NSC 301 - MEDICAL SURGICAL NURSING I.pdf

DELTA STATE UNIVERSITY, ABRAKA OPEN AND DISTANCE LEARNING FACULTY OF BASIC MEDICAL SCIENCES DEPARTMENT OF NURSING SCIENCE 1 COURSE CODE: NSC 301 COURSE TITLE: MEDICAL SURGICAL NURSING I COURSE TEAM Content Developer/Writer: Dr. M.I Ofili (Associate Professor) Department of Nursing Science Delta State University, Abraka Mrs Brotobor Deliverance Department of Nursing Science Delta State University, Abraka Content Coordinator: Dr. M.I Ofili (Associate Professor) Department of Nursing Science Delta State University, Abraka ODL Programme Director: Prof. Asiyai R.I Faculty of Education Delta State University, Abraka 2 Introduction Medical and Surgical I (NSC 301) is a part of the Medical and Surgical Nursing course. Medical and Surgical Nursing is an area of specialty in nursing that focus on the care for medical and surgical conditions. Medical and Surgical Nursing course has four parts and NSC 301 in the first and introductory part that introduces student nurses to medical and surgical concepts, medical and surgical nursing modalities and some fundamental the medical and Surgical nursing. Therefore, to have a good knowledge and foundation on Medical and Surgical Nursing, it is important you read this course contents very well. Course Objectives At the end of this course, the student should be able to: 1. discuss the concept of medical and surgical nursing 2. provide some fundamental care for patients with stress, shock, pain, wound care, fluid and electrolyte imbalance 3. explain the care to provide for patients with special needs like the unconscious patient, patient with burns, those for surgery and the palliative care given to the dying and end of life care. 4. discuss the care given to patient with immunological system disorders and those with infectious disease. Working through the Course To achieve the maximum grade required in this course, you are expected to carefully and thoroughly read through the different modules and sections in the contents of this course. It is advised you read the references recommended for further reading. Study Units Module 1- Concept and Terminologies Section 1: Concept of Medical and Surgical Conditions 239 Section 2: Tools used in the assessment of medical Surgical Cases Section 3: Patients Preparation for Diagnostic Measure in Medical and Surgical Conditions Module 2- Fundamentals of Medical Surgical Nursing Section 1: Nutrition and Temperature Control Section 2: Fluid and Electrolyte Balance 3 Section 3: Stress and Shock Section 4: Pain and Sleep Section 5: Skin Care and Wound management Module 3- Caring for Patients with Special Needs Section 1: Care of the Patient Having Surgery Section 2: Care of Patients Experiencing Trauma and Unconscious Patients Section 3: Care of Patients Receiving Palliative Care Section 4: Care of Patients with Burns and cancer Section 5: Loss, Grief and End of Life Care Module 4- Immune System and Care of Patients with Infectious Diseases Section 1: Caring for Patients with Altered Immune Status Section 2: Caring for Patients with Inflammation Section 3: Caring for Patients with Infectious Diseases Course Evaluation 30% for in-course assignment 70% for final assignment Grading Scale A= 70-100 B= 60- 69 C= 50-59 F= ≤49 Self-Assessment Questions: This will be provided at the end of each module. References: This will be provided at the end of each section in the different modules. 4 TABLE OF CONTENTS Module 1- Concept and Terminologies Section 1: Concept of Medical and Surgical Conditions 6 Section 2: Tools used in the assessment of medical Surgical Cases 20 Section 3: Patients Preparation for Diagnostic Measure in Medical and Surgical Conditions 29 Module 2- Fundamentals of Medical Surgical Nursing Section 1: Nutrition and Temperature Control 39 Section 2: Fluid and Electrolyte Balance 57 Section 3: Stress and Shock 76 Section 4: Pain and Sleep 96 Section 5: Skin Care and Wound management 109 Module 3- Caring for Patients with Special Needs Section 1: Care of the Patient Having Surgery 117 Section 2: Care of Patients Experiencing Trauma and Unconscious Patients 135 Section 3: Care of Patients Receiving Palliative Care 145 Section 4: Care of Patients with Burns and cancer 150 Section 5: Loss, Grief and End of Life Care 165 Module 4- Immune System and Care of Patients with Infectious Diseases Section 1: Caring for Patients with Altered Immune Status 173 Section 2: Caring for Patients with Inflammation 185 Section 3: Caring for Patients with Infectious Diseases 195 5 Module 1 Concept and Terminologies Section 1: Concept of Medical and Surgical Conditions Section 2: Tools used in the assessment of medical Surgical Cases Section 3: Patients Preparation for Diagnostic Measure in Medical and Surgical Conditions SECTION 1: Concept of Medical and Surgical Conditions CONTENT 1.0 Introduction 2.0 learning outcomes 3.0 Main content 3.1 Critical Thinking for Caring for Medical and Surgical Patient 3.2 Standards of Nursing Practice 3.3 Types of nursing care delivery models. 3.4 Health and Wellness Promotion: 3.5 Communication 4.0 Tutor-Marked Assignment 5.0 References / Further Reading 1.0 Introduction Medical and surgical conditions occur when there are deviations from the normal anatomical and physiological structure and functioning of the body. However, for appropriate care, nurses must be critical in thinking, have good interpersonal and communication skill, and be familiar with the models in which medical and surgical conditions are cared for. This section will examine these concepts in detail. 2.0 Learning Outcomes At the end of reading this sections, the student should be able to explain the basic concepts in medical and surgical nursing conditions and practice, such as critical thinking, models of nursing care, communication and how to relate to different patients. 6 3.0. Main Content 3.1 Critical Thinking for Caring for Medical and Surgical Patient Nursing students must learn to think critically; in other words, to think like a nurse. This means they must use their knowledge and skills to make the best decisions possible in patient care situations. Good thinking in nursing care has also been called clinical reasoning. Clinical reasoning is also defined as “thinking through the various aspects of patient care to arrive at a reasonable decision regarding the prevention, diagnosis, or treatment of a clinical problem in a specific patient.” Good thinking requires critical thinking attitudes and skills, which are described in this section. It also requires a good knowledge base, so your thinking is based on correct factual material. Our goal in this text is to provide you with solid medical-surgical knowledge on which to base good decisions. Traits of Critical Thinking 1. Intellectual Humility Have you ever known people who think they know it all? They do not have intellectual humility. People with intellectual humility have the ability to say, “I’m not sure about that.... I need more information.” Certainly, we want our patients to think we are smart and know what we are doing, but patients also respect nurses who can say, “I don’t know, but I’ll find out.” It is unsafe to care for patients when you are unsure of what you need to do. 2. Intellectual Courage Intellectual courage allows you to look at other points of view even when you may not agree with them at first. Maybe you really believe that 8-hour shifts are best for nurses, and you have a lot of good reasons for your belief. But if you have intellectual courage, you will be willing to really listen to the arguments for 12-hour shifts. Maybe you will even be convinced. Sometimes you have to have the courage to say, “Okay, I see you were right after all.” 3. Intellectual Empathy Consider the patient who snaps as you enter her room, “I’ve been waiting all morning for my bath. If you don’t help me with it right now I’m going to call your supervisor.” The first response that comes into your head is, “I have five other patients; you’re lucky I am here!” If you have intellectual empathy, however, you will be able to think, “If I were this patient, who is in chronic pain and is tired of being in the hospital, how would I feel?” Such thinking might change how you respond. 4. Intellectual Integrity One of your patients asks a hundred questions when you bring her a medication that has been newly prescribed for her high blood pressure. But later you notice she is taking an herbal remedy from her purse. It is good that she asks a lot of questions about her drug, which has been tested extensively by the Food and Drug Administration (FDA). Herbal remedies, however, are not held to the same standards as medications. Someone with intellectual integrity would want the same level of proof applied to both medications and herbal remedies to determine if they are safe and effective before using them. 5. Intellectual Perseverance Perseverance means you do not give up. Consider this scenario: You have concerns about some side effects you noticed after giving a new drug to a patient. You mention it to the health care provider, who says not to worry about it, but you are still concerned. If you have intellectual perseverance, you might do some research on the Internet, then go to your supervisor or the pharmacist to further discuss your concerns. 7 6. Faith in Reason If you have faith in reason, you believe in your heart that good clinical reasoning will result in the best outcomes for your patients. And if you really believe, you will be more likely to attend a seminar or read an article on developing your clinical reasoning skills. 7. Fair-Mindedness One of your coworkers wants to change the medication administration schedule on your unit. She says it will be better for the patients, but you think it might be because it is a better fit for her coffee-break schedule. If you have an intellectual sense of justice, you will be sure that your thinking is not biased by something that you just want for yourself, as seems to be happening with your coworker. You should examine your own motives as well as those of others when you are making decisions. So what does all this mean to you as a nursing student? The term metacognition means to “think about thinking.” It is important for you to try to develop the attitudes of a critical thinker and to learn to think clearly and critically about your patient care. To do that, you need to constantly reflect on how you are thinking. Are you practicing intellectual humility? Are you trying to be courageous and empathetic? These attitudes create an excellent base on which to build nursing knowledge and develop further thinking skills. Critical Thinking Skills -Problem Solving Problem solving is another way to think about clinical reasoning. Nurses solve problems every day. However, a problem can be handled in a way that may or may not help the patient. For instance, consider Mr. Frank, who is in pain and asks for pain medication. You check the medication record and find that his analgesic is not due for another 40 minutes. You can choose to manage this problem in several ways. A standard problem-solving method: (1) gather data, (2) identify the problem, (3) decide what outcome is desirable, (4) plan what to do, (5) implement the interventions in your plan, and (6) evaluate the plan of care. A few questions follow that you can ask yourself as you continue to develop your thinking skills. These are not in any order, nor would they all be asked for in a given situation. They are just some ideas to get you started. 1. Have I thought this through? 2. What information do I need? 3. How do I know? 4. Is someone influencing my thinking in ways I am not aware of? 5. What conclusions can I draw from the information I have? 6. Am I basing this decision on assumptions that may or may not be true? 7. Am I thinking creatively about this, or am I in a rut? 8. What do I need to watch for in order to prevent complications? 9. Is there an expert I can consult who can help me think this through? 10. Is there any supporting research or evidence that this is true? 11. Am I too stressed or tired to think carefully about this right now? Six Components of Caring 8 When a family member is being treated, families often do not remember the medications and the machines as much as they remember the caring spirit of the nurses. Nursing is a caring discipline with a foundation of nursing science guided by the application of moral and ethical principles of care and responsibility. Caring, which is directly derived from the ethical principle of beneficence (a kind deed: an act which benefits someone else), is the core of nursing and constitutes the essence of nursing regardless of the level at which nursing is practiced and conceptualized. Caring represents the unique aspect of nursing and is reflected in conscience, confidence, compassion, commitment, competence, and comportment. Without these components, nursing is a scientific and technical skill-based body of knowledge. Adding the components of caring to this body of knowledge enables nursing to be identified as a holistic profession. Without caring the nurse will not see the psychological and spiritual sufferings of the patient. The definition of each component of caring is outlined here: 1. Conscience is possessing a moral sense of what is right and wrong. The nurse’s conscience guides the nurse’s practice and serves as a strong deterrent to providing minimal or inappropriate care. Conscience is not easily displayed, but every action is led by the conscience. The conscience helps nurses decide right from wrong and guides the care nurses give to patients. 2. Confidence is defined as having a full belief in the trustworthiness or reliability of a person. Confidence in oneself is the belief in your own knowledge and skills and the ability to use them when necessary. Confidence in a fellow nurse means that you are totally secure in the accuracy and efficiency of your colleague. Being confident in both yourself and your colleagues minimizes conflict and provides an optimal working environment that ultimately benefits the patient. 3. Compassion is having a sympathetic feeling for another with an aspiration to help that individual. This is not just a feeling one possesses; it is accompanied by an action to do good. Effective holistic nursing requires a feeling of compassion for people who are sick and injured. 4. Commitment means being obligated to see something through to completion. Nurses must value their profession and be committed to delivering the highest level of nursing care. Professional commitment is manifested in different ways. To achieve positive outcomes, nurses must be committed to their patients as well as their institution. The institution also has a duty to be supportive of its nurses, to assist them in increasing their knowledge and skills, and to provide current monitoring equipment that promotes a safe patient care environment. 5. Competence refers to being capable and qualified to perform a job. Caring as it relates to nursing is not simply a matter of good intentions or warm regard; there also must be a foundation of knowledge. The nurse has a responsibility to the patient to be knowledgeable about the disease process and about the skills necessary to ensure safe patient care. 6. Comportment means that one is aware of one’s conduct and behavior around others. Professional comportment is an essential aspect of nursing because it is representative of the level of professionalism being exhibited. Additionally, it instills confidence in the patient and provides an atmosphere that alleviates anxiety. Nurses must conduct themselves professionally with their patients as well as their fellow health care workers. Being respectful of each other is germane to creating a positive work environment that promotes team building. 9 3.2 Standards of Nursing Practice Nurses are accountable to the public for their practice. Standards of nursing practice are authoritative statements by which the nursing profession describes the common level of performance or care by which the quality of practice can be determined, and responsibilities for which its practitioners are accountable. There are two parts to the standards of practice: standards of care and standards of professional performance. The standards of care are guidelines for nursing practice and are general to any setting or specialty, and follow the nursing process with the broad categories of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Standards of professional performance address the professional nursing role with regard to education, ethics, research, collegiality, and resource utilization. Standards of practice and performance focus on the nurse as the provider of patient care. They are process oriented and relate to what is expected of the provider. 3.3 Types of nursing care delivery models. a. Primary nursing. (1) An RN is responsible for assigned patients throughout their hospitalization, 7 days a week, 24 hours a day (primary nurse). (2) The primary nurse does not deliver all care personally, but is responsible for ensuring that comprehensive and individualized care is delivered. (3) Primary nursing requires more registered nurses; however, it might not be more costly because it improves collaboration, avoids delays and supports comprehensive care. (4) Communication is lateral; the primary nurse communicates directly with the nurses on the other shifts who are assigned to care for the patient. (5) Variations of primary nursing. Total patient-care: One nurse is responsible for the total care administered to a patient, but the nurse changes from shift to shift. Modular nursing: Nurses are assigned to patients within a small segment of a nursing unit to ensure that patients receive care from the same personnel on a regular basis. b. Team nursing. (1) An RN team leader is responsible for a group of patients’ plans of care and nursing care delivered and makes assignments based on the abilities of each team member, such as RNs, LPNs, and unlicensed nursing personnel. (2) Team members work together and share the work to be accomplished for a group of patients. 10 (3) The team leader is responsible for coordinating the team, planning care, and collaborating with professionals in other disciplines and often does not provide direct patient care. (4) Although the focus is on patient assignments rather than tasks, tasks are assigned within the team. (5) Communication occurs in a matrix (i.e., between the team leader and members and among team members). c. Functional nursing. (1) Functional nursing is a task-oriented approach whereby tasks are assigned based on a person’s educational preparation. (2) It is based on clearly defined job descriptions, policies, and procedures. (3) The focus is efficiency and productivity, but can lead to fragmentation of care and failure to meet the emotional needs of patients. (4) Communication occurs in a hierarchy from the head nurse to subordinates. d. Case management (total care) model. (1) An RN is responsible for planning, implementing, and evaluating care for a specific patient. (2) The case manager is responsible for patient care across the continuum of practice settings to promote continuity of care and limit fragmentation and redundancy of care. (3) This model commonly relies on critical pathways to ensure appropriate delivery of care and facilitate evaluation of the achievement of expected outcomes 3.4 Health and Wellness Promotion Concept The concept of health and wellness promotion has come to the fore front of healthcare issues. The focus has shifted from disease treatment to a holistic approach of disease prevention and promotion of wellness. People are more aware than ever before how the relationship between healthy lifestyles and habits impacts disease prevention. For example, most individuals regularly monitor their cholesterol and triglycerides and understand that lifestyle changes are necessary when the levels become elevated. Regular exercise programs and a well-balanced healthy diet have become a way of life for many individuals. Health–Illness Continuum The term health–illness continuum describes the continually shifting levels of health experienced by each person. One end of the continuum represents high-level health. The other end represents poor health and impending death. We all move about the continuum throughout our lives. A focus on prevention and providing services from birth to death under one integrated system is being used by many health care systems. Hospital consolidations led to health care systems that can cover large geographic areas. Hospitals provide the integrated care delivery network for the system. 11 Fundamental Concepts Each body system performs specific functions to sustain optimal life for an organism. Compensatory mechanisms for adjusting internal conditions promote the steady state of the organism, ensure its survival, and restore balance in the body. Pathophysiologic processes result when cellular injury occurs at such a rapid rate that the body’s compensatory mechanisms cannot make the adaptive changes necessary to remain healthy. Physiologic mechanisms must be understood in the context of the body as a whole. Each person has both an internal and external environment, between which information and matter are continuously exchanged. Within the internal environment, each organ, tissue, and cell is also a system or subsystem of the whole, each with its own internal and external environment, each exchanging information and matter. The goal of the interaction of the body’s subsystems is to produce a dynamic balance or steady state (even in the presence of change) so that all subsystems are in harmony with each other. Four concepts— constancy, homeostasis, stress, and adaptation—are key to the understanding of steady state. Constancy and Homeostasis Claude Bernard, a 19th-century French physiologist, first developed the biologic principle that for life there must be a constancy or “fixity of the internal milieu” despite changes in the external environment. The internal milieu is the fluid that bathed the cells, and the constancy the balanced internal state maintained by physiologic and biochemical processes. His principle implies a static process. Bernard’s principle of “constancy” underpins the concept of homeostasis, which refers to a steady state within the body. When a change or stress occurs that causes a body function to deviate from its stable range, processes are initiated to restore and maintain dynamic balance. An example of this restorative effort is the development of rapid breathing (hyperpnea) after intense exercise in an attempt to compensate for an oxygen deficit and excess lactic acid accumulated in the muscle tissue. When these adjustment processes or compensatory mechanisms are not adequate, steady state is threatened, function becomes disordered, and dysfunctional responses occur. For example, in heart failure, the body reacts by retaining sodium and water and increasing venous pressure, which worsens the condition. Dysfunctional responses can lead to disease (an abnormal variation in the structure or function of any part of the body), which is a threat to steady state. 3.5 Communication Communication is a dynamic, purposeful, reciprocal process of sending and/or receiving a message. The need to communicate is universal because it is the way people convey and fulfill needs. A Concepts about Communication 1. All verbal and nonverbal communication transmits meaning. 12 2. Communication is a learned process 3. Communication can occur within the self (intrapersonal); between two people (interpersonal); or when sending a message to or communicating within a group, such as with public speaking, small self-help and social groups, and group therapy. 4. Recurring ideas and thoughts (themes) communicated during an interaction provide insight to a patient’s feelings. 5. A trusting relationship is basic to effective communication. 6. A patient’s degree of expression (emotional affect) reflects the patient’s mood. 7. Humor is highly subjective; it can mean different things to different people 8. Patients have a potential for growth as a result of verbal and nonverbal communication. 9. Previous patterns of communication can become inadequate when one is ill or under stress. 10. Communication is confidential information and should be shared only with health team members. B Elements of Communication 1. Sender(encoder/source): Person who conveys a message. 2. Message: Information communicated; includes language, words, voice intonation, and gestures. 3. Channel (mode): Vehicle used to convey a message; includes written, oral, and touch. 4. Receiver(decoder): Person who acquires a message. 5. Feedback(response): Response from the receiver to the sender. C Factors Affecting the Communication Process 1. Attitudes, values, beliefs, and experiences. 2. Culture, education, and language. 3. Developmental level. a. The very young are concrete thinkers and have little or no experience. b. Adults are more abstract thinkers. c. Older adults may have vision and hearing loss that interferes with communication 4. Gender. a. Males and females generally communicate differently from an early age. b. Females seek intimacy and validation and reduce differences; boys use language to negotiate status and establish independence. c. Differences are changing as gender roles become less distinct. 5. Authority one ascribes to a role (e.g., some see nurses as authority figures, whereas others see nurses as servants). 6. Ineffective perception or selective inattention: May distort a message. D Barriers to Communication 13 1. Unwillingness to listen to another point of view. 2. Physical factors, such as an uncomfortable environment (e.g., too hot or too cold), excessive noise, or distractions. 3. Adaptation to disease, such as impaired ability to communicate through speech, writing, or signs because of brain dysfunction (e.g., receptive or expressive aphasia); impaired ability to say words (dysarthria); impaired cognition (e.g., dementia or delirium); oral problems; fatigue; and pain. 4. Treatment related factors, such as laryngectomy, or artificial airways, such as tracheostomy or endotracheal tube. 5. Psychological factors, such as lack of privacy, anxiety, and fear. E Phases of the Communication Process 1. Preinteraction phase. a. This phase occurs before meeting the patient. b. The nurse gathers information about the patient. 2. Orientation phase. a. Initially, the nurse is in the stranger role. b. The nurse meets a patient and begins to establish a relationship of rapport and trust. c. Introductions and initial exchange of information occurs. d. The purpose of the visit is explained, roles are clarified, and an agreement or contract about the relationship may be formulated. e. The termination phase is initiated in this phase. 3. Working phase. a. Most communication occurs during this phase. b. This phase is the active part of the relationship. c. The nurse and patient work together to address patient needs, feelings are shared, caring is demonstrated, and mutual respect is maintained. d. The nurse may function as caregiver, counselor, teacher, resource person, and so on. e. The nurse motivates a patient by identifying progress and supporting movement toward independence. f. Anxiety may increase during this phase as the patient may need to learn new adaptive behaviors. g. Preparation for the termination phase continues. 4. Termination phase. a. Actual termination occurs at the conclusion of a relationship. b. Termination occurs at discharge, at the end of a shift, or when the goals of the relationship are achieved. c. Goals and objectives are summarized, adaptive behavior is reinforced, and additional resources available are arranged for the patient. 14 d. Some patients become emotional during this phase because they feel angry, rejected, or fearful of leaving a safe environment; the nurse needs to address these feelings. F. Modes of Communication 1. Verbal communication: Uses spoken or written words to communicate a message. a. Characteristics. I. Clarity: Simple words and sentence structure are better understood. II. Intonation: Reflects feeling behind words; loud or soft volume, cadence, and pitch can impart a message, such as anger, excitement, sarcasm, and fear. III. Pacing: Speed, rhythm, and patterns of delivery can convey anxiety, indifference, and attention; pace must be fast enough to maintain interest, but slow enough for receiver to decode the message. IV. Relevance: Message needs to be conveyed when the receiver is ready and able to receive the message; information has to be important to the patient. b. Nursing care. I. Build a therapeutic relationship. Place oneself in the patient’s place mentally and emotionally (empathy). Acknowledge the patient’s individuality; be flexible when meeting needs. Address the patient by name; avoid using terms of endearment, such as “grandma” and “honey.” Respect values and beliefs. Provide privacy. Maintain credibility and genuineness; be truthful, respond to needs promptly, and follow through on promises. II. Let the patient take the lead in the communication process III. Use simple words and sentence structures; keep messages brief. IV. Ensure intonation and pace of words convey professional confidence, respect, interest, and acceptance of the patient. V. Ensure that message is relevant and a priority for the patient. VI. Use humor carefully; although it may lighten the mood, it can be misunderstood and offend a patient. VII. Validate congruence between verbal messages and nonverbal behavior. 2. Nonverbal communication: Message that is sent and received without use of spoken or written words; involves use of body language; may be more accurate than verbal communication because it is less consciously controlled a. Characteristics. 15 I. Facial expression: Can convey meaning or mask emotions; some expressions are universal, such as a smile (happiness) or a frown (displeasure); can be subtle, such as raising the eyebrows. II. Gestures: Emphasize spoken word; some have same meaning regardless of culture, such as waving indicates hello or goodbye; different gestures may have similar meanings, such as shaking a fist versus cold, stillness when angry; shaking the head “yes” may indicate the message has been received even though message is not understood. III. Eye contact: indicates interest and attention, whereas downcast eyes may indicate low self-esteem, powerlessness, and sadness; however, in some cultures, downcast eyes show respect IV. Posture and gait: Erect posture, head held up with a rapid gait indicates well- being and confidence; slumped, slow, shuffling gait with head held low indicates illness, depression, or impaired self-esteem; crossing legs and arms indicates a defensive posture. V. Touch: Generally conveys caring, concern, encouragement; some patients do not like to be touched, and touching is unacceptable in some cultures (e.g., only relatives can touch an orthodox Jewish man). VI. Territoriality and space: People have a physical zone around the body that is culturally and individually defined. Commonalities of Nursing Care 1. Reduce noise and minimize distractions. 2. Stand in front of the patient while making eye contact. 3. Be alert to nonverbal cues and behavior. 4. Explain everything that is going to be done and the reasons why using simple words and sentence structures. 5. Give the patient adequate time to formulate a message and respond to a message. 6. Seek feedback to ensure that the message is received as intended. 7. Repeat a message using different words if the message was not understood. How to handle Patients Who Are Angry 1. Assess for the cause of anger because all behavior has meaning. 16 2. Assess for verbal and nonverbal signs of escalating aggression, such as a loud voice, clenched fist and jaw, narrowed eyes, and physical agitation. 3. Model acceptable behaviors, such as keeping a calm voice with a normal volume, tone, and pace. 4. Validate the patient’s feelings. 5. Avoid touching the patient because it may be perceived as a threat 6. Do not turn your back to an angry patient or avert your eyes away from the patient; position yourself between the patient and the door. How to handle Patients Who Have Aphasia 1. Assess the patient’s ability to communicate through speech, writing, or alternate means of communication, such as gestures, a picture board, and computer programs. 2. Promote communication when the patient has an inability to formulate and/or send a message (expressive aphasia). a. Use questions that require a one-word answer or a short response. b. Give the patient ample time to formulate a message; do not complete sentences for the patient. c. Use alternate means of communication, such as picture cards, blinking the eyes once for yes and twice for no, a computer, a puff activated communication device, or a voice synthesizer 3.Promote communication when the patient has an inability to understand communicated information (receptive aphasia). a. Use simple words and sentences; vary words when repeating a message. b. Augment verbal messages with gestures and facial expressions. c. Augment verbal communication with picture cards or objects, such as holding up a cup of water to encourage fluid intake. How to handle Patients Who Are Confused 1. Use short sentences and convey concrete ideas. 2. Speak slowly. 3. Use questions that require a one-word answer or a short response. 4. Break down instructions into simple steps. 17 5. Augment verbal communication with picture cards or objects, such as holding up a comb to indicate the need for hair care. How to handle Patients Who Are Hearing Impaired 1. Ensure that the patient is wearing a hearing aid, if available; ensure that a hearing aid is functioning, is inserted properly, and is cleaned and stored with a label. 2. Stand on the patient’s side with more acute hearing; speak at a normal pace using a low tone because high-pitched sounds are harder to hear; use a slightly louder volume, but do not yell. 3. Face the patient, enunciate words (without exaggeration), and to facilitate lip reading avoid chewing gum or holding a hand in front of the mouth when speaking. 4. Use gestures and facial expression to augment verbal communicate. 5. Determine whether the patient knows sign language, and seek the assistance of sign-language specialists if applicable. 6. Provide writing materials to support communication if the patient is able to write and is literate. 4.0 Tutor-Marked Assignment 1. As a medical and surgical nurse, how would you handle an angry patient? 2. Enumerate the 6 Components of care Answer 1. Review the section above for management of an angry patient. 2. Components of care are: conscience, confidence, compassion, commitment, competence, and comportment. 5.0 References/ Further Reading Burke, K. M., LeMone, P., Mohn-Brown, E. & Eby, L. (2014). Medical-Surgical Nursing Care. 3rd Edition. Pearson. Osborn, K. S., Wraa, C. E. & Watson, A. B. (2010). Medical-Surgical Nursing Preparation for Practice. Pearson. 18 Paul, P., Day, R. A. & Williams, B. (2016). Brunner and Suddarth's Canadian Textbook, of Medical Surgical Nursing. 3rd Edition. Wolters Kluwer. Smeltzer, S. C., Bare, B. G, Hinkle, J. L. & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing. 12th Edition. Lippincolt Williams and Wilkins White, L., Duncan, G. & Baumle W. (2013). Medical-Surgical Nursing: An Integrated Approach. 3rd Edition. Delmar Cengaga Learning. Williams. S. S. & Hopper, P.D. (2007) Understanding Medical Surgical Nursing. 3rd Edition. E. A. Davis Company. 19 Section 2: Tools used in the assessment of medical Surgical Cases CONTENT 1.0 Introduction 2.0 learning outcomes 3.0 Main content 3.1 Reasons for Assessment of medical and surgical conditions 3.2 Assessment frameworks 3.3 Methods of assessment 3.4 Assessment tools 4.0 Tutor-Marked Assignment 5.0 References / Further Reading 1.0 Introduction For appropriate diagnosis of patients’ medical and surgical conditions, some assessment tools are used. The importance of assessment and the different assessment tools will be discussed briefly. 2.0 Learning Objectives After reading this section, the student should be able to Give the reasons for assessment of medical and surgical conditions Name to common tools for assessing medical and surgical cases Role of nurses during the assessment. 3.0 Main content 3.1 Reasons for Assessment of medical and surgical conditions The information gathered from an assessment when the patient is first admitted to hospital or first visits an outpatient clinic needs to be recorded. It provides the evidence to support clinical decisions and a rationale for the individualized patient care plan. Ongoing or continuous patient assessment when monitoring to evaluate changes in a patient’s condition in changing circumstances also needs to be recorded, and nursing actions documented. Assessment is the first step in determining the condition of the patient’s health and their immediate and long-term needs. The nursing assessment of patients on admission to hospital or on attendance at clinics is key to clinical decision-making and to planning patient care that takes account of the 20 individual patients’ needs and circumstances. Nurses have responsibility for carrying out the initial and ongoing patient assessments, for initiating interventions that take patients’ needs into consideration and for evaluating the effectiveness of these interventions. The nursing assessment is one component within a larger, multidisciplinary team assessment during which the patient is assessed by different healthcare professionals as part of the care pathway and patient referral process. A multifactorial assessment of the older person for falls, for example, can involve the nurse, doctor, physiotherapist, occupational therapist, optician and other healthcare professionals working in specialist areas of practice such as cardiac assessment. As a member of the multidisciplinary team, the nurse often plays a key role in coordinating the patient assessment and ensuring that appropriate referrals are made and followed up. The purpose of assessment is to achieve the following: 1. Obtain baseline data and track changes. On admission to hospital or on a first visit to the clinic, it is important to carry out a comprehensive assessment of the patient to establish a set of baseline data against which subsequent assessments can be compared and any changes indicating a deterioration or improvement in the patient’s condition tracked. 2. Early recognition of the critically ill or deteriorating patient. Identifying patients who are ‘at risk’ is key to initiating a rapid response from the medical emergency or rapid response team. ‘Track and Trigger’ incorporate objective physiological and subjective criteria that can be used to support the nurse’s decision about when to call the medical team for help and avert more serious patient emergency. If a Track and Trigger system has not been set up in the hospital, a nurse who is concerned about a patient should take urgent action and notify the medical team. 3. Risk assessment. Assessment is the first step in preventing complications, the aim being to identify patients who are ‘at risk’ of developing complications associated with their healthcare problem, hospitalization and reduced mobility. Key areas for risk assessment include pressure ulcers, infection, falls and constipation. Local hospital policy may include risk assessment tools as part of the admission procedure, for example the Braden, Waterlow and Norton scores to identify patients at risk of pressure ulcers and to activate an action plan and interventions to prevent pressure ulcers developing. 4. Screening for health problems. Nursing assessment provides an ideal opportunity for health promotion and for screening patients for risk factors associated with obesity, cancer, cardiovascular disease, diabetes mellitus and other major health problems. It also provides the opportunity to screen for specific problems such as emotional distress or organisms important in infection control (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant Enterococcus [VRE]). 5. Identify actual and potential problems and prioritize care. The patient’s current problems (actual problems) and problems that could develop in the future (potential problems) need to be identified so that the care plan can be tailored to individual patient 21 needs. Importantly, once the range of patient problems has been identified, care can be prioritized so that major problems are dealt with first. 6. Care planning, tailored to individual patient needs. The purpose of assessment is not only to determine and document the patient’s current condition, but also to provide evidence for the planning and provision of nursing care. Although standardized care plans are available in some units or hospitals, the nursing actions that are required to meet a patient’s needs and problems should be tailored to take account of individual patient needs. 7. Discharge planning. Patient assessment also includes the early identification of patients’ needs for forward planning and organizing the supports and community services necessary to facilitate a timely discharge from hospital. Recent trends indicate that patients’ stay in hospital is shortening, the use of day surgery is increasing, and policies on early discharge and discharge planning are setting the standards for healthcare practice. Although the reasons for a delay in discharging the patient home from hospital are multifactorial, patient assessment that includes information about the patient’s home and social circumstances, family and community supports will help prevent problems arising from a poor knowledge of a patient’s home situation or the support available, and will avert delays related to non- medical reasons. 3.2 Assessment frameworks An important principle underpinning the nursing approach to patient assessment is that it is systematic, comprehensive and person-centred. Many of the assessment frameworks used in clinical practice are linked to nursing theories such as the activities of living or the self-care deficit theory of nursing, or to other theory including Maslow’s hierarchy of needs. Nursing models and theories serve as a guide for clinical practice and provide for a structured approach insofar as they map out what areas to include in a patient assessment. The number of new or modified assessment frameworks for nursing practice is ever increasing, but a common feature across different nursing assessments is the inclusion of the core aspects of physical, psychosocial and spiritual assessment within the context of family, community and environment. The decision of which assessment framework to use is made by healthcare organizations and nursing management, who then oversee its implementation in their admission procedures and nursing documentation. This is important because it provides a way of assuring a standardized approach to nursing assessment and quality patient care. In terms of how this translates into practice and what information is gathered during the nursing assessment, the broad areas to consider include biographical and health data, a systematic review of patient systems and functions, and a social assessment: Biographical and health data. Obtaining information about the patient’s health history is vital for putting the current problem or illness into context. 22 Physical assessment. This involves a ‘head-to-toe’ systematic review of the patient. A review of systems and functions enables the nurse to elicit information about problems and provide vital clues to support a clinical diagnosis or uncover a problem of which the patient is unaware. The depth of the patient assessment will depend on the patient’s condition and the urgency of the clinical situation. Social assessment. Taking a social history enables an early identification of patients’ needs and problems that might delay discharge from hospital. Social history-taking is always considered a priority in acute healthcare services, but it helps nurses to identify the patient’s needs so that appropriate referrals can be made to the health and social services and service delivery is coordinate. 3.3 Methods of assessment The methods of assessment that are used to gather the information for clinical decision-making include interviewing the patient and obtaining a health history, carrying out a physical examination, making clinical observations and using risk assessment tools. 1 Interviewing and obtaining a health history Taking a patient history is an essential part of assessment as an accurate history can provide over 80% of the information required for diagnosis. Obtaining an accurate history is not just about asking a list of questions, but also requires establishing an effective patient–nurse relationship in which the patient feels that the nurse is interested in understanding their healthcare problems. This involves putting patients at their ease, providing as much privacy as possible, ensuring the nurse is familiar with any information already gathered, being sensitive to cultural differences and inviting patients to tell their story. Once the introductions have been completed, obtaining a health history begins with inviting the patient to tell their story and using an open question such as, ‘Can you tell me what has brought you here today?’ After an explanation has been given, the nurse moves to asking key and targeted questions to build up a comprehensive picture of the patient’s problem: ‘How has it affected you? Have you noticed what makes it worse or what helps? Have you noticed any changes in... ? How does this compare with previous times you have had this problem?’ More targeted questions are used to focus on eliciting whether there are any associated symptoms so the nurse needs to be familiar with the patterns associated with specific health problems. Investing in the end of the interview and considering the closing questions is vital to ensuring ongoing continuity in the patient–nurse relationship in future consultations. Ending the interview involves summarizing, framing information using the patient’s perspective and providing opportunity for the patient to add further information. A closing question such as ‘Is there anything else we haven’t covered that you would like to discuss?’ enables patients to provide additional information. During the first 23 nurse–patient encounter, some patients may find it difficult to disclose problems and may be unwilling to do so until they know and have established a trusting relationship with the nurse. One helpful way in which the nurse can let the patient know there will be further opportunities to discuss issues is by saying, for example, ‘If you think of anything else later on, let me know and we can have a chat then.’ 2 Physical examination Physical examination provides objective data and is used to corroborate evidence gathered from the patient interview and clinical observation. Examination involves measurement of the ‘vital signs’, including temperature, heart rate, respiratory rate and blood pressure. The patient’s weight is recorded and, if indicated, the patient’s body mass index may also be calculated to determine whether the patient has a normal weight or is under- or overweight. Urinalysis using a dipstick reagent strip and a clean sample of fresh urine from the patient is used to screen for abnormal substances such as glucose or protein. Any abnormalities detected in the urinalysis should be followed up by more specific laboratory tests to investigate the cause and perhaps detect a previously undiagnosed condition such as diabetes mellitus. The patient’s skin condition is examined; in addition to carrying out a pressure ulcer risk assessment, any abnormalities such as the presence of bruises, rashes and peripheral edema are noted. 3 Clinical observation Observation is an integral part of patient assessment as it provides an additional layer of information gathered during the patient–nurse interaction, physical examination and routine ward- based tests. Observation provides a means of gathering vital indicators about the patient’s condition and well-being, and this information contributes to the overall evidence supporting clinical decision-making. During the interaction with the patient, the nurse takes note of non-verbal cues. Indicators of patient anxiety or distress can prompt the nurse to investigate further using gentle questioning or to return for a follow-up visit if the patient is unwilling or not ready to discuss their problems at that time. Observing patients as they walk around the ward, move from chair to bed, get dressed and close buttons or zips can provide important information about their mobility, balance and dexterity. Observing the patient’s general appearance includes noting the color of the face and body and any abnormal signs such as nasal flaring, which can indicate respiratory distress. Abnormal smells or odors such as the odor of ketones on the patient’s breath may indicate fasting or diabetic ketoacidosis. Observing the patient’s behavior noting inappropriate responses and actions can indicate neurological, metabolic, endocrine or mental health problems. Information gathered from observing the patient is used along with that assimilated from the patient interview and physical examination to make sense of the patient’s health problem and to support clinical decision-making. 24 Focus of assessment The traditional steps to proper assessment are focused on four aspects. These are: inspection, palpation, auscultation and percussion. 1. Inspection is the first technique that includes the physical assessment and observation of each relevant body system in a more detailed way. It is inclusive of health history and general body observation for skin color, presence and size of lesions, edema, erythema, symmetery and pulsations. Specific body movements are noted for spasticity, muscle spasms, and abnormal gait. 2. Palpation is vital during the physical examination. Structures of the body that are not visible are assessed through this method. The technique used might be light or deep palpation. For example the superficial blood vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis and rectum. 3. Auscultation is the skill used to listen to sounds in the body cavity. Example is breath sound, bowel sound, heart sound, and cardiac murmur. Physiological sound may be expected (normal heart sound, usually first and second heart sounds) or pathological sounds (especially heart murmur during diastole and crackles in the lungs). The sound produced by the body are characterized by their intensity, frequency and quality. The intensity or loudness which are associated with physiologic sound is low. Hence, the need for a stethoscope. The frequency or pitch in normal physiological condition is noisy but quite low. The quality of sound relates to overtones that allow one to distinguish among various sounds. Sound quality enables the examiner to distinguish between the musical quality of high-pitchec wheezing and the low-pitched rumbling of a diastolic murmur. 4. Percussion is the application of physical force into sound. It is needed to give more detailed information about disease process in the chest and abdomen. The principle behind the forced sound is to set the chest wall or abdominal wall into vibration by striking it with a firm object. Then, the sound produced reflects the density of the underlying structure. Percussion allows the examiner to assess structures such as the livers, and movement of diaphragm during inspiration. It can also be used to determine the level of a plural effusion and c]location of consolidated area caused by pneumonia or atelctasis. Noted: when the abdomen is examined, auscultation is performed before palpation and percussion to avoid altering sounds. 3.4 Assessment tools 25 Nurses can make use of a range of assessment tools and rating scales as part of their assessment of the patient. These provide a standardized approach to assessing specific aspects of the patient’s condition that can otherwise be difficult to measure. These tools include. 1. Using the Glasgow Coma Scale, the patient is assessed on three specific items of (1) best eye-opening, (2) best verbal response, and (3) best motor response. The patient’s response on each of these items is converted into a numerical score, with the total score used to determine the level of consciousness. The Early Warning Score is an example of another type of tool that not only measures the patient’s status, but also identifies an action plan for the healthcare professional to follow. In the EWS, the physiological parameters are set and used to initiate further interventions. For example, if a patient’s temperature exceeds a predetermined level, blood cultures will be taken. 2. Other assessment tools are used to identify patients at risk, for example, of developing pressure ulcers. These predictive tools help nurses to identify at-risk patients so that interventions can be put in place to prevent pressure ulcers occurring. Pressure ulcer risk assessment tools are, however, only one component of risk assessment. Research found that tools such as the Braden, Waterlow and Norton scales are not always accurate as they can either over- or under predict risk. Therefore, pressure ulcer risk assessment tools serve as guides, and the nurse’s own clinical judgment should also be taken into consideration. 3. Patient self-assessment tools are also available whereby patients use a visual analogue scale or brief questionnaire to assess themselves. The pain thermometer is one example – on this, the patient scores how severe the pain is by using a rating scale of 1–10 where 1 is no pain and 10 is the worst pain imaginable. Another example of such a tool is the patient distress self-assessment tool developed by the National Comprehensive Cancer Network in America. This uses a distress ‘thermometer’ along with a tick box checklist of practical, family, emotional and physical problems and spiritual or religious concerns encountered with cancer patients. 4. Body Mass Index for nutritional assessment. It is the ratio based on body weight and height. The values taken are noted and compared over time. People who have a BMI lower than 24 are at risk of health problems related to poor nutritional status Documenting patient assessment and record-keeping After assessing the patient, it is important that nurses record their findings and so provide documentary evidence about the patient’s condition. This written information is vital for providing baseline data and ensuring continuity of patient care. It provides information that other nurses and healthcare professionals can refer to when planning and coordinating patient care. Although patient assessment forms and nursing documentation are set by local hospital policy and procedures, the national professional guidelines for recording nursing practice and patient assessment advise the following: 26 1. An accurate assessment of the person’s physical, psychological and social well-being, and, whenever necessary, the views and observations of family members in relation to that assessment’ should be included in a patient record. 2. Evidence in relation to the planning and provision of nursing care should be included as part of a patient record. 3. Record details of any assessment and reviews undertaken, and provide clear evidence of the arrangements made for future and ongoing care. This should also include details of information given about care and treatment. 4.0 Tutor-Marked Assignment 1. Assessment is the …………… step in determining the condition of the patient’s health needs. 2. Physical assessment involves a ……………systematic review of the patient. 3. during clinical assessment, …………………. relationship is very important 4. ………………. tool is used to determine patients’ nutritional status 5. ………………………is a skill used to listen to bowel sound, heart sound, and cardiac murmur and other cavity in the body. Answers 1. First 2. Head-to-toe 3. Nurse-patient 4. Body Mass index 5. Auscultation 5.0 References / Further Reading Burke, K. M., LeMone, P., Mohn-Brown, E. & Eby, L. (2014). Medical-Surgical Nursing Care. 3rd Edition. Pearson. Osborn, K. S., Wraa, C. E. & Watson, A. B. (2010). Medical-Surgical Nursing Preparation for Practice. Pearson. Paul, P., Day, R. A. & Williams, B. (2016). Brunner and Suddarth's Canadian Textbook, of Medical Surgical Nursing. 3rd Edition. Wolters Kluwer. 27 Smeltzer, S. C., Bare, B. G, Hinkle, J. L. & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing. 12th Edition. Lippincolt Williams and Wilkins White, L., Duncan, G. & Baumle W. (2013). Medical-Surgical Nursing: An Integrated Approach. 3rd Edition. Delmar Cengaga Learning. Williams. S. S. & Hopper, P.D. (2007) Understanding Medical Surgical Nursing. 3rd Edition. E. A. Davis Company. 28 Section 3: Patients Preparation for Diagnostic Measure in Medical and Surgical Conditions CONTENT 1.0 Introduction 2.0 learning outcomes 3.0 Main content 3.1 Computer tomography Scan (CT scanning) 3.2 Skull and Spinal X-rays 3.3 Angiographic studies 3.4 Electrophysiologic studies 3.5 Magnetic resonance imaging (MRI) 3.6 Electrocardiography 3.7 Echocardiography. 3.8 Exercise electrocardiography testing (stress test) 3.9 Cardiac catheterization 4.0 Tutor-Marked Assignment 5.0 Reference/Further Reading 1.0 Introduction: This section will highlight some basic diagnostic measure used for medical and surgical conditions and the responsibilities of nurses towards the procedures. 2.0 learning outcomes At the end of reading this section, the student should be able to Identify some basic diagnostic measures used in the assessment of the health problems for medical and surgical conditions The student should be able to know the indications for the diagnostic procedures The student nurse should be able to know their responsibilities expected for the procedures. 3.0 Main content 3.1 Computer tomography scan (CT scanning) 29 Computer tomography scan (CT scanning) combines radiology and computer analysis of tissue density (determined by the contrast dye absorption) to study structures. Although CT doesn’t show blood vessels as well as does an angiogram, it carries less risk of complications and cause less trauma than angiography. Indication for scan 1. A CT scan of the spine helps to assess spinal disorders such as A herniated disk Spinal cord tumors Spinal stenosis 2. A CT scan of the brain can help detect Brain contusion Brian calcifications Cerebral atrophy Hydrocephalus Inflammation Space-occupying lesions (tumors, hematomas, abscesses) Vascular anomalies (arteriovenous malformation, infarctions, blood clots, hemorrhage) Role of Nurses for CT Scan a) Explain procedure to the patient b) Reassure the patient c) Confirm that the patient is not allergic to iodine or shellfish. (A patient with these allergies may have an adverse reaction to the contrast medium and requires premedication with corticosteroids). d) If the test calls for a contrast medium, explain that an I.V. catheter will be inserted for injection of the contrast medium e) Explain to the patient that the contrast medium may cause a flushed feeling or a metallic taste in the mouth when it is injected (if used). f) Tell the paitent that the CT scanner will circle the patient for 10-30 minutes (depending on the procedure and type of equipment) and that it is important to lie still during the test. g) Encourage the patient to resume normal activities and a regular diet after the test h) Explain that the contrast medium may discolour the urine for 24 hours and encourage patient to drink more fluids to help flush this medium out of the system. 3.2 Skull and spinal X-rays 30 Typically, the skull X-ray is taken from two angles: anteroposterior (AP) and lateral. The practitioner may also order other angles, including Waters’ view to examine the frontal and maxillary sinuses, facial bones, and eye orbits and Towne’s view to examine the occipital bone. Indications Skull X-rays help detect: fractures bony tumors or unusual calcifications Pineal displacement (indicates a space-occupying lesion) Skull or sella turcica erosion (indicates a space-occupying lesion) Vascular abnormalities. Spinal X-rays help detect: Spinal fracture Displacement and subluxation (partial dislocation) Destructive lesions (such as primary and metastatic bone tumors) Arthritic changes or spondylolisthesis Structural abnormalities (such as kyphosis, scoliosis, and lordosis) Congenital abnormalities. Role of Nurses for X-ray Reassure the patient that X-rays are painless. Assist the patient to wear appropriate clothing for the procedure Assist to assume the proper position for the procedure Administer an analgesic before the procedure, as ordered, if the patient has existing pain so it can be done more comfortably. Remove a cervical collar if cervical X-rays reveal that no fracture is present and the practitioner orders it. Encourage thepatient to resume normal activities, as ordered. 3.3 Angiographic studies Angiographic studies include cerebral angiography and digital subtraction angiography (DSA). Cerebral angiography 31 For cerebral angiography, the radiologist injects a radiopaque contrast medium, usually into the brachial artery (through retrograde brachial injection) or the femoral artery (through catheterization). This procedure highlights cerebral vessels, making it easier to: Detect stenosis or occlusion associated with thrombi or spasms identify aneurysms and arteriovenous malformations (AVMs) Locate vessel displacement associated with tumors, abscesses, cerebral edema, hematoma, or herniation Assess collateral circulation. Role of Nurses for Cerebral Angiography Explain the procedure to the patient and answer any questions. Confirm that the patient isn’t allergic to iodine or shellfish. (A patient with these allergies may have an adverse reaction to the contrast medium and require premedication with corticosteroids.) The patient will need to be taught to lie still during the procedure Explain to the patient it is not uncommon to feel flushed sensation in the face as the dye is injected. Maintain bed rest, as ordered, and monitor vital signs Monitor the catheter injection site for signs of bleeding. Monitor vital signs frequently for signs of internal bleeding. As ordered, maintain pressure over the injection site. Monitor the patient’s peripheral pulse in the arm or leg used for catheter insertion (mark the site). Unless contraindicated, encourage the patient to drink more fluids to help flush remaining dye from the system. Monitor the patient for neurologic changes and such complications as hemiparesis, hemiplegia, aphasia, Monitor for an adverse reaction to the contrast medium, which may include restlessness, tachypnea and respiratory distress, tachycardia, facial flushing, urticaria, and nausea and vomiting. After consulting with physician, determine the amount of time needed to stop the medication prior to testing and establish how and when the patient should resume the medications as well as any follow-up testing to determine therapeutic levels. Inform the patient that he/she may not have anything to eat and/or drink at least 4 hours prior to the test. Explain that the test requires insertion of an I.V catheter and that it will be removed at the completion of the test, if done on an outpatient basis. The patient must remain still during the test. 32 Explain that there will probably be a feeling of flushing or possibly a metallic taste in the mouth as the contrast medium is injected. Tell the patient to alert the doctor immediately if any feeling of discomfort or shortness of breath. After the catheter is removed, encourage the patient to resume normal activities. Encourage the patient to drink more fluids for the rest of the day to help flush the contrast medium from the system. 3.4 Electrophysiologic studies Electrophysiologic studies are commonly performed and include EEG and electromyography. Electroencephalography (EEG) Indications for EEG By recording the brain’s continuous electrical activity, EEG can help identify seizure disorders, head injuries, intracranial lesions (such as abscesses and tumors), TIAs, stroke, brain death. In EEG, electrodes attached to standard areas of the patient’s scalp record a portion of the brain’s activity. These electrical impulses are transmitted to an electroencephalogram, which magnifies them 1 million times and records them as brain waves on moving strips of paper. Role of Nurses for EEG During an EEG, the patient is positioned comfortably in a reclining chair or on a bed. Explain that a technician will apply paste and attach electrodes to areas of skin on the patient’s head and neck after these areas have been lightly abraded to ensure good contact. Explain that the patient must remain still throughout the test. Discuss any specific activity that the patient will be asked to perform, such as hyperventilating for 3 minutes or sleeping, depending on the purpose of the EEG. Use acetone to remove any remaining paste from the patient’s skin. Encourage the patient to resume normal activities, as ordered Electromyography (EMG) 33 Electromyography records a muscle’s electrical impulses to help distinguish lower motor neuron disorders from muscle disorders—for example, amyotrophic lateral sclerosis (ALS) from muscular dystrophy. It also helps evaluate neuromuscular disorders such as myasthenia gravis. In this test, a needle electrode is inserted percutaneously into a muscle. The muscle’s electrical discharge is then displayed and measured on an oscilloscope screen. Role of Nurses for EMG Tell the patient that the test may take 1 hour to complete and that the test is done with the patient either sitting or laying down during the procedure. Warn the patient about a possible feeling of discomfort when the doctor inserts a needle attached to an electrode into the muscle andwhen a mild electrical charge is delivered to the muscle. Explain that the patient must remain still during the test except when asked to contract or relax a muscle. Explain that an amplifier may emit crackling noises whenever a muscle moves. Encourage the patient to resume normal activities, as ordered. Explain the importance of not taking any stimulants, depressants, or sedatives for 24 hours before the test. 3.5 Magnetic resonance imaging (MRI) MRI generates detailed pictures of body structures. The test involves the use of a contrast medium such as gadolinium. Compared with conventional X-rays and CT scans, MRI provides superior contrast of soft tissues, sharply differentiating healthy, benign, and cancerous tissue and clearly revealing blood vessels. In addition, MRI permits imaging in multiple planes, including sagittal and coronal views in regions where bones normally hamper visualization. MRI is especially useful for studying the CNS because it can detect the structural and biochemical abnormalities associated with such conditions as transient ischemic attacks (TIAs), tumors, multiple sclerosis (MS), cerebral edema, and hydrocephalus. Role of Nurses for MRI Explain to the patient that the procedure can take up to 1½ hours and that it will be important to remain still for intervals of 5 to 20 minutes. Have the patient remove all metallic items, such as hair clips, bobby pins, jewelry (including body piercing jewelry), watches, eyeglasses, hearing aids, or dentures. Ask the patient about feeling claustrophobic in confined spaces. Obtain an order for an anti-anxiety medication as needed. 34 Explain that the test is painless, but the machinery may seem loud and frightening and the tunnel confining. Tell the patient that the technician will provide earplugs for the noise, but there is also constant communication with the technician. Provide sedation, as ordered, to promote relaxation during the test. Encourage the patient to resume normal activities, as ordered. 3.6 Electrocardiography This common noninvasive diagnostic test records the electrical activity of the heart and is useful for detecting cardiac dysrhythmias, location and extent of MI, and cardiac hypertrophy, and for evaluation of the effectiveness of cardiac medications. Nursing Interventions a. Determine the patient’s ability to lie still; advise the patient to lie still, breathe normally, and refrain from talking during the test. b. Reassure the patient that an electrical shock will not occur. c. Document any cardiac medications the patient is taking 3.7 Echocardiography. This noninvasive procedure is based on the principles of ultrasound and evaluates structural and functional changes in the heart. It is used to detect valvular abnormalities, congenital heart defects, wall motion, ejection fraction, and cardiac function. Transesophageal echocardiography may be performed, in which the echocardiogram is done through the esophagus to view the posterior structures of the heart; this is an invasive exam and requires preparation and care similar to endoscopy procedures. Nursing Interventions: Advise the patient to lie still, breathe normally, and refrain from talking during the test. 3.8 Exercise electrocardiography testing (stress test) This noninvasive test studies the heart during activity and detects and evaluates coronary artery disease. Treadmill testing is the most commonly used mode of stress testing. If the patient is unable to tolerate exercise, an intravenous (IV) infusion of dipyridamole or dobutamine hydrochloride is given to dilate the coronary arteries and simulate the effect of exercise; the patient may need to be NPO (nothing by mouth) for 3 to 6 hours preprocedure. Preprocedure interventions. Ensure that an informed consent is obtained if required. Encourage adequate rest the night before the procedure. 35 Instruct the patient having a noninvasive test to eat a light meal 1 to 2 hours before the procedure. Instruct the patient to avoid smoking, alcohol, and caffeine before the procedure Instruct the patient to ask the primary health care provider (PHCP) or cardiologist about taking prescribed medication on the day of the procedure; theophylline products are usually withheld 12 hours before the test, and calcium channel blockers and beta blockers are usually withheld on the day of the test to allow the heart rate to increase during the stress portion of the test. Instruct the patient to wear nonconstrictive, comfortable clothing and supportive rubber- soled shoes for the exercise stress test. Instruct the patient to notify the PHCP if any chest pain, dizziness, or shortness of breath occurs during the procedure. Postprocedure interventions: Instruct the patient to avoid taking a hot bath or shower for at least 1 to 2 hours 3.9 Cardiac catheterization An invasive test involving insertion of a catheter into the heart and surrounding vessels. Obtains information about the structure and performance of the heart chambers and valves and the coronary circulation Preprocedure interventions a. Ensure that informed consent has been obtained. b. Assess for allergies to seafood, iodine, or radiopaque dyes; if allergic, the patient may be premedicated with antihistamines and corticosteroids to prevent a reaction. c. Withhold solid food for 6 to 8 hours and liquids for 4 hours as prescribed to prevent vomiting and aspiration during the procedure. d. Document the patient’s height and weight, because these data will be needed to determine the amount of dye to be administered. e. Document baseline vital signs and note the quality and presence of peripheral pulses for postprocedure comparison. f. Inform the patient that a local anesthetic will be administered before catheter insertion. g. Inform the patient that she or he may feel a fluttery feeling as the catheter passes through the heart, a flushed and warm feeling when the dye is injected, a desire to cough, and palpitations caused by heart irritability. h. The insertion site is prepared by shaving or clipping the hair and cleaning with an antiseptic solution i. Administer preprocedure medications such as sedatives if prescribed. j. Insert an IV line if prescribed. 36 Postprocedure interventions a. Monitor vital signs and cardiac rhythm for dysrhythmias at least every 30 minutes for 2 hours initially. b. Assess for chest pain and, if dysrhythmias or chest pain occurs, notify the PHCP c. Monitor peripheral pulses and the color, warmth, and sensation of the extremity distal to the insertion site at least every 30 minutes for 2 hours initially. d. Notify the PHCP if the patient reports numbness and tingling; if the extremity becomes cool, pale, or cyanotic; or if loss of the peripheral pulses occurs. This could indicate clot formation and is an emergency. e. Apply a sandbag or compression device (if prescribed) to the insertion site to provide additional pressure if required. f. Monitor for bleeding; if bleeding occurs, apply manual pressure immediately and notify the PHCP. g. Monitor for hematoma; if a hematoma develops, notify the PHCP. h. Keep the extremity extended for 4 to 6 hours, as prescribed, keeping the leg straight to prevent arterial occlusion. i. Maintain strict bed rest for 6 to 12 hours, as prescribed; however, the patient may turn from side to side. Do not elevate the head of the bed more than 15 degrees. j. If the antecubital vessel was used, immobilize the arm with an armboard. k. If the PHCP uses a vascular closure device to seal the arterial puncture site, there is no need for prolonged compression or bed rest, and patients may be out of bed in 1 to 2 hours. l. Encourage fluid intake, if not contraindicated, to promote renal excretion of the dye and to replace fluid loss caused by the osmotic diuretic effect of the dye. m. Monitor for nausea, vomiting, rash, or other signs of hypersensitivity to the dye. 4.0 Tutor-Marked Assignment Describe the following investigation and highlights the required nurses roles for them. 1. Magnetic Resonance Imaging 2. Chest X-ray 3. Computed Tomography Scan 4. Echocardiography Answer Review the nursing responsibilities in the various investigations above. 37 5.0 References / Further Reading Burke, K. M., LeMone, P., Mohn-Brown, E. & Eby, L. (2014). Medical-Surgical Nursing Care. 3rd Edition. Pearson. Osborn, K. S., Wraa, C. E. & Watson, A. B. (2010). Medical-Surgical Nursing Preparation for Practice. Pearson. Paul, P., Day, R. A. & Williams, B. (2016). Brunner and Suddarth's Canadian Textbook, of Medical Surgical Nursing. 3rd Edition. Wolters Kluwer. Smeltzer, S. C., Bare, B. G, Hinkle, J. L. & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing. 12th Edition. Lippincolt Williams and Wilkins White, L., Duncan, G. & Baumle W. (2013). Medical-Surgical Nursing: An Integrated Approach. 3rd Edition. Delmar Cengaga Learning. Williams. S. S. & Hopper, P.D. (2007) Understanding Medical Surgical Nursing. 3rd Edition. E. A. Davis Company. Self Assessment Questions 1. Discuss the concept of Care in medical and Surgical nursing 2. A patient has just been admitted from the outpatient clinic for further investigation to confirm diagnosis. Explain the modalities in physical assessment of a patient. 3. Identify five (5) commonly used diagnostic test used in medical and surgical conditions and state the nursing responsibilities for them. 38 MODULE 2 FUNDAMENTALS OF MEDICAL SURGICAL NURSING Section 1: Nutrition and Temperature Control Section 2: Fluid and Electrolyte Balance Section 3: Stress and Shock Section 4: Pain and Sleep Section 5: Skin Care and Wound management Section 1: Nutrition and Temperature Control CONTENT 1.0 Introduction 2.0 learning outcomes 3.0 Main content 3.1 Nutrition 3.2 Temperature control 4.0 Tutor-Marked Assignment 5.0 Reference/Further Reading 1.0 INTRODUCTION Nutrition plays a crucial role in both the prevention and treatment of disease. Inadequate nutrition can compromise the body’s support system. Likewise, temperature control is a mechanism by which the human body maintains temperature with tightly controlled self-regulated independence of external temperature. This section will explain in detail nutrition assessment, nutritional therapy and temperature control. 2.0 Learning Outcomes At the end of reading this section, the student should be able to 1. Explain components of a comprehensive nutrition assessment as part of the nursing care process. 2. Apply the nutritional component of national standards for disease prevention and treatment. 3. Discuss the metabolic effects of physiological stress and the potential impact on nutrition status. 39 4. Outline the nutrition therapy guidelines for patients with physiological stress 5. Differentiate among the principles of medical nutrition therapy in treating general medical conditions. 6. Explain the indications and nursing interventions associated with enteral and parenteral nutrition support. 7. Defend the important role of nursing care in successful medical nutrition therapy. 8. Explain temperature control and its mechanism. 3.0 MAIN CONTENT 3.1 NUTRITION Nutrition plays a crucial role in both the prevention and treatment of disease. Both overnutrition and undernutrition can lead to negative health outcomes. For example, overnutrition from excess intake of calories and fat can result in weight gain, elevated blood lipids, and risk of hypertension, diabetes, and some cancers. Undernutrition, in which dietary intake is less than the body’s requirement, can result in impaired wound healing, poor response to medical treatment, and loss of functional capacity. Medical nutrition therapy is an integral part of the health care process. Proper nutrition, whether accomplished through a therapeutic diet, nutrition support, or general healthy eating, is associated with positive outcomes. The nurse is uniquely positioned to take an active role in the nutrition care process of medical and surgical patients. The nutrition care process involves assessment, evaluation, and setting of patient goals and objectives in a fashion that can be easily dovetailed into the nursing care process. The registered dietitian is the health care professional with the primary responsibility for overseeing medical nutrition therapy in most settings. However, the nurse’s active position on the front line of patient care presents an important opportunity for improving nutritional care with efficient screening and assessment of nutrition status, appropriate and timely referrals, reinforcement of patient education, and close monitoring of nutrition intervention. Nutrition Assessment The cornerstone of all nutritional care is based on the foundation of a well-done nutrition assessment. Objective and subjective data gathered as part of the nursing assessment can be evaluated to determine a patient’s existing or potential risk for undernutrition or overnutrition. Appropriate nursing diagnoses and interventions can then be developed based on findings from the nutrition assessment. No one parameter or single piece of data should be used as an indicator of nutrition status. Data gathered during the physical exam and laboratory assays together with subjective data from the focused interview provide a comprehensive set of information on which to base a nutritional assessment. A nutrition assessment based on limited data has limited clinical value since many 40 parameters used in a nutrition assessment can be influenced by non-nutritional factors. When compiling a nutrition assessment, the nurse should use as many sources of data as are available along with sharp clinical judgment. Physical Assessment The physical assessment portion of a nutrition assessment includes the clinical exam along with anthropometric measurements. Pertinent data from the medical history and treatment plan should be considered for any influence on nutrition status because of alterations in physical health. The presence of pain, gastrointestinal symptoms, medication side effects, and impaired cognition or mobility are examples of physical factors that can have negative effects on nutrition status. Observations from the clinical examination can be incorporated into the nutrition assessment. Nutritional deficiencies can have few, if any, clinical symptoms until nutrient status is compromised for a length of time. The nurse should not dismiss suspicion of poor nutrition health simply because no physical findings are apparent. Anthropometric measurements are an important component of the assessment and include any scientific measurement of the body. Measured current weight and height should be obtained during an initial assessment. Weight should be measured at regular intervals thereafter. Self-reported height and weight are not considered accurate and are subject to over-reporting and underreporting bias by adults of all ages A weight history should also be obtained and confirmed by checking medical records. An unplanned weight loss of >5% in 1 month or >10% in 6 months is clinically significant and warrants attention. Patients who cannot stand to be measured or weighed can be measured using alternative methods. Chair and bed scales can be used to obtain current weight while arm span, knee height, or recumbent measures will provide estimates of height. Recumbent height will yield an overestimation of height by approximately 4 cm (1.5 in.) from changes in spinal compression when standing. Body mass index (BMI) is used to calculate appropriate weight for height using the formula weight (kg)/height2 (m).Morbidity and mortality statistics have been employed to determine cutoff points to define overweight, obesity, underweight, and healthy weight. Because BMI calculations use simple height and weight measurements, its use does not take into account body composition. Individuals with large bone structure or ample muscle mass can be categorized erroneously as overweight using this single assessment tool. The nurse should discover this discrepancy when conducting a physical exam. Waist circumference can be used in a nutrition assessment, especially when cardiovascular disease risk is suspected or known. Deposition of excess abdominal fat is considered to be an independent risk factor for heart disease in adults. 41 A waist circumference of >102 cm (40 in.) in men or >88 cm (35 in.) in women is associated with risk. Measurement should be made following proper technique with use of bony landmarks. Simply measuring waist circumference just below the umbilicus is not accurate in the obese patient in whom the position of the umbilicus has changed with weight gain. Waist circumference measurements are not of nutritional value in patients who are pregnant or have ascites or other fat free mass increases in abdominal girth because of disease. Biochemical Assessment Biochemical assessment reﬂects both the tissue level of a given nutrient and any abnormality of metabolism in the utilization of nutrients. These determinations are made from studies of serum (albumin, transferrin, retinolbinding protein, electrolytes, hemoglobin, vitamin A, carotene, vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine, riboﬂavin, niacin, and iodine). Some of these tests, while reﬂecting recent intake of the elements detected, can also identify below-normal levels when there are no clinical symptoms of deﬁciency. Low serum albumin and prealbumin levels are most often used as measures of protein deﬁcit in adults. Albumin synthesis depends on normal liver function and an adequate supply of amino acids. Because the body stores a large amount of albumin, the serum albumin level may not decrease until malnutrition is severe; therefore, its usefulness in detecting recent protein depletion is limited. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss due to burns, major surgery, infection, or cancer. Serial measurements of prealbumin. Dietary Data Commonly used methods of determining individual eating patterns include the food record, the 24-hour food recall, and a dietary interview. Each of these methods helps estimate whether food intake is adequate and appropriate. If these methods are used to obtain the dietary history, instructions must be given to the patient about measuring and recording food intake. Methods of Collecting Data Food Record. The food record is used most often in nutritional status studies. A person is instructed to keep a record of food actually consumed over a period of time, varying from 3 to 7 days, and to accurately estimate and describe the speciﬁc foods consumed. Food records are fairly accurate if the person is willing to provide factual information and is able to estimate food quantities. 24-Hour Recall. As the name implies, the 24-hour recall method is a recall of food intake over a 24-hour period. A person is asked to recall all foods eaten during the previous day and to estimate the quantities of each food consumed. 42 Because information does not always represent usual intake, at the end of the interview the patient is asked whether the previous day’s food intake was typical. To obtain supplementary information about the typical diet, it is also necessary to ask how frequently the person eats foods from the major food groups. Dietary Interview. The success of the interviewer in obtaining information for dietary assessment depends on effective communication, which requires that good rapport be established to promote respect and trust. The interviewer explains the purpose of the interview. The interview is conducted in a nondirective and exploratory way, allowing the respondent to express feelings and thoughts while encouraging him or her to answer speciﬁc questions. The manner in which questions are asked inﬂuences the respondent’s cooperation. The interviewer must be nonjudgmental and avoid expressing disapproval, either by verbal comments or by facial expression. RISK FACTORS for Poor Nutrition Health Chronic disease, acute illness and injury. Disease symptoms (including pain) or treatment can reduce appetite, reduce intake, cause malabsorption, or change nutritional requirements Multiple medications: Gastrointestinal side effects, altered taste, decreased saliva, nutrient interactions Restrictive eating Chronic dieting, disordered eating, food beliefs, or faddism can lead to poor intake Poor oral health Loose, missing teeth, ill-fitting dentures, gum disease, and mouth sores can reduce intake Alcohol abuse Poor dietary intake and nutrient absorption Psychosocial issues Depression, bereavement, social isolation can lead to reduce intake. Lack of finances or access to adequate food impairs intake. Lack of nutrition knowledge or food preparation skills can yield poor-quality intake Altered functional status Immobility, altered cognition can reduce intake Sensory changes Vision, hearing, taste alterations alter ability to prepare or enjoy food or dining. Analysis of Nutritional Status Physical measurements (BMI, waist circumference) and biochemical, clinical, and dietary data are used in combination to determine a patient’s nutritional status. Often, these data provide more information about the patient’s nutritional status than the clinical examination, which may not 43 detect subclinical deficiencies unless they become so advanced that overt signs develop. A low intake of nutrients over a long period may lead to low biochemical levels and, without nutritional intervention, may result in characteristic and observable signs and symptoms. A plan of action for nutritional intervention is based on the results of the dietary assessment and the patient’s clinical proﬁle. To be effective, the plan must meet the patient’s need for a healthy diet, maintain (or control) weight, and compensate for increased nutritional needs. Special Considerations Affecting Nutrition Care Both malnutrition and physiological stress place additional nutritional requirements on the medical-surgical patient. Existing malnutrition can compromise medical treatment and contribute to adverse medical and surgical outcomes. The presence of physiological stress increases nutritional requirements in the patient who may already be at nutritional risk because of a medical condition or disease. Malnutrition Malnutrition can be defined as a deficiency of one or more nutrients. The terms undernutrition and malnutrition are used interchangeably. A deficiency of macronutrients (carbohydrate, protein, and fat) can result in weight loss from insufficient energy and muscle wasting. Often the general term malnutrition is synonymous with the specific term protein-calorie malnutrition. Deficiency of any micronutrient may initially be less physically evident than with macronutrient deficiency because a lack of vitamins and minerals can take many weeks or months to manifest clinical symptoms. Malnutrition occurs because of decreased intake, increased losses, or unmet increased needs for energy or any nutrient. Patients have decreased intake for a number of medical and psychosocial reasons. Nutrient losses can occur from malabsorptive disease or drug interactions. Hypermetabolism during physiological stress, or increased energy needs because of growth, development, and physical activity can cause increased nutritional needs that must be met or malnutrition will develop. Malnutrition has adverse consequences such as poor wound healing, risk of decubitus ulcer development, loss of muscle mass (including respiratory and heart) with subsequent loss of strength and functional decline, diminished immune-competence, and altered pharmacokinetics Successful treatment of malnutrition is contingent on discovery of the underlying etiology. Provision of adequate nutrition in a well-tolerated form is best based on the recommendations of a registered dietitian who is trained to assess the impact of physiological stress, disease, and alterations in metabolism on baseline nutritional requirements across the life span. RISK FACTORS for Malnutrition Decreased Intake Anorexia Gastrointestinal symptoms: nausea, vomiting, diarrhea 44 Medication side effects Pain Dysphagia Poor dental health or chewing difficulties Sensory changes: loss of vision, taste, neuropathy Depression, anxiety, cognitive impairment, or other neuropsychological symptoms Socioeconomic issues: lack of finances, food insecurity, social isolation, bereavement, dependency on others for food or feeding Alcoholism. Increased Nutrient Losses Malabsorptive disease Short bowel syndrome Alcoholism Drug–nutrient interactions. Increased Nutrient Requirements Fever Infection or sepsis Wounds Fracture Hypermetabolic disease Increased energy expenditure from increased physical activity.. Physiological Stress A hypermetabolic response to injury or disease can have significant nutritional ramifications. Major surgery, thermal injury, sepsis, and trauma are examples of physiological stress. Unlike periods of inadequate energy intake that result in weight loss and some muscle wasting, a hypermetabolic response because of physiological stress can lead to rapid protein catabolism even when it seems energy and protein intake are sufficient. The body’s response to this metabolic stress leads to a cascade that includes release of catecholamines and cortisol, and a systemic inflammatory response. The result can be catabo

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