Identifying Expected Physical, Cognitive and Psychosocial Stages of Development

Age and developmental stages are assessed to determine if the client is at the expected level of growth and
development, to plan care that is age and developmentally appropriate and to modify care as based on the
age related characteristics and needs of our clients. These assessments include the physical, cognitive and
psychosocial stages of growth and development.

Cognitive Development: Jean Piaget

Jean Piaget's levels of cognitive development from birth until 12 years of age are used for the assessment of
children up to this age, after which the cognitive development of the child is complete.
In the correct sequential order, Jean Piaget's levels of cognitive development include:
 Sensorimotor thought: Infancy to About 2 Years of Age
The sensorimotor thought level has 6 sub stages; this level includes the development of the infant's and young
child's ability to manipulate concrete objects.
 Preoperational and symbolic functioning: From 2 to 7 Years of Age
Language and vocabulary progressively develop.
 Concrete operations: 7 to 11 Years of Age
Between these ages, the child is able to use logic and reasoning; they have also developed their ability to solve
concrete problems.
 Formal operations: 12 Years of Age
Under normal circumstances, the child at 12 years of age should have developed the ability to solve abstract
problems and to use complex thinking, logic and reasoning.

Psychosocial Development: Erik Erikson

Erik Erickson proposed 8 major stages of psychosocial development and expected tasks along the life span
from infancy to old age. People, including our own clients, who are able to resolve their age related tasks are
successfully able to progress to the next task; however, psychosocial development can become arrested when
a person is not able to achieve their age related developmental task.
Nurses must incorporate these developmental tasks and challenges into the plan of care and they must also
modify the plan of care according to these age related tasks.
Eric Erikson's stages, developmental tasks and signs of their lack of resolution are listed below.
 Age Group: Infant
Task: Trust
Failures to Resolve the Task: Mistrust and a failure to thrive
 Age Group: Toddler
Task: Autonomy, self-control and will power
Failures to Resolve the Task: Shame, doubt and a poor tolerance of frustration
 Age Group: Preschool
Task: Initiative, a sense of purpose, self-confidence, and self direction
Failures to Resolve the Task: The fear of punishment and guilt
 Age Group: School Age Child
Task: Industry, competence and self-confidence
Failures to Resolve the Task: Feelings of inferiority and fears that one cannot meet the expectations of others
 Age Group: Adolescent
Task: Identity formation and a sense of self as an individual
Failures to Resolve the Task: Role confusion, lowered self-esteem and a poor self concept
 Age Group: Young Adult
Task: Intimacy, love and affection
Failures to Resolve the Task: Isolation and the avoidance of relationships including intimate relationships
  Age Group: Middle Aged Adult
Task: Generativity, productivity, and genuine concern for others
Failures to Resolve the Task: Stagnation, self-absorption and a lack of concern about others
 Age Group: Older Adults
Task: Ego integrity, wisdom and the ability to participate in life with a sense of satisfaction
Failures to Resolve the Task: Despair and feelings that life is without any meaning and without any sense of
satisfaction

Psychosexual Development: Sigmund Freud

Sigmund Freud, often referred to as the father of psychotherapy, developed the concepts of id, ego and
superego, the psychological defense mechanisms such as sublimation and suppression, as well as the 5 stages
of psychosexual growth and development.
The id is an unconscious mechanism that operates in terms of instant gratification and instant pleasure. Some
say that infants are nothing more than a bundle of id. The ego is the person's sense of self that provides the
person with the ability to control oneself and one's behaviors. The superego is the person's conscience.
The 5 stages of Sigmund Freud's stages of psychosexual development are:
 The oral stage
 The anal stage
 The phallic stage
 The latency stage
 The genital stage
Some of the lesser known theories of growth and development include those of Stella Chess and Alexander
Thomas, Roger Gould, Robert Havighurst, and Robert Peck.

The Development of Temperament: Stella Chess and Alexander Thomas

Stella Chess and Alexander Thomas are credited with the development of the 9 temperamental qualities which
include:
1. Activity level
2. Sensitivity and reactions to external stimuli
3. Adaptability
4. Level of Intensity
5. Distractibility
6. Approach/Avoidance and Withdrawal
7. Persistence
8. Regularity and organization
9. Mood

Roger Gould
Roger Gould addresses 7 stages of growth and development that begins at age 16 and progresses to the older
adult.
These stages include:
1. Stage 1 – Ages 16 to 18: The adolescent strives to separate from the parents and to develop
autonomy.
2. Stage 2 – Ages 19 to 22: The autonomous young adult has fears and anxiety about having to return to
their family unit and parents.
3. Stage 3 – Ages 23 to 28: This young adult replaces their fears and anxiety about having to return to
their family unit and parents with a more secure sense of self and their abilities. Some may also have a
spouse and children.
 4. Stage 4 – Ages 29 to 34: At this age, the young adult no longer feels that they have to prove
themselves and many have a career, marriage and even children.
5. Stage 5 – Ages 35 to 43: This period of time is characterized with self reflection and values clarification.
6. Stage 6 – Ages 44 to 50: The person is well established and stable.
7. Stage 7 – Ages 51 to 60: This period of time is characterized with concerns about one's state of health
and one's own finality.

Robert Havighurst
This theorist developed 6 age groups and the physical, psychological and social tasks associated with each of
these 6 age groups.
These age groups and their associated developmental tasks are:
1. Infancy and Early Childhood: During this period of time the child develops the super ego, or
conscience, and they also develop and maintain emotional stability and relationships with the
members of their family unit and friends in their community.
2. Middle Childhood: The child continues their conscience development, and they also enhance their
value system, their sense of morality, and their values systems. Physical abilities continue to be
developed and refined; and intellectual skills are developed in their school and home environment.
3. Adolescence: Gender related roles are assumed, a personal ethical code emerges, mature relationships
with others are developed, and the adolescent begins to think about their future and desired goals in
terms of employment and/or advanced education.
4. Early Adulthood: Many start a family and relationships within the family and the community are
enhanced.
5. Middle Age: This period of time is typically characterized with stability and the empty nest syndrome
as well as major developmental changes like menopause and aging.
6. Later Maturity: During later maturity, the person adjusts to retirement, aging and the loss of loved
ones including spouses and friends.

Robert Peck
Robert Peck's theory focuses on aging and the aging process. Robert Peck's theory has 3 developmental tasks
that somewhat parallel those of Eric Erikson's phase of integrity versus despair in the later years.
Robert Peck's three developmental tasks associated with aging and the aging process include:
1. Ego Differentiation versus Work Role Preoccupation: The older adult adjusts to retirement and enjoys
leisure activities that they were unable to partake in while they were gainfully employed.
2. Ego Transcendence versus Ego Preoccupation: The individual accepts their own mortality without fear.
3. Body Transcendence versus Body Preoccupation: The aging person maintains a sense of wellbeing,
happiness and satisfaction despite the physical declines associated with the aging process.

Identifying Expected Body Image Changes Associated with the Client's Developmental Age
As with all other nursing care, nurses must be able to identify and report client deviations from what is
expected in terms of their growth and development and they must also be able to modify care and their
approaches to care as based on these deviations.
Nurses also determine the impact of expected body image changes on the client in terms of how the patient's
perceptions are interfering with the patient's quality of life and the continued performance of their activities
of daily living. Again, all maladaptation and/or poor coping skills must be determined, documented and
reported so that the patient's plan of care can be changed to meet these needs.
The major expected bodily changes and bodily image changes are those that occur with puberty, menopause,
pregnancy and the aging process.

Identifying Family Structures and Roles of Family Members

Family structures are numerous and becoming more numerous and varied than any other time in the past.
These family structures are discussed below:
 The Traditional Nuclear Family: This family structure consists of biological children and two marred
parents of different genders.
 The Nuclear Family: This family structure consists of two marred parents of a different gender and
children that can be step children, adopted children and/or foster children.
 The Extended Family: This family structure consists of one or more people with a child who resides
with others who are related biologically. For example, the extended family unit can consist of a
grandparent or grandparents.
 The Foster Family: This family structure consists of one or more foster children and one or two
parents.
 The Adoptive Family: The adoptive family is one that has at least one adopted child and one or two
parents.
 The Binuclear Family: The frequency of binuclear families has significantly increased over the last
several years as more and more divorced parents are sharing custody. This family structure consists of
two parents and at least one child. The parents in legal joint custody arrangements share responsibility
for the child or children.
 The Single Parent Family: This family has one parent and one or more children. These children can be
biological children, step children, adopted children and/or foster children.
 The Childless Family: This family structure consists of two adults with no children whatsoever.
 The Communal Family: The communal family is one that consists of group of unrelated adults who live
in a community with their children and who share responsibility for the children and their care, among
other things.
 The Gay, Lesbian and Transgender Family: This family structure consists of two adults of the same
gender who have one or more children.
 The Blended Reconstituted Family: This family consists of two adults who live in the home with one or
more step children from a previous marriage or another type of union.

Roles in the family have also changed over the past decades. In the past roles within the family were gender
based; now these roles are not usually based on gender. For example, in the past the mother stayed at home
and cared for the children while the father worked as the bread winner of the family. Now things are very
different. For example, some males are "stay at home dads" while the female in the family works outside of
the home as the bread winner of the family.
Other family roles that are assumed by the adults in the family are disciplinarian, teacher, housekeeper, cook
and shopper. Ideally, these roles and responsibilities are equally and equitably shared by the adults within the
family unit.
Like leadership styles, parenting styles also differ among members of the family when the family has one or
more children. For example, parents can be permissive, democratic, participative, laissez faire and
authoritarian.

Comparing Client Development to Expected Age/Developmental Stage and Reporting Any Deviations
As with all other nursing care, nurses must be able to identify and report client deviations from what is
expected in terms of their growth and development and they must also be able to modify care and their
approaches to care as based on these deviations.

Assessing the Impact of Change on the Family System

Families, like all other open systems within the environment including individual clients, are impacted with
changes. Some of these changes are expected and developmentally normal and other changes are unexpected
and often disruptive to the homeostasis of the family. For example, a family system can be impacted with the
empty nest syndrome which is an expected and developmentally normal change; and the death of a child or a
spouse is an unexpected and often disruptive change for members of the family.
Families, therefore, just like individual clients, often need the care and services of the health care team to
cope with any disruptive changes. Some major life changes that can significantly affect and impact on the
family unit are things like poverty, homelessness, divorce, chronic illnesses and legal concerns.
Families, like individual clients, often need the assistance of the nurse to cope with these changes.

Recognizing Cultural and Religious influences That May Impact Family Functioning
Similar to individual clients, families also have their own beliefs, practices, perspectives, values and views,
some of which are present as the result of their culture, while others may be related to their religion and still
more may just simply result from the family's personal preferences.
Culture impacts on virtually all aspects of the client-nurse relationship. For example, communication patterns,
beliefs about illness, who is the major family decision maker, family dynamics, perspectives about health and
health care, space orientation, time orientation, nutritional patterns, beliefs about elders and the elderly,
parenting, family size, and even death and death vigils are often driven by the family's culture, as passed on
from generation to generation.
Religious influences may also impact on the family and its functioning. Some of the same impacts that culture
has, religion also has. Religion may impact on the family's beliefs about illness, nutritional patterns, beliefs
about elders and the elderly, parenting, birth control, family size, and even death and death vigils are often
driven by the family's religion. For example, in terms of the perideath period, some religious practices include
a clergy person like a Catholic priest to perform that religion's Sacrament of the Sick.

Assisting the Client to Cope With Life Transitions

Throughout the life span, there are several significant expected life transitions that require the person to cope
and adjust. Some of these expected life transitions include attachment and bonding to the neonate, puberty,
pregnancy, care of the newborn, parenting, and retirement.
Nurses and other health care professionals assist clients to adapt to and cope with these normally occurring
life transitions and changes. For example, the nurse may also seek out community resources that could be
helpful to an elderly, retired person who needs transportation to and from doctor's appointments, a nurse
could teach the new mother and their partner about how to bond and attach to the newborn, and the nurse
could also conduct newborn care classes for new parents to assist these new person to cope with the
challenges associated with the care of a neonate and infant.

Modifying Approaches to Care in Accordance with the Client's Developmental Stage

As somewhat previously discussed with the "Integrated Process: Communication" and the "Integrated Process:
Teaching and Learning", communication and teaching are modified according to the client's age, level of
cognition, and developmental stage. Physical care, including medication administration, as will be discussed
later in this review, is also modified according to the client's age and developmental status.
Some of these modified approaches to care, communication, explanations, teaching and diversionary activities
include:
 The provision of parent or legal guardian patient education when an infant and the young child is being
cared for
 The provision of safe and nontoxic, large toys for infants and young children to prevent aspiration and
a foreign body obstructing the young child's respiratory tract
 The use of touch and a soft voice to communicate with an infant
 The use of a graphic pain assessment tool, rather than a numerical pain assessment scale, for young
children and elderly adults who have a cognitive impairment
 Using the vastus lateralis as the muscle of choice for an intramuscular injection among infants
Providing Education to the Client and Staff Members About Expected Age-Related Changes and Age-Specific
Growth and Development
Clients and staff members must be knowledgeable and educated about expected age related changes and age
specific characteristics and needs. Registered nurses can identify knowledge deficits and assess learning needs
among staff members by observing how well and how consistently their nursing care is modified according to
their clients' age specific characteristics and needs. Similarly, registered nurses can identify knowledge deficits
and assess the learning needs among their clients and family members across the life span in terms of their
knowledge about expected age related changes and age specific characteristics and needs.
For example, neonates and infants receive communication with the touch or a coo by an adult and they enjoy
colorful things like a mobile; infants and toddlers must not be given any small toys or toys that can
disassemble into small parts because they are in the oral stage of development where they place objects in
the mouth which places them at risk for aspiration and death; adolescents are rebellious and they want to be
with and accepted by their peers. Adults enjoy socialization and activities like different sports and an exercise
regimen; and older adults may be in need of activities such as those in an elder day care center and
reminiscence therapy.
When a staff or client/family learning need is assessed, the nurse then plans, implements and evaluates the
teaching that is given specific to the learners' needs. For example, a middle aged man caring for an elderly
parent may have the need to learn about the safety needs of the elderly and new parents may need education
related to age appropriate toys and car seats.

Evaluating the Client's Achievement of Expected Developmental Level and Milestones

When nurses assess clients they incorporate their knowledge of developmental levels into this assessment to
determine and evaluate whether or not the client is achieving the expected milestones associated with their
age. As previously detailed, these assessments include the clients' assessment of their physical growth and
development, their psychosocial growth and development, their cognitive growth and development, and their
psychosexual growth and development.

Determining the Impact of Expected Body Image Changes on the Client

In addition to the physical aspects of body image changes, there are also social and emotional impacts with
these changes. With the support of the health care team, the client should be able to adapt to the changes,
alter his or her life style as indicated, discard irrational beliefs and replace these with realistic expectations,
maintain social interactions, and enhance the bodily image with things like a breast prosthesis and a wig, for
example.

Evaluating the Impact of Expected Body Image Changes on the Client and Family
Body image changes such as those associated with aging, pregnancy, menopause, disfiguring surgery, and
others place challenges upon the client and the family in terms of coping and adaptation.
Some of the signs that indicate whether or not the client is coping with altered bodily image include the
client's acknowledgment of the changes as well as verbal and nonverbal comments about the change.
Providing Education to the Client and Staff Members About Expected Age-Related Changes and Age-Specific
Growth and Development

Staff members must be educated about the age related changes and the age specific characteristics and needs
of clients across the life span so that they can modify the care of their client's accordingly.
Clients should also be educated about the age related changes and the age specific characteristics and needs
of different age groups as necessary. For example, a young mother may be taught about her toddler's age
appropriate toys and a middle age adult may have a need to learn about depression among the elderly when
the parents are not coping with the normal changes of the aging process.
Evaluating the Impact of Expected Body Image Changes on the Client and Family
Nurses also determine and evaluate the impact of expected body image changes on the client and family in
terms of how their perceptions and beliefs may be interfering with the patient's quality of life and the
continued performance of their activities of daily living. Again, all maladaptation and/or poor coping skills
must be determined, documented and reported so that the patient's plan of care can be changed to meet
these needs.
Some of the most stressful expected body image changes that may adversely affect the client and family
include body image changes such as those associated with pregnancy, menopause, puberty, and aging. These
changes may occur with significant reactions and responses in terms of the person's physical, psychological
and social wellbeing.

Blood and Blood Products

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.
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.

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.

n 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.

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

Changes and Abnormalities in Vital Signs:

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.
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.

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.

Anti/Intra/Postpartum and Newborn Care

n this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of
antepartal, intrapartal, postpartum, and newborn care in order to:
  Assess client's psychosocial response to pregnancy (e.g., support systems, perception of pregnancy,
coping mechanisms)
 Assess client for symptoms of postpartum complications (e.g., hemorrhage, infection)
 Recognize cultural differences in childbearing practices
 Calculate expected delivery date
 Check fetal heart rate during routine prenatal exams
 Assist client with performing/learning newborn care (e.g., feeding)
 Provide prenatal care and education
 Provide care to client in labor
 Provide post-partum care and education
 Provide discharge instructions (e.g., post-partum and newborn care)
 Evaluate client's ability to care for the newborn

Introduction to the Female Reproductive System

The internal organs and structures of the female reproductive system are the:

Uterus

Anatomically, the uterus is comprised of the endometrium which is the most inner layer of the uterus, the
second layer of the uterus which is the myometrium and the perimetrium which encases the entire organ; and
two major sections which are the body or corpus of the uterus and the cervix which is the lower part of it.
The uterus is an internal organ of female reproduction, however, it enlarges to the point that it becomes an
abdominal organ at about the 12th week of gestation so that the growth of the fetus is accommodated.
In pregnancy and non pregnancy states, the cervix protects the internal environment of female reproduction
from the exterior environment; during pregnancy, the cervix additionally protects the fetus. For example,
during early pregnancy, a mucous plug is formed in the cervix to protect the developing fetus from the
external environment.

Vagina

This internal organ of reproduction connects the exterior female reproductive system structures to the
internal female reproductive organs and structures. It serves as a protection against infection during
pregnancy because it produces high acidity; and the vaginal also becomes more vascular during pregnancy.

Fallopian Tubes

The fallopian tubes are the site of fertilization; after about 4 days after fertilization, the fertilized ovum moves
from the trumpet like ampulla of the fallopian tube to the uterus, with the exception of ectopic pregnancies
which abnormally maintain the fertilized ovum in the fallopian tube.

Ovaries

Unlike other organs of reproduction, the ovaries serve as both an endocrine organ and a reproductive organ.
Anatomically, the ovaries are comprised of the three distinct layers which from the outer most to the
innermost layer, are:

 The tunica albuginea

 The medulla that contains ovarian circulation
  The cortex which contains the corpora lutea, the ova and the follicles

The ovaries, as an endocrine organ, produce hormones such as progesterone and estrogen. These hormones
play an integral part in the female's menstrual cycle, breast development, and the retention of a developing
fetus during pregnancy.

Bony Pelvis

The bony pelvis which consists of two innominate bones which are the sacrum and the coccyx, and that, unlike
other parts of the human's skeletal system, become more pliable and able to change in order to facilitate the
movement of the fetus to the external world during labor and a vaginal delivery.
The external organs and structures of the female reproductive system are the:

 Mons pubis
 Urethral meatus
 Vaginal vestibule
 Labia minora
 Labia majora
 Clitoris and the
 Perineal body

Conception

Conception and fertilization are complex processes that entail cellular division, gametogenesis, and
chromosomal arrangement. A singular cell is formed at the time of fertilization with mitosis and meiosis;
gametogenesis is the production of a single male sperm or a single female ova each of which has 23 pairs of
chromosomes and, that, after fertilization form the zygote of 46 pairs of chromosomes. Females and males
have a total of 23 pairs of chromosomes, two of which are sexually assigned autosomes and the remaining are
not. Females have XX female chromosomal arrangements and males have XY chromosomal arrangements.

Maternal Physical Changes During Pregnancy

Some of the physical changes that occur during pregnancy include the presumptive, probable and positive
signs of pregnancy, urinary system changes, circulatory system changes, endocrine system changes,
gastrointestinal system changes, skin changes, respiratory system changes, skeletal changes, central nervous
system changes, metabolic changes, and vital sign changes.
The presumptive signs of pregnancy are:

 Urinary frequency
 Fatigue
 Amenorrhea
 Nausea and vomiting which is referred to as morning sickness
 Breast soreness
 Darkened areolae
 Large Montgomery glands
 Uterine enlargement
 Vaginal discoloration
 Skin pigmentation changes and
 Fetal movement which is referred to as quickening
The probable signs of pregnancy include:

 Hegar's sign which is changes to the lower portion of the uterus

 Abdominal enlargement
 A positive human chorionic gonadotropin or HCG test
 Braxton Hicks contractions
 Chadwick's sign which is a blue tinge to the vagina and cervix
 Gooddell's sign which is the softening of the cervix
 The ability to palpate the fetus which is referred to as fetal ballottement and
 Cervical and uterine changes in terms of consistency, size and shape

And, lastly, the positive signs and symptoms of pregnancy are:

 Fetal heart tones

 Ultrasound evidence of a fetus and
 The objective assessment of fetal movement

Assessing the Client's Psychosocial Responses to Pregnancy

In addition to assessing the client's physiological changes and responses to pregnancy, the registered nurse
also assesses the client's psychosocial responses to pregnancy including those relating to the mother's
response to and perceptions of the pregnancy, the father's response to and perceptions of the pregnancy, the
coping mechanisms used by the mother and father as they cope with this developmental and maturation
change, the emotional preparedness of the parents for the pregnancy, and the support systems, including the
mother's and father's familial support systems and their utilization of appropriate and available support
systems in the community.
Many emotions and different perceptions can occur as a response to pregnancy. Some of these emotions
include joy, fear, mood swings, anxiety, financial concerns, depression, and adverse emotional reactions to the
bodily changes of pregnancy. The father may also have similar reactions. The emotions and perceptions can
vary among clients and they can also vary according to the particular clients' specific situation.
It is believed that about 50% of all pregnancies are unplanned and it is known that single mothers, including
teenage mothers, often become pregnant. Some mothers and fathers can successfully adapt to and welcome
an unwanted pregnancy and others cannot. Stressful decisions such as those relating to abortion and adoption
have to be supported by the nurse.
Social support systems are highly beneficial in terms of normal and abnormal coping with a pregnancy. Some
women may have a lot of social supports during this maturational milestone in terms of family members and
their spouse or partner and others may have little or no support. This is particularly true when the partner is
absent and/or not welcoming of an unwanted pregnancy.

Assessing the Maternal Client For Antepartal Complications

Although most pregnancies are without complications, there are many pregnancies that are adversely affected
with antepartal, intrapartal and postpartum complications. These antepartal complications will now be
discussed.
As you will learn in this section maternal antepartal complications during the antepartal periods include:

Infections

All infections pose antepartal dangers and risks for the pregnant woman and the developing fetus.
Some examples of these infections are briefly discussed below:

HIV/AIDS

The mother's immunosuppression can lead to the development of other infections and this virus can infect the
neonate perinatally as well as during breast feedings. The mother's treatment of HIV/AIDS continues as it did
prior to the pregnancy and all procedures during pregnancy that can increase the risk of infection to the fetus
are avoided whenever possible. Some of the invasive procedures and interventions that are avoided include
episiotomy, amniocentesis, internal fetal heart monitoring, forceps deliveries, and vacuum extractions

Salpingitis and Endometritis

Salpingitis is an inflammation or infection of the fallopian tubes; this infection most often occurs as the result
of untreated endometritis and it can lead to life threatening pelvic inflammatory disease, massive sepsis, tubo-
ovarian abscesses and infertility.
Endometritis, an inflammation or infection of the uterine endometrium, most often occurs after a miscarriage,
spontaneous abortion, after a planned abortion and as the result of another infection in the postpartum
period of time.
Diminished bowel sounds, tachycardia, elevated white cells, a fever, abdominal tenderness and pain and foul
smelling lochia are some of the signs and symptoms associated with endometritis and salpingitis.
Interventions, in addition to the administration of antimicrobial drugs such as clindamycin or gentamycin, can
include fluid rehydration, and the symptomatic relief of the fever and abdominal pain.

Tubo-Ovarian Abscesses

Tubo-ovarian abscesses, often the result of acute salpingitis, can also occur as the result of other infections
such as pelvic inflammatory disease after a delivery, abortions and spontaneous abortions. It, too, can lead to
massive sepsis and death when left untreated.
Tubo-ovarian abscesses can be signaled with foul smelling lochia, a high fever, and the signs of peritonitis
including abdominal and pelvic pain.
Intravenous broad scope antibiotics, fluid replacement, and electrolyte replacements, and hospitalization are
typically indicated.

Gonorrhea

Gonorrhea can also be transmitted to the fetus in utero and also with delivery. The signs and symptoms of this
sexually transmitted disease can include a yellowish – greenish vaginal discharge, dysmenorrhea, abdominal
discomfort and dysuria. This infection can also be asymptomatic. Medications used for the treatment of
gonorrhea include broad scope antibiotics such as ceftriaxone and azithromycin.

Chlamydia

Chlamydia, the most frequently occurring sexually transmitted disease, when symptomatic, can present with
vaginal spotting, perineal itching and dysuria. During pregnancy, the woman is treated with amoxicillin or
azithromycin for chlamydia.
Candida Albicans

This fungal infection most frequently occurs as the result of diabetes, the use of oral contraceptives and a
recent course of antibiotic therapy. Candida albicans can also be transmitted to the neonate upon delivery.
Oral candida albicans is characterized with white-gray patches on the tongue and other oral surfaces; and
vaginal candida albicans is characterized with a white vaginal discharge and genital redness. This infection is
treated with over the counter clotrimazole or fluconazole.

Chorioamnionitis

Choriomnionitis results from a bacterial infection of the chorionic membranes and the fetal amnion.
Choriomnionitis can occur as the result of a premature rupture of the membranes.
Choriomnionitis is associated with complications such as bacteremia, potentially life threatening sepsis, pelvic
abscesses, fetal complications and postpartum hemorrhage.
Choriomnionitis can be signaled with signs and symptoms such as a maternal fever, maternal leukocytosis of >
15000 to 18000 cells/μL, maternal tachycardia, uterine tenderness and a purulent vaginal discharge. The fetal
heart rate typically exceeds 160 beats per minute.
When immediate and intense intravenous antibiotic therapy is not successful, an emergency cesarean section
may be necessary.

TORCH Infections

TORCH is an acronym for:

 Toxoplasmosis
 Other infections
 Rubella
 Cytomegalovirus
 Herpes

The infections included in TORCH are clustered in this manner because all of these infections cross the
normally protective placental barrier and as such, not only threaten the health and wellbeing of the pregnant
woman, but they also serious threaten and jeopardize the growth and development of the developing fetus
with the adverse teratogenic effects that all of these infections have. Because these infections pose such great
dangers, immunological TORCH screening is often done to detect the presence of all of these offending
infections among pregnant women.
The risk factors and the treatments of these TORCH infection vary according to the specific infection and the
severity of each infection.
Toxoplasmosis can be contracted by handling of contaminated feline feces and from consuming meat that is
not cooked enough; rubella is transmitted with contacts with someone with the disease when the host is not
immunized against it; cytomegalovirus is spread via contact with bodily fluids, such as vaginal secretions,
semen, blood, placental tissue, breast milk, and other bodily fluids; and, lastly, maternal herpes simplex
infections occur as the result of direct contact with infectious genital or oral lesions, and the neonate is
exposed to this infection during a vaginal delivery when the pregnant woman has infectious and active herpes
simplex lesions on the genitalia at the time of delivery.
Group B Streptococcus B-Hemolytic Infection

Group B streptococcus B-hemolytic infections can also be transmitted to the fetus during the processes of
labor and delivery.
Some of the risk factors associated with group B streptococcus B-hemolytic infections are a premature
delivery, a low birth weight infant, a maternal history of group B streptococcus B-hemolytic infections, a
premature rupture of the membranes, a maternal age of less than 20 years of age, and also secondary to
invasive intrauterine fetal monitoring.
Intravenous amoxicillin and penicillin G are used for the treatment of group B streptococcus B-hemolytic
infections and, at times, for the prophylaxis of these infections during pregnancy.

Toxic Shock Syndrome

Toxic shock syndrome, a staphylococcus aureus or streptococcal infection, can occur as the result burns,
childbirth, surgical procedures, and other forms of trauma. Streptococcal toxic shock syndrome is typically
more serious and life threatening than staphylococcus toxic shock syndrome and the former is often
associated with systemic collapse.
The signs and symptoms of toxic shock syndrome include hypotension, skin desquamation of the palms of the
hands, an erythematous skin rash, a high fever, altered levels of consciousness, nausea, vomiting and elevated
nitrogen and creatinine levels.
The antimicrobial drugs of choice are a first generation cephalosporin or penicillin; however, those with a
sensitivity to or allergy to these antimicrobials, can receive vancomycin or clindamycin. Additionally,
hospitalization for treatments and closer monitoring of the pregnant woman may be indicated to prevent the
high morbidity and mortality rates associated with toxic shock syndrome during pregnancy.

Urinary Tract Infections (UTI)

The greatest risk period for a urinary tract infection during pregnancy is from the 6 th to the 24th week of
pregnancy. The risk of urinary tract infections among pregnant women is greater than other populations
because of the normal anatomical changes associated with pregnancy such as the increased size and weight of
the uterus which can block the free flow of urine through the urinary tract.
The classical signs and symptoms of urinary tract infections, such as a fever, dark or grossly bloody colored
urine, and pain occur.
The complications of urinary tract infections during pregnancy can affect the mother and the developing fetus.
Some of these complications can include maternal hypertension, a low birth weight, preterm labor and
possible renal damage. Levofloxacin, ampicillin and ciprofloxacin are typically the drugs of choice to treat
these urinary tract infections when their effectiveness is confirmed with a urine culture and sensitivity.

Pyelonephritis

Pyelonephritis, most likely caused by E. coli, is a risk for the pregnant woman particularly when the woman is a
diabetic and when they have a urinary tract infection, a urinary tract obstruction, bacteriuria, and/or chronic
kidney disease.
Although some clients with acute or chronic pyelonephritis may be asymptomatic, most present with an
elevated blood urea nitrogen level, malaise, dysuria, foul smelling urine, hematuria, increased white blood
cells, a fever and decreased creatinine clearance.
Cardiac Disease

Cardiac diseases and disorders during pregnancy, similar to those in a non-pregnancy state, are associated
with significant elevations in terms of morbidity and mortality rates. Even though cardiac diseases can preexist
prior to pregnancy, some mothers develop cardiac disease during the course of their pregnancy since
pregnancy increases the mother's cardiovascular demands because of the pregnancy.
Some examples of cardiac disorders that complicate pregnancy, in addition to preexisting and gestational
hypertension, are:

 All maternal, preexisting congenital heart disorders

 Cardiomyopathy associated with left ventricular dysfunction
 Pulmonary hypertension secondary to Eisenmengger syndrome which is left to right cardiac shunting
 Rheumatic heart disease
 Marfan syndrome, a genetic disorder that places the mother at risk for aortic dissection or rupture
 Mitral valve prolapse

Although the symptoms may vary among pregnant clients, among the different cardiac disorders, and
according to the severity of the cardiac disorder, some of the most common signs and symptoms experienced
by the pregnant woman include fatigue, shortness of breath and dyspnea, chest pain, palpitations, and
abnormal and adventitious breath sounds like rales.
Cardiac disease in classified according to its level of severity from Class I cardiac disease to Class IV cardiac
disease with Class I cardiac disease as the least severe and Class IV cardiac disease as the most severe of all.
Class I and Class II are associated with no limitations of symptoms with physical activity and symptoms with
exertion. These classifications do not typically lead to maternal complications, however, Class III and Class IV
cardiac disease may, particularly if left untreated, lead to maternal and fetal complications and even death.
Class III cardiac disease is characterized with maternal cardiac symptoms with normal exertion and Class IV
cardiac disease is characterized with maternal cardiac symptoms with rest and during periods of time without
any physical activity.

Diabetes

Some pregnant women have diabetes prior to their pregnancy and other pregnant women develop gestational
diabetes during the course of their pregnancy, but regardless of etiology diabetes during pregnancy is a
complication for pregnant woman because all diabetes adversely affects glucose. The ideal blood glucose level
is between 70 and 110 mg/dL during pregnancy.
As you should know, the commonly occurring risk factors associated with diabetes mellitus include obesity, a
family history of diabetes and a high body mass index. Additional risk factors that place pregnant women at
risk for gestational diabetes are an age at pregnancy of more than 25 years of age and a history of a stillborn
or an infant who was large for gestational age. Research indicates that almost half of the women who develop
gestational diabetes during pregnancy will have type 2 diabetes in the future.
Although many women with gestational diabetes may have the classical signs and symptoms of diabetes
mellitus, such as urinary frequency and thirst, many others are asymptomatic. For this reason, all pregnant
women are screened for the presence of diabetes.
The maternal complications of diabetes during pregnancy include:

 Hypertension
 Ketoacidosis
 Infections resulting from elevated urinary glucose such as urinary tract and vaginal infections
 Preeclampsia
  Eclampsia

The fetal complications of diabetes, when not effectively treated, include:

 Hydramnios
 Hypoglycemia
 Jaundice
 Respiratory distress syndrome
 Macrosomia which is excessive birth weight
 Spontaneous abortion
 Pre-term birth
 Hypertension
 Preeclampsia and eclampsia
 Preterm Labor/Post term Pregnancy

Hypertension

Like diabetes, pregnant women can be adversely affected by hypertension that they have had prior to the
pregnancy and they can also develop gestational hypertension during the course of their pregnancy, typically
with its onset at or about the 20th week of pregnancy. Pregnant women less than 20 years of age and older
than 40 years of age are more at risk for gestational hypertension than other women of other ages. Additional
risk factors associated with gestational hypertension are diabetes, renal disease, a family history and/or a
personal history of gestational hypertension, pregnancy with multiples, the mother's first pregnancy, and a
molar pregnancy.
In terms of its severity, hypertension during pregnancy is classified as mild hypertension, mild preeclampsia,
severe preeclampsia, and HELLP.
HELLP stands for:

 H: Hemolysis which can lead to anemia

 EL: Elevated liver enzymes
 LP: Low platelet count which can lead to disseminated intravascular coagulopathy (DIC),
thrombocytopenia and abnormal clotting

The treatment includes close medical monitoring and control including maternal life style choices such as diet
and exercise. When indicated, antihypertensive medications, such as methyldopa, hydralazine, labetalol, and
nifedipine, are used. Angiotensin II receptor blockers and ACE inhibitors are contraindicated in most cases.
Fetal complications associated with maternal hypertension include, among other things, premature delivery, a
low birth weight and the complications that can result from maternal preeclampsia and eclampsia, as
discussed immediately below.

Preeclampsia

Most often preeclampsia precedes eclampsia but this is not always the case. Preeclampsia typically has an
onset after the 20th week of gestation and it is typically initially identified and assessed with the presence
proteinuria and hypertension. The severity of preeclampsia and eclampsia and associated fetal and material
complications are greatest when the preeclampsia, or eclampsia, emerge before the 35 th week of gestation.
Untreated and unmanaged, it may progress to life threatening eclampsia.
The risk factors associated with preeclampsia and the progression of preeclampsia to eclampsia are:
  Diabetes
 Obesity
 Hypertension
 Multiple gestations
 Pregnancy after the age of 35 years of age
 African American descent

In addition to proteinuria and hypertension, the signs and symptoms of preeclampsia can impact on virtually
all bodily systems. These signs and symptoms are:

 Gastrointestinal alterations such as vomiting and nausea

 Hyperreflexia, headache, clonus and dizziness which indicate neurological alterations
 Elevated serum transaminase and elevated liver enzymes which indicate altered hepatic functioning
 Oligura, a creatinine level more than 90 µmol/L and proteinuria, as afore mentioned, indicate altered
renal functioning
 The emergence of hemolysis, a low platelet count, disseminated intravascular coagulation,
thrombocytopenia and HELLP which indicate alterations in the mother's circulatory system
 Other circulatory system changes such as edema
 Right upper quadrant and epigastric pain
 Respiratory changes as the result of pulmonary edema

Eclampsia

Of all the many possible complications of pregnancy, eclampsia is the leading cause of maternal death and
poor fetal outcomes.
In addition to the signs and symptoms of preeclampsia, as listed immediately above, eclampsia is
characterized with seizure activity that is not attributable or correlated with another cause such as
hypoglycemia, central venous sinus thrombosis and/or an amniotic fluid embolus.
Some of the maternal complications associated with eclampsia are:

 Seizures
 Cerebral, hepatic and renal damage
 Cerebral hemorrhage
 Coma
 Death

The possible fetal complications of eclampsia include:

 Placenta abruption
 Fetal demise
 Abnormal fetal growth and development
 Low birth weight
 A premature delivery
 Damage to organs such as the brain, liver and kidneys

Because of these serious fetal complications, the mother and the fetus are monitored on a frequent basis and,
when the need arises, the preservation of fetal life may depend on an immediate delivery. Some of the
interventions that can be indicated, as based on the current status and condition of the mother and the fetus,
include monitoring the urinary output and expecting it to be at least 30 mL per hour, monitoring the maternal
vital signs, assessing the mother's level of consciousness, checking maternal reflexes such as the deep tendon
reflex.
The treatments for eclampsia, and some cases of preeclampsia, can include:

 The administration of magnesium sulfate which is an anticonvulsant medication

 The administration of corticosteroids which facilitates lung development for the fetus and better
hepatic and platelet functioning
 The administration of antihypertensive medications to control maternal hypertension and to prevent
the complications associated with this hypertension
 The restriction of fluid intake
 Maintaining urinary output at 30 mL per hour
 Bed rest as indicated
 Labor induction or a planned delivery as indicated

Clients who are taking magnesium sulfate must be carefully monitored for the signs and symptoms of life
threatening magnesium sulfate toxicity including a diminished level of consciousness, cardiac arrhythmias,
respiratory depression, a urinary output of less than 30 mL per hour and neurological deficits such as an
absent patellar deep tendon reflex response.
Magnesium sulfate toxicity is treated with the immediate cessation of the magnesium sulfate IV, and the
administration of calcium gluconate which is the antidote for magnesium sulfate.

Preterm Labor

Preterm labor, technically defined, is the occurrence of true uterine contractions and the emergence of
cervical changes characteristic of the full term changes with a full term delivery, between the 20 th and 37th
weeks of gestation.
Some of the risk factors associated with preterm labor including, but not limited to:

 A lack of adequate prenatal care

 Diabetes
 Hypertension
 Multiple gestations
 Substance use and abuse
 Maternal age < 17 years of age or > 35 years of age
 Uterine abnormalities
 Hydramnios
 Infections, such as chorioamnionitis and others, that adversely affect amniotic fluid
 Multiple pregnancies in rapid succession
 A previous history of spontaneous abortions, preterm births or miscarriages

The signs and symptoms of preterm labor are the same as those of true, full term labor, as will be discussed in
a subsequent section of the NCLEX-RN review.
The goals of the treatments for preterm uterine contractions and cervical changes are to cease preterm labor
and maintain the pregnancy for as long as possible. Some of the treatments and interventions for preterm
labor include:

 Activity restriction
 Positioning on the left lateral position to decrease uterine activity
 Insuring hydration to prevent oxytocin release which stimulates contractions
  The administration of medications such as nifedipine or indomethacin to suppress contractions, and
magnesium sulfate to relax smooth muscle and to suppress contractions
 The administration of betamethasone to stimulate fetal lung surfactant production and to enhance
fetal lung maturation

Post Term Pregnancy

A post term pregnancy is defined as a pregnancy that lasts more than 294 days and WITHOUT any
miscalculations of the due date of delivery. Post term pregnancies can result from a number of different
factors and forces including, but not limited to, fetal anencephaly, a placental sulfatase deficiency, and
maternal primiparity.
The fetal complications associated with a post term pregnancy are oligohydramnios, the aspiration of
meconium, umbilical cord compression, a higher than normal mortality rate, birth trauma, and shoulder
dystocia.
Post term pregnancy does not typically lead to any maternal complications other than a more difficult labor
and delivery because of the typically large size and weight of a post term baby.

Subchorionic Hematoma

A subchorionic hematoma occurs when there is a blood clot between the membranes of pregnancy and the
wall of the uterus that separates and leads to maternal bleeding.
Although a rare complication of pregnancy, the signs and symptoms of a subchorionic hematoma include
vaginal bleeding and abdominal cramps. At times, the pregnant woman may be asymptomatic.

Hydatidform Moles

A hydatidform mole occurs as the result of a paternal chromosomal aberration. A hydatidform mole can be a
complete or a partial molar pregnancy. There is no fetus with a complete hydatidform mole.
The classic sign of a hydatidform mole is the formation of grape like clusters that can even be seen in the
vagina. Other signs and symptoms include pelvic pressure, maternal hypertension, vaginal bleeding during the
first trimester, an abnormally rapid growth of the uterus, anemia, and maternal nausea and vomiting.

Hyperemesis Gravidarum

Hyperemesis gravidarum, affectionately known as morning sickness, is a persistent and excessive amount of
maternal nausea and vomiting.
Hyperemesis gravidarum often occurs during the first trimester of pregnancy but some pregnant women may
be affected with hyperemesis gravidarum throughout the course of the entire pregnancy. It is medically
defined as nausea for the majority of the day and vomiting three or more times per day.
Other signs and symptoms include hypotension, tachycardia, dizziness, dehydration, and maternal weight loss.

Incompetent Cervix

Simply defined, an incompetent cervix, or cervical insufficiency, is a cervix that effaces and dilates too early
during the pregnancy. An incompetent cervix is diagnosed typically as early as the fourth month of gestation.
This premature effacement and dilation can lead to the rupture of the membranes and a miscarriage unless it
is successfully treated.
The signs and symptoms of an incompetent uterus include back, pelvic, and abdominal cramping, vaginal
spotting or bleeding, and other changes in the vaginal discharge.
Anemias

Iron deficiency anemia and folic acid deficiency anemia are also complications of pregnancy during the
antepartal period of time. Both of these anemias can have adverse effects on both the pregnant mother and
the developing fetus.
The risk factors associated with a folic acid deficiency include some medications that deplete folic acid, a
history of a neural tube defect pregnancy in the past, an abnormal excessive excretion of folic acid,
gastrointestinal malabsorption syndrome, and a less than adequate dietary intake of foods high in folic acid,
coupled with the need for increased folic acid during pregnancy. Some of the signs and symptoms of folic acid
deficiency anemia include diarrhea, depression, confusion, and glossitis.
Folic acid deficiency anemia, which can be simply prevented with the administration of folic acid
supplementation during the prenatal period, can lead to fetal brain abnormalities and other neural tube
abnormalities.
Iron deficiency anemia during pregnancy, like folic acid deficiency anemia, can result from a number of factors
and forces such as the increased need for iron during pregnancy, a lack of maternal iron stores to meet the
demands of pregnancy, an inadequate dietary intake of iron, and the fact that the maternal volume of plasma
expands without a proportionate increase in the mother's hemoglobin, thus creating an iron deficit. The
greatest need for iron occurs during the second trimester of pregnancy.
Some of the signs and symptoms suggestive of iron deficiency anemia include pallor, headache, irritability,
pica, shortness of breath with moderate exertion, fatigue, brittle finger and toe nails, irritability, and
palpitations.
A confirmative diagnosis is made when the laboratory diagnostic tests show a Hgb < 11 mg/dL during the 1st
and 3rd trimester, a Hgb < 10.5 mg/dL during the 2nd trimester and a Hct < 33%. The treatment of iron
deficiency anemia includes ferrous sulfate 325 mg bid or, when oral iron supplementation cannot be
tolerated, iron dextran can be used.
The effects of iron deficiency anemia in terms of the fetus can prematurity, a low birth weight, and fetal
demise; the mother, on the other hand, can be adversely affected with infections, postpartum hemorrhage
and preeclampsia, for example.

Cardiopulmonary Maternal Collapse

Cardiopulmonary maternal collapse is a severe antepartal complication that can be a life threatening medical
emergency for both the pregnant woman and the developing fetus.
The risk factors associated cardiopulmonary maternal collapse are:

 Hemorrhage including an intracranial bleed

 Heart disease
 Genitourinary tract infections
 Major trauma
 Eclampsia
 Thromboembolism
 A ruptured ectopic pregnancy
 An amniotic fluid emboli

The signs and symptoms of cardiopulmonary maternal collapse are INCREASED:

 Pulmonary capillary wedge pressure

 Systemic vascular resistance
 Clotting factors
  Tidal volume
 Volume of erythrocytes
 Sequestration of blood to the uterus
 Plasma volume by 40% to 50%
 Cardiac rate by 15 to 20 beats per minute
 Cardiac output by 40%
 Oxygen consumption by 20%
 Arterial blood pressure by 10 to 15 mm Hg
 Functional residual capacity by 25%

According to the physical status of the pregnant woman and the fetus, some of the life saving interventions for
the correction and treatment of cardiopulmonary maternal collapse include cardiopulmonary resuscitation
and advanced cardiac life support, an immediate caesarean section to preserve the lives of both the pregnant
woman and the baby, and a post mortem caesarean section to save the baby after the mother has died.

Disseminated Intravascular Coagulation

Disseminated intravascular coagulation, also referred to as DIC, is an acquired clotting factor abnormality that
can occur during pregnancy, particularly when the pregnant woman is affected with another disorder such as
an amniotic fluid embolism, eclampsia, an incomplete abortion, a retained dead fetus, or the retention of the
placenta.
The signs and symptoms of disseminated intravascular coagulation include the signs and symptoms of blood
clotting and the signs and symptoms of bleeding. Other signs and symptoms include possible decreases in the
level of consciousness, cyanosis, hypotension, hypothermia, tachycardia, behavioral and mood changes.
Without treatment, disseminated intravascular coagulation can lead to death.

Ectopic Pregnancy

Ectopic pregnancy is another complication of pregnancy. Ectopic pregnancy occurs when the fertilized egg is
implanted anywhere other than the uterus. Most ectopic pregnancies occur when the fertilized egg is
implanted in the fallopian tube. Unilateral pain, nausea, vomiting, a brown vaginal discharge, and faintness are
some of the signs and symptoms that can occur with an ectopic pregnancy.

Substance Use and Abuse

Substances both illicit and legal can adversely affect a pregnancy. For example, legal alcohol, prescription
drugs, over the counter drugs, cigarettes, other legal tobacco products pose risks in terms of the pregnancy.
For example, placental abruption, spontaneous abortions, a small for gestational age infant, as well as sudden
infant death syndrome after birth and attention deficit hyperactivity disorder as the infant matures can result
from tobacco use; fetal alcohol syndrome, impaired intrauterine fetal growth, mental retardation,
microcephaly and cardiac anomalies can result from alcohol use and abuse; and tobacco use can lead to
placental abruption, spontaneous abortions,
Prescription medications such as tranquilizers can cause fetal drug withdrawal, hypotonia, hypothermia, a low
APGAR score upon birth, cleft palate and/or lip, and respiratory compromise.
Medications are categorized according to five categories in terms of their degree of risk in terms of fetal
development and growth. Categories A and B are generally considered safe for pregnant women; and
medications classified as category C, D, and X are not considered safe, therefore, category C, D, and X
medications are not given to pregnant women unless they are absolutely necessary and the benefits
associated with the particular medication greatly outweigh the fetal complications associated with their
maternal use.
Additionally, the use of these illicit and illegal products and substances can lead to antepartal complications
for both the fetus and the pregnant woman. The substances and the potential complications associated with
each are listed below.

 Marijuana: Intrauterine growth restriction, neonatal withdrawal, and developmental and behavioral
abnormalities as the infant matures.
 Heroin: Impaired respiratory functioning, tremors, convulsions, and neonatal irritability and
withdrawal.
 Methadone: Preterm labor, placenta abruptio, meconium aspiration, and fetal withdrawal
 Barbiturates: Intrauterine fetal growth restrictions and fetal withdrawal
 Methylenedioxymethamphetaime (MDMA or Ecstasy): Memory and learning deficits
 Lysergic acid diethylamide (LSD): Chromosomal aberrations
 Crack/cocaine: Microcephaly, genitourinary abnormalities, cardiac abnormalities, central nervous
system depression and sudden infant death syndrome after birth.

Spontaneous Abortions

Spontaneous abortions, also referred to, as unintended abortions or miscarriages, most often occur during the
first trimester of the pregnancy. Spontaneous abortion is defined as all losses of the fetus with the exception
of an elective abortion to end an unwanted pregnancy.
Spontaneous abortions occur as the result of one or more factors including chemical and/or radiation
exposures, abnormalities of the mother's anatomical structures such as the uterus, and maternal diseases and
disorders such as infections, diabetes, and thyroid conditions.
Spontaneous abortions are classified into a number of different types of spontaneous abortions. An inevitable
abortion is accompanied with bleeding, abdominal cramping, cervical dilation, and perhaps the rupture of the
membranes. Threatened spontaneous abortions can be signaled with bleeding, abdominal, and back pain that
is not accompanied with any cervical dilation or the rupture of the membranes.
An incomplete abortion also has the signs and symptoms of abdominal and back cramping as well as bleeding,
but only part of the membranes is lost. A complete spontaneous abortion presents with severe bleeding,
severe cramping, and the complete loss of the membranes well before the expected date of delivery.
Ultrasound and a speculum examination confirm the diagnosis of a spontaneous abortion.
Some of the complications associated with spontaneous abortions include disseminated intravascular
coagulation (DIC), increases in terms of the maternal thromboplastin levels and fetal autolysis.
Dilation and curettage (D and C) is typically done to remove the products of the pregnancy; additionally,
misoprostol may be required in order to remove any remaining contents.
Other interventions after a spontaneous abortion, as based on the client's condition, intravenous fluid
replacement, blood or blood products, and a suction evacuation or dilatation and curettage (D & C) when the
products of conception are not expelled spontaneously.

Premature Rupture of the Membranes

Premature rupture of the membranes occurs when the amniotic membranes break and rupture 1 hour or
more prior to the onset of labor. Premature rupture of the membranes, a serious complication of pregnancy,
can lead to infection as a result of the premature loss of the protective amniotic sac and its fluids. For
example, an infection of the remaining amniotic membranes, referred to as chorioamnionitis, can occur as the
result of a premature rupture of the membranes.
In addition to infection, another serious complication of premature rupture of the membranes is a prolapsed
umbilical cord, accompanied with prolonged or variable deceleration, which can endanger the fetus prior to
delivery. This complication is confirmed with a direct inspection of the introitus and with fetal heart
monitoring that reveals prolonged or variable deceleration.
The signs and symptoms of a premature rupture of the membranes, referred to by many clients as "breaking
the water", may include:

 Pyrexia
 Leakage or gushing of the fluid from the vagina
 Foul smelling vaginal discharge
 Maternal tachycardia
 Increased fetal heart rate
 Positive findings with the ferning test
 Positive findings with a nitrazine paper test

The treatment of premature rupture of the membranes includes antibiotics to prevent infections,
betamethasone to facilitate fetal lung maturity and surfactant production, and to prepare for childbirth.

Multiple Gestations

Multiple gestations is defined as a pregnancy with two or more fetuses. Even though multiple gestations is
considered a risk, the risks associated with it are significantly decreased with good prenatal care.
In addition to the signs of pregnancy, multiple gestations are suspected during the first trimester when the
mother's has a greater than normally expected weight gain, fatigue, abdominal expansion, and/or nausea and
vomiting and when the fetal movements are felt sooner than normally. Multiples are confirmed with an
ultrasound examination.
Maternal complications can include a number of different disorders and complications such as anemia,
hydramnios, hyperammonemia, hypoglycemia, hypertension, preeclampsia and eclampsia, gestational
diabetes, pulmonary embolism, coagulopathy, and a premature rupture of the membranes.
The fetal complications related to multiple gestations during the first trimester include infections and the
complications of infection, spontaneous abortion, chromosomal anomalies, fetal growth restriction, an
incompetent cervix, spontaneous abortion and the "vanishing twin" phenomena which threaten the second
trimester of pregnancy with multiples. The "vanishing twin" phenomena occurs when one or more of the
multiple fetuses is reabsorbed.

Fetal Growth Restriction

Fetal growth restriction and a small for gestational age fetus can occur as the result of both genetic and non
genetic causes. Some of the maternal risk factors associated with restricted uterine growth are placental
insufficiency, kidney disease, some infections like cytomegalovirus, diabetes, hypertension, and substance
abuse.
The fetal complications of fetal growth restriction include perinatal asphyxia, polycythemia which gives the
neonate a ruddy complexion, tachypnea, lethargy, meconium aspiration, and hypoglycemia, of which the most
serious and life threatening is perinatal asphyxia which can occur during labor with each uterine contraction at
which time the maternal placental perfusion decreases. An immediate delivery is indicated when fetal distress
is present.
Oligohydramnios

Oligohydramnios is defined as an insufficient amount of amniotic fluid; the normal volume of amniotic fluid is
from 5 to 25 and values less than 5 are considered oligohydramnios.
Oligohydramnios can result from a number of causes including medications like NSAIDs and ACE inhibitors,
abruptio placentae, premature rupture of the membranes, restricted fetal growth, a post term pregnancy,
hypertension, preeclampsia, eclampsia, chromosomal abnormalities of the fetus, and a maternal thrombolytic
disorder.
The complications of oligohydramnios can include restricted fetal growth, impaired fetal lung development,
and fetal demise. Ongoing monitoring with biophysical profiles, ultrasonography, and nonstress testing is
done, and when necessary, induced labor or the immediate delivery of the fetus are done.

Polyhydramnios

Polyhydramnios is an excessive amount of amniotic fluid with a value of > 25.

Some of the factors that impact development of polyhydramnios are Rh incompatibility, hemolytic anemia,
multiple gestations, infection and genetic fetal abnormalities. Some of the signs and symptoms of
polyhydramnios are maternal respiratory distress and pre term labor contractions. The complications
associated with polyhydramnios are premature rupture of the membranes, life threatening umbilical cord
compression, preterm labor, abruption placentae, fetal distress and fetal death.
Continuous monitoring and the manual withdrawal of excessive amniotic fluid, may be indicated. This
withdrawal of amniotic fluid is referred to as an amnioreduction.

Assessing the Client For the Symptoms of Postpartum Complications

Maternal assessment and management continues after the delivery of the neonate. These assessments are
done with the knowledge that infections and hemorrhage are the most frequently occurring postpartum
complications.
During the immediate postpartum period the acronym BUBBLE is a good way to remember the essential
components of the postpartum assessment in addition to the assessment of the client's vital signs, the level of
pain and discomfort, and other assessments.
The acronym BUBBLE stands for the assessment of the mother's:

 The B of BUBBLE is the breasts

 The U of BUBBLE is the uterine fundus height, consistency and placement
 The B of BUBBLE is the bowel and other gastrointestinal functioning
 The second B of BUBBLE is bladder functioning
 The L of BUBBLE is lochia amount, consistency, color and odor
 The E of BUBBLE is episiotomy edema and redness

Vaginal discharge progresses from bloody vaginal drainage with some small clots for about 10 days after which
the vaginal drainage is brown and may continue for up to about 6 weeks. The breasts will be normally
engorged, particularly when the mother is breast feeding; urinary output may increase during the first day or
two of the postpartum period of time; about 12 or 13 pounds is lost by the new mother; and hormonal shifts
may lead to depression for about two weeks, after which this depression may be serious and a sign of
postpartum psychosis, rather than the "baby blues".
All the vital signs should return to their normal levels in about 24 hours after delivery. Infection and
postpartum hemorrhage must be ruled out when the signs of infection or hemorrhage present. 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 fatigue, chills, hyperthermia, 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.

Recognizing Cultural Differences in Childbearing Practices

Culture, cultural practices and cultural beliefs can impact on the childbearing practices of many clients. For
example, some cultures, more than others, promote the importance of large families, while others such as the
Chinese limit the size of the family. Some cultures also differ in terms of their beliefs relating to single
parenthood, pregnancies among unmarried couples, prenatal care, gender preference, breast feeding and
places where the delivery of the infant should take place.
These practices and beliefs can impact on the importance of having children, health practices during
pregnancy, beliefs about pregnancy and infant feeding.

Calculating the Expected Date of Delivery

The expected date of delivery is calculated using Nagle's rule which is:

 The first day of last menstrual period – 3 months + 7 days = the estimated date of delivery

Checking and Monitoring the Fetal Heart during Routine Prenatal Exams and During Labor

Now we will discuss monitoring the fetal heart rate during the antepartum period of time. Some of the terms
used in respect to fetal heart rate monitoring will be defined now.
 The baseline fetal heart rate is the average fetal heart rate per minute during a 10 minute period of
time WITHOUT any periods of significant variability or any period when the rate varies by more than 25
beats per minute.
 A wandering baseline fetal heart rate is a fluctuating fetal heart rate from the baseline. This abnormal
fetal heart rate pattern can indicate disorders like a congenital abnormality or metabolic acidosis.
 An acceleration is defined as an increased fetal heart rate over the fetal heart rate baseline with a less
than 30 second duration from the onset to the peak. Accelerations can be prolonged, episodic, or
periodic.
 A prolonged acceleration is an acceleration of the fetal heart rate that lasts more than 2 minutes.
 An episodic acceleration is defined as an assuring fetal heart rate pattern that normally occurs with
fetal movements.
 Periodic acceleration is an acceleration that occurs with contractions. They are normal.
 A deceleration is a fetal heart rate that is less than the baseline. Decelerations can be early, late,
variable or prolonged.
 The onset of deceleration is the point where the fetal heart rate falls below the baseline.
 The nadir of deceleration is the lowest point of the deceleration.
 The descent of deceleration is the time between the onset and the nadir of deceleration.
 The depth of deceleration is the number of beats per minute that occur during a deceleration until it
reaches its nadir.
 The duration of a deceleration is the time elapsed from the onset of the deceleration to the fetus'
baseline fetal heart rate.
 The recovery of the deceleration is the time elapsed from nadir to the fetus' baseline fetal heart rate.
 A late deceleration is a gradual decrease of the fetal heart rate heart rate below baseline during
contraction.
  An early deceleration is a gradual increase of the fetal heart rate below the baseline during contraction
which occurs during the peak of the contraction.
 Variable decelerations occur when the fetal heart rate suddenly decreases by at least 15 beats per
minute that lasts at least 15 seconds before it returns to the baseline.
 A prolonged deceleration is defined as a decrease in the fetal heart rate of 15 or more beats per minute
that persists more than 2 minutes from its onset to its return to the baseline.
 Variability is classified as with minimal variation when it varies by less than 5 beats per minute;
moderate variability occurs fetal heart rate varies by 6 to 25 beats per minute; and with marked and
severe variability the fetal heart rate varies by more than 25 beats per minute.

Nonreassuring fetal heart rates and heart rate patterns include the absence of any variability, late
decelerations, variable decelerations, fetal tachycardia, and fetal bradycardia. Noninvasive fetal heart rates
are monitored on a continuous or an intermittent basis. The necessity of fetal heart monitoring is underscored
when the mother has complications such as abnormal uterine contractions, hypertension, diabetes, a post
term pregnancy, and renal disease and/or the fetus is at risk as the result of one or more factors such as fetal
distress, meconium stained amniotic fluid, multiple gestations, placenta previa, abruptio placentae, an
abnormal contraction stress test, an abnormal nonstress test, bradycardia and intrauterine growth restriction.
Noninvasive external fetal monitoring is advantageous over invasive internal fetal heart monitoring because
there is less risk of infection, and there is no need for the rupture of the membranes or the dilation of the
cervix at 2 or more centimeters, and there is no need for the fetus to have a descended presenting part.
Invasive internal fetal monitoring, when compared and contrasted to external fetal monitoring, is
advantageous because it provides a higher quality and more accurate reading that is also not impaired with
factors such as maternal obesity, fetal positioning and maternal positioning.
Normally, fetal heart rate baselines are from 110 and 160 beats per minute excluding any decelerations,
accelerations, or episodes of variability over a 10 minute period of time. Fetal heart rates less than 100
indicate fetal bradycardia; and rates greater than 160 beats per minute indicate fetal tachycardia.

Assisting the Client with Performing/Learning Newborn Care

Mothers, particularly new mothers and significant others, need some assistance and support in terms of
newborn care and infant feeding. They must know the nutritional needs of the baby, how to breast feed or
bottle feed, how to provide cord care and circumcision care, diapering, bonding, attachment, preventing
accidents, such as placing the infant on their back to prevent suffocation, and how to respond to the baby's
crying.

Nutritional Needs and Feeding the Infant

The nutritional needs of the neonate include about 110 kcals per kilogram a day for the first 3 months of life
and then 100 kcals per kilogram a day until the infant is about 6 months of age. Neonates and infants also
need 2 ¼ to 4 grams of protein each day, and 140 to 160 mLs of fluid per day.
Human milk is considered the best form of nutrition for infants up to at least 6 months of age. Breast milk is
produced in the breast as the result of the hormone prolactin. Prolactin, in addition to oxytocin, both of which
are endocrine hormones that are secreted by the pituitary, regulate milk production. Breast milk is more
readily and easily absorbed and digested than formula milk.
The decision to breastfeed or formula feed is a personal decision that should be made by the mother after a
full discussion about the advantages and disadvantages of each type of infant feeding. Some of the factors and
forces that impact on this decision include cultural practices and beliefs, the mother's employment, life style
choices and socioeconomic status. For example, some cultures have the belief that breastfeeding is the
natural and preferable choice and other cultures may not share this same belief; life style choices like a desire
to drink alcoholic beverages after the delivery of the baby prevent the mother from breast feeding; and some
places of employment may not accommodate the needs of the breast feeding woman with breaks for
pumping and/or feeding the infant.
A healthy diet for the lactating breast feeding mother should include small amounts of fats, protein, whole
grains, dairy products, fresh fruits and vegetables. Special foods are not needed to produce milk or to maintain
an ample milk supply.
The normal breastfeeding process includes the proper positioning of the infant and mother, latch on and the
sucking and swallowing sequence.
Positioning and holding the neonate for breast feeding will become a personal preference, however, there a
number of positions that the mother should be instructed about including the football clutch hold position,
the cradle position, the modified cradle position, and the side lying position.
Latch on is placing the areola and a large portion of the breast into the baby's mouth. The infant's rooting
reflex promotes their latching on and it can be stimulated by stroking the baby's cheek when the nipple is in
the baby's mouth. The suck and swallow sequence starts when the infant starts to suck, the milk is then
moved with the infant's tongue to the back of the mouth and then the infant swallows.
Mothers who choose to bottle feed should be instructed about the safe and proper way to feed their infant.
They should be instructed to hold the baby and NOT prop the bottle up for automatic feeding.

Cord Care

The umbilical cord stump should be gently handled and kept clean in order to prevent an infection. The
umbilical cord stump typically dries up and falls off at about two to three weeks after birth.
Cleansing entails the use of plain water and NOT alcohol as was done in the past. After cleansing with water,
the stump should be permitted to air dry or dried with an absorbent pad. Sponge bathing, rather than tub
baths, is encouraged and the stump should be exposed to circulating air and not covered with a diaper in
order to promote its drying out and falling off.
The mother should also be instructed how to identify any signs or symptoms of umbilical cord stump infection
such as swelling, pus and redness.

Circumcision Care

The circumcision site is kept clean and inspected for any complications such as infection, bleeding and an
alteration in urinary output.
The penis is cleansed, coated with a bit of petroleum jelly, and then covered with a sterile dressing until it is
healed which typically occurs in about one week.

Diapering

New mothers also make choices in terms of what kind of diapers they will use for their infant until they are
toilet trained. Some choose cloth diapers and other new mothers choose disposable diapers. Some of the
factors that may come into play in terms of this decision include socioeconomic factors, the accessibility of a
washer and dryer and personal preferences in terms of convenience. For example, based on the fact that
many neonates and infants need 10 or more daily diaper changes, some parents choose cloth diapers because
the cost associated with disposable diapers is prohibitive; and some choose disposable diapers rather than
cloth diapers because they do not have access to a washer and dryer, and they prefer the convenience of
disposable diapers.
Diapering techniques are relatively simple for the new parents to learn, however, diapering safety has to be
emphasized. NO infant should ever be left unattended on a changing table or bed. These types of falls occur
far more frequently than you can imagine.
Bonding and Attachment

Bonding and attachment to the parents is critically important to the healthy growth and development of the
new baby. Bonding and attachments give the neonate and infant positive feelings of trust and intimacy.
Poor and absent bonding and attachments can lead to lifelong consequences such as mistrust, a lack of
intimacy, and impairments in terms of cognitive and psychological development.
Nurses can promote bonding and attachments by encouraging both parents, and siblings, to hold the infant, to
feed the infant and to communicate with the infant with touch, rocking and soothing cooing sounds.

Accident Prevention

The greatest safety risks among neonates and infants include suffocation, falls and strangulation. Suffocation
can be prevented by keeping all objects out of the crib and always positioning the infant on their back and not
on their stomach.

Providing Prenatal Care and Education

Prenatal care consists of a complete and thorough assessment of the mother, including a complete past
medical history and physical assessment, client education, and ongoing care.
The initial client assessment during the first contact with a woman that may be pregnant should minimally
consist of a complete health history and a complete physical assessment.
The components of this maternal health history, in addition to the data that is typically collected with other
health histories, include the mother's gynecological history, the number of living children, the number of full
term births, the number of preterm births, the number of spontaneous and elective abortions, any
complications experienced in prior pregnancies, any current medical concerns related to the pregnancy or
otherwise, the first day of the last menstrual period, the parents' genetic history, and the woman's
psychological and emotional responses to the current pregnancy.
Some of the maternal routine diagnostic tests that are done during the prenatal period of time include:

 Urinary or blood human chorionic gonadotropin to diagnose a pregnancy

 One hour glucose tolerance test and a possible three hour glucose tolerance test
 Tests for HIV, hepatitis B, gonorrhea, tuberculosis, Group B streptococcus, chlamydia, streptococcus,
and syphilis
 TORCH infections screening
 Blood type including the Rh factor
 Papanicolaou (PAP)
 Hgb electrophoresis to detect conditions like sickle cell anemia
 CBC with differential
 Hgb and Hct
 Rubella titer
 Serum alpha-fetoprotein

Some of the fetal diagnostic tests that are done during the prenatal period of time include:

 Biophysical Profile: This test measures and assesses fetal breathing, fetal movement, fetal tone, the
fetal heart rate acceleration and the volume of the amniotic fluid.
 Diagnostic Ultrasound: Transabdominal and transvaginal ultrasound, according to the American College
of Obstetricians and Gynecologists, is used for a wide variety of normal and abnormal conditions such
 as fetal presentation, gestational age, fetal growth, an ectopic pregnancy, abruptio placentae and
placenta previa.
 Lung Maturity Studies: Lung maturation studies include the lecithin/sphingomyelin or L/S ratio, the
lung profile and the phosphatidylglycerol (PG) level.

The lecithin/sphingomyelin or L/S ratio is the ratio of lecithin to the amount of sphingomyelin in the amniotic
fluid that comprises the fetus' lung surfactant. A ratio < 2:1 is abnormal and suggestive of the fact that the
newborn may be affected with respiratory distress syndrome and a ratio of < 1:5 indicate that the fetus is a
high risk for infant respiratory distress syndrome.
The presence of phosphatidylglycerol prior to the 36th week of gestation indicates the possibility of neonatal
respiratory distress syndrome; and the lack of phosphatidylglycerol indicates a significant risk of respiratory
distress syndrome.
A lung profile consists of the lecithin/sphingomyelin ratio and the phosphatidylglycerol (PG).

 Nonstress Test: This noninvasive, nonstress test monitors and measures the fetal heart rate and fetal
movements. The results of this test is considered normal and reactive when the fetus' heart rate
increases by at least 15 beats per minute over 15 seconds when the fetus moves; and the results of
nonstress test are considered abnormal and nonreactive when the fetus' heart rate does NOT increase
by at least 15 beats per minute over 15 seconds when the fetus moves.
 Contraction Stress Test: This noninvasive test measures fetal responses to contractions that are
stimulated with intravenous oxytocin or the mother's manual stimulation of her nipples. A normal
contraction stress test occurs when there are no late or variable decelerations during at least three
uterine contractions. This normal test is referred to as a negative contraction stress test. An abnormal,
positive contraction stress test occurs when there are late or variable decelerations during contractions.
 Amniocentesis: According to the American College of Obstetricians and Gynecologists, amniocentesis is
indicated when the pregnant woman is at risk for complications, is older than 35 years of age and when
there is a personal or family history of chromosomal aberrations and/or neural tube abnormalities.

Withdrawn amniotic fluid is laboratory tested to identify fetal abnormalities including fetal distress, for
example, when it is brown, red or green in terms of color.

 Chorionic Villus Sampling: Chorionic villus sampling, like amniocentesis, is beneficial for the
assessment of the fetus for fetal abnormalities.
 Percutaneous Umbilical Blood Sampling: Percutaneous umbilical blood sampling is effective for the
assessment of the fetus in terms of the presence of any infections and chromosomal abnormalities in
addition to the determination of the fetus' blood type and Rh factor.
 Alpha-Fetoprotein: Maternal alpha-fetoprotein, also referred to as α-fetoprotein, can identify genetic
disorders. Elevations of α-fetoprotein is suggestive of disorders such as anencephaly and spina bifida;
and lower than normal maternal alpha-fetoprotein levels can indicate the possibility that the fetus is
affected with Down's syndrome, hydatidiform mole and other abnormalities.
 Triple Screens: The maternal blood test includes the laboratory testing of maternal alpha-fetoprotein,

human chorionic gonadotropin and estriol to determine the presence of fetal abnormalities. For example,
elevated levels of human chorionic gonadotropin can indicate trisomy 21; and low levels of unconjugated
estriol can also indicate the presence of trisomy 21.

 Amniotic Fluid Index: The amniotic fluid index is used to assess fetal wellbeing. An amniotic fluid index
of < 5 indicates the need for further assessments and determinations.
Prenatal Education

Ideally, prenatal education should be provided to the client even before they plan a pregnancy. For example,
the client should be instructed about methods of birth control, the signs of pregnancy, and ways to prepare
for pregnancy.
Upon initial contact, the pregnant woman and their partner should be taught about a wide variety of things
that they will have to consider and make choices about. For example, they should be taught about their
choices in terms of the care provider that will care for the mother during pregnancy and delivery, the possible
birth settings, childbirth preparation classes, the birthing plan, who will be with the mother during labor and
delivery, newborn care classes, sibling preparation classes, breast feeding and bottle feeding and:

 Normal gestational growth and development

 Normal physiological changes that occur during pregnancy
 The presumptive, probable, and positive signs of pregnancy.
 The signs and symptoms of complications during pregnancy
 Nutrition during pregnancy
 Exercise during pregnancy
 The stages of labor and delivery
 The postpartum period

Some of the settings for childbirth include a hospital, a community based birthing center and the home of the
pregnant woman. All of these settings have their advantages and disadvantages. For example, a home delivery
may be a disadvantage when the mother and/or the neonate are in need for emergency care and treatments
and a hospital delivery may be perceived by the parents as impersonal and unnatural.
Choices in terms of the care provider that will care for the mother during pregnancy and delivery include an
obstetrician, a nurse midwife and a non nursing midwife. Possible support people during the labor and
delivery processes can include family members, spouses, a professional doula, friends, siblings and nursing
students.
Pregnant women also should make knowledgeable decisions about childbirth methods and childbirth
preparation classes should they elect to take advantage of them. The most common childbirth preparation
classes are the Lamaze method, the Kitzinger method, the Bradley method, the Alexander method and the
Hypno Birthing method.
The Lamaze method supports the fact that childbirth is a normal and natural process about which the mother
has instinctive knowledge about. The Lamaze method childbirth preparation classes include information and
education relating to pain management choices, methods of feeding the infant, the labor process, the
postpartum period, and relaxation and breathing techniques for each stage of labor.
The Bradley method childbirth preparation classes include deep abdominopelvic controlled breathing to use
during labor, good nutrition during pregnancy, breastfeeding, exercise during pregnancy, relaxation
techniques, and the stages of labor. The Bradley method is a partner coached birth that supports the fact that
participation in the labor and delivery processes is a satisfying and rewarding experience.
The Alexander method childbirth preparation classes include comfort measures to use during pregnancy and
labor, pushing during delivery, and ways to promote the pregnant woman's flexibility, movement, balance,
and coordination.
The Kitzinger method, a home delivery childbirth preparation method, consists of educational classes that
include the home delivery method that clients without the risk for complications can decide upon. These
classes include antepartum care, breast feeding, therapeutic touch during labor, chest breathing, abdominal
relaxation and the use of sensory memory to facilitate the mother's understanding of her body and its
functioning during pregnancy and the birth process.
Hypno Birthing childbirth preparation includes instruction on self hypnosis and how self hypnosis promotes
the release of endorphins which is considered a natural anesthetic. In addition to self hypnosis, the pregnant
woman is also taught about relaxation techniques and pushing techniques.

Providing Care to the Client in Labor

Labor is the natural process or induced process that consists of involuntary, rhythmic uterine contractions that
increase in terms of frequency and intensity. Labor leads to the necessary effacement and dilation of the
cervix that is needed for the vaginal delivery of the baby after pregnancy.
Effacement is the thinning and shortening of the cervix and dilation is the opening of the cervix. Labor usually
begins about two weeks prior to the expected delivery date; labor usually lasts from twelve to eighteen hours.
The stages of labor and delivery include the first, second, third and fourth stages of labor.
The first stage of labor consists of the latent, active and transition phases. The latent phase of the first stage of
labor typically lasts for several hours and the contractions are mild. During the active phase of the first stage of
labor, the contractions become more frequent and severe, the cervix dilates up to seven centimeters and the
fetus begins to descend in the birth canal. The transition phase of the first stage of labor is characterized with
the increased frequency, intensity and duration of the contractions. The cervix dilates up to 10 cm.
The second stage of labor begins when the cervix is dilated 10 cm and it ends with the birth of the infant. The
third stage of labor begins with the vaginal delivery of the baby and it ends when the products of conception,
that is the placenta, are expelled. The fourth stage occurs during the first several hours after delivery.
During the latent phase of the first stage of labor, the mother should be encouraged to rest, walk, perform
relaxation techniques and take deep breaths. Food and fluids are limited and restricted during this phase of
the first stage of labor. They should also be encouraged to urinate every hour.
During the active phase of the first stage of labor, the client should be encouraged to continue voiding every
hour and also to continue with ambulation, rest and relaxation exercises. At times, such as with prolonged
labor, intravenous fluids may be used to prevent and treat dehydration. Nurses promote comfort and provide
basic nursing are with things like massages, oral care and frequent positioning for comfort. The spouse or
significant other should also be encouraged to care for their partner during this and all the other stages of
labor.
Contractions and maternal vital signs are checked and monitored every 15 minutes; and the fetal heart rate is
also monitored at least every 15 minutes. Fetal assessments include assessing and monitoring the fetal heart
rate at least every 15 minutes as well and much more often and even continuously when the fetus is at risk.
The mother must be reminded to pant rather than push in spite of the fact that the woman in labor has a
strong urge to push.
The fetal lie, presentation, attitude, station and position are also monitored and assessed during labor.
Fetal lie is defined as the relationship of the fetus's spine to the mother's spine. Fetal lie can a longitudinal,
transverse or oblique life. Longitudinal lie, the most common and normal lie, occurs when the fetus' spine is
aligned with the mother's spine in an up and down manner; a transverse lie occurs when the fetus' spine is at
a right ninety degree angle with the maternal spine; and, lastly, an oblique lie occurs when the fetus' spine is
diagonal to the mother's spine.
Fetal presentation is defined by where the fetus' presenting part is within the birth canal during labor. The
possible fetal presentations are the cephalic presentation, the cephalic vertex presentation, the cephalic
sinciput presentation, the cephalic face presentation, the cephalic brow presentation, the breech
presentation, the complete breech presentation, the frank breech presentation, the shoulder breech
presentation, and the footling presentation.
The cephalic head presentation, the most common and normal presentation, is the fetus' head as the
presenting part. The cephalic presentation can be further classified and categorized as the cephalic vertex
presentation where the fetus' head is on its chest, the cephalic sinciput presentation where the head is partly
flexed, the cephalic face presentation where the face is the presenting part of the head because the fetus'
head is hyperextended, and the cephalic brow presentation which occurs when the fetus' head is extended.
A breech presentation occurs when a fetal body part, other than the head, is the presenting part. The breech
presentation can be further classified and categorized as the complete breech presentation when the fetus'
buttocks are the presenting part, the frank breech presentation that occurs when the buttocks present and the
legs are straight up, the shoulder breech presentation when the shoulder presents, and the footling
presentation were one or both of the feet presents.
Fetal attitude is the positioning of the fetus's body parts in relationship to each other. The normal attitude is
general flexion in the "fetal position". All attitudes, other than the normal attitude, can lead to a more intense
and prolonged labor.
Fetal station is level of the fetus' presenting part in relationship to the mother's ischial spines. Fetal station is
measured in terms of the number of centimeters above or below the mother's ischial spines. Fetal station is -1
to -5 when the fetus is from 1 to 5 centimeters above the ischial spines and it is from +1 to +5 when the fetus
is from 1 to 5 centimeters below the level of the maternal ischial spines.
Fetal position, simply stated, is the relationship of the fetus' presenting part to the anterior, posterior, right or
left side of the mother's pelvis. The relationship of the fetus's presenting body part, such as left anterior, left
posterior, right posterior and right anterior, in relationship to the maternal pelvis which is called the anterior,
posterior, right and left pelvis which are noted and documented as A, P, R or L. The presenting part of the
fetus is referred to as mentum, occiput, sacrum, and acromion. These presenting parts are noted and
documented as M, O, S, and A respectively. The only normal positions are the left and right occiput anterior
fetal position which is the ROA and the ROL, respectively.
Face presentation positions are noted and documented as:

 RMA for the right mentum anterior position

RMT for the right mentum transverse position
RMP for the right mentum posterior position
LMA for the left mentum anterior position
LMT for the left mentum transverse position
LMP for the left mentum posterior positionVertex presentation positions are noted and documented
as:
 ROA for the right occiput anterior position
 ROT for the right occiput transverse position
 ROP for the right occiput posterior position
 LOA for the left occiput anterior position
 LOT for the left occiput transverse position
 LOP for the left occiput posterior position

Breech presentation positions are noted and documented as:

 RSA for the right sacrum anterior position

RST for the right sacrum transverse position
RSP for the right sacrum posterior position
LSA for the left sacrum anterior position
LST for the left sacrum transverse position
LSP for the left sacrum posterior position

Acromian presentation positions are noted and documented as:

  RAA for the right acromian anterior position
RAT for the right acromian transverse position
RAP for the right acromian posterior position
LAA for the left acromian anterior position
LAT for the left acromian transverse position
LAP for the left acromian posterior position

There are several types of delivery including:

 Vaginal deliveries
 Operative deliveries such as a forceps delivery, a vacuum delivery and a Caesarean and a
 Vaginal Birth After a Caesarean Section

Vaginal deliveries are the most common form of delivery. Vaginal deliveries can be done with or without an
episiotomy. An episiotomy may be indicated when the baby is excessively large, when there is shoulder
dystocia, and/or maternal and/or fetal stress are present.
Forceps facilitate the delivery of the baby by providing traction and they can also facilitate the rotation of the
fetus' head to the vertex position. All forceps except Piper forceps are applied to the sides of the head and
only when the fetus' presentation is presenting downward. Piper forceps are used for breech presentations
after the fetus' head is reachable after the delivery of the rest of the body.
The complications of forceps deliveries include maternal trauma, lacerations, pelvic floor damage, bleeding
and an inadvertent extension of the episiotomy to the anus. Neonate complications include a low Apgar score,
neurological trauma and damage, a fractured clavicle and Erb's palsy.
Vacuum deliveries are done with the application of suction to the occipital part of fetal head to assist in the
delivery when the second stage of labor is extensively long and/or there is a nonreassuring fetal heart rate
pattern. Attempted vacuum deliveries are ceased when there is no success after about one half hour.
Cesarean births are indicated with placenta abruptio, placental previa, cephalopelvic disproportion, a
nonreassuring fetal heart pattern, and a cord prolapse. The incision can be a skin incision with can be vertical
or transverse and a uterine incision which is done into the uterus.
Some of the maternal complications associated with Cesarean births are infection, hemorrhage, shock, emboli
and adverse reactions to anesthetic agents.
Trial labor and a vaginal delivery can be attempted after the mother has had a Cesarean section in the past
except under some circumstances such as an inadequate pelvis.

Providing Post-Partum Care and Education Including Discharge Instructions

As previously detailed with the section entitled "Assessing the Client For the Symptoms of Postpartum
Complications", postpartum care and monitoring focuses on BUBBLE, and for the signs of infection and/or
hemorrhage, which are the two most frequently occurring postpartum complications.
Mothers, particularly new mothers and significant others, need some assistance and support in terms of
newborn care and infant feeding.

Evaluating the Client's Ability to Care for the Newborn

Again, new mothers are monitored in terms of their abilities to provide care to the infant. Teaching and the
reinforcement of teaching are necessary when a learning need is assessed.
The essentials of newborn care include bathing, feeding, quieting strategies, swaddling, diapering, cord care,
and circumcision care.
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.
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
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.

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.

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

Infectious Disease Signs and Symptoms Treatments

Respiratory symptoms such as dyspnea, Symptomatic relief of the respiratory and
coughing and a sore throat. cardiovascular symptoms; mechanical
Diphtheria Myocarditis, cardiac arrhythmias, and a ventilation when indicated and the
pseudomembrane on the nasal passages, correction of respiratory paralysis with
pharynx, and tonsils. diphtheria toxin.
A rash, sore throat, oral lesions, fever and
Cytomegalovirus Symptomatic relief of the symptoms such as
enlarged lymph nodes, headache, chest pain,
infections an analgesic and mouth rinses.
jaundice, splenomegaly, and photosensitivity.
Photophobia, a cough, conjunctivitis, Koplik Supportive and symptomatic relief with
spots, and a maculopapular, erythematous antipyretic drugs, rest, a dark room to
Measles (Rubeola)
rash that starts on the face and spreads to the relieve photophobia and cool mist for the
body followed by desquamation. cough.
Anorexia, headache, an ear ache and parotid Supportive and symptomatic relief with
Mumps gland swelling. antipyretic drugs and analgesia.

A pink skin rash that begins on the center of

Supportive and symptomatic relief with
the body and spreads outward to the face,
Roseola antipyretic drugs and analgesia.
peripheral limbs, and neck.

Fetal abnormalities when the woman is

pregnant, a sore throat, lymphadenopathy,
Supportive and symptomatic care and the
cough, coryza, and a classical rash that begins
isolation of the affected client from all
Rubella (German on the face and spreads in a downward
woman of childbearing age to protect a
measles) manner to the neck, shoulders, trunk and
developing fetus.
legs. Later, this rash disappears in an upward
manner.
A very pruritic rash on the trunk and scalp, Skin care with topical calamine lotion,
oral and perineal area lesions, vesicles that keeping fingernails short or mittened if the
Varicella change to pustules and then develop a crust child is scratching, and teaching the child to
(Chickenpox) which disappears over time. put pressure on itchy areas rather than
Skin scars can result when the affected client scratching.
scratches the itchy areas.
Supportive and symptomatic relief with
fluids, bed rest, and analgesics other than
A productive or dry cough, overall aches and Aspirin which can lead to Reyes syndrome.
pains, hoarseness, photophobia, fever, nasal Antiviral medications, such as Tamiflu or
Influenza
congestion, chills, diaphoresis and myalgia Relenza, may be given to abbreviate the
duration of the flu and to prevent serious
complications.
Pertussis A whooping cough, respiratory changes Supportive and symptomatic relief with
 fluids, bed rest, analgesics, respiratory care
and interventions, and the care and
including in terms of the depth of the treatment of any serious complications with
respirations, cyanosis and respiratory suctioning, mechanical ventilation and
(Whooping cough)
exhaustion, increased lacrimation, rhinorrhea, oxygen supplementation, as indicated.
conjunctivitis, and vomiting. The administration of erythromycin estolate,
azithromycin, or clarithromycin may also be
needed.
Thick mucus that occludes the bronchioles, Treatment includes supportive care,
Respiratory wheezing, respiratory stridor, dyspnea, symptom management and antibiotics if a
Syncytial Virus respiratory distress, tachynpea, cyanosis, secondary bacterial infection is suspected.
(RSV) respiratory hypercapnia and apnea in severe Hydration supplemental oxygen, and other
cases. respiratory interventions, as indicated.
Chills, dyspnea, dyspnea, muscular aches, The treatment of pneumonia can include
Pneumonia fatigue, enlarged lymph nodes, a sore throat antibiotics for bacterial pneumonia, fluids
and chest pain. and oxygen 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".

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.

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.

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.
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.

Advance Directives

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of
advance directives in order to:
  Assess client and/or staff member knowledge of advance directives (e.g., living will, health care proxy,
Durable Power of Attorney for Health Care [DPAHC])
 Integrate advance directives into the client plan of care
 Provide the client with information about advance directives

Assessing the Client and/or Staff Members' Knowledge of Advance Directives

When a learning need in respect to advance directives is assessed by the registered nurse, education should
be planned to correct any identified knowledge deficits in reference to all aspects of advance directives
including living wills, health care proxies, and durable power of attorney for health care [DPAHC] .
For example, when a client asks the registered nurse if they can change their advance directives, the
registered nurse should know that the client has a knowledge deficit relating to the fact that advance
directives can be changed at any time and when the supervising registered nurse manager audits client
medical records and documentation and learns that the staff are not including complete information about
whether or not the clients have or do not have advance directives, the supervising registered nurse manager
should know that the staff have a knowledge deficit relating to the fact that the presence or absence of
advance directives must be assessed and documented.
When such learning needs are identified, appropriate patient or staff education should be planned,
implemented, evaluated and documented as was previously discussed and detail with the Integrated Process
of Teaching and Learning.
The registered nurse is responsible and accountable for assessing educational needs in respect to advance
directives and to insure that the clients and staff members have the sufficient knowledge to make sound and
knowledgeable decisions relating to these important aspects of client care. This knowledge enables the clients
to make knowledgeable decisions about their own advance directives and it enables other members of the
nursing team to integrate the principles of advance directives into the care that they provide to their clients.

Integrating Advance Directives into the Client Plan of Care

Advance Directives are integrated into the client's plan of care by nurses and other healthcare professionals.
Any and all information about advance directives is also documented and communicated with other members
of the healthcare team so that all of these client's choices are upheld in all aspects of care and all clients
should be encouraged to initiate advance directives whenever they have failed to generate these important
documents in the past.
The ultimate purpose of advance directives is to guide professional decision making and direct the client's care
and treatments at the end of life. Advance directives also provide the legal basis for all clients to accept or
reject care as they wish because they have the innate right to autonomous decision making without coercion
and self-determination even when they are no longer competent to do so.
Nurses must review and verify the patient's advance directive status with their first patient contact because an
emergency life threatening situation like a cardiac or respiratory arrest can occur at any time with little or no
time to review these documents at that time. If, for example, the patient has an advance directive to NOT
have CPR, the nurse may administer CPR because they have failed to review the client's advance directive. This
CPR, then, is contrary to the patient's wishes.

The Elements and Components of End of Life Decisions and Advance Directives

The elements and components of The Patient Self Determination Act, which was passed by the US Congress in
1990, gives Americans the right to make decisions relating to future care and treatments when the person is
no longer able to give informed consent and/or the refusal of care and treatments because the person is
incapacitated to do so. These decisions are documented with an advance directive and/or made by the legally
appointed health care proxy or surrogate according to this national law.
The Patient Self Determination Act also mandates public education about advance directives and the fact that
all hospitals, including psychiatric facilities, and all health insurance plans have to follow and adhere to state
law specific relating to advance directives.
The Uniform Determination of Death Act, approved by most states in our nation, also provides healthcare
facilities and healthcare professionals with some guidance and direction relating to end of life decisions. The
Uniform Determination of Death Act defines death as either the irreversible cessation of respiratory and
circulatory functions OR the irreversible cessation of all brain functions including brain stem function.
The elements and components of end of life choices and advance directives can include:

 An election to donate some or all bodily organs according to the US Uniform Anatomical Gift Act
 A living will
 A health care proxy
 A durable power of attorney for health care (DPAHC) which is separate and distinct from a durable
power of attorney relating to financial and monetary decisions

The Uniform Anatomical Gift Act of the United States, simply stated, sets the regulations revolving around
organ donations and organ transplantations, including prohibitions against the sale and trafficking of human
organs. According to this law of the land, living people can elect to donate one or more of their bodily parts;
and it also contains mechanisms that enable surviving spouses and other relatives to donate organs after the
loss of love of a loved one when that person has not made a decision about whether or not they want to
participate in an organ donation.
A living will, which is often referred to as an advance directive, is a well thought out document that lists the
types of things and interventions that the client wants and does not want at the end of life when they are no
longer able to give knowledgeable consent or reject these things and interventions as the result of their loss of
their legal ability to consent to or reject these things. It should be as specific and as detailed as necessary.
Treatments and aspects of care that were not anticipated and included in the living will then become the
responsibility of the surrogate health care proxy to make.
Some of the most commonly aspects of care that are addressed in living wills are choices relating to whether
or not the client wants CPR, tube feedings, surgeries and other invasive procedures. Many living wills also
address the client's desire to have comfort and pain relief interventions at the end of life.
The health care proxy, or surrogate, is also referred to as the health care power of attorney and the durable
power of attorney for healthcare. The durable power of attorney for healthcare is separate and distinct from
any durable power of attorney for financial matters.
People with a legal power of attorney for healthcare can make decisions relating to healthcare decisions when
the client is no longer able to make these decisions and these decisions were not anticipated and documented
in the person's living will.
Despite the fact that all of these end of life decisions and documents can be acceptably and legally done and
executed by the client themselves or by the client and their family members, some elect to have an attorney
at law to perform this role.

Providing the Client With Information About Advance Directives

Clients should be provided with complete information about advance directives 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 their choices in the same manner that is done with all informed consent.
Some of the specific information that should be provided to the client, in writing and/or orally include
understandable information about:
  The Patient Self Determination Act
 The Uniform Determination of Death Act
 The Uniform Anatomical Gift Act
 Living wills
 Health care proxies and surrogates
 Durable powers of attorney for health care (DPAHC)

Another piece of useful information for both the client/family members and healthcare providers in terms of
advance directives is the Five Wishes which was developed with a Robert Wood Johnson Foundation grant.
The Five Wishes, which can and should be considered and addressed in the client's advance directive, include
the client's choices in respect to:

1. Who they desire to make healthcare related decisions for them about their care when they are no
longer able to make these important decisions
2. All medical care and treatments that the patient ELECTS TO HAVE and all of those that the client does
NOT want
3. How the client wants to be treated and cared for by others at the end of life
4. Decisions relating to the promotion of comfort and the relief of pain
5. Things that they want their loved ones to know

Another decision and document that may be highly useful to clients and their healthcare decisions makers is a
values history. Although not mandated by law, value histories are recommended and highly beneficial when it
comes to end of life care and decision making, particularly when a person is appointed as a health care proxy
or durable power of attorney for healthcare.
Values histories contain and consist of the client's general basic beliefs, values, opinions and principles relating
to these principles and beliefs in addition to others:

 The quality of life versus the quantity of life

 The management of pain even if it may shorten the duration of life
 Surgical procedures and associated alterations of the body image
 "Being a guinea pig"
 Dignity and maintaining dignity at the end of life

Assignment, Delegation and Supervision

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of
assignment, delegation, and supervision in order to:
 Identify tasks for delegation based on client needs
 Ensure appropriate education, skills, and experience of personnel performing delegated tasks
 Assign and supervise care provided by others (e.g., LPN/VN, assistive personnel, other RNs)
 Communicate tasks to be completed and report client concerns immediately
 Organize the workload to manage time effectively
 Utilize the five rights of delegation (e.g., right task, right circumstances, right person, right direction or
communication, right supervision or feedback)
 Evaluate delegated tasks to ensure correct completion of activity
 Evaluate the ability of staff members to perform assigned tasks for the position (e.g., job description,
scope of practice, training, experience)
 Evaluate the effectiveness of staff members' time management skills
The assignment of care to others, including nursing assistants, licensed practical nurses, and other registered
nurses, is perhaps one of the most important daily decisions that nurses make.
Proper and appropriate assignments facilitate quality care. Improper and inappropriate assignments can lead
to poor quality of care, disappointing outcomes of care, the jeopardization of client safety, and even legal
consequences.
For example, when a registered nurse delegates aspects of patient care to a licensed practical nurse that are
outside of the scope of practice of the licensed practical nurse, the client is in potential physical and/or
psychological jeopardy because this delegated task, which is outside of the scope of practice for this licensed
practical nurse, is something that this nurse was not prepared and educated to perform. This practice is also
illegal and it is considered practicing outside of one's scope of practice when, and if, this licensed practical
nurse accepts this assignment. All levels of nursing staff should refused to accept any assignment that is
outside of their scope of practice.

Delegation, simply defined, is the transfer of the nurse's responsibility for the performance of a task to
another nursing staff member while retaining accountability for the outcome. Responsibility can be
delegated. Accountability cannot be delegated. The delegating registered nurse remains accountable for all
client care despite the fact that some of these aspects of care can, and are, delegated to others. Identifying
Tasks for Delegation Based on Client Needs

Appropriate decisions relating to the successful assignment of care are accurately based on the needs of the
patient, the skills of the staff, the staffs' position description or job descriptions, the employing facility's
policies and procedures, and legal aspects of care such as the states' legal scopes of practice for nurses,
nursing assistants and other members of the nursing team.
The "Five Rights of Delegation" that must be used when assigning care to others are:

 The "right" person

 The "right" task
 The "right" circumstances
 The "right" directions and communication and
 The "right" supervision and evaluation

In other words, the right person must be assigned to the right tasks and jobs under the right circumstances.
The nurse who assigns the tasks and jobs must then communicate with and direct the person doing the task or
job. The nurse supervises the person and determines whether or not the job was done in the correct,
appropriate, safe and competent manner.

The "Right Task" and The "Right Person": Identifying Tasks for Delegation Based on Client Needs

The client is the center of care. The needs of the client must be competently met with the knowledge, skills
and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other
members of the nursing team must balance the needs of the client with the abilities of those to which the
nurse is delegating tasks and aspects of care, among other things such as the scopes of practice and the
policies and procedures within the particular healthcare facility.
Some client needs are relatively predictable; and other patient needs are unpredictable as based on the
changing status of the client. Some needs require high levels of professional judgment and skill; and other
patient needs are somewhat routinized and without the need for high levels of professional judgment and
skill. Some client needs are acute, ever changing and/or rarely encountered; and other patient needs are
chronic, relatively stable, more predictable, and more frequently encountered.
Based on these characteristics and the total client needs for the group of clients that the registered nurse is
responsible and accountable for, the registered nurse determines and analyzes all of the health care needs for
a group of clients; the registered nurse delegates care that matches the skills of the person that the nurse is
delegating to.
For example, a new admission who is highly unstable should be assigned to a registered nurse; the care of a
stable chronically ill patient who is relatively stable and more predictable than a serious ill and unstable acute
client can be delegated to the licensed practical nurse; and assistance with the activities of daily living and
basic hygiene and comfort care can be assigned and delegated to an unlicensed assistive staff member like a
nursing assistant or a patient care technician. Lastly, the care of a client with chest tubes and chest drainage
can be delegated to either another registered nurse or a licensed practical nurse, therefore, the registered
nurse who is delegating must insure that the nurse is competent to perform this complex task, to monitor the
client's response to this treatment, and to insure that the equipment is functioning properly.

Ensuring the Appropriate Education, Skills, and Experience of Personnel Performing Delegated Tasks

The staff members' levels of education, knowledge, past experiences, skills, abilities, and competencies are
also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
Some staff members may possess greater expertise than others. Some, such as new graduates, may not
possess the same levels of knowledge, past experiences, skills, abilities, and competencies that more
experienced staff members possess. Some may even be more competent in some aspects of client care than
other aspects of client care. For example, a licensed practical nurse on the medical surgical floor may have
more knowledge, skills, abilities, and competencies than a registered nurse in terms of chest tube
maintenance and care because they may have, perhaps, had years of prior experience in an intensive care
area of another healthcare facility before coming to your nursing care facility.
Delegation should be done according to the differentiated practice for each of the staff members. A patient
care technician, a certified nursing assistant, a licensed practical nurse, an associate degree registered nurse
and a bachelor's degree registered nurse should not be delegated to the same aspects of nursing care. Based
on the basic entry educational preparation differences among these members of the nursing team, care
should be assigned according to the level of education of the particular team member.
Also, staff members differ in terms of their knowledge, skills, abilities and competencies. A staff member who
has just graduated as a certified nursing assistant and a newly graduated registered nurse cannot be expected
to perform patient care tasks at the same level of proficiency, skill and competency as an experienced nursing
assistant or registered nurse. It takes time for new graduates to refine the skills that they learned in school.
Validated and documented competencies must also be considered prior to assignment of patient care. No
aspect of care can be assigned or delegated to another nursing staff member unless this staff member has
documented evidence that they are deemed competent by a registered nurse to do so. For example, a newly
hired certified nursing assistant cannot perform bed baths until a supervising registered nurse has observed
this certified nursing assistant provide a bed bath and has decided that they are now competent to do this task
without direct supervision.
All healthcare facilities and agencies must assess and validate competency before total care or any aspect of
care is performed by an individual without the direct supervision of another, regardless of their years of
experience. Competency checklists are used to document the competency of the staff; they must be referred
to as assignments are made. Care can be delegated to another only when that person is deemed competent to
perform the role or task and this competency is documented.
Scopes of practice are also considered prior to the assignment of care. All states have scopes of practice for
advanced nurse practitioners, registered nurses, licensed practical nurses and unlicensed assistive personnel
like nursing assistants and patient care technicians.

Assigning and Supervising the Care Provided by Others

The job of the registered nurse is far from done after client care has been delegated to members of the
nursing team. The delegated care must be followed up on and the staff members have to be supervised as
they deliver care. The registered nurse remains responsible for and accountable for the quality,
appropriateness, completeness, and timeliness of all of the care that is delivered.
The supervision of the care provided by others includes the monitoring the care, coaching and supporting the
staff member who is providing the care, assisting the staff member with priority setting and time management
skills, as indicated, educating the staff member about the proper provision of care, as indicated by a
knowledge or skills deficit, and also praising and positively reinforcing the staff for a job well done.
Remember, the delegating registered nurse is still responsible and accountable for all of the client care that is
delegated to others.

Communicating Tasks to be Completed and Report Client Concerns Immediately

Registered nurses who assign, delegate and/or provide nursing care to clients and groups of clients must
report all significant changes that occur in terms of the client and their condition. For example, a significant
change in a client's laboratory values requires that the registered nurse report this to the nurse's supervisor
and doctor.
They must also communicate and document all tasks that were completed and the client's responses to this
treatment. As the old adage says, "If it wasn't documented, it wasn't done."

Organizing the Workload to Manage Time Effectively

Time is finite and often the needs of the client are virtually infinite. Time management, organization, and
priority setting skills, therefore, are essential to the complete and effective provision of care to an individual
client and to a group of clients.
Priorities of care, as previously discussed, are established using a number of methods and frameworks
including the ABCs, Maslow's Hierarchy of Needs and the ABCs/MAAUAR method of priority setting.
Some time management techniques, in addition to priority setting, that you may want to consider using to
insure that you manage your workload and time effectively include:

 Clarifying your assignment as necessary

 Planning your work in an orderly and systematic manner knowing that priorities and clients' status
change frequently
 Avoiding all unnecessary interruptions
 Learning how to say no to others when they ask you for help and you have priority patient needs that
would not be addressed if you helped another

Utilizing the Five Rights of Delegation

As previously discussed, all delegation may be based on the "Five Rights of Delegation" which are:

 The "right" person

 The "right" task
 The "right" circumstances
 The "right" directions and communication
 The "right" supervision and evaluation

Evaluating Delegated Tasks to Ensure the Correct Completion of the Activity or Activities
In addition to the supervision of delegated tasks in terms of quality, appropriateness, and timeliness, the
registered nurse who has delegated tasks must insure that the assigned activities have been correctly
completed.
When assignments are made, the registered nurse must insure that the staff member will have ample time
during the shift to complete the assignment and, then, the registered nurse must monitor and measure the
staff members' progress toward the completion of assigned tasks throughout the duration of the shift.
This monitoring must be done in an ongoing and continuous manner and not at the end of the shift when it is
too late to make corrections.

Evaluating the Ability of Staff Members to Perform the Assigned Tasks for the Position

As previously discussed, staff members should have documented competency for all tasks that are assigned to
them. All nursing team members have the responsibility, however, to refuse an assignment if they believe that
they cannot do it properly. When this occurs, the registered nurse should either teach the staff member how
to perform the task and then document their competency in terms of this assigned task or assign the task to
another nursing team member who has documented competency and is sure that they can perform the task in
a correct manner.
Part of supervision entails the ongoing evaluation of staff's ability by the registered nurse to perform assigned
tasks using direct observations and with indirect observations of patient safety, the quality of the care
provided, the appropriateness of care provided, and the timeliness of care provided. For example, the
registered nurse can directly observe the performance of the nursing assistant while the client is being
transferred from the bed to the chair; and the registered nurse can review the medication administration
record to determine if the licensed practical nurse has administered medications in a timely manner which is
an example of indirect observation.
The ability of a staff member to perform a specific task is not only based on their competency but it is also
based on their:

 Legal scope of practice,

 Documented competency,
 Education and training,
 Past experiences,
 Position description which is also referred to as the job description and
 Healthcare facility specific policies and procedures.

All states throughout our nation have legally legislated scopes of practice for registered professional nurses,
licensed practical or vocational nurses, and advanced nursing practice nurses; and they also have legal
guidelines related to what an unlicensed, assistive staff member, such as a student nurse technician, patient
care aide, patient care technician or nursing assistant, can and cannot legally perform regardless of whether or
not the healthcare provider or the delegating nurse believes that they are competent to do.
Although these legal, legislated scopes of practice may vary a little from state to state, they share a lot of
commonalities and similarities. For example:

 The scope of practice for the registered nurse will most likely include the legal ability of the registered
professional nurse to perform all phases of the nursing process including assessment, nursing diagnosis,
planning, implementation and evaluation.
 The scope of practice for the licensed practical or vocational nurse will most likely include the legal
ability of this nurse to perform data collection, plan, implement and evaluate care under the direct
supervision and guidance of the registered nurse.
  The scope of practice for an advanced practice nurse, such as a nurse practitioner, will most likely
include the legal ability of the advanced practice registered professional nurse to perform all phases of
the nursing process including assessment, nursing diagnosis, planning, implementation and evaluation
in addition to prescribing some medications.

Nurses violate scope of practice statutes, or laws, when they function in roles and aspects of care that are
above, beyond and/or not included in their scope of practice. Permanent license revocation may occur when a
nurse practices outside of the legally mandated scope of practice. Additionally, licensed nurses who have
failed to either reapply for their license or have had it revoked as part of a state disciplinary action cannot and
continue to practice nursing are guilty of practicing nursing without a license.
Among the tasks that CANNOT be legally and appropriately delegated to nonprofessional, unlicensed assistive
nursing personnel, such as nursing assistants, patient care technicians, and personal care aides, include
assessments, nursing diagnosis, establishing expected outcomes, evaluating care and any and all other tasks
and aspects of care including but not limited to those that entail sterile technique, critical thinking,
professional judgment and professional knowledge.
Some examples of tasks and aspects of care that can be delegated legally to nonprofessional, unlicensed
assistive nursing personnel, provided they are competent in these areas, under the direct supervision of the
nurse include:

 Assisting the client with their activities of daily living such as ambulation, dressing, grooming, bathing
and hygiene
 Measuring and recording fluid intake and output
 Measuring and recording vital signs, height and weight
 The provision of nonpharmacological comfort and pain relief interventions such as establishing and
maintaining an environment conducive to comfort and providing the client with a soothing and
therapeutic back rub
 Observation and reporting changes in and the current status of the patient’s condition and reactions to
care
 The transport of clients and specimens and other errands and tasks such as stocking supplies
 Assistance with transfers, range of motion, feeding, ambulation, and other tasks such as making beds
and assisting with bowel and bladder functions

In addition to the legally mandated state scopes of practice, the registered nurse must also insure that the
delegated tasks are permissible according to the nursing team members' position description which is also
referred to as the job description, and the particular facility's specific policies and procedures relating to client
care and who can and who cannot perform certain tasks.
For example, intravenous bolus and push medications may be permissible for only licensed registered nurses
in certain areas of the healthcare facility such as the intensive care units; the administration of blood and
blood components may be restricted to only registered nurses; and the care of a client who is receiving
conscious sedation may be restricted to only a few registered nurses in the particular healthcare facility,
according to these job descriptions, policies and procedures.

Evaluating the Effectiveness of Staff Members' Time Management Skills

As previously mentioned, the registered nurse must allot a reasonable amount of time for staff members to
complete their assignments when care and tasks are delegated. The staff should be able to complete their
assignments within the allocated period of time. When an assignment is not done as expected, the delegating
nurse should determine why this has occurred and they must take corrective actions to insure task
completion.
One of the things that the delegating nurse will want to consider when an assignment is not completed within
the allotted time frame is determining whether or not the staff member is organizing their work and using
effective time management skills. If the staff member is not using effective time management skills, the nurse
must teach and assist the staff member about better time management and priority setting skills.

Planning Overall Strategies to Address Client Problems

Registered nurses must be able to identify and employ overall strategies to address client problems and
healthcare concerns.
Some of these strategies can include:

 Supervision and delegation to insure that all client care is done in a complete, effective, proper and
timely manner
 The complete, effective, proper and timely execution of the Nursing Process including assessments,
planning, implantation and evaluation
 Collaboration and communication with other members of the multidisciplinary health care team when
the need arises
 Actively engaging and involving the client in all aspects of care
 Providing education and training to clients and staff when the need arises

Acting as a Liaison Between the Client and Others

As previously discussed, registered nurses coordinate and manage care as they serve and act as the liaison
between the client and others as they advocate for the client and the fulfillment of their needs.
Often, the registered nurse serves and acts as the liaison between the client and family members, significant
others, other members of the multidisciplinary team, upper healthcare facility administrators and even
healthcare insurance companies to negotiate care that is medically necessary and to obtain reimbursement
for the necessary care and treatments that the client needs.

Managing Conflict Among Clients and Health Care Staff

One of the most upsetting and distressing things that occur when people work together is conflict. One thing
that we must understand, however, is that conflict can be beneficial and it is a natural process that will occur
and one that cannot be prevented among members of a group.
Simply stated, conflicts arise when two or more people have differences in terms of their beliefs or, opinions.
Conflicts can be readily identified when arguments, a lack of trust among those involved in the conflict arise,
when the flow of work is disrupted, when interpersonal relationships are impaired, when criticism of others
and frustration occur.
Conflicts can be beneficial when they are resolved in a healthy, mutually satisfying manner so that all involved
in the conflict can "win". Conflicts and healthy conflict resolution can lead to and promote personal and group
growth and development, creativity, innovation and innovate thought, the free expression of one's beliefs and
opinions, and lead to divergent thinking.
Conflict resolution and "win-win" conflict resolution is facilitated when group members and group leaders
focus on the issues at hand rather than differences between and among people with diverse opinions and
beliefs, when opinions and beliefs are presented in a clear, understandable manner after some research, when
all maintain respect for others and their diverse opinions and beliefs, and when the conflicting parties are
open to the viewpoints of others.
Ineffective conflict resolution and "win-lose" conflict resolution is destructive; it can lead to anger, frustration,
a lack of commitment to common goals, disputes, struggles for power and control, and impaired thinking
processes.
Registered nurses, therefore, must be able to recognize, identity, and report conflicts so that conflicts do not
tatter the team when they are not identified and resolved. Ignoring conflicts will cause problems; resolving
and addressing conflicts can lead to personal and group growth.
The stages of conflict and conflict resolution are:

 Frustration: Frustration occurs when those involved in the conflict believe that their goals and needs
are being blocked and not met.
 Conceptualization: Conceptualization occurs when those involved in the conflict begin to understand
what the conflict is all about and why it has occurred. This understanding often varies from person to
person and this personal understanding may or may not be accurate. The conflict continues.
 Taking action: Those involved in the conflict act. Some act in an active manner and others act in a
passive manner. For example, one person affected by the conflict may act out with anger, hostility and
even physical force; and another may just withdraw from the situation because they simply cannot
tolerate the feelings that the conflict evokes.
 Resolution: Resolution occurs when the group is able to come to some agreement with mediation,
negotiation or another method. This resolution is done with the participation of all of those who are
involved in the conflict.

Conflicts, according to Lewin who also developed a theory of planned change, include these four basic types of
conflict:

 Avoidance-Avoidance Conflicts: Avoidance-Avoidance conflicts occur when none of the people

involved in the conflict do NOT want any of the possible alternatives that could resolve the conflict.
 Approach- Approach Conflicts: Approach- Approach conflicts, in sharp contrast to Avoidance-
Avoidance conflicts, occur when the people involved in the conflict want more than one alternatives or
actions that could resolve the conflict.
 Approach-Avoidance Conflicts: Approach-Avoidance conflicts occur when the people involved in the
conflict see all of the alternatives or actions as NEITHER completely satisfactory and acceptable or
completely dissatisfactory and unacceptable.
 Double Approach – Avoidance Conflicts: Double Approach – Avoidance conflicts occur when the
people involved in the conflict are forced to choose among alternatives and actions, all of which have
BOTH positive and negative aspects to them.

Conflicts can be effectively resolved using a number of different strategies and techniques. These strategies
include those below:

 Collaboration and Open Communication: Collaboration and open communication within a trusting and
supportive environment can resolve conflicts in a beneficial manner. Collaboration and open
communication foster good working relationships among group members, it promotes the active
participation between and among conflicting parties, and it facilitates a deeper understanding of the
issue at hand.
 Compromise and Negotiation: Compromise and negotiation facilitates the conflicting parties to be and
remain to be assertive, rather than aggressive and cooperative; it also promotes a balance of power
between and among the conflicting parties.Negotiation consists of focusing on common goals and
interests rather than individuals and their different and disparate opinions, clearly separating the
conflicting parties from the conflict and problem, exploring options and alternatives in an open and
 trusting environment, and using objective characteristics and criteria to describe and define the
problem and the alternative solutions.
 Mediation: This strategy includes one-to-one communication with each of the conflicting parties to
learn about each person's concerns, beliefs and opinions after which members of the group can explore
and employ mutually beneficial actions to resolve the conflict.

Ineffective and unhealthy methods of conflict resolution include those below.

 Avoiding and Withdrawing: Avoiding and withdrawing is a form of passivity. Although a temporary
avoidance can give the conflicting party some time to cope with and think about the conflict and
possible resolutions, prolonged avoidance and withdrawal can lead the lack of conflict resolution.
Sticking one's head into the sand is not helpful in terms of conflict resolution.
 Competition: Competition thwarts conflict resolution because it is not consistent with group goals and
progress towards a shared mission or goal. Competition can lead to power and control struggles,
coercion, manipulation of others and an unhealthy desire of one or more of the conflicting parties to
"win" at all costs at the expense of others.
 Accommodating Others: The sacrificial accommodation of others is also detrimental to good conflict
resolution. Accommodating others is not assertive, it does not promote negotiation, compromise or
mediation, and it does not meet the needs of the person who is accommodating others.

Evaluating Management Outcomes

The outcomes of effective management can be measured and ascertained by scrutinizing the effects of
management in terms of a number of different outcomes and variables including but not limited to staff
satisfaction, staff productivity, and the provision of high quality effective, cost effective, and timely nursing
care and services. It can also be measured and ascertained by evaluating the outcomes of client care and their
level of satisfaction with the care and services that were provided to them, for example.

Legal Rights and Responsibilities

In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of
legal rights and responsibilities in order to:
 Identify legal issues affecting the client (e.g., refusing treatment)
 Identify and manage the client's valuables according to facility/agency policy
 Recognize limitations of self/others and seek assistance
 Review facility policy and state mandates prior to agreeing to serve as an interpreter for staff or
primary health care provider
 Educate client/staff on legal issues
 Report client conditions as required by law (e.g., abuse/neglect, communicable disease, gunshot
wound)
 Report unsafe practice of health care personnel and intervene as appropriate (e.g. substance abuse,
improper care, staffing practices)
 Provide care within the legal scope of practice
Some of the legal terms that you must be familiar with include these:
 Common Law: Common law is law that results from previous legal decisions. They are based on legal
precedent. (Berman and Synder, 2012)
 Statutory Law: Statutory law is law that is passed by a legislative body such as the state's legislature or
the US Congress. (Berman and Synder, 2012)
  Constitutional Law: Constitutional law is law that is included in the Constitution of the United States of
America and its amendments. (Berman and Synder, 2012)
 Administrative Law: Administrative law is rules and regulations that are legally enacted to support
some statutory law. For example, nursing boards enact administrative rules and regulations relating to
state enacted laws such as the state's nurse practice act and legislated continuing education
requirements for the relicensure of nurses. (Berman and Synder, 2012)
 Criminal Law: Criminal law, part of public law, covers acts that are illegal and against the law. Criminal
law includes felony and misdemeanor infractions of the law. (Berman and Synder, 2012)
 Civil Law: Civil law, also part of public law, covers torts and contract laws. (Berman and Synder, 2012)
 Torts: Torts are civil laws that address the legal rights of patients and the responsibilities of the nurse
in the nurse patient relationship. Some torts specific to nursing and nursing practice include things like
malpractice, negligence and violations relating to patient confidentiality. (Berman and Synder, 2012)
 Unintentional Torts: Unintentional torts include things like malpractice and negligence.
 Intentional Torts: Intentional torts include things like false imprisonment, assault, battery, breaches of
privacy and patient confidentiality, slander and libel.
 Liability: Liability is vulnerability and legal responsibility, simply stated. For example, nurses are liable
when they fail to carry out doctor's orders. (Berman and Synder, 2012)
 Respondeat Superior: Respondeat Superior is the legal doctrine or principle that states that employers
are legally responsible for the acts and behaviors of its employees. Respondeat Superior does not,
however, relieve the nurse of legally responsibility and accountability for their actions. They remain
liable. (Berman and Synder, 2012)
 Negligence: Negligence is a nonintentional tort. Negligence occurs when the nurse fails to follow
established policies, procedures and standards of care in the same manner that another "reasonable"
nurse would do in the same situation. (Berman and Synder, 2012)
 Malpractice: Malpractice, also a nonintentional tort, has six elements. The elements of malpractice
include a duty, a breach of duty as a nurse, reasonable foreseeability that the nurse's act has a
connection with the patient injury that occurred, the patient was harmed, the link that act directly led
to the harm and the patient has the right to financial compensation or damages. (Berman and Synder,
2012)
 Assault: Assault, an intentional tort, is threatening to touch a person without their consent. (Berman
and Synder, 2012)
 Battery: Battery, another intentional tort, is touching a person without their consent. (Berman and
Synder, 2012)
 False Imprisonment: False imprisonment is restraining, detaining and/or restricting a person's freedom
of movement. Using a restraint without an order is considered false imprisonment. (Berman and
Synder, 2012)
 Defamation: Defamation is making false statements about a person in writing or orally that leads to
the destruction of a person's reputation. (Berman and Synder, 2012)
 Slander: Slander is oral defamation of character using false statements.
 Libel: Libel is written defamation of character using false statements.

Identifying Legal Issues Affecting Staff and Clients

Some of the most commonly occurring legal issues that impact on nursing and nursing practice are those
relating to informed consent and refusing treatment as previously detailed, licensure, the safeguarding of
clients' personal possessions and valuables, malpractice, negligence, mandatory reporting relating to gunshot
wounds, dog bites, abuse and unsafe practices, for example, informed consent, documentation, accepting an
assignment, staff and client education relating to legal issues, and strict compliance with and adherence to all
national, state, and local laws and regulations.
Licensure

All registered and licensed practical, or vocational, nurses must be currently licensed to practice nursing in
their state of practice. Licensure protects the consuming public and insures that the nurse has completed a
state approved nursing school, has successfully passed their licensure examination and has also continuously
met the requirement(s) for relicensure each biennium without any suspensions or revocations of their license.
Practicing without a current and valid license is illegal and it amounts to practicing without a license.

The Safeguarding of Clients' Personal Possessions and Valuables

Nurses are responsible for the safeguarding and respecting the clients' personal possessions and valuables;
they must also NOT, under any circumstances, borrow or steal their personal possessions and valuables.
Although policies and procedures relating to the safeguarding of clients' personal possessions and valuables
may vary a little from one healthcare facility to another, these policies and procedures typically include
discouraging clients to retain personal possessions and valuables while hospitalized, and then securing
maintained and retained personal possessions and valuables in a locked and secure safe using an envelope
that fully documents the client's name, room number and the contents of the envelope, including things like
jewelry, cash and credit cards, that were collected from the client with their permission.
Items that are placed in this envelope are itemized and listed using a description such as a "ring with a purple
stone", a "yellow metal bracelet" or a "white metal necklace" rather than an amethyst ring, 14 carat gold
bracelet or a sterling silver necklace because the nurse cannot determine and confirm that indeed these items
are anything more than inexpensive costume jewelry.
Items are listed on the envelope. What appears to be gold, sterling silver or a ruby may indeed be only an
inexpensive gold, silver or ruby look alike and the nurse may have no idea whether it is real gold, silver or a
ruby or not. For this reason these items are listed as "yellow metal", "silver metal" and a "red stone",
respectively. In addition to jewelry, other valuable items that must be secured include cash, credit cards and
legal documents.
When the client is discharged from the facility or they choose to have their personal possessions and valuables
returned to them, the nurse and the client check and confirm that all of the items listed on the envelope are
indeed still in this envelope. The client also signs a statement that documents that they have been given back
their personal possessions and valuables.

Malpractice

Malpractice is an act of omission or commission that does not meet established standards of care and causes
some injury. Nurses, therefore, must provide all aspects of nursing care according to established standards of
care, in a safe and competent manner, and also done in a complete, appropriate and timely manner.
The six essential components of malpractice include causation, foreseeability, damages to the patient, a duty
that was owed to the client and this duty was breached, and, lastly, this breach of duty led to direct and/or
indirect harm to the client.
Actions of omission and commission that lead to client injury place the nurse in jeopardy for malpractice.

Negligence

Negligence is also an act of omission or commission that does not meet established standards of care. It differs
from malpractice because it lacks one or more of the six elements of malpractice that are essential to be
considered malpractice.
Actions of omission and commission that lead to client injury place the nurse in jeopardy for negligence.
Mandatory Reporting

Nurses are legally mandated to report abuse, neglect, gunshot wounds, dog bites, some communicable
diseases and any unsafe and/or illegal practices done by another health care provider.
Informed Consent and Refusals of Treatment which was fully detailed previously.

Documentation

All documentation and all forms of documentation are considered legal documents. Some of the legal aspects
of documentation, in addition to the legal mandates associated with confidentiality, include the strict legal
prohibitions against altering a record, obliterating entries in the medical record, and falsifying documentation.
Other guidelines for documentation include the use of permanent ink, the use of only accepted terms and
abbreviations, legible writing, accurate spelling, proper grammar, accurate dating and time of the entry, the
signature and title of the person who documented the entry, and a professional tone. If an error in
documentation occurs, a thin line that does NOT obliterate the entry is drawn through the erroneous entry,
the notation "Error" is written above the entry and the nurse signs this notation with their name and title.

The Acceptance of an Assignment

Nurse are legally accountable to accept only those assignments that are appropriate in terms of their nurse
practice act and their scope of practice, and only those that the nurse believes that they are competent to
perform.
RELATED:

 How is the Scope of Practice Determined for a Nurse?

 Scope of Practice vs Scope of Employment
 RN Scope of Practice

The Provision of Staff and Client Education Relating to Legal Issues

As with other educational needs, nurses assess client and staff member educational deficits and educational
needs relating to the legal issues that impact on their care and the care that nurses provide, respectively. After
this assessment, educational activities to meet identified educational needs are planned, implemented and
evaluated in terms of their effectiveness in meeting the educational need that was identified.

Compliance With and Adherence to Other Laws

Nurses are also expected to comply and adhere to other national, state, and local laws and regulations. For
example, the compliance with the Centers for Medicare and Medicaid Services must be adhered to, state laws
relating to professional licensure and mandatory reporting must be complied with, and local laws relating to
the disposal of biohazardous waste must also be followed without fail.

Recognizing the Limitations of Self/Others and Seeking Assistance When Needed

Nurse are legally accountable to accept only those assignments that are appropriate in terms of their nurse
practice act and their scope of practice, and only those that the nurse believes that they are competent to
perform.
Reviewing the Facility Policy, Federal Mandates and State Mandates Prior to Agreeing to Serve as an
Interpreter for Staff or Primary Health Care Providers

In addition to following the policies and procedures of the particular employing healthcare organization,
nurses must also follow and comply with any federal and state laws relating to interpreters and serving as an
interpreter.
Some of these laws include:

 The Americans with Disabilities Act of 1990 and the Rehabilitation Act of 1973 which forbid and
prohibit any discrimination against people with disabilities including those who are deaf. Sign language
interpreters could be used in healthcare facilities to comply with these laws.
 The Civil Rights Act of l964 and Title VI of this law states that "No person in the United States shall, on
ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or
be subjected to discrimination under any program or activity receiving Federal assistance."
 Title VI Prohibition Against Discrimination on the Basis of National Origin- Persons with Limited English
Proficiency states that, "Because of these language barriers, LEP (limited English proficiency) persons
are often excluded from programs or experience delays or denials of services from recipients of Federal
assistance. Such exclusions, delays or denials may constitute discrimination on the basis of national
origin, and in violation of Title VI".

Since the year 1999, all healthcare organizations and agencies that get federal funding must provide
interpreter services to those that need it.

Educating Clients and Staff on Legal Issues

As with other educational needs, nurses provide educational activities to clients, significant others, and other
staff members about legal issues that can impact on the care that they provide.

Reporting Client Conditions as Required by Law

Some of the conditions that nurses are mandated by law to report some communicable diseases, gunshot
wounds, and child and/or elder abuse or neglect.

Reporting Any Unsafe Practice by Health Care Personnel and Intervene as Appropriate

As previously mentioned, nurses are legally mandated to report any and all unsafe and inappropriate practices
of healthcare staff and personnel. Once identified, the nurse must attempt to cease the unsafe and/or
inappropriate practices and immediately report it.
Some examples of these practices and behaviors include improper client care, narcotic diversion, unsafe
staffing practices and substance abuse by a member of the healthcare team.

Providing Care That is Within the Legal Scope of Practice

Legally, nurses can only accept assignments and provide patient care that is appropriate in terms of their
nurse practice act and their scope of practice, and only those that the nurse believes that they are competent
to perform. These legal issues were extensively described and detailed previously.