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Basic care and comfort in nursing refers to a fundamental aspect of patient care that involves providing essential physical and emotional support to clients. This includes assisting clients in compensating for physical or sensory impairments, managing alterations in bowel and bladder elimination, performing irrigations (e.g., of bladder, ear, eye), assessing and maintaining skin integrity, applying, maintaining, or removing orthopedic devices, promoting circulation through techniques like range of motion exercises and positioning, assessing and managing pain, recognizing complementary therapies, offering non-pharmacological comfort measures, evaluating and addressing nutritional needs, assisting with activities of daily living, providing nutrition through tube feedings when necessary, monitoring intake and output, and assessing and intervening in clients’ sleep/rest patterns. Basic care and comfort are essential components of holistic nursing care aimed at enhancing the well-being and quality of life of patients.

Assistive Devices:

• Assess the client for a problem related to physical or sensory (e.g., communication, vision, hearing) impairment and the need for an assistive device.
• Assess the client for psychosocial alterations if an assistive device such as a brace, walker, cane, or crutches is needed for assistance in ambulating.
• Ensure that the prescribed orthopedic device (e.g., cast, external fixation, skin or skeletal traction, halo traction) is in good working order.
• Evaluate the effectiveness of the compensatory device or technique.

Casts:

• Assess the affected extremity for open draining areas before casting; a window may be cut into the cast by the health care provider if an open area is present.
• Keep the cast and extremity elevated for the first 24 to 48 hours to reduce swelling.
• Allow a wet plaster cast 24 to 72 hours to dry completely. (Synthetic casts dry in about 20 minutes.)
• Handle a wet cast with the palms of the hands until it is dry.
• Turn the extremity, unless contraindicated, so that all sides of a wet cast can dry.
• Examine the skin around the edges of the cast for pressure areas.
• Petal the cast (when dry); maintain smooth edges to prevent crumbling.
• Monitor the extremity for circulatory impairment (e.g., pain, swelling, discoloration, tingling, numbness, coolness, diminished pulse); notify the health care provider immediately if circulatory compromise is suspected and prepare for bivalving or cutting of the cast.
• Monitor the client’s temperature and be alert for the presence of a foul odor or warmth of the cast, which may indicate infection.
• Watch for drainage, which could indicate bleeding or infection; circle any area of drainage on the cast and notify the health care provider.
• Assess the cast periodically for wet spots, which may indicate a need for further drying or the presence of drainage under the cast.
• Instruct the client not to stick objects inside the cast.
• Instruct the client to keep the cast clean and dry.
• Teach the client isometric exercises to prevent muscle atrophy.
• Provide pain management as needed.
• Educate the client and family on cast care and signs of complications.
• Offer emotional support.

Traction:

• Maintain proper body alignment for the client.
• Ensure that traction weights hang freely and do not touch the floor.
• Do not remove or lift the weights without a health care provider’s prescription.
• Ensure that pulleys are not obstructed and that the ropes in the pulleys move freely.
• Tie knots in the ropes to prevent slippage.
• Check the ropes for fraying.
• Assess for pain and provide pain relief.
• Assist with repositioning and hygiene.
• Educate the client and family about traction care.
• Provide emotional support.

Skeletal Traction:

• Monitor extremity color, motion, and sensation.
• Monitor insertion sites for redness, swelling, and drainage.
• Provide care to the pin insertion site as prescribed.
• Assess for pain and provide pain relief.
• Educate the client on pin site care.
• Assist with mobility as allowed by the traction.
• Offer emotional support.

Internal Fixation:

• Monitor for signs of infection.
• Assess the surgical site.
• Assist with mobility and pain management.
• Educate the client on wound care.
• Encourage early mobility.
• Provide emotional support.

     

External Fixation:

• Monitor the external frame.
• Assess pin sites.
• Ensure proper alignment.
• Educate the client on pin site care.
• Provide pain relief.
• Assist with hygiene and comfort.
• Offer emotional support.

Buck’s Traction: This method involves using traction to relieve muscle spasms by applying a straight pull on the limb using weights. A boot appliance is typically used to facilitate this traction. The weights are attached to a pulley, allowing them to hang freely over the edge of the bed. It’s important to note that no more than 8 to 10 pounds (3.5 to 4.5 kg) of weight should be applied, and a healthcare provider’s prescription is required. Additionally, elevating the foot of the bed helps provide the desired traction.

• Ensure proper weight application.
• Monitor for skin breakdown.
• Assess the client’s pain.
• Provide pain relief.
• Educate the client on skin care and positioning.
• Promote mobility within traction limits.
• Offer emotional support.

Cervical Skin Traction: Cervical traction is a technique that uses various devices such as elastic bandages, adhesives, boots, or other tools to alleviate muscle spasms and relieve compression in the upper extremities and neck.

• Properly apply traction devices.
• Protect the ears.
• Assess the client’s comfort and skin integrity.
• Educate the client on care.
• Provide emotional support.

Pelvic Skin Traction: Pelvic traction is employed to alleviate low back, hip, or leg pain and reduce muscle spasms. To do so, apply the traction securely over the pelvis and iliac crests, and subsequently connect it to the weights.

• Apply traction snugly.
• Elevate the client’s knees.
• Monitor the client’s comfort and skin condition.
• Provide pain relief.
• Assist with positioning.
• Offer emotional support.

                                                     

                                                     Halo Traction:

• Halo traction is a static traction method used for treating cervical fractures. It involves inserting pins into the client’s skull, attaching them to a circular fixation device (halo ring), and connecting the halo ring to a jacket or cast for spinal immobilization.
  Nursing Responsibilities:
  • Neurological Monitoring: Nurses should continuously monitor the client’s neurological status, paying attention to any changes in movement or signs of diminished strength. Early detection of neurological changes is crucial for prompt intervention.
  • Handling: It’s essential never to move or turn the client by holding or pulling on the halo device. Special care must be taken to avoid putting pressure on the halo apparatus.
  • Jacket Fit: Regularly assess the tightness of the jacket by checking that one finger can be slipped between it and the client’s skin. Proper fit helps prevent skin complications and discomfort.
  • Skin Integrity: Monitor the client’s skin integrity, particularly around the pin sites. Ensure that the jacket or cast is not exerting excessive pressure on any part of the client’s body. Regular skin assessments are vital to prevent pressure ulcers or skin breakdown.
  • Pin Site Care: Provide sterile pin site care as prescribed by the healthcare provider. This involves cleaning and caring for the areas where the pins are inserted into the skull to prevent infection or complications.

 

Aphasia:

• Aphasia is the inability to use or understand language, typically resulting from left hemisphere brain damage.
• Interventions include providing repetitive directions, breaking tasks into one-step instructions, using communication aids, and being patient.
• Types of aphasia include expressive (damage to Broca’s area), receptive (damage to Wernicke’s area), and global/mixed (affects both expression and reception).

Impaired Hearing Interventions:

• Use written communication if possible.
• Ensure proper lighting.
• Gain the client’s attention before speaking.
• Maintain face-to-face communication.
• Eliminate background noise.
• Speak clearly and slowly.
• Keep hands away from the mouth.
• Rephrase and repeat information.
• Encourage lip-reading and use of hearing aids or assistive devices.

 

Pain

Types of Pain:

• Acute pain is short-term and often associated with injury or surgery.
• Chronic pain is long-lasting and linked to chronic illnesses.
• Phantom pain occurs after limb amputation, with sensations felt in the missing limb.

Physical Pain Assessment:

• Pain assessment should consider degree, quality, area, frequency, and cultural influences.
• Nonverbal indicators of pain include moaning, restlessness, and changes in vital signs.
• Clients with cognitive disorders may have difficulty expressing pain verbally.
• Pain scales help assess pain intensity.
• Nonpharmacological interventions include heat/cold therapy, massage, distraction techniques, and complementary therapies.

Complementary and Alternative Therapies:

• Include acupuncture, acupressure, biofeedback, meditation, herbal therapies, and therapeutic touch.
• Caution is needed with herbal remedies to avoid interactions with prescribed medications.
• Consider the client’s preferred spiritual practices.
• Heat/cold applications require careful monitoring to prevent burns.
• Clients should be educated on the risks and benefits of complementary therapies.

 

Nonpharmacological Interventions

 

• Herbal Remedies: Some healthcare providers consider herbal remedies as pharmacological therapy; inquire about herbal use to avoid potential medication interactions.
• Spiritual Measures: Understand the client’s preferred spiritual practices and integrate them into the care plan when using spiritual measures.
• Prescriptions: Some complementary and alternative therapies may require a healthcare provider’s prescription for safety and compatibility with other treatments.

Key Points for Nonpharmacological Interventions for Physical Pain:

• Individualized Assessment: Pain is highly individualized; assess pain based on its degree, quality, location, and frequency. Consider cultural variations in pain expression.
• Age-Related Differences: Pain perception varies with age; be aware that older clients may express pain differently.
• Clients with Cognitive Disorders: Use alternative methods to assess pain in clients with cognitive disorders who may have difficulty expressing pain verbally.
• Pain Assessment Tools: Utilize pain assessment tools, such as number-based or picture-based scales, for accurate pain quantification.
• Complementary and Alternative Therapies: Seek approval from the healthcare provider when using these therapies to ensure compatibility with prescribed treatments.
• Educating Clients: Inform clients about the risks and benefits of complementary and alternative therapies, including herbal substances.
• Variety of Therapies: Nonpharmacological interventions for pain management include meditation, relaxation techniques, imagery, music therapy, massage, touch therapy, laughter and humor, and spiritual practices.
• Heat and Cold Applications: Applying heat or cold, or alternating between them, can reduce inflammation and swelling. Teach clients safe application and skin integrity assessment if prescribed.

 

Points to Remember for Pain Management:

• Pain is subjective; assess its nature and intensity.
• Cultural differences may affect pain expression.
• Elderly and cognitively impaired clients may show pain differently.
• Use pain scales and nonverbal cues for assessment.
• Consider complementary therapies and educate clients about them.
• Properly monitor heat/cold applications to prevent skin damage.

 

 

 

Urinary Elimination Assessment:

• Assess urination patterns, including frequency, volume, changes, and symptoms of urinary alterations.
• Identify factors affecting urination, such as medications, surgery, or illness.
• Monitor skin integrity in incontinent clients and provide skin care.

Factors That Affect Urinary Elimination:

• Age: Assess for age-related changes in urination.
• Sociocultural: Consider cultural norms and preferences related to urination.
• Psychological: Recognize that anxiety and stress can affect urination.
• Fluid Balance: Be aware of how fluid intake and certain beverages can influence urine production.
• Surgery: Understand that surgery and anesthesia can affect circulatory fluid volume and urine output.
• Medications: Know how diuretics, anticholinergic drugs, and other medications can impact urination.
• Pregnancy: Be aware of how pregnancy can increase the frequency of urination.
• Diagnostic Procedures: Understand how certain procedures may affect urine output.

Methods of Promoting Urination:

• Maintain normal urination routines.
• Initiate bladder-retraining programs if needed.
• Encourage daily fluid intake of 2000 to 2500 mL.
• Provide privacy and time for urination.
• Maintain personal hygiene to prevent urinary tract infections.
• Encourage foods and fluids that acidify urine.
• Provide sensory stimuli to facilitate urination (e.g turn on a running tap).
• Evaluate the effectiveness of interventions.

Components of a Bladder Retraining Program:

• Teach Kegel exercises to strengthen pelvic floor muscles.
• Establish an individualized toileting schedule.
• Instruct clients to take diuretics and foods that increase diuresis early in the day.

Urinary Catheterization:

• Use strict aseptic technique for catheter insertion and care.
• Maintain a closed drainage system.
• Monitor for patency, positioning, and potential obstructions.
• Perform perineal hygiene at least three times a day and after defecation.

Continuous Bladder Irrigation:

• Maintain traction on the catheter if applied.
• Use only sterile bladder irrigation solution.
• Adjust the infusion rate as prescribed to keep urine pink.
• Manage obstructions and monitor output closely.

Steps for Bladder Irrigation:

Bladder irrigation is a medical procedure used to flush the bladder with a sterile solution. It is commonly performed after certain surgeries, such as prostate surgery, to prevent blood clots and maintain urinary tract health. Here are the steps for bladder irrigation:

Gather Supplies: Ensure you have all the necessary supplies, including a urinary catheter, sterile irrigation solution (usually normal saline), an irrigation set, a sterile drape, sterile gloves, and a receptacle for fluid drainage.

Explain the Procedure: Explain the procedure to the patient, emphasizing the importance of bladder irrigation for their postoperative recovery.

Hand Hygiene: Perform hand hygiene and put on sterile gloves.

Position the Patient: Position the patient in a supine or comfortable position, exposing the genital area.

Prepare the Equipment: Assemble the irrigation set and ensure that the irrigation solution is at the prescribed temperature.

Catheter Insertion: If not already in place, insert a urinary catheter into the patient’s bladder as per institutional protocols. Ensure that the catheter is secured.

Connect the Irrigation Set: Connect the irrigation set to the catheter, making sure the connections are secure and a closed system is maintained.

Start the Irrigation: Begin the irrigation by allowing the solution to flow into the bladder at the prescribed rate and pressure. The solution helps flush out clots, blood, or other debris.

Monitor: Continuously monitor the urine for clarity, and assess the patient for any discomfort or signs of complications.

Adjust Flow: Adjust the flow rate as needed to maintain effective irrigation without causing discomfort or overdistending the bladder.

Complete the Irrigation: When the irrigation fluid returns clear or as prescribed by the healthcare provider, disconnect the irrigation set from the catheter.

Secure Catheter: Ensure that the catheter is properly secured and positioned.

Monitor Response: Monitor the patient for any improvements in urinary output or other relevant indicators.

Document: Document the procedure, including the type and volume of irrigation solution used, the patient’s response, and any complications.

Urinary Diversion:

• Address skin irritation and skin breakdown.
• Offer emotional support for body image issues.
• Refer the client to an enterostomal therapist if necessary.

Bowel Elimination Assessment:

• Identify the client’s usual elimination pattern and factors affecting it.
• Assess routines related to diet, fluid intake, and exercise.
• Determine emotional status and stressors.
• Ask about medication use, including laxatives or enemas.
• Evaluate changes in stool pattern or characteristics.
• Inquire about past surgeries or illnesses affecting the gastrointestinal tract.
• Monitor skin integrity and provide skin care for incontinent clients.

Factors That Affect Bowel Elimination:

• Age: Consider developmental milestones and age-related changes.
• Diet: Promote regular daily food intake and a high-fiber diet.
• Fluid Intake: Encourage adequate fluid intake to soften stool.
• Physical Activity: Emphasize the role of activity in promoting peristalsis.
• Surgery and Anesthesia: Understand the effects of surgery and anesthesia on peristalsis.
• Medications: Be aware of the impact of laxatives, cathartics, and other medications on bowel elimination.
• Personal Habits: Recognize that changes in schedule or environment may affect bowel patterns.
• Position: Consider the client’s position for defecation, especially for immobilized clients.
• Pain: Address pain-related issues that may interfere with defecation.
• Pregnancy: Understand how pregnancy can affect bowel elimination.
• Psychological Factors: Recognize the impact of stress, anxiety, and depression.
• Diagnostic Tests: Know that certain tests may require bowel preparation.

Methods to Promote Elimination:

• Maintain the client’s normal elimination routine.
• Initiate a bowel retraining program if necessary.
• Avoid medications causing constipation and consider stool softeners.
• Include high-fiber foods and adequate fluids in the diet.
• Encourage regular exercise.
• Use proper positioning for clients using bedpans.
• Choose appropriate bedpans for specific client needs.
• Evaluate the effectiveness of elimination-promoting interventions.

Components of a Bowel Retraining Program:

• Choose a time compatible with the client’s normal pattern for defecation measures.
• Administer stool softeners or cathartic suppositories as prescribed.
• Provide a hot drink or juice to stimulate peristalsis.
• Ensure privacy and allow time for defecation.
• Assist the client in assuming a position that facilitates defecation.

 

 

General Principles of Enema Administration:

• A health care provider’s prescription is required before administering an enema.
• Wear gloves and other appropriate protective items.
• Sterile technique is unnecessary, as the colon contains bacteria.
• If prescribed “enemas until clear,” repeat enemas until clear and free of fecal matter. Consult the health care provider if three enemas do not produce clear results.
• Administer the enema with the client in the modified left lateral recumbent position.
• Ensure that the enema solution is warm (around 105°F or 40.5°C).
• Insert the lubricated tube to the appropriate depth (3-4 inches in adults, 2-3 inches in children, 1-1.5 inches in infants).
• Raise the enema container to the appropriate level above the anus per agency procedure.
• Lower the container or clamp the tube if the client experiences cramping or fluid leakage.

General Principles for Digital Removal of Stool:

• This procedure requires a health care provider’s prescription.
• Use oil retention enemas or other softening methods before stool removal.
• Take baseline vital signs.
• Position the client in a left side-lying position with knees flexed.
• Wear gloves and protective gear.
• Gently insert a gloved finger into the rectum and move it along the rectal wall toward the umbilicus.
• Massage and gently loosen the hardened fecal mass, working it downward.
• Stop the procedure if the client exhibits signs of vagal response, such as weakness, diaphoresis, pale skin/mucous membranes, or decreased consciousness.
• Monitor the client’s heart rate closely and stop the procedure if the heart rate drops or rhythm changes due to vagal response.

Bowel Diversion:

• A bowel diversion involves creating a temporary or permanent stoma to divert fecal flow.
• Clients may need to wear a stomal pouch at all times for fecal collection.
• Be aware of the possibility of local irritation and skin breakdown, especially with ileostomies.
• Clients with ileostomies are at risk of fluid and electrolyte imbalances.
• Recognize the potential impact on body image and the risk of social isolation.
• Consider referring the client to an enterostomal therapist and relevant ostomy associations for support and education.

 

Mobility Assessment:

• Mobility is the ability to move freely with or without assistive devices.
• Assessment includes coordination, balance, ability to ambulate, and activities of daily living (ADLs).
• Range of motion (ROM), gait, strength, motor skills, and activity tolerance are considered in a mobility assessment.

Nursing Interventions:

• Assess the client’s mobility, including coordination, balance, and ability to perform ADLs.
• Evaluate the client’s range of motion (ROM), gait, strength, and motor skills.
• Monitor the client’s activity tolerance and provide assistance as needed.

Common Immobilization Complications:

(Respiratory, Cardiovascular, Musculoskeletal, Gastrointestinal):

• Respiratory: Atelectasis, Pneumonia, Reduced gas exchange, Orthostatic hypotension.
• Cardiovascular: Thrombus formation, Thrombophlebitis, Pulmonary embolism.
• Musculoskeletal: Generalized weakness, Stiff joints, Joint contracture, Foot drop, Osteoporosis.
• Gastrointestinal: Abdominal distention, Constipation, Decreased appetite, Protein deficiency.

Nursing Interventions:

• Monitor respiratory status and encourage coughing and deep breathing to prevent atelectasis and pneumonia.
• Assist with mobility exercises to prevent generalized weakness and joint stiffness.
• Educate the client about the importance of maintaining mobility to reduce the risk of complications.

• Respiratory: Pooling of Secretions.
• Cardiovascular: Thrombus formation.
• Musculoskeletal: Foot Drop.
• Gastrointestinal: Negative Nitrogen Balance, Renal Calculi.

Nursing Interventions:

• Encourage and assist with coughing and deep breathing exercises.
• Promote mobility and ambulation to prevent foot drop.
• Monitor urinary output and encourage fluid intake to prevent renal calculi.

(Integumentary, Renal, Metabolic, Psychological):

• Integumentary: Skin breakdown, Pressure ulcers.
• Renal: Urinary stasis, Urinary tract infections, Renal calculi.
• Metabolic: Decreased metabolic rate, Altered metabolism, Fluid and electrolyte imbalances.
• Psychological: Disorientation, Confusion, Boredom, Anxiety, Loneliness, Depression.

Nursing Interventions:

• Perform regular skin assessments and provide appropriate skin care to prevent pressure ulcers.
• Encourage frequent position changes and mobility to prevent urinary stasis and infections.
• Monitor and maintain fluid and electrolyte balance.
• Provide emotional support and activities to address psychological effects of immobility.

General Nursing Interventions to prevent, assess and manage immobilization complications:

Respiratory: Atelectasis, Pneumonia, Reduced Gas Exchange, Orthostatic Hypotension:

1. Incentive Spirometry: Encourage deep breathing exercises and the use of incentive spirometers to promote lung expansion and prevent atelectasis.
2. Frequent Turning and Positioning: Reposition bedridden patients regularly to prevent pooling of secretions and maintain optimal lung function.
3. Coughing and Deep Breathing: Teach and assist patients in performing coughing and deep breathing exercises to clear airways and improve gas exchange.
4. Mobility: Promote early ambulation and progressive mobility to prevent orthostatic hypotension and enhance respiratory function.
5. Hydration: Ensure adequate hydration to help maintain mucous membrane integrity and prevent thick secretions.

Cardiovascular: Thrombus Formation, Thrombophlebitis, Pulmonary Embolism:

1. Compression Stockings: Encourage the use of compression stockings to prevent deep vein thrombosis (DVT) and thrombophlebitis.
2. Ambulation: Promote early ambulation and leg exercises for patients at risk of thrombus formation.
3. Anticoagulant Medications: Administer anticoagulant medications as ordered by the healthcare provider to prevent thrombus formation.
4. Regular Assessment: Perform frequent assessments of extremities for signs of swelling, redness, or pain to detect thrombus or thrombophlebitis early.

Musculoskeletal: Generalized Weakness, Stiff Joints, Joint Contracture, Foot Drop, Osteoporosis:

1. Range of Motion Exercises: Implement range of motion exercises to maintain joint flexibility and prevent stiffness and contractures.
2. Strength Training: Provide muscle-strengthening exercises to combat generalized weakness and prevent further muscle atrophy.
3. Use of Assistive Devices: Recommend assistive devices like splints, braces, or orthotics to prevent foot drop and maintain proper joint alignment.
4. Weight-Bearing Activities: Encourage weight-bearing activities and adequate calcium and vitamin D intake to prevent osteoporosis.

Gastrointestinal: Abdominal Distention, Constipation, Decreased Appetite, Protein Deficiency:

1. Regular Bowel Regimen: Establish a regular bowel care regimen with dietary fiber, hydration, and stool softeners to prevent constipation and abdominal distention.
2. Nutritional Support: Collaborate with a dietitian to develop a well-balanced diet that meets the patient’s nutritional needs and preferences.
3. Small, Frequent Meals: Recommend smaller, more frequent meals to combat decreased appetite and protein deficiency.
4. Monitor and Record Intake: Keep accurate records of dietary intake and bowel movements to track changes and make necessary adjustments.
5. Education: Educate patients on the importance of maintaining good nutrition and hydration for overall health and recovery.

Integumentary: Skin Breakdown, Pressure Ulcers:

1. Skin Assessment: Conduct regular skin assessments to identify areas at risk of breakdown. Pay close attention to bony prominences and moist areas.
2. Repositioning: Reposition bedridden or immobile patients frequently to relieve pressure on vulnerable areas. Use specialized support surfaces like pressure-relieving mattresses or cushions.
3. Skin Care: Keep the skin clean and dry, using mild soap and water. Apply appropriate moisturizers or barrier creams to maintain skin integrity.
4. Nutrition: Ensure patients receive adequate nutrition, including protein, vitamins, and minerals, to support tissue repair and prevent skin breakdown.
5. Education: Educate patients and caregivers on the importance of skin care, pressure relief techniques, and early detection of pressure ulcers.

Skin assessment scales are tools used by healthcare professionals to evaluate and document the condition of a patient’s skin. These scales help in the systematic assessment of various aspects of skin health, such as pressure ulcers, wound healing, and dermatological conditions. Commonly used skin assessment scales include:

• Braden Scale for Predicting Pressure Sore Risk: This scale assesses a patient’s risk of developing pressure ulcers. It considers factors like sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each category is scored, with lower scores indicating higher risk.
  
• Norton Scale: Similar to the Braden Scale, it assesses the risk of pressure ulcer development but includes additional factors like mental state and mobility. It uses a scoring system where lower scores indicate higher risk.
• Glasgow Coma Scale (GCS): Although primarily used for assessing a patient’s level of consciousness, the GCS also includes an eye response component that evaluates eye opening.
• Wong-Baker FACES Pain Rating Scale: This scale is often used with pediatric patients and individuals with communication challenges to assess pain levels. It uses a series of faces depicting varying degrees of pain.
• Visual Analog Scale (VAS): VAS is a simple tool for assessing pain intensity in adults. Patients mark a point on a line to indicate their pain level.
• Numeric Rating Scale (NRS): Similar to VAS, the NRS assesses pain intensity using numbers (e.g., 0 to 10).
• Pressure Ulcer Staging: The National Pressure Ulcer Advisory Panel (NPUAP) has developed a staging system to classify pressure ulcers into four stages based on tissue damage.
• Skin Tear Classification System: This scale categorizes skin tears into three levels based on tissue loss and skin flap mobility.
• Dermatology Life Quality Index (DLQI): Used in dermatology to assess the impact of skin conditions on a patient’s quality of life.
• Photographic Documentation: Involves taking standardized photographs of skin lesions, wounds, or skin conditions over time to provide a visual record for monitoring changes.

Renal: Urinary Stasis, Urinary Tract Infections, Renal Calculi:

1. Hydration: Encourage and monitor fluid intake to maintain proper hydration, which helps prevent urinary stasis and the formation of renal calculi.
2. Regular Toileting: Ensure regular toileting and promote a voiding schedule for patients at risk of urinary stasis.
3. Aseptic Catheter Care: If applicable, maintain strict aseptic technique during catheter insertion and care to prevent urinary tract infections (UTIs).
4. Education: Teach patients about the importance of maintaining good hydration, proper perineal hygiene, and signs and symptoms of UTIs or renal calculi.

Metabolic: Decreased Metabolic Rate, Altered Metabolism, Fluid and Electrolyte Imbalances:

1. Nutrition: Collaborate with a dietitian to provide patients with a well-balanced diet tailored to their metabolic needs. Monitor and adjust caloric intake as necessary.
2. Monitoring: Regularly monitor patients’ vital signs, weight, and fluid intake/output to detect early signs of fluid and electrolyte imbalances.
3. Medication Management: Administer medications as ordered to manage metabolic conditions, such as thyroid disorders or diabetes, and closely monitor their effects.
4. Education: Educate patients on their specific metabolic condition, medication management, and the importance of adhering to dietary and fluid restrictions.

Psychological: Disorientation, Confusion, Boredom, Anxiety, Loneliness, Depression:

1. Orientation: Provide a structured environment and orient patients to time, place, and person as needed to reduce disorientation and confusion.
2. Stimulation: Offer activities, hobbies, and mental stimulation to combat boredom and loneliness. Encourage social interactions and visits from family and friends.
3. Anxiety Management: Implement relaxation techniques, deep breathing exercises, and, if necessary, medications to manage anxiety and promote emotional well-being.
4. Therapeutic Communication: Engage in therapeutic communication to address patients’ emotional needs, including actively listening and providing emotional support.
5. Mental Health Services: Collaborate with mental health professionals when needed for patients experiencing severe depression or other psychological disorders.

Maintaining Body Alignment:

• Correct body alignment reduces strain on muscles, helps maintain muscle tone, contributes to balance, conserves energy, and reduces injury risk.

Nursing Interventions:

• Educate the client on proper body alignment during mobility and activities.
• Assist the client in maintaining correct posture and body alignment.

 

 

Ambulation: Nursing Considerations:

1. Explain to the patient how you are going to prepare for ambulation, including transfer techniques out of bed and safety precautions while walking. Tailor the explanation to the patient’s educational level and beliefs.
2. Explain and demonstrate the specific gait technique to the patient or family caregiver.
3. Check for the appropriate height and fit of the assistive device, such as a cane, crutches, or walker.

1. • a. For a cane: Measure the cane’s height and handle position.
   • b. For crutches: Measure patient’s height, distance between the crutch pad and axilla, and elbow flexion angle. Crutch pad is 2-3 finger widths under the axilla to prevent “crutch palsy” caused by damage to the radial nerve which passes the axilla.
   • c. For a walker: Adjust the height of the walker and handgrips.

1. Ensure that the ambulation device has rubber tips to prevent slipping.
2. Remove obstacles from pathways, such as throw rugs, fall pads, and electrical cords, and wipe up spills promptly. Avoid crowded areas that increase the risk of imbalance.

Ambulation with Assistive Devices: If using crutches, have the patient report any tingling or numbness in the upper torso.

1. Help the patient from a lying position to the side of the bed or from a chair.
2. Allow the patient to sit on the edge of the bed for a few minutes, perform ankle and lower leg exercises, and check for dizziness.
3. Apply a gait belt around the patient’s waist.
4. Assist the patient in standing at the bedside and assess the device’s height and size.
5. If the patient is unsteady, return them to a chair or bed.
6. Decide with the patient how far they will ambulate.
7. Implement ambulation around the patient’s other activities and take scheduled rest periods.
8. Assist the patient in walking with a cane, crutches, or walker based on their weight-bearing status and gait pattern.

Crutches: Positioning Crutches in Tripod Position:

1. Stand facing the patient who will be using the crutches.
2. Place the crutch tips about 15 centimeters (6 inches) to the side of the patient’s feet. Ensure that the crutch tips are parallel to each other and evenly spaced on both sides.
3. Position the crutch tips about 15 centimeters (6 inches) in front of the patient’s feet. This ensures that the crutches are not too far ahead or too close, providing proper support and stability.
4. Check that the crutches are secure and stable in this tripod position before assisting the patient in using them for walking or standing.
   
   Ambulation with Crutches (Gait):

• a. Four-point gait: Each leg moves alternately with each opposing crutch.
• b. Three-point gait: Patient bears all weight on one foot, with the affected leg not touching the ground.
• c. Two-point gait: Requires partial weight bearing on both feet.
• d. Swing-to and swing-through gait: Used by patients with lower extremity paralysis or wearing braces.

Ambulation on Stairs with Crutches (Partial Weight Bearing, One Leg):

Ascending stairs:

• a. Patient begins in a tripod position and transfers body weight to the crutches.
• b. The patient holds the handrail with one hand, and you carry one crutch.
• c. The patient supports their weight evenly between the handrail and crutch, steps up with the weight-bearing foot, and maintains balance.Descending stairs:

• a. Patient begins in a tripod position and transfers body weight to the crutches.
• b. The patient holds the handrail with one hand, and you carry one crutch.
• c. The patient descends the stairs by moving one leg down a step while maintaining balance.

For Crutches remember: Up with the good (unaffected leg) and down with the bad (affected leg)

Ambulation with a Walker:

Have the patient stand straight in the center of the walker and grasp the handgrips on the upper bars.

1. The patient moves the walker a comfortable distance forward and takes steps while keeping the walker close to maintain a broad base of support.
2. If the patient cannot bear weight on one leg, instruct them to hop to the center of the walker using the strong leg, supporting weight on their hands.
3. Advise the patient not to attempt stair climbing with a walker unless they have a specific walker for stairs. Instead, they should use handrails.

After Ambulation:  Help the patient return to their bed or chair and assist them in assuming a comfortable position.

Transfer from Bed to Chair (Using Transfer Belt):

1. Perform hand hygiene.
2. Help the patient sit on the edge of the bed with the bed at the appropriate height.
3. Allow the patient to sit for a few minutes to adjust.
4. Position the chair at a 45-degree angle to the bed, facing the foot of the bed.
5. Lower the bed to ensure the patient’s feet comfortably touch the floor.
6. If the patient has partial weight-bearing ability and upper body strength, apply a transfer belt securely around their waist.
7. Help the patient put on stable, nonskid shoes or socks and place their weight-bearing or strong leg forward on the floor, with the weak foot back.
8. Position yourself with your feet spread apart, flex your hips and knees, and align your knees with the patient’s knees.
9. Grasp the transfer belt along the patient’s sides, keeping your palms up.
10. Rock the patient up to a standing position while straightening your hips and legs, with knees slightly flexed, ensuring your body weight moves in the same direction as the patient’s.
11. Pivot on the foot farthest from the chair and instruct the patient to use the chair’s armrests for support while easing into the chair.
12. Flex your hips and knees to lower the patient into the chair, maintaining proper body mechanics.
13. Assess the patient’s alignment and provide support for any weakened extremities.

Transfer from Bed to Chair (Using Mechanical/Hydraulic Lift):

1. Perform hand hygiene.
2. Help the patient sit on the edge of the bed with the bed at the appropriate height.
3. Allow the patient to sit for a few minutes to adjust.
4. Position the chair near the bed, ensuring there is enough space for the transfer.
5. Raise the bed to a high position with the mattress flat.
6. Have a second nurse positioned at the opposite side of the bed.
7. Roll the patient onto their side away from you.
8. Place a sling under the patient, ensuring proper placement.
9. Roll the patient back toward you, ensuring the sling is in the correct position.
10. Return the patient to a supine position, making sure the sling is smooth over the bed surface.
11. Place the patient’s glasses away if applicable.
12. Position the base of the mechanical/hydraulic lift under the patient’s bed.
13. Lower the horizontal bar of the lift to sling level following the manufacturer’s instructions.
14. Attach hooks on straps or chains to the holes in the sling, securing the lift to the sling.
15. Elevate the head of the bed to Fowler’s position.
16. Instruct the patient to fold their arms over their chest.
17. Use the lift to raise the patient off the bed.
18. Move the patient to the chair using the lift, with another nurse alongside for support.
19. Roll the base of the lift around the chair and release the check valve slowly to lower the patient into the chair.
20. Close the check valve when the patient is safely in the chair, remove straps, and position the patient correctly for sitting.

Lateral Transfer from Bed to Stretcher (Using Slide Board or Air-Assisted Device):

1. Apply clean gloves if there is a risk of soiling. Lower the head of the bed and lock the bed brakes.
2. Cross the patient’s arms on their chest.
3. Lower the side rails and fanfold the drawsheet on both sides.
4. Position nurses on both sides of the bed toward which the patient will be turned.
5. On a count of three, roll the patient onto their side with smooth, continuous motion.
6. Place a slide board under the patient or apply an air-assisted device.
7. Line up the stretcher so its surface is slightly lower than the bed, ensuring it’s locked in place.
8. Two nurses on the stretcher side, one nurse on the bed side, grasp the drawsheet handles.
9. On a count of three, use the drawsheet to slide the patient onto the stretcher or inflate the air-assisted device to transfer the patient.
10. Position the patient in the center of the stretcher, raise the head of the stretcher if needed, and raise the side rails. Cover the patient with a blanket.

 

Transfer of patient from wheelchair to bed:

• Check wheelchair locks, wheels, and footplates for proper functioning before use.
• Assess the patient’s weight, height, strength, cognition, level of pain, and balance to determine their ability to help with the transfer.
• Explain the transfer process to the patient and ensure they understand the steps.
• Maintain patient safety throughout the transfer.

Equipment:

• Transfer belt
• Nonskid shoes
• Wheelchair
• Transfer board (if needed)

Steps to transfer patient from wheelchair to bed:

1. Transfer a cooperative, weight-bearing patient from a wheelchair to a bed using the pivot technique: a. Adjust bed height to match the wheelchair. b. Position the wheelchair at a 45-degree angle next to the bed. c. Lock the wheelchair and raise footplates. d. Secure a transfer belt around the patient’s waist. e. Assist the patient to stand and pivot onto the bed. f. Guide the patient to sit on the edge of the bed and assist with leg placement. g. Help the patient return to a comfortable position in bed.
2. Transfer a non-weight-bearing patient with upper body strength from a wheelchair to a bed using a transfer board: a. Position the wheelchair at a 45-degree angle next to the bed. b. Remove the armrest nearest to the bed and lock the wheelchair. c. Raise footplates and apply a transfer belt. d. Align the wheelchair seat with the bed mattress. e. Use a transfer board to slide the patient from the chair to the bed. f. Guide the patient to sit on the edge of the bed and assist with leg placement. g. Help the patient return to a comfortable position in bed.
3. Perform hand hygiene.
4. Monitor vital signs and assess the patient’s well-being after the transfer.
5. Note the patient’s behavioral response to the transfer.
6. Confirm the patient’s understanding using “Teach Back.”
7. Document the patient’s ability to tolerate the transfer in their medical record. Monitor vital signs after the patient has  been transferred. Ask if the patient feels dizzy or fatigued.

 

Nursing Responsibilities to Prevent Immobility Complications:

• Ensure client safety.
• Monitor respiratory status and encourage coughing and deep breathing every 1 to 2 hours to promote lung expansion.
• Monitor skin integrity, provide skin care, turn and reposition the client every 2 hours, and use pressure-relieving support surfaces such as special mattresses, beds, and other devices to help prevent skin breakdown.
• Provide active and passive ROM exercises as appropriate to promote circulation.
• Place elastic stockings on the client or use sequential compression stockings as prescribed; monitor peripheral circulation.
• Monitor dietary intake and provide a high-fiber diet. Determine the need for stool softeners.
• Encourage increased intake of fluids.
• Maintain the client’s orientation.
• Provide diversional activities.
• Teach the client and family measures to help prevent complications.
• Evaluate the client’s response to interventions to prevent complications of immobility and revise the plan of care as appropriate.

Body Mechanics for Nurses Guidelines for Moving and Lifting Clients:

• Obtain assistance whenever possible.
• Ask the client to help in moving and lifting if he or she is able.
• Bend and flex the knees.
• Use the thigh, arm, and leg muscles rather than back muscles.
• Avoid bending at the waist.
• Use a wide base of support and keep the feet about shoulder width apart.
• Use smooth, coordinated movements.
• Work at the same level or height as the object to be moved.
• Face in the direction of the movement, keep the trunk straight, and avoid twisting when lifting and pulling (pulling requires less effort than pushing or lifting).
• Keep the elbows close to the body.
• Tighten abdominal muscles and tuck the pelvis to provide balance and protect the back.
• Use the arms as levers when pulling the client; lock the elbows and rock back on the heels, using body weight to move the client.

Nursing Interventions:

• Educate nursing staff on proper body mechanics to prevent injury during client movement and lifting.
• Encourage teamwork and assistance from colleagues when moving or lifting clients.
• Assess the client’s ability to participate in movement and lifting to avoid unnecessary strain.
• Promote the use of assistive devices and equipment when moving or lifting clients.
• Monitor staff compliance with proper body mechanics guidelines.

 

 

Nutrition Assessment:

• Assess the client’s ability to consume fluids and food, including swallowing ability and the need for assistive devices.
• Inquire about the client’s normal eating pattern, daily fluid intake, preferences, dislikes, and cultural considerations.
• Determine if the client is on a specific diet or has dietary restrictions due to a health disorder.
• Assess the client’s hydration status and watch for signs of dehydration or fluid overload.
• Inquire about medications taken and potential food/medication interactions.
• Measure the client’s height and weight to calculate the body mass index (BMI).

Calculating BMI:

• Divide weight in kilograms by height in meters squared to calculate BMI.
• Example: Weight = 75 kg, Height = 1.8 m, BMI = 23.15 (75 ÷ 1.82 = 23.15).

Nutrition Interventions:

• Monitor the client’s nutritional status:

• • Record intake and output.

• Initiate calorie counts for specific clients:

• • Anorexic
  • Malnourished
  • Transitioning from tube feedings to oral.

• Provide nutritional supplements, like high-protein drinks, if intake is insufficient.
• Base food and fluid provision on:

• • Client’s disease
  • Prescribed diet
  • Preferences
  • Cultural considerations.

• Encourage client independence in eating.
• Teach the client about diet components and MyPlate guidelines.

Dietary Considerations:

• Clear Liquid Diet includes:

• • Water
  • Bouillon
  • Gelatin
  • Other clear fluids.

• Full Liquid Diet includes:

• • Clear liquids
  • Milk
  • Pudding
  • Strained soups
  • Fruit juices.

• Mechanically Altered Diet involves:

• • Avoiding certain foods
  • Opting for soft, liquid, chopped, or puréed options.

• Low-Fiber (Low-Residue) Diet includes limited intake of:

• • Whole grains
  • Nuts
  • Seeds
  • Raw fruits/vegetables.

• High-Fiber (High-Residue) Diet includes:

• • Fruits
  • Vegetables
  • Whole-grain products.

• Cardiac Diet restricts:

• • Fat (saturated, trans-, polyunsaturated, monounsaturated)
  • Cholesterol
  • Sodium intake.

• High-Calorie, High-Protein Diet promotes nutrient-dense, calorie-rich foods.
• Sodium-Restricted Diet suggests:

• • Fresh foods over processed
  • Limits high-sodium items.

• Protein-Restricted Diet involves:

• • Low-protein products
  • Consideration of protein in fruits and vegetables.

• Renal Diet controls:

• • Protein
  • Sodium
  • Phosphorus
  • Calcium
  • Potassium
  • Fluid intake.

• Potassium-Modified Diet includes low and high potassium food options (e.g tomatoes, orange, bananas, potatoes, apricot, leafy greens)
• High-Calcium Diet emphasizes dairy products as primary calcium sources (dairy, yogurt, cheese, canned sardine, salmon, tofu)
• Low-Purine Diet suggests avoiding purine-rich foods (purine foods- fish, seafood, shellfish).
• High-Iron Diet includes iron-rich foods like:

• • Organ meats
  • Legumes
  • Dark-green leafy vegetables.

• Vegetarian Diets may require attention to potential nutrient deficiencies (e.g B12 also called cobalamin).
• Gluten-Free Diet avoids Barley, Rye, Oats and Wheat (BROW).

Tube Feedings:

• Administered when oral intake doesn’t meet nutrient needs due to various reasons.
• Check the healthcare provider’s prescription and agency policy on residual amounts before administering.
• Assess bowel sounds:

• • Hold feeding and notify if absent.

• Verify tube placement by aspirating gastric contents and measuring pH:

• • pH should be ≤3.5.

• Warm feedings to room temperature to prevent discomfort.
• Use an infusion feeding pump for continuous feedings:

• • Maintain semi-Fowler position.

Tube Feedings Precautions:

• Change feeding solution per agency policy.
• Do not hang more solution than needed for a 4-hour period.
• Check formula expiration date before use.
• Administer slowly for bolus feedings:

• • Maintain a high Fowler position afterward.

• Gently flush the tube before and after medication administration and bolus feedings.
• Prevent vomiting by administering feedings slowly, measuring abdominal girth, and avoiding air entry.

Tube Feedings Complication Prevention:

• Diarrhea:

• • Assess for lactose intolerance
  • Use fiber-modified solution
  • Administer slowly.

• Aspiration:

• • Verify tube placement
  • Limit residual volume
  • Keep head of bed elevated
  • Manage aspiration as needed.

• Clogged Tube:

• • Flush with water before and after medication and bolus feedings.

• Vomiting Prevention:

• • Administer feedings slowly
  • Measure abdominal girth
  • Avoid air
  • Elevate the head of the bed.

Basic Needs Important Recall:

• Maintain and encourage client independence in performing activities of daily living as much as possible.
• Use proper body mechanics during bathing and hygiene activities and when moving or positioning a client.
• To promote elimination of urine, provide sensory stimuli (e.g., running water; placing the client’s hand in a pan of warm water; warming a bedpan, if one is needed; pouring warm water over the client’s perineum).
• Maintain the client’s normal routine with regard to bladder and bowel elimination.
• If the health care provider prescribes “enemas until clear” but three enemas have been administered and the results are still not clear, the nurse should consult with the health care provider, because excessive enema use depletes fluids and electrolytes.
• The enema is administered with the client in the modified left lateral recumbent position.
• Monitor the client’s heart rate closely when removing stool digitally; if the heart rate drops or the rhythm changes, stop the procedure, because a vagal response resulting from stimulation of the sphincter and rectal wall may have occurred.
• Position the hospitalized client to promote comfort and avoid unnecessary treatments and procedures that require awakening the client during the night.
• Assess the client’s ability to consume fluids and food (i.e., swallowing ability, ability to chew); be alert to the risk for aspiration.
• Determine whether the client needs assistive devices (e.g., dentures to chew foods, special eating utensils).
• Base the provision of fluids and foods on the client’s disease/illness, prescribed dietary likes and dislikes, and cultural considerations.
• Promote client independence in eating as much as possible.
• Teach the client about diet and the components of adequate nutrition and the MyPlate guidelines.
• Potential deficiencies in vegetarian diets include energy, protein, vitamin B12, zinc, iron, calcium, omega-3 fatty acids, and (if the client’s exposure to sunlight is limited) vitamin D.

Eye Irrigation:

Eye irrigation is performed to cleanse the eye, typically in response to chemical exposure or foreign body removal. Here are the steps for eye irrigation:

Safety Precautions: Ensure your safety by wearing appropriate personal protective equipment (PPE) such as gloves and protective eyewear.

Examine the Eye: Assess the eye for any visible foreign bodies or chemical contamination.

Explain the Procedure: Explain the procedure to the patient, reassuring them that it is essential for their eye’s well-being.

Hand Hygiene: Perform hand hygiene and put on gloves.

Position the Patient: Have the patient sit in a stable position with their head tilted slightly backward and looking up.

Stabilize the Head: Gently hold the patient’s head or ask them to stabilize it using their hands or a headrest.

Irrigation Solution: Use a sterile, preservative-free saline solution or an appropriate eye irrigating solution as recommended by your institution.

Irrigation Technique: Hold the irrigation bottle or container approximately 1-2 inches above the affected eye. Ensure that the tip of the irrigation solution container does not touch the eye’s surface.

Open the Eye: With one hand, gently hold the eyelids open to expose the eye fully.

Irrigation: Using a steady and controlled flow, direct the stream of irrigation solution across the eye from the inner corner (near the nose) toward the outer corner. Ensure that the solution flows away from the unaffected eye to prevent contamination.

Continue Irrigation: Irrigate the eye for the recommended duration, usually at least 15 minutes or as directed by institutional protocols.

Assist the Patient: Encourage the patient to blink several times during irrigation to help flush out contaminants effectively.

Assess and Repeat: Continuously assess the eye for signs of improvement or the presence of any foreign bodies. Repeat the irrigation if necessary.

Document: Document the procedure, including the type and volume of irrigation solution used, the patient’s response, and any complications.

Ear Irrigation:

Ear irrigation is performed to remove excess earwax or debris from the ear canal. Here are the steps for ear irrigation:

Gather Supplies: Ensure you have all the necessary supplies, including an ear irrigation kit (containing a bulb syringe or irrigation bottle), warm water, a basin or receptacle, a towel, and otoscope (if available).

Explain the Procedure: Explain the procedure to the patient, emphasizing the importance of ear irrigation for their ear health.

Hand Hygiene: Perform hand hygiene and put on gloves.

Position the Patient: Have the patient sit upright with their head tilted slightly to the side, exposing the ear that needs irrigation.

Examine the Ear: If available, use an otoscope to assess the ear canal for the presence of earwax or any blockages.

Prepare Warm Water: Warm a small amount of water to body temperature. Ensure it is not too hot or too cold.

Fill Irrigation Device: Fill the bulb syringe or irrigation bottle with warm water.

Irrigation Technique: Gently pull the patient’s earlobe backward and upward to straighten the ear canal.

Irrigate the Ear: Hold the irrigation device just outside the ear canal opening and direct a gentle, steady stream of warm water into the ear canal. Do not force the water.

Allow Drainage: Allow the water and dislodged debris to drain into a basin or receptacle.

Repeat if Necessary: If earwax or debris remains, repeat the irrigation process as needed, always using gentle pressure.

Assess the Ear: After irrigation, assess the ear canal to ensure it is clear and free of obstructions.

Dry the Ear: Gently dry the ear canal with a clean, dry cloth or sterile cotton ball. Be careful not to insert anything deep into the ear canal.

Document: Document the procedure, including the type of irrigation device used, the amount of water used, the patient’s response, and any complications.

 

Postmortem Care:

1. Treat the body after death with respect according to cultural and religious practices:

1. • Nursing Intervention: Respect for cultural and religious practices is paramount when providing care for a deceased person. The nurse should first inquire about the cultural or religious preferences and rituals of the family. This information guides the appropriate handling and preparation of the body. Some key considerations include:

Buddhism:

• Cultural Practice: Buddhists prefer a quiet place for death, use incense, cover the body with a cotton sheet, leave the deceased’s mouth and eyes open. Others should not touch the body. Maintain strict silence after death. Autopsy and organ donation are permitted.
• Nursing Interventions:

• • Respect and Privacy: Ensure the environment remains quiet and calm to accommodate the preference for a quiet place for death.
  • Incense and Cotton Sheet: Provide incense if requested and place a cotton sheet over the body per the tradition.
  • Mouth and Eyes: Leave the mouth and eyes of the deceased open as per the cultural practice.
  • Autopsy and Organ Donation: Confirm the family’s stance on autopsy and organ donation, and facilitate their wishes accordingly.

Christianity:

• Cultural Practice: Christian denominations have varying practices at the time of death. Bible texts may be read, sacraments like Holy Communion may be administered, and prayers are common. Autopsy and organ donation are generally permissible.
• Nursing Interventions:

• • Flexible Approach: Be flexible and accommodating to the specific Christian denomination’s practices.
  • Facilitate Sacraments: Facilitate the administration of sacraments or readings if requested.
  • Communication: Maintain open communication with the family to understand their specific religious preferences and rituals.
  • Autopsy and Organ Donation: Ensure the family’s consent regarding autopsy and organ donation if relevant.

Hinduism:

• Cultural Practice: Hindus prefer to die at home or in a quiet setting. Efforts are made to resolve relationships before death. Specific rituals like facing the head east, chanting mantras, washing the body, and cremation are followed.
• Nursing Interventions:

• • Preferred Setting: Respect the preference for a quiet setting or death at home if possible.
  • Resolving Relationships: Support the family in any efforts to resolve relationships before death.
  • Orientation: Ensure the deceased’s head faces east with a lamp nearby as per the tradition.
  • Chanting Mantras: Facilitate the chanting of mantras, even if done by a family member.
  • Cremation: Coordinate with the family and relevant authorities for cremation arrangements.

Islam:

• Cultural Practice: In Islam, a reader recites verses from the Qur’an when the person is near death. Family members prepare the body, and non-Muslims should not touch it. The eyes are closed, and the arms and legs are straightened. Autopsy or organ donation is generally not permissible, except as required by law.
• Nursing Interventions:

• • Facilitate Religious Practices: Provide a private space for Qur’anic recitation and facilitate the preparation of the body by family members.
  • Respect and Privacy: Ensure that non-Muslim individuals refrain from touching the body in accordance with Islamic practice.
  • Eyes and Limbs: Close the deceased’s eyes and straighten the arms and legs.
  • Autopsy and Organ Donation: Respect the cultural and religious stance on autopsy and organ donation and follow legal requirements.

Judaism:

• Cultural Practice: Orthodox Judaism involves death bed confessions, blessings, and readings from the Torah. A family member remains with the body until burial, which takes place within 24 hours, excluding the Sabbath. The deceased’s eyes are closed. There may be restrictions on organ donation and considerations for autopsies.
• Nursing Interventions:

• • Religious Practices: Facilitate the practice of death bed confessions, blessings, and readings from the Torah if requested.
  • Burial Timing: Understand the need for swift burials within 24 hours, with exceptions for the Sabbath.
  • Eyes: Close the deceased’s eyes in line with the tradition.
  • Organ Donation: Respect any restrictions on organ donation based on religious beliefs, and consider the stance on autopsies.

 

2. Legal considerations for organ and tissue donation:

1. • Nursing Intervention: Be aware of legal requirements regarding organ and tissue donation. In many states, individuals can express their wish to be donors on their driver’s licenses. Family members typically provide consent for donation at the time of death. Nurses play a role in:

1. • • Identifying potential organ donors.
     • Providing care for the donor’s body.
     • Assisting and supporting the family throughout the donation process.
     • Educating families about the concept of “brain death” and the process of organ donation.
     • Ensuring cultural and religious considerations are respected in the donation process.

3. Post-mortem examinations (autopsy):

1. • Nursing Intervention: Autopsies are performed to determine the cause of death, disease pathways, or for research purposes. Nurses should:

1. • • Be available to answer family questions regarding autopsies.
     • Support the family’s choices related to autopsies.
     • Inform the family about the autopsy procedure and any potential costs.
     • Clarify that autopsies typically do not delay burial or alter the body’s appearance significantly.

Delegation and Collaboration:

• The skill of caring for a body after death can often be delegated to nursing assistive personnel (NAP). However, it is essential for nurses to collaborate closely with NAP to ensure that postmortem care is provided with dignity, respect for cultural or religious rituals, and in adherence to agency policies. The nurse should direct NAP to:

• • Follow agency policy regarding autopsies or organ and tissue donation.
  • Respect cultural or religious rituals when performing postmortem care.
  • Handle the body with care and preserve privacy.

Equipment:

• Nurses and NAP should be prepared with appropriate equipment, including clean gloves, isolation gowns, plastic bags for waste disposal, washbasins and supplies for body washing, shroud kits, syringes for urinary catheter removal, scissors, pillows or towels for positioning, tape, gauze dressings, bags for belongings, and valuables envelopes.

 

 

Postmortem care Assessment:

1. Time of Death and Autopsy:

1. • Ask the healthcare provider to establish the time of death and determine if an autopsy is planned.
   • Use special precautions to preserve evidence in cases of possible crime or autopsy (per agency policy).

2. Family Presence and Information:

1. • Determine if family members or significant others are present and if they have been informed of the death.
   • Identify the patient’s surrogate (next of kin or durable power of attorney [DPOA]).

3. Organ and Tissue Donation:

1. • Determine if the patient’s surrogate has been asked about organ and tissue donation and ensure a donation request form has been signed.
   • Notify the organ request team per policy.

4. Provide a Private Place for Family:

1. • Offer family members and friends a private place to gather.
   • Allow them time to ask questions and discuss grief, including medical care-related questions.

5. Family Requests for Body Preparation:

1. • Ask family members if they have requests for the preparation or viewing of the body (e.g., washing, positioning, special clothing).
   • Determine if they wish to be present or help with the care of the body.

6. Support Person for Family:

1. • Contact a support person (e.g., pastoral care, social work) to stay with family members who are not helping to prepare the body.
   • Implement a bereavement care plan if family remains the focus of care after the patient’s death.

7. Special Care Directives:

1. • Consult healthcare provider’s orders for special care directives or specimens to be collected (for determining the cause of death).

8. Hand Hygiene and Protective Gear:

1. • Perform hand hygiene and apply clean gloves, gown, or protective barriers as needed.

9. Body Assessment:

1. • Assess the general condition of the body and note the presence of dressings, tubes, and medical equipment.

Expected Outcomes:

1. • Ensure the body is free of new skin damage.
   • Allow significant others to express grief.

Positioning and Environment:

1. • Place the body in a supine position with the head of the bed elevated 30 degrees to decrease livor mortis.
   • Position the patient in a private room, if possible, or temporarily move the roommate to another location.

Death Pronouncement:

1. • Ensure that a patient’s death is officially pronounced by someone in authority, and appropriate forms are completed.

Equipment Preparation:

1. • Direct nursing assistive personnel (NAP) to gather the necessary equipment and arrange it at the bedside.

Implementation:

1. Notifying Others:

1. • Help family members notify others of the death.
   • Promptly notify the mortuary as chosen by the family and discuss plans for postmortem care.

2. Tissue Donation:

1. • If the patient has made tissue donation arrangements, consult agency policy for specific guidelines.

3. Hand Hygiene and Protective Gear:

1. • Perform hand hygiene and apply clean gloves, gown, or protective barriers.

4. Patient Identification:

1. • Identify the patient using at least two identifiers and tag the body according to agency policy.

5. Removal of Indwelling Devices:

1. • Remove indwelling devices (e.g., urinary catheter, endotracheal tube).
   • Disconnect and cap off intravenous lines but do not remove them, except as per agency policy.

6. Oral Care:

1. • Clean the mouth, replace dentures, or handle them as appropriate according to cultural preferences.
   • Close the mouth with a rolled-up towel if culturally appropriate.

7. Positioning and Grooming:

1. • Position the body supine with a small pillow under the head or as per cultural preferences.
   • Do not tie hands together; check agency policy regarding securing hands and feet.
   • Arrange the hair into a preferred style if known.
   • Remove any clips, hairpins, or rubber bands.
   • Avoid shaving the patient, especially if against religious beliefs.

8. Body Washing and Dressing:

1. • Wash soiled body parts as needed, following cultural practices if required.
   • Change soiled dressings and replace with clean dressings, using paper tape or circular gauze bandaging.

9. Absorbent Pad:

1. • Place an absorbent pad under the buttocks.

10. Clothing and Gown:

1. • Place a clean gown on the body, and follow agency policy regarding gown removal before placing the body in a shroud.

11. Personal Belongings:

1. • Identify personal belongings to stay with the body and those to be given to the family.

12. Viewing and Privacy:

1. • If the family requests viewing, provide a private and culturally sensitive environment.
   • Allow family time alone with the body and encourage them to say goodbye with religious rituals and in a culturally appropriate manner.
   • Respect the grieving process and avoid rushing it.

13. After Viewing:

1. • Remove linens and gown per agency policy.
   • Place the body in a shroud provided by the agency and identify it if required.

14. Transportation:

1. • Arrange prompt transportation of the body to the mortuary or morgue if there is a delay anticipated.

Recording and Reporting:

• Record relevant information in the nurses’ notes or electronic health record (EHR), including time of death, actions taken, and the certifying professional.
• Document any special preparations for autopsy or organ/tissue donation.
• Record names of mortuary personnel, family members consulted, and their relationship to the deceased.
• Document the handling of personal articles and belongings.
• Note the time of body transportation and its destination, including body identification tags.

Special Considerations:

• Pediatric: Offer support and accommodate the specific wishes of parents when a child has passed away.
• Gerontological: Ensure that older adults with limited familial support have someone present during the time of death.
• Home Care: Educate family members caring for a patient at home about what to expect at the time of death.

 

 

Hygiene care: The primary goal during personal hygiene care is to prevent both infection and patient injury. Healthcare providers should use clean gloves when necessary, follow infection prevention protocols, and perform hygiene measures moving from clean to less clean areas.

 

1. Maintaining Skin Health: The skin is the body’s largest organ and serves multiple functions, including protection from infection. Dry skin and skin rashes are common issues that can be addressed through proper bathing techniques, moisturizing, and avoiding irritants.
2. Oral Care: Good oral hygiene is essential for preventing dental issues and maintaining overall health. Regular dental care, proper brushing and flossing, and addressing dry mouth (xerostomia) are important aspects of oral care.
3. Hair Care: Hair care includes maintaining the health and appearance of scalp and hair. Special attention may be needed for patients with unique hair care requirements, such as those with certain medical conditions or disabilities.
4. Nail Care: Proper nail care involves maintaining healthy nails and preventing nail-related problems. It’s important to address any issues with the nails and provide appropriate care.
5. Monitoring and Assessment: Healthcare providers are responsible for assessing and evaluating patients before and after hygiene care to detect unexpected outcomes and provide proper guidance to nursing assistive personnel (NAP) when delegating hygiene care.
6. Safety and Infection Control: Safety measures should be followed to prevent patient falls, burns, or other injuries during hygiene care. Additionally, infection control practices, including hand hygiene and the use of personal protective equipment (PPE), are crucial in preventing the spread of infections.

 

Principles of Bed Baths:

• Bathing is important for hygiene, circulation, and relaxation.
• Follow skin care guidelines, use mild cleansers, and avoid extreme water temperatures.
• Avoid excessive force and friction on the skin to prevent pressure injuries.
• Minimize factors causing skin drying, like low humidity and cold exposure.
• Utilize bath time for patient assessment and interaction.
• Encourage joint range-of-motion exercises.
• Consider partial vs. complete bed baths based on patient condition.

Types of Baths:

• Complete Bed Bath: For totally dependent patients.
• Partial Bed Bath: Focuses on specific areas causing discomfort if left unbathed.
• Sponge Bath at the Sink: Allows patient participation; nurse assists with hard-to-reach areas.
• Tub Bath: Immersion in a tub for thorough cleaning.
• Shower: Provides more thorough cleaning but can be tiring.
• Disposable Bed Bath/Travel Bath: Contains premoistened cloths for convenience.

Therapeutic Baths:

• Ordered for specific effects, like soothing the skin or promoting healing.
• Examples include sitz baths and medicated baths.

 

Steps for bathroom:

1. Offer Patient Bedpan or Urinal.
2. Perform Hand Hygiene and Glove Change.
3. Adjust Bed Position.
4. Use a Bath Blanket.
5. Remove Patient’s Gown or Pajamas.
6. Prepare the Wash Basin.
7. Lower Side Rail and Wash Face.

Raise the head of the bed 30 to 45 degrees if allowed.

1. Wash Upper Extremities and Trunk.
2. Hand and Nail Care.
3. Check Bath Water Temperature.
4. Wash Abdomen.
5. Dress the Patient.
6. Wash Lower Extremities.
7. Wash Back.
8. Provide Perineal Care.
9. Massage Back (if desired).
10. Apply Body Lotion.
11. Remove Gloves and Perform Hand Hygiene.
12. Check External Devices.
13. Replace Top Bed Linen.
14. Ensure Patient Comfort and Safety.
15. Clean and Disinfect Bed Basin.
16. Perform Hand Hygiene and Leave the Room.

NOTE: Do not soak fingers of patient with diabetes mellitus.

 

Perineal Care:

• Routine perineal care is part of the bath, focusing on external genitalia and surrounding skin.
• Special attention for patients at infection risk.

Steps for Perineal Care:

 

1. Identify the patient and assess the environment for safety.
2. Assemble the necessary supplies.
3. Perform hand hygiene and put on clean gloves.
4. Explain the procedure to the patient and ensure privacy.
5. For female patients: a. Allow the patient to clean herself if able. b. Help the patient assume a dorsal recumbent position. c. Position a waterproof pad under the patient’s buttocks. d. Drape the patient with a bath blanket. e. Wash and dry the upper thighs. f. Wash the labia majora, retracting gently if needed, using a front-to-back motion. g. Clean the labia minora, clitoris, vaginal orifice, and urethral meatus. h. Rinse and dry thoroughly, using a front-to-back motion. i. Fold the bath blanket back between the patient’s legs.
6. For male patients: a. Allow the patient to clean himself if able. b. Help the patient to a supine position. c. Fold the lower half of the bath blanket up to expose the upper thighs and wash them. d. Cover the thighs with bath towels and raise the bath blanket to expose the genitalia. e. Gently raise the penis and place a bath towel underneath. f. Wash the tip of the penis at the urethral meatus and clean in a circular motion. g. Rinse and dry the penis thoroughly. h. Clean the shaft of the penis and the scrotum, paying attention to skinfolds. i. Rinse and dry thoroughly. j. Ensure the foreskin is in its natural position for uncircumcised males. k. Fold the bath blanket back over the perineum.
7. Avoid placing tension on an indwelling catheter, if present, and clean around it thoroughly.
8. Observe the perineal area for any signs of irritation, redness, or drainage that persists.
9. Dispose of gloves and used supplies properly and perform hand hygiene. Use the Teach-Back method to confirm the patient’s understanding of perineal care instructions.

Equipment:

• Common items include washcloths, towels, soap, toiletry items, disposable wipes, warm water, gowns, gloves, washbasin, and more.

Delegation and Collaboration:

• Assessment cannot be delegated; only the bathing skill can.
• Ensure NAP follows specific instructions, like avoiding massaging reddened skin.

 

Hygiene Care of unconscious or debilitated patient:

1. Provide privacy by pulling curtains or closing the room door.
2. Perform hand hygiene and put on clean gloves.

1. Set up the equipment and raise the bed to a suitable height.
2. Position the patient in a Sims’ or side-lying position with the head of the bed elevated.
3. Place a towel under the patient’s head and an emesis basin under their chin.
4. Remove dentures or partial plates if the patient has them.
5. If the patient is uncooperative, insert an oral airway.
6. Clean the patient’s mouth using a soft-bristled toothbrush or toothette sponge moistened in water, applying toothpaste or an antibacterial solution first if needed.
7. Brush the teeth, gums, tongue, lips, and cheeks, avoiding stimulation of the gag reflex.
8. Rinse the mouth several times and use suction to remove secretions.
9. Apply a thin layer of water-soluble moisturizer to the lips.
10. Inform the patient that the procedure is complete and return them to a comfortable position.
11. Raise side rails and lower the bed while leaving the call light within reach.
12. Clean equipment and return it to its proper place, placing soiled linen in a dirty laundry bag.
13. Remove and dispose of gloves properly, and perform hand hygiene.

Apply clean gloves and use a tongue blade and penlight to inspect the oral cavity.

Ask the debilitated patient if their mouth feels clean.

Use the Teach-Back method to assess the patient’s understanding of preventing choking during mouth care at home.

Complications and Interventions:

• If secretions or crusts remain, provide more frequent oral hygiene.
• If inflammation or bleeding of gums or mucosa is present, provide more frequent oral hygiene with toothette sponges and apply a water-based mouth moisturizer.
• If the lips are cracked or inflamed, apply moisturizing gel or water-soluble lubricant more often.
• If the patient aspirates secretions, suction the oral airway as needed, elevate the head of the bed, and notify the healthcare provider if aspiration is suspected.

 

Graduated Compression Stockings:

1. Review medical record for an order.
2. Identify the patient.
3. Assess risk factors for DVT.
4. Check for contraindications.
5. Assess skin, pulses, and extremities.
6. Obtain healthcare provider’s order.
7. Assess prior knowledge of elastic stockings.
8. Explain the procedure and purpose.
9. Position the patient supine.
10. Perform hand hygiene and clean the patient’s legs.
11. Measure the leg for stocking size.
12. Optionally apply powder.
13. Turn stocking inside out.
14. Place toes in the foot, slide up smoothly.
15. Instruct the patient not to roll down stockings.

Sequential Compression Devices (SCDs):

1. Review medical record for an order.
2. Identify the patient.
3. Assess risk factors for DVT.
4. Check for contraindications.
5. Obtain healthcare provider’s order.
6. Assess prior knowledge of SCDs.
7. Explain the procedure and purpose.
8. Position the patient comfortably.
9. Perform hand hygiene.
10. Remove SCD sleeves before allowing the patient to get up.
11. Report any issues with the patient’s calf.
12. Attach SCD sleeve connector and turn on the mechanical unit.
13. Position the patient comfortably and monitor SCD functioning.
14. Remove compression stockings or SCD sleeves at least once per shift.
15. Evaluate skin integrity and circulation.
16. Educate the patient/family about care and prevention.
17. Use Teach-Back to confirm understanding.
18. Document all relevant information in medical records or EHR.

 

Sleep and Rest

Assessing Client Sleep/Rest Pattern: To assess a client’s sleep/rest pattern, nurses should gather comprehensive information regarding the client’s sleep habits and patterns. This assessment includes:

1. Sleep Duration: Determine the average amount of sleep the client gets per night and if there are variations in sleep duration on different days.
2. Sleep Quality: Ask the client to describe the quality of their sleep. Assess if they experience any disturbances, such as frequent awakenings, restlessness, or difficulty falling asleep (insomnia).
3. Sleep Routine: Explore the client’s bedtime routines and rituals, including activities they engage in before sleep.
4. Sleep Environment: Evaluate the client’s sleep environment, including factors like noise, light, temperature, and comfort of the bed.
5. Sleep Medications: Ask about any medications or substances the client uses to aid sleep, such as over-the-counter sleep aids, herbal supplements, or prescription medications.
6. Daytime Sleepiness: Assess if the client experiences excessive daytime sleepiness, fatigue, or trouble staying awake during the day.
7. Snoring and Breathing Patterns: Inquire about snoring, gasping, or choking episodes during sleep, as these may indicate sleep-disordered breathing, such as sleep apnea.

Types of Sleep Problems and Definitions:

Insomnia: Insomnia is a common sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or both. It can lead to reduced sleep duration and poor sleep quality.

Sleep Deprivation: Sleep deprivation occurs when an individual consistently fails to obtain an adequate amount of sleep to meet their physiological and psychological needs.

Disturbed Sleep Pattern: This refers to disruptions in the normal sleep-wake cycle, leading to irregular sleep patterns, frequent awakenings, or non-restorative sleep.

Readiness for Enhanced Sleep: This is a nursing diagnosis indicating a client’s potential for improving their sleep patterns and overall sleep quality.

Factors That Affect Sleep:

Several factors can affect a client’s sleep patterns, including:

1. Stress and Anxiety: High levels of stress or anxiety can make it difficult to relax and fall asleep.
2. Pain: Pain or discomfort from various medical conditions can interfere with sleep.
3. Environmental Factors: Noise, light, extreme temperatures, and uncomfortable bedding can disrupt sleep.
4. Medications and Substances: Certain medications, caffeine, nicotine, and alcohol can interfere with sleep.
5. Medical Conditions: Conditions like sleep apnea, restless legs syndrome, and chronic illnesses can contribute to sleep disturbances.
6. Lifestyle Choices: Irregular sleep schedules, shift work, and poor sleep hygiene practices can negatively impact sleep.

Nursing Interventions to Improve Sleep and Rest :

Nursing interventions depend on the specific sleep problem and contributing factors, but some general strategies include:

1. Sleep Hygiene Education: Teach clients about healthy sleep hygiene practices, such as maintaining a consistent sleep schedule, creating a comfortable sleep environment, and avoiding stimulating activities before bedtime.Sleep Hygiene Practices include:Consistent Sleep Schedule:
   • Maintain a regular sleep schedule by going to bed and waking up at the same times every day, even on weekends.

   Create a Comfortable Sleep Environment:

   • Make your bedroom a sleep-friendly environment. Ensure your mattress and pillows are comfortable and supportive.
   • Control the room temperature to keep it cool, typically between 60-67°F (15-20°C).
   • Eliminate noise and use earplugs or a white noise machine if necessary.
   • Use blackout curtains or an eye mask to block out light.
   • Position hospitalized clients for comfort and minimize unnecessary nighttime treatments and procedures.

   Limit Exposure to Screens:

   • Avoid screens from electronic devices like smartphones, tablets, and computers at least an hour before bedtime.

   Be Mindful of Diet and Hydration:

   • Avoid large meals, spicy foods, caffeine, and alcohol close to bedtime.
   • Suggest avoiding going to bed either hungry or overly full.
   • Encourage a light bedtime snack like warm milk due to its L-tryptophan content.

   Regular Physical Activity:

   • Engage in regular physical activity, but avoid strenuous exercise too close to bedtime.

   Establish a Relaxing Bedtime Routine:

   • Wind down before bedtime with calming activities, such as reading, gentle stretching, taking a warm bath, or practicing relaxation techniques like deep breathing or meditation.

   Limit Naps:

   • If you need to nap during the day, keep it short (20-30 minutes) and earlier in the day to avoid interfering with nighttime sleep.

   Manage Stress and Anxiety:

   • Practice stress-reduction techniques like mindfulness, yoga, or progressive muscle relaxation to manage worries and calm your mind before sleep.

   Limit Clock-Watching:

   • Avoid checking the clock frequently during the night if you wake up. It can create anxiety and make it harder to fall back asleep.

   Avoid Alcohol and Nicotine:

   • Alcohol and nicotine are known to disrupt sleep patterns. If you smoke or drink alcohol, do so in moderation and avoid them close to bedtime.

   Limit Fluid Intake:

   • Reduce the consumption of liquids, especially in the evening, to minimize the need to wake up for bathroom trips during the night.

   Get Exposure to Natural Light:

   • Exposure to natural daylight during the day helps regulate your body’s circadian rhythm, making it easier to fall asleep at night.

   Create a Relaxing Bedtime Environment:

   • Keep your bedroom tidy and clutter-free. A clean and organized space promotes relaxation.
   • Consider using aromatherapy with scents like lavender, which can have calming effects.

   Seek Professional Help When Needed:

   • If you continue to experience sleep problems despite practicing good sleep hygiene, consult a healthcare provider or sleep specialist. Underlying medical conditions or sleep disorders may require treatment.
2. Stress Reduction: Provide stress-reduction techniques, such as relaxation exercises, mindfulness, or meditation, to help clients manage stress and anxiety.
3. Medication Management: If prescribed, educate clients about the proper use of sleep medications, including potential side effects and precautions.
4. Pain Management: Assist clients in managing pain through appropriate interventions and medications to promote better sleep.
5. Environmental Modification: Encourage clients to make changes in their sleep environment, like reducing noise and light, to improve sleep quality.
6. Monitoring and Referrals: Continuously monitor the client’s sleep patterns and assess the effectiveness of interventions. Refer clients to sleep specialists or other healthcare providers when necessary, especially for suspected sleep disorders like sleep apnea.
7. Promoting Physical Activity: Encourage regular physical activity, which can improve overall sleep quality.
8. Dietary Recommendations: Advise clients to avoid caffeine and heavy meals close to bedtime.
9. Cognitive-Behavioral Therapy for Insomnia (CBT-I): For clients with chronic insomnia, consider referring them for CBT-I, which is a structured therapeutic approach to improve sleep patterns.
10. Assistance with Medication Management: If clients are taking medications that affect sleep, monitor for side effects and work with healthcare providers to adjust or change medications if needed. The use of sedatives or hypnotics for sleep should be prescribed by a healthcare provider and used only in the short term.
11. Safety Measures: In cases of severe sleep deprivation or sleep disorders, emphasize the importance of avoiding activities that require alertness, such as driving or operating heavy machinery.
12. Support Groups: Suggest support groups or counseling for clients dealing with sleep problems to share experiences and coping strategies.

General Principles of Adequate Rest and Sleep:

• Sleep is essential for healing and maintaining health.
• Inadequate sleep can lead to daytime drowsiness, fatigue, irritability, depression, reduced concentration and memory, and an increased risk of accidents.
• Sleep needs vary by age, with infants needing about 16 hours a day and adults requiring approximately 5 to 10 hours per day.