious diseases.
Passive immunity occurs when an antibody is introduced into the body by either natural or artificial
means. Passive natural immunity occurs when the fetus and neonate receive immunity as a natural
process through the placenta; and passive artificial immunity occurs when the client receives an
injection of immune globulin.

Applying a Knowledge of Nursing

Procedures and Psychomotor Skills
When Caring for a Client
Experiencing a Medical Emergency
Cardiopulmonary arrest is the sudden loss of cardiac function, the cessation of breathing and the
client's complete loss of consciousness, as the result of a significant disturbance of the heart'
electrical impulses, such as ventricular tachycardia and asystole, as discussed previously in the
sections entitled "Hemodynamics: Identifying Cardiac Rhythm Abnormalities" and "Intervening to
Improve the Client's Cardiovascular Status".
The immediate treatment for sudden cardiac arrest is cardiopulmonary resuscitation (CPR) and
defibrillation, as indicated by the client's condition.
Airway obstructions can be partial or complete. A complete airway obstruction is signalled with the
lack of any cough or other noises from the patient. The airway must be opened using the techniques
you have learned when you took your Basic Life Support course. Intubation, when necessary, is also
done.
A partial airway obstruction can be determined by listening to the patient's cough and other
respiratory noises. A cough that is not efficient indicates a more severe airway obstruction than a
cough that is effective in terms of clearing the airway of secretions and/or foreign bodies. The
patient who is coughing should be encouraged and prompted to continue to cough. Visible foreign
bodies that can be removed and should only be removed if there is no chance of pushing the foreign
body further into the airway.
The look, listen and feel assessment for breathing to determine whether or not the patient is
spontaneously breathing on their own includes looking at the chest to see if it rises and falls,
listening for any breath sounds from the nose or mouth, and feeling the chest and upper abdomen
to see if there is any movement present. Rescue breathing is done when the patient is not breathing
and the airway is open.
Chest compressions are done, as you learned in your Basic Life Support course, on all patients who
are unconscious, unresponsive, not breathing and pulse less.
Defibrillation gives an electric shock to the heart. There are standard external defibrillators which are
typically found in hospitals and other healthcare facilities and used by nurses, transvenous
defibrillators, implantable cardioverter defibrillators, and automated external defibrillators.
Automated external defibrillations are most often found in the community and outside of healthcare
facilities. Automated external defibrillations are simple to use and there is no need to be able to
recognize cardiac arrhythmias or interpret cardiac rhythm strips. Automated external defibrillations
are intended to be used by the general public without any healthcare or nursing knowledge of
experience.
The steps for using an automated external defibrillation is turn the machine on, put the pads on the
patient's chest as shown on the machine, and then listen to and follow the automated instructions of
the automated external defibrillation.

Unexpected Responses to
Therapies: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your
knowledge and skills of unexpected responses to therapies in order to:

 Assess the client for unexpected adverse response to therapy (e.g., increased intracranial
pressure, hemorrhage)
 Recognize signs and symptoms of complications and intervene appropriately when providing
client care
 Promote recovery of the client from unexpected response to therapy (e.g., urinary tract
infection)

Assessing the Client for Unexpected

Adverse Responses to Therapy
Virtually all treatments, therapies, interventions and procedures have potential risks and
complications. Some of the causes of these responses are accidental and inadvertent and others are
those that occur as a normal and/or relatively commonly occurring, but undesirable, response to
treatments, therapies, interventions and procedures such as an adverse response and reaction to a
medication.
Some of the accidental and inadvertent unexpected responses to therapy and procedures can include
the accidental and inadvertent:

 Maternal trauma, lacerations, pelvic floor damage, bleeding and an inadvertent extension of the
episiotomy to the anus when a forceps delivery of a new born is done

 Tube leakage, improper placement and the dislodgment of a nasogastric or another gastric tube

 Pneumothorax, hemothorax or hydrothorax when a total parenteral nutrition (TPN) catheter

perforates the vein and fluid enters the pleural space during insertion

 The punctures of major vessels can occur during a number of surgical interventions, invasive
procedures and some invasive diagnostic tests such as the puncture of the descending aorta
during a major abdominal surgical procedure, during the placement of an epidural catheter for
anesthesia and during a lung biopsy or the placement of a chest tube

 Contamination of a sterile field and its contents

 The lack of medical asepsis with contamination

 Retained sharps and other surgical instruments after a surgical procedure

The prevention, signs, symptoms and treatments for these inadvertent and accidental and
unexpected responses unexpected responses to therapy and procedures have been discussed
throughout this NCLEX RN review.
Some of the normal and/or relatively commonly occurring, but undesirable, responses to
treatments, therapies, interventions and procedures include:

 Healthcare associated infections (HAI) such as ventilated associated pneumonia (VAP), central
line associated blood infections (CLABI), surgical site infections (SSI), ventilator associated
pneumonia (VAP), and catheter associated urinary tract infections (CAUTI) and other infections
such as pneumonia which can occur simply as the result of infections spread in facilities and
institutions that have many clients with multiple infections and the infectious complications of
intravenous catheters

 The undesirable side effects, complications and adverse responses to medications and fluid
administration

The prevention, signs, symptoms and treatments for these unexpected responses to various other
treatments, therapies, interventions and procedures have been discussed throughout this NCLEX
RN review.

Recognizing the Signs and Symptoms

of Complications and Intervening
Appropriately When Providing Client
Care
Again, the signs, symptoms, preventive measures, complications and interventions for a wide variety
of medical diseases and disorders, including emergency medical situations, were discussed and
described throughout this NCLEX RN review.

Promoting the Recovery of the Client

From an Unexpected Response to
Therapy
As discussed in the previous sections of this NCLEX RN review entitled "Identifying External
Factors That May Interfere with Client Recovery", "Promoting Client Progress Toward Recovery
From an Alteration in Body Systems" and "Implementing Interventions to Manage the Client's
Recovery from an Illness", nurses play an highly important role in the promotion of the client's
recovery from an unexpected response to therapy in the same manner that they do for a primary
disorder.
For example, urinary tract infections, surgical wound infections and mechanical ventilator associated
infections are assessed and treated and the client is then evaluated in terms of these responses to
these interventions and treatments.