UNIT 1 – CARE OF THE HOSPITALIZED PATIENT ACROSS THE LIFESPAN 1

CHAPTER 1 (Iggy)
Scope of Medical-Surgical Nursing---Promote health and prevent illness or injury in patients 18 to older than 100
MS nursing = adult health nursing
What makes tx different? Growth and development! #1 goal – ensure patient safety as a priority in practice

National Patient Safety Goals (published by TJC)

 2000----Institute of Medicine (IOM)
 Force healthcare agencies to focus on high-risk issues. Money is the driving force! Insurance companies
did not want to cont to pay for mistakes that were not theirs.
o Drug administration
o Fall reduction
o Pressure ulcer prevention
o Communication among health care members

Rapid response teams – to save lives and decrease risk for harm
- Gives care BEFORE resp/cardiac arrest occurs
- Intervenes rapidly for those who are beginning to decline (observe: hypoTN, tachy, mental status changes)
- Consists of: ICU nurse, resp therapist, intensivist (internal medicine person who specializes in crit care)
- Notify when a patient has a slow or sudden deterioration in clinical condition!

IOM Competencies for Health Professionals (2003)

 Provide patient-centered care
 Collaborate with interdisciplinary health care teams
 Implement evidence-based practice
 Use quality improvement in patient care
 Use informatics in patient care
 Formed QSEN (Quality and Safety Education for Nurses) – PROVIDE PATIENT SAFETY

Nursing Activities are:

 Collaborative (INTERdependent)---mutually determined by the nurse and physician or other health care
professionals Ex. Administering meds

 Independent---initiated and carried out without direction from health care provider Ex. weighing a pt;
listening to breath sounds, elevating HOB

o Patient centered care requires that all members of the interdisciplinary team collaborate to achieve
optimal clinical outcomes.
 Nurse = coordinator/case manager; focus = provide quality and cost effective care

SBAR---formal method of communication btwn 2+ members of the healthcare team

Evidence-based Practice – Deliberate use of current best evidence to make decisions about patient care----
maintains patient safety and quality care

CHAPTER 3
Health Issues for Older Adults -  potential for problem by virtue of their age (p. 23)
 SPICES – 6 serious “marker conditions” that lead to longer hospital stays
1. Sleep disorders
2. Problems w/ nutrition
3. Incontinence – NOT a physiological change of aging; put on toileting schedule, train bladder
4. Confusion – delirium = acute confusion; dementia = chronic confusion
5. Falls - NPSGs require that all inpatient settings have fall risk assessment tool and fall
reduction program; recent hx of falling = most imp predictor for falls!!!
 UNIT 1 – Wilder 2

6. Skin breakdown – reposition often, create plan to  mobility/activity level, protocols for skin
cleansing, avoid friction/shearing, nutritional support

Ebersole – Ch. 1, 2 – THEORIES OF AGING – be familiar w/ names! (not what each of them actually are)

I. Biological – in the end, body as an organism becomes disorganized and chaotic and is no longer able to sustain
itself and death ensues
 Stochastic – aging results from an accum of random errors w/in the synthesis of DNA/RNA
 Wear and Tear Theory
 Cross-linkage Theory
 Free Radical Theory
 Nonstochastic – errors are pre-determined, intrinsic, and timed
 Programmed Theory
 Immunity Theory

II. Emerging Biological Theories

 Neuro-endocrine Control
 Pacemaker Theory
 Calories Restriction (metabolic)
 Genetic Research

III. Sociological Theories – attempt to explain/predict changes in roles and relationships in middle-late life with an
emphasis on adjustment; not empirically-based; must view historically
 Role Theory
 Activity Theory
 Disengagement Theory
 Continuity Theory
 Age Stratification Theory
 Social Exchange Theory
 Modernization Theory

IV. Psychological Theories – all students of Freud – aging is a developmental process

 Jung
 Erikson
 Peck
 Maslow’s hierarchy***

CHAPTER 16-18 (Iggy – pg. 242-301)

I. Pre-Op Care
- Surgery – art and science of treating disease, injuries, and deformities by operations and instrumentation
- Nurses – vital component to sx! (physically AND mentally!)
o Must have an idea about the nature of their disorder for explanations
o ID how this person is responding to sx
o Assess pre-op diagnostic tests
o ID potential complication based on gathered assessment data

1. 6 reasons for surgery:

 Diagnosis – determine origin/cause of disorder; cancer cell type; search for mass/lymph node
 Cure/care – resolve health problem by removing/repairing the cause; discovered a pathology
and can make you better by removing it
 Palliative –relieve symptoms that provide more comfort – NOT curing!!!
 Prevention – removing a suspicious mole before turning into skin cancer, etc
 Exploration – to determine the extent of the disease
UNIT 1 – Wilder 3

 Cosmetic Improvement

2. Primary Purpose of Pre-op Interview:

 Obtain pt health info
 Provide and/or clarify info about the surgery
 Assess pt emotional state/readiness for surgery
- PAST HEALTH HISTORY:
o Previous surgery? COMPLICATIONS?? (i.e. anesthesia, healing, bleeding, etc)
o Drug allergies? Latex allergies? AND how they respond if exposed to allergen?
o Problems with blood clots, DVT?
o Cognitive fxn ok? (respond/answer appropriately?)
o Renal fxn for older adult – check BUN/creatinine
o Liver fxn studies ok? B/c you want them to CLOT
o Diabetic?
o Obese = increased risk, don’t heal as well, wound dehisce, slower coming out of anesthesia (stored
in adipose tissue)

3. Pre-op Assessment:
 Overall goal—identify risks factors and plan care to ensure safety
 Other goals
 Establish baseline data
 ID ALL prescription medications, OTC drugs, vitamins, and herbal supplements
 Document pre-op lab---communicate results
 ID any cultural/ethical aspects that may need to be incorp into care
a. Muslim – anything done with left hand considered unclean
b. Native American – any body parts must be buried
c. Jehovah’s Witnesses – no blood transfusions
d. Is pain an option?!
 Questions all allergies (drug, nondrug)
 Determine if pt has adequate info to make an informed consent to surgery
a. Want them to FULLY UNDERSTAND
b. Our job is to clarify the sx. Doctor needs to explain the sx.
i. If they don’t understand, call physician back in
ii. Not our job to get it signed!
c. Everything must be spelled correctly and fully written out!
d. Do NOT ask them to sign form AFTER giving pre-op meds

4. Pre-op Teaching:
 Reduces post-op fear anxiety, stress
 Common fears – death, pain/discomfort, mutilation/alteration in body image,
anesthesia
 Decreases complications, length of hospitalizations, recovery time
 Arises from assessment: tells what you need to teach them
 ANY teaching done needs to be documented in writing!

5. Informed Consent
 Active shared decision-making process between health care provider and recipient of care
 3 conditions of informed consent that MUST be met:
 Adequate disclosure – risks, benefits, consequences, availability of alt treatments,
success rate, what happens if DON’T get it done (prognosis)

 Give consent voluntarily – pt can withdraw consent at ANY time

 UNIT 1 – Wilder 4

 Demonstrate clear understanding and comprehension of info – do not sign if

they have any unanswered questions
 If minor (<18), unconscious, mentally incompetent—may get permission from legally
appointed person or responsible family member (next of kin)
 HAS to be written, dated, and signed
 Physician ultimately responsible
 Nursing responsible for witnessing and verifying that pt understands
 True medical emergency may override the need for consent

6. Day of Surgery Nurse Responsibilities

 Final pre-op teaching
 Assessment/communication of pertinent findings
 Ensuring all pre-op orders done
 Ensuring records/reports complete/present
 Verify presence of signed informed consent with everything spelled correctly
 Give pre-op meds – put side rails up, inform them not to get up w/o help

II. Intra-operative Care

- Begins when pt enters sx suite and ends at time of transfer to recovery area
- Operating room – set up to minimize infection & allow smooth flow of patients, stuff, & equipment

1. Nursing Role – know diff btwn unsterile/sterile nurse & resp!

 Circulating/nonsterile – remains in the unsterile field
 Must document everything that happens
 Admit to OR suite, position client
 Measure fluid/blood loss
 ***count sponges, needles, supplies, & instruments***
 Resp for labeling specimen/delivery to right location

 Scrub = in STERILE field; “gown and glove”

 Pass instruments, assist with draping procedures, monitor aseptic technique of
everyone, assist with room preparation, hold body cavities open

2. Classification of Anesthesia
 General – put to sleep
 Loss of sensation w/ loss of consciousness
 IV or inhaled
 Usually combination of hypnotic, analgesia, & something to cause amnesia
 Causes skeletal muscle relaxation
 Eliminates cough, gag, & vomiting reflexes
 Regional
 Loss of sensation to a region of the body
 Most times, person is conscious
 Ex – epidural, nerve blocks
 Usually anesthetic, analgesic….do NOT need amnesiac

 Local – loss of feeling to an area; very short term

 MAC (monitored anesthesia care) (conscious sedation)
 Similar to general anesthesia; Usually a sedative or opiate but much lower dosage
 Does NOT involve inhalation – ALL IV! (ex – lidocaine, novocaine)
 Purposes – relieve anxiety, provide analgesia & amnesia
 Pt. is responsive & breathe on their own
 Ex – colonoscopy, wisdom teeth
 UNIT 1 – Wilder 5

3. Catastrophic Events in an OR
 Anaphylactic shock
 Only way it is defensible is if it is a new allergy the person has never had before
 Know where crash cart is! Considered life-threatening

 Malignant HYPERthermia (temp s)

 Usually happens under general anesthesia; believed to be genetic cause
 Considered an emergency bc it causes rigidity of skel muscles which can result in
death
a. Dantrium – ONLY avail tx!! Slows metabolism down, which reverses the
problem. Usually on every crash cart.
III. Post-op Nursing Care
- Begins immediately after surgery and continues until the person is discharged form the facility
- Involves
o Protecting the patient – Providing for safety (physical transfer & info transfers)
o Preventing complications
- Initial priorities
o Monitoring and managing respiratory and circulatory functions
o Pain
o Temperature
o Surgical Site

1. PHASES TO POST-OP CARE

 Phase I – expect verbal report from anesthesiologist/nurse anesthetist (Table 18.1 – 287)
 Care during the immediate post-anesthesia period
 ECG and more intense monitoring
 GOAL: monitor and maintain respir/circulatory fxn #1 thing = BREATHING!!!!!
 ABCs, pulse ox (<90 = not good), skin color, mucus membranes
 Pain, surgical site, GU, Neuro

2. Physical Signs of Inadequate Oxygenation:

 CNS – restlessness, agitation, muscle twitching, seizures, coma
 Cardiovascular – hyper/hypotension, tachy, brady, dysrhythmias, delayed capillary refill
 Skin – flushed, moist, cyanotic
 Resp – use of accessory muscles, abnormal breath sounds, abnormal blood gases
 Renal – urine output <0.5 mg/kg/hr

3. Potential Respiratory Problems:

 Airway Compromise
 Causes—obstruction, hypoventilation, hypoxemia
 High risks– hypoventilation (if pt has hx of this, then count on a problem), older, smokers,
lung disease, obese, undergone airway, thoracic, or abdominal surgery
 Evaluate patency, chest symmetry, depth, rate, & character of respirations
 Positioning
 unconscious— lateral (usually left side)
 conscious— supine (should elevate HOB if surgery allows)
 Encourage turn, cough, deep breath!!!! (10/hr)
 Obstruction – could be as simple as their tongue
 Common problems assoc w/ hypoxemia – pulmonary edema/embolism, bronchospasm

4. Potential Cardiac Problems:

 Causes—hypotension, HTN, dysrhythmias
 Hypo – usually caused by fluid/blood loss during sx
UNIT 1 – Wilder 6

 HTN – usually caused by stim of symp NS related to pain, anxiety

 Dysrryth – usually pre-existing cardiac condition; also, hypoxemia, alt in F/E
 High risk—Hx of CV disease, elderly, debilitated, critically ill
 Frequent monitoring of vital signs
 Accurate I&O
 Early ambulation (s effects of anesthesia)
 Change pt position slowly

5. Notify surgeon if:

 SBP < 90 or > 160; Pulse < 60 or > 120
 Pulse Pressure narrows (difference between systolic and diastolic pressure)
 Change in cardiac rhythm (individualized!)
 –Compare ECGs from pre-op
 Significant deviation from pre-op readings
6. **Other post-op nursing focuses:
 Most common post-op complication = N/V
 ALWAYS assess level of consciousness, orientation, ability to follow commands (sit up, roll
over, move fingers, etc)
 Know their pre-op orientation
 Emerging delirium – anesthesia affects pts in diff ways!
 Pain assessment – complication and expectation of sx.
 Person’s self report = most reliable acct
 S/S – restlessness, diaphoresis, change in VS
 Make them as comfortable as possible, within reason (massage, pillows, converse)
 Temperature assessment
 ALL ppl at risk for HYPOthermia
 Older pt, debilitated pt, intoxicated pt – expect temp variation
 Bowel – LAST thing to wake up from general anesthesia
 Assess abd distension & bowel sounds
 NEVER feed until they have passed gas
 I & O – bladder distension?
 Most ppl will urinate w/in 6-8 hr of sx
 First 24 hrs – btwn 500-1500 cc
 Should be similar after 24 hrs
 Assess surgical wounds & drainage on dressing
 Draw line around drainage and put time/date; reassess to determine amount of
drainage
 Do NOT take off dressings!!
 Color, consistency, odor of drainage to assess for infection
 UNIT 1 – Wilder 7

PEDIATRICS
Hockenberry: Ch. 26-27

I. Hospitalization of Children & Stressors

- Developmental milestones – determine what you do for each particular child! (TEST!)
- Children have limited coping abilities

1. Separation anxiety – (16-30 months through preschool – 5-6 yrs) biggest stressors! (Pg 965)
- BUT most children are resilient and it is usually not a permanent condition
 Protest
 Cries, screams, clings to parent, rejects strangers, searches for parents
 Verbally & physically attack strangers (“no, go away”)
 Attempts to escape to find parents; tries to physically force parent to stay
 Increased protests precipitated by approach of stranger
 Possibly lasting days to hours
 Protests often continuous, ceasing only w/physical exhaustion
 Despair
 Crying stops, depressed, less active, uninterested in environment, uncommunicative,
withdrawn, looks sad/lonely, regresses to earlier behavior (thumb sucking, wet bed)
 Behaviors lasting variable lengths of time
 Physical condition deteriorating from refusal to eat, drink, or move
 Detachment/denial – adjusts to the loss
 Worrisome if they don’t get better after 2nd phase!
 Increased interest in surroundings, appears happier
 Interacts w/ strangers or familiar caregivers
 Forms new, but superficial relationships

2. Loss of Control – Increases the perception of a threat & effects the child’s coping skills
- physical restriction, altered routine/rituals, dependency
 Infant
 will lose trust
 Toddler
 temper tantrums (rely on consistency, familiarity, daily rituals), will usually regress
 Preschoolers
 (egocentric, magical thinking) will not understand things as clearly
 School-age
 (striving for independence/productivity)
 hospitalization causes altered family roles, fear of death/abandonment
 UNIT 1 – Wilder 8

 difficult time period! – btwn being a kid vs adolescent

 Adolescence
 Need control to be independent and self-assured, PERSONAL IDENTITY!
 RXN – withdrawal, uncooperative, hard to get along with

3. Bodily Injury and Pain – impacted by what happens in childhood

 Infants
 Squirm, jerk; get someone to help hold!
 Toddlers
 Restless, overactive, screaming, emotionally upset
 Preschoolers (very literal and take it exactly as you say it!)
 Afraid of mutilation; must choose words carefully! (“cut off” “take out” “draw”)
 School-Age (active in their health, want ALL the facts and info)
 Afraid you are going to tell them something is wrong with them
 FIRST group you can trust to thoroughly communicate about their pain!
 Adolescents
 Care about what they will look like, will they be different from their friends?

4. Post hospital behaviors – pg 972 box 26-2

 Young kids
 Initial aloofness toward parents (may last minutes-days)
 Tendency to cling to parents; demand parents attn
 Vigorously oppose separation; withdrawals
 New fears; resist going to bed, nigh waking

5. Parental Reactions to Child’s illness

 Must try to understand their reactions! Major source of stress and anxiety for family
 Disbelief/Accepting – b/c of their guilt/anger
 Tend to search for reasons to blame themselves
 Stressful for siblings also! B/c sick child gets all the attn, esp if it’s a long-term illness
 Tend to have anger, resentment, jealousy, and guilt (depends on devel task)

 Factors affecting parent’s rxns to their child’s illness pg 973 table 26-4
 Seriousness of the threat to the child
 Previous experience w/illness or hospitalization
 Medical procedures involved in dx and tx
 Available support systems
 Personal ego strengths
 Previous coping abilities
 Additional stresses on family system
 Cultural/religious beliefs
 Communication patterns among family members

II. Strategies to Minimize Effect of Separation

- Learn age-appropriate toys: infants = bright blocks; adolescents = ipods
- SHOULD the parent be the one to hold the child? Child may assoc parent w/ something that is painful
- Nurse should hold child if procedure is painful! Parent should be in room as a comfort measure
- If parent “can’t handle it,” have them wait outside (i.e. important to observe relationship btwn child/parent)

1. Primary Nurse – helps to develop relationship!

2. Frequent visits from parents/family – depends on protocol
 UNIT 1 – Wilder 9

3. Favorite items from home – gives sense of familiarity

4. Maintain child routine—est daily schedule (ask parent ab their routine)
 Clock in room if they can tell time; regular cloths if older
5. Promoting self care
 Limited by illness, age, and developmental tasks but try to est as much independence as
possible
6. Anticipatory prep – minimizing anticipatory harm/fear based on developmental levels
 Adults – same explanation for everybody
 PEDS – what to expect, what’s going to happen before after and during, give them as much
info as you can give them
 Parents – explain what will happen, length of procedure
7. Do procedure quickly!!!!!!! BUT SAFELY!
8. Play is important – pg. 979
 Diversion, relaxation, security, puts them in an active role
 Way to express their thoughts and feelings no matter the age

III. Prep for Hospital – pg. 987

- Remember to think about everything from the parent’s perspective!!! It’s THEIR child.
- Pre-admin – assign room based on devel age, seriousness of diagnosis, communicability of illness, and
projected length of stay; prepare roommates for arrival of new patients
- Admin – introduce primary nurse
- Emergency admin – USE THE CHILD’S NAME!!!! Use Mr./Ms.
o Must ask – “Can I call you Bill?” – gives sense of control

1. Prep 1-2 days prior to procedure

2. School-age/adolescent – may be as much as a wk prior
3. Timing – Good to give clear, thorough explanation to parent and child
4. Tour – Give “tour” if possible to establish familiarity; Meet the primary nurse if possible
5. Special prep
 Isolation – further separation from family, more loss of control, components of sensory
deprivation
 Respiratory, enteric (diarrhea), contact isolation
 Must thoroughly explain everything and make sure they understand
 Will usually view isolation as punishment (lack of c/e relationship)
 ICU - prepare them for what they are going to see; prepare parent for what the child will look
like (tubes, etc); prepare siblings for their visit, plan length of visitation time from the parent;
provide uninterrupted sleep cycles! (infant = 60 min, older = 90 min); provide
opportunities for play

IV. Pediatric Variations - pg. 1002, 1003 – CHARTS!, pg 1004 – nonthreatening words, pg 1092, 1006 - play
1. Preparing children for procedures
 *Review parent’s/child’s level of understanding
 *Plan teaching based on developmental level
 Inform parents of their role – what they are suppose to be doing
 Use concrete terms – don’t be fancy!
 Be honest – tell them if it’s going to hurt! Explain. Quantify. “feels like a bee sting”
2. Infants
 Keep parents in infant’s line of sight
 Make advances slowly; non-threatening; cuddle/hug
 Have ALL restraining materials BEFORE starting
 Perform painful procedures in separate room
3. Toddler
 Explain in relation to senses! (see, hear, touch)
 Tell OK to cry, yell
UNIT 1 – Wilder 10

 Expect treatment to be resisted (“No!”)

 Firm, direct approach; Just do it.
4. Preschooler
 Explain a little more; Allow them to act out
 Apply adhesive bandages; LOVE band-aids!
 Encourage parental presence
 Give choices when possible
5. School Age
 Longer teaching sessions
 Include child more in decision-making
 Provide privacy from peers
6. Adolescent
 Explanations with reasons
 Provide privacy
 Expression of feelings

7. Feeding a sick child – pg. 1015

 Make eating time as much like home as possible – time, at table, large/small meals?
 Encourage parents to feed child
 Serve small frequent meals
 Provide foods that are children favorites
 Do not punish children for not eating

V. Informed Consent
1. Age of consent in most states = 18
 Must be voluntary, understand, properly explained
 Adults = usually treatments and surgeries
 Child
 Need consent to have child’s picture made/to release any medical information
 MUST have the consent of the parent who is the legal custodian
a. Must ask if they have the legal custody
b. Joint custody – usually okay for either parent to sign
c. Married – both must agree
 Emergency situation – can get consent over the phone but must have a witness

2. Emancipated minor – legal adult prior to age 18

 Pregnant and had a child; Married; Graduated from high school, esp if they are supporting
themselves; In the military
 Confidentiality – must have consent of the emancipated minor, not parent

VI. Restraining Methods

- MUST have an order that specifies the type, reason, length, include relaxation periods?

2 Types:
 Behavioral
 Medical-surgical – protect IV, perform procedure, etc

Kinds:
 Mummy
 Jacket
 Arm/leg
 Elbow

VII. Specimen Collection – Know variations in positions (pg. 1024)

UNIT 1 – Wilder 11

1. Lumbar – older child = more flexed/C’d

2. Urine

3. Stool

4. Respiratory

VIII. Medication Administration – REVIEW!

1. Safe dose
2. Oral
 Syringe
 Don’t add to infant formula
3. Injectable
 Ventrogluteal; 1 ml
4. Enema
 Isotonic solution

MISC:
a. Pg. 1016 – child with fever

b. Hygiene – think of it in relation to the age of child

 adolescent – bath everyday
 teeth – first dental visit around age 2-3
 toddler – may not need bath everyday