Fundamentals of Nursing Practice 1 PDF

FUNDAMENTALS OF NURSING PRACTICE 1 Complete destruction of all microorganisms. NATURE OF INFECTION REVISED CDC ISOLATION PRECAUTIONS It is important to know the difference betwee...

FUNDAMENTALS OF NURSING PRACTICE 1 Complete destruction of all microorganisms. NATURE OF INFECTION REVISED CDC ISOLATION PRECAUTIONS It is important to know the difference between an Standard precautions infection and a colonization. An infection results when a pathogen invades tissues and begins now apply to nonintact skin, mucous membranes, growing within a host. Colonization is the presence blood, all body fluids, secretions, and excretions and growth of microorganisms within a host but except sweat, regardless of whether they contain without tissue invasion or damage. visible blood. These general methods of infection prevention are indicated for all patients and are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. Transmission-based precautions are designed for patients documented or suspected to be infected or colonized with pathogens that require additional precautions beyond the standard precautions necessary to interrupt transmission. These precautions apply to airborne, droplet, and contact transmissions. The precautions may be combined for diseases that have multiple routes of transmission. Whether singly or in combination, they are always to be used in addition to standard precautions. Airborne transmission DEFENSES AGAINST INFECTION occurs by dissemination of either airborne droplet nuclei (small- particle residue [5 mm or smaller] of 1st line of defense evaporated droplets containing microorganisms physical and chemical barriers. skin, mucous that remain suspended in the air for long periods) or membranes, sweat, cilia, gag and cough reflexes. dust particles containing the infectious agent. 2nd line of defense Microorganisms carried in this manner can be dispersed widely by air currents and may be inhaled inflammatory responses, wbc's. by a susceptible host within the same room or over 3rd line of defense a longer distance from the source patient, depending on environmental factors; therefore, Immune response. special air handling and ventilation are required to prevent airborne transmission. Microorganisms transmitted by airborne transmission include LIMITING AND ELIMINATING INFECTION Mycobacterium tuberculosis and the measles and Cleaning varicella viruses. Physical removal of dirt and debris. Droplet transmission Disinfection theoretically, is a form of contact transmission. Physical and chemical process used to reduce However, the mechanism of transfer of the pathogen number of potential pathogens (bactericidal, to the host is quite distinct from either direct- or antiseptic, bacteriostatic). indirect- contact transmission. Sterilization 1 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 Therefore, droplet transmission is considered a and gowning to prevent gross soilage of clothes for separate route of transmission in this guideline. specific infectious diseases. Droplets are generated from the source person primarily during coughing, sneezing, and talking. (5 micrometre or more), (influenza, meningitis, Isolation Practices diphtheria, rubella) Initiation of practices to prevent the transmission of Contact transmission microorganisms is generally a nursing responsibility and is based on a comprehensive the most important and frequent mode of assessment of the client. This assessment transmission of nosocomial infections, is divided considers the status of the client's normal defense into two subgroups: direct-contact transmission mechanisms, the client's ability to implement and indirect- contact transmission. necessary precautions, and the source and mode of transmission of the infectious agent. Direct-contact transmission The nurse then decides whether to wear gloves, involves a direct body surface-to- body surface gowns, masks, and protective eyewear. In all client contact and physical transfer of microorganisms situations, nurses must cleanse their hands before between a susceptible host and an infected or and after giving care. In addition to the precautions colonized person, such as occurs when a person cited within this chapter, the nurse implements turns a patient, gives a patient a bath, or performs aseptic precautions when performing many specific therapies discussed throughout nursing other patient-care activities that require direct texts. The following are some examples: personal contact. ▪ Use strict aseptic technique when Indirect-contact transmission performing any invasive procedure (e.g., involves contact of a susceptible host with a inserting an intravenous needle or catheter) and when changing surgical dressings. contaminated intermediate object, usually ▪ Change intravenous tubing and solution inanimate, such as contaminated instruments, containers according to hospital policy needles, dressings, or contaminate hands that are (e.g., every 48 to 72 hours). not washed and gloves that are not changed ▪ Check all sterile supplies for expiration date between patients. and intact packaging. ▪ Prevent urinary infections by maintaining a closed urinary drainage system with a ISOLATION downhill flow of urine. Keep the drainage bag and spout off the floor. refers to measures designed to prevent the spread ▪ Implement measures to prevent impaired of infections or potentially infectious skin integrity and to prevent accumulation microorganisms to health personnel, clients, and of secretions in the lungs (for example, visitors. Several sets of guidelines have been used encourage the client to move, cough, and in hospitals and other health care settings. breathe deeply at least every 2 hours). Category-specific isolation precautions use seven categories: strict isolation, contact SAFETY isolation, respiratory isolation, tuberculosis isolation, enteric precautions, drainage/secretions A fundamental concern of nurses, which extends precautions, and blood/ body fluid precautions. from the bedside to the home to the community, is preventing injuries and assisting the injured. Motor Disease-specific isolation precautions vehicle crashes, falls, drowning, fire and burns, provide precautions for specific diseases. These poisoning, inhalation and ingestion of foreign objects, and firearm use are major causes of injury precautions delineate use of private rooms with special ventilation, having the client share a room and death. with other clients infected with the same organism, The ability of people to protect themselves from injury is affected by such factors as age and 2 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 development, lifestyle, mobility and health status, EXERCISE AND ACTIVITY sensory-perceptual alterations, cognitive awareness, emotional state, ability to EXERCISE communicate, safety awareness, and People participate in exercise programs to environmental factors. decrease risk factors for chronic diseases and to Nurses need to assess each of these factors when increase their health and well-being. Functional they plan care or teach clients to protect strength is another goal of exercise, and is defined themselves. as the ability of the body to perform work. Activity tolerance is the type and amount of exercise or Factors the "will prevent" threats and injuries ADLs an individual is able to perform without experiencing adverse effects. ▪ Foresight ▪ Practice to identify danger and hazards Isotonic (dynamic) exercises Those in which the muscle shortens to produce muscle contraction and active movement. Most SELECTED SAFETY HAZARDS THROUGHOUT physical conditioning exercises— running, THE LIFE SPAN walking, swimming, cycling, and other such Developing fetus activities —are isotonic, as are ADLs and active ROM exercises (those initiated by the client). Exposure to maternal smoking, alcohol consumption, addictive drugs, x-rays (first Isometric (static or setting) exercises trimester), certain pesticides Those in which muscle contraction occurs without Newborns and infants moving the joint (muscle length does not change). Falling, suffocation in crib, placement in the prone These exercises involve exerting pressure against position, suffocation when entangled in cords, a solid object and are useful for strengthening choking from aspirated milk or ingested objects, abdominal, gluteal, and quadriceps muscles used burns from hot water or other spilled hot liquids, in ambulation; for maintaining strength in automobile crashes, crib or playpen injuries, immobilized muscles in casts or traction; and for electric shock, poisoning endurance training. Toddlers Isokinetic (resistive) exercise Physical trauma from falling, running into objects, Involve muscle contraction or tension against aspiration of small toys, getting cut by sharp resistance. objects; automobile crashes; burns; poisoning; During isokinetic exercises, the person tenses drowning; and electric shock (isometric) against resistance. Special machines or Preschoolers devices pro vide the resistance to the movement. These exercises are used in physi cal conditioning Injury from traffic, playground equipment, and and are often done to build up certain muscle other objects; choking, suffocation, and obstruction groups. of airway or ear canal by foreign objects; poisoning; drowning; fire and burns; harm from other people Aerobic exercise or animals Is activity during which the amount of oxygen taken Adolescents into the body is greater than that used to perform the activity. Vehicular (automobile, bicycle) crashes, recreational injuries, firearms, substance abuse Aerobic exercises use large muscle groups that move repetitively. Older adults Anaerobic exercise Falling, burns, and pedestrian and automobile crashes (lighting and using non-slip paint) Involves activity in which the muscles cannot draw out enough oxygen from the bloodstream, and anaerobic pathways are used to provide additional 3 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 energy for a short time. This type of exercise is used in endurance training for athletes such as weightlifting and sprinting. EFFECTS OF IMMOBILITY Mobility and activity tolerance are affected by any disorder that impairs the ability of the nervous system, musculoskeletal system, cardiovascular system, respiratory system, and vestibular apparatus. Disorders of the nervous system such as PREVENTING BACK INJURIES Parkinson's disease, multiple sclerosis, central nervous system tumors, cerebrovascular accidents Understand that the use of body mechanics (strokes), infectious processes (e.g., meningitis), will not necessarily prevent injury if and head and spinal cord injuries can leave muscle manually handling a load greater than 35 groups weakened, paralyzed (paresis), spastic pounds without the use of assistive devices. (with too much muscle tone), or flaccid (without Avoid lifting anything greater than 35 muscle tone). Musculoskeletal disorders affecting pounds. Use assistive equipment, get help mobility include strains, sprains, fractures, joint from coworkers, and participate in the dislocations, amputations, and joint replacements. purchasing/ordering process of Inner ear infections and dizziness can impair appropriate assistive equipment for your balance. Many other acute and chronic illnesses work setting. that limit the supply of oxygen and nutrients Become consciously aware of your posture needed for muscle contraction and movement can and body mechanics. seriously affect activity tolerance. Examples When standing for a period of time, include chronic obstructive lung disease, anemia, periodically move legs and hips, and flex congestive heart failure, and angina. one hip and knee and rest your foot on an object if possible. When sitting, keep your knees slightly USING BODY MECHANICS higher than your hips. Use a firm mattress and soft pillow that Body mechanics is the term used to describe the provide good body support at natural body efficient, coordinated, and safe use of the body to curvatures. move objects and carry out the ADLs. When a Exercise regularly to maintain overall person moves, the center of gravity shifts physical condition and regulate weight; continuously in the direction of the moving body include exercises that strengthen the parts. Balance depends on the interrelationship of pelvic, abdominal, and spinal muscles. the center of gravity, the line of gravity, and the Avoid movements that cause pain or base of support. require spinal flexion with straight legs (e.g., toe-touching and sit-ups) or spinal rotation (twisting). When moving an object, spread your feet apart to provide a wide base of support. Wear comfortable low-heeled shoes that provide good foot support and reduce the risk of slipping, stumbling, or turning your ankle. 4 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 Patients who have undergone recent Position Description When used contraindications Prone Client lies face down Alternate position for immobilized patient Post abdominal surgery and among those with abdominal surgery Patients who are respiratory and spinal problems Sitting A seated position. Assessing of head, Elderly and weak neck, thorax, lungs, clients may require experiencing pain Pregnant patients in breast, upper and support lower extremities and reflexes Supine Lies flat on back Clients on bed rest, Clients with the abdomen. post spinal surgery & dyspnea and risk anesthesia for aspiration. Side-lying Client lies on the side with Client post hip weight on the hip and A choice position for replacement shoulder. clients with pressure Sims Semiprone position, lies on sores on bony Clients with spine Patients who have ostomies (such as a the side with weight prominence of back condition distributed towards the and sacrum anteriror ileum, humerus, and clavicle. colostomy, ureterostomy, ileostomy) Fowler’s bed position in which the head and trunk are raised 45° to 60° relative to the bed (vi Patients who are unable to tolerate the sualize a 90° right angle to Clients with difficulty orient your thinking) and of breathing. Also for Post spine or brain the knees may eating, improvement surgery or may not be flexed. of cardiac output pressure of the belt. Semi-fowler’s Semi-Fowler’s position is when the head and trunk are raised 15 to 45 degrees. Dorsal recumbent Supine with leg flexed and For vaginal rotated outward. examination Sit-to-stand pivot transfer Knee chest Lies prone with buttocks Rectal procedures Arthritis and other elevated and knees drawn and examination joint deformity to the chest Lithotomy Lies supine with hips For vaginal and flexed, and calves and rectal exam and heels parallel to the floor procedures A common technique for helping a patient to move using stirrups trendelenburg Lies supine with head 30-40 For postural Increased intra- degrees lower than the drainage and cranial pressure feet promotion of venous from a bed to a wheelchair or chair is the "Sit to return Stand Pivot Transfer." TRANSFERS Before transferring a patient from a bed to a chair or wheelchair: Explain the process The transfer belt to the patient A number of aids are available to help you to Position the chair at the head of the bed on transfer patients safely. One frequently-used aidis the patient's strong side (if applicable) and the transfer belt. remove any obstacles A transfer belt is placed around the patient's waist and secured snugly. The belt can be adjusted to fit Lock any wheels on the chair and bed different patients and usually fastens with velcro If transferring to a wheelchair, remove the and a buckle. If the transfer belt has loops, hold arm nearest the bed and remove the leg these loops to support the patient more firmly rests or swing them out of the way during transfer; if the belt does not have loops, hold onto the belt itself. You should use a transfer belt Adjust bed height so that the patient's hips with patients who can partially support their own will be slightly above the knees with the feet weight but need assistance. flat on the floor Make sure that the floor is dry and that both you and the patient are wearing non- slippery footwear Apply a transfer belt to the patient’s waist. The transfer itself is a simple process of standing the patient up, pivoting, and sitting the patient down. To perform this transfer, carry out the following steps: 1. Stand close to the patient to avoid leaning or over-reaching and place your foot that is closer to the head of the bed on the floor between the patient's legs. 2. Reach around the patient's waist and grip Transfer belts enable employees to grip patients the transfer belt. more firmly and control their movement during 3. Ask the patient to push against the bed with transfer. the arms and to stand with you on the count A transfer belt should not be used with some of 3. patients. These include: 4. Using a rocking motion, count to 3, and then stand the patient up. 5 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 5. Holding the patient close to your body, pivot on the foot between the patient's legs until the backs of the patients' legs touch the front of the chair. 6. With your knees bent, lower the patient into the chair using the transfer belt. 7. Throughout the process, ensure that your back is properly aligned with your ears, shoulders, and hips in a vertical line. When performing this transfer, if patients wish to Notice how the Spine is kept aligned the entire hold on to you for support, ask them to hold on to time. Remind the patient not to help. The staff your upper arms, forearms, or waist. Never allow a should have the body and head supported. This is patient to hold on to your neck. If you are difficult for patients who are awake and alert, they concerned that a patient may grab your neck, you tend to want to help. Note the pillow between the may grip the transfer belt by placing your arms knees is optional this is not necessary. around the patient’s arms. 1. When your procedure is done, the person If a second employee is available to help with the at the head of the bed will count to 3 and transfer, a similar process is used. The second everyone will roll the patient back onto their employee should be behind the patient with one back. knee on the bed. The second employee grips the transfer belt from the back. The first employee uses 2. Patients need to be kept in this position and a gentle rocking motion to stand the patient up. in C-Collars until they are cleared by the physician. As soon as the patient clears the bed, the second employee shifts the patient to the chair. Bed to Stretcher Transfer Log roll a patient Safe practice when performing lateral transfers 1. Explain to the patient what you are going to Healthcare is a physically demanding occupation. do and instruct the patient not to help that In fact, the nursing profession has one of the the staff will be doing all the work. highest rates of work-related back injuries. Many of these injuries occur during patient transfers. 2. Takes a minimum of 3 people to roll the patient and a 4th person to perform The most hazardous types of patient transfers are: whatever activity was going to be done, Bed to chair such as assessing the patients back. Bed to stretcher 3. Notice in the picture how one person takes control of the head. This person is the one Reposition in bed. who controls the rolling of the patient. It is important to follow proper transfer techniques When it is time to roll the patient the person to reduce the chance of injury. In addition, in control of the head should count to 3 and whenever you move a patient or lift, push, or pull everyone rolls the patient at the same time. an object, it is important to use good body This person holds the head and maintains mechanics. Even a light load can cause lower back C-Spine stabilization. strain if poor body mechanics are used. 4. The other 2 people will be on the same side Using good body mechanics includes keeping your of the patient. One person puts their hands back in proper alignment. To maintain the back's on the shoulder and hip. The second natural S-shape, keep the ears, shoulders, and person puts their hands on the hip (cross hips in a straight line. When bending forward, this hands with the first person) and on the straight line is maintained by bending at the hips, knee. Then on the count of 3 everyone not the waist. turns the patient at the same time. See the pictures below! 6 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 In addition to back injuries, there are other risks to that can be used to bridge small gaps between both patients and employees from improper surfaces. transfer techniques. These risks might include falls, dislocation, and shoulder strain to name a few. Transfer boards Transfer boards are also used. These may use various low-friction or roller technologies so that TYPES OF LATERAL SLIDING AIDS the patient can be pulled across easily. A lateral transfer is the movement of a patient, who is in a lying down position, from one flat surface to another. One example of a lateral transfer is a PERFORMING A LATERAL TRANSFER transfer from bed to stretcher. Before transferring a patient from a bed to a There are many types of aids available to make the stretcher, it is important to assess the situation. process of a manual lateral transfer easier. A sliding How much can the patient help? aid should always be used when performing a If a patient is able to move from the bed to stretcher lateral transfer. Lateral sliding aids include draw without help, you should only stand by for safety as sheets, transfer pads, and transfer boards. needed. If a patient can assist only partially or not at all, a lateral transfer will need to be done. Two employees should always participate in a lateral transfer and a lateral sliding aid should be used. If the patient is very heavy, three employees should assist or a mechanical transfer device should be used. You should not use any mechanical devices, however, if you have not been trained to use them. One common method of lateral transfer involves the use of a draw sheet or short sheet. Before transferring a patient from a bed to a stretcher using a draw sheet: Explain the process to the patient Position the stretcher alongside the bed Adjust the height of the bed and stretcher so that they are level Lock wheels on both the bed and stretcher If there is not already a draw sheet in place, position the draw sheet or short sheet beneath the patient in the same manner Draw sheets that you would do so when changing an sheetAcandrawbesheet or any used asshort sheet can a sliding be used aid. There occupieddesigned as aare also specially bed. roller sliding special aid. There fabrics thatarehave also specially designed inner low-friction roller surfaces. The layers of fabric sheets.the her during These are madetransfer. patient of special fabrics that have low-friction inner surfaces. The layers of fabric roll TO TRANSFER A PATIENT USING A DRAW or slide over one another during the patient SHEET OR OTHER SHORT SHEET transfer also available. These may be quilted pads with pull 1. straps Roll up and the sides of the sheet next to the a roller Transfer pads ds may also come with slats that can be used to bridge small gaps betweensides of the patient Various types of pads are also available. These may 2. One employee stand at one side of the be quilted pads with pull straps and a roller sheet patient underneath. The pads may also come with slats 3. Another employee stand at the other side sed. These may use various low-friction or roller technologies of the stretcherso that the ss easily. 7 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 4. Each employee hold the rolled up sheet Avoid twisting or turning the upper body when close to the patient's body carrying or lifting. 5. Use the sheet to move the patient onto the Explain what you are doing to patients and other stretcher employees who are participating. Make sure that both you and the patient are wearing non-slip 6. Both healthcare workers should maintain footwear. correct alignment of the back throughout the process Be sure the floor is dry and obstacles are removed. Get assistance whenever possible. Other sliding aids can also be used to transfer a patient from a bed to stretcher. Whatever type of Other factors that can help to maintain a healthy aid is used, always remember to: back include: Follow any procedures established by your Eating a proper diet facility Exercising regularly Reducing stress Become familiar with the type of sliding aids Removing hazards available PREPARING TO AMBULATE SAFELY Make sure there is enough space to perform the transfer Every time you prepare to move a patient, you should assess the situation. You need to know how Remove any obstacles much the patient can help and what other Keep your center of gravity as near the assistance you might need. patient as possible For example, a patient who has suffered a stroke Eliminate reaching and twisting may be much stronger on one side than the other. In this case, it will be important to support the Raise the bed to a comfortable height patient's weak side by walking on that side of the whenever possible patient. Apply brakes on both bed and stretcher If the patient is unstable, dizzy, or confused, you Clean the sliding aid between uses to may need additional assistance. This may include prevent infection. the help of another employee or the use of a transfer belt. It is also important to prepare the area before AMBULATING WITH THE PATIENT ambulating with the patient. Make sure that the room is not cluttered and remove any obstacles. A Safe practice when ambulating with the patient cluttered room increases the chances of trips or Your back is very important. It provides balance falls. and support to your whole body. Suffering a back You should also be aware that a small room, such injury can have a serious impact on the way you as a bathroom, may restrict your movements. Think live and on the things you can do. about how you will deal with such spaces before When ambulating with a patient, you walk beside you get there. the patient and provide assistance. If you are ambulating with a patient, performing a transfer, or doing any other job that requires lifting, follow WALKING WITH THE PATIENT these guidelines to help maintain a healthy back: When ambulating, or walking, with a patient, you Maintain the back's natural curves by keeping the may sometimes wish to use a transfer belt. A ears, shoulders, and hips aligned. Lift and lower transfer belt, or gait belt, is fitted snugly around the with your legs, not your back. patient's waist. The belt is simple to apply and provides a secure grip to assist the employee in Keep the weight close to your body. Bend at the transferring or walking with a patient. Some belts hips, not the waist. 8 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 have loops that can be used like handles to give a mechanics and support the patient's entire weight. better grip. Trying to hold the patient up could cause serious injury to both the caregiver and the patient. One employee may ambulate safely with patients who need some help walking but are reasonably Walker Steps Additional information 1. Ensure proper footwear is on the patient, Proper footwear is essential to prevent and let the patient know how far you will be accidental falls. stable. If one side is weaker than the other, support ambulating. Proper footwear is non-slip or slip- Footwear resistant footwear. If in acute care, check prescriber’s orders for any activity restrictions the patient's weak side by walking on that side. related to treatment or surgical procedures. 2. Measure client for walker height. The top of the walker should line up with the crease on the inside of the wrists when one is standing. Elbows should flex 15-30 degrees when standing inside the walker with hands on the hand grips. Support the patient by: Using one hand to support the patient's 3. Explain and demonstrate how to walk with a Assessment and instructions prior to elbow walker. ambulation 4. From a sitting position, instruct patient to Do not use the walker to pull oneself up. It is push up from the chair’s armrest to a standing not stable and could result in injury. position. Placing an arm around the patient's shoulder 5. Firmly grip both sides of the walker. Move the walker forward a short distance. The base of the walker provides a broad base of support. Once patient is standing and feels stable, move to the unaffected side. If using a gait belt, grasp Gripping a transfer belt around the patient's the belt in the middle of the patient’s back. 6. Step forward with the injured or weak leg first, taking weight through one’s hands. Then step with the stronger leg. Do not step forward if all four feet of the walker are not in contact with the floor. Walker – weak leg – strong leg. waist. Keep feet within the walker’s boundaries. Advise the patient to look forward not down at the floor. 7. To turn: Advise to take small steps, moving Avoid twisting the knee joint when turning. Two employees should participate if patients are the walker and then the legs. Walking in a large circle may be necessary. unstable or confused. To ambulate a patient safely Steps 1. Ensure proper footwear is on the patient, Additional Information Proper footwear is essential to prevent with 2 employees: and let the patient know how far you will be accidental falls. An informed patient is part of ambulating. Proper footwear is non-slip or slip- delivering safe patient care. resistant footwear. If in acute care, check prescriber’s orders for any activity restrictions related to treatment or surgical procedures. 2. Ensure crutch height is correct. Axilla height crutches: When standing, the 1. Ask the patient to sit on the side of the bed there should be two to three finger widths from the axilla to the top of the crutch. The height of the hand grip will be adjusted to allow the elbow to be flexed 15 to 30 degrees or to the 2. Apply the transfer belt wrist crease. There are different crutch walking techniques that depend on the patient’s ability to bear weight. 3. Stand the patient up (as if starting a sit-to- Forearm crutches: The elbows should be flexed 15 to 30 degrees when holding the hand grips. The forearms should be supported roughly mid- stand pivot transfer) point between the wrist and elbow. 3. Explain and demonstrate how to walk with An informed patient may result in reduced risk crutches. of falls. 4. From a sitting position, advise the patient to The patient should be cooperative and 4. Two employees stand on either side of the push up from the chair’s armrest to a standing position. Stand to gain balance. Advise the patient to not lean on the underarm supports. predictable, able to bear weight on own legs, and to have good trunk control. Apply gait belt if required for additional support. patient Pressure on the axilla can cause damage to tissues and nerves. 5 a. Advise patient accordingly: Bear in mind any weight bearing limitations. Two employees should participate if patients are unstable or confused. To ambulate a patient safely Ambulation method #1: 5. Place your arm round the patient's back with 2 employees: Establish balance. Move both crutches forward slightly. Move injured leg forward. Apply and holdbeltthe transfer belt on the far side o 1. Ask the patient to sit on the side of the bed Push down on the crutch hand grips. 2. the transfer Step through the crutches with the good leg. 3. Stand the patient up (as if starting a sit-to-stand pivot transfer) the patient Ensure balance is maintained. 4. Two employees stand on either side of the patient Repeat. 5 b. Ambulation method #2: Ambulation method #2 requires good balance 5. Place your arm round the patient's back and hold the transfer belt on the far side of and trunk strength. 6. with Walk the with patient.the patient. Establish balance. the patient Move the crutches and the injured leg 6. Walk forward simultaneously. Push down on the crutch hand grips. Step through the crutches with the good leg. Ensure balance is maintained. Repeat. 6 a. Ascending stairs: Strong leg – weak leg – crutches. Stand close to and facing the bottom step. Use of the hand rail may be helpful. Cane Steps Additional information 1. Let patient know how far you plan to Proper footwear is essential to prevent ambulate. accidental falls. An informed patient is part of Proper footwear is non-slip or slip-resistant delivering safe patient care. footwear. 2. Ensure cane height is correct. Cane height is the length from the greater trochanter to the floor. Allow 15 to 30 degree flexion at the elbow. 3. Explain and demonstrate how to walk with An informed patient may result in reduced risk crutches. of falls. 4. Encourage the patient to get to a standing Quad cane: Push up from the armrest of the position. chair to standing position. Grasp cane and establish balance. Standard cane: Hold the cane handle in one hand. Push up from the armrest to standing If patients are not used to getting up, allow them to sit on the side of the bed for a few position. Establish balance. If patients are not used to getting up, allow them to minutes before standing. This can help to prevent dizziness. 5. Advise the patient to move the cane forward Cane position is forward and slightly to the side a short distance. when ambulating. If the patient begins to fall, DO NOT try to stop the fall. Instead, ease the patient down gently. sit on the side of the bed for a few minutes before 6. Step forward with injured / weak leg. Put Cane – weak leg – strong leg. Provide support, bending your knees not using your back, and guide the patient to the floor. weight onto the cane handle. Then step with Do not try to get the patient up off the floor by yourself. the strong leg. 7 a. Ascending stairs: Strong leg – weak leg – cane. standing. This can help to prevent dizziness Stand close to and facing the bottom step. Quad canes may have to be turned sideways to A transfer belt is not intended to lift a patient. You are also not in a position to maintain good body Step up with the strong leg. fit on a stair. mechanics and support the patient's entire weight. Trying to hold the patient up could cause Ensure balance is maintained. serious injury to both the caregiver and the patient. Step up with the injured / weak leg. Use of hand rail may help improve balance. Bring cane up. If the patient begins to fall, DO NOT try to stop the Repeat. 7 b. Descending stairs: Stand close to the top step and face the stairs. fall. Instead, ease the patient down gently. Place cane down onto the next step. Step down with weak / injured leg. Ensure balance is maintained. Step down with good / strong leg. Repeat. Provide support, bending your knees not using your back, and guide the patient to the floor. SLEEP Do not try to get the patient up off the floor by Sleep is a basic human need; it is a universal yourself. biologic process common to all people. Humans spend about one third of their lives asleep. We A transfer belt is not intended to lift a patient. You require sleep for many reasons: to cope with daily are also not in a position to maintain good body stresses, to prevent fatigue, to conserve energy, to 9 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 restore the mind and body, and to enjoy life more NORMAL SLEEP PATTERNS AND fully. REQUIREMENTS Sleep enhances daytime functioning, and is vital Although it used to be believed that maintaining a for cognitive, physiological, and psychosocial regular sleep/wake rhythm is more important than function. the number of hours actually slept, recent research has shown that sleep deprivation is associated with PHYSIOLOGY OF SLEEP significant cognitive and health problems. Although Historically, sleep was considered a state of reestablishing the sleep/wake rhythm (e.g., after unconsciousness. More recently, sleep has come the disruption of surgery) is important, it is to be considered an altered state of consciousness appropriate to allow and encourage daytime in which the individual's perception of and reaction napping in hospitalized clients. to the environment are decreased. Sleep is Newborns sleep 12 to 18 hours a day characterized by minimal physical activity, variable levels of consciousness, changes in the body's On an irregular schedule with periods of 1 to 3 physiological processes, and decreased hours spent awake. Unlike older children and responsiveness to external stimuli. adults, newborns enter REM sleep (called active sleep during the newborn period) immediately. The cyclic nature of sleep is thought to be controlled by centers located in the lower part of Rapid eye movements are observable through the brain. Neurons within the reticular formation, closed lids, and the body movements and irregular located in the brainstem, integrate sensory respirations may be observed. information from the peripheral nervous system and relay the information to the cerebral cortex The preschool-age child (3 to 5 years of age) requires 11 to 13 hours of sleep per night Neurotransmitters, located within neurons in the brain, affect the sleep/wake cycles. For Particularly if the child is in preschool. Sleep needs example, serotonin is thought to lessen the fluctuate in relation to activity and growth spurts. response to sensory stimulation and gamma- aminobutyric acid (GABA) to shut off the infants awaken every 3 or 4 hours, eat, and then go activity in the neurons of the reticular activating back to sleep. Periods of wakefulness gradually system. Another key factor to sleep is exposure to increase during the first months. By 6 months, most darkness. Darkness and preparing for sleep (e.g., infants sleep through the night (from midnight to 5 lying down, decreasing noise) cause a decrease in am) and begin to establish a pattern of daytime stimulation of the RAS. During this time, the pineal naps. At the end of the first year, an infant usually gland in the brain begins to actively secrete the takes two naps per day and should get about 9 to natural hormone melatonin, and the person 12 hours of sleep in 24 hours. feels less alert. The school-age child (5 to 12 years of age) FUNCTIONS OF SLEEP needs 10 to 11 hours of sleep per night The effects of sleep on the body are not completely But most receive less because of increasing understood. Sleep exerts physiological effects on demands both the nervous system and other body (e.g., homework, sports, social activities). They structures. Sleep in some way restores normal may also be spending more time at the computer levels of activity and normal balance among parts and watching TV of the nervous system. Sleep is also necessary for protein synthesis, which allows repair processes to Between 12 and 14 hours of sleep are occur. The role of sleep in psychological well-being recommended for children 1 to 3 years of age. is best noticed by the deterioration in mental functioning related to sleep loss. Individuals with Most still need an afternoon nap, but the need for inadequate amounts of sleep tend to become mid-morning naps gradually decreases. The emotionally irritable, have poor concentration, and toddler may exhibit a great deal of resistance to experience difficulty making decisions. going to bed and may awaken during the night. Nighttime fears and nightmares are also common. 10 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 Adolescents (12 to 18 years of age) require 9 to hypocretin in the area of the cns that regulates 10 hours of sleep each night sleep. Clients with narcolepsy have sleep attacks or excessive daytime sleepiness However, few actually get that much sleep. Sleep apnea Most healthy adults get 7 to 8 hours of sleep per night (National Sleep Foundation, n.d.d). Sleep apnea is characterized by frequent short breathing pauses during sleep. However, individual needs do vary-some adults may be able to function well (e-B-, without Although all individuals have occasional periods of sleepiness or drowsiness) with 6 hours of sleep, apnea during sleep, more than five apneic and others may need 10 hours to function episodes or five breathing pauses longer than 10 optimally. seconds per hour is considered abnormal and should be evaluated by a sleep medicine specialist. A hallmark change with age is a tendency toward earlier bedtime and wake times. Older adults (65 to 75 years) usually awaken 1.3 hours earlier and go to bed approximately 1 hour earlier than younger PHYSIOLOGY OF URINARY ELIMINATION adults (ages 20 to 30). Older adults may show an Urinary elimination depends on the effective increase in disturbed sleep that can create a functioning of the upper urinary tract's kidneys and negative impact on their quality of life, mood, and ureters and the lower urinary tract's, urinary alertness. They may awaken an average of six bladder, urethra, and pelvic floor times during the night. (5 to 6 hours) KIDNEYS The paired kidneys are situated on either side of FACTORS AFFECTING SLEEP the spinal column, behind the peritoneal cavity. The Both the quality and the quantity of sleep are right kidney is slightly lower than the left due to the affected by a number of factors. Sleep quality is a position of the liver. They are the primary regulators subjective characteristic and is often determined of fluid and acid-base balance in the body. The by whether a person wakes up feeling energetic or functional units of the kidneys, the nephrons, filter not. Quantity of sleep is the total time the individual the blood and remove metabolic wastes. In the sleeps. average adult 1,200 mL of blood, or about 21% of the cardiac output, passes through the kidneys 1. Lifestyle every minute. 2. Emotional Stress 3. Stimulants and Alcohol Not all of the glomerular filtrate is excreted as urine. 4. Diet Approximately 99% is resorbed into the plasma, 5. Smoking with the remaining 1% excreted as urine (Huether 6. Motivation et al., 2008). The kidneys play a key role in fluid and electrolyte balance (see Chapter 41). Although COMMON SLEEP DISORDERS output does depend on intake, the normal adult urine output averages 1200 to 1500 mL/day. An Insomnia output of less than 30 mL/hr indicates possible is described as the inability to fall asleep or remain circulatory, blood volume, or renal alterations. asleep. Individuals with insomnia do not awaken The kidneys produce several substances vital to feeling rested. red blood cell (RBC) production, blood pressure, Hypersomnia and bone mineralization. They are responsible for maintaining a normal RBC volume by producing Hypersomnia refers to conditions where the erythropoietin. Erythropoietin functions within the affected individual obtains sufficient sleep at night bone marrow to stimulate RBC production and but still cannot stay awake during the day maturation and prolongs the life of mature RBCs Narcolepsy (Huether et al., 2008). Patients with chronic kidney conditions cannot produce sufficient quantities of Narcolepsy is a disorder of excessive daytime this hormone; therefore they are prone to anemia. sleepiness caused by the lack of the chemical 11 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 Renal hormones affect blood pressure regulation in effect is more likely to occur in the first and third several ways. In times of renal ischemia (decreased trimesters. blood supply), renin is released from juxtaglomerular cells (Fig. 45-3). Renin functions as The trigone (a smooth triangular area on the inner an enzyme to convert angiotensinogen (a surface of the bladder) is at the base of the bladder. substance synthesized by the liver) into An opening exists at each of the three angles of the angiotensin I. trigone. Two are for the ureters, and one is for the urethra. Angiotensin I is converted to angiotensin Il in the lungs. Angiotensin Il causes vasoconstriction and URETHRA stimulates aldosterone release from the adrenal Urine exits the bladder through the urethra and cortex. Aldosterone causes retention of water, passes out of the body through the urethral which increases blood volume. The kidneys also meatus. produce prostaglandin E2 and prostacyclin, which help maintain renal blood flow through Normally the turbulent flow of urine through the vasodilation. These mechanisms increase arterial urethra washes it free of bacteria. Mucous blood pressure and renal blood flow (Huether et al., membrane lines the urethra, and urethral glands 2008). secrete mucus into the urethral canal. Thick layers of smooth muscle surround the urethra. In addition, URETERS it descends through a layer of skeletal muscles The ureters are tubular structures that enter the called the pelvic floor muscles. When these urinary bladder. Urine draining from the ureters to muscles are contracted, it is possible to prevent the bladder is usually sterile. urine flow through the urethra (Huether et al., 2008). Peristaltic waves cause the urine to enter the bladder in spurts. The ureters enter obliquely In women the urethra is approximately 4 to 6.5 cm through the posterior bladder wall. This (image to image inches) long. The external urethral arrangement prevents the reflux of urine from the sphincter, which is composed of skeletal muscle bladder into the ureters during the act of micturition located about halfway down the urethra, permits by the compression of the ureter at the voluntary flow of urine. However, the internal ureterovesical junction (the juncture of the ureters sphincter muscle is composed of smooth muscle with the bladder). An obstruction within a ureter and therefore is not under voluntary control. The such as a kidney stone (renal calculus) results in short length of the urethra predisposes women and strong peristaltic waves that attempt to move the girls to infection. It is easy for bacteria to enter the obstruction into the bladder. These waves result in urethra from the perineal area. pain often referred to as renal colic. In men the urethra, which is both a urinary canal BLADDER and a passageway for cells and secretions from reproductive organs, is about 20 cm (8 inches) The urinary bladder is a hollow, distensible, long. The male urethra has three sections: muscular organ (detrusor muscle) that stores and prostatic, membranous, and penile. excretes urine. When empty, the bladder lies in the pelvic cavity behind the symphysis pubis. In men the bladder lies against the anterior wall of the ACT OF URINATION rectum, and in women it rests against the anterior walls of the uterus and vagina. Several brain structures influence bladder function, including the cerebral cortex, thalamus, The bladder expands as it becomes filled with hypothalamus, and brainstem. Together they inhibit urine. Pressure within it is usually low even when the urge to void or allow voiding. Normal voiding partly full, a factor that protects against infection. involves contraction of the bladder and When the bladder is full, it expands and extends coordinated relaxation of the urethral sphincter and above the symphysis pubis. A greatly distended pelvic floor muscles. bladder may reach the level of the umbilicus. In a pregnant woman the developing fetus pushes FACTORS INFLUENCING URINATION. against the bladder, reducing the capacity of the Many factors influence the volume and quality of bladder and causing a feeling of fullness. This urine and the patient's ability to urinate. Some 12 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 pathophysiological conditions are acute and returns shortly after voiding. Emotional tension reversible (urinary tract infection [UTI]), whereas makes it difficult to relax abdominal and perineal others are chronic and irreversible (slow, muscles. progressive development of renal dysfunction). Sociocultural factors, psychological factors, fluid Attempting to void in a public restroom sometimes balance, and surgical and diagnostic procedures results in a temporary inability to void. Privacy and affect urine and urination in several ways. In adequate time to urinate are usually important to addition, medications, including anesthesia, most people. interfere with both the production and FLUID BALANCE characteristics of urine, affect the act of urination, and affect the ability to completely empty or control The kidneys primarily maintain the balance voiding. between retention and excretion of fluids (see Chapter 41). If fluids and the concentration of electrolytes and solutes are in equilibrium, an DISEASE CONDITIONS increase in fluid intake causes an increase in urine production. This amount varies with food and fluid Disease processes that affect urine elimination intake. The volume of urine formed at night is about affect renal function (changes in urine volume or half of the volume formed during the day because quality), the act of urine elimination, or both. both intake and metabolism decline. Nocturia Conditions that affect urine volume and quality are (awakening to void one or more times at night) is generally categorized as prerenal, renal, or often a sign of renal alteration. In a healthy person postrenal in origin. the intake of water in food and fluids balances the output of water in urine, feces, and insensible Decreased blood flow to and through the kidney losses in perspiration and respiration, An excessive (prerenal), disease conditions of the renal tissue output of urine is polyuria. A urine output that is (renal) and obstruction in the lower urinary tract decreased despite normal intake is called oliguria. that prevents urine flow from the kidneys (postrenal) sometimes alter renal function. Oliguria often occurs when fluid loss through other Conditions of the lower urinary tract, including means (e.g., perspiration, diarrhea, or vomiting) narrowing of the urethra, altered innervation of the increases. It also occurs in early kidney disease. bladder, or weakened pelvic and/or perineal Often in severe kidney disease no urine is muscles, affect urinary elimination. produced (anuria). Diabetes mellitus and neuromuscular diseases Ingestion of certain fluids directly affects urine such as multiple sclerosis cause changes in nerve production and excretion. Coffee, tea, cocoa, and functions that can lead to possible loss of bladder cola drinks that contain caffeine promote increased tone, reduced sensation of bladder fullness, or urine formation (diuresis). Alcohol inhibits the inability to inhibit bladder contractions. Older men release of antidiuretic hormone (ADH), also often suffer from benign prostatic hyperplasia resulting in increased water loss in urine. (BPH), which makes them prone to urinary retention and incontinence. Some patients with ALTERATIONS IN URINARY ELIMINATION cognitive impairments, such as Alzheimer's Most patients with urinary problems are unable to disease, lose the ability to sense a full bladder or store urine or fully empty the bladder. These are unable to recall the procedure for voiding. disturbances result from impaired bladder function, Diseases that slow or hinder physical activity obstruction to urine outflow, or inability to interfere with the ability to void. Degenerative joint voluntarily control micturition. disease and Parkinsonism are examples of conditions that make it difficult to reach and use Some patients may have permanent or temporary toilet facilities. changes in the normal pathway of urinary excretion. The surgical formation of a urinary PSYCHOLOGICAL FACTORS diversion temporarily or permanently bypasses the Anxiety and emotional stress cause a sense of bladder and urethra as the exit routes for urine. urgency and increased frequency of urination. Permanent urinary diversions are often necessary Anxiety often prevents a person from being able to in the patient with cancer of the bladder. The urinate completely; as a result, the urge to void patient with a urinary diversion has a stoma 13 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 (artificial opening) on the abdomen to drain urine. Lifestyles He or she has many special needs because urine drains to the outside through a stoma. many individual's family and sociocultural variables influences a person's usual elimination habits. The URINARY RETENTION long-term effect of bowel training, the availability of toilet facilities, embarrassment about odors and Urinary retention is an accumulation of urine need to privacy, also affect the fecal elimination resulting from an inability of the bladder to empty patterns. properly. Normally urine production slowly fills the bladder and prevents activation of stretch Fluids receptors until it distends to a certain level of stretch. The micturition reflex occurs, and the both the type and amount of fluid digested affect bladder empties. In urinary retention the bladder is elimination. Healthy fecal elimination is facilitated unable to respond to the micturition reflex and thus by a daily intake of 2000 to 3000mL. is unable to empty. Urine continues to collect in the Activity and muscle tone bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the regular exercise improves gastrointestinal motility symphysis pubis, restlessness, and diaphoresis and muscle tone while inactivity decreases both. (sweating). Adequate tone in the abdominal muscles, the diaphragm and the perineal Psychological factors BOWEL ELIMINATION emotional stress affects the body in many ways. Defecation is the expulsion of feces from the anus Persons with anxiety causes persons with and the rectum. It is also called a bowel movement. depression causes slower intestinal motility The peristaltic waves move the feces into the resulting sigmoid colon and the rectum, the sensory nerves in the rectum are stimulated and the individual Pathological conditions becomes aware of the need to defecate. spinal cord and head injuries decrease sensory There are two centers governing the reflex to stimulation for defecation. defecate. One is situated in the medulla and Impaired mobility limits the patient's ability to subsidiary one is in the spinal cord. When respond to the urge to defecate. Ribbon like stools parasympathetic stimulation occurs, the internal in appearance due to tumor in the colon. anal sphincter relaxes and the colon contracts. The defection reflex is stimulated chiefly by the fecal Medications mass in the rectum. When the rectum is distended the intrarectal pressure rises, the defecation reflex narcotic analgesics cause constipation by is stimulated by the muscle stretch, and the desire decreased gastrointestinal mobility. Many to eliminate results. medications have diarrhea as undesirable side effect. FACTORS AFFECTING BOWEL ELIMINATION Diagnostic procedure Age and Development barium salts used in radiologic examinations. It there is a marked difference between the stools of hardens if allowed to remain in the colon, an infant and an older person. The very young are producing constipation and sometimes an unable to control elimination until the impaction neuromuscular system is developed, usually between the ages of 2 to 3 years. Surgery and anaesthesia Daily Patterns direct manipulation of the bowel during abdominal surgery inhibits peristalsis causing a condition most people have regular patterns of bowel termed as paralytic ileus. General anesthetic elimination which include frequency, timing agents that are inhaled also inhibit peristalsis by considerations, position and place changes in any blocking the parasympathetic impulses to the of these may upset a person routine and actually intestinal muscle lead to constipation. 14 KAYE V. BELLO, SN  FUNDAMENTALS OF NURSING PRACTICE 1 Irritants spicy foods, bacterial toxins and poisons can irritate the intestinal tract and produce diarrhea and often large amounts of flatus Pain patients who are experience discomfort when defecating. E.g. following hemorrhoid surgery will often suppress the urge to defecate to avoid the pain COMMON PROBLEMS IN BOWEL ELIMINATION Constipation it refers to the passage of small, dry hard stool or the passage of no stool for a period of time. The causes are irregular defecation habits, inappropriate diet, insufficient fluid, insufficient exercises and increased psychological stress Fecal impaction it is a mass or collection of hardened feces in the folds of the rectum. The causes are prolonged retentions and accumulation of fecal material, poor defecation habits and constipation and medications Diarrhea it refers to the passage of liquid feces and an increased frequency of defecation or it is the lischarge of frequent loose stool to the rapid passage of content through the intestines. The causes re emotional stress and infection Fecal incontinence it refers to loss of voluntary ability to control fecal and gaseous discharge through the anal sphincter or inability to control the expulsion of feces. The causes are spinal cord trauma and tumors of the external sphincter muscles Flatulence it is the presence of excess in the intestine and leads to stretching and inflation of the intestine (intestinal distension) air or gas in the gastrointestinal tract is called flatus 15 KAYE V. BELLO, SN