‫جامعة البلقاء التطبيقية ‪ /‬كلية رفيدة األسلمية‬

‫للتمريض والقبالة والمهن الطبية المساندة‬

‫‪Basic in Nursing Care‬‬

‫‪Anesthesia‬‬

‫االستاذ عبد الباسط الحليقاوي‬

‫‪2020/2021‬‬

‫‪2021‬‬
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 Unit 1. : Introduction to Nursing Care
Definitions of Nursing
 There are many definitions for nursing such as:
 Common dictionary definitions refer to the nurse as “a person, usually a woman, trained to
care for the sick”.
 Florence Nightingale (1860) defined nursing as “the act of utilizing the environment of
the patient to assist him in his recovery”. She considered a clean, well ventilated and
quiet environment essential for recovery.
 Professional nursing associations have examined nursing and developed their
definitions of it.
 In 1973, the ANA (American Nursing Association) described nursing practice as “direct,
goal oriented, and adaptable to the needs of the individual, the family, and
community during health and illness” (ANA, 1973, p. 2).
 In 1980, the ANA changed this definition of nursing to this: “Nursing is the diagnosis
and treatment of human responses to actual or potential health problems” (ANA,
1980, p. 9).
 The current definition of nursing remains unchanged from the 2003: “Nursing is the
protection, promotion, and optimization of health and abilities, preventions of illness
and injury, alleviation of suffering through the diagnosis and treatment of human
response, and advocacy in the care of individuals, families, Communities, and
populations” (ANA, 2010, p. 10; ANA, 2015b, p. 7)
The Metaparadigm for Nursing
In the late 20th century, much of the theoretical work in nursing focused on articulating
relationships among four major concepts: person, environment, health, and nursing. Because
these four concepts can be superimposed on almost any work in nursing, they are collectively
Referred to as the metaparadigm for nursing.
 The term originates from two Greek words: Meta, meaning“with,” and paradigm,
meaning “pattern.” Many consider the following four concepts to be central to nursing:
1. The individuals or clients are the recipients of nursing care (includes individuals, families,
groups, and communities).
2. The environment is the internal and external surroundings that affect the client.
3. Health is the degree of wellness or well-being that the client experiences.

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4. Nursing is the attributes, characteristics, and actions of the nurse providing care on behalf
of, or in conjunction with, the client.
 During this time, a number of nurse theorists developed their own theoretical definitions
of nursing.

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Historical Back Ground
Nursing today is far different from nursing as it was practiced years ago, and it is expected to
continue changing during the 21st century.
Nursing has undergone dramatic change in response to societal needs and influences.
Women’s Roles
 Traditional female roles of wife, mother, daughter, and sister have always included the
care and nurturing of other family members. From the beginning of time, women have
cared for infants and children; thus, nursing could be said to have its roots in the home.
Additionally, women, who in general occupied a subservient and dependent role, were
called on to care for others in the community who were ill.
 Generally, the care provided was related to physical maintenance and comfort. Thus, the
traditional nursing role has always entailed humanistic caring, nurturing, comforting, and
supporting.
Men’s Roles
 Men have worked as nurses as far back as before the Crusades. Although the history of
nursing primarily focuses on the female figures in nursing, schools of nursing for men
existed in the United States from the late 1880s until 1969.
 Male nurses were denied admission to the Military Nurse Corps during World War II
based on gender. It was believed at that time that nursing was women’s work and combat
was men’s work.
During the 20th century, men were denied admission to most nursing programs.
War
Throughout history, wars have accentuated the need for nurses.

 During the Crimean War (1854–1856), the inadequacy of care given to soldiers led to a
public outcry in Great Britain.
 The role Florence Nightingale played in addressing this problem is well known.
Nightingale and her nurses transformed the military hospitals by setting up sanitation
practices, such as hand washing. Nightingale is credited with performing miracles; the
mortality rate, for example, was reduced from 42% to 2% in 6 months.
 During the American Civil War (1861–1865), several nurses emerged who were notable
for their contributions to a country torn by internal [Link] Dix she became the
Union’s superintendent of female nurses responsible for recruiting nurses and supervising
the nursing care of all women nurses working in the army hospitals.

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  Progress in healthcare occurred during World War I, particularly in the field of surgery.
For example, advancements were made in the use of anesthetic agents, infection control,
blood typing, and prosthetics.
 World War II casualties created an acute shortage of caregivers, and the Cadet Nurse
Corps was established in response to a marked shortage of nurses also at that time,
auxiliary healthcare workers became prominent.
 “Practical” nurses, aides, and technicians provided much of the actual nursing care under
the instruction and supervision of better prepared nurses. Medical specialties also arose at
that time to meet the needs of hospitalized clients.
 During the Vietnam War, approximately 11,000 American military women stationed in
Vietnam were nurses. Most of them volunteered to go to Vietnam right after they
graduated from nursing school, making them the youngest group of medical personnel ever
to serve in war time .
Nursing Leaders
 Nightingale (1820–1910)
The contributions of Florence Nightingale to nursing are well documented. Her achievements in
improving the standards for the care of war casualties in the Crimea earned her the title “Lady
with the Lamp.” Her efforts in reforming hospitals and in producing and implementing
public health policies also made her an accomplished political nurse:
 She was the first nurse to exert political pressure on government. Through her
contributions to nursing education—perhaps her greatest achievement—she is also
recognized as nursing’s first scientist-theorist for her work
 Nightingale was born to a wealthy and intellectual family. She believed she was “called by
God to help others . . . [and] to improve the well-being of mankind”.

Some of Muslim Women who offered help in nursing and who shared in wars:
 Rufaidah Bent Saad AL Aslamiah
She was one of the women who received prophet Mohammed ( peace on him), she immigrated
from Mecca to Medina, after two years of this immigration, battle of Badr took place and that was
on 17 Ramadan second year of Hijra, that was 13 march 624, she wanted to help the injured
soldiers in this battle and her role was:
1. Encouraging the fighters
2. Treating wounded fighters
3. Offering food and water to the fighters

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After the battle of badr she decided to keep on fulfilling her message, and in the time of peace she
offered her services and established the first medical center inside the prophet mosque (peace on
him), then she participated in the battles Uhod and Alkhandak and she proved her intelligence
when (Saad Bin Moath) was injured, a sword get into his chest, she didn’t take it out of his chest
to stop bleeding on the contrary she kept near to him encouraging him till he died.

 Nusailbah Bent Kaab Al Mazeniah (Um Emarah):

She played a role in the Islamic wars and it’s the same role of that Red Cross association is
played at our time, she participated in Uhod battle helping injured fighters and offering food.

Duties of a nurse:
A nurse's duties can vary based on their workplace, licenses, and experience level. Typically,
here are 10 duties of a nurse:

1. Conduct physical examinations

Nurses often perform a physical exam at the start of a patient’s visit to assess overall health.
This can include checking temperature, weight, heartbeat, and blood pressure, as well as
testing reflexes and examining the eyes, ears, nose, and throat. The exam helps provide an
update on the patient’s health and opens discussions about health goals and concerns.
Nurses may also pay attention to non-verbal cues, which can help identify underlying health
issues.

2. Perform diagnostic tests

Nurses often perform various diagnostic tests, such as checking vitals and collecting tissue,
blood, stool, or urine samples for analysis. Nurses may also analyze results and share their
findings with the medical team to ensure proper patient [Link] to detail can be critical,
as accurate testing helps diagnose patients and create effective treatment
[Link]: Key Nurse Resume Skills to Highlight for Career Success

3. Record medical history and symptoms

Nurses may be responsible for recording and maintaining accurate patient health records to
ensure proper treatment. This typically begins with gathering details about a patient's medical
history, including past diagnoses, surgeries, current medications, allergies, and family
medical [Link] also document any symptoms and vitals during the visit. If a
patient receives a new diagnosis, medication, or treatment plan, nurses update their records
accordingly. Keeping thorough and accurate records can be critical to providing optimal care
for patients.

4. Administer medications and treatments

Nurses can administer medications and treatments to patients under a physician’s order and
may help develop treatment plans. Specialized nurses, like nurse practitioners, may prescribe
medications [Link] may also assist with tasks like cleaning wounds, changing
bandages, and inserting catheters. Some nurses can support doctors with advanced

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procedures and provide emergency care for critical patients. Ensuring accurate medication
records and maintaining IV lines are key responsibilities to ensure patients receive proper
treatment.

5. Communicate and collaborate with teams for patient care

Nurses play a significant role in gathering information from patients and relaying it to their
medical team. They closely monitor and observe patients to document and communicate
symptoms and relevant details that may influence diagnoses or treatment [Link] critical
responsibility typically requires nurses to possess strong verbal and written
communication skills for effective collaboration with physicians and other healthcare
professionals. Clear and concise communication may also ensure that patients and their
families fully understand the information they [Link]: Communication Skills in
Nursing: Definition and Examples

6. Provide support and advice to patients

Nurses play an important role in ensuring that patients feel cared for, listened to, and
understood, particularly when delivering difficult medical news. Patients often turn to nurses
for support and guidance as they navigate their diagnoses and determine next [Link]
demonstrating empathy, nurses can offer comfort and direction during these challenging
times, equipping patients with coping strategies and resources for both inpatient and
outpatient care. In addition, bedside nurses may provide support with bedside care tasks,
such as helping patients bathe and maintain hygiene, while also offering emotional support.

7. Operate and maintain medical equipment and supplies

Nurses utilize a range of diagnostic tools to provide patient care, including stethoscopes,
glucometers, pulse oximeters, thermometers, and blood pressure monitors. Depending on
their workplace and training, nurses may also operate specialized equipment such as
intravenous infusion pumps, ventilation systems, and wound drainage devices. A strong
foundation in technology and mathematics may enhance their ability to effectively use this
medical equipment and analyze [Link] nurses may take on additional
responsibilities, such as inventory management and ordering supplies, with senior nurses
often supervising entire departments. Proper organization and timely restocking of supplies
are key to ensuring that the medical team has the necessary resources to deliver quality
patient care.

8. Educate patients about how to manage illnesses

Nurses play a vital role in educating patients about medical conditions and providing guidance
on managing symptoms. This may include explaining necessary medications, scheduling
follow-up appointments, and outlining rehabilitative exercises or [Link] may also
communicate post-treatment care requirements to patients' families or caregivers, offering
recommendations for diet, nutrition, exercise routines, and physical therapy. In addition, some
nurses engage in proactive health education by speaking at seminars, assisting with blood
drives, or volunteering at health screening and immunization [Link]: A Day in the
Life of a Nurse: Typical Daily Activities and Duties

9. Advocate for the health and well-being of patients

Nurses may serve as advocates for their patients' health and well-being, ensuring they
receive proper care and safety. This advocacy can include translating complex medical

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 information and diagnoses from doctors, helping patients understand critical [Link]
tend to encourage patients to ask questions and connect them with resources at facilities
better suited to their needs. In addition, they actively listen to patient concerns, respect their
wishes, and communicate those preferences with family members and other healthcare staff.

10. Train and educate staff

In addition to their clinical responsibilities, experienced nurses often play train and supervise
newer members of the medical team, such as practical nurses and nursing aides. Some
nurses may also collaborate with local colleges to offer training courses for nursing students
or provide continuing education programs for nurses seeking career advancement. This
mentorship helps ensure a high standard of care within the healthcare setting.

Communication in Nursing
Inter- personal relation
• The term communication has various meanings, depending on the context in which it is
used. To some, communication is the interchange of information between two or more
people; in other words, the exchange of ideas or thoughts. This kind of communication
uses methods such as talking and listening or writing and reading. However, painting,
dancing, and storytelling are also methods of communication. In addition, thoughts are
expressed to others not only by spoken or written words but also by gestures or body

actions. Communication may have a more personal meaning than the interchange of ideas
or thoughts. It can be a transmission of feelings or a more personal and social interaction
between individuals.

 Communication can occur on an intrapersonal level within a single individual as well

as on interpersonal and group levels.
 Intrapersonal communication is the communication that you have with yourself; another
name is selftalk.
 Both the sender and the receiver of a message usually engage in self-talk. It involves
thinking about the message before it is sent, while it is being sent, and after it is sent, and it
occurs constantly. Consequently, intrapersonal communication can interfere with an
individual’s ability to hear a message as the sender intended (Figure 16.1 ■).

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The Communication Process
 Face-to-face communication involves a sender, a message, a receiver, and a response, or
feedback (Figure 16.2 ■). In its simplest form, communication is a two-way process
involving the sending and the receiving of a message.
 Because the intent of communication is to elicit a response, the process is ongoing; the
receiver of the message then becomes the sender of a response, and the original sender
then becomes the receiver.

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Sender
The sender, an individual or group wishing to communicate a message to another, can be
considered the source encoder. This term suggests that the individual or group sending the
message must have an idea or reason for communicating (source) and must put the idea or feeling
into a form that can be transmitted.
Encoding involves the selection of specific signs or symbols (codes) to transmit the message,
such as which language and words to use, how to arrange the words, and what tone of voice and
gestures to use.
For example, if the receiver speaks English, the sender usually selects English words. If the
message is “Mr. Johnson, you have to wait another hour for your pain medication,” the tone of
voice selected and a shake of the head can reinforce it.
 The nurse must not only deal with dialects and foreign languages but also cope with two
language levels—the laypersons and the health professionals.

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Message
The second component of the communication process is the message itself—what is actually
said or written, the body language that accompanies the words, and how the message is
transmitted.
 The method used to convey the message can target any of the receiver’s senses. It is
important for the method to be appropriate for the message, and it should help make the
intent of the message clearer.
 For example, talking face to face with an individual may be more effective in some
instances than telephoning, emailing, or texting a message. Written communication is
often appropriate for long explanations or for a communication that needs to be preserved.
 Another form of communication has evolved with technology—electronic
communication.
 Common forms of electronic communication are email and texting, in which an
individual can send a message, by computer or smartphone, to another individual or group
of people.
 The use of email and texting has become prevalent as a primary form of personal
communication. It is important to know the rules of etiquette for each.
For example, emails should be short and to the point, and punctuation matters.
Acronyms should be used sparingly, and do not write in all caps because it implies you are
shouting. Texting is even more concise, and if the information is complex, consider using
email or telephone or speaking with the individual in person.
 Communicating by email and text does not provide the sender relevant information, such
as if the receiver is confused, upset, or needs clarification. Therefore, it is important to
reread what you email or text before pressing the send button.
 Nurses need to know when it is and when it is not appropriate to use email for
communicating with clients,
 The nonverbal channel of touch is often highly effective. Nurses use touch in two key
circumstances.
 For example, touch is used frequently when completing a physical task while providing
nursing care of a client (e.g., taking blood pressure, administering medications, changing a
dressing). The other circumstance is driven by an emotional response to a client’s
distress (e.g., holding a hand, stroking a shoulder, providing a comforting embrace).

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Receiver
The receiver, the third component of the communication process, is the listener, who must listen,
observe, and attend. This individual is the decoder, who must perceive what the sender intended
(interpretation). Perception uses all the senses to receive verbal and nonverbal messages.
 To decode means to translate the message sent via the receiver’s knowledge and
experiences to sort out the meaning of the message. Whether the message is decoded
accurately by the receiver, according to the sender’s intent, depends largely on their
similarities in knowledge and experience and sociocultural background.
 If the meaning of the decoded message matches the intent of the sender, then the
communication has been effective.
 Ineffective communication occurs when the receiver misinterprets the sent message. For
example, Mr. Johnson may perceive the message accurately—“No pain medication for
another hour.” However, if experience has taught him that he can receive the pain
medication early if a certain nurse is on duty, he will interpret the intent of the message
differently.
Response
The fourth component of the communication process, the response, is the message that the
receiver returns to the sender. It is also called feedback. Feedback can be either verbal,
nonverbal, or both.
Nonverbal examples are a nod of the head or a yawn. Either way, feedback allows the sender to
correct or reword a message.
Modes of Communication
Communication is generally carried out in two different modes: verbal and nonverbal.
 Verbal communication uses the spoken or written word
 Nonverbal communication uses other forms, such as gestures, facial expressions, and
touch. Although both kinds of communication occur concurrently, most communication
is nonverbal.
Verbal Communication
Verbal communication is largely conscious because people choose the words they use. The words
used vary among individuals according to culture, socioeconomic background, age, and education.
As a result, countless possibilities exist for the way ideas are exchanged. An abundance of words
can be used to form messages. In addition, a wide variety of feelings can be transmitted when
people talk.

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  Nurses need to consider the following when choosing words to say or write: pace and
intonation, simplicity, clarity and brevity, timing and relevance, adaptability, credibility,
and humor.
PACE AND INTONATION
The manner of speech, as in the rate or rhythm and tone, will modify the feeling and impact of a
message.

 The tone of words can express enthusiasm, sadness, anger, or amusement.

 The rate of speech may indicate interest, anxiety, boredom, or fear. For example, speaking
slowly and softly to an excited client may help calm the client.
SIMPLICITY
Simplicity includes the use of commonly understood words, brevity, and completeness.
 The use of complex technical terms becomes natural to nurses. However, clients often
misunderstand these terms. Words such as Vasoconstriction or cholecystectomy are
meaningful to the nurse and easy to use but not advised when communicating with clients.
 Nurses need to select appropriate, understandable, and simple terms based on the client’s
age, knowledge, culture, and education.
 For example, instead of saying to a client, “I will be catheterizing you for a urine
analysis,” it may be more appropriate and understandable to say, “I need to get a sample
of your urine, so I will collect it by putting a small tube into your bladder.”
 The latter statement is more likely to elicit a response from the client asking why it is
needed and whether it will be uncomfortable because the client understands the message
being conveyed by the nurse.
CLARITY AND BREVITY
 A message that is direct and simple will be effective.
 Clarity is saying precisely what is meant, and brevity is using the fewest words
necessary. The result is a message that is simple and clear.
 An aspect of this is congruence, or consistency, where the nurse’s behavior or nonverbal
communication matches the words spoken. When the nurse tells the client, “I am
interested in hearing what you have to say,” the nonverbal behavior would include the
nurse facing the client, making eye contact, and leaning forward.
 The goal is to communicate clearly so that all aspects of a situation or circumstance are
understood. To ensure clarity in communication, nurses also need to enunciate
(pronounce) words carefully.

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TIMING AND RELEVANCE
Nurses need to be aware of both relevance and timing when communicating with clients.
 No matter how clearly or simply words are stated or written, the timing needs to be
appropriate to ensure that words are heard.
 Furthermore, the messages need to relate to the client or to the
Client’s interests and concerns. This involves sensitivity to the client’s needs and concerns.
 For example, a client who is fearful of the possibility of cancer may not hear the nurse’s
explanations about the expected procedures before and after gallbladder surgery. In this
situation, it is better for the nurse first to encourage the client to express concerns and then
to deal with those concerns.
 Another problem in timing is asking several questions at once. For example, a nurse
enters a client’s room and says in one breath, “Good morning, Mrs. Brody. How are you
this morning? Did you sleep well last night? Your husband is coming to see you before
your surgery, isn’t he?” The client no doubt wonders which question to answer first, if
any.
 A related pattern of poor timing is to ask a question and then not wait for an answer
before making another comment. Conversely, by allowing the client to respond to the
social talk or chat, the nurse develops rapport with the client that can help facilitate
effective therapeutic communication.
ADAPTABILITY
 The nurse needs to alter spoken messages in accordance with behavioral cues from the
client. This adjustment is referred to as adaptability. What the nurse says and how it is
said must be individualized and carefully considered.
 For example, a nurse who usually smiles, appears cheerful, and greets the client with an
enthusiastic “Hi, Mrs. Brown!” notices that the client is not smiling and appears
distressed. It is important for the nurse to then modify his or her tone of speech and
express concern by facial expression while moving toward the client.
CREDIBILITY
 Credibility means worthiness of belief, trustworthiness, and reliability.
 Credibility may be the most important criterion for effective communication. Nurses
foster credibility by being consistent, dependable, and honest.
 The nurse needs to be knowledgeable about what is being discussed and to have accurate
information.

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 HUMOR

 The use of humor can be a positive and powerful tool in the nurse–client relationship, but
it must be used with care.
 Humor can be used to help clients adjust to difficult and painful situations.
 When using humor, it is important to consider the client’s perception of what is
considered humorous. Timing is also important to consider.
 Although humor and laughter can help reduce stress and anxiety, the feelings of the client
need to be considered.
Nonverbal Communication
 Nonverbal communication, sometimes called body language,
Includes gestures, body movements, use of touch, and physical appearance, including
adornment.
 Nonverbal communication often tells others more about what an individual is feeling than
what is being said because nonverbal behavior is controlled less consciously than verbal
behavior.
 Nonverbal communication either reinforces or contradicts what is said verbally.
 For example, if a nurse says to a client, “I’d be happy to sit here and talk to you for a
while,” yet glances nervously at a watch every few seconds, the actions contradict the
verbal message. The client is more likely to believe the nonverbal behavior, which
conveys “I am very busy and need to leave.”
 Observing and interpreting the client’s nonverbal behavior is an essential skill for nurses
to develop. To observe nonverbal behavior efficiently requires a systematic assessment
of the client’s overall physical appearance, posture, gait, facial expressions, and gestures.

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Electronic Communication
 Computers play an increasing role in nursing practice.
Many healthcare agencies are moving toward electronic medical records where nurses document
their assessments and nursing care. Email can be used in healthcare facilities for many purposes:
to schedule and confirm appointments, to report normal laboratory results, to conduct client
education, and for follow-up with discharged clients.
 EMAIL is the most common form of electronic communication.
Therapeutic Communication
 Therapeutic communication promotes understanding and can help establish a constructive
relationship between the nurse and the client. Unlike a social relationship, where there
may not be a specific purpose or direction, the therapeutic helping relationship is client
and goal directed.
 Nurses need to respond not only to the content of a client’s verbal message but also to the
feelings expressed. It is important to understand how the client views the situation and
feels about it before responding. The content of the client’s communication is the words
or thoughts, as distinct from the feelings.

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 Therapeutic Communication
Therapeutic communication is an interpersonal
interaction between the nurse and the client during
which the nurse focuses on the client’s specific needs to
promote an effective exchange of information.
Skilled use of therapeutic communication techniques
helps the nurse understand and empathize with the
client’s experience.

The Helping Relationship

Nurse–client relationships are referred to by some as interpersonal
relationships, by others as therapeutic relationships, and by still others as helping relationships.
 Helping is a growth-facilitating process that strives to achieve three basic goals:
1. Help clients manage their problems in living more effectively and develop unused or underused
opportunities more fully.
2. Help clients become better at helping themselves in their everyday lives.
3. Help clients develop an action-oriented prevention mentality in their lives. A helping
relationship may develop over weeks of working with a client, or within minutes.
 The keys to the helping relationship are
(a) The development of trust and acceptance between the nurse and the client

(b) An underlying belief that the nurse cares about and wants to help the client.

Phases of the Helping Relationship

 The helping relationship process can be described in terms of four sequential phases, each
characterized by identifiable tasks and skills.
 The relationship must progress through the stages in succession because each builds on
the one before.
 Nurses can identify the progress of a relationship by understanding these phases:
preinteraction phase, introductory phase, working (maintaining) phase, and
resolution phase.

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Pre interaction Phase
 The preinteraction phase is like the planning stage before an interview. In most
situations, the nurse has information about the client before the first face-to-face meeting.
 Such information may include the client’s name, address, age, medical history, and social
history.
 Planning for the initial visit may generate some anxious feelings in the nurse. If the nurse
recognizes these feelings and identifies specific information to be discussed, positive
outcomes can evolve.
Introductory Phase
 The introductory phase, also referred to as the orientation phase or the prehelping
phase, is important because it sets the tone for the rest of the relationship.
 During this initial encounter, the client and the nurse closely observe each other and form
judgments about the other’s behavior.
 The goal of the nurse in this phase is to develop trust and security within the nurse–client
relationship (Boyd, 2017).
 Other important tasks of the introductory phase include getting to know each other and
developing a degree of trust.
 By the end of the introductory phase, clients should begin to:
• Develop trust in the nurse.
• View the nurse as a competent professional capable of helping.
• View the nurse as honest, open, and concerned about their welfare.
• Believe the nurse will try to understand and respect their cultural values and beliefs.
• Believe the nurse will respect client confidentiality.
• Feel comfortable talking with the nurse about feelings and other sensitive issues.
• Understand the purpose of the relationship and the roles.
• Feel that they are active participants in developing a mutually agreeable plan of care.
Working Phase
 During the working phase of a helping relationship, the nurse and the client begin to
view each other as unique individuals. They begin to appreciate this uniqueness and care
about each other.
 Caring is sharing deep and genuine concern about the welfare of another individual. Once
caring develops, the potential for empathy increases.
 The working phase has two major stages: exploring and understanding thoughts and
feelings, and facilitating and acting.

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  The nurse helps the client to explore thoughts, feelings, and actions and helps the client
plan a program of action to meet preestablished goals.

1. EXPLORING AND UNDERSTANDING THOUGHTS AND FEELINGS

 The nurse must have the following skills for this phase of the helping relationship:
Empathetic listening and responding:

 Nurses must listen attentively and communicate (respond) in ways that indicate they have
listened to what was said and understand how the client feels.
 The nurse responds to content or feelings or both, as appropriate. The nurse’s nonverbal
behaviors are also important.
 Nonverbal behaviors indicating empathy include moderate head nodding, a steady gaze,
moderate gesturing, and little activity or body movement.
 According to Boyd (2017), empathy is the ability to experience, in the present, a situation
as another did at some time in the past, the ability to put oneself in another individual’s
circumstances and imagine what it would be like to share their feelings.
 Empathetic listening focuses on “being with” clients to develop an understanding of them
and their world.
 The result of empathy is comforting and caring for the client and a helping, healing
relationship.
Respect:
 The nurse must show respect for the client’s willingness to be available, a desire to work
with the client, and a manner that conveys the idea of taking the client’s point of view
seriously.
Genuineness:
 The ability to be real or honest with another is genuineness.
 To be effective, genuineness must be based on a solid relationship that is empathic and
not phony.
 Phoniness can be expressed in a variety of ways, such as pretending to like someone when
you do not or overstressing your professional role (e.g., I am the expert, the one with all
the answers).
 The nurse who is genuine is more likely to help the client.

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Concreteness:
 The nurse must assist the client to be concrete and specific rather than to speak in
generalities. When the client says, “I’m stupid and clumsy,” the nurse narrows the topic
to the specific by pointing out, “You tripped on the rug.”
Confrontation:
 The nurse points out discrepancies between thoughts, feelings, and actions that inhibit the
client’s self-understanding or exploration of specific areas. This is done empathetically,
not judgmentally.
 During this first stage of the working phase, the intensity of interaction increases, and
feelings such as anger, shame, or self-consciousness may be expressed.
2. FACILITATING AND TAKING ACTION
 Ultimately, the client must make decisions and take action to become more effective. The
responsibility for action belongs to the client. The nurse, however, collaborates in these
decisions, provides support, and may offer options or information.
Resolution Phase
 The final phase of the relationship is resolution, which begins when the actual problems
are resolved and ends with the termination of the relationship (Boyd, 2017).
 Many methods can be used to terminate relationships.
 Summarizing or reviewing the process can produce a sense of accomplishment.
This may include sharing reminiscences of how things were at the beginning of the
relationship and comparing them to how they are now.
 Follow-up phone calls and emails are other interventions that ease the client’s transition
to independence.
Developing Helping Relationships
 There are many ways of helping clients that do not require special training:
 Listen actively.
 Help to identify what the client is feeling. Clients who are troubled are often unable to
identify or label their feelings and consequently have difficulty working them out or
talking about them.
 Put yourself in the client’s shoes (i.e., empathize). Communicate to the client in a way that
shows an understanding of the client’s feelings and the behavior and experience
underlying these feelings.
 Be honest. In effective relationships, nurses honestly recognize any lack of knowledge by
saying “I don’t know the answer to that right now”.

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 Be genuine and credible. Clients will sense whether you are truly concerned.
 Be aware of cultural differences that may affect meaning and understanding. To facilitate
nurse–client interaction, recognize the language(s) and dialect(s) the client uses. Provide a
bilingual interpreter as needed for clients who have limited English language skills.
 Maintain client confidentiality. To maintain the client’s right to privacy, share information
only with other healthcare professionals as needed for effective care and treatment.
 Know your role and your limitations. Every client has unique strengths and problems.
When you feel unable to handle some problems, the client should be informed and
referred to the appropriate health professional.
.

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 Unit 2: Management of some of the Nursing Process

Health Assessment

Vital signs:
 The traditional vital signs are body temperature, pulse, respirations, and blood pressure.
 Many agencies such as the Veterans Administration, American Pain Society, and The
Joint Commission have designated pain as a fifth vital sign, to be assessed at the same
time as each of the other four
 Oxygen saturation is also commonly measured at the same time as the traditional vital
signs and could be considered the sixth vital sign.
 Vital signs, which should be looked at in total, are checked to monitor the functions of the
body. The signs reflect changes in function that otherwise might not be observed.
 A nurse should assess vital signs more often if the client’s health status requires it.
Examples of times to assess vital signs are listed in Box.

Times to Assess Vital Signs

 On admission to a healthcare agency to

obtain baseline data
 When a client has a change in health
status or reports symptoms such as
chest pain or feeling hot or faint
 Before and after surgery or an
invasive procedure
 Before and after the administration of a
medication that could affect the

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 respiratory or cardiovascular systems;
for example, before giving a digitalis
preparation
 Before and after any nursing
intervention that could affect the vital
signs (e.g., ambulating a client who
has been on bed rest)

Body Temperature

 Body temperature reflects the balance between the heat produced and the heat lost from
the body, and is measured in heat units called degrees.
 There are two kinds of body temperature: core temperature and surface temperature.
 Core temperature is the temperature of the deep tissues of the body, such as the
abdominal cavity and pelvic cavity. It remains relatively constant. The normal core body
temperature is a range of temperatures (Figure 28.1 ■).When measured orally , the average
temperature of an adult is between 36.7 C (98F) and 37C ( 98.6F)
 The surface temperature is the temperature of the skin, the
Subcutaneous tissue, and fat. It, by contrast, rises and falls in response to the environment.

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 When the amount of heat produced by the body equals the amount of heat lost, the client is
in heat balance
Alterations in Body Temperature

 The normal range for adults is considered to be between 36°C and 37.5°C (96.8°F to
99.5°F).
 There are two primary alterations in body temperature: pyrexia and hypothermia.
Pyrexia
 A body temperature above the usual range is called pyrexia, hyperthermia, or (in lay
terms) fever.
 A very high fever, such as 41°C (105.8°F), is called hyperpyrexia (Figure 28.4 ■).

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 Variation in Normal Vital Signs by Age

Pulse Rate Respiration

Temperature in Blood pressure
Age ( Average and ( Average and
Degree ( Celsius) mmHg
Range) Range)
Newborns 36.8 (Axillary) 130 ( 80-180) 35(30-80) 73/55
1-3 Years 37.7 ( Rectally) 120(80-140) 30(20-40) 90/55
6-8 Years 37 (Orally) 100(75-120) 20(15-25) 95/57
10 Years 37 (Orally) 70( 50-90) 19(15-25) 102/62
Teen Years 37 (Orally) 70( 50-90) 18(15-20) 120/80
Adult 37 (Orally) 80(60-100) 16(12-20) 120/80
Older Adult 36 (Orally) 80(60-100) 16(15-20) Possible increased diastolic
> 70 Years
 The client who has a fever is referred to as febrile; the one who does not is afebrile.
 Four common types of fevers are intermittent, remittent, relapsing, and constant.
 During an intermittent fever, the body temperature alternates at regular intervals between
periods of fever and periods of normal or subnormal temperatures. An example is with the
disease malaria.

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 During a remittent fever, such as with a cold or influenza, a wide range of temperature
fluctuations (more than 2°C [3.6°F]) occurs over a 24-hour period, all of which are above
normal.
 In a relapsing fever, short febrile periods of a few days are interspersed with periods of 1
or 2 days of normal temperature.
 During a constant fever, the body temperature fluctuates minimally but always remains
above normal. This can occur with typhoid fever.
 A temperature that rises to fever level rapidly following a normal temperature and then
returns to normal within a few hours is called a fever spike. Bacterial blood infections
often cause fever spikes.
 In some conditions, an elevated temperature is not a true fever. Two examples are heat
exhaustion and heat stroke.
 Heat exhaustion is a result of excessive heat and dehydration. Signs of heat
exhaustion include paleness, dizziness, nausea, vomiting, fainting, and a
moderately increased temperature (38.3°C to 38.9°C [101°F to 102°F]).
 Individuals experiencing heat stroke generally have been exercising in hot
weather, have warm, flushed skin, and often do not sweat. They usually have a
temperature of 41.1°C (106°F) or higher, and may be delirious, unconscious, or
having seizures.
 The clinical signs of fever vary with the onset, course, and abatement stages of the fever

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 Nursing interventions for a client with fever are :

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 Hypothermia
 Hypothermia is a core body temperature below the lower limit of normal.
 The three physiologic mechanisms of hypothermia are
(a) Excessive heat loss
(b) Inadequate heat production to counteract heat loss, and
(c) Impaired hypothalamic thermoregulation.

The clinical signs of hypothermia are:

 Hypothermia may be induced or accidental.

 Induced hypothermia is the deliberate lowering of the body temperature to
decrease the need for oxygen by the body tissues such as during certain surgeries.
 Accidental hypothermia can occur as a result of
(a) Exposure to a cold environment,
(b) immersion in cold water, and
(c) Lack of adequate clothing, shelter, or heat.
 Managing hypothermia involves removing the client from the cold and rewarming the
client’s body.
 For the client with mild hypothermia, the body is rewarmed by applying blankets;
for the client with severe hypothermia, a hyperthermia blanket (an electronically
controlled blanket that provides a specified temperature) is applied, and warm IV
fluids are given. Wet clothing, which increases heat loss because of the high
conductivity of water, should be replaced with dry clothing.

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 Nursing interventions for clients who have hypothermia

Assessing Body Temperature

 The most common sites for measuring body temperature are oral, rectal, axillary,
tympanic membrane, and temporal artery.
 The body temperature may be measured orally.
If a client has been taking cold or hot food or fluids or smoking, the nurse
should wait 30 minutes before taking the temperature orally to ensure that
the temperature of the mouth is not affected by the temperature of the food,
fluid, or warm smoke.
 Rectal temperature readings are considered to be very accurate.
Rectal temperatures are contraindicated for clients who are undergoing
rectal surgery, have diarrhea or diseases of the rectum, are
immunosuppressed, have a clotting disorder, or have significant
hemorrhoids.
 The axilla is often the preferred site for measuring temperature in newborns
because it is accessible and safe.
Axillary temperatures are lower than rectal temperatures.
Some clinicians recommend rechecking an elevated axillary temperature
with one taken from another site to confirm the degree of elevation.
 The tympanic membrane, or nearby tissue in the ear canal, is a frequent site for
estimating core body temperature
 The temperature may also be measured on the forehead using a chemical
thermometer or a temporal artery thermometer.
 Forehead temperature measurements are useful for infants and children when a
more invasive measurement is not necessary.

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  Temporal artery thermometry is also beneficial for adults when any invasive or
uncomfortable measure should be avoided, such as with cancer patients (Mason et
al., 2017).
Temperature Scales

 Sometimes a nurse needs to convert a body temperature reading in Celsius (centigrade) to

Fahrenheit, or vice versa.
 To convert from Fahrenheit to Celsius, deduct 32 from the Fahrenheit reading
and then multiply by the fraction 5/9; that is:
C = (Fahrenheit temperature - 32) * 5/9
For example, when the Fahrenheit reading is 100:
C = (100 - 32) * 5/9 = (68) * 5/9 = 37.8
 To convert from Celsius to Fahrenheit, multiply the Celsius reading by the
fraction 9/5 and then add 32; that is:
F = (Celsius temperature * 9/5) + 32
For example, when the Celsius reading is 40:
F = (40 * 9/5) + 32 = (72 + 32) = 104

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Thermometer Placement

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 Advantages and Disadvantages of Sites Used for Body Temperature Measurements

Site Advantages Disadvantages

Oral Accessible  Thermometers can break if bitten.
and  Inaccurate if client has just ingested hot or cold
convenient food or fluid or smoked.
 Could injure the mouth following oral surgery
Rectal Reliable  Inconvenient and more unpleasant for clients;
measuremen difficult for client who cannot turn to the side.
t  Could injure the rectum.
 Presence of stool may interfere with
thermometer placement.
Axillary
Safe and  The thermometer may need to be left in place a
noninvasive long time to obtain an accurate measurement
Tympan Readily  Can be uncomfortable and involves risk of
ic accessible; injuring the membrane if the probe is inserted
membra reflects the too far.
ne core  Repeated measurements may vary. Right and
temperature; left measurements can differ if there are
very fast anatomic or pathologic differences (e.g.,
infection).
 Presence of cerumen can affect the reading.
Tempor Safe and  Requires electronic equipment that may be
al noninvasive; expensive or unavailable. Variation in technique
artery very fast needed if the client has perspiration on the
forehead

Pulse

 The pulse is a wave of blood created by contraction of the left ventricle of the heart.
Generally, the pulse wave represents the stroke volume output or the amount of blood
that enters the arteries with each ventricular contraction.
 Cardiac output is the volume of blood pumped into the arteries by the heart and equals
the result of the stroke volume (SV) times the heart rate (HR) per minute.
 Cardiac output = Stroke volume x heart rate /minute
 For example, 65 mL * 70 beats per minute = 4.55 L per minute.

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  When an adult is resting, the heart pumps about 5 liters of blood each minute
 In a healthy individual, the pulse reflects the heartbeat; that is, the pulse rate is the same
as the rate of the ventricular contractions of the heart. However, in some conditions, the
heartbeat and pulse rates can differ.
 For example, a client’s heart may produce very weak pulse waves that are not
detectable in a pulse far from the heart. In these instances, the nurse should assess
both the heartbeat (apical pulse) and the peripheral pulse.
 A peripheral pulse is a pulse located away from the heart, for example, in the foot or
wrist. The apical pulse, in contrast, is a central pulse; that is, it is located at the apex of the
heart. It is also referred to as the point of maximal impulse (PMI).
Factors Affecting the Pulse

The rate of the pulse is expressed in beats per minute (beats/min). Consider each of the
following factors when assessing a client’s pulse:
Age: As age increases, the average pulse rate gradually decreases.

Variations in pulse rates from birth to adulthood.

Sex: After puberty, the average male’s pulse rate is slightly lower than the female’s.
Exercise: The pulse rate normally increases with activity. The rate of increase in the
professional athlete is often less than in the average individual because of greater cardiac
size, strength, and efficiency.
Fever: The pulse rate increases (a) in response to the lowered blood pressure that results
from peripheral vasodilation associated with elevated body temperature and (b) because of
the increased metabolic rate.

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 Medications: Some medications decrease the pulse rate, and others increase it. For
example, cardiotonics (e.g., digitalis preparations) decrease the heart rate, whereas
epinephrine increases it.
Hypovolemia or dehydration: Loss of fluid from the vascular system increases the pulse
rate. The loss of circulating volume results in an adjustment of the heart rate to increase
blood pressure as the body compensates for the lost blood volume.
Stress: In response to stress, sympathetic nervous stimulation increases the overall
activity of the heart. Stress increases the rate as well as the force of the heartbeat. Fear
and anxiety as well as acute pain stimulate the sympathetic system.

Position: When a client is sitting or standing, blood usually pools in dependent vessels of
the venous system. Pooling results in a transient decrease in the venous blood return to the
heart and a subsequent reduction in blood pressure and increase in heart rate.
Pathology: Certain diseases such as some heart conditions or those that impair
oxygenation can alter the resting pulse rate.

Pulse Sites

A pulse is commonly measured in nine sites (Figure 28.13 ■):

1. Temporal, where the temporal

artery passes over the temporal bone of the head.

The site is superior (above) and lateral to

(Away from the midline of) the eye.

2. Carotid, at the side of the neck

where the carotid artery runs between the

trachea and the sternocleidomastoid muscle.

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 3. Apical, at the apex of the heart. In an adult
this is located on the left side of the chest,

about 8 cm (3 in.) to the left of the

sternum (breastbone) at the fifth intercostal space (area between the ribs). In older adults, the apex
may be further left if conditions are present that have led to an enlarged heart. Before 4 years of age,
the apex is left of the midclavicular line (MCL); between 4 and 6 years, it is at the MCL (Figure 28.14
■). For a child 7 to 9 years of age, the apical pulse is located at the fourth or fifth intercostal space.

4. Brachial, at the inner aspect of the biceps muscle of the arm or medially in the antecubital
space.
5. Radial, where the radial artery runs along the radial bone, on the thumb side of the inner aspect
of the wrist.
6. Femoral, where the femoral artery passes alongside the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee.
8. Posterior tibial, on the medial surface of the ankle where the posterior tibial artery passes
behind the medial malleolus.
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9. Dorsalis pedis, where the dorsalis pedis artery passes over the bones of the foot, on an
imaginary line drawn from the middle of the ankle to the space between the big and second toes.
The radial site is most commonly used in adults. It is easily found in most people and readily
accessible.

Assessing the Pulse

A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The middle three
fingertips are used for palpating all pulse sites except the apex of the heart. A stethoscope is used
for assessing apical pulses. A Doppler ultrasound stethoscope (DUS; Figure 28.15 ■) is used for
pulses that are difficult to assess.

 A pulse is normally palpated by applying moderate pressure with the three middle fingers
of the hand.
 The pads on the most distal aspects of the finger are the most sensitive areas for detecting a
pulse. With excessive pressure, one can obliterate a pulse, whereas with too little pressure
one may not be able to detect it. Before the nurse assesses the resting pulse, the client
should assume a comfortable position.
The nurse should also be aware of the following:
• Any medication that could affect the heart rate.
• Whether the client has been physically active. If so, wait 10 to 15 minutes until the client has
rested and the pulse has slowed to its usual rate.
• Any baseline data about the normal heart rate for the client. For example, a physically fit athlete
may have a resting heart rate below 60 beats/min.

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• Whether the client should assume a particular position (e.g., sitting). In some clients, the rate
changes with the position because of changes in blood flow volume and autonomic nervous
system activity.

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Characteristics of Pulse

When assessing the pulse, the nurse collects the following data: the rate, rhythm, volume,
arterial wall elasticity, and presence or absence of bilateral equality.

 Rate: the normal range of pulse is between 60 – 100 beat / minute.

 An excessively fast heart rate (e.g., over 100 beats/min in an adult) is referred to as
tachycardia. A heart rate in an adult of less than 60 beats/min is called
bradycardia. If a client has either tachycardia or bradycardia, the apical pulse
should be assessed.
 The pulse rhythm is the pattern of the beats and the intervals between the beats. Equal
time elapses between beats of a normal pulse.
 A pulse with an irregular rhythm is referred to as a dysrhythmia or arrhythmia. It
may consist of random, irregular beats or a predictable pattern of irregular beats
(documented as “regularly irregular”). When a dysrhythmia is detected, the apical

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 pulse should be assessed. An electrocardiogram (ECG or EKG) is necessary to
define the dysrhythmia further.
 Pulse volume, also called the pulse strength or amplitude, refers to the force of blood
with each beat.
 Usually, the pulse volume is the same with each beat. It can range from absent to
bounding.
 A normal pulse can be felt with moderate pressure of the fingers and can be
obliterated with greater pressure.
 A forceful or full blood volume that is obliterated only with difficulty is called a
full or bounding pulse.
 A pulse that is readily obliterated with pressure from the fingers is referred to as
weak, feeble, or thready.
 The elasticity of the arterial wall reflects its expansibility or its deformities.
 A healthy, normal artery feels straight, smooth, soft, and pliable.
 Older adults often have inelastic arteries that feel twisted (tortuous) and irregular
on palpation.
 When assessing a peripheral pulse to determine the adequacy of blood flow to a particular
area of the body (perfusion), the nurse should also assess the corresponding pulse on the
other side of the body. The second assessment gives the nurse data with which to
compare the pulses. For example, when assessing the blood flow to the right foot, the
nurse assesses the right dorsalis pedis pulse and then the left dorsalis pedis pulse. If the
client’s right and left pulses are the same volume and elasticity, the client’s dorsalis pedis
pulses are bilaterally equal.
 The pulse rate does not need to be counted when assessing for perfusion and equality.
When a peripheral pulse is located, it indicates that pulses more proximal to that location
will also be present. For example, if the dorsalis pedis, the most distal pulse of the lower
extremity, cannot be felt, the nurse next palpates for the posterior tibial pulse. If it is not
felt, the popliteal pulse must be assessed. If the popliteal pulse is found, it is not
necessary to assess the femoral pulse since it must also be present in order for the more
distal pulse to exist

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 Respirations

 Respiration is the act of breathing.

 Inhalation or inspiration refers to the intake of air into the lungs.
 Exhalation or expiration refers to breathing out or the movement of gases from the lungs
to the atmosphere.
 Ventilation is also used to refer to the movement of air into and out of the lungs.
 There are basically two types of breathing: Costal (thoracic) breathing and
diaphragmatic (abdominal) breathing.
 Costal breathing involves the external intercostal muscles and other accessory
muscles, such as the sternocleidomastoid muscles. It can be observed by the
movement of the chest upward and outward.
 By contrast, diaphragmatic breathing involves the contraction and relaxation of the
diaphragm, and it is observed by the movement of the abdomen, which occurs as a result
of the diaphragm’s contraction and downward movement.
Mechanics and Regulation of Breathing

 During inhalation, the following processes normally occur (Figure 28.16 ■): The
diaphragm contracts (flattens), the ribs move upward and outward, and the sternum moves
outward, thus enlarging the thorax and permitting the lungs to expand.

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  During exhalation (Figure 28.17 ■), the diaphragm relaxes, the ribs move downward and
inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs
are compressed.
 A normal adult inspiration lasts 1 to 1.5 seconds, and an expiration lasts 2 to 3 seconds.
 Respiration is controlled by (a) respiratory centers in the medulla oblongata and the pons
of the brain and (b) chemoreceptors located centrally in the medulla and peripherally in
the carotid and aortic bodies. These centers and receptors respond to changes in the
concentrations of oxygen (O2), carbon dioxide (CO2), and hydrogen (H+) in the arterial
blood
Assessing Respirations

 Resting respirations should be assessed when the client is relaxed because exercise
affects respirations, increasing their rate and depth. Anxiety is likely to affect
respiratory rate and depth as well.
 Respirations may also need to be assessed after exercise to identify the client’s
tolerance to activity.
 Before assessing a client’s respirations, a nurse should be aware of the following:
• The client’s normal breathing pattern
• The influence of the client’s health problems on respirations
• Any medications or therapies that might affect respirations
• The relationship of the client’s respirations to cardiovascular function. The rate,
depth, rhythm, quality, and effectiveness of respirations should be assessed.
Rate:

 The respiratory rate is normally described in breaths per minute.

 Breathing that is normal in rate and depth is called Eupnea.
 Abnormally slow respirations are referred to as bradypnea,
 And abnormally fast respirations are called tachypnea or polypnea.
 Apnea is the absence of breathing.
Depth:

 The depth of an individual’s respirations can be established by watching the movement of

the chest.
 Respiratory depth is generally described as normal, deep, or shallow.

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  Deep respirations are those in which a large volume of air is inhaled and exhaled,
inflating most of the lungs.
 Shallow respirations involve the exchange of a small volume of air and often the
minimal use of lung tissue.
 During a normal inspiration and expiration, an adult takes in about 500 mL of
air. This volume is called the tidal volume.
Volume:

 Hyperventilation refers to an increase in the amount of air in the lungs , characterized by

very deep, rapid respirations;
 Hypoventilation refers to a reduction in the amount of air in the lungs, characterized by
very shallow respirations.
Rhythm or Pattern:

 Respiratory rhythm refers to the regularity of the expirations and the inspirations. Also to
the time between one breath to the next one, Normally, respirations are evenly spaced.
 Respiratory rhythm can be described as
 Regular or irregular. An infant’s respiratory rhythm may be less regular than an
adult’s.
Respiratory quality or character :( Ease or effort)

 Refers to those aspects of breathing that are different from normal, effortless breathing.
 Usually, breathing does not require noticeable effort.
 Sometimes, however, clients can breathe only with substantial effort—this is
referred to as labored breathing.
 Dyspnea: refers to difficult and labored breathing, during which the individual has
persistent, unsatisfied need for air and feel distressed.
 Orthopnea: refers to a ability to breath only in upright sitting or standing
Breath Sounds:

 The sound of breathing is also significant. Normal breathing is silent, but a number of
abnormal sounds such as a wheeze are obvious to the nurse’s ear.
 Many sounds occur as a result of the presence of fluid in the lungs and are most clearly
heard with a stethoscope.

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  Abnormal breath sounds that are audible without amplification are:

 Stridor: is a shrill, harsh sound heard during inspiration with laryngeal

obstruction
 Stertor: is snoring respiration , usually due to partial obstruction of the upper
air way
 Wheeze: is continuous, high pitched musical squeak or whistling sound
occurring on expiration and sometimes on inspiration when air moves through
a narrowed or partially obstructed airway
 Bubbling: is gurgling sound heard as air passes through moist secretions in the
respiratory tract
 Abnormal breath sound that are audible by stethoscope are:
Crackles: are dry or wet crackling sounds stimulated by rolling a lock of hair near the ear.
Generally hard on inspiration as air moves through accumulated moist secretions.

Gurgles (rhonchi): is coarse, dry, wheezy, or whistling sound more audible during expiration as
the air moves through tenacious mucus or narrowed bronchi

Pleural friction rub: is coarse, leathery, or grating sound produced by the rubbing together of
inflamed pleura

Secretions and Coughing:

 Hemoptysis: is the presence of blood in sputum

 Reproductive cough: is cough accompanied by expectorated secretions.
 Non – productive cough: is a dry, harsh cough with secretions.
Factors Affecting Respirations

 Factors influence respiratory rate. Those that increase the rate include
 Exercise (increases metabolism),
 stress (readies the body for “fight or flight”),
 increased environmental temperature, and
 Lowered oxygen concentration at increased altitudes.
 Factors that may decrease the respiratory rate include
 Decreased environmental temperature,
 Increased intracranial pressure.

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  Body position also affects the amount of air that can be inhaled.
 People in a supine position experience two physiologic processes that suppress
respiration: An increase in the volume of blood inside the thoracic cavity and
compression of the chest. Consequently, clients lying on their back have poorer
lung aeration, which predisposes them to the stasis of fluids and subsequent
infection.
 Certain medications also affect the respiratory depth. For example,
narcotics such as morphine and large doses of barbiturates such as pentobarbital
depress the respiratory centers in the brain, thereby depressing the respiratory
rate and depth.
Blood Pressure

 Arterial blood pressure is a measure of the pressure exerted by the blood as it flows
through the arteries. Because the blood moves in waves, there are two blood pressure
measurements.
 The systolic pressure is the pressure of the blood as a result of contraction of the
ventricles, that is, the pressure of the height of the blood wave.
 The diastolic pressure is the pressure when the ventricles are at rest. Diastolic pressure,
then, is the lower pressure, present at all times within the arteries.
 The difference between the diastolic and the systolic pressures is called the pulse
pressure.
 A normal pulse pressure is about 40 mmHg but can be as high as 100 mmHg during
exercise.
 Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a fraction:
systolic pressure over the diastolic pressure.
 A typical blood pressure for a healthy adult is 120/80 mmHg (pulse pressure of 40).
 A consistently elevated pulse pressure occurs in arteriosclerosis. A low pulse pressure
(e.g., less than 25 mmHg) occurs in conditions such as severe heart failure.
 Sometimes, it is useful to also determine the mean arterial pressure (MAP) because this
represents the pressure actually delivered to the body’s organs.
 The MAP can be calculated in several different ways, one of which is to add two-thirds of
the diastolic pressure to one-third of the systolic pressure. A normal MAP is 70 to 110
mmHg.

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Determinants of Blood Pressure

Arterial blood pressure is the result of several factors: the pumping action of the heart, the
peripheral vascular resistance (the resistance supplied by the blood vessels through which
the blood flows), and the blood volume and viscosity
Pumping Action of the Heart

When the pumping action of the heart is weak, less blood is pumped into arteries (lower
cardiac output), and the blood pressure decreases. When the heart’s pumping action is
strong and the volume of blood pumped into the circulation increases (higher cardiac
output), the blood pressure increases.
Peripheral Vascular Resistance

 Peripheral resistance can increase blood pressure. The diastolic pressure especially is
affected.
 Normally, the arterioles are in a state of partial constriction.
Increased vasoconstriction, such as occurs with smoking, raises the blood pressure, whereas
decreased vasoconstriction lowers the blood pressure.

 If the elastic and muscular tissues of the arteries are replaced with fibrous tissue, the
arteries lose much of their ability to constrict and dilate. This condition, most common in
middle-aged and older adults, is known as arteriosclerosis.
Blood Volume

When the blood volume decreases (for example, as a result of a hemorrhage or dehydration), the blood
pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increases
(for example, as a result of a rapid IV infusion), the blood pressure increases because
of the greater fluid volume within the circulatory system.

Blood Viscosity

Blood pressure is higher when the blood is highly viscous (thick), that is, when the proportion of red blood
cells to the blood plasma is high. This proportion is referred to as the hematocrit. The viscosity increases
markedly when the hematocrit is more than 60% to 65%

Factors Affecting Blood Pressure

Among the factors influencing blood pressure are age, exercise, stress, race, sex, medications,
obesity, diurnal variations, medical conditions, and temperature.

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Age: The pressure rises with age, reaching a peak at the onset of puberty, and then tends to decline
somewhat. Newborns have a systolic pressure of about 75 mmHg, in older adults, elasticity of
the arteries is decreased (the arteries are more rigid and less yielding to the pressure of the blood).
This produces an elevated systolic pressure. Because the walls no longer retract as flexibly with
decreased pressure, the diastolic pressure may also be high.

Exercise: Physical activity increases the cardiac output and hence the blood pressure. For reliable
assessment of resting blood pressure, wait 20 to 30 minutes following exercise.

Stress: Stimulation of the sympathetic nervous system increases cardiac output and
vasoconstriction of the arterioles, thus increasing the blood pressure reading; however, severe
pain can decrease blood pressure greatly by inhibiting the vasomotor center and producing
vasodilation.
Race: African American individuals older than 35 years tend to have higher blood pressures than
other races of the same age, and African American women have higher rates of high blood
pressure than African American men.

Sex: After puberty, females usually have lower blood pressures than males of the same age; this
difference is thought to be due to hormonal variations. After menopause, women generally
have higher blood pressures than before. After age 65, the rate of high blood pressure is higher in
women than it is in men of the same age

Medications: Many medications, including caffeine, may increase or decrease the blood pressure.
Obesity: Both childhood and adult obesity predispose to hypertension.

Diurnal variations: Pressure is usually lowest early in the morning, when the metabolic rate is
lowest, then rises throughout the day and peaks in the late afternoon or early evening.
Medical conditions: Any condition affecting the cardiac output, blood volume, blood viscosity, or
compliance of the arteries has a direct effect on the blood pressure.

Temperature: Because of increased metabolic rate, fever can increase blood pressure. However,
external heat causes vasodilation and decreased blood pressure. Cold causes vasoconstriction
and elevates blood pressure.

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The Conditions are reflected by changes in blood pressure are:

Hypertension

 A blood pressure that is persistently above normal is called hypertension.

 A single elevated blood pressure reading indicates the need for reassessment.
 Hypertension cannot be diagnosed unless an elevated blood pressure is found
when measured twice at different times. It is usually asymptomatic and is often a
contributing factor to myocardial infarctions (heart attacks).
 An elevated blood pressure of unknown cause is called primary hypertension.
 An elevated blood pressure of known cause is called secondary hypertension.
 Factors associated with hypertension include:
 Thickening of the arterial walls, which reduces the size of the arterial lumen, and
inelasticity of the arteries, as well as such lifestyle factors as cigarette smoking,
obesity, heavy alcohol consumption, lack of physical exercise, high blood
cholesterol levels, and continued exposure to stress.
Classification of Blood Pressure

Hypotension
Hypotension: is a blood pressure that is below normal, that is, a systolic reading consistently
between 85 and 110 mmHg in an adult whose normal pressure is higher than this.

 Orthostatic hypotension (or postural hypotension) is a blood pressure that

decreases when the client changes from a supine to a sitting or standing
position. It is usually the result of peripheral vasodilation in which blood
leaves the central body organs, especially the brain, and moves to the periphery,
often causing the client to feel faint.
 Hypotension can also be caused by analgesics such as meperidine hydrochloride
(Demerol), bleeding, severe burns, and dehydration.

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Assessing Blood Pressure

 Manual blood pressure measurement is performed with a blood pressure cuff, a

sphygmomanometer, and a stethoscope.
 The blood pressure cuff consists of a bag, called a bladder that can be inflated with air
(Figure 28.18 ■).
 It has two tubes attached to it. One tube connects to a bulb that inflates the bladder. A
small valve on the side of this bulb traps and releases the air in the bladder. The other tube
is attached to a sphygmomanometer.

 The sphygmomanometer indicates the pressure of the air within the bladder.
 There are two types of sphygmomanometers: aneroid and digital.
 The aneroid sphygmomanometer has a calibrated dial with a needle that points to the
calibrations (Figure 28.19 ■).

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 Many agencies use digital (electronic) sphygmomanometers (Figure 28.20 ■), which
eliminate the need to listen for the sounds of the client’s systolic and diastolic blood
pressures through a stethoscope.
 The systolic pressure is the point where the first tapping sound is heard
 The diastolic pressure is the point where the sounds become inaudible

 Blood pressure cuffs come in various sizes because the bladder must be the correct width
and length for the client’s arm (Figure 28.21 ■). If the bladder is too narrow, the blood
pressure reading will be erroneously elevated; if it is too wide, the reading will be
erroneously low.

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Medication:

 Medication: is a substance administered for the diagnosis, cure, treatment, or relief of a

symptom or for prevention of disease.
 In the healthcare context, the words medication and drug are generally used
interchangeably.
 The term drug also has the connotation of an illicitly obtained substance such as
heroin, cocaine, or amphetamines.
 The written direction for the preparation and administration of a drug is called a
prescription.
 One drug can have as many as four kinds of names: its generic name, trade
name (or brand name), official name, and chemical name.
The generic name is assigned by the United States Adopted Names (USAN)
Council and is used throughout the drug’s lifetime.
A drug’s trade name (sometimes called the brand name) is the name given by
the drug manufacturer and identifies it as property of that company.
For example, the drug hydrochlorothiazide (generic name) is known by the trade
names Esidrix and HydroDIURIL.
The official name is the name under which a drug is listed in one of the official
publications (e.g., the United States Pharmacopeia).
The chemical name is the name by which a chemist knows it; this name describes
the constituents of the drug precisely.

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Common Abbreviation Used in Medication Orders

Abbreviation Explanation
Ac Before meals
Pc After meals
Po By mouth
Q Every
qAM Every morning
Qh Every hour
Qid Four times a day
Qod Every other day
Bid Twice a day
Tid Three times a day
- With
C
- Without
S
PRN When needed ( per required need)
SOS If it is needed‫عند الحاجة أو عند اللزوم‬
stat At once
tab Tablet
sus Suspension
Sup or supp Suppository
cap Capsule
hs At bed time ( hour of sleep)
OD Right eye
OS Left eye
OU Both eye

Routes of Administration

 The route of administration should be indicated when the drug is ordered.

 When administering a drug, the nurse should ensure that the pharmaceutical
preparation is appropriate for the route specified.

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Routes of Administration

Oral
Oral administration is the most common, least expensive, and most convenient route for most
clients.

In oral administration, the drug is swallowed. Because the skin is not broken as it is for an
injection, oral administration is also a safe method. The major disadvantages can include an
unpleasant taste of the drugs, irritation of the gastric mucosa, irregular absorption from the GI
tract, slow absorption, and, in some cases, harm to the client’s teeth. For example, the liquid
preparation of ferrous sulfate (iron) can stain the teeth.

Sublingual
In sublingual administration a drug is placed under the tongue, where it dissolves (Figure 35.7 ■).
In a relatively short time, the drug is largely absorbed into the blood vessels on the underside of
the tongue. The medication should not be swallowed. Nitroglycerin is one example of a drug
commonly given in this manner.

Buccal
Buccal means “pertaining to the cheek.” In buccal administration, a medication (e.g., a tablet) is
held in the mouth against the mucous membranes of the cheek until the drug dissolves (Figure
35.8 ■). The drug may act locally on the mucous membranes of the mouth or systemically when it
is swallowed in the saliva.

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Parenteral

 The parenteral route is defined as other than through the alimentary or respiratory tract;
that is, by needle. The following are some of the more common routes for parenteral
administration:
• Subcutaneous (hypodermic)—into the subcutaneous tissue, just below the skin
• Intramuscular (IM)—into a muscle
• Intradermal (ID)—under the epidermis (into the dermis)
• Intravenous (IV)—into a vein.

 Some of the less commonly used routes for parenteral administration are intra-
arterial (into an artery), intracardiac (into the heart muscle), intraosseous (into a
bone), intrathecal or intraspinal (into the spinal canal), intrapleural (into the
pleural space), epidural (into the epidural space), and intra-articular (into a joint).
 Sterile equipment and sterile drug solution are essential for all parenteral therapy.
The main advantage is fast absorption.
Topical
Topical applications are those applied locally to the skin or to the mucous membranes. They
affect only the area to which they are applied. Topical applications include the following:
• Dermatologic preparations—applied to the skin

• Instillations and irrigations—applied into body cavities or orifices, such as the urinary bladder,
eyes, ears, nose, rectum, or vagina

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• Inhalations—administered into the respiratory tract by a nebulizer or positive pressure breathing
apparatus. Air, oxygen, and vapor are generally used to carry the drug into the lungs.

Parenteral Medications

 Parenteral administration of medications is a common nursing procedure. Nurses give

parenteral medications intradermally (ID), subcutaneously, intramuscularly (IM), or
intravenously (IV).
 Because these medications are absorbed more quickly than oral medications and are not
retrievable once injected, the nurse must prepare and administer them carefully and
accurately.
 Administering parenteral drugs requires the same nursing knowledge as for oral and
topical drugs; however, because injections are invasive procedures, aseptic technique must
be used to minimize the risk of infection.
Equipment

To administer parenteral medications, nurses use syringes and needles to withdraw medication from
ampules and vials.

Syringes
Syringes have three parts: the tip, which connects with the needle; the barrel, or outside part, on which the
scales are printed; and the plunger, which fits inside the barrel (Figure 35.14 ■).

 When handling a syringe, the nurse may touch the outside of the barrel and the handle of
the plunger; however, the nurse must avoid letting any unsterile object touch the tip or
inside of the barrel, the shaft of the plunger, or the shaft or tip of the syringe.

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 Several kinds of syringes are available in differing sizes, shapes, and materials. Syringes
range in sizes from 1 to 60 mL. A nurse typically uses a syringe ranging from 1 to 3 mL in
size for injections (e.g., subcutaneous or intramuscular).
 A hypodermic syringe comes in 3- and 5-mL sizes. The choice of syringe depends on
many factors, such as medication, location of injection, and type of tissue.
 Syringes ranging from 1 to 3 mL may have two scales marked on them: the minim and
the milliliter. The milliliter scale is the one normally used; the minim scale is used for
very small dosages (Figure 35.15 ■).

 The larger sized syringes (e.g., 10, 20, and 60 mL) are not used to administer drugs
directly but can be useful for adding medications to IV solutions, pushing medication
through an IV line, or irrigating wounds.
 The tip of a syringe varies and is classified as either a Luer-Lok (sometimes spelled Luer-
Lock) or non–LuerLok, also known as a Slip Tip syringe.
 A Luer-Lok syringe has a tip that requires the needle to be twisted onto it to avoid
accidental removal of the needle (Figure 35.16 ■).

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 A non–Luer-Lok or Slip Tip syringe: has a smooth graduated tip, and needles are slipped
onto it. The larger 60-mL non– Luer-Lok syringe is often used for irrigation purposes (e.g.,
wounds, tubes). See Figure 35.17.

 Most syringes used today are made of plastic, are individually packaged for sterility in a
paper wrapper or a rigid plastic container (Figure 35.18 ■), and are disposable.
 The syringe and needle may be packaged together or separately. Needleless systems are
also available in which the needle is replaced by a plastic cannula or a more rigid blunt tip
instead of a sharp tip.

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 Injectable medications are frequently supplied in disposable prefilled unit-dose
systems. These are available as (a) prefilled syringes ready for use or (b) prefilled
sterile
cartridges and needles that require the attachment of a reusable holder (injection
system) before use (Figure 35.19 ■).

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 An insulin syringe is similar to a hypodermic syringe, but the scale is specially
designed for insulin: a 100-unit calibrated scale intended for use with U-100
insulin. This is the only syringe that should be used to administer insulin. Several
low-dose insulin syringes are also available (e.g., 30-unit and 50-unit). These
syringes frequently have a non removable needle.

 An insulin pen: is an insulin injector device that looks like a pen and contains an
insulin cartridge. The pen is easy to use: The client attaches a new needle for each
injection, primes the pen per the manufacturer’s directions, dials in a dose, inserts
the needle into the injection site, presses the injection button, and holds the
injection button and pen against the skin for at least 5 seconds after the injection to
deliver the insulin. The parts of an insulin pen are shown in Figure 35.21 ■.

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  The tuberculin syringe was originally designed to administer tuberculin solution.
It is a narrow syringe, calibrated in tenths and hundredths of a milliliter (up to 1
mL) on one scale and in sixteenths of a minim (up to 1 minim) on the other scale.
This type of syringe can also be useful in administering other drugs, particularly
when small or precise measurement is indicated (e.g., pediatric dosages).

Needles
Needles are made of stainless steel, and most are disposable. A needle has three parts: the hub,
which fits onto the syringe; the cannula, or shaft, which is attached to the hub; and the bevel,
which is the slanted part at the tip of the needle that helps the needle cut through the skin with
minimal trauma (Figure 35.23 ■).

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A disposable needle has a plastic hub, which is color coded (Figure 35.24 ■).

 Needles used for injections have three variable characteristics:

1. Slant or length of the bevel. The bevel of the needle may be short or long. Longer
bevels provide the sharpest needles and cause less discomfort. They are commonly used
for subcutaneous and intramuscular injections. Short bevels are used for intradermal and
IV injections because a long bevel can become occluded if it rests against the side of a
blood vessel.
3. Length of the shaft. The shaft length of commonly used needles varies from 1/2 to 2
inches. The appropriate needle length is chosen according to the client’s muscle
development, the client’s weight, and the type of injection.
3. Gauge (or diameter) of the shaft. The gauge varies
from #18 to #30. The larger the gauge number, the smaller the diameter of the shaft.
Smaller gauges produce less tissue trauma, but larger gauges are necessary for viscous
medications, such as penicillin. For an adult requiring a subcutaneous injection, it is
appropriate to use a needle of #24 to #26 gauge and 3/8 to 5/8 inch long. Obese clients may
require a 1-inch needle. For intramuscular injections, a longer needle (e.g., 1 to 1 1/2 in.)
with a larger gauge (e.g., #20 to #22 gauge) is used. Slender adults and children usually
require a shorter needle.
 The nurse must assess the client to determine the appropriate needle length.
Preparing Injectable Medications

Injectable medications can be prepared by withdrawing the medication from an ampule or vial into
a sterile syringe, using prefilled syringes, or using needleless injection systems. Figure 35.29 ■

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 shows an example of a needleless system used to access medication from a vial.

Ampules and Vials

Ampules and vials (Figure 35.30 ■) are frequently used to package sterile parenteral medications.

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 An ampule is a glass container usually designed to hold a single dose of a drug. It is made
of clear glass and has a distinctive shape with a constricted neck. Ampules vary in size
from 1 to 10 mL or more.
 Most ampule necks have colored marks around them, indicating where they are prescored
for easy opening.
 To access the medication in an ampule, the ampule must be broken at its constricted neck.
 Today plastic ampule openers are available that prevent injury from broken glass. The
device consists of a plastic cap that fits over the top of an ampule. The head of the ampule,
when broken, remains inside the cap and is placed into a sharps container
(Figure 35.31 ■).

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  If an ampule opener is not available, the nurse can clean the ampule neck with an alcohol
swab and, using dry sterile gauze, snap off the top of the ampule.

 A vial is a small glass bottle with a sealed rubber cap.

Vials come in different sizes, from single-use vials to
Multi-dose vials. They usually have a metal or plastic cap that protects the rubber seal and must
be removed to access the medication.

 To access the medication in a vial, the vial must be pierced with a needle. In addition, air
must be injected into a vial before the medication can be withdrawn.

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 Failure to inject air before withdrawing the medication leaves a vacuum within the vial that
makes withdrawal difficult.
 A single-dose vial (SDV): contains only one dose of medication and should only be used
once.
 Usually an SVD contains more than the single dose. Never save this leftover medication
because SVDs lack an antimicrobial preservative. Discard the vial after every use.
 In contrast, a multi dose vial (MDV) is a bottle of liquid medication that contains more
than one dose, such as insulin or vaccination vials.
 If an MDV vial must be used, both the needle or cannula and syringe used to access the
vial must be sterile.

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 Some drugs (e.g., penicillin) may be dispensed as powders in vials. A liquid (diluent)
must be added to a powdered medication before it can be injected.
 The technique of adding a diluent to a powdered drug to prepare it for administration is
called reconstitution.
 Powdered drugs usually have printed instructions (enclosed with each packaged vial) that
describe the amount and kind of solvent to be added.
 Commonly used diluents are sterile water or sterile normal saline. Some
preparations are supplied in SDVs; others come in MDVs.
 The following are two examples of the preparation of powdered drugs:
1. Single-dose vial: Instructions for preparing an SVD state that 1.5 mL of sterile water is
to be added to the sterile dry powder, thus providing a single dose of 2 mL. The volume of
the drug powder was 0.5 mL.
Therefore, the 1.5 mL of water plus the 0.5 mL of powder results in 2 mL of solution. In
other instances, the addition of a solution does not increase the volume. Therefore, it is
important to follow the manufacturer’s directions.
2. Multidose vial: A dose of 750 mg of a certain drug is ordered for a client. On hand is a
10-g multidose vial.
The directions for preparation read: “Add 8.5 mL of sterile water, and each milliliter will
contain 1.0 g or 1000 mg.”
To determine the amount to inject, the nurse does these calculations:

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The nurse will give 0.75 mL of the medication.

Mixing Medications in One Syringe

Frequently, clients need more than one drug injected at the same time. To spare the client the
experience of being injected twice, two drugs (if compatible) are often mixed in one syringe and
given as one injection.

 It is common, for instance, to combine two types of insulin in this manner or to combine
injectable preoperative medications such as morphine with atropine or scopolamine. Drugs
can also be mixed in IV solutions.
Mixing Medications from Two Vials

 Take the syringe and draw up a volume of air equal to the volume of medications to be
withdrawn from both vials A and B.
 Inject a volume of air equal to the volume of medication to be withdrawn into vial A.
Make sure the needle does not touch the solution. Rationale: This prevents cross-
contamination of the medications.
 Withdraw the needle from vial A and inject the remaining air into vial B.
 Withdraw the required amount of medication from vial B.
 Rationale: The same needle is used to inject air into and withdraw medication from the
second vial. It must not be contaminated with the medication in vial A.
 Using a newly attached sterile needle, withdraw the required
amount of medication from vial A. Avoid pushing the plunger
because that will introduce medication B into vial A. If using a syringe with a fused
needle, withdraw the medication from vial A. The syringe now contains a mixture of
medications from vials A and B.

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Mixing Medications from One Vial and One Ampule

 First prepare and withdraw the medication from the vial. Rationale: Ampules do not
require the addition of air prior to withdrawal of the drug
 Then withdraw the required amount of medication from the ampule.
Ten “Rights” of Medication Administration

Intradermal Injections

 An intradermal (ID) injection is the administration of a drug into the dermal layer of the
skin just beneath the epidermis.
 Usually only a small amount of liquid is used, for example, 0.1 mL.
 This method of administration is frequently used for allergy testing and tuberculosis (TB)
screening.
 Common sites for ID injections are the inner lower arm, the upper chest, and the back
beneath the scapulae (Figure 35.33 ■). The left arm is commonly used for TB screening and
the right arm is used for all other tests.

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Administering an Intradermal Injection

For an intradermal injection, the

needle enters the skin at a 5 to 15
degree

 Equipment used in Intradermal injection is Sterile 1-mL syringe calibrated into hundredths
of a milliliter (i.e., tuberculin syringe)
 Needle is short and fine, a #25- to #27-gauge safety needle that is 1/4 to 5/8 inch long
 With the non-dominant hand, pull the skin at the site until it is taut. For example, if using
the ventral forearm, grasp the client’s dorsal forearm and gently pull it to tighten the

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 ventral skin. Rationale: Taut skin allows for easier entry of the needle and less
discomfort for the client.
 Insert the tip of the needle far enough to place the bevel through the epidermis into the
dermis. The outline of the bevel should be visible under the skin surface.
 Stabilize the syringe and needle. Inject the medication carefully and slowly so that it
produces a small wheal on the skin. Rationale: This verifies that the medication entered
the dermis.
 Withdraw the needle quickly at the same angle at which it was inserted.
 Do not massage the area. Rationale: Massage can disperse the medication into the tissue
or out through the needle insertion site.
 Dispose of the syringe and needle into the sharps container. Rationale: Do not recap the
needle in order to prevent needlestick injuries.
 Remove and discard gloves.
 Perform hand hygiene.
 Circle the injection site with ink to observe for redness or induration (hardening)

Subcutaneous Injections

 Among the many kinds of drugs administered subcutaneously are vaccines, insulin, and
heparin.
 Common sites for subcutaneous injections are the outer aspect of the upper arms and
the anterior aspect of the thighs. These areas are convenient and normally have good
blood circulation. Other areas that can be used are the abdomen, the scapular areas of the
upper back, and the upper ventrogluteal and dorsogluteal areas (Figure 35.34 ■).

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 Only small doses (0.5 to 1 mL) of medication are usually injected via the subcutaneous
route.
 The type of syringe used for subcutaneous injections depends on the medication being
given. Generally a 1- or 2-mL syringe is used for most subcutaneous injections.
 However, if insulin is being administered, an insulin syringe is used; if heparin is being
administered, a prefilled cartridge may be used.
 Needle sizes and lengths are selected based on the client’s body mass, the intended angle
of insertion, and the planned site. Generally a #25-gauge, 5/8-inch needle is used for adults
of normal weight and the needle is inserted at a 45° angle; a 3/8-inch needle is used at a
90° angle. A child may need a 1/2-inch needle inserted at a 45° angle.
 One method nurses use to determine length of needle is to pinch the tissue at the site and
select a needle length that is half the width of the skinfold.
 To determine the angle of insertion, a general rule to follow relates to the amount of tissue
that can be pinched or grasped at the site. A 45° angle is used when 1 inch of tissue can be
grasped at the site; a 90° angle is used when 2 inches of tissue can be grasped.
 When administering insulin to adults, the current standard needle gauge is #30 gauge with
a short needle (4 to 6 mm). Most clients prefer the shorter and thinner needles because they
are less painful. The risk of injecting into the muscle is lessened with the shorter needle.

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Administering a Subcutaneous Injection

 Grasp the syringe in your dominant hand by holding it between your thumb and fingers.
With palm facing to the side or upward for a 45° angle insertion, or with the palm
downward for a 90° angle insertion, prepare to inject. ❶

 Using the nondominant hand, pinch or spread the skin at the site, and insert the needle
using the dominant hand and a firm, steady push. The most important consideration is the
depth of the subcutaneous tissue in the area to be injected.

 If the client has more than 1/2 inch of adipose tissue in the injection site, it would
be safe to administer the injection at a 90° angle with the skin spread.
 If the client is thin or lean and lacks adipose tissue, the subcutaneous injection
should be given with the skin pinched and at a 45° to 60° angle. One way to check
that the pinch of skin is subcutaneous tissue is to ask the client to flex and extend
the elbow. If any muscle is being held in the pinch, you will feel it contract and
relax. If so, release the pinch and try again. ❷

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  When the needle is inserted, move your nondominant hand to the end of the plunger. Some
nurses find it easier to move the nondominant hand to the barrel of the syringe and the
dominant hand to the end of the plunger.
 Inject the medication by holding the syringe steady and depressing the plunger with a slow,
even pressure. Rationale: Holding the syringe steady and injecting the medication at an
even pressure minimizes discomfort for the client.
 It is recommended that with many subcutaneous injections, especially insulin, the needle
should be embedded within the skin for 5 seconds after complete depression of the
plunger. Rationale: This ensures complete delivery of the dose.
Intramuscular Injections

 Injections into muscle tissue, or intramuscular (IM) injections, are absorbed more
quickly than subcutaneous injections because of the greater blood supply to the body
muscles.
 Muscles can also take a larger volume of fluid without discomfort than subcutaneous
tissues can,
 An adult with well-developed muscles can usually safely tolerate up to 3 mL of medication
in the gluteus medius and gluteus maximus muscles (Figure 35.35 ■).

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  A volume of 1 to 2 mL is usually recommended for adults with less developed muscles.
 In the deltoid muscle, volumes of 0.5 to 1 mL are recommended. Usually a 3- to 5-mL
syringe is needed.
 The size of syringe used depends on the amount of medication being administered.
 The standard prepackaged intramuscular needle is 1 1/2 inches and #21 or #22 gauge.
 A major consideration in the administration of IM injections is the selection of a safe site
located away from large blood vessels, nerves, and bone.
 Several body sites can be used for IM injections. These sites are discussed in detail next.
Contraindications for using a specific site include tissue injury and the presence of
nodules, lumps, abscesses, tenderness, or other pathology
Ventrogluteal Site

 The ventrogluteal site is in the gluteus medius muscle, which lies over the gluteus
minimus (see Figure 35.35). The ventrogluteal site is the preferred site for IM injections
because the area:
• Contains no large nerves or blood vessels.
• Provides the greatest thickness of gluteal muscle consisting of both the gluteus medius
and gluteus minimus.
• Is sealed off by bone.
• Contains consistently less fat than the buttock area, thus eliminating the need to
determine the depth of subcutaneous fat.
 The client position for the injection can be a back, prone, or side-lying position. The side-
lying position, however, helps locate the ventrogluteal site more easily
 Position the client on his or her side with the knee bent and raised slightly toward
the chest.
 The trochanter will protrude, which facilitates locating the ventrogluteal site.
 To establish the exact site, the nurse places the heel of the hand on the client’s
greater trochanter, with the fingers pointing toward the client’s head. The right
hand is used for the left hip, and the left hand for the right hip. With the index
finger on the client’s anterior superior iliac spine, the nurse stretches the middle
finger dorsally (toward the buttocks), palpating the crest of the ilium and then
pressing below it.
 The triangle formed by the index finger, the third finger, and the crest of the ilium
is the injection site

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Vastus Lateralis Site

 The vastus lateralis muscle is usually thick and well developed in both adults and
children.
 It is recommended as the site of choice for IM injections for infants and young
children because it is the largest muscle mass. Because there are no major blood vessels or
nerves in the area, it is desirable for infants whose gluteal muscles are poorly developed.
 It is situated on the anterior lateral aspect of the infant’s thigh (Figure 35.38 ■).

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 The middle third of the muscle is suggested as the site.
 In the adult, the landmark is established by dividing the area between the greater
trochanter of the femur and the lateral femoral condyle into thirds and selecting the middle
third (Figures 35.39 ■ and 35.40 ■).
 The client can assume a back-lying or a sitting position for an injection into this site.

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Rectus Femoris Site

 The rectus femoris muscle, which belongs to the quadriceps muscle group, is used only
occasionally for IM injections. It is situated on the anterior aspect of the thigh (Figure
35.41 ■).
 Its chief advantage is that clients who administer their own injections can reach this site
easily.
 Its main disadvantage is that an injection here causes considerable discomfort.

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Deltoid Site

 The deltoid muscle is found on the uppermost part of the upper arm.
 It is a relatively small muscle. No more than 1 mL of solution can be administered.
 This site is recommended for the administration of immunizations and vaccines in adults
because these medications are usually small in volume.
 The nurse locates the upper landmark for the deltoid site by placing four fingers across
the deltoid muscle with the first finger on the acromion process. The top of the axilla is
the line that marks the lower border landmark (Figure 35.42 ■).

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 A triangle within these boundaries indicates the deltoid muscle about 5 cm (2 in.) below
the acromion process (Figures 35.43 ■ and 35.44 ■).

Firmly pressing the injection site for 10 seconds before inserting the needle is thought to
reduce the sensory input from an injection, regardless of the site.

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Intramuscular Injection Technique

Inject the medication using the Z-track technique.

 Use the ulnar side of the nondominant hand to pull the skin approximately 2.5 cm (1 in.)
to the side. Under some circumstances, such as for an emaciated client or an infant,
the muscle may be pinched ❶

 Holding the syringe between the thumb and forefinger (as if holding a pen), pierce the skin
quickly and smoothly at a 90° angle (see Figure 35.40), and insert the needle into the
muscle. ❷

• Hold the barrel of the syringe steady with your nondominant hand and aspirate by pulling back
on the plunger with your dominant hand. ❸ Aspirate for 5 to 10 seconds. Rationale:

If the needle is in a small blood vessel, it takes time for the blood to appear. If blood appears in
the syringe, withdraw the needle, discard the syringe, and prepare a new injection.

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  If blood does not appear, inject the medication steadily and slowly (approximately 10
seconds per milliliter)
 After the injection, wait 10 seconds if using the ventrogluteal site. Rationale: Waiting
permits the medication to disperse into the muscle tissue, thus decreasing the client’s
discomfort.
Intravenous Medications

 Because IV medications enter the client’s bloodstream directly by way of a vein, they are
appropriate when a rapid effect is required.
 This route is also appropriate when medications are too irritating to tissues to be given
by other routes.
 Methods for administering medications intravenously include the following:
• Intermittent intravenous infusion (e.g., piggyback setup)
• Volume-controlled infusion (often used for children)
• Intravenous push (IVP) or bolus
• Intermittent injection ports (devices).
 In all of these methods, the client has an existing intravenous line or an IV access site such
as a saline lock.
 With all IV medication administration, it is very important to observe clients closely for
signs of adverse reactions. Because the drug enters the bloodstream directly and acts
immediately, there is no way it can be withdrawn or its action terminated.
 Before adding any medications to an existing IV infusion, the nurse must check for the
“rights” and check compatibility of the drug and the existing IV fluid. Be aware of any
incompatibilities of the drug and the fluid that is infusing.

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  For example, the drug phenytoin (Dilantin) is incompatible with dextrose and will
form a precipitate if injected through a port in an IV line with glucose or dextrose
infusing.
Intermittent Intravenous Infusions

 An intermittent infusion is a method of administering a medication mixed in a small

amount of IV solution, such as 50 or 100 mL. It is important for the label on an IV
Intermittent medication to be designed to prevent medication errors.. See Figure 35.45 ■ for a
sample label.

The drug is administered at regular intervals, such as every 4 hours, with the drug being
infused for a short period of time such as 30 to 60 minutes. A commonly used additive or
secondary IV setup is the piggyback.
 Most infusion sets include one or more injection ports for administering IV
medications or secondary infusions.
 When more than one solution needs to be infused at the same time, secondary sets
such as the piggyback IV setups are used.
In the piggyback setup (Figure 35.46 ■), a second set connects the second container to the
tubing of the primary container at the upper port. This setup is used solely for intermittent
drug administration.

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Needleless systems can use threaded-lock or lever-lock cannulas
to connect the secondary set to the ports of the primary infusion.

 Needleless systems are used because they reduce the risk of needle stick injury and
contamination of the IV line. The needleless ports can be accessed with a syringe that has a
Luer-Lok to administer medications (Figure 51.25 ■).

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  Another method of intermittently administering an IV medication is by a syringe pump or
mini-infuser. The medication is mixed in a syringe that is connected to the primary IV line
via a mini-infuser (Figure 35.47 ■).

Volume-Control Infusions

 Intermittent medications may also be administered by a volume-control infusion set

such as Buretrol, Soluset, Volutrol, and Pediatrol (Figure 35.48 ■).
 a volume-control set, which is used if the volume of fluid or medication administered is to
be carefully controlled

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  Such sets are small fluid containers (100 to 150 mL in size) attached below the primary
infusion container so that the medication is administered through the client’s IV line.
 Volume-control sets are frequently used to infuse solutions into children and older clients
when the volume administered is critical and must be carefully monitored. Box 35.9
provides additional information.
Intravenous Push

 Intravenous push (IVP) or bolus is the IV administration of an undiluted drug directly into
the systemic circulation.
 It is used when a medication cannot be diluted or in an emergency.
Intermittent Infusion Devices

 Intermittent infusion devices (Figure 35.49 ■) may be attached to a peripheral IV

catheter to allow medications to be administered intravenously without requiring a
continuous intravenous infusion.

 The Infusion Nurses Society (2016) recommends considering use of an extension set
between the peripheral catheter and needleless connector to reduce catheter
manipulation. This device has a port to insert into the peripheral catheter and a needleless
injection cap at the other end with the extension tubing between the two ends (Figure
35.50).

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 Intermittent injection ports have a port that allows a needleless adapter to be connected
for administering medications.
 Intermittent injection ports must be flushed prior to and after medication administration.
Most agencies use saline flushes with medication administration through
peripheral IV lines.
 Clients who require long-term venous access for administering medications (e.g., people
receiving chemotherapy for cancer treatment) may have a specialized catheter or port to
allow central venous access. The catheter may be tunneled subcutaneously and accessed
through an intermittent injection port attached to the distal end of the venous catheter.
 Other devices have an implantable port or vascular access port surgically inserted under
the skin so that no portion of the device exits the body.
 To administer medications, the port is accessed using a specialized needle through the
skin.

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 Unit 3+4: Patient Care

Pre – Post Operative Care

Care of Surgical Patients

 Surgery is a unique experience of a planned physical alteration encompassing three

phases: preoperative, intraoperative, and postoperative.
 These three phases are together referred to as the perioperative period.
 Perioperative nursing is the delivery of nursing care through the framework of the nursing
process. It also includes collaborating with members of the healthcare team, making
nursing referrals, and delegating and supervising nursing care.
 Perioperative nursing is practiced in hospital-based inpatient and outpatient surgical,
laser, and endoscopy suites, physician office–based surgical suites (outpatient), and
freestanding outpatient and ambulatory surgical centers
 The preoperative phase begins when the decision to have surgery is made; it ends when
the client is transferred to the operating table.
 The nursing activities associated with this phase include:
 assessing the client
 identifying potential or actual health problems
 planning specific care based on the individual’s needs, and
 Providing preoperative teaching for the client, the family, and significant others.
 The intraoperative phase begins when the client is transferred to the operating table and
ends when the client is admitted to the post anesthesia care unit (PACU), also called the
post anesthesia room (PAR).
 The nursing activities related to this phase include a variety of specialized procedures
designed to create and maintain a safe therapeutic environment for the client and the
healthcare personnel. These activities include:
 Interventions that provide for the client’s safety
 maintaining an aseptic environment
 ensuring proper functioning of equipment, and
 Providing the surgical team with the instruments and supplies needed during the
procedure.
 The postoperative phase begins with the admission of the client to the PACU or PAR
and ends when healing is complete.

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  During the postoperative phase, nursing activities include:
 assessing the client’s response (physiologic and psychologic) to surgery
 performing interventions to facilitate healing and prevent complications
 Teaching and providing support to the client and support people, and planning for ome
care. The goal is to assist the client to achieve optimal health status.
Types of Surgery

 Surgical procedures are commonly grouped according to (a) purpose, (b) degree of urgency,
and (c) degree of risk.
Purpose
Surgical procedures may be categorized according to their purpose (Box 37.1).

Purposes of Surgical Procedures

Diagnostic Confirms or establishes a diagnosis; for example, biopsy of a mass in a breast
Palliative Relieves or reduces pain or symptoms of a disease; it does not cure; for
example, resection of nerve roots
Ablative Removes a diseased body part; for example, removal of a gallbladder
(cholecystectomy)
Constructive Restores function or appearance that has been lost or reduced;
for example, cleft palate repair
Transplant Replaces malfunctioning structures; for example, kidney transplant

Degree of Urgency

 Surgery is classified by its urgency and necessity to preserve the client’s life, body part, or
body function.
 Emergency surgery is performed immediately to preserve function or the life of the client.
 Surgeries to control internal hemorrhage or repair a fracture are examples of emergency
surgeries.
 Elective surgery is performed when surgical intervention is the preferred treatment for a
condition that is not imminently life threatening (but may ultimately threaten life or well-
being), or to improve the client’s life. Examples of elective surgeries include
cholecystectomy for chronic gallbladder disease, hip replacement surgery, and plastic surgery
procedures such as breast reduction.

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Degree of Risk
 Surgery is also classified as major or minor according to the degree of risk to the client.
 Major surgery involves a high degree of risk, for a variety of reasons:
 It may be complicated or prolonged, large losses of blood may occur, vital organs may
be involved, or postoperative complications may be likely. Examples are organ transplant,

open heart surgery, and removal of a kidney. In contrast,

 Minor surgery normally involves little risk, produces few complications, and is often
performed in an outpatient setting. Examples are breast biopsy, removal of tonsils, and
cataract extraction.
 The degree of risk involved in a surgical procedure is affected by the client’s age,
general health, nutritional status, presence of sleep apnea, use of medications, and
mental status.
Preoperative Phase
Preoperative Consent
 Prior to any surgical procedure, informed consent is required from the client or legal
guardian. Informed consent implies that the client has been informed and involved in
decisions affecting his or her health.
 The surgeon is responsible for obtaining the informed consent by providing the
following information to the client or legal guardian:
• The nature of and the reason for the surgery
• All available options and the risks associated with each option
• The risks of the surgical procedure and its potential outcomes
• Name and qualifications of the surgeon performing the procedure
• The right to refuse consent or later withdraw consent.
 The surgeon documents the informed consent conversation with the client or legal
guardian in the preoperative progress note.
 This consent form becomes part of the client’s medical record and goes to the operating
room (OR) with the client.
 The RN ensures consent is in the client’s chart prior to releasing the client to surgery.
the nurse ensures that the consent form is signed and serves as a witness to the signature
 Informed consent is only possible when the client understands the provided information,
that is, speaks the language and is conscious, mentally competent, and not
sedated.

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NURSING MANAGEMENT

Assessing

 Preoperative assessment includes collecting and reviewing physical, psychologic, and

social client data to determine the client’s needs throughout the three perioperative phases.
The client’s mobility and ability to function should also be assessed in the preoperative
phase.
 The essential preoperative information that should be included.
Preoperative Assessment Data
Current health status. Essential information includes general health status and the
presence of any chronic diseases, such as diabetes or asthma, which may affect the client’s
response to surgery or anesthesia.
Allergies. Include allergies to prescription and nonprescription drugs, food allergies, and
allergies to tape, latex, soaps, or antiseptic agents. Some food allergies may indicate a
potential reaction to drugs or substances used during surgery or diagnostic procedures
Medications. List all current medications. Certain medication such as anticonvulsant must
be continued throughout the operative period to prevent adverse effect previous surgeries.
Previous surgical experiences may influence the client’s physical and psychologic
responses to surgery or may reveal unexpected responses to anesthesia.
Mental status. The client’s mental status and ability to understand and respond
appropriately can affect the entire perioperative experience. Note any developmental
disabilities, mental illness, history of dementia, or excessive anxiety related to the
procedure.
Understanding of the surgical procedure and anesthesia. The client should have a good
understanding of the planned procedure and what to expect during and after surgery as
well as the expected outcome of the procedure.
Smoking. Smokers may have more difficulty clearing respiratory secretions after surgery,
increasing the risk of postoperative complications such as pneumonia and atelectasis and
delayed wound healing.
Obstructive sleep apnea (OSA). The majority of adults do not know that they have OSA,
which puts them at risk for postoperative pulmonary complications.

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 Alcohol and other mind-altering substances. Use of substances that affect the central
nervous system, liver, or other body systems can affect the client’s response to anesthesia
and surgery, and postoperative recovery.
Physical Assessment

 Preoperatively, the nurse performs a brief but complete physical assessment, paying
particular attention to systems that could affect the client’s response to anesthesia or
surgery.
 A brief or “mini” mental status examination provides valuable baseline data for
evaluating the client’s mental status and alertness after surgery. It is also important to
evaluate the client’s ability to understand what is happening. For example, assessment of
hearing and vision help guide perioperative teaching. Respiratory and cardiovascular
assessments not only provide baseline data for evaluating the client’s postoperative status
but also may alert care providers to a problem (e.g., a respiratory infection or irregular
pulse rate) that may affect the client’s response to surgery and anesthesia. Other systems
(gastrointestinal, genitourinary, and musculoskeletal) are examined to provide baseline
data
screening Tests
 The surgeon or the anesthesiologist orders preoperative diagnostic tests. Abnormalities
may require treatment prior to surgery.
 The nurse’s responsibility is to check the orders carefully, to see that they are carried out,
and to ensure that the results are obtained and in the client’s record prior to surgery. Table
37.2 lists routine preoperative screening tests. In addition to these routine tests, diagnostic
tests directly related to the client’s disease are usually appropriate (e.g., gastroscopy to
clarify the pathologic condition before gastric surgery).

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Physical Preparation

 Preoperative preparation includes the following areas:

nutrition and fluids, elimination, hygiene, medications, sleep, care of valuables and
prostheses, special orders, surgical skin preparation, temperature, safety protocols,
vital signs, antiemboli stockings, and sequential compression devices.
 In many agencies a preoperative checklist is used on the day of surgery. Forms may differ
among agencies. Figure 37.1 ■ reflects the most common elements of a preoperative
checklist.

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 It is essential that all pertinent records (laboratory records, x-ray films, consents) be
available to perioperative personnel for reference and all physical preparation is
completed to ensure client safety.

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Nutrition and Fluids

 Adequate hydration and nutrition promote healing.

Nurses need to identify and record any signs of malnutrition or fluid imbalance. If the
client is on IV fluids or on measured fluid intake, nurses must ensure that the fluid intake
and output are accurately measured and recorded.
 The order “NPO after midnight” has been a longstanding tradition because it was
believed that anesthetics depress gastrointestinal functioning and there was a danger the
client would vomit and aspirate during the administration of a general anesthetic. Re-
evaluation and research, however, do not support this tradition. As aresult, the
American Society of Anesthesiologists (ASA) revised its practice guidelines for
preoperative fasting in healthy clients undergoing elective procedures requiring general
anesthesia, regional anesthesia, or sedation analgesia. According to the ASA , the current
guidelines allow for:
• The consumption of clear liquids (no alcohol) up to 2 hours before surgery
• The consumption of breast milk up to 4 hours before surgery; infant formula may be
ingested up to 6 hours before surgery
• A light meal may be ingested up to 6 hours before the procedure
• A heavier meal (fried or fatty foods) may be eaten up to 8 hours before surgery.
Elimination
 Enemas before surgery are no longer routine, but cleansing enemas may be ordered if
bowel surgery is planned.
 The enemas help prevent postoperative constipation and contamination of the surgical area
(during surgery) by feces.
 Prior to surgery, a straight catheterization or an indwelling Foley catheter may be ordered
to ensure that the bladder remains empty. This helps prevent inadvertent injury to the
bladder, particularly during pelvic surgery. If the client does not have a catheter, it is
important to empty the bladder prior to receiving preoperative medications.
Hygiene
 In some settings, clients are asked to bathe or shower the evening or morning of surgery
(or both) with either soap or an antiseptic solution. The purpose of hygienic measures is to
reduce the risk of wound infection by reducing the amount of bacteria on the client’s skin.

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  The client’s nails should be trimmed and free of polish, and all cosmetics should be
removed so that the nail beds, skin, and lips are visible when circulation is assessed
during the perioperative phases.
 Intraoperatively the client will be required to wear a surgical cap. The surgical cap
contains the client’s hair and any microorganisms on the hair and scalp.
 Before going into the OR the client should remove all hairpins and clips because they
may cause pressure or accidental damage to the scalp when the client is unconscious. The
client also removes personal clothing and puts on an OR gown.
Medications

 The anesthetist or anesthesiologist may order routinely taken medications to be held the
day of surgery.
 In some settings, selected preoperative medications are given to the client prior to going to
the OR and others are given while in the OR.
 Commonly used preoperative medications include the following:
• Benzodiazepines such as midazolam (Versed) may be administered IV prior to surgery to
reduce anxiety and ease anesthetic induction.
• Opioid analgesics such as morphine provide client sedation and reduce the required amount
of anesthetic.
• Anticholinergics such as atropine, scopolamine, and glycopyrrolate (Robinul) reduce oral
and pulmonary secretions and prevent laryngospasm.
• Dopamine blockers such as droperidol (Inapsine) are administered parenterally to prevent
nausea and vomiting; reduce anxiety, and relax muscles
• Histamine-receptor antihistamines such as cimetidine (Tagamet) and ranitidine (Zantac)
reduce gastric fluid volume and gastric acidity.
• Neurolept analgesic agents such as Innovar induce general calmness and sleepiness.
 Preoperative medications administered to the client before surgery are given at a scheduled
time or “on call,” that is, when the OR notifies the nurse to give the medication.
Sleep
 Nurses should do everything to help the client sleep the night before surgery. Often a sedative
is ordered. Adequate sleep helps the client manage the stress of surgery and helps healing.

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 Valuables
 Valuables such as jewelry and money should be sent home with the client’s family or
significant other. If valuables and money cannot be sent home, they need to be labeled and
placed in a locked storage area per the agency’s policy.
 Removing jewelry also means removing body-piercing jewelry because there is a risk of
injury from burns if an electrosurgical unit is used.
 Wedding bands must be removed, however, if there is danger of the fingers swelling after
surgery. Situations warranting removal include surgery on or cast application to an arm, or a
mastectomy that involves removal of the lymph nodes. (Mastectomies may cause edema of the
arm and hand.)
Prostheses

 All prostheses (artificial body parts, such as partial or complete dentures, contact lenses,
artificial eyes, and artificial limbs) and eyeglasses, wigs, and false eyelashes must be removed
before surgery.
 In some hospitals, dentures are placed in a locked storage area; in others they are placed in
labeled containers and kept at the client’s bedside. Partial dentures can become dislodged
and obstruct an unconscious client’s breathing.
 The nurse also checks for the presence of chewing gum or loose teeth. Loose teeth are a
common problem with 5- or 6-year-olds undergoing tonsillectomy because they can become
dislodged or aspirated during anesthesia
Special Orders

 The nurse checks the surgeon’s orders for special requirements (e.g., the insertion of a
nasogastric tube prior to surgery; the administration of medications, such as insulin; or the
application of antiemboli stockings).
Skin Preparation

 When the appropriate skin antisepsis is implemented, the risk for a surgical site infection
(SSI) may be reduced. Some clients may need to complete a full-body wash using
antimicrobial soap the night before the planned surgery. In most agencies, skin preparation
is carried out during the intraoperative phase. The surgical site is cleansed with an
antimicrobial to remove soil and reduce the resident microbial count to subpathogenic
levels. Recent evidence supports using dual-agent skin antiseptics rather than a single

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 agent.
Temperature
 Surgical clients are at risk of losing body heat; therefore, temperature management is an
important aspect of perioperative client safety and comfort.
 There are many possible causes for hypothermia including minimal clothing (i.e., only
a hospital gown), inactivity while in the holding area, skin exposure during insertion of IV
and during surgery, and low temperatures in the OR; in addition, the administration of
anesthesia impairs both thermoregulation and the ability of the body to generate and retain
heat
 Complications associated with perioperative hypothermia include increased blood loss,
delayed wound healing, increased risk of an SSI, and increased length of stay in the hospital.
Safety Protocols
 The Joint Commission established the Universal Protocol for Preventing Wrong Site,
Wrong Procedure, and Wrong Person Surgery in 2004. This protocol involves three
steps.
 The first step requires preoperative verification. The frequency and scope of the
verification process depends on the type and complexity of the procedure.
 Possibilities include when the procedure is scheduled, at the time of preadmission testing
and assessment, at the time of admission for the procedure, and before the client leaves the
preprocedure area or enters the procedure room
 The second step involves marking of the operative site.
 The essential focus is that the mark must be unambiguous and a clear communication to all
involved.
 The mark must be permanent and visible after the client has been prepped and draped for
surgery.
 The third step is called “time-out.” Before surgery begins the surgical team takes a
time-out to conduct a final verification of the correct client, procedure, and site. Any
questions or concerns must be resolved before the procedure can begin.
Vital Signs

 In the preoperative phase the nurse assesses and documents vital signs for baseline data.
The nurse reports any abnormal findings, such as elevated blood pressure or elevated
temperature.

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Antiemboli Stockings

 Antiemboli (elastic) stockings are firm elastic hose that compress the veins of the legs and
thereby facilitate the return of venous blood to the heart. They also prevent edema of the
legs and feet. These stockings are frequently applied to surgical clients to prevent the
potential postoperative problem of venous thromboembolism (VTE).
Intraoperative Phase

 The intraoperative nurse uses the nursing process to design, coordinate, and deliver care to
meet the identified needs of clients whose protective reflexes or self-care abilities are
potentially compromised because they are having operative or other invasive procedures.
Types of Anesthesia
 Anesthesia is classified as general or regional.
 An anesthesiologist or a certified registered nurse anesthetist (CRNA) administer
anesthetic agents.
 General anesthesia is the loss of all sensation and consciousness. Under general
anesthesia, protective reflexes such as cough and gag reflexes are lost.
 A general anesthetic acts by blocking awareness centers in the brain so that amnesia (loss
of memory), analgesia (insensibility to pain), hypnosis (artificial sleep), and relaxation
(rendering a part of the body less tense) occur.
 General anesthetics are usually administered by IV infusion or by inhalation of gases
through a mask or through an endotracheal tube inserted into the trachea.
 Regional anesthesia is the temporary interruption of the transmission of nerve impulses to
and from a specific area or region of the body. The client loses sensation in an area of
the body but remains conscious. Several techniques are used:
 Topical (surface) anesthesia is applied directly to the skin and mucous
membranes, open skin surfaces, wounds, and burns. The most commonly used
topical agents are lidocaine (Xylocaine) and benzocaine.
Topical anesthetics are readily absorbed and act rapidly.
 Local anesthesia (infiltration) is injected into a specific area and is used for
minor surgical procedures such as suturing a small wound or performing a
biopsy. Lidocaine or tetracaine 0.1% may be used.
 A nerve block is a technique in which the anesthetic agent is injected into and
around a nerve or small nerve group that supplies sensation to a small area of the
body.

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 Major blocks involve multiple nerves or a plexus (e.g., the brachial plexus
anesthetizes the arm);
Minor blocks involve a single nerve (e.g., a facial nerve).
 Spinal anesthesia is also referred to as a subarachnoid block (SAB).

An anesthetic agent is injected into the subarachnoid space surrounding

the spinal cord.
Spinal anesthesia is often categorized as a low, mid, or high spinal.
Low spinals (saddle or caudal blocks) are primarily used for surgeries
involving the perineal or rectal areas.
Mid-spinals (below the level of the umbilicus—T10) can be used for
hernia repairs or appendectomies, and
High spinals (reaching the nipple line—T4) can be used for surgeries
such as cesarean births.
 Epidural (peridural) anesthesia is an injection of an anesthetic agent into the
epidural space, the area inside the spinal column but outside the dura mater.
Surgical Skin Preparation

 Surgical skin preparation involves cleaning the surgical site, removing hair only if
necessary, and applying an antimicrobial agent.
 The purpose of a surgical skin preparation is to reduce the risk of SSIs, the most common
type of healthcare-associated infection in the surgical population and a serious
complication.
Positioning
 The position of the client during a surgical procedure is essential to the maintenance of
client safety.
 Inadequate padding and incorrect positioning can cause serious pressure injuries.
 The entire operating room team is responsible for minimizing the client’s risk of
perioperative complications related to positioning.
 The anesthesiologist or nurse anesthetist is responsible for directing staff to protect the
client from injury.

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The client’s position should provide:

• Optimal visualization of and access to the surgical site

• Optimal access to IV lines and monitoring devices
• Protection of the client from harm (anatomic and physiologic considerations).

 Positioning is performed after anesthesia is induced and before surgical draping of the
client.
 The client is lifted into position to prevent shearing forces on the skin from sliding or
rolling.
 The exact position for the client depends on the operation, that is, the surgical approach.
For example, a lithotomy position is usually used for vaginal surgery. Straps maintain
positions on the operating table, and body prominences are frequently padded.
Postoperative Phase

 Nursing during the postoperative phase is especially important for the client’s recovery
because anesthesia impairs the ability of clients to respond to environmental stimuli and to
help themselves, although the degree of consciousness of clients will vary. Moreover,
surgery itself traumatizes the body by disrupting protective mechanisms and homeostasis.
Immediate Post anesthetic Phase

 Recovery of surgical clients who required anesthesia (Immediate Post anesthetic) is

performed in the post anesthesia care unit (PACU) or post anesthesia room (PAR) or
recovery room (RR).
 PACU nurses, have specialized skills to care for clients recovering from anesthesia and
surgery.
 During the immediate post anesthetic stage, an unconscious client is positioned on the
side, with the face slightly down. A pillow is not placed under the head. In this
position, gravity keeps the tongue forward, preventing occlusion of the pharynx and
allowing drainage of mucus or vomitus out of the mouth rather than down the respiratory
tree.
 The nurse ensures maximum chest expansion by elevating the client’s upper arm on a
pillow.
 The upper arm is supported because the pressure of an arm against the chest reduces
chest expansion potential.

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  An artificial airway is maintained in place, and the client is suctioned as needed until
cough and swallowing reflexes return.
Clinical Assessment: Immediate post anesthesia Phase

 Adequacy of airway
• Oxygen saturation
• Adequacy of ventilation:
•Respiratory rate, rhythm, and depth
• Use of accessory muscles
• Breath sounds
• Cardiovascular status:
• Heart rate and rhythm
• Peripheral pulse amplitude and equality
• Blood pressure
• Capillary filling
• Level of consciousness:
• Not responding
• Arousable with verbal stimuli
• Fully awake
• Oriented to time, person, and place
• Presence of protective reflexes (e.g., gag, cough)
• Activity, ability to move extremities
• Skin color (pink, pale, dusky, blotchy, cyanotic, jaundiced)
• Fluid status:
• Intake and output
• Status of IV infusions (type of fluid, rate, amount in container, patency of tubing)
• Signs of dehydration or fluid overload
• Condition of operative site:
• Status of dressing
• Drainage (amount, type, and color)
• Patency of and character and amount of drainage from catheters, tubes, and drains
• Discomfort (i.e., pain) (type, location, and severity), nausea,
vomiting
• Safety (i.e., necessity for side rails, call bell within reach)

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 The return of the client’s reflexes, such as swallowing
and gagging, indicates that anesthesia is ending.
 Nurses should arouse clients by calling them by name and
in a normal tone of voice repeatedly telling them that the
surgery is over and that they are in the PACU.
 Clients are usually discharged from the PACU when:
• They are conscious and oriented.
• They are able to maintain a clear airway, breathe deeply,
cough, and maintain a desirable oxygen saturation
level.
• Vital signs have been stable or consistent with preoperative vital signs for at least 30
minutes.
• Protective reflexes (e.g., gag, swallowing) are active.
• They are able to move all extremities.
• Intake and urinary output are adequate.
• Post anesthesia nausea and vomiting is controlled.
• Temperature is between 96.8 and 100.4°F (36–38°C).
• Dressings are dry and intact; there is no overt drainage.
 Once the health status has stabilized, the client is returned to the nursing unit or the
outpatient surgery discharge area.
Preparing for Ongoing Care of the Postoperative Client
 While the client is in the operating room, the client’s
bed and room are prepared for the postoperative phase.
 In some agencies, the client is brought back to the unit
on a stretcher and transferred to the bed in the room. In
other agencies, the client’s bed is brought to the surgery
suite, and the client is transferred there. In the latter
situation, the bed needs to be made with clean linens
as soon as the client goes to surgery so that it can be
taken to the OR when needed.
 In addition, the nurse must obtain and set up any special equipment, such as an IV pole,
suction, oxygen equipment, and orthopedic appliances (e.g., traction).

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NURSING ROLE IN POST OPERATIVE PHASE Assessing

 As soon as the client returns to the nursing unit, the nurse conducts an initial assessment.
The sequence of these activities varies with the situation. For example, the nurse may need
to check the primary care provider’s stat orders before conducting the initial assessment; in
such a case, nursing interventions to implement the orders can be carried out at the same
time as assessment.
 The nurse consults the surgeon’s postoperative orders to learn the following:
• Food and fluids permitted by mouth
• IV solutions and IV medications
• Position in bed
• Medications ordered (e.g., analgesics, antibiotics)
• Laboratory tests
• Intake and output, which in some agencies are monitored for all postoperative clients
• Activity permitted, including ambulation
 The nurse also checks the PACU record for the following data:
• Operation performed
• Presence and location of any drains
• Anesthetic used
• Postoperative diagnosis
• Estimated blood loss
• Medications administered in the PACU.
 Many hospitals have postoperative protocols for regular assessment of clients. In
some agencies, assessments are made every 15 minutes until vital signs stabilize, every
hour for the next 4 hours, then every 4 hours for the next 2 days. It is important that the
assessments be made as often as the client’s condition requires.
 The nurse assesses the following:
• Level of consciousness. Assess orientation to time, place, and person. Most clients are
fully conscious but drowsy when returned to their unit. Assess reaction to verbal stimuli
and ability to move extremities.
• Vital signs. Take the client’s vital signs (pulse, respiration, blood pressure, and oxygen
saturation level) every 15 minutes until stable or in accordance with agency protocol.
Compare initial findings with PACU data. In addition, assess the client’s lung sounds and
assess for signs of common circulatory problems such as postoperative hypotension,

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 hemorrhage, or shock. Hypovolemia due to fluid losses during surgery is a common cause
of postoperative hypotension. Hemorrhage can result from insecure ligation of blood
vessels or disruption of sutures. Massive hemorrhage or cardiac insufficiency can lead to
shock postoperatively.
 Common postoperative complications with their manifestations and preventive
measures are listed in Table 37.3.
• Skin color and temperature, particularly that of the lips and nail beds. The color of the
lips and nail beds is an indicator of tissue perfusion (passage of blood through the
vessels). Pale, cyanotic, cool, and moist skin may be a sign of circulatory problems.
.Comfort Assess pain with the client’s vital signs and as needed between vital sign
measurements. Assess the location and intensity of the pain. Do not assume that reported
pain is incisional; other causes may include muscle strains, flatus, and angina. Ask the
client to rate pain on a scale of 0 to 10, with 0 being no pain and 10 the worst pain
imaginable.

 Evaluate the client for objective indicators of pain: pallor, perspiration, muscle tension,
and reluctance to cough, move, or ambulate. Determine when and what analgesics were
last administered, and assess the client for any side effects of medication such as nausea
and vomiting.
Fluid balance. Assess the type and amount of IV fluids, flow rate, and infusion site. Monitor the
client’s fluid intake and output. In addition to watching for shock, assess the client for signs of
circulatory overload, and monitor serum electrolytes.

• Dressing and bedclothes. Inspect the client’s dressings and bedclothes underneath the client.
Excessive bloody drainage on dressings or on bedclothes, often appearing underneath the client,
can indicate hemorrhage.

The amount of drainage on dressings is recorded by describing the diameter of the stains or by
denoting the number and type of dressings saturated with drainage.

• Drains and tubes. Determine color, consistency, and amount of drainage from all tubes and
drains. All tubes should be patent, and tubes and suction equipment should be functioning.
Drainage bags must be hanging properly.

• Any difficulties with voiding or bladder distention.

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Nursing interventions designed to promote client recovery and prevent complications
include (a) pain management, (b) appropriate positioning, (c) deep-breathing and coughing
exercises (d) leg exercises, (e) early ambulation, (f) adequate hydration, (g) promoting urinary and
gastrointestinal function, (h) diet, and (i) suction maintenance.

Pain Management

 Pain is usually greatest 12 to 36 hours after surgery, decreasing after the second or third
postoperative day.
 During the initial postoperative period, patient-controlled analgesia (PCA) or continuous
analgesic administration through an IV or epidural catheter is often prescribed.
The nurse monitors the infusion or amount of analgesic administered by PCA, assesses
the client’s pain relief, and notifies the primary care provider if the client is experiencing
unacceptable side effects or inadequate pain relief
 As-needed (prn) parenteral or oral analgesics should be administered on a routine basis
(every 2 to 6 hours, depending on the drug, route, and dose) for the first 24 to 36 hours.
 Because muscle tension increases pain perception and responses, nurses need to use
non pharmacologic measures in addition to prescribed analgesia. These include ensuring
that the client is warm and providing back rubs, position changes, diversional activities,
and adjunctive measures such as imagery
Positioning

 Position the client as ordered.

 Clients who have had spinal anesthetics usually lie flat for 8 to 12 hours.
 An unconscious or semiconscious client is placed on one side with the head slightly
elevated, if possible, or in a position that allows fluids to drain from the mouth. Otherwise,
follow the client’s preference. most people prefer a back lying position
Deep-Breathing and Coughing Exercises
 Deep-breathing exercises help remove mucus, which can form and remain in the lungs due
to the effects of general anesthetic and analgesics.
 Deep breathing helps prevent pneumonia and atelectasis, which may result from stagnation
of fluid in the lungs.
 Deep breathing frequently initiates the coughing reflex.
 Voluntary coughing in conjunction with deep breathing facilitates the movement and
expectoration of respiratory tract secretions.

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  Encourage the client to do deep-breathing and coughing exercises hourly, or at least
every 2 hours, during waking hours for the first few days.
 Assist the client to a sitting position in bed or on the side of the bed.
 The client can splint the incision with a pillow when coughing, or the nurse can splint the
incision for the client to reduce discomfort.
Leg Exercises

 Encourage the client to do leg exercises taught in the preoperative period every 1 to 2
hours during waking hours. Muscle contractions compress the veins, preventing the stasis
of blood in the veins, a cause of thrombus (stationary clot adhered to the wall of a vessel)
formation and subsequent thrombophlebitis (inflammation of a vein followed
by formation of a blood clot) and emboli (a blood clot that has moved). Contractions also
promote arterial blood flow.
Moving and Ambulation

 Encourage the client to turn from side to side at least every 2 hours. Alternate turning
allows for each lung to be in the uppermost position, allowing for maximum lung
expansion.
 Avoid placing pillows or rolls under the client’s knees because pressure on the popliteal
blood vessels can interfere with blood circulation to and from the lower extremities.
 Generally clients begin ambulation the evening of the day of surgery or the first day after
surgery, unless contraindicated.
 Early ambulation prevents respiratory, circulatory, urinary, and gastrointestinal
complications. It also prevents general muscle weakness.
 Schedule ambulation for periods after the client has taken an analgesic or when the client is
comfortable.
 Ambulation should be gradual, starting with the client sitting on the bed and dangling the
feet over the side.
 A client who cannot ambulate is periodically assisted to a sitting position in bed, if
allowed, and turned frequently. The sitting position permits the greatest lung expansion.
Hydration
 Maintain IV infusions as ordered to replace body fluids lost either before or during
surgery.

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 When oral intake is permitted, initially offer only small sips of water. Large amounts of
water can induce vomiting because anesthetics and narcotic analgesics temporarily inhibit
the motility of the stomach.
 The client who cannot take fluids by mouth may be allowed by the surgeon’s orders to
suck ice chips. Provide mouth care and place mouthwash at the client’s bedside.
 Postoperative clients often complain of thirst and a dry, sticky mouth. These discomforts
are a result of the preoperative fasting period, preoperative medications (such as atropine),
and loss of body fluid.
 Measure the client’s fluid intake and output for at least 2 days or until fluid balance is
stable without an IV infusion.
Urinary and Gastrointestinal Function
 Anesthetic agents temporarily depress urinary bladder tone, which usually returns
within 6 to 8 hours after surgery.
 Surgery in the pubic area, vagina, or rectum, during which the surgeon may manipulate
the bladder, often causes urinary retention. Provide measures that promote urinary
elimination; for example, help male clients stand at the bedside, or female clients to a
bedside commode if allowed, and ensure that fluid intake is adequate. Determine whether
the client has any difficulties voiding and assess the client for bladder distention.
 Report to the surgeon if a client does not void within 8 hours following surgery, unless
another time frame is specified.
 If all measures to promote voiding fail, a urinary catheterization is often ordered.
 Measure the fluid intake and output (I&O) of all new postoperative clients. Generally
I&O records are kept for at least 2 days or until the client re-establishes fluid balance
without an IV or catheter in place.
 Anesthetic agents, handling of the intestines during abdominal surgery, fasting, opioids
for pain management, and inactivity all inhibit bowel peristalsis. Most clients regain bowel
function several hours after surgery except in pelvic or abdominal surgery where the return
may be delayed for 24 to 48 hours or longer.
 Assess the return of peristalsis by auscultating the abdomen. Gurgling and rumbling
sounds indicate peristalsis. Bowel sounds should be carefully assessed every 4 to 6 hours.
Oral fluids and food are usually started after the return of peristalsis.
Diet

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  The surgeon orders the client’s postoperative diet. Depending on the extent of surgery and
the organs involved, the client may be allowed nothing by mouth for several days or may
be able to resume oral intake when nausea is no longer present.
 When “diet as tolerated” is ordered, offer clear liquids initially. If the client tolerates
these with no nausea, the diet can often progress to full liquids and then to a regular diet,
provided that gastrointestinal functioning is normal. Assist very weak clients to eat.
Observe the client’s tolerance of the food and fluids ingested and note and report the
passage of flatus or abdominal distention.
Suction

 Some clients return from surgery with a gastric or intestinal tube in place and orders to
connect the tube to suction.
 The suction ordered can be continuous or intermittent. The
Surgeon orders the type and amount of suction
Potential Postoperative Problems

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 Unit 5: Sterility and Sterilization

Infection

An invasion of pathogens or Micro organisms into the body that are capable of producing
Diseases.
Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility
of transferring microorganisms from one place to another, aseptic technique is used. The two basic
types of asepsis are medical and surgical.

Medical asepsis includes all practices intended to confine a specific microorganism to a

specific area, limiting the number, growth, and transmission of microorganisms.

In medical asepsis, objects are referred to as clean, which means the absence of almost all
microorganisms, or dirty (soiled, contaminated), which means likely to have microorganisms,
some of which may be capable of causing infection.

Surgical asepsis, or sterile technique, refers to those practices that keep an area or object free of
all microorganisms; it includes practices that destroy all microorganisms and spores (microscopic
dormant structures formed by some pathogens that are very hardy and often survive
common cleaning techniques).

Surgical asepsis is used for all procedures involving the sterile areas of the body.
Sepsis is the condition in which acute organ dysfunction occurs secondary to infection.

Method of Transmission of Microorganism

After a microorganism leaves its source or reservoir, it requires a means of transmission to

reach another individual or host through a receptive portal of entry. There are three
mechanisms:

1. Direct transmission. Direct transmission involves immediate and direct transfer of

microorganisms from individual to individual through touching, biting, kissing, or
sexual intercourse. Droplet spread is also a form of direct transmission but can occur
only if the source and the host are within 1 m (3 ft) of each other. Sneezing, coughing,
spitting, singing, or talking can project droplet spray into the conjunctiva or onto the
mucous membranes of the eye, nose, or mouth of another individual.

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 2. Indirect transmission. Indirect transmission may be either vehicle borne or vector
borne:
a. Vehicle-borne transmission. A vehicle is any substance that serves as an
intermediate means to transport and introduce an infectious agent into a susceptible
host through a suitable portal of [Link] as handkerchiefs, toys, soiled clothes,
cooking or eating utensils, and surgical instruments or dressings, can act as vehicles.
Water, food, blood, serum, and plasma are other vehicles. For example, food or
water may become contaminated by a food handler who carries the hepatitis A virus.
The food is then ingested by a susceptible host.
b. Vector-borne transmission. A vector is an animal or flying or crawling insect that
serves as an intermediate means of transporting the infectious agent. Transmission may
occur by injecting salivary fluid during biting or by depositing feces or other materials
on the skin through the bite wound or a traumatized skin area
3. Airborne transmission. Airborne transmission may involve droplets or dust. Droplet nuclei,
the residue of evaporated droplets emitted by an infected host such as someone with tuberculosis,
can remain in the air for long periods. Dust particles containing the infectious agent (e.g., C.
difficile, spores from the soil) can also become airborne. The material is transmitted by air currents
to a suitable portal of entry, usually the respiratory tract, of another individual.

Nosocomial and Healthcare-Associated Infections

Nosocomial infections are classified as infections that originate in the hospital. Nosocomial
infections can either develop during a client’s stay in a facility or manifest after discharge.
Nosocomial microorganisms may also be acquired by personnel working in the facility and can
cause significant illness and time lost from work.

Nosocomial infections are a subgroup of healthcare associated infections (HAIs)—those that

originate in any healthcare setting—and of hospital-acquired conditions (HACs), which include
other types of conditions besides infections.

The CDC (2016) reports that central intravenous line–associated bloodstream infections, catheter-
associated urinary tract infections, surgical site infections, and ventilator-associated pneumonia
account for the majority of HAIs.

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Cleaning, Disinfecting and Sterilization

Cleaning
The process of removing dirt and soils, but not killing micro organisms and spores.
Disinfection
The process of destroying all pathogenic micro organisms, but not bacterial spores.
Sterilization
The process of destroying all forms of microbial life on inanimate surfaces, including bacterial
spores.

Disinfecting and Sterilizing

 The first links in the chain of infection, the etiologic agent and the reservoir, are interrupted by
the use of antiseptics (agents that inhibit the growth of some microorganisms) and
disinfectants (agents that destroy pathogens other than spores) and by sterilization.
Disinfecting
 An antiseptic is a chemical preparation used on skin or tissue. A disinfectant is a chemical
preparation, such as phenol or iodine compounds, used on inanimate objects.
 Disinfectants are frequently caustic and toxic to tissues.
 Antiseptics and disinfectants often have similar chemical components, but the disinfectant is a
more concentrated solution.
 Both antiseptics and disinfectants are said to have bactericidal or bacteriostatic properties.

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 A bactericidal preparation destroys bacteria, whereas a bacteriostatic preparation prevents the
growth and reproduction of some bacteria.
An agent known to be effective against a particular type of bacteria should be selected. Spore-
forming bacteria such as C. difficile, which is a frequent cause of nosocomial diarrhea, and
Bacillus anthracis (anthrax) may be inhibited by only a few of the agents normally effective
against other forms of bacteria.
 When disinfecting, nurses need to follow agency protocol and consider the following:
1. The type and number of infectious organisms. Some microorganisms are readily destroyed,
whereas others require longer contact with the disinfectant.
2. The recommended concentration of the disinfectant and the duration of contact.
3. The presence of soap. Some disinfectants are ineffective in the presence of soap or detergent.
4. The presence of organic materials. The presence of saliva, blood, pus, or excretions can
readily inactivate many disinfectants.
5. The surface areas to be treated. The disinfecting agent must come into contact with all
surfaces and areas.
Sterilizing
Sterilization is a process that destroys all microorganisms, including spores and viruses. Four
commonly used methods of sterilization are moist heat, gas, boiling water, and radiation.
Moist Heat
To sterilize with moist heat (such as with an autoclave), steam under pressure is used because it
attains temperatures higher than the boiling point.
Gas
Ethylene oxide destroys microorganisms by interfering with their metabolic processes. It is also
effective against spores. Its advantages are good penetration and effectiveness for heat-
sensitive items. Its major disadvantage is its toxicity to humans.
Boiling Water
This is the most practical and inexpensive method for sterilizing in the home. The main
disadvantage is that spores and some viruses are not killed by this method. Boiling a minimum
of 15 minutes is advised for disinfection of articles in the home.
Radiation
Both ionizing (such as alpha, beta, and x-rays) and nonionizing (ultraviolet light) radiation are
used for disinfection and sterilization. The main drawback to ultraviolet light is that the rays do
not penetrate deeply. Ionizing radiation is used effectively in industry to sterilize foods, drugs,

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 and other items that are sensitive to heat. Its main advantage is that it is effective for items
difficult to sterilize; its chief disadvantage is that the equipment is very expensive.
Infection Prevention and Control

Because it is not always possible to know which clients may have infectious organisms, guidelines are
established by the CDC and other organizations outlining steps all healthcare workers must follow
to reduce the chances that organisms in blood (blood borne pathogens) and potentially infectious
organisms from other body tissues will be transmitted from the client to other individuals.

 The guidelines contain a two-tiered approach. The first tier is standard precautions (SP).
Some agencies may use an earlier term—universal precautions (UP)—reflecting their
applicability in all client care situations.
Universal Precaution for Infection Prevention (Isolation Precaution)

Isolation refers to measures designed to prevent the spread of infections or potentially infectious
microorganisms to health personnel, clients, and visitors. Several sets of guidelines have been used in
hospitals and other healthcare settings.

Category-specific isolation precautions use seven categories: strict isolation, contact isolation,
respiratory isolation, tuberculosis isolation, enteric precautions, drainage and secretions precautions,
and blood and body fluid precautions.

Disease-specific isolation precautions provide precautions for specific diseases. These precautions
delineate use of private rooms with special ventilation, having the client share a room with other clients
infected with the same organism, and gowning to prevent gross soilage of clothes for specific infectious
diseases.
Standard Precautions

Standard precautions are used in any situations involving blood; all body fluids, excretions, and
secretions except sweat; nonintact skin; and mucous membranes (whether or not blood is present or
visible). SP include

(a) hand hygiene; (b) use of personal protective equipment (PPE), which includes gloves, gowns,
eyewear, and masks; (c) safe injection practices; (d) safe handling of potentially contaminated
equipment or surfaces in the client environment; and (e) respiratory hygiene or cough etiquette
that calls for covering the mouth and nose when sneezing or coughing, proper disposal of tissues, and

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separating potentially infected individuals from others by at least 1 m (3 ft) or having them wear a
surgical mask.

Transmission-Based Precautions

Transmission-based precautions are used in addition to standard precautions for clients with
known or suspected infections that are spread in one of three ways: by airborne or droplet
transmission, or by contact. The three types of transmission-based precautions may be used alone
or in combination but always in addition to SP. Recommended practices for standard and
transmission-based precautions

Airborne precautions are used for clients known to have or suspected of having serious illnesses
transmitted by airborne droplet nuclei smaller than 5 microns.

Examples of such illnesses include measles (rubeola), varicella, and tuberculosis.

Droplet precautions are used for clients known to have or suspected of having serious illnesses
transmitted by particle droplets larger than 5 microns. Examples of such illnesses are diphtheria
(pharyngeal); mycoplasma pneumonia; pertussis; mumps; rubella; streptococcal pharyngitis,
pneumonia, or scarlet fever in infants and young children; and pneumonic plague.
Contact precautions are used for clients known to have or suspected of having serious illnesses
easily transmitted by direct client contact or by contact with items in the client’s environment.
such illnesses include GI, respiratory, skin, or wound infections or colonization with multidrug-
resistant bacteria; specific enteric infections such as E. coli, Shigella, and hepatitis A, for diapered
or incontinent clients; respiratory syncytial virus, parainfluenza virus, or enteroviral infections in
infants and young children; and highly contagious skin infections such as herpes simplex virus,
impetigo, pediculosis, and scabies.

Compromised Clients

Compromised clients (those highly susceptible to infection) are often infected by their own
microorganisms, by microorganisms on the inadequately cleansed hands of healthcare personnel,
and by nonsterile items (food, water, air, and client-care equipment). Clients who are severely
compromised include those who:

• Have diseases, such as leukemia, or treatments such as chemotherapy, that depress the client’s
resistance to infectious organisms.

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• Have extensive skin impairments, such as severe dermatitis or major burns, which cannot be
effectively covered with dressings.

 The 2007 CDC guidelines (Siegel et al., 2007) for care of severely compromised
(immunocompromised) clients include the use of SP Isolation Practices
Initiation of practices to prevent the transmission of microorganisms is generally a nursing
responsibility and is based on a comprehensive assessment of the client. This
assessment takes into account the status of the client’s normal defense mechanisms, the
client’s ability to implement necessary precautions, and the source and mode of
transmission of the infectious agent. The nurse then decides whether to wear gloves,
gowns, masks, and protective eyewear. In all client situations, nurses must cleanse their
hands before and after giving care.
Personal Protective Equipment
All healthcare providers must apply PPE (clean or sterile gloves, gowns, masks, and
protective eyewear) according to the risk of exposure to potentially infective materials.
Gloves
Gloves are worn for three reasons: First, they protect the hands when the nurse is likely to
handle any body substances, for example, blood, urine, feces, sputum, and nonintact skin.
Second, gloves reduce the likelihood of nurses transmitting their own endogenous
microorganisms to individuals receiving care.
 Nurses who have open sores or cuts on the hands must wear gloves for protection. Third,
gloves reduce the chance that the nurse’s hands will transmit microorganisms from one
client or an object to another client. In all situations, gloves are
changed between client contacts.
 The hands are cleansed each time gloves are removed for two primary reasons:
(1) The gloves may have imperfections or be damaged during wearing so that they could
allow microorganism entry and (2) the hands may become contaminated during glove
removal.
Gowns
Clean or disposable impervious (water-resistant) gowns or plastic aprons are worn during
procedures when the nurse’s uniform is likely to become soiled. Sterile gowns
may be indicated when the nurse changes the dressings of a client with extensive wounds (e.g.,
burns). Single-use gown technique (using a gown only once before it is discarded or laundered) is
the usual practice in hospitals.

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After the gown is worn, the nurse discards it (if it is paper) or places it in a laundry hamper. Plastic
aprons should be discarded after use.

Face Masks
Masks are worn to reduce the risk for transmission of
organisms by the droplet contact and airborne routes and
by splatters of body substances. The CDC recommends
that masks be worn:
• By those close to the client if the infection (e.g., measles,
mumps, or acute respiratory diseases in children) is
transmitted by large-particle aerosols (droplets). Largeparticle aerosols are transmitted by
close contact and
generally travel short distances (about 1 m, or 3 ft).
• By all individuals entering the room if the infection
(e.g., pulmonary tuberculosis and SARS-CoV) is transmitted by small-particle aerosols
(droplet nuclei).
Small-particle aerosols remain suspended in the air and
thus travel greater distances by air. Special masks that
provide a tighter face seal and better filtration may be
used for these infections.
Various types of masks differ in their filtration effectiveness and fit.
Single-use disposable surgical masks are effective for use while the nurse provides care
to most clients but should be changed if they become wet or soiled.
These masks are discarded in the waste container after
use.
Disposable particulate respirators of different types may be effective for droplet
transmission, splatters, and airborne microorganisms.
Some respirators now available are effective in preventing inhalation of tuberculin
organisms.
the category “N” respirator at 95% efficiency (referred to as an N95 respirator) meets
tuberculosis, SARS, and influenza control
criteria.
During certain techniques requiring surgical asepsis
(sterile technique), masks are worn (a) to prevent droplet

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 contact transmission of exhaled microorganisms to the sterile field or to a client’s open
wound and (b) to protect the
nurse from splashes of body substances from the client.

Eyewear
Protective eyewear (goggles, glasses, or face shields) and masks are indicated in situations
where body substances may splatter the face. If the nurse wears prescription eyeglasses,
goggles must still be worn over the glasses because the protection must extend around the
ides of the glasses.
Disposal of Soiled Equipment and Supplies
Many pieces of equipment are supplied for single use only and are disposed of after use.
Some items, however, areb reusable. Agencies have specific policies and procedures
for handling soiled equipment (e.g., disposal, cleaning, disinfecting, and sterilizing); the
nurse needs to become familiar with these practices in the employing agency.
guidelines to handle and bag soiled items:• Place garbage and soiled disposable equipment,
including dressings and tissues but not sharps, in the appropriate and labeled bag or container and
immediately close it. If the bag is sturdy and impermeable to microorganisms (waterproof or solid
enough to prevent organisms from moving through it even when wet), a single bag is adequate. If
not, place the first bag inside another impermeable bag.

• Place nondisposable or reusable equipment that is visibly soiled in a labeled container before
removing it from the client’s room or cubicle, and send it to a central processing area for
decontamination

• Disassemble special procedure trays into component parts.

• Bag soiled client clothing before sending it home or to the agency laundry.
Linens
Handle soiled linen as little as possible and with the least agitation possible. Roll the linen with the
soiled side in before placing it in the laundry hamper. This prevents gross microbial contamination
of the air and individuals handling the linen. Close the bag before sending it to the laundry in
accordance with agency practice.

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Laboratory Specimens

Laboratory specimens, if placed in a leak proof container with a secure lid with a biohazard label,
need no special precautions. Use care when collecting specimens to avoid contaminating the
outside of the container.

Containers that are visibly contaminated on the outside should be placed inside a sealable plastic
bag before sending them to the laboratory. This prevents personnel from having hand contact with
potentially infective material.

Dishes and Utensils

ishes and utensils require no special precautions. Soiling can largely be prevented by encouraging
clients to cleanse their hands before eating. Some agencies use disposable dishes for convenience.
Blood Pressure Equipment

Blood pressure equipment needs no special precautions unless it becomes contaminated with
infective material. If it does become contaminated, follow agency policy to decontaminate it.
Cleaning procedures vary according to whether it is a wall or portable unit. In some agencies, a
disposable cuff is used. Stethoscopes should be cleaned frequently and between clients to remove
gross contamination. Dedicated stethoscopes are used when a client is in isolation.

Disposable Needles, Syringes, and Sharps

Place all needles, syringes, and “sharps” (e.g., lancets, scalpels, and broken glass) into a labeled,
puncture-resistant container approved only for this use. To avoid puncture wounds, use safety or
needleless systems and do not detach needles from the syringe or recap the needle before
disposal.

Infection Prevention for Healthcare Workers

publishes and enforces regulations to protect healthcare workers from occupational injuries,
including exposure to blood borne pathogens in the workplace. Occupational
exposure is defined as skin, eye, mucous membrane, or parenteral contact with blood or other
potentially infectious materials that may result from the performance of an employee’s duties.
There are three major modes of transmission of infectious materials in the clinical setting:
• Puncture wounds from contaminated needles or other sharps

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• Skin contact, which allows infectious fluids to enter through wounds and broken or damaged
skin

• Mucous membrane contact, which allows infectious fluids to enter through mucous membranes
of the eyes, mouth, or nose.

Using proper precautions with general medical asepsis, appropriately using PPE (gloves,
masks, gowns, goggles, special resuscitative equipment), and avoiding carelessness in the clinical
area will place the caregiver at significantly less risk for injury.

Role of the Infection Prevention Nurse

All healthcare organizations must have interdisciplinary infection prevention committees.

Representatives from the clinical laboratory, housekeeping, maintenance, dietary, and client care
areas are included. An important member of this committee is the infection prevention nurse.
This nurse is specially trained to be knowledgeable about the latest research and practices in
preventing, detecting, and treating infections. All infections are reported to the nurse
in a manner that allows for recording and analyzing statistics that can assist in improving infection
prevention practices. In addition, the infection prevention nurse may be involved in employee
education and implementation of the blood borne pathogen exposure plan

Sterility in Operating Room

Operating theater

• The design of the OT should allow for ease of access to the storage areas for delivery of
OT consumables; and controlled access from an external corridor is highly desirable.
 The main principle behind the design of an OT is the establishment of: a central
sterile core, which consists of the patient on the operating table, the surgeon and scrub
nurse, the scrub room, the set-up room and induction room (where applicable).
 The clean zone connects the OT via the clean passage to the holding and recovery areas
and the store rooms that directly supply the OT.
 The clean zone separates the OT (sterile zone) from the potentially contaminated areas
(the general zone) such as the offices, staff change areas, reception and the disposal areas
(the dirty zone) such as the sluice and waste areas.
RINCIPLE
The Operating Theatre (

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 • The four zones, are areas of varying degrees of cleanliness in which the bacteriological
count progressively diminishes from the outer to the inner zones (sterile core), and is
maintained by a differential pressure gradient cascading from the inner zone (sterile core)
to the outer zone. This pressure gradient is established and maintained by the ventilation
system.
• Important principles to incorporate in the planning and design include:
• Exclusion of contamination from outside the OT;

• Separation of clean areas from contaminated areas within the OTU; and

• Efficient, controlled traffic patterns within the OTU.

The Operating Theatre (OT) Services flow pathway

STERILE CORE PRINCIPLE
 The routes and method of transport of waste and contaminated items through the operating
unit need to be carefully considered in how they pertain to cross-infection, contamination
and patient views.
 A one-way flow of supplies into the operating room, and then of soiled goods and trash out
of the operating room, is preferred.
 The shared use of a corridor for staff and patient access into the OR is acceptable, but this
same
corridor should not be used for delivery of sterile supplies into the OR
 Sterile supplies and instruments should have a separate, dedicated pathway from the
central sterile supply into the operating room without encountering staff or patient traffic,
whether in scrubs or not.
A separate service corridor backing on to the theatres could be a solution.

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 This corridor will link through to the CSSD and the dirty utility room, from which waste
can be collected externally.

Operation
Theater

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