The Basics: A Comprehensive Outline of Nursing School Content

By Kaplan Nursing

Kaplan’s The Basics provides comprehensive review of essential nursing school content so you can ace your assignments and exams.

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• All the essential content you need, presented in outline format and easy-access tables for efficient review
• Chapters mirror the content covered in your nursing school curriculum so you know you have complete content coverage
• Used by thousands of students each year to succeed in nursing school and beyond

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• Language: English
• Publisher: Kaplan Test Prep
• Release date: Jun 2, 2020
• ISBN: 9781506262901

Book preview

The Basics

A COMPREHENSIVE OUTLINE OF NURSING SCHOOL CONTENT

Table of Contents

Chapter 1: Health Assessment

Section 1: Health History

Section 2: Physical Assessment

Section 3: Mental Status Assessment

Chapter 2: Fundamentals of Nursing

Section 1: Normal Mobility

Section 2: Altered Functions Related to Immobility

Section 3: Safety

Section 4: Altered Functions Related to Pain

Section 5: Protection from Communicable Diseases

Section 6: Maintenance of Skin Integrity

Section 7: Perioperative Care

Chapter 3: Fluid and Electrolyte Balance

Section 1: Fluid Regulation

Section 2: Electrolyte Imbalances

Section 3: Nursing Measures for Intravenous Therapy

Chapter 4: The Cardiovascular System

Section 1: The Cardiovascular System Overview

Section 2: Alterations in Cardiac Output

Section 3: Vascular Alterations: Hypertension

Section 4: Selected Disorders of Tissue Perfusion

Section 5: Vascular Disorders

Chapter 5: The Respiratory System

Section 1: The Respiratory System Overview

Section 2: Alterations in Airway Clearance and Breathing Patterns

Chapter 6: Hematological and Immune Disorders

Section 1: Overview of Hematology

Section 2: Disorders of the Blood

Section 3: The Immune System

Chapter 7: The Gastrointestinal System

Section 1: Concepts Basic to Nutrition

Section 2: Alterations in Metabolism

Section 3: Selected Disorders

Section 4: Accessory Organs of Digestion (Liver, Gallbladder, Pancreas)

Section 5: The Lower Intestinal Tract

Chapter 8: The Endocrine System

Section 1: The Endocrine System Overview

Section 2: Endocrine Disorders

Chapter 9: The Renal and Urological Systems

Section 1: The Urinary System Overview

Section 2: Urinary Function

Section 3: Selected Disorders

Chapter 10: The Musculoskeletal System

Section 1: Alterations in Musculoskeletal Function

Chapter 11: Sensory and Neurological Function

Section 1: Sensation and Perception Functions

Section 2: Alterations in Vision

Section 3: Alterations in Hearing

Chapter 12: Oncology

Section 1: Cancer

Section 2: Leukemia

Section 3: Skin Cancer

Section 4: Intracranial Tumors

Section 5: Pancreatic Tumors

Section 6: Carcinoma of the Larynx

Chapter 13: Maternity and Gynecological Nursing

Section 1: The Reproductive System

Section 2: Childbearing—Antepartal Care

Section 3: Labor and Delivery

Section 4: Postpartum

Section 5: The Neonate

Section 6: Childbearing—Maternal Complications

Section 7: Childbearing—Neonatal Complications

Chapter 14: Pediatric Nursing

Section 1: Growth and Development

Section 2: Pediatric Assessment/Wellness

Section 3: Alterations in Pediatric Health

Chapter 15: Psychosocial Integrity

Section 1: Basic Concepts

Section 2: Anxiety

Section 3: Situational Crises

Section 4: Depressive Disorders

Section 5: Bipolar Disorder

Section 6: Altered Thought Processes

Section 7: Social Interactions

Section 8: Abuse

Chapter 16: Pharmacology

Section 1: Listing of Medications

Chapter 17: Terminology

Section 1: Nursing Abbreviations

Section 2: Medication Terminology

Section 3: Terminology Used for Documentation

Guide

Cover

Table of Contents

Start of Content

Judith A. Burckhardt, Ph.D., R.N.

Joanne Brown, M.S.N., M.P.H., R.N.

Barbara J. Irwin, M.S.N., R.N.

Marlene Redemske, M.S.N., M.A., R.N.

Pamela Gardner, M.S.N., R.N.

Contributing Editors

Susan Sanders, D.N.P, R.N., NEA-BC

Vice President, Kaplan Nursing

Amy Kennedy, M.S.N., R.N.

Nursing Curriculum Specialist II

This book is solely intended for use as preparation for the NCLEX examination. It is not a guide to the clinical treatment of clients. Neither the authors nor the publisher shall be responsible for any harm caused by the use of this book other than for its intended purpose. This book is just a small portion of the Kaplan materials available for you to prepare for the NCLEX examination.

This publication is designed to provide accurate information in regard to the subject matter covered as of its publication date, with the understanding that knowledge and best practice constantly evolve. The publisher is not engaged in rendering medical, legal, accounting, or other professional service. If medical or legal advice or other expert assistance is required, the services of a competent professional should be sought. This publication is not intended for use in clinical practice or the delivery of medical care. To the fullest extent of the law, neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons or property arising out of or related to any use of the material contained in this book.

© 2020 by Kaplan, Inc.

Published by Kaplan Publishing, a division of Kaplan, Inc.

750, Third Avenue

New York, NY 10017

ISBN: 978-1-5062-6290-1

All rights reserved. The text of this publication, or any part thereof, may not be reproduced in any manner whatsoever without written permission from the publisher. This book may not be duplicated or resold, pursuant to the terms of your Kaplan Enrollment Agreement.

Chapter 1

Health Assessment

1

Health History

DEMOGRAPHIC DATA

Date

Biographical information

Client as reliable historian

Age, sex, marital status

Reason for seeking health care

History of present illness/condition

PAST HEALTH HISTORY

Past health history

Medical history

Surgical history

Medications

Communicable diseases

Allergies

Injuries/accidents

Disabilities/handicaps

Blood transfusions

Childhood illnesses

Immunizations

Family health history

Genogram

Familial/genetic diseases

Social history

Alcohol/tobacco/drug use

Travel history

Work environment

Home environment

Hobbies/leisure activities

Stressors

Education

Economic status

Military service

Religion

Culture

Roles/relationships

Sexual history

Patterns of daily living

Health maintenance

Sleep

Diet

Exercise

Stress management

Safety practices

Patterns of health care practices

Review of systems

2

Physical Assessment

PURPOSE

Assess client’s current health status

Interpret physical data

Decide on interventions based on data obtained

PREPARATION

Gather equipment

Ophthalmoscope

Tuning fork

Cotton swabs

Snellen eye chart

Thermometer

Penlight

Tongue depressor

Ruler/tape measure

Safety pin

Balance scale

Gloves

Nasal speculum

Vaginal speculum

Provide for privacy (drape) in quiet, well-lit environment

Explain procedure to client

Ask client to empty bladder

Drape client for privacy

Compare findings on one side of body with other side and compare with normal

Make use of teaching opportunities (dental care, eye exams, self-exams of breasts or testicles)

Use piece of equipment for entire assessment, then return to equipment tray

TECHNIQUES USED IN ORDER PERFORMED, EXCEPT FOR ABDOMINAL ASSESSMENT

General assessment

Inspection

Palpation

Percussion

Auscultation

Abdominal assessment

Inspection

Auscultation

Percussion

Palpation

Inspection (visually examined)

Start with first interaction

Provide good lighting

Determine

Size

Shape

Color

Texture

Symmetry

Position

Palpation (touch)

Warm hands

Approach slowly and proceed systematically

Use fingertips for fine touch (pulses, nodes)

Use dorsum of fingers for temperature

Use palm or ulnar edge of hand for vibration

Start with light palpation, then do deep palpation

Use bimanual palpation (both hands) for deep palpation and to assess movable structure (kidney). Place sensing hand lightly on skin surface, place active hand over sensing hand and apply pressure

Ballottement—push fluid-filled tissue toward palpating hand so object floats against fingertips

Determine

Masses

Pulsation

Organ size

Tenderness or pain

Swelling

Tissue fullness and elasticity

Vibration

Crepitus

Temperature

Texture

Moisture

Percussion (tap to produce sound and vibration)

Types

Direct—strike body surface with 1 or 2 fingers

Indirect—strike finger or hand placed over body surface

Blunt—use reflex hammer to check deep tendon reflexes; use blunt percussion with fist to assess costovertebral angle (CVA) tenderness

Sounds (produced by direct or indirect percussion)

Resonance—moderate to loud, low-pitched (clear, hollow) sound of moderate duration; found with air-filled tissue (normal lung)

Hyperresonance—loud, booming, low-pitched sound of longer duration found with over-inflated, air-filled tissue (pulmonary emphysema); normal in child due to thin chest wall

Tympany—loud, drum-like, high-pitched or musical sound of moderately long duration found with enclosed, air-filled structures (bowel)

Dull—soft, muffled, moderate to high-pitched sound of short duration; found with dense, fluid-filled tissue (liver)

Flat—very soft, high-pitched sound of short duration; found with very dense tissue (bone, muscle)

Determine

Location, size, density of masses

Pain in areas up to depth of 3–5 cm (1–2 in)

Performed after inspection and palpation, except for abdominal assessment; for abdomen, perform inspection, auscultation, percussion, palpation

Auscultation (listen to sounds)

Equipment

Use diaphragm of stethoscope to listen to high-pitched sounds (lung, bowel, heart); place firmly against skin surface to form tight seal (leave ring)

Use bell to listen to soft, low-pitched sounds (heart murmurs); place lightly on skin surface

Listen over bare skin (not through clothing); moisten body hair to prevent crackling sounds

FINDINGS

General survey

General appearance

Apparent age

Sex

Racial and ethnic groups

Apparent state of health

Proportionate height and weight

Posture

Gait, movements, range of motion

Suitable clothing

Hygiene

Body and breath odor

Skin color, condition

Presence of assistive device, hearing aid, glasses

General behavior

Signs of distress

Level of consciousness, oriented ×3, mood, speech, thought process appropriate

Level of cooperation, eye contact (culture must be considered)

Vital signs (see Table 1-1)

Temperature (see Table 1-2)

Infants—performed axillary

Intra-auricular probe allows rapid, noninvasive reading when appropriate

Tympanic membrane sensors—positioning is crucial, ear canal must be straightened

Pulse (rate, rhythm)

Respirations (rate, pattern, depth)

Adult—costal (chest movement), regular, expiration slower than inspiration, rate 12–20 respirations/min

Neonates—diaphragmatic (abdominal movement), irregular, 30–60 respirations/min

Breathing patterns

Abdominal respirations—breathing accomplished by abdominal muscles and diaphragm; may be used to increase effectiveness of ventilatory process in certain conditions

Apnea—temporary cessation of breathing

Cheyne-Stokes respirations—periodic breathing characterized by rhythmic waxing and waning of the depth of respirations

Dyspnea—difficult, labored, or painful breathing (considered normal at certain times, e.g., after extreme physical exertion)

Hyperpnea—abnormally deep breathing

Hyperventilation—abnormally rapid, deep, and prolonged breathing

Caused by central nervous system disorders, medications that increase sensitivity of respiratory center, or acute anxiety

Produces respiratory alkalosis due to reduction in CO2

Hypoventilation—reduced ventilatory efficiency; produces respiratory acidosis due to elevation in CO2

Kussmaul’s respirations (air hunger)—marked increase in depth and rate

Orthopnea—inability to breathe except when trunk is in an upright position

Paradoxical respirations—breathing pattern in which a lung (or portion of a lung) deflates during inspiration (acts opposite to normal)

Periodic breathing—rate, depth, or tidal volume changes markedly from one interval to the next; pattern of change is periodically reproduced

Cyanosis—skin appears blue because of an excessive accumulation of unoxygenated hemoglobin in the blood

Stridor—harsh, high-pitched sound associated with airway obstruction near larynx

Cough

Normal reflex to remove foreign material from the lungs

Normally absent in newborns

Blood pressure

Check both arms and compare results (difference 5–10 mm Hg normal)

Pulse pressure is difference between systolic and diastolic readings; normal 30–40 mm Hg

Cover 50% of limb from shoulder to olecranon with cuff; too narrow: abnormally high reading; too wide: abnormally low reading

Nutrition status

Height, weight; ideal body weight, men: 106 lb for first 5 ft, then add 6 lb/in; women: 100 lb for first 5 ft, then add 5 lb/in; add 10% for client with larger frame; subtract 10% for client with small frame

Skin

Check for pallor on buccal mucosa or conjunctivae, cyanosis on nail beds or oral mucosa, jaundice on sclera

Scars, bruises, lesions

Edema (eyes, sacrum), moisture, hydration

Temperature, texture, turgor (pinch skin, tented 3 seconds or less is normal), check over sternum for elderly

Hair

Hirsutism—excess

Alopecia—loss or thinning

Nails (indicates respiratory and nutritional status)

Color

Shape, contour (normal angle of nail bed ≤160°; clubbing: nail bed angle ≥180° due to prolonged decreased oxygenation)

Texture, thickness

Capillary refill—blanch nail beds of fingers or toes and quickly release pressure; color should quickly return to normal (≤3 seconds)

Head

Size, shape, symmetry

Temporal arteries

Cranial nerve function (see Table 1-3)

Eyes

Ptosis—drooping of upper eyelid

Color of sclerae, conjunctivae

Pupils: size, shape, equality, reactivity to light and accommodation (PERRLA)

Photophobia—light intolerance

Nystagmus—abnormal, involuntary, rapid eye movements

Strabismus—involuntary drifting of one eye out of alignment with the other eye; lazy eye

Corneal reflex

Visual fields (peripheral vision)

Visual acuity—Snellen chart, normal 20/20

Ophthalmoscope exam

Red reflex—red glow from light reflected from retina

Fundus

Optic disk (the blind spot)

Macula

Gerontologic considerations–sclera yellowish-colored; milky-colored ring around periphery of cornea; decreased corneal reflex; decreased tear secretion; delayed pupil reflex and accommodation; cataracts; presbyopia; increased incidence of floaters

Ears

Pull pinna up and back to examine children’s (≥3 years of age) and adults’ ears

Pull pinna down and back to examine infants’ and young children’s (less than 3 years of age) ears

Tympanic membrane—cone of light at 5 o’clock position right ear, 7 o’clock position left ear

Weber test—assesses bone conduction; vibrating tuning fork placed in middle of forehead; normal: hear sound equally in ears

Rinne test—compares bone conduction with air conduction; vibrating tuning fork placed on mastoid process, when client no longer hears sound, positioned in front of ear canal; normal: should still be able to hear sound; air conduction greater than bone conduction by 2:1 ratio (positive Rinne test)

Nose and sinuses

Septum midline

Alignment, color, discharge

Palpate and percuss sinuses

Mouth and pharynx

Oral mucosa

Teeth (normal: 32)

Tongue

Hard and soft palate

Uvula, midline

Tonsils

Gag reflex

Swallow

Taste

Neck

Range of motion of cervical spine

Cervical lymph nodes (normal ≤1 cm round, soft, mobile) non-tender

Trachea position

Thyroid gland

Carotid arteries—check for bruit and thrill

Jugular veins

Thorax and lungs

Alignment of spine

Anteroposterior to transverse diameter (normal adult 1:2 to 5:7); 1:1 barrel chest

Respiratory excursion

Respirations

Tactile fremitus—vibration produced when client articulates 99

Diaphragmatic excursion—assesses degree and symmetry of diaphragm movement; percuss from areas of resonance to dullness

Breath sounds—bilaterally equal

Normal

Vesicular—soft and low-pitched breezy sounds heard over most of peripheral lung fields; inspiraton ≥ expiration

Bronchovesicular—medium-pitched, moderately loud sounds heard over the mainstem bronchi; inspiration = expiration

Bronchial—loud, coarse, blowing sound heard over the trachea; inspiration ≤ expiration

Adventitious (abnormal); caused by fluid or inflammation

Fine Crackles—crackling or popping sounds commonly heard on late inspiration; atelectatic crackles clear with coughing

Coarse Crackles—harsh, moist popping sounds heard commonly on early inspiration; originate in large bronchus

Sonorous wheeze—low pitched, coarse snoring sounds commonly heard on expiration

Sibilant wheeze—squeaky sounds heard during inspiration and expiration associated with narrowed airways

Pleural friction rub—grating sound or vibration heard during inspiration and expiration

Vocal resonance

Bronchophony—say 99 and hear more clearly than normal; loud transmission of voice sounds caused by consolidation of lung

Egophony—say E and hear A due to distortion caused by consolidation of lung

Whispered pectoriloquy—hear whispered sounds clearly due to dense consolidation of lung

Costovertebral angle percussion—kidneys

Heart sounds

Angle of Louis—manubrialsternal junction at second rib

Aortic and pulmonic areas—right and left second intercostal spaces alongside sternum

Erb’s point—third intercostal space just left of sternum

Tricuspid area—fourth or fifth intercostal space at lower left of sternal border

Mitral area—fifth intercostal space at left midclavicular line (apex of heart)

Point of maximal impulse (PMI)

Impulse of the left ventricle felt most strongly

Adult—left fifth intercostal space in the midclavicular line (8–10 cm to the left of the midsternal line)

Infant—lateral to left nipple; heart failure–displaced down and to left

S1 and S2

S1 lub—closure of tricuspid and mitral valves; dull quality and low pitch; onset of ventricular systole (contraction); louder at apex; use diaphragm

S2 dub—closure of aortic and pulmonic valves; snapping quality; onset of diastole (relaxation of atria, then ventricles); loudest at base; use diaphragm

Murmurs—abnormal sounds caused by turbulence within a heart valve; turbulence within a blood vessel is called a bruit; three basic factors result in murmurs:

High rate of blood flow through either a normal or abnormal valve

Blood flow through a sclerosed or abnormal valve, or into a dilated heart chamber or vessel

Blood flow regurgitated backward through an incompetent valve or septal defect

Pulse deficit—difference between apical and radial rate

Jugular veins—normally distend when client lies flat, but are not visible when the client’s head is raised 30 to 45°

Peripheral vascular system

Pulses

Radial—passes medially across the wrist; felt on radial (or thumb) side of the forearm

Ulnar—passes laterally across the wrist; felt on the ulnar (little finger) side of the wrist

Femoral—passes beneath the inguinal ligament (groin area) into the thigh; felt in groin area

Carotid—pulsations can be felt over medial edge of sternocleidomastoid muscle in neck

Pedal (dorsalis pedis–dorsal artery of the foot)—passes laterally over the foot; felt along top of foot

Posterior tibial—felt on inner side of ankle below medial malleolus

Popliteal—felt in popliteal fossa, the region at the back of the knee

Temporal—felt lateral to eyes

Apical—left at fifth intercostal space at midclavicular line

Breasts and axillae

Size, shape, symmetry

Gynecomastia—breast enlargement in males

Nodes—normal: nonpalpable

Abdomen

Knees flexed to relax muscles and provide for comfort

Inspect and auscultate, then percuss and palpate

Symmetry, contour (flat, rounded, protuberant, or scaphoid)

Umbilicus

Bowel sounds; normal high-pitched gurgles heard with the diaphragm of the stethoscope at 5- to 20-s intervals

Hypoactive: less than 3/min

Hyperactive: loud, frequent

Aortic, renal, iliac, femoral arteries auscultated with the bell of the stethoscope

Peritoneal friction rub—grating sound varies with respirations; inflammation of liver

Liver and spleen size

Inguinal lymph nodes

Rebound tenderness—inflammation of peritoneum

Kidneys

Abdominal reflexes

Neurological system

Deep tendon reflexes (DTRs)—assess sensory and motor pathways; compare bilaterally; O (absent) through 4+ (hyperactive) scale

Cerebellar function—coordination; point-to-point touching, rapid, alternating movements, gait

Mental status (cerebral function) (see Unit 3 of this chapter)

Cranial nerve function

Motor function

Strength

Tone

Sensory function

Touch, tactile localization

Pain

Pressure

Temperature

Vibration

Proprioception (position sense)

Vision

Hearing

Smell

Taste

Musculoskeletal system

Muscle tone and strength

Joint movements; crepitus-grating sound abnormal

Genitalia

Provide privacy

Use firm, deliberate touch

Male

Penis—foreskin, glans

Hypospadias—meatus located on underside of penile shaft

Epispadias—meatus located on upper side of penile shaft

Scrotum

Inguinal area

Female

Lithotomy position

Cervix

Ovaries

Vaginal canal

Anus and rectum

Rectal prolapse—protrusion of rectal mucous membrane through anus

Hemorrhoids—dilated veins

Anal sphincter

Male—prostate gland

Stool—normal color brown; assess for presence of blood

3

Mental Status Assessment

Done during interview and neurological assessment

DATA GATHERING

Observation

Gait and posture

Mode of dress

Involuntary movements

Voice (consider language and culture)

Affect and speech content

Logic, judgment, speech patterns

Attention, memory, insight

Spatial perception, calculation, abstract reasoning, thought processes and content

GENERAL FINDINGS

Note client’s ability to wait patiently

Posture relaxed, slumped, or stiff

Body movement: look for control and symmetry

Abnormal: restlessness, tenseness, pacing, slumped posture, slow gait, poor eye contact (culture must be considered), slow movements or speech, and poor personal hygiene may indicate mental illness

Communication findings

Note client’s ability to speak coherently and carry out commands

Note client’s affect—abnormal findings: blunt, inappropriate, elated, hostile

Note presence of aphasia

Cognitive findings—client should be able to:

Demonstrate orientation to time, place, and person

Correctly repeat a series of 5 or 6 numbers

Give important facts, such as dates or names, and repeat information given in the previous five minutes during exam

Make decision(s) based on sound reasoning

Demonstrate a realistic awareness of self

Copy simple figures and identify familiar sounds

Perform simple calculations

Give the meaning of a simple figure of speech, as in a stitch in time saves nine

Give responses that are based in reality and that are logical, goal-oriented, and clear

Abnormal findings

Inability to: recall immediate or long-term information, recognize objects (agnosia), perform purposeful movements (apraxia), calculate (dyscalculia), describe in abstractions, generalize, apply general principles

Impaired judgment

Unrealistic perceptions of self

Illogical thought processes

Blocking

Flight of ideas

Confabulation (making up answers unrelated to facts)

Echolalia (involuntary repetitions of words spoken by another person)

Delusions of grandeur or persecution

Hallucinations, illusions, and delusions

STANDARDIZED INSTRUMENT SCREENING TOOL

Mini-Mental State exam (MMSE)

Used to diagnose dementia or delirium

Tests orientation, short-term memory and attention, ability to perform calculations, language, and construction

Cannot be used if client cannot read, write, or speak English

Mental Status Exam

Provides a baseline of current cognitive processes

Used frequently to assess changes in the client’s stauts

Chapter 2

Fundamentals of Nursing

1

Normal Mobility

NORMAL DEVELOPMENTAL STRUCTURES AND FUNCTIONS—MUSCULOSKELETAL SYSTEM

Developmental stages and related functions (see Table 2-1)

Joint movement and action (see Table 2-2)

General data base

Physical assessment

Body build, height, weight—proportioned within normal limits

Posture, body alignment—erect

Gait, ambulation—smooth

Joints—freely moveable

Skin integrity—intact

Muscle tone, elasticity, strength—adequate

History

Psychosocial assessment

Exercise level

Rest and sleep patterns

Sexual activity

Job-related activity

Health history

Pregnancy

Structural or functional defects of the nervous system

Structural or functional defects of the musculoskeletal system

Diagnostic procedures and medical or surgical treatments that require activity restriction

Conditions or treatments that result in pain

Endocrine disorders that affect rest and activity

Potential problems

Joints—contractures and deformities

Body alignment

Poor posture

Lower back pain

Lumbar lordosis—exaggerated concavity in the lumbar region

Kyphosis—exaggerated convexity in the thoracic region

Scoliosis—lateral curvature in a portion of the vertebral column

Gerontologic considerations

Bones—less dense; less strong; more brittle; decreased mineralization; elderly females have increased osteoclatic bone resorption; osteoporosis incidence higher in women; high incidence of deformity, pain, stiffness, fractures; increased osteoporosis with smoking, decreased calcium intake, alcohol use, physical inactivity

Joints—rigid, fragile cartilage; decreased water content in cartilage; decreased intervertebral disk height; limited or painful stiff movement; crepitation with movement

Muscles—loss of muscle mass, tone, agility and strength; slowed reaction time; muscle fatigue; muscle function can be maintained with exercise

MAINTENANCE AND PROMOTION OF NORMAL BODY STRUCTURE AND FUNCTION

Rest—basic physiological need

Allows body to repair its own damaged cells

Enhances removal of waste products from the body

Restores tissue to maximum functional ability before another activity is begun

Sleep—basic physiological body need, although the purpose and reason for it are unclear; possible theories include:

To restore balance among different parts of the central nervous system

To mediate stress, anxiety, and tension

To help a person cope with daily activities

Gerontologic considerations

Older adults do not need more sleep

Hypothalamus changes—decreased stage IV sleep; difficulty getting to sleep, remaining asleep; decreased sleep time; awaken more at night

Contributing factors—depression, heart disease, pain, cognitive dysfunction, sleep apnea, medication

Chronic sleep deprivation—disorientation, increased risk of falls

Activity and exercise

Activity

Maintains muscle tone and posture

Serves as outlet for tension and anxiety

Exercise

Maintains joint mobility and function

Promotes muscle strength

Stimulates circulation

Promotes optimum ventilation

Stimulates appetite

Promotes elimination

Enhances metabolic rate

Prevents injury

Motor vehicle accidents—use of seat belts and helmets

Job-related accidents—following safety procedures

Contact sports—proper body conditioning and use of protective devices

Aging—rugs should be secure; stairways lit and clear of debris

Pregnancy—bathtub grips; low-heeled shoes

Gerontologic concerns

Assess present activity level, medications that may affect activity, range of motion, muscle strength

Include warm-up and cool-down exercises

Maintain hydration and temperature during exercise

Do 30 minutes activity 5 times a week

Swimming, walking, games, exercise programs

2

Altered Functions Related to Immobility

PREDISPOSING FACTORS

Musculoskeletal injuries/trauma

Congenital defects affecting the musculoskeletal system

Diseases of the musculoskeletal system

Therapeutic procedures related to the musculoskeletal system

ADVERSE EFFECTS OF IMMOBILITY 

(see Table 2-3)

REHABILITATION PRINCIPLES OF MOBILITY

Positioning

Purpose

To prevent contractures

To promote circulation

To promote pulmonary function

To relieve pressure on body parts

To promote pulmonary drainage

Common client positions and their corresponding therapeutic functions (see Table 2-4)

Different forms of exercise and their therapeutic functions (see Table 2-5)

Ambulation

Use of tilt table

Weight bearing on long bones to prevent decalcification, resulting in weakening of the bone and renal calculi

Stimulate circulation to lower extremities

Use elastic stockings to prevent postural hypotension

Should be done gradually; blood pressure should be checked during the procedure

If blood pressure goes down and dizziness, pallor, diaphoresis, tachycardia, or nausea occurs, stop procedure

Transfer activities

Definition—to move a client from one surface to another. (i.e., from a bed to a stretcher)

Basic guidelines

If client has a stronger and a weaker side, move the client toward the stronger side (easier for client to pull the weak side)

Use the larger muscles of the legs to accomplish a move rather than the smaller muscles of the back

Move client with drawsheet; do not slide a client across a surface

Always have an assistant standing by if there is any possibility of a problem in completing a transfer

Technique for sitting client at edge of bed

Place hand under knees and shoulders of client

Instruct client to push elbow into bed; at same time lift shoulders and bring legs over edge of bed, or use one leg to move other leg over edge of bed

Technique for assisting client to stand

Place client’s feet directly under body; client should wear nonskid slippers

Face client and firmly grasp each side of rib cage

Push one knee against one knee of the client

Rock client forward as client comes to a standing position

Ensure that client’s knees are locked while standing

Give client enough time to balance while standing

Pivot with client to position and transfer client’s weight quickly to chair placed on client’s stronger side

Use of a transfer board

Teaching ADL—guidelines

Observe what client can do and allow client to do it

Encourage client to exercise muscles used for activity

Start with gross functional movement before going to finer motions

Extend period of activity as much and as fast as the client can tolerate

There are alternative ways of doing one thing

Give immediate positive feedback after every act of accomplishment

Crutch walking

General guidelines

Client should support weight on handpiece, not in axilla—brachial plexus may be damaged, producing crutch palsy

Position crutches 8–10 inches to side

Crutches should have rubber tips

Crutch gaits—description and uses (see Table 2-6)

GENERAL NURSING GOALS AND INTERVENTIONS FOR IMMOBILITY

Assist with self-care

Assess client’s activity level

Encourage motion necessary to improve activity level

Start with simple, gross activity before going to finer motor movements

Increase period of activity as rapidly as client can tolerate

Support client with positive feedback for effort/accomplishments

Gerontologic considerations

Assess range of motion, ability to perform ADLs, activity level

Good supportive footwear

Walker or cane as needed

Avoid environmental hazards (steps, throw rugs)

Aerobic exercise

Rise slowly from bed or sitting position

Prevent contracture of muscle

Frequent position change and range of motion exercises

Proper body alignment

Use pillows and trochanter rolls

Balanced diet

Prevent osteoporosis

Weight-bearing on long bones

Balanced diet

Prevent negative nitrogen balance—give high-protein and easily digestible diet in small, frequent feedings

Prevent constipation

Ambulation as appropriate

Increase fluid intake

Ensure privacy in use of bedpan or commode

Administer stool softeners, e.g., Colace

Prevent urinary stasis

Have client void in normal position, if possible

Increase fluid intake

Low-calcium diet—increase acid-ash residue to acidify urine and prevent formation of calcium stones

Evaluate adequacy of urine output

Prevent pressure injuries

Frequent turning, skin care, keep skin dry

Ambulation as feasible

Use draw sheet when turning to avoid shearing force

Balanced diet with adequate protein, vitamins, and minerals

Use air mattress, flotation pads, elbow and heel pads, sheepskin

Assist with use of Stryker frame or Circ-O-Lectric bed

Gerontologic considerations

Increased risk—poor nutritional status and weight loss, vitamin and protein deficiencies, decreased peripheral sensation, moisture

Identify clients at risk–Braden scale, weight loss greater than total body weight, serum albumin less than 3.5 g/dL, pressure areas

Avoid friction during position change, eliminate moisture, move weight bearing from pressure areas (e.g., heel protectors), include high protein, vitamins, and carbohydrates in diet

Prevent thrombus formation

Leg exercises—flexion, extension of toes and feet for five minutes every hour

Ambulation as appropriate

Frequent change of position

Avoid gatching bed or using pillow to support knee flexion for extended periods

Use of TEDs or elastic hose

Prevent increase in cardiac workload

Use of trapeze to decrease Valsalva maneuver

Teach client how to move without holding breath

Teach client to rise from bed slowly

Increase activity gradually

Prevent stasis of respiratory secretions

Teach client the importance of turning, coughing, and deep breathing

Administer postural drainage as appropriate

Teach use of incentive spirometer

Prevent depression and boredom

Allow visitors, use of radio, television

Schedule occupational therapy

Usual problems

Alterations in comfort

Impaired ambulation

Inability to perform ADLs

Complications of immobility

Infection

Safety

Fatigue

Insomnia

3

Safety

PRIMARY HEALTH CONCERN OF NURSING

Second level of Maslow’s hierarchy of human needs

Besides prevention of injury, includes protection from physical and psychological harm, freedom from pain, and provision of a stable, dependable, orderly, and predictable environment

Nursing has primary responsibility for ensuring the safety of clients in health care facilities and influencing the safety of persons in the home, work, and community environments

Factors affecting safety

Age/development

Children—accidents constitute leading cause of death in all age groups except infancy

Infants—accidents occur primarily in second half of first year

Mouthing any object that they handle

Unsupervised/unrestrained rolling over, crawling, walking can result in falls and enhance accessibility to small objects, electric cords, poisonous substances, etc.

Toddlers—high incidence of accidents

Increasing curiosity; exploring using all senses (especially taste and touch); learning by trial and error

Increasing gross and fine motor activity, climbing, running, grasping, etc.

Totally uncomprehending and fearless of consequences; increasing negativism as part of autonomy

Preschoolers—continued risk

lncreasing imitative behavior

Refining fine and gross motor ability without cognitive ability to foresee potential dangers

School-ages—although better muscular control, increased cognitive capacity, and more readiness to respond to rules, there continues to be increased risk of accidents related to identification with super heroes, increased involvement and competitiveness in sports, and sensitivity to peer pressure

Adolescents—high incidence; caused by motor vehicles, physical awkwardness related to growth changes, conflict over dependence/independence; peer orientation and approval seeking; increasing goal orientation and risk-taking behavior; and inner perception of omnipotence and immortality

Adults—disregard for safety regulations

Elderly—diminished muscular strength and/or coordination, diminished sensory acuity, and impaired balance create special problems

Awareness of environment, self, and others

Impacts ability to perceive and react to surroundings/circumstances

Factors that may reduce perceptual awareness and ability to perform ADL

Level of consciousness

Neurological function

Sensory perception

Illness-associated signs and symptoms, treatments, anxiety, and degree of weakness/impaired mobility

Hospitalization

Lack of sleep

Medication(s)

Ability to communicate—physical impairment, language barrier, illiteracy

Environment

Work place, e.g., hazardous machinery, chemicals, high stress

Residence, e.g., high crime areas, poorly maintained living conditions

Unfamiliar surroundings in which specific safety information is essential, e.g., hospital

Physical and biological dimensions

Space—defined personal areas sufficient for the purpose (play, chores, hobby), with privacy as appropriate

Lighting—natural/artificial appropriate to function (as above) as well as to provide for day- night cycle; night lights in bathroom or bedroom

Temperature and humidity—the very young (especially neonate) and very old are particularly vulnerable to extreme variations

Ventilation

Smoking should not be allowed in any confined areas where susceptible individuals may be affected, e.g., any health care facility

Room or central air conditioners should have high-quality filters that are changed frequently

Steps and hallways; hand rails

Sound—chronic exposure to loud noises can lead to permanent hearing loss, interfere with work performance, precipitate sleep problems and psychological stress

Physical layout

Neatness and cleanliness—clutter may create hazards

Immediate physical environment at home, work, hospital may have to be adapted to the functional ability of the inhabitant

Steps and hallways; hand rails

Community resources

Food and water quality

Waste disposal

Air quality

Traffic management

Child restraint laws

Advocacy situations, e.g., traffic light for areas of high elderly/children populations, gun laws

Assessment for individual risk factors at home and in health care facilities (see Table 2-7)

History of accidents—if previous incident(s) of accidents, there is increased risk for other mishap(s)

Concern for/perception of hazards; cognitive or sensory deficits

Evidence of unsafe behaviors—smoking in bed, non-use of seat belts, storage of toxic substances within reach of children

Physical/psychological impediments to safe function—level of alertness, mental status, sensory acuity, mobility limitations

Plan/Implementation—requires attention to general principles of safety as well as identification of specific hazards/risks and subsequent measures to prevent injury; includes appropriate anticipatory and responsive client education, and prevention of injury by active/passive identification of hazards such as:

Orient new client to the immediate environment—call-bell/signal, bed controls, location of bathroom, operation of overhead and bed lights, schedule of unit activities

Maintain the bed in the lowest position except when care is being provided, side rails in raised position when client is in bed

Provide adequate help when ambulating client, especially for the first time

Ensure client area is free of clutter—mop up or call housekeeping to remove spills

Never leave