.54 CHAPTER 4: The Health Care Delivery System 57 Types of Health Care Services.. .74 UNIT II: NURSING PROCESS: THE STANDARD OF CARE CHAPTER 5: Critical Thinking and the Nursing Process
Trang 2OF NURSING
Trang 3About the
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Trang 4New Orleans, Louisiana
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Trang 5Patricia K Ladner
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Fundamentals of nursing: Standards & practice / Sue C DeLaune, and Patricia K Ladner— 2nd ed.
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1 Nursing 2 Nursing—Practice I DeLaune, Sue C (Sue Carter) II Ladner, Patricia K (Patricia Kelly) RT41.F8816 2002
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Trang 6To Jay, Jennifer, Katie, and Sarabeth A special thank you to Carol Ren Kneisl, my friend and mentor,
who continues to open doors for me.
Trang 7Procedures xxxii
Contributors xxxiv
Reviewers xxxvi
Preface xxxix
Acknowledgments xliii
About the Authors xliv
How to Use This Text xlvi
UNIT I: NURSING’S PERSPECTIVE: PAST, PRESENT, AND FUTURE
Historical Overview .4
Evolution of Nursing .5
Religious Influences .5
Florence Nightingale .9
Research Focus .9
Nursing and the Civil War .10
The Women’s Movement .11
Nursing Pioneers .11
Nursing Leaders .13
Nursing in the 20th Century .15
Flexner Report .15
Early Insurance Plans .16
Landmark Reports in Nursing Education .16
Other Health Care Initiatives .17
Selected Legislation .17
Education and Practice: Contemporary Reports 17
Social Forces Affecting Nursing .18
Healthy People Initiatives .19
Alternative Methods of Health Care Delivery .19
Costs and Quality Controls .19
Health Care Reform 20
The Future of Nursing .20
VI
Trang 8Contents VII
Components of the Theoretical Foundation .24
What Is a Concept? .24
What Is a Proposition? 24
What Is a Theory? .24
Use of Theories from Other Disciplines 25
Importance of Nursing Theories .25
Scope of Theories .26
Research Focus .26
Grand Theory .27
Middle-Range Theory .27
Micro-Range Theory .27
The Evolution of Nursing Theory 27
Knowledge Development in Nursing 27
The Metaparadigm of Nursing .27
Paradigms in Nursing .30
Selected Nursing Theories .31
Florence Nightingale .31
Early Nursing Theories 32
Contemporary Nursing Theories .33
Theories for the New Worldview of Nursing 36
Continuing Evolution of Nursing Theory .37
CHAPTER 3: Nursing Education and Research 39 Nursing Education .40
Types of Programs 40
Education Reform Mandates .43
Trends in Nursing Education .44
Research Focus .46
Research: Substantiating the Science of Nursing .49
Historical Development .49
Framework .50
Application .52
Organizational Structure .53
Research Focus .53
Trends in Nursing Research .54
CHAPTER 4: The Health Care Delivery System 57 Types of Health Care Services .58
Primary: Health Promotion and Illness Prevention .58
Secondary: Diagnosis and Treatment 59
Tertiary: Rehabilitation .59
Health Care Settings .59
Public Sector .59
Private Sector .60
Health Care Team .62
Nurse .62
Trang 9Economics of Health Care .63
Private Insurance .63
Managed Care .63
Federal Government Insurance Plans .65
Canadian Health Insurance .65
Research Focus .65
Factors Influencing the Delivery of Health Care .66
Cost 66
Access .67
Quality .67
Challenges within the Health Care System .67
Disillusionment with Professionals 68
Loss of Control .68
Decreased Hospital Use .68
Changing Practice Settings 69
Ethical Issues .69
Vulnerable Populations .69
Nursing’s Response to Health Care Challenges .70
Nursing’s Agenda for Health Care Reform .70
Standards of Care .71
Advanced Practice 71
Public versus Private Programs .72
Public Health .72
Community Health .72
Long-Term Care .73
Trends and Issues .74
UNIT II: NURSING PROCESS: THE STANDARD OF CARE CHAPTER 5: Critical Thinking and the Nursing Process 79 Critical Thinking 80
Components of Critical Thinking .80
Phases of Critical Thinking 81
Development of Critical Thinking Skills .81
Critical Thinking and Creativity .81
Critical Thinking and Problem Solving .82
Critical Thinking and Decision Making .83
The Nursing Process .83
Historical Perspective .83
Overview of the Nursing Process 83
Assessment .84
Diagnosis 85
Outcome Identification and Planning .87
Implementation .88
Evaluation .88
Research Focus .88
Critical Thinking Applied in Nursing .89
Trang 10Contents IX
Purpose of Assessment .94
Types of Assessment .94
Comprehensive Assessment .95
Focused Assessment .95
Ongoing Assessment .95
Data Collection .95
Types of Data .96
Sources of Data .96
Methods of Data Collection .96
Data Verification .101
Data Organization .102
Assessment Models .102
Research Focus .103
Data Interpretation .104
Data Documentation .104
Types of Assessment Formats .104
CHAPTER 7: Nursing Diagnosis 113 What Is a Nursing Diagnosis? 114
Comparison of Nursing and Medical Diagnoses .114
Historical Perspective .115
Research .116
Research Focus .116
Purposes of Nursing Diagnosis .117
Nursing Diagnoses and Diagnostic-Related Groups 118
Components of a Nursing Diagnosis .118
The Two-Part Statement .118
The Three-Part Statement .122
Categories of Nursing Diagnoses .122
Taxonomy of Nursing Diagnosis .123
Developing a Nursing Diagnosis .124
Assessing Database .124
Validating Cues .124
Interpreting Cues 124
Clustering Cues .125
Consulting NANDA List of Nursing Diagnoses .125
Writing the Nursing Diagnosis Statement .125
Avoiding Errors in Developing a Nursing Diagnosis .126
Problem with Assessment Data .126
Incomplete Collection of Assessment Data 126
Restricted Data Collection .126
Failure to Validate Data 126
Misinterpretation of Data .126
Inappropriate Data Clustering Associated with Lack of Clinical Knowledge .126
Incorrect Writing of the Nursing Diagnosis Statement .126
Trang 11Limitations of Nursing Diagnosis 127
Overcoming Barriers to Nursing Diagnosis .127
CHAPTER 8: Outcome Identification and Planning 131 Purposes of Outcome Identification and Planning .132
Process of Outcome Identification and Planning .132
Critical Thinking .133
Establishing Priorities .133
Establishing Goals and Expected Outcomes .134
Writing Goals .135
Problems Frequently Encountered in Planning .137
Planning Nursing Interventions .138
Evaluating Care .140
Nursing Outcomes Classification (NOC) .140
Plan of Care .141
Strategies for Effective Care Planning .142
Research Focus .143
CHAPTER 9: Implementation 147 Purposes of Implementation 148
Requirements for Effective Implementation 148
Implementation Activities .148
Ongoing Assessment .149
Establishment of Priorities 149
Allocation of Resources .150
Nursing Interventions .153
Evaluating Interventions .157
Documentation of Interventions .157
Research Focus .157
CHAPTER 10: Evaluation 161 Evaluation of Client Care .162
Components of Evaluation .162
Techniques .163
Sources of Data .163
Goals and Expected Outcomes 164
Methods of Evaluation .164
Establishing Standards .164
Collecting Data .164
Determining Goal Achievement .164
Relating Nursing Actions to Client Status .164
Judging the Value of Nursing Interventions .164
Reassessing the Client’s Status .164
Modifying the Plan of Care .165
Critical Thinking and Evaluation .165
Evaluation and Quality of Care .165
Elements in Evaluating the Quality of Care .165
Trang 12Contents XI
Research Focus .166
Nursing Audit .167
Peer Evaluation .167
Evaluation and Accountability .168
Multidisciplinary Collaboration in Evaluation .170
UNIT III: THE THERAPEUTIC NATURE OF NURSING CHAPTER 11: Nursing, Healing, and Caring 175 Nursing’s Therapeutic Value .176
Definition of Nursing .176
Nursing: A Blend of Art and Science .176
Purposes of Nursing .176
Nursing: A Healing Modality .177
Caring: An Integral Component of Nursing .177
Care in the High-Tech Environment .178
Nurse-Client Relationship .179
Phases of Therapeutic Relationship .179
Therapeutic Use of Self 181
Characteristics of Therapeutic Relationships .182
Warmth .182
Hope .182
Rapport 182
Trust .183
Empathy .183
Acceptance .183
Research Focus .183
Active Listening .184
Humor .184
Compassion 184
Self-Awareness 185
Nonjudgmental Approach .185
Flexibility 185
Risk-Taking .186
Therapeutic Value of the Nursing Process .186
Nursing Roles 186
Caregiver .186
Counselor .186
Teacher .186
Client Advocate .186
Change Agent .187
Team Member .187
Resource Person .187
CHAPTER 12: Therapeutic Communication 189 The Communication Process .190
Components of the Communication Process .190
Trang 13Factors Influencing Communication .191
Levels of Communication .193
Modes of Communication .194
Verbal Messages .194
Nonverbal Messages .194
Metacommunication .196
Types of Communication 196
Interdisciplinary Communication .196
Therapeutic Communication .196
Research Focus .197
Therapeutic Approaches with Clients .199
Barriers to Therapeutic Interaction 199
Language Differences .199
Cultural Differences .199
Gender .201
Health Status 201
Developmental Level .202
Knowledge Differences .202
Emotional Distance .202
Emotions .202
Daydreaming 202
Communication Blocks .202
Communication, Critical Thinking, and Nursing Process .202
Assessment .202
Nursing Diagnosis .204
Outcome Identification and Planning .205
Implementation .205
CHAPTER 13: Client Education 209 The Teaching-Learning Process .210
Purposes of Client Teaching 210
Facilitators of Learning .211
Barriers to Learning .212
Domains of Learning .212
Professional Responsibilities Related to Teaching 213
Legal Aspects 213
Documentation .213
Learning Throughout the Life Cycle .216
Children .216
Adolescents .216
Older Adults .219
Teaching-Learning and the Nursing Process .219
Assessment .219
Learning Styles .219
Research Focus .219
Learning Needs .220
Potential Learning Needs 221
Ability to Learn .221
Trang 14Contents XIII
Readiness to Learn .221
Client Strengths .221
Previous Experience and Knowledge Base .222
Nursing Diagnosis .222
Outcome Identification and Planning 222
Implementation .224
Evaluation .225
CHAPTER 14: Nursing and Complementary/Alternative Treatment Modalities 229 Historical Influences on Contemporary Practices .230
From Ancient Tradition to Early Science .230
Shamanistic Tradition .231
Allopathic Medicine 232
Contemporary Trends .232
Mind-Body Medicine and Research .233
Holism and Nursing Practice .233
The Nature of Healing .233
Complementary/Alternative Interventions .234
Mind-Body: Self-Regulatory Techniques .234
Body-Movement: Manipulation Strategies .236
Energetic-Touch Healing .237
Spiritual Therapies .245
Nutritional Therapies 245
Other CAM Methodologies .249
Research Focus .251
Nursing and Complementary/Alternative Approaches .252
Nurse as Instrument of Healing .253
UNIT IV: THE INDIVIDUAL AND HEALTH CHAPTER 15: Health, Holism, and the Individual 259 Health, Illness, and Wellness .260
Models of Health .260
Illness Perspectives .262
Wellness Perspectives .262
Health Behaviors .262
Variables Influencing Health Behaviors .263
Health Promotion .264
Health Promotion Activities .265
Health Protection Activities .266
Disease Prevention Activities .266
Nurse’s Role in Health Promotion, Health Protection, and Disease Prevention .266
Health Promotion and Vulnerable Populations .267
The Individual as a Holistic Being .267
Needs and Health .268
Trang 15Physiological Dimension .269
Psychological Dimension .269
Sociocultural Dimension .269
Intellectual Dimension .269
Spiritual Dimension .269
Research Focus .276
Sexual Dimension .276
CHAPTER 16: Cultural Diversity 283 Concepts of Culture .284
Culture .284
Ethnicity and Race 285
Labeling and Stereotyping .285
Dominant Values in the United States .285
Multiculturalism in the United States .286
Value of Diversity .286
Organizing Phenomena of Culture .286
Communication 286
Space .291
Orientation to Time 291
Social Organization .291
Cultural Disparities in Health and Health Care Delivery .294
Vulnerable Populations .294
Environmental Control .296
Folk Medicine .296
Biologic Variations 296
Transcultural Nursing .296
Cultural Competence .299
Cultural Competence and Nursing Process .299
Assessment .300
Nursing Diagnosis .300
Research Focus .300
Outcome Identification and Planning 302
Implementation .302
Evaluation .303
CHAPTER 17: The Life Cycle 305 Fundamental Concepts of Growth and Development 306
Principles of Growth and Development .306
Factors Influencing Growth and Development .306
Theoretical Perspectives of Human Development .308
Physiological Dimension .308
Psychosocial Dimension .308
Cognitive Dimension .309
Moral Dimension 312
Spiritual Dimension .313
Holistic Framework for Nursing 315
Stages of the Life Cycle .315
Trang 16Contents XV
Prenatal Period .315
Safety Considerations .317
Neonate .317
Infant .320
Toddler .323
Preschooler .326
School-Aged Child .328
Preadolescent .328
Adolescent .334
Young Adult .339
Research Focus .339
Middle Adult .341
Older Adult .342
CHAPTER 18: The Older Client 351 Defining Old Age .352
Theories of Aging .352
Myths and Stereotypes of Aging .353
Quality of Life among the Elderly .353
Changes Associated with Aging .354
Developmental Changes .354
Physiological Changes .354
Research Focus .356
Psychosocial Changes .361
Medications and the Older Adult .363
Adverse Drug Reaction .363
Compliance .364
Mistreatment of the Older Adult .364
Nursing Process and the Older Adult .365
Assessment .365
Nursing Diagnosis .366
Outcome Identification and Planning .367
Implementation .367
Evaluation .372
CHAPTER 19: Self-Concept 375 Components of Self-Concept .376
Identity .376
Body Image .376
Self-Esteem .377
Role Performance .377
Development of Self-Concept .378
Childhood .378
Adolescence .378
Adulthood .379
Factors Affecting Self-Concept .379
Altered Health Status 379
Research Focus .380
Trang 17Developmental Transitions .381
Experience .381
Assessment .381
Diagnosis .382
Outcome Identification and Planning .383
Implementation .383
Initiate Therapeutic Interaction .383
Support Healthy Defense Mechanisms .383
Ensure Satisfaction of Needs .384
Promote Positive Self-Esteem Across the Life Span 384
Evaluation .385
CHAPTER 20: Stress, Anxiety, and Adaptation 389 Stress, Anxiety, and Adaptation 390
Sources of Stress .390
Responses to Stress .390
Physiological Response to Stress .390
Manifestations of Stress .391
Outcomes of Stress .391
Stress and Illness .395
Impact of Illness and Treatment .396
Stress and Change .396
Types of Change .397
Theories of Change .397
Resistance to Change 398
Changing Paradigms .398
Nurse As Change Agent .399
Assessment .399
Nursing Diagnosis .400
Outcome Identification and Planning .400
Implementation .400
Meeting Basic Needs .400
Environmental Strategies 400
Verbalization .400
Involvement of Family and Significant Others .402
Stress Management Techniques .402
Crisis Intervention .405
Evaluation .406
Personal Stress Management Approaches for the Nurse .406
Burnout and Nurses .406
Research Focus .409
CHAPTER 21: Loss and Grief 413 Loss .414
Loss as Crisis .414
Types of Loss .414
Grief 415
Theories of the Grieving Process .415
Trang 18Contents XVII
Types of Grief 416
Factors Affecting Grief 418
Research Focus .421
Assessment .422
Diagnosis 422
Outcome Identification and Planning .422
Implementation .423
Evaluation .424
Death 424
End-Of-Life (EOL) Care .424
Stages of Death and Dying .424
Ethical Implications .426
Assessment .426
Diagnosis 426
Outcome Identification and Planning .426
Implementation .426
Care After Death .430
Care of the Body .431
Legal Aspects 431
Care of the Family .431
Nurse’s Self-Care .432
UNIT V: PROFESSIONAL ACCOUNTABILITY CHAPTER 22: Professional Accountability and Leadership 437 Professional Nursing Practice .438
Criteria of a Profession .438
Professional Accountability .441
Elements of Professional Accountability .441
Legislative Accountability .443
Advanced Practice Nursing .448
Leadership in Nursing .449
Managerial Functions .449
Leadership Styles 450
Leadership Characteristics .452
Power .453
Networking .455
Empowerment .456
Politics of Nursing .456
Research Focus .457
CHAPTER 23: Legal Accountability and Responsibilities 459 Legal Foundations of Nursing .460
Sources of Law .460
Legal Liability in Nursing .462
Negligence and Malpractice 462
Informed Consent .463
Trang 19Assault and Battery .465
False Imprisonment 465
Restraints or Seclusion .465
Privacy and Confidentiality .465
Defamation .466
Fraud .466
Unprofessional Conduct 466
Controlled Substances .466
Safety .467
Understaffing .467
Executing Prescribed Orders .467
Legal Responsibilities and Roles of Professional Nurses .467
Provider of Service .467
Expert Witness .468
Forensic Specialist .468
Reporting Responsibilities .468
Legal Responsibilities of Students .468
Legal Safeguards for Nursing Practice 468
Institutional Policies .468
Professional Liability Insurance .468
Risk Management Programs .468
Incident Reports .469
Client Education .469
Legislation Affecting Nursing 469
Advance Directives .469
Abortion .470
The Americans with Disabilities Act .470
Good Samaritan Acts .471
Research Focus .471
National Practitioner Data Bank .472
Occupational Safety and Health Act 472
Legal Issues Related to Death .472
Do Not Resuscitate Orders .472
Euthanasia .472
Wills .472
Pronouncement of Death .472
Care of the Deceased .472
Organ Donation .473
Autopsies .473
CHAPTER 24: Ethical Obligations and Accountability 475 Concept of Ethics .476
Relationship Between Legal and Ethical Concepts .476
Ethics in Health Care .477
Ethical Theories .477
Teleology 477
Deontology .477
Ethical Principles .478
Trang 20Contents XIX
Autonomy .478
Nonmaleficence .478
Beneficence .479
Justice .479
Veracity .479
Fidelity .480
Values and Ethics 480
Values Clarification .480
Ethical Codes .480
Clients’ Rights .482
Ethical Dilemmas 482
Ethical Decision Making 482
Framework for Ethical Decision Making .482
Euthanasia .483
Refusal of Treatment .484
Research Focus .484
Scarce Resources .485
Ethics and Nursing 485
Ethics Committees .485
Nurse As Client Advocate .485
Nurse As Whistle-Blower .486
CHAPTER 25: The Role of Quality Management in Accountability 489 The Quality Movement in Health Care .490
Evolution 490
Role of the JCAHO in the Quality Movement .490
Defining Quality .490
Factors Influencing the Quality Movement in Health Care .491
Legal and Ethical Implications .492
Quality and Cost .494
Quality Improvement .494
Principles .494
Customer Perspective .495
Organizational Structure for Quality Management .495
Organizational Culture 496
Work Force Diversity .496
Research Focus .496
Empowerment .498
Leadership .498
Teamwork .498
Process Improvement .499
Prioritization .499
Scientific Approach .499
Tools .499
Nursing’s Role in Quality Management .500
Trang 21CHAPTER 26: Accountability: Documentation
Documentation as Communication .504
Documentation Defined .504
Purposes of Health Care Documentation .505
Principles of Effective Documentation .509
Elements of Effective Documentation .510
Methods of Documentation .512
Narrative Charting .512
Source-Oriented Charting .513
Problem-Oriented Charting .513
PIE Charting .513
Focus Charting 513
Charting by Exception .514
Computerized Documentation 515
Case Management Process 516
Forms for Recording Data .517
Kardex .517
Flow Sheets .517
Nurses’ Progress Notes .517
Discharge Summary .522
Trends in Documentation .522
Nursing Minimum Data Set (NMDS) .522
Nursing Diagnoses .522
Nursing Intervention Classification (NIC) 522
Nursing Outcomes .524
Reporting 524
Summary Reports .524
Walking Rounds 525
Telephone Reports and Orders .525
Incident Reports .526
Research Focus .526
UNIT VI: DIAGNOSTIC AND THERAPEUTIC INTERVENTIONS CHAPTER 27: Vital Signs and Physical Assessment 533 Vital Signs .534
Physiological Function .535
Factors Influencing Vital Signs 538
Age .538
Gender .539
Heredity .539
Race .539
Lifestyle 539
Environment .539
Medications 540
Pain .540
Trang 22Head and Neck .578
Thorax and Lungs .592
Heart and Vascular System .594
Breasts and Axillae .603
Abdomen .608
Female Genitalia and Anus .609
Male Genitalia, Anus, and Rectum .609
Understanding Diagnostic Testing .628
Noninvasive and Invasive Diagnostic Testing .629
Nursing Care of the Client .629
Trang 23Echocardiograms .665 Doppler Ultrasonography .665 Magnetic Resonance Imaging .666 Radioactive Studies .666 Electrodiagnostic Studies 666 Electrocardiography .666 Electroencephalography .666 Endoscopy .667 Aspiration/Biopsy .669 Amniocentesis .669 Bone Marrow Aspiration/Biopsy .669 Paracentesis .669 Thoracentesis .669 Cerebrospinal Fluid Aspiration 670
Drug Standards and Legislation .674 Standards .674 Federal Legislation .674 State and Local Legislation .675 Health Care Institution Regulations .675 Pharmacokinetics .675 Absorption .675 Distribution .676 Metabolism .677 Excretion .677 Drug Nomenclature 677 Drug Action .677 Pharmacology .677 Drug Interaction .680 Side Effects and Adverse Reactions .680 Food and Drug Interactions .680 Factors Influencing Drug Action .681 Professional Roles in Medication Administration .681 Types of Medication Orders .683 Parts of the Drug Order .684 Systems of Weight and Measure .684 Metric System .684 Apothecary System .684 Household System .684 Approximate Dose Equivalents .684 Converting Units of Weight and Volume .685 Drug Dose Calculations .686 Safe Drug Administration .686 Guidelines for Medication Administration .687 Documentation of Drug Administration 689 Drug Supply and Storage .690 Drug Abuse .690 Medication Compliance 692
Trang 24Administer Oral Drugs .696
Administer Parenteral Drugs .700
Administer Topical Medications .721
Trang 25Interventions .771 Evaluation and Discharge from the PACU .774 Ongoing Postoperative Care .774 Evaluation .776
UNIT VII: NURSING MANAGEMENT OF BASIC NEEDS
CHAPTER 31: Safety, Infection Control, and Hygiene 779
Safe Environment .780 Factors Affecting Safety .780 Age .780 Lifestyle 781 Sensory and Perceptual Alterations .782 Mobility 782 Emotional State .782 Types of Accidents 782 Potential Occupational Hazards .783 Infection Control Principles .784 Pathogens, Infection, and Colonization .784 Chain of Infection .784 Normal Defense Mechanisms .786 Stages of the Infectious Process .788 Nosocomial Infections .788 Blood-Borne Pathogens .789 Hygiene .789 Factors Influencing Hygienic Practice 789 Assessment .790 Physical Examination 791 Diagnostic and Laboratory Data .793 Nursing Diagnosis .794 Risk for Injury .794 Risk for Infection .795 Self-Care Deficits .795 Other Nursing Diagnoses .795 Outcome Identification and Planning .796 Implementation .796 Raise Safety Awareness and Knowledge 797 Prevent Falls .799 Research Focus .800 Reduce Bathroom Hazards .804 Prevent Fire 805 Ensure Safe Operation of Electrical Equipment .805 Reduce Exposure to Radiation .805 Prevent Poisoning .806 Reduce Noise Pollution .806 Ensure Asepsis 806
Trang 26Contents XXV
Reduce or Eliminate Infectious Agents 820
Practice Standard and Isolation Precautions .822
Alternative Therapies .832
Provide for Client Bathing Needs .833
Provide Clean Bed Linen .838
Provide Skin Care .841
Offer Back Rubs 845
Provide Foot and Nail Care .848
Provide Oral Care .848
Fluoride .848
Provide Hair Care .854
Provide Eye, Ear, and Nose Care .856
Evaluation .863
Physiology of Oxygenation .868
Ventilation .868
Alveolar Gas Exchange .869
Oxygen Transport and Delivery .870
Ineffective Airway Clearance .882
Ineffective Breathing Patterns .882
Impaired Gas Exchange .882
Decreased Cardiac Output .882
Ineffective Tissue Perfusion .882
Other Nursing Diagnoses .883
Outcome Identification and Planning .884
Implementation .884
Interventions to Promote Airway Clearance .884
Interventions to Improve Breathing Patterns .895
Interventions to Improve Oxygen Uptake and Delivery .899
Interventions to Increase Cardiac Output and Tissue Perfusion .903
Trang 27CHAPTER 33: Comfort and Sleep 915
Pain .916 Nature of Pain 916 Physiology of Pain .918 Factors Affecting the Pain Experience .921 Assessment .923 Nursing Diagnosis .927 Outcome Identification and Planning .927 Implementation .928 Evaluation .941 Rest and Sleep .942 Physiology of Rest and Sleep .942 Biological Clock .944 Factors Affecting Rest and Sleep .945 Illness or Hospitalization .946 Alteration in Sleep Patterns .947 Hypersomnia or Narcolepsy 947 Assessment .948 Nursing Diagnosis .948 Outcome Identification and Planning .948 Implementation .948 Evaluation .950
Overview of Mobility .954 Body Alignment .954 Body Mechanics .956 Physiology of Mobility .956 The Musculoskeletal System .956 Nervous System 956 Exercise .957 Types of Exercise .958 Physical Fitness .958 Factors Affecting Mobility .959 Health Status 959 Developmental Stage 959 Environment .965 Attitudes and Beliefs .965 Lifestyle 966 Physiological Effects of Mobility and Immobility .966 Neurological Effects/Mental Status .966 Cardiovascular Effects .966 Respiratory Effects 967 Musculoskeletal Effects .967 Digestive Effects .967 Elimination Effects 967 Integumentary Effects .968
Trang 28Restorative Nursing Care .975
Health Promotion and Fitness .975
Implementation .976
Meeting Psychosocial Needs .976
Applying Principles of Body Mechanics .976
Maintaining Body Alignment: Positioning .977
Performing Range-of-Motion Exercises .984
Physiology of Wound Healing .1011
Factors Affecting Wound Healing .1014
Physiology of Pressure Ulcers .1039
Risk Factors for Pressure Ulcers .1039
CHAPTER 36: Sensation, Perception, and Cognition 1049
Physiology of Sensation, Perception, and Cognition 1050
Components of Sensation and Perception .1050
Components of Cognition .1053
Factors Affecting Sensation, Perception, and Cognition .1054
Age .1054
Trang 29Environment .1055 Lifestyle 1055 Stress 1055 Illness .1056 Medications 1056 Sensory, Perceptual, and Cognitive Alterations 1056 Sensory Deficits .1056 Sensory Deprivation .1056 Sensory Overload .1057 Assessment .1057 Health History .1058 Physical Examination 1058 Mental-Status Assessment .1059 Functional Abilities .1060 Environment .1060 Diagnosis .1062 Outcome Identification and Planning 1062 Implementation .1064 Managing Sensory Deficits .1064 Managing Sensory Deprivation .1065 Managing Sensory Overload .1065 Caring for the Unconscious Client .1066 Use of Restraints .1067 Complementary/Alternative Therapies 1067 Research Focus .1067 Evaluation .1068
CHAPTER 37: Fluid, Electrolyte, and Acid-Base Balance 1073
Physiology of Fluid and Acid-Base Balance .1074 Fluid Compartments .1074 Body Water Distribution .1075 Electrolytes .1075 Movement of Body Fluids .1075 Regulators of Fluid Balance .1078 Acid-Base Balance .1079 Regulators of Acid-Base Balance .1079 Factors Affecting Fluid and Electrolyte Balance .1080 Age .1080 Lifestyle 1080 Disturbances in Electrolyte and Acid-Base Balance .1080 Electrolyte Disturbances .1080 Acid-Base Disturbances .1088 Assessment .1092 Health History .1092 Physical Examination 1092 Diagnostic and Laboratory Data .1094 Nursing Diagnosis .1096 Excess Fluid Volume .1096 Deficient Fluid Volume .1096
Trang 30Contents XXIX
Risk for Deficient Fluid Volume .1097
Other Nursing Diagnoses .1097
Outcome Identification and Planning .1098
Implementation .1098
Monitor Daily Weight 1098
Measure Vital Signs .1098
Measure Intake and Output .1098
Provide Oral Hygiene 1100
Initiate Oral Fluid Therapy 1100
Maintain Tube Feeding .1101
Monitor Intravenous Therapy .1101
Promoting Proper Nutrition .1152
Dietary Reference Intakes and Recommended Daily Allowances .1152
The Food Guide Pyramid .1153
Imbalanced Nutrition: Less Than Body Requirements .1163
Imbalanced Nutrition: More Than Body Requirements or
Risk for More Than Body Requirements 1164
Other Nursing Diagnoses .1164
Outcome Identification and Planning .1164
Trang 31Implementation .1165 Monitoring Weight and Intake .1165 Initiating Diet Therapy 1165 Assistance with Feeding .1166 Research Focus .1166 Providing Nutrition Support 1167 Providing Enteral Nutrition .1169 Research Focus .1178 Providing Parenteral Nutrition 1179 Administering Medication through a Feeding Tube .1182 Evaluation .1186
Physiology of Elimination .1190 Urinary Elimination .1190 Bowel Elimination .1192 Factors Affecting Elimination .1193 Age .1193 Diet .1194 Exercise 1194 Medications 1194 Common Alterations in Elimination .1194 Urinary Elimination .1194 Bowel Elimination .1196 Assessment .1198 Research Focus .1198 Physical Examination 1199 Diagnostic and Laboratory Data .1202 Nursing Diagnosis .1202 Impaired Urinary Elimination .1202 Stress Urinary Incontinence .1202 Reflex Urinary Incontinence .1202 Urge Urinary Incontinence 1202 Functional Urinary Incontinence .1203 Total Urinary Incontinence .1203 Urinary Retention .1203 Constipation .1203 Perceived Constipation .1203 Diarrhea .1203 Bowel Incontinence .1203 Other Diagnoses .1203 Outcome Identification and Planning .1204 Implementation .1204 Maintain Elimination Health .1204 Initiate Exercise Regimen 1206 Suggest Environmental Modifications .1208 Initiate Behavioral Interventions .1208 Monitor Skin Integrity .1209 Apply a Containment Device .1209
Trang 32Initiate Rectal Stimulation .1220
Monitor Elimination Diversions .1223
Monitor Surgical Management 1226
Complementary Therapies 1226
Evaluation .1228
Appendix D Educational Resources for Caregivers 1239
Trang 33Procedure 14-1 Administering Therapeutic Massage 240
Procedure 27-1 Measuring Body Temperature 547
Procedure 27-2 Assessing Pulse Rate 555
Procedure 27-3 Assessing Respirations 559
Procedure 27-4 Assessing Blood Pressure 560
Procedure 28-1 Venipuncture 636
Procedure 28-2 Skin Puncture 640
Procedure 28-3 Urine Collection—Closed Drainage System 643
Procedure 28-4 Urine Collection—Clean Catch, Female 644
Procedure 29-1 Administering an Oral Medication 696
Procedure 29-2 Withdrawing Medication from an Ampule 702
Procedure 29-3 Withdrawing Medication from a Vial 705
Procedure 29-4 Mixing Insulins in One Syringe 706
Procedure 29-5 Administering an Intradermal Injection 708
Procedure 29-6 Administering a Subcutaneous Injection 710
Procedure 29-7 Administering an Intramuscular Injection 713
Procedure 29-8 Administering Medications by IV Piggyback to an Existing IV 718
Procedure 29-9 Administering an Eye Medication 723
Procedure 29-10 Instilling an Ear Medication 727
Procedure 29-11 Instilling Nose Drops 729
Procedure 29-12 Teaching Self-administration with a Metered-dose Inhaler 730
Procedure 29-13 Administering a Rectal Suppository 733
Procedure 29-14 Administering a Vaginal Suppository 735
Procedure 30-1 Postoperative Exercise Instruction 755
Procedure 31-1 Application of Restraints 803
Procedure 31-2 Handwashing 807
Procedure 31-3 Surgical Asepsis: Preparing and Maintaining a Sterile Field 809
Procedure 31-4 Performing Open Gloving and Removing of Soiled Gloves 814
Procedure 31-5 Applying a Surgical Mask 817
Procedure 31-6 Surgical Handwashing 817
Procedure 31-7 Performing Gowning and Closed Gloving 819
Procedure 31-8 Initiating Strict Isolation Precautions 827
Procedures
XXXII
Trang 34Procedures XXXIII
Procedure 31-9 Adult Bath 834
Procedure 31-10 Bedmaking: Unoccupied Bed 838
Procedure 31-11 Bedmaking: Occupied Bed 842
Procedure 31-12 Perineal Care 845
Procedure 31-13 Oral Hygiene 849
Procedure 31-14 Eye Care: Artificial Eye and Contact Lens Removal 857
Procedure 32-1 Performing Tracheostomy Care 888
Procedure 32-2 Performing Nasopharyngeal and Oropharyngeal Suctioning 892
Procedure 32-3 Performing Tracheostomy Suctioning 896
Procedure 32-4 Administering Oxygen 901
Procedure 32-5 Clearing an Obstructed Airway 905
Procedure 32-6 Performing Adult Cardiopulmonary Resuscitation (CPR) 907
Procedure 34-1 Practicing Proper Body Mechanics 978
Procedure 34-2 Positioning a Client in Bed 982
Procedure 34-3 Performing Range-of-Motion (ROM) Exercises 985
Procedure 34-4 Moving a Client in Bed 989
Procedure 34-5 Logrolling a Client 990
Procedure 34-6 Transferring a Client from Bed to Chair 991
Procedure 34-7 Transferring a Client from Bed to Stretcher
with Minimum Assistance 993
Procedure 34-8 Transferring a Client from Bed to Stretcher
with Maximum Assistance 993
Procedure 34-9 Using a Hydraulic (Mechanical) Lift 995
Procedure 34-10 Assisting a Client with Ambulation 999
Procedure 34-11 Assisting a Client with Crutch Walking 1004
Procedure 35-1 Culturing a Wound 1020
Procedure 35-2 Irrigating a Wound 1024
Procedure 35-3 Applying a Dry Sterile Dressing 1030
Procedure 35-4 Applying a Wet to Dry Dressing 1033
Procedure 37-1 Measuring Intake and Output 1099
Procedure 37-2 Preparing an Intravenous Solution 1108
Procedure 37-3 Administering an IV Solution 1113
Procedure 37-4 Managing IV Therapy and Dressing Change 1121
Procedure 37-5 Administering a Blood Transfusion Procedure 1130
Procedure 38-1 Inserting a Nastrogastric or Nasointestinal Tube
for Suction and Enteral Feeding 1170
Procedure 38-2 Administering Enteral Tube Feedings 1174
Procedure 39-1 Positioning and Removing a Bedpan 1206
Procedure 39-2 Applying a Condom Catheter 1211
Procedure 39-3 Performing Urinary Catheterization: Male Client 1214
Procedure 39-4 Performing Urinary Catheterization: Female Client 1216
Procedure 39-5 Irrigating an Open Catheter 1218
Procedure 39-6 Irrigating a Closed Catheter 1219
Procedure 39-7 Administering a Large Enema 1221
Procedure 39-8 Administering a Small (Mini-) Enema 1222
Procedure 39-9 Changing a Colostomy Pouch 1225
Trang 35Jan Corder, DNS, RN
Dean, School of NursingNortheast Louisiana UniversityMonroe, Louisiana
Chapter 5: Critical Thinking and the Nursing Process
Julie Coy, MS, RN, C
Pain Consultation ServiceThe Children’s HospitalDenver, Colorado
Chapter 33: Comfort and Sleep
Mary Ellen Zator Estes, MSN, RN, CCRN
Assistant Professor School of NursingMarymount UniversityArlington, Virginia
Chapter 27: Vital Signs and Physical Assessment
Mary Frost, RN, BSN
Covington, Louisiana
Chapter 14: Nursing and Complementary/
Alternative Treatment Modalities
Norma Fujise, MS, RN, C
School of NursingUniversity of HawaiiHonolulu, Hawaii
Chapter 35: Skin Integrity and Wound Healing
Mikel Gray, PhD, CURN, CCCN
Nurse Practitioner/Clinical InvestigatorAssociate Professor
Department of UrologyUniversity of Virginia Health Sciences CenterCharlottesville, Virginia
and
Adjunct ProfessorLancing School of NursingBellarmine College
Chapter 36: Sensation, Perception, and Cognition
Billie Barringer, RN, CS, APRN
Loyola University—New Orleans
New Orleans, Louisiana
Chapter 2: Theoretical Foundations of Nursing
Chapter 18: The Older Client
Ann H Cary, PhD, MPH, RN, A-CCC
Director, Institute for Research, Education, and
Trang 36Janet Kula Harden, RN, MSN
Faculty
Wayne State University
College of Nursing
Detroit, Michigan
Chapter 29: Medication Administration
Lucille Joel, EdD, RN, FAAN
Professor
College of Nursing
Rutgers—The State University of New Jersey
Newark, New Jersey
Chapter 4: The Health Care Delivery System
Georgia Johnson, MS, RN, CNAA, CPHQ
Quality Support Services Coordinator
Southeast Louisiana Hospital
Our Lady of Holy Cross College
New Orleans, Louisiana
Chapter 2: Theoretical Foundations of Nursing
Judy Martin, MS, RN, JD
Nurse Attorney
Louisiana Department of Health and Hospitals
Health Standards Section
Baton Rouge, Louisiana
Chapter 23: Legal Accountability and Responsibilities
Linda McCuistion, PhD, RN
Assistant Professor
School of Nursing
Our Lady of Holy Cross College
New Orleans, Louisiana
Chapter 8: Outcome Identification and Planning
Elizabeth “Betty” Hauck Miller, MPH, BSN
Director of Education
Meadowcrest Hospital, Gretna, Louisiana and
JoEllen Smith Regional Medical Center,
New Orleans, Louisianna
Chapter 21: Loss and Grief
Mary Anne Modrcin-McCarthy, PhD, RN
Associate Professor and Director
of the Undergraduate Program
Barbara Morvant, RN, MN
Executive DirectorLouisiana State Board of NursingMetairie, Louisiana
Chapter 22: Professional Accountability and Leadership
Brenda Owens, PhD, RN
Associate ProfessorSchool of NursingLouisiana State University Medical CenterNew Orleans, Louisiana
Chapter 29: Medication Administration
Demetrius Porche, DNS, RN, CCRN
Associate Professor and DirectorBachelor of Science in Nursing ProgramNicholas State University
Adjunct Assistant ProfessorTulane University
School of Public Health and Topical Medicine
Chapter 31: Safety, Infection Control, and Hygiene
Suzanne Riche, RN, C, MS
Associate ProfessorCharity School of NursingNew Orleans, Louisiana
Chapter 6: Assessment
Cheryl Taylor, PhD, RN
Associate Professor of NursingNorth Carolina Agricultural and Technical State UniversityGreensboro, North Carolina
Chapter 16: Cultural Diversity
Lorrie Wong, RN, MS
School of NursingUniversity of HawaiiHonolulu, Hawaii
Chapter 35: Skin Integrity and Wound Healing
Martha Yager, RN
Assistant Director of NursesBennington Health and Rehabilitation CenterBennington, Vermont
Contributors XXXV
Trang 37Bellin College of Nursing
Green Bay, Wisconsin
Beth A Beaudet, RW-c, BSN, MS ed., MSn, FNP
Family Nurse Practitioner
Associate Professor of Nursing
Lakeland Community College
Debbie Dalrymple, RN, MSN, CRNIMontgomery County Community CollegeBlue Bell, Pennsylvania
Sharon Decker, RN, CS, MSN, CCRNAssociate Professor of Clinical NursingSchool of Nursing
Texas Tech University Health Sciences CenterLubbock, Texas
Toni S Doherty, RN, MSNAssociate ProfessorDepartment Head, NursingDutchess Community CollegePoughkeepsie, New YorkColleen Duggan, RN, MSNJohnson County Community CollegeOverland Park, Kansas
Mary Lou Elder, RN, MSInstructor of NursingCentral Community CollegeGrand Island, NebraskaJoanne M Flanders, MS, RNMidwestern State UniversityWichita Falls, Texas
Kathy Frey, RN, MSNUniversity of South AlabamaMobile, Alabama
Marcia Gellin, RN, EdDErie Community CollegeBuffalo, New York
XXXVI
Trang 38Indiana State University
Terre Haute, Indiana
Jan Kinman, RN
Lane Community College
Eugene, Oregon
Marjorie Knox, RN, MA, MPA
Community College of Rhode Island
Lincoln, Rhode Island
Anne M Larson, RN, C PhD
Associate Professor of Nursing
Midland Lutheran College
Fremont, Nebraska
Hope B Laughlin, BSN, MEd, EdD, MSN
Coordinator of Fundamentals of Nursing Courses
Pensacola Junior College
Pensacola, Florida
Patty Leary, MEd, RNMecosta Osceola Career CenterBig Rapids, Michigan
Denise LeBlancHumber CollegeEtobicoke, Ontario, CanadaPatricia M Lester, RN, MSNAssociate Professor
Cumberland Valley Technical CollegePineville, Kentucky
Sharon Little-Stoetzel, RN, MSAssistant Professor of NursingGraceland University
Independence, MissouriPatricia Kaiser McCloud, RN, BSN, MSUniversity of Michigan
Ann Arbor, MichiganSuzanne McDevitt, RN, MSN, CCRNUniversity of Michigan
Ann Arbor, MichiganChris McGeeverSchool of Nursing
St Xavier UniversityChicago, Illinois Myrtle Miller, RN, BSN, MAAssistant Professor
DeKalb CollegeClarkson, GeorgiaMaureen P Mitchell, RN, BScN, MNCenter for Health Studies
Mount Royal CollegeCalgary, Alberta, CanadaPertice Moffitt, RN, BSNAurora College
Yellowknife, Northwest Territories, Canada Regina Nicholson, RN
Hospital for Joint DiseasesNew York, New YorkKatherine Bordelon Pearson, FNP, RN, CS
A D N Department FacultyTemple College
Temple, TexasEdith Prichett, RN, MSNAsheville Buncombe Technical Community College
Asheville, North Carolina
Reviewers XXXVII
Trang 39Carol Rafferty, RN, PhD
Northeast Wisconsin Technical College
Green Bay, Wisconsin
Chattanooga State Practical Nursing
and Surgical Technological Programs
Chattanooga, Tennessee
Ruth Schaffler, RN, MSN, MA, ARNP
Pacific Lutheran University
Tacoma, Washington
Sandy J Shortridge, RN, MSNSouthwest Virginia Community CollegeKeenmtu, Virginia
Gail Smith, MSN, RNDepartment of NursingMiami-Dade Community CollegeMiami, Florida
Maria A Smith, DSN, RN, CCRNSchool of Nursing
Middle Tennessee State UniversityMurfreesboro, Tennessee
Sharon Staib, RN, MSAssistant ProfessorOhio UniversityZanesville, OhioPaula P Thompson, BSN, RNEducator
Carilion Roanoke Memorial HospitalSchool of Practical Nursing
Roanoke, VirginiaAnita Thorne, RN, MAArizona State UniversityTempe, Arizona
Elizabeth K Whitbeck, MS, RNAssistant Professor of NursingMaria College
Albany, New York
Trang 40Health care is changing like never before Every day
there are new technologies, new treatments, and new
pressures Changes in response to social, political, and
economic factors are challenging and changing
every-thing—including nursing This text addresses these
changes by recognizing that students, now and in the
future, will have less clinical experience in acute care
settings and more exposure to alternate settings, such as
skilled nursing units, home health, and outpatient
clin-ics, for clinical learning experiences
A holistic concept of people, health, wellness, and
healing is used to avoid the fragmentation that may
occur in some health care settings A holistic perspective
focuses on all dimensions of an individual, including
physiological, psychological, social, cultural, cognitive,
and spiritual An individual cannot be divided into
sep-arate entities and still be viewed as a unique being In
keeping with the holistic perspective, many concepts
(such as sexuality, spirituality) have been integrated
throughout the text
Special attention has been given to provide a clear,
concise presentation of content that is realistic for the
beginning nursing student This text is timely in its
approach to content, recognizing the inherent changes
affecting the health care delivery system and the nursing
curriculum The authors recognize the student as an
active participant who assumes a collaborative role in
the learning process Content is presented to challenge
the student to develop critical thinking skills
ORGANIZATION
Unit I, Nursing’s Perspective: Past, Present and
Future, explores many aspects that are essential to
nursing A historical overview of early leaders and
social forces that have influenced the development of
nursing practice is provided The theoretical
frame-works for guiding professional practice and the icance of incorporating research into nursing practiceare emphasized The evolution of our current healthcare delivery system is discussed with attention given
signif-to proposals for change
Unit II, Nursing Process, The Standard of Care,explains each component of the nursing process Thenursing process is the framework for delivering holisticcare in an organized scientific manner A chapter oncritical thinking leads the unit discussion of the fivephases of the nursing process
Unit III, The Therapeutic Nature of Nursing, cusses the caring nature of nursing as demonstratedthrough therapeutic communication and actions.Nursing, by definition and purpose, is a therapeuticprocess Improving interpersonal and therapeutic effec-tiveness through knowledge and skills are key to thisunit presentation Nurses’ roles in client education areaddressed Complementary and alternative treatmentmodalities are presented here
dis-Unit IV, The Individual and Health, focuses on theholistic nature of individuals and nursing as a holisticdiscipline The impact on an individual's health relatedbehaviors are discussed in relation to the life cycle,aging, stress, culture, self-concept and reaction to loss.Unit V, Professional Accountability, addressesaccountability from the professional, legal and ethicalperspectives Documentation and quality managementare discussed in detail in this unit
Unit VI, Diagnostic and Therapeutic Interventions,present many of the fundamental skills and tools forproviding nursing care Step-by-step instruction andrationale are provided for each of the skills presented.Unit VII, Nursing Management of Basic Needs, dis-cusses areas of nursing care that are common to everyarea of practice Concepts such as safety and infectioncontrol, mobility, fluid and electrolyte balance, skinintegrity, and nutrition are described Step-by-step skillpresentation with rationale is also presented for eachchapter
XXXIX