In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of alterations in body systems in order to:

  • Assess adaptation of a client to health alteration, illness and/or disease
  • Assess tube drainage during the time the client has an alteration in body systems (e.g., amount, color)
  • Assess client for signs and symptoms of adverse effects of radiation therapy
  • Identify signs of potential prenatal complications
  • Identify signs, symptoms and incubation periods of infectious diseases
  • Apply knowledge of nursing procedures, pathophysiology and psychomotor skills when caring for a client with an alteration in body systems
  • Educate client about managing health problems (e.g., chronic illness)
  • Assist with invasive procedures (e.g., central line, thoracentesis, bronchoscopy)
  • Implement and monitor phototherapy
  • Implement interventions to address side/adverse effects of radiation therapy (e.g., dietary modifications, avoid sunlight)
  • Maintain optimal temperature of client (e.g., cooling and/or warming blanket)
  • Monitor and care for clients on a ventilator
  • Monitor wounds for signs and symptoms of infection
  • Monitor and maintain devices and equipment used for drainage (e.g., surgical wound drains, chest tube suction, negative pressure wound therapy)
  • Perform and manage care of client receiving peritoneal dialysis
  • Perform suctioning (e.g. oral, nasopharyngeal, endotracheal, tracheal)
  • Perform wound care or dressing change
  • Promote client progress toward recovery from an alteration in body systems
  • Provide ostomy care and education (e.g. tracheal, enteral)
  • Provide care to client who has experienced a seizure
  • Provide care to a client with an infectious disease
  • Provide pulmonary hygiene (e.g., chest physiotherapy, incentive spirometry)
  • Provide care for client experiencing complications of pregnancy/labor and/or delivery (e.g., eclampsia, precipitous labor, hemorrhage)
  • Provide care for client experiencing increased intracranial pressure
  • Provide postoperative care
  • Remove sutures or staples
  • Evaluate client response to surgery
  • Evaluate achievement of client treatment goals
  • Evaluate client response to treatment for an infectious disease (e.g., acquired immune deficiency syndrome [AIDS], tuberculosis [TB])
  • Evaluate and monitor client response to radiation therapy

Assessing the Adaptation of a Client to a Health Alteration, Illness and/or Disease

Nurses, as discussed throughout this NCLEX RN review, assess the physical and psychological adaptation of the client to health alterations, illnesses and diseases after which appropriate interventions are incorporated into the client's plan of care.

Nurses assess the psychological adaptation and coping of the client and the family members to health alterations, illnesses and diseases as fully discussed and detailed in the previous major section "Psychosocial Integrity" under its subsections of:

Some of these interventions include patient education, behavioral cognitive therapy and the adoption of more effective coping mechanisms after which the outcomes of these interventions are evaluated in terms of how well the client and family members are able to psychologically adapt to any acute, chronic, temporary and permanent health alterations, illnesses and diseases.

Nurses also assess the physiological adaptation of the client and the family members to health alterations, illnesses and diseases. For example, registered nurses assess the physical adaptation of the client in terms of all interventions and therapeutic procedures including medications, chemotherapy, therapeutic radiation therapy, total parenteral nutrition, artificial ventilation and many, many other medical and nursing therapeutic interventions.

Assessing Tube Drainage During the Time the Client Has an Alteration in Body Systems

All drainage including wound drainage, respiratory secretion drainage, chest tube drainage are assessed and documented in an ongoing manner in terms of the quantity, color, consistency and other characteristics of the drainage.

The nurse will intervene in the appropriate manner when the drainage is not considered normal in any of its aspects. Often, the first intervention is notifying the client's doctor of any abnormality in terms of this drainage.

Assessing the Client for the Signs and Symptoms of the Adverse Effects of Radiation Therapy

As discussed in the previous section entitled "Ensuring the Safe Implementation of Internal and External Radiation Therapy" there are two basic types of radiation therapy namely external and internal radiation therapies; and, the three principles of radiation safety include time distance and shielding; therapeutic internal radiation, or brachytherapy, is a therapeutic procedure that entails the internal placement of high doses of radioactive material into or near the client's tumor; external radiation, or teletherapy is applied to the affected bodily area with a linear accelerator that delivers electron and gamma ionizing radiation; the side effects of radiation therapy can be localized or systemic, acute and long term; some of the short term effects include alopecia, damage to the skin and mucosa and bone marrow suppression; some of the long term affects are ulcerations, dental caries, fatigue, immunosuppression, radiation pneumonia, pulmonary fibrosis, cataracts, atrophy and strictures depending on the area(s) treated.

All of the signs and symptoms related to the adverse effects of radiation were fully described in the section entitled ""Ensuring the Safe Implementation of Internal and External Radiation Therapy".

Identifying the Signs of Potential Prenatal Complications

The signs, symptoms, risk factors and treatments for a wide variety of prenatal complications were fully discussed above under the section entitled "Assessing the Maternal Client For Antepartal Complications" and they include:

  • Cardiac Disease
  • Infections of all types both sexually transmitted and otherwise
  • Diabetes
  • Hypertension
  • Preeclampsia
  • Eclampsia
  • Preterm Labor
  • Post term Pregnancy
  • Subchorionic Hematoma
  • Hydatidform Moles
  • Hyperemesis Gravidarum
  • The Effects of Drugs and Substances
  • An Incompetent Cervix
  • Anemias
  • Cardiopulmonary Maternal Collapse
  • Disseminated Intravascular Coagulation
  • Ectopic Pregnancy
  • Substance Use and Abuse
  • Spontaneous Abortions
  • Premature Rupture of the Membranes
  • Multiple Gestations
  • Fetal Growth Restriction
  • Oligohydramnios
  • Polyhydramnios

Identifying the Signs, Symptoms and Incubation Periods of Infectious Diseases

The local signs and symptoms, in addition to the visual signs such as a skin pustule, include pain at the site of the infection, redness, heat, swelling and some bodily part dysfunction. The systemic signs and symptoms of infection include a fever, fatigue, prodromal malaise, chills, tachycardia, nausea, vomiting, anorexia, and confusion, in addition to infection specific signs and symptoms such as dysuria, hematuria, and urinary frequency when the client has a urinary tract infection; and respiratory infections lead to coughing, dyspnea and adventitious breath sounds.

As more fully described in the section entitled "Understanding Infections and Communicable Diseases and the Modes of Organism Transmission", incubation periods are simply defined as the durations of time between the entry of the pathogenic organism into the body upon initial exposure until the signs and symptoms of the infection begin; and periods of communicability, simply defined, is the duration of time that a pathogen can indirectly or directly transmit an infection to another. This period of time varies according to the microorganism.

Some pathogens are associated with brief periods of communicability, others are characterized with longer periods of communicability; and some pathogens are associated with short periods of incubation and others are associated with longer periods of incubation.

Applying a Knowledge of Nursing Procedures, Pathophysiology and Psychomotor Skills When Caring for a Client with an Alteration in Body Systems

All care of the client with an alteration in their body systems requires the registered nurse to apply a knowledge of nursing procedures, pathophysiology and psychomotor skills.

The knowledge of nursing procedures includes the application of the phases of the nursing process, and procedures related to each of these phases as well as the procedures for teaching, communication, informed consent, admission to a facility or service, discharges from a facility or service, transfers within a facility or service, preoperative care and monitoring medical devices; these procedures are established in nursing standards of care, nursing standards of practice, and the policies and procedures within a particular health care facility.

As stated in several previous sections of this NCLEX RN review, nurses must apply their knowledge of and principles relating to the pathophysiology of the client. For example, the nurse know and apply the pathophysiology associated with diabetes, heart failure, chronic obstructive pulmonary disease, increased intracranial pressure, venous stasis, and a pneumothorax to the care of the client with these disorders and alterations of bodily systems.

Psychomotor skills are also applied in the care of many clients as well. For example, the nurse uses and applies psychomotor skills when inserting an intravenous line, when irrigating a surgical wound, when moving a client up in bed using good body mechanics, and when performing complete, passive range of motion to a client.

Educating the Client about Managing Health Problems

Nurses educate clients, significant others and caregivers about how a health problem can and should be managed. These health problems can be acute or chronic.

Some of the acute health problems that the nurse teaches the client about include managing and caring for a traumatic or surgical wound, managing medications that are used for an acute infectious disease such as pneumonia, and managing dependent edema, for example.

Some of the commonly occurring chronic health problems that the client is educated about include diseases and disorders such as chronic heart disease, chronic respiratory diseases like chronic asthma and amyotrophic lateral sclerosis or Lou Gehrig's disease, chronic and progressive neurological disorders such as Alzheimer's disease and Parkinson's disease, and diabetes.

The teaching about these chronic health problems should include initial and ongoing education and reinforcement about the:

  • Nature of the health problem
  • Risk factors associated with it
  • Factors that promote effective management
  • Factors that impede effective management
  • Medications and other treatments such as a nebulizer for example
  • The side effects, adverse effects and complications associated with ordered medications and treatments
  • When to call the physician
  • The need for follow up care in the community setting
  • The community resources , including self help peer support groups, that can assist the client and family members to manage their chronic disorder and prevent any complications associated with it

Assisting with Invasive Procedures

Nurses assist physicians and other licensed independent practitioners with invasive procedures. Some of this assistance can be done by either a licensed practical nurse or a registered nurse, and others may be restricted to only the registered nurse according to the legal state scope of practice and/or the specific policies and procedures of the particular health care facility.

Many of these invasive procedures are done at the bedside so nurses working outside of special care areas and special invasive procedure units must be knowledgeable about their role and ready to perform when asked to do so.

Some of these invasive procedures include things like the placement of a central line, a needle biopsy, a spinal tap, the placement of chest tubes, a thoracentesis, and a bronchoscopy or intubation.

The general guidelines for these invasive procedures include:

  • The verification of the doctor's order
  • The accurate identification of the client using two unique identifiers
  • The gathering of the necessary equipment and supplies
  • Setting up the sterile field if indicated
  • Maintaining sterile technique before, during and after the procedure, as indicated
  • Taking and documenting the client's vital signs and other assessments, as indicated
  • Caring for the client during the invasive procedure
  • Monitoring and reassessing the client after the invasive procedure
  • Complete, timely and accurate documentation of all aspects of the invasive procedure including documentation of data pre intervention, during the procedure and after the procedure

The procedure specific procedures for intubation to connect to a mechanical ventilator include the elements of the MSMAID mnemonic. MSMAID is:

  • M: Monitors like blood pressure, pulse oximetry, and ECG monitors or telemetry
  • S: Suctioning equipment and supplies
  • M: Machines like a mechanical ventilator
  • A: Airway supplies like artificial airways and a laryngoscope
  • I: Intravenous supplies, equipment and intravenous access
  • D: Drugs for emergencies and anesthetics

The procedure specific procedures for a diagnostic bronchoscopy, in addition to the general guidelines listed above, include:

  • Maintaining the client's NPO status for at least 6 hours prior to the procedure whenever possible
  • The administration of atropine to decrease respiratory secretions
  • The administration of moderate conscious sedation or general anesthesia
  • The administration of nebulized lidocaine to numb the patient's pharynx and vocal cords
  • The lubrication of the bronchoscope
  • Passing the bronchoscope into the bronchi of the lungs

The procedure specific procedures for a needle biopsy are:

  • Positioning and maintaining the client's position so that the site of the needle biopsy is exposed
  • Prepping the site with betadine
  • Covering the surrounding site with a sterile fenestrated drape
  • The administration of a topical local lidocaine if ordered
  • The administration of a local anesthetic
  • Obtaining the specimen using the needle
  • Labelling and transporting the specimen to the diagnostic laboratory for processing
  • Covering the site with a sterile dressing

The procedure specific procedures for a thoracentesis are:

  • Positioning the client in a sitting and leaning forward position over a bedside table to expose the area that will be used for the withdrawal of excessive fluids
  • Prepping the site with betadine
  • Covering the surrounding site with a sterile fenestrated drape
  • The administration of a topical local lidocaine if ordered
  • The administration of a local anesthetic
  • The withdrawal of the fluid with a 16 gauge needle attached to a 50 cc syringe
  • Labelling and transporting the specimen to the diagnostic laboratory for processing
  • Covering the site with a sterile dressing

The procedure specific procedures for the placement of a central line are:

  • Positioning the client in a position to expose the entry site
  • Prepping the site with betadine
  • Covering the surrounding site with a sterile fenestrated drape
  • The administration of a local anesthetic to the entry site area
  • Positioning the head in the opposite direction of the entry site
  • Using ultrasound, the needle is advanced until blood return is seen
  • Insertion of the guide wire and placement of the catheter over the guide wire
  • Flushing the catheter
  • Suturing the catheter in place
  • Confirmation of proper insertion and placement with a chest x-ray
  • Covering the site with a sterile dressing

The procedure specific procedures for chest tube insertion are:

  • Positioning the client in a supine position
  • Prepping the site with betadine
  • Covering the surrounding site with a sterile fenestrated drape
  • The administration of a local anesthetic to the entry site area
  • A small incision and the placement of the chest tube
  • Connecting the chest tube to the pleural drainage system
  • Covering the site with a sterile dressing

The procedure specific procedures for a spinal tap, also referred to as a lumbar puncture, are:

  • Positioning and maintaining the position of the client on their side with their back arched so that the client's knees are up to their chest OR sitting and leaning over a bedside table
  • Prepping the site with betadine
  • Covering the surrounding site with a sterile fenestrated drape
  • The administration of a local anesthetic to the entry site area
  • The insertion of the needle into the two lowest vertebrae
  • Withdrawing the cerebrospinal fluid, measuring its pressure and assessing the color and amount
  • Placing and maintaining the client in a flat position to avoid post procedure headaches
  • Labelling and transporting the specimen to the diagnostic laboratory for processing
  • Covering the site with a sterile dressing

Implementing and Monitoring Phototherapy

Phototherapy is used to treat psoriasis, but it is most commonly employed for the treatment of neonatal hyperbilirubinemia and jaundice which can occur among both full term and pre term infants.

The complications of neonatal hyperbilirubinemia can include the depositing of bilirubin in the fatty tissues, so when the levels of bilirubin are high, phototherapy with the use of direct light or a bilirubin blanket is used to facilitate and promote the breakdown and excretion of excessive bilirubin from the neonate.

Although newer and improved methods to deliver phototherapy are safer and less prone to the complications associated with older methods. For example, older methods of phototherapy employ the use of direct light onto the infant's skin when the infant is only clothed in a diaper; this method of phototherapy requires the placement of eye patches and lubricating eye drops to protect the infant from ocular damage as the result of this direct light, the avoidance of photosensitizing medications like furosemide and tetracycline, and the monitoring of the client's temperature to assess for any hypothermia which can result from the absence of clothing and a blanket over the infant.

Newer methods of phototherapy, using a bilirubin blanket, are less prone to complications and risks of complications. Bilirubin blankets use light with filtered out harmful infrared and ultraviolet light. This blanket, which is as effective as the older methods of phototherapy, can be used 24 hours a day and it is rather simple to use so it can be used in the new mother's home as well as in the acute care setting or the birthing center.

When a client is getting phototherapy, the nurse delivers the treatment according to the doctor's order in terms of hours per day and they also monitor and document the client's:

  • Skin for changes in color that may indicate an increase or decrease in the amount of bilirubin in the client's blood
  • Laboratory bilirubin levels to determine whether or not the client's bilirubin levels are decreasing as the result of the phototherapy
  • Volume, color and characteristics of the stool because phototherapy can lead to frequent, loose stools as well as a color change to green colored stools

Implementing Interventions to Address Side/Adverse Effects of Radiation Therapy and Radiation

As discussed in the section entitled "Identifying the Client with Increased Risk for Cancer", one of the risk factors associated with cancer is exposure to sunlight and external ultraviolet radiation and another is exposure to the ionizing radiation that is in diagnostic x-rays and therapeutic radiation therapy for cancer.

Nurse address the adverse effects of radiation from sunlight and external ultraviolet radiation by educating the client relating to the risks of tanning beds and sun bathing as well as the use of preventive measures such as the use of sun screen lotions, the use of protective clothing such as a hat, and avoiding the worst times of the day to be in the sun. They also educate clients about the signs of skin cancer including changes of the skin and the signs of a possible precancerous lesion, a basil cell carcinoma, a squamous cell carcinoma and multiple myeloma.

As previously discussed in the above section entitled "Assessing the Client for the Signs and Symptoms of the Adverse Effects of Radiation Therapy", the short term effects of therapeutic radiation therapy include alopecia, damage to the skin and mucosa, dry mouth and bone marrow suppression; and some of the long term affects are ulcerations, dental caries, fatigue, immunosuppression, radiation pneumonia, pulmonary fibrosis, cataracts, atrophy and strictures depending on the area(s) treated. Other commonly occurring side effects and adverse effects include nausea, vomiting, diarrhea, and anorexia, all of which can jeopardize the client's nutritional status.

Some of the interventions to address the side effects and adverse effects of radiation therapy and chemotherapy include:

  • Alopecia: Psychological support for this alteration in terms of body image, adopting a shorter hair style until the hair begins to regrow, wearing a wig or a hair piece, wearing a cold cap to protect the hair, and gently caring for the hair with a mild shampoo, a soft brush, and protecting the head from the sun with a hat.
  • Damage to the skin: Blanching, ulcerations, cracking, erythema, sloughing and desquamation of the skin can occur. Topical skin lubricants and lidocaine may be helpful. More severe skin damage must be assessed and treated according to the nature and extent of the skin damage.
  • Xerostomia or dry mouth: Xerostomia, or dry mouth, can lead to damage to the mucosa of the mouth and dental caries. Dry mouth is a complication of both therapeutic radiation and chemotherapy; it occurs because these treatments decrease the production of saliva from the salivary glands. The treatment of xerostomia can consist of a preventive medication such as amifostine, salivary gland stimulating medications such as pilocarpine or cevimeline, sucking on sugar free hard candies or chewing gum, mouth rinses with carmellose, hyprolose or hyetellose, using a cool mist humidifier, sucking on ice chips, and using fluoride mouth rinses and small sips of water throughout the day to relieve this oral dryness and to prevent the complications associated with it.
  • Damage to the mucosa: Severe pain can result from ulcerations of mucous membranes, and the patient can be more susceptible to infection as the result of this damage and mouth sores. In addition to the interventions discussed above for dry mouth, other interventions for oral sores and lesions can include a mouth wash that contains lidocaine for relief from the pain, rinsing the mouth with a baking soda and salt mixture, the administration of a mild over the counter analgesic such as acetaminophen, a bland food diet and minimizing the use of dentures.
  • Dental caries and oral infections: Regular professional dental examinations and care, brush, flossing and oral mouth rinsing at least 3 times per day, and the administration of antibiotics, antiviral drugs, and/or antifungal drugs to treat any oral infections.
  • Fatigue: Fatigue can be alleviated with a number of different interventions including the correction of any and all underlying causes of sleep deprivation such as pain, anemia, depression and anxiety, the promotion of stress and relaxation techniques, and the promotion of exercise and a healthy diet,
  • Nausea and vomiting: Nausea and vomiting can be controlled by treating any underlying cause such as changing a medication that can be leading to the nausea and vomiting, in addition to stress, relaxation and distraction techniques, herbs like ginger, medications such as metoclopramide to prevent vomiting, and antiemetics as ordered.
  • Anorexia: Anorexia can sometimes be successfully treated with appetite stimulants such as megestrol acetate, steroid medications, metoclopramide, dronabinol, the guidance of a dietitian, eating smaller more frequent meals, dietary supplements like Ensure and, when necessary and elected to by the client, enteral or parenteral nutrition to maintain the client's nutritional status and fluid balances.
  • Diarrhea: Diarrhea can be controlled by treating any underlying cause such as changing a medication that can be leading to it, in addition to the avoidance of spicy and troublesome foods, the consumption of foods such as rice and bananas, consuming a low fiber, low residue diet, and medications such as dipenoxylate in combination with atropine (Lomotil) and loperamide (Imodium).
  • Bone marrow suppression and immunosuppression: Bone marrow suppression and immunosuppression place the client at risk for infections. The client must be monitored for the signs and symptoms of infection and infections should be treated when they occur and according to the cultures and sensitivities.
  • Radiation pneumonia, radiation pneumonitis and radiation pulmonary fibrosis: These respiratory complications result from the destruction of normal, healthy cells with radiotherapy, particularly when the chest area is treated. Radiation pneumonitis typically occurs during a long duration of radiation therapy and up to even 6 months after the therapeutic radiation therapy has been completed. Radiation pneumonitis, an inflammation of lung tissue, can be asymptomatic and it can also lead to a fever, coughing and shortness of breath. It can also be characterized with an elevated sedimentation rate and abnormal white blood cell counts. When it is not treated with anti-inflammatory medications such as steroid medications, it can lead to often irreversible pulmonary radiation fibrosis that can occur a year after the completion of the radiotherapy because the tissue continues to be altered after the course of radiotherapy has been completed.
  • Other fibrosis: Radiation fibrosis can affect bones, nerves, ligaments, muscles, blood vessels, tendons, and the heart in addition to the lungs. Fibrosis occurs as the result of abnormal fibrin and protein accumulation within normal irradiated tissue. It can be treated according to the symptoms and the severity of this disorder. For example, physical and occupational restorative and rehabilitation therapy may be indicated when the neuromuscular system is adversely affected with this complication of therapeutic radiation therapy and it leads to treatable atrophy and strictures, for example.
  • Cataracts: Cataracts, which is the clouding of the lens of the eye, can also be a complication of radiation therapy as well as other causes. Cataracts can be treated with ocular surgery, including laser surgery.

Maintaining the Optimal Temperature of the Client

The range for normal bodily temperature has a very small range for individual variations except for some small dip in temperature as the result of the normal bodily physiological changes as the result of the circadian rhythm.

Hypothermia, a less than normal bodily temperature, occurs when the heat production of the body is less than heat losses; and hyperthermia, a more than normal bodily temperature, occurs when the heat production of the body is more than the bodily heat losses. Hypothermia is simply defined as a core bodily temperature of less than 95 degrees; and hyperthermia is simply defined as a core bodily temperature of more than 99.5 degrees.

The risk factors associated with hyperthermia include infection, strenuous exercise, damage to the hypothalamus, some medications like monoamine oxidase inhibiting psychotropic medications, hyperthyroidism, and exposures to extremely hot and humid environmental temperatures.

The risk factors associated with hypothermia include a normal change associated with the aging process, diabetes, trauma, are aging, hypothyroidism, diabetes, trauma, and exposures to extremely cold environmental temperatures.

The signs and symptoms of hyperthermia are a fever, nausea, vomiting, hypotension, seizures, hot skin, dehydration, confusion, dizziness, tachycardia, rapid respirations, coma, and even death when the hyperthermia is not treated; the treatments for hyperthermia include the correction of any underlying disorders, fluid hydration to make up for the patient's fluid losses, and the provision of coolness with wet packs or a hypothermia warming blanket to decrease the client's temperature to its normal level.

Hypothermia, on the other hand, presents with signs and symptoms such as confusion, shallow, slow respirations, shivering, lethargy, slurred speech, a loss of consciousness, coma and death when left untreated; the treatment of hypothermia includes the use of a warming blanket, the application of warm packs and the encouragement of warm oral fluids to increase the client's temperature to its normal level.

Monitoring and Caring for Clients on a Ventilator

Mechanical ventilation delivers air under pressure that keeps the alveoli open during inspiration and it prevents alveolar collapse during expiration; this respiratory intervention improves the client's oxygenation, it enhances the client's gas exchanges, it increases lung capacity, and it decreases the client's work of breathing. Many facilities have registered certified respiratory therapists who work in collaboration with nurses to monitor and care for clients who are on a ventilator. Mechanical ventilators are found in special intensive care units, on regular medical and surgical care units in an acute care facility, in long term care facilities and even in the home.

Despite the great benefits of mechanical ventilation, nurses must be aware that there are some complications associated with the use of mechanical ventilation. Nurses, therefore, must monitor the client in terms of the therapeutic effects of the mechanical ventilation in terms of improved respiratory function and blood gases as well as for the complications associated with this therapeutic intervention.

Some of the complications associated with mechanical ventilation include:

  • Alveolar Over Distention: Alveolar over distention is the most frequently occurring complication associated with mechanical ventilation. This complication occurs as the result of causes such as high tidal volume, high ventilating pressures and atelectrauma as a result of the rapid opening and closing of the alveoli accompanied with low lung volume. Alveolar over distention can lead to increased work of breathing, subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, a decrease in lung compliance and leaking around the client's endotracheal tube. The correction and treatment of alveolar over distention include decreasing PEEP and the tidal volume, high frequency oscillatory ventilation or high frequency jet ventilation and extracorporeal membrane oxygenation.
  • Cardiovascular Complications Such as Decreased Cardiac Output, Decreased Venous Return, and Decreased Myocardial Blood Flow: These cardiovascular complications can be prevented with increasing the circulating volume and when they do occur, they can be treated with the administration of a nitrogen oxygen mixture of medical gases with low oxygen content or the administration of carbon dioxide.
  • Oxygen Toxicity: Oxygen toxicity can result from oxygen supplementation therapy when the level of oxygen concentration is too high; and this complication can be identified by closely monitoring the client's arterial oxygen and carbon dioxide blood gases and insuring that the PaO2 level is maintained between 50 and 60.
  • Denitrogenation Absorption Atelectasis: Denitrogenation absorption atelectasis is defined as the elimination of nitrogen from the client's bodily tissues and lungs; this complication can occur when the client is receiving more than 80% oxygen.
  • Hypoventilation: Hypoventilation and under inflation of the lungs can occur as the result of an inadvertent extubation or disconnection from the mechanical ventilator. This complication can be prevented with the use of and prompt attention to low pressure and disconnect safety alarms and the careful handling of the tubings and artificial airways, particularly when the client is being moved about in bed, when the client is being transferred from the bed to a chair, and also during transport to another area of the health care facility. These complications are monitored for in terms of the client's flow volumes, pressure volumes and resistance.
  • Hyperventilation: Hyperventilation can also occur as a complication of mechanical ventilation. Hyperventilation can result from a defective sensitivity setting, the presence of respiratory secretions in the client's airway, ventilator autocycling because there is a leak in the system, and when the neonatal client is given surfactant. Hyperventilation can be prevented with the close monitoring of the client's minute volume, tidal volume, sensitivity levels and levels of carbon dioxide.
  • Hospital Acquired Ventilator Infections: The most commonly occurring ventilator related infections include pneumonia and other pathogens that can lead to respiratory distress syndrome. These infections can be prevented with basic infection control procedures and techniques such as handwashing, standard precautions and the adherence to the principles and procedures relating to asepsis. For example, suctioning of the client is a sterile procedure. In addition to following infection control procedures, nurses also monitor the client for the signs of infection and any respiratory complications.
  • Ventilator Related Airway Complications: Examples of ventilator related air way complications include vocal cord trauma, airway obstructions secondary to mucus plugs and the kinking of any tubings, tracheal trauma, glottis injuries and trauma,
  • Other Complications: Other possible ventilator related complications are renal impairment, fluid retention, increased intracranial pressure, periventricular leukomalacia, and interventricular hemorrhage.

Monitoring Wounds for the Signs and Symptoms of Infection

The local signs of infection are site pain, redness, heat, swelling and some bodily part dysfunction; and the systemic signs and symptoms of infection include a fever, fatigue, chills which produces bodily heat, diaphoresis, prodromal malaise, tachypnea, tachycardia, nausea, vomiting, anorexia, confusion, incontinence, abdominal cramping and diarrhea, among other signs and symptoms as based on the type of infection.

Nurses monitor for these signs and symptoms of infection in addition to the monitoring of the client's diagnostic laboratory results such as an increased sedimentation rate, an increased white blood cell count, and increased C reactive protein, and a lower blood viscosity, for example.

Monitoring and Maintaining Devices and Equipment Used for Drainage

As previously discussed, surgical wound drains, chest tube suctioning devices and negative pressure wound therapy devices are monitored and maintained to insure proper drainage and safe operation. The nurse also monitors the drainage from these closed systems in terms of quantity, color, and other characteristics.

Performing and Managing the Care of the Client Receiving Dialysis

Renal dialysis filters wastes and excessive fluids from the body and it also corrects and maintains the client's normal pH balance. Dialysis replaces the normal diffusion, osmosis and ultrafiltration of the kidney and it is most often used as a permanent and ongoing treatment for end stage renal failure, although, it can be used on a temporary basis such as when a client is adversely affected with a serious disorder such as oseptic shock tumor and tumor lysis syndrome. Nurses care for clients before, during and after dialysis treatments, often in collaboration with certified dialysis technicians.

The two types of dialysis are hemodialysis and peritoneal dialysis; both of these types of dialysis can be done in a dialysis center in the community, in some acute care facilities, and in the home when it can be managed by the client and their care giver in the home environment.

Hemodialysis

Hemodialysis treatments are typically given to long term renal failure clients 3 times per week and each session can last for three to five hours in duration. Hemodialysis is given through an AV fistula, an AV graft, or a vascular access central line. The vascular access central line is typically reserved for clients who will only be getting short term dialysis and also for those clients who cannot get an AV fistula or graft because the risk of an infection with a vascular access central line is the greatest when compared to the other hemodialysis access lines.

AV fistulas are surgically placed by a vascular surgeon into the client's upper arm of their lower forearm. This is the access of choice for dialysis because it can remain usable for a longer period of time than other devices, and it is less prone to infection and clotting than other hemodialysis accesses.

Prior to the surgical placement of an AV fistula, the vascular surgeon does vascular mapping using a Doppler ultrasound to evaluate the adequacy of the blood vessels that may be used and to determine which vessel is the best. After the AV fistula is done it takes about two or three months for it to mature to the point that it can be used for the client's dialysis treatments.

When the AV fistula is matured, an arterial needle is inserted into the fistula to transport the client's blood from their body to the hemodialysis machine; and a venous needle is inserted to transport the blood back to the client's body after processing,

AV grafts are done when an AV fistula placement is not possible because the client's veins are not adequate enough to support it or a placed AV fistula does not mature that way it should to accommodate for hemodialysis.

AV grafts are more prone to clotting off and infection when compared to AV fistulas.

An AV graft, like an AV fistula, is surgically placed by a vascular surgeon using a local anesthetic. AV grafts also take time to develop and mature before they can be used for hemodialysis treatments. Using an AV graft or fistula prior to this complete maturation process can lead to blood clotting and low blood flow through it.

A venous catheter can also surgically placed by a vascular surgeon into the groin area, the chest or the neck. These catheters split into two tubes at the exterior to the body; these two tubes are covered with caps and sterile technique is used when taking off and replacing these caps. Additionally, the client should wear a mask and turn their head to the opposite direction when the caps are removed and replaced and these two tubes are clamped off during cap changes and whenever a cap is removed and not immediately replaced. One of these tubes is connected to the dialyzing machine to carry and transport blood from the client to the dialyzing machine and the other transports blood back to the client after it has passed through the hemodialysis machine.

The complications associated with venous dialysis include infection, blood clots, and the narrowing of the vein as the result of scar tissue formation. Except under unusual circumstances, therefore, venous access devices are used only when the anticipated course of the dialysis is less than three weeks in duration.

Prior to the hemodialysis treatment, the nurse collects pre-procedure data such as the client's vital signs, weight, and blood glucose levels; they also assess the access site and patency. For example, graph patency is assessed and deemed as patent when a thrill or bruit is present.

During the hemodialysis treatment, the nurse monitors, provides care and reassesses the client and the dialysis treatment. For example, the nurse can administer any ordered anticoagulants; the nurse will measure and document the client's intake and output in terms of the amount of dialysate that was instilled and the amount of fluid that was drained off the client during this treatment. They will monitor the hemodialyzer for proper functioning and trouble shoot problems when they arise, they will assess and document the color of the drainage, and they will monitor and assess the client for any complications that can arise from this renal treatment such as disequilibrium syndrome, extreme fatigue, infection, clotting, hypotension and hypovolemia.

After the hemodialysis session is completed the nurse will then monitor and document the duration of the session, the client's weight, their post treatment vital signs, blood glucose levels and any laboratory values.

Peritoneal Dialysis

Peritoneal dialysis is done through a catheter that is placed in the peritoneal space; this type of dialysis is indicated for clients at risk for complications associated with the anticoagulant medications that are necessary for hemodialysis and when the client has poor venous access. Like hemodialysis, peritoneal dialysis can also be done in the home, but unlike hemodialysis, peritoneal dialysis is done on a daily basis and most often during the night time hours when the client is sleeping. This renal treatment consists of a fill, a dwell and a drain cycle using the ordered dialysate.

Prior to the hemodialysis treatment, the nurse collects pre-procedure data such as the client's vital signs, weight, and blood glucose levels; they also assess the access site and patency.

During the peritoneal dialysis treatment, the nurse monitors, provides care and reassesses the client and the dialysis treatment. For example, the nurse will measure and document the client's intake and output in terms of the amount of dialysate that was instilled and the amount and color of fluid that was drained off the client during this treatment. This drainage should be clear, light yellow and without any clots. They will monitor the dialyzer for proper functioning and trouble shoot problems when they arise, and they will monitor and assess the client for any complications that can arise from this renal treatment such as peritonitis, tube insertion site infections, respiratory distress, protein depletion, hyperglycemia and mechanical problems such as an obstruction of the periotoneal dialysis catheter.

When the flow is obstructed, the nurse will insure that the drainage bag is kept below the level of the abdomen and they can also milk the tube to release any fibrin clots and reposition to client to promote better inflow and outflow.

After the peritoneal dialysis session is completed the nurse will again assess, monitor and document the duration of the session, the client's weight, their post treatment vital signs, blood glucose levels and any laboratory values.

Performing Suctioning

Oral, nasopharyngeal, endotracheal, and tracheal airways, including artificial airways, must be maintained with suctioning. In addition to the content that was more fully discussed in the previous section entitled "Maintaining Tube Patency: Artificial Airway Tube Patency: Endotracheal and Tracheostomy Tubes", the procedure for suctioning the client is as follows.

  1. Identify the client
  2. Instruct the client about the procedure and the purpose of the procedure
  3. Pre oxygenate the client
  4. Open the suctioning catheter wrapper
  5. Don a sterile glove on the dominant hand
  6. Lubricate the tip of the suctioning catheter with a water soluble jelly while maintaining strict sterile technique with the dominant hand
  7. Insert and rotate the suction catheter in the client's natural or artificial airway to remove respiratory secretions
  8. Repeat the procedure as necessary but only after the client has rested and been pre oxygenated between suctioning sessions

Performing Wound Care and Dressing Changes

Wound care, cleansing of a wound, and dressing changes are sterile procedures that require surgical asepsis. For this reason, these sterile procedures cannot be delegated to an unlicensed nursing staff member like a nursing assistant.

Wound care consists of cleaning the wound and dressing the wound. The cleansing solutions that are used for wounds include sterile normal saline and other solutions such as those that contain an antiseptic to prevent wound infection; the wound and its surrounding area are cleansed starting at the cleanest part of the wound and then outward to the most contaminated areas of the wound. Gauze is carefully used to remove exudate and debris. A fresh sterile gauze is used for each gentle wipe of the wound in a manner that does not disrupt the newly forming granulating tissue.

Wounds can also be irrigated with sterile solutions to cleanse them, to prevent infection and to promote good healing.

As discussed previously in the section "Performing a Skin Assessment and Implementing Measures to Maintain Skin Integrity and Prevent Skin Breakdown", nurses assess the wound and the surrounding area on a frequent basis, they assess wounds for color, size, location, odor, the underlying tissue, and drainage or exudate in terms of amount, color and other characteristics. This wound drainage can be serous, sanguineous, serosanguinous or purulent. They also inspect and assess the surrounding areas. As also discussed in this same section, the three types of wound healing are primary intention healing, secondary intention healing and tertiary intention healing and the treatment of pressure ulcer wounds is based on the RYB Color Code of Wounds which are the colors of red, yellow and black and, at times, wounds like pressure ulcers and other wounds, need surgical, mechanical, enzymatic, and autolytic debridement.

Other less commonly employed types of wound care and wound cleansing include those described below.

Hydrotherapy

Hydrotherapy is sometimes indicated when the client has a severe wound such as a severe burn, or the wound has otherwise untreatable necrosis and when the wound is very large in size. Hydrotherapy is done with a therapeutic whirlpool at about 37 degrees centigrade and, at times, an ordered antiseptic solution can be added to the water. Hydrotherapy is not indicated for client's affected with arterial insufficiency or venous ulcer wounds. Some of the complications of hydrotherapy include the cross contamination of infections because these whirlpools are used by multiple clients; this complication can sometimes be prevented with scrupulous disinfection of the whirlpool after each client use and rinsing the client's wound area after exposure to the water in the therapeutic whirlpool.

Pulsed Lavage

Pulsed lavage is employed by using saline and a pulsatile high pressure lavage device to irrigate a wound and remove exudate. The complications associated with pulsed lavage include wound disruption when the pressure of the pulsed lavage is too great and occupational related infection when impervious personal protective equipment such as googles, face masks, gowns and gloves is not used to protect the staff members from sprays and splashes.

Sterile wound dressings are selected as based on its stage of healing and other characteristics. Some of these wound dressings include traditional gauze dressings, interactive and transparent dressings which contain polymeric, and bioactive dressings that contain alginate, collagen and hydrocolloids.

Promoting Client Progress Toward Recovery From an Alteration in Body Systems

Like all other health related disorders, clients' progress toward recovery from an alteration in body systems can be promoted as well as negatively affected with and impacted by intrinsic and extrinsic factors. For example, diabetes is an intrinsic factor that can negatively impact on a client's recovery from a physical alteration in the client's body system and the presence and involvement of a solid social support systems can positively impact on a client's recovery from an acute psychiatric mental health problem such as substance abuse. Conversely, the lack of affordable and accessible community resources, social stigma, impaired family dynamics, stress, and the lack of culturally competent care can negatively impact on the client's physical and psychological recovery.

The Dimensions of Health model is helpful to remembering and understanding the factors that impact on the patient's recovery, as follows:

  • The Biological Dimension of Health: Favorable genetics, full term pregnancies, and protective immunizations enhance recovery; and comorbid diseases like heart disease and diabetes prevent optimal recovery.
  • The Psychological Dimension of Health: An internal locus of control, high levels of cognition, the effective use of stress management techniques, and the client's orientation x 3 enhance recovery; and psychiatric mental diseases, high levels of incapacitating stress, and an external locus of control prevent optimal recovery.
  • The Environmental Dimension of Health: Fluorinated water, clean air without toxins, and clean drinking water and food enhance recovery; and contaminated water and contaminated food sources prevent optimal recovery.
  • The Behavioral Dimension of Health: Active participation in the treatment plan and adherence to the medication and other treatment regimens enhance recovery; and a lack of adherence to the treatment regimen and depression prevent optimal recovery.
  • The Sociocultural Dimension of Health: Available resources in the community and the presence of a good social support system enhance recovery; and the lack of economic resources and follow up care prevent optimal recovery.
  • The Health Systems Dimension of Health: Culturally competent care and the accessibility of community health care resources enhance recovery; and the lack of affordable and accessible heath care systems and resources in the community prevent optimal recovery.

Providing Ostomy Care and Education

Nurses provide ostomy care and ostomy education to clients with bowel diversion ostomies as well as ostomies of the trachea and enteral ostomies.

The education related to these ostomies include the purpose of the ostomy, care of the ostomy, the risks associated with and the possible side effects of the ostomy, the care of the ostomy, and things that should be reported to the doctor when the ostomy is being managed by the client and/or family member.

Care of the client with an ostomy, in addition to the specific interventions related to a particular type of ostomy, other interventions include monitoring the site of the ostomy, maintaining the patency of the ostomy and the prevention of any complications and side effects of the ostomy.

As discussed in the sections entitled "Providing Client Nutrition Through Continuous or Intermittent Tube Feedings" and "Evaluating the Side Effects of Client Tube Feedings and Intervening, as Needed", enteral tube feeds can be are given with a nasointestinal tube, a nasogastric tube, a nasojejunal tube, a nasoduodenal tube, a jejunostomy tube, a gastrostomy tube, and a percutaneous endoscopic gastrostomy (PEG) tube, with the latter three tubes, that is the jejunostomy, a gastrostomy and percutaneous endoscopic gastrostomy (PEG) tube, creating ostomies that are monitored and care for by the nurse. For example, the nurse monitors and assesses the surgical entry site, they maintain the patency of these tubes, they determine and validate the proper placement of these tubes, they measure and monitor the client's intake and output, they administer feedings and they evaluate the client's responses to these feedings, including the measurement of residual and the presence of any complications.

As discussed in the previous sections entitled "Assessing and Managing the Client with an Alteration in Elimination", and "Urinary and Fecal Diversion", the different types of colostomies include a transverse colostomy, a descending colostomy, an ascending colostomy, and a sigmoid colostomy, and the different urinary diversion ostomies include an ileal conduit, the neobladder, the Miami pouch, the Indiana pouch, and a nephrostomy; again, the nurse monitors and cares for these ostomies in terms of the surgical entry site, they maintain the patency of these ostomies, they measure and monitor the client's intake and output, and they evaluate the client's responses to these urinary and fecal diversion ostomies in terms of the presence of any complications such as necrosis, stomal retraction, stomal stenosis, stomal infection, urinary tract infections, renal calculi and any other complications.

Also, as previously discussed in the section entitled "Artificial Airway Tube Patency: Endotracheal and Tracheostomy Tubes", the nurse monitors and cares for these tracheostomies in terms of the surgical entry site, they maintain the patency of these ostomies, they measure and monitor the client's respiratory secretions output, they validate the correct placement of this ostomy, and they evaluate the client's responses to the presence of this artificial airway and they provide the necessary humidity and suctioning.

Providing Care to the Client Who Has Experienced a Seizure

Seizures can occur as a primary disorder, which is referred to as a seizure disorder like epilepsy, and also as a secondary disorder such as can result from and as a complication of another disorder such as hypoglycemia, a traumatic closed head injury, illicit drug over dosages, increased intracranial pressure and a high fever.

As discussed in the previous section entitled "Implementing Seizure Precautions for At-Risk Clients", nurses implement seizure precautions for clients at risk for seizures, they remain with the client, they call for the help of others, they protect the client from injury, and they initiate emergency medical measures, as indicated by the client's status during the seizure.

Seizures vary in terms of their signs and symptoms according to the type of seizure. These seizure types and symptoms are:

  • A generalized tonic-clonic or grand mal seizures: Convulsions, muscular rigidity and a state of unconsciousness
  • An absence seizure: This type of seizure is characterized with simply a short lived and brief state of unconsciousness.
  • A clonic seizure: A clonic seizure presents with ongoing and repetitive muscular jerking.
  • A myoclonic seizure: A myoclonic seizure presents with intermittent and sporadic muscular jerking.
  • An atonic seizure: This seizure entails the loss of muscular tone and muscular movement.
  • A tonic seizure: This seizure entails muscular rigidity and stiffness.

The care of the client after a seizure includes the assessment of the client, notifying the physician and the documentation of all events, interventions and patient responses prior to, during and after the seizure.

Some of the elements of this care and documentation include:

  • Events prior to the seizure such as the presence of any aura
  • The nature, type and duration of the seizure activity
  • Vital signs, pulse oximetry and blood glucose levels
  • The client's level of consciousness
  • The client's respiratory status
  • The client's cardiovascular status
  • The emergency interventions that were provided to the client and the client's responses to these interventions

Providing Care to a Client with an Infectious Disease

The care of a client with an infectious disease, simply stated, entails the assessment and reassessment of the client, the provision of interventions to treat the infectious disease, the provision of interventions including medications to treat the symptoms of the infectious disease, the prevention of complications, the protection of others against the transmission of the client's infectious disease, the evaluation of the client's recovery from the infectious disease, follow up care in the community as indicated and client and family education.

Some of the assessments and reassessments of the client include the identification of the local and systemic signs and symptoms of infectious diseases including inflammation and an elevated temperature, respectively, in addition to the many others, the assessment of laboratory data during the course of treatment including the client's erythrocyte sedimentation rate, the white blood cell count, the plasma viscosity and the levels of C reactive protein, as more fully discussed in the section entitled "Applying a Knowledge of Pathophysiology to the Monitoring for Complications: Infections".

Some infectious diseases such as can be treated with medications such as a broad scope antibiotic and other infectious diseases simply have symptomatic relief because the offending microorganism cannot be treated with an antimicrobial medication. Some examples of symptomatic relief medications include the application of Calamine lotion to chicken pox lesions, the administration of an antipyretic medication such as Tylenol when a client is adversely affected with an infectious disease such as Rubella that leads to a high temperature, and the administration of an analgesic medication when the infection is accompanied with pain.

Some of the most commonly occurring infectious diseases, their signs and symptoms over and above the typical malaise, fever, and chills, as well as their common treatments in addition to the necessary transmission based precautions including contact transmission precautions, droplet transmission precautions and airborne transmission precautions, are shown in the table below:

Infectious Disease

Signs and Symptoms

Treatments

Diphtheria

Respiratory symptoms such as dyspnea, coughing and a sore throat.

Myocarditis, cardiac arrhythmias, and a pseudomembrane on the nasal passages, pharynx, and tonsils.

Symptomatic relief of the respiratory and cardiovascular symptoms; mechanical ventilation when indicated and the correction of respiratory paralysis with diphtheria toxin.

Cytomegalovirus infections

A rash, sore throat, oral lesions, fever and enlarged lymph nodes, headache, chest pain, jaundice, splenomegaly, and photosensitivity.

Symptomatic relief of the symptoms such as an analgesic and mouth rinses.

Measles (Rubeola)

Photophobia, a cough, conjunctivitis, Koplik spots, and a maculopapular, erythematous rash that starts on the face and spreads to the body followed by desquamation.

Supportive and symptomatic relief with antipyretic drugs, rest, a dark room to relieve photophobia and cool mist for the cough.

Mumps

Anorexia, headache, an ear ache and parotid gland swelling.

Supportive and symptomatic relief with antipyretic drugs and analgesia.

Roseola

A pink skin rash that begins on the center of the body and spreads outward to the face, peripheral limbs, and neck.

Supportive and symptomatic relief with antipyretic drugs and analgesia.

Rubella (German measles)

Fetal abnormalities when the woman is pregnant, a sore throat, lymphadenopathy, cough, coryza, and a classical rash that begins on the face and spreads in a downward manner to the neck, shoulders, trunk and legs. Later, this rash disappears in an upward manner.

Supportive and symptomatic care and the isolation of the affected client from all woman of childbearing age to protect a developing fetus.

Varicella (Chickenpox)

A very pruritic rash on the trunk and scalp, oral and perineal area lesions, vesicles that change to pustules and then develop a crust which disappears over time.

Skin scars can result when the affected client scratches the itchy areas.

Skin care with topical calamine lotion, keeping fingernails short or mittened if the child is scratching, and teaching the child to put pressure on itchy areas rather than scratching.

Influenza

A productive or dry cough, overall aches and pains, hoarseness, photophobia, fever, nasal congestion, chills, diaphoresis and myalgia

Supportive and symptomatic relief with fluids, bed rest, and analgesics other than Aspirin which can lead to Reyes syndrome. Antiviral medications, such as Tamiflu or Relenza, may be given to abbreviate the duration of the flu and to prevent serious complications.

Pertussis (Whooping cough)

A whooping cough, respiratory changes including in terms of the depth of the respirations, cyanosis and respiratory exhaustion, increased lacrimation, rhinorrhea, conjunctivitis, and vomiting.

Supportive and symptomatic relief with fluids, bed rest, analgesics, respiratory care and interventions, and the care and treatment of any serious complications with suctioning, mechanical ventilation and oxygen supplementation, as indicated.

The administration of erythromycin estolate, azithromycin, or clarithromycin may also be needed.

Respiratory Syncytial Virus (RSV)

Thick mucus that occludes the bronchioles, wheezing, respiratory stridor, dyspnea, respiratory distress, tachynpea, cyanosis, respiratory hypercapnia and apnea in severe cases.

Treatment includes supportive care, symptom management and antibiotics if a secondary bacterial infection is suspected. Hydration supplemental oxygen, and other respiratory interventions, as indicated.

Pneumonia

Chills, dyspnea, dyspnea, muscular aches, fatigue, enlarged lymph nodes, a sore throat and chest pain.

The treatment of pneumonia can include antibiotics for bacterial pneumonia, fluids and oxygen supplementation, as indicated.

Providing Pulmonary Hygiene

Pulmonary hygiene consists of a number of different procedures and techniques including relatively simple and easy techniques such as coughing and deep breathing and more advanced techniques such as vibration and percussion are used for the removal of respiratory secretions.

Coughing, deep breathing, incentive spirometry, postural drainage, percussion, vibration and Inspiratory respiratory exercises and the techniques for each were previously discussed and described in the section entitled "Applying a Knowledge of Nursing Procedures and Psychomotor Skills When Providing Care to Clients with Immobility".

The correct client positioning for postural drainage is shown in the table below:

Lobe of the Lung

Section of the Lobe

Client Positioning

The Upper Lobe

Anterior bronchus

Apical bronchus

Posterior bronchus

Supine with a pillow under the knees

Semi-Fowler's position and then leaning to the right, to the left and then forward

Up at a 45 degree angle and up against a pillow at 45 degrees on the left side and then on the right side

The Middle Lobe

Medial and lateral bronchus

A 30 degree Trendelenburg position and turned slightly to the left or a 14 to 16 inch elevation of the foot of the bed and turned slightly to the left

The Lingula (The small projection from the lower portion of the upper lobe)

Apical bronchus:

Medial bronchus:

Lateral bronchus:

Posterior bronchus:

Superior and inferior bronchus

Prone position and a pillow under the client's hip

A 45 degree Trendelenburg position and turned on the right side or an 18 to 20 inch elevation of the foot of the bed and turned on the right side

A 45 degree Trendelenburg position and turned on the left side or an 18 to 20 inch elevation of the foot of the bed and turned on the left side

A 45 degree prone Trendelenburg position and a pillow under the client's hip

A 30 degree Trendelenburg position and turned slightly to the right or a 14 to 16 inch elevation of the foot of the bed and turned slightly to the right

Percussion is performed by placing a cupped over the area and doing percussion to remove secretions. Each area is percussed for at least one minute while the client is holding his or her breath. Vibration is performed by laying the hand on the area and applying rapid vibrating movements while the client is deeply exhaling.

The correct hand placement for percussion and vibration is shown in the table below:

Lobe of the Lung

Section of the Lobe

Client Positioning

The Upper Lobe

The anterior bronchus

The apical bronchus

The posterior bronchus

The area immediately under the clavicles over the anterior chest

The area over the shoulder blades to the clavicle

The area over the shoulder blades and on both sides

The Middle Lobe

The medial and lateral bronchii

The area from the axillary fold across to the mid anterior chest in addition to over the lateral right chest and the anterior right chest

The Lingula

The apical bronchus

The medial bronchus

The lateral bronchus

The posterior bronchus

The superior and inferior bronchus

The bilateral area over the lower third of the posterior rib cage

The area over the lower third of the left posterior rib cage

The area over the lower third of the right posterior rib cage

The lower third of the posterior rib cage bilaterally

The area extending from the left axillary fold to the midanterior chest

Providing Care for the Client Experiencing Complications of Pregnancy/Labor and/or Delivery

The maternal, fetal and neonate complications during pregnancy, labor, delivery and during the postpartum period were fully discussed with "Assessing the Maternal Client For Antepartal Complications" and "Assessing the Client For the Symptoms of Postpartum Complications", "Providing Care to the Client in Labor", "Providing Prenatal Care and Education", and "Checking and Monitoring the Fetal Heart during Routine Prenatal Exams and During Labor".

Providing Care for Clients Experiencing Increased Intracranial Pressure

The diagnosis, etiology, signs and symptoms, and the care and treatment of clients experiencing increased intracranial pressure were fully detailed and discussed in the previous section entitled "Evaluating Invasive Monitoring Data: Increased Intracranial Pressure".

Providing Postoperative Care

Preoperative, intraoperative and postoperative education and care were previously discussed and detailed under the sections entitled "Providing Preoperative Care", "Providing Intraoperative Care" and "Managing the Client During and Following a Procedure with Moderate Sedation".

Removing Sutures and Staples

The process for removing surgical sutures and staples after the validation of the order to remove these surgical closures and the proper identification of the client using two unique identifiers is below.

  • Cleanse and disinfect the surgical wound with a topical antiseptic
  • Carefully lift each knot up with a sterile forceps
  • Clip the suture with sterile scissors
  • Cleanse the surgical wound again with an antiseptic when all the sutures are removed
  • Place steri strips over the incision for additional healing and closure

Staples are removed using the same procedure without the use of sterile forceps and scissors, but instead, by using a special surgical staple remover.

Evaluating the Client Response to Surgery

Client responses to surgery were previously discussed and detailed under the section entitled "Evaluating the Client's Response to Post-Operative Interventions to Prevent Complications".

Evaluating the Achievement of Client Treatment Goals

As discussed with the section entitled "Integrated Process: The Nursing Process", the evaluation of the achievement of client treatment goals reflects the client's current condition and status, as compared and contrasted to the client's baseline data and the established expected outcomes of care, which were established during the planning phase of the nursing process.

The five steps of the evaluation process are:

  • Collecting data related to client's current condition and the established expected outcome
  • The analysis of this data
  • Comparing this analyzed data to the expected outcomes
  • Connecting the interventions to the data and the expected outcomes
  • Drawing conclusions about the success of the interventions and treatments using critical thinking and professional judgment skills
  • Making a decision about whether to continue the plan of care, or to modify it or to discontinue it all together

Evaluating the Client's Responses to the Treatment For An Infectious Disease

With the exception of acquired immune deficiency syndrome (AIDS) and tuberculosis (TB), a wide variety of infectious diseases, including a large number of infectious childhood diseases, was previously discussed in the section entitled "Providing Care to a Client with an Infectious Disease". This discussion covered each infectious disease in terms of its signs, symptoms, and treatments.

Some of the assessments and reassessments of the client including the signs and symptoms of infection and laboratory data that indicate the presence or absence of infection during the recovery stage of the infection was fully previously discussed in the section entitled ""Applying a Knowledge of Pathophysiology to the Monitoring for Complications: Infections". This data is used to evaluate the client's responses to the treatment for an infectious disease.

Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) are blood borne pathogens that can affect humans of all ages around the globe.

HIV infections can range from an asymptomatic state to overt AIDS which, without effective treatment, can lead to opportunistic infections and death. Some of these opportunistic infections include Kaposi's sarcoma, herpes simplex, histoplasmosis, salmonella, toxoplasma gondii, tuberculosis, cytomegalovirus, mycobacterium avium infections, candidiasis, and Pneumocystis jirovecii pneumonia, which was formerly known as pneumocystis carinii pneumonia. Other disorders associated with HIV/AIDS include arthralgia, bodily wasting, blindness, peripheral neuropathy, acid-base imbalances and fluid and electrolyte disorders.

In addition to the presence of an opportunistic infection and other HIV/AIDS related disorders, some of the signs and symptoms associated with this infection include headaches, lymphadenopathy, edema, stiff neck, confusion chills, diarrhea, oral lesions, abdominal discomfort, weight loss, fever, night sweats, dry cough, dyspnea, lethargy, malaise, skin rash, and seizures.

The treatment of this sexually transmitted and blood borne infectious disease, which is transported and transmitted among humans with blood and all other bodily fluids, consists of highly active combination antiretroviral therapy (HAART). The goal of HAART is to prevent the occurrence of opportunistic infections, to decrease the viral load and to increase the client's CD4 T cells.

HAART consists of lifelong treatments with reverse transcriptase inhibitors, like Zidovudine, nonnucleoside reverse transcriptase inhibitors like Efavirenz, fusion inhibitors and a combination of antiretroviral agents like Combivir and Trizivir. The evaluation of the client's responses to the treatment for AID/HIV, therefore, is based on the outcomes of these medications and other treatments in terms of the client's ongoing physical status.

Tuberculosis (TB)

Tuberculosis is an airborne transmitted infection that is caused by the tubercle bacilli.

The signs and symptoms of tuberculosis include pallor, fever, chills, night sweats, anorexia, a productive purulent cough that can sometimes contain blood, dyspnea, chest pain and extreme fatigue. The most serious complication of TB is the emergence of an untreatable drug resistant strain of tuberculosis.

Some of the medications that are used to treat TB include rifampin, rifabutin, rifapentine, INH, pyrazinamide, ethambutol, streptomycin, capreomycin, aminosalicylate sodium, cycloserine and ethionamide. Combination therapy, rather than a single medication, is the most effective form of treatment.

Like AIDS/HIV and other diseases and disorders, the outcomes of these medications and other treatments for TB are evaluated in terms of the client's ongoing physical status from diagnosis through recovery.

Evaluating and Monitoring the Client's Responses to Radiation Therapy

The client responses to radiation therapy, like their responses to other therapies and treatments including side effects, adverse side effects, and therapeutic effects are evaluated and monitored by the nurse.

The responses to radiation therapy were previously detailed and discussed under the sections entitled "Implementing Interventions to Address Side/Adverse Effects of Radiation Therapy and Radiation" and "Assessing the Client for the Signs and Symptoms of the Adverse Effects of Radiation Therapy and Chemotherapy".

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