a p p e n d i x

Chapter Summaries
Chapter 1
The art of nursing declined in England with the exile of Catholic

religious orders, forcing the government to assume responsibility

for caring for the sick, aged, and infirm. Eventually the state delegated this care to untrained and generally uninterested people of
questionable character.
Florence Nightingale changed the image of nursing by training
nurses to care for the sick, selecting only those with upstanding
character as potential nurses, improving the sanitary conditions
within clients environments, significantly reducing the morbidity and mortality rates of British soldiers, providing formal nursing classes separate from clinical experience, and arguing that
nursing education should be a life-long process.
Training schools in the United States deviated from the pattern
established by Nightingale. No criteria established which hospitals were to train nurses. Students staffed the hospitals without
being paid. There was no uniformity in what was taught; students learned more by experience than by formal instruction.
Nursing students were taught from a physicians perspective.
Students were required to work and to live at the beck and call
of the hospital administrator and after graduation students were
left to seek employment elsewhere.
In addition to employment within hospitals, early graduates of
nursing programs met the health needs of poor immigrants by living among them in settlement houses in the ghettos of large cities,
by serving as midwives for rural women who lacked medical
care, and by caring for sick and wounded soldiers.
What started as an art, passing on the skills of nursing from one
practitioner to another, was soon augmented by science, a unique
body of knowledge that made it possible to predict which nursing interventions would be most appropriate for producing
desired outcomes. Most recently nursing has become theorybased, which means that nursing scholars are proposing what the
process of nursing encompasses by explaining the relationship
between four essential components: humans, health, environment, and nursing.
One of the earliest definitions of nursing outlined the scope of
practice as caring for the sick. More recently the definition has
been refined with the addition of the nurses role in health promotion and independent practice.
Those who wish to pursue a career in nursing may choose from
a practical/vocational nursing program or a registered nursing
program taught in a career center, hospital school, community or
junior college, or university.
The choice of nursing educational program depends on ones
career goals, location of schools, costs involved, length of the program, reputation and success of graduates, flexibility in course
scheduling, opportunities for part-time or full-time enrollment,
and ease of articulation to the next level of education.
Continuing education is necessary for contemporary nurses because it demonstrates personal accountability, promotes the pub-

lics trust, ensures competence in current nursing practice, and

keeps the nurse abreast of how technology is affecting client care.
Several trends are affecting health care. One of the major issues
is the growing shortage of nurses. Additionally many people, such
as older adults, minorities, and the poor, are not receiving adequate health care. The number of uninsured people is rising. Various cost-containment practices reduce access to tests, treatment,
and services, increase ratios of clients per nurse in employment
settings, and contribute to a higher acuity of clients in previously
nonacute settings.
Regardless of educational background, all nurses use assessment,
caring, counseling, and comforting skills in clinical practice.

Chapter 2
The nursing process is an organized sequence of steps used to
identify health problems and to manage client care.

Characteristics of the nursing process are that it is within the

legal scope of nursing, based on unique knowledge, planned,

client-centered, goal-directed, prioritized, and dynamic.
The steps in the nursing process are assessment, diagnosis, planning, implementation, and evaluation.
Resources for data include the client, the clients family, medical
records, and other health care workers.
Data base assessments provide vast information about a client at
the time of admission. Focus assessments, which are ongoing,
expand the database with additional information.
A nursing diagnosis is a health problem that nurses can treat
independently. A collaborative problem is a physiologic complication that requires the skills and interventions of both nurses
and physicians.
A nursing diagnostic statement generally consists of three parts:
the problem, the etiology for the problem, and the signs and
symptoms or evidence for the problem.
Setting priorities for care helps to maximize efficiency in minimal time.
Short-term goals are those the nurse expects to accomplish in a few
days to 1 week usually when caring for clients in acute care settings (e.g., hospitals). Long-term goals may take weeks to months
to accomplish after discharge from the health care agency. They
are identified when caring for clients with chronic problems who
are receiving nursing care in a long-term health facility or through
community health agencies or home health care.
Methods of documentation include writing the problems, goals,
and nursing orders by hand; individualizing a standardized or
computer-generated care plan; or following an agencys written
standards for care or clinical pathways.
Nurses demonstrate implementation of the plan of care by correlating the written plan with nursing documentation in the
medical record.

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812

APPENDIX A Chapter Summaries

When evaluating the clients progress, nursing orders are discontinued if the client has met the goal and the problem no longer
exists. The nurse revises the care plan if the client has made
progress but the goal remains unmet or if there has been no
progress in reaching a desired outcome.

Chapter 3

Values are the ideals that an individual believes are honorable

attributes. Beliefs are concepts that individuals hold to be true.

Most Americans believe that health is a resource, a right, and a

personal responsibility.

How whole or well a person feels is the sum of his or her phys-

The six types of laws are constitutional, statutory, administrative,

common, criminal, and civil.

Each states nurse practice act defines the unique role of

the nurse and differentiates it from that of other health care

practitioners.
Each states board of nursing is the regulatory agency for managing its nurse practice act.
Violations of civil laws include intentional and unintentional
torts. In an intentional tort, a private citizen sues another for a
deliberately aggressive act. In an unintentional tort, the lawsuit
charges that harm resulted from a persons negligence even
though he or she intended no harm.
Negligence lawsuits allege that a persons actions, or lack thereof,
caused harm. The defendant is held to a standard expected of any
other reasonable person. In the case of malpractice, the plaintiff
alleges that a professionals actions, or lack thereof, caused harm.
The defendant is held to the standard expected of others with similar knowledge and education.
In a malpractice case, the prosecution must prove that the defendant had a duty to carry out in relation to the plaintiff, the defendant breached that duty, the breach of duty was the direct cause
for harm, and injury occurred.
Liability for malpractice may be limited or reduced by the use of
Good Samaritan laws, expiration of the statute of limitations, a
timely and well-written incident report, or a privately composed
anecdotal record.
Professional liability insurance is advantageous for nurses to
obtain because (1) nurses are increasingly being named in medical
lawsuits, (2) financial damages, when awarded, can be extremely
high, and (3) it ensures having an attorney working on the nurses
behalf.
A nurses professional liability can be mitigated by laws such
as a states Good Samaritan Act, expiration of the statute of
limitations, legal principles such as a clients assumption of
risk, accurate and complete documentation, and aggressive risk
management.
Ethics refers to moral or philosophical principles that classify
actions as right or wrong.
A code of ethics is a written statement that describes ideal behavior for members of a particular discipline.
There are two ethical theories: teleology and deontology. Teleology proposes that the best ethical decision is the one that will
result in benefits for the majority of individuals. Deontology proposes that the basis for an ethical decision is simply whether the
action is morally right or wrong.
Some common ethical issues that nurses encounter in everyday practice include telling the truth, protecting clients confidentiality, ensuring that clients wishes for withholding and
withdrawing treatment are followed, advocating for the nondiscriminatory allocation of scarce resources, and reporting incompetent or unethical practices.

Chapter 4

ical, emotional, social, and spiritual health, a concept referred to

as holism. Any change in one component, positive or negative,
automatically creates repercussions in the others.
There are five levels of human needs: physiologic (first level),
safety and security (second level), love and belonging (third level),
esteem and self-esteem (fourth level), and self-actualization (fifth
level). By satisfying needs at each subsequent level, individuals can
realize their maximum potential for health and well-being.
Illness is a state of discomfort that results when a persons health
becomes impaired through disease, stress, or an accident or injury.
Morbidity refers to the incidence of a specific disease, disorder, or
injury. Mortality refers to the death rate from a specific condition.
An acute illness is one that comes on suddenly and lasts a short
time. A chronic illness is one that comes on slowly and lasts a long
time. A terminal illness is one in which there is no potential for
cure.
A primary illness is one that developed independently of another
disease. Any subsequent disorder that develops from a preexisting condition is referred to as a secondary illness.
Remission refers to the disappearance of the signs and symptoms
associated with a particular disease. An exacerbation refers to
the time when the disorder becomes reactivated or reverts from
a chronic to an acute state.
A hereditary condition is one acquired from the genetic codes of
one or both parents. Congenital disorders are those that are
present at birth but result from faulty embryonic development.
An idiopathic illnesss cause is unexplained.
Primary care refers to the services provided by the first health care
professional or agency an individual contacts. Secondary care pertains to the services to which primary care givers refer clients for
consultation and additional testing such as a cardiac catheterization laboratory. Tertiary care takes place in a hospital where complex technology and specialists are available. Extended care
involves meeting the health needs of clients who no longer require
hospital care but who continue to need health services.
Two programs that help to finance healthcare for the aged, disabled, and poor are Medicare and Medicaid.
Methods for controlling escalating healthcare costs include a system of prospective payment known as the diagnosis-related
group, managed care, health maintenance organizations, preferred provider organizations, and capitation.
Two national health goals have been set for the year 2010: to
increase years of healthy life and to eliminate health disparities.
One of several patterns may be used when providing nursing care
for clients. In functional nursing, each nurse on a unit is assigned
specific tasks. The case method involves assigning one nurse to
administer all the care a client needs for a designated period of
time. In team nursing, many nursing personnel divide the client
care and all work until everything is completed. Primary nursing
is a method in which the admitting nurse assumes responsibility
for planning client care and evaluating the progress of the client.
In managed care, a nurse manager plans the nursing care of
clients based on their illness or medical diagnosis and evaluates
client progress so that each client is ready for discharge by the
time designated by prospective payment systems.

Chapter 5

The World Health Organization (WHO) defines health as a

Homeostasis refers to a relatively stable state of physiologic equi-

state of complete physical, mental, and social well-being and not

merely the absence of disease or infirmity.

librium. Physiologic, psychological, social, and spiritual stressors

affect homeostasis.

APPENDIX A Chapter Summaries

The philosophic concept of holism leads to two commonly held

beliefs: both the mind and body directly influence humans, and
the relationship between the mind and body has the potential for
sustaining health as well as causing illness.
Adaptation refers to how an organism responds to change. Successful adaptation is the key to maintaining and preserving homeostasis. Unsuccessful adaptation leads to illness and death.
Adaptive changes occur through the cortex, which communicates
with and through the reticular activating system, the hypothalamus, the autonomic nervous system, and the pituitary gland along
with other endocrine glands under its control.
The sympathetic nervous system, a division of the autonomic nervous system, accelerates the physiologic functions that ensure
survival through strength or a rapid escape.
The parasympathetic nervous system, a second division of the
autonomic nervous system, inhibits physiologic stimulation,
which restores homeostasis and provides an alternative mechanism for dealing with stressors.
Stress involves the physiologic and behavioral reactions that
occur when the bodys equilibrium is disturbed.
People vary in their response to stressors depending on the intensity and duration of the stressor, the number of stressors at one
time, physical status, life experiences, coping strategies, social
support system, and personal beliefs, attitudes, and values.
The general adaptation syndrome, a physiologic stress response
described by Hans Selye, consists of the alarm stage, stage of resistance, and stage of exhaustion. In most cases, the alarm stage and
stage of resistance restore homeostasis. When the stage of resistance is prolonged, however, adaptive resources are overwhelmed
and the person enters the stage of exhaustion, which is characterized by stress-related disorders and, in some cases, death.
Psychological adaptation occurs through the use of coping mechanisms and coping strategies. Healthy use of coping mechanisms
and coping strategies allows people to postpone the emotional
effects of stress, permitting them to deal with reality eventually
and gain emotional maturity. Unhealthy use of coping mechanisms tends to distort reality to such an extent that the person fails
to see or correct his or her weaknesses. Nontherapeutic coping
strategies provide temporary relief but eventually cause problems.
Nursing care of clients under stress includes identifying stressors, assessing the clients response to stressors, eliminating or
reducing stressors, preventing additional stressors, promoting
adaptive responses, supporting coping strategies, maintaining a
clients network of support, and implementing stress reduction
and stress management techniques.
Stress-related disorders and their consequences are minimized at
three levels. Primary prevention involves reducing the potential
for a disorder. Secondary prevention involves public screening
and early diagnosis. Tertiary prevention uses rehabilitation and
aggressive management when a disorder develops.
Four methods for preventing, reducing, or eliminating a stress
response include using stress reduction techniques such as providing adequate explanations in understandable language; implementing stress management interventions such as progressive
relaxation; promoting the release of endorphins through massage, for example; and manipulating sensory stimuli as might be
done with aromatherapy.

813

people based on some general characteristic, and ethnocentrism,

the belief that ones own ethnicity is superior to all others.
U.S. culture is said to be Anglicized because many of the values,
beliefs, and practices evolved from the early English settlers.
Some examples of Anglo-American culture include speaking English; valuing work, time, and technology; holding parents responsible for the health care, behavior, and education of minor
children; keeping government separate from religion; and seeking
assistance from licensed individuals when health care is necessary.
A subculture is a unique cultural group that coexists within the
dominant culture. The four major U.S. subcultures are African
American, Latino, Asian American, and Native American.
Subcultural groups differ from Anglo-Americans in one or more
of the following ways: language, communication style, biologic
and physiologic variations, prevalence of diseases, and health
beliefs and practices.
The four characteristics of culturally sensitive nursing care are
data collection of a cultural nature, acceptance of each client as
an individual, knowledge of health problems that affect particular cultural groups, and planning care within the clients health
belief system to achieve the best health outcomes.
Some ways that nurses can demonstrate cultural sensitivity
include learning a second language, performing physical assessments and care according to the clients unique biologic differences, consulting each client as to his or her cultural preferences,
arranging for modifications in diet and dress according to the
clients customs, and allowing clients to continue relying on cultural health practices (if they are not harmful).

Chapter 7
In a nurseclient relationship, nurses meet client needs by per

Chapter 6
Culture refers to the values, beliefs, and practices of a particular

group. Race refers to biologic variations such as skin color, hair

texture, and eye shape. Ethnicity is the bond or kinship a person
feels with his or her country of birth or place of ancestral origin.
Two factors that interfere with perceiving others as individuals
are stereotyping, which involves ascribing fixed beliefs about

forming any or all of the following roles: caregiver, educator,

collaborator, and delegator.
The role of clients is to be actively involved in their care, to communicate, to ask questions, to assist in planning their care, and
above all to retain as much independence as possible.
Some principles underlying a therapeutic nurseclient relationship include treating each client as a unique person; respecting the
clients feelings; striving to promote the clients physical, emotional, social, and spiritual well-being; encouraging the client to
participate in problem solving and decision making; and accepting that a client has the potential for growth and change.
A nurseclient relationship usually encompasses three phases:
introductory, working, and termination.
Communication involves sending and receiving messages
between two or more people followed by feedback indicating that
the information was understood or requires further clarification.
Therapeutic communication refers to using words and gestures
to accomplish a particular objective.
Examples of therapeutic verbal communication techniques include
questioning, reflecting, paraphrasing, sharing perceptions, and
clarifying. Examples of nontherapeutic verbal communication
techniques include giving false reassurance, using clichs, giving
approval or disapproval, demanding an explanation, and giving
advice.
Some factors that may affect oral communication include language compatibility; verbal skills; hearing and visual acuity;
motor functions involving the throat, tongue, and teeth; sensory
distractions; and interpersonal attitudes.
The four forms of nonverbal communication are kinesics (body
language), paralanguage (vocal sounds), proxemics (how space is
used in communication), and touch.
Task-related touch involves the personal contact required when
performing nursing procedures. Affective touch is used to demonstrate concern or affection.

814

APPENDIX A Chapter Summaries

Affective touch is appropriate in many situations. Examples

include caring for clients who are lonely, uncomfortable, near
death, or anxious and those with sensory deprivation.

Chapter 8
The three learning domains are the cognitive domain (information usually provided in oral or written forms), the affective
domain (information that appeals to a persons feelings, beliefs,
or values), and the psychomotor domain (learning by doing).
Three age-related categories of learners are pedagogic (children),
androgogic (young and middle-aged adults), and gerogogic (older
adults).
Examples of characteristics unique to gerogogic learners are that
they are motivated to learn by a personal need, they may be experiencing degenerative physical changes, and they can draw on a
vast repertoire of past experiences.
Before teaching a client, the nurse assesses the clients learning
style, age and development, capacity to learn (includes level of literacy, any sensory deficits, and cultural differences), ability to
pay attention and concentrate, motivation, learning readiness,
and learning needs.

legibly; record the time of each entry; fill all the space on a line;
use only approved abbreviations; describe information objectively, providing precise measurements when possible; avoid
obliterating information; and sign each entry by name and title.
Written forms of communication other than the medical record
include the nursing care plan, nursing Kardex, checklists, and
flow sheets.
In addition to the written record, the health care team may
exchange information during change of shift reports, client care
assignments, team conferences, rounds, and telephone calls.

Chapter 10
The process of admission involves obtaining authorization from

Chapter 9
Medical records are used as a permanent account of a persons

health problems, care, and progress; to share information among

health care personnel; as a resource for investigating the quality
of care in an institution; to acquire and maintain JCAHO accreditation; to obtain reimbursement for billed services and products;
to conduct research; and as legal evidence in malpractice cases.
Medical records generally contain an information sheet about the
client, medical information, a plan of care, nursing documentation, medication administration records, and laboratory and
diagnostic test results.
Health care agencies may organize information in the medical
record using a source-oriented or a problem-oriented format.
Source-oriented records categorize information according to the
source reporting it; problem-oriented records are organized
according to the clients health problems regardless of who does
the documentation.
Nurses may document information in the medical record using
one of the following methods: narrative charting, SOAP charting, focus charting, PIE charting, charting by exception, and computerized charting.
HIPAA legislation was enacted originally to protect health information communicated from one insurance company to another
when a person changed employment. Recent revisions to that
legislation now regulate methods for further ensuring the clients
privacy in the workplace and security of data.
Regardless of the charting style, all documentation in an acute
health care agency includes ongoing assessment data, a plan of
care, a record of the care provided, and the outcomes of the implemented care.
Nurses use only agency-approved abbreviations when documenting information to promote clarity in communication
among health professionals and to ensure accurate interpretation
of the documented information if the chart is subpoenaed as legal
evidence.
Military time is based on a 24-hour clock. Each time is indicated
using a different four-digit number. After noon, the time is identified by adding 12 to each hour.
Some principles of charting include the following: ensure that the
documentation form identifies the client; use a pen; print or write

a physician, obtaining billing information, completing nursing

responsibilities such as orienting the client and obtaining a data
base assessment, developing an initial plan for nursing care, and
fulfilling medical responsibilities such as documenting the
clients history and results of a physical examination.
Some common reactions of newly admitted clients are anxiety,
loneliness, potential for compromised privacy, and loss of identity.
The discharge process consists of obtaining a written medical
order for discharge, completing discharge instructions, notifying
the business office, helping the client leave the agency, writing a
summary of the discharge in the medical record, and requesting
that the room be cleaned.
A transfer involves discharging a client from one unit or agency
and admitting him or her to another without going home in the
interim. A referral involves sending a client who will be discharged to another person or agency for special services.
Extended care facilities, such as nursing homes, may provide
skilled, intermediate, or basic care.
To determine the level of care a client requires, federal law
requires licensed extended care facilities to complete a Minimum
Data Set assessment form on admission and every 3 months
thereafter or whenever the clients condition changes.
The demand for home health care services has increased due to
limits on insurance reimbursement for hospital stays and the
growing number of older adults in the population who need
health care assistance.

Chapter 11
Vital signs include temperature, pulse, respirations, and blood
pressure.

Shell temperature is the degree of warmth at the skin surface;

core temperature is the degree of warmth near the center of the

body where vital organs are located.
Temperature is measured using the Celsius or Fahrenheit scale.
The mouth, rectum, axilla, and ear are common sites for assessing body temperature; the temperature of the tympanic membrane in the ear is the closest approximation of core temperature.
Electronic, infrared, chemical, and digital thermometers are used
to assess body temperature; glass mercury thermometers are no
longer recommended for use because mercury is an environmental and human toxin.
A fever exists when a client has a body temperature that exceeds
99.3F (37.4C). Hyperthermia is a life-threatening condition
characterized by a body temperature that exceeds 105.8F
(40.6C).
A fever generally has four phases: prodromal, onset or invasion,
stationary, and resolution or defervescence.
A fever is accompanied by chills, flushed skin, irritability, and
headache as well as several other signs and symptoms.

APPENDIX A Chapter Summaries

An infrared tympanic thermometer is the best assessment tool

for measuring subnormal temperatures because other common

clinical thermometers cannot accurately measure temperatures
in hypothermic ranges and the blood flow in the mouth, rectum,
and axilla is generally so low that measurements taken from
these sites are inaccurate.
Subnormal temperatures are accompanied by shivering, pale
skin, listlessness, and impaired muscle coordination as well as
several other signs and symptoms.
A pulse assessment includes the rate per minute, rhythm, and
volume.
The radial artery is the most common pulse assessment site; however, similar data may be obtained by assessing the apical heart
rate or the apical-radial rate or by using a Doppler ultrasound
device.
Respiration refers to the exchange of oxygen and carbon dioxide.
Ventilation is the movement of air in and out of the chest. The
rate of ventilations is assessed when obtaining vital signs.
Some abnormal breathing characteristics that may be noted are
tachypnea (rapid breathing), bradypnea (slow breathing), dyspnea (labored breathing), and apnea (absence of breathing).
Blood pressure measurements reflect the ability of the arteries to
stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood.
Systolic pressure is the pressure within the arterial system when
the heart contracts. Diastolic pressure is the pressure within the
arterial system when the heart relaxes and fills with blood.
A stethoscope, an inflatable cuff, and a sphygmomanometer are
usually required for measuring blood pressure.
During an auscultated blood pressure assessment, five distinct
sounds, called Korotkoff sounds, are heard. Phase I is characterized by faint tapping sounds; in phase II, the sounds are swishing; in phase III, the sounds are loud and crisp; in phase IV, the
sound becomes suddenly muffled; and in phase V there is one last
sound, followed by silence.
Besides mercury and aneroid manometers, blood pressure may
be measured with an electronic sphygmomanometer, which provides a digital display of the pressure measurements; there is a
movement to eliminate the use of mercury sphygmomanometers.
The blood pressure also can be measured by palpating the
brachial pulse while releasing the air from the cuff bladder, by
using a Doppler stethoscope or an automated blood pressure
machine, or taking the blood pressure at the thigh.

Chapter 12
Physical assessments are performed to evaluate the clients cur-

rent physical condition, to detect early signs of developing health

problems, to establish a database for future comparisons, and to
evaluate responses to medical and nursing interventions.
There are four physical assessment techniques: inspection, percussion, palpation, and auscultation.
Before performing a physical assessment, the nurse needs gloves,
examination gown, cloth or paper drape, stethoscope, penlight,
and tongue blade as well as other assessment instruments for taking vital signs and weighing and measuring the client.
The assessment environment should be near a restroom, private,
warm, and adequately lit. There should be an adjustable examination table or bed.
During an initial survey of a client, the nurse observes physical
appearance, level of consciousness, body size, posture, gait, movement, use of ambulatory aids, and mood and emotional tone.
Drapes during a physical examination protect the clients modesty and provide warmth.
There are two approaches for data collection. The head-to-toe
approach involves gathering data from the top of the body then

815

working toward the feet. The systems approach organizes data

collection according to the functional systems of the body.
The body may be divided into six general components when
organizing data collection: the head and neck, the chest, the
extremities, the abdomen, the genitalia, and the anus and rectum.
Whenever an opportunity arises, nurses teach adult clients how
to perform breast and testicular self-examinations.

Chapter 13
An examination is a procedure that involves the physical inspec

tion of body structures and evidence of their functions. A test

involves the examination of body fluids or specimens.
Whenever clients undergo special examinations and tests, the
nurse is generally responsible for determining the clients understanding of the procedure, checking that the consent form is
signed, following test preparation requirements or teaching outpatients how to prepare themselves, obtaining equipment and
supplies, arranging the examination area, positioning and draping clients, assisting the examiner, providing clients with physical and emotional support, caring for specimens, and recording
and reporting significant information.
The five common examination positions are dorsal recumbent,
Sims, lithotomy, kneechest, and modified standing.
A pelvic examination involves the inspection and palpation of
the vagina and adjacent organs. This examination often includes
the collection of secretions for a Pap test to identify any abnormal cells, levels of hormone activity, and identity of infectious
microorganisms.
Tests and examinations commonly involve the use of x-rays,
endoscopes, radioactive substances, sound waves, and electrical
activity.
When determining how particular tests are performed, it is helpful to understand four word endings: -graphy, as in angiography,
means to record an image; -scopy, as in bronchoscopy, means to
look through a lensed instrument; -centesis, as in amniocentesis,
means to puncture; and -metry, as in pelvimetry, means to measure with an instrument.
Nurses often are called on to assist with sigmoidoscopy (inspecting the rectum and sigmoid section of the lower intestine with an
endoscope), paracentesis (puncturing the skin and withdrawing
fluid from the abdominal cavity), and lumbar puncture (inserting a needle between lumbar vertebrae in the spine but below the
spinal cord itself); to collect a throat culture specimen; and to
measure capillary blood glucose levels using a glucometer.
When the client undergoing special examinations and tests is an
older adult, the nurse faces special challenges such as preventing
fatigue and dehydration, maintaining or adjusting current drug
therapy and avoiding misinterpretation of laboratory test results
that are based on norms for younger adults.

Chapter 14
Nutrition is the process by which the body uses food. Malnutrition results from inadequate consumption of nutrients.

The components of basic nutrition include adequate calories,

proteins, carbohydrates, fats, vitamins, and minerals.

Some factors that affect nutritional needs include age, height and
weight, growth, activity, and health status.

The food pyramid is a guide for promoting a healthy intake of

food. It recommends the number of servings and the portion sizes
for meat or its substitute, dairy products, fruits, vegetables, and
grain products to acquire 2000 calories per day.
Nutrition labels must indicate the serving size in household measurements and the daily value for specific nutrients per serving.

816

APPENDIX A Chapter Summaries

They must meet specified criteria if they make health-related
claims for the product.
Protein complementation is the practice of combining two or
more plant protein sources to obtain all the essential amino acids
required for healthy nutrition.
A diet history is the information obtained by asking a person to
describe his or her eating habits and factors that may affect
nutrition.
Data that provide objective information about a persons nutritional status include anthropometric measurements, physical
examination data, and results from laboratory tests.
Problems commonly identified after a nutritional assessment
include weight problems, anorexia, nausea, vomiting, and stomach gas.
Common hospital diets are regular, light, soft, mechanical soft,
full liquid, and clear liquid, and various therapeutic modifications
to these diets.
Nurses are generally responsible for ordering and canceling diets
for clients, serving and collecting meal trays, helping clients to
eat, and recording the percentage of food eaten.
Nurses must know the type of diet prescribed for each client, the
purpose for the diet, and its characteristics.
Influences on the nutritional status of older adults include agerelated physical changes, underlying medical conditions, adverse
effects of medication therapy, functional impairments, psychosocial conditions, and socioeconomic and environmental barriers.

vented or unvented tubing, which drop size is most appropriate,

and whether or not a filter is needed.
IV fluids may be infused by gravity or with the assistance of an
infusion device such as a pump or volumetric controller.
When selecting a vein for venipuncture, the nurse gives priority to
a vein in the nondominant hand or arm that is fairly straight, is
larger than the needle or catheter gauge, is likely to be undisturbed
by joint movement, and appears unimpaired by previous trauma
or use.
Complications of IV fluid therapy include infiltration, phlebitis,
infection, circulatory overload, thrombus formation, pulmonary
embolus, and air embolism.
An intermittent venous access device is used in clients who
require intermittent IV fluid or medication administration or for
emergency access to the vascular system.
When administering blood, the nurse assesses vital signs before
and during the transfusion; uses no smaller than a 20-gauge needle or catheter, normal saline solution, and Y-set tubing; and
infuses the blood within 4 hours or less.
During a blood transfusion, the nurse monitors the client closely
for incompatibility; febrile, septic, and allergic reactions; chilling;
circulatory overload; and signs of hypocalcemia.
Parenteral nutrition is a technique for providing nutrients, such
as protein, carbohydrate, fat, vitamins, minerals, and trace elements, intravenously rather than orally.

Chapter 16
Chapter 15

Hygiene refers to practices that promote health through personal

cleanliness.

Body fluid is a mixture of water, chemicals called electrolytes and

Hygiene practices that most people perform regularly include

nonelectrolytes, and blood cells.

bathing, shaving, oral hygiene, hair care, and nail care.

Body fluid is distributed inside cells, called the intracellular com-

A partial bath is more appropriate for older adults than a daily

partment, and outside cells, called the extracellular compartment;

the latter is subdivided further into the fluid between cells (interstitial fluid) and within blood (intravascular fluid).
Fluid and its components are distributed within each fluid compartment by means of osmosis, filtration, passive diffusion, facilitated diffusion, and active transport.
The nurse assesses fluid volume status by measuring a clients
intake and output, obtaining daily weights, obtaining vital signs,
monitoring bowel elimination patterns and stool characteristics,
observing the color of urine, and assessing skin turgor, the condition of the oral mucous membranes, lung sounds, and level of
consciousness.
Fluid volume is restored by treating the underlying disorder,
increasing oral intake, administering IV fluid replacements, controlling fluid losses, or a combination of these measures.
Fluid volume excess is reduced or eliminated by treating the
underlying disorder, restricting or limiting oral fluids, reducing
salt consumption, discontinuing IV fluid infusions or reducing
the infusing volume, administering drugs that promote urine
elimination, or a combination of these interventions.
IV fluids are administered to maintain or restore fluid balance,
maintain or replace electrolytes, administer water-soluble vitamins, provide calories, administer drugs, and replace blood and
blood products.
Crystalloid solutions are mixtures of water and substances such as
salt and sugar that totally dissolve. Colloid solutions are mixtures
of water and suspended, undissolved substances such as blood cells.
An isotonic solution has the same concentration of dissolved substances as plasma; a hypotonic solution has fewer dissolved substances; and a hypertonic solution is more concentrated than
plasma.
When selecting tubing for administering IV solutions, the nurse
must consider whether to use primary or secondary tubing and

tub bath or shower, because they do not perspire as much as

young adults and soap tends to dry their skin.
Towel and bag baths add lubrication to the skin; avoid friction to
preserve skin integrity; reduce transmission of microorganisms
from one part of the body to another; save time; provide more
opportunity for self-care; and promote comfort because of the
warmth of the liquid.
Use of a safety razor is contraindicated for clients who have clotting disorders, those receiving anticoagulants and thrombolytics,
and those who are depressed and suicidal.
Most dentists recommend using a soft-bristled or electric toothbrush, tartar-control toothpaste with fluoride, and dental floss.
The chief hazard in providing oral hygiene for unconscious clients
is aspiration of liquid into the lungs. To prevent aspiration, nurses
position unconscious clients on the side with the head lower than
the body. They use oral suction equipment to remove liquid from
the mouth.
To prevent damage during cleaning, the nurse holds dentures over
a plastic or towel-lined container and uses cold or tepid water.
The nurse can detangle a clients hair by applying conditioner,
using a wide-toothed comb, and combing from the end of the hair
toward the scalp.
The nurse consults the physician about nail care for clients with
diabetes or poor circulation.
Daily hygiene also includes cleaning and caring for visual or
hearing devices such as eyeglasses, contact lenses, artificial eyes,
or hearing aids.
Clients who cannot insert and care for contact lenses may consider wearing eyeglasses, using a magnifying lens, or doing without while they are ill.
The sound that a hearing aid produces may be altered as a
result of dead or weak batteries, batteries that are not making
full contact, corroded batteries, malposition within the ear,

APPENDIX A Chapter Summaries

excessive volume, impacted cerumen, and dirty or damaged
components.
Infrared listening devices are an alternative to hearing aids. They
convert sound into infrared light then reconvert the light to
sound through a receiver worn in a headset with earphones.

Chapter 17

Comfort is a state in which a person is relieved of distress. Rest

is a waking state characterized by reduced activity and mental

stimulation. Sleep is a state of arousable unconsciousness.
Some environmental factors that promote comfort, rest, and
sleep are colorful walls and room decor, reduced noise, increased
natural sunlight, and a comfortable climate.
Standard furnishings in all client rooms are the bed, the overbed
table, the bedside stand, and at least one chair.
Sleep is a basic human need. Among other things, it reduces
fatigue, stabilizes mood, increases protein synthesis, promotes
cellular growth and repair, and improves the capacity for learning and memory storage.
The two phases of sleep are nonrapid and rapid eye movement
sleep. During nonrapid eye movement (NREM) sleep and its
four subdivisions, the body is active but the brain is not. During
rapid eye movement (REM) sleep, the body is physically inactive
but the brain is highly active.
As humans age, they sleep fewer hours and spend less time in
REM sleep. Newborns spend 16 to 20 hours of each day sleeping,
approximately half in the REM phase. Older adults require 7 to
9 hours of sleep and spend only 13% to 15% in the REM phase.
Circadian rhythms, activity, the environment, motivation, emotions and moods, food and beverages, illness, and drugs can affect
the amount and quality of sleep.
Four major categories of drugs either promote or interfere with
sleep. Sedatives and tranquilizers produce a relaxing and calming
effect, hypnotics induce sleep, and stimulants excite structures in
the brain, causing wakefulness.
Sleep questionnaires, sleep diaries, polysomnographic evaluations, and the multiple sleep latency test are techniques used to
assess sleep patterns.
Sleep disorders fall into four major categories: insomnia (difficulty
falling asleep or staying asleep, or early-morning awakening),
hypersomnias (conditions resulting in daytime sleepiness despite
adequate nighttime sleep), sleepwake cycle disturbances (resulting from desynchronized periods of sleeping and wakefulness), and
parasomnias (associated with activities that cause arousal or partial arousal usually during transitions in NREM periods of sleep).
Sleep is promoted by exercising regularly during the day; avoiding alcohol, nicotine, and caffeine; performing sleep rituals; going
to bed and getting up at about the same time every day; and getting out of bed if sleep does not come easily and returning after
some nonstimulating activity.
To promote relaxation, which facilitates the onset of sleep, nurses
assist clients with progressive relaxation exercises or provide a
back massage.
Older adults tend to have more difficulty falling asleep, they
awaken more readily, and they spend less time in the deeper
stages of sleep. This explains why some older adults feel tired
even though they have slept an appropriate time.

Chapter 18

817

School-aged children suffer play-related injuries, and adolescents

are often the victims of sport-related injuries. Young adults commonly are involved in motor-vehicle accidents. Middle-aged
adults suffer a variety of physical traumas such as back injuries.
Falls are common among older adults.
Environmental hazards often contribute to injuries and deaths
from latex sensitization, burns, asphyxiation, electrical shock,
poisoning, and falls.
Measures to reduce latex sensitization include using nonlatex
gloves and medical equipment, washing hands after removing
latex gloves, and avoiding use of petroleum-based hand creams
or lotions, which retain latex protein on the skin.
Most fire plans incorporate four steps: rescue those in danger,
sound an alarm, confine the fire, and extinguish the blaze.
There are four classes of fire extinguishers. Class A extinguishers
are used for paper, wood, and cloth fires. Class B extinguishers are
used on fuels and flammable liquids. Class C extinguishers are
used for electrical fires. Class ABC extinguishers can be used on
any type of fire.
Methods of preventing burns include installing and maintaining
smoke detectors, developing and practicing a fire evacuation
plan, and never going back into a burning building.
Common causes of asphyxiation include smoke inhalation, carbon monoxide poisoning, and drowning.
Measures to prevent drowning are wearing approved flotation
devices, avoiding alcohol consumption when around water, and
never swimming alone.
Humans are susceptible to injury from electrical shock because
the human body is predominately composed of water and electrolytes, which are good conductors of electrical current.
Electrical shock may be prevented by using three-pronged
grounded equipment, making sure all cover plates are intact, and
replacing equipment with frayed electrical cords.
Substances commonly implicated in poisonings include chemicals such as drugs, cleaning agents, paint solvents, heavy metals,
cosmetics, and plants.
Poisonings may be prevented by using childproof caps on medication bottles, installing latches on storage cupboards, and never
transferring a toxic substance to a container generally associated
with food.
Older adults in general are prone to falling because they have gait
and balance problems resulting from age-related changes, visual
impairment, postural hypotension, and urinary urgency.
Although physical restraints prevent falls, they create concomitant risks for constipation, incontinence, infections such as pneumonia, pressure ulcers, and a progressive decline in the ability to
perform activities of daily living.
The overuse of physical restraints in health care facilities has led
to the passage of legislation and accreditation standards regulating their use.
Restraints are devices that restrict movement; restraint alternatives are protective and adaptive devices that clients can remove
independently.
Restraint use may be justified when clients have a history of previous falls or may experience life-threatening consequences, when
there has been an unsatisfactory response to restraint alternatives,
when clients are seriously impaired mentally or physically, or if
their movement must be restricted during a life-threatening event.
If an accident occurs, the nurses first concerns are the safety of
the client and the potential for allegations of malpractice.

Chapter 19

Accidental injuries vary according to the victims stage of development. Because infants must rely on their caretakers, they are
susceptible to falls. Poisonings are common among toddlers.

Pain is an unpleasant sensation usually associated with disease

or injury.

818

APPENDIX A Chapter Summaries

The sensation of pain is transmitted over nerves to peripheral

Nurses can improve the oxygenation of clients by positioning

receptors called nociceptors. Once the nerve impulse is transmitted up the spinal cord, it is delivered to the thalamus, cortex,
and limbic system areas of the brain.
The pain threshold is the point at which pain-transmitting neurochemicals reach the brain and cause conscious awareness known
as pain perception. Pain tolerance is the amount of pain a person
endures once the threshold has been reached.
Endogenous opioids are naturally produced chemicals with
morphine-like characteristics. It is believed that these chemicals
bind to sites on the nerve cells membrane, blocking the transmission of pain-producing neurotransmitters.
The five general types of pain are cutaneous pain, visceral pain,
neuropathic pain, acute pain, and chronic pain.
Acute pain differs from chronic pain in its duration, etiology, and
response to therapeutic measures.
When performing a basic pain assessment, the nurse asks the
client to describe the pains onset, quality, intensity, location,
and duration.
Four commonly used pain-intensity assessment tools are a numeric scale, a word scale, a linear scale, and a picture scale like
the Wong-Baker FACES Pain Rating Scale.
A pain assessment is performed, at a minimum, on admission,
once per shift when pain is an actual or potential problem, and
before and after implementing a pain-management intervention.
The physiologic basis for pain management involves interrupting pain-transmitting chemicals at the site of injury, altering
pain transmission at the spinal cord, and blocking pain perception in the brain.
Three categories of drugs used to manage pain are nonopioids,
opioids, and adjuvant drugs. The injection of botulinum toxin is
a fairly new method for treating painful skeletal muscle conditions and headaches.
Rhizotomy and cordotomy are surgical pain-management techniques used when other methods are ineffective.
Examples of nondrug/nonsurgical methods of pain management
are educating clients about pain and its control and using
imagery, meditation, distraction, relaxation, and interventions
such as applications of heat and cold, transcutaneous electrical
nerve stimulation, acupuncture and acupressure, percutaneous
electrical nerve stimulation, biofeedback, and hypnosis.
Clients often request frequent doses of pain-relieving medications because the dosage or schedule for administration is not
controlling the pain.
The fear of addiction leads to inadequate pain management.
A placebo is an inactive substance given as a substitute for an
actual drug. The positive effect some clients have from placebos
probably results from the trust they have in the physician or
nurse.

clients with the head and chest elevated and teaching them to
perform breathing exercises.
When oxygen therapy is prescribed, a source for the oxygen, a
flowmeter, an oxygen delivery device, and in some cases an oxygen analyzer or humidifier are all needed.
Oxygen may be supplied through a wall outlet, in portable tanks,
within a liquid oxygen unit, or with an oxygen concentrator.
Most clients receive oxygen therapy through a nasal cannula, any
one of several types of masks, or a face tent. Those who have had
an opening created in their trachea may receive oxygen through
a tracheostomy collar, T-piece, or transtracheal catheter.
Whenever oxygen is administered, nurses must be concerned
about two hazards: the potential for fire and oxygen toxicity.
Older adults have unique respiratory risk factors for several
reasons. They often have age-related structural and functional
changes that may compromise ventilation and respiration.

Chapter 21
Microorganisms are living animals or plants visible only with a
microscope.

Some examples of microorganisms are bacteria, viruses, fungi,

rickettsiae, protozoans, mycoplasmas, helminths, and prions.

Nonpathogens are generally harmless microorganisms, whereas

Chapter 20

Ventilation is the act of moving air in and out of the lungs. Respiration refers to the mechanisms by which oxygen is delivered
to the cells.
External respiration takes place through alveolarcapillary membranes. Internal respiration occurs at the cellular level via hemoglobin and body cells.
The oxygenation status of clients can be determined at the bedside by performing focused physical assessments, monitoring
ABGs, and using pulse oximetry.
Five signs of inadequate oxygenation are restlessness, rapid
breathing, rapid heart rate, sitting up to breathe, and using accessory muscles.

pathogens have a high potential for causing infections and

contagious diseases. Resident microorganisms are generally
nonpathogens that are always present on the skin. Transient
microorganisms are generally pathogens that are more easily
removed through handwashing. Aerobic microorganisms require
oxygen for survival, whereas anaerobic microorganisms do not.
Some microorganisms have ensured their survival by developing
the capacity to form spores and resist antibiotic drug therapy.
The components of the chain of infection are an infectious agent,
a reservoir for growth and reproduction, an exit route from the
reservoir, a mode of transmission, a port of entry, and a susceptible host.
Several biologic defenses reduce susceptibility to infectious
agents. Examples include intact skin and mucous membranes;
reflexes such as sneezing, coughing, and vomiting; infectionfighting blood cells; enzymes such as lysozyme, which is present
in tears, saliva, and other secretions; the acidity of gastric acid;
and antibodies.
Nosocomial infections are those acquired by previously uninfected
clients while they are being cared for in a health care facility.
Asepsis refers to practices that decrease the numbers of infectious agents, their reservoirs, and vehicles for transmission.
Medical asepsis involves practices that confine or reduce
microorganisms.
Principles of medical asepsis include frequent handwashing or
hand antisepsis and maintaining intact skin (the best methods
for reducing the transmission of microorganisms); using personal protective equipment (gloves, gown, mask, goggles, and
hair and shoe covers); and maintaining a clean environment.
Surgical asepsis involves measures that render supplies and
equipment totally free of microorganisms and practices that
avoid contamination during their use.
Surgical asepsis involves sterilization measures such as ultraviolet radiation, heat, or chemicals.
Three of the principles of surgical asepsis are as follows: sterility
is preserved by touching one sterile item with another sterile
item; once a sterile item touches something that is not sterile, it
is considered contaminated; and any partially unwrapped sterile
package is considered contaminated.

APPENDIX A Chapter Summaries

819

Nurses apply principles of surgical asepsis when they create a

Ergonomics is a field of engineering science devoted to pro-

sterile field, add supplies or liquids to a sterile field, and don sterile gloves.

moting comfort, performance, and health in the workplace by

improving the design of the work environment and equipment
that is used. Two examples of ergonomic recommendations are
to use assistive devices when lifting or transporting heavy
items and to use alternatives for tasks that require repetitive
motions.
Disuse syndrome is associated with weakness, atony, poor alignment, contractures, foot drop, impaired circulation, atelectasis,
urinary tract infections, anorexia, and pressure sores.
Common client positions are supine (on the back), lateral (on the
side), lateral oblique (on the side with slight hip and knee flexion),
prone (on the abdomen), Sims (semiprone on the left side with
the right knee drawn up toward the chest), and Fowlers (semisitting or sitting).
Positioning devices include the following: adjustable bedallows
the position of the head and knees to be changed; pillows
provide support and elevate a body part; trochanter rolls
prevent legs from turning outward; hand rollsmaintain function of the hand and prevent contractures; and foot boardskeep
the feet in normal walking position.
Pressure-relieving devices include the following: siderailshelp
clients to change position; mattress overlaysreduce pressure
and restore skin integrity; and cradlekeeps linen off clients
feet or legs.
Devices used to help transfer clients include a transfer handle, a
transfer belt, a transfer board, and a mechanical lift.
Guidelines to follow when transferring clients include the following: know the clients diagnosis, capabilities, weaknesses, and
activity level; be realistic about how much you can safely lift;
transfer clients across the shortest distance possible; solicit the
clients help; and use smooth rather than jerky movements.

Chapter 22
Infectious diseases, also called community-acquired, contagious,

or communicable diseases, are spread from one person to another.

An infection is a condition that results when microorganisms

cause injury to their host. Colonization refers to a condition in

which microorganisms are present but the host is not damaged
and has no signs or symptoms.
Infectious diseases usually follow five stages: incubation, prodromal, acute, convalescent, and resolution.
Infection control measures are designed to curtail the spread of
infectious diseases.
The two major categories of infection control measures are standard precautions and transmission-based precautions.
Standard precautions are measures for reducing the risk of microorganism transmission from both recognized and unrecognized
sources of infection.
Transmission-based precautions are measures to control the
spread of infectious agents from clients known to be or suspected
of being infected with pathogens.
The three categories of transmission-based precautions are airborne precautions, droplet precautions, and contact precautions.
Airborne precautions are used to block very small pathogens that
remain suspended in the air or are attached to dust particles.
Droplet precautions are used to block larger pathogens contained
within moist droplets. Contact precautions are used to block the
transmission of pathogens by direct or indirect contact.
Personal protective equipment is defined as garments that block
the transfer of pathogens from a person, place, or object to oneself or others.
When removing personal protective equipment, nurses perform
an orderly sequence, accompanied by handwashing, to prevent
self-contamination and transmission of pathogens to others.
Double-bagging is an infection control measure for removing
contaminated items such as trash or laundry from the clients
environment. It involves placing one bag within another held by
someone outside the clients room.
Clients with infectious diseases often have decreased social
interaction and sensory deprivation because they are confined to
their room.
To prevent infections, people should obtain appropriate immunizations; practice a healthy lifestyle such as eating the recommended number of servings from the Food Pyramid; and avoid
sharing personal items such as washcloths and towels, razors,
and cups.
Symptoms of infectious disorders tend to be subtler in older adults.

Chapter 23
Posture involves standing, sitting, and lying postions.
When standing, keep the feet parallel and distribute weight equally
on both feet to provide a broad base of support.
When sitting, the buttocks and upper thighs are the base of support on the chair; both feet rest on the floor.
Correct posture for lying down is the same as for standing but in
the horizontal plane; body parts are in neutral position.
Principles of correct body mechanics include the following: distribute gravity through the center of the body over a wide base of
support; push, pull, or roll objects rather than lifting them; and
hold objects close to the body.

Chapter 24
Regular exercise has many benefits including reduced blood pres

sure, blood glucose and blood lipid levels, tension, and depression
and increased bone density.
Fitness refers to a persons capacity to perform physical activities.
Factors that interfere with fitness include chronic inactivity, concurrent health problems, impaired musculoskeletal function,
obesity, advancing age, smoking, and high blood pressure.
Several approaches can be used to determine a persons level of
fitness. Two objective methods are a stress electrocardiogram
and a submaximal fitness test such as a step test.
Exercise, regardless of type, should be performed within the persons target heart rate, which is calculated by subtracting the
persons age from 220 (maximum heart rate) then multiplying
that number by 60% (0.6) to 90% (0.9), based on the persons
fitness level.
Metabolic energy equivalent (MET) is the measure of energy and
oxygen consumption that a persons cardiovascular system can
support safely. When an exercise prescription is given, exercises
are correlated with their MET value.
Fitness exercises are physical activities that develop and maintain
cardiorespiratory function, muscular strength, and endurance in
healthy adults. Therapeutic exercises involve physical activities
designed to prevent health-related complications from an established medical condition or its treatment or to restore lost physical functions.
Isotonic exercise involves movement and work; an example is
aerobic exercise. Isometric exercise refers to stationary activities
performed against a resistive force; examples are body building
and weight lifting.

820

APPENDIX A Chapter Summaries

Active exercise is performed independently after proper instruction. Passive exercise is performed with the assistance of another
person.
Range-of-motion (ROM) exercise is a form of therapeutic exercise that moves joints in the directions they normally permit.
ROM exercises can be active or passive. Two common reasons
for performing them are to maintain joint mobility and flexibility, especially in inactive clients, and to evaluate the clients
response to a therapeutic exercise program.
Nurses encourage older adults to exercise by walking in shopping
malls or joining social groups that include activities such as line
dancing or ballroom dancing.

Parallel bars and walking belts are devices used to assist clients
with ambulation.

Three types of ambulatory aids are canes, walkers, and crutches.

Walkers are the most stable form of ambulatory aid. Straight
canes are the least stable.

Crutches should permit the client to stand upright with the shoul-

Chapter 25
Immobilization is used to relieve pain and muscle spasm, sup

port and align skeletal injuries, and restrict movement while

injuries heal.
Four types of splints include inflatable splints, traction splints,
immobilizers, and molded splints.
Slings are cloth devices used to elevate and support parts of the
body. Braces are custom-made or custom-fitted devices designed
to support weakened structures during activity.
Cast are rigid molds used to immobilize an injured structure that
has been restored to correct anatomic alignment. Casts are formed
from plaster of Paris or fiberglass.
Three types of casts are cylinder, body, and spica.
Appropriate nursing care of clients with casts includes checking
circulation, mobility, and sensation in the area of the cast; using
the palms of the hands to handle a wet cast; elevating the casted
extremity to reduce swelling; circling areas where blood has
seeped through; and padding and reinforcing the cast edges to
prevent skin breakdown.
Most casts are removed with an electric cast cutter, an instrument
that looks like a circular saw.
Traction is the application of a pulling effect on a part of the
skeletal system.
Three types of traction are manual traction, skin traction, and
skeletal traction.
To be effective, traction must produce a pulling effect on the
body, countertraction must be maintained, the pull of traction
and the counterpull must be in exactly opposite directions,
splints and slings must be suspended without interference, ropes
must move freely through each pulley, the prescribed amount of
weight must be applied, and the weights must hang free.
An external fixator is used to stabilize fragments of broken bones
during healing.
Pin site care is essential for preventing infection because the
insertion of pins impairs skin integrity and provides a port of
entry for pathogens.

Chapter 27
Perioperative care refers to the nursing care that clients receive
before, during, and after surgery.

Perioperative care spans the preoperative, intraoperative, and

postoperative periods.

Inpatient surgery is performed on clients who remain in the hos

Chapter 26

Activities that help to prepare clients for ambulation include performing isometric exercises with the lower limbs, strengthening
the upper arms, dangling at the bedside, and using a tilt table.
Two isometric exercises that tone and strengthen the lower
extremities are quadriceps setting and gluteal setting.
The upper arms are strengthened by a regimen of flexing and
extending the arms and wrists, raising and lowering weights
with the hands, squeezing a ball or spring grip, and performing
modified hand push-ups while in a bed or chair.
Clients dangle or are placed on a tilt table to normalize their blood
pressure and help them adjust to being upright.

ders relaxed, provide space for two fingers between the axilla and
the axillary bar, and facilitate approximately 30 degrees of elbow
flexion and slight hyperextension of the wrist.
A temporary prosthesis facilitates early ambulation, promotes an
intact body image, and controls stump swelling immediately after
surgery.
The permanent prosthesis is constructed when the surgical
wound heals and the stump size is relatively stable.
Components of permanent prostheses for BK amputees are a
socket, a shank, and an ankle/foot system; AK prostheses also
include a knee system.
To apply a prosthetic limb, the client covers the stump with an
optional nylon sheath over which one or more stump socks are
applied. A nylon stocking is used to ease the sock-covered stump
into the socket and is eventually removed. The client pumps the
stump within the socket to expel air and create a vacuum seal. If
the socket has supportive belts or slings, they are fastened when
the stump is well seated in the socket.
Older adults tend to acquire flexion of the spine as they get older;
this may alter their center of gravity. They tend to compensate
by flexing their hips and knees when walking and may have a
swaying or shuffling gait.

pital at least overnight. Outpatient surgery is performed on

clients who return home the same day.
Laser surgery, which can be performed on an outpatient basis,
offers several advantages: it is cost effective, requires smaller
incisions, results in minimal blood loss, and produces less pain.
Some clients choose to donate their own blood before surgery or
ask specific donors to do so.
Four major activities for nurses to complete during the immediate preoperative period are conducting a nursing assessment,
providing preoperative teaching, preparing the skin, and completing the surgical checklist.
Nurses teach preoperative clients how to perform deep breathing, coughing, and leg exercises.
Surgical clients wear antiembolism stockings to prevent thrombi
and emboli.
Preoperative skin preparation consists of the removal of hair
with electric clippers, depilatory agents, or a safety razor depending on agency policy and medical orders.
On the preoperative checklist, the nurse verifies that the history
and physical examination have been completed, the name of the
procedure matches the one scheduled, the surgical consent form
has been signed and witnessed, the client is wearing an identification bracelet, and all laboratory test results have been returned
and reported if abnormal.
The receiving room, the operating room, and the surgical waiting room are three areas in the surgical department used during
the intraoperative period.
During immediate postoperative care, nurses focus on monitoring the client for complications, preparing the clients room, and
continuing assessments to detect developing problems.

APPENDIX A Chapter Summaries

Common postoperative complications are airway obstruction,

hemorrhage, pulmonary embolus, and shock.
During recovery, a pneumatic compression device may be prescribed to promote circulation of venous blood and relocation of
excess fluid into the lymphatic vessels.
Discharge instructions for surgical clients include how to care for
the incisional site, signs of complications to report, and how to
self-administer prescription drugs.
Older adults have unique surgical needs and problems. For example, the period of fluid restriction before surgery may be shortened
for older adults to reduce their risk for dehydration and hypotension. Also, the cardiac status of older adults must be monitored
carefully after surgery because they may not be able to circulate
or eliminate intravenous fluids given at standard rates.

Four types of tubes used to intubate the GI system are orogastric,

nasogastric, nasointestinal, and transabdominal tubes.

Common assessments performed before inserting a tube nasally

Chapter 28

A wound is damaged skin or soft tissue.

Wound repair involves three sequential phases: inflammation,

proliferation, and remodeling.

Signs and symptoms classically associated with inflammation are
swelling, redness, warmth, pain, and decreased function.
Phagocytosis, a process that removes pathogens, coagulated blood,
and cellular debris, is performed by white blood cells known as
neutrophils and monocytes.
The integrity of damaged skin and tissue is restored by resolution, regeneration, or scar formation.
Wounds heal by first, second, or third intention.
Two common types of wounds that require special care are pressure ulcers and surgical wounds.
Some purposes for covering a wound with a dressing are keeping
it clean, absorbing drainage, and controlling bleeding.
A moist wound heals more quickly because new cells grow more
rapidly in a wet environment.
Open or closed drains are placed in or near a wound to remove
blood and drainage.
Sutures or staples hold the edges of an incision together.
A bandage or binder helps to hold a dressing in place especially
when tape cannot be used or the dressing is extremely large;
reduces pain by supporting the wound; or limits movement to
promote healing.
A T-binder is used to secure a dressing to the anus, perineum, or
groin.
Four methods used to debride nonliving tissue from a wound are
sharp debridement, enzymatic debridement, autolytic debridement, and mechanical debridement. A wound irrigation is an
example of mechanical debridement.
An irrigation is used to flush debris from a wound or body area
such as the eye, ear, or vagina.
Heat is applied to promote circulation and speed healing; cold is
used to prevent swelling and control bleeding.
Methods for applying heat or cold include ice bags, compresses,
soaks, and therapeutic baths.
Five factors that place clients at risk for developing pressure
ulcers are inactivity, immobility, malnutrition, dehydration, and
incontinence.
Techniques for preventing pressure ulcers include changing
clients positions every 1 to 2 hours, keeping the skin clean and
dry, and preventing friction and shearing force on the skin.

The urinary system is composed of the kidneys, ureters, bladder,

Chapter 29

ications; obtain diagnostic samples; remove poisons, gases, and

secretions; and control bleeding.

include determining the clients level of consciousness, the characteristics and location of bowel sounds, the structure and
integrity of the nose, and the clients ability to swallow, cough,
and gag.
A NEX measurement helps to determine how far to insert a tube
for stomach placement. It is the distance from the nose to the earlobe then to the xiphoid process.
Nurses check stomach placement of tubes by aspirating gastric
fluid, auscultating the abdomen as they instill a bolus of air, and
testing the pH of aspirated fluid.
Nasointestinal feeding tubes differ from their nasogastric counterparts in that they are longer, narrower, and more flexible;
their lubricant is bonded to the tube; they are frequently inserted
with a stylet; and an x-ray is used to confirm their placement.
Although transabdominal feeding tubes can be used for long periods, they are prone to leaking and causing skin impairment.
Enteral nutrition refers to nourishing clients by means of the
stomach or small intestine rather than the oral route.
Four common schedules for administering tube feedings are
bolus, intermittent, cyclic, and continuous.
Nurses check gastric residual to determine if the rate or volume
of feeding exceeds the clients physiologic capacity.
Caring for clients with feeding tubes involves maintaining tube
patency, clearing any obstructions, providing adequate hydration,
dealing with common formula-related problems, and preparing
clients for home care.
Before discharge, nurses provide clients who will administer their
own tube feedings at home with written instructions on ways to
obtain equipment and formula, the amount and schedule for each
feeding, guidelines for delaying a feeding, and skin or nose care.
When assisting with the insertion of a tungsten-weighted tube,
nurses are responsible for promoting and monitoring its movement into the intestine.

Chapter 30

Intubation refers to the insertion of a tube into a body structure.

GI intubation is used to provide nourishment; administer med-

821

and urethra. Collectively these organs serve to produce urine,

collect it, and excrete it from the body.
Various factors affect urination such as a persons neuromuscular development, the integrity of the spinal cord, the volume of
fluid intake, fluid losses from other sources, and the amount and
type of food consumed.
The physical characteristics of urine include its volume, color,
clarity, and odor.
Nurses often collect voided urine specimens, clean-catch urine
specimens, catheter specimens, and 24-hour urine specimens.
Some common abnormal patterns of urinary elimination include
anuria, oliguria, polyuria, nocturia, dysuria, and incontinence.
Other than a conventional toilet, a person may eliminate urine
in a commode, urinal, or bedpan.
Continence training is the process used to restore the ability to
empty the bladder at an appropriate time and place.
The three general types of catheters are external, straight, and
retention.
When using a closed drainage system, it is important to avoid
dependent loops in the tubing and the collection bag must be kept
below the level of the bladder.
Catheter care is important because it helps to deter the growth
and spread of colonizing pathogens.
Catheters are irrigated to keep them patent, or free-flowing. They
may be irrigated using an open or closed system or continuously
by way of a three-way catheter.

822

APPENDIX A Chapter Summaries

A urinary diversion is a procedure in which one or both ureters

are surgically implanted elsewhere.
Skin impairment is a common problem in clients with a urostomy
because they require frequent appliance changes and the contact
of urine with the skin causes skin irritation.
Older adults tend to have diminished bladder capacity and relaxation of pelvic floor muscles.

Chapter 31

A common problem when administering drugs through an enteral

tube is maintaining the tubes patency.

If a medication error occurs, nurses must report it to the prescriber and supervisor, assess the client for ill effects, and document the situation on an incident report or accident sheet.
Because older adults have age-related changes in digestion, metabolism, and elimination, nurses observe them closely for adverse
reactions to medications.

Chapter 33

Defecation, the elimination of stool, occurs when peristalsis

moves fecal waste toward the rectum and the rectum distends,
creating an urge to relax the anal sphincters; this releases stool.
Two components of a bowel elimination assessment include
elimination patterns and stool characteristics.
Constipation, fecal impaction, flatulence, diarrhea, and fecal
incontinence are common alterations in bowel elimination.
The four types of constipation are primary constipation (which
nurses can treat independently), secondary constipation, iatrogenic constipation, and pseudoconstipation.
When bowel elimination does not occur naturally, inserting a rectal suppository or administering an enema can promote defecation.
Two categories of enemas are cleansing and oil retention. Cleansing enemas are administered by instilling tap water, normal
saline, soap and water, and other solutions. Oil retention enemas
are given to lubricate and soften dry stool.
When caring for clients with intestinal ostomies, nursing activities are likely to include providing peristomal care, applying an
ostomy appliance, draining a continent ileostomy, and irrigating
a colostomy.

Topical medications are applied to the skin or mucous membranes.

Common locations for topical medications are the skin, eye, ear,
nose, mouth, vagina, and rectum.

An inunction is a medication incorporated into a vehicle, or

transporting agent, such as an ointment, oil, lotion, or cream.

Skin patches and applications of paste are two methods for

administering transdermal medications.

Skin patches can be applied to any skin area with adequate circu

Chapter 32
A medication is a chemical substance that changes body function.
A complete drug order contains the date and time of the order; the

name of the client; the name of the drug, its dose, route, and frequency of administration; and the signature or name of the writer.
A drugs trade name is the name used by the manufacturer of the
drug. The drugs generic name is a chemical name that is not the
exclusive use of any drug company.
Common routes of medication administration are oral, topical,
inhalant, and parenteral.
The oral route is used to administer drugs intended for absorption
in the gastrointestinal tract. Oral medications can be instilled by
enteral tube when clients cannot swallow them.
A medication administration record (MAR) is a form used to document and ensure timely and safe drug administration.
Methods of supplying drugs to nursing units include an individual supply, a supply of unit dose packets, and a stock supply.
Nurses are responsible for keeping the supply of narcotic medications locked and maintaining an accurate record of their use.
The five rights involve making sure that the right client receives
the right drug, in the right dose, at the right time, and by the right
route.
Once nurses have converted drug doses to the same system of measurement and the same measurement within that system, they can
calculate the amount to administer by dividing the desired dose by
the dose on hand then multiplying it by the quantity of the supply.
The nurse checks drug labels three times before administering
the medication.
When teaching clients about taking medications, nurses advise
them to inform each health care provider of all prescription and
nonprescription drugs currently being taken.

lation. Each time a new patch is applied, it is placed in a different

location.
Eye medications are applied onto the mucous membrane, or conjunctiva, of the eye, which lines the inner eyelids and the anterior surface of the sclera.
The major difference in the technique for administering ear medications to adults and children is how the ear is manipulated to
straighten the auditory canal.
The rebound effect is a phenomenon characterized by rapid
swelling of the nasal mucosa. It is likely when clients chronically
administer more than the recommended amount of nasal decongestant or use the drug too frequently.
For sublingual administration, the drug is placed under the
tongue. For buccal administration, the medication is placed in
contact with the mucous membrane of the cheek.
Vaginal applications are used most often to treat local infections.
Drugs administered rectally usually are in the form of suppositories.
The inhalant route is used for medication administration because
the lungs provide an extensive area of tissue from which drugs
may be absorbed.
To create an aerosol, liquid medication is forced through a narrow
channel under high pressure.
Drugs are commonly inhaled using turbo-inhalers or metereddose inhalers. A turbo-inhaler delivers a burst of fine powder at
the time of inhalation. A metered-dose inhaler releases a measured volume of aerosolized drug when its canister is compressed.
A spacer provides a reservoir for aerosol medication, which can
then be inhaled beyond the time of the initial breath.

Chapter 34
Three parts of a syringe are the barrel, plunger, and tip.
When selecting a syringe and needle, the nurse considers the type
of medication, depth of tissue, volume of prescribed drug, viscosity of the drug, and size of the client.
Conventional syringes and needles are being redesigned to
reduce the potential for needlestick injuries and transmission of
blood-borne pathogens.
Pharmaceutical companies supply drugs for parenteral administration in ampules, vials, and prefilled cartridges.
Before combining two drugs in a single syringe, it is important to
consult a drug reference or a compatibility chart to determine
whether or not a chemical interaction may occur.

APPENDIX A Chapter Summaries

823

Nurses use any of four parenteral injection routes: intradermal,

Structures to protect the airway include the epiglottis, which

subcutaneous, intramuscular, and intravenous.

A common site for an intradermal injection is the inner forearm;
subcutaneous injections are commonly given in the thigh, arm,
or abdomen; intramuscular injections are given in the buttocks,
hip, thigh, or arm.
An intradermal injection is given with a tuberculin syringe.
Insulin is administered subcutaneously with an insulin syringe.
Intramuscular injections are usually given with a syringe that
holds a volume of 3 mL.
For an intradermal injection, the needle is inserted at a 10 to
15 angle. For a subcutaneous injection, a 45 or 90 angle is used
depending on the clients size. For an intramuscular injection, a
90 angle is used.
When two separate insulins are combined, they must be administered within 15 minutes to avoid equilibration (the loss of each
insulins unique characteristics).
To prevent bruising when heparin is administered, the nurse
avoids aspirating with the plunger and massaging the site
afterward.
Five sites used for administering intramuscular injections are the
dorsogluteal, ventrogluteal, vastus lateralis, rectus femoris, and
deltoid.
Intramuscular injections are given by Z-track technique to seal
irritating substances in the muscle and to reduce discomfort after
an injection.

seals the airway when swallowing food and fluids; the rings of
tracheal cartilage, which keep the trachea from collapsing; the
mucous membrane, which traps particulate matter; and the cilia,
which beat debris upward in the airway so it can be coughed,
expectorated, or swallowed.
Methods of airway management include liquefying secretions,
mobilizing secretions to promote their expectoration with chest
physiotherapy, and mechanically suctioning mucus from the
airway.
When suctioning the airway, nurses use one of several
approaches: nasopharyngeal, nasotracheal, oropharyngeal, oral,
and tracheal suctioning.
Artificial airways are used when clients are at risk for airway
obstruction or when long-term mechanical ventilation is
necessary.
Two examples of artificial airways are an oral airway and a tracheostomy tube.
Tracheostomy care includes cleaning the skin around the stoma,
changing the dressing, and cleaning the inner cannula.

Chapter 35
IV medications can be given into peripheral or central veins.
The IV route is appropriate when a quick response is needed dur-

ing an emergency, when clients have disorders that affect the

absorption or metabolism of drugs, and when blood levels of
drugs need to be maintained at a consistent therapeutic level.
IV medications can be administered continuously or intermittently.
Two methods for administering a bolus of IV medication are via
a port on the IV tubing or a medication lock.
IV medication solutions may be administered intermittently
using secondary (piggyback) infusions or a volume-control set.
A piggyback solution is a small volume of diluted medication that
is connected to and positioned higher than the primary solution.
A volume-control set is used to administer IV medication in a small
volume of solution at intermittent intervals to avoid overloading
the circulatory system.
A central venous catheter is a venous access device that extends
to the vena cava or right atrium.
The three general types of central venous catheters are percutaneous, tunneled, and implanted.
When administering antineoplastic drugs, the nurse should wear
a cover gown, one or two pairs of gloves, and a disposable or respirator mask to protect against contact with or inhalation of the
medication.

Chapter 37
Airway obstruction is life-threatening because it interferes

Chapter 36

Airway management refers to skills that nurses use to maintain

natural or artificial airways for compromised clients.

Structures of the airway are the nose, pharynx, trachea, bronchi,

bronchioles, and alveoli.

The airway serves as the collective system of tubes in the upper

and lower respiratory tract through which gases travel during
their passage to and from the blood.

with ventilation and subsequently deprives cells and tissues of

oxygen.
Signs of airway obstruction include grasping the throat with the
hands, making aggressive efforts to cough and breathe, and producing a high-pitched sound while inhaling.
In cases of partial airway obstruction, appropriate actions include
encouraging and supporting the victims efforts to clear the
obstruction independently and preparing to call for emergency
assistance if the victims condition worsens.
The Heimlich maneuver is the technique used to relieve a complete airway obstruction by performing a series of subdiaphragmatic thrusts or chest thrusts on conscious victims.
Subdiaphragmatic thrusts are appropriate for almost all adults
and children beyond infancy. Chest thrusts are appropriate for
obese adults and women in advanced pregnancy.
To dislodge an object from an infants airway, the rescuer delivers a series of back blows followed by a series of chest thrusts.
When a person with an airway obstruction becomes unconscious,
rescuers perform basic CPR rather than the Heimlich maneuver because chest compressions create enough pressure in unconscious victims to eject a foreign body from the airway.
The Chain of Survival is a series of four steps that improve the
outcome of resuscitating a person in cardiac arrest. The steps
include early recognition and access of emergency services, early
cardiopulmonary resuscitation (CPR), early defibrillation, and
early advanced life support.
CPR refers to the techniques used to restore breathing and
circulation.
The ABCs of resuscitation involve opening the airway and
assessing and initiating breathing and circulation.
Rescuers can safely open a victims airway under most circumstances by using the head tilt/chin lift technique or the jaw-thrust
maneuver.
Methods of administering rescue breathing are mouth-to-mouth,
mouth-to-nose, or mouth-to-stoma.
The purpose of chest compressions is to circulate blood
systemically.
An automated external defibrillator is a portable, battery-operated
device that analyzes heart rhythm and can deliver a series of electrical shocks to resuscitate a person who is lifeless or experiencing a lethal dysrhythmia. Ideally an AED is used within 5 minutes

824

APPENDIX A Chapter Summaries

of resuscitation efforts outside the hospital and within 3 minutes

of resuscitation efforts within a health care facility.
Once CPR begins, it is never interrupted for more than 7 seconds
(except in certain circumstances such as when advanced electronic equipment is used).
The decision to stop resuscitation efforts often is based on the time
that elapsed before resuscitation began, the length of time that
resuscitation has continued without any change in the victims
condition, and the age and diagnosis of the victim.

Hospice care involves helping clients to live their final days in

comfort, with dignity, and in a caring environment.

Some aspects that nurses address when providing terminal care

Chapter 38

A terminal illness is one from which recovery is beyond reasonable expectation.

The five stages of dying, as described by Dr. Elisabeth KblerRoss, are denial, anger, bargaining, depression, and acceptance.

Nurses can promote acceptance by providing emotional support

to dying clients and helping them to arrange their care.

Respite care provides relief for caregivers of dying loved ones.

are hydration, nourishment, elimination, hygiene, positioning,

and comfort.
Many terminal illnesses result in death from multiple organ
failure. Signs of multiple organ failure include hypotension,
rapid heart rate, difficulty breathing, cold and mottled skin, and
decreased urinary output.
When the criteria for organ donation are met, permission for
organ removal must be obtained in a timely manner to ensure a
successful transplant.
Criteria used to confirm that a client has died include cessation
of breathing and heart beat and absence of whole brain function.
Postmortem care involves cleaning the body, ensuring proper
identification, and releasing the body to mortuary personnel.
Although grieving is painful, it promotes resolution of the loss.
One sign that a person is resolving his or her grief is that he or
she can talk about the deceased person without becoming emotionally overwhelmed.