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دانلود کتاب Fundamentals of Nursing: The Art and Science of Person-Centered Care
دانلود کتاب مبانی پرستاری: هنر و علم مراقبت فرد محور
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Fundamentals of Nursing: The Art and Science of Person-Centered Care
ویرایش: [9 ed.] نویسندگان: Carol Taylor, Pamela Lynn, Jennifer L. Bartlett سری: ISBN (شابک) : 2018024801, 9781496362186 ناشر: Lippincott Williams & Wilkins سال نشر: تعداد صفحات: [5257] زبان: English فرمت فایل : PDF (درصورت درخواست کاربر به PDF، EPUB یا AZW3 تبدیل می شود) حجم فایل: 469 Mb
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Fundamentals of Nursing The Art and Science of Person-Centered Care CONTENTS ACKNOWLEDGMENTS PREFACE LEARNING EXPERIENCE ORGANIZATION Unit I, Foundations of Nursing Practice Unit II, Health Care Delivery Unit III, Person-Centered Care and the Nursing Process Unit IV, Promoting Health Across the Lifespan Unit V, Actions Basic to Nursing Care Unit VI, Promoting Healthy Physiologic Responses Unit VII, Promoting Healthy Psychosocial Responses THEMES Thoughtful Practice and Person-Centered Care Emphasis on Partnering With Patients, Family, and Professional Caregivers Integrated Nursing Process Nursing as an Art and Science Health and Health Disparities Orientation Holistic Care Across the Lifespan Attention to Special Needs of the Older Person Critical Thinking and Clinical Reasoning Healthy Work Environments Focus on Nursing Skills Focus on Community and Expanded Nursing Roles Focus on Safety Evidence-Based Practice Up-to-Date Clinical and Practice Information Self-Assessment Guides SPECIAL FEATURES A FULLY INTEGRATED COURSE EXPERIENCE Lippincott CoursePoint: An Adaptive Learning Experience Lippincott CoursePoint+ SIMULATION, SKILLS, AND VIDEO RESOURCES ADDITIONAL MEDIA AND PRINT RESOURCES Additional Instructor Assessment and Preparation Resources REVIEWERS CONTRIBUTORS HOW TO USE Fundamentals of Nursing HERE’S HOW TO GET STARTED! FOLLOW THE STORY LINES! GET READY TO LEARN! STAY CURRENT ON SAFETY, TECHNOLOGY, AND LEGAL DEVELOPMENTS! DEVELOP CRITICAL THINKING AND CLINICAL REASONING SKILLS! MAKE REFLECTIVE PRACTICE AN ESSENTIAL PART OF YOUR PROFESSIONAL PRACTICE! MASTER NURSING PROCESS! DEVELOP THE NECESSARY SKILLS! PROMOTE HEALTH AND WELLNESS! BE A PATIENT ADVOCATE! GAIN NEW INSIGHTS! EXAMINE THE EVIDENCE! PREPARE FOR NCLEX! COORDINATE YOUR STUDY PLAN! LIPPINCOTT COURSEPOINT IN MEMORIAM Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Guidelines for Nursing Care Case Studies in this Book TWO-PART CASES THAT UNFOLD ACROSS CHAPTERS UNIT I: Foundations of Nursing Practice Unit II: Health Care Delivery Unit III: Person-Centered Care and the Nursing Process Unit IV: Promoting Health Across the Lifespan Unit V: Actions Basic to Nursing Care Unit VI: Promoting Healthy Physiologic Responses Unit VII: Promoting Healthy Psychosocial Responses CASES THAT UNFOLD WITHIN CHAPTERS Unit I: Foundations of Nursing Practice Unit II: Health Care Delivery Unit III: Person-Centered Care and the Nursing Process Unit V: Actions Basic to Nursing Care Unit VI: Promoting Healthy Physiologic Responses Unit VII: Promoting Healthy Psychosocial Responses 1 Introduction to Nursing HISTORICAL PERSPECTIVES ON NURSING Development of Nursing from Early Civilizations to the 16th Century Florence Nightingale and the Birth of Modern Nursing Development of Nursing from the 19th to 21st Centuries DEFINITIONS OF NURSING NURSING’S AIMS AND COMPETENCIES Promoting Health Preventing Illness Restoring Health Facilitating Coping With Disability and Death NURSING AS A PROFESSIONAL DISCIPLINE EDUCATIONAL PREPARATION FOR NURSING PRACTICE Practical and Vocational Nursing Education Registered Nursing Education Diploma in Nursing Associate Degree in Nursing Baccalaureate in Nursing Emerging Entry Points Graduate Education in Nursing Continuing Education In-Service Education PROFESSIONAL NURSING ORGANIZATIONS International Nursing Organization National Nursing Organizations American Nurses Association National League for Nurses American Association of Colleges of Nursing National Student Nurses Association Specialty Practice and Special-Interest Nursing Organizations GUIDELINES FOR NURSING PRACTICE Standards of Nursing Practice Nurse Practice Acts and Licensure Code of Ethics and Professional Values Nursing Process CURRENT TRENDS IN HEALTH CARE AND NURSING SELF-CARE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 2 Theory, Research, and Evidence-Based Practice NURSING KNOWLEDGE Sources of Knowledge Traditional Knowledge Authoritative Knowledge Scientific Knowledge Significance of Knowledge Sources Historical Influences on Nursing Knowledge Nightingale’s Contributions Societal Influences on Nursing Knowledge NURSING THEORY Interdisciplinary Base for Nursing Theories General Systems Theory Adaptation Theory Developmental Theory Nursing Theories Common Concepts in Nursing Theories Nursing Theory in Clinical Practice NURSING RESEARCH The Evolution of Nursing Research Methods of Conducting Nursing Research Quantitative Research Methods Qualitative Research Methods Protection of the Rights of Human Subjects Application of Research to Practice EVIDENCE-BASED PRACTICE Johns Hopkins Nursing Evidence-Based Practice Model Rationale for Using Evidence-Based Practice Steps in Implementing EBP QUALITY IMPROVEMENT DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 3 Health, Wellness, and Health Disparities CONCEPTS OF HEALTH AND WELLNESS CONCEPTS OF ILLNESS AND DISEASE Classifications of Illness Acute Illness Chronic Illness Illness Behaviors STAGE 1: EXPERIENCING SYMPTOMS STAGE 2: ASSUMING THE SICK ROLE STAGE 3: ASSUMING A DEPENDENT ROLE STAGE 4: ACHIEVING RECOVERY AND REHABILITATION Effects of Illness on the Family DISPARITIES IN HEALTH CARE FACTORS AFFECTING HEALTH AND ILLNESS Basic Human Needs The Human Dimensions Physical Dimension Emotional Dimension Intellectual Dimension Environmental Dimension Sociocultural Dimension Spiritual Dimension Self-Concept Risk Factors for Illness or Injury HEALTH PROMOTION AND ILLNESS PREVENTION Primary Health Promotion and Illness Prevention Secondary Health Promotion and Illness Prevention Tertiary Health Promotion and Illness Prevention MODELS OF HEALTH PROMOTION AND ILLNESS PREVENTION The Health Belief Model The Health Promotion Model The Health–Illness Continuum The Agent–Host–Environment Model Stages of Change Model NURSING CARE TO PROMOTE HEALTH AND PREVENT ILLNESS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 4 Health of the Individual, Family, and Community THE INDIVIDUAL’S BASIC HUMAN NEEDS Physiologic Needs Safety and Security Needs Love and Belonging Needs Self-Esteem Needs Self-Actualization Needs Applying Maslow’s Theory THE FAMILY Family Structures Nuclear Family Single-Parent Family Other Family Structures Family Functions Developmental Tasks of Families The Family in Health and Illness Family Risk Factors Nursing Interventions to Promote Family Health THE COMMUNITY Social Support Systems Community Health Care Structure Economic Resources Environmental Factors Effect on Individuals and Families Nursing in the Community DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 5 Cultural Diversity CONCEPTS OF CULTURAL DIVERSITY AND RESPECT Culture Ethnicity Race Factors Inhibiting Sensitivity to Diversity CULTURAL INFLUENCES ON HEALTH CARE Physiologic Variations Reactions to Pain Mental Health Biological Sex Roles Language and Communication Orientation to Space and Time Food and Nutrition Family Support Socioeconomic Factors Health Disparities CULTURAL INFLUENCES ON HEALTH AND ILLNESS CULTURALLY RESPECTFUL NURSING CARE Cultural Assessment Guidelines for Nursing Care Develop Cultural Self-Awareness Develop Cultural Knowledge Accommodate Cultural Practices in Health Care Respect Culturally Based Family Roles Avoid Mandating Change Seek Cultural Assistance DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 6 Values, Ethics, and Advocacy VALUES Development of Values Values Essential to the Professional Nurse Values Clarification Example of Values Clarification by the Nurse Clinical Applications PATIENT PLACES LOW VALUE ON HEALTH AND HEALTH BEHAVIORS VALUES OF PATIENT AND FAMILY MEMBERS CONFLICT ETHICS Nursing Ethics Theories of Ethics Principle-Based Approach Care-Based Approach Feminist Ethics ETHICAL CONDUCT Moral Agency The Virtues of Nurses Nursing Codes of Ethics Nursing Standards of Practice Bill of Rights for Registered Nurses ETHICAL EXPERIENCE AND DECISION MAKING Moral Distress and Resiliency Conscientious Objection Making Ethical Decisions Ethically Relevant Considerations Examples of Ethical Problems Paternalism Deception Privacy and Social Media Confidentiality Allocation of Scarce Nursing Resources Valid Consent or Refusal Conflicts Concerning New Technologies Unprofessional, Incompetent, Unethical, or Illegal Physician Practice Unprofessional, Incompetent, Unethical, or Illegal Nurse Practice Short Staffing Issues Beginning-of-Life Issues End-of-Life Issues Nurses and Ethics Committees CONFLICTS OF COMMITMENT ADVOCACY IN NURSING PRACTICE Representing Patients Promoting Self-Determination Whistle-Blowing Being Politically Active A Final Note About Trustworthiness DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 7 Legal Dimensions of Nursing Practice LEGAL CONCEPTS Definition of Law Sources of Laws Constitutions Statutory Law Administrative Law Common Law The Court System PROFESSIONAL AND LEGAL REGULATION OF NURSING PRACTICE Nurse Practice Acts Standards Credentialing Accreditation Licensure Certification CRIMES AND TORTS Crime Torts Intentional Torts ASSAULT AND BATTERY DEFAMATION INVASION OF PRIVACY FALSE IMPRISONMENT FRAUD Unintentional Torts NEGLIGENCE AND MALPRACTICE ELEMENTS OF LIABILITY STANDARDS OF CARE Malpractice Litigation NURSE AS DEFENDANT NURSE AS FACT WITNESS NURSE AS EXPERT WITNESS LEGAL SAFEGUARDS FOR THE NURSE Competent Practice Issues That Affect Competent Practice Nurse Fatigue The Impaired Nurse Informed Consent or Refusal Contracts Collective Bargaining Patient Education Executing Provider Orders Delegating Nursing Care Documentation Appropriate Use of Social Media Adequate Staffing Whistle-Blowing Professional Liability Insurance Risk Management Programs Just Culture Incident, Variance, or Occurrence Reports Sentinel Events Never Events Patients’ Rights Good Samaritan Laws Student Liability LAWS AFFECTING NURSING PRACTICE Occupational Safety and Health National Practitioner Data Bank Reporting Obligations Controlled Substances Discrimination and Sexual Harassment Health Insurance Portability and Accountability Act Restraints People With Disabilities Wills Legal Issues Related to Dying and Death DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 8 Communication THE PROCESS OF COMMUNICATION FORMS OF COMMUNICATION Verbal Communication Nonverbal Communication Touch Eye Contact Facial Expressions Posture Gait Gestures General Physical Appearance Mode of Dress and Grooming Sounds Silence Electronic Communication Social Media E-Mail and Text Messages LEVELS OF COMMUNICATION Intrapersonal Communication Interpersonal Communication Group Communication Small-Group Communication Organizational Communication Group Dynamics FACTORS INFLUENCING COMMUNICATION Developmental Level Biological Sex Sociocultural Differences Roles and Responsibilities Space and Territoriality Physical, Mental, and Emotional State Values Environment USING PROFESSIONAL COMMUNICATION IN THE NURSING PROCESS Assessing Diagnosing Outcome Identification and Planning Implementing Evaluating DOCUMENTING COMMUNICATION EFFECTIVE PROFESSIONAL COMMUNICATION Hand-off Communication: SBAR I-SBAR-R and the QSEN Institute SBAR and The Joint Commission: The Hand-off TST Rising Level of Concern Communication: CUS USING PROFESSIONAL COMMUNICATION IN THE HELPING RELATIONSHIP A Helping Relationship Versus a Social Relationship Characteristics of the Helping Relationship Goals of the Helping Relationship Phases of the Helping Relationship Orientation Phase Working Phase Termination Phase Factors Promoting Effective Communication Within the Helping Relationship Dispositional Traits WARMTH AND FRIENDLINESS OPENNESS AND RESPECT EMPATHY HONESTY, AUTHENTICITY, AND TRUST CARING COMPETENCE Rapport Builders SPECIFIC OBJECTIVES COMFORTABLE ENVIRONMENT PRIVACY CONFIDENTIALITY PATIENT VERSUS TASK FOCUS USING NURSING OBSERVATIONS OPTIMAL PACING DEVELOPING PROFESSIONAL THERAPEUTIC COMMUNICATION SKILLS Conversation Skills Listening Skills Silence Touch Humor Interviewing Techniques Open-Ended Question or Comment Closed Question or Comment Validating Question or Comment Clarifying Question or Comment Reflective Question or Comment Sequencing Question or Comment Directing Question or Comment Assertive Versus Aggressive Behaviors and Communication BLOCKS TO COMMUNICATION Failure to Perceive the Patient as a Human Being Failure to Listen Nontherapeutic Comments and Questions Clichés Questions Requiring Only a Yes or No Answer Questions Containing the Words Why and How Questions that Probe for Information Leading Questions Comments that Give Advice Judgmental Comments Changing the Subject Giving False Assurance Gossip and Rumor Disruptive Interpersonal Behavior and Communication Incivility and Bullying Responses to Disruptive Behaviors and Communication IMPAIRED VERBAL COMMUNICATION REFLECTIVE PRACTICE LEADING TO PERSONAL LEARNING DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 9 Teaching and Counseling AIMS of Teaching and Counseling Maintaining and Promoting Health Preventing Illness Restoring Health Facilitating Coping Promoting Outcomes THE NURSE AS A TEACHER Factors Affecting Patient Learning Age and Developmental Level CHILD AND ADOLESCENT LEARNERS ADULT LEARNERS Family Support Networks and Financial Resources Cultural Influences and Language Deficits Health Literacy Promoting Health Literacy IN PATIENTS WHO SMOKE Patient Scenario Nursing Considerations: Tips for Improving Health Literacy Learning Domains Effective Communication Techniques NURSING PROCESS FOR PATIENT AND CAREGIVER TEACHING THE NURSE AS COUNSELOR Types of Counseling Short-Term Counseling Long-Term Counseling Motivational Interviewing Referrals DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 10 Leading, Managing, and Delegating LEADERSHIP Leadership Qualities Personal Leadership Skills Leadership Styles Autocratic Leadership Democratic Leadership Laissez-Faire Leadership Servant Leadership Quantum Leadership Transactional Leadership Transformational Leadership DEVELOPMENT OF THE MAGNET RECOGNITION PROGRAM SIGNIFICANCE OF MAGNET RECOGNITION IMPLEMENTATION OF A “JUST CULTURE” MANAGEMENT Centralized and Decentralized Management Structures Conflict Management and Engagement Managing Change Change Theory Planned Change Resistance to Change THREAT TO SELF LACK OF UNDERSTANDING LIMITED TOLERANCE FOR CHANGE DISAGREEMENTS ABOUT THE BENEFITS OF CHANGE FEAR OF INCREASED RESPONSIBILITY Overcoming Resistance to Change Power IMPLEMENTING LEADERSHIP AND MANAGEMENT SKILLS IN NURSING CARE Patient Care Coordination Clinical Nurse Leader Role Delegating Nursing Care Knowledge of the Administrative Structure Nursing Department Employing Institution or Facility Support for Leadership Training Mentorship Preceptorship Participation in Nursing and Other Professional Organizations Continuing Education Developing Resilience DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 11 The Health Care Delivery System HEALTH CARE: THE BIG PICTURE Access to Health Care Who Are the Uninsured? Shortage of Providers Legislation Addressing Health Care Access Quality and Safety Reliable Care Accountability Matrix Pay for Performance/Value-Based Purchasing Penalties for Excess Readmissions Affordability How Health Care is Financed How the U.S. Health Care Dollar Is Spent How the U.S. Health Care System Compares Internationally HEALTH CARE REFORM ORGANIZING HEALTH CARE: PRIMARY, SECONDARY, AND TERTIARY CARE ORGANIZING HEALTH CARE: HEALTH CARE DELIVERY SYSTEMS AND CARE COORDINATION Health Care Providers and Hospitals Multispecialty Group Practice Community Health Centers Prepaid Group Practice Accountable Care Organizations Medical Homes to Medical Neighborhoods Care Coordination PAYING FOR HEALTH CARE Out-of-Pocket Payment Individual Private Insurance Employer-Based Private Insurance Government Financing Medicare Medicaid Children’s Health Insurance Program Veterans Health Administration HEALTH CARE SETTINGS AND SERVICES Hospitals Classification Size and Services Inpatient and Outpatient Services Nurses’ Role in Hospitals Primary Care Centers Ambulatory Care Centers and Clinics Home Health Care Extended-Care Services Specialized Care Centers and Settings Daycare Centers Mental Health Centers Rural Health Centers Schools Industry Homeless Shelters Rehabilitation Centers Parish Nursing Health Care Services for the Seriously Ill and Dying Respite Care Hospice Services Palliative Care HEALTH CARE FACILITIES Voluntary Facilities Other Government Facilities Public Health Service Public Health Facilities COLLABORATIVE CARE: THE HEALTH CARE TEAM TRENDS AND ISSUES IN HEALTH CARE DELIVERY Focus on Preventive Care Knowledgeable and Engaged Consumers Mobile Health HEALTH CARE: A RIGHT, A PRIVILEGE, OR AN OBLIGATION OF A MORAL SOCIETY? NURSES’ ROLE IN HEALTH CARE REFORM DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 12 Collaborative Practice and Care Coordination Across Settings COMMUNITY-BASED NURSING CARE Qualities of the Community-Based Nurse Knowledgeable and Skilled Independent in Making Decisions Accountable Roles of the Community-Based Nurse Patient Advocate Coordinator of Services Patient and Family Educator CONTINUITY OF CARE COLLABORATIVE PRACTICE Components of Effective Team Structure Core Competencies for Interprofessional Collaborative Practice CARE COORDINATION Validation of Nursing Care Coordination Activities Why Care Coordination Now? The Care Coordinator Populations With Special Care Coordination Needs Admissions, Transfers, and Discharges Admission to an Ambulatory Care Facility Admission to the Hospital PREPARING THE ROOM FOR ADMISSION ADMITTING THE PATIENT TO THE UNIT Transferring Within and Between Health Care Settings TRANSFER WITHIN THE HOSPITAL TRANSFER TO AN EXTENDED CARE FACILITY Discharge from a Health Care Setting DISCHARGE PLANNING GUIDELINES FOR DISCHARGE PLANNING Assessing and Identifying Health Care Needs Setting Goals With the Patient Teaching Meeting Eligibility Requirements for Community-Based Settings EVALUATING DISCHARGE PLANNING EFFECTIVENESS Leaving the Hospital Against Medical Advice HOME HEALTH CARE NURSING Types of Home Health Care Facilities Patients and Family Caregivers Referrals for Home Care Orders for Home Care Safety Considerations Infection Prevention Reimbursement Sources Legal Considerations THE HOME VISIT The Pre-entry Phase of the Home Visit The Entry Phase of the Home Visit Identifying Needs and Determining Interventions Teaching the Patient and Caregivers Documenting Care Given in the Home DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 13 Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care THOUGHTFUL PRACTICE PERSON-CENTERED CARE Theories of Caring THE PROFESSIONAL NURSE Personal Attributes Knowledge Base Blended Competencies Developing Cognitive Competencies DEVELOPING THE METHOD OF CRITICAL THINKING Purpose of Thinking Adequacy of Knowledge Potential Problems Helpful Resources Critique of Judgment/Decision Focused Critical Thinking Guides DEVELOPING THE PERSONAL ATTRIBUTES TO THINK CRITICALLY Developing Technical Competencies Developing Interpersonal Competencies PROMOTING HUMAN DIGNITY AND RESPECT ESTABLISHING CARING RELATIONSHIPS PREPARING YOUR ATTENTION AND INTENTION FOR EACH CLINICAL ENCOUNTER ENJOYING THE REWARDS OF MUTUAL EXCHANGE Developing Ethical and Legal Competencies QSEN Competencies Clinical Reasoning, Judgments, and Decision Making Problem Solving TRIAL-AND-ERROR PROBLEM SOLVING SCIENTIFIC PROBLEM SOLVING INTUITIVE PROBLEM SOLVING CRITICAL THINKING: INTUITIVE, LOGICAL, OR BOTH? Creative Thinking Decision Making and Clinical Reasoning THE NURSING PROCESS Historical Perspective Description of the Nursing Process Nursing Process Trends Characteristics of the Nursing Process Systematic Dynamic Interpersonal Outcome Oriented Universally Applicable in Nursing Situations Documenting the Nursing Process Benefits of the Nursing Process Evaluating the Use of the Nursing Process Concept Mapping Promoting Health Literacy IN PATIENTS AND FAMILIES WITH ASTHMA Patient Scenario Nursing Considerations: Tips for Improving Health Literacy REFLECTIVE PRACTICE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 14 Assessing UNIQUE FOCUS OF NURSING ASSESSMENT ASSESSMENT AND CLINICAL REASONING ASSESSMENT AND INTERPERSONAL COMPETENCE TYPES OF NURSING ASSESSMENTS Initial Assessment Focused Assessment Emergency Assessment Time-Lapsed Assessment Patient-Centered Assessment Method PREPARING FOR DATA COLLECTION Establishing Assessment Priorities Health Orientation Developmental Stage Culture Need for Nursing Structuring the Assessment COLLECTING DATA Sources of Data The Patient The Family and Significant Others The Patient Record MEDICAL HISTORY, PHYSICAL EXAMINATION, AND PROGRESS NOTES CONSULTATIONS REPORTS OF LABORATORY AND OTHER DIAGNOSTIC STUDIES REPORTS OF THERAPIES BY OTHER HEALTH CARE PROFESSIONALS Assessment Technology Other Health Care Professionals Nursing and Other Health Care Literature Methods of Data Collection Nursing History COMPONENTS OF A NURSING HISTORY PATIENT INTERVIEW Physical Assessment Problems Related to Data Collection IDENTIFYING CUES AND MAKING INFERENCES VALIDATING DATA CLUSTERING RELATED DATA AND IDENTIFYING PATTERNS REPORTING AND RECORDING DATA Timing Documentation Privacy, Confidentiality, and Professionalism DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 15 Diagnosing EVOLUTION OF NURSING DIAGNOSES UNIQUE FOCUS OF NURSING DIAGNOSIS Nursing Diagnosis Versus Medical Diagnosis Nursing Diagnosis Versus Collaborative Problem DIAGNOSTIC REASONING AND CLINICAL REASONING DIAGNOSTIC REASONING AND INTERPERSONAL COMPETENCE DATA INTERPRETATION AND ANALYSIS Recognizing Significant Data Recognizing Patterns or Clusters Identifying Strengths and Problems Determining Patient and Family Strengths Determining the Patient’s Problem Areas Determining Problems the Patient Is Likely to Experience Identifying Potential Complications Reaching Conclusions No Problem Possible Problem Actual or Potential Nursing Diagnosis or Problem or Issue Clinical Problem Other Than Nursing Diagnosis Partnering With the Patient and Family FORMULATING AND VALIDATING NURSING DIAGNOSES Terminology for Writing Nursing Diagnoses Types of Nursing Diagnoses Problem-Focused Nursing Diagnoses Risk Nursing Diagnoses Health Promotion Nursing Diagnoses Parts of Nursing Diagnosis Statements Problem Etiology Defining Characteristics Guidelines for Writing Nursing Diagnoses What Is Not a Nursing Diagnosis Validating Nursing Diagnoses Next Steps DOCUMENTING NURSING DIAGNOSES Importance of Nursing Diagnoses in Electronic Health Records NURSING DIAGNOSIS: A CRITIQUE DEVELOPING CRITICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 16 Outcome Identification and Planning UNIQUE FOCUS OF NURSING OUTCOME IDENTIFICATION AND PLANNING Critical Thinking/Clinical Reasoning in Outcome Identification and Planning Interpersonal Competence in Outcome Identification and Planning: Working With Patients and Families COMPREHENSIVE PLANNING Initial Planning Ongoing Planning Discharge Planning ESTABLISHING PRIORITIES Maslow’s Hierarchy of Human Needs Patient Preference Anticipation of Future Problems Critical Thinking/Clinical Reasoning and Establishing Priorities IDENTIFYING AND WRITING OUTCOMES Deriving Outcomes From Nursing Diagnoses Establishing Long-Term Versus Short-Term Outcomes Determining Patient-Centered Outcomes Family Involvement Ensuring Quality Outcomes Using Cognitive, Psychomotor, and Affective Outcomes Identifying Clinical, Functional, and Quality-of-Life Outcomes Identifying Culturally Appropriate Outcomes Identifying Outcomes Supportive of the Total Treatment Plan Writing Patient-Centered Measurable Outcomes Avoiding Common Errors in Outcomes IDENTIFYING NURSING INTERVENTIONS Nurse-Initiated Interventions Identifying and Selecting Appropriate Nurse-Initiated Interventions Individualizing Evidence-Based Interventions Recording Nurse-Initiated Interventions in the Patient Record Physician-Initiated and Collaborative Interventions Structured Care Methodologies Consulting DEVELOPING EVALUATIVE STRATEGIES COMMUNICATING AND RECORDING THE NURSING CARE PLAN Institutional and Facility Care Plans Types of Nursing Care NURSING CARE RELATED TO BASIC HUMAN NEEDS NURSING CARE RELATED TO NURSING DIAGNOSES/PROBLEMS NURSING CARE RELATED TO THE MEDICAL AND INTERDISCIPLINARY CARE PLAN Formats for Care Plans COMPUTERIZED CARE PLANS CONCEPT MAP CARE PLANS CHANGE-OF-SHIFT REPORTS MULTIDISCIPLINARY (COLLABORATIVE) CARE PLANS Student Care Plans Assessing Diagnosing Outcome Identification and Planning Implementing Evaluating PROBLEMS RELATED TO OUTCOME IDENTIFICATION AND PLANNING A FINAL WORD ABOUT STANDARDIZED LANGUAGES AND HOLISTIC, PERSON-CENTERED CARE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 17 Implementing UNIQUE FOCUS OF NURSING IMPLEMENTATION The Nursing Interventions Taxonomy Structure Care Coordination, Continuity, and the Nurse CRITICAL THINKING/CLINICAL REASONING AND IMPLEMENTING IMPLEMENTING AND INTERPERSONAL COMPETENCE TYPES OF NURSING INTERVENTIONS Nursing Interventions Classification Independent and Collaborative Interventions Protocols and Standing Orders IMPLEMENTING THE CARE PLAN Reassessing the Patient and Reviewing the Plan of Care Using Patient Boards or Whiteboards Clarifying Prerequisite Nursing Competencies Planning Ahead and Organizing Resources Patient and Patient Visitors Equipment Environment Personnel Anticipating Unexpected Outcomes and Situations Ensuring Quality and Patient Safety: Preventing Errors and Omissions Promoting Self-Care: Teaching, Counseling, and Advocacy Assisting Patients to Meet Health Outcomes Patient Variables DEVELOPMENTAL STAGE PSYCHOSOCIAL BACKGROUND AND CULTURE Nurse Variables Resources Current Standards of Care Research Findings Ethical and Legal Guides to Practice CONTINUING DATA COLLECTION AND RISK MANAGEMENT DOCUMENTING NURSING CARE WHEN A PATIENT DOES NOT COOPERATE WITH THE PLAN OF CARE DELEGATING NURSING CARE Delegation and the Student Nurse GUIDE FOR STUDENTS Organizing Care Nursing Oneself DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 18 Evaluating UNIQUE FOCUS OF NURSING EVALUATION CRITICAL THINKING/CLINICAL REASONING AND EVALUATING Identifying Evaluative Criteria and Standards Collecting Evaluative Data Types of Outcomes Time Criteria Interpreting and Summarizing Findings Documenting Your Judgment Modifying the Care Plan EVALUATING QUALITY CARE Performance Improvement in Everyday Clinical Practice Establishing and Sustaining Healthy Work Environments Evaluative Programs Quality Assurance From Quality Assurance to Quality Improvement Patient Satisfaction Nursing’s Patient Safety and Quality Initiative Concurrent Versus Retrospective Evaluation DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 19 Documenting and Reporting DOCUMENTING CARE Guidelines for Effective Documentation Privacy and Confidentiality What Information Is Confidential? Health Information Privacy Facility Policies Delegating Documentation Purposes of Patient Records Communication Diagnostic and Therapeutic Orders VERBAL ORDERS Care Planning Quality Process and Performance Improvement Research Decision Analysis Education Credentialing, Regulation, and Legislation Legal Documentation Reimbursement Historical Documentation Methods of Documentation Computerized Documentation and Electronic Health Records PERSONAL HEALTH RECORDS HEALTH INFORMATION EXCHANGE Source-Oriented Records Problem-Oriented Medical Records PIE Charting: Problem, Intervention, Evaluation Focus Charting Charting by Exception Case Management Model COLLABORATIVE PATHWAYS OCCURRENCE CHARTING Formats for Nursing Documentation Initial Nursing Assessment Care Plan Patient Care Summary Critical/Collaborative Pathways Progress Notes Flow Sheets and Graphic Records Medication Administration Records (MARs) Acuity Records Discharge and Transfer Summary Home Health Care Documentation Long-Term Care Documentation REPORTING CARE Change-of-Shift/Handoff Reports Telephone/Telemedicine Reports Transfer and Discharge Reports Reports to Family Members and Significant Others Incident Reports CONFERRING ABOUT CARE Consultations and Referrals Nursing and Interdisciplinary Team Care Conferences Nursing Care Rounds Purposeful Rounding DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 20 Nursing Informatics HISTORY OF NURSING INFORMATICS NURSING INFORMATICS DEFINED NURSING INFORMATICS EDUCATION NURSING INFORMATICS PRACTICE THE SYSTEM DEVELOPMENT LIFECYCLE Analyze and Plan Design Test Train Implement Maintain Evaluate IMPORTANT INFORMATICS CONCEPTS TO UNDERSTAND System Usability System Optimization Standard Terminologies Interoperability Security and Privacy of Electronic Data EMERGING AREAS IN THE FIELD OF INFORMATICS Patient Portals Health Care Analytics Data Visualization Predictive Analytics Big Data Example: Using Analytics and Big Data to Support Population Health Telehealth and Mobile Technologies Genetics and Genomics: Precision Medicine DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 21 Developmental Concepts PRINCIPLES OF GROWTH AND DEVELOPMENT FACTORS INFLUENCING GROWTH AND DEVELOPMENT Genetics, Genomics, and Epigenetics Prenatal, Individual, and Caregiver Factors Environment and Nutrition OVERVIEW OF DEVELOPMENTAL THEORIES Theory of Psychoanalytic Development Sigmund Freud ORAL STAGE (AGES 0 TO 18 MONTHS) ANAL STAGE (AGES 8 MONTHS TO 3 YEARS) PHALLIC STAGE (AGES 3 TO 7 YEARS) LATENCY STAGE (AGES 7 TO 12 YEARS) GENITAL STAGE (AGES 12 TO 20 YEARS) Theory of Cognitive Development Jean Piaget SENSORIMOTOR STAGE (BIRTH TO 2 OR 3 YEARS) PREOPERATIONAL STAGE (AGES 2 OR 3 TO 6 OR 7 YEARS) CONCRETE OPERATIONAL STAGE (AGES 6 OR 7 TO 11 OR 12 YEARS) FORMAL OPERATIONAL STAGE (AGES 11 OR 12 TO 14 OR 15 YEARS) Theories of Psychosocial Development Erik Erikson TRUST VERSUS MISTRUST (INFANT) AUTONOMY VERSUS SHAME AND DOUBT (TODDLER) INITIATIVE VERSUS GUILT (PRESCHOOL) INDUSTRY VERSUS INFERIORITY (SCHOOL-AGED CHILDREN) IDENTITY VERSUS ROLE CONFUSION (ADOLESCENCE) INTIMACY VERSUS ISOLATION (YOUNG ADULTHOOD) GENERATIVITY VERSUS STAGNATION (MIDDLE ADULTHOOD) EGO INTEGRITY VERSUS DESPAIR (LATER ADULTHOOD) Robert J. Havighurst INFANCY AND EARLY CHILDHOOD MIDDLE CHILDHOOD ADOLESCENCE YOUNG ADULTHOOD MIDDLE ADULTHOOD Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Early Child Care and Adolescent Functioning at the End of High School Related Research Relevance to Nursing Practice LATER MATURITY Roger Gould AGES 18 TO 22 YEARS: LEAVING THE PARENTS’ WORLD AGES 22 TO 28 YEARS: GETTING INTO THE ADULT WORLD AGES 29 TO 34 YEARS: QUESTIONING AND REEXAMINATION AGES 35 TO 43 YEARS: MIDLIFE DECADE AGES 43 TO 50 YEARS: RECONCILIATION AND MELLOWING AGES 50 AND OVER: STABILITY AND ACCEPTANCE Daniel Levinson and Associates THE NOVICE PHASE SETTLING DOWN: BUILDING A SECOND ADULT LIFE STRUCTURE MIDLIFE TRANSITION AND ENTERING MIDDLE ADULTHOOD Theories of Moral Development Lawrence Kohlberg PRECONVENTIONAL LEVEL CONVENTIONAL LEVEL POSTCONVENTIONAL LEVEL Carol Gilligan LEVEL 1—PRECONVENTIONAL: SELFISHNESS LEVEL 2—CONVENTIONAL: GOODNESS LEVEL 3—POSTCONVENTIONAL: NONVIOLENCE Theory of Faith Development James Fowler PRESTAGE: UNDIFFERENTIATED FAITH STAGE 1: INTUITIVE–PROJECTIVE FAITH STAGE 2: MYTHICAL–LITERAL FAITH STAGE 3: SYNTHETIC–CONVENTIONAL FAITH STAGE 4: INDIVIDUATIVE–REFLECTIVE FAITH STAGE 5: CONJUNCTIVE FAITH STAGE 6: UNIVERSALIZING FAITH APPLYING THEORIES OF GROWTH AND DEVELOPMENT TO NURSING CARE DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 22 Conception Through Young Adult CONCEPTION AND PRENATAL DEVELOPMENT Pre-embryonic Stage Embryonic Stage Fetal Stage NEONATE: BIRTH TO 28 DAYS Physiologic Development Health of the Neonate INFANT: 1 MONTH TO 1 YEAR Physiologic Development Cognitive Development Psychosocial Development Developmental Theories Special Considerations ATTACHMENT AND BONDING PLAY TEMPERAMENT Health of the Infant Infant Colic Failure to Thrive Accidental Injuries Sudden Infant Death Syndrome and Sudden Unexpected Infant Death Child Maltreatment Role of the Nurse in Promoting Health and Preventing Illness TODDLER: 1 TO 3 YEARS Physiologic Development Cognitive Development Psychosocial Development Freud’s Theory Teaching Tips 22-1 Erikson’s Theory Havighurst’s Theory Health of the Toddler Role of the Nurse in Promoting Health and Preventing Illness PRESCHOOLER: 3 TO 6 YEARS Physiologic Development Cognitive Development Psychosocial Development Freud’s Theory Erikson’s Theory Teaching Tips 22-2 Havighurst’s Theory Special Considerations Moral and Spiritual Development Health of the Preschooler Role of the Nurse in Promoting Health and Preventing Illness Teaching Tips 22-3 SCHOOL-AGED CHILD: 6 TO 12 YEARS Physiologic Development Cognitive Development Psychosocial Development Freud’s Theory Erikson’s Theory Havighurst’s Theory Special Considerations Moral Development Spiritual Development Health of the School-Aged Child Obesity Learning Disabilities and Related Disorders Enuresis Role of the Nurse in Promoting Health and Preventing Illness Teaching Tips 22-4 THE ADOLESCENT AND YOUNG ADULT Physiologic Development Cognitive Development Psychosocial Development Freud’s Theory Erikson’s Theory Havighurst’s Theory Levinson’s Theory Gould’s Theory Special Considerations CHOOSING AN OCCUPATION OR CAREER ESTABLISHING A FAMILY Moral Development Spiritual Development Health of the Adolescent and Young Adult Injuries Suicide (Self-harm) Substance Abuse Pregnancy Nutritional Problems Sexually Transmitted Infections Developmental and Situational Stressors STRESSORS RELATED TO SEXUAL ORIENTATION FAMILY STRESSORS Role of the Nurse in Promoting Health and Preventing Illness Teaching Tips 22-5 DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 23 The Aging Adult BIOLOGICAL THEORIES OF AGING Genetic Theory Neuroendocrine and Immunity Theories Stochastic Theories THE MIDDLE ADULT Physiologic Development Cognitive Development Psychosocial Development Erikson’s Theory Havighurst’s Theory Levinson’s Theory Gould’s Theory Adjusting to the Changes of Middle Adulthood Employment Spousal Relationships Relationships With Children and Aging Family Members Moral Development Spiritual Development Health of the Middle Adult Role of the Nurse in Promoting Health and Preventing Illness THE OLDER ADULT A Unique Population Ageism and Common Stereotypes Physiologic Development Cognitive Development Psychosocial Development Disengagement Theory Erikson’s Theory Havighurst’s Theory Adjusting to the Changes of Older Adulthood Physical Strength and Health Retirement and Reduced Income Spouse or Partner Health Relating to Age Group Social Roles Living Arrangements Family and Role Reversal Moral and Spiritual Development Health of the Older Adult Chronic Illness IMPLICATIONS FOR HEALTH CARE Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Polypharmacy in Older Adults Related Research Relevance to Nursing Practice DIVERSITY AND CHRONIC ILLNESS Accidental Injuries Dementia, Delirium, and Depression DEMENTIA DELIRIUM DEPRESSION Elder Abuse Older Adults and the Health Care System Role of the Nurse in Promoting Health and Preventing Illness CARING FOR AN AGING POPULATION DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 24 Asepsis and Infection Control INFECTION Infection Cycle Infectious Agent IDENTIFICATION OF INFECTIOUS AGENTS COLONIZATION VERSUS INFECTION Reservoir OTHER PEOPLE OTHER RESERVOIRS Portal of Exit Means of Transmission Portal of Entry Susceptible Host Stages of Infection Incubation Period Prodromal Stage Full Stage of Illness Convalescent Period The Body’s Defense Against Infection Inflammatory Response Immune Response Factors Affecting the Risk for Infection Focus on the Older Adult THE NURSING PROCESS FOR INFECTION PREVENTION AND CONTROL Assessing Diagnosing Outcome Identification and Planning Implementing Using Medical Asepsis PERFORMING HAND HYGIENE Promoting Health 24-1 INFECTION CONTROL PRECAUTIONS AND BARRIER TECHNIQUES Assessment Checklist Self-Care Behaviors Bacteria Cleansing Agents Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Improving Hand Hygiene at Eight Hospitals in the United States by Targeting Specific Causes of Noncompliance Related Research Relevance to Nursing Practice Techniques ►Guidelines for Nursing Care 24-1 HAND HYGIENE: USING AN ALCOHOL-BASED HANDRUB Preventing Health Care–Associated Infections USING INVASIVE MEDICAL DEVICES REPORTING HEALTH CARE–ASSOCIATED INFECTIONS (HAIS) DEALING WITH MULTIDRUG-RESISTANT ORGANISMS MRSA VISA, VRSA, and VRE CRE Acinetobacter baumannii Clostridium difficile STERILIZING AND DISINFECTING Method Selection USING PERSONAL PROTECTIVE EQUIPMENT AND SUPPLIES Gloves Gowns Masks Protective Eyewear HANDLING AND DISPOSING OF SUPPLIES USING STANDARD AND TRANSMISSION-BASED ISOLATION PRECAUTIONS Current CDC Guidelines PREVENTING OCCUPATIONAL EXPOSURES REPORTING ACCIDENTAL EXPOSURES PROVIDING CARE IN SPECIAL SITUATIONS Using Surgical Asepsis OPENING A STERILE PACKAGE AND PREPARING A STERILE FIELD POURING STERILE SOLUTIONS ADDING STERILE SUPPLIES TO A STERILE FIELD PUTTING ON STERILE GLOVES POSITIONING A STERILE DRAPE Meeting Needs of Patients Requiring Infection Control Precautions Raising Ethical Concerns About Infection Risks Working With the Infection Preventionist Nursing Advocacy in Action Patient Scenario Implications for Nursing Advocacy Teaching About Infection Control Evaluating Skill 24-1 ►Performing Hand Hygiene Using Soap and Water (Handwashing) DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION SPECIAL CONSIDERATIONS Skill 24-2 ►Using Personal Protective Equipment (PPE) DELEGATION CONSIDERATIONS EQUIPMENT DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Skill 24-3 ►Preparing a Sterile Field and Adding Sterile Items to a Sterile Field DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Skill 24-4 ►Putting on Sterile Gloves and Removing Soiled Gloves DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 25 Vital Signs Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Vital Signs and Documentation Related Research Relevance to Nursing Practice TEMPERATURE Physiology of Body Temperature Heat Production Heat Loss Factors Affecting Body Temperature Circadian Rhythms Age and Biological Sex Physical Activity State of Health Environmental Temperature Normal Body Temperature Increased Body Temperature Physical Effects of Fever Treatment of Fever ►Guidelines for Nursing Care 25-1 USING A HYPOTHERMIA BLANKET TO REGULATE BODY TEMPERATURE Decreased Body Temperature Physical Effects of Hypothermia Treatment of Hypothermia Assessing Temperature Equipment ELECTRONIC AND DIGITAL THERMOMETERS TYMPANIC MEMBRANE THERMOMETERS TEMPORAL ARTERY THERMOMETERS DISPOSABLE SINGLE-USE THERMOMETERS AUTOMATED MONITORING DEVICES Sites and Methods of Assessing Body Temperature ASSESSING AN ORAL TEMPERATURE ASSESSING A TYMPANIC MEMBRANE TEMPERATURE ASSESSING A TEMPORAL ARTERY TEMPERATURE ASSESSING AN AXILLARY TEMPERATURE ASSESSING A RECTAL TEMPERATURE PULSE Physiology of the Pulse Factors Affecting the Pulse Age and Biological Sex Physical Activity Fever and Stress Medications Disease Normal Pulse Rate Increased Pulse Rate Decreased Pulse Rate Pulse Amplitude (Quality) Pulse Rhythm Assessing the Pulse Equipment STETHOSCOPE DOPPLER ULTRASOUND ►Guidelines for Nursing Care 25-2 ASSESSING PERIPHERAL PULSE USING A PORTABLE DOPPLER ULTRASOUND DEVICE Sites and Methods of Assessing the Pulse ASSESSING PERIPHERAL ARTERIAL PULSES ASSESSING THE APICAL PULSE ASSESSING THE APICAL–RADIAL PULSE RESPIRATIONS Physiology of Respirations Factors Affecting Respirations Normal Respiratory Rate ►Guidelines for Nursing Care 25-3 ASSESSING THE APICAL PULSE Increased Respiratory Rate ►Guidelines for Nursing Care 25-4 TAKING AN APICAL–RADIAL PULSE Decreased Respiratory Rate Respiratory Depth and Rhythm Assessing Respirations BLOOD PRESSURE Physiology of Blood Pressure Short-Term Regulation of Blood Pressure Long-Term Regulation of Blood Pressure Factors Affecting Blood Pressure Normal Blood Pressure Increased Blood Pressure Promoting Health Literacy IN PATIENTS WITH HYPERTENSION Patient Scenario Decreased Blood Pressure ►Guidelines for Nursing Care 25-5 ASSESSING ORTHOSTATIC HYPOTENSION Assessing Blood Pressure Equipment SPHYGMOMANOMETER AUTOMATED BLOOD PRESSURE MONITORS DOPPLER ULTRASOUND DIRECT ELECTRONIC MEASUREMENT ►Guidelines for Nursing Care 25-6 ASSESSING BLOOD PRESSURE USING A DOPPLER ULTRASOUND Korotkoff Sounds Sites and Methods of Assessing the Blood Pressure Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Arm Versus Ankle Blood Pressure Measurement Related Research Relevance to Nursing Practice ASSESSING BLOOD PRESSURE AT THE BRACHIAL ARTERY ASSESSING BLOOD PRESSURE AT THE RADIAL ARTERY ASSESSING BLOOD PRESSURE AT THE POPLITEAL ARTERY PALPATING THE BLOOD PRESSURE ►Guidelines for Nursing Care 25-7 ASSESSING BLOOD PRESSURE AT THE POPLITEAL ARTERY NURSING DIAGNOSES Focus on the Older Adult TEACHING VITAL SIGNS FOR SELF-CARE AT HOME Skill 25-1 ►Assessing Body Temperature DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 25-2 ►Assessing a Peripheral Pulse by Palpation DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 25-3 ►Assessing Respiration DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 25-4 ►Assessing Blood Pressure by Auscultation DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 26 Health Assessment HEALTH ASSESSMENT Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Key Concepts and Physical Assessment Competencies Related Research Relevance to Nursing Practice Lifespan Considerations Cultural Considerations and Sensitivity Patient Preparation Environmental Preparation THE HEALTH HISTORY Biographical Data Reason for Seeking Health Care History of Present Health Concern Past Health History Family History Functional Health Assessment Psychosocial and Lifestyle Factors Review of Systems PHYSICAL ASSESSMENT Preparing for a Physical Examination Equipment THERMOMETER AND SPHYGMOMANOMETER SCALE FLASHLIGHT OR PENLIGHT STETHOSCOPE METRIC TAPE MEASURE AND RULER EYE CHART Positioning and Draping Techniques of Physical Assessment Inspection Palpation Percussion Auscultation Conducting a Physical Assessment Performing a General Survey HEALTH HISTORY APPEARANCE AND BEHAVIOR HEIGHT AND WEIGHT BODY MASS INDEX AND WAIST CIRCUMFERENCE ►Guidelines for Nursing Care 26-1 OBTAINING HEIGHT AND WEIGHT WITH AN UPRIGHT BALANCE SCALE VITAL SIGNS PAIN Assessing the Integument HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Head and Neck HEALTH HISTORY PHYSICAL ASSESSMENT ►Guidelines for Nursing Care 26-2 MEASURING PUPILLARY REACTION, SIZE, ACCOMMODATION, AND CONVERGENCE ►Guidelines for Nursing Care 26-3 ASSESSING EXTRAOCULAR MOVEMENTS AND PERIPHERAL VISION NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Thorax and Lungs HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Cardiovascular and Peripheral Vascular Systems HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Breasts and Axillae HEALTH HISTORY PHYSICAL ASSESSMENT ►Guidelines for Nursing Care 26-4 PALPATING THE BREASTS NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Abdomen HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing Female Genitalia HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing Male Genitalia HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Rectum and Anus HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Musculoskeletal System HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT Assessing the Neurologic System ►Guidelines for Nursing Care 26-5 ASSESSING MUSCLE STRENGTH HEALTH HISTORY PHYSICAL ASSESSMENT NORMAL AGE-RELATED VARIATIONS: INFANT/CHILD NORMAL AGE-RELATED VARIATIONS: OLDER ADULT DOCUMENTATION OF DATA THE NURSE’S ROLE IN DIAGNOSTIC PROCEDURES Skill 26-1 ►Using a Portable Bed Scale DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Skill 26-2 ►Assessing the Neurologic, Musculoskeletal, and Peripheral Vascular Systems DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 27 Safety, Security, and Emergency Preparedness INTRODUCTION FACTORS AFFECTING SAFETY Developmental Considerations Lifestyle Occupation Social Behavior Environment Mobility Sensory Perception Promoting Health 27-1 SAFETY IN THE COMMUNITY Assessment Checklist Self-Care Behaviors Knowledge Ability to Communicate Physical Health State Psychosocial Health State THE NURSING PROCESS FOR MAINTAINING SAFETY Assessing Assessing the Person NURSING HISTORY PHYSICAL EXAMINATION Assessing the Environment Performing a Specific Risk Factor Assessment FALLS FIRES POISONING SUFFOCATION AND CHOKING FIREARM INJURIES Diagnosing Outcome Identification and Planning Implementing Teaching to Promote Safety PREVENTING ACCIDENTS ADDRESSING DEVELOPMENTAL CONSIDERATIONS Neonate and Infant Teaching Tips 27-1 Toddler and Preschooler School-Aged Adolescent Adult Older Adult Orienting the Person to Surroundings Preventing Falls PREVENTING FALLS IN THE HOME Preventing Falls in the Health Care Facility Using Restraints in Health Care Facilities USING SIDE RAILS AS RESTRAINTS USING ALTERNATIVES TO RESTRAINTS USING RESTRAINTS AS A LAST RESORT Preventing Fires and Maintaining Fire Safety Preventing Poisoning Focus on the Older Adult TEACHING TIPS TO PREVENT MEDICATION-RELATED POISONING Preventing Suffocation Preventing Injury From Firearms Preventing Equipment-Related Accidents Preventing Procedure-Related Accidents Filing a Safety Event Report Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Improving Patient Safety With Error Identification in Chemotherapy Orders by Verification Nurses Related Research Relevance to Nursing Practice Maintaining Emergency Preparedness ADDRESSING BIOLOGIC THREATS ADDRESSING CHEMICAL THREATS ADDRESSING RADIATION THREATS ADDRESSING CYBER TERROR PREPARING FOR MASS TRAUMA TERRORISM IDENTIFYING DISASTER RESOURCES ADDRESSING PSYCHOLOGICAL ASPECTS OF DISASTERS Evaluating REFLECTIVE PRACTICE LEADING TO PERSONAL LEARNING Skill 27-1 ►Performing a Situational Assessment DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION Skill 27-2 ►Applying an Extremity Restraint EQUIPMENT IMPLEMENTATION DOCUMENTATION DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 28 Complementary and Integrative Health INTRODUCTION TO COMPLEMENTARY HEALTH APPROACHES Conventional Medicine and Complementary Health Approaches Holism Integrative Care Complementary Health Approaches and Nursing Use of Complementary Health Approaches in the United States Prevalence of Complementary Health Approaches Reasons for Using Complementary Health Approaches Most Frequently Used Complementary Health Approaches Use of Complementary Health Approaches With Children Growth of the Complementary Health Approaches Industry COMPLEMENTARY HEALTH APPROACHES CATEGORIES Mind–Body Practices Relaxation Meditation Guided Imagery Yoga Qi Gong and Tai Chi Acupuncture Chiropractic Health Care Aromatherapy Energy Healing Therapies THERAPEUTIC TOUCH HEALING TOUCH SOUND HEALING Manipulative and Body-Based Practices Natural Products Botanicals (Herbal Products) and Nutritional Supplements Nutritional Therapy Other Complementary Health Approaches Ayurveda Traditional Chinese Medicine Shamanism Homeopathy Naturopathy NURSING IMPLICATIONS OF COMPLEMENTARY HEALTH APPROACHES Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Hatha Yoga Related Research Implications for Nursing DEVELOPING CLINICAL REASONING PREPARING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 29 Medications INTRODUCTION PRINCIPLES OF PHARMACOLOGY Drug Nomenclature Types of Drug Preparations Drug Classifications Drug Indications Mechanisms of Drug Action Pharmacokinetics ABSORPTION DISTRIBUTION METABOLISM EXCRETION Pharmacodynamics Adverse Drug Reactions Allergic Effect Drug Tolerance Toxic Effect Idiosyncratic Effect Drug Interactions Factors Affecting Drug Action Developmental Considerations Weight Biological Sex Cultural and Genetic Factors Focus on the Older Adult Psychological Factors Pathology Environment Timing of Administration Drug Dose and Serum Drug Levels Drug Legislation PRINCIPLES OF MEDICATION ADMINISTRATION Medication Prescriptions and Orders Types of Orders Parts of the Medication Order PATIENT’S NAME AND A SECONDARY IDENTIFIER (DATE OF BIRTH, MEDICAL RECORD NUMBER) DATE AND TIME THE ORDER IS WRITTEN NAME OF DRUG TO BE ADMINISTERED DOSAGE OF THE DRUG ROUTE BY WHICH THE DRUG IS TO BE ADMINISTERED FREQUENCY OF ADMINISTRATION OF THE DRUG SIGNATURE OF THE PRESCRIBING PROVIDER Checking the Medication Order Questioning the Medication Order Medication Supply Systems Dosage Calculations Systems of Measurement METRIC SYSTEM HOUSEHOLD SYSTEM Methods for Computing Drug Dosages FORMULA METHODS DIMENSIONAL ANALYSIS Pediatric Calculations Using Safety Measures While Preparing Drugs Three Checks and the Rights of Medication Administration Maintaining a Safe Environment Handling Controlled Substances Safely Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Practice Environments and Medication Errors Related Research Relevance to Nursing Practice Identifying the Patient THE NURSING PROCESS FOR ADMINISTERING MEDICATIONS Assessing Diagnosing Outcome Identification and Planning Implementing Administering Oral Medications Administering Parenteral Medications Guidelines for Nursing Care 29-1 USING AN INSULIN INJECTION PEN Guidelines for Nursing Care 29-2 Guidelines for Nursing Care 29-3 Guidelines for Nursing Care 29-4 Guidelines for Nursing Care 29-5 Guidelines for Nursing Care 29-6 Guidelines for Nursing Care 29-7 Guidelines for Nursing Care 29-8 Teaching Tips 29-1 Skill 29-1 ►Administering Oral Medications DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-2 ►Removing Medication From an Ampule DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-3 ►Removing Medication From a Vial DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-4 ►Mixing Medications From Two Vials in One Syringe DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-5 ►Administering an Intradermal Injection DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-6 ►Administering a Subcutaneous Injection DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-7 ►Administering an Intramuscular Injection DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-8 ►Administering Medications by Intravenous Bolus or Push Through an Intravenous Solution DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-9 ►Administering a Piggyback Intermittent Intravenous Infusion of Medication DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 29-10 ►Administering Medications by Intravenous Bolus or Push Through a Medication or Drug-Infusion Lock DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES MEDICATION CALCULATION PROBLEMS ANSWERS TO MEDICATION CALCULATION PROBLEMS TAYLOR SUITE RESOURCES 30 Perioperative Nursing THE SURGICAL EXPERIENCE The Perioperative Phases Surgical Procedure Classification Surgery Based on Urgency Surgery Based on Degree of Risk Surgery Based on Purpose Anesthesia General (Systemic) Anesthesia Moderate Sedation/Analgesia Regional Anesthesia Topical and Local Anesthesia Informed Consent and Advance Directives Outpatient/Same-Day Surgery THE NURSING PROCESS FOR PREOPERATIVE CARE Assessing Health History Focus on the Older Adult Physical Assessment Diagnosing Outcome Identification and Planning Implementing Preparing the Patient Psychologically Through Communicating Preparing the Patient Psychologically Through Teaching Preparing the Patient Physically Preparing the Patient on the Day of Surgery Evaluating THE NURSING PROCESS FOR INTRAOPERATIVE CARE Assessing Diagnosing Outcome Identification and Planning Implementing Positioning Draping Documenting Transferring to the PACU Evaluating POSTOPERATIVE NURSING CARE Immediate Postoperative Assessment and Care Respiratory Status Cardiovascular Status Central Nervous System Status Fluid Status Wound Status Pain Management General Condition Ongoing Postoperative Care THE NURSING PROCESS FOR ONGOING POSTOPERATIVE CARE Assessing Diagnosing Outcome Identification and Planning Implementing Preventing Cardiovascular Complications Preventing Respiratory Complications Preventing Surgical Site Complications Promoting a Return to Health Helping the Patient Cope Providing Outpatient/Same-Day Surgery Postoperative Care Evaluating Skill 30-1 ►Providing Preoperative Patient Care DELEGATION CONSIDERATIONS EQUIPMENT (Varies, Depending on the Type of Surgery and Surgical Setting) IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 30-2 ►Providing Postoperative Care DELEGATION CONSIDERATIONS EQUIPMENT (Varies, Depending on the Surgery) IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 31 Hygiene HYGIENE PRACTICES FACTORS AFFECTING PERSONAL HYGIENE Culture Socioeconomic Class Spiritual Practices Developmental Level Health State Personal Preferences THE NURSING PROCESS FOR SKIN CARE AND PERSONAL HYGIENE Assessing Nursing History Physical Assessment Diagnosing Outcome Identification and Planning Implementing Providing Scheduled Hygiene Care Focus on the Older Adult Assisting With Bathing and Skin Care Providing Vaginal Care Providing Care for Body Piercing Assisting With Oral Hygiene Providing Eye Care Providing Ear Care Providing Nose Care Providing Hair Care Providing Fingernail Care Providing Foot Care Providing Environmental Care Teaching Patients About Skin Care Evaluating Skill 31-1 ►Providing a Bed Bath DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 31-2 ►Assisting the Patient With Oral Care DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 31-3 ►Providing Oral Care for the Dependent Patient DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 31-4 ►Making an Unoccupied Bed DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 31-5 ►Making an Occupied Bed DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 32 Skin Integrity and Wound Care ANATOMY AND PHYSIOLOGY OF THE INTEGUMENTARY SYSTEM Structures of the Skin Functions of the Skin and Mucous Membranes Factors Affecting Skin Integrity Developmental Considerations State of Health Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES IN SKIN WOUNDS AND PRESSURE INJURIES Wound Classification Intentional Wounds and Unintentional Wounds Open and Closed Wounds Acute and Chronic Wounds WOUND HEALING Phases of Wound Healing HEMOSTASIS INFLAMMATORY PHASE PROLIFERATION PHASE MATURATION PHASE Factors Affecting Wound Healing LOCAL FACTORS SYSTEMIC FACTORS Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES IN WOUND HEALING Wound Complications INFECTION HEMORRHAGE DEHISCENCE AND EVISCERATION FISTULA FORMATION Pressure Injury Factors in Pressure Injury Development EXTERNAL PRESSURE FRICTION AND SHEAR Risks for Pressure Injury Development IMMOBILITY NUTRITION AND HYDRATION MOISTURE MENTAL STATUS AGE Pressure Injury Staging Psychological Effects of Wounds and Pressure Injuries Pain Anxiety and Fear Activities of Daily Living Changes in Body Image THE NURSING PROCESS FOR WOUNDS AND PRESSURE INJURIES Assessing Nursing History Skin Assessment Wound Assessment Pressure Injury Assessment Pain Assessment Diagnosing Outcome Identification and Planning Implementing Preventing Pressure Injuries Promoting Health Literacy IN PATIENTS WITH BREAST CANCER Wound Care/Wound Management Changing the Dressing Caring for Patients With Wound Drains Collecting a Wound Culture Using Additional Techniques to Promote Wound Healing Removing Sutures or Staples Teaching Wound Care at Home ► Guidelines for Nursing Care 32-5 REMOVING STAPLES AND SUTURES Documenting Wound Care Evaluating HEAT AND COLD THERAPY Effects of Applying Heat Effects of Applying Cold Physiologic Considerations THE NURSING PROCESS FOR HEAT AND COLD THERAPY Assessing Assessing Overall Status Assessing the Area of Application Assessing the Condition of Equipment Diagnosing Outcome Identification and Planning Implementing Applying Heat Applying Cold Evaluating Skill 32-1 ►Preventing Pressure Injury DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 32-2 ►Cleaning a Wound and Applying a Dressing (General Guidelines) DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 32-3 ►Performing Irrigation of a Wound DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS GENERAL CONSIDERATIONS Skill 32-4 ►Caring for a Jackson–Pratt Drain DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 32-5 ►Caring for a Hemovac Drain DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 32-6 ►Collecting a Wound Culture DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS GENERAL CONSIDERATIONS Skill 32-7 ►Applying Negative Pressure Wound Therapy DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 32-8 ►Applying an External Heating Pad DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 33 Activity PHYSIOLOGY OF MOVEMENT AND ALIGNMENT Skeletal System Muscular System Nervous System Normal Movement and Alignment Body Alignment or Posture Balance Coordinated Body Movement Postural Reflexes Patient Care Ergonomics Orthopedics FACTORS AFFECTING MOVEMENT AND ALIGNMENT Developmental Considerations Physical Health Muscular, Skeletal, or Nervous System Problems CONGENITAL OR ACQUIRED POSTURAL ABNORMALITIES PROBLEMS WITH BONE FORMATION OR MUSCLE DEVELOPMENT PROBLEMS AFFECTING JOINT MOBILITY TRAUMA TO THE MUSCULOSKELETAL SYSTEM PROBLEMS AFFECTING THE CENTRAL NERVOUS SYSTEM Problems Involving Other Body Systems Mental Health Lifestyle Attitude and Values Fatigue and Stress External Factors EXERCISE Types of Exercise Muscle Contraction Body Movement Effects of Exercise on Major Body Systems Cardiovascular System Respiratory System Musculoskeletal System Metabolic Processes Gastrointestinal System Urinary System Skin Psychosocial Outlook Risks Related to Exercise Precipitation of a Cardiac Event Orthopedic Discomfort and Disability Other Health Problems Effects of Immobility on the Body Cardiovascular System Respiratory System Musculoskeletal System Metabolic Processes Gastrointestinal System Urinary System Skin Psychosocial Outlook THE NURSING PROCESS FOR ACTIVITY Assessing Nursing History Physical Assessment GENERAL EASE OF MOVEMENT AND GAIT ALIGNMENT Focus on the Older Adult KATZ INDEX OF INDEPENDENCE IN ACTIVITIES OF DAILY LIVING JOINT STRUCTURE AND FUNCTION MUSCLE MASS, TONE, AND STRENGTH ENDURANCE Diagnosing Outcome Identification and Planning Implementing Application of Ergonomics to Prevent Injury Ensuring Safe Patient Handling and Movement SAFE PATIENT TRANSFER EQUIPMENT AND ASSISTIVE DEVICES Gait Belts Stand-Assist and Repositioning Aids Lateral-Assist Devices Friction-Reducing Sheets Mechanical Lateral-Assist Devices Transfer Chairs Powered Stand-Assist and Repositioning Lifts Powered Full-Body Lifts Positioning Patients in Bed COMMON DEVICES TO PROMOTE CORRECT ALIGNMENT Foam Wedges and Pillows Mattresses Adjustable Beds Trapeze Bar Additional Equipment PROTECTIVE POSITIONING Fowler’s Position Supine or Dorsal Recumbent Position Side-Lying or Lateral Position Prone Position Using Graduated Compression Stockings and Pneumatic Compression Devices GRADUATED COMPRESSION STOCKINGS PNEUMATIC COMPRESSION DEVICES Turning the Patient in Bed Moving a Patient Up in Bed Moving a Patient from Bed to Stretcher Moving a Patient from Bed to Chair Assisting With Range-of-Motion Exercises Helping Patients Ambulate PHYSICAL CONDITIONING TO PREPARE FOR AMBULATION Quadriceps and Gluteal Setting Drills (Sets) Pushups Dangling Daily Activities for Purposeful Exercise PROVIDING ASSISTANCE WITH WALKING One-Nurse Assist Two-Nurse Assist MECHANICAL AIDS FOR WALKING Walker Canes Braces Crutches Promoting Exercise PREVENTING ILLNESS AND PROMOTING WELLNESS THROUGH EXERCISE DESIGNING EXERCISE PROGRAMS Evaluating Focus on the Older Adult NURSING STRATEGIES TO PROMOTE EXERCISE AND ACTIVITY FOR AGE-RELATED CHANGES Skill 33-1 ►Applying and Removing Graduated Compression Stockings DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 33-2 ►Assisting a Patient With Turning in Bed DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 33-3 ►Moving a Patient Up in Bed With the Assistance of Another Caregiver DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 33-4 ►Transferring a Patient From the Bed to a Stretcher DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 33-5 ►Transferring a Patient From the Bed to a Chair DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 34 Rest and Sleep REST AND SLEEP PHYSIOLOGY OF SLEEP Circadian Rhythms Stages of Sleep Non–Rapid Eye Movement Sleep Rapid Eye Movement Sleep Sleep Cycle REST AND SLEEP REQUIREMENTS AND PATTERNS PHYSICAL AND PSYCHOLOGICAL EFFECTS OF INSUFFICIENT SLEEP FACTORS AFFECTING REST AND SLEEP Developmental Considerations Motivation Culture Lifestyle and Habits Physical Activity and Exercise Dietary Habits Smoking Environmental Factors Psychological Stress Illness Medications COMMON SLEEP DISORDERS Insomnia Sleep-Related Breathing Disorder Central Disorders of Hypersomnolence Circadian Rhythm Sleep–Wake Disorders Parasomnias Sleep-Related Movement Disorders Sleep Deprivation Promoting Health Literacy IN PATIENTS WITH RESTLESS LEGS SYNDROME Patient Scenario Nursing Considerations: Tips for Improving Health Literacy THE NURSING PROCESS FOR REST AND SLEEP Assessing Rest and Sleep Nursing History Sleep Diary Physical Assessment Diagnosing Disturbed Sleep Pattern as the Problem Disturbed Sleep Pattern as the Etiology Outcome Identification and Planning Implementing Preparing a Restful Environment Focus on the Older Adult AGE-RELATED CHANGES AND NURSING STRATEGIES FOR REST AND SLEEP Promoting Bedtime Rituals Offering Appropriate Bedtime Snacks and Beverages Promoting Relaxation Promoting Comfort Respecting Normal Sleep–Wake Patterns Scheduling Nursing Care to Avoid Unnecessary Disturbances Minimizing Sleep Disturbances in Health Care Settings Using Medications to Promote Sleep Teaching About Rest and Sleep Evaluating DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 35 Comfort and Pain Management THE PAIN EXPERIENCE The Pain Process Transduction Transmission of Pain Stimuli Perception of Pain Modulation of Pain The Gate Control Theory of Pain Types of Pain Duration of Pain Localization/Location of Pain Etiology Responses to Pain FACTORS AFFECTING THE PAIN EXPERIENCE Cultural and Ethnicity Variables Family, Sex, Gender, and Age Variables Religious Beliefs Environment and Support People Anxiety and Other Stressors Past Pain Experience THE NURSING PROCESS FOR COMFORT AND PAIN MANAGEMENT Assessing Routine Pain Assessment Common Misconceptions Components of a Pain Assessment Assessment of Special Populations Diagnosing Pain or Chronic Pain as the Problem Pain or Chronic Pain as the Etiology Outcome Identification and Planning Implementing Establishing a Trusting Nurse–Patient Relationship Manipulating Factors Affecting the Pain Experience Initiating Complementary Health Approaches and Integrative Health Care Managing Pharmacologic Relief Measures Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING COMFORT Teaching the Patient and Family About Pain Promoting Health Literacy IN PATIENTS WITH PAIN Patient Scenario Nursing Considerations: Tips for Improving Health Literacy Ensuring the Ethical and Legal Responsibility to Relieve Pain Understanding the Placebo Controversy Evaluating The Pain Experience Management Regimens Patient and Family Response Skill 35-1 ►Giving a Back Massage DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PREPARING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 36 Nutrition PRINCIPLES OF NUTRITION Energy Balance Metabolic Requirements Body Weight Standards BODY MASS INDEX (BMI) WAIST CIRCUMFERENCE Caloric Requirements Energy Nutrients Carbohydrates CLASSIFICATION AND METABOLISM FUNCTIONS AND RECOMMENDED DIETARY ALLOWANCE Protein CLASSIFICATION AND METABOLISM FUNCTIONS AND RECOMMENDED DIETARY ALLOWANCE Fats CLASSIFICATION AND METABOLISM FUNCTIONS AND RECOMMENDED DIETARY ALLOWANCE Regulatory Nutrients Vitamins Minerals Water Digestion Adequate Diet Selection Dietary Recommendations Dietary Reference Intakes MyPlate Food Guide Food Labeling FACTORS AFFECTING NUTRITION Physiologic and Physical Factors that Influence Nutrient Requirements Developmental Considerations INFANTS TODDLERS AND PRESCHOOLERS SCHOOL-AGED CHILDREN ADOLESCENTS ADULTS PREGNANT AND LACTATING WOMEN OLDER ADULTS Biological Sex State of Health Alcohol Abuse Medication Megadoses of Nutrient Supplements Physical, Sociocultural, and Psychosocial Factors That Influence Food Choices Economic Factors Religion Meaning of Food Culture Additional Sociocultural Factors Affecting Nutritional Intake Food Intake Decreased Food Intake Increased Food Intake THE NURSING PROCESS FOR NUTRITION Assessing Dietary Data Diagnosing Imbalanced Nutrition as the Problem Imbalanced Nutrition as the Etiology Wellness Diagnosis Outcome Identification and Planning Implementing Teaching Nutritional Information Monitoring Nutritional Status Stimulating Appetite Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING NUTRITION Assisting With Eating Providing Oral Nutrition Providing Enteral Nutrition Providing Parenteral Nutrition Evaluating Skill 36-1 ►Assisting a Patient With Eating DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 36-2 ►Administering a Tube Feeding DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 36-3 ►Caring for a Gastrostomy Tube DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 36-4 ►Obtaining a Capillary Blood Sample for Glucose Testing DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 37 Urinary Elimination ANATOMY AND PHYSIOLOGY Kidneys and Ureters Bladder Urethra Act of Urination Frequency of Urination FACTORS AFFECTING URINATION Developmental Considerations Toilet Training Effects of Aging Food and Fluid Intake Psychological Variables Activity and Muscle Tone Pathologic Conditions Medications THE NURSING PROCESS FOR URINARY ELIMINATION Assessing Nursing History Physical Assessment BLADDER URETHRAL ORIFICE SKIN INTEGRITY AND HYDRATION Urine Characteristics Special Assessment Techniques MEASURING URINE OUTPUT COLLECTING URINE SPECIMENS POINT-OF-CARE URINE TESTING ASSISTING WITH DIAGNOSTIC PROCEDURES Diagnosing Urinary Functioning as the Problem Urinary Functioning as the Etiology Outcome Identification and Planning Implementing Promoting Normal Urination Promoting Health 37-1 URINE ELIMINATION Assessment Checklist Self-Care Behaviors MAINTAINING NORMAL VOIDING HABITS PROMOTING FLUID INTAKE Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING URINARY ELIMINATION STRENGTHENING MUSCLE TONE ASSISTING WITH TOILETING Caring for Patients With Urinary Tract Infections RISK FACTORS DIAGNOSTIC EVALUATION TREATMENT Caring for an Incontinent Patient TYPES OF URINARY INCONTINENCE ASSESSMENT TREATMENT INCONTINENCE-ASSOCIATED DERMATITIS Applying an External Urinary Sheath (Condom Catheter) Catheterizing the Patient’s Bladder REASONS FOR URINARY CATHETERIZATION IMPORTANT CONSIDERATIONS ABOUT THE LOWER URINARY TRACT TYPES OF CATHETERS CATHETER-ASSOCIATED HARM EQUIPMENT PATIENT PREPARATION Urethral Catheter Insertion CARING FOR PATIENTS WITH AN INDWELLING CATHETER PATIENT EDUCATION IRRIGATING THE INDWELLING CATHETER OR BLADDER REMOVING THE INDWELLING CATHETER Caring for a Patient With a Urologic Stent Caring for a Patient With a Urinary Diversion GENERAL CARE GUIDELINES EXTERNAL APPLIANCES PATIENT EDUCATION Caring for a Patient Receiving Dialysis Evaluating Skill 37-1 ►Assessing Bladder Volume Using an Ultrasound Bladder Scanner DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 37-2 ►Assisting With the Use of a Bedpan DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION SPECIAL CONSIDERATIONS Skill 37-3 ►Assisting With the Use of a Urinal DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION SPECIAL CONSIDERATIONS Skill 37-4 ►Applying an External Urinary Sheath (Condom Catheter) DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Skill 37-5 ►Catheterizing the Female Urinary Bladder DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 37-6 ►Catheterizing the Male Urinary Bladder DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 37-7 ►Emptying and Changing a Stoma Appliance on a Urinary Diversion DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 38 Bowel Elimination ANATOMY AND PHYSIOLOGY Stomach Small Intestine Large Intestine Nervous System Control Defecation FACTORS AFFECTING BOWEL ELIMINATION Developmental Considerations Infant Toddler School-Aged Child, Adolescent, and Adult Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING BOWEL ELIMINATION Older Adult Daily Patterns Food and Fluid Activity and Muscle Tone Lifestyle Psychological Variables Pathologic Conditions Medications Diagnostic Studies Surgery and Anesthesia THE NURSING PROCESS FOR BOWEL ELIMINATION Assessing Nursing History Physical Assessment Stool Characteristics Diagnostic Studies Diagnosing Bowel Elimination as the Problem Bowel Elimination as the Etiology Outcome Identification and Planning Implementing Promoting Regular Bowel Habits Providing Comfort Measures Preventing and Treating Constipation Preventing and Treating Diarrhea Decreasing Flatulence Emptying the Colon of Feces Managing Bowel Incontinence Designing and Implementing Bowel-Training Programs Maintaining a Nasogastric Tube Meeting the Needs of Patients With Bowel Diversions Evaluating Skill 38-1 ►Administering a Large-Volume Cleansing Enema DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 38-2 ►Inserting a Nasogastric Tube DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 38-3 ►Removing a Nasogastric Tube DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Skill 38-4 ►Irrigating a Nasogastric Tube Connected to Suction DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 38-5 ►Emptying and Changing an Ostomy Appliance DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 39 Oxygenation and Perfusion ANATOMY AND PHYSIOLOGY OF OXYGENATION Respiratory System Anatomy of the Respiratory System Physiology of the Respiratory System PULMONARY VENTILATION RESPIRATION PERFUSION Regulation of the Respiratory System Alterations in Respiratory Function Cardiovascular System Anatomy of the Cardiovascular System Physiology of the Cardiovascular System Regulation of the Cardiovascular System Blood Flow to the Cardiovascular System Alterations in Cardiovascular Function FACTORS AFFECTING CARDIOPULMONARY FUNCTIONING AND OXYGENATION Level of Health Developmental Considerations Infants Toddlers, Preschoolers, School-Aged Children, and Adolescents Older Adults Focus on the Older Adult Medication Considerations Lifestyle Considerations Environmental Considerations Promoting Health 39-1 OXYGENATION Assessment Checklist Self-Care Behaviors Psychological Health Considerations THE NURSING PROCESS FOR OXYGENATION Assessing Nursing History Physical Assessment INSPECTION PALPATION PERCUSSION AUSCULTATION Common Diagnostic Tests ELECTROCARDIOGRAPHY PULMONARY FUNCTION STUDIES Spirometry Peak Expiratory Flow Rate PULSE OXIMETRY CAPNOGRAPHY THORACENTESIS Procedure PICOT in Practice ASKING CLINICAL QUESTIONS: CAPNOGRAPHY Nursing Responsibilities Diagnosing Alterations in Oxygenation as the Problem Alterations in Oxygenation as the Etiology Outcome Identification and Planning Implementing Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Health-Related Self-Management Education Related Research Relevance to Nursing Practice Promoting Optimal Function HEALTHY LIFESTYLE VACCINATION Pneumococcal Disease Promoting Health Literacy IN PATIENTS WITH COPD Patient Scenario TEACHING ABOUT POLLUTION-FREE ENVIRONMENTS REDUCING ANXIETY MAINTAINING GOOD NUTRITION Promoting Comfort POSITIONING MAINTAINING ADEQUATE FLUID INTAKE PROVIDING HUMIDIFIED AIR Promoting Proper Breathing DEEP BREATHING USING INCENTIVE SPIROMETRY PURSED-LIP BREATHING ►Guidelines for Nursing Care 39-1 TEACHING PATIENTS TO USE AN INCENTIVE SPIROMETER DIAPHRAGMATIC BREATHING Promoting and Controlling Coughing VOLUNTARY COUGHING INVOLUNTARY COUGHING USING COUGH MEDICATIONS Expectorants Cough Suppressants Lozenges Teaching about Cough Medications Performing Chest Physiotherapy Suctioning the Airway Meeting Oxygenation Needs with Medications ADMINISTERING INHALED MEDICATIONS TEACHING PATIENTS ABOUT INHALED MEDICATIONS Providing Supplemental Oxygen SOURCES OF OXYGEN OXYGEN FLOW RATE HUMIDIFICATION OXYGEN DELIVERY SYSTEMS Nasal Cannula ►Guidelines for Nursing Care 39-2 TRANSPORTING A PATIENT WITH A PORTABLE OXYGEN CYLINDER Face Masks OXYGEN THERAPY IN THE HOME Positive Airway Pressure (PAP) Managing Chest Tubes ►Guidelines for Nursing Care 39-3 MONITORING A PATIENT WITH A CHEST TUBE Using Artificial Airways OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS ►Guidelines for Nursing Care 39-4 INSERTING AN ARTIFICIAL AIRWAY ENDOTRACHEAL TUBE TRACHEOSTOMY Tracheostomy Procedure and Tubes Providing Tracheostomy Care TRACHEAL SUCTIONING ASSISTING VENTILATION Clearing an Obstructed Airway Administering Cardiopulmonary Resuscitation Evaluating Nursing Care Plan for Joan McIntyre 39-1 Skill 39-1 ► Using a Pulse Oximeter DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 39-2 ► Suctioning the Oropharyngeal and Nasopharyngeal Airways DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 39-3 ► Administering Oxygen by Nasal Cannula DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 39-4 ► Administering Oxygen by Mask DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 39-5 ► Providing Care of a Tracheostomy Tube DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 39-6 ► Suctioning a Tracheostomy: Open System DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 40 Fluid, Electrolyte, and Acid–Base Balance PRINCIPLES OF FLUID, ELECTROLYTES, AND ACID–BASE BALANCE Body Fluids Body Fluid Compartments Variations in Fluid Content Fluid Balance Electrolytes Regulation and Homeostatic Mechanisms of Fluid and Electrolyte Balance Organs and Body Systems Osmosis Diffusion Active Transport Capillary Filtration Acid–Base Balance Chemical Buffer Systems CARBONIC ACID–SODIUM BICARBONATE BUFFER SYSTEM PHOSPHATE BUFFER SYSTEM PROTEIN BUFFER SYSTEM Respiratory Regulation of Hydrogen Ions Renal Regulation of Hydrogen Ions DISTURBANCES IN FLUID, ELECTROLYTE, AND ACID–BASE BALANCE Fluid Imbalances Fluid Volume Deficit Fluid Volume Excess Electrolyte Imbalances Hyponatremia and Hypernatremia Hypokalemia and Hyperkalemia Hypocalcemia and Hypercalcemia Hypomagnesemia and Hypermagnesemia Hypophosphatemia and Hyperphosphatemia Hypochloremia and Hyperchloremia Acid–Base Imbalances Metabolic Acidosis and Alkalosis Respiratory Acidosis and Alkalosis THE NURSING PROCESS FOR FLUID, ELECTROLYTE, AND ACID–BASE BALANCE Assessing Nursing History Physical Assessment Fluid Intake and Output Daily Weights Laboratory Studies COMPLETE BLOOD COUNT SERUM ELECTROLYTES, BLOOD UREA NITROGEN, AND CREATININE LEVELS ► Guidelines for Nursing Care 40-1 MEASURING FLUID INTAKE AND OUTPUT The Patient’s Fluid Intake Includes the Following The Patient’s Fluid Output Includes the Following URINE pH AND SPECIFIC GRAVITY ARTERIAL BLOOD GASES Diagnosing Fluid, Electrolyte, and Acid–Base Disturbances as the Problem Fluid and Electrolyte Disturbances as the Etiology Outcome Identification and Planning Implementing Preventing Fluid and Electrolyte Imbalances Developing a Dietary Plan Modifying Fluid Intake Focus on the Older Adult NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING FLUID BALANCE INCREASING FLUIDS RESTRICTING FLUIDS Administering Medications MINERAL–ELECTROLYTE PREPARATIONS DIURETICS Administering Intravenous (IV) Fluid Therapy EQUIPMENT VASCULAR ACCESS DEVICES Peripheral Venous Catheters Midline Peripheral Catheters Central Venous Access Devices PERIPHERAL VENOUS CATHETER SITE SELECTION Accessibility of a Vein Condition of the Vein Type of Fluid to Be Infused INITIATION OF AN IV INFUSION INFUSION REGULATION AND MONITORING ► Guidelines for Nursing Care 40-2 REGULATING IV FLOW RATE SOLUTION AND TUBING CHANGES COMPLICATIONS OF IV THERAPY VENOUS ACCESS CARE AND MANAGEMENT Site Care Entry-Point Disinfection Passive Disinfection Caps Needleless Connectors Multiple Continuous Infusions Venous Catheter Securement/Stabilization Devices CAPPING A PRIMARY LINE FOR INTERMITTENT USE DISCONTINUATION OF THE INFUSION HOME INFUSION Administering Blood and Blood Products ► Guidelines for Nursing Care 40-3 REMOVAL OF A PICC BLOOD TYPING AND CROSS-MATCHING Blood Types Rh Factor BLOOD DONORS BLOOD COMPONENTS INITIATION AND TRANSFUSION OF BLOOD Administering Parenteral Nutrition Evaluating Skill 40-1 ►Initiating a Peripheral Venous Access IV Infusion DELEGATION GUIDELINES EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 40-2 ►Monitoring an IV Site and Infusion DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION Unexpected Situations and Associated Interventions Skill 40-3 ►Changing a Peripheral Venous Access Site Dressing DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS Skill 40-4 ►Capping for Intermittent Use and Flushing a Peripheral Venous Access Device DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Skill 40-5 ►Administering a Blood Transfusion DELEGATION CONSIDERATIONS EQUIPMENT IMPLEMENTATION DOCUMENTATION UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS SPECIAL CONSIDERATIONS DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 41 Self-Concept OVERVIEW OF SELF-CONCEPT Dimensions of Self-Concept Self-Knowledge: “Who am I?” Self-Expectations: “Who or What Do I Want to Be?” Self-Evaluation: “How Well Do I Like Myself?” Formation of Self-Concept Factors Affecting Self-Concept Developmental Considerations Culture Internal and External Resources History of Success and Failure Crises or Life Stressors Aging, Illness, or Trauma THE NURSING PROCESS FOR PATIENTS WITH ALTERATIONS IN SELF-CONCEPT Assessing Personal Identity Personal Strengths Body Image Self-Esteem Role Performance Diagnosing Important Distinctions Outcome Identification and Planning Implementing Helping Patients Identify and Use Personal Strengths Helping At-Risk Patients Maintain a Sense of Self Teaching Self-Compassion Modifying a Negative Self-Concept Developing a Positive Body Image Developing Self-Esteem in Children and Adolescents Enhancing Self-Esteem in Older Adults Evaluating Focus on the Older Adult DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 42 Stress and Adaptation BASIC CONCEPTS OF STRESS AND ADAPTATION Stress Stressors Physiologic Stressors Psychosocial Stressors Adaptation Homeostasis MAINTENANCE OF PHYSIOLOGIC AND PSYCHOLOGICAL HOMEOSTASIS Physiologic Homeostasis Local Adaptation Syndrome REFLEX PAIN RESPONSE INFLAMMATORY RESPONSE General Adaptation Syndrome ALARM REACTION STAGE OF RESISTANCE STAGE OF EXHAUSTION Psychological Homeostasis Mind–Body Interaction Anxiety MILD ANXIETY MODERATE ANXIETY SEVERE ANXIETY PANIC ANXIETY DISORDERS Coping Mechanisms Defense Mechanisms EFFECTS OF STRESS Stress and Basic Human Needs Stress in Health and Illness Long-Term Stress Family Stress Promoting Health Literacy IN PATIENTS EXPERIENCING LONG-TERM STRESS Crisis FACTORS AFFECTING STRESS AND ADAPTATION Sources of Stress Developmental Stress Situational Stress Personal Factors STRESS AND ADAPTATION IN NURSING THE NURSING PROCESS FOR THE PATIENT WITH STRESS AND ANXIETY Assessing Nursing History Physical Assessment Diagnosing Stress as the Problem Stress as the Etiology Outcome Identification and Planning Implementing Teaching Healthy Activities of Daily Living Encouraging Use of Support Systems Encouraging Use of Stress Management Techniques Providing Crisis Intervention Evaluating DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 43 Loss, Grief, and Dying CONCEPTS OF LOSS AND GRIEF Loss Grief Grief Reactions Dysfunctional Grief DYING AND DEATH Definitions of Death Signs of Impending Death A “Good Death” Responses to Dying and Death Terminal Illness Effect on the Patient Effect on the Family Palliative Care and Hospice Ethical and Legal Dimensions Advance Care Planning Allow Natural Death, Do Not Resuscitate, or No Code Order Comfort Measures Only and Other Special Orders Terminal Weaning Voluntary Cessation of Eating and Drinking Active and Passive Euthanasia Palliative Sedation Death Certificate Organ Donation Autopsy FACTORS THAT AFFECT GRIEF AND DYING Developmental Considerations Family Socioeconomic Factors Cultural, Biological Sex, and Religious Influences Cause of Death SUICIDE PREVENTION: MENTAL HEALTH FIRST AID THE NURSE AS ROLE MODEL THE NURSING PROCESS FOR GRIEVING OR DYING PATIENTS AND FAMILIES Assessing Diagnosing Response to Loss as the Problem Response to Loss as the Etiology Outcome Identification and Planning Implementing Focus on the Older Adult MEASURING QUALITY OF CARE AT THE END OF LIFE Developing Trusting Nurse–Patient and Nurse–Family Relationships Explaining the Patient’s Condition and Treatment Teaching Self-Care and Promoting Self-Esteem Promoting Health Literacy IN CAREGIVERS OF TERMINALLY ILL PATIENTS Patient Scenario Nursing Considerations: Tips for Improving Health Literacy Teaching Family Members to Assist in Care Meeting the Needs of the Dying Patient Meeting the Needs of the Family Providing Postmortem Care Evaluating DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 44 Sensory Functioning THE SENSORY EXPERIENCE Reception and Perception Arousal Mechanism DISTURBED SENSORY PERCEPTION Sensory Deprivation Sensory Overload Sensory Deficits Sensory Processing Disorder Sensory Poverty FACTORS AFFECTING SENSORY STIMULATION Developmental Considerations Culture Personality and Lifestyle Focus on the Older Adult Stress and Illness Medication THE NURSING PROCESS FOR SENSORY STIMULATION Assessing Identifying At-Risk Patients Assessment of the Sensory Experience Physical Assessment Assessment of the Ability to Perform Self-Care Diagnosing Disturbed Sensory Perception Outcome Identification and Planning Implementing Promoting Health Literacy IN PATIENTS WITH HEARING DEFICITS Patient Scenario Nursing Considerations: Tips for Improving Health Literacy Evaluating DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES 45 Sexuality SEXUAL HEALTH SEXUAL EXPRESSION Masturbation Sexual Intercourse Vaginal Intercourse Anal Intercourse Oral–Genital Stimulation Abstinence Alternative Forms of Sexual Expression FACTORS AFFECTING SEXUALITY Developmental Considerations Culture Religion Ethics Lifestyle Menstruation The Menstrual Cycle Premenstrual Syndrome and Premenstrual Dysphoric Disorder Sexual Response Cycle Excitement Plateau Orgasm Resolution Female Sexual Response: A Nonlinear Model Childbearing Considerations Sexually Transmitted Infections Sexual Dysfunction Male Primary Sexual Dysfunctions ERECTILE DYSFUNCTION PREMATURE EJACULATION DELAYED EJACULATION Female Primary Sexual Dysfunctions INHIBITED SEXUAL DESIRE DYSPAREUNIA VAGINISMUS VULVODYNIA Effects of Illness, Injury, and Medications Diabetes Mellitus Cardiovascular Disease HYPERTENSION MYOCARDIAL INFARCTION Diseases of the Joints and Mobility Surgery and Body Image Spinal Cord Injuries Chronic Pain Mental Illness Medications SEXUAL HARASSMENT Effects of Harassment Responding to Harassment in the Nursing Environment THE NURSE AS ROLE MODEL THE NURSING PROCESS FOR THE PATIENT WITH A SEXUAL HEALTH NEED Assessing Sexual History The BETTER Model Physical Assessment Diagnosing Focus on the Older Adult Outcome Identification and Planning Implementing Establishing a Trusting Nurse–Patient Relationship Teaching About Sexuality and Sexual Health Promoting Health Literacy IN PATIENTS RECEIVING THE HPV VACCINE Patient Scenario Nursing Considerations: Tips for Improving Health Literacy Promoting Responsible Sexual Expression Form of Sexual Expression Prevention of Unwanted Pregnancy Prevention of STIs Sex Education Considering Contraception Behavioral Methods Barrier Methods Diaphragm Condom Cervical Cap Spermicides Vaginal Sponge Hormonal Methods Oral Contraceptives Norplant System Implanon Depo-Provera Transdermal Contraceptive Patch Vaginal Ring Intrauterine Devices Emergency Contraception Methods Sterilization Future Trends Female Contraceptives Unisex Reversible Contraceptives Male Contraceptives Facilitating Coping With Special Sexual Needs Health Care Needs of Lesbian, Gay Male, Bisexual, and Transgender People Advocating Sexuality Needs of Patients Counseling the Patient Regarding Sexuality Abortion Counseling Counseling in Cases of Abusive Relationships and Rape Evaluating DEVELOPING CLINICAL REASONING Practicing for NCLEX ANSWERS WITH RATIONALES Taylor Suite Resources 46 Spirituality SPIRITUAL DIMENSION CONCEPTS RELATED TO SPIRITUALITY AND SPIRITUAL HEALTH Spirituality Faith Religion Hope Love Spiritual Health and Healing Spirituality and Everyday Living Spirituality, Health, and Illness Guide to Daily Living Habits Source of Support Source of Strength and Healing Source of Conflict FACTORS AFFECTING SPIRITUALITY Developmental Considerations Family Ethnic Background Formal Religion Life Events RELIGION AND LAW, ETHICS, AND MEDICINE PARISH NURSING THE NURSING PROCESS FOR SPIRITUAL HEALTH Assessing Nursing History Promoting Health 46-1 SPIRITUALITY Assessment Checklist Self-Care Behaviors Research in Nursing BRIDGING THE GAP TO EVIDENCE-BASED PRACTICE Critical Care Nurses’ Perceived Need for Guidance in Addressing Spirituality in Critically Ill Patients Related Research Relevance for Nursing Practice Nursing Observation Diagnosing Outcome Identification and Planning Enhancing Spiritual Health Addressing Spiritual Distress Implementing Spiritual Care Ethical and Professional Boundaries Offering Supportive or Healing Presence Facilitating the Practice of Religion Nurturing Spirituality Praying With Patients Praying for Patients Counseling Patients Spiritually Contacting a Spiritual Counselor Resolving Conflicts Between Spiritual Beliefs and Treatments Nursing, Religion, and Conscientious Objection Evaluating REFLECTIVE PRACTICE LEADING TO PERSONAL LEARNING Nursing Care Plan for Mr. Gargan 46-1 DEVELOPING CLINICAL REASONING PRACTICING FOR NCLEX ANSWERS WITH RATIONALES TAYLOR SUITE RESOURCES APPENDIX A GUIDELINES FOR DELEGATION DECISION MAKING INTRODUCTION DELEGATION CRITERIA DELEGATION PROCESS FIVE RIGHTS OF DELEGATION “DO-NOT-DELEGATE” CARE DELEGATION DECISION TREE Taylor Suite Resources APPENDIX B EQUIVALENTS METRIC UNITS Length Volume Weight METRIC UNITS AND THEIR HOUSEHOLD EQUIVALENTS APPENDIX C NORMAL ADULT LABORATORY VALUES* COMMONLY USED ABBREVIATIONS GLOSSARY INDEX
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