Key Points Exam One PDF

Key points Ch 15 A clinical judgment model contains the elements that allow you to make the right clinical decisions in every type of patient situation. Clinical judgment is an observed outcome that uses nursing knowledge and experience to observe and assess presenting situations,identify a prior...

Key points Ch 15 A clinical judgment model contains the elements that allow you to make the right clinical decisions in every type of patient situation. Clinical judgment is an observed outcome that uses nursing knowledge and experience to observe and assess presenting situations,identify a prioritized patient concern, and generate the best possible evidence-based solutions to make the decisions needed to deliver safe patient care. When striving to make sound clinical judgments, nurses rely on a critical thinking process (the nursing process) that involves open-mindedness, continual inquiry, and perseverance. Effective problem solving requires you to obtain information that clarifies the nature of a problem, suggest possible solutions, and try the solution over time compared with diagnostic reasoning, a form of decision making that involves being able to understand and think through clinical problems, analyze individual cues, understand the evidence, and know when there is enough information to make an accurate diagnosis. To prioritize patient problems in clinical situations, use decision criteria that include the clinical condition of the patient, a review of the advantages and disadvantages of each option, Maslow's hierarchy of needs, the risks involved in treatment delays, environmental factors, and patients' expectations of care. A basic critical thinker is task oriented, whereas a complex critical thinker uses experience to anticipate how to individualize a nursing procedure when problems arise. Knowledge is a critical thinking component that prepares you to better anticipate and identify patient problems by understanding their origin and nature. With experience, you begin to understand clinical situations, anticipate and recognize cues from patients' health data, and interpret the patterns of data as relevant or irrelevant. During the clinical care of patients, apply critical thinking attitudes for how to approach a problem, knowing when you need more infor-mation, knowing when information is misleading, and recognizing your own knowledge limits. Intellectual standards are guidelines or principles for rational thought to apply during all steps of the nursing process. After making a clinical decision, use reflection to consider the meaning of your findings and to explore the possible meaning of those findings in solving a patient problem.  Key Points Ch 16 Competence in the assessment process involves application of all critical thinking components so that you are deliberate and systematic in collecting data that allow you to make accurate clinical judgments about your patients. Nursing assessment involves two steps: (1) the collection of information from as many sources as possible, and (2) the interpretation and validation of data to determine whether more data are needed or if the database is complete to make clinical judgments about patients. A nurse will conduct different types of assessments based on a patient's condition and the clinical situation. Patient-centered interviews are conducted during nursing history taking; periodic assessments are conducted during ongoing patient care; and physical examination is a specific skill used to supplement either of the first two types. The components of critical thinking guide assessment; with nurses applying knowledge and theory to direct the collection of patient data, consider environmental and time-related factors and then use critical thinking attitudes and standards to make clinical judgments about patient needs. The type of an assessment you conduct is based on your judgment, triggered by how a patient is responding (presenting signs and symptoms), whether the patient's condition is urgent, and the time you have to gather data. Use the knowledge you gain through your experience to determine when you need to make an adaptation to a skill based on your patient's assessment data. Professional standards and clinical guidelines offer a roadmap for what to assess in specific clinical situations. Critical thinking attitudes foster the exploration of all data sources in detail to ensure a thorough patient database. A patient-centered interview is relationship based and is an organized conversation focused on learning about a patient's concerns and needs. Through each phase of an assessment interview, nurses use communication principles and interview techniques that support patient self-expression and encourage full discussion of patient problems and concerns. Display professionalism and a caring approach during an interview by looking at the patient and not the data categories on a computer screen. The assessment process involves thorough data collection based on critical thinking and the interpretation and validation of the data to ensure that informed and accurate clinical judgments can be made.  Key Points Ch 18 Clinical judgment during planning involves use of the six components of critical thinking to guide nurses in making relevant and appropriate clinical decisions needed for patient-centered care. After identifying a patient's nursing diagnoses and collaborative problems, you begin planning, which involves setting priorities based on patient diagnoses and problems, and then identifying expected outcomes and selecting nursing interventions for each diagnosis. Critical thinking offers a methodical approach to individualize a plan of care; it includes the application of knowledge about a patient and the patient's clinical condition, experience with other patients, and knowledge of attitudes and standards. Care plans should be developed with the patient's involvement and focused on improving the patient's well-being. Environmental factors within the health care setting impact the timing and efficiency of any plan of care. Collaboration with patients and family caregivers, as well as health care team members, aids in determining the priority or urgency of identified nursing diagnoses or problems. Determining whether an outcome is relevant to a nursing diagnosis involves asking what is the best approach to address and resolve the nursing diagnosis and what does the patient need to achieve (physically, psychologically, socially, and spiritually). Prioritization of nursing diagnoses occurs when you use nursing and scientific knowledge to recognize patterns of data from a patient assessment and allow certain knowledge triggers to guide you to understand which diagnoses require more immediate intervention and when you need to take action. One helpful way to prioritize is to think of your patient's nursing diagnoses and problems as high, intermediate, or low in importance. By ranking a patient's nursing diagnoses in order of importance and always monitoring changing signs and symptoms of patient problems, you attend to each patient's most important needs and better organize ongoing care activities. Outcomes must be measurable so that you can measure or observe whether a change takes place in a patient's physiological status or in a patient's knowledge, perceptions, and behavior. A properly written outcome statement sets the desired response that indicates resolution of the patient's health problems. Using the SMART acronym, each outcome should be Specific, Measurable, Attainable, Realistic, and Timed. Choosing suitable nursing interventions requires applying nursing knowledge and scientific evidence about a patient's health problems, assessment findings about the patient, and experience in caring for patients with similar nursing diagnoses. Independent nurse-initiated interventions are autonomous actions based on scientific rationale. Dependent nursing interventions require an order from a health care provider to perform. You initiate a consult when your patient is experiencing a problem you cannot solve independently as a professional nurse or when you need the advice of another health care professional to provide quality patient care. Interprofessional collaboration involves all health care providers working together to achieve common outcomes for a patient, with collaborators respecting the expertise of those in other disciplines and being aware of the professional roles and responsibilities of other team members.  Key Points Ch 17 Nursing diagnosis is a clinical judgment based on critical analysis and interpretation of data cues that classifies the response to illness by an individual, family, or community Nursing diagnoses provide clear directions as to the types of nursing interventions nurses are licensed to provide independently Nurses cannot treat medical diagnoses; instead, they treat patients' responses to the medical health conditions. The exception to this is advanced practice nurses. Nurses treat patients responses to health conditions Nurses intervene in collaboration with personnel from other health care professions to manage collaborative problems Using standardized terminology for nursing diagnoses provides diagnostic clarity and effective interprofessional communication and enables nurses to formulate nursing diagnoses and the associated intervention and to assess the outcomes of nursing care The application of knowledge and clinical experience, the consideration of environmental factors, and the use of critical thinking attitudes and intellectual and professional standards improve diagnostic accuracy The nursing diagnostic reasoning process involves analyzing data gathered about a patient for pattern recognition and validation of available cues. Logically interpreting the data requires making a clinical judgment in selecting an accurate nursing diagnosis The components of a nursing diagnostic statement include a diagnostic label or diagnosis, related factors or etiologies (for problem focused and negative diagnoses) and as an option, major assessment findings Data analysis involves critically organizing all data elements about a patient into meaningful patterns also called data clusters or sets of assessment findings/defining characteristics A problem focused nursing diagnosis or negative diagnosis identifies actual undesirable human response to existing health problems, while a risk nursing diagnosis identifies when there is an increased potential or vulnerability for a patient to develop a problem or complication An important form of clinical judgement is prioritization of nursing diagnoses, demonstrated when nurses apply their experience and knowledge about patients various health problems to critically interpret which diagnosis is a priority As you recognize data elements from an assessment, you will cluster or group them together in meaningful patterns in a logical way that during interpretation will clearly identify the nursing diagnoses Identify nursing diagnoses from a cluster of assessment findings and not just a single symptom Errors occur in the nursing diagnostic process during date collection; analysis of data, clustering, or pattern formation and interpretation in choosing a nursing diagnostic statement  Key Points Ch 19 The professional scope of nursing practice identifies the nature and intent of the ways nurses intervene, which includes the domains of practice, with each domain including direct and indirect nursing interventions. When making decisions as to whether an intervention is patient centered, consider who is the patient; how might the patient's attitudes, values, preferences, and cultural background affect how you provide care; which clinical situation is a priority; and how could you best support or show caring as you intervene. Standard nursing interventions such as those in practice guidelines and protocols enable nurses to deliver evidence-based interventions to improve patient outcomes; however, standard interventions must be individualized to a patient's unique needs and clinical status. A care bundle is a group of interventions related to a disease condition that when implemented together result in better patient outcomes by preventing the most common complications associated with their condition; however, clinical staff must be consistent in performing all interventions within a bundle. Consider the context in which you deliver care to each patient and the many interventions available to make the clinical decisions needed to deliver appropriate care in each clinical situation. Critical thinking allows you to consider the complexity of interven-tions, changing priorities, alternative approaches, and the amount of time available to act. Your knowledge of pathophysiology and experience with previous patients helps you identify potential complications that can occur. ​ The evidence or scientific rationale for how interventions prevent or minimize complications helps you select the most appropriate preventive measures. Your experience and knowledge of a patient's condition and risk factors enables you to observe for and recognize the risks, adapt your choice of interventions to each situation, assess the relative benefit of the intervention versus the risk, and then take risk-prevention measures. When implementing patient care, you must consider an organization's goals of efficiency and cost control while still focusing on competently providing timely, thoughtful, safe, patient-centered care. The ability to manage care in a timely way conveys caring and concern to your patients. A cognitive skill involves knowing the rationale for therapeutic interventions and understanding normal and abnormal physiological and psychological responses, enabling you to adapt skills when necessary and to properly monitor patients as interventions as performed. A psychomotor skill such as suctioning an airway or inserting an intravenous catheter is an integration of cognitive and motor activities that must be delivered competently. All three implementation skills are employed together to provide direct and indirect care measures successfully. Effective patient education requires you to present health care prin-ciples, procedures, and techniques in such a way that patients can adapt what they learn to their personal daily routines at home to achieve self-care. When you educate patients, respect their expertise with their own health and symptoms, their daily routines, the diversity of their human experiences, their values and preferences as to how they learn, and the importance of shared decision making. Timely, relevant, and accurate communication with other health care professionals prevents misinformation, duplication of interventions, delays in procedures, and uncompleted tasks.  Key Points Ch 29 For the body temperature to stay constant and within an acceptable range, various mechanisms maintain the relationship between heat production and heat loss. Body temperature will decrease using measures that increase radiation, evaporation, convection, and conduction of heat. Fever serves as an important mechanism to enhance the immune system's ability to fight infection. Fever increases metabolism, which requires additional energy and oxygen. Vital sign assessment requires an organized approach. Patient age, gender, activity, medications, and health status influence vital signs. Measurement location and time of day influence vital signs. Acceptable vital signs fall within a normal range, with infant and children values higher for pulse and respirations and lower in blood pressure, compared with adults. Changes related to aging influence the vital sign values of older adults. Assessment of a child's vital signs requires you to consider that the brachial or apical pulse is the best site for assessing an infant's or a young child's pulse, and when measuring respirations, infants tend to breathe less regularly. Self-measurement of blood pressure helps patients adhere to treatment regimens, but findings should not be used for treatment decisions. Document route and site when measuring temperature, blood pressure, pulse, and oxygen saturation. When vital signs are above or below expected values, enter a note in the patient's record regarding the finding, any intervention, and the patient's response. Vital signs can be delegated to assistive personnel when the patient's condition is stable; however, the skill of apical pulse measurement cannot be delegated.  Key Point Ch 20 Critical thinking and clinical judgment are integral to evaluation as evidenced by (1) examining the results of care according to clinical data collected; (2) comparing achieved effects with expected outcomes; (3) recognizing errors or omissions; and (4) understanding a patient situation, participating in self-reflection, and correcting errors. A nurse applies knowledge about a patient's clinical status, signs and symptoms of health conditions, and anticipated effects of interventions to make the judgment needed to determine whether patients are progressing or problems are worsening. Expertise in evaluation relies on experience, requiring a nurse to have witnessed the effects of interventions in the past, to have witnessed clinical change, and then to make evaluative decisions. The criterion-based standards used in evaluation are the expected outcomes established during planning. Critical thinking attitudes and intellectual standards for measurement are important for ensuring thorough and accurate evaluation. Although you may measure or observe patient data in the same way during assessment and evaluation, an assessment identifies what, if any, problems exist, while evaluative measures determine whether the problems you identified during assessment have remained the same, improved, or otherwise changed. By using the right evaluative measure, the expected outcome identified during planning, you are more likely to accurately identify whether there has been a change in a patient's condition. Standards for evaluation are often outcomes developed from well-established clinical guidelines and protocols. During the evaluation phase of the nursing process you perform evaluative measures to compare clinical assessment data, patient behavior, and patient self-reported data collected before implementation with data gathered after administering nursing care to determine whether the results of care match the expected outcomes for a patient. The evaluation process involves the use of observational skills, critical thinking, intellectual standards, knowledge, and reflection to recognize errors or omissions so that adjustments to interventions can be made in care plan revision. Conducting evaluation involves reviewing evaluative measures to determine whether outcomes are met successfully so that decisions can be made to continue, discontinue, or revise a plan of care. When patients do not meet outcomes, you perform a reassessment and identify the factors that interfere with their achievement, which usually involves a change in a patient's condition, needs, or abilities.  Key Points Ch 27 Clinical judgment is complex when promoting safety because it requires understanding a patient's perspective of safety as well as the risks posed by any physical conditions. Vulnerable populations (e.g., infants, children, older adults, persons with chronic disease) are especially at risk for alterations in safety because of reduced access to health care, fewer resources, and increased morbidity? Common environmental hazards to safety include vehicle accidents, poisonings, conditions causing falls, and fire hazards. A nurse's role in managing environmental hazards is to educate patients about the common hazards in the home and at work, teaching them how to prevent injury and emphasizing the hazards to which patients are the most vulnerable. A patient's developmental stage can create threats to safety because of lifestyle choices, cognitive and mobility status, sensory impairments, and safety awareness. Use the Banner Mobility Assessment Tool (BMAT) or Timed Up and Go (TUG) test to determine a patient's ability to walk, need for assistance, and progress of balance, sit to stand, and walking. Conduct a fall risk assessment in a hospital by using a validated tool containing major risk categories such as age, fall history, elimination habits, high-risk medications, mobility, and cognition. At a minimum, conduct the assessment on admission, following a change in a patient's condition, after a fall, and when the patient is transferred to a new health care setting. A procedure-related accident is less likely to occur when you strictly follow policies and procedures or standards of nursing practice, and when you minimize distractions and interruptions. An assessment of psychosocial factors that influence patient safety must include a review of a patient's health literacy, cultural background, and perception of health and safety. Patients with actual or potential risks to safety require you to make clinical judgments necessary in selecting the patient-centered interventions that prevent and minimize the specific threats to safety. It is important to learn a patient's routines and willingness to make changes in the environment, because decisions on ways to change the environment require the patient's full participation. Evidence-based alternatives to physical restraints include offering diversional activities, using de-escalation techniques, providing visual and auditory stimuli, and promoting relaxation techniques. Before applying restraints, review the medical record for underlying causes) of agitation and cognitive impairment, assess whether the patient has a history of dementia or depression, and review medications and current laboratory values. When a patient is in a physical restraint, assess the placement of the restraint, and note skin integrity, pulses, skin temperature and color, and sensation of the restrained body part.  Key Points Ch 28 Transmission of infection can occur if the six elements of the infection malaise, and lymph nodes that are enlarged, swollen, and tender chain are present and uninterrupted. Normal body flora and body system defenses help the body resist infection by reducing the number of pathogenic organisms The vascular response to acute inflammation includes rapid vasodilation, allowing more blood to be delivered near the location of the injury. The increase in local blood flow causes the redness and localized warmth at the site of inflammation, and the body releases chemical mediators that increase the permeability of small blood vessels, which leads to edema of interstitial spaces. The cellular response results in an increase in WBCs to the site of inflammation. If the inflammation becomes systemic, cellular responses result in increased WBCs in the bloodstream. Health care-associated infections lead to adverse patient events and significantly higher health care costs that are often not reimbursed. Multiple factors influence a patient's susceptibility to infection; patients may have one or more of these factors. Careful analysis of data and cues allow you to recognize patient risks such as poor nutrition, stress, chronic disease, and treatments that compromise the immune response.  igns of localized infection are more targeted and include swelling, redness, pain, and S restriction of movement in the affected body part, whereas the signs and symptoms of systemic inflammation are more generalized and include fever, fatigue,nausea/vomiting, malaise, and lymph nodes that are enlarged, swollen, and tender. You use basic medical aseptic techniques such as handwashing and use of barrier precautions with all patients to break the chain of infection. Surgical asepsis, such as sterile gloving, is a more stringent technique than medical asepsis. Proper handling and management of urinary catheters and drainage sets prevents infection by eliminating a potential portal of entry for microorganisms. Proper storage and refrigeration of food prevents a reservoir of infection from developing in food. Standard Precautions are applied in all patient care activities to prevent patients and health care workers from transmitting infection even in the absence of disease. Hand hygiene using antiseptic hand rub or washing with soap and water is the most effective basic technique in preventing and controlling infection transmission. Hands must remain in contact with antimicrobial agent long enough to clean hand surfaces. Transmission-based precautions, including airborne, droplet, contact, and protective environment, are used in addition to Standard Precautions for patients with highly transmissible pathogens. For example, Airborne Precautions focus on diseases that are transmitted by large droplets expelled into the air and by being within 3 feet of a patient, requiring use of a surgical mask when within 3 feet of the patient, proper hand hygiene, and dedicated personal protective equipment. Proper application of personal protective equipment protects the patient and health care worker from transmission of pathogens. When entering isolation, apply a cover gown first, followed by a surgical mask or respirator, then eyewear or face shield and, finally, clean gloves. In the home setting, educating patients and caregivers on infection prevention is critical, adapting interventions to a patient's unique home environment. Health care workers believed to have been exposed to hepatitis B will receive the vaccine and vaccination series. A blood test (titer) is offered in some health care settings.  Key Points Ch 40 Various health beliefs, personal, sociocultural, economic, and developmental factors influence patients' hygiene preferences and practices. Sound clinical judgment requires you to consider a patient's condition, anticipate any risks or problems, gather thorough assessment data, and then analyze data to form nursing diagnoses. Hygiene needs, preferences, and the ability to participate in care change as people age. Assess a patient's skin, feet and nails, oral mucosa, hair, and eyes and ears to obtain a complete assessment of the patient's hygiene needs. Assess a patient's physical and cognitive ability to perform basic hygiene measures. Vascular insufficiency and reduced mobility, cognition, and sensation increase a patient's risk for impaired skin integrity. Diabetes mellitus and peripheral vascular diseases increase the patient's risk for foot and nail problems. Clinical judgment and critical thinking about a patient's hygiene preferences, needs, and ability to participate in care results in patient-entered hygiene care matching the patient's needs and preferences. Administering therapies to relieve symptoms such as pain or nausea before hygiene better prepares patients for any procedure. Position patients and make suction available to reduce the risk for aspiration when providing oral care to unconscious patients. A patient's environment needs to be comfortable, safe, and large enough to provide care and allow the patient and visitors to move about freely. Evaluation of hygiene procedures is based on outcomes of care; a patient's sense of comfort, relaxation, and well-being; and a patient's understanding of hygiene techniques.  Key Points Ch 43 The 24-hour sleep-wake cycle is a circadian rhythm that influences physiological function and behavior. The control and regulation of sleep depend on a balance among regulators within the CNS. During a typical night's sleep, a person passes through four to five complete sleep cycles. Each sleep cycle contains three NREM stages of sleep and a period of REM sleep; time in each stage varies. Sleep provides physiological and psychological restoration. Sleep requirements vary by age, with neonates sleeping on average 16 hours a day and older adults needing 7 to 8 hours of sleep a night The hectic pace of a person's lifestyle, emotional and psychological stress, and alcohol ingestion frequently disrupt the sleep pattern. An environment with a darkened room, reduced noise, comfortable bed, and good ventilation promotes sleep. A regular bedtime routine of relaxing activities prepares a person physically and mentally for sleep The most common type of sleep disorder is insomnia. Characteristics of insomnia include the inability to fall asleep, to remain asleep during the night, or to go back to sleep after waking up earlier than desired. If a patient's sleep is adequate, assess the usual bedtime, normal bedtime ritual, preferred environment for sleeping, and usual preferred rising time When planning interventions to promote sleep, consider the usual characteristics of the patient's home environment and normal lifestyle Important nursing interventions for promoting sleep in the hospitalized patient are to establish periods for uninterrupted sleep and rest and to control noise levels.​ Use your patient's self-report to determine whether sleep was restful.  Key Points Ch 49 Reception, perception, and reaction are the three components of any sensory experience. Your senses receive information from your environment. Perception occurs when you become conscious of a stimulus. You usually react to stimuli that are the most meaningful or significant. Sensory alterations occur when a person has difficulty receiving or perceiving stimuli (sensory deficits), when external stimuli are meaningless or deficient (sensory deprivation), or when there is excessive stimulation (sensory overload). Many factors affect sensory function. For example, aging results in a gradual decline of acuity in all senses, and excessive environmental stimuli cause sensory overload. Sensory alterations can affect a patient's well-being and limit the ability to interact and function within the environment. A thorough assessment of the sensory system, which includes components such as assessment of a patient's mental status, a physical assessment, and a survey of environmental hazards, allows you to develop and implement an individualized plan of care. You make clinical judgments about a patient's sensory problems by using critical thinking, anticipating expected signs and symptoms of a sensory condition, and matching with data you gather from a patient. While assessing a patient's sensory alteration, consider the patho-physiology of the patient's deficit and the degree to which the deficit affects the patient's lifestyle, health, and safety. Select nursing diagnoses after reviewing patterns of assessment findings that reveal alterations in the patient's ability to function. Involve your patient to develop a realistic plan and prioritize nursing diagnoses and outcomes after taking time to recognize and analyze cues that indicate what is important to your patient and how your patient is affected by sensory deficits. Preventive actions and the early identification of sensory alterations require periodic health screenings. Involve patients and their families to create effective individualized plans of care that help patients adapt to alterations in sensory function. Analyze hazards in the environment when recommending and implementing strategies to reduce the risk of injury in patients with sensory deficits. When evaluating care, include your patient's perceptions and use evaluative data to determine if your care improved or maintained your patient's ability to interact and function in the environment. Key points Ch 38 The musculoskeletal and nervous systems work in coordination to maintain balance, posture, and body alignment during lifting, bending, moving, and activities of daily living. Regular physical activity elevates mood, boosts energy level, manages stress, and promotes a better quality of sleep. ​ ​ Safe patient handling includes standardized methods for determining how to handle, move, and mobilize patients based on individual patient characteristics and conditions, thereby reducing overexertion injuries to staff and reducing patient falls and injuries. ​ Clinical judgment involves applying critical thinking to consider knowledge about the relationship between the musculoskeletal system and a patient’s health alterations when deciding on interventions for problems related to activity and exercise. To assess a patient’s activity tolerance, observe the individual after ambulation, self-bathing, or sitting in a chair for several hours, and obtain a verbal self-report of fatigue, shortness of breath, or weakness. Also assess heart rate and blood pressure response to activity by comparing with baseline rates at rest. Assess a patient’s readiness to exercise by applying the Transtheoretical Model (TTM). First ask to what extent the patient enjoys exercising and the patient’s belief in the ability to exercise, and then compare the patient’s responses with the six stages of change to identify patient-centered interventions that will help the patient engage in exercise. Outcome selection for patients requiring activity and exercise therapies is focused on improving functional status and independence. A nurse uses clinical judgment, considering a patient’s current activity tolerance, the nature of the health condition, and the type of exercise best suited to the patient’s needs, as part of selecting patient-centered interventions based on patient preferences. A nurse will analyze assessment findings and refer to safe patient- handling algorithms to select the transfer technique best suited for the patient’s weight, weight-bearing capability, and need for transfer devices and personnel assistance. Ensuring that a patient is safe during assisted ambulation requires you to use a gait belt, to stand on the correct side by the patient, and to monitor the patient’s tolerance to walking. Sound clinical judgment in patient evaluation involves comparing a patient’s baseline mobility and activity tolerance measures (e.g., pulse, blood pressure, respirations, strength, self-report of fatigue, and psychological well-being) with expected outcomes and stan- dards for improvement. Key points 39 Injuries or disease processes that affect coordination and regulation of muscle groups pathologically influence mobility. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Periods of immobility due to disability or injury or prolonged bed rest during hospitalization cause major physiological, psychological, and social effects; the greater the extent and the longer the duration of immobility, the more pronounced the consequences. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Immobility increases the risk of skin breakdown and is also directly related to the development of deep vein thrombosis (DVT) and pulmonary embolus (PE). Immobility can negatively affect the ability to complete daily activities and can lead to boredom and social isolation. Clinical judgment in your approach to caring for patients who are immobilized is complicated. Anticipate the physical effects of any restrictions in movement caused by a sudden illness or injury and apply knowledge of a patient’s preexisting health conditions so you can consider a broad number of potential complications. ​ ​ Observe the appearance of extremities and measure the range of motion (ROM) of joints in various body positions to assess for correct body alignment and mobility. Critical analysis of all assessment data and comparing findings with the anticipated effects of mobility alterations reveal patterns of data indicating nursing diagnoses. ​ ​ ​ ​ ​ ​ ​ ​ Understanding what a patient can physically do compared with what the patient potentially and realistically can achieve helps you set realistic patient-centered outcomes for the plan of care. ​ ​ Patients with impaired body alignment and mobility require the use of correct positioning techniques. ​ Working collaboratively with health care providers, a nurse will identify patient risk factors for DVT and employ nursing interventions that reduce risk, such as early ambulation; leg, foot, and ankle exercises; regularly provided fluids; and frequent position changes. ​ ​ ​ ​ ​ ​ When a care plan includes interventions designed to prevent com- plications of immobility, compare a patient’s baseline with the signs and symptoms of complications for which the patient is most at risk.  Key points Ch 46 ​ ​ ​ ​ Micturition involves complex interactions among the central nervous system, bladder, and urinary sphincter. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Multiple factors affect urinary function such as fluid intake, medi- cations, functional ability, environment, medical problems outside the urinary tract, and dysfunction within the urinary tract. ​ ​ ​ ​ ​ ​ ​ ​ Common urinary tract symptoms include urgency, dysuria, frequency, hesitancy, polyuria, oliguria, nocturia, dribbling, hematuria, and urinary retention. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ The presence or recent history of an indwelling catheter increases risk for a urinary tract infection (UTI). ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ To minimize the risk for infection when caring for a patient with a closed bladder drainage system, nursing care must include careful attention to aseptic technique. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Planning care for a patient who is incontinent requires selecting interventions specific to the type of incontinence. ​ ​ ​ ​ ​ ​ ​ ​ Inserting a catheter using aseptic technique, maintaining a closed urinary drainage system, and removing an indwelling catheter as soon as it is no longer needed are essential in preventing CAUTIs. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Integrating a patient’s typical voiding habits into the plan of care and ensuring patient privacy foster a patient’s normal urinary elimination. ​ ​ ​ ​ ​ ​ ​ ​ ​ Interventions that prevent UTIs include promoting adequate fluid intake, promoting perineal hygiene, and encouraging patients to void at regular intervals. Prevention of catheter-associated urinary tract infection (CAUTI) requires use of an evidence-based “bundle” to perform all elements of care at one time. ​ ​ ​ ​ ​ Key points Ch 47 ​ ​ ​ ​ ​ ​ The GI tract consists of the alimentary canal, which extends from the mouth to the anus, and its accessory organs. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ The GI tract and organs work together to absorb high volumes of fluids and to help maintain fluid and electrolyte balance. ​ ​ ​ ​ ​ ​ ​ ​ The interaction among multiple physiological and psychological factors (e.g., age, diet, stress, physical activity, health status, and medications) affects a patient’s elimination patterns. For example, stress, exercise, and increased fiber and fluid intake usually increase peristalsis. ​ ​ ​ ​ ​ ​ ​ ​ Listening carefully to patients and their family caregivers, completing a thorough physical assessment, and using clinical judgment to recog- nize and analyze cues are necessary to determine the appropriate plan of care for patients with alterations in their usual elimination patterns. ​​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ When preparing patients for gastrointestinal diagnostic and/or screening procedures, use your clinical judgment to identify a patient’s educational needs. Provide timely patient education about the diagnostic or screening procedure, preparation needed (e.g., bowel prep, NPO status), and what to expect following the procedure. Select patient-centered nursing interventions to promote normal bowel elimination, including lifestyle changes, medications, and procedures that patients need to learn to improve bodily function and quality of life. Your clinical judgment helps you determine the best approach, when to deliver the interventions, and when adjustments are needed ​ ​ ​ ​ ​ ​ A patient with a new ostomy has a unique combination of physical, emotional, and educational needs. Begin teaching patients early during their hospital stay to prepare them for discharge, and ensure that they have appropriate follow-up care after discharge, which includes a referral to a nurse with specialized ostomy training. ​ ​ ​ ​ ​ ​ Nurses need to be proficient in the skills needed to relieve physical and psychological discomfort from altered bowel elimination. This proficiency ensures that the skills are delivered safely and effectively to patients and that the nurses meet the patients’ individualized needs. ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Every patient has bowel elimination needs regardless of age, care setting, diagnosis, and co-morbid conditions. You use critical thinking and clinical decision making to promote normal bowel elimination and provide safe and effective nursing care to patients with altered bowel elimination. ​ ​ ​ ​ ​ ​ ​ ​ ​