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Rapid Response Team (RRT) and
Patient-Centered Care
Overview of Professional Nursing Concepts
for Medical-Surgical Nursing
Client-Centered Care
Nurse demonstrates client-centered care by assessing for cultural influences affecting health care. This involves focusing on communication, culture, respect, compassion, client education, and empowerment.
Rapid Response Team (RRT)
The purpose of the RRT is to intervene when clients are deteriorating before they suffer respiratory or cardiac arrest. Significant changes in vital signs, mental status, heart rate, and pain should prompt the nurse to call the RRT.
Patient Safety
Ensuring client safety is the top priority for the professional nurse. Encouraging the client to be an active partner in their health care is crucial for promoting patient safety. Clients should be advised to bring a list of all their medications and what they are for, to help prevent medication errors.
Ethical Principles
Respect for autonomy involves ensuring the client has accurate information and can make informed decisions about their care. Other ethical principles include veracity (giving accurate information), social justice (treating clients fairly), and keeping promises made to clients and families.
Diversity and Inclusion
When caring for clients from the LGBTQ community, the nurse should avoid making assumptions and instead ask respectful questions to understand the client's needs. This population may be reluctant to seek health care due to past discrimination, so a sensitive approach is important.
Communication
The SBAR (Situation, Background, Assessment, Recommendation) format is a recommended method for communicating with other healthcare providers. Appropriate background information to include would be the client's allergies to medications.
Delegation
When delegating tasks to unlicensed assistive personnel (UAP), the nurse remains responsible for monitoring the client's condition and responding appropriately to changes. Significant changes in the client's status, such as blood pressure and mental status, require the nurse to intervene directly.
Overview of Health Concepts for Medical-
Surgical Nursing
Acid-Base Balance
Acid-base balance is the maintenance of arterial blood pH between 7. and 7.45 through hydrogen ion production and elimination. Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by an excessive amount of hydrogen ions in the body. Maintaining a healthy lifestyle, such as avoiding or quitting smoking, exercising regularly, and eating healthy and well-balanced meals, is the best way to maintain acid-base balance.
Cellular Regulation
Cellular regulation is the process that controls cellular growth, replication, and differentiation to maintain homeostasis. Malignant (cancerous) cells have the ability to invade healthy cells, tissues, and other organs through tumor formation and invasion, unlike benign cells.
Hemostasis and Thrombosis
Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activated when an injury occurs to promote clotting. Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive platelet stickiness, which can impair blood flow. Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can be observed locally, while arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ.
Minimum Hourly Urinary Output
The minimum hourly urinary output in a normal healthy adult should be at least 30 mL per hour. A decrease in urinary output is a sign of diminished kidney activity and fluid deficit.
Indicators of Fluid Volume Changes
The best indicator of fluid volume changes in the body is changes in blood pressure. Monitoring blood pressure, checking pulse rate and quality, and assessing skin and mucous membranes for dryness are strong secondary indicators.
Types of Immunity
Natural Passive Immunity : Occurs when antibodies are passed from the mother to the fetus through the placenta or through breast milk. Artificial Passive Immunity : Occurs via a specific transfusion. Natural Active Immunity : Occurs when an antigen enters the body and the body creates antibodies to fight off the antigen. Artificial Active Immunity : Occurs via vaccination or immunization.
Malnutrition Indicator
A major serum protein that is below normal in patients who have inadequate nutrition is Albumin. A serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition.
Older Adult Health Considerations
Improving Morale and Emotional Health in
Older Adults
An exercise program to improve physical function would be the most effective way to address morale and emotional health in older adults living in the community.
Assessing Oral Health in Older Adults
Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist.
Fastest Growing Subset of the Older
Population
The old old, comprising those 85 to 99 years of age, is the fastest growing subset of the older population.
Addressing Dehydration in Older Adults
Older adults often lose their sense of thirst, so the best remedy is to have the older adult drink something each hour or two, whether or not they feel thirsty.
Fiber Intake in Older Adults
Older adults need 25 to 50 grams of fiber a day. Foods high in fiber include barley, beans, and whole wheat products.
Exercise Regimens for Homebound Older
Adults
Exercise regimens for homebound older adults should focus on increasing strength and flexibility to help maintain functional ability for activities of daily living.
Assessing Role Changes in Older Adults
When older adults retire, they may lose their entire social network, leading them to feel depressed and lonely. The nurse should assess the role that work played in the client's life.
Assessing Coping in Older Widows
Friendship and support enhance coping in older widows. A statement indicating the presence of a long-term best friend would best indicate potential for successful coping.
Home Safety Interventions for Older Adults
Installing contrasting color strips at the end of each step will help increase the older adult's awareness of where their foot is on the step, which can improve safety on the stairs.
The nurse's most appropriate action is to report the findings as per agency policy, as healthcare providers are mandatory reporters for suspected abuse. Calling the police or Adult Protective Services directly is not the nurse's first step, as the agency's internal reporting process should be followed first.
Assessing Competence for Consent in Older Adults
The nurse is concerned an older client may not be competent to give consent for upcoming surgery. The best action is to discuss the concerns with the healthcare team, as there may be physiological reasons for the client's temporary incompetence. Calling Adult Protective Services or not allowing the client to sign the consent are not appropriate actions at this time. The legal procedure and facility policies should be followed to determine the client's competence.
Pain Assessment and Management
Pain Assessment
A nurse assessing pain on a confused older client who has difficulty with verbal expression should choose the Wong-Baker FACES Pain Scale as it is preferred by both cognitively intact and cognitively impaired adults. A comprehensive pain assessment includes information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration of pain. The best question for the nurse to ask the client to complete the assessment is "What pain rating would be acceptable to you?" When assessing pain in an older adult, the best action for the nurse is to sit down, ask one question at a time, and allow the client to answer. This conveys time, interest, and availability, and allows the client enough time to respond. When assessing pain in a client who is preoccupied with physical symptoms and demanding, the most appropriate statement or question by the nurse is "Help me understand how pain is affecting you right now." This provides the client the chance to explain the emotional effects of pain in addition to the physical ones. When using the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia who scores a zero, the best action by the nurse is to assess physiologic indicators and vital signs, as even a low score on this index does not mean the client does not have pain.
Pharmacologic Pain Management
A multimodal approach, using different types of analgesia, is the preferred method of pain control, as pain is a complex phenomenon that often responds best to a regimen that uses different types of pain medications. For severe postoperative pain, the best intervention is round-the-clock analgesia with PRN analgesics, as this will provide continuous pain control. When caring for a client receiving patient-controlled analgesia (PCA), the nurse should intervene if the nursing student presses the button for the client, as the client is the only person who should press the PCA button. When a client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis, the finding in the client's health history that would lead the nurse to consult with the provider is drinking 3 to 5 beers a day, as this may indicate underlying liver disease. When preparing to give a client ketorolac (Toradol) intravenously for pain, the assessment finding that would lead the nurse to consult with the provider is urine output of 20 mL/2 hr, as drugs in this category can affect renal function.
Pharmacologic Pain Management
Transdermal Fentanyl Patch
A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. The most important action by the nurse for client safety is to remove the old patch when applying the new one. This is to prevent accidental overdose from the residual fentanyl in the old patch. Assessing and recording the client's pain every 4 hours, ensuring a high-fiber diet, and monitoring bowel function are also appropriate but not as important for safety.
Opioid Analgesics for a Client with Comorbidities
A hospitalized client has a history of depression, morphine allergy, and alcoholism. After surgery, several opioid analgesics are prescribed. The nurse should choose hydromorphone (Dilaudid) as it is a good alternative to morphine for moderate to severe pain. Lorcet (hydrocodone and acetaminophen) should not be used due to the client's history of alcoholism. Tramadol should not be used due to the potential for interactions with the client's sertraline. Meperidine is rarely used and often restricted.
Safety Considerations for Epidural Patient-Controlled
Analgesia (PCA)
The most important action by the nurse to ensure client safety is to have another nurse double-check the PCA pump settings. Assessing and recording vital signs, instructing the client to report unrelieved pain, and monitoring for numbness and tingling are also important, but not as vital as double-checking the pump settings.
Addressing Reluctance to Participate in Physical Therapy
When a postoperative client is reluctant to participate in physical therapy, the nurse should first ask the client about their pain goals and if they are being met. Adequate pain control is necessary to allow full participation in therapy. The nurse should not simply increase the dose of analgesia or tell the client that therapy is required, as these actions do not address the underlying issue.
Discharge Instructions for Clients on Opioid Analgesics
The most important discharge instruction for a client being discharged on hydrocodone and acetaminophen (Lorcet) is to advise them to check any over-the-counter medications for acetaminophen. This is a crucial safety measure to prevent acetaminophen overdose. Other appropriate instructions include calling the doctor if the Lorcet does not relieve pain and taking measures to prevent constipation.
Genetic Concepts for Medical-Surgical
Nursing
Understanding X-Linked Recessive Disorders
X-linked recessive disorders, such as red-green color blindness, are expressed more frequently in males than females due to the difference in the number of X chromosomes.
Males have only one X chromosome, a condition called hemizygosity. As a result, X-linked recessive genes have a dominant expressive pattern of inheritance in males.
Females have two X chromosomes. If one X chromosome carries the recessive gene, the other X chromosome can balance the expression of the recessive gene, leading to a recessive expressive pattern of inheritance in females. The difference in the number of X chromosomes between males (1) and females (2) is the reason why X-linked recessive disorders are more commonly expressed in males.
Genetic Concepts in Blood Typing
The nurse's statement indicating a need for further genetic education is:
"If the client has a dominant and a recessive blood type allele, only the dominant will be expressed."
This statement is incorrect. In blood typing, if a client has a dominant and a recessive allele (e.g., AO blood type), both the dominant and recessive alleles will be expressed.
Blood type is determined by three possible gene alleles: A, B, and O. Each blood type allele is inherited from the mother or the father. The blood type AB is heterozygous, while the blood type OO is homozygous.
Genetic Considerations in Medication Administration
When caring for a client of Asian descent who is prescribed warfarin (Coumadin), the nurse should first confirm that the prescription starts the client on a lower-than-normal dose.
Individuals of Asian descent often have a genetic mutation in the CYP2C9 gene that results in reduced metabolism of warfarin.
This genetic mutation can lead to increased bleeding risks and other serious side effects if the client is started on a standard warfarin dose. The priority action for the nurse is to check the prescription and confirm that the client is started on a lower-than-normal warfarin dose to account for this genetic factor.
Genetic Testing and Counseling
The client who should be discussed for predisposition genetic testing is the middle-aged woman whose mother died at age 48 of breast cancer.
Predisposition testing should be discussed with clients who are at high risk of hereditary breast, ovarian, and colorectal cancers, such as those with a strong family history.
The client with symptoms of rheumatoid arthritis should be given information about symptomatic diagnostic testing.
The client with a familial history of sickle cell disease and the client of Eastern European Jewish ancestry should be given information about carrier genetic testing.
When a client tests positive for a BRCA1 gene mutation and wants to disclose this information to her adult daughter, the nurse should provide emotional support during the conversation.
Genetic Counseling
Genetic counseling should be nondirective, with the nurse providing information about the risks and benefits of testing without influencing the client's decision. Clients who receive negative genetic test results may still need counseling and support, as they may have unrealistic views or feel guilty.
Genetic Mutations and Inheritance Patterns
Clients with genetic mutations that increase the risk of certain diseases, such as the BRCA1 mutation and colon cancer, should be advised to limit exposure to environmental factors that may worsen the condition. Carrier genetic testing is recommended for recessive genetic disorders like sickle cell disease, hemophilia, and cystic fibrosis. Autosomal dominant disorders like Huntington's disease, Marfan syndrome, and some forms of breast cancer have a pattern of inheritance where only one copy of the mutated gene is needed to cause the condition.
Rehabilitation Care
Participation in Exercise
Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must determine the client's ability to tolerate different activity levels. Asking the client to notify the nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in developing an appropriate cardiac rehabilitation plan.
Transferring Clients
Use mechanical lifts to minimize staff work-related musculoskeletal injuries. The bear-hug method and the use of several members of the team to carry the client do not eliminate staff injuries. Physical therapy should be consulted but cannot be depended upon for all transfers. Nursing staff must be capable of transferring a client safely.
Range of Motion Exercises
Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance.
Splinting the joint, applying weights to the extremity, or progressively increasing joint motion beyond resistance will not assist the client's range of motion and may cause damage.
Preventing Fractures
Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fracture. Increasing calcium in the diet alone will not reduce the client's susceptibility to bone fracture. Foot support and pressure-relieving devices will not help prevent fracture, but may help with mobility and skin integrity.
Exercises for Clients with Weakness
Active range of motion is a part of a restorative nursing program and will promote strength, range of motion, and independence with activities of daily living. Passive range of motion, resistive range of motion, and aerobic exercise may also be appropriate depending on the client's condition and goals.
Preventing Pressure Ulcers
Assessing serum albumin levels helps determine the client's nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. Assessing pressure ulcer diameter and depth, wound drainage, and dressing site are more treatment-oriented rather than prevention- oriented.
Intermittent Self-Catheterization
At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections. The nurse should refer the client to the social worker to explore financial concerns, rather than instructing the client to boil or reuse catheters.
Delegating Ambulation
Before the client gets out of bed, have the client sit on the bed with legs dangling on the side to enhance safety. A gait belt should be used for all clients during ambulation. The unlicensed nursing assistant cannot teach the client to use a walker or assess the client's pain.
Assessing Elimination
Bowel elimination varies from client to client and must be evaluated on the basis of the client's normal routine.
Physical therapist : Assists clients with ambulation and walker training, helping them achieve self-management by focusing on gross mobility. Recreational therapist : Works to help clients continue or develop hobbies or interests. Vocational counselor : Assists with job placement, training, or further education for clients, particularly those who have experienced head injuries. Registered dietitian : Develops client-specific diets to ensure that clients meet their needs for nutrition.
Strategies for Clients Experiencing Fatigue
Use a cart to push belongings instead of carrying them : This takes less energy than carrying items. Plan to gather all supplies needed for a chore prior to starting the activity : This decreases unneeded steps. Break large activities into smaller parts to allow rest periods between activities : This allows the client to still have a sense of completion even if unable to finish the whole task.
Nurse's Role in the Rehabilitation Team
Coordinate rehabilitation team activities to ensure implementation of the plan of care. Support the client's choices by acting as an advocate for the client and family. The social worker assists clients with support services and resources. The clinical psychologist counsels clients and families on their psychological problems and on strategies to cope with disability.
End-of-Life Care
Prioritizing Symptom Management
The nurse should treat the client's pain first, as it is a distressing symptom that interferes with the client's comfort. Other symptoms, such as anorexia or hair loss, should only be treated if they are causing distress for the client.
Developing the Plan of Care
The nurse should ask the client where they want to die (e.g., at home) when developing the plan of care. Advance directives do not need to be notarized. A physical therapist would not be involved in end-of-life care. The client should discuss resuscitation with the healthcare provider and family; do-not-resuscitate status should be the client's decision.
Appropriate Pharmacologic Interventions
Pain medications should be scheduled around the clock to maintain comfort and prevent recurrence of pain. Other medications, such as albuterol for wheezes, atropine for excessive secretions, and sodium biphosphate for impacted stool, may be appropriate for the dying client.
Grief and Bereavement Support
Frequent crying is a normal response to grief, even several months after a loss. The nurse should validate the client's feelings and let them know that this is okay. The client may benefit from talking with a grief counselor, but this is not always necessary.
Advance Directives and Hospice Care
An advance directive is a written document that specifies a person's wishes for healthcare when they can no longer make decisions. Hospice care focuses on a holistic approach to care, using an interdisciplinary team to address the client's and family's needs and facilitate a peaceful death. Hospice care neither hastens nor postpones death but provides relief of symptoms.
End-of-Life Care Interventions
When a client is experiencing the "death rattle," the nurse should reposition the client onto their side with a towel under the mouth to collect secretions. Complementary therapies, such as music therapy, may be used in conjunction with traditional therapies to help manage anxiety and restlessness. After a client's death, the nurse should first ask the family members if they would like to spend time alone with the client before moving the body.
Respiratory Assessment in End-of-Life Care
Respiratory Rate Monitoring
Even with other symptoms, the nurse should continue to assess the client's respiratory rate throughout the dying process. As the respiratory rate drops significantly and breathing becomes agonal (irregular and labored), death is near.
Judaism: According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. Catholic: A priest performs the Sacrament of the Sick for ill or dying people.
Hospice Nurse Interventions
Teach family members about the physical signs of impending death. Encourage the management of adverse symptoms to facilitate the client's peaceful death. Assist family members by offering an explanation for their loss. Encourage reminiscence by both the client and family members. Encourage spirituality if the client is agreeable, regardless of whether the client's religion is the same as the nurse's.
Determining Decision-Making Capacity
To have decision-making ability, a person must be able to: - Receive information (but not necessarily be oriented to all aspects of their situation)
- Evaluate, deliberate, and mentally manipulate the information - Communicate a treatment preference
The client does not need to read or write at a specific level, complete an advance directive, or be oriented to all aspects of their situation to make their own medical decisions.
Complementary Therapies for Pain
Management
Appropriate complementary therapies for pain management in hospice care include: - Music therapy - Aromatherapy (e.g., applying lavender lotion)
Nurses should avoid massaging over sites of tissue damage, such as from radiation therapy.
Signs and Symptoms of Approaching Death
Common physical signs and symptoms of approaching death include: - Decreased appetite - Congestion and gurgling - Coolness of extremities - Increased sleeping - Irregular and slowed breathing rate - Incontinence - Disorientation - Restlessness
Trauma Centers and Emergency Nursing
Levels of Trauma Centers
Level IV Trauma Centers : These centers are usually located in rural and remote areas. They provide basic care, stabilization, and advanced life support while making arrangements to transfer clients to higher- level trauma centers. Level I Trauma Centers : These centers provide care for most clients and transport them to Level I centers when their needs exceed the resource capabilities of the lower-level centers.
Primary Survey in Emergency Nursing
When an unresponsive client with an oxygen mask is brought to the emergency department, the nurse's first action should be to assess that the client is breathing adequately. This is the highest-priority intervention in the primary survey, as establishing adequate breathing is crucial.
Infection Control and Staff Safety
When caring for a trauma client in cardiac arrest with multiple open wounds, the nurse should first don personal protective equipment (PPE) before providing advanced cardiac life support. This is to recognize and plan for the high risk of contamination with blood and body fluids during trauma resuscitation. Proper PPE includes an impervious cover gown, gloves, eye protection, a facemask, a surgical cap, and shoe covers.
Triage in Emergency Nursing
A client with a cough and a temperature of 102°F should be considered urgent, as they are at risk of deterioration and need to be seen quickly, but are not in an immediately life-threatening situation. A client with a chest stab wound and tachycardia, or a client with new- onset confusion and slurred speech, should be triaged as emergent. A client with a skin rash and a sore throat would be triaged as nonurgent, as they are not at risk of deterioration.
Caring for Clients and Families in Crisis
When dealing with a client who has died from a suspected homicide, the nurse should communicate the client's death to the family in a simple and concrete manner to minimize confusion. Tubes must remain in place for the medical examiner, and the family should be allowed to view the body. Offering to call for additional family support during the crisis is suggested.
Emergency Department Case Management
Case management interventions for a homeless client in the emergency department include: - Communicating client needs and restrictions to
