Solution Manual For Fundamentals of Nursing 3rd Edition by Sue C. DeLaune, Patricia Kelly Ladner, La

Contents Key terms .............................................................................................................................................................. 1 Instructional strategies ......................................................................................................................................... 2 Resource aids........................................................................................................................................................ 3 Online resources................................................................................................................................................... 3 Evaluation strategies ............................................................................................................................................ 3 Review questions.................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................. 6

Chapter 1 Evolution of nursing education and theory Key terms Autonomy Being self-directed and taking initiative instead of waiting for direction from others; ethical principle that refers to the individual’s right to choose for oneself and the ability to act on that choice.

Concept The basic building block of a theory.

Discipline Field of study.

Existentialism A movement that is centred on individual existence in an incomprehensible world, driven by free will and our search for meaning.

Grand theory Concepts that represent global and extremely complex phenomena.

Metaparadigm The unifying force that names the phenomena of concern to each discipline.

Micro-range theory A concrete and narrow theory that establishes guidelines and frameworks for specific practices.

Middle-range theory Theory that addresses more concrete and more narrowly defined phenomena than a grand theory but does not cover the full range of phenomena of concern to a discipline.

Multidimensionally Acting based on the belief that we live at many realms of the universe all at once.

Nursing research Systematic application of formalised methods for generating valid and dependable information about the phenomena of concern to the discipline of nursing.

Nursing theory Provides a perspective from which to define the ‘what’ of nursing, to describe the ‘who’ of nursing and when nursing care is needed, and to identify © Cengage Learning Australia 2024

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the boundaries and goals of nursing’s therapeutic activities.

Paradigm Pattern, model or mindset that strongly influences one’s decisions and behaviours.

Phenomenon Observable fact or event that can be perceived through the senses and is susceptible to description and explanation.

Proposition Statement that proposes a relationship between concepts.

Self-care A learned behaviour and a deliberate action in response to need.

Self-care deficit Exists when the person is not able to perform one or more of the ADL. Simultaneity paradigm Nursing viewpoint that focuses on the quality of life from the individual’s perspective and conceptualises the interaction between person and environment as mutual and simultaneous.

Theory Set of concepts and propositions that provide an orderly way to view phenomena.

Totality paradigm Centred on the person who is defined as a combination of biological, psychological, social and spiritual features while in constant interaction with the environment to accomplish goals and maintain balance.

Instructional strategies • Highlighting and contextualising events of the transition of nursing in the nineteenth century assists students to understand that debates regarding care models continue today. Discuss similarities and the differences between the ideas of Florence Nightingale and the Sisterhood and the debate occurring in nursing practice at the time.

• Studying the history of nursing helps the student understand issues that face nurses today. Discuss the current issues with nursing, including autonomy (being self-directed), unity within the profession, supply and demand, salary, education and current practice.

• At the time Nursing Registration had some positive and negative impacts on practice. Ask the students to search in the literature for some further contextual information about the journey to achieving registration. In groups ask students to evaluate the seen and unseen consequences of nursing registration such as the exclusion of men, poor pay and conditions, the loss of duty nurses and the loss of autonomy.

• After achieving nursing registration, the next issue to face nursing was educational opportunities. Access some oral history recordings of past nurses reflecting on their training. Ask students to reflect on their own experience as a university student in comparison to the experiences of the hospital trained nurses.

• The process of transferring nursing education from the hospital system to the tertiary sector was a slow process that resulted in the production of government reports and inquiries. Access one of the reports and ask students to identify the key arguments made for the transfer of nursing education to the tertiary sector.

• Each profession has a distinct set of metaparadigms that helps define the profession and guide actions.

How is nursing’s metaparadigm different from that of medicine? Nursing’s metaparadigm is broader and focuses on interventions that influence the person, health, and the environment. Medicine focuses on interventions that directly impact the body and changing the body’s response to illness or disease.

Nursing focuses on how the person is responding to the disease or illness. Nursing also includes the concept of care as a basic element. © Cengage Learning Australia 2024

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• According to Parse, there are currently two paradigms existing within nursing: totality and simultaneity.

Explain the difference between the two paradigms. In the totality paradigm, the person is in constant interaction with the environment to establish goals and maintain balance. The person receiving nursing care is ill, and nursing goals within this paradigm focus on health promotion, care, cure of the sick, and prevention of illness. This is the prevailing paradigm in nursing. In the simultaneity paradigm, the person cannot be separated from the whole of the universe. Both the person and the universe change in unpredictable ways, creating health. Nursing’s goals within this paradigm focus on the person’s definition of quality of life, and the main decision maker within this paradigm is the person, not the nurse.

• Contemporary nursing theories are useful in many different nursing settings. Some theories pertain more specifically to acute care nursing, some to community nursing, and some to more specific clientele. Have your students ask several nurses from the university setting, hospital, homecare, and so forth, what, if any, nursing theory guides their practice. Discuss the results from this informal questioning. It will highlight that nursing theory is fluid in practice.

• Discussing theory and contextualising it to practice will make it relevant to students. Select four theories and ask students to consider how they might implement the ideas into their practice.

Resource aids Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation of conceptual models of nursing (2nd ed.). F. A. Davis.

Fawcett, J., & Gigliotti, E. (2001). Using conceptual models of nursing to guide nursing research: The case of the Neuman systems model. Nursing Science Quarterly, 14(4), 339–345.

Gage, J.D., & Hornblow, A.R. (2007). Development of the New Zealand nursing workforce: Historical themes and current challenges. Nursing Inquiry, 14(4), 330–334.

Helmstadter, C., & Godden, J. (2011). Nursing before Nightingale, 1815-1899. Farnham, Surrey: Ashgate.

National Library of Australia. (n.d.). Music, sound and video. Nursing Oral History. http://trove.nla.gov.au/music/result?q=nursing+oral+history Nightingale, F. (1946). Notes on nursing. Lippincott. (Original work published 1859.)

Online resources • The Australian Nursing and Midwifery History Project: http://anmhp.unimelb.edu.au • Nursing Theory: http://www.nursing-theory.org • Nursing Theories: http://currentnursing.com • Watson Caring Science Institute & International Caritas Consortium: https://www.watsoncaringscience.org/jean-bio/caring-science-theory

Evaluation strategies • Why is it important for a beginning nursing student to know and understand the history of nursing?

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• Discuss how Florence Nightingale was and remains a woman of her time?

• Discuss how early nursing leaders in Britain, New Zealand and Australia helped foster the growth of the nursing profession.

• Identify the main arguments for the transfer of nursing education from the hospital system to the tertiary sector.

• Have students analyse early nursing theory and compare /contrast with more contemporary nursing theories.

• The major metaparadigm concepts that provide structure to the domain of nursing are person, environment, health, and nursing. Have the students select one nursing theorist and determine how the theorist addressed each of these metaparadigm concepts.

• Have students select an article in a current nursing research journal and identify whether it is based on a nursing theory. Discuss the implications of theory-based practice with the students.

Review questions 1.

Since the formalisation of nursing, notably with Florence Nightingale, sociopolitical influences on the role of nursing have included (select all that apply): a. the cost of living for sick people b. the role of women in society c. technological advances improving health outcomes d. access to clean water, hygiene and employment e. registration and professionalisation of nurses.

Answer: b, c & e Rationale: The medical profession influenced the role and education of nurses in Britain, New Zealand and Australia during the 1880s until the 1980s. However technological advances and lobbying by nurses such as Fenwick (1887) led to registration and professionalisation of the nursing profession.

2.

In the 19th century, the Anglican High Church nuns: a. began training nurses at St Thomas’ Hospital b. introduced university-based nursing education c. set up their training school at the Sydney Hospital d. were the dominant model of nursing reform in England e. developed the first nursing theories.

Answer: d Rationale: It is the work of Helmstadter and Godden that is now highlighting the significance of this group of women in the development of nursing education and practice.

3.

Which was the first country to enact legislation to register nurses? a. Australia b. New Zealand c. Britain d. United States of America

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e. Germany.

Answer: b Rationale: The first country to enact legislation to register nurses was New Zealand in 1901. New Zealand has and continues to be innovative in developing nursing practice and education.

4.

Identify some of the key moments in the development of nursing practice and nursing education: a. 1811 Sydney Hospital opens, New South Wales (NSW), Australia b. 390–407 Early Christianity, deaconesses, like deacons, also ministered to the sick and poor c. 2011 Royal College of Nursing (RCN) Australia and the College of Nursing unite to form the Australian College of Nursing (ACN) d. 1945 The psychiatric nurse qualification is acknowledged and administered by the Nurses and Midwifery Board in New Zealand.

Suggested solution: Refer to Table 1-1. All of the options are possible answers.

5.

Nursing’s metaparadigm includes: a. concepts, theory, health and environment b. health, clinicians, environment and nursing c. providers, standards, models and clients d. the person, environment, health and nursing e. theory, health, environment, person.

Answer: d Rationale: People, environment, health and nursing are the unifying forces that define nursing as a discipline. Providers implement models and standards of practice for their specific discipline. Nursing’s metaparadigm is relevant when providing care for any client in any setting.

6.

A micro-range theory: a. is composed of concepts representing global and complex phenomena b. is the most concrete and narrow of theories that establishes nursing care guidelines c. describes, explains and predicts complex situations and directs interventions d. provides an overall framework for structuring broad, abstract ideas e. answers questions about nursing phenomena without covering the full range of concern to the discipline.

Answer: b Rationale: Micro-range theories are strongly connected to the clinical environment and result in recommending specific frameworks and practice often directing a specific nursing specialty or work environment.

7.

An organised, coherent set of concepts and their relationship to each other that is proposed to explain a given phenomenon best defines which of the following? a. A concept. b. A proposition. c. A theory. d. A discipline.

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e. A paradigm.

Answer: c Rationale: A theory is an organised set of related ideas and concepts; whereas concepts and propositions are structural elements of a theory, and a discipline is a field of study.

8.

Why are nursing theories important to the profession? (Select all that apply.) a. To guide nursing practice. b. To promote problem identification. c. To guide nursing research. d. To develop a language for nurses. e. To define professional nursing practice.

Answer: c, d & e Rationale: Nursing theories provide a framework for communicating nursing practice in coherent and meaningful ways. Further, research is used in nursing to test existing theories or generate new ones that are defining the unique contribution of nursing.

Spotlight on critical thinking It has been argued that nursing history has been presented from a predominantly female perspective.

1.

2.

3.

How could this have impacted the role of men in the nursing and midwifery profession?

Explain how this could imply that ‘caring’ is a female trait?

Explain why you think nursing history, until recently, has excluded certain groups of nurses from its history.

Suggested solutions: Women have been prominent in nursing leadership and practice. There is evidence that men were purposely excluded from practising as registered nurses. This exclusion may be based on patriarchal perceptions of the role of men in healthcare. Nursing historians are now only beginning to explore a series of excluded groups from the historiography such as men, indigenous populations and working-class women. Societal perceptions of women in the caring role have been reinforced to reflect the ‘motherhood’ role of nurturing or caring.

Nursing history is reflecting a more comprehensive understanding of nursing practice and nursing participants. It is now a more complex area of study.

4.

Why do you think, from a historical perspective, it is important to represent the nursing profession within the wider context of society as a whole?

Suggested solution: Students may consider the statement that researching where we have come from assists us to understand where we are now, enabling future planning. Nursing needs to be engaged with its community to respond to community needs and be able to offer services and care for society at large.

Nursing theories sit within two main paradigms: totality paradigm or simultaneity paradigm.

5.

Identify which paradigm of nursing aligns with your personal beliefs and values.

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6.

Many nurses state ‘they want to help people’ as a reason for entering the nursing profession. Explain how nurses might ‘help’ people who are unwell using one nursing theorist from the following • Grand nursing theory • Middle-range theory • Micro-range theory.

Suggested solution: Grand and middle-range nursing theories provide a framework on how nurses interact with people who are unwell. For example, Watson’s theory of caring focuses on a holistic approach such as creating a healing environment and assisting with basic needs. Peplau’s theory of interpersonal relations creates a relationship between the nurse and the person being cared for, where the nurse assists the individual to manage their illness. On the other hand, a micro-range theory would enable nurses to assist unwell people such as caring for individuals living with a chronic health condition by promoting adequate social support systems.

7.

Both New Zealand and Australian registered nurses are subject to standards for practice or competency domains. Discuss how these are used in nursing practice.

Suggested solution: These assist in curriculum development for undergraduate degrees and ensure ongoing assessment of and critical reflection by practising registered nurses.

8.

It is suggested that you should both incorporate an acknowledgement of cultural diversity and maintain cultural safety in your nursing practice. a. Explain what each term means. b. How can you apply this suggestion in your everyday interactions with patients?

Suggested solution: Cultural safety is the nursing practice of a person or family from another culture (different from the nurse) that is determined by the person or family. This requires reflection, knowledge and acceptance. Maintaining cultural safety begins becoming culturally aware, listening to people and their significant others, and accepting differences and preferences.

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Contents Key terms .............................................................................................................................................................. 1 Instructional strategies ......................................................................................................................................... 2 Resource aids........................................................................................................................................................ 3 Online resources................................................................................................................................................... 4 Evaluation strategies ............................................................................................................................................ 4 Review questions.................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................. 6

Chapter 2 Research and evidence-based practice Key terms Abstract Summary statement of a research article that identifies the purpose, methodology, findings and conclusions.

Concepts The basic building block of a theory.

Conceptual framework Structure that links global concepts together to form a unified whole.

Conceptualisation Process of developing and refining abstract ideas.

Construct Abstraction or mental representation inferred from situations, events or behaviours.

Dependent variable Outcome variable of interest.

Ethics Branch of philosophy concerned with determining right from wrong on the basis of a body of knowledge.

Evidence-based practice (EBP) The application of the best available empirical evidence, including recent research findings, to clinical practice in order to aid clinical decision-making.

Full disclosure Communication of complete information to potential research subjects regarding the nature of the study, the subject’s right to refuse participation, and the likely risks and benefits that will be incurred.

Hypothesis Statement of an asserted relationship between dependent variables.

Independent variable Variable that is believed to cause or influence the dependent variable.

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Informed consent Individual understands the reason for the proposed intervention, knows its benefits and risks, and agrees to the treatment by signing a consent form.

Joanna Briggs Institute (JBI) International not-for-profit, research and development arm of the School of Translational Science, based within the Faculty of Health Sciences at the university of Adelaide, South Australia Nursing research Systematic application of formalised methods for generating valid and dependable information about the phenomena of concern to the discipline of nursing.

Primary source Major provider of information about self or client; research article written by one or more researchers.

Qualitative analysis Integration and synthesis of narrative, non-numeric data.

Qualitative research Systematic collection and analysis of subjective narrative materials using procedures for which there tends to be a minimum of research-imposed control.

Quantitative research Systematic collection of numerical information, often under conditions of considerable control.

Recontextualising Exploration of the developed theory in terms of its applicability to other settings or groups.

Research Systematic method of exploring, describing, explaining, relating, or establishing the existence of a phenomenon, the factors that cause changes in the phenomenon and how the phenomenon influences other phenomena.

Research design Overall plan used to conduct the research.

Secondary source Source of data other than the client, family members, other health care providers, or medical records; research article in which an author addresses the research of someone else.

Theory Set of concepts and propositions that provide an orderly way to view phenomena.

Value Variation of the variable.

Variable Anything that may differ from the norm.

Instructional strategies • Describe the steps in the research process. The research process is based on sequential, interrelated steps. The researcher first formulates a research question or problem. The purpose of the study is defined, and the researcher then conducts a review of the literature relevant to the problem identified. A conceptual framework is developed to provide a structure that links global concepts together to form a unified whole. The researcher develops research objectives, questions, and/or hypotheses. Research variables are defined, and a research design is selected. The population, sample, and setting are defined.

A pilot study is conducted. Data are collected and analysed, and findings are communicated via various forms.

• Leaders in the discipline of nursing encourage practitioners to base clinical decision-making on evidencebased practice. Why is basing our clinical practice on research findings essential to the profession of

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nursing? The identification of the knowledge generated from research findings/evidence contributes to achieving client outcomes and making nursing practice credible.

• What is the purpose of an abstract? An abstract is a summary of a research study that includes four parts.

The first part provides the title of the study. The next section introduces the scientific problem. The third section reviews the methodology. The final section provides the results.

• Prior to conducting a research study, the population must be obtained. What steps must be taken to ensure that human rights are protected in the population being studied? There are six steps to protect human rights in research. Step one is self-determination. This means that the person has the right to control his or her own destiny. Step two is privacy. This means that the person has to determine the time, extent, and circumstances under which private information will be shared or withheld from others. Step three is anonymity. This means that any data collected will be kept confidential. Step four is fair treatment. In fair treatment, the person is to be treated fairly and should receive what he or she is due or owed. Step five, protection from discomfort and harm, is based upon the ethical principle of beneficence and means that the person is to be protected from physical, emotional, social, and economic harm. And the final step, informed consent, means that the person understands the reason for the study, the benefits, and the risks, and agrees to participate by signing a consent form.

Resource aids Adhikari, R., Tocher, J., Smith, P., Corcoran, J., & Macarthur, J. (2020). A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Nurse Education Today, 34(2), 185–90. https://doi.org/10.1016/j.nedt.2013.10.008 Bosewell, C. (2007). Introduction to nursing research: Incorporating evidence-based practice. Jones and Bartlett.

Gray, J. R. & Grove, S. K. (2020). Burns and Grove’s The practice of nursing research, appraisal, synthesis, and generation of evidence (9th ed.). St. Elsevier.

Lin, F., Gillespie, B.M., Chaboyer, W., L, Y., Whitelock, K., Morley, N., Morrissey, S., | O’Callaghan, F., Marshall, A.P. (2019). Preventing surgical site infections: Facilitators and barriers to nurses’ adherence to clinical practice guidelines: A qualitative study. Journal of Clinical Nursing, 28(9-10), 1643–1652. https://doi.org/10.1111/jocn.14766 Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Wolters Kluwer/Lippincott Williams & Wilkins.

Ollivier, R., Aston, M., & Price, S. (2019). Let's talk about sex: A feminist poststructural approach to addressing sexual health in the healthcare setting. Journal of Clinical Nursing, 28(3-4), 695–702. https://doi.org/10.1111/jocn.14685 Polit, D. F. & Beck, C.T. (2020). Nursing research: Generating and assessing evidence for practice. (11th ed.).

Wolters Kluwer Renolen, Å., Hjälmhult, E., Høye, S., Danbolt, L. J., & Kirkevold, M. (2019). Evidence-based practice integration in hospital wards-The complexities and challenges in achieving evidence-based practice in clinical nursing. Nursing Open, 6(3), 815–823. https://doi.org/10.1002/nop2.259

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Richardson-Tench, M., Nicholson, P. (2022). Research in nursing, midwifery and allied health evidence for best practice (7th ed). Cengage.

Sherriff, K. L., Wallis, M., & Chaboyer, W. (2007). Nurses' attitudes to and perceptions of knowledge and skills regarding evidence-based practice. International Journal of Nursing Practice, 13(6), 363–369. https://doi.org/10.1111/j.1440-172X.2007.00651.x

Online resources • Nursing and midwifery board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Have students discuss major differences in quantitative versus qualitative research and which type of nursing studies would benefit by one application or the other.

• Students often mistake popular literature for scientific literature. Select two articles – one from a popular magazine such as Good Housekeeping and an article on the same subject from a nursing journal – and have students identify the differences in the two articles.

• Have students select a research study appearing in a current nursing journal and identify key terms of the research chapter.

• Have students do an internet search to identify current nursing research topics. Discuss how the use of the internet has advanced the position of nursing research as a body of knowledge.

• Have students select a research study regarding a subject that will be discussed in the course (e.g., hand washing). In small groups, have the students present their selected studies and identify the steps of the research process.

• Have students research best practices. From the list of best practices, the students should then document if the best practice is evidenced-based and provide evidence of such.

• Have students ask current nursing staff if they utilise research in the planning and provision of care. If so, list the types of research the nursing staff use. If not, identify the barriers the staff provide as reasons for not utilising research in practice.

Review questions 1.

The research process is best described as a: a. method to select a frame of reference b. set of rules that govern the selection of subjects c. series of steps completed in a logical order d. plan that directs the research design e. way of choosing the research setting.

Answer: c Rationale: Research is a systematic investigative process used by all science-based disciplines. Evidence, experience and critical thinking are factors that might influence the research process or results.

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2.

Qualitative research is interested in questions that involve: a. cause-and-effect b. consciousness and subjectivity c. control and measurement d. generalisation and prediction e. statistical analysis and power.

Answer: b Rationale: Qualitative research is interested in questions that involve human consciousness and subjectivity and that value humans and their experiences in the research process.

3.

Informed consent requires that the researcher communicate which of the following to the participant?

(Select all that apply.) a. The nature of the study. b. The subject’s right to refuse participation. c. That the data will be shared with all health care providers. d. The expected outcomes, risks and benefits, of the study. e. That the family and the prescribing practitioner determine the client’s right to participate. f. That the agency has the right to use the data freely.

Answer: a, b, d Rationale: Informed consent requires full disclosure, including the nature of the study, the subject’s right to refuse participation, and the likely risks and benefits of the study. Research data collected are kept confidential.

4.

Clinicians have problems in applying research due to lack of: a. time b. evidence c. research skills d. awareness e. all of the above.

Answer: d Rationale: While nursing has an inadequate scientific base, nurses are often not prepared to utilise research and are limited to resources and communication with researchers.

5.

Number the following steps of evidence-based reports in the appropriate order. a. Level of evidence b. Ask the clinical question c. Analysis of scientific data a. Recommendations for practice.

Answer: b, c, a, d Rationale: Using a step-by-step approach ensures that the nurse will obtain the strongest available evidence to apply in client care. Evidence reports identify the need for information, analysis of scientific data, level of evidence, and recommendations for practice.

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Spotlight on critical thinking Research 1.

Explain the basis for research and knowledge development in nursing.

Suggested solution: Research and knowledge development is fundamental for advancing nursing practice and the profession. The nursing profession requires research and knowledge development to occur in order to provide evidence-based practice to the patients who receive nursing care. The use of evidence-based practice optimises the quality of care patients receive and the environment in which nursing care is delivered.

Research proposal 2.

Discuss why research proposals are necessary.

Suggested solution: A research proposal is necessary to demonstrate the quality and significance of the proposed research. The research proposal also demonstrates your ability to undertake the proposed research.

3.

What basic information is needed before a research proposal can be written?

Suggested solution: It is important for the researchers to consider the research idea, including what problem the research will address. The specific research question and the research approach, including research design are also required.

Your research class is debating the importance of providing a detailed explanation of the research design in a research proposal.

4.

Explain the importance of this.

Suggested solution: A detailed description of the research design in the proposal is important for the evaluation of the proposal. Enough detail of the design must be provided so that the reader can understand how the question is intended to be answered.

5.

Discuss some possible reasons for a research project not achieving its stated aims and objectives.

Suggested solution: A research project may not achieve its stated aims and objectives if sufficient participants are not recruited or if participants withdraw from the study; the budget may be insufficient to complete the research; the timeline may not be enough to collect the data and complete analysis.

Evidence-based practice 6.

Discuss the value of EBP for the person, for the individual nurse and for the discipline of nursing?

Suggested solution: For the person, EBP means the care they receive is based on the best available evidence and is decided in collaboration with them. For the individual nurse, it means they are communicating effectively with people they are providing care for and the healthcare team about the rationales for their decision-making and care plans and they are developing their knowledge. For the discipline of nursing, it means that a greater scientific base of knowledge is being generated.

A call for expressions of interest has been circulated in the hospital for staff to be involved in the development of clinical practice guidelines (CPGs) for preventing falls in elderly people. You have been working in the geriatric ward and have become concerned about the lack of consensus regarding how to manage this clinical problem.

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7.

Discuss the relationship between clinical practice guidelines and evidence-based practice.

Suggested solution: Clinical practice guidelines bridge the gap between research and clinical practice by providing practice recommendations based on rigorously developed systematic reviews and consensus among clinical experts and key stakeholders. They guide clinicians in the implementation of evidencebased practice.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 5

Chapter 3 Health care delivery Key terms Comorbidity More than one disease, illness or condition occurring at the same time but independently of each other. The two (or more) conditions may interact, causing a greater impact on the health of the person.

An example would be having two chronic conditions like hypertension and anaemia.

Continuous quality improvement (QMI) Approach to quality management in which scientific, data-driven approaches are used to study work processes that lead to long-term system improvements.

Cross-functional team An interdepartmental, multidisciplinary group that is assigned to study an organisation-wide process.

Functional team Interdepartmental, multidisciplinary group that is assigned to study an organisation-wide process.

Health care system Mechanism for providing services that meet the health-related needs of individuals.

Organisational culture Commonly held beliefs, values, norms, and expectations that drive the workforce.

Performance improvement Activities and behaviours that each individual does to meet customers’ expectations.

Primary care provider Health care provider whom a person sees first for health care; typically, a family practitioner (prescribing practitioner/nurse), internist or paediatrician.

Primary health care Person’s point of entry into the health care system; includes assessment, diagnosis, treatment, coordination of care, education, preventive services, and surveillance.

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Process improvement Process that examines the flow of individual care between departments to ensure that the processes work as they were designed and that acceptable levels of performance are achieved.

Quality Meeting or exceeding requirements of the individual.

Quality assurance (QA) Traditional approach to quality management in which monitoring and evaluation focus on individual performance, deviation from standards, and problem-solving.

Secondary health care Health care provided by health care professionals who do not have the initial contact with the person. This type of care is usually delivered in a hospital/clinic with the initial referral being made by another health care professional. Examples include specialist medical professionals, physiotherapists and dieticians.

Team Group of individuals who work together to achieve a common goal.

Tertiary health care Specialised health care provided in an acute hospital setting that requires 24-hour support and monitoring.

Instructional strategies • Describe types of health care services and explain how these are funded. Public agencies in Australia and New Zealand are overseen and financed by their respective governments; thus, these agencies are accountable to the public. The Australian governments funding includes three major national subsidy schemes: Medicare, the Pharmaceutical Benefits Scheme and the Private Health Insurance Rebate.

Medicare provides access to doctors of choice for out of hospital care, free public hospital care and subsidised pharmaceuticals.

In New Zealand the public sector involves The Ministry of Health at the Federal level being responsible for the oversight and funding of twenty District Health Boards (DHB). The DHBs are funded by the government and are responsible for providing or funding health and disability series in their district.

The private component of the health care system in Australia and New Zealand consists of all nongovernmental sources. The private sectors provision of health care includes private medical practitioners, private hospitals, pathology services and pharmacies. Individuals and families can purchase private health insurance to cover some of the costs of health care as a private patient. Private health insurance can cover private hospital charges and a portion of medical fees for inpatient services. Private insurance also covers allied health services such as physiotherapy and some aids and appliances.

• Ask your students to elaborate on the meaning of quality in health care and what it means to the consumer. In relation to nursing care, the consumer may include the following in the determination of quality care: food served hot and in a timely manner, failure to respond to a call light in a punctual fashion, perceived long wait for treatments and pain medication, and unemptied bedpans.

• How does implementation of total quality management (TQM) in a facility affect the nursing staff? The implementation of a TQM model promotes an organisational culture that supports customer needs and empowers employees. It moves the decision-making power to the staff at the point of service. It encourages employees to become autonomous and creative. Staff satisfaction increases with this approach to business and that leads to less turnover. Management is concerned less with authority and power and more with development of a collaborative and supportive relationship with the staff.

• Using Table 3-2 ‘Health care providers’ in the text, have students identify members of the multidisciplinary health care team used to treat a person with diabetes, a person who has a wound, and a

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pregnant woman with twin gestation. It is important to include the physician, nurse, podiatrist, dietician, social worker, physiotherapist and occupational therapist, and chaplain in a multidisciplinary approach. It is beneficial to include the primary nurse and case management staff of the hospital or nursing care unit who are directly involved with the person’s care.

• The health care industry is under scrutiny by the federal government, payers and individuals. What are some of the most pressing issues facing the industry today, and how do these issues impact nursing? The population is getting older, which means more individuals will need health care. As resources are becoming more controlled, the need for health care services increases, and nurses need to be prepared to deliver care to an ageing population. The nation is becoming more diverse, which increases the need for nurses to be adept at cultural diversity. With the advances in technology, nurses need to be prepared to utilise technology while not losing sight of the person. More emphasis is being placed on wellness and individual responsibility for personal health and care. Nurses must be prepared to instruct people on wellness activities.

Resource aids Australian Council on Healthcare Standards. (2021). The ACHS EQuIP 6 guide (6th ed.). https://www3.achs.org.au/programs-services/equip6 Australian Government. (2020). Addendum to the National Health Reform Agreement. http://www.federalfinancialrelations.gov.au/content/national_health_reform.aspx Australian Indigenous HealthInfoNet. (201721). Overview of Aboriginal and Torres Strait Islander health status 201620. http://www.healthinfonet.ecu.edu.au/health-facts/overviews Australian Institute of Health and Welfare. (2020). Health expenditure Australia 2015–16. Health and welfare expenditure series no. 58. Cat. no. HWE 68. Australia’s Health 2020: In brief. Australia’s health series no.17 Cat. no. AUS 232. AIHW. Department of Health and Human Services. (2021). Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Act 2015. https://www.legislation.vic.gov.au/in-force/acts/safe-patient-care-nursepatient-and-midwife-patient-ratios-act-2015/008 Health Workforce Australia (2014). Australia’s future health workforce – Nurses overview. HWA. Kohn, L., Corrigan, J., & Donaldson, M. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.

Online resources • Australian Commission on Safety and Quality in Health Care: http://www.safetyandquality.gov.au • Australian Council on Healthcare Standards: https://www.achs.org.au • Australian Indigenous HealthInfoNet: https://healthinfonet.ecu.edu.au • Private Healthcare Australia: https://www.privatehealthcareaustralia.org.au

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Evaluation strategies • Ask a representative from the relevant nursing union to elaborate to the class the state of the health care delivery system and how nurses individually or in organisations can influence health care trends.

• For a month, have students collect newspaper and magazine articles related to current health care issues, especially as they relate to the nursing profession, and discuss in class.

• Discuss the evolution of different health care settings and how the nursing profession has adjusted to new placement for services.

• Have students identify the health care delivery systems that are available in their community. Discuss the realities of the economic side of health care.

• Have students interview nurses in various practice settings on how they improve quality on an individual basis.

• Discuss with students how the implementation of a quality improvement initiative can decrease the cost of providing health care.

• Encourage student discussion regarding their health care experiences. Discuss what characteristics of a facility and its personnel produce both positive and negative encounters.

• Have students research an actual or potential care delivery problem in a health care facility. From this problem, design a total quality improvement study to address the problem. Include all applicable health care providers, processes, and expected outcomes from the study of the problem.

• Health care organisations must adopt an organisational culture of customer service. Using the dimensions listed in Table 3-6, ‘Organisational culture’, have the students provide examples of each dimension observed in a health care organisation. Identify the dimension, the observed behaviour, and whether the behaviour is either that of a traditional organisation or that of a high-performance organisation.

Review questions 1.

In Australia, what agency of the Department of Health develops the National Clinical Safety and Quality Standards? a. The National Health and Medical Research Council b. The Therapeutic Goods Administration c. The Australian Institute of Health and Welfare d. The Australian Commission on Safety and Quality in Health Care e. The Australian Nursing and Midwifery Accreditation Council.

Answer: d Rationale: The Australian Commission on Safety and Quality in Health Care develops the National Clinical Safety and Quality Standards.

2.

A nurse who is working in a rehabilitation facility is providing which level of care? a. Primary b. Secondary c. Tertiary d. Palliative

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e. Community.

Answer: c Rationale: Rehabilitation is a tertiary prevention that restores the person to their pre-illness functioning, or as near to that level as is possible.

3.

According to the Institute of Medicine, the six essential characteristics of health care are: a. safe, effective, patient-centred, timely, efficient and equitable b. safe, effective, accountable, timely, respectful and equitable c. safe, accountable, timely, efficient, respectful and appropriate d. safe, accountable, patient-centred, timely, efficient and equitable e. safe, accountable, timely, efficient, respectful and equitable.

Answer: a Rationale: The IOM states that care should be safe, effective, patient-centred, timely, efficient and equitable.

4.

Which of the following is not a critical issue in health care reform? a. Cost b. Quality c. Access d. Hierarchy e. Efficiency.

Answer: d.

Rationale: Hierarchy is not a critical issue in health care reform.

5.

The aim of continuous quality improvement is to: a. study work processes that promote system improvements b. observe communication between staff c. analyse patient outcomes d. critique best-practice guidelines e. maintain current level of care.

Answer: a.

Rationale: Continuous quality improvement (CQI) is the approach to quality management in which scientific, data-driven approaches are used to study work processes that lead to long-term system improvements.

Spotlight on critical thinking Caring and compassion 1.

If you were to develop a core of basic health care services to which all Australian and New Zealanders would have access, what would be included?

Suggested solution: Consider, among other things, timely and inexpensive access to hospitals, clinics, GPs, consultants, public health and community health services, preventative services, dentists, physiotherapists, dietitians, pharmacy services, physio and occupational therapists, podiatrists, rehabilitation services, mental health services, and natural therapists.

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Professionalism Before focusing on the problems within the current health care delivery system, stop and think! The Australian health care system is at the forefront of technologic advances, biomedical research, and state-ofthe-art clinical equipment and facilities. Yet even with these advantages, many consider that this system is in crisis.

2.

From your perspective, is the Australian health care system in a position of strength or weakness?

Explain why.

Suggested solution: Consider, among others things, wait times, more frequent co-payment proposals, increased expectations, an ageing population, decreased spending on medical research, rural and remote hospital consolidations, diversity of the population, and increasing cost of nurse education.

3.

Outline the role of the registered nurse in health care within Australia and New Zealand.

Suggested solution: Roles include acute care (clinical care in all facets of health care delivery, team member, coordinator of care), prevention (primary, secondary, tertiary), nurse practitioner, teaching, patient advocate, researcher, manager.

Legal/ethical You are working in an aged care facility. Regulations require that unlicensed personnel complete training to work as nursing assistants. You discover that there has been a recent turnover in staff and many newly employed nursing assistants are not yet trained.

4.

What are the legal and ethical ramifications of this situation?

Suggested solution: There are regulatory requirements which regulate this aspect of health care. Health care facilities have a responsibility to provide a safe work environment, safe systems of work and a safe environment for patients and visitors. This means that things like infection control measures, safe lifting practices, and fire safety must be taught to new employees. Most facilities offer these periodically (monthly or second monthly) as a package during orientation of the new employee.

Ethically, new employees will need to be shown safe practices as soon as they enter the unit, especially if the orientation is still to be done.

5.

What should you do?

Suggested solution: You can assist new employees to remain safe and safeguard their patients by demonstrating good practice, talking to the new nursing assistant about the risks and the need for the standards, and helping them to practise good techniques.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 4 Critical thinking, decision-making and the nursing process Key terms Actual problem A set of data have been collected indicating that a problem exists; composed of the diagnostic label, related factors, and signs and symptoms.

Analysis Breaking the whole down into parts that can be examined.

Assessment First step in the nursing process; includes collection, verification, organisation, interpretation and documentation of data.

Collaborative problems Certain physiological complications that nurses monitor to detect onset of changes in status.

Critical thinking Disciplined, deliberate method of thinking used to search for meaning; uses strategies of asking questions, evaluating evidence, identifying assumptions, examining alternatives and seeking to understand various points of view.

Decision-making The consideration and selection of interventions that facilitate the achievement of a desired outcome.

Evaluation Fifth step in the nursing process; involves determining whether an individual’s goals have been met, partially met or not met.

Expected outcome Detailed, specific statement that describes the measurable results of nursing action such as direct nursing care, health care teaching.

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Goal Aim, intent or end.

Implementation Fourth step in the nursing process; involves the execution of the nursing plan of care formulated during the planning phase of the nursing process.

Problem Identification Second step in the nursing process; a clinical judgement about individual, family, or community (aggregate) responses to actual, possible, or risk of (potential) health problems, wellness states, or syndromes.

Nursing diagnosis: Synonym for problem identification (Second step in the nursing process; a clinical judgement about individual, family or community (aggregate) responses to actual, possible or risk of (potential) health problems, wellness states or syndromes).

Nursing intervention Action performed by a nurse that helps the client achieve the results specified by the goals and expected outcomes.

Nursing process Systematic method of providing care to clients; consists of five steps: assessment, diagnosis, outcome identification and planning, implementation and evaluation.

Objective data Observable and measurable data obtained through both standard assessment techniques performed during the physical examination, and laboratory and diagnostic tests.

Planning Third step of the nursing process; includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing-identified problems and the development of the person’s ‘plan of care’.

Potential problem A situation exists in which a problem could arise unless preventive action is taken; a ‘hunch’ or intuition by the nurse that cannot be confirmed or eliminated until more data have been collected. It is composed of the diagnostic label and related factors.

Primary source Major provider of information about self, client; research article written by one or more researchers.

Problem identification Second step in the nursing process; a clinical judgement about individual, family or community (aggregate) responses to actual, possible or risk of (potential) health problems, wellness states or syndromes.

Process Series of steps or acts that lead to accomplishment of a goal or purpose.

Secondary source Source of data other than the individual, such as family members, other health care providers, or medical records; article in which an author addresses the research of someone else.

Subjective data Data from the individual’s viewpoint, including feelings, perceptions and concerns.

Synthesis Putting data together in a new way.

Instructional strategies • Critical thinking is composed of three separate components: mental operations, knowledge and attitudes.

Explain each of these components with the role they play in the ability to think critically. Mental operations include activities such as decision making and reasoning. Nurses use these activities when searching for solutions and developing outcomes. The mental operations enable nurses to make sound clinical judgements by analysing information and applying knowledge. Knowledge is either declarative (specific facts) or operative (understanding the knowledge). Knowledge is needed in critical thinking to

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solve problems and make decisions. Specific attitudes are needed for a person to be able to think critically. These attitudes are a sense of curiosity, intuition, open-mindedness, tolerance, persistence, respect for others, comfort with ambiguity, intellectual humility, self-confidence, flexibility, and good organisational skills.

• The nursing process has five components: assessment, problem identification, planning, implementation, and evaluation. What activities occur in each step of the nursing process? In assessment, the nurse collects, validates, and organises data. The primary source for data is the patient. Data can be objective or subjective. Asking a person about his or her pain level would constitute assessment (subjective) data.

Problem identification is the second step, in which the nurse synthesises the collected data and formulates the problem statement. This becomes the focus for nursing care throughout the remaining steps. The patient can have more than one identified problem, and problems can be actual or at-risk problems. The person who rates his or her pain level an 8 (on a scale of 0–10) may receive the problem statement of pain (acute or chronic). Planning is the third step of the nursing process. The nurse prioritises the identified problems and specific interventions are developed. An identified problem of pain related to abdominal surgery would fit the above person. The goals of the plan are as follows: (1) person verbalises relief from pain, (2) person able to ambulate as needed (PRN), and (3) person able to take deep breath and cough without discomfort. Implementation is the fourth step in the nursing process. This stage involves execution of the nursing care plan derived during the planning phase. During this phase, there is a continuing assessment of the person’s condition. The nurse would give pain medications as ordered to the patient in pain. Evaluation is the fifth and final step in the nursing process. The nurse determines whether or not the goals have been met. If the person verbalises pain relief after drug administration, then the plan was effective. If there was no relief after medication administration, then the intervention must be adjusted appropriately.

• A large part of the assessment phase is determining objective versus subjective data. Ask students to differentiate between the two. Objective data are observable and measurable data. Blood pressure, pulse, and temperature are examples of objective data. Urine output of 200 mL in an 8-hour shift is another example of objective data. Height, weight, and age are again examples of objective data.

Subjective data, conversely, are derived from the person’s point of view. ‘My pain is worse today than yesterday,’ ‘I get more aches and pains in the morning than the evening,’ and ‘I feel better after I eat breakfast’ are examples of subjective data. This information is also valuable and must be viewed with objective data to render a sound problem statement.

• Differentiate between actual, at-risk and possible (potential) problem identification. An actual identified problem indicates that a problem actually exists. A young woman who attempts to take her life over the breakup of a relationship by overdosing will have a problem statement of ineffective coping related to. An at-risk problem statement is given to a person who does not have the problem but is at special risk of developing it. A new mother with a baby in the intensive care nursery on a ventilator is at risk for disorganised infant behaviour related to. The possible problem identification indicates a situation in which a problem could arise unless preventive action is taken. An older person on bed rest for many days may receive the possible problem of impaired skin integrity related to.

• Implementation involves specific nursing skills. What are these skills? Successful implementation includes psychomotor skills and is seen when providing injections, changing dressings, and assisting with range of motion exercises. Interpersonal skills are needed when interacting with people to collect data, when

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teaching, and during the provision of care. Critical thinking skills are used when the nurse thinks through situations and asks questions to help make decisions about patient care.

Resource aids Alfaro-LeFevre, R. (2019). Critical thinking and clinical judgment: A practical approach (7th ed.). Saunders.

Carpenito, L. J. (2021). Nursing diagnosis: Application to clinical practice (16th ed.). Lippincott Williams & Wilkins.

Nursing and Midwifery Board of Australia (NMBA) (2016). Registered Nurse Standards for Practice. Retrieved from https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professionalstandards/registered-nurse-standards-for-practice.aspx

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Provide the class with a case study. Have students analyse the case and determine assessment information, possible problems, nursing plan of care, implementation of the plan, and evaluation of the nursing care.

• Have students apply problem identifications to various patient data. Encourage actual, at-risk, and potential problems. Use patient information from obstetric, medical-surgical, and paediatric patients.

• Critical thinking is a process that is not exclusive to any one domain of learning. However, the Nursing and Midwifery Board of Australia (2006) is now identifying it as an essential nursing competency for nurses. Have students discuss the dynamics of the critical thinking process and how it can be applied to the nursing process.

• Provide the class with a case study and use Figure 4-1 ‘Components of the nursing process’ to illustrate the interactive and sequential nature of the nursing process. The use of a visual model will help the students to integrate the learning processes of continued assessment and evaluation leading to goal attainment.

• In a large group, have students choose problem identification statements that are appropriate for the patient. Then in small groups of two or three, assign students one of the problems and have them identify specific interventions for their assigned problem.

• Have the students observe one nurse provide patient care (shadow). During the course of care, analyse the nurse’s behaviour in regard to critical thinking. Which of the four stages of the critical thinking process did the nurse use? What is an example of the phase the nurse used? Discuss these findings in small groups.

• Create a list of patient care problems (poor appetite, refusing to ambulate postoperatively, refusing pain medication, learning to provide own injected medications, etc.). Have the students determine creative interventions to address these potential patient problems. Evaluate the interventions according to creativity and potential patient adherence. © Cengage Learning Australia 2024

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Review questions 1.

When reviewing a person’s biochemical laboratory results, you must have a knowledge base that includes which of the following types of knowledge in order to think critically? a. Affective b. Declarative c. Non-judgemental d. Psychomotor e. Intuitive.

Answer: b Rationale: Declarative knowledge consists of specific facts and information. The nurse must know normal lab values in order to analyse lab data. Affective and psychomotor skills refer to specific types of requisite skills needed to implement nursing actions. Non-judgemental describes the attitude that nurses must use when working with people.

2.

The steps, in order, of the nursing process are: a. assessment, planning, problem identification, implementation, evaluation b. assessment, problem identification, planning, implementation, evaluation c. planning, assessment, problem identification, implementation, evaluation d. planning, problem identification, assessment, implementation, evaluation e. problem identification, assessment, planning, implementation, evaluation.

Answer: b Rationale: The steps in the nursing process are assessment, problem identification, planning, implementation, evaluation.

3.

Implementation involves: a. determining whether patient goals have been met b. the collection, verification, organisation and interpretation of data c. further analysis and synthesis of the data that have been collected d. the execution of the nursing plan of care derived during the planning phase e. planning the care that needs to be provided.

Answer: d Rationale: Implementation is enacting the plan of care.

4.

Which of the following is an example of objective personal data? a. 500 ml of amber-coloured urine in collection bag b. A person complaint of nausea c. A person states pain is 9 on a scale of 1–10 d. Self-reporting of insomnia e. A family member raises concern regarding the patient.

Answer: a Rationale: Objective data are observable and measurable and are obtained through physical examination, observation and diagnostic testing. People’s feelings and concerns are subjective.

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5.

A person in the intensive care unit (ICU) has several health problems. Which of the following should be of priority concern to you? a. Malnutrition: less than body requirements b. Impaired skin integrity c. Ineffective airway clearance d. Risk for injury (falls) e. Altered coping.

Answer: c Rationale: The diagnosis that presents a life-threatening situation is ineffective airway clearance; thus, this problem must be attended to before the other problems are addressed.

6.

When referring to a person’s medical record for information, you are using which data source? a. Analytical b. Primary c. Secondary d. Tertiary e. Paper.

Answer: c Rationale: The person is the primary source of health-related information. Secondary sources of assessment data include significant others, health care providers and medical records.

Spotlight on critical thinking 1.

Why is critical thinking essential in nursing?

Suggested solution: Critical thinking is so important in nursing because: • it is essential for nursing competency • it is an accreditation criterion • it fosters tolerance, open-mindedness, non-judgemental mind-set, curiosity, persistence, intellectual courage, respect for others' perspectives, comfort dealing with ambiguity, uncertainty, Intellectual humility (knowing that one does not have all the answers), self-confidence (belief in own ability to think things through and make appropriate decisions), flexibility and organisation.

2.

Provide a rationale for validating assessment data.

Suggested solution: Validating assessment data increases completeness and correctness of the information obtained during assessment. It is also directly related to the accuracy of the problem identification, planning and implementation phases of the nursing process, and eliminates or reduces 'jumping to conclusions'.

3.

Why is the nursing process non-linear?

Suggested solution: The nursing process is non-linear because: • the steps are overlapping and bridge to each other • it deals with individuals • conditions change and new data will influence the remaining steps.

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4.

How can you involve your patient and their family in the plan of care?

Suggested solution: Ask what their goals of care are and co-construct a plan of care that includes their desired outcomes. Inform them what is expected of them daily in order to achieve the goals of care and actively involve them and their families in decisions.

5.

Describe why certain attitudes affect a person’s ability to think critically.

Suggested solution: Certain attitudes might: • allow you to (or not) question assumptions on which decisions are made • allows you to (or not) see a problem from the other person's perspective • helps you to look at a problem with a fresh perspective (not routine or habit).

For example: • Tolerance allows you to accept what is rather than use a stereotype.

• Curiosity helps you to delve deeper into a data set to find the real problem.

• Humility opens your mind to fresh ideas as you do not 'know it all'.

• Courage and self-confidence allows you to question ideas rather than blindly accepting.

• The ability to deal with ambiguity allows you to really hear what another is telling you and not stereotype them or the problem.

• Flexibility allows you to change your mind when new information comes to hand

6.

Why is it necessary that nurses include collaborative problems when planning care?

Suggested solution: Collaborative problems are managed through the use of interventions prescribed by other prescribing practitioners and nurses, and include those conditions in which the nurse seeks medical input for treatment of potential medical problems. Usually, collaborative problems involve alterations in organ or system function or structure (e.g. myocardial infarction, duodenal ulcer).

Collaborative problems begin with the label potential complication (PC) followed by the situation – for example, PC: thrombophlebitis.

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Contents Key terms .......................................................................................................................................................1 Instructional strategies ..................................................................................................................................2 Resource aids .................................................................................................................................................4 Online resources ............................................................................................................................................4 Evaluation strategies......................................................................................................................................4 Review questions ...........................................................................................................................................5 Spotlight on critical thinking ..........................................................................................................................8

Chapter 5 Clinical assessment Key terms Assessment First step in the nursing process; includes collection, verification, organisation, interpretation, and documentation of data.

Assessment model Framework that provides a systematic method for organising data.

Closed questions Interviewing technique that consists of questions that can be answered briefly or with yes or no responses.

Comprehensive assessment Type of assessment that provides baseline personal data, including complete health history and current needs assessment.

Data clustering Process of grouping significant cues together according to a specific assessment model to establish ‘problem identification’.

Data interpretation Recognition of patterns in data to identify problems.

Data verification Process through which data are validated as being complete and accurate.

Focused assessment Type of assessment that is limited in scope in order to focus on a particular need, health care problem or potential health care risk.

Health history Review of the person’s functional health patterns prior to the current contact with a health care agency.

Interview Therapeutic interaction that has a specific purpose. © Cengage Learning Australia 2024

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Objective data Observable and measurable data that are examined through both standard assessment techniques performed during the physical examination and laboratory and diagnostic testing.

Observation Skill of watching carefully and attentively.

Ongoing assessment Type of assessment that includes systematic monitoring and observation related to specific problems.

Open-ended questions Interview technique that encourages the person to elaborate about a particular concern or problem.

Review of systems (ROS) A brief account of any recent signs or symptoms related to any body system.

Subjective data Data from the person’s viewpoint, including feelings, perceptions and concerns.

Instructional strategies • Assessment is the first step of the nursing process. Discuss the three different types of assessments and when they are used. The first type of nursing assessment is comprehensive. This is usually done upon admission to a health care facility and includes a complete health history, physical assessment, psychosocial assessment, and the person’s risk and coping factors. A focused assessment is limited in scope and focuses on one health problem or need such as an emergency department or outpatient surgical centre visit. An ongoing assessment is systematic monitoring and follow up of specific problems or needs that have been identified once interventions have been provided.

• The health history gives you information related to any deviation from the person's norm. What are the elements of the health history? Demographic data are obtained, including age, gender, occupation, and relationship status. You must elicit the reason for seeking health care, for example, a pregnant woman contracting every 5 minutes, an elevated temperature for 2 days in an infant, or a man with pain in his right knee. You need to know what previous health problems the person has had; any relevant family health history, allergies, routine medications used (reason, dose), immunisations or exposures to communicable diseases; ability to adequately respond to questions; sociocultural and psychosocial history; lifestyle; and ability to perform activities of daily living. Perform a physical review of the body systems as the next step in the person's assessment.

• Accurate data collection is paramount to quality nursing care. Discuss with the class examples of what situations may arise out of poor nursing assessment. There are infinite difficulties that may arise; however, some examples follow. You may misunderstand the transportation arrangements of the person and may discharge the person after the last bus has left the facility. This may leave the person stranded and create problems. A nurse who fails to notice a decubitus injury (pressure injury) on an elderly person would not provide a plan to treat it, thereby causing it to enlarge and worsen. A nurse who fails to respond to verbal and nonverbal clues may mistake spousal, elder, or child abuse for an accident. Use examples from your own practice to demonstrate the need for accuracy of assessment.

• The interview is another important strategy for gathering assessment data. Identify and describe the interview stages. An interview has three basic stages. The first, introduction, is where goals are established, care is taken to put the person at ease and to provide a positive atmosphere of comfort and privacy, an atmosphere for trust is established and the individual–nurse relationship begins. The second stage, the working phase, involves the substance of the interview, where information is collected. The © Cengage Learning Australia 2024

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final interview stage is decided on when adequate information is obtained. The nurse summarises what was covered during the interview and plans are made, if indicated, to schedule any necessary follow-up interviews.

• Have students read the Safety First ‘Assessment for Allergies’. Discuss the implications of the sensitivity and reaction, and importance of accurate documentation to a potential allergic response. It is not only important to document the presence of an allergy but almost equally important to state what happened as a response. This can help to clearly identify the seriousness of the situation and whether a higher index of suspicion should be utilised during the assessment process that might require further analysis.

• Generate a list of objective and subjective data, and give each student 5 or 6 cues from your list. Make sure there are some of each type for each student. Ask the students to determine which of their cues are objective and subjective, and what they based their decision on. Discuss any that are problematic.

• A person is admitted with abdominal pain. Ask the students what data should be collected about the person’s main symptom. The person has abdominal pain, so the abdomen would be the location. The nurse needs to find out the character of the pain such as sharp, dull, or stabbing. The nurse should ask the person to rate the pain on a scale from 1 to 10, where one is very little pain and 10 is extreme. The person should be asked when the pain occurs, the duration, the frequency, and any precipitating factors. Lastly, the person should be asked if there are any situations in which the pain is improved or made worse. This scenario can be used for more senior students if you include physiology and pathophysiology (e.g., A&P of the gastrointestinal tract, female reproductive system, and some of the conditions that cause pain, specific assessment techniques associated, and normal and abnormal findings, you could add a discussion of medication classes (antispasmodics, PPI, laxatives, antacids, etc).

• Situational awareness is an important skill for students to develop to enhance the outcome for the people in their care. Ask the students what they think are important steps of situational awareness and how can they achieve each. Your list might include: o Take a breath. Slow down for a second and don't rush to 'do the obs' or 'do the meds' This is difficult in the busy ward situation, but vital, so important cues are not missed. o

Focus on one task at a time to improve your ability to stay in the present moment. Prioritise tasks to reduce spinning out of control. Avoid wool gathering – daydreaming.

o

Stay calm but use all your senses to assess the person/environment.

o Use your knowledge to orient your assessment (e.g., a pulse rate of 120 indicates very different things in a 1 year of compared to a 25-year-old) – know what you are looking for (listen to reports, read about diseases, medications, procedures, diagnostic test results, ask questions), and then contextualise that information – giving it meaning and making it actionable. o

Maintain a healthy physical body (eat, sleep exercise well) and mental state, and avoid problematic emotional states (e.g., fear, intimidation, anger). Be aware of your thoughts; that is, be selfobservant. This is mindfulness, which assists you to be observant.

• Discuss some aspects of situational awareness from your own practice, including the following criteria: o Perception: vigilance, observing the person in care and their environment, obtaining data; for example, an elderly person was just admitted to the unit following a fall at home, it is nighttime, and the person is confused, in pain and angry. © Cengage Learning Australia 2024

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o

Comprehension: using clinical reasoning to understand what is going on, clinical evaluation of cues, linking disparate pieces of data to make sense of a situation. In the above scenario, you might put the elements together and decide that this person may be at increased risk of falling due to confusion, pain medication, emotional turmoil and unfamiliar surroundings.

o

Projection: being aware of what might happen based on your comprehension and your knowledge base. The person should be given appropriate pain medication but assessed more frequently than would be the case otherwise. If possible, they should be placed near the nursing unit. You would reinforce the use of the call bell if they need to get up and assist them out of bed and to the toilet if they are awake. Night 'rounds' would be more frequent, and oncoming staff alerted to the risks.

Resource aids Carpenito, L. J. (2007). Handbook of nursing diagnosis (12th ed.). Lippincott Williams & Wilkins.

Christensen, M. (2003). Nursing process [video]. Cengage Learning.

Seaback, W. (2006). Nursing process concepts and application. Cengage Learning.

Online resources • The following website has some interesting information about interviewing young people who are at a health care facility. It is quite an advanced assessment, but should be easily understood by beginning nursing students: https://headspace.org.au/assets/Uploads/headspace-psychosocial-assessment.pdf • Information on this website is for anyone working in an emergency room situation or even gathering assessment data on a newly admitted person. Again, it is advanced knowledge, but interesting and easily understood by the beginner and it is easy to incorporate into interviews: http://www.charlydmiller.com/COMM/sample.html • Melbourne's Royal Children's Hospital has developed a suite of paediatric/adolescent assessment tools and information for nurses. These are available at: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_Assessment

Evaluation strategies • Have students pair off and practise their interviewing skills. Have them relay their information back to the person interviewed to check for accuracy of assessment.

• Discuss how the nurse would perform an assessment on a difficult person; for example, a head-injured person, young child, or person with a language difficulty.

• Have students interview a person (or student) using the assessment forms in the back of the chapter and practise interviewing and assessing people (e.g., their parents, grandparents, siblings, friends, significant others). This can be extended by asking the students to organise their data using various nursing models (Gordon's, Orem's, Roy's or others used in your institution) and non-nursing models (body system, Maslow's).

• Discuss the value of using the formats discussed in the text for obtaining, organising and storing information about the individual. © Cengage Learning Australia 2024

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• In a large group, ask students to read a prepared scenario in which the person has Alzheimer's and is accompanied by a well informed and well-intentioned spouse. Ask who is the best source of data in this situation and why. Present an equally compelling case scenario with a different type of secondary source (e.g., accompanying social worker, police person, neighbour) and ask the students to justify their responses and to consider ways they could obtain more credible information.

• Ask students for volunteers willing to share, without sharing personal health information, a negative or a positive interviewing experience related to a nurse’s assessment in their lives. Start by sharing from your own experiences. Many students desire to become nurses because of a positive and sometimes negative experience with the health care system. Sharing these experiences reminds future nurses of the importance of respect and communication with individuals.

• At the beginning of the discussion related to the importance of observation, show a scene from a movie, or ask a colleague to come into the room to 'deliver a message' to you. After the scene, ask students to identify as many objects or as much information as they can remember. Keep an accurate list yourself.

Replay the scene or ask your colleague to come back to the room. Give a prize for the most correct answers.

• Create scripts for groups of scenarios for the students to role play. One script is the nurse assessing the person based upon an assessment model. The other script is the person and the behaviours that they should demonstrate during the interview. These behaviours should range from short answers to long lengthy explanations. Their problems should range from acute pain episodes to chronic major organ problems. Keep the two sets of scenarios separate and have the students select the role. Continue to practise until all students have had an opportunity to interview every type of problem prepared.

Review questions 1.

Which of the following nursing responses is an example of an open-ended question? a. ‘How are you coping with the pain?’ b. ‘Do you have any pain now?’ c. ‘Tell me about your health.’ d. ‘Tell me how many children you have.’ e. ‘Who is your primary source of support?’

Answer: c is an example of an open-ended questions.

Rationale: This question encourages a person to give full and detailed information about their health.

Answers a, b, d and e are all questions with brief answers (well/not well; yes/no; number of children; name of primary support).

2.

The process of assessment includes which of the following activities? (Select all that apply and number them in order of use.) a. Collecting b. Documenting c. Interpreting d. Organising e. Planning f. Verifying.

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Answer: a, f, d, c, b, e Rationale: Collecting data is the first step because nothing can be determined without it; verification ensures the data is complete and accurate, information gained should be reviewed to inaccuracies; organisation of data into clusters helps to identify strengths and weaknesses; interpretation is based on recognition of patterns that assist you to determine the problems; information is documented to foster communication, safety of the person and demonstrate quality of care. Planning is the next step in the nursing process and is based on the previous five steps of the assessment and is dependent on the accuracy of each step. Planning is developing a plan of action based on the individual's identified health problems (from the assessment), and setting mutual achievable goals for resolving these with the person.

3.

A 42-year-old woman comes to the surgical unit for an elective laparoscopy. What type of assessment is most appropriate for her? a. Comprehensive b. Focused c. Ongoing d. Subjective e. Speciality physical.

Answer: a Rationale: A focused assessment revolves around a specific need and is ideal for persons experiencing acute problems. Focused assessments are usually performed in emergency departments in order to collect data about urgent needs.

4.

You are performing an admission assessment. Which of the following are examples of objective data?

(Select all that apply.) a. 25 mL of emesis (vomitus) in basin b. Warm, flushed cheeks and skin c. A statement of ‘My head is aching’ d. Complaint of fever by person e. Tympanic temperature 40 °C f. Rapid, thready pulse g. Feeling of faintness h. 150 mL of dark malodorous urine in the drainage bag.

Answer: a, b, e, f, h Rationale: Subjective data include things that the person tells you. You cannot measure or see subjective data; although in the case of the complaint of feeling feverish, the tympanic temperature of 40°C verifies the person’s subjective feeling.

5.

When performing an assessment, beside the person, you use their married partner as a source of data?

What kind of source are they? a. Intimate b. Secondary c. Familial d. Informed

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e. None of the above Answer: b Rationale: Anyone other than the person you are assessing who provides information is a secondary source. The other descriptors (intimate, familial, informed) might be used as descriptors of the secondary source.

6.

Which of the following statements accurately describes the ROS? a. You perform it at the earliest possible time. b. It is the person’s statement about perceived health status. c. ROS should be performed only by advanced nurse practitioners. d. You do a head-to-toe physical examination of the person. e. It prevents adverse outcomes during admission procedures.

Answer: b Rationale: ROS is the person’s explanation about problems with any of the body systems and provides subjective data that are important in establishing a baseline data set.

7.

A young woman newly admitted to your unit states that she has a severe headache. Which of the following actions do you do first? a. Administer pain medication as ordered in her medical record. b. Check the woman’s VSs. c. Have her sign consent forms for treatment and diagnostic procedures. d. Orient her to the unit. e. Explain safety guidelines to the woman.

Answer: b, Rationale: Assessing vital signs must be done prior to administering any medication, including analgesics. Remember that assessment is the first step of the nursing process. Consent should be obtained for any imminent invasive procedures before pain relief, which might impair judgement (although this step could change if there is nothing imminent planned). Following the assessment, pain relief should be given as quickly as possible. Safety guidelines and orientation to the unit can generally be left until the pain is under control.

8.

SA is important in caring for a person because (select all that apply): a. it improves teamwork b. it prevents errors from happening c. it improves outcomes for people in your care d. it helps you interpret what is happening e. it helps you to make decisions based on an understanding of what could happen f. all the above.

Answer: f Rationale: Situational awareness is a way of thinking in which nurses perceive data, prevent errors and improve outcomes for people in their care, interpret what is happening, and make decisions based on their understanding of what could happen. It also improves teamwork.

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Spotlight on critical thinking Often during assessment of an individual, you will encounter personal and ethical problems that you will need to deal with. To do so, you will have had to consider these problems in relation to your own values and beliefs. Some of these problems are illicit drug use, self-inflicted injuries, violence towards health care workers and domestic violence.

1.

Discuss your values in relation to these situations or conditions with a trusted colleague.

Suggested solution: Answers will depend on the individual student, but consider such things as cultural values, religious values, parent's values, peer values, what they learned at school, and through the media, and how each of these influence their feelings and values about each of these situations.

2.

How would you demonstrate sensitivity and a non-judgemental approach to someone with one of these problems whom you are interviewing?

Suggested solution: Consider such communication techniques as maintaining appropriate eye contact, voice (tone, loudness), use of words (keep them respectful, avoiding derogatory or denigrating terms like drug addict, wife-beater, looney, retard), do not ‘talk down' to the person, and avoid using jargon.

Maintain a non-judgemental and non-discriminatory attitude. Be aware of your own biases and put them aside. Introduce yourself with a smile. Keep facial expression neutral to friendly. Sit at the same level as the person, facing them, leaning toward them. Touch the person (as appropriate) with firmness and gentleness and be aware of their need for extra personal space (again as appropriate). Listen carefully to their answers to your questions (attending behaviour). Maintain an air of calmness and selfconfidence. Respect the person as an individual.

Mrs Blake, a 78-year-old widow, was admitted to hospital with a severe urinary tract infection. She is dehydrated. Her neighbour, who brought her to hospital, says she is confused. The neighbour is very concerned but must return home. When you speak to her, she thinks you are her daughter and refuses to drink ‘from the poisoned chalice’.

3.

What sources of data would be most appropriate in this situation?

Suggested solution: The neighbour would have to provide the information that they could. You would have to assess the answers that Mrs Blake provides to determine their validity.

4.

What preparation for the assessment would be useful?

Suggested solution: Mrs Blake: the room should be comfortable, quiet and well lit. Privacy is important.

Ensure that any aides (glasses, hearing aides) are in working order. Provide pain relief for Mrs Blake.

The Nurse: Use a medical-surgical text or gerontology text to improve your knowledge of the signs and symptoms and treatment of urinary tract infections in elderly people. See if Mrs Blake's medical records indicate any previous urinary tract infections and what was done at that time. Determine normal laboratory results and ward urine results so you can compare Mrs Blake's results. Speak in a clear voice, speak to both of them, include Mrs Blake as much as possible. Do not rush them if at all possible.

5.

Use Gordon’s functional health patterns to plan an assessment for Mrs Blake. Explain your reasoning.

Suggested solution: Gordon's functional health patterns provide for a systematic assessment that allows the gathering and clustering of information about usual patterns and any recent changes. For example,

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most of Mrs Blake's health patterns would be affected, data collection would be focused on the nutritional–metabolic, elimination, cognitive–perceptual, sleep–rest, role–relationship, activity– exercise, and coping–stress patterns both before the onset of the problem and how the problem has impacted on their lifestyle and her functional ability.

Mr. Bishop is a 64-year-old man who is admitted for a prostatectomy. You are assigned to admitting him to the surgical unit and assessing him. His medical notes from the previous admission indicate that he has had asthma for most of his life and was hospitalised a year ago for removal of a benign tumour in his left lung.

6.

Explain which type of questions you would use to gain the most useful and complete information from Mr Bishop when conducting an assessment.

Suggested solution: Open ended questions elicit the most information.

A young woman is admitted to the unit for a gender reassignment surgery. Non-discrimination in the workplace is enshrined in law and policy. Consider your own personal bias or feelings towards people who are lesbian, gay, transgender or intersexual.

7.

How could you make this woman feel welcome in the unit?

Suggested solution: Students may have different levels of understanding about gender reassignment. Making this person feel comfortable and welcome in the unit is a professional responsibility. Treating her with respect, greeting her with a smile, introducing yourself, using her preferred name and pronouns, attending to any worries and questions will all convey a welcoming attitude.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 5

Chapter 6 Problem identification Key terms Aetiology Related cause of or contributor to a problem.

Causal factor The aetiology can precede, be associated with, contribute to, or be related to nurse identified problems in some type of patterned relationship.

Cluster Set of data cues in which relationships between and among cues are established to identify a specific health state or condition.

Cues Small amount of data applied to the decision-making process.

Defining characteristics Collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations.

Definition A clear description that differentiates one problem from other similar problems.

Diagnosis Science and art of identifying problems or conditions.

Diagnostic label Consists of one or more nouns (can also include an adjective) that name the diagnosis; can be a word or a phrase that describes the pattern or related cues.

Medical diagnosis Clinical judgement by the physician that identifies or determines a specific disease, condition, or pathologic state.

Nursing informatics (NI) The use of information and computer technology to support all aspects of nursing practice.

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Patient problem Second step in the nursing process; a clinical judgement about individual, family or community (aggregate) responses to actual, possible or risk (potential) of health problems, wellness states or syndromes.

Problem identification Second step in the nursing process; a clinical judgement about individual, family, or community (aggregate) responses to actual, possible, or risk (potential) of health problems, wellness states, or syndromes.

Problem label Also called the problem concept; consists of one or more nouns (may also include an adjective) that name the problem and can be a word or a phrase that describes the pattern of related cues.

Related factors Elements that can precede, be associated with, contribute to, or be related to nursing diagnoses in some type of patterned relationship.

Risk factors Those things which increase our potential for ill health; for example, people with obesity and high BP are at increased risk of stroke and coronary heart disease.

Instructional strategies • Define the term problem identification and discuss how identified problems differ from a medical diagnosis. Problem identification is defined as a clinical judgement about individual, family, or community responses to actual and potential health problems/life processes. Problem identifications provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.

Problem identifications help nurses define their scope of practice and clarify the legal boundaries for practice. Medical diagnosis is terminology used for clinical judgement by a physician and determines a specific condition or pathology. Problem identification is terminology used for clinical judgement by a nurse that identifies the person’s actual, risk, or wellness responses to a health condition. Medical diagnosis and problem identification differ in purpose, goals, and therapeutic intervention.

• What errors can occur in the development of problem identification? The nurse must have accurate assessment data to formulate an accurate identified problem. Without that accuracy, an error may occur with the problem identification. Incomplete data may produce the same problem identification error. The nurse must confirm accuracy of previous data collected. If previous data were inaccurate, a problem that is not appropriate or no longer effective would be perpetuated incorrectly. A common error when beginning to use problem identification is to use the wrong terminology when writing the problem. This may change a problem identified into a medical diagnosis.

• List the categories of problem identification and how they relate to people’s health problem(s). Actual problems are those health problems that are already in existence. Risk problems are health problems that might occur but are not in existence at this point in time. Health promotion problems identify behaviours that indicate a desire to increase well-being. The selection of specific categories of identified problems helps to clearly define a person’s health problem. The categories include actual (realised), potential, and supportive problems to provide a comprehensive focus on people’s problems and behaviours.

• What are the four components of problem identification? Problem identification includes a diagnostic label. This is a label that describes the pattern of related cues. The defining characteristics are observable manifestations of specific problems. Risk factors are those elements that increase the chances of an individual, family, or community of being susceptible to a disease state or life event that will have an

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impact on health. Finally, related factors can precede, be associated with, contribute to, or be related to problem identification in some type of patterned relationship.

• Some nurses prefer to use a two-part problem identification statement, while others use a three-part statement. What is the difference between the two types? A two-part statement includes statement of the problem that describes the person’s response to an actual, possible, or risk health problem or a wellness condition. The second component of a two-part statement is the aetiology or the reason for the problem. A three-part statement includes the defining characteristics or clinical manifestations of the person’s problem in addition to the problem and aetiology.

• Present students with different case studies and discuss appropriate problem identification for each one.

These may include the following: 1.

37-year-old woman 1 day after a mastectomy. a. Pain related caused by surgical incision b. Disturbed body image caused by loss of right breast c. Ineffective sexuality pattern caused by loss of right breast d. Deficient knowledge caused by hospitalisation.

2.

12-year-old boy hospitalised for 2 weeks with sickle cell crisis. a. Pain caused by impaired oxygen supply to tissues b. Impaired gas exchange caused by decreased circulating mature red blood cells (RBCs) c. Social isolation caused by prolonged hospitalisation d. Deficient knowledge caused by disease process.

3.

24-year-old non–English-speaking Asian woman after delivery of a term stillborn infant. Father of baby verbally abusive toward staff. a. Impaired verbal communication caused by language difficulty b. Deficient knowledge caused by unknown cause of stillbirth.

4.

72-year-old man with a fractured hip s/p fall. a. Activity intolerance caused by loss of stability of hip joint b. Impaired physical mobility caused by skin traction c. Impaired skin integrity caused by prolonged bed rest.

Resource aids Alfaro-LeFevre, R. (2016). Critical thinking in nursing: A practical approach (6th ed.). Saunders.

Carpenito-Moyet, L. J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.

Wilkinson, J. M. (2011). Nursing process and critical thinking (5th ed.). Prentice-Hall.

Online resources • Alfaro-LeFevre, R. (2019). Critical thinking and clinical judgment: A practical approach (7th ed.). Saunders.

• Carpenito, L. J. (2021). Nursing diagnosis: Application to clinical practice (16th ed.). Lippincott Williams & Wilkins.

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• Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Have students identify problem identification statements that may be appropriate for specific medical diagnoses/conditions.

• The more they practise, the more comfortable students will feel using problem identification statements.

Instruct students to read Nursing highlights box ‘Problem Identification’. Have students bring to class written problem identification statements related to that case study.

• Invite a panel of nurses from various clinical settings to discuss their use of problem identification and how identifying problems drive their nursing practice and quality of care.

• Problem identification is used in various aspects of nursing practice. Discuss with students the possible applications for the use of problem identification in the clinical setting.

• Discuss the concept of problem identification as a universal language. Have students ask practising nurses how they feel about the development and use of problem identification and the response of other members of the health care team to the concept of problem identification.

• Generate person scenarios with a variety of health problems, risks and wellness goals. Provide the students with these scenarios and ask them to create problem identifications appropriate to the person data provided in the scenario.

Review questions 1.

Which of the following is a nurse-identified patient problem? a. Pressure injury b. Depression c. Pulmonary embolus d. Pneumonia e. Pancreatic cancer Answer: a Rationale: All of the responses apart from (a) pressure injury require medical diagnosis.

2.

The specialty within nursing that focuses on the methods and tools needed for dealing with information within nursing practice is: a. evidence-based practice b. nursing interventions c. nursing informatics d. nursing documentation e. nursing research Answer: c Rationale: The specialty within nursing that focuses on dealing with information is nursing informatics.

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3.

A person who underwent hip replacement surgery has an identified problem of impaired physical mobility caused by pain. Which of the following nursing interventions would be a priority for a client with this problem? a. Elevating the person’s foot b. Administering regular analgesic medication as ordered c. Providing a walker for ambulation d. Teaching the person techniques for safely transferring from the bed to a wheelchair e. Instructing the person to drink at least 1.5 litres of water each day Answer: b Rationale: The nursing intervention should address the aetiological factor of the nursing diagnosis, in this case, pain. The other interventions may be therapeutic but are of lesser importance than addressing the client’s comfort needs.

4.

An elderly person with thin, dry skin has a nursing identified problem of impaired skin integrity. Which of the following nursing interventions should be implemented? (Select all that apply.) a. Repositioning the person every two hours b. Keeping the bed linens dry c. Reducing the person’s fluid intake d. Encouraging the person to consume a high-fibre diet e. Making sure that the bed linens are wrinkle-free f. Instructing the person to take deep breaths and cough Answer: a, b, e Rationale: Nursing interventions should be directed at the causative factors. Turning the client frequently relieves pressure on bony prominences, which are most likely to experience skin breakdown.

Bed linens that are wet and wrinkled promote skin breakdown.

5.

You identify a problem of impaired physical mobility caused by pain. Which of the following is the causative factor? a. Immobility b. Impaired skin integrity c. Malnutrition d. Pain e. Falls Answer: d Rationale: The aetiology for this client’s potential immobility is pain. Therefore, nursing interventions should be planned to address the pain.

Spotlight on critical thinking 1.

What is the purpose of identifying patient problems?

Suggested solution: It focuses on a patient's response to a health problem rather than on the problem itself, and it provides the structure through which nursing care can be delivered.

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2.

How does a nursing identified problem differ from a medical diagnosis?

Suggested solution: The terminology used for a clinical judgement by the physician that identifies or determines a specific disease, condition, or pathologic state, the nurse identified problem focusses on the person's response to that condition or state.

3.

Explain the difference between an actual and potential problem?

Suggested solution: An actual problem is one that is already in existence. A potential problem is one for which there is potential of a risk of the person's response becoming a problem

4.

How do nurses verify data cues?

Suggested solution: By undertaking further investigations and assessments.

5.

What is the difference between subjective and objective data?

Suggested solution: Subjective data is what the person feels, and it cannot be measured other than by reports from the person (e.g., pain levels, urinary urgency, nausea, anxiety). On the other hand, objective data can be measured by external means, e.g., TPR, volume of urinary output, colour and consistency of emesis.

6.

What data sources are available to you in the acute care setting?

Suggested solution: • the person (and their significant others) • medical records including nursing notes/progress record, intake and output sheets, TPR records, Theatre records, medication administration records, etc.

• laboratory reports (C&S, urine analytes, blood components, drug levels) • diagnostic records (X-ray, MRI).

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 7 Planning Key terms Aetiology The cause, set of causes, or initiating factor in a condition or disease.

Collaboration A partnership in which all parties are valued for their contribution.

Consultation Method of soliciting help from a specialist to resolve diagnoses.

Criteria Standards used to evaluate whether the behaviour demonstrated indicates accomplishment of the goal.

Dependent nursing intervention Nursing action that requires an order from a physician or other health care professional.

Discharge planning Planning that involves critical anticipation and planning for the person’s needs after discharge; the person begins to resume self-care activities before leaving the health care environment.

Expected outcome Detailed, specific statement that describes the measurable results of nursing action such as direct nursing care, health care teaching.

Goal Aim, intent or end.

Independent nursing intervention Actions that are implemented in a collaborative manner by the nurse with other health care professionals.

Initial planning Development of the beginning of care by the nurse who performs the admission assessment and gathers the comprehensive admission assessment data.

Interdependent nursing intervention Nursing action that is implemented in a collaborative manner with other health care professionals.

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Long-term goal Statement written in objective format demonstrating an expectation to be achieved in resolution of the identified problem over a long period of time, usually over weeks or months.

Nursing care plan Outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support problems identified by nursing assessment.

Nursing intervention Action performed by a nurse that helps the person achieve the results specified by the goals and expected outcomes.

Ongoing planning Planning that entails continuous updating of the individual ‘plan of care’.

Planning Third step of the nursing process; includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing-identified problems and the development of the person’s ‘plan of care’.

Rationale Explanation based on the theories and scientific principles of natural and behavioural sciences and the humanities.

Short-term goal Statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time; usually a few hours or days.

Instructional strategies • What is the purpose of using outcome identification and planning? How is it beneficial for guiding nursing practice? Outcome identification and planning as essential principles for ensuring the delivery of competent nursing care. The overall purpose of a plan of care is to maintain or improve health to an optimal level. The planning component is instrumental in providing direction for nursing care, communicating with other staff, and providing continuity of care. The benefit of planning is that it is sequential, dynamic, and future oriented. Planning enables the nurse to establish priorities, develop nursing interventions, and document care provided.

• How are short-term goals similar to or different from long-term goals? When should each be used? Goals should be established to meet person’s immediate and long-term prevention and rehabilitation needs. A short-term goal is a statement written in objective format demonstrating an expectation to be achieved in a short period of time. A long-term goal is a statement written in objective format demonstrating an expectation to be achieved over a longer period of time. In general, short-term goal statements range from a time frame of a few minutes (as in critical care situations) to a time frame of a few days (as in expected date of discharge). The selection of short-term goal time frames is highly specific to the individual person. The achievement of a short-term goal for a critical care patient may be from minute to minute, as in the example of airway management. Long-term goal statements refer to a longer time frame resolution and are usually written over weeks or months. Again, the selection of long-term goal time frames is highly specific to the individual person. A person with a chronic life-threatening disease such as cancer may have a long-term goal projected for a minimum of 6 months, but the reality of a poor prognosis may impact a long-term goal statement and shorten it considerably. The most important key to both short and long-term goal statements is that they be realistic given the context of the person’s situation.

• A person has an extensive list of identified problems. What should the nurse do to prioritise this list? The person’s safety, basic needs, desires, and anticipated future problems must all be considered. One method to prioritise problems would be to follow Maslow’s Hierarchy of Needs, which requires that life-

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threatening problems be addressed first followed by those that concern a safe environment or stable living condition. The list should progress up the hierarchy until all problems have been prioritised. The person is to be involved in the prioritisation process, and individual preferences should also be taken into consideration when prioritising the problem identification list.

• Nursing interventions are classified according to three categories: independent, interdependent and dependent. Give examples of how these different classifications are used. Independent nursing interventions are those that are sanctioned by nursing practice acts. They are generally related to activities such as daily living, health education, health promotion and counselling. Interdependent nursing interventions are those implemented in collaboration with other health care professionals. These interventions require consultation with others involved in the person’s care, for example, dietician, physiotherapist and social worker. Dependent nursing interventions are actions that require an order from a physician or other health care professional. For example, medication administration, a nursing action, requires a physician order before the drug is given. All three classifications of nursing interventions are planned and carried out by the registered nurse.

• Once goals are set and interventions are planned, the nurse then documents the nursing care plan. What are the parts of a nursing care plan, and how should they be written? Nursing care plans are statements that specify direction and individualise a person’s plan of care. They include the date, action verb, detailed description, time frame and signature.

Resource aids Alfaro-LeFevre, R. (2016). Critical thinking in nursing: A practical approach (6th ed.). Saunders.

Carpenito, L. J. (2016). Handbook of nursing diagnosis (15th ed.). Lippincott Williams & Wilkins.

Wilkinson, J. M. (2011). Nursing process and critical thinking (5th ed.). Prentice-Hall.

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Have students provide a list of 10 problem identifications. Using that list, encourage students to determine appropriate outcome identification and planning for each.

• From a list of problem identifications, have students create short and long-term goals including all of the components of subject, task statement, criteria, conditions and time frame.

• Create a list of incorrectly written goals. Have students identify the errors within the goals, such as nursecentred instead of person-centred, unrealistic, negative instead of positive, copied from a reference and not individualised to a person, unmeasurable, non-specific, non-behavioural, vague, wordy and lacking a time frame for completion.

• Instruct students to read the case study presented in the Spotlight on critical thinking for this chapter.

Discuss in class various ways student nurses can handle the problem described in the case study.

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• Show many different types of standardised written nursing care plans used in various clinical settings.

Ideally include computerised care plans. Encourage students to discuss the variations, decide which ones appear to be more ‘user friendly,’ and select independent, interdependent and dependent nursing interventions.

• Discuss the impact of setting realistic goals for the following people: 1. 10-year-old child with acute leukaemia 2. 38-year-old pregnant woman (gravida 1, para 0) with a twin gestation 3. 45-year-old man with a prolonged history of migraines (over 3 months) 4. 68-year-old woman with a fractured hip.

Review questions 1.

Which of the following best describes the plan of nursing care? a. Patient assessment data, medical treatment regime and rationales, and diagnostic test results and significance. b. Prescribing practitioner’s orders, demographic data, and medication administration and rationales. c. Collected documentation of all team members providing care for the person. d. Assessment data, nursing diagnoses, goals and expected outcomes, and nursing interventions. e. Medical diagnosis, diagnostic results, nursing care and other treatments.

Answer: d.

Rationale: A nursing care plan addresses each phase of the nursing process: assessment, diagnosis, planning, implementation and evaluation.

2.

What is the main purpose of the expected outcome? a. To describe the education plans to be taught to the patient. b. To describe the behaviour the client is expected to achieve as a result of nursing interventions. c. To provide a standard for evaluating the quality of health care delivered to the patient during the hospital stay. d. To make sure that the patient’s treatment does not extend beyond the time allowed under the diagnosis-related group system. e. To communicate the plan of care to the health care team.

Answer: b.

Rationale: The expected outcome lists client behaviour that occurs in response to nursing interventions.

3.

Which of the following are the essential components of an expected outcome? a. Identified problems, interventions and expected patient behaviour. b. Target date, nursing action, measurement criteria and desired patient behaviour. c. Nursing action, patient behaviour, target date and conditions under which the behaviour occurs. d. Patient behaviour, measurement criteria, conditions under which the behaviour occurs and target date. e. Identified problems, interventions, expected patient behaviour and nursing actions.

Answer: b

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Rationale: Conditions under which behaviour occurs is not always necessary therefore at times not essential. Also, identified problems not part of the expected outcome 4.

When planning care, which of the following should you use as a guideline? a. Choose actions that a nurse can perform without leaving the unit or consulting with medical staff. b. Make intervention statements specific to ensure continuity of care. c. Write interventions in general terms to allow maximum flexibility and creativity in delivering nursing care. d. Make sure that nursing care activities receive priority over other aspects of the treatment regime. e. Do not inform family members of the planned care.

Answer: b.

Rationale: Statements need to be written in specific, precise terms that can be measured.

5.

Which of the following statements is correctly stated as a patient expected outcome? a. Patient will ambulate on fourth post-operative day. b. Patient will ambulate safely. c. Patient may ambulate safely. d. Patient will be able to safely walk down the hallway. e. Patient will safely walk unassisted to the end of the hallway within four days.

Answer: e.

Rationale: Option e has all the components of a well-constructed client outcome, including subject, expected action, criteria, condition and time.

6.

The four critical elements of planning care are: a. establishing priorities, setting goals and developing expected outcomes, planning nursing interventions, and documenting b. establishing priorities, data clustering, planning nursing interventions and documenting. c. identifying problems, setting goals and developing expected outcomes, planning nursing interventions and documenting d. identifying problems, data clustering, planning nursing interventions and documenting e. identifying problems, hypothesising, delivering care and documenting.

Answer: a Rationale: The elements are establishing priorities, setting goals and developing expected outcomes, planning nursing interventions, and documenting

7.

Which two of the following are not phases of planning nursing care? a. Initial phase b. Transition phase c. Ongoing phase d. Discharge phase e. Micro phase.

Answer: b and e Rationale: The phases of planning care are the initial, ongoing and discharge phase.

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Spotlight on critical thinking 1.

List the four critical elements of planning.

Suggested solution: • establishing priorities • setting goals and developing expected outcomes • planning nursing interventions (with collaboration and consultation as needed) • documenting.

2.

Why are critical-thinking skills essential in the nursing process?

Suggested solution: To be able to make intelligent, effective and safe decisions to resolve the person's problems proficiently.

3.

Do you think patients participate in establishing priorities for their care? Why/ why not?

Suggested solution: For consideration: • paternalism of nursing staff • person's inability to participate – lack of knowledge, lack of motivation, lack of suggested solution or knowledge of consequences (all amenable to education) • perceived lack of time by staff.

4.

Describe the difference between a goal and an expected outcome.

Suggested solution: A goal is an aim, an intent or an end. A goal is a broad or globally written statement describing the intended or desired change in the person’s behaviour, response or outcome.

An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved. Expected outcomes are addressed through direct nursing care activities, such as health care education.

5.

How can you ensure that your interventions are best practice?

Suggested solution: • Using the most recent literature to base practice on, • Using best practice guidelines supported by current research, • Consulting nurse practice acts and professional standards for nursing care.

6.

Describe strategies for effective care planning.

Suggested solution: • use critical thinking skills • collaborate with other health care professionals • communicate effectively with other healthcare professionals. Clear, precise language, establish realistic goals, timeframes and interventions.

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7.

What are some reasons why goals may be unmet?

Suggested solution: • Persons’s condition may change.

• The goals may be re-prioritised by the patient or the health care team.

• The goals may have been unrealistic.

Caring: coordination of care Mr Mathew Soon has been admitted with arthritis. His left knee is extremely oedematous and the prescribing practitioner has ordered heat application of 38°C to the left knee four times a day for two hours.

In considering the appropriateness of this order, the nurse detects an error regarding the time frame because heat produces maximum vasodilation in 20–30 minutes to dissipate the oedema; further application of heat may lead to a rebound phenomenon of tissue congestion and vessel constriction, as well as potential burns. At this point, the nurse needs to seek clarification of the order from the prescribing practitioner.

8.

What would be appropriate methods of handling this situation?

Suggested solution: As a student, report to the RN in charge of Mr Soon's care. She will contact the prescribing practitioner for clarification. In the meantime, apply the heat for 20 minutes at a time, for effectiveness and as a safety measure.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 8 Implementation Key terms Case management Methodology for organising care through an episode of illnesses so that specific clinical and financial outcomes are achieved within an allotted time frame.

Delegation Process of transferring a selected nursing task in a situation to an individual who is competent to perform that task.

Functional nursing Type of care-delivery system in which nursing care is divided into tasks to be completed; various levels of personnel provide care depending on the complexity of the task.

Implementation Fourth step in the nursing process; involves the execution of the nursing ‘plan of care’ formulated during the planning phase of the nursing process.

Nursing intervention Action performed by a nurse that helps the person achieve the results specified by the goals and expected outcomes.

Primary nursing Nursing management system in which the professional nurse assumes complete responsibility for total care for a small number of people.

Protocol Series of standing orders or procedures that should be followed under certain specific conditions.

Rationale Explanation based on the theories and scientific principles of natural and behavioural sciences and the humanities.

Standing order Standardised intervention written, approved and signed by a prescribing practitioner and kept on file within health care agencies to be used in predictable situations or in circumstances requiring immediate attention.

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Team nursing Type of nursing care-delivery system in which a variety of personnel (professional, technical and unlicensed) provide care.

Total patient care Variation of the primary nursing management system in which responsibility for the individual’s care changes from shift to shift with the assigned caregiver.

Instructional strategies •

What skills does a nurse need to successfully implement person-centred care? The nurse needs three different types of skills: cognitive, psychomotor and interpersonal communication. Cognitive skills are needed to make observations, to understand the rationale for activities performed and for critical thinking. Psychomotor skills are needed to perform activities such as using medical equipment, administering medications and assisting with basic care needs such as bathing, positioning, and ambulating. Interpersonal communication skills are needed for communication with patient, families, and other health care providers.

•

Have students refer back to the chapters on assessment, problem identification and planning and discuss how errors in those three steps affect the implementation phase of the nursing process. The nursing plan of care is based on the initial assessment data collected by the nurse and the problem statements derived from that data. Because a person’s condition can change rapidly or new data may become available, ongoing assessment is necessary for an appropriate nursing plan of care. If incorrect data have been compiled or new data are not observed and documented, these errors affect the implementation of care that will be appropriate for this person. If the identified problem is mistakenly written as a medical diagnosis, then again it will be difficult to adhere to nursing implementation.

•

After care has been taken to establish the nursing care plan, what is the rationale for a continued assessment? A person’s condition is dynamic, and an ongoing assessment at all times is indicated. If the intervention demands change throughout the course of the person’s treatment, not assessing continuously will lead to inappropriate nursing care. A problem that has been resolved and not addressed in the care plan will lead to unnecessary intervention on the part of the nurse.

•

Discuss the importance of documenting nursing interventions. An important reason for documenting nursing interventions is that the information is then passed on to the nurses on the following shifts. It is the legal responsibility of the nurse to document all interventions and observations related to the person’s response to treatment. Written documentation may also be used as part of the billing process and as quality control tracking. Thorough and detailed communication of implementation activities is fundamental to ensuring that care and progress toward goals can be adequately evaluated.

•

Establishing priorities for care involves ongoing assessment and coordination of available resources.

Discuss the importance of change-of-shift report, time management, and allocation of resources to implement a plan of care. Change-of-shift report establishes a clinical baseline with which the nurse can begin to prioritise a person’s care. It is important to have a comprehensive report that addresses pertinent patient concerns (e.g., medical diagnosis, laboratory results, ongoing testing and pending results). Time management is an important factor in the implementation of nursing care because it provides a basis of organisation and structure. Certain care activities may have specific time constraints and therefore will lead to further prioritisation. For example, suctioning will be more important than hygiene care in a person with respiratory compromise. Allocation of resources is an important aspect of

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implementation because it enables the nurse to coordinate/delegate possible client care activities while maintaining client safety and leading to achievement of client care outcomes.

•

Health care organisations can have different types of nursing interventions. What is the difference between a standing order and a protocol? A standing order is a standardised intervention that has been written, signed, and approved to be used during predictable situations. A protocol is a series of standing orders or procedures that should be followed under certain specific conditions such as care after a procedure or diagnostic test.

Resource aids •

Alfaro-LeFevre, R. (2019). Critical thinking and clinical judgment: A practical approach (7th ed.).

Philadelphia, PA: Saunders.

•

Carpenito, L. J. (2021). Nursing diagnosis: Application to clinical practice (16th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies •

Ask students to watch nurses in their clinical setting and observe their nursing care in relation to implementation. What types of interventions were observed?

•

What is the importance of nurses being familiar with the standing orders at their agency? Are nurses obligated to perform an action in the standing orders if they are unskilled at the procedure?

•

Have students create a plan of care to include each of the six different types of nursing intervention activities.

•

Have students give examples of the types of activities that may be delegated to other health care workers.

Discuss the delegation to enrolled nurses and unregistered health care personnel.

•

Ask students to observe the types of management systems used in their respective clinical settings (functional, team, primary, total care, modular nursing and case management). Where do they see the different elements displayed in the clinical setting? Discuss the advantages and disadvantages of the different management systems.

•

Discuss the idea of supervision and coordination of personnel in the clinical setting with regard to collaborative interventions. How would the nurse (RN) be able to validate that interventions have been done?

•

Have students attend a ‘change of shift’ report/handover in a health care organisation and report back to the class the content of the report. What areas were included? What areas were not addressed?

What could have been done to improve the report provided?

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Review questions 1.

Which of the following best describes the purpose of ongoing evaluation when implementing nursing activities? a. To be sure the activities performed are independent activities b. To determine patient progress toward expected outcomes c. To ensure compliance with agency protocols d. To identify patient problems e. To cluster data in meaningful ways.

Answer: b Rationale: During the implementation phase, the nurse continuously monitors the client’s response in order to determine progress or lack of progress toward expected outcomes. Neither classification of the type of activities (dependent, independent or interdependent) nor protocol compliance is the purpose of evaluation. The nursing diagnosis must be established prior to implementing nursing interventions.

2.

Establishing priority among several nursing interventions depends on which of the following? (Select all that apply.) a. Availability of resources b. Patient perception c. Patient’s willingness to comply d. Education level of nurse e. Length of time necessary for the intervention f. Nurse determination of importance.

Answer: a, b, f Rationale: In order to establish priority interventions, the nurse must consider resource availability, the client’s perception and the nurse’s determination of importance. The client’s willingness to comply with the treatment plan will affect the outcome but should not determine the priority.

3.

Which of the following is an example of the functional nursing approach to care delivery? a. The team member has an assigned task to perform for the patient b. Full responsibility for total patient care rests with the RN c. The RN coordinates care for the client across the entire care continuum d. The RN works with ENs and PCAs to deliver care e. The EN delivers all patient care.

Answer: a Rationale: Option (a) accurately describes functional nursing. Option (b) describes the primary nursing model. Option (c) refers to the case management approach. Option (d) describes the team nursing approach to care delivery.

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4.

Which of the following should you do initially when performing a procedure you have never done before? a. Review the procedure guidelines b. Seek help from another nurse who is proficient in performing the procedure c. Inform the nursing supervisor that you are unwilling to do the procedure because it is a new skill for you d. Try to remember all the steps of the procedure you learned at university e. Ask a colleague to undertake the procedure while you observe.

Answer: b Rationale: Nurses should always ask for help when performing a procedure with which they are unfamiliar.

5.

Which of the following statements made by a new nurse indicates a need for further guidance when performing handover? a. ‘The person had a good night.’ b. ‘The person is scheduled to have a CT scan this morning.’ c. ‘The person slept five uninterrupted hours after receiving paracetamol.’ d. ‘We did not get all the blood glucose levels drawn this morning.’ e. ‘At 0600 the person rated their pain as 3/10 on the numerical pain scale.’

Answer: a Rationale: Option (a) is vague, not measurable and provides no specific information about the client’s status. When verbalising a report, it is important for the nurse to share information about upcoming diagnostic activities, specific information in client status and unfinished tasks.

6.

Which of the following is not a type of nursing management system? a. Functional nursing b. Primary nursing c. Secondary nursing d. Team nursing e. Total patient care.

Answer: c Rationale: All of the answers are types of nursing management systems apart from (c) secondary nursing.

7.

In the nursing process, which number step is implementation? a. The second step b. The third step c. The fourth step d. The fifth step e. The sixth step Answer: c Rationale: Implementation is the fourth step in the nursing process.

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8.

Delegation is the process of: a. transferring a selected nursing task to an individual who is competent to perform that task b. transferring a selected nursing task to an individual who is experienced in the clinical setting c. transferring responsibility of a selected nursing task to an individual who is competent to perform that task d. transferring accountability of a selected nursing task to an individual who is competent to perform that task e. transferring accountability of a selected nursing task to a family member.

Answer: a Rationale: Delegation is the process of transferring a selected nursing task in a situation to an individual who is competent to perform that specific task. It must be remembered that although some activities can be assigned to enrolled nurses and other health care personnel, the registered nurse remains accountable for appropriate delegation and supervision of care provided by these individuals.

Spotlight on critical thinking 1.

What skills are required of you to implement quality care?

Suggested solution: Application of cognitive (understanding the scientific and logical rationale), psychomotor (being able to accomplish a skill smoothly, efficiently and proficiently) and psychological (developing trust, appropriate use of emotional and interpersonal skills) skills to accomplish goals and make progress toward expected outcomes.

2.

Why is it important to involve patients when implementing care?

Suggested solution: Involving patients when implementing care helps with establishment of priorities; bring knowledge of immediate effectiveness, as well as effectiveness of previous caregiving. It also validates the effect of care and increases the knowledge of the person (trust leads to more assessment information being elicited).

3.

To implement care what activities are expected of you?

Suggested solution: When implementing care, you are expected to: • assist with activities of daily living (ADL) • deliver skilled therapeutic interventions • monitor and surveillance of response to care • provide patient education • undertake discharge planning • supervise and coordinate nursing personnel.

4.

Is there a need to prioritise identified problems when implementing care? Why/why not?

Suggested solution: Yes, identified problems are usually many, with some overlapping. The most important problems are addressed first – maybe the most important to the person, or to their health and well-being. Sometimes problems are nested or layered and one has to be solved or addressed before the next can be considered.

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5.

What are the goals of patient education?

Suggested solution: The goals of patient education include: • helping the person modify their behaviours in response to potential health risks and actual health alterations • helping them to understand the health alteration or potential risks • educating them so they become self-monitoring and self-sufficient (e.g. medication administration, insulin adjustment for an insulin dependent diabetic).

6.

What do you need to consider before delegating care?

Suggested solution: It is important to consider each health care team members scope of practice and their knowledge and understanding of the care to be delivered.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 1 Resource aids....................................................................................................................................................... 2 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 3 Spotlight on critical thinking ................................................................................................................................ 5

Chapter 9 Evaluation Key terms Evaluation Fifth step in the nursing process; involves determining whether client goals have been met, partially met or not met.

Nursing audit Process of collecting and analysing data to evaluate the effectiveness of nursing interventions.

Outcome evaluation Process of comparing the client’s current status with the expected outcomes.

Peer evaluation Process by which professionals provide critical performance appraisal and feedback that is geared toward corrective action.

Process evaluation Measurement of nursing actions by examination of each phase of the nursing process.

Structure evaluation Determination of the health care agency’s ability to provide the services offered to its client population.

Instructional strategies • Evaluation is the fifth step in the nursing process. Explain why evaluation is a necessary component of this process. This step determines whether the person goals set forth earlier in the process have been met, partially met or not met. Even though this is the fifth and final step in the nursing process, it is used to evaluate care and to establish new patient goals or interventions, if necessary. Remember that the patient’s health status is dynamic and changing and that the evaluation step is also an ongoing process.

The evaluation is used to determine whether a patient is progressing.

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• Evaluation is partially done to evaluate nursing care (see the Nursing Checklist ‘Evaluating Nursing Care’).

Give examples of how not performing an adequate evaluation can affect the quality of nursing care.

Evaluation will determine whether nursing goals are appropriate to the person. Without an ongoing evaluation, nursing actions and interventions may be inappropriate for the person’s health problem. Even if interventions are appropriate, without evaluation, the nurse does not know whether they are working.

The evaluation process also determines patient satisfaction, cost effectiveness and patient outcomes. This also helps nurses establish their value in the health care system.

• Evaluation is a complex yet orderly process that includes seven steps. Review these steps with the students.

The steps within the evaluation process include establishing standards, collecting data related to the goals and expected outcomes, determining goal achievement, relating nursing actions to patient status, judging the value of nursing interventions in assisting patient’s to achieve goals and objectives, reassessing the patient’s status and modifying the plan of care if necessary.

• Ask students to explain how evaluation is a critical thinking activity. Evaluation is a deliberate mechanism used to analyse and make judgements. Evaluation involves analysis through comparing patient responses with expected behaviours. Nurses make conclusions about whether the expected outcomes have been met.

• In settings where a hierarchy evaluation may not be feasible or in a setting where it is not preferred, peer evaluation may be used. Give benefits and pitfalls of using peer review. Peer evaluation has been postulated as the basis of nursing’s autonomy and self-governance. Peer review promotes professional and individual accountability. Peer review feedback can increase the quality of nursing. The pitfalls of nursing peer review include personalisation of the process, a misunderstanding of the purpose, and delivery of non-objective feedback. When the process focuses on emotions or personalities, peer evaluation can be threatening.

• Using the following patient scenarios, have the students discuss the idea of multidisciplinary collaboration in evaluation.

1. 6-month-old infant admitted for dehydration 2. 11-year-old child admitted for tonsillectomy 3. 28-year-old woman admitted for preterm labour 4. 48-year-old patient admitted for exacerbation of chronic obstructive pulmonary disease (COPD) 5. 65-year-old patient admitted for acute myocardial infarction (AMI) 6. 80-year-old patient admitted for hip fracture.

• How would a multidisciplinary approach contribute to positive health care outcomes? When and where would this ‘collaborative effect’ meet? It is important for students to understand that nursing must interact with other health care disciplines in the successful management of patient outcomes. By using clinical scenarios illustrating life-span considerations, the student will understand that the benefits of a multidisciplinary approach are for all patients regardless of age, sex or disease process. It is also important for the student to be aware of time frame issues with regard to arranging for members of the team to meet. Collaboration requires cooperation and organisation. The student must begin to learn at an early level that health care involves a team approach with individual recognition.

Resource aids Alfaro-LeFevre, R. (2019). Critical thinking and clinical judgment: A practical approach (7th ed.). Saunders.

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Carpenito, L. J. (2021). Nursing diagnosis: Application to clinical practice (16th ed.). Lippincott Williams & Wilkins.

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Arrange the students into small groups. Have each group come up with criteria that reflect the concept of evaluation in a 10-minute time frame. Then have one member from each group place the group’s criteria ‘list’ on the board for class discussion. See if the students’ approach reflects consistency. Discuss the aspects of consistency and quality care as they relate to the evaluation process. This activity will help students to critically think about how patient goals can be accomplished when everyone is using a common framework.

• Have students read Spotlight on critical thinking about peer evaluation and friendship in the end of chapter resources. In groups of two, ask students to discuss how they would handle the situation and then share in a large group setting.

• Divide the students into groups to discuss structure, process, and outcome evaluation and give examples of each. For the clinical area, ask the students to observe structure, process, and outcome evaluations and report back to the group examples of each.

• Have the students look at the clinical evaluation tool form that their school uses as a piece of the ‘evaluation’ process. Using a round-table approach, have the students reflect on what the tool objectively states and how they perceive its benefit during the nursing program.

• Obtain different nursing chart audit forms from a variety of health care organisations. Distribute the audit forms, and have students utilise the tool and conduct a nursing audit on one to three medical records documents. Once the tool has been used, have students report on the use of the audit, areas included, areas that could be improved and overall findings from the audit.

• Schedule the students to participate in a peer evaluation after a series of clinical episodes. Do not pair the students into groups of two, but rather keep the student being evaluated and peer evaluator random. Create a criteria sheet to help guide the peer evaluator with areas to focus on when evaluating.

At the end of the clinical day, have the peer evaluator provide feedback to the student being evaluated.

Critique the peer evaluator’s content and the responses of the student being evaluated.

Review questions 1.

Which of the following accurately describes the purposes of evaluation? (Select all that apply.) a. Determine patient progress toward achievement of expected outcomes b. Determine effectiveness of the nursing care c. Establish patient expected outcomes d. Establish priorities for nursing interventions e. Promote nursing accountability f. Write the plan of care, including specific measurable goals.

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Answer: a, b, e Rationale: One purpose of evaluation is to decide how the person is responding to nursing interventions; finding out if the person is progressing toward goal achievement as a result of nursing action. Evaluation is also done to promote nursing accountability and to see whether nursing care is effective in assisting clients.

2.

Fragmentation of care is decreased when: a. all health care providers are involved in evaluation b. all nursing tasks are undertaken in a timely manner c. all health care providers achieve their goals d. all staff communicate effectively with patients e. all staff communicate effectively with patients and their families.

Answer: a Rationale: The team approach mandates active involvement of all care providers in the evaluation of quality care. Multidisciplinary evaluation helps promote a continuum of care for the person, from the preadmission phase to discharge planning and follow-up care.

3.

Which of the following patient statements are indicators of patient strengths? (Select all that apply.) a. ‘I don’t think that I’ll be able to stop smoking.’ b. ‘I dropped out of school in Year 8 to go to work.’ c. ‘I have no relatives to bother me.’ d. ‘My family is willing to change their eating habits since I’m on a diet.’ e. ‘My wife and I are both employed as schoolteachers.’

Answer: d Rationale: Family support is considered a patient strength.

4.

In which of the following situations are you performing an evaluation? a. Asking a person about their health care goals b. Developing expected patient outcomes c. Asking a person if pain is relieved after administration of analgesics d. Writing an individualised nursing care plan for a person e. Assessing a person’s vital signs (VSs).

Answer: c Rationale. By asking the person if their pain has been relieved you are evaluating the effectiveness of the administered analgesia.

5.

Which of the following statements best describes the evaluation of quality care? a. Carried out to determine whether the person feels better b. Determined after the project is completed c. Performed only by nursing d. A shared responsibility of the multidisciplinary team e. Determined by the medical consultant.

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Answer: d Rationale All members of the multidisciplinary health care team are responsible for the quality of care delivered and should participate in the evaluation of care quality.

6.

You help reposition a client who has difficulty breathing. Which of the following nursing actions, when performed after the intervention, demonstrates evaluation? a. Arranging pillows behind the person’s back b. Changing the rate of flow for oxygen delivery c. Checking the person’s respiratory status d. Instructing the person on the importance of mobility e. Asking the person if they would like a glass of water.

Answer: c Rationale: Evaluation is done following an intervention to determine its efficacy in assisting patients to reach expected outcomes; thus, checking the patient’s respiratory status will provide such data.

Spotlight on critical thinking 1.

What is the purpose of evaluation?

Suggested solution: Evaluation improves nursing care and outcomes for the person by: • determining the patient's progress or lack of progress toward achievement of expected outcomes • determining the effectiveness of nursing care in helping patients achieve the expected outcomes • determining the overall quality of care provided • promoting nursing accountability • improving decision making • enhancing ability to act safely, effectively • improving efficiency.

2.

Why is it necessary for people and their families to participate in evaluating their plan of care?

Suggested solution: Evaluation can uncover lack of progress toward goal achievement – the person and their family know how effective their care plan is proving to be. They can assist to revise the problems, develop new or revised goals and expected outcomes.

3.

How is evaluation related to the quality of care?

Suggested solution: It is the mechanism used by nurses in determining the need for improvement, evaluation assists in the provision of quality care.

4.

What information is required when evaluating care?

Suggested solution: Objective and subjective data are required to evaluate care. This data should include feedback from all stakeholders in care including the patient and their families.

5.

Why is peer evaluation an important aspect of professional development?

Suggested solution: Peer evaluation improves the quality of care by addressing specific behaviour of the nurse being evaluated.

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Professionalism: Peer evaluation and friendship Your co-worker is also a close friend. You are assigned to perform a peer evaluation together. Before the process begins, they ask you to be especially lenient when evaluating their performance. When collecting information about the quality of their work, you discover that they are often hurried and unorganised, a practice that results in them providing only mediocre care. You know that if the evaluation is not above average, your friend will likely experience disciplinary action from their supervisor.

6.

In view of your friendship, what do you do in this situation?

Suggested solution: This scenario is difficult – ask the students to consider: • giving constructive feedback informally, and asking for a longer timeframe so you can evaluate them more formally when their performance improves • asking to be reassigned to another co-worker who is not a personal friend • if you have to give feedback at this point of time, warn your friend that you are going to tell it like it is.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 7

Chapter 10 Leadership and delegation Key terms Accountability Willingness of the individual or organisation to take responsibility for actions they take.

Accreditation Process by which a voluntary, non-governmental organisation appraises and grants accredited status to institutions and programs or services that meet predetermined structure, process and outcome criteria.

Advanced practice nursing Practice of nursing at a level requiring an expanded knowledge base and clinical expertise in a specialty area.

Autocratic leadership style Style of leadership in which the leader maintains strong control, makes the decisions and solves all the problems.

Competency Ability, qualities and capacity to function in a particular way.

Delegation Process of transferring a selected nursing task in a situation to an individual who is competent to perform that task.

Democratic leadership style Style of leadership that is based on the belief that every group member should have input into the development of goals and problem-solving; also called participative leadership.

Empowerment Process of enhancing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes; the process helps people gain control over their own lives.

Laissez-faire leadership style Style of leadership in which the leader assumes a passive, non-directive and inactive style.

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Leadership Interpersonal process that involves motivating and guiding others to achieve goals.

Legal regulation Process by which the state attests to the public that the individual licensed to practice is competent to do so.

Management Accomplishment of tasks either by oneself or by directing others.

Networking Process of building connections with others.

Organisation Means by which members of a profession join to promote and protect the profession as a valuable service to society.

Politics Way in which people try to influence decision-making, especially decisions about the use of resources.

Power Ability to do or act, resulting in the achievement of desired results.

Profession Group (vocational or occupational) that requires specialised education and intellectual knowledge.

Professional regulation Process by which nursing ensures that its members act in the public interest by providing a unique service that society has entrusted to them.

Professional standards Authoritative statements developed by the profession by which quality of practice, service, or education can be judged.

Registration Recording of professional qualification information relevant to government registration.

Scope of practice Framework of the legally allowable practice an individual is permitted to perform within the limitations of the profession.

Situational leadership Style of leadership in which there is a blending of styles based on current circumstances and events.

Synergy Combined power of many people.

Instructional strategies • Explain the duties and the role of the Nursing and Midwifery Board of Australia or the Nursing Council of New Zealand. o Establish legal standards of practice o Approve educational programs that prepare individuals for registration o Grant registration to individuals who meet minimum qualifications o Renew registration for competent practitioners o Discipline registered nurses as necessary to protect the public.

• Looking back at the earlier chapters of the book, explain how nursing as a profession has grown and accountability increased from the beginning of the profession. There is more specialised education involved in nursing and intellectual knowledge. Since the early 20th century, the public has granted nursing the right and responsibility for self-regulation through registration Acts. These Acts have made nurses become individually accountable to the public. Nursing has expanded its knowledge base to meet the demands of health care delivery. Nursing has removed itself from apprentice-based nursing education into higher-education based on specialised knowledge, skills and abilities. Nurse educators are branching out into new settings and have educated more advanced practice nurses to meet the

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changing health care demands. Nursing theorists are presenting the profession with a myriad of models on which to base practice. Nursing research has come into its own, in both quantitative and qualitative aspects. Nursing administrators have a more powerful place in the structure and hierarchy of health care systems. The International Council of Nurses (ICN) has a long-standing code of ethics, many of which have been incorporated into nurse practice acts, thus establishing them as legal requirements.

• Two elements of professional accountability are accreditation and registration. What is the difference between these two elements? o

Accreditation is the process by which an agency appraises and grants status to institutions that meet predetermined criteria. The Australian Nursing and Midwifery Council (ANMAC) is Australia’s single independent accrediting authority for nursing and midwifery under the National Registration and Accreditation Scheme.

o

Registration is the method by which the nominated regulating body holds the nurse accountable for safe practice to citizens of that country. Registration grants the nurse legal authority to perform certain acts, to use a specific title that reflects one's practice rights, and to offer one's services and receive compensation for those services in the country that issues the registration. Registration is granted based on evidence that the individual has attained the minimum degree of competency (the ability, qualities and capacity to function in a particular way) to ensure that one is a safe practitioner.

• Have students discuss their responsibility relating to ‘Student Accountability’. In Australia, nursing students are registered with the Nursing and Midwifery Board of Australia (NMBA) in the interests of public safety. Student registration allows the NMBA to act on matters relating to students with impairment or when convictions of a serious nature may affect public safety. It is the responsibility of the education provider to provide the NMBA with the details of all students enrolled in their approved program. In New Zealand nursing students function legally as an exception to the registration requirements while enrolled in a nursing program that is approved by the Nurses Council of New Zealand. Students have the responsibility to be prepared for clinical practice, engage only in those skills for which they have gained competence and seek instruction as necessary.

Resource aids Australian Nursing and Midwifery Accreditation Council. (2021). About ANMAC. https://www.anmac.org.au/about-anmac/about-us College of Nursing Aotearoa New Zealand (2022). About us. http://www.nurse.org.nz/about-us.html International Council of Nurses. (2019). Our mission, strategic intent, core values and priorities. Retrieved [07/08/23] from https://www.icn.ch/who-we-are/mission-vision-constitution-and-strategic-plan Nursing and Midwifery Board of Australia. (2016). Registered Nurse Standards for Practice. Retrieved [07/08/23] from https://www.nursingmidwiferyboard.gov.au/codes-guidelinesstatements/professional-standards/registered-nurse-standards-for-practice.aspx Nursing Council of New Zealand. (2023). Accrediting and monitoring pre-registration programmes. https://www.nursingcouncil.org.nz/Public/Education/Approving_and_monitoring_programmes/NCNZ/Ed ucation-section/Approving_and_monitoring_programmes.aspx?hkey=262d7d05-8ac5-428a-920968cd0275edd2

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Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Divide the class into nine groups. Each group is to select or be assigned one criterion of a profession (Table 10-1). Each group is to determine examples of the assigned criterion. Have each group report back to the entire class.

• Nurses have professional accountability. What challenges are there for the nurse when working with unregistered assistive personnel?

• In what ways does nursing registration protect the public? What competencies does the general public expect when working with a registered nurse?

• Divide the class into three groups, each representing one style of leadership: autocratic, democratic, and laissez-faire. Introduce a scenario that involves the need to reach a decision. How would a leader practising that style of leadership resolve the issue? Are there situations where one style of leadership might be more effective than another? What type of leader do you believe yourself to be? How would you resolve the issue?

• Have the students discuss the concept of ‘scope of practice’ and give different clinical situations illustrating how nurses should respond to practise safely within mandated guidelines.

• Have students access their relevant Board or Nursing Web site and be prepared to discuss available resources listed on the site.

• Have the students reflect on how they will continue to ensure professional accountability to the public.

Discuss the concept of continuing education and additional certification and their impact on professional development.

• Have the students to reflect on what it means to be a leader. Ask the students the following questions to facilitate discussion: (1) Do you feel that everyone has leadership potential? (2) Do you perceive nurses as being ‘leaders’? (3) Do you think that nurses are ‘change agents’?

• During the next clinical experience, assign the students to observe and document evidence of the standards of professional performance (Table 10-2) as shown by the registered nurse in the clinical agency. Discuss the examples and evidence at the end of the clinical experience.

• Depending on availability, assign the students to shadow an advanced practice nurse (clinical nurse specialist, nurse practitioner, etc.). After the shadowing experience, have the students report back to the group the activities and challenges that the advanced practice nurse addressed during the course of providing patient care. In addition, identify areas in which the advanced practice nurse conducted care that would be considered ‘above and beyond’ that of a registered nurse.

• In the clinical area, assign the students to identify types of power (Table 10-5) demonstrated among the nursing staff by answering the questions: What is the registered nurse’s role? What is the source of the power? How was the power demonstrated?

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Review questions 1.

Accountability is: a. the process in which individuals are answerable for their actions and have an obligation (or duty) to act b. the process in which individuals provide evidence of their professional registration c. the process in which process of ensuring quality and safe health care d. the process in which teams are answerable for their actions and have an obligation (or duty) to act e. the process in which patients are responsible for their actions and must comply with care instructions.

Answer: a Rationale: Accountability is where individuals are responsible for their actions and have an obligation (duty) to act.

2.

Boards of nursing are authorised to: a. discipline medical practitioners as necessary to protect the public b. develop Bachelor of Nursing curriculums c. develop health care curriculums d. grant registration to individuals who do not meet the minimum qualifications e. renew registration for competent practitioners.

Answer: e Rationale: The boards of nursing are legally responsible registering eligible nurses and act for the safety of the public. Medical practitioners have their own agency to certify their safety to practice.

ANMAC is involved in the accrediting of nursing curricula. Individuals who do not meet minimum qualifications are not registrable.

3.

Which of the following is an ineffective leader behaviour? a. Clarifying a misunderstanding b. Confronting a supervisor c. Yelling at a co-worker d. Yielding on an unimportant issue e. Consulting with colleagues.

Answer: c Rationale: Yelling at a co-worker is demeaning and leads to a loss of credibility for the manager.

Effective leaders clarify misunderstandings, confront supervisors when needed and can compromise when the issues are not urgent.

4.

A nurse manager understands that the autocratic leadership style is most appropriate: a. during crisis situations b. when a manager prefers a ‘telling’ style c. when followers cannot agree on a course of action d. when problems are routine e. when you do not like a particular staff member.

Answer: a

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Rationale: The autocratic leadership style is best suited for emergencies when there is limited time for consensus building among team members.

5.

In Australia, the independent accrediting authority for nursing and midwifery education is the: a. Australian Nursing and Midwifery Accreditation Board b. ACN c. Australian Nursing and Midwifery Accreditation Council d. Royal College of Nursing.

Answer: c Rationale: ANMAC is the authority charged with accrediting curricula for educational institutions to ensure that graduates meet the competency standards set for registration. ANMAB is non-existent.

The colleges are combined and provide expert advice to the government and other entities for policy development.

6.

The nurse manager calls a meeting of the nursing staff to discuss cost-cutting strategies. Staff members are encouraged to share their ideas and comments. The manager is demonstrating the importance of using which type of leadership style? a. Autocratic b. Democratic c. Laissez-faire d. Social trait e. Directive.

Answer: b Rationale: The democratic leader is one who invites discussion from group members. A group led by a democratic leader is more participative, demonstrates ownership in problem solving, and has a high degree of morale. Managers using the autocratic and laissez-faire leadership styles do not encourage group participation.

7.

In planning care for a group of people, which assignment planned by the RN would be most appropriate? a. Asking a nursing assistant to explain to the client how to empty a urine collection bag b. Assigning the nursing assistant to orient a new graduate practical nurse to the unit c. Delegating the administration of all medications to the EN d. Delegating the administration of an intermittent tube feeding to the EN e. Delegating the administration of all medications to the nursing assistant.

Answer: d Rationale: Administering intermittent tube feedings is within the legal scope of practice for enrolled nurses. Client teaching cannot be delegated to nursing assistants or other unlicensed personnel.

Unlicensed personnel are not to orient individuals with higher educational preparation. It is not appropriate for the registered nurse (RN) to delegate administration of all medications because some people may need the education, which should be provided by the RN.

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8.

When you are preparing to assign duties to the unit staff, which element must be present to ensure effective delegation? a. Solid information base b. Adequate supplies and equipment c. Experienced staff members d. Informed patients and families/significant others e. Informed allied health care team members.

Answer: a Rationale: The delegator must know which personnel is knowledgeable and able to perform the assigned task. The nurse must never delegate a task to a person who is not competent to perform that task.

9.

Legal boundaries of practice for health professionals are: a. the scope of practice b. the nursing standards c. the accreditation standards d. the regency of practice e. the standards of practice.

Answer: a Rationale: Scope of practice refers to the legal boundaries of practice for health care providers.

Legislation defines the legal rights granted to the profession by the public. It is essential to public wellbeing that nursing regulate its practice to ensure that only those individuals qualified to practise are allowed to do so.

10. True or false? In New Zealand, students must pass a state final exam to register as a RN a. True b. False Answer: a Rationale: In New Zealand, nursing students are required to sit and pass the New Zealand Nursing Council State Final Examination to become either a Registered Nurse or Enrolled Nurse.

Spotlight on critical thinking Indicators of professionalism Observe RNs in various practice settings: 1.

How do the nurses interact with one another and other members of the health care team? How do the nurses demonstrate professional commitment?

2.

Are they involved in professional activities, such as continuing education and professional association activities?

3.

How do these nurses contribute to the public's perception of the nursing profession?

Suggested solution: Consider such things as interpersonal communication, willingness to assist others, maintaining currency of practice, using research and evidence-based guidelines further than habitual care and demonstrating reflective practice.

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Accountability 4.

Think of the following actions as ways to demonstrate professional accountability: • • • • •

5.

assuming only those responsibilities that are within one's scope of practice not assuming responsibility for activities in which competency has not yet been mastered evaluating the outcomes of one's own actions admitting mistakes rather than blaming others documenting nursing interventions.

Select one day of your clinical experience and identify ways in which you demonstrated accountability.

Suggested solution: Answers will vary; however, ask the students to provide specific examples of how they demonstrated the suggested activities and discuss the strategies within the class.

Legal/ethical: Student accountability You are working as a nursing assistant (unlicensed personnel) part-time while studying for a Bachelor of Nursing.

6.

What would be your appropriate response if asked to perform a nursing procedure such as medication administration?

Suggested solution: Sorry, I cannot do it because it is outside my scope of practice, and therefore illegal.

7.

Would the fact that you have performed the procedure previously as a nursing student affect your response?

Suggested solution: It should not, working as a nursing assistant has its own scope of practice.

Delegation Your employer, a large acute care hospital, has hired consultants to examine the cost of care expended in the facility and recommend a more cost-effective system. These consultants recommend decreasing the number of both RNs and ENs and increasing the responsibilities of unregistered assistive personnel.

8.

As a RN in charge of the care of medical-surgical patients, what questions would you ask regarding this proposal?

Suggested solution: Provision for safety of the patients, scope of practice defined for the assistive personnel, who would take responsibility for the assistive personnel's actions when the RN did not feel it was appropriate to delegate an action to them, what is the NMBA's view on this recommendation, Is it legal? Is it ethical?

9.

In what ways do you think your responsibilities would increase because of this situation? Do you think your responsibilities would decrease significantly?

Suggested solution: There would be increased supervision, workload and responsibility as a registered nurse because you would need to assume a greater patient load so that the work is done safely.

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10. What impact would this proposal have on the ethical delivery of care to people, specifically the nurse's need to cause no harm and promote good?

Suggested solution: The registered nurse’s time would be stretched too thin to provide legally and ethically appropriate care.

11. What are the legal implications of this recommendation?

Suggested solution: This is an illegal action. The scope of practice of the assistive personnel would be expanded beyond their ability and knowledge base.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 4 Resource aids....................................................................................................................................................... 5 Online resources.................................................................................................................................................. 6 Evaluation strategies ........................................................................................................................................... 7 Spotlight on critical thinking .............................................................................................................................. 10

Chapter 11 Legal and ethical responsibilities Key terms Act A law made by parliament.

Active euthanasia Process of taking deliberate action that will hasten the person’s death.

Advance care directives (ACD) Document in which an individual, in consultation with relatives or other personal advisers, provides precise instructions for the type of health care they want or do not want if they are incapacitated.

Assault Intentional and unlawful offer to touch a person in an offensive, insulting or physically intimidating manner.

Assent The agreement of a child or adult not able to give legal consent to participate in the care provided.

Assisted suicide Situation in which a health care professional provides a person in their care with the means to end his or her own life.

Autonomy Being self-directed and taking initiative instead of waiting for direction from others; ethical principle that refers to the individual’s right to choose for oneself and the ability to act on that choice.

Battery Touching another person without consent.

Beneficence Ethical principle regarding the duty to promote good and prevent harm.

Bicameral A parliamentary structure that consists of two Houses of Parliament.

Bioethics Application of general ethical principles to health care.

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Categorical imperative Concept that states that one should act only if the action is based on a principle that is universal.

Civil law Law that deals with relations between individuals.

Common law Law created by judges in a court hierarchy system.

Confidentiality The principle where information is not revealed to another party without the individual’s consent.

Consent Permission or an agreement to be allowed to act or complete some form of care.

Consequentialism Ethical theory that states that the moral value of a situation is determined by its consequences.

Constitutional conventions Informal political procedural agreement.

Criminal law Legal framework governing acts or offences against the welfare or safety of the public.

Defamation Act that occurs when information that damages an individual’s reputation is communicated to a third party either in writing (libel) or verbally (slander).

Deontology Ethical theory that considers the intrinsic moral significance of an act itself as the criterion for determination of good.

Electronic health records (EHRs) A systematic collection of an individual’s information that is transferable between health organisations.

Ethical dilemma Situation in which there is a conflict between two or more ethical principles.

Ethical principles Beliefs that govern actions.

Ethical reasoning Process of thinking through what one ought to do in an orderly, systematic manner in order to provide justification of actions based on principles.

Ethical theories A philosophically coherent set of propositions which attempts to provide general norms for the guidance and evaluation of moral conduct.

Ethics Branch of philosophy concerned with determining right from wrong on the basis of a body of knowledge.

Ethics of care To avoid causing harm with an emphasis on nurturance rather than justice and equality.

Euthanasia Intentional action or lack of action causing the merciful death of someone suffering from a terminal illness or incurable condition; derived from the Greek word euthanatos, which literally means ‘good or gentle death’.

Executive Branch of government that puts law into operation.

Good Samaritan Caregiver who aids at the scene of an emergency without expecting or receiving any remuneration and without intentionally or recklessly causing injury. Such caregivers are subject to laws protecting them from being liable for any injury caused.

Greatest Happiness Principle Ethical principle that determines an action is right insofar as it promotes the greatest happiness of the greatest number of those affected.

Human Rights Commission Government body overseeing legislation in the areas of human rights, antidiscrimination, social justice and privacy. © Cengage Learning Australia 2024

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Hypothetical imperatives The requirements for achieving a desired end.

Implied consent Not expressly granted by a person but rather inferred from a person’s actions Incident reports Documentation of an unusual occurrence or an accident in delivery of a person’s care.

Judiciary System of courts that interprets the law, ensures accountability and protects democratic principles.

Justice Ethical principle based on the concept of fairness that is extended to each individual.

Laws Rules or regulations that are enacted by legal entities.

Moral philosophy Concerned with theories related to ethics.

Morality Behaviour in accordance with custom or tradition that usually reflects personal or religious beliefs.

Negligence Failure of an individual to provide the care in a situation that a reasonable person would ordinarily provide in a similar circumstance.

Non-maleficence Ethical principle that means the duty to cause no harm to others.

Nursing and Midwifery Board of Australia (NMBA) Statutory body responsible for the regulation and standards of Australian nursing and midwifery practice.

Nursing Council of New Zealand (NCNZ) Statutory body responsible for the regulation and standards of New Zealand nursing practice. Also known as Te Kaunihera Tapuhio Aotearoa.

Parliament Body having legislative power within the state.

Parliamentary law Law created in parliament, which is known as a statute or an Act of parliament.

Passive euthanasia Process of cooperating with the individual’s dying process.

Paternalism Attitude of superiority in which health care providers decide what is ‘best’ for an individual and then attempt to coerce the person to act against their own choices.

Patient advocate Person who speaks up or acts on behalf of the person in care.

Professional misconduct Inappropriate conduct in a practice.

Professional regulation To safeguard and promote the health, safety and welfare of the public by ensuring that licensed practitioners work to a certain standard.

Rights A justified entitlement to something.

Risk management Identifying and limiting risk.

Scope of practice Framework of the legally allowable practice an individual is permitted to perform within the limitations of the profession.

Separation of powers The division of legislative, executive and judiciary powers of government into separate bodies.

Teleology Ethical theory that states that the moral value of a situation is determined by its consequences.

Tort Civil wrong committed upon a person or property stemming from a direct invasion of some legal right of the person, the infraction of some public duty, or the violation of some private obligation by which damages accrue to the person.

Unethical Lacking moral principles.

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Unicameral Legislatives that contain only one House of Parliament.

Unprofessional conduct Conduct by a professional person that could adversely affect the health and welfare of the public.

Values Principles that influence the development of beliefs and attitudes.

Values clarification Process of analysing one’s own values to better understand what is truly important to oneself.

Veracity Ethical principle that means that one should be truthful, neither lying nor deceiving others.

Verbal consent The person verbally agrees to the treatment or action.

Written consent In cases of surgical and medical procedures that require an anaesthetic or intravenous sedation, or where there are definable risks, the person must sign a legally binding form agreeing to the treatment.

Instructional strategies • Law is an arbitrary term. There are varying approaches to classifying and defining law. What are some of the approaches? o Common Law is law defined by court decisions whereas statue law is passed by parliaments. Common law has developed from the process of recording judgments and using those judgments to support future decisions. o Law can be classified by the subject that surrounds the issue such as environmental law, Treaty of Waitangi law, constitutional law, personal property law, commercial law, tort law, criminal law, taxation law. o Classification between laws can be related to criminal and civil law. Criminal law is engaged when a behaviour is deemed as unacceptable and requires some type of punishment. It is used as a measure to tame society to behave within certain boundaries. If these boundaries are breached then there is usually some type of personal punishment such as a warning, fine, community service requirement or going to gaol. Civil cases are not based on punishment and are based on compensation. While criminal law requires the accused be considered innocent before being found guilty the Crown has the responsibility to prove the case beyond reasonable doubt in civil cases it is a balance of probabilities where reasonable cause is used to judge the case.

• What is the difference between negligence and malpractice? How do standards of care help to protect both the nurse and the client? Negligence refers to a breach of duty whereby an individual fails to perform what is considered a reasonable action and this results in harm to the other party. Malpractice refers to a professional person’s actions that do not meet standards of care and result in harm to the other party. Standards of care help to protect the nurse and client by providing established, accepted goals that reflect common and usual practices. The standards are consistent with accepted practice.

When nurses follow standards of care, the client can be assured that all reasonable and customary measures have been undertaken.

• Applying restraints to a client can lead a nurse to be charged with false imprisonment or assault and battery. What can a nurse do to avoid these criminal charges? Besides the use of safety measures, chemical restraints in the form of psychotropic medications have been used to control hyperactive © Cengage Learning Australia 2024

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behaviour of agitated clients. If a nurse must apply restraints in the event of a violent client, the nurse must immediately obtain an order for the restraints from a physician.

• In what ways can nurses face disciplinary action, and how can nurses protect themselves? Actions or omissions that can potentially adversely affect the health and welfare of the public would fall under the guise of unprofessional conduct. This includes failure to use sufficient knowledge, skills, or nursing judgement when practicing nursing. Being aware of the standards of practice and being prepared for duty will decrease the risk of unprofessional conduct. Improper use of controlled substances is cause for disciplinary action.

• What options does a nurse have when faced with the need to obtain informed consent from a non– English-speaking client? The nurse can confer with the appropriate health care provider to determine whether the necessary procedure has been sufficiently explained and the client fully understands the risks. The nurse may also elicit the aid of a family member or other agency staff to translate the consent and assist in obtaining proper informed consent.

• Describe the difference between and give examples of ethics and morals. Ethics, a branch of philosophy, does not involve individual opinions but is the distinction of right from wrong on the basis of a body of knowledge. It is more than an intellectual exercise; it is a philosophy of beliefs and action. Laws, for example, are ethical considerations. Morality, on the other hand, is behaviour manifested on a personal level. A nurse who believes abortion is wrong has a moral belief. However, it is legal to undergo an abortion, so it is not unethical.

• Discuss the five ethical principles that are found within health care. Autonomy is the respect for an individual’s right to self-determination. Non-maleficence is the obligation to do or cause no harm.

Beneficence is the duty to do good to others and to maintain a balance between benefits and harms.

Justice is the equitable distribution of potential benefits and risks. Veracity is the obligation to tell the truth.

• How does the process of values clarification lead a nurse to balance the relationship between values and ethics when providing care to clients? The process of values clarification helps the individual to understand what is of most importance. The nursing profession cares for clients with many different values, and the recognition of that individuality must be acknowledged. Nurses also need to be aware of their values so that they will not be placed in a situation where there may be ethical conflicts. For example, a nurse may have a change in values by virtue of experience or time and have to change their place of practice because of ethical and value conflicts.

Resource aids Albert, J., Younas, A. & Sana, S. (2020). Nursing students' ethical dilemmas regarding patient care: An integrative review. Nurse Education Today, 88. https://doi.org/10.1016/j.nedt.2020.104389 Atkins, K., de Lacey, S., Ripperger, B. & Ripperger, R. (2020). Ethics and law for Australian nurses (4th ed.).

Cambridge University Press.

Clavel, N., Paquette, J., Dumez, V., Del Grande, C., Ghadiri, D., Poney, M. & Normandin, L. (2021). Patient engagement in care: A scoping review of recently validated tools assessing patients' and healthcare

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professionals' preferences and experience. Health Expectations, 24(6), 1–12. https://doi.org/10.1111/hex.13344 Joustra, C. & Moloney, A. (2019). Clinical Placement Manual. Australia: Cengage.

McDonald, F. & Then, S. (2019). Ethics, Law & Health Care: a guide for nurses and midwives. (2nd ed.).

London: Macmillan Education.

Milliken, A. (2018). Ethical awareness: What it is and why it matters. Online Journal of Issues in Nursing, 23(1). https://doi.org/10.3912/ojin.vol23no01man01 Morley, G., Bradbury-Jones, C. & Ives, J. (2019). What is ‘moral distress’ in nursing? A feminist empirical bioethics study. Nursing Ethics, 27(5): 1297-1314.

Staunton, P. & Chiarella, M. (2020). Law for nurses and midwives (9th ed.). Elsevier.

Online resources • Accident Compensation Corporation (ACC). (2021). Accident Compensation Act 2001. https://www.legislation.govt.nz/act/public/2001/0049/latest/DLM99494.html • Australian Commission on Safety and Quality in Health Care (ACSQHC). (2019). Australian charter of healthcare rights (2nd ed.). https://www.safetyandquality.gov.au/consumers/working-your-healthcareprovider/australian-charter-healthcare-rights • Australian Human Rights Commission. (2019). Australia and the Universal Declaration of Human Rights. https://humanrights.gov.au/our-work/publications/australia-and-universal-declaration-humanrights#:~:text=The%20Universal%20Declaration%20on%20Human%20Rights%20%28the%20Universal,eig ht%20nations%20involved%20in%20drafting%20the%20Universal%20Declaration • Australian Law Reform Commission. (2019). The future of law reform: a suggested program of work 20202025. https://apo.org.au/node/270231 • Commonwealth of Australia. Department of Health. (2021). Advance care directive. https://www.health.gov.au/health-topics/palliative-care/planning-your-palliative-care/advance-caredirective • Health and Disability Commissioner. (2021). The code and your rights. https://www.hdc.org.nz/disability/the-code-and-yourrights/#:~:text=The%20Code%20and%20your%20rights.%20In%20New%20Zealand%2C,fairly.%20The%2 0right%20to%20dignity%20and%20independence.%20 • Human Rights Commission. (2021). Human rights legislation - New Zealand. https://www.hrc.co.nz/yourrights/human-rights-legislation-new-zealand/ • Ministry of Justice. (2021). Courts. Retrieved from http://www.justice.govt.nz/courts • New Zealand Nurses Organisation (NZNO). (2019). Guideline - code of ethics. https://www.nzno.org.nz/Portals/0/publications/Guideline%20%20Code%20of%20Ethics%202019.pdf?ver=2019-06-27-094754-100

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• Nursing Council of New Zealand (NCNZ). (2016). Competencies for registered nurses. https://www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursingsection/Standards_and_guidelines_for_nurses.aspx?hkey=9fc06ae7-a853-4d10-b5fe-992cd44ba3de • Nursing Council of New Zealand. (2012). Code of Conduct. https://www.nursingcouncil.org.nz/Public/Nursing/Code_of_Conduct/NCNZ/nursingsection/Code_of_Conduct.aspx?hkey=7fe9d496-9c08-4004-8397-d98bd774ef1b • Nursing and Midwifery Board of Australia (NMBA). (2016). Registered Nurse Standards for Practice. http://www.nursingmidwiferyboard.gov.au/News/2016-02-01-revised-standards.aspx • Nursing and Midwifery Board of Australia (NMBA). (2018). Code of conduct for nurses in Australia. http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx • Nursing and Midwifery Board of Australia. (2018). Retrieved from ICN-Code of ethics for nurses in Australia. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professionalstandards.aspx • Waitangi Tribunal. (2020). The treaty of waitangi/te tiriti o waitangi. Ministry of Justice. https://waitangitribunal.govt.nz/treaty-of-waitangi/

Evaluation strategies • What is the role of the nurse when confronted with a case that challenges his or her moral code/values (e.g., therapeutic abortion or sterilisation)?

• Have students locate the Nursing and Midwifery Board of Australia or the Nursing Council of New Zealand web page. Ask them to explore the page to assist them in finding guidelines and competency of practice.

• Have students research on the internet cases of nurse misconduct. Using nursing competencies, ethical and professional codes and guides identify which specific values and competencies have been breached by the nurse. Ask students to determine if the outcome of the case was appropriate or satisfactory.

• Have the students read the Nursing checklist on page 169 entitled ‘Actions to improve patient safety’.

Have the students break up into small groups and discuss how by following these statements they are ensuring patient safety and emphasise the importance of protecting their own professional safety as well.

• Since many clients in the clinical setting have advance directives, what does this mean for nurses who participate in their care? Encourage students to express how they will feel as a practitioner about enacting and supporting this patient driven directive?

• Have students, in small groups, discuss their values around both passive and active euthanasia, abortion and institutional care.

• Discuss ways in which novice nurses can handle concerns about other nurses, physicians, or health care providers. Possible scenarios include witnessing illegal drug administration, physician ordering of a placebo, and falsifying patient records.

• Due to recent technology, there have been many advances with regard to biotechnology and cloning.

Have the students discuss the ethical and moral implications that can arise from this technology in relation to healthcare.

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Review questions 1

Which of the following is based on the teleological (consequentialism) theory of ethics? a Dialysis for people with end-stage renal disease (ESRD) b Immunisations for all preschool children c Parenting classes in outpatient prenatal clinics d Protection for health care workers e Provision of counselling services for post-trauma patients Answer: b.

Rationale: Teleology determines the rightness of an act based on the principle of utility, that is provision of the greatest good to the greatest number of people. Preschool immunisation benefits the largest number of people, as opposed to actions geared to fewer recipients (e.g., clients with ERSD or who are pregnant, or to health care providers).

2

You instruct a patient, ‘I have to change your dressing now. If you don’t let me change it, it may will make you septic and die’. Which of the following best describes your illegal act? a Assault b Battery c False imprisonment d Libel e Fraud Answer: a Rationale: Assault is a statement of intent to touch another person. Battery is the actual touching of another person without his or her consent. False imprisonment refers to holding clients against their will. Fraud is intentional deception to secure unfair or unlawful gain, or to deprive a victim of a legal right.

3

Which of the following statements best describes requirements with professional liability insurance for a registered nurse in Australia? a Advanced practice registered nurses (APRNs) are the only nurses who need to purchase professional liability insurance. b Each nurse should purchase professional liability insurance. c Nurses are protected by their employer’s insurance. d Nurses will be represented by the employer’s attorney. e Nurses only need professional liability insurance if they are working in the private health care system.

Answer: b Rationale: Every nurse should purchase his or her own insurance for protection against civil action. It is a requirement for Registration in Australia and is recommended for New Zealand nurses.

4

You are preparing a patient for a surgical procedure. Which of the following should you do if there is no surgical consent form signed by the patient? a Explain the procedure and its risks to the patient and have them sign the consent form. b Notify the surgeon of the patient’s need for informed consent. c Send the patient to surgery with a notation that the consent form is unsigned.

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d Inform the patient that the form must be signed prior to surgery. e Send the patient to surgery assuming that the theatre nurse will deal with this.

Answer: b Rationale: Written consent is generally required for medical or surgical procedures. The consent must be obtained by the person performing the procedure.

5

The medication order form is missing the route required for the prescribed medication. Which of the following actions should you take? a Administer the medication via the most common route. b Ask the nursing supervisor what should be done. c Contact the prescriber and clarify the order. d Withhold the medication, noting this on the medication chart and ask the prescriber to clarify next time you see them on the ward.

Answer: c Rationale: Whenever you have a question about a medication order, the prescribing practitioner should be contacted for clarification of the order. It is outside the nurse’s scope of practice to change the medication dosage. The nurse who administers an incorrect dose of medication is legally responsible for client harm, even if the dosage was ordered by a prescriber.

6

Which of the following nursing actions is based on the ethical principle of autonomy? a Removing a throw rug from the patient’s bedside b Respecting a patient’s refusal of treatment c Telling a patient the truth about a negative diagnosis d Using a paternalistic approach when answering patient questions Answer: b Rationale: Autonomy refers to the patient’s right to make his or her own health care decisions.

Removing obstacles to prevent falls is an example of non-maleficence. Veracity means the obligation to tell the truth, and paternalism violates the client’s right to self-determination.

7

The sharing of limited resources among healthcare teams during the Covid-19 pandemic, involves which of the following ethical principles? a Autonomy b Beneficence c Veracity d Justice e Advocacy Answer: d Rationale: Justice refers to the equitable distribution of potential benefits and risks. Autonomy refers to one's personal liberty and independent decision making. Beneficence is the duty to do well to others, and veracity is the obligation to tell the truth.

8

Which of the below represents the five steps used in the ethical decision-making model. a Assessment, analysis, planning, implementation, and evaluation b Analysis, assessment, planning, implementation, and evaluation

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c Planning, analysis, assessment, implementation, and evaluation d Assessment, planning, analysis, implantation, and evaluation Answer: a

Spotlight on critical thinking You are on a clinical practicum and you want to fit into your new work environment. You are to perform some care. The registered nurse you are working with tells you not to inform the person that you are a nursing student.

1

What is your legal and ethical responsibility to disclose that you are a nursing student to the person you are caring for?

Suggested solution: Regarding legal obligations, it is important for students to realise that when they are on clinical practicum they have a legal obligation to disclose that they are a student so the person is giving informed consent to any treatment the student administers and that they have the right to refuse care from the student. In addressing this question, it is also important to highlight that the general public are usually very generous with students and are eager to support their learning.

Regarding ethical obligations, this can be connected with ethical principles including autonomy, justice and veracity. It can also be connected to ethical theories with the Greatest Happiness Principle Kant’s sense of duty. The discussion needs to consider how does this connect with caring ethics which is not centred on justice and equity but rather empathy and relationships. How will your actions support or detract from the nurse-patient relationship and the caring relationship?

2

How do you address this issue with the RN you are working with?

Suggested solution: Addressing the registered nurse should not be an ethical debate but rather as an opportunity to reflect on your professional role sometimes you will need to be a leader and should directly disclose that you are a student, ready to care for the person under the guidance of a qualified registered nurse.

You are on a clinical placement assisting in caring for an 87-year-old person who is in the medical unit with a tracheostomy. The use of this medical technology makes it possible for them to continue breathing as long as the tracheostomy remains patent; at this time, without the tracheostomy, they would die. But what are the costs: emotional, physical, psychological and fiscal? And what is the quality of a life prolonged by technology?

3

Using the ethical decision-making model, can you resolve this issue?

Suggested solution: By placing this issue in a framework, students will be able to appreciate the complexity of every individual case which may assist in identifying the importance of the ethics of caring model, ethics beyond justice and duty. Issues to highlight that are generally concerning to nurses are the person’s age, quality of life, overall outcome of treatment, pain and suffering and respect. Not knowing what the person actually wants and how long treatment should continue makes it a complex issue and there will be varying responses amongst your peers.

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You are caring for a young man in his early 20s who has just been diagnosed with hepatitis C. He confides to you that he takes narcotics intravenously, but that he has not told his family and does not want them to know. His parents come in to visit and ask you how he could possibly have contracted this disease.

4

From a legal perspective, what is your obligation?

Suggested solution: Legal aspect: This is an issue of respecting patient confidentiality and legally you are not allowed to disclose this information.

5

What are your responsibilities from an ethical theory and ethical principles perspective?

Suggested solution: When responding to this question ethically you may consider the ethics of caring perspective and who the person actually is and are you practicing patient-centred or family-centred care. The ethical principles can be broken down to assist you to develop an appreciation of the differences in ethical positions and how this can alter your perspective and decision-making processes.

6

Are any ethical principles put at risk by your legal actions?

Suggested solution: No, in this scenario the legal requirements support the ethical principles for the individual.

You are on a clinical placement at a tertiary hospital, caring for a 93-year-old male. He has dementia and has been transferred from a nursing home, having been diagnosed with pneumonia. He does not have the capacity to make decisions, but he does have an advance care directive (ACD) which states that he does not want to be fed or given fluids of any type if he is hospitalised with any illness. He wants pain relief and to be kept comfortable. He refuses to eat or drink, and you read in the transfer notes that this is not unusual behaviour for him. The medical officer orders that he is to be fed via a nasogastric tube.

7

What are the legal and ethical ramifications of this order?

Suggested solution: When responding to this series of questions you may reflect on the legality and binding nature of the advanced health directive. You need to identify the ethical dilemma not just simply for themselves but for other health care workers. Medicines are highly influenced by bioethics and are also open to legal liability if they fail to meet their duty of care. The issue of the person refusing food not being an unusual practice for this individual and that he does not have capacity to make health care decisions complicates this case study and it is the complexity, not the one-line answer that you should be expressing in the response.

8

What do you perceive to be your responsibilities in relation to the care of this person?

Suggested solution: Discussion should focus on respecting the patient’s wishes and advocating for the patient’s wishes to be actualized. It is vital to engage all stakeholders in the discussion relating to the patient’s care.

You are caring for two patients in a double room. One of the patients is of the Muslim faith and is wearing a hijab. The other patient in the room tells you that they are strongly opposed to Islam because they have a belief that Muslim people are responsible for acts of terrorism. The patient indicates that they want to be either transferred to another room or discharged.

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9

What are your ethical and professional responsibilities to both patients?

Suggested solution: When responding to this question, students may consider that both patients have rights that need to be respected and that ethically, as a nurse caring for people in a shared space with individuals who have their own sense of place, this conflict can arise. It is a case of finding a solution.

You would accommodate the right of the Muslim patient to adhere to the requirements of their faith, but what of the other patient? Do they have rights too?

10 How would you manage this situation?

Suggested solution: Explore the underlying rationale/reasons for the non-Muslim patient’s belief regarding Islam. This may be achieved by asking questions of the patient and listening to their responses. Developing an understanding of where their belief stems from will help to inform your response and next actions. Education would be an important part of managing the situation. Discussion should also include consideration of unconscious bias of the nursing student in addressing this and other similar situations.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions ................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 7

Chapter 12 Documentation and informatics Key terms Advance care directive (ACD) Document in which an individual, in consultation with relatives or other personal advisers, provides precise instructions for the type of health care they want or do not want if they are incapacitated.

Case management (managed care) Methodology for organising care through an episode of illness so that specific clinical outcomes are achieved within an allotted time frame.

Charting by exception (CBE) Charting method that requires the nurse to document only deviations from preestablished norms.

Clinical decision support systems (CDSS) The software systems that analyse data for the clinician to combine with their clinical knowledge to directly aid clinical decision-making (e.g., blood test results).

Computer literacy Familiarity with the use of personal computers, including the use of software tools.

Critical pathway Abbreviated summary of key elements from the case-management plan.

Documentation Written evidence of the interactions between and among health care professionals, individuals and their families, and health care organisations; the administration of tests, procedures, treatments and health care education; the result or individual response to these diagnostic tests and interventions.

Enduring guardian Someone appointed to make personal or lifestyle decisions for a person when they are not capable of doing this.

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E-prescribing The electronic transmission of medication prescriptions to a pharmacy from a hospital-based inpatient ordering system, personal digital assistants, wireless computers or other handheld devices.

Focus charting Documentation method using a columnar format to chart data, action and response.

Incident report Documentation of an unusual occurrence or an accident in delivery of person’s care.

Informatics The science of turning data into information.

Information technology Refers to the management and processing of information with the assistance of computers.

Narrative charting A story format of documentation that describes the persons status, interventions and treatments, and the response to treatments.

Nursing informatics (NI) The use of information and computer technology to support all aspects of nursing practice.

Problem, intervention, evaluation (PIE) Subset of the nursing process where the problem is identified, and the intervention is applied and then evaluated.

Problem-oriented medical record (POMR) Documentation focused on the person’s problem with a structured, logical format to narrative charting called SOAP (subjective and objective data, assessment, plan).

SOAP Documentation method using subjective data, objective data, assessment and plan.

Source-oriented (SO) charting Narrative recording by each member (source) of the health care team on a separate record.

Variations Goals not met, or interventions not performed according to the time frame; also called variance.

Instructional strategies • The purpose of documentation has been discussed in other chapters. There are additional reasons for health care documentation by the nursing staff. Discuss some of those reasons. Two primary reasons that health care professionals document are professional responsibility and accountability. Nurses use documentation to communicate with other nurses and members of the health care team. Nurses, including nursing students, use documentation to educate themselves about disease processes, complications, medical and nursing diagnoses, and interventions. Nursing students can learn ways to chart that are objective and complete. Documentation can be used for research purposes. Some nursing studies gather data from chart recordings. Documentation is pivotal for legal and practice implications for nurses. Failure to document or inappropriate documentation can lead to legal problems for the nurse.

Peer review organisations monitor and evaluate the quality and appropriateness of care given.

• Discuss the two types of hospital information systems. A clinical information system is a large, computerised database that includes smaller systems such as order entry, admission, laboratory, pharmacy, radiology and documentation that supports and enhances care. Administrative information systems manage financial and demographic information and provide reporting capabilities to support care.

• Review the characteristics of an electronic health record. An electronic health record is a longitudinal record of patient health information generated by one or more encounters in any health care setting.

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Because every encounter is stored, the information can be accessed when needed to identify quality issues, link interventions with outcomes, and make evidence-based decisions.

• Discuss what constitutes personal health information. Personal health information is any information contained in automated records that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications regarding patients, and written communications.

• Review how a health care organization ensures security of personal health information. Security mechanisms use a combination of two basic measures termed logical and physical restrictions. Automatic sign-off from a computer is an example of a logical restriction. After a period of inactivity on a computer, the computer will automatically log the user off. Physical restrictions include firewalls and antivirus and spyware detection software. Individuals who access the computers that contain personal health information need to be identified by password or access code.

• Discuss the different functions of advance directives and durable power of attorney. An advance directive is a statement made by a person that defines the type of care he or she deems acceptable if they become incapacitated. People, while competent, can participate in decisions that may occur later in their lives. A person involved in a life-threatening accident where he or she was unable to respond would have an advance directive in place to determine the type of care the person would have wanted. If the person becomes able to make decisions again, he or she may revoke the advance directive. An enduring power of attorney allows a designated person to make health-related decisions when the person is unable to make them.

• Discuss how the elements of effective documentation can help to support and maintain standards of care in the clinical setting. It is important to acknowledge that effective documentation requires (1) legibility, (2) use of only authorised abbreviations and symbols, (3) factual and time-sequenced organisation, and (4) accurate recording of errors in the paper based or electronic incident reporting system. If nursing students (nurses) include all these elements in their charting, then accurate information can be conveyed to appropriate health care team members. Correct documentation will provide a systematic review by which a person’s records can be evaluated.

Resource aids Advance Care Planning Australia (2021). Advance care planning explained https://www.advancecareplanning.org.au/understand-advance-care-planning/advance-careplanning-explained Hebda, T., Hunter, K. M. & Czar, P. (2019). Handbook of informatics for nurses and healthcare professionals (6th ed.). Pearson.

Nursing and Midwifery Board of Australia (NMBA). (2016). Registered Nurse Standards for Practice. http://www.nursingmidwiferyboard.gov.au/News/2016-02-01-revised-standards.aspx Nursing and Midwifery Board of Australia (NMBA). (2018). Code of conduct for nurses, 2018. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professionalstandards.aspx

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Te Kaunihera Tapuhi o Aotearoa: Nursing Council of New Zealand (NCNZ). (2016). Competencies for the registered nurse- amended 2016. https://www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursingsection/Standards_and_guidelines_for_nurses.aspx?hkey=9fc06ae7-a853-4d10-b5fe-992cd44ba3de

Online resources • The Australian Commission on Safety and Quality in Health Care website reports on the development of a National Medication Chart for Australia: https://www.safetyandquality.gov.au/our-work/medicationsafety/medication-charts/national-standard-medication-charts • Australian Commission on Safety and Quality in HealthCare explains Observation and response Charts, https://www.safetyandquality.gov.au/publications-and-resources/resource-library/recognising-andresponding-clinical-deterioration-use-observation-charts-identify-clinical-deterioration • The Health, Quality and Safety Commission, New Zealand website explains the National Medication Chart used in New Zealand: https://www.hqsc.govt.nz/our-work/system-safety/reducingharm/medicines/projects/national-medication-chart/ • Advanced Care Planning Australia explains Advanced Care Planning and Health Care directives: https://www.advancecareplanning.org.au/

Evaluation strategies • Have students prepare documentation from a case study. Pretend that the nurse is required to explain the care they have given to a person in a legal setting. Discuss how the documentation is supportive of proper nursing care, and where there are weak areas that may be open to criticism.

• Determine what type of charting is done at the clinical site. Discuss that type of charting in relation to various other types of charting. What do students think about computer charting?

• Develop a clinical scenario for the students. Divide the students into groups and have each group prepare nursing documentation using a different method of documentation. Compare each different method and evaluate whether important patient information has been documented correctly.

• Provide the students with a patient scenario that requires an incident report to be filed. Have the students provide the necessary documentation to fill out this type of form and discuss the importance of patient safety.

• Have students discuss the importance of charting. Ask them what they think the saying, ‘If it is not charted, then it wasn’t done’ means.

• Provide the students with examples of inaccurate, illegible charting. Discuss the impact of potential safety and legal issues for the patient and the nurse. Have the students come up with methods to verify the order and correct the problems.

• Have the students locate, in the clinical site, the health care organisation’s policy regarding the use of approved/unapproved abbreviations. Encourage a discussion as to the use of abbreviations while documenting care.

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Review questions 1.

Which of the following best describes the person’s health care record? a. It serves as a legal document for recording all patient activities assessed and initiated by health care practitioners. b. It provides a written record for nurses to document all phases of the nursing process. c. It is a systematic documentation of critical elements of care performed by nurses. d. As it contains the person’s medical record, it can be used for educational purposes. e. It is appropriate to discuss a person’s health care record with hospital staff not involved in the person’s direct care.

Answer: a Rationale: The medical record is a legal document of written evidence of the interactions of the person with all health care practitioners regarding the administration of tests, procedures, treatments, and health care education and the results or the person’s response to these diagnostic tests and interventions. Items (b), (c) and (d) are partial functions of the medical record; all health care practitioners use the medical record to document their interactions with the person.

2.

When forming a diagnosis based on the collection of a person’s vital signs, you are collecting what type of data? a. Assessment b. Historical c. Subjective d. Objective.

Answer: a Rationale: Subjective data refer to what the person or family states. Assessment is the diagnosis based on the data, and objective data refer to that which is measured and observed.

3.

Which of the following charting entries is written in the most accurate way? a. Person up, out of bed, walked to the bathroom with assistance, tolerated well. b. Person up, out of bed, walked 12 m to the bathroom and back to bed, tolerated well. c. Person up, out of bed, walked 12 m to the bathroom and back to bed with assistance from the nurse. d. Person up, out of bed, walked 12 m to the bathroom and back to bed with assistance from the nurse, heart rate 84 and regular before exercise, 92 and regular after exercise. e. Person up, out of bed, walked to bathroom and back to bed.

Answer: d Rationale: This is the most specific charting option with objective data to document the person’s tolerance to the exercise. Use of the terms ‘tolerated well’ is making a judgement without objective data.

4.

Select the two (2) answers that best describe the actions taken when a medication error occurs. a. The nurse should ignore it, it is only a small error and doesn’t really matter. b. The nurse should apologise to the person and promise not to make the same error again. c. The error should be reported as soon as it is discovered and an incident report should be completed.

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d. The person should be seen by the medical officer to ensure that the error does not result in adverse harm to the patient. e. The person should be monitored and the error should only be reported if it results in adverse harm to the person.

Answer: c, d 5.

You must document the assessment findings of a surgical incision with staples and retention sutures.

However, the pop-up screen on the computer provides for only staples. How should the nurse document the findings regarding the retention sutures? a. Document the assessment of the staples on the computer screen and click to go to the next screen with no mention of the retention sutures. b. Document the retention sutures assessment to the paper chart. c. Document assessment of the retention sutures as free text in summary notes attached to the appropriate nursing documentation computer page. d. Call the surgeon, give an oral report of the assessment findings, and document the phone call in the computerised nursing progress notes. e. Do not include documentation of the staples or retention sutures.

Answer: c Rationale: The pop-up screen has the option to add additional notes not addressed on the screen. All pertinent assessment data must be documented. The paper chart should be used only in accord with agency policy, for example, when the computers are down. The surgeon should be called only to clarify an order or to report emergent events.

6.

Which of the following actions would make you more vulnerable to legal action? a. Documenting all pertinent patient information. b. Following agency documentation policies. c. Discussing a person’s case with a peer in the elevator. d. Assisting a person to find appropriate websites. e. Working within your scope of practice.

Answer: c Rationale: If others hear health-protected information, the person’s privacy and confidentiality have been breached.

7.

One (1) identified concern in implementing an EHR is: a. cost b. utilisation c. privacy d. accuracy. e. staff health Answer: c Rationale: Control over access to confidential computerised personal health information is the greatest concern. Challenges are present regarding cost factors and ensuring that all health care providers document on the electronic health record. Computerised data have proven accurate.

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8. A person identifies as an Aboriginal and Torres Strait Islander, which of the following is the most culturally safe way to document this? a. ATSI b. Aboriginal c. Torres strait Islander d. Aboriginal and Torres Strait Islander Answer: c Rationale: It is culturally acceptable and respectful to use capitals when referring to Aboriginal and/or Torres Strait Islanders. It is important to recognise both cultural identities. The abbreviation ATSI is considered disrespectful.

9.

Which two (2) of the following are important principles of documentation? a. Legibility b. Abbreviating everything c. Story telling d. Accuracy Answers: a, d Rationale: Documentation must be accurate and legible. Only abbreviations found on the official abbreviation list of the health care facility should be used.

Spotlight on critical thinking Legal/ethical The following scenarios are an opportunity to reflect on why clear, relevant and accurate documentation are a crucial aspect of nursing care. Consider them as examples of how forgetting to document patient information can have devastating effects.

A nurse forgets to document that they have given a 2-year-old child with diabetes mellitus Type 1 their regular dose of insulin.

1.

What are the potential consequences if another nurse checks the medication chart and assumes that the child’s insulin dose has not been given?

Suggested solution: The child will receive a double dose of insulin and may experience an episode of hypoglycaemia. Nurses must always ensure they document all medications given.

When a nurse is assisting an elderly woman in the shower, the nurse notices that the woman has several large bruises on her upper arms and on her abdominal. The woman tells the nurse that her only visitor is her son who sometimes gets very frustrated that his mother requires so much help. The nurse decides that it is not her business to ask questions about the woman’s private family business and does not document the woman’s injuries in the nursing documentation. The woman is discharged into her son’s care the next day.

2.

Why is it important for nurses to investigate and document bruises and wounds in nursing documentation?

Suggested solution: These types of injuries should always be investigated and reported so that appropriate care can be put in place to avoid future incidences of abuse.

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3.

What are the consequences of not assessing the cause of bruises and wounds and ensuring that the person receives the support they require?

Suggested solution: If the woman goes home and her son is her only visitor, it is likely she will continue to be physically abused.

A nurse takes a person’s vital signs and finds that they have a blood glucose level of 20.0mmol/L. The nurse writes this on a piece of paper because the person’s notes are not on the end of the bed, but later forgets to record this in the patient’s BGL chart and does not report this finding to the medical officer. Later, the person is found in bed unresponsive and unable to move after experiencing ketoacidosis.

4.

How can a nurse ensure that information vital to the person is recorded in the health care record so it can be accessed by all members of the health care team in a timely manner, even if the observation chart is not in the place it is usually found?

Suggested solution: The nurse needs to find the chart so the BGL can be recorded immediately, they should not be transcribed from another source because this can result in transcription errors.

5.

Is there anything else the nurse in this scenario could have done after the person was found to be ketoacidosis?

Suggested solution: The nurse needs to check the person’s chart to see if any insulin has been prescribed. If not, the nurse needs to call the medical officer for a clinical review to be completed as soon as possible.

6.

Where should this nursing intervention be recorded?

Suggested solution: The BGL should be recorded on the BGL chart and the nurse’s inventions needs to be recorded in the nursing documentation. This should be done immediately not at the end of the shift.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Reference ............................................................................................................................................................ 4 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 8

Chapter 13 Nursing, healing and caring Key terms Active listening Listening that focuses on the feelings of the individual who is speaking.

Advocate To publicly safeguard a person’s decisions, wishes and preferences; to ensure a person is treated with respect and that they have the necessary information and support to make an informed choice.

Attending behaviours A set of non-verbal listening skills that conveys interest in what the other person is saying.

Catharsis A feeling of renewal or relief after the release of emotions.

Depersonalisation reating an individual as an object rather than as a person; a perception of a loss of self as an individual.

Empathy Understanding another person’s perception of a situation.

Empowerment Process of enhancing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes; the process helps people gain control over their own lives.

Evidence-based practice (EBP) The application of the best available empirical evidence, including recent research findings, to clinical practice in order to aid clinical decision-making.

Healing Process of recovering from illness, accident or disability.

Health care relationship therapeutic affiliation between a nurse and a person in their care.

Orientation (or introductory) phase First stage of the therapeutic relationship, in which the nurse and individual in care become acquainted, establish trust and determine the expectations of each other.

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Paraverbal communication The way in which a person speaks, including voice tone, pitch and inflection.

Presence The process of just being with another; a therapeutic nursing intervention.

Rapport Bond or connection between two people that is based on mutual trust.

Role Set of expected behaviours associated with a person’s status or position.

Termination (concluding) phase Third and final stage of the therapeutic relationship; focuses on evaluation of goal achievement and effectiveness of treatment.

Therapeutic Describes actions that are beneficial to the individual in care.

Therapeutic relationship Deliberate relationship formed between the person with mental disorder and the health worker; there is agreement that it is a collaborative relationship with the purpose of recovery for the person with the mental disorder.

Therapeutic use of self Process in which nurses deliberately plan their actions and approach the relationship with a specific goal in mind before interacting with the person.

Transcultural nursing Formal area of study and practice focused on comparative analysis of different cultures and subcultures with respect to cultural care, health and illness beliefs, values and practices, with the goal of providing health care within the context of the individual’s culture.

Working (or exploitative) phase Second stage of the therapeutic relationship in which problems are identified, goals are established, and problem-solving methods are selected.

Instructional strategies • Caring has been described as a core concept for nursing. How does nursing compare to medicine in relation to the person seeking health care using this concept? A medical practitioner may be more likely to look at the pathology of a disease, a more scientific approach to the person. As nursing incorporates science and art, a more therapeutic manner evolves, the core of which is caring. The medical approach is generally more concerned with treatment and cure. Nursing’s approach is to facilitate a person’s return to their optimal level of functioning. Due to technologic progress, person-centred care can become depersonalised by a biomedical approach. Nurses counteract depersonalisation by emphasising a person’s individuality and advocating for a personalised approach to care. Caring is the hallmark of the effective nurse.

• Why is it important for nurses to integrate concepts of transcultural nursing when providing personcentred care? Transcultural nursing focuses on the study and analysis of different cultures. When nurses see problems from a person’s cultural point of view, they are more able to understand, appreciate, and work effectively with the person. Every culture has systems and methods for health care. These systems and methods are often unknown by nurses of other cultures.

• With the addition of medical equipment and computers, how has nursing become more challenging when providing person-centred care? A nurse is more prone to providing care to the machinery than to the person seeking health care. The machinery is an extension of the person, and the nurse can easily overlook this person by failing to respond to them by demonstrating a lack of interest in what the person says. We must remember that we assess and treat people, regardless of what the machine attached to them are displaying.

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• Using Table 13-4 ‘Comparison of social and therapeutic relationships’ have the beginning nursing students identify the differences between social and therapeutic relationships. Upon entering the nursing profession, the student must understand the differences between social interaction and therapeutic relationships. The student must be educated to see the evolvement of therapeutic communication from the very beginning of nursing education. This will help to maintain focus on person-centred goals, meeting a person’s needs by providing information and appropriate referral, engaging and being accepted by the person seeking health care, planned communication strategies with follow-up, and lastly, defined boundaries and confidentiality. Social relationships can have mutual benefits and shared interests as well as be spontaneous in nature. By defining a true picture of a ‘therapeutic’ relationship early in the nursing program, the student will understand the importance of the nurse−patient relationship. Refer to the ATTACH mnemonic, shown in Table 13-1, as a description for the essential qualities and skills required to develop a therapeutic relationship.

• Name the phases of the therapeutic relationship and nursing actions within those phases. The orientation phase is the first stage of the therapeutic relationship. The person seeking health care and the nurse become acquainted and establish trust during this time. Nursing assessment of the person’s needs, strengths and limits, coping mechanisms, and support system are important nursing actions taken during the orientation phase. The working phase is the second stage of the therapeutic relationship. Goals are established, and problem-solving methods are selected. Nursing actions during this phase are to support the person during this drive to recovery. Teaching is important in this stage as well. The termination phase is the third and final stage of the therapeutic relationship. The nurse evaluates the person’s goals and the effectiveness of their treatment(s). The trust established in the first phase is again useful as the nurse–patient relationship ends. A person’s interaction with the nurse may be a determining factor in future health care decisions.

• Nurses use therapeutic use of self when caring for the person seeking health care. How can a nurse establish a therapeutic relationship with a person? Nurses begin the therapeutic relationship by first introducing themselves to the person. After explaining the role of the nurse to the person, the nurse works to establish trust and boundaries. The nurse needs to assess the person’s perception of his or her health problem and what they expect from care. The nurse should communicate at the person’s level of comprehension and involve the person in all aspects of care. Refer to http://www.hellomynameis.org.uk • Invite discussion regarding the use of humour in nursing practice. Is humour the best medicine? The therapeutic nurse uses humour when working with people seeking healthcare. Florence Nightingale recognised the effectiveness of humour as a nursing intervention. Nurses can build a trusting relationship with proper use of humour. Of course, a nurse must be careful that the use of humour is appropriate and culturally acceptable. Some studies demonstrate measurable physical responses to laughter, including an increase in endorphins and a decrease in blood pressure. It has been shown to ease stress as well.

• Have students research the use of humour in medicine and bring an example to class for discussion in small group format. They should use a multimedia approach. Have the student present the item and explain whether it is considered ‘therapeutic’. It is important for students to realise that there are an infinite number of types of humour available. Television, radio, newspapers, magazines, and the Internet all contribute to humour. By looking at various forms of humour, the student will understand that one’s individual perception can influence whether something is perceived as being funny. It is important that nurses understand how individuals determine the appropriateness of humour.

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Reference Leininger, M., & McFarland, M. R. (2002). Trans-cultural nursing: Concepts, theories, research, and practice.

McGraw-Hill.

Resource aids Bennett, P. N., Parsons, T., Ben‐Moshe, R., Weinberg, M., Neal, M., Gilbert, K., & Hutchinson, A. (2014).

Laughter and humor therapy in dialysis. Paper presented at the Seminars in dialysis.

Chenoweth, L., Low, L.-F., Goodenough, B., Liu, Z., Brodaty, H., Casey, A.-N., Fleming, R. (2014). Potential benefits to staff from humor therapy with nursing home residents. Journal of Gerontological Nursing, 40(2), 47–52. https://doi.org/10.3928/00989134-20130930-01 Dossey, B., & Keegan, L., &. (2012). Holistic nursing: A handbook for practice (6th ed.). Jones & Bartlett.

Feagai, H. E. (2011). Let humor lead your nursing practice. Nurse Leader, 9(4), 44–46. https://doi.org/10.1016/j.mnl.2010.10.005 Tanay, M. A., Wiseman, T., Roberts, J., & Ream, E. (2014). A time to weep and a time to laugh: Humour in the nurse–patient relationship in an adult cancer setting. Supportive Care in Cancer, 22(5), 1295–1301. https://doi.org/10.1007/s00520-013-2084-0

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Using the internet, have students obtain nursing research related to caring in a nursing environment.

What types of continuing education offerings are available for the concept of caring? What other resources are available to assist with learning about caring?

• Have the students observe nurses providing care in the clinical setting. Identify episodes of when care was provided with empathy versus sympathy.

• Hope is one characteristic of the therapeutic relationship. Have the students brainstorm ways to instil a sense of hope when working with people and determine how to avoid the use of false assurance.

• Have student’s interview nurses in various settings about their use of humour in the workplace. Invite some nurses to speak to the class regarding therapeutic uses of humour.

• Encourage class discussion after reading the Respecting our differences box, ‘Caring and compassion: Acceptance of people’. How will the students respond when caring for someone whose behaviour opposes their basic values? Do students have experiences to share where they have believed their care was less than optimal due to some prejudice?

• Have the students identify how the nurse functions in a variety of roles (caregiver, counsellor, teacher, patient-advocate, change agent, team member, and resource person) in the clinical setting. Ask the

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students if they see themselves as being able to function in that capacity as a professional nurse. Do students believe that their experiences with nurses in the health care setting have been reflective of the many roles of nursing discussed in this chapter?

• Have students reflect on the impact of technology and the aspect of caring in nursing. Discuss how nursing has maintained the common aspects of caring and healing with emerging technologic advances.

Review questions 1.

You are assigned a new patient, Ms Temple. Which of the following nursing actions fall into the orientation phase of developing a therapeutic relationship? (Select all that apply.) a. Introducing yourself to Ms Temple, describing your role and what you’re going to do for her as part of this episode of care and asking is there anything else she needs b. Formalising your perception of Ms Temple’s clinical problems c. Discussing your problems in meeting Ms Temple’s clinical problems d. Establishing therapeutic boundaries e. Explaining the guidelines for confidentiality f. Setting the groundwork for trust.

Answer: a, d, e, f Rationale: Answers (a), (d), (e) and (f) all focus on the person being cared for, their immediate needs and their understanding of their disease and care process, whilst (b) and (c) place the focus on the nurse.

2.

If compassion and respect are central tenets to providing effective nursing care, how can we demonstrate this as nurses? a. Introducing ourselves, if unknown to the person b. Consider the person’s desired outcomes and goals for this episode of care as well as their overall health and wellbeing goals c. Ask the person what they want from this episode of care d. Seek consent for every action when working with a person e. Acknowledge that we are working with a person to provide an expert function of their healthcare, that this is the person’s healthcare journey (life) that we participate in f. All of the above Answer: f Rationale: The essential elements of compassionate care are empathy and sensitivity, listening and responding, providing dignity and respect, valuing diversity and developing cultural competence, and supporting people to make choices.

3.

Empathy is a constructive, person-centred connection between the nurse and the person. Nurses use empathy to develop an effective means to understand and address the health care issues individual people experience. Choose the two empathetic responses from the following statements. g. ‘It must be awful to be so tired all the time.’ h. ‘Help me to understand your situation.’ i. ‘I’m so sorry you feel this way.’

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j. ‘I can’t imagine what it must be like.’ k. ‘I get the sense that you are feeling anxious.’

Answer: a and e Rationale: Answers (a) and (e) demonstrates the nurse’s ability to recognise and share the feelings of the person cared for. Answer (b) does not demonstrate the nurse has listened to or recognised the specifics of the person’s situation. Answers (c) and (d) are Sympathetic responses that are nurse focused and do not provide any opportunity to engage therapeutically with the person.

4.

You observe another RN providing depersonalised care to a person. Which of the following behaviours would have alerted you to this issue? (Select all that apply.) a. Addressing a person as sweetheart, darling or petal b. Conversing with another nurse while showering a person c. Knocking on the person’s door before entering their room d. Talking to the person and their visiting family members e. Focusing on the task at hand, so you do a good job.

Answer: c and d Rationale: Answers (c) and (d) demonstrate the nurse’s attention to, and respect of the person and their loved ones. Whilst answers (a), (b) and (e) are distractors that indicate to the person being cared for they are not the centre of the nurse’s attention.

5.

A person scheduled for discharge the next day tells you that they are concerned about going home.

Which of the following is an example of empathy? a. ‘Everyone feels like this before they go home.’ b. ‘I’m sure everything will be fine.’ c. ‘Don’t worry your feelings of anxiety are normal.’ d. ‘You sound very anxious about going home can you tell me why.’ e. ‘Ask your family to stay with you for the first couple of days.’

Answer: d Rationale: The statement ‘You sound very anxious about going home can you tell me why’ demonstrates the nurse’s attention to the specific issue and provides the person with an opportunity to share their concern. Answers (a), (b), (c) and (e) disregard the person’s concerns and do not open any opportunities for problem resolution.

6.

Which of the following nursing actions demonstrates that you are acting as an advocate? a. Administering medications according to the doctor’s prescription. b. Recording and discussing a person’s concerns with their treating doctor. c. Insisting that the person be independent in their own health care decisions. d. Urging the person to consent to a treatment procedure that they are refusing. e. Telling the persons’ family and friends about medical management changes.

Answer: b Rationale: By discussing a person’s concerns with their treating doctor, the nurse demonstrates their ability to listen to and communicate the expressed concerns of the person they are caring for to the health care team so they can include those concerns in care planning.

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7.

What are some ways you can link caring behaviours as a nurse to positive patient outcomes? a. Addressing your patient by their preferred name so they feel valued b. Making sure they have all their treatment, even the elements they refuse c. Respecting your patient’s choice, even when you don’t agree with it d. Ensure you’ve provided adequate information so the person can make an informed choice about their care e. Coercing the person to take their medications and eat, even when they don’t want to as you know that will help them get better.

Answer: a, c, d Rationale: <add text>

8.

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Providing holistic care to patients is done most effectively as an interprofessional team. It is important to demonstrate compassion and respect to the other team members as well as the patient because: a. The patient will feel confident with a team that acts professionally towards each other as well as them b. A difference of opinion can be a healthy source of learning and provide a paradigm shift, it does not have to be present as conflict between health care team members c. Respecting other health care team members and the patient, ensures the patient feels psychologically safe and valued d. All the above.

Answer: d Rationale: Whilst we practice independently, we are also part of an interprofessional team providing care for our patients. If as a team we cannot interact and communicate professionally and respectfully, our patients care may be compromised. It is also part of our expectation of practice as reflected in the NMBA Code of Conduct and International Council of Nurses Code of Ethics.

9.

To be an active listener, you need to understand the true intent of what your patient is saying. What do you need to consider? a. Their opinion, your opinion and the truth b. Verbal, paraverbal and non-verbal communication c. Listening to what they are not saying; listening for the meaning behind their words and for any presuppositions included in their dialogue.

Answer: b Rationale: Verbal refers to the words spoken, paraverbal refers to the way communication is delivered and non-verbal refers to the congruence of body language with the spoken word. Active listening needs to consider all three elements of communication.

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Spotlight on critical thinking Legal/ethical: confidentiality in the therapeutic relationship Nurses have ethical and legal responsibilities to protect patient confidentiality. Consider what you would do in each of the following situations.

1.

You are assisting Ms Maruka with her personal care when she says, ‘Isn’t it just terrible about Mrs Smith in the next bed? I heard that her tests came back negative. What are her chances of getting better?’

Suggested solution: Explain that it is lovely that she is showing an interest and concern for the other person and she could show her support directly with that person. You, however, are not able to discuss any aspect of another person without their direct permission.

2.

While you are seated at the nurses’ station, a patient’s visitor asks you why their friend is going in for surgery tomorrow. How do you respond?

Suggested solution: Explain that you are not able to discuss any aspect of another person without their direct permission, referring them back to their friend so they can decide what they want to share.

3.

While travelling together on a bus, your co-worker and friend begins talking with you about one of the patients he was working with that day.

Suggested solution: It is unethical and unprofessional to discuss any aspect of a persons care in any nonwork-related environment or during any social situation. You are required to cease the conversation and change the subject to a non-work related one.

Caring and compassion: hope versus false reassurance Nurses need to be mindful not to provide false reassurance. Consider what you would do in the following situation. Mrs Nguyen is awaiting results of diagnostic testing that will confirm or deny the suspected diagnosis of cancer. She says to you, ‘I think it’s taking a long time to get the results. Something must be wrong’. You reply, ‘Oh, don’t worry. Everything’s going to be just fine!’

4.

What do you think motivated your response to the question asked by Mrs Nguyen?

Suggested solution: Answers will vary, as this is a subjective question.

5.

What will be the impact of your answer on Mrs Nguyen if her tests reveal that she does have cancer?

Suggested solution: The reasons people tell pleasant lies or mistruths is to soften unpleasant facts.

Consider the impact of your own professional standing and what nursing governance, standards of care and ethics have to say about nurses stating mistruths about a person’s prognosis or telling someone a potentially painful procedure will not hurt.

Hope versus hopelessness Paul Brown, a 21-year-old footballer, was spear-tackled to the ground four weeks earlier, leaving him with a spinal injury and no feeling below his waist. He is asked to verbalise his rehabilitation goals during a case conference, and he informs the rehabilitation team, ‘I want to walk out of here’. The physiotherapist responds to Paul’s statement in a light, breezy fashion: ‘You will need to be more realistic and concentrate

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on your upper body strength so that you can transfer from your bed to your chair’.

6.

Do you think the physiotherapist’s response was appropriate?

Suggested solution: Answers will vary as this is a subjective question.

7.

What impact could the physiotherapist’s statement have on Paul’s motivation and subsequent rehabilitation progress?

Suggested solution: Paul may be less motivated to work on his immediate needs and short-term goals if he feels that his long-term outlook is bleak.

8.

What do you think motivated the physiotherapist’s response to the statement made by Paul?

Suggested solution: Answers but may include a desire to set realistic expectations for the person, or to encourage a focus on short-term goals and immediate needs.

9.

What other, more appropriate responses could have been chosen?

Suggested solution: All people work through aspects of hope and grief differently. You need to encourage and support an individual to focus on their immediate needs and short-term goals. In this way Paul will be able to modify and refocus his long-term goals accordingly and at his own time and pace.

Accommodation Getting to know people from diverse cultural backgrounds will expand your knowledge base and help you become more tolerant and open-minded. Making small adjustments to include someone has far reaching benefits for both you and the other person. For example, you ask a friend over for a BBQ whom you know will not eat meat or any meat products.

10. Do you plan your BBQ accordingly, or just expect your friend to find something they can eat from what is on offer.

11. How do you think this will affect your ongoing friendship?

12. What specific aspects of your relationship will be strengthened?

13. How does this scenario translate into a health care setting?

Suggested solution: By accepting a person who has different beliefs you convey the message that they are important and respected. This provides a safe environment that encourages a person to be genuine and honest whilst adding value to the relationship. Discuss and document your client’s cultural preferences into all care and care planning.

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Contents Key terms ......................................................................................................................................................... 1 Instructional strategies .................................................................................................................................... 2 Resource aids................................................................................................................................................... 4 Online resources.............................................................................................................................................. 4 Evaluation strategies ....................................................................................................................................... 5 Review questions............................................................................................................................................. 6 Spotlight on critical thinking ............................................................................................................................ 7

Chapter 14 Communication Key terms Aphasia Impaired, unfocused or absence of language function.

Artefacts A specific type of nonverbal message that includes items in the person’s environment, grooming, or use of clothing and jewellery.

Auditory channel Transmission of messages through spoken words and by cues.

Channel Medium through which a message is transmitted.

Chronemics Study of the effects of time on the communication process.

Cohesiveness Bonding of group members with one another.

Encoded Use of language and other specific signs and symbols for sending messages.

Feedback Information the sender receives about the receiver’s reaction to a message.

Group communication A complex level of communication that occurs when three or more people meet in face-to-face encounters or through another communication medium, such as a conference call.

Group dynamics Study of the events that take place during small-group interaction and the development of subgroups Interpersonal communication Process that occurs between two people either in face-to-face encounters, over the telephone or through other communication media.

Intrapersonal communication Message one sends to oneself, including ‘self-talk’ or communication with oneself.

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Kinaesthetic channel Transmission of messages through sensation of touch.

Message Stimulus produced by a sender and responded to by a receiver.

Metacommunication Relationship aspect of communication that refers to the message.

Non-verbal message Message communicated without words.

Paraverbal communication The way in which a person speaks, including voice tone, pitch and inflection.

Perception Person’s sense and understanding of the world.

Proxemics Study of the distance between people and objects.

Receiver Person who intercepts the sender’s message.

Sender Person who generates a message.

Small-group ecology Study of proxemics in small-group situations.

Therapeutic communication Use of communication for the purpose of creating a beneficial outcome for the person.

Therapeutic relationship Deliberate relationship formed between the person with mental disorder and the health worker; there is agreement that it is a collaborative relationship with the purpose of recovery for the person with the mental disorder.

Verbal message A message communicated through words or language, both spoken and written.

Visual channel Transmission of messages through sight, observation and perception.

Instructional strategies • Communication permeates our life in verbal and nonverbal forms. How critical is it for nurses to be aware of the complex process of communication? Communication is the process that establishes a therapeutic relationship with people. The quality of that communication determines the quality of the nurse–patient relationship. Health care education, case management, and basic assessments all demand proper and consistent communication from the nursing staff. It is of vital importance that both verbal and nonverbal communication be congruent.

• Discuss barriers to therapeutic interaction for students to consider while studying nursing. As determined in an earlier chapter, language differences affect the type and quality of communication in nurse–patient relationships. The following interventions can assist in overcoming communication barriers: o The use of an interpreter assists with communication in these situations. o The nurse will care for people of many different sociocultural backgrounds. o The nurse should keep in mind that these differences influence communication. o Care needs to be taken to communicate in language that is familiar to the person. Often, a nursing term used daily by the staff is not understandable by the general public. For example, asking people if they voided may have no meaning to them. o It is also important for nurses to remember that communication has gender differences that need to be acknowledged. o Health status and developmental level are necessary components of the person’s makeup that affect communication attempts by the nursing staff.

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• Communicating effectively is a skill that most nurses have. What would hinder or block effective communication with a person? Refer to Table 14-7 ‘Communication roadblocks’ and provide examples of each roadblock to the class. Consider the following examples: o Overall, any type of communication that would be used during a social interaction would not be therapeutic when communicating with a person. o Other ways that nurses can block communication include reassuring, agreeing, approving, defending, using closed questions, stereotyping, changing focus, judging, blaming, belittling, advising, rejecting, disapproving, and probing.

• Using Table 14-6 ‘Therapeutic communication techniques’ discuss these techniques and examples in class.

Students may already be using these techniques effectively but do not have definitions for them. Some techniques allow the person to set the pace. o The nurse is open, calm and patient and uses silence to allow opportunity for the person to begin and direct the session. o Open-ended versus closed-ended questions encourage discussion and elicit more verbalisation from the person. o Techniques that encourage spontaneity include the use of open-ended questions, listening more than talking, restating, and using reflection. o Certain techniques focus on the person. These are exploring, recognising, focusing, and directing. o Techniques that encourage exploration and expression of feelings include trying to translate thinking statements into feeling statements. o Observation of a particular emotion may encourage a feeling discussion.

• At times, a person may not be able to verbally communicate. As the students to review how aphasia affects a person and provide suggestions to communicate. o When communicating with a person with aphasia, the nurse needs to learn the person’s usual method of communication and then adapt the communication to meet the person’s abilities. o Suggestions to communicate include providing written information, letter boards, or yes/no cards. o The nurse should provide ample time for the person to respond and not answer for the person. o The use of one-word responses facilitates communication with the person with aphasia. o The nurse should also repeat the communication when necessary and speak directly to the person. o The use of nonverbal facial expressions and gestures also helps when communicating with a person with aphasia.

• Clinical handover is a procedure that the nurse may perform several times during a shift. What information is it necessary to include when giving a clinical handover to another healthcare professional?

Ideally this is performed at the person’s bedside and the person should be encouraged to participate. o Make sure you properly identify yourself and your title. o Introduction: State the person’s name, their age, their attending medical officer, and any other demographic information such as the person’s cultural background as required by your facilities’ clinical handover policy. ideally this is performed at the person’s bedside. o Situation: State why the person has been admitted, their current diagnosis, and any relevant procedures or investigations. The nurse should also ensure that any patient alerts, such as allergies or the person’s infectious status are stated. Document that a verbal transaction has occurred. o Background: State any information that may impact on the person’s current condition, such as other illnesses, family history, current living situation, psychosocial issues, and any other relevant information. © Cengage Learning Australia 2024

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o Assessment: The nurse makes an assessment of the person’s current problems or needs based on the person’s information above and other clinical data such as their recent clinical observations, results of tests and pathology, and other relevant information. o Recommendations: The nurse outlines the planned nursing care and any interventions ordered by other members of the healthcare team.

• Always make sure that the healthcare professional that receives the clinical handover understands the person’s information that was transferred before they that responsibility for the person.

Resource aids Bumb, M., Keefe, J., Miller, L. & Overcash, J. (2017). Breaking bad news: An evidence-based review of communication models for oncology nurses. Clinical Journal of Oncology Nursing, 21(5), 573–80. https://doi.org/10.1188/17.CJON.573-580 Burgess, A., van Diggele, C., Roberts, C. & Mellis, C. (2020). Teaching clinical handover with ISBAR. BMC Medical Education, 20(459). https://doi.org/10.1186/s12909-020-02285-0 Feo, R., Rasmussen, P., Wiechula, R., Conroy, T., & Kitson, A. (2017). Developing effective and caring nursepatient relationships. Nursing Standard, 31(28), 54–63. https://doi.org/10.7748/ns.2017.e10735 Forde, M., Cofey, A., & Hegarty, J. (2020). Bedside handover at the change of nursing shift: A mixed‐ methods study. Journal of Clinical Nursing, 29(19-20), 3731–42.

Kitney, P., Tam, R., Bramley, D. & Simons, K. (2020). Handover using ISBAR principles in two perioperative sites: A quality improvement project. Journal of Perioperative Nursing, 33(4), 38–45 Levett-Jones, T. (2019). Critical conversations for patient safety: An essential guide for healthcare students.

(2nd ed.) Pearson.

Minnican, C. & O’Toole, G. (2020). Exploring the incidence of culturally responsive communication in Australian healthcare: The first rapid review on this concept. BMC Health Services Research, 20(1), 20– 20.

O'Kane, D., & Smith, A. (2018). Therapeutic communication. In L. Moxham, M. Hazelton, E. Muir-Cochrane, T. Heffernan, C. Kneisl, & E. Trigoboff (Eds.), Contemporary psychiatric-mental health nursing: Partnerships in Care. pp. 172-193. Pearson.

Peplau, H. (1960). Talking with patients. American Journal of Nursing, 60(7), 964.

Pickles, K., Cvejic, E., Nickel, B., Copp, T., Bonner, C., Leask, J., Ayre, J., Batcup, C., Cornell. S., Dakin, T., Dodd, R., Isautier, J. & McCaffery, K. (2021). COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey. Journal of Medical Internet Research, 23(1):e23805.

Ruesch, J. (1961). Therapeutic communication. Norton.

Online resources •

Australian Commission on Safety and Quality in Health Care (ACSQHC). (2019a).

Implementation toolkit for clinical handover improvement. https://www.safetyandquality.gov.au/our-work/communicating-safety/clinicalhandover/implementation-toolkit-clinical-handover-improvement.

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•

Australian Nursing & Midwifery Journal Staff. (2020). 5 Tips to a good clinical handover. https://anmj.org.au/5-tips-to-a-good-clinicalhandover/#:~:text=1%20Be%20organised.%20Try%20to%20follow%20an%20organised,it%E2% 80%99s%20critical%20that%20all%20important%20information%20is%20relayed

•

Ministry of Health. (2021). Improving the health of New Zealanders https://www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/surveys/newzealand-health-survey/improving-health-new-zealanders

•

Starship. (2021). Nursing handover of an infant, child or young person https://starship.org.nz/guidelines/nursing-handover-of-an-infant-child-or-young-person/

Evaluation strategies •

Have the students listen to the clinical handover developed by the educator from an example in the clinical setting. Have the students reflect on the concept of accountability, documentation, and reporting and discuss whether the report was ‘complete’.

•

There are different styles of learning, including the visual, auditory and kinaesthetic learner. Have students review the ‘Respecting our differences: Your dominant channel’ box, and then determine their dominant style of learning and how they can best facilitate effective communication when working with people of different styles.

•

Have students watch and record a nurse–patient interaction. How did the nurse communicate with the person? Were verbal and nonverbal communication efforts congruent? Suggest ways in which the quality of that interaction could have been improved.

•

Have the students break into small groups to discuss the elements of therapeutic communication (Table 14-5). Have the students provide examples of nurses’ behaviours to support each element.

•

Encourage group discussion on the different levels of communication. Have students give examples of interpersonal, intrapersonal, small group, and organisational communication.

•

Assign the students the task of observing a nurse in the clinical area communicate with a patient. What techniques did the nurse use to encourage communication? What roadblocks occurred during the episode of communication? How did the nurse convey empathy and support therapeutic communication?

•

Using a ‘Chinese Whispers’ approach, have students start out with a basic line of communication (such as, ‘Mr. Smith, a 68-year-old man admitted with congestive heart failure’) and whisper it in each other’s ears until the last student has been told the message. Analyse the difference between the real message and the end message. Discuss the impact of altered information for people and family members who are in a stressful state and how nurses can help enhance communication to ensure that it is clear and effective.

•

Have the students identify situations in which a person might have a temporary reduction in the ability to communicate (intubated, sleeping after receiving pain medication, recovering from anaesthesia, etc.). From this list, the students should then brainstorm ways that would encourage effective communication.

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Review questions 1

A person who is crying states, ‘I just don’t understand why they won’t let me go for a walk’. Which of the following nursing responses demonstrates the use of clarification? a. ‘I’m sure they are just doing what they think is best for you.’ b. ‘Maybe you just misunderstood them.’ c. ‘Tell me who they are.’ d. ‘Well, of course you can go for a walk. I’ll help you.’ e. ‘Can you tell me why you would like to get up?’

Answer: c Rationale: Clarification is used to clear up ambiguities or misconceptions. Asking who ‘they’ are helps the nurse to fully understand what the person is trying to communicate.

2

You are conducting a self-catheterisation education session. Which of the following patient behaviours indicates that a person’s dominant sensory channel is visual? a. Asking you to explain in more detail about the process b. Asking you to repeat the information c. Wanting to demonstrate how they self-catheterise d. Reading the handout distributed by you e. Asking you to show different types of catheters Answer: d Rationale: Reading is a behaviour preferred by visual learners. Asking for explanation or repetition of information indicates a dominant auditory channel. Demonstration is preferred by individuals who are kinaesthetic dominant.

3

A nurse manager is meeting with a staff nurse to provide feedback so that the nurse can improve their performance in the clinical setting. Which of the following actions by the manager demonstrates the effective use of feedback? Select all that apply. a. Avoiding discussion of the poor performance in order to boost the staff nurse’s self-confidence. b. Discussing the staff nurse’s performance in a staff meeting. c. Scheduling the feedback session immediately following the poor performance. d. Stating exactly what needs to be done to show improvement. e. Using words that clearly describe the unsatisfactory performance. f. Waiting to discuss the staff nurse’s actions at the annual performance evaluation.

Answer: c, d, e Rationale: Effective feedback, whether directed at patients or co-workers, should be specific, descriptive and clear. It should be presented in a non-threatening and private environment.

4

Which of the following communication techniques encourages a person to be spontaneous and to openly express what they are feeling about their situation during an interaction? a. The nurse confronts the person about their situation and tells the patient what they should do b. The nurse makes observations based on the nurse’s assumptions c. The nurse asks open-ended questions so the person can explain what is happening to them

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d. If the nurse needs further clarification, the nurse asks focused questions design to get more information e. The nurse asks the person what they believe is the best course of action in this situation.

Answer: c Rationale: Open-ended comments or questions encourage the person to take the lead in conversations.

Confronting is done to encourage the person to make necessary changes. The nurse makes observations in order to point out person’s behaviour. Focusing is done when the nurse is assisting the person to expand on a specific topic or area.

5

5. Which of the following nursing comments demonstrates the use of reassurance? a. ‘I think you should talk with your friend about that.’ b. ‘That’s the way the cookie crumbles. Oh well, you made your bed, so you can lie on it.’ c. ‘You shouldn’t feel like that. How can I help you with this problem?’ d. ‘You will feel better soon. Tell me how that makes you feel.’ e. ‘I understand that you are very upset about this, please tell me more about what is happening’.

Answer: d Rationale: Reassurance blocks communication in that it indicates that the person’s concerns are unwarranted or unimportant. The other options – giving advice and using clichés – also block communication but do not illustrate reassurance.

6

A person who has been informed they need urgent surgery, tells the nurse that they are afraid. Which of the following nursing responses is therapeutic for this person? a. ‘Are you saying you’ve changed your mind about having the surgery?’ b. ‘I’m sure you will be fine.’ c. ‘Tell me more, why are you afraid?’ d. ‘You have nothing to worry about. Your surgeon is the best!’ e. ‘Would you like me to call your surgeon so you can discuss the procedure again?’

Answer: c Rationale: The nurse’s goal is to encourage the person to verbalise his feelings; Option (c) is the only response that communicates the desire to listen to the person.

Spotlight on critical thinking Professionalism: clinical handover ISBAR is a tool designed to ensure that the health care professional who assumes responsibility for the person’s care receives all the necessary information about their condition, care and their response to care given. If important information is not transferred at clinical handover, there is a risk that they could be harmed.

1

List the possible consequences of this omission of patient information in situations when a nurse is required to transfer patient information using ISBAR. Suggested solution: The major consequence is that the person will not receive the care they require to manage their diabetes.

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2

List the advantages of conducting a clinical handover at the person’s bedside.

Suggested solution: Advantages may include: • It allows the person to be involved in clinical handover and in their care.

• You can see the person and can assess the person’s condition while receiving handover.

• It promotes patient safety as you can review the person and any bedside charts during the handover.

Understanding non-verbal messages Non-verbal behaviour is a more accurate indicator of the individual’s intended message than words.

3

Do you think the adage ‘Actions speak louder than words’ is true?

Suggested solution: Student responses will vary.

4

A person yells, ‘I am NOT angry!’ while pounding his fist on the bedside table. Which message – the verbal or the non-verbal – do you pay attention to? Why? Suggested solution: If nonverbal messages indicate the person’s true feelings more accurately than verbal messages, the nurse needs to heed the nonverbal message in this exchange.

Avoiding roadblocks when communicating with patients You should enable people to explore their feelings and anxieties. This requires you to help the person open up and discuss what is really going on with them, their feelings and their fears. For example, a person tells you that they do not want to go home after they are told that they are to be discharged the following day.

5

Which of the following comments encourages the person to discuss their concerns with you? How does each of the other responses cause a ‘roadblock’?

•

‘Don’t worry, as soon as you get home you will feel so happy you are no longer in hospital.’

•

‘The doctors wouldn’t let you go home unless they thought you were well. Besides, we need the bed.’

•

‘Didn’t your family visit today?’

•

‘Can you tell me why you are feeling that way?’

Suggested solution: The last response is correct because it allows the person to explain their feelings about discharge to the nurse.

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Communication in the therapeutic relationship Communication is key to the development of the therapeutic relationship between you and the person.

However, to be successful, therapeutic relationships require you to develop high quality-quality communication skills.

6

Consider how your communication style differs when a therapeutic relationship develops from when you are communicating with a friend. Make a list of the differences in between the two styles of communication.

Suggested solution: Therapeutic relationship

7

Friendship

Time limited: the relationship begins when the person is admitted to clinical facility and ends when the person is discharged.

Time is unlimited: the relationship can remain without an end or until one or both parties decides to end it.

The purpose of the relationship is the provision of quality care to the person by the nurse.

The purpose of the relationship is for the enjoyment of both parties.

Focused on the person’s needs: Communication is directed towards the person with only minimal selfdisclosure of personal information by the nurse.

The relationship is focused on the needs of both parties: Communication is open and personal information can flow freely.

The nurse works with the person to determine their needs and to develop care plans to meet those needs.

Communication is centred around agreed goals.

The relationship can be goal directed if there is a specific activity that both parties are involved in, but this is not necessarily required.

Which of the following communication skills enable a nurse to develop a therapeutic relationship with a person? (Select all that apply.)

• Listening to what the person wants • Asking questions with a yes/no answer (closed-ended questions) • Looking at your phone while the person is speaking and interrupting the conversation to return a text from your friend about where you are meeting tonight • Maintaining good eye contact with the person and mirroring the way they are sitting • Telling the person all about yourself and how you would solve their problem if you were in their situation.

Suggested solution: Students should identify listening to what the person wants and maintaining good eye contact with the person and mirroring the way they are sitting as reasonable responses. See communication channels and communication roadblocks section of the chapter for more information

Communication with vulnerable patient groups Many people are vulnerable to receiving care that does not meet their needs because they are living with impairments that can make communication with health care professionals difficult. To facilitate a therapeutic relationship between you and a person from vulnerable group, you need to understand how to overcome any barriers to communication that may exist.

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8

How can you overcome communication barriers with the following people?

•

A person who is visually impaired Suggested solution: When speaking to visually impaired people, always face them as if they were sighted. Follow the cues of the person in order to allow as much independence as possible. Look directly at the person. Speak in a normal tone of voice. Ask for permission before touching the person. Orient the person to the immediate environment.

•

A person with hearing loss Suggested solution: Determine if the person reads lips. If so, face the person and reduce background noise to a minimum. If the person is using a hearing aid, check to see that it is in working order.

Always face the person. Speak at a normal pace in a normal tone of voice. Focus on nonverbal cues from the person. Use gestures and facial expressions to reinforce verbal messages. Provide pen and paper to facilitate communication if the person is literate.

•

A person with a diagnosis of dementia, who is experiencing confusion and disorientation Suggested solution: Maintain appropriate eye contact. Keep background noises to a minimum. Use simple, concrete words and sentences. Use pictures and symbols. Use closed rather than openended questions. Give the person time to respond.

•

A person with aphasia or language impediment Suggested solution: Assess the person's usual method of communication; adapt the interaction to accommodate the person's abilities. Use a written interview format, letter boards, or yes/no cards.

Allow additional time for person's responses. Do not answer for the person. Use closed (one-word response) questions when possible. Repeat or rephrase the comment if the person does not understand. Speak directly to the person, not to the intermediary. To reinforce verbal messages, use facial expressions, gestures and voice tone.

•

A person who is unconscious Suggested solution: Assume the person can hear. Talk to the person in a normal tone of voice.

Engage in normal conversational topics as with any person. Speak to the person before touching.

Use touch to communicate a sense of presence.

Communication with people from culturally and linguistically diverse backgrounds When you communicate with a person from a CALD background, you need to consider how both cultural and language factors can impair verbally and non-verbal communication.

9

Consider how communication can be impaired if you do not keep in mind how a person from a CALD background might react to your verbal or non-verbal communication.

Suggested solution: Any communication between the nurse and a person from a culturally or linguistically diverse background that does not consider these differences will be unsuccessful. The nurse and the person will be unable to develop a therapeutic relationship and this will put the person at risk and compromise their health outcomes.

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10 When talking to a person from a CALD background with an interpreter, who should the nurse talk to, the person or the interpreter?

Suggested solution: When having a conversation with someone with the assistance of an interpreter, always direct the conversation toward the person you are conversing with and not the interpreter.

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Contents Key terms ......................................................................................................................................................... 1 Instructional strategies .................................................................................................................................... 3 Resource aids................................................................................................................................................... 4 Online resources.............................................................................................................................................. 4 Evaluation strategies ....................................................................................................................................... 5 Review questions............................................................................................................................................. 5 Spotlight on critical thinking ............................................................................................................................ 7

Chapter 15 Health and wellness promotion Key terms Acute illness Disruption (usually reversible) in functional ability characterised by rapid onset, intense manifestations and a relatively short duration.

Adaptation Component of cognitive development that refers to the changes that occur as a result of assimilation and accommodation; ongoing process by which an individual adjusts to stressors to achieve homeostasis.

Basic human needs Needs that must be met for survival; also known as ‘universal needs’.

Behaviour Observable response of an individual to external stimuli.

Bisexuality Having an equal or almost equal preference for partners of any sex or gender.

Body image Individual’s perception of physical self, including appearance, function and ability.

Chronic illness Disruption in functional ability usually characterised by a gradual, insidious onset with lifelong changes that are usually irreversible.

Gender identity The sense of one’s gender that may or may not align with the assigned sex at birth (male or female). Gender can be binary (man or woman) or non-binary (genders that are not only man or woman).

Health Process through which a person seeks to maintain an equilibrium that promotes stability and comfort; includes physiological, psychological, sociocultural, intellectual and spiritual wellbeing.

Health literacy. he cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.

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Health-promoting behaviours Actions that maintain or increase well-being or quality of life.

Health promotion Process undertaken to maintain or increase levels of wellness in individuals, families, and communities.

Health-seeking behaviours Activities that are directed toward attaining and maintaining a state of wellbeing.

Heterosexuality Sexual activity between a man and a woman.

High-level wellness State in which individuals function at their maximum health potential while remaining in balance with the environment.

Homeostasis Equilibrium (balance) between physiological, psychological, sociocultural, intellectual, and spiritual needs.

Homosexuality Sexual activity between two members of the same sex.

Illness Inability of an individual’s adaptive responses to maintain physical and emotional balance that subsequently results in an impairment in functional abilities.

Locus of control person’s perception of the source of control over events and situations affecting their life.

Need Anything that is absolutely essential for existence.

Psychoneuroimmunology (PNI) Study of the complex relationship between the cognitive, affective and physical aspects of humans.

Self-concept Individual’s perception of self; includes self-esteem, body image and ideal self.

Self-efficacy A person’s beliefs and their ability and capacity to accomplish a task and/or deal with the challenges of life.

Self-esteem Individual’s perception of self-worth and self-value; includes judgements about oneself and one’s capabilities.

Sex roles Culturally determined patterns associated with being male and female.

Sexuality Human characteristics that refer not just to genital sex but also to all aspects of being male or sexually transmitted infections (STIs) Infections that are transmitted between people during sexual activity female, including feelings, attitudes, beliefs and behaviour.

Sexual orientation Individual’s preference for ways to express sexual feelings.

Social determinants of health Concept of health measured by the physical wellbeing and distinct qualities, behaviours and associated features of an individual. These aspects fall within social, economic and environmental domains.

Spirituality Multidimensional aspect of self that refers to one’s relationship with oneself, a sense of connection with others, and a relationship with a higher power or divine source. transtheoretical model of behavioural change (TTM) Model which describes the stages and steps a person takes to act on a new, healthier behaviour Vulnerable Increased exposure and susceptibility, or increased need for support and protection from environmental and social influences that are harmful to health and wellbeing.

Wellness Condition in which an individual functions at optimal levels.

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Instructional strategies • Discuss the concepts of illness and wellness perspectives and how they form the basis for health beliefs and attitudes. The illness perspective focuses on how a disease or injury affects the normal functioning of the body and results in an inability to meet one’s needs. Illness is further divided into acute and chronic categories. Acute illness is characterised by a rapid onset that is intense in nature and brief in duration.

Chronic illness is characterised by a gradual onset that affects lifelong changes that have profound effects and require adaptation. The wellness perspective focuses on a health continuum approach whereby one proceeds from a level of optimum health (wellness) to a maladaptive state (illness). Wellness implies that an individual is trying to obtain optimal function while in a dynamic changing state.

• Discuss with the students the variables that influence health behaviours. The first variable is lifestyle.

These are activities that influence a person’s health status and include such activities as smoking, exercise, alcohol intake, drug use and weight management. Locus of control is the perception a person has of his or her ability to control events and situations in his or her life. Self-efficacy is when an individual believes he or she can make changes in behaviour and is a form of self-confidence. Health care attitudes are what a person practices or believes that contribute to or shape the person’s willingness to participate in health care. Self-concept is an individual’s perception of self. Self-concept influences a person’s health behaviours in that people who think highly of themselves will tend to take better care of themselves.

• Encourage a discussion about healthy behaviours in nurses by asking students to list behaviours that would be considered not healthy and interventions that might assist them with their own healthy behaviour needs. Nurses are people and thus are prone to developing the same unhealthy behaviours as those who are not in a health care profession. These behaviours include smoking, obesity, sedentary lifestyle and lack of stress management. Nurses should be encouraged to improve their own health so as to be better able to work with people who are demonstrating the same behaviours. Nurses who do not demonstrate healthy behaviours should not be criticised but should receive the same non-judgemental approach as a client who is demonstrating a non-healthy behaviour.

• Encourage the students (through discussion and providing examples) to explore the differences and influences of individual health literacy and environment health literacy. Nurses should be very aware of the individual factors such as education, knowledge, critical thinking and health care beliefs that will influence a person’s understanding and ability to seek out health care support. They also need to be able to understand how the health care environment will influence their ability to seek health care support as well. This can be in the form of limited availability of health care services, language barriers and cultural norms not being considered. Nurses should not blame people for not seeking health care or for not following advise or direction. It is imperative that the nurse works collaboratively with the people in their care to ensure that a partnership of understanding and support is developed and maintained.

• Review disease prevention activities with the students. Disease prevention can be of three different types.

Primary prevention includes those activities that decrease the person’s vulnerability to disease, such as education, personal hygiene and avoiding toxins such as smoking. Secondary prevention is screening for diseases and preventing the spread of communicable illnesses. Tertiary prevention is used after a chronic condition already exists. Activities in tertiary prevention are those that would minimise the effects of the chronic condition and prevent further disability.

• Students, especially those dealing with a clientele whose culture and family structures are different from theirs, must have a sense about how those aspects influence health beliefs. Describe how cultural and

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family influences affect health care. Cultural influences dictate the individual’s health and illness beliefs and expectation of treatment when illness occurs. For example, some southern African Americans consider health a gift from God and illness retribution for sin. Some people of Chinese descent may believe that a balance of female and male energy is necessary to achieve or maintain health. Family structure can determine when to seek treatment, what type to seek, where to seek it, and who will be the provider of that service. It is imperative that nurses incorporate cultural and family influences to optimise health care and health-related behaviours.

• Maslow defines a need as a satisfaction whose absence causes illness. Basic needs have what common characteristics? o Its absence breeds illness. o Its presence prevents illness. o Its restoration cures illness. o Under certain situations of free choice, it is preferred by a deprived individual over other satisfactions. o It is found to be inactive or functionally absent in the healthy person.

• A nurse’s own views on sexuality affect assessment, teaching and nursing care of the person seeking health care. In what ways can a therapeutic relationship be enhanced when working with a person who identifies as gay or lesbian? Nurses should be aware that although health care supports a heterosexist view of its clientele, nurses do work with gay and lesbian populations. Language that provides an opportunity for people to discuss their sexual orientation allows for disclosure of a more accurate picture of the family structure and social supports of the person seeking health care. Accurate social history and personal lifestyle behaviours enhance the nurse’s ability to assess accurately and provide more appropriate teaching. A nonjudgmental attitude and acknowledgement of sexual orientation will improve the nursing care given.

• Ask the students what would be indications that a person seeking health care has experienced sexual abuse? Indications for sexual abuse include bruises, lacerations, or scars around the genital area; the diagnosis of a sexually transmitted disease; extreme anxiety or guarding during a physical examination; suspiciousness or reluctance to answer questions; and lack of eye contact. Most states and territories have laws that mandate nurses to report suspected and/or actual evidence of sexual abuse. Each nurse must know the health care organisation’s policies regarding abuse.

Resource aids Examining the Kinsey report; Homosexuality; Sexual dysfunction [videos]. Films for the Humanities and Sciences. Alfred Kinsey: Social Science in America’s Bedroom Maville, J. A. & Huerta, C. G. (2012). Theoretical foundations of health promotion. In J. A. Maville & C. G. Huerta (Eds.), Health promotion in nursing (3rd ed. pp. 38–52). Cengage Learning.

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

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Evaluation strategies • Have students read the Respecting our differences box ‘The media and health beliefs’ and be prepared to discuss how the media impacts health care consumers. Identify specific patient populations such as pregnant women, the client who has arthritis, and the diabetic client, and encourage discussion of how the media has affected health care beliefs. On a final note, have the students relate some of their own personal beliefs about health and health care that have been influenced by the media.

• Have the students examine the Table 15-4 ‘Basic human needs’, before coming to class. Have the students reflect on how nursing can help to achieve realisation of these goals. Ask students how they can, both individually and as a group, help their family and community toward achieving these goals.

• Have the students research the Internet for health protection activities that are being enacted in their school community and home communities. Encourage a discussion about these activities and what the students can do to promote or support them.

• During a clinical episode or a personal encounter, have the students interview an older person to determine health promotion activities. List the activities that the person participates in to maintain their own health. What does the person do if there is a change in health status?

• Using a PowerPoint presentation entitled ‘Holistic Perspective of the Individual’ and ‘Maslow’s hierarchy of needs’ in class, have the students divide into groups and come up with their own diagrams based on the holistic perspective and dynamic nature of each diagram.

• Have the students read the Respecting our differences box ‘Sexual values and gender’ In groups of two, have students discuss what their actions would be in response to the scenario presented.

Review questions 1.

Albert Bandura’s (1977) theory of self-efficacy relies on a person’s ability to exercise control. For anyone to feel a sense of control they need to: a. believe that their behaviour will not produce desirable results b. believe that their behaviour will produce desirable results c. believe they cannot perform the behaviour d. believe the outcome will produce the desired behaviour e. believe the outcome will produce more challenges.

Answer: b Rationale: A nurse who values their own ability and knowledge is highly likely to produce positive outcomes. Conversely, a nurse who is not confident with their ability and knowledge is more likely to fail or give up.

2.

Which of the following statements accurately describes Murdaugh, Parsons and Pender’s (2019) healthpromotion model? (Select all that apply.) a. A person is more likely to perform health-promoting behaviours when he or she can identify the benefits of the behaviour. b. Group values exert great influence on a person’s behaviour. c. Health is viewed as an attempt to achieve one’s fullest potential.

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d. People who perceive health as being within their control are more likely to perform healthy behaviours. e. People who are ill are more motivated than healthy ones to develop health-promoting behaviours.

Answer: a and d Rationale: People who value health, perceive health as being within their control, can identify benefits in self-care activities and have a positive perception of their own health status are more likely to focus on activities that improve their wellness and prevent disabilities.

3.

Which of the following patient statements demonstrates that a person is receptive to changing a behaviour? a. ‘I think that an exercise program is just what I need.’ b. ‘I need to ask my partner if they think this is the best option.’ c. ‘I have tried unsuccessfully to do this in the past.’ d. ‘I know I should start losing weight.’ e. ‘I have so much to think about, how will this change affect me?’

Answer: a, c, d and e Rationale: These statements are indicative of a person contemplating change. Answer (c) also requires the person to identify the contributing factors that lead to the failed attempt, modify them so they are assured of success next time

4.

Listed below are nursing activities. Rank them in terms of priority according to Maslow’s hierarchy of needs (1970).

Rank in order of 1= to be done first, 2 = to be done second, and so on. a. _____ Administering analgesic medication for a headache. b. _____ Identifying the person’s strengths in order to boost self-esteem. c. _____ Lowering the person’s bed and placing the call light within reach. d. _____ Referring the person to a support group that consists of peers with similar health problems.

Answer: a = 1; b = 4; c = 2; d = 3

5.

You are preparing to talk to a person about healthy lifestyle changes. Which of the following actions must you do initially with this person? a. Assess their motivation for change. b. Assess their pain level. c. Determine their current knowledge level. d. Provide brochures that are written at their level of comprehension. e. Ask their family to be part of the conversation.

Answer: b

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Spotlight on critical thinking Caring: nurses as healthy role models Nurses have an opportunity to model healthy behaviours. Think about the messages you communicate through certain behaviours such as smoking, overwork and inadequate use of stress-management techniques.

1.

Do you think you have an obligation to demonstrate healthy behaviours? Explain the rationale for your answer.

Suggested solution: The positive and negative role models they use. Explain that while they themselves cannot change the world, by doing the right thing, their actions will be noticed and other people will change their behaviour to match.

2.

What type of health-promoting behaviours do you demonstrate?

Suggested solution: Students who work can be asked, who they like working with and what is it that they like about their co-worker they value. In the majority of answers students often highlight the other person being reliable, dependable and organised.

Exercise Think about the last time you decided to go on a diet or to start a new exercise regime. Consider the stages of the transtheoretical model of behavioural change.

3.

How long did you spend on each of these stages when undertaking your new activity?

4.

Which stage did you find the most difficult and why?

Suggested solution: How many new-year resolutions have they made and how many of these resolutions have being translated into their life: • Why do people make decisions to change aspects of their behaviour and why are these aspects change challenging?

• What motivates their ability to achieve change?

• Get them to consider the challenges of undertaking a university course, what challenges have they faced or need to face in order to do well in their nursing course. How have they incorporated study into their life?

Compassion and values: sexual activity You are working in an aged care residential facility when, late one evening, you pop into a man’s room to check on him. On entering, you note another resident in bed with the man. They are engaged in sexual intercourse.

5.

What feelings does this situation provoke in you?

Suggested solution: Answers will vary as this is a subjective question. Discussion points could include: What is it about the act of having sex that students find embarrassing? Would they feel this same level

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of embarrassment if it was a friend the same age as themselves? Is it different when an older person is having sex? How many students consider their parents as being sexually active? Ask the students to consider if they, themselves were found in this situation how would they want the incident to be managed.

6.

How might you approach both people to provide an opportunity for them to ask questions or seek support from you in relation to their sexual health?

Suggested solution: Provide both people with an opportunity to discuss their sexual health, what their intimacy requirements are and how you can support them in achieving these. People have a right to express and experience their sexuality. Privacy should be provided rather than restricting sexual activity.

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Contents

Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 3 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 16 Family and community health Key terms Aggregates Individuals, families and other subgroupings of people who are associated because of similar social, personal or health care needs; a defined group or population.

Community Group of people united by some common element or shared interest.

Community health nursing Nursing specialty that is divided into two sections: public health and home health care nursing.

Culturally and linguistically diverse (CALD) Describes people who have a diverse cultural background and who speak a language other than English.

Disaster Any event (human-made or natural) that causes destruction that cannot be relieved without assistance.

Disaster preparedness Overinvolvement or lack of separateness of family members; occurs because of unhealthy boundaries within the family unit.

Enmeshment Over-involvement or lack of separateness of family members; occurs as a result of unhealthy boundaries within the family unit.

Epidemiology The study of the distribution and determinants of health-related states or events in populations.

Family A dynamic system of people living together who are united by significant emotional bonds.

Family functions Roles that allow family members to adapt in order to develop as individuals and as members of the family unit.

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Family roles Behaviours expected of family members.

Family structure Form a family takes in adapting and maintaining itself as a dynamic system of people living together who are united by significant emotional bonds.

Instructional strategies • Discuss the sociocultural changes that have affected Australian and New Zealand families. The increasing divorce rate has led to a proliferation of single-parent families. Individuals often live together who are unrelated through biologic or legal bonds and often are considered to be a family. Nurses should ask clients who they consider to be their family members in order to include significant others in the provision of health care.

• Respecting our differences in the concept of the collectivist kinship system of family. Families Australia developed a definition of family that reflects the complexity of Aboriginal family life. Nurses need to be aware of how the kinship system works and that adults and children often move between households and the impact that this may have when planning for discharge and education for after-hospital care.

• Compare the characteristics of a healthy family with those of a dysfunctional family. Healthy families communicate and listen to each other, support the members, teach respect for others, develop trust, play and share a sense of humour, have a strong sense of family with rituals and traditions, and seek help with problems when necessary. Dysfunctional families lack problem-solving skills and deteriorate in adaptive abilities when confronted with stressors (see Table 16-1, ‘Comparison of healthy and unhealthy families’).

• What problems are considered threats to family integrity? A healthy family supports and protects its members from harm. Domestic violence is an ever-increasing social problem that can result in acute trauma, death, unwanted pregnancy, depression, suicide, post-traumatic stress disorder, and substance abuse. Child abuse can result in physical pain and emotional damage that may last a lifetime. Elder abuse may take many forms, including physical, sexual, and psychological abuse and financial exploitation. Most victims of spouse or partner abuse are women. One in three women are physically, sexually, or emotionally abused by their intimate partners every year. Factors associated with this abuse include young age, low-income status, pregnancy, mental health problems, substance abuse by victims and/or perpetrators, separated or divorced status, and history of childhood sexual and/or physical abuse.

• Nurses are often the first health care providers to see a victim of abuse. What should the nurse do when abuse is suspected? When abuse is suspected, the nurse should document their findings and report them in accordance with the policies and procedures outlined by your workplace setting. Documentation should include verbal statements from the victim, photographs, and descriptions of the injuries. The nurse should provide the victim with the telephone numbers of local shelters and crisis hotlines. The victim should also be referred to mental health professionals for counselling.

• Discuss the role of a community health nurse. Community health nurses work with individuals or families in efforts to improve the health of the population. These nurses can be found in primary care offices, schools, workplaces, and public health units. Community health nurses identify vulnerable populations and those living in violence-prone neighbourhoods to plan specific strategies to address special health needs. Public health nursing and home health care nursing are two additional examples of community health nursing.

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Resource aids Antai-Otong, D. (2008). Psychiatric nursing: Biological and behavioral concepts (2nd ed.). Cengage Learning.

Australian Institute of Health and Welfare. (2012). A picture of Australia’s children 2012. Author.

Forster, E., & Fraser, J. (2018). Paediatric nursing skills for Australian nurses. Cambridge University Press Lin, V., Smith, J & Fawkes, S. (2014). Public health practice in Australia. A&U Academic McMurray, A. and Clendon, J. (2018). Community health and wellness: Primary health care in practice (6th ed.). Elsevier Stanhope, M., & Lancaster, J. (2019). Public health nursing. Population-centered health care in the community. Mosby

Online resources •

Family by family, https://vimeo.com/channels/familybyfamily/23614071

•

Family Relationships Online, https://www.familyrelationships.gov.au

•

Raising Children, http://raisingchildren.net.au

Evaluation strategies •

Have students review Figure 16-1, ‘There are diverse family structures and types’. In groups of two, have students identify examples of the types of families. Show a portion of an episode of the television hit show, ‘Modern family. Ask students to identify healthy and dysfunctional characteristics in the Dunphy, Pritchett-Delgado, and Pritchett-Tucker families.

•

Ask the students to discuss the different family rituals they observe within their own families.

•

Assign students to explore what community resources are available for victims of domestic violence, child abuse, elder abuse and partner abuse in your community. Assign students group presentations of the various community agencies/resources that are available.

•

Have students identify how the 2015 earthquake in Nepal affected community health. How do regional disasters affect the world at large? What actions could have prevented the devastating loss of human life of this disaster?

•

Choose a recent disaster, such as a bush fire, a flood or an earthquake and, through internet resources, have students identify what the effect was on the health of the members of that community, what resources were available to individuals, and how long the area was without the basic services of electricity, gas and water.

Review questions 1.

Which of the following statements about domestic violence is correct? a. Alcohol, drug abuse, stress and mental illness cause domestic violence.

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b. If you are educated and have money, abuse does not happen. c. The abuser will often apologise and promise to stop. d. Domestic violence only happens to underprivileged women. e. Domestic violence is a justifiable response to stress.

Answer: c Rationale: It frequently occurs that in domestic violence situations the abuser will often apologise and promise to stop.

2.

IPV is a growing concern in both Australia and New Zealand. Which of the following statements are correct? (Select all that apply.) a. Women are at greater risk of being killed than men during IPV. b. Women from CALD backgrounds have less risk of IPV once they arrive in Australia. c. Risk factors for IPV include high income and high stress jobs. d. Separation or divorce status is a risk factor for IPV. e. Aboriginal, Torres Strait Islander and Māori women endure more IPV than other Australians and New Zealanders.

Answer: a, b, d and e Rationale: Refer to section ‘Spouse and partner abuse’.

3.

You are working as a community nurse and have been asked by a visiting student to give an example of your public health role. The most correct answer would be: a. I help families deal with their daily stressors. b. I provide immunisation services and advice. c. I teach and support mothers how to breastfeed, and I design and implement health education campaigns that aim to prevent disease. d. I provide individual people with wound-care management. e. I conduct health assessments that identify the client’s health requirements.

Answer: b Rationale: Community nurses fill many roles, one of them being to provide immunisation services and advice.

4.

True or false? As a nurse working in Australia, you are not required to report suspected child abuse or neglect because you must maintain a person’s confidentiality. a. True b. False Answer: b Rationale: There are mandatory reporting guidelines for health professionals that must be followed if suspicions arise.

5.

True or false? All New Zealand nurses are mandated to report suspected child abuse or neglect. a. True b. False Answer: b Rationale: There is no law in New Zealand that makes the reporting of abuse of children, adults or the elderly mandatory

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6.

The long-term consequences of child abuse have been recognised as resulting in: a. an adult who becomes an abusive and neglectful parent. b. an adult who becomes an advocate for others. c. higher incidences of psychiatric and behavioural problems. d. lower rates of emotional and behavioural problems. e. an adult who does not want a family of their own.

Answer: c Rationale: Higher incidences of psychiatric and behavioural problems have been recognised as a longterm consequence of child abuse.

7.

Which of the following is a trait of a functional (healthy) family? a. Ambiguous communication b. Enmeshment c. Hierarchy of rules d. Timely feedback e. Rigid social roles Answer: d Rationale: Timely feedback is one of the traits of a functional (healthy) family. The other options might indicate a family that is not functional.

8.

Disaster preparedness is a set of measurements that are undertaken by: a. Private organisations to ensure that financial loss is minimal b. Insurance companies to mitigate risk and promote recovery c. Governments, communities, and individuals to better respond and cope with the immediate aftermath d. Reserve Bank of Australia to ensure that inflation does not escalate.

Answer: c Rationale: The Australian government has the overarching responsibility for leading the disaster and emergency management response. They are supported by state and local government, volunteer organisations and community responses.

9.

Which of the e during the response to a disaster? (Select all that apply.) a. Airway, breathing and circulation maintenance b. Confidentiality c. Documentation of care d. Elective procedures e. Infection-control practices f. Safety for both you and the person you are treating.

Answer: a, e and f Rationale: Airway, breathing and circulation maintenance; infection-control practices; and safety for both you and the person you are treating must be implemented during the response to a disaster.

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Spotlight on critical thinking Family rituals Apply the following questions to your own family: 1.

What are some traditions valued by your family (e.g., special holiday celebrations)?

2.

Are there rituals performed by your family (e.g., having a special meal or going to a special place on vacation)?

3.

How have these traditions and rituals strengthened your sense of family?

Suggested solution: The impact of having family traditions, are they a form of support or are they seen as a burden. Do the student’s families have the expectation that a tradition is carried forward by the student? How does the class feel about these family expectations?

Prevalence of violence and neglect Search your local news service to identify reports about domestic violence in the past seven days. Explore the variety of services that victims of domestic violence could be referred to.

Suggested solution: Ask students to research and list the types and number of domestic violence services offered by: • the local community groups • local Government (i.e., councils) • state (territory) Government • the federal Government.

Nursing process in a disaster Imagine yourself as part of the disaster response team following the devastation of a bushfire or flood.

Consider the potential human responses of the bushfire or flood victims as you study these questions.

4.

5.

6.

7.

What community services need to be put into place to meet the needs of those who are affected?

What short-term victim responses would you expect to encounter as you respond to this disaster?

What are the long-term health needs of this affected population as they attempt to rebuild?

Consider how your answers might vary if these questions were applied to victims of a terrorist act or other human-made disaster.

Suggested solution for Questions 5–8: Student responses may vary. Emergency services may be affected by disaster planning or level of preparedness and essential services may be limited. Regardless of the circumstance, nurses will be expected to play a vital role. In the short term, the greater good (utilitarian approach) may be prioritised, and this may impact the type of actions the nurse may take and the overarching application of ethical standard; however, the nurse is required to work within their scope of practice. Roles may vary but the following standards of care remain critical: • maximise the safety of the care provider and the person being treated • maintain the respiration and circulation of the person being rescued • maintain or establish infection-control interventions.

In the longer term, the community may require charitable intervention from the government and from people in the community in order to recover. Responses to these questions may vary somewhat based on personal perspectives when the disaster is human made, but even in these extreme circumstances, the nurse is required to maintain their scope of practice.

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Contents Key terms .............................................................................................................................................................. 1 Instructional strategies ......................................................................................................................................... 2 Resource aids........................................................................................................................................................ 3 Online resources................................................................................................................................................... 3 Evaluation strategies ............................................................................................................................................ 3 Review questions.................................................................................................................................................. 3 Spotlight on critical thinking ................................................................................................................................. 6

Chapter 17 The life cycle Key terms Accommodation Component of cognitive development that allows for readjustment of the cognitive structure (mindset) to take in new information. Also: Reflex eye response to change of focal distance (CNII and III) comprised of convergence, altered lens shape and pupil constriction or dilation.

Adaptation Component of cognitive development that refers to the changes that occur because of assimilation and accommodation; ongoing process by which an individual adjusts to stressors to achieve homeostasis.

Assimilation Component of cognitive development that involves taking in new experiences or information.

Critical period Time of the most rapid growth or development in a particular stage of the life cycle in which an individual is most vulnerable to stressors of any type.

Development Behavioural changes, and changes in functional abilities and skills.

Developmental stage Divisions of people’s change and evolution into distinct stages that are characterised by qualitative differences in behaviour.

Developmental tasks Certain goals that must be achieved during each developmental stage of the life cycle.

Ego-dystonic When thoughts and actions are divergent with a person’s concept of self.

Ego-syntonic Describes a person who believes that their opinions, desires, attitudes and behaviour are in harmony with their identity or ego.

Fixation Inadequate mastery or failure to achieve a developmental task that inhibits healthy progression through subsequent stages. © Cengage Learning Australia 2024

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Growth Quantitative (measurable) changes in the physical size of the body and its parts.

Intrapsychic theory Theory that focuses on an individual’s unconscious processes. Feelings, needs, conflicts and drives are motivators of behaviour.

Learning Process of assimilating information, with a resultant change in behaviour.

Maturation Process of becoming fully grown and developed; involves physiological and behavioural aspects.

Middle adulthood Developmental stage from the ages of 40–65 years.

Moral maturity Ability to decide for oneself what is ‘right’.

Older adulthood Developmental stage occurring from the age of 65 and beyond Young adulthood Developmental stage from the ages of 21 years to approximately 40 years.

Instructional strategies • What factors can interfere with ‘normal’ growth and development? Inaccurate genetic information can interfere with growth and development from conception. For example, a child with trisomy 21, or Down syndrome, will have definite changes in the rate of growth and behaviour. An infant born with foetal alcohol syndrome (FAS) may have trouble developmentally. Life experience is also a factor in growth and development. Denying a child of basic needs (food, shelter, and health care) surely has an impact on normal physical growth and development. Health status is a factor when illness or disability impairs normal growth and development. A child with diabetes may not grow at the rate of other children, and issues around insulin management and chronic disease may affect developmental growth. Another factor influencing normal growth and development is one of cultural expectations. Chinese binding of young girls’ feet or some African traditions of female circumcision hinder normal growth and development. In our geographic regions, traditional cultural expectations of women as housewives impair cognitive development. Likewise, the view of men as strong and stoic influences their ability to exhibit nurturing behaviours.

• Discuss with the class the process of moral maturity. Moral maturity is closely related to emotional and cognitive development. According to Kohlberg, there are six stages of moral development that a person moves through sequentially. However, not everyone reaches stages 5 or 6. Moral development begins at birth and continues through the lifespan. The stages begin with punishment and obedience when the concepts of ‘right’ and ‘wrong’ are introduced. As a person moves through the stages, respect for authority, approval of others, and conformity to rules are learned. The final stages of moral maturity focus on the principles of human rights and personal conscience.

• Have students review listed developmental theories and discuss appropriate nursing assessments for a 15year-old in her 25th week of pregnancy. Erikson describes this developmental stage as ‘identity versus role diffusion’ and the developmental task as ‘integration of childhood experiences into personal identity’. A possible nursing assessment could include whether this young person is taking an active part in the pregnancy decisions or whether her family is taking on that role. Erikson stresses the importance of social expectations on development. Does the person have peer pressure to engage in unhealthy behaviours, for example, smoking or drinking, or not wearing a seat belt? Havighurst calls this developmental stage ‘adolescence’. The developmental tasks associated with this stage include establishment of more mature relationships, achievement of a gender-specific social role, acceptance of

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own body, establishment of emotional independence, and preparation for occupation, marriage, and family. Nursing assessments could include her nutritional status. What she eats? How much weight has she gained in the pregnancy? The strength of her relationships with her parents, the father of the baby, and others? Is she planning for the arrival of the child? Where will she be living? What income will she have? These would be appropriate nursing assessment questions using Havighurst’s developmental theory.

Resource aids Estes, M. E. Z. (2020). Estes health assessment and physical examination (5th ed.). Cengage Learning Australia.

Maville, J. A., & Huerta, C. G. (2013). Health promotion in nursing (3rd ed.). Cengage Delmar Learning.

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Have students discuss the difference between growth and development.

• Have the students read the Respecting our differences box, ‘Nature or nurture?’ Divide the students into small groups and have them discuss the determinants of a person’s behaviour and what nurses can do to support different types of behaviour.

• Have students discuss the importance of critical period concepts with regard to growth and development.

• Have students reflect on developmental stages and developmental tasks and determine if they are meeting their own individual developmental milestones.

• Have students compare the major developmental theories cited in the text. In a round-table discussion, discuss the similarities and differences in their respective approaches.

• Divide the students into groups of three and have them look at various stages of the life cycle and determine what types of nursing education, assessment and intervention are appropriate for that stage.

Review questions 1.

Sally is 21 years old and she is seeking a single-dose Levonorgestrel, an emergency contraceptive pill, two days after having a consensual unprotected sexual experience with someone she had just met. She states, ‘This is so unlike me; I feel awful, but I had been drinking and I didn’t think it through at the time’. Sally’s statement indicates: a. She is morally mature b. An ego-syntonic thought c. She is morally immature d. An ego-dystonic thought e. She has poor problem-solving skills.

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Answer: c Rationale: Sally’s statement indicates that she is morally immature.

2.

According to Piaget’s phases of cognitive development, which one of the following would be cognitively appropriate for a one-year-old child? a. Develops significant rituals and routines b. See the world from another’s point of view c. Thinking is more logical and organised d. Is beginning to use deductive logic e. Can resolve simple social problems or conflicts.

Answer: a Rationale: According to Piaget’s phases of cognitive development, it would be cognitively appropriate for a one-year-old child to develop significant rituals and routines

3.

Which of the following statements made by a 50-year-old person indicates the achievement of developmental tasks? a. ‘At this stage of my life, everyone should take care of me.’ b. ‘I’m busy with my family and job.’ c. ‘I’m not sure in which direction my life is going.’ d. ‘I’ve had a full, happy life and am ready to die when my time is up.’

Answer: b Rationale: By saying ‘I’m busy with my family and job’ a 50-year-old person indicates the achievement of developmental tasks.

4.

The health focus of a 30-year-old woman is more on the issues around: a. reproductive health b. establishing a home c. making a contribution to society d. being with their growing family. e. caring for her aging relatives.

Answer: a Rationale: The health focus of a 30-year-old woman would be more focused around reproductive health in many cases.

5.

The middle-aged man prefers health information that: a. is shared with others, relevant and easy to apply. b. is practical, simple to understand and time consuming c. is practical, relevant and does not interrupt their responsibilities d. does not interrupt their responsibilities and can be shared with others e. is complex and well referenced.

Answer: d Rationale: Middle-aged men would more likely prefer health information that is practical, relevant and does not interrupt their responsibilities.

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6.

Which of the following statements regarding growth is the most correct? a. Growth only occurs in early and late childhood. b. Growth rates are primarily unpredictable. c. Growth occurs at a steady rate throughout a person’s life. d. Growth rates are predictable. e. Growth is an individual experience.

Answer: d Rationale: Growth rates are predictable in a typically developing individual.

7.

According to Kohlberg’s stages of moral development, a person is said to have obtained interpersonal concordance when they are able to: a. find comfort and approval within their peer group b. understand and respect the rights and personal choices of others c. understand that people need to make and learn from their mistakes d. independently decide what is morally right e. argue their point of view.

Answer: d Rationale: According to Kohlberg, a person has obtained moral maturity when they are able to independently decide what is morally right.

8.

Fowler’s construct of spiritual development encompasses six stages of faith development. A person is said to demonstrate characteristics of the ’conjunctive faith stage’ when they: a. take responsibility for their own beliefs b. accept their parents’ beliefs without question c. integrate their parents’ beliefs with their own d. question and challenge their parents’ beliefs. e. question and integrates different community faiths Answer: d Rationale: According to Fowler, a person is said to demonstrate characteristics of the syntheticconventional stage when they question and challenge their parents’ beliefs.

9.

Stan is a 60-year-old male, lives alone and doesn’t cook much. He enjoys fishing and watching television. Which of the following health topics would be appropriate and relevant to educate Stan? a. Reproductive health b. Optimal nutrition and weight loss c. Risk taking behaviours d. Avoidance of falls e. Using appropriate judgement Answer: b Rationale: Given Stan’s age and lifestyle, optimal nutrition and weight loss would be appropriate topics.

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10. Improving and education on nutrition in the older adult can assist with which of the following? a. Decreasing depression rates b. Acceptance of mortality c. Improved reproductive function d. Improved Immunity and mobility e. Reduction in falls risk Answer: d Rationale: Optimal nutrition in the older client assists with immunity and increasing their mobility.

Spotlight on critical thinking Consider how we personally interpret and stereotype people Your patient has no hair on his head and he does not speak. You are asked to feed and change his incontinence pad. What mental picture have you formed of this person?

1.

Did you visualise: • A new-born infant?

• A young brain-injured man post-brain-surgery?

• A man in his 50s receiving chemotherapy for prostate cancer?

• A man who is 80 years old with dementia?

Take some time to explore your preconceptions and prejudices and consider how they may affect the provision of your nursing care.

Suggested solution: Ask the students to write down the mental picture they formed as you read out the statement. Discuss why they constructed these pictures, was it based on their work or lived experience, did it raise positive, negative or neutral person-centred feelings. Be aware that negative stereotyping or implicit biases leads to poor health outcomes, clinical judgements, and decision-making.

Consider the issue of spirituality 2.

Is it possible for you, as a nurse, to offer spiritual comfort to a person without compromising your own values and beliefs?

Suggested solution: Discuss with the students the differences between religion and spirituality. One definition that can be used is that spirituality is a search for meaning, a sense of connection to something bigger than the individual person. It typically involves a search for meaning in life. Ask the students to discuss ways they can support a person in this quest. Some answers may include: • being with the person • listening to the person • accepting and respecting the person.

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A primary course of the COVID-19 vaccine is mandated for all nurses working in health care environments 3.

Discuss why you think this vaccine has been mandated in terms of self-care and its importance to maintaining the flow, quality and safety of the health care system.

4.

You have just completed your primary course of COVID-19 vaccines. Apply your actions to Kohlberg and Gilligan’s theories of moral development, where do they fit in and why?

Suggested solution: Engage students in a discussion that will explore both the monetary and nonmonetary value of protecting others from potential harm. Include in this discussion, the importance of protecting and maintaining the workforce in healthcare in order for the health system to function safely through outbreaks.

• Kohlberg Stage 5 – It is ‘wrong to violate others’ rights’: this may be true in the sense that this vaccine has been mandated and nurses feel that their right to choose has been taken away. Also, they may also feel that they are protecting others’ rights to good health by getting vaccinated.

• Kohlberg Stage 6 – Universal ethics orientation: the person understands the principles of human rights and personal conscience. Person believes that trust is basis for relationships.

• Gilligan Level 3 – post-conventional morality: assumes responsibilities for own decisions; holds basic tenet to hurt no-one, including self, is not dependent on others’ perceptions for self-judgement but rather on consequences and intentions of actions.

Assimilation, accommodation and adaptation The individual learns by interacting with their environment through three processes: assimilation, accommodation and adaptation.

5.

Consider a time when you learned something new and identify how you used assimilation, accommodation and adaptation to do this.

Suggested solution: Ask the student to provide three examples: the first from their workplace the second related to their circle of friends and last from a law or government body.

Culture’s role in growth and development 6.

Consider how you would incorporate ‘Pūrākau states of human development’ into your care for a Māori person.

Suggested solution: Include family in any information giving and care. Empathy and culturally appropriate input into care. Recognising that self-determination is essential and at different stages the need to be cared for. The Pūrākau states are fluid and can move back and forward, they start before birth.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 18 Paediatric care Key terms Adolescence Developmental stage from the ages of 12–20 years that begins with the appearance of the secondary sex characteristics (puberty).

Anorexia nervosa A complex mental health disorder that manifests in self-imposed starvation that results in a 15 per cent or more loss of body weight.

Bonding Formation of attachment between parent and child.

Bulimia nervosa A complex mental health disorder that manifests in episodic binge eating followed by purging.

Embryonic stage Developmental stage that occurs during the first 2–8 weeks after fertilisation of a human egg.

Foetal alcohol spectrum disorder (FASD) A group of conditions that can occur in an individual whose mother drank alcohol during pregnancy. Problems include low birth weight, distinctive facial features, heart defects, behavioural problems and intellectual disability.

Fetal stage Intrauterine developmental period from eight weeks to birth.

Germinal stage Developmental stage that begins with conception and lasts approximately 10–14 days.

Infancy Developmental stage from the first month to the first year of life.

Menarche Onset of first menstrual period.

Neonatal period First 28 days of life following birth. © Cengage Learning Australia 2024

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Obesity Weight that is 20 per cent or more above the ideal body weight.

Older adult Developmental stage occurring from the age of 65 and beyond.

Preadolescence Developmental stage from the ages of approximately 10–12 years.

Prenatal period Developmental stage beginning with conception and ending with birth.

Preschool stage Developmental stage from the ages of three to six years.

Puberty Appearance of secondary sex characteristics that signals the beginning of adolescence.

School-age period Developmental stage from the ages of six to 12 years.

Teratogenic substance Substance that can cross the placental barrier and impair normal growth and development.

Toddler Developmental stage beginning at approximately 12–18 months of age, when a child begins to walk, and ending at approximately age three years.

Instructional strategies • Often the care of a toddler can be challenging. What can a nurse do to facilitate caring for a toddler?

Toddlers will be fearful and demonstrate anxiety, making a hospitalization a negative experience. The primary reason for the anxiety is separation from parents. Parents can aid in reducing the stress by holding the toddler in the presence of the nurse. The nurse should also explain all procedures in a calm tone of voice and use play to alleviate anxiety. Directions should be short and simple, and after a painful procedure, comfort the child with cuddling or rocking. The parents should be encouraged to participate in the care of the toddler as much as possible.

• Name safety issues related to specific stages of the life cycle: o Prenatal period: poor nutrition, substance abuse, alcohol intake, or cigarettes can have harmful effects on the foetus. o Neonate: accidents are the primary cause of neonatal mortality. Neonates must be in approved car seats whenever traveling in a vehicle. Appropriate skin care to prevent nappy rash/diaper dermatitis is important. o Infancy: immunisation is important to prevent morbidity and mortality from vaccine preventable illnesses in infancy. Safe sleeping is also important to reduce the risk of sudden unexplained infant death. o Toddler: again, accidents, including accidental drowning, are the most frequent cause of toddler mortality and morbidity. Constant parental supervision and accidental drowning prevention is needed in this age group. There has been an increase in button battery ingestion which can be life threatening. The home environment must be monitored for hazards including button battery hazards, and toys should be checked for age appropriateness. o Preschooler: burns, falls, drowning, animal bites and poison ingestion are preventable accidents for the preschooler. o School-aged child: accidents during play are frequent experiences. Children this age should be taught safety rules for playing, especially in proximity to traffic. Child abduction is also a possibility at this age.

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o Preadolescent: sports and play activity injuries are a risk for the preadolescent. They are prone to violence both in and outside the home. Beginning use of street drugs and sexual activity are other concerns for this age group. o Adolescent: injury is a major cause of death among adolescents. Mental health is also a major concern for young people and awareness of risk and protective factors as well as suicide prevention strategies are needed for health professionals working with young people. Substance and alcohol abuse, smoking, unsafe sex practices, and risk-taking behaviours are also a concern in this age group.

Resource aids Calleja, P., Theobald, K., Harvey, T., & Estes, M. E. Z. (2020). Estes health assessment and physical examination (3rd Australian & New Zealand ed.). Cengage Learning.

Forster, E., & Fraser, J. A. (eds.) (2017). Paediatric nursing skills for Australian nurses. Cambridge University Press.

Fraser, J. A., Waters, D., Forster, E., Brown, N. (2022). Paediatric nursing in Australia and New Zealand (3rd ed.). Cambridge University Press.

Marjoram, A. (2012, April 21). Conception to birth – visualized. https://www.youtube.com/watch?v=sqpmzEefWrk Detroit Public TV. (2013, December 3). Pre-School-U – Introduction to social and emotional development. https://www.youtube.com/watch?v=YqI11XAmqVA

Online resources • Queensland Health – Red Flags Early Identification Guide. A health resource for health and other professionals who work with young children and families. It can be helpful for identifying developmental concerns in children aged 1–5 years as early as possible, so that you can assist them to obtain the right support from suitable health professionals. https://www.childrens.health.qld.gov.au/resources/healthservices/child-development-service/red-flags-early-identification-guide-birth-to-5-years-brochure • UNSW (2020) – The importance of safe and brave spaces for LGBTIQ+ young people and allies. Discusses the importance of safe and brave spaces for young LGBTIQ+ people and allies. https://youtu.be/kRqKLS4sQW0 • Beyondblue – A great resource for mental health and suicide prevention for young people: http://www.beyondblue.org.au • Headspace – Another great source of mental health early intervention resources for young people and is established by the National Youth Mental Health Foundation. http://www.headspace.org.au

Evaluation strategies • Assign students to a childhood age group and have them present normal growth and development for that stage. Have students present toys that are appropriate for that age group and evaluate the possible positive and negative/harmful effects from the toys.

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• Have students formulate wellness promotion strategies for a pre-school child of 4 years old; a school aged child of 10 years and an adolescent who is 17 years of age who has an identified health problem, such as diabetes, and for another pre-school child of 4 years old; a school aged child of 10 years and an adolescent who is 17 years of age with no health problems.

• Have the students prepare a plan to instruct a preadolescent or adolescent client on the prevention of sexually transmitted diseases. Australasian Society for HIV Medicine (ASHM) and the Australian STI Management Guidelines are great sources of up-to-date information regarding the most common STIs and their management can be accessed at: • http://ashm.org.au • http://sti.guidelines.org.au.

• Using the recommended immunisation schedules (Table 18-6) in the text, have the students identify which immunisations are indicated for each stage of the life cycle. Have the students identify which immunisations they have received or need to receive. Discuss reasons why individuals might refuse to receive immunisations. Would the lack of sufficient immunisation create public health concerns? Why or why not?

The following publication may be helpful to use to guide discussion about working with vaccine hesitant parents/caregivers: A discussion paper on how to communicate with vaccine hesitant parents: top 10 tips for effective communication Smith, S. E., Sivertsen, N., Lines, L., De Bellis, L. (2022). A discussion paper on how to communicate with vaccine hesitant parents: top 10 tips for effective communication. Journal of Children and Young People’s Health; 3(1), 4–7 https://doi.org/10.33235/jcyph.3.1.4-7 Vaccine hesitancy is an increasing problem in middle- to high-income countries. Australia currently has high levels of childhood immunisation uptake; however, COVID-19 vaccine uptake during pregnancy remains suboptimal. This paper acknowledges the important role of nurses and midwives in the promotion and provision of immunisation and recognises that many feel under-prepared for encounters with vaccine hesitant parents and pregnant women. The aim of this paper is to discuss the current literature on vaccine hesitancy, conduct a balanced discussion, and provide the top ten tips for effectively communicating with vaccine hesitant parents

Review questions 1.

During a clinic visit, a mother of a 4-month-old baby boy tells you she is exhausted, as her baby just doesn’t sleep. Which of the following options is the correct response? a. ‘Try and establish a regular sleep schedule in a quiet room.’ b. ‘Don’t pick your baby up, he just needs to learn he must sleep.’ c. ‘Everyone is exhausted at this stage of a baby’s life.’ d. ‘Your baby is obviously hungry, you need to increase his feeds.’ e. ‘You should take your son to the doctor for a check-up.’

Answer: a Rationale: At 4 months of age, trying to establish a regular sleep schedule in a quiet room can be beneficial.

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2.

During a clinic visit, a mother of a 6-month-old, breastfed baby tells you she would like to start introducing solid foods to her baby. Which one of the following options is the most correct nursing response? a. ‘You can’t introduce any solid foods to your child until he is 12 months old.’ b. ‘This is a great time to introduce solid food, alongside breastfeeding.’ c. ‘This is a good time for solid foods, stop breastfeeding and start him on solid foods.’ d. ‘I am surprised you haven’t already started your baby on solid foods.’ e. ‘Sit your child in an upright position when providing solid foods to prevent choking.’

Answer: b Rationale: At 6-months of age, solids can be introduced alongside breastfeeding. At this age, breastmilk/formula is still the main source of nutrients for a baby and should be augmented by solids.

3.

When teaching accident prevention to high school students, which one of the following topics is the most important for you to include? a. Fall prevention b. Fire prevention c. Motor vehicle safety d. Transmission of STIs e. Stranger danger.

Answer: d Rationale: Education about the transmission of STIs would be important to provide to this age group.

4.

Which of the following statements made by a pregnant woman indicates a need for further prenatal teaching? a. Every morning I feel so sick to my stomach, like I’m going to vomit. b. I feel tired most of the time. c. I take prenatal vitamins every day. d. It’s OK for me to drink wine if I do so in moderation. e. I am avoiding eating smoked and raw fish products.

Answer: d Rationale: If a pregnant woman made the statement ‘It’s OK for me to drink wine if I do so in moderation’, this would be a good opportunity to provide additional prenatal teaching.

5.

A parent raises a concern about the vaccinations you are offering to her baby. After listening to their concerns, you decide to: a. give them the information booklet on immunisation for them to read b. tell them they have a right to refuse, but they will be putting other children at risk c. provide information in line with their individual need and education level d. tell them that they are making a poor decision which will put their child at risk e. support the parent in their decision.

Answer: c Rationale: It would be appropriate to provide information in line with their individual need and education level to address their concerns.

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Spotlight on critical thinking Values: stereotyping 1.

Traditionally young people were labelled as either ‘male’ or ‘female’ and used gender pronouns of he/him and she/her. However, in recent times it has been acknowledge that gender identity transcends these restrictive binary terms. What gender identities are you familiar with?

2.

Consider the social media’s impact regarding gender identities and sexual orientation, what is positive and negative and how might young people respond to these social media messages? How do you celebrate gender diversity and inclusivity in relation to sexual orientation in your community (educational or health care setting)?

Suggested Solution: It can be helpful here to explore terms such as cisgender, gender identity, gender diversity, non-binary gender, misgender, sex-assigned at birth, transgender. The following article about gender identity and pronouns may be useful to guide discussions Brown, C., Frohard-Dourlent, H., Wood, B. A., Saewyc, E., Eisenberg, M. E., & Porta, C. M. (2020). "It makes such a difference": An examination of how LGBTQ youth talk about personal gender pronouns. Journal of the American Association of Nurse Practitioners, 32(1), 70–80. https://doi.org/10.1097/JXX.0000000000000217 Additionally, the following article about social media’s role in supporting LGBTQI+ adolescents may be helpful to guide discussions about social media and its influence in relation to gender identity and sexual orientation.

Berger, M. N., Taba, M., Marino, J. L., Lim, M. S. C., Cooper, S. C., Lewis, L., Albury, K., Chung, K. S. K., Bateson, D., & Skinner, S. R. (2021). Social media's role in support networks among LGBTQ adolescents: a qualitative study. Sexual health, 18(5), 421–431. https://doi.org/10.1071/SH21110

Ethical: nutrition for babies 3.

Do you think it is the responsibility of the government to ensure that babies are predominantly breastfed?

4.

Consider how breastfeeding may impact on the early attachment between: a. a father and child b. a mother and child.

Suggested Solution: Discuss the ‘Australian National Breastfeeding Strategy: 2019 and beyond’ (https://www.health.gov.au/sites/default/files/documents/2022/03/australian-national-breastfeedingstrategy-2019-and-beyond.pdf) and the ‘National Breastfeeding Strategy for New Zealand Aotearoa, Rautaki Whakamana Whāngote, A roadmap to action: 2020 and beyond’ (https://www.babyfriendly.org.nz/news/article/national-breastfeeding-strategy-for-new-zealand-aotearoarautaki-whakamana-whangote) These strategies aim to provide women with an enabling and empowering environment that protects, promotes, supports, and values breastfeeding as the biological and social norm for infant and young child feeding.

• A father and child -– Feeding is only one tiny portion of a baby’s life. Non-breastfeeding partners are an integral part of the baby’s life they can: o advocate for continued breastfeeding,

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o provide skin-to-skin contact o give baby massages and cuddle times o enjoy spending time with the baby o bottle-feed with expressed breast milk o It is also important to emphasise the significant role that partners including fathers play in supporting continuation of breastfeeding. It may be helpful here for students to brainstorm ways that fathers can support breastfeeding mothers.

• A mother and child – Breastfeeding is highly associated with strong maternal-infant bonding and responsiveness.

Values: values clarification As a nurse, you will often encounter young people whose value systems conflict with your own beliefs. How will you provide care to sexually active adolescents if you think their behaviour is immoral or ‘wrong’?

5. Is it ethical for you to try to change the adolescent’s values to be congruent with yours?

6. Should you change your values to be congruent with those of the adolescent?

Suggested Solution: Engage the students in an extended discussion about how they currently protect and project their beliefs. How do students feel when confronted with someone who wants to alter their beliefs?

Some emotional responses they may wish to consider are, fear, anger or denial.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 7

Chapter 19 The older adult Key terms Ageism A term used to describe attitudes of older people based on stereotypes rather than facts. This often leads to discrimination and incorrect beliefs about the older person.

Chronological age The exact time a person has been alive since birth. Measured in time, generally expressed as number of years.

Delirium An acute state of confusion, usually with a rapid onset that reduces the person’s awareness of their environment accompanied by confused thinking. It is a serious condition generally brought on by a severe or chronic illness, infection, drug interaction, change in metabolic balance or other possible contributing factors.

Lentigo senilis Brown pigmented areas on older people, commonly on the face, hands and arms because of sun exposure. These coloured areas are flat tan or brown spots on the skin, are commonly referred to as ‘liver spots’ or ‘age spots’ and are benign.

Person-centred care A term used to describe the approach of care that acknowledges that the person’s perception of their own needs is central to the care that is provided to them. The wishes of each individual person along with their lifestyle and health choices are acknowledged and prioritised when providing and planning all care.

Polypharmacy The use of multiple medications during the same period. These medications include prescribed, over-the-counter (OYC) and complementary categories. It is commonly used to describe the taking of five or more medicines.

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Presbycusis The term used to describe hearing loss that gradually occurs as a person ages, due to the natural ageing of the auditory system. Hearing is often more difficult with high-pitched sounds and the person with presbycusis often experiences difficulty in hearing conversations, particularly those involving women’s voices.

Residential aged care facility (RACF) A term used within Australia to describe a facility purposefully operated for older people to reside within who need assistance with their medical, personal and psychosocial needs on a 24-hour basis. In New Zealand these facilities continue to be referred to as nursing homes and/or hostels Restorative nursing care/rehabilitative nursing care Nursing care provided to those who have residual impairment as a result of disease or injury; seeks to increase the person’s independence and ability to perform self-care.

Instructional strategies • The population in the Australia and New Zealand, like most of the world, is rapidly ageing. As we grow in this country, we have beliefs and perceptions about the older adult. Discuss some myths and stereotypes about ageing. Most myths about ageing tend to have negative associations. When asked for descriptions of older adults, terms such as senility, hard of hearing, nonsexual, ill, grumpy, and rigid often come to mind. The elderly population is thought to live in nursing homes and to be economically disadvantaged.

However, these are myths and stereotypes. Ageism, the process of systematically stereotyping and discriminating based on age, is often the result when accepting these negative attitudes about older adults. Although some definitions fit a portion of the population, these attributes are not related to chronological age. Older adults must be looked at by their individual characteristics.

• Even though we just discussed myths and stereotypes about ageing, certain changes are associated with ageing. What types of physical changes occur in the older adult population? o Developmental changes: becoming a grandparent, gaining insight or wisdom, developing new hobbies or skills, traveling, adjusting to death of partner, physical limitations, retirement and subsequent change in financial income level, loss and loneliness, and living independently or dependently. o Physiological changes: decrease in rate of cell mitosis, elasticity and reserve functional capacity.

Greying hair, and sight and hearing impairment are visible physiological changes. Other physiological changes may vary with lifestyle behaviours of the individual. o Neurological changes: reaction time is slower, which can lead to an increased risk for falls, burns, and other injuries. o Sensory and perceptual changes: decreased response to sensory, perceptual, and environmental stimuli. Taste perception declines with advancing age, and salivation is diminished. Olfactory nerve cells decrease with age, so sense of smell is not as strong in the older adult. o Cardiovascular and respiratory changes: functioning of the cardiovascular system decreases. The arteries have thickened with fat deposits, and decreased cardiac output discourages aggressive physical activity. It is not uncommon for functional respiratory reserve capacity to decrease. Other changes make older adults prone to ineffective clearing of the respiratory system. o Gastrointestinal changes: loss of teeth, gum recession, and degeneration of the mandible can lead to inadequate nutritional intake. The saliva is more alkaline. A decrease in peristalsis of the

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gastrointestinal tract leads to a decreased emptying of the stomach and increasing heartburn.

Impaired elimination can lead to a decreased absorption of nutrients and constipation. o Genitourinary changes: loss of muscle tone accounts for structure changes in this system. Nocturia, incontinence and bladder infections are often the result of this muscle tone loss. o Endocrine changes: metabolism slows, blood levels of certain hormones drop and the older adult struggles more to respond effectively to stress. o Reproductive changes: testes become softer and smaller, and production of sperm decreases. Women experience a decline in estrogen levels, which cause vaginal walls to thin and discharge to decrease.

Women may experience pain with intercourse and should be encouraged to use water-soluble lubricants. o Musculoskeletal changes: posture becomes stooped; joints, ligaments, and tendons become hardened and rigid, and walking is sometimes a painful activity. o Integumentary changes: skin wrinkles occur, wounds take longer to heal, and skin tears more easily in the older adult. Lentigo senilis, a brownish discoloration, appears. Hair thickens, nails thicken and become brittle, and the number of sweat glands decreases. o Mental status changes: these changes can range from mild to severe. Acute confusion can last a few hours to a few weeks. Chronic confusion, dementia, Alzheimer’s disease, and depression are all seen in this population.

• Mistreatment of the elderly is a problem that nurses are expected to recognise and refer to appropriate authorities. Discuss the forms of and the nurse’s role in situations of elder abuse. The forms of elder abuse include physical abuse, neglect, psychological abuse and exploitation. It is of vital importance that when mistreatment is suspected, the nurse provides a safe environment and portrays a nonjudgmental attitude. The nurse who establishes a trusting, therapeutic relationship with the older adult will be more likely to promote sharing. Taking a health history and performing a thorough physical examination are critical in relationship to suspected elder abuse. Signs of physical mistreatment and indicators of psychological abuse in the elderly are highlighted in the text.

• Discuss the concept of polypharmacy and how age-related changes of drug therapy can affect the elderly client. What assessment methods can the nurse utilise to prevent such occurrences? Many hospital admissions of elderly clients are a result of polypharmacy. The elderly client frequently takes a large number of medications on a daily basis. Sometimes, the medication may have been prescribed by more than one doctor, leading to an increase in potential interactions if the provider is not aware of all medication that the client is taking. In addition, clients may keep medication in their home just in case they need it again. It is easy to get into a routine of taking medication and just adding more pills, rather than stopping them. The elderly client, by virtue of age-related changes, has a decrease in metabolism and elimination status. This can lead to potential drug toxicities, even though they might be on a normal therapeutic dose. Elderly clients should be closely monitored both for the types of medications that they are taking and for their renal and liver function ability to metabolise and excrete the drugs. The nurse should ask specific questions related to medication use, both over-the-counter (OTC) and prescription. In addition, when doing a home assessment, it is important to inspect all medications for expiration dates and indications. Often, elderly clients have collections of medications but do not remember or understand why they are taking them anymore. Specific laboratory tests regarding renal and liver function may be needed, along with serum level testing (if warranted). If an older person is being admitted to hospital it is advisable to ask them to bring with them all medication they are taking. Do not be surprised if they bring in bags full, many of which the doctor is unaware they are taking.

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Resource aids Sayers, J., & Cotton, A. (2014). Chapter 2: Understanding the ageing process. In A. Johnson & E. Chang (Eds.) Caring for Older people in Australia. John Wiley & Sons Webb, M., Skinner, J., & Hee, L. (2015). Stories of ageing. Elsevier. This is a textbook that is based on 18 videos of various people discussing ageing and its issues.

Online resources •

Dementia Australia. The website from Dementia Australia has a variety of information for people with AD, carers/family members and health professionals https://www.dementia.org.au

•

Alzheimer’s New Zealand. The website from Alzheimer’s New Zealand is a similar website full of resources and information well worth a look. http://www.alzheimers.org.nz

•

The Telegraph, 105-year-old is New Zealand's oldest driver: One minute video to stimulate thoughts about feeling old, ageism and independence for the older person. https://www.youtube.com/watch?v=KXnBIhnpUUg

Evaluation strategies •

Invite a group of older adults to be on a panel to talk to the class. Topics can include their perception of treatment by society in general and health care experiences more specifically. Alternatively, the resource by Webb, Skinner and Hee (2015) is full of videos that could be used in the place of panel members.

•

Provide students with the opportunity to perform a comprehensive health history and physical examination on an older adult. Have them document their findings.

•

There are many activities available in the community for the older adult. Have the students perform a community assessment and collect information regarding agency services and recreational activities geared toward the older adult.

•

Driving Miss Daisy, a popular Warner Brothers movie, gives some insight into perceptions of ageing and treatment of the older adult in the western world. Have students view the movie and give a brief report on the impact of the movie.

•

Divide the students into small groups and select a medication. Have each group research the agerelated effects for an elderly client taking that medication.

•

Have the students access the Dementia Australia Website https://www.dementia.org.au This site includes lots of information about Dementia disease including facts sheets and links to videos and stories from people who have been affected by AD. Have the students investigate a section and discuss the information provided.

•

Schedule the students to visit an assisted living, extended care, or senior housing facility. Have the students participate in routine care activities and social activities. Have the students conduct a health assessment on an elderly resident. After the experience, encourage a discussion regarding the environment, activities, strengths, and challenges that face the elderly population.

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•

Have the students access the website for the site containing social groups for people over the age of 50. https://www.aboutover50.com.au/social.html

•

Ask them to find 3 groups their parents or grandparents would be interested in. How would they introduce the groups to them without promoting ageism?

Review questions 1.

You are administering medications to an older client. Which of the following is most important for the nurse to assess to prevent medication toxicity? a. CNS function b. Genito-urinary system function c. Renal function d. Thyroid function e. Cognitive function.

Answer: c Rationale: Impaired renal functioning can slow the excretion of drugs and increase the half-life, which leads to possible toxicity.

2.

Which of the following nursing interventions are appropriate for an older woman to promote bone health? a. Encourage to avoid physical activity b. Instruct to eat dairy products c. Remind of need to be more sedentary d. Teach the importance of consuming antioxidants e. Stay in the sun between 10 a.m. and 3 p.m. to absorb maximum vitamin D. Answer: b Rationale: Consuming dairy products provides calcium, which is necessary for development of bone.

3.

You are discussing a person’s complaint of pain in their lower back and legs. A nursing assistant replies, ‘What do you expect? The person is 90 years old.’ Which of the following is the best response by you to the assistant? a. ‘Pain is not an expected result of ageing.’ b. ‘The client is probably exaggerating.’ c. ‘The client is probably just seeking attention.’ d. ‘Yes, everyone’s pain level increases as they get older.’ e. ‘Just give her a cup of tea, she’ll forget it in a minute.’

Answer: a Rationale: Health care providers need to be aware that pain is not a normal physiological change due to ageing.

4.

Which of the following age-related physiological changes may lead to the development of hypertension (high blood pressure)? (Select all that apply.) a. Calcification of the chest wall b. Decreased elasticity of blood vessels

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c. Decreased percentage of body fat d. Increased cardiac output e. Development of heart murmurs f. Decreased arterial diameter.

Answer: b, f Rationale: With ageing, blood vessels become narrow and lose elasticity; these changes put the individual at risk for developing hypertension since the heart has to pump harder to circulate blood through the smaller vessels.

5.

Which of the following statements about older adults is true? a. Most older adults live in poverty. b. Older adults have sexual needs. c. The majority of older adults see themselves as ill. d. The majority of older adults reside in extended care facilities. e. The older a person gets, the less they can use a computer Answer: b Rationale: Interest in sexual activity is normal in older adults. Less than 10 per cent of elderly Australians or New Zealanders live in poverty. The majority of older adults self-rate their health as good or better. Less than 10 per cent of older Australians or New Zealanders reside in long-term care facilities.

6.

Which of the following nursing actions are best to be implemented for a person experiencing agerelated visual changes? (Select all that apply). a. Instruct on the need to avoid use of artificial tears. b. Suggest the use of eye drops. c. Encourage the wearing of sunglasses each time they go outside, to avoid glare. d. Use pastel colours to reduce eyestrain. e. Be sure to replace all light bulbs with the brightest ones available.

Answer: b Rationale: Eye drops and artificial tears may relieve dryness caused by decreased tear production.

Bright colours compensate for the decline in colour discrimination.

7.

An older person with dementia gets upset after she is brought back to the RACF after a day’s outing with her daughter. The client says’ I can’t remember where the money is. Don’t hit me’ and then wanders off. Do you: a. ignore it, she has dementia b. contact the daughter and ask her about the money c. document it and report it to the supervisor d. wait and see if she says it again after her next outing with her daughter e. search her room for lost money.

Answer: c Rationale: It is important to take things seriously from older people, even if they have dementia. It may be an experience from the past the resident is reliving, or it may be a true reflection of the recent outing. You must document and report to the supervisor for further investigation.

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8.

Which of the following is not a cause of delirium? a. Dehydration b. Urinary tract infection c. Ageing process d. Trauma e. Pneumonia Answer: c Rationale: Delirium is not a normal part of the ageing process. It is a serious medical condition frequently brought on by dehydration, urinary tract infections, pneumonia or other infections or posttrauma.

9.

Although many people over 65 have a chronic health problem, most have found ways to keep these ailments from interfering with their enjoyment of life. Ways to encourage this positive outlook include: a. reminding them of the contribution they can make as a grandparent b. promoting volunteering c. reminding them they only have a few years left to live so they need to do something positive d. telling them there are plenty of other people that have the same ailment, and they do not complain e. providing education about the exercises they can do to proactively reduce impact of their ailment.

Answer: a, b, e.

Rationale: A positive outlook and adaptive ability contribute to the high quality of life enjoyed by many older adults today. Good nutrition, proper exercise, continued work, travel, recreation, hobbies and companionship are just a few of the healthy lifestyle choices many older people now have the means to enjoy.

Spotlight on critical thinking Understanding the meaning of loss Consider the perspective of an older client who has experienced the loss of loved ones, such as a spouse of 50 years or a child.

1.

Do you feel you will be able to relate to and show empathy to an older adult whose life experiences may differ dramatically from your own?

2.

What steps can you take to ensure that you treat these people with dignity, respect, and compassion?

Suggested solution: When answering these questions students may consider how the older person is more likely to have experienced more loss than younger people; however, this should not prevent the nurse from demonstrating empathy. They should reflect on how they think they may want to be treated themselves in a situation of experiencing a significant loss.

Simple steps are required for treating anyone, including an older person experiencing loss, with dignity, respect and compassion. Students should consider what these are and be sure to include active listening, taking time to listen to them, ask questions about their family members they have lot. Offer to contact another family member or friend for them, offer support services such as the grief counsellor, or social worker. Sometimes just offering a cup of tea and 5 minutes of your time to listen can provide as much support as they need.

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Reminiscence As the nurse manager of an RACF you want to establish a program to encourage clients to engage in life review. You decide to conduct a weekly session for interested residents who want to share their life experiences.

3.

How would you prepare for the sessions?

4.

How would you evaluate the effectiveness of the session?

Suggested solution: Ask students to consider what may assist older people to reflect on previous times, what types of things may stimulate memories of days gone by? What do they like to talk about from their past?

Old photos of local towns, fashions, schools, vehicles, and so forth may assist. Types of music they enjoyed 20 or 30 years ago (not everything needs to be from the war era), even recipes, or pictures of food so they can discuss their favourite food when they went to school, ate on weekends, and so on.

The agenda would focus on one area only, select one theme and concentrate on that for the session. Gather prompts together relevant to that session (such as mentioned above). Evaluation could be determined by the active engagement of the residents within the session, gauging reflection, contribution to conversation and overall positive behaviours. Ask the students to think about what they may observe in a positive session.

Positive ageing You are talking to a fit looking gentleman who says to you ‘I turn 70 tomorrow. My wife died last year. I suppose there’s nothing left for me now’ 5.

How would you react? What advice could you give?

6.

What groups would you recommend in your local community to this man?

Suggested solution: When responding to this question, have the students reflect on why they think he stated this? Consider if he is simply reflecting back on the previous years because of his birthday or is he lonely since the loss of his wife? Is he looking for new purpose?

What organisations are the students aware of in their local community that older people could attend? Are their organisations they haven’t considered before, that may reflect their stereotyping of the older person? Maybe the local football club is a great place if he used to follow or play football when he was younger, it can be a place where he can meet with both younger and other older people with the same interests. Maybe he could volunteer in their fundraising efforts, something that can provide him with a purpose in life and expand his social circles.

This could lead the students into a discussion re stereotypes they had themselves that they had not considered as well as how inclusion is an important part of positive ageing.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 1 Evaluation strategies ........................................................................................................................................... 2 Online resources.................................................................................................................................................. 2 Review questions................................................................................................................................................. 2 Spotlight on critical thinking ................................................................................................................................ 4

Chapter 20 Palliative care Key terms Artificial nutrition and hydration (ANH) The provision of either nutrition (food) or hydration (fluids) using either tubes or technology; this is an interventional medical treatment.

Disease trajectories Ｔｈｅ ｐａｔｈｗａｙ ｏｒ ｌｉｎｅ ｏｆ ｐｒｏｇｒｅｓｓ ｏｆ ａ ｄｉｓｅａｓｅ． Hospices Institution that can provide palliative care to individuals and families in the inpatient or community setting.

Palliative care Control of the symptoms rather than cure.

Palliative care units (PCUs) Specific inpatient multidisciplinary or interdisciplinary unit that provides holistic palliative care for people with life-limiting illness and their families/carers.

Percutaneous enteral gastrostomy (PEG) A means of providing artificial nutrition and hydration by inserting a tube through the abdominal wall directly into the duodenum.

Total parenteral nutrition (TPN) The provision of nutrition and hydration solely through the use of intravenous infusion of solutions containing lipids, proteins, carbohydrates, electrolytes and vitamins.

Instructional strategies • Most students will have some experience of palliative care – this may be either directly, personally or vicariously through the experience or stories of others.

• This is valuable in terms of being able to get students to directly identify their knowledge (whether positive or negative) as a starting point.

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Evaluation strategies • Ask students to identify how they see their role as a health professional in the provision of palliative care.

What skills do they have they would be able to support a person through their palliative journey.

• What are the skills/knowledge that the student may think that they would need to feel confident in providing palliative care.

Online resources • Palliative Care Australia – http://www.palliativecare.org.au • Palliative Care Association NSW – https://palliativecarensw.org.au/new • Care Search – http://www.caresearch.com.au/Caresearch/Default.aspx • Palliative Care New Zealand – http://www.health.govt.nz/our-work/life-stages/palliative-care • St Christopher’s Hospice – http://www.stchristophers.org.uk • Cancer Council Australia NSW – http://www.cancercouncil.com.au • Cancer Council New Zealand – http://www.cancernz.org.nz • JBI COnNECT+ – https://connectplus.jbi.global

Review questions 1. As a clinical specialty, a palliative approach to care is provided: a. in a dedicated inpatient unit or hospice b. in a hospice setting when active treatment has been stopped c. in the community d. in all clinical and community-based settings where people are living with a life-limiting illness or disease. e. exclusively in aged care settings.

Answer: d 2. Palliative care is aimed at people who have been diagnosed with: a. cancer b. cancer or end-stage cardiac disease c. undesirable symptoms, such as pain and nausea d. a medically incurable condition. e. a psychologically disturbing condition.

Answer: d 3. Providing palliative care to frail older people requires you to: a. provide the same kinds of care that is offered to younger people in order to avoid ageism b. be able to distinguish between normal age-related changes and pathological changes related to the person’s life-limiting disease c. limit resources to the elderly person, given the ageing of the population

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d. work in a residential aged-care facility. e. discuss with the person in palliative care the opportunity to use experimental medications to improve their quality of life.

Answer: b 4. Malnutrition is: a. understood as weight loss due to not having enough to eat b. normal in people in palliative care and does not need to be addressed when a person has a lifelimiting illness c. evident when a person presents with significant weight loss, metabolic alterations, asthenia, anorexia, fatigue, muscle tissue catabolism and deteriorating sense of general well-being d. a serious condition which must always be reversed in person with life-limiting illness or disease e. a condition where the body does not get enough of the essential amino acids to support organ function.

Answer: c 5. ANH is: a. a form of medical treatment b. always provided to palliative care people who have an alteration in their nutritional status c. a basic aspect of nursing care in people with end-stage disease d. commonly administered in hospice settings. e. always delivered via a PEG tube in end-stage palliation Answer: a 6. Medically futile treatment is: a. treatment that does not cure the person of their illness or disease b. treatment that has not been proven in research trials to be popular with people c. treatment that does not sustain life, improve a person’s condition, or bring comfort to the person d. treatment that is painful e. treatment that provides hope to the palliative person and their family.

Answer: c 7. Palliative care teams: a. work exclusively with people in hospice-based care. b. provide expert opinions to people and their loved ones. c. are guided by the team leader. d. are interdisciplinary groups which place the person at the centre of decision-making and care provision. e. work in aged care settings to assist relatives in making decisions regarding appropriate care.

Answer: d 8. Pharmacological methods of analgesia include: a. sedatives, opioids and barbiturates. b. weak opioids, strong opioids, and aperients.

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c. antibiotics, opioids and sedatives. d. simple analgesics and NSAIDs, weak opioids and strong opioids. e. NSAIDs, hypoglycaemics and sedatives.

Answer: d 9. The best method for the administration of medications and analgesics in end-stage palliative care is determined by: a. the person’s ability to swallow, pharmaceutical properties of the medication and the availability of medications. b. the person’s ability to swallow, pharmaceutical properties of the medication and absorption rate of the medication c. the person’s ability to swallow, availability of medication and absorption rate of medication. d. the person’s ability to swallow, availability of medication and cost of medication. e. the person’s ability to swallow, their tolerance of the method of administration and personal preference.

Answer: b 10. Assessing fatigue in the palliative care setting is based on the: a. subjective reports of sleepiness, depression and weakness. b. objective measurement of hours slept at night. c. objective reports of forgetfulness, depression and hours slept each night. d. subjective reports of an increasing need to rest or lie down, loss of interest in enjoyable activities, increased reports of depression, or increased experience of weakness e. subjective reports from family regarding the person’s feelings of anxiety and loss of appetite.

Answer: d 11. Pathological fatigue can be caused by: a. anaemia, metabolic disturbances and social commitments. b. anaemia, electrolyte imbalance and lack of discipline. c. anaemia, electrolyte imbalance and environmental noise. d. anaemia, metabolic disturbances and poor nutritional intake. e. anaemia, metabolic disturbances and over activity.

Answer: d

Spotlight on critical thinking What are the primary components of palliative care provision that can be applied to any context or place of care?

1.

How does providing palliative care differ from providing care in an acute care setting?

Suggested solution: Palliative care: • can be provided alongside curative treatments • has a focus of care is on holistic care rather than on a narrow set of symptoms or care outcomes • can incorporate a breadth of treatments – dependent on the needs of the person.

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2.

What is the core knowledge you need in order to provide care for a person with advanced disease?

Suggested solution: This can include: • effective communication skills • effective clinical assessment skills • a sound knowledge of palliative care medications and their pharmacological properties and where to access pharmacological information • knowledge of self-care strategies and how to access self-care resources

3.

What is the role of the family/significant others in providing care to a person in palliative care?

Suggested solution: This includes the family being: • a core part of the care provision • care providers in their own right (particularly in the community/out of hospital setting).

• if the person you are caring for has no ‘family’, consider what supports are available for this person.

4.

How can your own culture, age and religion influence the way you provide care to a palliative patient?

Suggested solution: • It is essential that you give yourself the opportunity to consider and draw strength from your own beliefs and influences about the palliative experience.

• Consider that your own cultural beliefs and values that can be different to the person you are caring for, and this may cause some issues for you in provision of care.

5.

What resources are available within the community to help the family/next of kin during bereavement?

Suggested solution: A bereavement risk assessment should be part of the holistic assessment of the person and family/carer.

• Normal bereavement response: family and friends, general practitioners; community health nurses; allied health professions, such as social workers; pastoral care workers; and faith-based support.

• 6.

For those at risk of complex bereavement: all of those listed above as well as specialist palliative care services, and referral to psychologists trained in grief and bereavement.

How can you protect your own emotional self when caring for a person with advanced disease?

Suggested solution: working with and caring for people who are dying can be confronting and a profound experience. Nurses need to be able to identify others with whom they feel safe enough to discuss these issues and aspects of care about, which they feel unsure or find confronting. Workplaces offer professional counselling services or debriefing sessions for staff. Your colleagues may be a source of support. Additionally, constructive reflective practice may enable you to learn from the issues and concerns that you have.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 7

Chapter 21 Cultural diversity Key terms Aboriginal and Torres Strait Islander peoples The diverse cultures, languages and na�ons of the First Peoples of Australia.

Accultura�on Process that consists of learning norms, beliefs and behavioural expecta�ons of a group through which people of a subculture assume the characteris�cs of the majority culture.

Assimila�on Component of cogni�ve development that involves taking in new experiences or informa�on.

Colonisa�on Mul�plica�on of microorganisms on or within a host that does not result in cellular injury; also, occupancy by people foreign to land or country that setle and overlook exis�ng systems and impose their own governance structures that impact on the health and wellbeing of the original inhabitants.

Country The lands of First Na�ons communi�es.

Cultural assimila�on Process by which individuals from a minority group are absorbed by the majority culture and take on the characteris�cs of the majority culture.

Cultural competence Provision of nursing care that is appropriate to the person’s cultural context.

Cultural diversity Individual differences among people that result from racial, ethnic and cultural variables.

Cultural safety The provision of quality health care that acknowledges and uses the everyday values and beliefs of the individual who is of a culture different to the nurses’ and/or the majority culture.

Culturally and linguis�cally diverse (CALD) Describes people who have a diverse cultural background and who speak a language other than English.

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Culture Dynamic and integrated structures of knowledge, beliefs, behaviours, ideas, a�tudes, values, habits, customs, languages, symbols, rituals, ceremonies and prac�ces that are unique to a par�cular group of people; growing microorganisms to iden�fy a pathogen.

Culture-centred care A pa�ent-centred approach to health care that priori�ses the cultural context and needs of people in the provision of care. It involves understanding and respec�ng the unique beliefs, values, prac�ces and experiences of people and incorpora�ng these into the delivery of care.

Decolonisa�on Is about reversing the impacts of colonisa�on and revolves around a cri�cal understanding of the impacts of colonisa�on on knowledge systems.

Ethnicity Cultural group members’ percep�on of themselves (group iden�ty) and others’ percep�on of them.

Ethnocentrism Assump�on of cultural superiority and an inability to accept other cultures’ ways of organising reality.

First Na�ons Refers to the Aboriginal and Torres Strait Islander peoples of Australia, and/or the Ma¯ori people of Aotearoa, New Zealand.

Majority culture The group whose values prevail within a society.

Minority group Group of people who cons�tute less than a numerical majority of the popula�on and who, because of their cultural or physical characteris�cs, are labelled and treated differently than others in the society.

Oppression Condi�on in which the rules, modes and ideals of one group are imposed on another group.

Race Grouping of people based on biological similari�es, such as physical characteris�cs.

Racism Discrimina�on directed towards individuals who are misperceived to be inferior because of biological factors.

Stereotyping Belief that all people within the same racial, ethnic or cultural group act alike and share the same beliefs and a�tudes.

Strengths-based Approaches focusing on abili�es, knowledge and capaci�es rather than deficits, or things that are lacking.

Telehealth Australia-wide telecommunica�ons network strategy designed to bring quality health care to isolated areas via videoconferencing, reducing the need to travel vast distances for a medical consulta�on.

Instructional strategies • Discuss examples of ethnocentrism, stereotyping, and racism found in health care today. Some cultures may practice non-traditional methods of health care. Nurses who ridicule these people, disbelieve or disapprove of their methods, and feel as though their own type of medical or nursing care is superior are guilty of ethnocentrism. In the past, people with HIV/AIDS were often presumed to be promiscuous individuals, homosexuals, or intravenous (IV) drug users. Nurses who believed this to be the case were stereotyping these people. A nurse who believes that all IV drug users are unemployed could be accused of stereotyping. A NUM who always puts people from an Anglo-Saxon background a private room but puts non-Anglo-Saxon people in four-bed rooms is practicing racism. Nurses who belittle a person from a CALD background for not being able to speak fluent English are demonstrating racist behaviour. © Cengage Learning Australia 2024

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• Discuss the concepts of cultural diversity, multiculturalism, acculturation, and cultural assimilation. How can nursing help to maintain cultural integrity and diversity while promoting multicultural unity? Although cultural diversity looks to recognise the differences between groups of people as a result of ethnic, racial, and cultural variables, it is not meant to be a divisive approach. The rich aspect of culture implies a group of shared ideals, beliefs, norms, and values. Multiculturalism recognises that a large group composed of different cultures comes together to form a functional group. Cultural assimilation is where individuals from a minority group are absorbed into the mainstream of the dominant culture. Nursing helps to maintain cultural diversity by dealing with individuals, family groups, and population groups on an individualised basis, paying attention to identified needs and goals. This recognition of the importance of individual cultural beliefs helps to establish an open line of communication. Nurses are aware of the individual client and client populations that they interact with and are a part of in the general population.

• Discuss the different types of family patterns and give examples of how they can influence health care decisions and health care beliefs. The linear pattern is based on a patriarchal structure. The patriarch sets goals, and the elders are respected. In this type of family pattern, the patriarch sets the direction for health care decisions and helps to model health care beliefs for the entire family. Children are incorporated into the family structure. The collateral pattern reflects the nuclear family of male adult, female adult, and children. Decisions are mutually based, but the male is traditionally still the ‘head of the household.’ Family goals are more important than individual member goals. Children are valued in this type of pattern. In this type of family pattern, there is input into health care decisions by both partners, who work to model health care beliefs for the entire family. The individualist pattern places emphasis on the individual goals, accountability, and self-responsibility. Elders and authority figures are not regarded in high esteem. In this type of family pattern, there is emphasis on individual health decisions and health care beliefs.

• The six organising phenomena of culture are communication, space, orientation to time, social organisation, environmental control and biologic variation. Give examples of each phenomenon and how it influences nursing care. o Communication – Dissimilar cultures o�en use languages different from the language of the predominant culture. This type of communica�on barrier is cri�cal when providing nursing care. Both verbal and nonverbal nursing communica�on can be misunderstood by the client and family members.

This can have consequences around teaching issues, informed consent, and pa�ent confiden�ality.

Enlis�ng the services of an interpreter will enhance the nurse’s ability to provide quality care. o Space – Culture determines the amount of personal and environmental space needed by a person.

Certain types of touching may be reasonable to the predominant culture but considered disrespec�ul to another cultural group. The nurse should be aware of what types of space requirements are needed to maintain a person’s comfort. o Orientation to time – This refers to a cultural group being focused on the past, present, or future.

Nurses should have some understanding of �me orienta�on when working with people who are culturally different than themselves. o Social organisation – Family structure, kinship �es, religious groups, and ethnic groups are examples of social organisa�ons. There are more specific gender roles for families from some cultures. Decisions may be made by the dominant family member, who is o�en the husband or father. There are also many other types of families, including single-parent families and families with same-sex parents. © Cengage Learning Australia 2024

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These all need to be recognised and acknowledged. The nurse should be respec�ul of these rela�onships, even if these people’s lifestyles differ from the nurse’s personal values and beliefs. o Environmental control – Environmental controls refer to the rela�onships between people and nature and to a person’s ability to control ac�vi�es of nature. Tradi�onal healers, for example, may be called in to provide home remedies. Nurses must be able to relate care and treatment within the client’s cultural context. o Biologic variation – Some cultures, especially geographically located, have biologic varia�ons that dis�nguish one cultural group from another. For example, Polynesians and those from islands in the South Pacific have a body structure different from western Europeans. These varia�ons are noteworthy for the nurse to consider when providing care. Biologic varia�ons may also contribute to health problems that affect certain cultures.

• Discuss why homelessness is a major problem today. There are specific societal factors that contribute to homelessness. These factors include lack of affordable housing, increasing difficulty in meet public assistance criteria, reduced social service resources, under- or lack of employment, personal history of psychosocial trauma, and deins�tu�onalisa�on of clients from mental health facili�es without adequate community support. In addi�on to these factors, many homeless people have some form of mental illness or addic�on to drugs or alcohol.

• What potential difficulties may arise if the client and nurse are from different cultures and have different health beliefs? Inadequate or insensi�ve care is a concern when values clash. A nurse with litle or no understanding of a client’s culture will likely have difficulty mee�ng the client’s needs. The nurse may also have trouble with assessment of the client. The nurse may not ask the proper ques�ons to obtain informa�on relevant for the client’s nursing care. Again, any language barrier will affect assessment, teaching, and evalua�on of the client.

• Discuss the three major nursing interventions needed when caring for culturally diverse clients. The first interven�on is that of self-awareness. The nurse must be aware of the poten�al for bias or misunderstanding. Self-awareness helps nurses recognise their own stereotypes, biases, and prejudgments about culturally different clients. The second interven�on is the use of a nonjudgmental approach. The nurse who provides care sensi�ve to the client’s background will enable the client to provide open, honest feedback and achieve a posi�ve health care partnership. The last interven�on is client educa�on. Educa�on is an integral part of nursing care that must be provided in a culturally sensi�ve manner.

Resource aids Henderson, S., & Kendall, E. (2011). Culturally and Linguis�cally diverse people's knowledge of accessibility and u�lisa�on of health services: exploring the need for improvement in health service delivery.

Australian Journal of Primary Health, 17(2), 195–201.

NIRA Review Working Group. (2011). Review of the National Indigenous Reform Agreement (NIRA) performance framework: Final report. Canberra, ACT: Department of Prime Minister and Cabinet.

Nursing Council of New Zealand. (2011). Guidelines for Cultural Safety, the Treaty of Waitangi and Maori Health in Nursing Education and Practice. New Zealand: Nursing Council of New Zealand.

Nursing and Midwifery Board of Australia (NMBA). (2008). Code of ethics for nurses. Retrieved from www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines.aspx © Cengage Learning Australia 2024

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Lesley Siegloff lecture: Looking for the person, not the stereotype htp://www.ausmed.com.au/online/looking-for-the-person-not-the-stereotype-audiolecture-3898042 Munoz, C., & Luckmann, J. (2005). Transcultural communication in nursing (2nd ed.). Cli�on Park, NY: Cengage Delmar Learning.

Sarah Vogel Transcultural Nursing in Australia htp://www.ausmed.com.au/blog/entry/transcultural-nursingin-australia

Online resources •

Nursing and Midwifery Board of Australia: htp://www.nursingmidwiferyboard.gov.au/

•

Nursing Council of New Zealand: htp://www.nursingcouncil.org.nz/

Evaluation strategies •

Have students of different backgrounds share experiences they have had with ethnocentrism, stereotyping and racism. Encourage discussion of how these behaviours influence the quality of nursing care.

•

Invite nurses of different cultural backgrounds to discuss with the class the types of overt and covert misunderstandings and communica�on problems inherent in dealing with a diversified client popula�on and how nurses can surmount these barriers.

•

Divide the class into four groups and assign each group one of the cultural groups iden�fied in Table 213. Each group will research and discuss the non-tradi�onal healing prac�ces found within each of the cultural groups. Discuss how the non-tradi�onal healing prac�ce can be linked to the Western medicine approach and how an individual from the cultural group might respond to the Western approach to medicine.

•

Have the students discuss the advantages and disadvantages of using an interpreter when assessing and providing care to a client who does not speak English.

•

Have students examine the concept of noncompliance, then relate this examination to a person who speaks a foreign language and does not understand the treatment options offered. While it may be true that the person is not participating in his or her care, it is a result of a lack of understanding due to a language barrier rather than an inherent refusal to participate in the care.

Review questions 1.

A nurse tells a person who recently immigrated from Afghanistan, ‘You will have to follow the rules here in order to get beter’. Which of the following is illustrated by the nurse’s statement? a. b. c. d. e.

Cultural competence Cultural sensi�vity Cultural awareness Ethnocentrism Transcultural nursing

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2.

Why do nurses need to understand that CALD cultures differ from First Peoples’ cultures? a. Because language barriers, lower health literacy and difficul�es naviga�ng an unfamiliar system put CALD communi�es at greater risk of poorer quality health care, service delivery and poorer health outcomes compared with First Peoples in their respec�ve countries b. Because understanding diversity of cultures is essen�al for providing culturally sensi�ve and effec�ve care c. Because the role of culture is a factor in enhancing the effec�veness of health communica�on within a health care system d. Because First Peoples’ health should be viewed separately from other cultural groups as they have unique cultural, historical and social experiences that shape their perspec�ves on health and illness e. Because a one-size-fits-all approach to culture is not effec�ve f. All the above.

Answer: f

3.

Which of the following nursing ac�ons highlights your use of cultural safety? a. b. c. d. e.

Do not touch anyone if you do not have to Ask if a member of the person’s family can interpret your instruc�ons Reflect on how your own values and beliefs influences the care you provide Speak clearly and slowly so that the person can understand you Do not hold prolonged eye contact with the person.

Answer: c 4.

Which of the following statements demonstrates the correct defini�on of accultura�on? a. b. c. d. e.

When an individual’s behaviour and beliefs resemble those of the majority culture When an individual’s behaviour and belief is the same as the majority culture When immigrants become indis�nguishable from all other members of the majority culture When a person maintains cultural dis�nc�veness and congruence with the majority culture When a person maintains cultural dis�nc�veness that is incongruent with the majority culture.

Answer: d 5.

Decolonisa�on is: a. a phase in the nursing process b. an understanding by nurses that we can make a difference to improve health outcomes for First Peoples c. is not culture-centred care d. an understanding that cultural and social factors play a role in health outcomes and seeks to address the root causes of health dispari�es rather than simply trea�ng symptoms e. is the first part of the cultural safety process Answer: d

6.

How did the COVID-19 pandemic impact mul�cultural Australia? a. COVID-19 highlighted long-standing inequi�es in the health system b. Mul�cultural Australians experienced poorer mental health support for a variety of reasons, including lack of interpreters and culturally responsive care, s�gma, and lack of resources in languages other than English

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c. During COVID-19 there was an increase in mental health condi�ons posing a serious risk to culturally diverse Australians’ safety, including suicide and self-harm d. CALD communi�es were strong and resilient during the COVID-19 pandemic e. All the above.

Answer: e 7.

What does a strengths-based approach mean when we are talking about health outcomes? a. b. c. d.

That culturally diverse people have an op�mis�c look on life and a strong cultural iden�ty That everyone in Australia experiences health equity That systemic failure, rather than any inherent vulnerabili�es, result in health inequi�es That culture is not a part of the nursing process, but up to the individual.

Answer: c 8.

Why are communica�on and language in health care important tools for nurses? a. b. c. d.

Communica�on is not a priority because we can and should use interpreters Communica�on is important, and all nurses should atend communica�on courses annually Communica�on is important to demonstrate respect and inclusion to CALD communi�es Communica�on is a part of the nursing process, and nurses can ask family/significant others for help when needed.

Answer: c

Spotlight on critical thinking Discussion points: socioeconomic status and health care 1.

When you see a child who is dirty and unkempt, how does it make you feel? Why? Suggested solution: The answer here is a subjec�ve reflec�on and will vary from person to person.

However, for many people, seeing a child who is dirty and unkempt can evoke various emo�ons, such as concern, sadness, or compassion. Many people might feel an urge to help or find out if the child is in a safe environment. These reac�ons are o�en based on human empathy and the natural inclina�on to protect and care for the vulnerable, especially children. If you or someone you know encounters a child in need, it is important to take appropriate ac�ons to ensure their wellbeing.

2.

If an adult approaches you on the street asking for money, how do you respond? Why? Suggested solution: If an adult approaches someone on the street asking for money, the response can be mul�faceted, as it is influenced by personal values, experiences, and the context of the situa�on. Some individuals might feel empathe�c and opt to give money, believing that this immediate assistance could be helpful. Others might prefer to offer alterna�ve forms of aid, such as purchasing food or providing informa�on on local resources and shelters, to address more directly the person's needs. There are also those who might politely decline, either due to concerns about how the money will be used or because they might feel that contribu�ng to organised chari�es is a more effec�ve way to help. Addi�onally, some individuals might choose not to engage, either by ignoring the request or quickly moving on, especially if they feel unsafe or uncomfortable in the situa�on.

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3.

What do you think creates disadvantage or economic impoverishment? Is disadvantage (e.g., poverty) a result of socioeconomic or political conditions, the individual’s lack of initiative or other factors?

Suggested solution: Disadvantage or economic impoverishment is often created by a complex interplay of various factors including socioeconomic, political, individual, and sometimes even geographical elements. Socioeconomic conditions, such as limited access to quality education, employment opportunities, and health care, can significantly contribute to economic impoverishment.

In communities where these resources are scarce or unequally distributed, individuals often struggle to escape the cycle of poverty.

Political conditions, such as government policies, corruption or political instability, can also have a profound impact on economic circumstances. For example, policies that do not favour wealth redistribution or social safety nets may perpetuate economic inequality, while corruption can divert resources away from those who need them the most.

While socioeconomic and political conditions are crucial factors, the role of individual initiative cannot be completely discounted. Personal choices and behaviours do have an impact on an individual's economic status. However, it is important to recognise that individual actions are often heavily influenced by the socioeconomic and political environment in which a person operates.

Cultural factors and societal norms can play a role in economic disadvantage. For example, in some societies, cultural attitudes may limit employment opportunities for certain groups of people.

Impoverishment is not the result of a single factor but rather a combination of various elements including socioeconomic and political conditions, individual choices, and cultural factors. This complexity makes it essential to approach poverty alleviation with multifaceted strategies that address the diverse causes.

4.

Discuss whether you consider health care a right or a privilege.

Suggested solution: The classifica�on of health care as a right or a privilege varies by philosophical beliefs and governmental policies. Many argue that health care is a fundamental human right, essen�al for the dignity and well-being of individuals. This perspec�ve is supported by interna�onal declara�ons like the Universal Declara�on of Human Rights. However, in some countries, health care is o�en treated as a privilege accessible mainly to those who can afford it. As socie�es evolve, there is a growing consensus on the importance of universal health care access, with an increasing number of countries implemen�ng policies to ensure that health care is accessible to all ci�zens.

5.

In what way does disadvantage, poverty or lack of secure housing affect the management of chronic conditions such as diabetes?

Suggested solution: Disadvantage, poverty or lack of secure housing can significantly affect the management of chronic condi�ons like diabetes in several interconnected ways. First and foremost, financial constraints associated with poverty make it difficult for individuals to afford necessary medica�ons and supplies, such as insulin and glucose monitoring devices. Without consistent access to these essen�al tools, managing diabetes effec�vely becomes extremely challenging.

A lack of secure housing can contribute to high levels of stress, which can, in turn, have a detrimental effect on blood sugar levels. The instability and uncertainty associated with not having a stable place to live may also make it difficult for individuals to establish and maintain rou�ne health care appointments, which are crucial for managing chronic condi�ons.

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Nutri�on is another cri�cal component in managing diabetes, but poverty o�en limits access to healthy food op�ons. Individuals in economically disadvantaged areas may have limited access to stores selling fresh produce and may instead rely on cheaper, processed foods that are high in sugars and unhealthy fats, which are detrimental to diabetes management.

Similarly, educa�on plays a vital role in the management of chronic diseases. Individuals in poverty-stricken areas may not have access to adequate educa�onal resources to understand their condi�on and its management thoroughly. They may also lack the social support systems that can help in managing chronic illnesses.

Transporta�on is another issue; poverty and lack of housing might mean that individuals do not have easy access to transporta�on for regular check-ups and to get necessary supplies.

Lastly, it’s worth no�ng that other comorbidi�es, which is more common among those who are economically disadvantaged, can complicate the management of diabetes. For instance, someone dealing with both mental health issues and diabetes may find it par�cularly challenging to manage their condi�ons effec�vely.

6.

How does socioeconomic status impact access to health care and health outcomes, and what policies and interventions can be implemented to reduce disparities in health outcomes across different socioeconomic groups?

Suggested solution: In Australia and New Zealand, socioeconomic status is a significant determinant of access to health care and health outcomes. Those with lower socioeconomic status o�en face barriers such as financial constraints, reduced health literacy, and limited access to quality health care. This results in higher rates of chronic illnesses and shorter life expectancies among disadvantaged groups. To address these dispari�es, both countries can invest in community-based health services in underprivileged areas, improve health literacy through educa�on, and ensure that public health policies are inclusive. Addi�onally, strengthening social safety nets and suppor�ng programs that address the social determinants of health, such as housing and employment, are essen�al for reducing health inequali�es in these socie�es.

Examples of programs, policies and interven�ons to reduce dispari�es in health outcomes across different socioeconomic groups could be: • • • • • • •

Subsidised health care: implemen�ng or expanding programs that subsidise the cost of health care services and medica�ons for low-income individuals can remove financial barriers to access.

Community health centres: inves�ng in community health centres in underprivileged areas to ensure that individuals in these regions have access to quality health care.

Health literacy programs: developing health literacy programs that educate individuals on the importance of preventa�ve care and managing chronic condi�ons.

Culturally sensitive care: providing cultural competency training to health care professionals to ensure culturally sensi�ve care for Indigenous and migrant popula�ons.

Telemedicine: expanding telemedicine services, especially in rural areas, to improve access to health care for those who live far from medical facili�es.

Social support programs: strengthening social support programs that address the underlying social determinants of health such as housing, educa�on, and employment opportuni�es.

Mental health support: expanding mental health services and reducing the s�gma associated with mental health, as this is o�en an overlooked aspect of overall health.

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• • •

7.

Nutritional support: implemen�ng programs that provide access to nutri�ous foods, as diet plays a significant role in health outcomes.

Indigenous health programs: developing and expanding health programs specifically tailored to address the health needs and cultural preferences of Indigenous popula�ons.

Data monitoring and research: con�nually monitoring health dispari�es through data collec�on and research to iden�fy areas where interven�ons are needed and evaluate the effec�veness of exis�ng programs.

What are some of the social determinants of health that are closely linked to socioeconomic status, and how can health care providers and policymakers work together to address these broader structural factors that contribute to health inequities?

Suggested solution: Social determinants of health closely linked to socioeconomic status include educa�on, income, housing, and access to health care. Educa�on is a fundamental determinant, as individuals with higher educa�onal atainment o�en have beter access to health informa�on and resources, and typically engage in healthier behaviours. Income is directly related to an individual's ability to afford health care services, medica�ons, and a healthy lifestyle. Housing impacts health as those in poor living condi�ons may be exposed to health risks such as mould, pests, and inadequate hea�ng, which can contribute to respiratory problems and other health issues. Access to health care is also cri�cal, as those with low socioeconomic status may not have the insurance or financial means to obtain proper medical care.

Health care providers and policymakers can work together to address these structural factors through several approaches; they can advocate for policies that ensure equitable access to educa�on and create opportuni�es for economic advancement. For instance, inves�ng in educa�on and voca�onal training in underserved communi�es can be a pathway to beter jobs and, consequently, improved health outcomes. Also, health care providers can play a crucial role in iden�fying the social needs of their people for whom they are providing care and connec�ng them with appropriate resources. This might include referring people to social services, housing assistance, or nutri�on programs.

Policymakers can work to expand access to health care, especially for marginalised popula�ons. This can involve policies that make health care and insurance more affordable and accessible. Collabora�on between health care providers and policymakers can also involve community-level interven�ons, such as establishing community health centres in underserved areas, and promo�ng preven�ve care and health educa�on.

8.

How do cultural attitudes and beliefs about health and illness intersect with socioeconomic status to shape health care utilisation and health outcomes, and what strategies can be employed to promote more culturally responsive and patient-centred care for diverse socioeconomic groups?

Suggested solution: Cultural a�tudes and beliefs about health and illness o�en intersect with socioeconomic status to shape health care uptake and health outcomes. For example, cultural s�gmas around mental health may discourage individuals from seeking necessary care, and when coupled with low socioeconomic status, this reluctance is exacerbated by financial barriers or limited access to services. Similarly, cultural preferences for tradi�onal treatment may delay seeking conven�onal medical treatment. To promote culturally responsive and pa�ent-centred care, it is essen�al to employ strategies such as cultural safety training for health care professionals. This ensures understanding and respect for cultural diversity. Addi�onally, making interpre�ve services available can improve communica�on with people who speak different languages. Providing educa�onal resources that are culturally appropriate can also be invaluable.

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Discussion points: cultural diversity, disadvantage and health in Australia and New Zealand 9.

What are some of the challenges faced by culturally diverse communities in Australia and New Zealand, and how can we promote greater social inclusion and understanding in health care?

Suggested solution: •

Language barriers: difficulty in communica�on due to language differences o�en hinders proper health care access and understanding for culturally diverse communi�es.

•

Cultural misunderstandings: health care providers may lack awareness of cultural prac�ces and beliefs, leading to miscommunica�on and non-personalised care.

•

Historical mistrust: indigenous groups like the Māori and Aboriginal Australians may hold mistrust towards health care systems due to historical mistreatment.

•

Access and affordability: culturally diverse communi�es o�en face socioeconomic challenges which limit their access to and affordability of health care.

To address these challenges: •

Cultural safety training: equip health care professionals with skills to reflect on own prejudice, understand and respect different cultural norms.

•

Language services: offer transla�on and interpreta�on services in health care se�ngs to bridge language barriers.

•

Community engagement: involve community leaders in health care planning and decision-making to build trust and ensure culturally appropriate services.

•

Accessible and inclusive services: develop policies ensuring equitable access to health care and consider cultural sensi�vi�es in service delivery.

•

Education and outreach: conduct culturally tailored health educa�on campaigns to increase health literacy among diverse communi�es.

By implemen�ng these measures, health care systems in Australia and New Zealand can become more inclusive and beter cater to the needs of culturally diverse communi�es.

10. In what ways has cultural diversity contributed to the cultural and social fabric of Australian and New Zealand societies, and what role does this diversity play in shaping national identity?

Suggested solution: • Culinary Diversity: The variety of foods from different cultures has enriched the culinary scene in Australia and New Zealand, offering a wide array of interna�onal cuisines and fusion dishes.

• Ar�s�c Influence: Cultural diversity has brought a wealth of ar�s�c tradi�ons, including music, dance, and visual arts, which have blended and contributed to a unique and vibrant arts scene.

• Language and Expression: The presence of mul�ple languages and dialects has enriched linguis�c expression and encouraged cross-cultural communica�on and understanding.

• Economic Contribu�ons: Diverse communi�es contribute significantly to the economies through various businesses, labour skills, and entrepreneurial ventures.

• Cultural Fes�vals: Various cultural fes�vals celebrated by different ethnic groups add vibrancy and colour to the social life in both countries.

• Inclusive Policies: The recogni�on of cultural diversity has led to the formula�on of inclusive policies and human rights protec�ons. © Cengage Learning Australia 2024

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• Na�onal Iden�ty: Cultural diversity has played a central role in shaping the na�onal iden�ty of both Australia and New Zealand, as both countries increasingly recognise and celebrate diversity as a core value.

• Educa�on: The exposure to different cultures enriches educa�onal environments and offers opportuni�es for learning about global perspec�ves.

• Social Cohesion: Despite challenges, cultural diversity can foster social cohesion by encouraging mutual understanding and shared values among various communi�es.

Through embracing and integra�ng the various aspects of different cultures, Australia and New Zealand have built dynamic socie�es that are rich in tradi�ons, expressions, and social experiences, which are integral to their na�onal iden��es.

11. How have government policies and programs evolved to address the needs of culturally diverse communities in Australia and New Zealand, and what more can be done to ensure equitable outcomes for all?

Suggested solution: Government policies and programs in Australia and New Zealand have evolved to address the needs of culturally diverse communi�es through measures such as mul�culturalism policies, an�-discrimina�on laws, and the provision of culturally appropriate services. For example, Australia’s Na�onal Mul�cultural Policy promotes diversity, respect, and inclusion. New Zealand has taken steps to honour the Treaty of Waitangi, addressing historical grievances of the Māori. Although room for further improvement, con�nued engagement with culturally diverse communi�es to understand their specific needs is vital. Implemen�ng cultural safety training for health care providers and ensuring equitable access to educa�on, health care, and economic opportuni�es can further promote social inclusion and equity for all members of these socie�es.

12. How have perceptions of cultural diversity in Australia and New Zealand changed over time, and what factors have contributed to these shifts in attitudes and values?

Suggested solution: Percep�ons of cultural diversity in Australia and New Zealand have undergone significant transforma�ons over the past decades. Ini�ally, both countries had policies that favoured European immigra�on and assimila�on into the dominant Anglo-Saxon culture. However, with �me, there has been a growing recogni�on and apprecia�on of cultural diversity.

In Australia, the shi� began in the 1970s with the abandonment of the White Australia policy. This policy, which favoured European immigrants, was replaced with a more inclusive approach that encouraged immigra�on from various parts of the world. The mul�culturalism policy adopted in the following decades recognised the value of cultural diversity and aimed to promote understanding and acceptance among different cultural groups. The influx of immigrants from Asia, Africa, and other parts of the world have since contributed to the rich cultural tapestry of Australia.

Similarly, in New Zealand, there has been a growing recogni�on of the Māori culture and the contribu�ons of Pacific Islanders. The Treaty of Waitangi, which is considered New Zealand's founding document, has played a significant role in acknowledging the rights of the Māori people. Over �me, New Zealand has also welcomed immigrants from a diverse range of countries, adding to its cultural diversity.

Several factors have contributed to these shi�s in a�tudes and values. Globalisa�on has played a significant role by facilita�ng the movement of people and ideas across borders. Interna�onal trade, tourism, and educa�on have exposed Australians and New Zealanders to different cultures, fostering apprecia�on and understanding.

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The realisa�on of the economic benefits of a diverse workforce has also contributed to more posi�ve a�tudes towards cultural diversity. Immigrants bring new skills, perspec�ves, and networks that can be invaluable for economic development.

Social movements and advocacy groups have been influen�al in promo�ng cultural diversity and figh�ng discrimina�on. Through educa�on, ac�vism, and lobbying, people have pushed for policies that recognise and protect the rights of all cultural groups. Australia and New Zealand have evolved from socie�es with policies that once favoured homogeneity to ones that embrace and celebrate cultural diversity.

13. What role can education and awareness-raising initiatives play in promoting greater understanding and appreciation of cultural diversity in Australia and New Zealand, and how can we foster more meaningful cross-cultural interactions and exchanges in health care?

Suggested solution: Educa�on and awareness-raising ini�a�ves are integral in fostering a society that understands and appreciates cultural diversity in Australia and New Zealand. By incorpora�ng mul�cultural perspec�ves into educa�onal curricula, and hos�ng cultural events and workshops, society can cul�vate an environment of empathy, respect, and openness towards diverse cultures. In health care, this translates into improved pa�ent–provider rela�onships and beter health outcomes. To foster meaningful cross-cultural interac�ons in health care, cultural safety training for health care professionals is vital. This training should encompass self-reflec�on of one’s own culture and worldview, an understanding of different cultural health beliefs, communica�on styles, and tradi�onal prac�ces. In addi�on, involving community leaders in the design and implementa�on of health care services ensures that the services are culturally sensi�ve. Encouraging the recruitment and reten�on of a diverse health care workforce also plays a role in ensuring that people see themselves represented among health care providers. Furthermore, language services should be made readily available to minimise language barriers. These are examples of some efforts that can contribute to health care systems and services becoming more inclusive and effec�ve in providing care to culturally diverse popula�ons in Australia and New Zealand.

14. In what ways do socioeconomically disadvantaged communities in Australia and New Zealand experience greater barriers to accessing health care services compared to more affluent communities, and how do these disparities impact health outcomes? What can be done to address these inequalities, and how can health care providers and policymakers work together to ensure equitable access to health care for all Australians and New Zealanders?

Suggested solution: Socioeconomically disadvantaged communi�es in Australia and New Zealand o�en face greater barriers in accessing health care services compared to more affluent communi�es. These barriers include financial constraints, lack of transporta�on, lower health literacy, and limited availability of services in underprivileged areas. The culmina�on of these barriers leads to delayed care, unmanaged chronic condi�ons, and poorer health outcomes. To address these inequi�es, a mul�-faceted approach is essen�al. Increasing funding for community health centres, subsidising health care costs, and providing transporta�on services can improve access. Health educa�on programs can be implemented to improve health literacy. Policymakers and health care providers need to work collabora�vely to develop policies that are inclusive and responsive to the needs of diverse communi�es. This includes consul�ng with community leaders and members in policymaking, and training health care professionals in cultural competency. Lastly, addressing broader social determinants of health, such as housing, educa�on, and employment, is crucial to ensuring equitable health outcomes for all Australians and New Zealanders.

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For Indigenous and Māori communi�es, addi�onal barriers exist. Historical mistreatment, cultural disconnect, language barriers, and discrimina�on contribute to dispari�es in health outcomes.

Addressing these challenges requires culturally appropriate health care delivery, engagement with Indigenous and Māori communi�es in policy development, suppor�ng Indigenous health care leadership, and implemen�ng strategies to address the social determinants of health specific to these communi�es. Collabora�on between health care providers, policymakers, and Indigenous/Māori leaders are crucial in developing solu�ons that ensure equitable access to health care for all Australians and New Zealanders, including the Indigenous and Māori popula�ons.

15. How do cultural factors intersect with socioeconomic disadvantage to shape health care utilisation and health outcomes for diverse communities in Australia and New Zealand, and what steps can be taken to promote more culturally responsive and patient-centred care? What role do health care providers, policymakers, and community organisations play in addressing these complex social determinants of health?

Suggested solution: In Australia and New Zealand, cultural factors and socioeconomic disadvantage intertwine to influence health care provision and health outcomes among diverse communi�es. Cultural beliefs and prac�ces o�en shape how individuals perceive illness, seek treatment, and adhere to medical advice. For example, Indigenous Australians may prefer tradi�onal healing prac�ces and could be hesitant to seek mainstream health care. This reluctance can be compounded by socioeconomic disadvantage, as individuals from lower income backgrounds might find it harder to access health care due to cost or transporta�on barriers.

The legacy of colonisa�on and historical mistreatment by health systems can contribute to mistrust among Indigenous popula�ons. In New Zealand, the Māori popula�on has faced dispari�es in health care, partly due to cultural insensi�vity within the health system and socioeconomic disadvantage.

To promote culturally responsive and culture-centred care, health care providers should undergo cultural safety training. This includes self-reflec�on, understanding and respec�ng cultural differences and incorpora�ng cultural preferences into care plans.

Policymakers play a cri�cal role in ensuring equitable access to health care for all communi�es. This involves alloca�ng resources to underserved areas, and incorpora�ng the perspec�ves of diverse communi�es in policy-making. Providing financial support to improve access to health care for disadvantaged popula�ons is also crucial.

Community organisa�ons can act as bridges between health care providers and diverse communi�es. They can facilitate communica�on, provide educa�on, and advocate for the needs of their communi�es.

16. What are the ethical implications of addressing health disparities associated with socioeconomic disadvantage and cultural diversity in Australia and New Zealand? How can we ensure that policies and interventions aimed at reducing these disparities do not reinforce or perpetuate existing power imbalances, and instead promote greater social justice and equity? What role do diverse stakeholders, including patients, health care providers, policymakers, and community members, play in shaping a more equitable health care system?

Suggested solution: Addressing health dispari�es associated with socioeconomic disadvantage and cultural diversity in Australia and New Zealand raises important ethical considera�ons. It requires a commitment to social jus�ce and equity to ensure that policies and interven�ons do not perpetuate exis�ng power imbalances, such as involving diverse stakeholders in decision-making processes.

Recipients of health care and community members should have a voice in shaping health care policies, as their lived experiences provide valuable insights into the challenges they face. Engaging with health © Cengage Learning Australia 2024

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care providers ensures that their exper�se and understanding of the system are taken into account and that their voices are heard. Policymakers play a crucial role in crea�ng and implemen�ng equitable policies that address the needs of disadvantaged popula�ons.

Promo�ng social jus�ce and equity requires a comprehensive approach. It involves addressing systemic factors such as educa�on, employment, and housing that contribute to health dispari�es.

Policies should focus on improving access to health care, reducing financial barriers, enhancing cultural safety in care, and providing tailored services for marginalised communi�es. Transparency and accountability are vital in monitoring the impact of policies and interven�ons. Regular evalua�on should be conducted to iden�fy any unintended consequences or dispari�es that may arise, allowing for adjustments and refinements to ensure equity.

Building a more equitable health care system requires ongoing collabora�on, open dialogue, and shared responsibility among stakeholders. By centring the voices and experiences of those directly affected by dispari�es, policies and interven�ons can be designed to address the underlying social determinants of health, ul�mately leading to a more just and equitable society.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 2 Online resources.................................................................................................................................................. 2 Evaluation strategies ........................................................................................................................................... 3 Spotlight on critical thinking ................................................................................................................................ 3

Chapter 22 Aboriginal and Torres Strait Islander peoples’ health Key terms Aboriginal and Torres Strait Islander peoples The diverse cultures, languages and nations of the First Peoples of Australia.

Acknowledgement of Country Recognition of the ancestral custodians of the locality on which you are on.

Colonisation Multiplication of microorganisms on or within a host that does not result in cellular injury; also, occupancy by people foreign to land or country that settle and overlook existing systems and impose their own governance structures that impact on the health and wellbeing of the original inhabitants.

Country The lands of First Nations communities.

Cultural diversity Individual differences among people that result from racial, ethnic and cultural variables.

Cultural safety The provision of quality health care that acknowledges and uses the everyday values and beliefs of the individual who is of a culture different to the nurses’ and/or the majority culture.

Culture Dynamic and integrated structures of knowledge, beliefs, behaviours, ideas, attitudes, values, habits, customs, languages, symbols, rituals, ceremonies and practices that are unique to a particular group of people; growing microorganisms to identify a pathogen.

First Nations Refers to the Aboriginal and Torres Strait Islander peoples of Australia, and/or the Māori people of Aotearoa, New Zealand.

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Institutional racism The embedded value system within a society that supports and allows discrimination, establishing barriers and access to quality health care for some.

Kinship Cultural groups that have ways of interacting that are common to members of that group, and which may be delineated by family and community members; also, the social structure that determines how people relate to one another and what obligations and responsibilities they hold towards one another.

Racism Discrimination directed towards individuals who are misperceived to be inferior because of biological factors.

Systemic racism The embedded value system within a society that supports and allows discrimination, establishing barriers and access to quality health care for some.

Welcome to country A welcome speech given by the ancestral custodians of the locality on which you are on.

Instructional strategies • Begin with an Acknowledgement of Country (you will need to know which Aboriginal nation are the traditional owners and custodians of the land the class is meeting on).

• Read chapter’s opening letter written by Nicole Hewlett, in particular the idea that this chapter requires the student to take a personal inward journey.

• Have an Aboriginal and/or Torres Strait Islander person deliver this component of the course.

• Invite Aboriginal and/or Torres Strait Islander people/organisations to participate as guest speakers.

Resource aids Adams, M. (2014). Men’s Business: A study into Aboriginal and Torres Strait Islander men’s sexual and reproductive health. Magpie Goose Publishing.

Fejo-King, C. (2013). Let’s Talk Kinship: Innovating Australian social work education, theory, research and practice through aboriginal knowledge. Christine Fejo-King Consulting.

St John Ambulance WA and Respect Workshop (Optamus & Matt De Koning), Help! Respect workshop https://www.youtube.com/watch?v=slAAgchiauM Films such as The First Australians, Rabbit Proof Fence, the Sapphires and Bran Nue Dae. Australian Bureau of Statistics (ABS) National Aboriginal and Torres Strait Islander Health Survey: provides demographic and statistical information on areas of Aboriginal and Torres Strait Islander people’s health, https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples

Online resources • My rehab, my journey – Gadjigadji, https://aci.health.nsw.gov.au/projects/my-rehab: information about gadjigadji (a Gamilaraay word meaning regrowth). Think about how cultures are shown in every aspect of the project (ACI, 2022). What do you observe about the languages and artwork used? What do you notice about the consultation process and the implementation resources? Do you think these ways of ‘knowing, being and doing’ would benefit other cultures?

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• Acquire new knowledge from the IAHA’s online cultural safety training modules, which uses a cultural responsiveness framework: https://iaha.com.au/iaha-consulting/cultural-responsiveness-training • Learn from the CATSINaM cultural safety training e-learning modules: https://catsinam.org.au/culturalsafety-1-day-workshop • Discover these clinical yarning e-learning modules: https://www.clinicalyarning.org.au • Explore Aboriginal and Torres Strait Islander peoples’ experiences and learn about local cultures near you: https://www.welcometocountry.com • Learn about and practise dadirri: https://www.miriamrosefoundation.org.au/dadirri • Visit the Healing Foundation website to learn more about the Stolen Generations and how to educate all age groups: https://healingfoundation.org.au • Learn more about Aboriginal kinship systems from Sydney University: https://www.sydney.edu.au/aboutus/vision-and-values/our-aboriginal-and-torres-strait-islander-community/kinship-module.html • Watch this video to understand intergenerational trauma: https://healingfoundation.org.au/intergenerational-trauma • Explore more about the history of stolen wages: https://www.creativespirits.info/aboriginalculture/economy/stolen-wages/stolen-wages • Invest in learning First Nations’ words: https://www.abc.net.au/radionational/programs/wordup; https://australianaudioguide.com/podcast/word-up

Evaluation strategies • Have students write a reflective journal that explores their learning during this course.

Spotlight on critical thinking 1.

What thoughts and assumptions come up for you when you think of Aboriginal and Torres Strait Islander peoples? How has the content in this chapter impacted on those thoughts and assumptions?

2.

If a person identifies as having First Nations heritage, why is it important not to assume that person is automatically connected to Country, kinship or culture?

3.

Why is understanding Australia’s history so important to being a culturally responsive nurse?

4.

In your opinion, what are five strengths of First Nations cultures?

5.

What are some ways that you can build trust and connection with Aboriginal and Torres Strait Islander peoples and co-workers?

6.

Why is your role as a nurse critical to creating access to health care among Aboriginal and Torres Strait Islander peoples?

7.

How will you continue your culturally responsive journey?

Suggested responses: These questions are reflective and require a subjective answer, so answers will vary.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 23 Rural and remote health Key terms Bigotry Intolerance and prejudice concerning the beliefs and opinions of others; thoughtless behaviour that demonstrates a lack of understanding of the feelings, beliefs and perspective of others.

Biomedical model A model of health based on the perception that health is defined purely as the absence of disease. The biomedical model excludes any influence of the psychosocial construct or environment the person lives upon their health status.

Burden of disease The impact or ‘burden’ or hardship and losses related to disease or illness, also used as a measure of population health.

Climate change A change in global or regional climate patterns attributed largely to the increased levels of pollution in the air that have dangerous effects on the environment, the economy and our wellbeing.

Colonisation Multiplication of microorganisms on or within a host that does not result in cellular injury; also, occupancy by people foreign to land or country that settle and overlook existing systems and impose their own governance structures that impact on the health and wellbeing of the original inhabitants.

Discrimination Unjust or prejudicial treatment of different categories of people, especially on the grounds of race, age, religion or gender, where the physical, psychosocial, cultural and spiritual environment threatens individual/group safety and security.

Fly-in/fly-out (FIFO) Model of care that does not require permanent medical or nursing staff onsite, a solution to the chronic staff shortages in the Australian outback.

Isolated outback communities Families living on properties that require long-distance travel to access health care and other services.

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Morbidity The condition of suffering from a medical condition or disease; can also refer to the rate of disease in a population.

Mortality Related to death, the number of deaths during a specific time, or in relation to a specific cause.

Outback Interchangeable term with ‘the bush’; rural, remote and very remote.

Remote Term often used interchangeably with ‘rural’, applying the characteristics of road distance from a locality, population size and access to services.

Resilience An approach to health and wellbeing whereby individuals (and communities) have the power and ability to adapt, overcome and recover readily from illness, depression and adversity, and to rebuild their lives.

Risk factors Those things which increase our potential for ill health; for example, people with obesity and high BP are at increased risk of stroke and coronary heart disease.

Rural See ‘remote’.

Social determinants of health Concept of health measured by the physical wellbeing and distinct qualities, behaviours and associated features of an individual. These aspects fall within social, economic and environmental domains.

Social model of health Founded in the philosophy of primary health care, a positive and collaborative model of health care.

Sustainability Principle whereby members of a community, under the guidance and supervision of government agencies, design and maintain programs in order for that community to survive, become selfsufficient, and continue to grow and flourish.

Telehealth Australia-wide telecommunications network strategy designed to bring quality health care to isolated areas via videoconferencing, reducing the need to travel vast distances for a medical consultation.

Tertiary hospital A large hospital in a metropolitan area that has intensive care units, specialised surgical operating theatres and care units, and trauma centres.

Vulnerable Increased exposure and susceptibility, or increased need for support and protection from environmental and social influences that are harmful to health and wellbeing.

Instructional strategies • Lead a discussion among students about the social determinants of health, chronic disease and health outcomes and mortality rates. For further review, advise students to visit the Australian Bureau of Statistics Site and Australian Institute of Health and Welfare for cultural and statistical web links.

• Schedule students to obtain clinical experience in clinics, general practices, and community organisations involved in providing family health care. Students may also be assigned to work with community health nurses.

• Have students visit the PCC4U site and work through the Topic 2 Toolkit: Caring for Australian Indigenous peoples affected by life-limiting illness, available at https://pcc4u.org.au/learning/topics/topic2 • In preparation for group work and discussion, have students visit the National Heart Foundation website and read ‘For professionals: Cardiovascular disease risk assessment for Aboriginal and Torres Strait

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Islander peoples’, which is available at: (https://www.heartfoundation.org.au/bundles/forprofessionals/fp-absolute-cvd-risk-atsi).

• Have students find and review The Primary Clinical Care Manual as an example of rural and remote clinical guidelines that nurses use.

Online resources • Association for the Welfare of Child Health. http://www.awch.org.au • Australian Bureau of Statistics health statistics at https://www.abs.gov.au/statistics#health – this website provides up to date demographic and statistical information on all areas of Australian health.

• Beyond Blue: http://www.beyondblue.org.au • Bush Support Services: https://crana.org.au/mental-health-wellbeing/overview • Chronic Conditions Manual: 2nd edition ccm-2nd-edition210121.pdf (health.qld.gov.au) • Lifeline: https://www.lifeline.org.au – provides information and guidelines for the public and health professionals, about the 24 hour crisis support and suicide prevention services.

• National Heart Foundation of Australia http://www.heartfoundation.org.au This website provides information and guidelines for the public and health professionals, about cardiovascular disease.

• Nursing and Midwifery Board of Australia https://www.nursingmidwiferyboard.gov.au • The Primary Clinical Care Manual 11th edition View Current Edition | Queensland Health • WA Aboriginal Child Health Survey. https://www.telethonkids.org.au/our-research/aboriginalhealth/waachs

Evaluation strategies • Have students work collaboratively to prepare and participate in a group presentation. Students will create a clear picture of communicating with different cultural groups; the role of the nurse in rural and remote settings; the relationship between risk factors and health outcomes.

The teacher will guide the class in peer evaluation. Individuals will reflect upon and evaluate some of the strengths and weaknesses of the presentation and also highlight a few issues that they may need to clarify or consider more fully.

Student learning outcomes - development of intellectual understanding, ability of the students to communicate clearly, critical thinking and teamwork skills, personal and professional growth, reflective practices (reviewing and reflecting, planning for the future).

• Prepare weekly topics for students to participate in online discussions. Students lead the online discussions, exchange ideas about each topic, share information and benefit from each other’s opinions and input; students can view and respond to others’ postings; the teacher will monitor and guide the discussions.

This forum is a useful way of achieving focused discussion. The discussion can provide structure and redirect learning, allow expression of affect, and encourage higher level thought processes.

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Review questions 1.

How are rural and remote areas of Australia categorised? a. By the number of farming communities b. Only as communities that house Aboriginal and Torres Strait Islander people c. As geographical divisions d. As mining communities that employ FIFO nurses e. Everywhere outside of major cities.

Answer: c

2.

Could reviewing social determinants of health offer insights to improve health of communities? a. No, social determinants of health are overrated, it’s really all up to the individuals’ choices. b. Yes, as the conditions into which people are born and grow, live and work influence their education and choices which contributions to their health across the lifespan. c. Possibly, as there are people who come from wealthy mining communities that are very well serviced, and yet they have really poor health. d. Yes, as well as working with the community to empower their engagement in making and sustaining improvements to the social determinant, while considering cultural safety and relational accountability.

Answer: d

3.

Which social and personal forces have the greatest impact on the supply of, and demand for, nurses in rural and remote areas? a. Housing and schooling b. Friends and family c. Lifestyle and sporting clubs d. Education and training e. All of the above.

Answer: b

4.

Rural Australians have the highest mortality rates for which of the following diseases? (Select all that apply.) a. Heart disease b. Diabetes c. Cancer d. Road trauma e. Mental illness.

Answer: a, b

5.

What contribution do people living in rural and remote areas make to regional and national Australia? a. Rural housing development b. Economic and social development c. Manufacturing and processing d. Sporting and hospitality e. Art and culture.

Answer: b

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6.

The health and wellbeing of people in rural and remote areas are disadvantaged through which of the following? (Select all that apply.) a. Access to health services b. Higher rates of teenage pregnancies c. environmental factors, including climate change d. Lower rates of education and employment opportunities e. Geographical distance and isolation.

Answer: a, b, c, d, e

7.

Why are there a higher number of individuals at risk of mental health problems in rural communities compared with major cities? a. Personal vulnerability b. Alcohol and other drug misuse c. Accessing appropriate, timely, confidential and private care d. Strong social and family groups and kinship networks.

Answer: a & c

8.

Working in partnership with remote communities to improve health requires: a. policy makers managing programs for the community b. providing healthy food to isolated areas c. implementing an immunisation program for community elders d. working with the community to have their input to contextually relevant and meaningful programs, delivered locally. e. health promotion programs that are designed by experienced health professionals.

Answer: b, d

9.

Telehealth offers a sustainable model of health care into the future for those living in rural and remote communities because: a. it reduces the burden of travel to access health professionals b. it is helpful if the consumer has some level of digital literacy c. if they have phone or internet connection where they live d. for some consultations it is suitable and for others it is not e. the consumer may be open to using technology.

Answer: a, b, c, d & e

10. Communication may be a barrier to understanding healthy lifestyle behaviours for people in remote areas. Strategies to overcome communication barriers include: a. use of yarns and storytelling b. use of a universal dialect common to all First Nations communities c. the doctor repeating information at least three times d. communicating in a contextually and culturally appropriate non-jargonised way and linking it to their way of life e. providing magazines for people to read about their illness Answer: a, d

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Spotlight on critical thinking Access to health care In a bush nursing station, a young boy with a suspected broken arm and complaining of pain 7/10 is brought in by his father. There are no X-ray machines or diagnostic services.

1.

Who can the nurse call upon to perform a thorough physical examination and what information would the nurse need to provide?

2.

How can the nurse care for the person considering there is no X-ray machine or diagnostic service?

3.

What impact does the context have on the provision of quality health care?

Suggested solution: The nurse can refer to Primary Clinical Care Manual and follow the specific health management protocol and then use the telecommunication services to video-conference with the general practitioner or medical specialist. The Royal Flying Doctor Service operates clinics to remote locations and maintains medical chests that contain supplies and equipment.

Role of the nurse The role of the nurse often involves on-call work, and the individual is considered a public figure, which can disrupt family and social life.

4.

What can happen when work has such demands on an individual (personally and professionally)?

5.

What impact does the role of the nurse have on the conflicting role of parent and spouse?

Suggested solution: A realistic approach is to provide adequate relief, accommodation, transport, housing, and schools so that family structure in not disrupted. Self-referral to specialised support services for rural and remote health care worker and their families such as Bush Support Services. The FIFO model of care minimises time away from family and friends.

Communication and health care Language and health literacy are often barriers to health care.

6.

How can you ensure a person understands their medical condition? Do you take time to explain about healthy behaviours?

Suggested solution: Practise consultation and collaboration. Listen carefully to clarify and interpret the needs of the client. Discuss misconceptions, false impressions and mistaken beliefs. Include use of yarns and storytelling and pictures or drawings.

Suggested reading: Trudgen, R. 2001 (2010 reprint), Why warriors lie down and die. Aboriginal Resource and Development Services Inc.

7.

As a nurse how can you overcome communication barriers?

Suggested solution: Show understanding of a person’s attitudes, knowledge, beliefs and customs.

Interpret the person’s body language. Use of audio-visual and printed resources in different languages.

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Support mechanisms People living in small communities share many aspects of their lives.

8.

What happens when someone has a problem they cannot share? Could you share personal information with the family so they can help the person who is ill?

Suggested solution: Determine the reason the problem cannot be shared. The person may not be able to find the right words to use. There may be barriers such as age or gender. Referral services are available. The nurse can seek help and support to manage such situations.

9.

As a nurse, how do you share your problems and what are the consequences if you do not?

Suggested solution: The nurse needs to be aware of the legal and ethical implications associated with a person’s personal information. The nurse should also be aware that it is not appropriate to share his or her own personal problems with the client. Referral to Bush Support Services can assist the nurse.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids ....................................................................................................................................................... 3 Online resources .................................................................................................................................................. 3 Evaluation strategies............................................................................................................................................ 4 Review questions ................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 24 Health care education Key terms Affective domain Area of learning that involves attitudes, beliefs and emotions.

Auditory learners Style of learning in which an individual learns by hearing.

Cognitive domain Area of learning that involves intellectual understanding.

Health literacy. The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.

Kinaesthetic learners Learning style in which a person processes information by experiencing the information or by touching and feeling.

Learning plateaus Peak in effectiveness of teaching and depth of learning.

Learning styles Way in which an individual incorporates new information.

Philosophies Statement of beliefs that are the foundation for one’s thoughts and actions.

Psychomotor domain Area of learning that involves performance of motor skills.

Readiness for learning Evidence of willingness to learn.

Self-efficacy A person’s beliefs and their ability and capacity to accomplish a task and/or deal with the challenges of life.

Teaching Active process in which one individual shares information with another as a means to facilitate behavioural changes.

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Teaching–learning process Planned interaction that promotes a behavioural change that is not a result of maturation or coincidence.

Teaching strategies Techniques used by the teacher to promote learning.

Visual learners Style of learning in which people learn by processing information by seeing.

Instructional strategies • Discuss the processes of teaching and learning in relationship to nursing. Teaching is an active process that occurs when one individual shares information with another, for the intent of making behavioural changes. Teaching includes all the tools used by the teacher to promote change. Teaching is goal oriented. The nurse provides an active role in teaching people seeking health care. Most people come into a health care setting with knowledge deficits that hinder their recovery from illness or injury. The role of the nurse in this relationship is to provide information to help bridge that gap. Learning is the process of assimilating information with a resultant change in behaviour. The nurse has a shared responsibility in the teaching-learning process. For nursing, the bottom line is person-centred education.

Nurses are in a position to provide health care education that will enhance the person’s ability to care for himself or herself.

• Discuss the three learning domains and give an example for each. There are three learning domains: cognitive, affective, and psychomotor. The cognitive domain is learning that involves the acquisition of facts and data and is used when problem-solving or making decisions. An example of learning in this domain would be that the person is able to identify foods that are low in saturated fat. The affective domain is learning that involves changing an attitude, emotion, or belief. This domain is used when making judgements. An example of learning in this domain would be the person accepting that alcohol intake damages his pancreas and liver, realising that the person makes the decision not to drink alcohol.

The psychomotor domain is learning that involves gaining motor skills and is used for the physical application of knowledge. An example of this domain is the person demonstrating the correct use of a blood glucose monitoring device, glucometer.

• Learning needs change throughout the life cycle. The nurse who recognises this will be a more effective health educator. Discuss specific guidelines for teaching-learning by developmental stages. o Children: the maturational level dictates readiness for learning. It may be at this stage that the nurse works closely with the young child’s family. Young children primarily learn through play; therefore, the use of puppets, toys, and a creative style will promote the uptake of health-education. Older children also benefit from family involvement and play. o Adolescents: the adolescent is capable of comprehending more information, and at this stage, the encouragement of peer involvement enhances learning. Health education is also enhanced by showing respect and encouraging the adolescent to be independent in their decision making. o Older adults: health education in this developmental stage becomes more sensitive to physiological changes that may affect the learning process. Perceptual, vision, and hearing changes will need to be assessed before effective education can be started. Be careful to assess learning readiness because age alone is not the only determining factor in the provision of appropriate health education.

Additional factors, such as, fatigue, pain, depression, and anxiety can restrict the person from learning. As an effective educator the nurse should be aware of these and other impediments and make suitable learning adjustments.

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•

Looking at the nursing process, discuss teaching-learning in relation to assessment, problem identification, planning, implementation, and evaluation. Nurses should perform assessments for each learning situation. Learning needs, the person to be ready for, and have an ability to learn, a person’s strengths, and previous experience all factor into the effective teaching-learning process. After assessment is completed, the nurse will be able to identify a knowledge deficit problem. Most people have a knowledge deficit of some kind in relation to their current situation. If a particular risk or impaired behaviour exists, the problem identification will be specified as a health teaching-learning goal. Once the nurse has identified the problem(s), a plan is developed. Teaching is a goal-directed and requires a purposeful process in which teaching-learning activities must be planned. The nurse must decide what is to be taught, how it will be taught, who will teach it, and when and where it will be performed. The effective nurse often involves members from other disciplines in the education process.

Next is implementation of that plan. Ideally, the nurse has successfully established a therapeutic, trusting relationship with the person and their family members. Then, reviewing the components of the nursing care plan, the nurse carries out that plan. There is a two-part evaluation of the teachinglearning process: (1) determination of what the person has learned and (2) assessment of the nurse’s teaching effectiveness. Has behaviour changed? Ways to evaluate person-centred learning include verbal questioning, observation, return demonstration and written follow-up. Ways to evaluate effectiveness of teaching include feedback from the learners, feedback from colleagues, situational feedback, and self-evaluation.

•

Discuss how the nurse knows when a client is ready to learn. Readiness to learn means the person is ready to receive and integrate new information and teaching. Readiness is related to growth and development. Learning readiness is present when the person begins to ask questions. The person is ready to learn when they begin to participate in learning activities such as being able to demonstrate changing a wound dressing.

•

Discuss the concept of barriers to learning. Review Table 24-4 ‘Barriers to Learning’, have the students reflect on how individuals can be taught, supposedly learn, but yet not act on the processed information.

It is important for students to understand that external and internal barriers exist and can limit an individual’s ability to receive and process information. An individual may know and understand that a specific behaviour, such as the harmful effects of smoking, but still may choose to continue smoking.

When the nurse is aware of barriers to learning and can appropriately respond to them, the person seeking health education may be in a better position to implement their learnings. For example, if the person has difficulties comprehending English, obtaining the use of an interpreter will support the person in learning.

Resource aids Cuellar, N. G., & Mauk, K. L. (2014). Teaching older adults and their families. In K. L. Mauk (Ed.), Gerontological nursing: Competencies for care.3rd edition. Jones & Bartlett.

Knowles, M. S. (1990). The adult learner: A neglected species (4th ed.). Gulf Publishing.

Online resources • Wuchopperen: Australian Nurse-Family Partnership Program https://www.youtube.com/watch?v=K0no1pZYYP4

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• WorkThatMatters: The Men's Educational Rural Van – Community Health Team https://www.youtube.com/watch?v=n6vuNYbkIXs • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz • Therapeutic Communication in Acute Care [YouTube video] https://www.youtube.com/watch?v=h2_FdDqI7BI

Evaluation strategies • Give students a particular topic and have them prepare an informal teaching presentation for the class.

Have them consider the different domains of learning and different types of learning styles. Discuss interventions to teach the same topic, paying attention to different learning styles. Have the students evaluate their own teaching presentations. Provide feedback from the class as to the effectiveness of teaching.

• Provide the class with various case studies (of different developmental stages) involving a deficit of health care knowledge. Explore ways in which the student can recognise these deficits and then determine ways of effectively providing education to that person.

• Ask students to think about words they use in the clinical setting when performing health care education.

Is the terminology suitable for the particular person? If the person does not learn based on the nurse’s expectations, determine how the teaching-learning process might have been performed more effectively.

Encourage discussion of examples from other students describing effective versus non-effective methods of health care education.

• Have students determine their learning style by analysing how they learn best. Have students reflect on whether their learning needs are being met and identify what methods could be used to enhance their own learning during their nursing degree.

• Get students to discuss the ‘ideal’ learning environment. Then have the students look at a healthy person and a person with multiple health problems to see if both could learn in an ideal learning environment.

• Provide the students with items that will alter sensory perception (e.g., earmuffs, rubber gloves, visionchanging eyeglasses). In small groups, have the students practise instructing each other on a psychomotor skill while one student is wearing the items to alter sensory perception. Have the students describe the challenges met when attempting to instruct another with an alteration in sensory perception. Have the students explain what was done to change the instruction so that the person with the alteration in sensory perception was able to learn the information.

• Have the students shadow a nurse educator, diabetes educator, enterostomal educator, or other type of health care educator from the clinical setting or invite the educators into the classroom. If in the clinical setting, have the students document the types of education provided. Were there any particular challenges? What did the educator do to prepare for the education session? How was the person’s response to education? What did the educator do to evaluate the success of the educational episode? If the educators are coming into the classroom, have the students prepare questions that address education challenges, preparation for education, evaluation of client response, and evaluation of educational episodes.

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• Have students bring examples of ‘patient teaching forms’ from their clinical setting. Have the students discuss the aspects of identifying patient learning needs and documentation of these learning behaviours.

Have students talk to nurses in their clinical setting to see how they perform client teaching.

Review questions 1.

If you are a reflective learner, what would be the approach best suited to you? a. I best learn new skills by doing the entire task myself. b. I best learn new skills when another person shows me how to do the task. c. I best learn new skills when I can think about the information provided to me d. I best learn new skills when I have done some reading about the task. e. I best learn new skills when they are important for me.

Answer: a

2.

An older person with hearing loss is being started on a new medication. Which of the following nursing actions is most appropriate for this person? a. Avoid the use of gestures. b. Face the person directly when speaking. c. Raise voice, pitch and tone. d. Speak loudly and slowly. e. Assess the person’s knowledge about the medication to address any knowledge gaps.

Answer: b

3.

You have been asked to teach a young 25-year-old paraplegic man about pressure injury prevention.

Which of the following beginning teaching strategies would best promote his learning? a. Provide him with written material highlighting the relationship between pressure injury and bony prominences. b. Include him in a regular group session meeting for people with spinal cord injuries. c. Provide him with the internet address to obtain relevant pressure injury information and instruction. d. Provide him with the answers to his most pressing questions related to pressure injury prevention. e. Show him a video demonstrating the relationship between shear, friction and pressure injury development.

Answer: d

4.

Which of the following activities addresses a person’s psychomotor learning needs? a. Asking a person to describe their feelings about self-administering injections b. Supporting the person to accept their recent diagnosis c. Helping a person to read instructions on a prescription label d. Providing knowledge and demonstration as to how to self-administer the person’s injection e. Emotionally supporting the person as they self-administer their medication.

Answer: d

5.

Which of the following nursing statements is most helpful for teaching a post-operative person to safely ambulate? a. ‘If you don’t get out of bed, you could develop complications like pneumonia.’

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b. ‘Getting up out of bed and walking will help you recover more quickly because …’ c. ‘Your doctor has told you that you must start ambulating, today.’ d. ‘You need to dangle your feet before getting up to ambulate.’ e. ‘Ask your relatives to walk with you to the coffee shop downstairs.’

Answer: b 6.

Which of the following is a priority nursing action for person-centred education? a. Establish what your person’s individual learning needs are b. Select a teaching method you are familiar with c. Establish an understanding of your person’s self-awareness d. Ensure that the person is always able to give feedback and ask questions e. Ask the person what they would like to learn about.

Answer: c

7.

You are teaching a 65-year-old gentleman who has a mild ID (IQ of 68). Which of the following nursing actions is most appropriate for meeting this person’s learning needs? a. Provide information that aligns with his cognitive abilities for understanding b. Avoid repeating the information c. Provide regular opportunities to practise learned skills d. Use abstract terms when communicating e. Teach his primary carer to do the skill.

Answer: c

8.

Which of the following factors will most likely interfere with a person’s ability to learn? a. Curiosity b. Increased self-efficacy c. Low motivational levels d. Knowledge deficit.

Answer: b

Spotlight on critical thinking Professionalism: Incorporating and acknowledging your beliefs about learning Consider the information in Table 24-2 about learning theories: 1.

Which statements mirror your own philosophy about learning?

2.

Which statements are most congruent with a nursing philosophy that views the person not as the recipient of care but as a partner in the caring and healing process?

Suggested solution: Using the learning theories stated in table 24-2 engage the students in a discussion about the different types of teaching styles they have experienced. Break them into three groups each group should consider one of the following: Primary school, high school and university ask them to consider what learning theory was dominant.

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Caring: barriers to learning 3.

Do you think knowledge acquisition alone results in learning (behaviour change)?

4.

Why or why not?

Consider the information available regarding the harmful effects of smoking. Every cigarette package has a similar statement warning people that cigarette smoking can cause lung cancer, heart disease, emphysema and interfere with pregnancy. However, dissemination of this information has not led to the complete cessation of smoking in our society.

5.

Why do you think this is so?

6.

What learning barriers may be interfering with acting in response to this warning?

7.

What therapeutic nursing considerations would you ensure when a person who smokes is admitted into your unit?

Suggested solution: A person’s motivation to act on information about cessation of smoking is closely related to their level of health literacy and self-efficacy. Ask the students to Incorporate ideas from Table 24-4.

8.

What strategies would you employ as a registered nurse (RN) to assist the person to quit smoking?

Suggested solution: Discuss therapeutic strategies: 1. Assess the person who continues to smoke about their readiness to quit smoking.

2. Assess the person’s level of nicotine dependence in order to predict whether they would benefit from using NRT to relieve withdrawal symptoms.

3. Advise the person of the importance of quitting use, unambiguous, supportive, and nonconfrontational words.

4. Assist the person by providing them with community-based helpful services, such as the Quitline.

5. Provide ongoing encouragement and support.

Professionalism: the use of nursing and medical jargon in teaching sessions Consider the professional jargon and medical terms nurses use and take for granted. Remember your last clinical placement or a teaching session in a simulation lab.

9.

Did you understand every word that was used?

10. What did you do to get a better understanding of what was being discussed?

11. How did your knowledge deficit make you feel?

Suggested solution: Answers to these questions will vary due to their subjective nature.

Think of the following frequently used terms, that are easily misunderstood by patients and their families: to ambulate; to defecate; to pass flatus; your vital signs; actions that are contraindicated.

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12. Do you think a patient would have the opportunity or ability to use similar confirming strategies as you employ?

Suggested solutions: Use language that is clear yet appropriate to the health care setting by using language the person is comfortable with you will form a trusting relationship where the person feels comfortable in asking you to explain unfamiliar words. Ensure you take into account the persons paraverbal and non-verbal cues that may indicate misinterpretation or misunderstanding.

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Contents Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 3 Review questions................................................................................................................................................. 4 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 25 Self-concept Key terms Body image Individual’s perception of physical self, including appearance, function and performance ability.

Identity What sets one person apart as a unique individual; may include a person’s name, gender, ethnic identity, family status, occupation and various roles.

Person-centred care A term used to describe the approach of care that acknowledges that the person’s perception of their own needs is central to the care that is provided to them. The wishes of each individual person along with their lifestyle and health choices are acknowledged and prioritised when providing and planning all care.

Role Set of expected behaviours associated with a person’s status or position.

Role conflict Occurs when the expectations of one role compete with the requirements of other roles.

Role overload The requirements of multiple roles result in conflicting priorities. The outcome is that the most important role (or roles) may be completed to the neglect of others.

Self-concept Individual’s perception of self; includes self-esteem, body image, identity and role performance.

Self-efficacy A person’s beliefs and their ability and capacity to accomplish a task and/or deal with the challenges of life.

Self-esteem Individual’s perception of self-worth and self-value; includes judgements about oneself and one’s capabilities.

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Instructional strategies • Describe the four components of self-concept. Identity is one component of self-concept. Identity is a sense of one’s own self that sets a person apart as an individual. This identity may include name, age, gender, ethnicity, family status and relationships, occupation, sexual orientation and social structure.

Body image is the second component of self-concept. This includes how an individual thinks he or she physically appears and how he or she feels about that appearance. This also involves how the individual thinks that others perceive them. Self-esteem is another component of self-concept. Self-esteem is the individual’s generalised sense of worth and value and is heavily influenced by one’s achievements in the areas that they value most highly. The fourth component of self-concept is role performance. This component refers to a set of behaviours expected by the person’s status. This includes expectations from family, culture and society. All these components make up the broader self-concept.

• Discuss the stressors that affect role performance. When a person is unable to fulfil the expectations of a role, self-concept is impaired. If the expectations of one role conflict with another, role conflict can occur.

There are four types of role conflict: inter-role, interpersonal, role overload, and person-role. In inter-role conflict, the expectations of one role oppose the expectations of another role. In interpersonal role conflict, the role expectations held by one or more people are incompatible. Role overload occurs when excessive demands of numerous roles have conflicting priorities. Person-role conflict occurs when an individual’s values are violated by the demands of a role.

• How does self-concept influence health behaviours and the solicitation of health care? From infancy to preschool, health behaviours are mostly dictated by parents or other adults in one’s life. If the child is from a family or culture that has certain health beliefs, those will get passed on to the individual. Once in school, those with less positive health behaviours may change some habits. For instance, a child who drinks only fruit punch at home may drink only milk at school. A child from a culture that did not have routine health screening available may now have vision and hearing screening.

• Discuss how self-concept develops throughout the life span. Self-concept is developed primarily through social interactions and personal experiences. Shaped from early childhood, an infant whose individual needs are met generally develops a positive self-worth. They adopt a sense of self as they develop as a toddler, becoming autonomous and constructing a self-image. This development of self continues into the school years as they undergo new experiences, becoming aware of their own strengths and weaknesses. Adolescents have definite issues as they struggle with identity, sensitivity toward body image, expectations as teens, and traumatic self-esteem issues. Many adolescents have poor health behaviours as a result of these developmental challenges. With adulthood self-concept continues to develop as the individual progresses through life. Body image alterations through ageing, as well as obligations and activities related to family, work and community will influence the individual’s perception of self. Positive health behaviours may once again emerge. Families who practise preventive care are more prone to have children who use health care prophylactically and for episodic treatment. Families with little money or access to health care tend to use emergency departments and urgent care clinics for episodic treatment and rarely seek preventive health care.

• Describe health issues that may affect self-concept. These health issues may be divided into the four components of self-concept. The first is identity which may be affected by developing dementia, or suffering burns or having a mastectomy. The second is body image which may be affected by requiring a colostomy after a bowel resection, or suffering paralysis as a result of an accident. Requiring an

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amputation, being in the final weeks of pregnancy or developing anorexia may affect the individual’s selfesteem. Finally, one’s role performance may be affected by the changes experienced with the body’s natural ageing process, as well as with mental illness and anxiety.

• Explain the role of experience in the development of self-concept. Positive or negative experiences will shape a person’s expectation for the success or failure of experiences going forward. If a person has a number of unsuccessful experiences, the person might perceive themselves as a failure and perform at unsuccessful levels going forward in order to meet the self-fulfilling expectation as a failure. On the other hand, the person with a number of positive experiences will approach new experiences with a positive attitude and set the stage for a positive self-concept.

Resource aids Collyer, D. A., Boseovski, J. J., & Marcovitch, S. (2018). Reviewing the development of self-concept: Implications for an enhanced model. journal of educational and developmental psychology, 8(1), 171– 177. https://doi.org/10.5539/jedp.v8n1p171 Franchina, V. & Lo Coco G. (2018). The influence of social media use on body image concerns. International Journal of Psychoanalysis and Education, 10(1), 7–14.

Hamamura, T. & Septarini, B. (2017). Culture and self-esteem over time: A cross-temporal meta-analysis among Australians, 1978–2014. Social Psychological and Personality Science, 8(8), 904–909. https://doi.org/10.1177/1948550617698205

Online resources •

Closing the Gap Clearinghouse: provides numerous links to resources providing evidence-based research focusing on overcoming Indigenous disadvantage. https://www.aihw.gov.au/reportsdata/population-groups/indigenous-australians/overview

•

Lifeline: provide a number of services to assist individuals with crisis support and self-harm prevention services. https://www.lifeline.org.au/get-help/facts-and-information

•

National Eating Disorders Collaboration (NEDC): an initiative of the federal Department of Health and Ageing, and contains information related to this issue within Australia, see https://www.nedc.com.au/eating-disorders/eating-disorders-explained/something/eating-disorders-inaustralia/

Evaluation strategies • Have students read the Nursing highlights box ‘Assessment of self-concept’ and write down their feelings about their own self-concepts. Encourage them to describe themselves using self-esteem, role expectations, identity, and body image. Then have them determine whether they consider themselves as having poor, average, or above-average self-concepts.

• Have the students discuss the different roles they fulfil by identifying the expectations for each of the roles and whether there are any conflicts between the roles. Encourage discussion on ways to reduce conflicts between the roles.

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• Nurses typically practise selfless behaviour. Discuss how nurses can improve self-care efforts while being expected to put the needs of others first.

• Using clinical examples to illustrate developmental transitions (e.g., pregnant person, menopausal person, newly paralysed teenager), have students develop nursing interventions to assist these people.

• Have students discuss methods that can be used to promote self-esteem across the life span for children, adolescents, adults and the elderly.

• Have students read the Respecting our differences box ‘Culture and self-esteem’ and be prepared to discuss the cultures within Australia and New Zealand whose members may be suffering low self-esteem, and what nursing interventions may be required to care for them holistically.

Review questions 1

Which of the following is not included as a part of a person’s identity? a. Gender b. Ethnicity c. Physical performance d. Culture e. Occupation.

Answer: c Rationale: A person’s gender, ethnicity, culture and occupation all help shape a person’s identity.

Physical performance is more accurately aligned with an individual’s body image.

2

Select the correct two (2) words to complete this sentence: An indicator of low self-esteem may be __________ posture and ___________ eye contact. a. b. c. d.

Stooped Increased Erect Limited.

Answer: a, d Rationale: These indicators of low self-esteem reflect a person who lacks self-confidence, and, therefore, low self-esteem.

3

A nursing student is teaching a person how to improve their self-esteem. Which of the following patient statements indicates that further teaching is needed? a. ‘I will do something, like take a walk, the next time I feel down.’ b. ‘If I just wait long enough, I’ll start to feel better.’ c. ‘When I feel bad, I should think of something positive.’ d. ‘When I feel good about myself, I have good self-esteem.’ e. ‘Reminding myself of some of my achievements helps me when I feel negative about myself.’

Answer: b Rationale: Reflecting on past accomplishments or enjoying the environment are both demonstrated methods of improving a person’s self-esteem.

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4

A nursing student is stressed because they have clinical experience scheduled at the same time as their child’s parent–teacher conference. Which of the following is the student nurse experiencing? a. Body image disturbance b. Person–role conflict c. Interpersonal role conflict d. Role overload e. Role confusion.

Answer: d Rationale: Having too many roles to fulfil simultaneously is called role overload.

5

Select the correct two (2) words to complete the sentence. Meeting a person’s ________, is __________ to their self-concept. a. Ideals b. Detrimental c. Beneficial d. Needs.

Answer: d, c Rationale: Having basic needs met, such as their personal appearance, usually positively affects a person’s self-concept, especially when they are empowered to do it for themselves.

6

Which of the following patient statements indicates a high degree of self-esteem? a ‘I am so tired of failing.’ b ‘I’ve solved problems before so I feel like I can do so now.’ c ‘There’s no use in trying because nothing will change.’ d ‘Why bother? Everything I do turns out wrong anyway!’ e ‘If anyone gets in my way then they might get hurt.’

Answer: b Rationale: Past accomplishments help develop a person’s sense of worth and therefore a high degree of self-esteem.

7

Which of the following factors is most likely to aid in the successful implementation of strategies to help the person achieve their goals? a Instruct the person on the best way to do things. b Assist the person to identify their strengths and help them to build on them further. c Work with the family behind the person’s back. d Develop a plan of care with the health care team and direct the person to follow it. e Encourage the person to depend on the nurses for support.

Answer: b Rationale: A person’s strengths are a foundation on which they can build to achieve their goals.

8

Select the correct two (2) words to complete the sentence. During adolescence, the greatest impact on a young person’s identity may shift from their _________ to their _________. a Pets b Parents

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c Peers/idols.

Answer: b, c Rationale: This shift reflects the young person developing independence and shaping their own individual identity.

9

Which of the following actions can be implemented by the nurse to improve the self-concept of older people? a. Encourage the person to talk about current events, instead of those in the past. b. Remove personal items to keep the health care environment free of clutter. c. Use touch to promote feelings of acceptance. d. Assist them as much as possible because they are old.

Answer: c Rationale: Touch can help decrease a sense of isolation and promotes feelings of belonging.

10 Select the correct three (3) words to complete the sentences. When a person is in the stage of denial it reflects a ________ of coping ability. The nurse should assist the person to develop a __________ method of coping before ________ the defense mechanism. a. Lack b. Negative c. Positive d. Adding e. Surplus f. Removing.

Answer: a, c, f Rationale: When a person is in the stage of denial it reflects a lack of coping ability. The nurse should assist the person to develop a positive method of coping before removing the defense mechanism.

Spotlight on critical thinking Professionalism: personal roles Consider the various roles you currently fulfil. Perhaps your role of student may at times conflict with your role of friend or parent (e.g., you need to be in class at the same time as you need to attend a parent– teacher conference or be available to your friend who is undergoing a crisis). Or your need to study for an examination (student role) is superseded by your need to work (role of wage earner).

1.

What are some of the potential conflicts inherent in your multiple roles?

Suggested solution: A discussion of potential role conflicts may provide the students the opportunity to discuss issues pertinent to them.

2.

Have your role priorities changed during your nursing program?

Suggested solution: Answers will vary depending on individual experience.

3.

What are some strategies that you can use to assist you to meet your role responsibilities?

Suggested solution: Discussion of the strategies that the students use to prioritise these conflicting roles may be of interest to other students, as well as educators.

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Carer’s self-concept While this chapter has focused on the individual’s self-concept, its relationship with illness, and the resultant nursing care requirements, the nurse is also responsible for being aware of how their own self-concept may affect the care that they give.

4.

Do you think you have a positive or negative self-concept?

Suggested solution: When initiating this discussion, it is worth considering how one’s self-concept is a very personal construct. Some students may be very open in discussing their own self-concept while others may prefer not to. This discussion could be driven by the educator being open about their own self-concept and how certain life experiences have influenced their own over their life journey.

5.

Have you ever had to assume a ‘sick role’ yourself? If so, has that enabled you to have further insights into how your patients may feel in that role?

Suggested solution: Experiencing a ‘sick role’ may lead to some individuals entering nursing, so this may be an opportunity for a discussion from some of your students from a person’s point of view. Encourage discussion involving the feelings and vulnerabilities of patients if at all possible.

6.

Do you feel that your own self-concept affects your ability to take on a caring role for people whom you are responsible for?

Suggested solution: When responding to this question encourage students to answer honestly, some students may feel that their own self-concept doesn’t (or shouldn’t) affect their care of the people whom you are responsible, other students may wish to debate that stance. Students who currently work as health care providers may have additional insight into this question.

Feeling challenged This chapter has identified several illnesses, injuries and disorders that can challenge different aspects of the person’s self-concept. Some of the coping mechanisms that people may use to cope with these challenges may be confronting to the nurse, including verbal aggression.

7.

What do you think your reaction would be if a person was verbally aggressive towards you?

Suggested solution: Student responses may vary but should refer to communication strategies from the nursing process that identify that aggression may be a defence mechanism.

8.

What are some communication strategies that you could use when caring for a person who was verbally aggressive?

Suggested solution: Student responses may vary based on their own experiences but should refer back to resources from Chapter 8.

9.

Health facilities may have resources to assist the nurse in the care of a person who was verbally aggressive. Are you able to identify three resources that may be of assistance in this situation?

Suggested solution: Student responses may vary based on their own experiences but should refer back to resources from Chapter 8.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 8

Chapter 26 Stress, anxiety, adaptation and change Key terms Acute stress reaction Disruption (usually reversible) in functional ability characterised by a rapid onset, intense manifestations and a relatively short duration.

Adaptation Component of cognitive development that refers to the changes that occur because of assimilation and accommodation; ongoing process by which an individual adjusts to stressors to achieve homeostasis.

Anxiety Subjective response that occurs when a person experiences a threat to wellbeing, a diverse feeling of dread or apprehension.

Burnout State of physical and emotional exhaustion that occurs when caregivers deplete their adaptive energy; characterised by fatigue, depersonalisation, and decreased feelings of personal accomplishment.

Catharsis A feeling of renewal or relief after the release of emotions.

Change Dynamic process in which an individual’s response to a stressor leads to an alteration in behaviour.

Change agent Individual who intentionally originates and creates change.

Cognitive reframing Stress management technique in which the individual changes their own negative perception of a situation or event to a more positive, less-threatening perspective.

Crisis Acute state of disorganisation that occurs when the individual’s usual coping mechanisms are no longer effective.

Crisis intervention Specific technique used to assist individuals in regaining equilibrium.

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Defence mechanisms Unconscious operations that protect the mind from anxiety.

Depersonalisation Treating an individual as an object rather than as a person; a perception of a loss of self as an individual.

Distress Experienced when stressors evoke an ineffective response.

Eustress Type of stress that results in positive outcomes.

Fight-or-flight response State in which the body becomes physiologically ready to respond to a stressor by either fighting or running away from the danger (which may be actual or perceived).

Freud Sigmund Freud (1856–1939) developed psychoanalysis which views development as influenced by unconscious forces. Freud’s five stages of psychosexual development centre around body zones.

General adaptation syndrome (GAD) Physiological response that occurs when a person experiences a stressor.

Guided imagery A process in which the person uses all the senses to experience the sensation of relaxation.

Homeostasis Equilibrium (balance) between physiological, psychological, sociocultural, intellectual, and spiritual needs.

Imagery Relaxation technique in which the individual uses the imagination to visualise a pleasant, soothing image.

Maladaptation A deficient adaptation that results in harm or a lack of stability.

Proactive Initiating change rather than responding to change imposed by others.

Progressive muscle relaxation (PMR) Stress-management technique involving tensing and relaxing muscles.

Related factors Elements that can precede, be associated with, contribute to, or be related to nursingidentified problems in some type of patterned relationship.

Secondary gains Outcomes of the ‘sick role’ other than alleviation of anxiety (primary gain); examples include gaining attention and sympathy, avoiding responsibilities, and receiving financial compensation or reward.

Stress The state of mental or emotional strain caused by adverse circumstances.

Stressor Any stimulus encountered by an individual; leads to the need to adapt.

Instructional strategies •

What is the general adaptation syndrome (GAS), and what are some examples of common stressors?

The syndrome was introduced by Canadian Hans Selye in 1976. This concept refers to the physiological response to stress. The physiological response is the same regardless of the source of the stress. The response is the same whether the stressor is actual or imagined, present or potential. Physiological stressors include trauma, illness, sleep disturbances, hunger and pain. Psychological stressors include fear, anger, and happiness. Environmental stressors include temperature, air and noise pollution, crowding, and time pressures. Sociocultural stressors of job loss or promotion, change in interpersonal relationships, and interpersonal conflict are common stressors. It is important to note that stress can be either good or bad.

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•

The manifestations of stress (see Table 26-3 Common manifestations of stress) affect every bodily system and can have a major impact on a person’s homeostasis. Discuss a range of these manifestations with the students and possible methods of modifying the stress reactions, including the introduction of various coping behaviours.

•

Hospitalisation is an example of a stress. Fighting an illness and recuperating from an injury are causes of stress. What are some ways that the nurse can decrease the person’s response to stress? What can the nurse do when the person is in crisis? The nurse can and should encourage people to talk about the feelings of stress in their lives. Verbalisation of stress is helpful, and laughter is beneficial for stress. It may put the stress into perspective and make it easier to deal with. Encouraging the person to exercise is another way that stress can be relieved. When the person is in crisis, it is important for the nurse to provide limits and structure and to maintain patient safety. The Nursing checklist ‘Actions to promote patient control’ has additional actions to promote patient control.

•

As the health care system is changing, so is the role of the nurse in that structure. Nurses must be able to cope with change effectively to make a somewhat smooth transition into a new nursing paradigm.

Discuss the following theory of change and how it can relate to the nursing profession. Lewin’s Theory of Change is a classic theory that states that the change process occurs in three stages: unfreezing, moving and refreezing. A person recognises the need for change, implements the change, and new behaviour is established. Most people (including nurses) tend to resist change. However, critical thinking about new ideas lends itself to the opportunity to learn how to adapt positively to change.

•

What are the steps of crisis intervention? Give the students an example of a person who is in a crisis state, and have the students propose interventions to get the person out of the crisis state. The steps of crisis intervention are (1) identification of the problem, (2) identification of alternatives, (3) selection of an alternative, (4) implementation, and (5) evaluation. Figure 26-9 ‘Steps of crisis intervention’ can be used to illustrate the concept of progression of care. It is important for the student to understand that the steps in the process begin with the identification of the respective problem. The student must also understand that when a person is in a crisis state, appropriate timely referral to other members of the health care team may be warranted.

Mental health disorders are much more prevalent in the Indigenous populations of Australia and New Zealand (see the Respecting our Differences box ‘Mental health disorders‘). Discuss potential reasons for this with the students and using the various text and online resources, identify intervention strategies that may be utilised by the nurse when caring for Indigenous people in various health care settings.

•

The nurse has identified the nursing diagnosis of powerlessness for a patient (see Table 26-9). What did the nurse most likely assess in the person to determine this diagnosis? Characteristics for the nursing diagnosis of powerlessness include the person verbalised dissatisfaction over the inability to control the situation, the person was hostile and aggressive, the person had difficulty expressing himself, and the person appeared depressed.

•

Discuss the role of cognitive reframing when providing care. Cognitive reframing is a technique used to modify the interpretation of an event in order to reduce the negativity and stress associated with the event. When providing care, this technique can be used to help a person work through a difficult medical diagnosis. This technique causes the person to stop and think about the emotions attached to

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the health problem or diagnosis. The person is guided to alter the perceptions and interpretation by changing thoughts about the situation.

•

Review how the autonomic nervous system of the body responds to stress (including the fight-or-flight response). Compare the body’s reaction to perceived stress or real stress. The sympathetic nervous system (SNS) responds to stress by increasing heart rate, blood pressure, respiratory rate, blood glucose production, gastric acid, and metabolism and decreasing the rate of digestion. The parasympathetic nervous system helps to maintain normal functioning and acts opposite to the SNS. It is important for the student to understand that there is no difference to the person whether it is perceived stress or actual stress. The body reacts to the idea of stress. The range of symptom response varies with the nature of the stress, and the individual’s perception and reaction to the stressor. It is important to understand the basic concept of physiological response, but it is also important to look at the individual’s overall response to a stressor.

Burnout, the state of physical and emotional exhaustion that occurs when caregivers deplete their adaptive energy is a major issue for nurses and the profession of nursing itself. Using Table 26-10 and the accompanying Nursing checklist, ‘Managing professional stress’, discuss with the students the importance of self-nurturing and strategies that can be used to prevent nursing burnout.

Resource aids Beyondblue. (2022). Personal stories. Hawthorn West, Victoria. Retrieved from https://www.beyondblue.org.au/who-does-it-affect/personal-stories?category=48e1a0f3-4f66-4946a425-a947f57363c7 ReachOut. (2022). Mental health issues. https://au.reachout.com/mental-health-issues Selye, H. (1974). Stress without stress. New American Library.

World Health Organization (WHO). (2020). Doing what matters in times of stress. https://www.who.int/publications/i/item/9789240003927

Online resources •

Beyond Blue is an excellent resource, especially in relation to Indigenous marginalisation and its effects, as well as in regard to anxiety and depression. This can be accessed at http://www.beyondblue.org.au

•

The Australian Psychological Society website contains numerous resources and information related to stress and anxiety and may be accessed at http://www.psychology.org.au

Evaluation strategies •

Discuss sources of stress that nursing student’s experience. What activities do students use to help relieve that stress?

•

Have the students identify one nurse, practising in the clinical area, who demonstrates hardiness. What characteristics does this nurse possess? Ask the nurse what he or she does to relieve stress. Discuss the characteristics of hardiness together in a group.

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•

Give students different examples of patients and have them identify potential sources of stress. It is important for the nursing student to understand that although nursing school is stressful, all individuals who live on this earth have their own share of stress. It will be helpful to have the students recognise that all individuals live and work under some level of stress and still maintain healthy and well-balanced lives.

•

Assign students to locate community resources that assist people with stress and crisis, including refugee settlement. Encourage them to determine what people they serve, services they provide, fees, if any, and hours of service. Locate emergency services as well.

•

Using Table 26-7, ‘Common defence mechanisms’, have the students identify which defence mechanisms they use to combat stress. Provide examples of the defence mechanisms and supply the situations in which they were used. Discuss the situations and defence mechanisms in small groups.

•

The quotation for this chapter reads, ‘There is nothing either good or bad, but thinking makes it so’ (William Shakespeare). Have students reflect on how this phrase would help them to deal with a ‘stressful’ situation in their own life and when dealing with a person in a stressful situation.

•

Take the students to a nice place on campus. Bring a blanket. Have the students close their eyes and think of something (place, hobby, or pastime) that makes them feel at peace. Using guided imagery and relaxation techniques, encourage the student to utilise this method to help deal with stressors. The entire activity should take no more than five minutes to complete, and it will make you and your students appreciate the merits of relaxation and stress management.

Review questions 1.

When assessing a person for anxiety, which of the following indicators would the nurse look for? Select the four (4) that apply. a. Decreased blood pressure b. Dry skin c. Increased pulse rate d. Increased respiratory rate e. Rapid, shallow breathing f. Shortness of breath verbalised by person.

Answer: c, d, e, f Rationale: Anxiety arouses the autonomic nervous system, with resultant manifestations of increased blood pressure, diaphoresis, increased pulse rate, and shallow rapid respirations. The person will often complain of a smothering sensation or shortness of breath.

2.

True or false? Wellness is an adaptive state; that is, the well person is one who is coping effectively with stressors to maintain a high level of wellbeing. a. True b. False Answer: a Rationale: Wellness is an adaptive state. A well person is coping effectively with stressors and maintaining a level of wellbeing.

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3.

Which three (3) of the following statements accurately describe a crisis situation? a A crisis can be successfully resolved without intervention from others. b Crisis has a slow, insidious onset. c Prompt intervention is necessary to prevent an extended period of crisis. d The person perceives the event as overwhelming. e A crisis can last for an extended period of time.

Answer: c, d, e Rationale: Crisis is particular to the individual person however they do have these same three characteristics. The person experiences the crisis event as overwhelming and it can last for an extended period of time, unless prompt intervention is initiated.

4.

Which of the following is an example of suppression used by a nursing student? a Arguing with a roommate instead of expressing concerns to the instructor b Deciding to go to bed early the night before the exam instead of cramming c Stating that poor exam performance was a result of poorly written test questions d Stating that the instructor was ‘out to get me’ e Playing amateur football to release study stress.

Answer: c Rationale: This is an example of consciously suppressing painful thoughts. Blaming a poorly created test, rather than accepting personal responsibility for failing the exam.

5.

Complete the sentence: An extended and unresolved response to an extremely traumatic event may develop into a _________ stress disorder. a. Posttraumatic b. Anxiety-driven c. Repression d. Trauma-driven.

Answer: a Rationale: Extremely traumatic events, if extended and unresolved, may develop into posttraumatic stress disorders (PTSD).

6.

True or false? The GAS response to stress involves only physiological components. a. True b. False Answer: a Rationale: The GAS response involves physiological responses to actual or imagined stresses.

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7.

Which of the following is an example of a situational crisis? a. Being a victim of a school shooting b. Hospitalisation following an automobile accident c. Losing one’s home due to a hurricane d. Sadness experienced by a woman during menopause. e. A teenager struggling with the advancement to high school.

Answer: e Rationale: Answers (a), (b), (c) are more adventitious events (rare and unpredictable), while (d) is a developmental type.

8.

Which of the following approaches for dealing with stress is not a positive coping strategy? a. Meditation b. Exercising c. Changing routine d. Self-medicating e. Positive thinking.

Answer: d Rationale: The choices (a), (b), (c), (e) have the demonstrated ability to assist a person to positively deal with stress. Self-medicating can involve alcohol as well as over-the-counter and prescription medication and is a negative coping strategy.

9.

Complete the sentence. Guided imagery is a technique used to manage stress in all patients except those experiencing ____________ instability. a. Behavioural b. Emotional c. Physical d. Sexuality Answer: emotional Rationale: Guided imagery is not suitable for people with emotional instability as they may not be able to cope with the emotions that can be experienced during this counselling technique.

10. A mother brings her 4-year-old son to the clinic for an annual check-up. The mother tells the nurse that the child began sucking his thumb 2 months ago when his little brother was born. The nurse recognises the child’s behaviour as an example of which of the following defence mechanisms? a Denial b Reaction formation c Regression d Symbolisation e Repression.

Answer: c Rationale: This is an example of regression which involves reverting to a former, less developed state or behaviour.

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Spotlight on critical thinking Professionalism: nurses as risk takers By its very nature, decision-making involves taking risks. Because you make decisions when planning and carrying out your patient’s care, you are involved in taking risks regularly.

1.

Do you perceive the decisions that you make as risk taking?

Suggested solution: Students may not generally consider decision-making as risk taking, though as the degree of risk involved in the decision increases, they may perceive this differently. Students may benefit by considering the difference in risk taking between making a decision whether to provide hygiene care to a bed bound person before or after morning tea, or to not wear personal protective equipment when caring for a person with a highly transmittable disease. Students may wish to discuss some of their decision-making/risk-taking experiences from their own clinical placements.

2.

How does the use of critical thinking effect the element of risk in making decisions?

Suggested solution: When responding to this question consider the principles of critical thinking and how in making sound clinical decisions, nurses use critical thinking. This skill, essential for nursing practice, results in decision making which is evidence-based and decreases risks when providing care.

3.

What resources are available to help you with your decision making in health care settings?

Suggested solution: Student responses may vary based on resources available in their institution and include the NMBA decision-making framework.

Caring: self-nurturers Consider the section in this chapter on ‘nursing burnout’ and the strategies that nurses can use to cope with professional stress.

4.

Society often labels people who prioritise their self-care as ‘selfish’. Do you agree? Why or why not?

Suggested solution: This provides an opportunity for discussion with the students on whether nurse’s self-nurturing is selfish. A point for discussion could be that if nurses don’t maintain their own wellbeing, then how are they able to provide holistic care for their patients; thereby introducing an ethical element to this topic.

5.

Practising self-care has several positives, both for yourself and for those who you provide care for.

Brainstorm some of these positives with your nursing friends.

Suggested solution: Student responses will vary based on discussion and individual experiences.

6.

What are some specific things you can do now to take better care of yourself? Make a list of these selfcaring practices and challenge yourself to complete one item off the list per week. Place it somewhere that you can access regularly.

Suggested solution: Examples are provided in Table 26-11 ‘Strategies for coping with professional stress’. Students may have other ideas that they wish to discuss.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Evaluation strategies ........................................................................................................................................... 4 Review questions ................................................................................................................................................ 4 Spotlight on critical thinking ................................................................................................................................ 6

Chapter 27 Spirituality Key terms Colonisation Multiplication of microorganisms on or within a host that does not result in cellular injury; also, occupancy by people foreign to land or country that settle and overlook existing systems and impose their own governance structures that impact on the health and wellbeing of the original inhabitants.

Country The lands of First Nations communities.

Culture Dynamic and integrated structures of knowledge, beliefs, behaviours, ideas, attitudes, values, habits, customs, languages, symbols, rituals, ceremonies and practices that are unique to a particular group of people; growing microorganisms to identify a pathogen.

Faith A dynamic system of people living together who are united by significant emotional bonds.

First Nations Refers to the Aboriginal and Torres Strait Islander peoples of Australia, and/or the Ma¯ori people of Aotearoa, New Zealand.

Hope Factor that enables one to cope with distressing events.

Kinship Cultural groups that have ways of interacting that are common to members of that group, and which may be delineated by family and community members; also, the social structure that determines how people relate to one another and what obligations and responsibilities they hold towards one another.

Mindfulness Therapeutic practice of being aware of the present moment including awareness of any thoughts, emotions and bodily sensations.

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Religion Set of beliefs associated with a formal organised group, such as a church, synagogue, mosque or temple.

Ritual Series of culturally based actions carried out in a prescribed order.

Spiritual assessment Initial stage in identifying how a person resources their hopes, strength, comfort, meaning of life, love and connection; the assessment is also used to identify the role that organised religion, spiritual beliefs and cultural practices impact on the person’s acceptance of or refusal to participate in their health care.

Spiritual distress State experienced when an individual perceives that his or her belief system, or that person’s place within it, is threatened.

Spiritual wellbeing Sense of connectedness between the self, others, nature and a higher power that can be accessed through prayer or other means.

Spirituality

Instructional strategies • Describe the characteristics of spirituality. The characteristics of spirituality are identified in Table 27-1; that is, relationship with self, relationship with others, harmony with nature and relationship with a higher power. Relationship with self can be described as having knowledge of who one is and one’s capabilities. It also includes reference to one’s source of ultimate meaning. Relationship with others is described as caring for others when they need help or the sharing of self. Harmony with nature is described as the knowledge of plants and animals, preserving nature, and communing with nature.

Relationship with a higher power can be described as meditation, prayer, participating in religious services, and performing religious rituals.

• Explain the difference between spirituality and religion. Religion is a subset of spirituality. It is based on denomination and usually includes rituals. Religion is cognitive and practised in public. Spirituality is universal. It has no one specific denomination but rather is ecumenical. The practice of spirituality is spontaneous and is an affective function. Spirituality is practised in private but may also be shared with others.

• What characteristics of faith do nurses have in their own lives, and how does this affect the care they provide? Individuals with spiritually satisfying lives are those people who have a source of inner strength.

Spiritual beliefs can enhance self-esteem and help protect individuals from stress. Nurses who have reviewed their own personal beliefs are likely to be more comfortable discussing the spiritual needs of a client.

• Identify world religions and their health implications. Nurses are not required to know all religions and their related implications; however, at least a basic understanding of the most common religions is useful for clinical practice. Also, health practices associated with the religion that conflict with health care modalities should be explored (i.e., Jehovah’s Witness and refusal of blood products). Nurses should be aware that members of religious traditions may have regular practices (prayer and rituals) that are based upon the religion but also function as important sources of spiritual nourishment for clients.

• Discuss collaborative efforts to meet a client’s spirituality needs. Clients should be asked if they would like to see their spiritual leader or advisor. After gaining permission, the nurse can contact the health care

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organisation’s pastoral care department for clergy to visit with the client. The organisation also can conduct formal services and support groups. The nurse can also identify a colleague who might have more experience with the client’s spirituality needs and utilise the colleague as a resource.

Resource aids Burkhardt, M. A., & Nagai-Jacobson, M. G. (2008). Transcultural and spiritual issues. In M. A. Burkhardt & A. K. Nathaniel (Eds.), Ethics and issues in contemporary nursing (3rd ed.). Cengage Delmar Learning.

Egan, R., Llewellyn, R., Cox, B., MacLeod, R., McSherry, & Austin, p. (2017) New Zealand Nurses’ Perceptions of Spirituality and Spiritual care: Qualitative Findings from a National Survey. Religions 8(79), 5. https://doi.org/10.3390/rel8050079 Hodge, D. R. & Derezotes, D. S. (2008) Postmodernism and spirituality: Some pedagogical implications for teaching content on spirituality. Journal of Social Work Education, 44(1), 103–123.

Hughes, P., DeGregory, C., elk, r., Graham, D., Hall, E.J. Spiritual care and nursing: A nurse’s contribution and practice. https://www.spiritualcareassociation.org/docs/resources/nurses_spiritual_care_white_paper_3_22_201 7.pdf Mauk, K., & Schmidt, N. (2003). Spiritual care in nursing practice. Lippincott Williams & Wilkins.

Pye, J., Sedgwick, P., Todd, A. (2015). Critical care: Delivering spiritual care in healthcare contexts. Jessica Kingslea.

Selman, L. E., Brighton, L. J., Sinclair, S., Karvinen, I., Egan, R., Speck, P., Powell, R. A., Deskur-Smielecka, E., Glajchen, M., Adler, S., Puchalski, C., Hunter, J., Gikaara, N., Hope, J., & InSpirit Collaborative (2018).

Patients' and caregivers' needs, experiences, preferences and research priorities in spiritual care: A focus group study across nine countries. Palliative Medicine, 32(1), 216–230. https://doi.org/10.1177/0269216317734954 Solari-Twadell, P., & McDermott, M. (1999). Parish nursing: Promoting whole person health within faith communities. Sage Publications.

Zubrzycki, J., Green, S., Jones, V., Stratton, K., Young, S., Bessarab, D. (2014) Getting it right: Creating partnerships for change. Integrating Aboriginal and Torres Strait Islander knowledges in social work education and practice. Teaching and Learning Framework Australian Government Office for Learning and Teaching.

Online resources • This section of the Health QLD site provides a handbook for the care of Muslim patients. Other handbooks are also available for the care of Hindu and Sikh patients: https://www.health.qld.gov.au/multicultural/health_workers/hbook-muslim • This section of the Health QLD site provides the response of the Queensland government to the assessment of the health care needs of Māori and Pacific Islander peoples. https://www.health.qld.gov.au/multicultural/health_workers/pac_island

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• The NZ Ministry of Health site offers valuable information for gaining some insight into the model for Māori health developed in 1982 by Professor Mason Durie. Further investigation of his work offers important ideas for appropriate care of Indigenous persons in a range of health care situations. http://www.health.govt.nz/our-work/populations/maori-health/maori-health-models

Evaluation strategies • Have the students read ‘Respecting Our Differences: Spiritual Questions’ and answer the questions for themselves. In groups of two, have students share their reflections on two of the questions.

• Use the Spiritual assessment tool in Table 27-3 for student practice. Encourage the students to practise using the tool on themselves, a family member and a classmate. Students often complain that they are uncomfortable asking clients about their spiritual beliefs. Exposure and practice using this assessment can help alleviate students’ fear.

• (Voluntary Student Participation) Prepare a list of different religions’ houses of worship in the area.

Provide the list to the students and encourage them to select one house of worship to attend. During the next class session, have the students who attended the different houses of worship describe the experience. Students who elect to not participate in this can be assigned to create a list of Internet resources, books, texts, television shows, and other resources that can be used to help support a client’s spirituality needs. The list can be printed and shared with all class members. See the article by Hodge and Derezotes for strategies in relation to spirituality.

• Present a case study that includes a client who is experiencing spiritual distress. Assign students to develop a plan of care for this client.

• Have the students share their individual experiences with religion and spirituality by answering the following questions: Do you participate in one particular religious group? What is the term used for the house of worship? What is the term used to identify the leader of the group conducting the worship?

Identify any particular rituals conducted. What is the focus of the worship?

Review questions 1.

What is the first step in becoming more spiritually competent? (Select all that apply.) a Learning a second language b Becoming aware of the assumptions from which you develop your judgements. c Reading hospital policies d Taking a class about different religions and cultures (Wintz & Cooper, 2000) e Practising mindfulness daily.

Answer: b Rationale: Spiritual competency begins with self-understanding and awareness of our preconceptions

2. A mum is standing beside her baby’s cot in the ICU. She is crying. You ask her what is wrong, and she says, ‘I don’t understand why god is doing this!’ What would be the best response? a Assure her that God has a plan for the baby. b Ask her if she goes to church. c Listen actively and allow her to express her feelings. d Ignore her comments and check the baby’s IV (Wintz & Cooper, 2000) e Offer to call a chaplain or priest. © Cengage Learning Australia 2024

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Answer: c Rationale: Good reflective listening will enable the mother to express and explore her feelings and identify her core beliefs. Depending upon the outcome it may be relevant to then refer to a chaplain or pastoral care team.

3.

When should a nurse perform a spiritual assessment on a hospitalised person? a. At time of discharge b. Just prior to discharge or transfer to another facility c. On admission d. When client is admitted and throughout hospitalisation e. When the person raises spiritual concerns.

Answer: d Rationale: A spiritual assessment, just like any other type assessment, is a continuous process. It should be conducted when the client enters the hospital, as well as throughout the hospital stay, as spiritual needs may change.

4.

A person has recently been informed of a terminal diagnosis. The client says, ‘I wonder why God is doing this to me. It’s not fair!’ Which of the following nursing diagnoses is appropriate for this person? a. Energy field disturbance b. Readiness for enhanced spiritual well-being c. Risk for spiritual distress d. Spiritual distress e. Risk for energy field disturbance.

Answer: d Rationale: Spiritual distress is the client’s perception that one’s belief system is threatened. The client’s belief that he is being treated unfairly by his God is an example of such a perception.

5.

6.

Culturally and spiritually sensitive or competent care includes: a. respecting difference b. eagerness to learn c. willingness to accept other views d. recognising your own limitations e. all the above. (Wintz & Cooper, 2000) Answer: e The practice of focusing only on the present moment is known as: a. Collaboration b. Mindfulness c. Mysticism d. Spiritual distress e. Presence.

Answer: b Rationale: Mindfulness is a form of meditation in which one focuses only on the present moment. The practice of mindfulness leads to relaxation and, for many, the opportunity to appreciate the spiritual aspect of life.

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7.

A person who is dying says, ‘You know I wonder what will happen to me after I die?’ Which of the following nursing responses demonstrates provision of spiritual care? a. ‘Would you like someone from Pastoral care to visit?’ b. ‘I have asked my pastor to add your name to the prayer list.’ c. ‘Oh, don’t talk like that. You know you’ll feel better soon.’ d. ‘You sound anxious. I can help with that. Let’s talk about it.’ e. ‘Tell me more about what you are wondering?’

Answer: d Rationale: Encouraging the client to express feelings is important in promoting spiritual well-being. The nurse should respect the client’s privacy when engaging in prayer or other religious rituals. Nurses who offer to call their own clergy or to pray for a client are imposing their own beliefs on the client. Offering false reassurance increases client anxiety and interferes with the development of trust between client and nurse.

Spotlight on critical thinking Caring 1.

Provide an example to explain why empathy is important in responding to the spiritual needs of a person in the health care setting.

Suggested solution: Students may consider times when they have experienced isolation and fear or panic and relate these feelings to clients who suffer sudden illness or injury.

2.

What communication skills are most important to develop to demonstrate empathy?

Suggested solution: Skills such as reflective listening to show the client that they have been heard, appropriate body-language (non-verbal) and genuine respect shown for the client’s worldview.

3.

Name three common sources of meaning in the lives of contemporary Australians and New Zealanders and give an example to demonstrate how one of these sources might assist a person in their recovery.

Suggested solution: Many people in Australia and New Zealand, including Indigenous Peoples, derive meaning from family connections. Some cite work satisfaction or goals they establish for their lives, such as academic or sporting achievements. A sense of an ‘ultimate’ or ‘core’ meaning to human existence is also evident not only in those who belong to a religious faith tradition, but also in those who generously serve in community organisations (e.g., firefighters).

4.

Why is it important for human beings to give meaning to their existence?

Suggested solution: The experience of Victor Frankl imprisoned in a Nazi concentration camp in World War II was that prisoners who had an awareness of their ‘inner life’ were often more resilient and so more likely to survive than even those who were more physically able. This suggests that ‘having a goal’ or a source of meaning is important. This is also true because the goal helps us to perceive the transcendent dimension of human experience. This is a source of resilience when ‘times are tough’.

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5.

What steps might be taken to assist a person who perceives that his/her health care plan conflicts with their religious or spiritual beliefs?

Suggested solution: This might call for consultation from a number of angles. Clearly the first step is the practice of the communication skills associated with empathy mentioned above. Respect for the person’s worldview is important, but the client may not be aware that other members of their faith tradition may have different perspectives. It would be helpful to seek the guidance of a spiritual leader in the client’s faith, to reassure them in case the client is mistaken, or to affirm them if s/he is not mistaken.

6.

Why is an assessment of a patient’s spiritual wellbeing an important part of the initial encounter with them?

Suggested solution: This helps to establish a rapport with the person and can provide suggestions in the development of an appropriate health care plan. For example, the person may have an interest in art or music which can assist healing.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 4 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 8

Chapter 28 Loss and grief Key terms Algor mortis Physiological change occurring after death in which the body temperature decreases with a resultant lack of skin elasticity.

Anticipatory grief Occurrence of grief work before an expected loss.

Autopsy Postmortem examination to determine the cause of death.

Bereavement Period of grief following the death of a loved one.

Bonanno George Bonanno (1950–) is an American clinical psychologist and researcher who is best known for his work on resilience, grief and trauma.

Bowlby John Bowlby (1907–1990) was a British psychiatrist and psychoanalyst who is best known for his pioneering work on attachment theory.

Complicated grief Associated with traumatic death such as death by homicide, suicide, or accidental.

Crisis Acute state of disorganisation that occurs when the individual’s usual coping mechanisms are no longer effective.

Crisis intervention Specific technique used to assist individuals in regaining equilibrium.

Disenfranchised grief Grief that is not recognised by others (i.e., society) such as loss of friends, or death of a pet.

Dysfunctional grief Persons who do not progress through the stages of overwhelming emotions associated with grief; or they fail to demonstrate any behaviours commonly associated with grief.

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Grief work Process experienced by the bereaved in which the person experiences freedom from attachment to the deceased, becomes reoriented to the environment in which the deceased is no longer present, and establishes new relationships.

Hospice Type of care for the terminally ill, founded on the concept of allowing individuals to die with dignity and surrounded by those who love them.

Klass Dennis Klass (1940–) is an American author, researcher and educator who is known for his work on the psychological impact of death, grief and loss on children and families.

Lindemann Erich Lindemann (1900–1974) was a German-American writer and psychiatrist who specialised in bereavement.

Liver mortis Physiological change occurring after death in which the body exhibits a bluish-purple discoloration that is a by-product of red blood cell destruction.

Loss Situation (actual, potential, or perceived) in which a valued object is changed or is no longer accessible to the individual.

Nickman Steven L Nickman (1940–) is an American clinical psychologist and researcher who is known for his work on grief, loss and bereavement.

Maturational loss Example is the adolescent who loses the younger child’s freedom from responsibility.

Mourning Period of time during which the grief is expressed and resolution and integration of the loss occur.

Palliative care Focused on the control of physiological symptoms rather than the cure.

Rigor mortis Stiffening of the body due to contraction of skeletal and smooth muscles.

Schut Henk Schut (1957–) is a Dutch social and health psychologist who is known for his research on grief and loss, coping and resilience.

Silverman Phyllis R Silverman (1927–2016) was an American clinical psychologist and researcher who is known for her work in the field of bereavement and grief.

Situational loss Occurs in response to external events, usually beyond the individual’s control (death of a significant other).

Stroebe Wolfgang Stroebe (1941–) is a German social psychologist who is known for his research on social psychology, social influence, and group dynamics.

Uncomplicated grief The grief reaction that normally follows a significant loss.

Worden James William Worden (1942–) is an American psychologist and grief counsellor who is best known for his work in the field of thanatology, which is the study of death, dying and bereavement.

Instructional strategies • People experience different types of loss in their lives. Differentiate between those types of losses. Loss can be any situation, actual, potential, or perceived, in which a valued object is changed or is no longer accessible to the person. Everyone deals with loss in their life. Loss can be something as intense as the death of a loved one (actual loss) or as seemingly benign as misplacing tickets to a ball game (potential loss). A perceived loss is one that is felt by the individual but is not tangible to others. A person moving from one maturational stage to the next experiences some loss. An infant moving into the toddler stage may feel the change from breast feeding to a cup as a loss. It may be the loss a parent feels when a child

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goes off to college. This is called maturational loss. A situational loss may be a pending divorce. Loss is often a tangible loss, perceived by others. However, loss can be intangible, not comprehended by others.

Loss of self-esteem, for example, is an intangible loss, as is the loss of privacy. Amputation of a limb, loss of eyesight, and loss of mobility related to ageing are examples of physical losses. Psychological loss includes decreased memory function and loss of self-worth.

• Grieving is a normal part of loss. The grief process is a normal reaction following a significant loss.

However, clinicians have determined that grief can become dysfunctional, causing greater problems.

Elaborate on when and why grief becomes dysfunctional. Normal grieving follows a fairly normal path and is marked by the ability of that person to regain functioning. With dysfunctional grieving, the person does not pass through that same path or may fail to demonstrate behaviours associated with grief.

Dysfunctional grief is manifested by a persistent pattern of intense grief that does not result in reconciliation of feelings. The bottom line is that the person experiencing dysfunctional grief is unable to adapt to life without the deceased person. A time element is associated with dysfunctional grief. Shortterm dysfunctional reactions to loss may be normal, but these same reactions over the long term more significantly point toward dysfunctional grief.

• Discuss Engle’s theory of grief and the three stages of mourning. Engle has identified grief to occur in three stages. Stage I is shock and disbelief. This stage can last from a few minutes to days. Characteristics of this stage are disorientation, perceived helplessness, and denial. Stage II is developing awareness. In this stage, there is an increase in emotional pain as the reality of the loss occurs. The individual in this stage feels powerless to change the situation. Additional characteristics of this stage include anger, guilt, sadness, isolation, and loneliness. Stage III is restitution and resolution. Characteristics of this stage include the emergence of bodily symptoms, idealisation of the deceased, mourner comes to terms with the loss, and the establishment of new social patterns and relationships.

• Kübler-Ross did much work around death and dying. Nurses have embraced her five stages as a way to identify and assist with transition through the process of dying. Discuss the five stages and why it is useful for nurses to have a theoretical basis for individual responses to dying. The five stages of dying are denial, anger, bargaining, depression, and acceptance. People move through these stages, not always sequentially. The first stage, denial, is seen as a useful coping mechanism when initially presented with the grim prognosis. The second stage, anger, is seen as a response to being powerless with the situation.

Bargaining, the third stage, occurs when the person attempts to postpone or reverse the inevitable.

Depression sets in when the person realises that bargaining will not reverse or postpone the inevitable.

This fourth stage is seen as a therapeutic tool for the dying person. The fifth stage, acceptance, comes with an awareness of peace and contentment. Not all people end their lives in this acceptance stage. The importance for nurses to use this theoretical framework is that appropriate interventions can be suggested and performed based on the stage the person is in. When a person is in the denial stage, the nurse should approach the person with understanding and work to establish a healthy nurse–patient relationship. In anger, it is important for nurses to understand that the anger they see is not directed toward them. With bargaining and depression, nurses enhance a person’s ability to cope by providing adequate support systems for the person and family. When the person is in the acceptance stage, nurses reinforce the person’s feelings and sense of personal worth. They may also help ensure that the person completes any unfinished business.

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• Discuss why the nurse needs to consider a person’s developmental level when a person is experiencing grief. Grief is individual, and depending on the person’s developmental level, the response will be experienced differently. Children vary in their ability to comprehend the meaning of death. Adolescents may have an intellectual understanding of death but may feel they are immune to death. In early adulthood, the concept of death is primarily a reflection of cultural values and spiritual beliefs. In middle adulthood, when the potential for loss increases, death forces one to acknowledge vulnerability to death.

In the older adult, death is recognised as inevitable.

• Discuss the concept of individualised loss and perception of grief. Can one theory of grief account for all expressions? It is important to understand that loss and grief are highly individualised and that people place value on what they perceive as holding importance. Even though there are many theories regarding grief, there is no one comprehensive theory to explain the grief process. It is important to look at all theories (Bowlby, Worden, Lindemann, Engle, and Kübler-Ross) and, by doing so, see how the grieving process is characterised. It is also important to include personal family experiences and the essence of cultural diversity, which will shape and format the person’s reactions and behavioural responses.

Resource aids Australian Indigenous HealthInfoNet. (2022). Grief, loss and trauma. https://healthinfonet.ecu.edu.au/learn/health-topics/social-and-emotional-wellbeing/grief-losstrauma Carpenito, L. J. (2021). Handbook of nursing diagnosis (16th ed.). Lippincott Williams & Wilkins.

Palliative Care Australia (PCA). (2018). National Palliative Care Standards (5th ed.). https://palliativecare.org.au/publication/standards Parliament of Victoria (2017). Voluntary Assisted Dying Bill 2017: Research Note (1).

Higgins, R., 'Tangihanga – death customs', Te Ara - The Encyclopedia of New Zealand, http://www.TeAra.govt.nz/en/tangihanga-death-customs

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies •

Discuss with students the ways in which nurses can assist people in the grieving process. Elaborate on determining signs of dysfunctional grief as opposed to normal grieving patterns. Refer to the Nursing highlight box ‘Problem identification: Complicated grieving’.

•

Have students write out the feelings and beliefs that they have about death and dying. Have them begin to look at how they expect to provide care to a dying person. Are there issues around death and dying that may affect the type of care they are able to give?

•

Have the students read the Spotlight on critical thinking box ‘Compassion: Allowing time to grieve entitled’. Break the students into small groups to answer the associated questions. Discuss the answers to the questions in a larger group.

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Use a case study in which the dying person has given permission to surrender his organs at his death for transplantation purposes. The grieving family members are against this procedure. You have already called a nurse from a transplant team to talk with the family. Have students assume the roles of patient, family members, transplant nurse, clergy, and social worker and act out this situation. What issues appear? What role does the nurse play? How are personal beliefs of the nurse manifested in this situation?

•

Invite palliative care nurses to the classroom to discuss their role in providing care to terminally ill people. If able, have students participate in care provided to these people in the form of a home care clinical experience. Afterward, discuss as a group the experience, challenges, and personal feelings when working with people experiencing end-of-life issues.

•

In a large group, discuss the care that is provided to a person who has died. What needs to be done to prepare the body to be viewed by the family? What if the person is having an autopsy? What are the religious and cultural considerations for a person who has died?

•

Invite a panel of clergy to discuss different religious views of death and dying. Perhaps add some people with different cultural views.

•

Have students discuss the different aspects of grief and loss as represented in society by looking at films, television, and news documentaries. How does society shape our perception of death and our responses to end of life?

•

Discuss concepts of grief and loss for people from different cultures.

Review questions 1.

Which of the following statements is correct? a. There is no one comprehensive theory to explain grief. b. There are no resources for supporting a person experiencing grief. c. People experiencing grief follow a set trajectory of bereavement. d. People who are grieving always desire to be surrounded by their family and friends. e. There are no resources about care of the dying person.

Answer: a Rationale: There is no one comprehensive theory to explain grief. Traditionally grief has been described as consisting of a series of phases. It is now recognised that not everyone may experience each phase in the order described or in fact each specific phase when grieving.

2.

Which of the following nursing actions are therapeutic for dying people? a. Apply nursing presence. b. Avoid the use of touch. c. Discuss only issues over which the person has control. d. Limit family visits in order to conserve person’s energy.

Answer: a Rationale: Nursing presence (being with the person) encourages verbalisation, reduces anxiety, and reinforces self-esteem. Touch should be used with the dying person (within culturally acceptable beliefs) to promote a sense of comfort. It is important for people to express their feelings of

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powerlessness over the inevitability of death. Family members should be encouraged to participate in care of the dying person.

3.

Rigor mortis occurs approximately: a. 2–4 hours after death b. 6–8 hours after death c. 10–12 hours after death d. 14–16 hours after death e. 16–24 hours after death.

Answer: a Rationale: Approximately 2–4 hours after death, rigor mortis occurs; this is a stiffening of the body caused by contraction of skeletal and smooth muscles.

4.

Which of the following postmortem activities by the nurse helps decrease the effects of rigor mortis? a. Close the body’s eyelids and mouth b. Lower the head of the bed c. Place the body in the high-Fowler’s position d. Remove tape carefully from the skin e. Do not touch the person Answer: a Rationale: To prevent disfiguring effects of rigor mortis, as soon as possible after death you should close the eyelids, insert dentures (if applicable), close the mouth, and position the body in a natural position.

5.

A person is admitted to the hospital and is in the terminal stage of cancer. The nurse enters the person’s room to administer some medicine and finds the person crying. Which of the following is the most therapeutic nursing action? a. Administer the person’s medication and leave so the person can cry in private. b. Call the family to come to the hospital to stay with the person. c. Sit down and hold the person’s hand. d. Tell the person that you will call the person’s minister. e. Quietly leave the room Answer: c Rationale: Spending time with the person demonstrates the use of nursing presence, which is therapeutic to all people, especially those who are frightened or anxious.

6.

A terminally ill person has been referred to hospice care. Which of the following information should a nurse give this person and their family? a. ‘Hospice uses minimal pain medication in order to improve the quality of life.’ b. ‘Hospice will make you accept the impending death.’ c. ‘The focus of hospice care is to make you more comfortable.’ d. ‘The major purpose of hospice is to support the family after their loss.’ e. ‘The aim of hospice care is to rehabilitate health.’

Answer: c Rationale: Hospice care is provided to help maintain the dignity and comfort of dying people. Pain relief is a major component of Hospice care.

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7.

A recently widowed person describes how she is having difficulty sleeping. She states that last night she woke up because she heard the voice of her husband calling her name. Which nursing response is most therapeutic? a. Inform the prescribing practitioner that the person needs a prescription for sleeping pills. b. Reassure the person that these behaviours are a normal part of grieving. c. Refer the person to a mental health clinic for immediate assessment. d. Tell the person that she will feel better soon. e. Inform the patient that it must be in their imagination.

Answer: b Rationale: Experiencing the presence of the deceased is a normal response in the early stages of grief.

These experiences can occur through any sensory perceptual channel, for example, seeing the deceased, hearing the voice of the deceased, or smelling the cologne used by the deceased.

8.

A nurse is providing postmortem care for a person. Which of the following interventions would be appropriate prior to allowing the family to visit? a. Call the prescribing practitioner to verify the time of death before allowing the family to see the body. b. Keep the sheet over the person’s face until the family is comfortably seated in the room. c. Prepare the body to look as clean and natural as possible. d. Wear sterile gloves to pack the anal canal with gauze. e. Ask the family to wait until you finish your lunch break.

Answer: c Rationale: The body should be prepared to look as natural as possible. Therefore, the nurse removes all tubes, equipment and so forth and cleanses the body for family viewing.

9.

Which of the following losses can result in grief? a. Loss of an external object b. Loss of familiar environment c. Loss of aspect of self d. Loss of significant other e. All of the above.

Answer: e Rationale: These are the four major categories of loss. Grief can be associated with all types of loss.

10. Which of the following is not a type of grief? a. Uncomplicated grief b. Abnormal grief c. Disenfranchised grief d. Anticipatory grief Answer: b Rationale: Grief is a universal health response to loss. There are many different types of grief.

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Spotlight on critical thinking Compassion: allowing time to grieve Your co-worker, who is also your friend, has just lost a loved one whose funeral was today. Tomorrow your friend must return to work because his 5-day bereavement leave is over. He is dealing with many intense emotions as well as a lack of energy. Society dictates that he returns to work.

1.

How do you deal with his lack of productivity at work?

Suggested solution: Work with him as a team to look after both of your patients. (You might need to ask the RN to reduce the patient load for each of you). Remind him to do some of the things (e.g., medication rounds) as they are due and check medications with him (grief affects your ability to concentrate). Help him to document appropriately.

2.

How do you provide support to him?

Suggested solution: Express your condolences, then just listen to him, give him time, be silent with him as appropriate. Do not offer advice unless asked. Do not try to distract him from the grief. Bring him to the here and now when necessary – such as when on duty.

3.

How would you respond if he continued to display a lack of energy 6 months from now?

Suggested solution: Continue to listen to him and provide support.

Caring: nurses and the vulnerability of grieving Nurses need to feel as free to ask for help in dealing with feelings about a dying person as they would in asking for assistance in lifting and repositioning a person in bed. Asking for help means taking a risk to be vulnerable; some nurses fear appearing emotionally vulnerable or overwhelmed.

4.

How can nurses support each other in dealing with the grief of caring for dying people?

Suggested solution: Allowing expressions of grief in the tearoom, etc. Discuss death, dying, grief at a time when there is no one dying. Listen to colleagues as they express grief. Do not be embarrassed by their or your own expressions of grief.

5.

Consider strategies that you would use if feeling emotionally vulnerable or overwhelmed.

Suggested solution: Seek support and counselling from peers, a trusted RN or chaplain. Talk about the grief. Cry when appropriate.

6.

Is it acceptable to display your emotions when caring for dying people?

Suggested solution: Yes, tears in your eyes when caring for someone who is dying demonstrates your regard for them, but do not be too vocal – no wailing or overt crying/sobbing as this adds to the burden of the person and of their family.

7.

What resources are available to support nurses’ wellbeing when caring for dying people?

Suggested solution: Resources include supports within the health care organisation such as pastoral care and counselling services.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 3 Online resources.................................................................................................................................................. 3 Review questions................................................................................................................................................. 5 Spotlight on critical thinking ................................................................................................................................ 7

Chapter 29 Mental health Key terms Asylum A protected and safe place.

Cultural safety The provision of quality health care that acknowledges and uses the everyday values and beliefs of the individual who is of a culture different to the nurses’ and/or the majority culture.

Deinstitutionalisation Within the context of mental health care, refers to the downsizing of large psychiatric institutions and caring for people with mental disorder within the general community.

Delusions A fixed, false belief that is not amenable to reason by another person.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Publication by the American Psychiatric Association detailing a classification system for mental disorders to aid with assessment, treatment and outcomes; DSM-5 is the current version.

Hallucination A sensory perception that occurs in the absence of external stimuli and is not based on reality.

Mental disorder A condition or illness that can cause dysfunction in the psychological, affective, behavioural, physical and social aspects of a person’s daily existence.

Mental health State of being where a person is functional within the psychological, affective, behavioural, physical and social aspects of their daily existence.

Mental health legislation Legal process put in place primarily to deal with involuntary assessment and treatment; also covers independent review of involuntary treatment and the individual’s rights.

Mental health nurses Specialty practice area of nursing that focuses on people who have a mental illness, dysfunction or disorder.

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Mental health promotion Population-based approach to ensuring programs are in place to improve every person’s mental health and prevent mental disorder.

Mental state assessment (MSA) Standardised procedure for gathering information to determine the cause, diagnosis, prognosis and treatment of mental conditions.

Pharmacological therapy Prescription and administration of medication to treat mental and physical disorders.

Psychological therapy Prescription and administration of psychological therapies (e.g., cognitive behavioural therapy) to treat mental disorder.

Recovery model Model of care instituted as soon as mental disorder begins; aims to instil hope, positivity and how to live healthfully no matter on which part of the trajectory the person finds themselves.

Stigma Phenomenon in which a person is exposed to discriminatory practices by other people based on fear and ignorance.

Therapeutic relationship Deliberate relationship formed between the person with mental disorder and the health worker; there is agreement that it is a collaborative relationship with the purpose of recovery for the person with the mental disorder.

Instructional strategies • Differentiate between mental health and mental disorder and give an example of each. o Mental health – defined by the World Health Organization as a state of wellbeing in which every individual realises his or her own potential, can cope with the normal stressors of life, can work productively and fruitfully, and is able to make a contribution to their community. It is not just the absence of mental disorder. An example would be a young person who successfully attends university, describes themselves as happy and healthy and volunteers at a community centre. o Mental disorder – is usually a diagnosable condition which interferes in a person’s life to the extent that they may have challenges in carrying out activities of daily living. Examples include depression, anxiety, and schizophrenia.

• Describe the history of mental health care and how it has influenced current mental health care practice.

A summary of the history of mental health care is provided in the chapter. Through its chronological presentation, the evolution of current practice is clearly demonstrated. There is opportunity for students to explore the different eras of mental health care and study the persons or institutions that were influential in that time period. Alongside of this is the study of the mental health care system changes driven through major government policy directives and legislative changes.

• Discuss stigma and how this may be overcome by the actions of a nurse. People with mental disorder not only have to cope with what is often a severe, limiting and chronic condition but also with a society that on the whole is fearful and rejecting. As a qualified health worker, it is the responsibility of the nurse to understand stigma, how it makes a person with mental disorder feel and how it compounds problems for the recovery process. Combating stigma can be done at a public health level and at an individual level which can involve the nurse. In this topic, the student can explore what is being done at a public health level and examine the effectiveness of these strategies and what is preventing a stigma free society. The student can examine their own attitudes and ways of dealing with stigma when it occurs.

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• Issues with psychotropic medication administration. Psychotropic medications are used to treat all the major mental disorders such as schizophrenia, mania, depression, and anxiety. Theories on what causes mental disorder and how they have driven the development of psychotropic medications. For example, excessive amounts of dopamine in the brain are thought to cause psychotic symptoms. Therefore, antipsychotic medication blocks the release of dopamine. However, this may result in the occurrence of extrapyramidal symptoms (EPS). Some EPS can be permanent and highly undesirable for the person with the mental disorder to the extent whereby they will refuse to take the medication. Students can explore what to do if this situation occurs. Understanding the medication and its action is only part of the responsibility of the nurse in medication administration and when educating a person who has been prescribed these medications. Other issues to explore in relation to this topic include tolerance, adherence, dependence and withdrawal.

• Discuss the difference between delusions and hallucinations. These are often confusing concepts for students and one way to help with understanding is to use experiential learning techniques, such as, role play. In this instance students can work in pairs, where one plays the role of the nurse and the other the person with a mental disorder. They can then switch roles to get a better perspective of what the person is experiencing and the importance of well-developed interpersonal skills and the value of the therapeutic relationship. Feeding back the experience to the larger group of students will help to consolidate the learning experience.

Discuss the different types of mental disorder. This can be an encompassing topic which takes in prevalence rates and how a diagnosis is established through the use of the DSM-5. Using a case example, from child and youth through to older persons, the students can look assessment and the compare and contrast the different therapeutic approaches – physical and psychological – used for treatment.

Resource aids American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 There are many movies, you-tube videos, books, and autobiographies that can be used to illustrate mental disorder and its effect on a person.

Online resources • Australian Integrated Mental Health Initiative (AIMhi) aims to improve outcomes for remote Indigenous clients of mental health services in remote Top End communities. Two key interventions are: development of two-way mental health promotion resources (for health professionals, clients, and carers) and development of new approaches to service delivery. http://www.menzies.edu.au/page/Research/Projects/Mental_Health_and_wellbeing/AIMhi_NT__Australian_Integrated_Mental_Health_Initiative/ • Māori health is a comprehensive website to access information related Māori health including He Korowai Oranga: Māori Health Strategy; Māori philosophy towards health which is based on a wellness or holistic health model; Whānau Ora which places families/whānau at the centre of service delivery; and, Rongoā Māori (Māori medicine) which is informed by a body of knowledge that has as its core the enhancement of Māori wellbeing http:/www.health.govt.nz/our-work/populations/maori-health

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• Mental Health Australia (MHA) is the peak, national non-government organisation representing and promoting the interests of the Australian mental health sector, committed to achieving better mental health for all Australians. MHA members include national organisations representing consumers, carers, special needs groups, clinical service providers, public and private mental health service providers, researchers, and state/territory mental health peak bodies: https://mhaustralia.org • Mental Health in Multicultural Australia provides a national focus for advice and support to providers and governments on mental health and suicide prevention for people from culturally and linguistically diverse (CALD) backgrounds. https://mhaustralia.org/tags/mhima • Office of the Health and Disability Commissioner (New Zealand; HDC) it is the role of the HDC to promote and protect the rights of health and disability service consumers. Thus, the HDC’s statutory role includes the monitoring of mental health and addictions services, and advocating for service improvements to improve mental health and wellbeing: https://www.hdc.org.nz • Convene a panel of mental health care experts (consumer, carer, registered nurses) to discuss the topic of ‘What to expect and what to do on your first mental health clinical placement’. Have students be prepared to ask questions of the expert panel in terms of the importance of therapeutic communication, assessment, and symptom management for clients who require mental health care.

• Have students write a reflective journal on how important reducing stigma is in maintaining mental health. What problems do they think will occur when clients experience stigma?

• Have students listen to a recording of delusional or hallucinatory content and while the recording is ongoing ask them to undertake some tasks, for example, carry out a conversation, read some material, watch television or work at a computer. Discuss the information gained from the experience and how distressing these symptoms would be and the potential impact on a person’s ability to carry out activities of daily living. Another useful task is to have students undertake a roleplay experience of hearing voices where one student tells a story to another while a third student reads from a script into the ear of the storyteller. It helps students understand how concentration might be impacted in the presence of voices or other phenomenon.

• In the clinical area, have students identify clients who are prescribed medications for mental disorder.

Identify the type of medication prescribed, actions and the range of possible side effects. Assess the client for effectiveness of psychotropic medication. Include in the assessment how the client feels after using a psychotropic medication and what side effects they experience. Discuss the client assessments after the clinical experience.

• Have students analyse how delusions, hallucinations and negative thoughts are managed in clients in the clinical setting. Have students provide documentation of what interventions are used and whether or not responses to interventions are documented in the clinical notes.

• Have students discuss appropriate assessment and intervention for a client suspected of practising drugseeking behaviour. Give examples of effective assessments for distinguishing between actual physical need and psychological demand for addictive substances.

• Encourage class discussion on how physical health and mental health issues are related. Include respiratory status, elimination, and mobility.

• Have students debate whether people with mental disorder should be routinely institutionalised or treated within the community? © Cengage Learning Australia 2024

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• Have students practise mental state assessment among various age groups with appropriate mental state assessment forms.

• In the laboratory setting, provide complementary or alternative mental disorder management modalities for the students to practise, such as relaxation tapes, guided imagery, progressive muscle relaxation techniques, and massage techniques.

Review questions 1.

Which of the following nursing interventions are most appropriate for a person who threatens selfharm or suicide: i. Know the whereabouts of the person at all times. ii. Provide a consistent, structured environment for the person. iii. Decrease environmental stimuli for the person. iv. Observe, record and report any changes in the person's mood. a. i and ii b. i and iv c. ii and iii d. None of the above.

Answer: b Rationale: A person who threatens self-harm or suicide would be evaluated as a high risk and therefore would require close or one-to-one supervision by a staff member. They may not reveal what their plans are and therefore it is important for the nurse to know the whereabouts of the person at all times.

Sudden mood changes can be an indication of an increased risk of self-harm or suicide.

2.

A person tells the nurse that his neighbour was putting nerve gas through cracks in the walls of his house. This person is possibly experiencing: a. a delusion b. an hallucination c. a depressive episode d. an episode of apathy e. none of the above.

Answer: a Rationale: A delusion is a fixed, false belief that is not amenable to reason by another person. It is not a hallucination as there is no sensory involvement. Such a statement is not an example of a symptom of a depressive episode.

3.

Of the groups of medications listed below, which is an antidepressant? a. Benzodiazepines b. Tricyclics c. Phenothiazines d. Butyrophenones e. Anxiolytics.

Answer: b

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Rationale: Tricyclics are a type of antidepressant. Tricyclics stop the uptake of nor epinephrine and/or serotonin which increases the availability of monoamine neurotransmitters.

4.

Which of the following reflects a therapeutic response by the nurse? a. ‘This is a hospital. No one is going to hurt you.’ b. ‘It must be frightening to think that others want to hurt you.’ c. ‘Does this thinking have its basis in the fact that you were given ECT.’ d. ‘I can see that you’re uncomfortable with me around, so I will leave you alone.’ b. ’ Medication is the best treatment for your anxiety.’

Answer: b Rationale: This response reflects what feelings the person is experiencing, and it demonstrates that the nurse understands what the person is going through. It opens up the opportunity to discuss how to deal with frightful feelings and takes the emphasis off external factors that may be beyond the control of the person. The other choices do not reflect empathy or caring.

5.

Which of the following characteristics is not likely to indicate a psychotic disorder? a. Loss of sense of reality b. Hallucinations c. Severe motor impairments d. Delusions e. Poverty of speech and loss of motivation.

Answer: c Rationale: A psychotic disorder is characterised by the person losing touch with reality and disordered thoughts which include hallucinations. Poverty of speech and loss of motivation are also very common.

Severe motor impairment can occur in very extreme cases of psychotic disorder.

6.

A person comes to the emergency department saying, ‘Maybe I need help. I don’t know’. The nurse performing triage can initially function on the assumption that the person is: a. suicidal b. potentially homicidal c. misperceiving reality d. manic e. anxious and confused.

Answer: e Rationale: When in crisis, anxiousness is a common reaction with a person’s perceptual field narrowing as a consequence. The act of thinking logically becomes difficult and a person can be confused.

7.

A patient was admitted to the inpatient unit two days ago in a depressed mood and has not left her room to go to the dining room for meals. The nurse’s most appropriate therapeutic response to encourage the person out of their room might be to say: a. ‘You will feel better if you go to the dining room and eat with the others.’ b. ‘I will walk with you to the dining room and sit with you while you eat.’ c. ‘Where would you like to eat your meal?’ d. All the patients must attend the dining room at least once per day.’

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Answer: b Rationale: At this early stage it is important to allow the person to identify what might be most comfortable with a priority to encourage the person to eat. The nurse presents self in a supportive therapeutic way in order to encourage the person to take some time out of their room.

8.

Which of the following might the nurse observe in the person with mania? a. Hyperactivity b. Decreased need for sleep c. Rapid speech d. Grandiosity e. All of the above.

Answer: e Rationale: All of the responses given may be evident in a person experiencing mania.

9.

What is the first step in ensuring a nurse works in a culturally safe way? a. Learning the language of the person they are caring for b. Reading about the cultural practices of diverse cultural groups c. Undertaking a process of self-reflection and self-awareness d. Asking the patients spouse what to do e. All of the above.

Answer: c Rationale: The first part of becoming a culturally safe nurse is to reflect on self as a cultural being and then in doing so realise that every other person has their own cultural ways.

10. Which of the following is a reason someone may be placed under the Mental Health Act? a. The person is depressed b. The person hears voices c. The person has suicidal thoughts d. The person presents a risk to self or others e. All of the above.

Answer: d Rationale: There must be a risk for the Mental Health Act to be initiated. Not all people who experience mental health symptoms present with risks.

Spotlight on critical thinking Stigma A close friend has been diagnosed with schizophrenia.

1.

What do you think they are experiencing at this time?

2.

How are you going to react and what are you going to say the next time you see them?

Suggested solution: When responding to these questions, students may consider the impact of diagnosis and how a person may react to this given the prognosis for mental disorders. It is important to emphasise that as a qualified health worker their response is expected to be considered, informed and empathetic.

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3.

How might a diagnosis of a mental disorder differ from a diagnosis of a physical disorder?

Suggested solution: When responding to this question students may consider how a person may be treated when they are diagnosed with a physical disorder such as diabetes and how a person may be treated if they are diagnosed with any mental disorder.

Recovery 4.

What would constitute recovery for a young person with schizophrenia?

5.

What would be the challenges to the recovery process?

Suggested solution: When responding to this question students may consider how individualised and person-centred mental health care needs to be to ensure recovery for a person. There needs to be an appreciation for the complex nature of the impact of mental disorder on a person and the difficulties a person faces on a daily basis.

Mental state assessment You have been given an opportunity to conduct a MSA on a person who has never previously been admitted for a mental disorder.

6.

How are you going to engage with this person so that they trust you and feel valued, respected and included in the decisions made about their care?

Suggested solution: When responding to this question students may consider all the aspects to developing a therapeutic relationship.

Medication You are unfamiliar with the current medications used to treat depression. Access a pharmacology text and note the medications for the treatment of depression and collate the answers to the following question: 7.

What are the desired medication effects and the adverse reactions?

Suggested solution: When responding to this question students may consider that physical therapy such as medication administration is often a key feature of treatment and as a qualified health worker, they are expected to have in-depth knowledge of this subject to ensure the safety and comfort of the person.

Mental health promotion 8.

Why is physical health care just as important as mental health care for a person with mental disorder?

9.

Why is this an aspect of care that gets overlooked?

Suggested solution: When responding to this question students may consider that mental health care is closely related to and often dependent on physical care and vice versa.

Culturally safe nursing practice There is much written about practising nursing in a culturally safe way and how important this is to ensure practice is person centred.

10. What are three important components of culturally safe nursing practice to ensure care is personcentred and safe?

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Suggested solution: When responding to this question students may consider the important of selfreflection and awareness by the nurse in recognising own cultural values and beliefs in order to respect the values and beliefs of others that will be different to them. They may also talk about how being sensitive to the cultural needs of others is also really important as well as realising that it is the person who decides if the care provided is safe, not the nurse.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 3 Resource aids....................................................................................................................................................... 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking ................................................................................................................................ 9

Chapter 30 Vital signs Key terms Adenosine triphosphate (ATP) Transports energy within cells for metabolism.

Afterload Force against which the heart must work or the amount of pressure the ventricle must work against during contraction.

Anaerobic respiration Respiration without oxygen; this form of metabolism is less efficient than aerobic and produces waste products such as lactic acid.

Arterial oxygen saturation (SaO2) Measurement of the amount of oxygen carried in the arterial blood.

Arterial partial pressure of oxygen (PaO2) Pressure exerted by the oxygen within the arterial system.

Atherosclerosis Disease characterised by narrowing and eventual occlusion of the lumen (opening of the arteries) by deposits of lipids, fibrin and calcium on the interior walls of the arteries.

Auscultatory gap The temporary disappearance of sounds at the end of Korotkoff phase I and beginning of phase II. Basal metabolic rate (BMR) Energy needed to maintain essential physiological functions when a person is at complete rest both physically and mentally.

Blood pressure (BP) Measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole.

Bradycardia A heart rate less than 60 beats per minute in an adult.

Bradypnoea Respiratory rate of 10 or fewer breaths per minute.

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Cardiac output Measurement of blood pumped by the heart in one minute; measured by multiplying the heart rate by the ventricle’s stroke volume.

Conduction Loss of heat to an object in contact with the body.

Contractility Strength and force of the contraction that ejects the blood.

Convection Movement of heat away from the body’s surface through the air.

Costal (thoracic) breathing Occurs when the external intercostal muscles are used to move the chest upward and outward.

Cyanosis Blue or grey discolouration of the skin resulting from reduced oxygen levels in the arterial blood.

Diaphragmatic (abdominal) breathing Occurs when the diaphragm contracts and relaxes, as observed by the movement of the abdomen.

Diastole Process of cardiac chamber filling.

Dyspnoea Difficulty in breathing as observed by laboured or forced respirations through the use of accessory muscles in the chest and neck to breathe.

Dysrhythmia Irregular heartbeat.

Escalation The processes instituted for those individuals who are clinically deteriorating to improve their recovery and survival.

Eupnoea Easy respirations with a normal breath rate of breaths per minute that are age-specific.

Evaporation Continuous insensible heat loss from the skin and lungs when water is converted from a liquid to a gas.

Expiration Movement of gases from the lungs to the atmosphere.

Haemodynamic regulation Physiological function of blood circulating to maintain an appropriate environment in tissue fluids.

Haemoglobin Oxygen transport protein found in red blood cells.

Heart rate The number of times the heart ejects blood out of the ventricle per minute.

Hypertension Refers to a persistent systolic pressure greater than 135–140 mmHg and a diastolic pressure greater than 90 mmHg. Hyperventilation Characterised by deep, rapid ventilations.

Hypotension Systolic blood pressure less than 90 mm Hg or 20−30 mm Hg below the client’s normal systolic pressure.

Hypoventilation A systolic BP less than 90 mmHg or 20–30 mmHg below the person’s normal BP. Insensible heat loss Heat that is lost through the continuous, unnoticed water loss that occurs with evaporation.

Inspiration Intake of air into the lungs.

Korotkoff's sounds Noises heard over (usually) the brachial artery through the stethoscope during auscultation while reading the BP. They are caused by initially reducing the pressure in the artery to below

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the systolic pressure, then releasing the pressure so that blood flows through the artery with each pulsation.

The turbulence causes vibrations against the artery wall, and this is heard as characteristic noises.

Lactic acid A form of incomplete intracellular breakdown of sugar, or other organic compounds in the absence of oxygen that releases adenosine triphosphate (ATP). multiparameter (aggregate scoring) system Assigns a score to each vital sign based on the level of abnormality; sometimes referred to as a modified early warning score (MEWS).

Neurogenic fever Long-term elevation of body temperature thought to result from a disruption of the normal body temperature set point because of damage to the hypothalamus.

Orthostatic hypotension (OH) Refers to a sudden drop of 25 mmHg in systolic pressure and 10 mmHg in diastolic pressure when the person moves from a lying to a sitting position, or from a sitting to a standing position.

Oxygen (O2) Chemical element used in cellular respiration.

Oxygen delivery Volume of the chemical element oxygen being transported to tissues per minute.

Peripheral oxygen saturation (SpO2) Measurement of the oxygen attached to the haemoglobin in the peripheral arterial blood.

Peripheral vascular resistance (PVR) Resistance to blood flow that must be overcome to push blood through the blood vessels.

Piloerection Hairs standing on end because of the body’s decrease in body temperature, reaction to fear.

Pleura Lining of the chest cavity.

Preload The volume of blood that enters the heart (i.e., the end diastolic volume).

Pulse deficit Condition in which the apical pulse rate is greater than the radial pulse rate.

Pulse equality Comparison of pulses between sites, such as apical to radial with same site on different side of the body; unequal pulse may indicate blockages or a reduction in flow.

Pulse oximeter Sensor device used to measure the oxygen saturation level of the haemoglobin in peripheral blood.

Pulse pressure (PP) Measurement of the ratio of stroke volume to compliance (total distensibility) of the arterial system.

Pulse rate Indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point.

Pulse rhythm Regularity of the heartbeat.

Pulse volume Measurement of the strength or amplitude of the force exerted by the ejected blood against the arterial wall with each contraction.

Pyrexia When heat production exceeds heat loss and body temperature rises above the normal range.

Radiation Loss of heat in the form of infrared rays.

Respiration The act of breathing.

Respiratory rate (RR) The number of breaths per minute.

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Shock State of inadequate oxygen delivery to the tissues.

Single parameter systems An escalation for medical review may be triggered by one vital sign abnormality.

Sphygmomanometer Device used to measure BP. Stroke volume Measurement of blood that enters the aorta with each ventricular contraction.

Sympathetic blockade The actions of medications (such as beta blockers) that block the sympathetic response resulting in reduced heart rate.

Systole Process of cardiac chamber emptying or ejecting blood.

Tachycardia A heart rate more than 100 beats per minute in an adult.

Tachypnoea RR greater than 20 breaths per minute in an adult.

Thermoregulation Body’s physiological function of heat regulation to maintain a constant internal body temperature.

Track and trigger system Vital signs are recorded, and a score is allocated to those that are outside of the normal range. Individual scores are summed to a total which indicates the severity of abnormal vital signs, and if high enough can then trigger an escalation pathway for clinical review.

Vasoconstriction The narrowing of the vessels, usually leading to reduced blood flow Vasodilation The widening of the vessels, usually leading to increased blood flow.

Vital signs (VSs) Measurement of the person’s body temperature (T), pulse (P) and RR, blood pressure (BP), oxygen saturation, LOC and pain assessment.

Instructional strategies • Understanding vital signs as indications of adequate (or not) indicators of tissue oxygen perfusion is integral to being a safe nurse.

• Ask the students to discuss each of the following in small groups and report back to the large group to collate the material and discuss the integration of each with the others. Nurses need to understand the very complex and integrated relationship between these assessments in order to detect, analyse and act on the changes noted.

• Oxygen importance: a person's well-being is dictated by the adequacy of the circulation system to service the needs of the body tissues. A critical service is the delivery of oxygen to tissues. Oxygen is essential for adequate production of a cell’s source of energy, adenosine triphosphate (ATP), to allow for normal cellular function. In the absence of adequate oxygen delivery, inadequate amounts of energy (ATP) are formed through anaerobic respiration with the production of a waste product, lactic acid. The inadequate amounts of energy (ATP) results in cellular dysfunction, which can lead to organ dysfunction. Anyone with organ dysfunction is at risk of critical illness and death.

• The classical vital signs (pulse, blood pressure and respiratory rate and oxygen saturation) provide an insight into the adequacy of oxygen delivery to the tissues, which will reflect the overall well-being of the person.

• the oxygen delivery equation is important so the nurse can understand changes in vital signs that may reflect compensation or decompensation in the person’s condition. © Cengage Learning Australia 2024

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• Compensation – what is it and how does it occur?

• Decompensation – what is it and how does it occur? What happens to the person if they decompensate?

• Baseline vital sign values establish the norm. Outline the normal values for adults and the elderly. What other factors may influence normal values (e.g., obesity, chronic diseases, medication) Variations from normal may indicate possible problems with the person’s health status. Identify vital sign variations from normal (e.g., aging, illness, medications, exercise, etc). o Pulse – The pulse rate is measured in beats per minute. A normal pulse rate ranges between 60 and 100 beats per minute in adults. A pulse rate above 100 beats per minutes is tachycardia, and a pulse below 60 beats per minute is bradycardia. Discuss the effect on tissue oxygenation of both tachycardia and bradycardia. What compensatory mechanisms are there for these o Blood pressure – Blood pressure is measured in millimetres of mercury (mm Hg). A systolic blood pressure less than 90 mm Hg or 20 to 30 mm Hg below the person’s baseline is called hypotension.

How does the body compensate for hypotension? Hypertension refers to a persistent systolic blood pressure greater than 135 to 140 mm Hg and a diastolic blood pressure greater than 90 mm Hg. That pressure must be sustained for a period of time to receive the diagnosis of hypertension. Does the body compensate for hypertension? o Respirations – Respirations are measured in breaths per minute. Normal respirations are characterised by a respiratory rate ranging from 12 to 20 breaths per minute. A rate greater than 24 breaths per minute is called tachypnoea. How does tachypnoea affect tissue oxygenation (think about hyperventilating, panic)? A rate at or below 10 breaths per minutes is bradypnoea. What is the compensatory mechanism for this? o Oxygen Saturation – Oxygen Saturation is measured as a percentage of haem binding sites on the haemoglobin molecule that are saturated with oxygen. A normal saturation for a fit healthy adult is above 95 per cent on room air. A variation below this should be reviewed. Review the oxygen dissociation curve chart. o Temperature – Body heat is measured in units called degrees. The normal ‘core’ internal temperature is 37ºC). The normal range does not vary more than 0.77ºC. Above normal baseline is hyperthermia.

How does the body deal with hyperthermia? A reading below normal is hypothermia – what mechanisms does the body use to raise the temperature?. o Level of consciousness – Level of consciousness is assessed as part of the vital signs to measure the oxygen delivery and energy production of the brain cells. Measurement scales can vary between different health organisations. AVPU is one method. A – Alert is assigned to anyone who has spontaneous eye opening and who interacts without prompting. V – Voice; this is assigned to a person who requires a verbal interaction such as calling their name in order to gain a response. P – Pain; this is assigned to someone who requires a painful stimulus in order to gain a response. Painful stimulus such as a trapezius squeeze may be used to elicit a response. U – Unresponsive this is a person who does not respond despite the application of a painful stimulus. Anyone who has changed a category or who scores a P or U (who previously were alert) requires immediate medical review. o Cardiac output is the product of stroke volume and heart rate. (In the presence of reduced oxygen delivery, the body will attempt to compensate by increasing the heart rate to improve cardiac output.

In addition, the respiratory rate will increase to improve the amount of inspired oxygen but also to

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attempt to remove the waste products of anaerobic metabolism. Hence a rise in respiratory and heart rate can be early signs of inadequate oxygen delivery. o Decompensation – Once the compensatory mechanisms are exhausted, they begin to fail and then there will be a subsequent drop in cardiac output and blood pressure. In addition, the oxygen saturations may begin to fall. o Trends – It is important when measuring vital signs not to just measure individual parameters but to complete a full set to see the entire picture of vital signs that might indicate compensation.

• Discuss factors that influence vital signs. Several factors can cause changes in the vital signs: age, gender, heredity, race, lifestyle, environment, medications, pain, exercise, metabolism, anxiety, stress, postural changes, diurnal variations and hormones. The nurse needs to take into consideration all of these factors when assessing the vital signs of an individual before determining if a finding is a normal variation or an abnormal finding.

• Why are observation response charts linked to an escalation pathway important? Observation response

charts make it easy for the clinician to see when the parameters fall outside of the normal range. Linking the response chart to an escalation pathway ensures that the sicker the person is the faster and more senior the medical review they will receive.

Resource aids Estes, M. E. Z., Calleja, P., Theobald, K. & Harvey, T. (2020). Health assessment and physical examination (Australia and New Zealand 3nd ed.). Cengage Learning.

Vital signs [video]. Health Sciences Consortium.

Evaluation strategies • Identify what factors cause or contribute to a change in baseline vital signs.

• How does pain affect vital signs?

• When student nurses begin obtaining vital signs, they may have difficulty. Encourage students to verbalise and offer techniques or suggestions to aid in their comfort level with taking vital signs.

• In a laboratory setting, provide the students with different scenarios that illustrate proper techniques of taking vital signs. Examples include (1) a person being admitted (look at position, environment, clothing, activity, ingestion of stimulants, cuff size and placement, quiet); (2) an obese individual who has to have his or her blood pressure taken, (3) an infant who has to have his or her temperature taken with an axilla thermometer, and (4) an individual on whom you need to obtain a carotid pulse. Discuss the importance of both accurate findings and identification of correct techniques and equipment to obtain results.

• Have the students practise using electronic and manual equipment. Have students identify strategies to assess the accuracy of the electronic equipment such as the measurement of a manual pulse when using a pulse oximeter.

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• Divide the students into groups of two and have them conduct a complete vital sign measurement on their partners. When measuring pulse rate, suggest that the students practise more than one pulse point (such as the carotid, radial, ulnar, and popliteal). When measuring blood pressure, have the students measure the pressure on both arms.

• Provide role play scenarios where observation charts require interpretation and escalation. Students can practise a clinical handover of the abnormal findings.

Review questions 1.

The measurement of blood that enters the aorta with each ventricular contraction is called the: a. pulse b. stroke volume c. aortic input d. cardiac output e. PP Answer: b Rationale: Stroke volume is the measurement of blood that enters the aorta with each ventricular contraction. The pulse is the pressure wave of blood flow in an artery. Cardiac output is the volume of blood pumped by the heart in 1 minute and is measured by multiplying the heart rate by the ventricle’s stroke volume. Pulse pressure is a measurement of the ratio of stroke volume to compliance of the arterial system.

2.

In a set of VSs, you observe tachycardia. How does tachycardia relate to a failing oxygen delivery to the tissues? Tachycardia delivers more oxygen to the tissues: a. by speeding up the rate of ventricular contraction b. by increasing the oxygen levels in the bloodstream c. by increasing the uptake of oxygen to the haemoglobin in the blood d. by increasing the strength of ventricular contraction to deliver a larger bolus of blood per beat e. all of the above.

Answer: a Rationale: Tachycardia generally occurs when the body's cells are not getting enough oxygen to produce energy. The heart increases the speed of contraction to compensate and deliver more oxygen. If this occurs, the rate and depth of respiration also increase if the increased rate of the heart do not deliver sufficient oxygen to the tissues.

3.

Compensation for a decreased oxygen delivery will include which of the following options? a. Increased urine output b. Decreased PVR c. Decreased RR d. Increased RR e. Increased heart rate.

Answer: e

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Rationale: Per the previous question the increased heart rate is the bodies attempt to compensate for poor oxygen delivery. In regard to the other parameters listed there is likely to be the opposite effect with an increase in respiratory rate, a reduction in urine output and, dependent on the cause of the condition, an effect on peripheral vascular resistance.

4.

A person is admitted following exposure to a winter sea. Which problem identification would be most appropriate for this person? a. Risk for imbalanced body temperature b. Hyperthermia c. Hypothermia d. Ineffective thermoregulation e. Malignant hyperthermia.

Answer: a Rationale: With neurogenic fever there is a long-term elevation of temperature resulting from damage to the hypothalamus.

5.

According to National Heart Foundation’s 2016 Guidelines a BP reading of 168/105 would be considered: a. normal b. prehypertension c. Grade 1 hypertension d. Grade 2 hypertension. e. an isolated systolic hypertension.

Answer: c Rationale: Grade 1 (mild) hypertension is defined by a systolic reading between 140 and 159 and a diastolic reading between 90 and 99.

6.

VSs are assessed regularly to: a. monitor the person’s health and wellbeing b. detect deterioration of the person’s condition c. enable escalation of care d. determine the adequacy of oxygenation to the tissues e. All of the above.

Answer: e Rationale: Each answers given is valid, however, (d) determining the adequacy of oxygenation to the tissues is the focus of this chapter and assists you to determine the overall status of the person, helps you to determine the need for escalation of care and reassures the person that you are monitoring their status.

7.

The effects of decreased oxygen delivery to the tissues includes all of the following except: a. lactic acid production b. anaerobic metabolism c. dyspnoea d. acidosis

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e. eupnoea Answer: e Rationale: Primarily, it is the increase in carbon dioxide levels in the blood that stimulate the respiratory drive. Severely decreased oxygen delivery to the tissues will stimulate (increase) the respiratory drive.

8. Effective oxygenation of the tissues depends on (among other things): a. adequate diaphragm and intercostal muscle movement b. adequate and saturated haemoglobin levels c. effective cardio pulmonic and peripheral circulation d. intact respiratory centre in the brain e. all of the above.

Answer: a All of these factors interact to produce effective respiration. Inadequate diaphragm and intercostal muscle movement would reduce the volume of inspired air. Alveoli that are damaged cannot expand thereby reducing the surface area for transport of oxygen/carbon dioxide across the membranes into the circulation. Effective circulation is required to carry the dissolved gasses to and from the lungs/tissues. An intact respiratory centre is essential to stimulate respiration.

9. Hypertension is of great concern because (select all that apply): a) it affects 90 per cent of the population b) it indicates massive haemorrhage c) it leads to dehydration d) it can result in end-stage renal disease e) it limits the oxygen that is delivered to the tissues.

Answer: d, e Rationale: Hypertension affects about 20 per cent of the adults of the world. It does not cause obesity, but obesity is a contributing factor to the development of hypertension. End stage renal disease can result from hypertension, but it is not a 'usual' outcome. Oxygen delivery to the tissues remains adequate (due to compensatory mechanisms, such as an enlarged left ventricle) until the damage to the arteries (tears plaques) is advanced, when the oxygen delivery to the tissues is affected.

10. Usually, the BP is measured on the brachial artery; however, which of the following conditions preclude use of that site? a. the person has had shoulder, breast or lymph node surgery b. there is an intravenous access device c. the arms or hands are in casts d. the person has an arteriovenous fistula in situ e. All of the above.

Answer: e Rationale: Each of the answers involves damage or interference with the vascular/lymph system of the involved arm, and increasing the vascular pressure (as you do when the cuff of the sphygmomanometer is inflated) can increase the damage to the vessels.

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11. When assessing RRs, you should: a. assess the nail beds for cyanosis b. place your hand lightly on the chest and feel the rise and fall c. inform the person you are assessing of their respiratory status d. estimate the rate using previous notions in the ADDS e. place the person in the ‘tripod’ position to ease breathing.

Answer: b Rationale: Placing your hand lightly on the person's chest allows you to feel their respiratory cycle and enables you to count the rate. Cyanosis of the nail beds indicates poor peripheral oxygenation from many causes but does not help you to assess the respiratory rate. If you tell the person that you are assessing their respirations, they will unconsciously alter their rate. Watching the abdomen for movement does assist you to count the rate, however, many people (especially women) do not often use their abdominal muscles to breathe. The tripod position is used for some people when they are short of breath and does not assist you to count their respiratory rate.

Spotlight on critical thinking 1.

Why should you be concerned about a rising RR? Suggested solution: A rising respiratory rate indicates reduced oxygenation to the critical organs (and retained carbon dioxide in the blood causing acidosis). This combination stimulates the respiratory drive to increase the rate of respirations. The rising RR is an early and sensitive indicator of the person's clinical deterioration and must be understood. Senior professionals should be notified if you see an increased RR even if the person still has no other clinical signs (e.g., tachycardia, confusion, falling BP).

2.

Differentiate between heat stroke, heat exhaustion, fever and pyrexia.

Suggested solution: Heat stroke is a critical increase in body temperature to between 41 and 44ºC. It is a medical emergency caused by (usually) exposure to high temperatures and physical exertion. Dry, hot skin is the most important sign. The person becomes confused or delirious and experiences thirst, abdominal distress, muscle cramps and visual disturbances. Loss of consciousness occurs if untreated.

The person requires immediate cooling, hydration and transport to hospital.

Heat exhaustion is an increase in body temperature to between 38 and 40ºC usually caused by high environmental temperatures, dehydration and exertion. Loss of excessive amounts of water and sodium from perspiring leads to thirst, nausea, vomiting, weakness and disorientation. The person requires cooling, rehydration and rest.

Fever is an increase in body temperature above the normal range. There are many causes of fever (infection, inflammation, sepsis, neurogenic). It is often accompanied by shivering, warm hands and often a low blood pressure and tachycardia. Usually, fluid replacement is required Pyrexia is another word for fever.

3.

Why is it important to manually take a pulse when the rate is displayed on the pulse oximeter machine automatically?

Suggested solution: The pulse oximeter can tell you the rate of the pulse but gives no indication of the rhythm of the pulse or force of each contraction.

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4.

A person you are caring for has a low BP and cold hands. What are two possible physiological reasons for this?

Suggested solution: Some medications cause low peripheral resistance resulting in a low BP and cold peripheries (vasodilators, some anaesthetics). Pregnancy can reduce peripheral resistance and cause these signs. Sepsis – an overwhelming immune response to an infection by a bacteria, virus or fungus –can cause also these symptoms, along with an altered mental state, increased respiratory rate, tachycardia, decreased SaO2 (from arterial blood gases because SpO2 can be unreliable due to low BP, cool peripheries), reduced urine output, skin colour changes (ashen, mottled in fair skinned people; dull, darker and greyish in dark skinned people ), non-blanching skin rash and cyanosis (lips, tongue).

5.

Why should you be concerned about a rising respiratory rate?

Suggested solution: A rising respiratory rate is a compensatory mechanism for a reduced oxygen delivery. When there is inadequate oxygen to the tissues, anaerobic respiration takes place with the production of lactic acid. When lactic acid builds up, the body attempts to increase the pH of the blood by reducing the carbon dioxide in the blood. This is done by increasing the tidal volume either by increasing the respiratory rate or increasing the depth of breathing. When there is also a reduced amount of oxygen being carried in the blood, the compensatory mechanism is to increase the respiratory rate in an attempt to increase the amount of oxygen in the blood.

6.

How can someone be well with a low heart rate?

Suggested solution: As long as the person maintains a normal oxygen delivery, they will be oxygenated.

A low heart rate can result from extreme fitness because as the body becomes fitter, the heart muscle is stronger and can eject a greater volume of blood with each stroke. So, even if the heart rate is low the cardiac output is maintained (I.e., the rate times the stroke volume) and the individual will maintain adequate oxygenation. If a person reaches a physiological trigger point, what action needs to be taken?

7.

If a person reaches a physiological trigger point, what action needs to be taken?

Suggested solution: One of the major reasons for measuring vital signs is to identify those at risk of deterioration. If a person reaches a physiological trigger, the local escalation pathway should be followed. This action includes notifying a more senior nurse who will assess the situation and if warranted, notify the medical officer. For a more deranged physiological trigger, the escalation point should be to a more senior medical officer to ensure that the person receives timely appropriate management.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 5 Resource aids....................................................................................................................................................... 6 Online resources.................................................................................................................................................. 6 Animations........................................................................................................................................................... 6 Evaluation strategies ........................................................................................................................................... 7 Review questions................................................................................................................................................. 7 Spotlight on critical thinking .............................................................................................................................. 10

Chapter 31 Physical assessment Key terms Adventitious breath sounds Superimposed sounds on the normal vesicular, bronchovesicular and bronchial breath sounds.

Analyte A substance that is the subject of chemical analysis, a solute.

Aneurysm Weakness in the wall of a blood vessel.

Angina Pain in the chest, neck or arm resulting from myocardial ischaemia.

Angiography Visualisation of the vascular structures using fluoroscopy with a contrast medium.

Aphasia Impaired, unfocused or absence of language function.

Arteriosclerosis Build-up of plaques in the inner layers of the walls of large to medium-sized arteries.

Arthritis Inflammation of the joints that causes pain and swelling.

Ascites An accumulation of fluid in the abdomen causes pressure that can interfere with breathing or gastrointestinal tract (GIT) function.

Atrial fibrillation Rapid, random contractions of the atria with irregular ventricular beats.

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Atrophy Thinning of skin surface and loss of markings; thin, flabby muscles due to a reduction in muscle size and shape.

Auscultation Physical examination technique that involves listening to sounds in the body that are created by movement of air or fluid.

Biopsy Excision of a small amount of tissue.

Bronchial sounds Loud and high-pitched sounds with a hollow quality heard longer on expiration than inspiration.

Bronchovesicular sounds Loud and high-pitched sounds with a hollow quality heard longer on expiration than inspiration from air moving through the trachea.

Bruits Blowing sounds that are heard when the blood flow becomes turbulent as it rushes past an obstruction.

Computed tomography (CT) Radiological scanning of the body with X-ray beams and radiation detectors that transmit data to a computer that transcribes the data into quantitative measurement and multidimensional images of the internal structures.

Contrast medium Radiopaque substance that facilitates roentgen imaging of the body’s internal structures.

Crepitus Grating or crackling sensation caused by two rough surfaces rubbing together.

Cyanosis Blue or grey discolouration of the skin resulting from reduced oxygen levels in the arterial blood.

Cystocele Bulging of the urinary bladder into the vagina.

Dermatome map Cutaneous area whose sensory receptors and axons feed into a single dorsal root of the spinal cord.

Digital subtraction angiography Computerised imaging of the vasculature of an organ with visualisation on a monitor screen following the intravenous injection of iodine through a catheter.

Dullness A muffled thud-like sound that occurs over dense tissue on percussion.

Endoscopy Visualisation of a body organ or cavity through a scope.

Extinction Inability to discriminate the points of distance when two body parts are simultaneously touched.

General anaesthesia Anaesthesia that causes the loss of all sensation and consciousness; used for major surgical procedures.

Glasgow Coma Scale (GCS) International scale used in grading neurologic responses to determine the person’s LOC. Graphesthesia Ability to identify numbers, letters or shapes drawn on the skin.

Haematuria Blood in the urine; microscopic haematuria is the presence of blood noted on microscopic examination of the urine; gross haematuria is the presence of blood visible to the naked eye.

Halitosis Bad breath.

Heaves Lifting of the cardiac area secondary to an increased workload and force of left ventricular contraction. hypertonicity Increased muscle tone.

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Hypertrophy Increase in muscle size and shape due to an increase in muscle fibre.

Hypotonicity A decrease in muscle tone.

Incidence Refers to the prevalence of a disease in a population or community. The predictive value of the same test can be different when applied to people of differing ages, genders and geographic locations.

Inspection Physical examination technique that involves careful visual observation.

Integumentary system Skin, hair, scalp and nails.

Invasive Accessing the body tissues, organs or cavities through some type of instrumentation procedure.

Ischaemia Oxygen deprivation, usually caused by poor perfusion, that is usually temporary and localised.

Local anaesthesia Anaesthesia that causes the loss of sensation to a localised body part (e.g., spraying the back of the throat with lidocaine decreases the gag reflex).

Mammography A low-dose radiographic study of the breast tissue.

Murmur Swishing or blowing sounds of long duration heard during the systolic and diastolic phases, created by turbulent blood flow through a valve.

Myocardial infarction Necrosis of the heart muscle.

Non-invasive The body is not entered with any type of instrument.

Nystagmus Involuntary rhythmical oscillation of the eyes.

Observation Skill of watching carefully and attentively.

Osteoarthritis Most common type of degenerative arthritis, in which the joints become stiff and tender to touch.

Palpation Physical examination technique that uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses and tenderness.

Percussion Physical examination technique that uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs.

Pericardial friction rub Grating sound produced by the rubbing together of two inflamed surfaces of the pericardium (e.g., following a myocardial infarct, pericarditis).

Pleural friction rub Heard on either inspiration or expiration over the anterior lateral lungs as a continuous creaking, grating sound.

Predictive value The ability of screening test results to correctly identify the disease state, such as a true positive correctly identifies persons who actually have the disease, whereas a true negative correctly identifies persons who do not actually have the disease.

Procedural sedation A minimally depressed LOC (permitting stillness, dissociating from unpleasant sensations and reducing pain) during which the person retains the ability to maintain a continuously patent airway and respond appropriately to physical stimulation or verbal commands.

Pulsations Rhythmic throbs or beats (as of the pulse of the heart).

Radiography Study of X-rays or gamma ray–exposed film through the action of ionising radiation.

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Regional anaesthesia Anaesthesia that causes the loss of sensation in a particular area of the body (e.g., laparoscopy for a tubal sterilisation).

Regurgitation Backward flow of blood through a diseased heart valve, also known as insufficiency.

Rhonchi Heard predominantly on expiration over the trachea and bronchi as a continuous, low-pitched musical sound.

Sensitivity Determines the susceptibility of a pathogen to an antibiotic; the ability of a test to correctly identify those individuals who have the disease.

Snellen chart Chart to determine visual acuity that contains various-sized letters with standardised numbers at the end of each line of letters.

Specificity he ability of a test to correctly identify those individuals who do not have the disease.

Stenosis Narrowing or constriction of a blood vessel or valve.

Stereognosis Ability to identify objects by manipulation and touch.

Striae Red or silvery-white streaks due to rapid stretching of skin with resultant damage to elastic fibres of dermis.

Stridor Sound heard predominantly on inspiration as a continuous crowing sound.

Supernumerary nipples Extra nipples that appear as pigmented moles along the ‘milk line’ of the breast.

Tactile fremitus Vibrations created by sound waves.

Thrombophlebitis Inflammation of a vein with a formed blood clot.

Time out The surgical team’s short pause, just before incision, to confirm that they are about to perform the correct procedure on the correct body part of the correct patient.

Tomography An imaging technique in which a selected body plane is isolated from the tissues on either side.

It is particularly useful in visualising air-filled structures such as the lungs and paranasal sinuses.

Transducer Instrument that converts electrical energy to sound waves.

Tympany Musical drum-like sound produced by percussion that occurs over air-filled cavities.

Ultrasound Use of high-frequency sound waves instead of X-ray film to visualise deep body structures; also called an echogram.

Venepuncture Puncturing of a vein with a needle to aspirate blood.

Vesicular sounds Soft, breezy, low-pitched sounds heard longer on inspiration than expiration that result from air moving through the smaller airways over the lung’s periphery, except for the scapular area.

Wheezes Lung sounds heard predominantly on expiration all over the lungs as a continuous sonorous wheeze (low-pitched snoring) or sibilant wheeze (high-pitched musical sound).

Xeroradiography An X-ray imaging technique that uses a photoelectric process rather than the photochemical process of conventional X-rays; the images are printed on paper like that of a typical office photocopier.

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Instructional strategies • Discuss the assessment of each of the major body systems. Ask student groups to determine/list the assessments/ techniques and normal findings of each of the body systems (this will take time – to consult texts, notes), then report back to the group.When assessing the integumentary status, the skin, hair, scalp, and nails are assessed. Inspect for colour, lesions, moisture, temperature, texture, mobility, and turgor. Assess the head and neck to include the skull, face, eyes, ears, nose, mouth, pharynx and neck.

Inspection and palpation are used throughout this assessment, with auscultation used to assess carotid artery blood flow. When assessing the thorax and lungs, the techniques of inspection, palpation, percussion, and auscultation are used. The assessment of the heart and vascular system utilises the techniques of inspection, palpation, and auscultation. Inspection and palpation are used to assess the breasts and axilla of both males and females. The assessment of the abdomen includes the gastrointestinal and genitourinary systems. The sequence of assessment for the abdominal assessment is inspection, auscultation, percussion, and palpation. When assessing the musculoskeletal system, inspection, palpation, range of motion, and muscle testing are done on the major skeletal muscles and joints. The neurologic examination includes an assessment of mental status, sensation, cranial nerves, motor functioning, cerebellar function, and reflexes. Assessment of the female and male genitalia includes the techniques of inspection and palpation. Assessment of the anus and rectum are done using the techniques of inspection and palpation.

• Describe health care teaching that can occur during the physical assessment. The nurse can instruct a female in self-examination of the breasts and a male in self-examination of the testicles. Any obvious deficiency in health maintenance – halitosis, dental caries, skin or nail neglect, smoking, alcohol or other substance abuse, weight maintenance, exercise, and any knowledge deficiencies detected during the examination – can be addressed • Once the complete physical assessment has been done, documentation of the data is important. What should the student keep in mind when documenting? Nurses should become comfortable with the particular agency forms. It is necessary for accuracy that information be charted in the appropriate place.

Use of medical terminology is important. Attention to the legal requirements of charting (pen, colour, time, date notes, printed name, designation, signature) is mandatory. Legibility of your writing and a systematic approach to the in-progress notes improves communication with other health professionals. It is important to note the type of charting used in the facility and use that system. Use of electronic charting is individual to the institution, and the student will be required to familiarise themselves with it while on clinical placement.

While documenting, comparison of current assessment data to previous recorded data gives the nurse clues to a possible change in condition. Remember that documentation is subject to confidentiality.

Do not leave personal information where it can be seen by non-clinical staff or other individuals (visitors, volunteers). Because nurses are subject to liability, remember to document facts, not opinions (do not use terms like 'seems' or 'appears' – write what you see) to avoid future legal trouble.

• How is bilateral comparison used in performing physical assessment and documentation of findings?

Bilateral comparison is a necessary component of all physical examinations. It is important for the beginning student to understand that attention must be focused on evaluating the total body structure.

For example, for someone who has a deep venous thrombosis (DVT) on the right lower leg, it is just as important to have the left leg assessed as it is to have the right leg assessed. Bilateral comparison in this instance would provide the student with additional information regarding whether or not the person was © Cengage Learning Australia 2024

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experiencing any additional vascular compromise or if findings were within normal range limits. Bilateral comparison provides you with the person's own normal (usually) as a basis to compare an abnormal finding.

Resource aids Adult physical assessment; Comprehensive health history: Key to diagnosis; Efficient assessment: A systems approach to admission assessment [videos]. American Journal of Nursing.

Beginning physical assessment [video]. Chapel Hill, NC: Health Sciences Consortium.

Estes, M. E. Z., Calleja, P., Theobald, K., & Harvey, T. (2020). Health assessment and physical examination (Australian and New Zealand 3rd ed.). Cengage Learning.

Online resources • This resource from the Melbourne Royal Children's Hospital provides structure for physical assessment and screening tools for infants, paediatrics and adolescents – https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/ • This resource focuses on the geriatric person's assessment and describes areas requiring special emphasis or attention (all text) – http://projects.galter.northwestern.edu/geriatrics/ • The following website is student oriented and describes several focussed assessments at the beginning level – https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/

Animations • Play the animation VISION for the students – https://www.youtube.com/watch?v=s0B_CiOEXSI – and review how vision impulses reach the brain for interpretation. The eyes provide sensory information on length, depth, width, and distance and colour. The sclera is the outer white layer of the eye that provides the eye with shape and supports the eye muscles for eye movements. There are two chambers in the eye. The anterior chamber is filled with aqueous humour and extends from the dome shaped, clear cornea to the iris. The iris is a muscle that controls the amount of light that enters the eye and changes the size of the pupil. The lens sits behind the pupil and bends or refracts light. It is a biconcave clear structure that is able to change shape, with the help of the ciliary muscles. The posterior chamber fluid is the vitreous humour. The choroid is the vascular layer of the eye that contains blood vessels. The choroid lies between the retina and the sclera and brings nutrients and oxygen to the retina. The retina contains bipolar cells, rods, cones, and ganglia cells. The rods detect light, and the cones detect colour. Light enters the eye, the rods sense the light, the cones sense colour, and the information from the rods and cones is transmitted to the bipolar cells, then to the ganglia cells, and finally to the optic nerve and the occipital lobe of the brain for interpretation. The following visual provides a simple schematic explanation of the anatomy of the eye.

• The cardiac animation – excellent simple and clear description of the heart. https://www.youtube.com/watch?v=UMTDmP81mG4 • Play the animation ENDOCRINE for the students. Discuss the glands of the endocrine system and the role they play regarding hormones. The endocrine system is a system of ductless glands that secrete

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hormones needed for a variety of bodily functions. The hormones are secreted directly into the bloodstream. The glands of the endocrine system are the hypothalamus, pituitary (or the master gland), thyroid, adrenal glands (composed of the medulla and cortex), testes, ovaries, pineal gland, thymus gland and pancreas.

Evaluation strategies • Have the students practise the various positions used for the physical examination. Refer to Table 31-2 for these positions. Ask them to assist a volunteer (another student) into the positions.

• In the laboratory setting, set up different stations that illustrate the different areas of physical assessment. Have the students rotate through each of the stations and submit written documentation regarding the physical findings illustrated in each station. It is helpful to have both normal and abnormal findings illustrated in the stations. For example, the respiratory assessment station could reflect abnormal lung sounds, while the cardiac assessment station could reflect normal heart sounds. If your facility allows for physical examination of other students (or has volunteers for physical examination), ask each student to undertake at least one physical examination and chart it. Discuss their feelings regarding touching another person, asking intimate questions, anxiety, finding landmarks and so on, following physical examination.

• In the clinical area, assign students to individuals to conduct a complete physical assessment. After the clinical experience, have the students discuss assessment findings and variations. Include the questions about their feelings regarding touching another person – a stranger, asking intimate questions, anxiety, finding landmarks and so on, following the physical examination.

• Discuss the importance of cultural diversity in physical assessment findings. How would you adequately document physical assessment findings (think about skin colour variations, hair texture, hair distribution, body mass index) in various population groups (e.g., Aboriginal, Asian, the elderly).

Review questions 1.

Preparing the person for diagnostic testing includes which of the following options? (Select all that apply.) a. Individualised education b. Placing in the correct position c. Initiating Standard Precautions d. Providing emotional support e. Telling the person the results of the test.

Answer: a, b, c, d Rationale: Standard Precautions are undertaken by the health care professional in every instance of contact with people in their care and are automatically used. Initiating them to prepare a person for diagnostic testing is redundant. Documentation is not part of the preparation of the person.

2.

You are performing an assessment of a person’s gastrointestinal system. Which of the following factors may cause abdominal distension? a. Pregnancy

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b. Indigestion c. Ascites d. Positive Allen test e. Adipose tissue Answer: a and c Rationale: See section ‘Abdomen’ and the Nursing Checklist: The Seven F’s of Abdominal Distension.

3.

Which of the following methods is useful for assessing skin turgor? a. Indenting the ankle b. Pinching a skinfold c. Touching to determine degree of moisture d. Using the percussion hammer e. Using the dorsum of your hand to assess for temperature.

Answer: b Rationale: Skin turgor is assessed by gently pinching a fold of skin and noting the skin’s resiliency.

Indenting dependent body parts helps determine the presence of pitting oedema. The percussion hammer is a tool for measuring reflexes.

4.

Why do you use the assessment technique of percussion (if used) and palpation last during a physical examination of the abdomen? a. To reduce the effect of tickling b. To reduce the possibility of stimulating peristalsis c. To increase the motility of the intestines d. Because loudest bowel sounds are heard before the intestines are stimulated e. To ensure that borborygmi is felt on palpation.

Answer: b Rationale: Auscultation of the abdomen follows observation so that bowel sounds can be heard with the abdomen relaxed. Both percussion and palpation involve putting pressure on the abdominal contents and stimulating movement of the intestines, air and fluid, changing the bowel sounds.

5.

A person becomes irritable, nauseas and has increased bowel motions. Which of the following assessments is most important for you to perform? a. Cardiovascular b. Integumentary c. Neurologic d. Visual e. Mental status.

Answer: d Rationale: It is important to focus on the body system most closely associated with the symptoms the person presents with. In this example it is the GIT. The irritability may be associated with a neurological problem, or mental status, but the nausea and increased bowel motions are paramount and an irritable bowel may lead to generalised pain and irritability. If the onset of irritability preceded the onset of the GIT symptoms by more than a day or so, you would look at other factors such as neurological or mental status problems.

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6.

The person you are examining is a 72-year-old Aboriginal male. He weighs 106 kg, and his current blood pressure is 178/102. Which of the following is not a modifiable risk factor for cardiovascular disease presented by this person? a. Diet b. Exercise levels c. Obesity d. Sedentary lifestyle e. Race.

Answer: e Rationale: Obesity can be modified through lifestyle changes, such as diet and exercise. Unmodifiable risk factors for cardiovascular disease include age, family history, gender and race.

7.

You are performing a PA of the lungs. Which of the following assessment findings should be reported immediately to the primary care provider? a. Vesicular sounds over the peripheral lung fields b. Anterior-posterior ratio of 1:1 c. Bronchial sounds at the left mid-axillary line d. Adventitious sounds over the anterior thorax e. Tactile fremitus strongest at the bronchial bifurcation.

Answer: c

8.

Which of the following assessment findings indicate cyanosis in a person with dark skin? a. Blue nail beds b. Bluish colouration on lips c. Dark, dull, lifeless-looking skin d. Generalised mottled, dusky-blue hue e. All of the above.

Answer: a, c Rationale: Cyanosis (an indicator of hypoxia) usually manifests in people with dark skin as dull, dark, and lifeless skin. Cyanosis is relatively easy to detect in people with light skin because there is a generalised dusky-blue tinge to the skin, and the lips and nail beds have a bluish coloration. Cherry colouration indicates carbon monoxide poisoning. Dull, lifeless skin and dark circles under the eyes often indicate fatigue, ill health.

9.

Which of the following tests would the nurse perform to test visual acuity? a. Allen b. Romberg c. Snellen d. Visual fields e. Cardinal fields of gaze.

Answer: c Rationale: The Snellen test is used to assess visual acuity. The Cardinal Fields of Gaze involves the person using the eye muscles to move the eyes in all directions (EOMs). The Allen test determines

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patency of the radial and ulnar arteries, while Romberg's test assesses the neurological function of balance, and visual fields maps both central and peripheral vision 10. Which assessment finding should you urgently report when assessing a person with light skin? a. Bright cherry-red cheeks and neck b. Pigmented areas on nipples that are darker than surrounding skin c. Pink nail beds d. White sclera e. Dark circles under their eyes.

Answer: a Rationale: Bright cherry-red colouration in the face and neck occurs with carbon monoxide poisoning.

The nipples are normally darker than surrounding skin. Nail beds normally have a pink hue, and healthy sclera is white. Dark circles under the eyes can be a normal finding or can indicate lack of sleep. Ask the person if this is a new phenomenon and about their rest/sleep regime before reporting it as abnormal.

Spotlight on critical thinking Diagnostic testing and confidentiality Mr Takahashi comes to the Ambulatory Surgery Clinic for his preoperative diagnostic testing. You overhear the staff saying that Mr Takahashi has had a history of hepatitis. Your instructor gathers all the student nurses and asks, ‘Who needs the experience of performing a venipuncture?’ Two of your classmates indicate to the instructor that they have not had the opportunity to perform this procedure.

1.

Should you say anything to the instructor?

2.

Would you share with your classmates Mr. Takahashi's history?

3.

If you said something, would this be a breach of confidentiality?

Suggested solution: Ask the students to discuss confidentiality – what is it? How does it apply between people involved in an individual's care? Should this information be recorded on the chart? What if the overheard conversation was misheard? How does his hepatitis status impact on the students' risk for injury? How do standard precautions come into the equation?

Assessment and legal matters 4.

What would you do if a woman in the emergency room in which you were practising showed signs of abuse?

Suggested solutions: For discussion – ask a professional (RN, physician) to examine the woman with you. Share your suspicions with them in a private setting. Ask for advice. Be able to articulate and then document what you have seen. Find out the woman’s explanation of the injuries. Also be aware that what you see as signs of abuse may be due to disease processes (e.g., immune thrombocytopenic purpura), age (elderly people have frail vessels and skin, bruise and tear their skin easily, often have balance problems) or to medications (e.g., anticoagulant use).

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5.

What extra precautions would you use to conduct the physical examination?

Suggested solution: Cautiously, gently and with someone else in the room, ask the woman about the visible signs of abuse (e.g., bruising, tears etc) and listen to what she says – try to determine if the answer is reasonable. Note any bruising that is in a place where it would not be feasible to harm yourself (e.g., back) or in an intimate part of the anatomy (e.g., breasts, inner thighs, anal area).

6.

What is the law in your state/territory in regard to reporting abuse?

Suggested solution: Have the students research the laws in your state/country. It is important they know their legal responsibility in the case of abuse. What is the facility policy about reporting abuse (i.e., who do you tell? Do you chart any report?) Report back for discussion.

Assessment and your confidence Nurses (of all genders) may feel anxious about physical examination of a person of the opposite sex. It is important that you work through your own feelings to help increase your confidence and comfort while examining the person. Familiarise yourself with lay terminology for the various body areas and functions, as many persons do not know the correct anatomic terms for body parts and do not recognise such terms as ‘void’, ‘vulva’, ‘perineum’ or ‘anus’.

7.

Discuss – with you classmates or with another person you trust – ways to increase your confidence in PA. Suggested solution: Practise interviewing (with someone you feel comfortable with) the interview questions. How can you help the other person feel more comfortable? (change your focus to the person you are interviewing rather than your own embarrassment). This may be as simple as remaining calm and matter of fact about the examination or interview. Project self-confidence (tone of voice, eye contact, slow deliberate movements). Accompany an experienced health care professional as they conduct this type of assessment and interview and note their attitude and the questions they ask/words they use.

Cultural values and assessment Many people in our society are obese. Some are severely obese. What are your thoughts on obesity? Do you think you have any biases? Think of the terms (labels) ‘fat’, ‘lazy’ or ‘gross’ that are often heard in reference to severely obese people.

8.

What do you think happens to the assessment process and the care given to someone when such valueladen terms are used?

Suggested solutions: Discussions about how people who are not 'liked' are treated in our society (often ignored, shunned, treated like objects, talked to like children, treated brusquely, given limited interaction). Assessment may become perfunctory and care minimal.

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9.

How can you avoid this?

Suggested solutions: Discussion about how to avoid this might include recognising own biases and those of the greater society, getting to know people as individuals, listening to their stories, learning more about the complexity of weight gain/maintenance.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 5 Resource aids....................................................................................................................................................... 6 Visual resources................................................................................................................................................... 7 Online resources.................................................................................................................................................. 7 Animation ............................................................................................................................................................ 7 Evaluation strategies ........................................................................................................................................... 8 Review questions................................................................................................................................................. 8 Spotlight on critical thinking .............................................................................................................................. 11

Chapter 32 Safety, infection control and hygiene Key terms Acquired immunity Formation of antibodies that protect the individual against invading agents such as lethal bacteria, viruses, toxins, and foreign tissues from other animals.

Agent An entity that is capable of causing disease.

Airborne transmission Occurs when a susceptible host contacts droplet nuclei or dust particles that are suspended in the air.

Alcohol-based hand rub (ABHR) Solution composed of at least 70 per cent alcohol that is used to reduce microorganisms on the hands.

Anthropogenic Changes in the environment due to human activity (e.g., air, water pollution, elevated carbon levels).

Antibody/antibodies An immunoglobulin produced by the body in response to bacteria, viruses or other antigenetic substances; counteracts and neutralises the effects of antigens and destroys bacteria and other cells. Agglutinin is one type of antibody.

Antigens A substance, usually a protein, that causes the formation of an antibody and reacts specifically with that antibody (e.g., agglutinogen).

Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent.

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Asepsis Absence of microorganisms.

Aseptic technique Infection-control practice used to prevent the transmission of pathogens.

Autoimmune disorder A malfunction of the body’s immune system that causes the body to attack its own tissues.

Biological agent Living organisms that invade the host, such as bacteria, viruses, fungi and protozoa.

Body image Individual’s perception of physical self, including appearance, function and performance ability.

Chain of infection Phenomena of developing an infectious process.

Chemical agent Substances that can interact with the body, such as pesticides, food additives, medications and industrial chemicals.

Chemical restraints Medications used to control a person’s behaviour.

Clean object Object considered to have the presence of some microorganisms that are usually not pathogenic.

Cleansing Removal of soil or organic material from instruments and equipment used in providing patient care.

Colonisation Multiplication of microorganisms on or within a host that does not result in cellular injury; also, occupancy by people foreign to land or country that settle and overlook existing systems and impose their own governance structures that impact on the health and wellbeing of the original inhabitants.

Communicable agent Infectious agents that are capable of being transmitted to a person by direct or indirect contact through a vehicle (or vector) or airborne route.

Communicable disease Diseases produced by infectious agents.

Compromised host Person who’s normal defence mechanisms are impaired and who is therefore susceptible to infection.

Contact transmission Direct physical transfer of an agent from an infected person to a host through direct contact with a contaminated object or close contact with contaminated secretions.

Contaminated wound Open, traumatic wound or intentional wound in which there was a major break in aseptic technique, spillage from the gastrointestinal tract, or incision into infected urinary or biliary tracts.

Convalescent stage Period of time from the beginning of the resolution of acute symptoms until the person returns to the previous state of health.

Dirty (soiled) object Object considered to have a high number of microorganisms, with some that are potentially pathogenic.

Disinfectant Chemical solutions used to clean inanimate objects.

Disinfection Elimination of pathogens, except spores, from inanimate objects.

Emerging infectious disease An infectious disease that has newly appeared in a population, or that has been known for some time but is rapidly increasing in incidence or geographic range (e.g., tuberculosis, Ebola virus).

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Environment In the discussion of infection control, the environment is everything in the person’s surroundings other than the person themselves (host) and the agent (pathogen) that affects the chain of infection.

Equipment accidents Results from the malfunction or improper use of medical equipment (e.g., electrocution and fire).

Flora Microorganisms on the human body.

Germicide Chemical that can be applied to both animate and inanimate objects to eliminate pathogens.

Gingivitis Inflammation of the gums.

Halitosis Bad breath.

Hand hygiene A general term that applies to the maintenance of hygiene of the hands, and which can apply to handwashing or to antiseptic handwash or hand rub.

Handwashing Use of soap and water to wash hands. health care-associated infections (HAIs) Infections acquired in the hospital or other health care facilities that were not present or incubating at the time of admission.

Health literacy The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.

Hospital-acquired complications (HAC) Also called a ‘never event’ because it is an event that should never happen in a hospital, such as a pressure ulcer or fall.

Host Simple or complex organism that can be affected by an agent.

Humoral immunity Stimulation of B cells and antibody production.

Hygiene The science of health.

Iatrogenic Relating to illness or harm caused during medical treatment.

Illness stage When the person is manifesting specific symptoms of an infectious process.

Incubation period Time interval between entry of an infectious agent in the host and the onset of symptoms.

Infection Invasion and a multiplication of microorganisms in body tissue that result in cellular injury.

Infectious agent Microorganism that causes infections.

Inflammation Non-specific cellular response to tissue injury or infection.

Localised infection Limited to a defined area or single organ with symptoms that resemble inflammation (redness, tenderness and swelling).

Lymphokine A substance of low molecular weight that is not an antibody, is secreted by T cells in response to stimulation by antigens and has a role in cell-mediated immunity.

Mode of transmission Process that bridges the gap between the portal of exit of the biological agent from the reservoir or source and the portal of entry of the susceptible ‘new’ host.

Pathogenicity Ability of a microorganism to produce disease.

Pathogen Microorganisms that cause diseases in humans.

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Perineal care Cleansing of the external genitalia, perineum and surrounding area.

Person behaviour accidents Mishaps that occur when the individual’s behaviour or actions precipitate the incident.

Physical agent Factors in the environment that can cause disease, such as heat, light, noise, radiation and machinery.

Physical restraints (PRs) Reduce the person’s movement through the application of a device.

Poison Any substance that causes an alteration in a person’s health, such as injury or death, when inhaled, injected, ingested or absorbed by the body.

Prodromal stage Time interval from the onset of non-specific symptoms until specific symptoms of the infectious process begin to manifest.

Pyorrhoea Periodontal disease.

Resident flora Microorganisms that are always present, usually without altering the individual’s health.

Restraints Protective devices used to limit the physical activity of a person or to immobilise a person or extremity.

Risk for infection State in which an individual’s potential for being invaded by pathogenic organisms is increased.

Sebum Substance produced by the skin; contains fatty acids that kill some bacteria.

Self-care deficit Exists when the person is not able to perform one or more of the ADL. Sensory overload Increased perception of the intensity of auditory and visual stimuli.

Spores Single-celled microorganisms, or microorganisms in the resting or inactive stage.

Sterilisation The total elimination of all microorganisms, including spores.

Stomatitis Inflammation of the oral mucosa.

Surgical asepsis Sterile technique: consists of those practices that eliminate all microorganisms and spores from an object or area.

Surgical hand antisepsis ‘Antiseptic handwash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora. Antiseptic detergent preparations often have persistent antimicrobial activity’ (CDC. [2002]. Guideline for hand hygiene in healthcare settings.

Retrieved from www.cdc.gov/Handhygiene).

Susceptible host Person who lacks resistance to an agent and is thus vulnerable to disease.

Systemic infection Affects the entire body and involves multiple organs.

Therapeutic procedure accidents Occur during the delivery of medical or nursing interventions.

Vaccination Provides acquired immunity against specific diseases.

Vector-borne transmission Occurs when an agent is transferred to a susceptible host by animate means, such as mosquitoes, fleas, ticks, lice and other animals.

Vehicle transmission Occurs when an agent is transferred to a susceptible host by contaminated inanimate objects, such as water, food, milk, medications and blood.

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Instructional strategies • How can nurses help prevent accidents in an acute care setting and in-home care settings? Discussion in

small groups or ask the whole group to suggest solutions and list them for visualisation. Some ideas to get started: o Acute care setting – Infants need to be placed in an environment (e.g., cribs) with sides to prevent falls. Do not leave an infant unattended (e.g., change table). Parents of new infants must be taught how to position an infant to decrease risk of aspiration. For toddlers and small children, keep medicines out of reach, electrical outlets plugged, and hazardous objects put safely away. The bed area should be secured, with side rails up. The school-aged child’s area should be kept free of medical equipment. The bed area should be secure and also arranged to prevent falls. Adults; Among many other safety precautions: oxygen equipment is secured and warning signs present, fire equipment and evacuation routes are known to students, all tubes (IV, catheter, chest drain) are securely taped to the person, explanation and prompt attendance to call bells will prevent falls. Floor areas are kept clear, equipment is returned to storage (not left in room or hall). Anyone who is assessed as a 'falls risk' will require assistance to ambulate.

o The older adult (or adolescent and young adults with head injuries) should be adequately assessed for fall risk. Side rails up as appropriate (e.g., unconscious), call light within reach, and any accessory doors locked are aspects to be checked. Unused equipment removed from area. Medication administration or food/fluid intake may need close supervision to prevent aspiration. If a person is in restraints, make sure to follow appropriate guidelines for their use. o Home care setting – Any home with an infant or toddler needs a thorough assessment. Keeping a baby monitor will help keep tabs on the infant when not in the room. Stairs are blocked with gates, cabinets locked, electrical outlets plugged, and hot appliances kept away from a toddler are important things to check. School-aged children should have play areas free from dangerous chemicals and objects. With the older adult, fall risk assessment is important to perform. Area rugs, uneven steps or stairs, and unsafe furniture can pose problems. Make sure the telephone is reachable and usable; perhaps wearing an alert monitor would benefit many older adults. Assess the person for safety equipment that may aid in ambulation or activities of daily living (e.g., walker).

• Explain the nurse’s role in preventing the spread of infection. This could be a game for a small group.

Provide a drawing of the 'chain of infection' for each group and ask them to label each link and explain what it means. Possible solution: The nurse breaks the chain of infection by applying proper infection control practices to interrupt the mode of transmission. The chain of infection is also broken by interrupting or blocking the agent, portal of entry, or portal of exit; by destroying the agent; or by decreasing the host’s susceptibility. Nurses prevent the spread of infection through hand hygiene, personal care and hygiene of the person, hygiene of environment, isolation when warranted, utilising personal protective equipment, and administering medications and/or treatments that either improve the host’s immunity or reduce the impact of the infectious organism on the host.

• Discuss what a nurse can do to minimise or remove potential hazards from the workplace. Since nurses are at risk for injury in the workplace, nurses need to adhere to identified standards to reduce the risk of injury. Standards that will accomplish this include latex allergy standards, standards to avoid the transmission of pathogens through the blood, standards to minimise the onset of work-related musculoskeletal injuries, standards to prevent injury from administering chemotherapeutic agents, and © Cengage Learning Australia 2024

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standards that address environmental pollution and violence. The nurse needs to be familiar with each of these different types of standards and strive to adhere to the recommendations while providing individual care.

• Explore the differences between medical asepsis and surgical asepsis. Asepsis refers to the absence of microorganisms. Medical asepsis is referred to as a clean technique. Objects are considered to be either clean or dirty in medical asepsis. Even though microorganisms are present with medical asepsis, objects are considered clean. Nurses and others on the health care team perform medical asepsis with handwashing, changing linens, and cleaning floors and furniture. Surgical asepsis is referred to as a sterile technique (ANTT) The effective performance of surgical asepsis is considered removal of all microorganisms and spores from an object. Nurses perform surgical asepsis with handwashing, sterile gloves, use of surgical attire, handling of sterile equipment, and preservation of a sterile field.

• Assistance with activities of daily living for people is an important part of nursing care. Assistance with hygiene includes many different activities. Name the different skills nurses perform when assisting with hygiene needs. Many incapacitated people require help with bathing. The nurse will prepare the bathing area (tub or shower) or gather supplies to perform a bed bath. Refer to the complete procedure for adult bathing. Clean linen should also be placed on the bed. Skin care and back rubs can be performed in conjunction with the bath. Nail and foot care may also be required. A podiatrist may be asked to consult and provide nail care for the person. Oral care is also part of hygiene needs. Teeth should be brushed, and dentures should be washed and soaked. A person may need help with hair care. Washing hair or using a dry shampoo will provide the person with a renewed sense of well-being. Shaving may be performed also.

Using a safety razor or an approved electric razor to shave a beard is a necessary skill for nurses to have.

Beards and moustaches may need to be trimmed. Remember, hygienic practices are influenced by body image, culture, personal preference, socioeconomic status, and knowledge. During hygiene care, you must assess the person in light of their medical condition and for psychological, emotional and physical changes.

• A person is becoming agitated and confused as the night shift continues. A belt restraint is placed on

them. At this time, you are the nurse coming on for the day shift. What are the key elements of restraint documentation that you would expect to see on the chart? What other form of communication would you expect to have regarding the application of a restraint on a person? The initiation of restraints can be done to protect the person from injury. However, it is important to have adequate documentation that clearly states the reason for and type and application of the restraint. Documentation should include the date, time, and person’s response to the restraint. In addition, records of frequent monitoring and release to maintain circulation and observation of skin integrity are required. An order must be placed on the chart for physician signature if the use of restraints is to be continued. Also, shift-to-shift communication of those in restraints is necessary to ensure the safety aspects of care are fulfilled. This communication should be at the primary nurse and charge nurse level so as to ensure that everyone involved in the person’s care is aware of the restraint application.

Resource aids Centers for Disease Control and Prevention. (2009). CDC Features: Wash Your Hands. https://www.cdc.gov/handwashing/when-how-handwashing.html

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Guideline for Hand Hygiene in Health-Care Settings. (2002). Morbidity and Mortality Weekly Report. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf Kennamer, M. (2007). Basic infection control for healthcare providers (2nd ed.). Cengage Delmar Learning.

Visual resources Adapting the physical environment [video]. Irvine, CA: Concept Media.

Bathing; Grooming; Oral hygiene [video]. Irvine, CA: Concept Media.

Breaking the chain of nosocomial infection [video]. Chapel Hill, NC: Health Sciences Consortium.

Infection control in the health care setting [video]. Chapel Hill, NC: Health Sciences Consortium.

Outbreak [film]. (1994). MGM UA studios.

Online resources • Cultural safety in New Zealand was given a great boost when Papps and Ramsdan published the following paper (1996). http://dx.doi.org/10.1093/intqhc/8.5.491 • The following website (Patient Safety and Quality, an Evidence Based Handbook for Nurses) offers a list of safety issues of concern to nurses with links to discussions about each. http://www.ncbi.nlm.nih.gov/pubmed/21328752 • The Center for Disease Control presents a website discussing antimicrobial/antibiotic resistant disease, how they occur, the most common culprits, how to protect yourself and how to prevent antimicrobial/antibiotic resistant disease. http://www.cdc.gov/drugresistance/ • University of California, Los Angeles (2014) The Hygiene Games. Online – a fun look at hand hygiene (two problems that students can identify – nail polish and watch). https://www.youtube.com/watch?v=5uZjgGD_9vY • WHO. It’s in your hands. The official song for the world hand hygiene day. https://www.youtube.com/watch?v=ABzRdMw26E0

Animation • Alila Medical Media – Infectious Diseases Overview, Animation.https://youtu.be/Wmrlpa1XyMI. • Lecturio Nursing – What Causes an INFECTION? Breaking the Chain of Infection. https://youtu.be/EXtTTG6YYAI – This video discusses the chain of infection Discuss with the students how the chain of infection can be broken. The chain of infection includes the elements of infectious agent, reservoir or source, portal of exit, mode of transmission, portal of entry to the host, and susceptible host.

To break the chain at the infectious organism link, thorough cleansing, disinfection, and proper handwashing need to be done. To break the chain at the reservoir or source link, keep skin intact and wash hands. To break the chain at mode of transmission link, wash hands, wash and disinfect injuries, cover with a sterile/clean dressing, and wash hands again. To break the chain at the susceptible host link, ensure a well-balanced diet, exercise, get sufficient sleep, and practise good personal hygiene.

• Global Health Media – The Story of Cholera https://youtu.be/jG1VNSCsP5Q – An interesting animation about spreading and containing pathogens.

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Evaluation strategies • Have students locate nursing research dealing with infection control. What did the study determine, if anything? Can the study be replicated? Are there implications for nursing practice or for the nursing student?

• Have the students read the section ‘Caring and compassion: Self-care deficits’ in the Spotlight on critical thinking box for this chapter. Have the students answer the questions and discuss responses as a group.

Explain the importance of providing for the hygiene demands of the dependent person.

• In a laboratory setting, have available a variety of restraints used in adult and paediatric care. Assign the students to groups of two and have the groups practise applying and wearing the restraints. After this session, have the students discuss their feelings while applying the restraint and their feelings when wearing the restraint. How will a vulnerable person respond to being required to wear a restraint?

• Have the students locate and identify fire equipment in the clinical area. Identify whether there are any fire hazards in the clinical area. Where is the fire evacuation procedure located? Are the hallways accessible in the event of a fire? What individual care issues exist in the event of a fire in the clinical area?

Emphasise the need for the student to familiarise themselves with the fire equipment, location and evacuation procedure for each clinical rotation.

• In the laboratory setting, provide all items used for hand hygiene. After demonstrating the techniques, have each student practise them.

• In the laboratory setting, provide all items used for personal protection. After demonstrating the application and removal of the items, have each student practise applying and removing the personal protection items.

• Simulate a home setting in the clinical laboratory and have students use the ‘Home Safety Risk Appraisal’ in this chapter to determine potential dangers and offer solutions to rectify problems. Ask the students to appraise their own homes, a friend's home and their grandparents’ homes as appropriate.

• Have students watch the film Outbreak (2014) and trace the spread of infection of the pathogen. Discuss preventative health measures that could have been instituted to prevent spread of infection and control contamination.

Review questions 1. Which strategy most enhances our ability to be culturally safe? a. Reflecting on our own culture, attitudes and beliefs about ‘others’ b. Reading about a person’s culture before we take care of them c. Undertaking a comparative religion study course d. Discussing the language and terms to use when talking to people of a different ethnic origin to us e. Working with a colleague from a different culture.

Answer: a Rationale: Cultural safety examines our own cultural identities and attitudes, and means being openminded and flexible in our attitudes towards those from other cultures. Understanding how our own

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culture influences how we think, feel and behave is crucial to understanding others. Cultural safety incorporates cultural awareness and cultural sensitivity and is underpinned by good communication, and recognition of the diversity of views nationally and internationally between ethnic groups. Working with people of other cultural backgrounds helps us to open our minds to cultural safety. We would benefit from the other strategies, but looking at ourselves, and keeping an open mind are the most effective strategies.

2.

Both the psychological and the physiological development of a middle school child increases the risk for which of the following? (Select all that apply.) a. Drowning b. SIDS c. Fractured limbs d. Traffic accidents e. Falls.

Answer: a, c, d and e Rationale: Middle school children are gaining independence, they are physically active and usually have not developed an adequate sense of risk and self-preservation, they are beginning to feel the effects of peer pressure. They may know how to swim well enough to keep their heads out of the water, but tire easily and often panic when they feel out of control. Climbing trees, jungle gyms riding skateboards, bicycling are all good exercise, but falls can result in fractures of soft tissue injuries. Traffic accidents (both as a passenger and a pedestrian) occur dues to lapses in concentration, attention, (e.g., running into traffic after a ball) or to flouting of the rules (e.g., seatbelts) as the child demonstrates their independence.

3.

When an infectious disease is transmitted to a person who is immune suppressed, the person is called a: a. host b. susceptible host c. infectious host d. communicable disease victim e. reservoir.

Answer: b Rationale: A susceptible host is a person who lacks resistance (e.g., is immune suppressed) and is easily affected by an agent and is therefore, vulnerable to disease. Susceptibility refers to the ability of an exposed individual (or group of individuals) to resist infection or limit disease or not as a result of their biological makeup. (e.g., age extremes, pregnancy, other diseases, immune suppression). A host is any person who has or may contract a communicable disease (depends on the infectivity/pathogenicity/virulence of the infecting agent plus the environmental factors (physical, social, behavioural, cultural, political, and economic factors) that brings the agent and host together, causing infection and disease to occur in the host. An infectious host is someone who has the pathogen in their body, and is able to pass it on to another person (e.g., through talking, coughing, fomites) The reservoir is the source of the infectious agent – where it resides and multiplies (e.g., another human, an animal, part of the environment – soil, water that supports its existence.

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4.

The family member of a person diagnosed with HIV asks you how to avoid infecting other family members. Your response would be based on the understanding that HIV is primarily spread by: a. sexual contact with an infected person who does not show symptoms of the disease b. casual contact with an infected person who does not show symptoms of the disease c. contaminated needles from a person who has AIDS d. blood transfusions of improperly prepared blood e. using the same toilet facilities as the infected person.

Answer: a Rationale: Hepatitis C is a blood borne pathogen spread mostly by exposure to blood, including illicit IV drug use; occupational exposure to blood by needle-stick injury; perinatal exposure via an HCV-infected mother; exposure to contaminated equipment; or sexual contact with an infected person. Casual contact and faecal/oral transfer do not transmit HCV. Needles must be contaminated with the HCV (not other types) to transmit this virus. Blood transfusions are screened for HCV among other viruses in Australia and New Zealand.

5.

One of the major concerns of nurses in the workforce is: a. The threat of malpractice b. Job security c. Exposure to blood-borne infection by NSIs d. Exposure to contaminated equipment e. The threat of violence at work.

Answer: c Rationale: Nurses’ greatest concern is needle-stick injuries from those people with a blood-borne infection such as HCV or HIV. The remaining answers can be of some concern to some nurses but are not major to most practices.

6.

What makes ABHR more useful than hand washing with SAW? (Select all that apply.) a) Warm water, soap and paper towelling can cause dermatitis b) ABHR eliminates C. difficile and its spores c) Dispensers are readily available at the point of care d) You can use the ABHR on visibly soiled hands e) There is less chance of contact dermatitis.

Answer: a, c, e Rationale: If hands are visibly soiled, or the organism C. difficile or a norovirus is suspected, hand hygiene should be performed using soap and water.

7.

When performing a burn dressing, which PPE should be used? a. Gloves b. Apron c. Face shield d. Goggles e. All of the above.

Answer: e

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Rationale: Wear full personal protective equipment when splashes or sprays of contaminated materials could occur.

8.

Which of the following hospitalised people would you identify to be at greatest risk for the development of pneumonia HAI? Justify your reasoning? a. A 74-year-old male suspected of Parkinson’s disease who has severe halitosis and dental caries b. A toddler with nausea and vomiting c. An 84-year-old physically active male who has pancreatic cancer d. A 34-year-old male admitted for a fracture of the fibula e. A 60-year-old obese female smoker with cholecystitis.

Answer: a Rationale: The elderly gentleman (74-year-old) has Parkinson's disease which limits his mobility and his ability to swallow – increasing his risks for both bacterial/viral pneumonia (limited lung excursion) and aspiration pneumonia. Poor oral hygiene and dental caries are proven contributors to pneumonia and other respiratory diseases.

9.

When considering the person’s personal preferences for hygiene, which factor should you deem as primary? a. Keep the nursing schedule on time b. Determine their preferred hygiene practices c. Knowing that hygiene is a routine procedure d. Recognising that no two persons perform hygiene in the same way e. Get all hygiene procedures performed before the doctor’s visit.

Answer: b Rationale: Hygienic practices are unique to each person, and the nurse should provide individualised care based on the person’s preferences and try to accommodate their usual hygiene practices.

10. The primary goal in providing eye hygiene on an unconscious person is to prevent: a. lagophthalmos b. misosis c. astigmatism scleral degeneration d. corneal abrasions.

Answer: d Rationale: Corneal ulcers occur quickly if the very delicate tissue of the cornea is abraded (e.g., on bed linen) and easily invaded by bacteria. They can cause severe pain, corneal perforation and vision loss.

Eye care on a regular basis (assessment, cleansing, lubrication and taping the eye shut) can prevent abrasion and subsequent infection of the cornea.

Spotlight on critical thinking Surgery clinic health care teaching You are caring for a person newly diagnosed with DM. 1.

What do you need to know about the person to begin teaching them about this disease?

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Suggested solution: You would need to know: • what type of DM they are diagnosed with • what they already know about DM and what they think they know about DM • their literacy level, and their health literacy level • whether they are visual, auditory or kinaesthetic learners.

2.

What do you need to know about the disease to explain it to the person?

Suggested solution: You would need to know: • the relevant anatomy and physiology • pathophysiology of DM (types) • blood glucose levels and the types • the basic diagnosis, treatment (diet, exercise, medications [both insulin and the oral hypoglycaemic medications]) and monitoring they will need to know • if insulin dependent, you will need to know about injecting insulin.

3.

What barriers to their learning might you encounter?

Suggested solution: barries might include: • Fear • lack of literacy, health literacy • cultural, language barriers • time • physiological barriers (age, blindness, deafness, intellectual disability)

4.

What teaching strategies would you use?

Suggested solution: • • • •

lecture one to one discussion/teaching appropriate brochures or pamphlets vetted YouTube presentations

• coaching or return demonstration.

Caring and compassion: Self-care deficits Imagine that you are blind and unable to shop or prepare food to feed yourself. You can dress yourself with some help but are unable to leave your home without assistance. You are dependent on caregivers since you have no family or friends to assist you.

5.

How do you feel about being dependent on caregivers to meet your basic needs? (Think about scheduling, choosing clothing, food, being alone in the dark.)

6.

What happens if the caregivers do not respond when you ask for help?

7.

How do you feel when others make decisions for you?

Suggested solution: This is purely reflective thinking. The students should consider their own values and beliefs and if willing, discuss these with the class. Another approach is to ask the students to answer these questions with their reasoning on paper, then, share with another student or small group. Place the results on a whiteboard or similar and discuss as a large group.

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Use of restraints Gloria Ricci is an 83-year-old widow who fractured her hip when she fell in the bath. She had hipreplacement surgery yesterday. Tonight, she is very confused and is trying to dislodge the bandage and stitches. The RN is considering restraint for Mrs Ricci’s protection.

8.

What type of restraints might be chosen?

Suggested solution: Check the facility's policy on restraint – most types of restraint will increase her confusion and you would be better off trying the other nursing activities. For this instance, perhaps mitts or armboards on the wrists (if permitted) would prevent her dislodging the bandages.

9.

What other nursing activities could have been implemented prior to the use of restraints?

Suggested solution: Consider the following: • assessment (need for toilet, oxygenation status, pain level, check bandages for constriction, thirst, psychosocial assessment, and others as necessary) and attention to her needs • orientation, explanation and reassurance • ask a volunteer (family, friend, preferably) to sit with her and keep her oriented • distraction via favourite TV show, music.

10. Do you think that restraints will affect Mrs Ricci's mental status? If so, in what ways? Discuss the physiological effects and dangers of using restraints.

Suggested solution: yes – she is already confused, restraining her will increase the confusion, frustration, anxiety and fear, which could then escalate to more violent attempts at freeing herself.

Physiological effects and dangers of using restraints include decreased movement, decreased oral intake, faecal and urinary incontinence, increased incidence of pressure injury, muscle wasting and as a result increased frailty and reduced mobility; loss of bone density due to prolonged healing of hip fracture, possibility of aspiration (supine restraint) , strangulation, trauma and injury from trying to free herself. Bedrails increase risk of strangulation, falls.

11. How would you feel about the use of restraints if Mrs Ricci were your grandmother?

Suggested solution: Ask the students to explore their own experiences of being immobile or even restrained, and relating that to using restraints. They may: • feel anger, fear for her safety, sadness to see her restrained • know her usual mental status, ability to be reasoned with, memory and could help avoid the use of restraint • understand the possible risks involved in restraint and may feel anxiety for their grandmother • understand the ability of family to sit with her to prevent the use of restraints • need to look at the difference between the emotional attachment for a grandparent, and the professional relationship with elderly people. Empathy is an important skill that needs reflection on stereotyping, biases, etc.

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Reflection on hygiene Nurses work through their bodies. Discuss the importance of your own daily hygiene practices to your nursing care. Consider daily bathing, deodorant use, wearing perfume or aftershave, smoking prior to caregiving, and nail, oral and hair care.

12. Do you think that hospital/university rules about personal hygiene of nurses are warranted?

Suggested solution: This is a balance between personal choice and professional behaviour.

The hospital/university has rights to decree that its employees.

Students adhere to the standards set by the profession.

Consideration of others (what if it was you who lay in bed with someone who reeked of body odour or cigarette smoke or whose halitosis was overpowering).

• Consideration of nursing as a hygiene-based profession and setting an example.

• Most of the above daily hygiene practices are also infection control practices and are practical when caring for vulnerable people.

• • • •

13. Have you seen nurses who do not follow these rules? For example, hair over collar, wearing jewellery, artificial or long nails, perfume or aftershave, halitosis, smelling of cigarette smoke.

Suggested solution: This is a discussion question and should raise issues of personal choice versus professional presentation; consideration of others (what if it was you who lay in bed with someone who reeked of body odour or cigarette smoke or whose halitosis was overpowering) and consideration of nursing as a hygiene-based profession and setting an example.

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Content Key terms ....................................................................................................................................................................1 Instructional strategies ...............................................................................................................................................3 Resource aids ..............................................................................................................................................................4 Online resources .........................................................................................................................................................4 Evaluation strategies...................................................................................................................................................5 Review questions ........................................................................................................................................................6 Spotlight on critical thinking .......................................................................................................................................8

Chapter 33 Medication administration Key terms Absorption Process by which the end products of digestion pass through the epithelial membranes in the small and large intestines into the blood or lymph system, passage of a medication from the site of administration into the bloodstream.

Addition Physiological and psychological dependence upon a substance.

Adverse reactions Any medication effect other than what is therapeutically intended.

Aspiration Procedure performed to withdraw fluid that has abnormally collected, or to obtain a specimen, the inhalation of regurgitated gastric contents into the pulmonary system.

Bioavailability Readiness to produce a medication effect.

Buccal Pertaining to the inside cheek.

Dependence Reliance on or need to take a medication.

Dissolution Rate at which a medication becomes a solution.

Distribution Movement of medications from the blood into various body fluids and tissues.

Duration The time a medication remains in the system in a concentration great enough to have a therapeutic effect.

Enteral instillation Administration of medications through a gastrointestinal tube.

Excretion Elimination of medications from the body.

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Fundamentals of Nursing 3e: Instructors Manual

Half-life Time it takes the body to eliminate half of the blood concentration level of the original medication dose.

Idiosyncratic reaction Reaction of overresponse, under-response or an atypical response.

Intradermal (ID) Injection into the dermis Intramuscular (IM) Injection into the muscle.

Intravenous (IV) Injection into the vein.

Medication Chemical substance (or combination of substances) that is taken into the body to cure a disease (e.g., antibiotic), treat a condition (e.g., antidepressant), relieve symptoms of an illness or condition (e.g., analgesic or pain reliever), or prevent a disease (e.g., vaccine). The term generally refers to a prescription medication but may include herbal remedies. ‘Drug’ is an alternate term.

Medication allergy Hypersensitivity to a medication.

Medication tolerance Reaction that occurs when the body becomes accustomed to a specific medication and requires larger doses of the medication to produce the desired therapeutic effect.

Metabolism The combination of all chemical reactions in every body cell.

Onset of action Time it takes the body to respond to a medication after administration.

Parenteral Introducing a medication into the system by any route other than the oral–gastrointestinal tract.

Patency Openness of tube, lock or bodily passageway.

Peak plasma level Achievement of the highest blood concentration of a single medication dose until the elimination rate equals the rate of absorption.

Pharmacognosy The study of the biochemical aspects of natural products.

Pharmacokinetics Study of the absorption, distribution, metabolism and excretion of medications.

Phlebitis Inflammation of a vein.

Plateau Level at which a medication’s blood concentration is maintained.

PRN Medication orders that are administered as needed.

Side effects Mild, non-therapeutic medication effects.

Stat order An order for a single dose of medication to be given immediately.

Stock supplied Certain medications dispensed and labelled in large quantities.

Subcutaneous (subcut) Injection into the subcutaneous tissue.

Sublingual (subling) Under the tongue.

Suppositories A dosage form used to deliver medications by insertion into a body orifice (usually rectum or vagina) where it dissolves or melts to exert local or systemic effects.

Therapeutic range Achievement of a constant therapeutic blood level of a medication within a safe range.

Toxic effect Reaction that occurs when the body cannot metabolise a medication, causing the medication to accumulate in the blood.

Trough The lowest blood serum concentration of a medication in a person’s system. © Cengage Learning Australia 2024

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Unit-dose form System of packaging and labelling each dose of medication, usually for a 24-hour period Z-track (zigzag) technique Method of intramuscular injection that seals the medication in the muscle, preventing the medication from irritating the subcutaneous tissue.

Instructional strategies • Discuss the different methods of medication administration and give examples of what types of drugs are given in those ways: o Oral route: this is the most common form of medication administration. It is also the least expensive way to give medications. Medications like vitamins, aspirin, paracetamol, and most maintenance medications are given orally. o Sublingual route: medications given sublingually have more rapid absorption rates. Angina medications, as such glyceryl trinitrate, are commonly given sublingually. o Topical route: medications to be absorbed in the skin are administered topically. Liniments and ointments for various skin ailments are administered this way. o Inhalant route: medications to work on the respiratory system are often given this way. They tend to be quick acting. Medications for asthma or respiratory compromise are given in an inhalant form. o Parenteral route: this route includes medications administered by intradermal (ID), subcutaneous (subcut), intramuscular (IM), or intravenous (IV) methods. Medications given by these routes may be quick acting and have systemic effects. Pain medication is often given parenterally.

• What are the essential parts of a medication order? All medication orders must have the following information to be considered a complete order. The order must have the name of the person. It must include the date and the time the order was written or requested. The name of the drug needs to be included in the order. The amount (dose) of the drug to be given and the route of administration are specific parts of the complete medication order. An order is not complete without describing the time of administration requested and the frequency. The provider who writes the order needs to sign the order, and nurses who take a verbal or telephone order need to sign their name as well as the name of the requesting provider. Some facilities or units have standing orders or medication protocols. Nurses have a responsibility to know what standing orders and protocols are in effect in their unit of work. The nurse has an obligation to question any incomplete order or clarify any order that is not specific or correct.

• Discuss the ‘rights’ of medication administration. Nurses learn that there are ‘six rights’ to medication administration: right medication, right route, right patient, right dose right time, and right documentation. Even with diligence in adhering to these rights, medication errors occur. Because of this, many organisations have added other ‘rights’ such as the right reason and right effect.

• What is being done to reduce the incidence of medication errors? Even with the implementation of the ‘rights’ of medication administration, errors occur. To help reduce the likelihood of a medication error, nurses should question any medication orders that are confusing or unclear. The organisation should also create and publish a ‘do not use’ abbreviation list, which will reduce the chances of a medication order being misread or misinterpreted. The use of computerised medication administration systems has also been implemented in some organisations. These systems use bar coding to input patient information and link this information to the person’s medication administration record.

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• A patient is to be discharged with a prescription for an essential medication. How should a prudent nurse assess the person before discharge to help ensure that they will continue on the medication regimen?

Before discharge, the nurse should assess whether they have taken the specific medication before. He or she should be taught how and when to take the medication and if any special restrictions apply. For example, some medications should be taken with food, some without. Some medications can be discontinued suddenly (analgesic medication), and some are not to be abruptly discontinued (steroids and antidepressants). The person or their family must be able to have the prescription filled. Can the person get to a pharmacy? Is there a family member who can go to the pharmacy for the person? Does the person have money to buy the medication? Does the person know how to administer the medication? Has he or she verbalised understanding or given a demonstration of how to properly administer the medication ordered? Assessing a person before discharge regarding medication administration is of vital importance to help ensure continuing proper medication administration.

• Discuss the importance of monitoring therapeutic serum levels of medications in the clinical setting. When are peak and trough levels drawn, and how is this information important to the clinical management of patients? Serum therapeutic drug levels are indicated for specific drugs used in the clinical setting, such as digoxin, aminophylline, phenytoin, heparin, and certain antibiotics (gentamycin and vancomycin).

People who are receiving such drug therapy should have their serum levels monitored so that drug administration is both safe and therapeutic. Both of these variables must be addressed so that the person may benefit from the administration of the drug. Peak levels are drawn when the drug is at the highest level in the blood stream. The time it is drawn varies with the type of medication. Nurses should refer to laboratory and pharmacy personnel in their clinical setting for exact time determinants. The trough level is drawn when the drug is at the lowest level in the blood stream. This usually coincides with immediately before the next scheduled dose is to be hung. Nurses work with laboratory personnel to coordinate timing for blood collection relative to peak and trough levels. The combination of peak and trough levels is used to provide information relative to safety and efficacy of the intended therapy. Dose adjustments may be indicated, or the medication may be withheld depending on the laboratory findings. It is important for the nurse to be aware that these tests are ordered for the person and that the results are communicated to the health care provider before resuming drug therapy.

Resource aids Rice, J. (2002). Medications and mathematics for the nurse. Cengage Delmar Learning.

Spratto, G. R., & Woods, A. L. (2013).2013 Delmar Nurse’s Drug Handbook. Cengage Delmar Learning.

Online resources • Australian Health Practitioner Regulation Agency. (2020). Guidelines: Mandatory notifications about registered health practitioners. Retrieved fromhttp://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Codes-Guidelines/Guidelines-for-mandatory-notifications.aspx – Discusses the registered nurse’s obligations for mandatory notifications regarding conduct or impairment.

• Nursing and Midwifery Board of Australia. (2022). Endorsement for scheduled medicines for registered nurses (rural and isolated practice). Retrieved from https://www.nursingmidwiferyboard.gov.au/Registration-Standards/Endorsement-for-scheduled-

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medicines.aspx – Sets out the qualifications and other requirements for a registered nurse to obtain, supply, and administer scheduled medications.

Evaluation strategies • Have students practise identifying landmarks and sites for IM injections on anatomic diagrams.

• In the laboratory setting, have the students practise preparing medications for administration. This should include oral route (tablets, liquid), subcut injection, IM injection, ID injection, eye drops, ear drops, nose drops, topical, and IV. (If unable to secure ampoules for practice, contact the pharmacy department of a clinical practice site to obtain outdated ampoules for practice purposes.)

• In the laboratory setting, have available nasogastric tubes and gastrostomy tubes for the students to practise providing medications through these devices.

• In the laboratory setting, have available intravenous administration solutions, tubing, extension sets, and the related supplies for the students to practise administering medications through this route.

• Prior to the students providing medications to patients in the clinical setting, have the students research the prescribed medications for the patient assignment. Research should include medication trade and generic names, routes of administration, dose, category, expected action, side effects, adverse effects, peak effects, and duration of action.

• Medication errors are a common source of concern for the nursing student, novice (graduate) nurse, and experienced nurse. Have a round-table discussion on how the students feel on this topic. Discuss what methods they can utilise to prevent errors from occurring and how they perceive the potential for nursing errors to occur in the clinical environment.

• Have students discuss how they would handle the following medication scenarios: (1) a patient who refuses to take any medication, (2) a paediatric patient whose mother wants to administer the medication, (3) an adult patient who only wants to take half the dose ordered, (4) an older man who wants to take his own medications that he brought from home, and (5) a patient who refuses to take any medications until someone explains why each of them was ordered.

• Have students do Internet research on the amount and type of possible drug–food interactions. Discuss how this type of drug interaction is handled in the clinical setting.

• Have the students read the section ‘Medication abuse’ in this chapter. Chemical dependence in the profession of nursing can occur. Discuss the questions in a large group.

• Discuss the concepts of alternative therapies, complementary medicine, and integrative therapy in the clinical setting. Have students go into their clinical settings and see how these types of therapies are addressed in the admission interview, during the hospital admission, and upon discharge.

• Divide students into small groups and give them various parts of a medication order. Have students determine what information they have and what information they need, to have a correct medication order.

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Review questions 1.

The purpose of medication management is to produce the desired medication action by maintaining a constant medication level. The time it takes the body to eliminate half of the blood concentration level of the original medication dose is called: a onset of action b peak plasma level c half-life d plateau e trough.

Answer: c Rationale: Once the peak plasma level is reached, the blood concentration level will decrease steadily unless another drug dose is given. Onset refers to the time it takes the body to respond to a drug. Halflife is the time it takes the body to eliminate half of the blood concentration level of the original drug dose. Plateau refers to the blood concentration level that is maintained after a series of scheduled drug doses.

2.

A nurse cannot understand the prescribing practitioner’s standing orders. What should she do? a. Contact the nurse unit manager to interpret the order. b. Have the ward clerk call the prescribing practitioner. c. Call the prescribing practitioner to have the order clarified. d. Send the order to pharmacy and let the pharmacist fill the order. e. Ask another nurse what the order is.

Answer: c Rationale: The nurse is responsible and held accountable for questioning any medication order if the order is not clear; the nurse must contact the prescribing practitioner.

3.

The prescribing practitioner has ordered 150 mg of a medication for a person. The medication comes in 100 mg tablets. How many tablets does the nurse give to the person? a 0.5 tablet b 1 tablet c 1.5 tablets d 2 tablets e 4 tablets.

Answer: c Rationale: 150mg (what you need) ÷ 100mg (the table strength you have) = 1.5 tablets.

4.

What information should be obtained from the medication history? a. Prescription medications b. Allergies c. Herbal supplements d. Over-the-counter medications e. Sensory and cognitive status.

Answer: a, b, c, d, e Rationale: The drug history information is used by the nurse in determining the person’s plan of care.

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5.

A person is ordered a medication PRN. What does the term PRN mean? a. Immediately b. When required c. Three times a day d. By mouth e. Hourly.

Answer: b Rationale: A medication may be ordered on a PRN (as needed) basis as circumstances indicate. The medication is administered when, according to your judgement, the person’s condition requires it.

6.

What is the usual dosage range for intradermal injections? a. 0.01–0.1 mL b. 0.1–0.15 mL c. 1.15–0.2 mL d. 0.2–0.25 mL e. 0.5–2.0 mL Answer: a Rationale: Intradermal injections are administered into the epidermis with small amounts of solutions.

7.

The prescribing practitioner ordered 5 mL of a medication be given deep IM for a 45-year-old female who weighs 65 kg and is 170 cm tall. What is the most appropriate method for administering this injection? a. A 5-mL syringe, 20–23-gauge, 3 cm needle b. A 5-mL syringe, 23–25 gauge, 3 cm needle c. Two 3-mL syringes, 20–23-gauge, 3 cm needle d. Two 3-mL syringes, 23–25-gauge, 3 cm needle e. Two 2-mL syringes, 20–23-gauge, 3 cm needle.

Answer: c Rationale: The nurse needs to divide the 5 mL into two 2.5-mL injections; 5mL is too large a volume to be injected into one site. The person is of average height and weight, and depending on muscle mass, the needle length of 3 cm should be used since the order stated ‘to be given deep IM’. IM injections are usually given with a 20–23-gauge needle.

8.

The correct way to administer eardrops to an adult is to pull the pinna: a. straight back b. down and back c. upward and outward d. straight down e. upward and backward.

Answer: c Rationale: The nurse must pull the pinna upward and outward to straighten the ear canal to administer eardrops in the adult. The pinna would be pulled down and back in children.

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9.

A person is ordered 2.5 mg of IMI morphine. It is stocked as morphine 20 mg in 2 ml. What volume does the nurse need to draw up? a b c d e

0.25 mL 0.75 mL 1.25 mL 1.50 vmL 2.00 vmL

Answer: a 10. A registered nurse (RN) has just received word of a new admission to the unit with the diagnosis of shortness of breath and indigestion-type pain. The RN needs to delegate procedures to other personnel and retain certain nursing functions. Which nursing functions can be delegated? Delegated to an: a. endorsed enrolled nurse (EEN) the administration of a PRN IM injection for pain. b. EN the assessment of the new admission. c. assistant in nursing (AIN) the vital signs of the new admission. d. AIN the observation of patient self-administering a metered-dose nebuliser. e. AIN the administration of the IMI for pain.

Answer: a Rationale: It is usually within the scope of practice for an EN to administer PRN IM injections for pain.

The RN needs to assess and evaluate the care of the new admission to include the vital signs since the person has shortness of breath and is having pain. The skill of medication administration is not delegated to ancillary personnel in acute care settings; evaluation of the person’s ability to selfadminister is part of medication administration.

Spotlight on critical thinking Chemical dependence 1.

What are the nurse’s obligations under Mandatory Notifications (Ahpra, 2020) guidelines to report nurses intoxicated by alcohol or medications while at work??

Suggested solution: While it is a challenging situation, the nurse is required by the guidelines to report any nurse or practitioner who is intoxicated by medications or alcohol. Not reporting your suspicions may place your own nurse registration at risk.

2.

What are the implications for the continued nursing practice of nurses who are intoxicated by alcohol or medication while working?

Suggested solution: An impaired nurse who continues to provide care places the people being cared for at risk. Nurses with reported addictions may be able to seek help and may be able to continue working with restrictions on their practice.

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Medication error While monitoring a person who has an order for cefazolin (an anti-bacterial drug) intravenously, you notice that ceftriaxone (an anti-bacterial drug) is in the person's room. You recheck the order to make sure that the original order was for cefazolin and that the order was not changed.

3.

What should your next action be?

Suggested solution: You need to report the medication error to the nurse unit manager.

4.

How do you feel about the nurse who made the medication error but did not recognise it?

Suggested solution: It is very easy to make an error. The mistake needs to be brought to the attention of the nurse, and it needs to be determined if there were any contributing factors that lead to the error.

Medication non-compliance A person has a serious bacterial infection. They decline to take his oral antibiotic.

5.

What are the common reasons for people’s refusal to take their medications?

Suggested solution: Student responses may vary but should refer to the fact that the person is asymptomatic, side effects of medications, and inconsistencies with dosages of self-medication. The student may also mention that the person could be concerned by medication cost.

6.

What would you do in this situation?

Suggested solution: You first need to identify why the person refused to take his oral antibiotic. You must explain to the person the importance of the antibiotic in treating his serious bacterial infection.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 3 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking ................................................................................................................................ 9

Chapter 34 Traditional and complimentary therapies Key terms acupressure The use of finger pressure applied to specific points (energy pathways) on the body to promote healing. acupuncture A complementary therapy in which fine needles are inserted into selected locations on the body to align energy flow.

Allopathic That which is recognised by a specific culture as being traditional, conventional or mainstream.

Aromatherapy Therapeutic use of concentrated essences or essential oils that have been extracted from plants and flowers.

Ayurvedic medicine A healing system based on Hindu philosophy and Indian philosophy that embraces the concept of an energy force in the body that seeks to maintain balance or harmony.

Biofeedback Measurement of physiological responses that yields information about the relationship between the mind and body and helps people learn how to manipulate these responses through mental activity.

Bodymind Inseparable connection and operation of thoughts, feelings and physiological functions.

Chakra A concentrated area of energy that influences the physical body, emotions, mental patterns and spiritual awareness.

Chiropractic Promotion of healing through manipulation of the spinal column.

Complementary medicine (CM) ‘A broad set of health care practices that are not part of that country’s own tradition or conventional medicine and are not fully integrated into the dominant health-care system’ (WHO, 2019, p. 8).

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Complementary therapies Treatment approaches that can be used in conjunction with conventional medical therapies.

Effleurage Massage technique consisting of long, smooth strokes used at the beginning and end of treatment and between other movements.

Endorphins Group of opiate-like substances produced naturally by the brain; these substances raise the pain threshold, produce sedation and euphoria, and promote a sense of wellbeing.

Energy therapies Techniques in which the hands are used to direct or redirect the flow of the body’s energy fields to enhance balance within the fields.

Friction Force of two surfaces moving against one another; massage technique whereby the heels of the hands or the thumb pads are used to apply deep, penetrating pressure on knotted muscles.

Guided imagery A process in which the person uses all the senses to experience the sensation of relaxation.

Healing touch (HT) Energy-based therapeutic modality that alters the energy fields using touch, thereby affecting physical, mental, emotional and spiritual health.

Holism The connection between mind, body and spirit.

Integrative therapy A clinical approach that combines Western technological medicine with techniques from Eastern and traditional medicine.

Meditation Quieting the mind by focusing one’s attention.

Mindfulness Therapeutic practice of being aware of the present moment including awareness of any thoughts, emotions and bodily sensations.

Music-thanatology Holistic and palliative method for use of music with dying people; solely concerned with dissipating any obstacle to a peaceful death.

Neuropeptides Amino acids produced in the brain and other sites in the body that act as chemical communicators.

Neurotransmitters Chemical substances produced by the body that facilitate nerve impulse transmission.

Ngangkari Name used to describe Aboriginal and Torres Strait Islander traditional doctors in many parts of Australia who practice holistic healing, including to address physical, psychological and spiritual ill health.

Nutraceuticals Natural substances found in plant or animal foods that act as protective or healing agents.

Petrissage Massage technique using squeezing, kneading and rolling movements to release muscle tension and stimulate circulation.

Phytonutrients Chemicals found in plants (also known as phytochemicals).

Psychoneuroimmunology (PNI) Study of the complex relationship between the cognitive, affective and physical aspects of humans.

Relaxation response State of increased arousal of the parasympathetic nervous system that leads to a relaxed physiological state.

Shaman Folk healer–priest who uses natural and supernatural forces to help others.

Shamanism Practice of entering altered states of consciousness with the intent of helping others.

Tapotement Massage technique using a light tapping of the fingers that stimulates movement in tired muscles.

Therapeutic massage Application of pressure and motion by the hands with the intent of improving the recipient’s wellbeing.

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Therapeutic touch (TT) Holistic technique that consists of assessing alterations in a person’s energy fields and using the hands to direct energy to achieve a balanced state.

Traditional and complementary medicine (T&CM) ‘Merges the terms TM and CM to encompass products, practices and practitioners.’ (WHO, 2019, p. 8).

Traditional medicine (TM) ‘The sum total of the knowledge, skill and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness’ (WHO, 2019, p. 8).

Vibration Massage technique using rapid movements that stimulate or relax muscles.

Instructional strategies Discussions: (with some of the points to consider): • Both modern medicine and nursing have had historical influences from many ancient cultures that have shaped practice. Discuss what some of these influences are. Ancient Greece contributed the philosophy of balance, rest and such healing therapeutics as music, humour and massage. The Far East has also contributed the concept of balance for health. China practiced herbalism and acupuncture. In India, there was a holistic view of health and life. Contemporary uses of India’s medicine include yoga, herbs, diet and exercise, and massage.

• In some areas of Australia and New Zealand, traditional and complementary medicine are used with the biomedical model. Describe some traditional and complementary interventions that might be used in the hospital setting, and when these might be used. o Meditation is the quieting the mind by focusing attention and is useful for reducing stress. It causes physiological changes in the body, such as lowering heart rate, blood pressure and respiratory rate. It is useful prior to and during stressful procedures, such as dressing changes or diagnostic tests. o Relaxation is the incorporation of meditation into a therapeutic process. Relaxation is useful with individuals with high blood pressure and heart disease. Relaxation techniques work to reduce pain and anxiety and stress. Progressive Relaxation involves tensing different muscles in your body and then releasing the tension. o Autogenic Training uses a series of mental exercises involving relaxation and ideas you suggest to yourself (autosuggestion), your mind focuses on your body’s experience of relaxation. o Hypnosis introduces an altered state of consciousness. This altered state allows therapy through the use of suggestion. Hypnosis introduces an altered state of consciousness. This altered state allows therapy through the use of suggestion. Self-Hypnosis is a technique used to produce the relaxation response when prompted by a phrase nonverbal cue (called a “suggestion”) of their own. o Breathing Exercises are accomplished by focussing on taking slow, deep breaths—also called diaphragmatic breathing. o Guide Imagery is a type of thinking without words evoking a person’s imagination to picture objects, scenes, or events that are associated with relaxation to produce a similar feeling of calm. A person in chronic pain can use imagery to reduce that pain. o Biofeedback is a process that yields information (usually using an electronic device) about the relationship between the mind and body and recognising how to manage the response to stress to manipulate that relationship. Biofeedback has been used to lower blood pressure, relieve migraine headaches, and restore sensation and functioning.

• Describe the emerging field of psychoneuroimmunology (PNI) and how the concept of ‘bodymind’ has led to new medical research breakthroughs. PNI is a new field of science that studies ‘the complex relationship between the cognitive, affective, and physical aspects of humans’. New area of research led to the recognition of the importance of neurotransmitters and their effect on the brain, human body, and overall immune function. Research in this area has supported the premise that the human mind can © Cengage Learning Australia 2024

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influence human physiology. By studying the vast area of chemical transmitters, it is hoped further insight will be provided as to improving immune function.

• Nurses often strive to provide holistic care. Discuss the concept of holism. Holism is based on the concept that body, mind, and spirit are interrelated. In nursing, holism takes into consideration a person’s physiological, psychological, sociocultural, intellectual, and spiritual aspects. Holism is demonstrated when nurses practise the art and science of caring for the whole person. Concepts within holism include the mind and body are one, not separate; people are responsible for their own choices; people have the power to solve their own problems; and well-being is multifaceted.

• Discuss the therapeutic benefits of exercise and identify people who might benefit from this type of therapy. The therapeutic benefits of exercise include promotion of circulation, which helps the cardiovascular and peripheral vascular systems. Movement of blood and gas exchange during exercise helps to improve respiratory function. Exercise also helps to aid the process of metabolism and elimination by promoting hormonal response. Endorphin release from the brain is activated and immune function is enhanced as chemical messengers respond to the increased activity of the muscles and body.

Strength, endurance and stamina are all built gradually with continued exercise. Most people will benefit from some type of exercise program. The exercise program must be individualised to allow for warm-up, activity and cool-down periods. People who are hospitalised also benefit from moving their body.

Maintenance and restoration of function and flexibility, improvement in strength, reduction in pain, improved blood flow and respiratory effort assist healing, immune response.

• Nurses use touch when providing care. Discuss therapeutic touch and healing touch. Both types of ‘touch’ were researched and identified by nurses. Therapeutic touch consists of altering a person’s energy field and using the hands to direct energy to achieve a balanced state. It can be done with the hands on or off the body and achieves a relaxation state. Healing touch is also an energy-based therapeutic modality where the body’s energy fields are balanced and used to provide relaxation and treat problems such as headaches, spinal problems, and pain. When implementing therapeutic touch, the nurse works through five phases: centring, assessment or scanning, unruffling or clearing, treatment or balancing, and evaluation.

• Discuss the emergence of nutraceuticals, phytonutrients, and herbal therapy, and their effect on the health care ‘consumer’. What factors might influence choice of these methods?

• ‘Nutraceuticals’ and ‘phytonutrients’ are recent terms used to describe food products that contain natural substances that offer some therapeutic benefit. Herbal therapy has a longer history with regard to offering therapeutic benefits and has been used by many cultures to support, enhance, and maintain overall good health. In today’s world, these methods are being advertised as an alternative (integrative) approach to support one’s overall health status. Factors that might influence the choice of these methods include advertising promotions, word-of-mouth testimonials from family and friends, desire for improvement of condition and added benefit, and belief in a more holistic approach to one’s health care.

Resource aids Awaye Program highlighting the work of Aboriginal traditional healers Aboriginal healers working to keep traditional medicine alive, http://www.abc.net.au/radionational/programs/awaye/aboriginal-healersworking-to-keep-traditional-medicine-alive/5471058 Spirits in the balance: Ngangkari healers Anangu Pitjintjatja Yangkunjatjara (APY) lands in northern South Australia, traditional health knowledge is alive and well, and working in a contemporary setting, http://www.abc.net.au/radionational/programs/awaye/ngangkari/5467558

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Online resources •

Aṉangu Ngangkaṟi Tjutaku Aboriginal Corporation (ANTAC) is a ngangkaṟi’s Aboriginal corporation, http://antac.org.au

•

Australian Acupuncture and Chinese Medicine Association Ltd (AACMA) is the peak professional body of qualified acupuncture and Chinese herbal medicine practitioners in Australia., http://www.acupuncture.org.au

•

Australian Foundation for Healing Touch Inc is a non-profit membership and educational organisation established in 1997 to administer and co-ordinate Healing Touch Programs in Australia. http://www.healingtouch.org.au

•

Australian Indigenous HealthInfoNet is an innovative Internet resource to inform practice and policy in Indigenous health. https://healthinfonet.ecu.edu.au

•

Australasian Integrative Medicine Association (AIMA) is the peak medical body representing the doctors and other health care professionals who practise integrative medicine. https://www.aima.net.au

•

Australian Traditional-Medicine Society (ATMS) is Australia’s largest national professional association of natural medicine practitioners http://www.atms.com.au

•

Healing Touch New Zealand Inc (HTNZ), the professional organisation for students and practitioners of Healing Touch http://www.healingtouchnz.com

•

Māori health follow the link for statistical publications and data sets on Māori health http://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets/maori-health-data-andstats?mega=Health%20statistics&title=M%C4%81ori%20health

•

National Centre for Complementary and Alternative Medicine provides information about complementary health products and practices. https://www.nih.gov/health-information

•

National Institute of Complementary Medicine (NICM) was established to provide leadership and support for strategically directed research into complementary medicine and translation of evidence into clinical practice and relevant policy to benefit the health of all Australians. https://nicm.edu.au/health_information

•

New Zealand Natural Medicine Association is an organization of health professionals dedicated to the promotion of integrative healthcare incorporating Allopathic Complementary and Alternative Healthcare. https://nznma.com

Evaluation strategies • How can nurses who are strong proponents of alternative methods of treatment and healing incorporate their beliefs into their nursing practices?

• Discuss the legal responsibility of caring for a person who wishes a traditional or complementary practitioner to render care when under treatment at your facility.

• Using Table 34-1, ‘Comparison of allopathic and T&CM’, divide students into two groups and debate the benefits of each perspective. Following the debate exercise, ask students to analyse the other group’s position statement and suggest ways to balance (combine) the two approaches.

• Have the students keep a log of advertisements used to promote the benefits of food (nutraceuticals,

phytochemicals, and herbs) for a period of a week and bring these to tutorial. Have the group examine

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the amount of information the health care consumer is exposed to regarding this area of nutrition. Look at the veracity of the information provided – are the advertisements based on celebrity endorsement, public's testimonials, 'expert' opinion (who is the expert, what can you find out about him/herqualifications, background, any complaints, etc), how do you know that the advertisement is not fraudulent and product is beneficial. Does it claim to 'cure'? Would you take this product if you were suffering from the symptoms it claims to treat?

Review questions 1.

Which of the following T&CM interventions should be avoided when caring for toddlers? a. Movement b. Hypnosis c. Massage d. Energy therapies e. Music.

Answer: b Rationale: Hypnosis is not an appropriate treatment modality for very young children due to their cognitive level. It is appropriate for older school-aged children, adolescents, and adults. Art/drawing, massage, and music can all be therapeutic for toddlers.

2.

A nurse is caring for Mrs Brown, who uses herbs to promote health. Which of the following herbs is useful in treating mild depression? a. Aloe vera b. Chamomile c. Ginger d. St John’s wort e. Sage.

Answer: d Rationale: St. John's Wort has research to back its claim to reducing mild to moderate depression. In fact, some research has shown it is as effective as several prescription antidepressants. It's unclear whether it's beneficial in the treatment of severe depression. It has also been found to be useful in ameliorating some menopausal symptoms (hot flushes). However, it should be noted that this herb interacts with many medications. Some studies indicate that St. John's wort might be beneficial for the treatment somatic symptom disorder, which is a condition that causes severe anxiety about physical symptoms such as pain, weakness or shortness of breath. Ginger has been shown to be effective with reducing nausea associated with motion sickness and pregnancy. Aloe vera promotes healing of wounds, especially burns. Calendula aids in promoting skin integrity, and sage has antibacterial properties.

3.

Aboriginal and Torres Strait Islander peoples’ healing practices are strongly rooted in which of the following? a. Allopathic medicine b. New Age concepts c. Spiritual beliefs d. Ayurvedic practices e. Yoga techniques.

Answer: c Rationale: Spiritual beliefs underpin the Aboriginal and Torres Strait Islander peoples healing practices.

Allopathic medicine refers to modern, scientific methods of medicine; New Age concepts are a range of

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spiritual beliefs often with occult and mystical overtones; yoga techniques are associated with Ayurveda (Indian) traditional medicine.

4.

Which of the following nursing responses is most therapeutic for Mr Smith, who expresses interest in using herbal remedies? a. ‘I use lavender and valerian to help me relax at night.’ b. ‘Why would you want to try something that has no proof?’ c. ‘My herbalist recommends the use of St. John’s wort to promote healing.’ d. ‘Since they are natural, herbs are completely safe.’ e. ‘Do you know how to assess a potential naturopath/herbalist?’

Answer: e Rationale: This can be tricky – the herbalist/naturopath would need to have valid credentials from an accredited education institute to ensure that: • their work is 'complementary' – they are happy to work with and refer to a medical practitioner • they use evidence-based herbs and treatments as much as possible, or tell you that the treatment is traditional • they discuss possible side effects and risks of the prescribed herb/treatment • they don't make claims that are unrealistic • they listen to the person in their care.

Answers (a) and (c): recommending specific herbs is outside your scope of practice. They may interfere with the person's medical treatment – interacting with medicine, causing either a agonistic or synergistic effect. Answer (b) denigrating the person's practices/choices reduces their trust in you.

Finally, answer (d) herbs are not without risk – they are active pharmacologically and may enhance or interfere with allopathic treatment.

5.

A combination of biomedical care and traditional and/or complementary care is called: a. integrative care b. holism c. allopathy d. mixed method medicine e. TCM. Answer: a Rationale: Combining traditional care with complementary care is called integrative care.

6.

Which of the following foods are dietary sources of phytosterols? (Select all that apply). a. Butter b. Sunflower oil c. Flaxseed d. Soybeans e. Parsley f. Olives g. Pumpkin seeds h. Red meat Answer: b, d, f, g Rationale: Sunflower oil, soybeans, olives and pumpkin seeds are all sources of phytosterols. Butter and red meat have high fat content that can metabolise into free radicals that harm cells. Flaxseed contains Omega3 fatty acids, lignan and dietary fibre, and parsley has effective antioxidant properties.

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7.

Which of the following is a reason why some health care professionals discourage the use of CM therapies? a. CM therapies are more expensive. b. There are often fraudulent claims for the benefits of various CM practices. c. Insurance companies reimburse for most CM therapies. d. The CM practices have been proven to be ineffective. e. Allopathic treatment methods are totally effective.

Answer: b Rationale: CM practices are often fraudulently advertised. They can be very expensive; most are not reimbursed by insurance companies; there is a dearth of research evidence to prove or disprove most CM practices; not all allopathic treatments are effective.

8.

Which of the following best describes the Ayurvedic perspective of health? a. Absence of disease equals health. b. Harmony is maintained through use of natural and supernatural forces. c. Prana in the body maintains a state of balance. d. Use of totems, fetishes, dance and chanting promotes health. e. The various gods are responsible for an individual’s health.

Answer: c Rationale: Ayurvedic practitioners believe that prana, the life force, is in a state of balance, which equals health. The view of health as absence of disease is the foundation of allopathic medicine.

Maintenance of harmony by use of supernatural and natural forces is typical of Native American shamans. The shaman’s practice incorporates the use of totems, fetishes, dance, chanting, drumming and other rituals to promote health.

9.

Which of the following statements best suits the practice of mega-vitamin supplementation? a. It is always safe. b. It may have adverse effects and should be used only under supervision. c. It is effective for everyone. d. It has no proven benefit. e. It can be implemented only by a registered naturopath.

Answer: b Rationale: Megavitamin supplementation can have toxic effects, be ineffective for the symptoms it was taken for and is not always safe. Individuals can choose to take megadoses of vitamins (OTC), however, research into megavitamin supplementation is ongoing and has not proven its benefits (if any). Holistic nurses respect clients’ beliefs and honour their choices. A person’s belief system strongly affects healing and recovery.

10. Which of the following statements accurately describes CM? (Select all that apply.) a. CM considers the whole person through use of bodymind interventions. b. CM is most effective in treating acute, emergency situations. c. The Australian public has a negative view of CM approaches. d. There has been little scientific research to support the use of CM modalities. e. Use of CM modalities is increasing in Australia and New Zealand. f. Scientific interest and research in CM modalities are increasing.

Answer: a, e, f Rationale: Complementary/alternative modalities use a holistic approach by treating the bodymind as one entity. CM is most effective in treating chronic conditions. There is an increasing trend for Australians and New Zealanders to use CM modalities. The Australasian Integrative Medicine

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Association and the National Institute of Complimentary Medicine are the government’s lead agencies on research on integrative treatment methods.

Spotlight on critical thinking 1.

Outline the ways in which you would assess a person’s T&CM use during a health history.

Suggested solution: Asking the person how what practices they incorporate; have they used or are they using any traditional or bush medicines or treatments, vitamins or supplements; if they are seeing or have seen a complimentary practitioner; what benefits have they gained from CM. Have they noticed any adverse responses? Also, ask what they understand about the ‘interactions’ between their current biomedical management and CM.

2.

Have you encountered music therapy or music medicine in use in the hospital? Consider some of the people who might benefit from music therapy or music medicine, even as a distraction from their pain or other situation.

Suggested solution: Teens use music therapy as distraction. Music has been demonstrated to assist those in pain and those who are dying. Children often find music soothing.

3.

One of the people you are caring for uses reiki for arthritic pain control. How could you integrate their use of T&CM into their care?

Suggested solution: They could request their reiki practitioner to visit them in the hospital. Discuss with the attending physician the benefits the person gains from reiki.

4.

The text highlighted some interactions of which you must be aware; for example, the effect Ginkgo biloba has on platelet function, and its contraindication if the person is prescribed warfarin or aspirin.

List three other examples of interactions between a herbal therapy and a prescription medication.

Suggested solution: See Table 34-6, Medicinal value of herbs

5.

Consider how biomedical, T&CM modalities may improve a person’s health. Discuss your findings with your class or colleagues.

Suggested solution: This depends on the student’s responses – it is a discussion, therefore, it will be student driven.

6.

Do you use any of the T&CM therapies described in this chapter? Discuss how these assist you to maintain your health and wellbeing.

Suggested solution: This depends on which students use and how they find these assist them to maintain their health and wellbeing.

7.

Consider animal-assisted therapy. What objections could you think of that may make this therapy difficult in a hospital? In your opinion, would the benefits outweigh the difficulties? What about companion animals at home? Are there clear benefits to having a companion animal? What are they?

Suggested solution: there are objections to animals visiting in the hospital – chief among them is transmission of disease. Animals who visit regularly are vet-checked on a schedule for any diseases, immunised, flea and tick free and bathed prior to the visit. Pet therapy plays an important role when people are in long-term care; however, some people's only family is their 'furkids' and being away from them, worrying about their welfare is detrimental to their recovery. Animals have demonstrated the ability to assist with relaxation, lower BP, reduce loneliness, improve morale and improve mood.

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Content Key terms ......................................................................................................................................................... 1 Instructional strategies .................................................................................................................................... 5 Resource aids................................................................................................................................................... 6 Online resources.............................................................................................................................................. 7 Animations....................................................................................................................................................... 7 Evaluation strategies ....................................................................................................................................... 7 Review questions............................................................................................................................................. 8 Spotlight on critical thinking .......................................................................................................................... 11

Chapter 35 Oxygenation Key terms Activities of daily living (ADL) Activities performed every day without assistance, such as eating, dressing, toileting and walking. Climbing stairs and undertaking work like sweeping, gardening and leisure activities may be included. These activities use most of the muscles of the body and maintain them in functioning condition.

Acute pain Discomfort identified by sudden onset and relatively short duration, mild-to-severe intensity, and a steady decrease in intensity over several days or weeks.

Aerobic metabolism Metabolism of nutrients in the presence of oxygen; a metabolic pathway that uses oxygen to convert glucose into cellular energy.

Allen test Assessment procedure that measures the collateral circulation to the radial artery.

Anaemia Reduction in the amount of haemoglobin in the blood, thus decreasing the oxygen-carrying capacity of the blood.

Anaerobic metabolism Metabolism of nutrients in the absence of oxygen; a metabolic pathway that converts glucose into energy in the absence of oxygen.

Angina Pain in the chest, neck or arm resulting from myocardial ischaemia.

Angina pectoris Pain caused by tissue ischaemia in the heart.

Angiography Visualisation of the vascular structures using fluoroscopy with a contrast medium.

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Anxiety Subjective response that occurs when a person experiences a threat to wellbeing, a diverse feeling of dread or apprehension.

Aspiration Procedure performed to withdraw fluid that has abnormally collected, or to obtain a specimen, the inhalation of regurgitated gastric contents into the pulmonary system.

Assessment First step in the nursing process; includes the collection, verification, organisation, interpretation and documentation of data.

Atelectasis Collapsed alveoli. atherosclerosis Disease characterised by narrowing and eventual occlusion of the lumen (opening of the arteries) by deposits of lipids, fibrin and calcium on the interior walls of the arteries. atherosclerotic plaque A thick, hard deposit on the walls of arteries that can clog the inner arteries of the heart and the brain.

Autoregulation Redistribution of blood flow to areas of greatest need. cardiac catheterisation Radiographic study with the use of a contrast medium injected into a vascular catheter that is threaded into the heart, coronary or pulmonary vessels. cardiac conduction system Specialised cells in the heart that generate and conduct electrical impulses; consists of the sinoatrial node, internodal pathways, atrioventricular node, bundle of His, right and left bundle branches and Purkinje fibres.

Cardiac cycle Series of electrical and mechanical events resulting in a cycle of atrial and ventricular contraction and relaxation.

Cardiac output Measurement of blood pumped by the heart in one minute; measured by multiplying the heart rate by the ventricle’s stroke volume.

Cardiopulmonary resuscitation (CPR) Technique of applying respiration and chest compressions to support oxygenation in the event of cardiac and respiratory arrest.

Chest physiotherapy (CPT) Technique of percussing or vibrating the chest wall to mobilise pulmonary secretions; usually accompanies postural drainage.

Chronic obstructive pulmonary disease (COPD) Category of alterations in ventilation including emphysema, asthma and chronic bronchitis.

Contrast medium Radiopaque substance that facilitates roentgen imaging of the body’s internal structures.

Cyanosis Blue or grey discolouration of the skin resulting from reduced oxygen levels in the arterial blood.

Deadspace Area of lung tissue which is well ventilated but poorly perfused.

Diaphragmatic (abdominal) breathing Occurs when the diaphragm contracts and relaxes, as observed by the movement of the abdomen.

Diastole Process of cardiac chamber filling.

Diffusion capacity Reflects the extent of the damage to the blood vessels in the lungs. It may also reflect any scarring of the lungs.

Diffusion defect Decrease in efficiency of gas diffusion from the alveolar space into the pulmonary capillary blood.

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Doppler Handheld transducer.

Echocardiogram Ultrasonic procedure used to reveal abnormal structure or motion of the heart wall and thrombi.

Enzymes Protein produced in the body that catalyses chemical reactions in organic matter.

Erythrocytes Red blood cells (RBCs).

Gallop Extra heart sounds.

Health history Review of the person’s functional health patterns prior to the current contact with a health care agency.

Heart failure Inability of the heart to pump enough blood to meet the metabolic needs of the body; often accompanied by a backup of blood in the venous circuits (congestive heart failure).

Hypercapnia Elevation of carbon dioxide levels in the blood indicating inadequate alveolar ventilation.

Hypoxaemia Decreased oxygen level in the blood.

Hypoxia Oxygen deprivation of the body’s cells.

Infarction Death (necrosis) of an area of tissue caused by oxygen deprivation.

Insomnia Refers to the chronic inability to sleep or inadequate quality of sleep due to sleep that prematurely ends or is interrupted by periods of wakefulness.

Intermittent claudication Ischaemia to the extremities usually brought on by activity and relieved by rest.

Internal respiration Process of gas exchange between capillary blood and the body’s cells, in which the cells receive oxygen and carbon dioxide is removed.

Ischaemia Oxygen deprivation, usually caused by poor perfusion, that is usually temporary and localised.

Late potentials Electrical activity that occurs after normal depolarisation of the ventricles.

Lipoproteins Blood lipids bound to protein.

Lung volumes Amount of air that moves into and out of the lungs normally, and in specific circumstances (forced inspiration or expiration), part of the pulmonary function studies.

Murmurs Swishing or blowing sounds of long duration heard during the systolic and diastolic phases, created by turbulent blood flow through a valve.

Obstructive pulmonary disease Category of lung diseases characterised by obstruction of the airways and trapping of air distal to the obstruction.

Oedema Detectable accumulation of increased interstitial fluid.

Oxygen uptake Process of oxygen diffusing from the alveolar space into the pulmonary capillary blood; also called ‘external respiration’.

Oxygenation The delivery of oxygen to the body’s tissues and cells.

Oxyhaemoglobin dissociation curve Graphic representation of the relationship between partial pressure of oxygen and oxygen saturation.

Paroxysmal nocturnal dyspnoea Episode of sudden shortness of breath occurring during sleep.

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Plan of care A comprehensive, individualised plan that outlines the steps a health care professional will take to identify, treat and manage a person’s health condition. The plan is based on the patient’s medical history, current symptoms and test results, and is designed to achieve specific goals and objectives in the management of the person’s health.

Pneumothorax Collection of air or gas in the pleural space, causing the lungs to collapse.

Postural drainage A technique of positioning that promotes gravitational drainage of specific lung lobes.

Precapillary sphincters Smooth muscles surrounding the smallest arterioles that control blood flow through the capillary beds.

Problem identification Second step in the nursing process; a clinical judgement about individual, family or community (aggregate) responses to actual, possible or risk of (potential) health problems, wellness states or syndromes.

Pulmonary function studies (PFS) A set of non-invasive tests that measure different aspects of a person’s breathing.

Radiofrequency ablation The delivery of low-voltage, high-frequency alternating electrical current to cauterise the abnormal myocardial tissue.

Restrictive pulmonary disease A category of lung diseases characterised by impaired mobility or elasticity of the lungs or chest wall.

Shunting Condition in which alveolar regions are well perfused but not adequately ventilated.

Signal-averaged electrocardiography (SAECG) Surface electrocardiogram that amplifies late potentials.

Sleep apnoea A syndrome in which breathing periodically ceases during sleep, often associated with heavy snoring.

Spirometry Measurement of the breathing capacity of the lungs. It measures the amount of air inhaled and exhaled and how quickly the exchange occurs.

Stress test Measures the person’s cardiovascular response to exercise tolerance.

Surfactant Phospholipid secreted by type 2 alveolar cells that reduces the alveolar surface tension and thus helps prevent alveolar collapse.

Systole Process of cardiac chamber emptying or ejecting blood.

Tachypnoea A heart rate more than 100 beats per minute in an adult.

Thallium Radionuclide that is the physiological analogue of potassium.

Thoracentesis The aspiration of fluids from the pleural cavity.

Thrombus Blood clot.

Tracheotomy A surgical procedure in which an opening (stoma) is made through the anterior neck into the trachea; an artificial airway (tracheostomy tube) is placed into the stoma.

Ventilation Movement of air into and out of the lungs for the purpose of delivering fresh air to the alveoli.

Ventilation-perfusion (V/Q) mismatching Condition in which perfusion and ventilation of the lung areas are not adequately balanced.

Work of breathing Amount of muscular energy (work) required to accomplish ventilation.

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Instructional strategies • Discuss some factors that contribute to respiratory status of the person and their oxygenation needs: o Age contributes to the person's respiratory status. Older adults, especially those who have had a lifetime of unhealthy behaviours (smoking, poor diet, sedentary lifestyle) require increased effort to expand lungs. o Environmental factors, such as exposure to toxic chemicals and emotional stress, contribute to oxygenation needs. o Disease processes can affect respiratory status. Obstructive pulmonary disease, pneumonia, atherosclerosis, heart failure, and anaemia are examples of disease processes that affect oxygenation requirements.

• Since many students have trouble understanding the oxyhemoglobin dissociation curve, compare the

difference between saturation and binding affinity. Give clinical examples of how physiological variables influence the nature of oxygenation.

• Saturation refers to the degree or extent to which something is dissolved or absorbed compared with the maximum possible, usually expressed as a percentage. Oxygen saturation reflects the total amount of haemoglobin at a defined PO2 level. Binding affinity refers to a measure of how well a substance holds together. Binding affinity can be affected by chemical and physiological variables such as temperature, PO2 level, and acid-base imbalances. As binding affinity increases, the associated saturation (SaO2) will be higher. Physiological changes that will cause this to occur include alkalosis, hypothermia, or decrease in 2,3-diphosphoglycerate (2,3-DPG). As binding decreases, the SaO2 will be lower. Physiological changes that will cause this to occur include acidosis, hyperthermia, or an increase in 2,3-DPG.

• Describe the types of data the nurse must elicit from a person while performing a health history in relation to respiratory status.

o The nurse must take a complete health history of the person. Examples of appropriate questions include those about: occupation, lifestyle behaviours and social history, surgeries or hospitalisations, and respiratory complaints or symptoms. o Physical assessment is important to perform as well. General observation of the person includes checking for any signs of respiratory compromise, any discolouration of lips (circumoral cyanosis) or skin (cyanosis) or clubbing of the fingernails. o Vital signs give information regarding respiratory status of the person. o Auscultation of lung fields and heart generates data. o Any laboratory or diagnostic testing data must be reviewed by the nurse.

• What problem identification can be used by the nurse when caring for a person with a respiratory problem?

o Ineffective airway clearance is frequently used when dealing with a person with respiratory involvement such as a foreign body obstruction or disease process that obstructs normal airway. o Impaired gas exchange is another common problem used for those with emphysema or chronic obstructive pulmonary disease (COPD). © Cengage Learning Australia 2024

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o Deficient knowledge is also frequently used. Lifestyle behaviours such as smoking, sedentary lifestyle, and working around toxic substances, are examples where health education is warranted. o Activity intolerance is often seen in conjunction with the above nursing problems. Many people with respiratory difficulty need to monitor exertion and perform activities of daily living slowly with frequent rest periods.

• What interventions are helpful to promote airway clearance in a person? o The first helpful intervention is teaching effective coughing. One coughing technique, huffing, is a series of short forceful exhalations prior to actual coughing. The next intervention to promote airway clearance is postural drainage and chest physiotherapy. o In some health care organisations, chest physiotherapy can only be implemented with a physician’s order. o Postural drainage is positioning the person to drain the different lung segments. Each person will need to be assessed for tolerance of the different positions with this technique. Hydration is the next intervention to promote airway clearance. o Hydration thins secretions to increase the ease of expectorating. Each person needs to be assessed for fluid tolerance since fluids might be restricted because of other health problems. o Certain medications are used to promote airway clearance, and the nurse should provide these as prescribed by the physician. o Environmental and lifestyle considerations constitute another intervention to promote airway clearance. o The person should be assessed for allergies and smoking, with interventions provided accordingly. o The use of artificial airways in a person with insufficient airway clearance depends on the person's condition. Artificial airways include nasal airways, oral airways, endotracheal tubes, and tracheotomy. o The last intervention is suctioning the airway. This intervention removes secretions that the person cannot remove by coughing.

• Discuss the impact of heart failure on oxygenation. In heart failure, there is a generalised decrease in

tissue perfusion. The heart is unable to pump enough blood to meet the body’s metabolic needs. Blood will back up in the venous system, leading to congestive heart failure. The increase of blood in the veins causes oedema in the tissues. Oedema can also develop in the lungs, leading to pulmonary oedema, which further restricts the body’s oxygenation.

Resource aids Heart Foundation – Information on cardiac diseases – https://www.heartfoundation.org.au/Bundles/ForProfessionals?selectedfilter=clinical%20info Respiratory nursing [video]. Williams & Wilkins.

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Online resources •

This online discussion of the respiratory system was reviewed in May, 2015. It presents a thorough discussion of the anatomy and physiology of the respiratory system, with good, clear graphics: http://www.myvmc.com/anatomy/respiratory-system

•

The following article from the Medical Journal of Australia discusses the importance of accurately counting and recording the respiratory rate of all hospitalised people. Although it is old (2008), it demonstrates the effectiveness of this vital sign in alerting health care professionals to deterioration of the person with a respiratory illness, and discusses the use of the rate in escalating care: https://www.mja.com.au/journal/2008/188/11/respiratory-rate-neglected-vital-sign

•

The Asthma Australia website has a great deal of information on asthma and other chronic lung conditions suitable for the first-year nursing student. https://asthma.org.au

Animations •

Play the animation Anatomy of the HEART for the students. (https://www.youtube.com/watch?v=UMTDmP81mG4&t=165s

•

Play the animation 'electrical conduction of the heart' https://www.youtube.com/watch?v=FIeCPC7Hpf8 Review the normal conduction of the electrical impulse through the heart. The electrical impulse begins in the sinoatrial node and moves to the atrioventricular node. From here, the impulse travels to the right and left bundle branches and finally to the Purkinje fibres. The electrocardiogram reflects the electrical activity of the heart where the P wave is atrial contraction, QRS complex is ventricular contraction, and the T wave is the heart at rest. The complete cardiac cycle repeats 72 to 80 times each minute.

•

Play the Crash Course animations Respiratory system: Anatomy and physiology of respiration Parts 1& 2 for the students. (This is lightened with humour but effectively explains the information in a friendly, understandable way) (https://www.youtube.com/watch?v=bHZsvBdUC2I and https://www.youtube.com/watch?v=Cqt4LjHnMEA) These explain diffusion, partial pressure and oxygen dissociation curve well. If you don't like this one there are more (more professional) animations online.

Discuss the structures of respiration and the process of ventilation. There are several structures involved with respiration. Air moves through the nose, nasal cavity, pharynx, larynx, trachea, bronchi, bronchioles, and alveolar sacs to the capillaries within the lungs. The process of ventilation occurs by diffusion. Oxygen reaches the alveolar sacs and diffuses to the capillaries where it is picked up in the blood and circulated throughout the body. Carbon dioxide is released into the blood and circulates through the capillaries to the alveolar sacs where it is expelled through expiration.

•

Discuss the oxygen dissociation curve and how it impacts on oxygenation

Evaluation strategies •

Invite a respiratory therapist to demonstrate equipment used in respiratory treatments and additional respiratory assessment strategies for students to perform. Ask them to demonstrate postural drainage and have the students practise this skill.

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•

Discuss with students particular health problems that may lead to increased risk for respiratory problems.

•

Discuss ways that student nurses can encourage effective communication with anyone with an artificial airway or a tracheotomy.

•

Have students look at arterial blood gas (ABG) values for a variety of people with different respiratory problems in the clinical setting (or prepare some for the classroom). Discuss the elements of ABGs and what information they provide about a person who has oxygenation problems.

•

Discuss ways in which student nurses can assist a person who is having airway management problems in the following clinical areas: emergency department, medical-surgical floor, ambulatory centre and physician’s office.

•

For each of the following identified problems have students prioritise goals and identify interventions for a person with a chronic airway disease: Ineffective airway clearance, Ineffective breathing pattern, Impaired gas exchange, and Imbalanced nutrition.

•

Have students identify required assessments for someone receiving oxygen therapy in the clinical setting and in the home setting.

•

In the laboratory setting, have a variety of airways available for the students to inspect. Have suction equipment in addition to tracheostomy tubes, tapes, and supplies available. In groups of two, have the students practise using the suction equipment and practise tracheostomy care.

•

If this has not already been done, plan to have the students become CPR certified. Schedule a CPR instructor to come into the laboratory with manikins to conduct the training with the students.

Review questions 1.

Normal vesicular breath sounds heard over both lungs are described as being: a. loud b. intermediate c. breezy d. soft e. adventitious.

Answer: c or d Rationale: Normal breath sounds, vesicular are soft and low-pitched. Breezy is also used for 'soft' breath sounds. Loud and intermediate breath sounds are heard over the bronchi. Adventitious sounds are abnormal.

2.

What is the classic sign of chronic hypoxia? a. Cyanosis b. Confusion c. Decreased level of consciousness d. Clubbing of the fingers e. Brown mottling of the skin on the lower legs.

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Answer: d Rationale: Clubbing of the fingers, a flattened angle of the nailbed and a rounding of the fingertips, is a sign of chronic perfusion deficits and poor circulation.

3.

The breath sound ‘sonorous wheezes’ is indicative of which condition? a. Asthma b. Bronchitis c. COPD d. Atherosclerosis e. Foreign body obstruction.

Answer: b Rationale: Sonorous wheezes are typically associated with secretions that are obstructing the larger airways. They are low pitched and rumbling sounds. People with Asthma and COPD often exhibit sibilant wheezes due more to narrowed airways. Atherosclerosis does not produce a wheeze. Foreign body obstruction produces a crowing sound called stridor.

4.

Frothy pink (blood-tinged) sputum is indicative of: a. asthma b. bacterial infection c. emphysema d. viral infection e. pulmonary oedema Answer: e Rationale: The frothy pink mucous produced by people with pulmonary oedema is produced by the oedematous lung tissue exuding fluid and blood into the alveoli where it is coughed up. Asthma coughs are usually non-productive. Emphysema usually does not produce sputum as it involves the destruction of lung tissue leading to the collapse of smaller airways trapping air in the alveoli. Bacterial coughs are often green or yellow and viral coughs usually produce clear or whitish sputum.

5.

Which person is most prone to problems while receiving oxygen? a. Someone who is post-operative b. Someone who is asthmatic c. Someone who has a MI d. Someone who is obese e. Someone who has COPD. Answer: e Rationale: The person with COPD will most likely have the most problems when receiving oxygen. Their body has adapted to the high carbon dioxide levels caused by the difficulties they have in exhaling and high carbon dioxide is no longer a reliable trigger to breathe. Their breathing is triggered by low levels of oxygen in their blood, so if they are given high supplemental oxygen, they may become apnoeic.

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6.

Hydration should be restricted in people experiencing: a. hepatitis b. COPD c. hypertension d. pneumonia e. congestive heart failure.

Answer: e Rationale: People experiencing congestive heart failure have retained excess fluid in their cardiovascular/respiratory systems because their heart muscle is inefficient and cannot adequately perfuse the body. The kidneys respond by retaining fluid which is sequestered in tissues and the lungs.

In the lungs the accumulated fluid reduces gas exchange. Anyone with hepatitis or hypertension does not usually require fluid restriction. Those with renal failure are usually advised to increase their fluids (if they were 'low water drinkers') or drink to satisfy their thirst. They may require fluid restriction in the very late stages of the disease. Anyone with pneumonia should take extra water to help liquidate mucous secretions so they are more easily raised and expectorated.

7.

Which of the following nursing interventions is appropriate for someone with reduced cardiac output/perfusion? a. Help the person ambulate around the unit at least three times a day b. Encourage hydration by offering their favourite warm beverage often c. Elevate their head and upper body, leaving the legs dependent d. Provide a high-calorie diet of their choice e. Teach the person the importance of aerobic exercises.

Answer: c Rationale: Reduced cardiac output indicates that the tissues are not receiving enough oxygen. Elevating the head and upper body with dependent legs reduces the venous return to the heart ( preload is reduced), pulmonary congestion is reduced, and the pressure on the diaphragm is minimised. The semiFowlers position helps prevent the compression of major blood vessels by avoiding undue pressure on the chest or abdomen. This ensures blood flow to and from the heart is not compromised, the other options are all excellent nursing activities, but are not directed at the problem. This person will be on fluid restriction, so encouraging hydration is not a choice here. They will probably be on restricted activity, so ambulating and aerobic exercises are contraindicated. The high calorie diet does not address their low cardiac output.

8.

The oxyhaemoglobin dissociation curve represents which of the following? a. The level of CO carried in the haemoglobin b. the relationship between oxygen saturation of haemoglobin and the oxygen dissolved in the plasma c. The ability of haemoglobin to carry oxygen d. The percentage of haemoglobin that is SaO2 e. The response of the haemoglobin to hyperthermia, hypoxia and an increased acidity in the blood.

Answer: b

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Rationale: The oxyhemoglobin dissociation curve relates to oxygen saturation (SO2) and partial pressure of oxygen in the blood (PO2), and is determined by what is called ‘haemoglobin affinity for oxygen’; that is, how readily haemoglobin acquires and releases oxygen molecules into the fluid that surrounds it.

Oxygen saturation reflects the total amount of oxygen carried by the haemoglobin at a defined plasma level of oxygen. Binding affinity refers to a measure of how well a substance holds together.

Binding affinity can be affected by chemical and physiological variables such as temperature, PO2 level, and acid-base imbalances. Carbon monoxide is a gas that is more easily bound to the haemoglobin than oxygen, thus displaces it, and is not useable by the tissues. The amount of oxygen bound to haemoglobin is the SaO2, saturation of the haemoglobin with oxygen.

9.

Which nursing interventions can be used to improve oxygenation? (Select all that apply.) a. Increasing the rate of oxygen flow b. Reapplying a nasal cannula c. Lowering the head of the bed d. Assisting with breathing exercises e. Managing the fluid balance.

Answer: a, b, d, e Rationale: Adjusting the rate (within the ordered amounts) can increase the oxygen fraction of inspired air. Reapplying the cannula can ensure that the ordered rate of oxygen is being delivered. Assisting with breathing exercises increases the amount of inspired oxygen, inflates underused alveoli and removes secretions from alveoli and airways to increase gas exchange. Managing fluid balance is useful in some instances (congestive cardiac failure, pneumonia).

10. After drawing ABG, you should: a. Pack the blood sample in ice for transport to the laboratory b. Keep pressure on the radial artery puncture site for at least one minute c. Transfer the blood sample to a heparinised test tube d. Draw the second sample in 10 minutes e. Store the sample in the refrigerator at less than 4 °C. Answer: a Rationale: Ice reduces the rate of oxygenation of the sample. Pressure should be kept on the radial artery for a minimum of 5 minutes. The blood is drawn into a heparinised tube (not transferred) and transported in that tube to the laboratory. A second sample is not required. The sample is sent immediately to the laboratory or assessed at the point of care – not refrigerated as the oxygen levels will alter over a short time.

Spotlight on critical thinking Professionalism: Mouth-to-mouth breathing Concern over the possibility of disease transmission during mouth-to-mouth breathing has led to the development of newer variations on this technique. Several styles of masks that fit over the victim's mouth and contain a one-way valve through which the rescuer breathes are available for both in-hospital and community use.

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1.

Have you ever performed mouth-to-mouth breathing through one of these masks?

2.

Knowing that there is a possibility of disease transfer, would you be willing to administer mouth-tomouth breathing without a mask?

Suggested solution: • Consider transfer of microbes, effectiveness of masks, ease of use of the mask (e.g. the one-way valve makes artificial respiration more difficult for most people). What happens in the community when a mask is unavailable? Many incidents of CPR are performed on family and friends – do you need a mask, or is your trust level high enough?

• Find out what the rate of infection is with mouth-to-mouth respirations • What do you do following CPR without a mask? Wash mouth and face thoroughly with soap and water.

Urgent action You are caring for Mrs Leare, who has just returned from the operating theatre. When you check her pulse oximetry reading, it shows 55 per cent.

3.

What actions should you take?

Suggested solution: • Check that her airway is clear and she is breathing easily (respiratory assessment); her colour is good (no cyanosis); the sensor probe is in place and there is no IV fluid infusing near the probe; she has no nail polish on that fingernail and it is clean; there are no constricting bandages on the limb; she is warm and she is not moving the limb excessively (shivering).

• Give her oxygen (or turn it up if she is already receiving some) to a minimum of 6L/min with a simple face mask.

• Assess her respirations more thoroughly (rate, depth, rhythm, pattern) other VS (Temp – hypo or hyperthermia; pulse – tachycardia, rhythm and BP).

• Notify the senior RN/physician.

Arterial blood gases Dr Strong has just obtained arterial blood from the femoral artery of Mrs Leare.

4.

How do you treat the specimen?

Suggested solution: Label, biohazard bag, place on ice, deliver to lab ASAP

5.

What nursing interventions are required for Mrs Leare?

Suggested solution: • Pressure on the puncture site for 10 minutes, • Keep the limb straight • Cold or ice to the artery for 20 minutes • Bed rest for several hours; monitor the limb for neurovascular obs.

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Planning 6.

Discuss how the following secondary problems interrelate with and impact on oxygenation problems. a. Insomnia Suggested solution: • awaken with apnoea or air hunger • position – generally head raised, may need to sleep in an armchair. b. Inadequate nutrition Suggested solution: • too tired to eat – may need high calorie, high protein food supplement, small meals, frequent snacks • oxygen delivery (mask) may interfere with eating (need nasal cannulae) • chewing and swallowing fatigues them more – dental soft diet needed – unpalatable and this reduces their intake; increases propensity to constipation • hydration – increased from insensible loss from rapid respirations, often too tired to drink and do not want to use toilet often as it involves a walk. c. Diminished ability to mobilise Suggested solution: • may require frequent rests (chairs positioned around room, house, corridor, garden, top and bottom of steps) • carrying/pulling the oxygen equipment is tiring. d. obesity Suggested solution: • can affect oxygenation by increasing the work of breathing as well as the cardiac workload. e. poor hygiene Suggested solution: • People with poor hygiene may have impaired ADLs (eating [sordes, gingivitis], socialisation, elimination [UTIs] ).

• Gingivitis/ Peridontitis is one cause of lung inflammation/infection

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 4 Resource aids....................................................................................................................................................... 5 Online resources.................................................................................................................................................. 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking .............................................................................................................................. 10

Chapter 36 Fluids and electrolytes Key terms Acid-base balance Regulation of hydrogen ion concentration.

Acid-base buffer system A solution containing two or more chemical compounds that prevents marked changes in the hydrogen ion concentration when either an acid or a base is added to a solution.

Acidosis A condition that occurs when there is an excessive number of hydrogen ions in a solution.

Administration set (infusion set) The plastic disposal tubing that provides for the infusion of a solution.

Agglutination Clumping together of red blood cells.

Agglutinin A specific kind of antibody whose interaction with antigens is manifested as agglutination.

Agglutinogen Any antigenic substance that causes agglutination by the production of agglutinin.

Alkalosis Excessive removal of hydrogen ions from a solution.

Anions Ions with a negative charge.

Antibody/antibodies An immunoglobulin produced by the body in response to bacteria, viruses or other antigenetic substances; counteracts and neutralises the effects of antigens and destroys bacteria and other cells. Agglutinin is one type of antibody.

Antigens A substance, usually a protein, that causes the formation of an antibody and reacts specifically with that antibody (e.g., agglutinogen).

Arterial blood gases (ABGS) Measurement of levels of oxygen and carbon dioxide, as well as pH and bicarbonate ion, in arterial blood.

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Base A molecule or an ion that will combine with hydrogen ions.

Body fluid The water and electrolytes contained within the body.

Body water The water contained within the body.

Butterfly (scalp vein or wing-tipped) needles Scalp vein or winged-tipped needle.

Cations Ions with a positive charge.

Colloids Non-diffusible substances.

Crystalloids Electrolyte solution with the potential to form crystals.

Cytomegalovirus (CMV) DNA virus that causes intranuclear and intracytoplasmic changes in infected cells.

Deficient fluid volume (DFV) When a person experiences vascular, interstitial or intracellular dehydration.

Diffusion Movement of molecules in a solution or a gas from an area of high concentration to one of low concentration.

Electrochemical gradient Sum of all the diffusion forces acting on the membrane.

Electrolyte Element or compound that, when dissolved in water or another solvent, dissociates (separates) into ions (electrically charged particles) and provides for cellular reactions.

Excess fluid volume (EFV) When a person has increased interstitial and intravascular fluid retention and oedem.

Flow rate Volume of fluid to infuse over a set period.

Flushing The instillation of a solution into an IV cannula.

Haematocrit (HCT) The volume of red blood cells expressed as percentage of the total volume of blood.

Haemoconcentration Reduced volume of plasma water and increased concentration of blood cells, plasma proteins and protein-bound constituents; occurs with increased capillary hydrostatic pressure, which causes water to shift from the intravascular into the interstitial space.

Haemolysis A breakdown of red blood cells and the release of haemoglobin.

Homeostasis Cessation of bleeding that occurs by vasoconstriction of large blood vessels in the affected area.

Hydrostatic pressure Pressure that a liquid exerts on the sides of the container that holds it; also called filtration force.

Hypercalcaemia Excess in the extracellular level of calcium.

Hyperchloraemia Excess in the extracellular level of chloride.

Hyperkalaemia Excess in the extracellular level of potassium.

Hypermagnesaemia Excess in the extracellular level of magnesium.

Hypernatraemia Excess in the extracellular level of sodium.

Hyperphosphataemia Excess in the extracellular level of phosphorus.

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Hypertonic Solution with less solute in proportion to the volume of water; also called a hypoosmolar solution.

Hypervolaemia Increased circulating fluid volume.

Hypocalcaemia Deficit in the extracellular level of calcium. hypochloraemia Deficit in the extracellular level of chloride. hypoglycaemia Condition characterised by a blood glucose level of less than 4 mmol/L. hypokalaemia Deficit in the extracellular level of potassium. hypomagnesaemia Deficit in the extracellular level of magnesium.

Hypophosphataemia Deficit in the extracellular level of phosphorus.

Hypotonic Solution with less solute in proportion to the volume of water; also called a hypoosmolar solution.

Hypoxaemia Decreased oxygen level in the blood.

Implantable port Device for injecting medication with a radiopaque silicone catheter and a plastic or stainless-steel injection port with a self-sealing silicone-rubber septum.

Infiltration Seepage of foreign substances into the interstitial tissue.

Isotonic Solution with body water and solutes (sodium) in equal amounts; also called an isosmolar solution.

Oedema Detectable accumulation of increased interstitial fluid.

Osmolality Measurement of the total concentration of dissolved particles (solutes) per kilogram of water.

Osmolarity Concentration of solutes per litre of cellular fluid.

Osmole Unit of measure of osmotic pressure.

Osmosis Process caused by a concentration difference of water.

Osmotic pressure Force that develops when two solutions of different strengths are separated by a selectively permeable membrane.

Peripheral intravenous (PI) and saline/heparin lock A device that establish a venous route as a precautionary measure for anyone whose condition may change rapidly or who may require intermittent infusion therapy or intravenous medication without the additional fluid.

Peripherally inserted central catheter (PICC) A silicone or polyurethane catheter inserted into one of the major veins in the antecubital fossa or upper extremity, with the distal tip terminating in the lower-third section of the superior vena cava.

Permeability Capability of a substance, molecule or ion to diffuse through a membrane.

Phlebitis Inflammation of a vein.

Product integrity The sterility of the equipment.

Rate of metabolism Determines the formation of carbon dioxide.

Rh factor An antigen found on the red blood cells that designates blood type.

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Skin turgor Normal resiliency of the skin.

Solute A substance dissolved in a solution; also called an analyte.

Solvent A liquid with a substance in solution.

Type and crossmatch Laboratory test that identifies the person’s blood type (e.g., A or B) and determines the compatibility of the blood between potential donor and recipient.

Urine osmolality A measurement of the total concentration of dissolved particles per kilogram of water in urine, recorded in millimoles per kilogram (mmol/kg).

Vascular access devices (VADS) Include various catheters and implanted ports that allow for long-term IV therapy or repeated access to the central venous system.

Venepuncture Puncturing of a vein with a needle to aspirate blood.

Instructional strategies • Discuss the major fluid compartments in the body and what regulates the fluids. The body has three fluid compartments: cells, blood vessels, and tissue space. Intracellular fluid is the fluid within cells.

Intravascular fluid is fluid within blood vessels. Interstitial fluid is the fluid that surrounds cells. These three types of fluids are further categorised as being either intracellular or extracellular. Intracellular is the fluid within the cell. Extracellular fluid includes intravascular and interstitial fluid. Body fluid is regulated by fluid and food intake and loss, skin, lungs, gastrointestinal tract, and kidneys. Body fluid moves through several physiological forces: diffusion, osmosis, active transport, hydrostatic pressure, filtration, and colloidal osmotic pressure.

• Discuss the main electrolytes in the body and the importance of each. The main electrolytes in the body are sodium, potassium, calcium, and magnesium. Sodium regulates fluid volume, controls water distribution between extracellular fluid compartments and intracellular fluid compartments, and is responsible for neuromuscular and nerve functioning. Potassium regulates osmolality of intracellular fluid, is involved in nerve impulses and contraction of skeletal and smooth muscle impulses, and regulates acid-base balance. Calcium is useful for promotion of strong bones and teeth, is also involved in nerve impulses and neuromuscular functioning, is essential for blood coagulation, and activates enzyme reactions and hormone secretions. Magnesium activates enzyme systems, is also responsible for neuromuscular functioning, and helps with regulation of other electrolytes.

• Identify factors that help to regulate fluid, electrolyte, and acid-base balance in the body. The main regulators of fluid balance in the body are fluid and food intake, skin, lungs, gastrointestinal tract, and kidneys. When working together, all of these regulatory factors (organs) help to maintain a person’s fluid balance. The factors affecting the regulation of electrolytes in the body include the person’s age and lifestyle. In addition to these factors, other variables become factors depending on the client’s overall health status and whether there are any contributory or comorbid disease conditions. Lifestyle factors include environment, psychological adaptations, and diet. Chemical buffer systems and respiratory and renal regulation control the main regulators of acid-base balance in the client. All of these mechanisms work together to help maintain the delicate balance of the internal environment.

• Discuss the regulators of acid-base balance in the body. Acid-base balance is regulated by three buffer systems. The primary buffer system is the bicarbonate-carbonic acid system, which works by stabilising the pH by combining with hydrogen ions. The second buffer system is the respiratory system. The

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respiratory system maintains acid-base balance by controlling the content of carbon dioxide in extracellular fluid. The last buffer system is the renal system. The kidneys control extracellular fluid pH by eliminating either hydrogen ions or bicarbonate ions from body fluids.

• Electrolyte balance is a requirement for healthy bodies. In what ways can electrolytes become unbalanced? The balance of body fluid affects electrolyte balance. A change in one can upset the balance in the other. Age can influence the balance of electrolytes because body water distribution varies from infant to older adult. The person’s lifestyle can affect the balance. Exercise, dietary habits, stress, and environmental stimuli can be factors in electrolyte balance. Medications can also cause an imbalance in electrolytes.

• How do nurses assess for potential or actual fluid, electrolyte, or acid-base imbalances? A thorough health history needs to be obtained. A physical examination gives clues to the person’s fluid status and electrolyte functioning. Daily weight and frequent vital signs are also useful indicators of problems or potential problems. Monitoring a person’s intake and output and checking tone and condition of skin and mucous membranes all present a picture to assist in the nursing assessment. Laboratory and diagnostic testing information are also helpful for adequate and correct assessment.

• Review how vital signs reflect hydration status of a person. The monitoring, recording, and trending of vital signs are basic assessment skills that can provide information regarding the hydration status of a person. Elevated temperatures can cause an increased loss of body fluid that can lead to possible dehydration. Changes in pulse rate, quality, and rhythm indicate changes in hydration status. Increased pulse rate and weak pulse volume are consistent with dehydration, or fluid volume deficit (FVD).

Increased pulse volume and the presence of extra heart sounds are consistent with fluid volume excess (FVE). Assessment of a person’s respiratory rate and depth and auscultation of lung sounds can reveal pertinent information leading to hydration status. If the person has laboured breathing and adventitious lung sounds, this is consistent with fluid retention. If the person has altered breathing patterns, then this can be consistent with acid-base imbalances and compensatory responses. Lowering of blood pressure is consistent with dehydration, and orthostatic hypotension may occur. An increase in (widened) pulse pressure is consistent with FVE, whereas a decrease in (narrowed) pulse pressure is consistent with FVD. It is important for the nurse to assess for vital sign changes and monitor the person so that accurate information is documented.

Resource aids Kee, J., Paulanka, B. & Polek, C. (2010). Fluids and electrolytes with clinical applications: A programmed approach (8th ed.). Delmar/Cengage Learning.

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Using a laboratory setting, have students identify and demonstrate equipment that is used in treating people with fluid balance alterations. Include intravenous (IV) pumps, fluid selections, IV therapy

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cannulas, and intake and output tools. Have the students identify which patients could use each type of equipment and what are the relative benefits and disadvantages of the equipment.

• What problem identification would be appropriately given to a person with a fluid imbalance? An electrolyte imbalance? An acid-base imbalance?

• Have students record their intake and output for three days. How do the intake and output reconcile?

What factors affect their fluid balance?

• Have students in the clinical setting assess a client’s intake and output for the same period of 3 days.

Have the students bring the following for discussion: (1) appropriate forms used to monitor intake and output status in the clinical setting, (2) shift and 24-hour shift totals, and (3) how the information was documented and communicated to the next shift and to the physician who was responsible for monitoring the client’s overall care.

• Have students determine the appropriate IV solution for people with varying electrolyte or fluid imbalances.

• Have students discuss the nursing responsibilities required for the administration of blood transfusions in the clinical setting. What blood components are available for administration? How will they, as nurses, react to people who refuse blood products in the clinical setting? What alternative methods are there for people who refuse blood products?

• Using a schematic approach, divide the students into groups for each of the electrolytes discussed in the chapter and have them prepare a flow sheet for the clinical management of electrolyte imbalances. This will both reinforce the material and help the students to master the information needed to support their clinical knowledge base in the years to come. Have each group make copies and share the information with their peers after group discussion has demonstrated that the material is accurate and understood.

• Provide a variety of simulated arterial blood gas results that represent acid-base imbalances. Have the students analyse the results to identify the imbalance. What interventions would be appropriate for each of the imbalances?

• Have the students conduct a physical assessment for fluid and electrolyte balance on a person.

Assessment areas include weight, vital signs, intake and output, thirst, food intake, oedema, skin turgor, oral mucous membranes, eyes, jugular and hand veins, neuromuscular system, and analysis of laboratory data. Based on the assessment findings, identify interventions that would be appropriate for the person’s fluid and electrolyte status. Why would the interventions be appropriate?

• Provide the students with simulated intravenous infusion orders. Have the students calculate the infusion rate per hour and drops per minute according to infusion sets drop rates.

Review questions 1.

Which of the following is not a body fluid compartment? a. Intracellular b. Intravascular c. Interstitial d. Intercellular e. Veins.

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Answer: d Rationale: The body’s fluid is contained: within cells (intracellular), within blood vessels (intravascular) and within the tissue space (space between the cells and blood vessels; interstitial). Veins are blood vessels that return blood to the heart.

2.

Which client is most at risk for fluid volume deficit? a. A 30-year-old woman with a fractured tibia b. An 82-year-old woman with a fractured hip c. A 58-year-old man with a myocardial infarction d. A 35-year-old woman who just delivered a baby e. A 14-year-old boy with a fractured tibia.

Answer: b Rationale: Although all these clients might experience fluid volume deficit, older clients, in this case the 82-year-old, are at the greatest risk for a fluid volume deficit.

3.

The priority nursing action for a client with a serum sodium level of 130 mEq/L is: a. frequent oral hygiene b. monitor vital signs every two hours c. seizure precautions d. cardiac rhythm monitoring e. none of the above.

Answer: c Rationale: With hyponatraemia, there is either a sodium deficit or a water excess; a hypo-osmolar state exists because the ratio of water to sodium is too high. The water moves out of the vascular space into the interstitial space and then into the intracellular space, causing oedema. The low extracellular serum sodium causes water to enter the cells in the brain, thereby producing cerebral oedema as manifested by the cognitive and sensory changes.

4.

A person receiving 5 per cent dextrose at 100 mL/h is most at risk for developing: a. hyponatraemia b. hypernatraemia c. FVD d. FVE e. diabetes mellitus.

Answer: a Rationale: 5 per cent dextrose is a hypotonic IV solution. While administration of large volumes of any IV solution may result in fluid volume excess, a hypotonic IV solution places the client at risk for hyponatraemia. Fluid volume deficit is not a risk for IV fluid therapy.

5.

The priority nursing assessment for a client with hypokalaemia is: a. blood pressure b. Chvostek’s sign c. oedema d. heart rhythm

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e. respiratory effort.

Answer: d Rationale: The major risk for a client with a low potassium level is cardiac dysrhythmia. Chvostek’s sign is associated with hypocalcaemia, and oedema is associated with fluid balance.

6.

The priority nursing action for a person with a serum potassium level of 5.5 mmol/L who has received an oral dose of sodium polystyrene sulfonate (Resonium) is to monitor: a. urine output b. blood pressure c. bowel movement d. seizure activity e. cardiac rhythm.

Answer: c Rationale: Resonium causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If the client does not have stools, the drug cannot work properly.

Monitoring the client’s urinary output and blood pressure are important to hyperkalaemia but not specific to Kayexalate. Chvostek’s sign is associated with hypocalcaemia.

7.

The priority nursing action for a person who is immobile with a serum calcium level of 3.24 mmol/L is to: a. monitor ECG for changes b. teach the client to increase intake of whole grains and nuts c. place a tracheostomy tray at the bedside d. administer calcium gluconate IM as prescribed e. monitor their respiratory effort.

Answer: a Rationale: A client with a calcium level of 13 mg/dL has hypercalcaemia. Normal serum calcium is 8.5 to 10.5 mg/dL (4.5 to 5.5 mmol/L). Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing action for hypocalcaemia. Although calcium gluconate may be administered in hypocalcaemia, it is never administered IM.

8.

A woman is admitted to the hospital with a history of vomiting for 3 days and decreased oral intake.

Which set of arterial blood gases would indicate that she is in a state of metabolic acidosis? a. pH of 7.43, PaCO2 of 36 mmHg, HCO3 of 26 b. pH of 7.41, PaCO2 of 49 mmHg, HCO3 of 30 c. pH of 7.33, PaCO2 of 35 mmHg, HCO3 of 17 d. pH of 7.25, PaCO2 of 56 mmHg, HCO3 of 28 e. pH of 7.4, PaCO2 of 40mmHg, HCO3 of 24.

Answer: c Rationale: A pH of 7.33, PaCO2 of 35 mmHg, and HCO3 of 17 and a pH of 7.25, PaCO2 of 56 mmHg, and HCO3 of 28 both indicate acidosis; however, the pH of 7.25 is a respiratory acidosis. A pH of 7.41, PaCO2 of 49 mm Hg, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PaCO2 of 36 mmHg, and HCO3 of 26 is normal.

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9.

A male with a small bowel obstruction and a nasogastric tube connected to low intermittent suction for 2 days should be monitored for which acid-base disorder? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis e. All of the above.

Answer: c Rationale: Clients with gastric suctioning can lose hydrogen ions, resulting in a metabolic alkalosis.

10. Which statement about VAD placement reflects best practice? a. To maintain patency, infuse 0.9% sodium chloride solution immediately after VAD insertion. b. Document the total length of the catheter prior to infusing any solution. c. Confirm and document the tip’s correct anatomic location from the radiology department before using the VAD. d. If the person’s VAD was placed at another facility, you don’t need to confirm tip location. e. The VAD is always placed percutaneously.

Answer: c Rationale: All central catheters must be radiopaque to allow for radiographic verification of placement of the catheter and its tip prior to the administration of any solution.

11. When priming the IV tubing for a blood transfusion, which type of IV solution should you use? a. 3 per cent sodium chloride b. 5 per cent glucose c. Compound sodium lactate d. 0.9 per cent sodium chloride e. Dextran 70 Answer: d Rationale: 0.9 per cent sodium chloride is used to prime IV tubing for blood transfusions. Blood transfusions are incompatible with dextrose and with Ringer’s solution; together, they cause haemolysis, clumping of RBCs. 12. Of the following, which sign confirms a person’s fluid volume? a. Glasgow coma score a. Urine output b. Bowel movements c. Temperature d. Chekov’s sign Answer: b Rationale: If a person does not have an adequate fluid volume, they will not produce adequate urine output.

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13. Haemolysis is: a. immunoglobins produced by the body. b. a laboratory test that identifies a person’s blood type. c. the breakdown of RBCs. d. an indictor of serum albumin. e. the confirmation of blood type.

Answer: c Rationale: Haemolysis is the breakdown of red blood cells releasing haemoglobin. Rapid, turbulent flow of blood through small-bore needles and exposure to large negative pressures from the syringe or vacuum tube cause haemolysis. To minimise the possibility of haemolysis, a large-bore needle, moderate flow rates, and moderate negative pressures are used.

Spotlight on critical thinking 1.

Why are older people at greater risk of developing a fluid and electrolyte imbalances compared with younger adults?

Suggested solution: Older people (over 65 years of age) have a different body composition than younger adults. Rather than 60 per cent fluid, their bodies may contain only 45–55 per cent fluid, putting them at greater risk of imbalances. Their thirst mechanism in the medulla is less responsive to fluid deficit.

2.

Provide a rationale for undertaking a set of vital signs on a person prior to commencing a blood transfusion?

Suggested solution: Vital signs are obtained prior to beginning a blood transfusion to provide a baseline measurement in case a transfusion reaction or hypervolaemia were to occur.

3.

What signs and symptoms may indicate a person’s current fluid intake is adequate?

Suggested solution: Lack of thirst, moist mucous membranes, good skin turgor, adequate urinary output, urine pale straw coloured, intake over 2000 ml per day, VS within normal limits, weight stable.

Intake =output + 400–500 ml (insensible loss), no puffiness of the eyelids or sunken eyes, HCT is normal.

4.

How does a person’s diet and lifestyle affect their fluid and electrolyte status?

Suggested solution: a. Stress increases blood volume and this dilutes ADH, causing retention of fluid. b. Exercise and hot humid conditions increase sweating and cause hypovolaemia. c. Adequate intake of fluids, carbohydrates, potassium, calcium, sodium, fats, and protein is essential in helping the body maintain homeostasis and function properly.

5.

Would you adapt the education you provide to a person from a non-English speaking background about restricting fluids?

Suggested solution: You could provide an interpreter services if needed and a brochure in the persons preferred language with information about restricting fluids.

6.

Why is it necessary to check a person’s fluid and electrolyte status when they are confused?

Suggested solution: • alterations in fluids and electrolytes are common causes of various CNS signs, including confusion.

• FVD, FVE

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• • • • 7.

hyponatraemia, hypernatraemia hypokalaemia hypomagnesaemia hypophosphataemia.

What is a common cause of respiratory acidosis and how is it treated?

Suggested solution: Respiratory acidosis is caused by an excess of hydrogen ions and carbonic acid in the blood, brought about by depression in the rate or depth of respirations and by CNS depression causing a drop in the respirations (hypoventilation). Some common causes are drug-induced CNS depression, asthma, cystic fibrosis, emphysema, pneumonia and atelectasis, pulmonary oedema, respiratory distress syndrome, pneumothorax, hypoventilation, poliomyelitis, chest trauma, brain and spinal cord injury. Treatment consists of positioning to maximise respirations (or for safety), administer Oxygen, medications as ordered, monitor I&O, VS, ABG, may require mechanical ventilation.

Stimulation to breathe deeply (e.g. following anaesthesia) helps to prevent respiratory acidosis.

8.

What are the signs and symptoms of a person experiencing sepsis from an IV catheter?

Suggested solution: The person complains of chills and fever, backache, headache, malaise, nausea and vomiting. Unexplained fever may be related to catheter sepsis. Pulse rate increases and temperature is usually above 37.8°C if IV-related sepsis occurs

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 5 Resource aids....................................................................................................................................................... 6 Evaluation strategies ........................................................................................................................................... 6 Review questions................................................................................................................................................. 7 Spotlight on critical thinking .............................................................................................................................. 10

Chapter 37 Nutrition Key terms Absorption Process by which the end products of digestion pass through the epithelial membranes in the small and large intestines into the blood or lymph system, passage of a medication from the site of administration into the bloodstream.

Acupuncture A complementary therapy in which fine needles are inserted into selected locations on the body to align energy flow.

Aerobic metabolism Metabolism of nutrients in the presence of oxygen; a metabolic pathway that uses oxygen to convert glucose into cellular energy.

Anabolism Constructive phase of metabolism, in which smaller molecules (i.e., amino acids) are converted to larger molecules (i.e., proteins).

Anaerobic metabolism Metabolism of nutrients in the absence of oxygen; a metabolic pathway that converts glucose into energy in the absence of oxygen.

Anorexia nervosa A complex mental health disorder that manifests in self-imposed starvation that results in a 15 per cent or more loss of body weight.

Anthropometric measurements Measurement of the size, weight and proportions of the body.

Antioxidants Substances that block or inhibit destructive oxidation reactions.

Appetite Desire for specific foods instead of food in general (hunger); involves a psychological desire or craving.

Ascites An accumulation of fluid in the abdomen causes pressure that can interfere with breathing or gastrointestinal tract (GIT) function.

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Atherosclerosis Build-up of plaques in the inner layers of the walls of large to medium-sized arteries.

Ayurvedic medicine A healing system based on Hindu philosophy and Indian philosophy that embraces the concept of an energy force in the body that seeks to maintain balance or harmony.

Basal metabolic rate (BMR) Energy needed to maintain essential physiological functions when a person is at complete rest both physically and mentally.

Body mass index (BMI) Determines whether a person’s weight is appropriate for height by dividing the weight in kilograms by the height in metres squared.

Bulimia nervosa A complex mental health disorder that manifests in episodic binge eating followed by purging.

Calorie Quantity of heat required to raise the temperature of 1 g of water 1°C. Carbohydrates (CHO) Organic compound composed of carbon, hydrogen and oxygen.

Catabolism Destructive phase of metabolism, in which larger molecules (i.e., glycogen) are converted to smaller molecules.

Central parenteral nutrition (CPN) Used for long-term therapy to infuse highly hypertonic solutions directly into the superior vena cava.

Chiropractic Promotion of healing through manipulation of the spinal column.

Cholesterol Lipid that is produced by the body and used in the synthesis of steroid hormones. Cholesterol is excreted in bile.

Chylomicrons Lipoproteins synthesised in the intestines that transport triglycerides to the liver.

Deamination Removal of the amino groups from the amino acids.

Deglutition Swallowing of food.

Diabetes mellitus A disease in which the pancreas fails to secrete adequate levels of insulin to accommodate blood glucose levels.

Dietary fibre The part of food that body enzymes cannot digest and absorb.

Digestion Mechanical and chemical processes that convert nutrients into a physically absorbable state.

Disaccharide Double sugar.

Enteral nutrition (EN) The delivery of nutrients through a gastrointestinal tube.

Enterostomy The surgical creation of an artificial fistula (gastrostomy, jejunostomy) in the intestines by an incision through the abdominal wall.

Essential amino acids Amino acids that are required for growth and development and must be obtained from food.

Fat-soluble vitamins Vitamins that require the presence of fats for their absorption from the gastrointestinal tract and for cellular metabolism.

Fatty acids Basic structural units of most lipids that contain carbon chains and hydrogen.

Food security The availability of nutritionally appropriate and safe foods, and the access to acquire these foods in a conventional way.

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Free radical scavengers Substances that remove or destroy free radicals.

Free radicals Atoms or groups of atoms that can cause damage to cells.

Gluconeogenesis Conversion of amino acids into glucose or glycogen.

Glycolysis Breakdown of glucose by enzymes located inside the cell’s cytoplasm.

High-biological-value proteins (complete proteins) Proteins that contain all the essential amino acids.

Hunger A craving for food.

Hyperglycaemia Condition characterised by a blood glucose level greater than 10 mmol/L Hyperthyroidism Increased secretion of thyroid hormones, which increases the rate of metabolism.

Hypoglycaemia Condition characterised by a blood glucose level of less than 4 mmol/L. Hypothyroidism Decreased secretion of thyroid hormones, which decreases the metabolic rate.

Insulin Pancreatic hormone that aids in the diffusion of glucose into the liver and muscle cells and the synthesis of glycogen.

Intrinsic sugars Sugars present naturally within the cellular structure of food, mainly found in fruits and vegetables.

Ketogenesis Conversion of amino acids into keto acids or fatty acids.

Ketones Products of incomplete fat metabolism.

Kilocalories Equivalent to 1000 calories.

Laparoscopy A visualisation of the abdominal structures from the peritoneal cavity used to detect cysts, adhesions, liver lacerations and cirrhosis.

Lipids Organic compounds that are insoluble in water but soluble in organic solvents such as ether and alcohol; also known as fats.

Low-biological-value proteins (incomplete proteins) Proteins lacking in one or more of the essential amino acids.

Malnutrition Nutritional alterations related to inadequate intake, disorders of digestion or absorption, or overeating.

Mastication Chewing into fine particles and then mixing the food with enzymes in saliva.

Metabolic rate Rate of heat liberated during chemical reactions.

Metabolism The combination of all chemical reactions in every body cell.

Microbiome All of the genetic material within a microbiota (i.e., the entire collection of microorganisms in a specific niche, such as the human gut).

Microminerals Chemical elements required by your body in trace amounts, usually as a part of a vital enzyme, to function well. They include chromium, copper, fluorine, iodine, iron, manganese, molybdenum, selenium, silicon and zinc.

Mid-upper-arm circumference (MAC) Measures skeletal muscle mass and serves as an indicator of protein reserve.

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Minerals Inorganic elements.

Monosaccharides Simple sugars.

Monounsaturated fatty acids Fatty acids with one double or triple bond.

Nasogastric intubation The insertion of a tube through the nostril into the stomach.

Negative nitrogen balance Condition that exists when nitrogen output exceeds intake and protein catabolism exceeds anabolism.

Nitrogen balance Net result of intake and loss of nitrogen that measures protein anabolism and catabolism.

Non-essential amino acids Amino acids that can be synthesised in the adult body.

Obligatory loss of proteins Degradation of the body’s own proteins into amino acids in response to inadequate protein intake.

Overweight An energy imbalance in which more food is consumed than is needed, causing a storage of fat.

Paracentesis The aspiration of fluid from the abdominal cavity for either diagnosis or treatment.

Parenteral nutrition (PN) Nutrients bypass the small intestine and enter the blood directly.

Peristalsis Coordinated, rhythmic, serial contraction of the smooth muscles of the gastrointestinal tract, ureters.

Phospholipids Composed of one or more fatty acid molecules and one phosphoric acid radical, and usually contain a nitrogenous base.

Polysaccharide Complex sugar.

Polyunsaturated fatty acids Fatty acids that have many carbons unbonded to hydrogen atoms.

Positive nitrogen balance Condition that exists when nitrogen intake exceeds output, and protein anabolism exceeds catabolism.

Prealbumin Precursor of albumin.

Prebiotics Provide food to the symbiotic and commensal bacteria in the microbiome; promotes the growth of beneficial microorganisms Probiotics Live microorganisms that, when administered in sufficient quantities, provide health benefits Proteins Organic compounds of amino acid polymers connected by peptide bonds that contain carbon, hydrogen, oxygen and nitrogen.

Refeeding syndrome Complication that can occur during the initial phase of EN or PN therapy, oral intake or dextrose-containing IV fluids in which the person adapts to nutritional deprivation and compensates by decreasing basal energy requirements.

Saccharides Sugar units.

Satiety Feeling of fulfilment from food.

Saturated fatty acids Glycerol esters of organic acids whose atoms are joined by a single-valence bond.

Skinfold measurement Measures the amount of body fat.

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Total parenteral nutrition (TPN) The provision of nutrition and hydration solely using intravenous infusion of solutions containing lipids, proteins, carbohydrates, electrolytes and vitamins.

Transferrin Combination of a blood protein and iron.

Triglycerides Lipid compounds consisting of three fatty acids and a glycerol molecule.

Ultrasound Use of high-frequency sound waves instead of X-ray film to visualise deep body structures; also called an echogram.

Under weight An energy imbalance in which more calories are expended than consumed.

Unsaturated fatty acids Glycerol esters of organic acids whose atoms are joined by double- or triple-valence bonds.

Water-soluble vitamins Vitamins that require daily ingestion in normal quantities because they are not stored in the body.

Instructional strategies • There are six categories of nutrients. List these six nutrients and their value for the human body. o Water is the most abundant nutrient in the body. Water is acquired from diet. It makes up the bulk of the body weight. o Vitamins are needed in small quantities. Vitamins are essential for normal body metabolism. o Minerals, which include macrominerals and microminerals, are one of the six nutrients. Minerals serve as catalysts in biochemical reactions, play an essential role in metabolism, play a role in wound healing, and are necessary for teeth formation. o Carbohydrates are organic compounds. They play a role in cell energy and are instrumental in normal body functioning. o Proteins are also organic compounds. After water, proteins are the most abundant intracellular substance. Proteins are essential for almost all functions of the body. o Lipids (fats) are organic compounds that are insoluble in water. Lipids are a source of energy, maintain body temperature, provide for some synthesis, and are necessary for cell membrane integrity.

• For the body to adequately utilise nutrients, these nutrients must be processed and broken down for body use. Discuss this process. There are several processes involved with the breakdown of nutrients for body use. o Digestion: the mechanical and chemical process that converts nutrients into physically absorbable particles. o Absorption: the end products of digestion pass through epithelial membranes in the small and large intestines into the blood or lymph systems. o Metabolism: describes all chemical reactions and processes in every body cell as they relate to the distribution of nutrients in the blood after digestion.

• Discuss the difference between fat-soluble and water-soluble vitamins. o Fat-soluble vitamins, or vitamins A, D, E, and K, are those vitamins that, when ingested, are stored in the fatty tissue within the body. The body stores the vitamins for use when necessary. o The water-soluble vitamins are those that cannot be stored in the body and must be ingested in adequate amounts on a daily basis.

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o It is possible to ingest toxic amounts of both types of vitamins. Once the body’s metabolic demands for the vitamin have been met, the remaining amounts of vitamins act as free radicals in the body, leading to toxicity.

• The recommendations for daily food choices have changed over recent years. In Australia the National Health and Medical Research Council recommends that the following five food groups are included in a daily menu plan: o plenty of vegetables with a variety of colours and types including legumes and beans o fruit o grain (cereal), mostly wholegrains and/or high fibre varieties of bread, cereals, rice, pasta, polenta, couscous, oats, quinoa, and barley o lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/ beans o milk, yogurt, cheese and/or alternatives that are fat reduced.

• Australians eat out frequently due to busy schedules, more diverse family structures, and popularity of fast food restaurants. What are some ways that Australians can be more assured to get adequate nutrition with this occurring? First, people can learn to stay home for more meals. However, when eating out, avoiding foods high in calories and fat will provide for a more balanced intake. In a restaurant, study the menu carefully to avoid items too rich in fat. Be aware of food groups; try to eat fruits and vegetables for snacks instead of potato chips or other high-sodium, high-fat food items.

Resource aids Backholer, K., Mannan, H. R., Magliano, D. J., Walls, H. L., Stevenson, C., Beauchamp, A., Shaw, J. E., & Peeters, A. (2012). Projected socioeconomic disparities in the prevalence of obesity among Australian adults. Australian and New Zealand Journal of Public Health, 36(6), 557–563. https://doi.org/10.1111/j.1753-6405.2012.00885.x Esper, D.H., (2015). Utilization of nutrition-focused physical assessment in identifying micronutrient deficiencies. Nutrition in Clinical Practice, 30(2), 194–202. https://doi.org/10.1177/0884533615573054 National Health and Medical research Council. (2013). Australian Dietary Guidelines. National Health and Medical Research Council.

Ride, L.A. (2018) Review of nutrition among Aboriginal and Torres Strait Islander people. Australian Indigenous HealthBulletin, 18(1). https://healthbulletin.org.au/articles/review-of-nutrition-amongaboriginal-and-torres-strait-islander-people

Evaluation strategies • Assign students the task of keeping a diary or journal of what foods they eat over the period of one week.

Discuss any surprising discoveries students make regarding their food intake.

• Have the students calculate their own BMI. Based upon the BMI and information gained from a food diary, have the students identify ways to adjust eating to meet the recommended BMI for normal weight.

• Have students explore community resources that deliver food or meals to elderly or house-bound community members. Are there requirements or restrictions for retaining this service? Is there a cost involved? Is this resource well known in the community?

• Special food preferences may affect a person’s ability to receive adequate nutrition on a daily basis. What types of information can the nurse provide for clients with limited food preferences? © Cengage Learning Australia 2024

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• Have students organise a collaborative plan of care for a culturally diverse client in an acute health care setting as well as a client in a community health care setting, for the management of diet selection.

• Have students go to a local supermarket and pick a food group selection such as vegetables. Have them provide a listing of food availability and pricing. Then have the students compare available community resources and assess potential stressors such as limited resources and limited mobility. It is important to have the students understand the nature of available food items and how resources and mobility issues of the individual client can influence and possibly prevent food selection.

• Have the students identify current food fads. Discuss the students’ responses in a large group.

• In the laboratory setting, have available equipment used to insert a nasogastric tube. Have a variety of nasogastric tubes available. Provide equipment that would be used for nasogastric tube- and/or gastrostomy-tube feedings. Provide samples of different types of solutions used for tube feedings. Have the students analyse the contents of the tube feedings and identify which types of clients would benefit from the different types of tube feedings.

Review questions 1.

Which are considered basic nutrients in the body? (Select all that apply.) a. Water b. Vitamins c. Minerals d. Carbohydrates e. Proteins f. Lipids.

Answer: a, b, c, d, e, f Rationale: Water is the most abundant nutrient in the body. Vitamins regulate cellular metabolism.

Minerals serve as catalysts in biochemical reactions. Carbohydrates play a significant role in providing cells with energy and supporting normal functioning of the body. Proteins, after water, are the most abundant intracellular nutrient. Lipids are a source of concentrated energy and essential fatty acids, and they promote the absorption of fat-soluble vitamins.

2. The evidence-based guidelines issued by the National Health and Medical Research Council of Australia recommend losing weight by restricting intake and increasing physical activity. Which food items should be reduced or eliminated from a person’s diet to achieve these guidelines? a. Animal fats b. Added sugar and salt c. Alcohol d. Green leafy vegetables e. Dark fruits.

Answer: a, b, c Rationale: Animal fats, added sugar, salt, and alcohol are associated with a high incidence of coronary heart disease, obesity, and diabetes. Increasing fresh fruits and vegetables helps achieve a healthy weight when combined with physical exercise; average weight is relative to energy balance (energy intake equals energy output).

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2.

Post-op diet education includes the increase of which nutrient to assist with tissue repair? a. Vitamin b. Carbohydrate c. Protein d. Fat e. Trace elements.

Answer: c Rationale: The essential amino acids are needed by cells for anabolism and repair.

3.

Which subjective assessment should you include when assessing a person’s GI tract? a. Rebound tenderness b. Diarrhoea c. Generalised red abdominal rash d. Haematuria e. Vomiting.

Answer: a Rationale: Assessment includes both subjective and objective data. Rebound tenderness is sudden pain when the examiner palpating the abdomen removes the examining fingers and the client complains of pain. Diarrhoea, generalised red abdominal rash, and haematuria are all observable and, therefore, objective, not subjective, data.

4.

You are completing a nutritional assessment via telehealth as the person you are caring for lives in a remote area. Identify two steps you would take prior to beginning the session. (Select all that apply.) a. Send a follow-up message to the person b. Engage and explain process with the person c. Document who provided answers to which questions d. Test the audio and visual functions.

Answer: b, d Rationale: Engaging the client prior to the process is important so the client knows how the consultation will progress and that they are comfortable using the equipment. Testing the audio and visual is working, ensures that the equipment is working.

5.

Which anthropometric measurement indicates the amount of body fat? a. Weight b. BMI c. Skinfold d. Waist measurement.

Answer: d Rationale: Skinfold measurement indicates the amount of body fat. The body mass index determines whether a person’s weight is appropriate for height.

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6.

You obtain a pH of eight when aspirating for gastric contents when assessing correct tube placement.

The nurse evaluates a pH of eight to be: a. alkaline, indicating respiratory secretions b. a neutral pH c. acidic, confirming gastric secretions d. indicative of intestinal secretions e. water.

Answer: a Rationale: When checking for correct nasogastric tube placement, a pH of 8.0 indicates the presence of alkaline and respiratory secretions. Fluid aspirate with a pH higher than 6.0 indicates pleural fluid from the tracheobronchial tree. A pH range of 1.0 to 5.5 indicates proper tube placement. Fluid aspirated with a pH higher than 6.0 may also indicate the tube is placed in the intestine because intestinal secretions are less acidic than the stomach.

7.

You are sending Greg home with a Nasogastric tube, he is 10 years old and his mother, June, will be administering his feeds at home. Identify two assessments that you need to complete related to home feeding before he is discharged. (Select all that apply.) a. Assessment for gag reflex b. Assessing Greg’s intravenous cannula site for infection c. The ability of June to safely manage feeds. d. Assessing benefits of continuing therapy at home e. The availability of oxygen and suction at home.

Answer: c, d Rationale: It is important that the PN is deemed necessary and beneficial to Greg in order for him to have this continued at home. June needs to be confident and able to administer the feeds safely with the appropriate hygiene at home to maintain Greg’s nutritional status.

8.

The type of malnutrition that most commonly occurs in the acutely ill hospitalised person is: a. anorexia nervosa b. mixed malnutrition c. marasmus d. protein-energy malnutrition e. hospital malnutrition.

Answer: d Rationale: Protein-energy malnutrition depletes body cell mass and impairs tissue and organ function.

Marasmus results from caloric deficiency secondary to acute diseases such as diarrheal diseases of infancy, deficiency in nutritional composition, malabsorption, child abuse, and failure to thrive.

Anorexia nervosa is an eating disorder marked by weight loss, emaciation, a disturbance in body image, and a fear of weight gain.

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10. Which of the following types of PN formula is most suitable for someone with a normally functioning digestive tract? a. Peptide based formula b. Polymeric formula c. Modular formula d. Disease specific formula e. None of the above.

Answer: b Rationale: Polymeric formula contains intact protein molecules. These are suitable for people who have normally functioning digestive tracts and should be able to digest and tolerate intact proteins.

Spotlight on critical thinking The nurse’s role in promoting good nutrition Nurses play an important role in ensuring that patients do not develop malnutrition during their admission to hospital. Two important considerations are making sure that all patients have the support they require to access their meal, and that the environment is conducive to eating.

1.

If someone is admitted to your clinical area with dementia, how would you develop a care plan to ensure that they maintained their nutritional state?

Suggested solution: A person with dementia may require bedside interventions and this should be considered in the care plan. Students should refer to the Implementation section of the chapter when formulating responses.

2.

What measures can a nurse take to ensure that a person will eat their meals? Think about whether they are positioned so that they can eat? Is there anything near them that might affect their appetite, such as a urinal?

Suggested solution: To ensure that the environment encourages, rather than discourages, the person to eat, the nurse should ensure the following: • that the ward area is clean and tidy, all bedpans, urinals, and commodes are removed • the person is positioned comfortably and can reach the table where their food is placed • if necessary, the person can be toileted before their meal and offered a wet towel to wash their face and hands • that all routine clinical procedures, should as observations, dressings, or medications that do not require to be given with food, do not occur during mealtimes.

• nurses should encourage other healthcare professionals to not disturb people while they are eating • nurse’s meal breaks can be organised to ensure that there are as many nurses as possible to assist the people with their meals • provide a communal eating area for those that can manage as to promote socialisation at mealtime • if a patient is having difficulty with their meals, this information is recorded in the healthcare record and communicated to all staff at clinical handover. If a patient continues to have difficulty eating for a twenty-four-hour period, the patient should be referred to the multidisciplinary team for assessment.

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The media and nutrition We are bombarded by messages in the media and advertising about food. Healthcare professionals need to combat these messages when they have a harmful effect the people in their care.

3.

What role does the media play in forming an individual's food beliefs? Think about how celebrity chefs encourage us to ‘season’ (or put salt) on our food for taste. Do diets promoted by celebrities, such as a paleo diet where the person does not eat carbohydrates or the no sugar diet where the person does not eat fruit, affect a person’s nutritional status?

Suggested solution: The nurse can devise education programs to encourage patients to avoid unhealthy eating practices and in collaboration with dietitians can encourage patients to use alternatives to unhealthy foods, such as salt (lemon can be used to flavour food instead).

Many media images present unrealistic pictures of both men and women, encouraging many people (across the life span) to attempt to achieve these body types, or to eliminate whole food groups.

This could result in under nutrition because a person may not eat the required amounts of nutrients. An example of a chronic illness that can result from a lack of nutrients is osteoporosis if a person does not consume enough foods containing calcium.

4.

What programs can nurses develop in collaboration with other members of the health care team to counteract nutrition messages from the media and advertising?

Suggested solution: Nurses can devise many educational programs covering all aspects of nutrition to assist their patients to maintain good nutrition or to change unhealthy eating practices. All programs can be designed with other members of the healthcare team. Nurses can also be involved with assisting patients to make healthy choices when buying groceries and can led or assist in cooking lessons or demonstrations

Legal and ethical: withholding nutritional support The obligation to promote the good of the person is basic to being a health care provider and is part of each professional's duty to them. This obligation underlies the requirement to evaluate the benefits and burdens of a treatment from the individual’s perspective.

5.

When and by whom should a decision be made to withhold or withdraw NS in the absence of an advance directive? Consider the benefits to the patient and the burden that NS places on the person, family and caregiver.

Suggested solution: There is no benefit in withdrawing nutrition or hydration when a person is at the end stage of their life. Generally, a person’s hydration status is maintained for their comfort and fluids can be given subcutaneously when the person can no longer take fluids orally. The person should be offered food until they can no longer tolerate eating. Diets should be modified in collaboration with the dietitian to assist the person to eat.

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Culture and food: nutrition in Aboriginal and Torres Strait Islander cultures First Australians are more likely to be malnourished and at higher risk of chronic diseases such as Type 2 diabetes and cardiovascular disease. As nurses we are expected to assess nutritional status holistically, which should include cultural factors.

6.

Consider how colonisation of Australia has affected the diet and subsequently the health of present-day Aboriginal and Torres strait Islander peoples. Consider the types of foods now eaten in comparison to a traditional diet as well as socioeconomic factors and how this has affected their health.

Suggested solution: The colonisation of Australia introduced an energy-dense westernised diet, high in fat and refined sugars. Their traditional diet varied and was nutrient-dense, high in fibre and low in fat and refined carbohydrates. This diet has led to a higher burden of disease as body composition of first Australians was not intended to process a westernised diet high in fat and sugar.

Inadequacies in nutritional intake through a range of socioeconomic (low income, lack of education, unemployment), environmental (legal challenges to access land and certain foods) and geographic (remote locations) factors have influenced the availability of healthy and affordable food, with most supermarkets and outlets providing only energy-dense, nutrient-poor items.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 5 Resource aids....................................................................................................................................................... 6 Online resources.................................................................................................................................................. 6 Evaluation strategies ........................................................................................................................................... 7 Review questions................................................................................................................................................. 8 Spotlight on critical thinking .............................................................................................................................. 11

Chapter 38 Pain management, comfort and sleep Key terms Acupuncture A complementary therapy in which fine needles are inserted into selected locations on the body to align energy flow.

Acute pain Discomfort identified by sudden onset and relatively short duration, mild-to-severe intensity, and a steady decrease in intensity over several days or weeks.

Adjuvant medications Medications used to enhance the analgesic efficacy of opioids, treat concurrent symptoms that exacerbate pain, and provide independent analgesia for specific types of pain.

Afferent (ascending) pain pathways Ascending the spinal cord.

Allodynia Pain caused by a stimulus that does not normally evoke pain.

Biofeedback Measurement of physiological responses that yields information about the relationship between the mind and body and helps people learn how to manipulate these responses through mental activity.

Biological clock Endogenous mechanism capable of measuring time in a living organism.

Bolus A measured amount of analgesic received when pressing the button during patient-controlled analgesia.

Bruxism Teeth grinding during sleep.

Cancer pain Either acute (usually caused by treatment or investigation) or chronic pain caused by the malignant disease. The tumour may compress surrounding tissue such as nerves or bone, or infiltrate nearby

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body parts such as the spinal cord, or cancer can affect hormonal balances and immune responses to produce painful conditions.

Ceiling effect As the dose of medication is increased above a certain level, the analgesic effect remains the same.

Chronic acute pain Discomfort that occurs almost daily over a long period, has the potential for lasting months or years, and has a high probability of ending.

Chronic non-malignant pain (CNP) Discomfort that occurs almost daily and lasts for at least six months, with intensity ranging from mild-to-severe and not caused by a malignant disease.

Chronic pain Discomfort that is persistent, nearly constant and long-lasting (six months or longer); recurrent pain that produces significant negative changes in a person’s life.

Chronic persistent pain Discomfort that is persistent, nearly constant and long-lasting (6 months or longer); or recurrent pain that produces significant negative changes in a person’s life.

Chronic postsurgical pain (CPSP) Pain that is correlated to a surgical procedure and persists for at least two months post procedure.

Chronobiology A relatively new branch of science that studies rhythms that are controlled by our biological clocks.

Circadian rhythms Biological rhythms that cycle on a daily basis.

Colic Acute abdominal pain.

Counter stimulation Techniques believed to activate the endogenous opioid and monoamine analgesia systems.

Cutaneous pain Caused by stimulation of the cutaneous nerve endings in the skin, resulting in a welllocalised ‘burning’ or ‘prickling’ sensation.

Distraction Focusing attention on stimuli other than pain.

Efferent (descending) pain pathways Descending the spinal cord.

Endorphins Group of opiate-like substances produced naturally by the brain; these substances raise the pain threshold, produce sedation and euphoria, and promote a sense of wellbeing.

Enuresis Bed wetting; involuntary urination during sleep.

Gate control pain theory Combines cognitive, sensory and emotional components, in addition to the physiological aspects, and proposes that they can act on a gate control system to block the individual’s perception of pain.

Hyperalgesia Extreme sensitivity to pain.

Hypersomnia An alteration in sleep pattern characterised by excessive sleep, especially in the daytime.

Imagery Relaxation technique in which the individual uses the imagination to visualise a pleasant, soothing image.

Insomnia Refers to the chronic inability to sleep or inadequate quality of sleep due to sleep that prematurely ends or is interrupted by periods of wakefulness.

Ischaemic pain Pain occurring when the blood supply of an area is restricted or cut off completely. © Cengage Learning Australia 2024

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Lancinating Piercing or stabbing pain.

Mindfulness Therapeutic practice of being aware of the present moment including awareness of any thoughts, emotions and bodily sensations.

Modulation Changing pain impulses.

Myofascial pain syndromes Group of muscle disorders characterised by pain, muscle spasm, tenderness, stiffness and limited motion.

Narcolepsy A sleep alteration that manifests as sudden uncontrollable urges to fall asleep during the daytime.

Neuralgia Paroxysmal pain that extends along the course of one or more nerves.

Neuropathic pain Arises from damage to portions of the peripheral or central nervous system.

Nociception The process by which an individual becomes consciously aware of pain.

Nociceptive pain Pain resulting from activation of nociceptors due to damaged non-neural tissue.

Nociceptors Receptive neurons for painful sensations that, together with the axons of neurons, convey information to the spinal cord where reflexes are activated.

Pain A universal human experience defined as ‘a state in which an individual experiences and reports the presence of severe discomfort or an uncomfortable sensation’ (Carpenito, 2003, p. 58).

Pain catastrophising The tendency to magnify or ruminate on the pain experience. The person may also feel helpless or fearful about the experience.

Pain threshold The level of intensity at which pain becomes appreciable or perceptible; varies with each individual and type of pain.

Pain tolerance The level of intensity or duration of pain the person is willing or able to endure.

Paraesthesia Abnormal sensation such as burning, prickling or tingling.

Parasomnia Refers to sleep alterations resulting from ‘an activation of physiological systems at inappropriate times during the sleep-wake cycle’ (American Psychiatric Association, 1994, p. 579).

Partial opioid agonists Medications that bind to opioid receptors but have less efficacy compared with pure agonists, therefore producing a submaximal effect.

Patient-controlled analgesia (PCA) Device that allows the individual to control the delivery of intravenous or subcutaneous pain medication in a safe, effective manner through a programmable pump.

Perception Person’s sense and understanding of the world; conscious awareness of pain.

Phantom limb pain Neuropathic pain in which pain sensations are referred to an area of an extremity that has been amputated.

Physical dependence Reaction of the body, commonly known as withdrawal syndrome, to abrupt discontinuation of an opioid after repeated use.

Primary sleep disorders Disorders in which the sleep alteration is the fundamental problem.

Progressive muscle relaxation (PMR) Stress-management technique involving tensing and relaxing muscles.

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Psychosocial assessment An assessment performed to identify the person’s attitudes and beliefs regarding pain and social support.

Pure opioid agonists Medications which bind to the cells’ opioid receptors and produce a maximal response from cells.

Recurrent acute pain Identified by repetitive painful episodes that may recur over a prolonged period or throughout the person’s lifetime.

Referred pain The sensation of pain is not felt in the organ itself but instead is perceived at the spot where the organs were located during fetal development.

Reframing A technique that teaches people to monitor their negative thoughts and replace them with ones that are more positive.

Relaxation techniques A variety of methods used to decrease anxiety and muscle tension.

Rest A state of relaxation and calmness, both mental and physical.

Secondary sleep disorders Disorders in which the alteration has a medical or clinical cause that results in or contributes to the sleep alteration.

Sleep A state of altered consciousness during which an individual experiences minimal physical activity and a general slowing of the body’s physiological processes.

Sleep apnoea A syndrome in which breathing periodically ceases during sleep, often associated with heavy snoring.

Sleep cycle The sequence of sleep that begins with the four stages of non-rapid eye movement sleep in order, with a return to stage 3, then 2, then passage into the first rapid eye movement stage.

Sleep deprivation A term used to describe prolonged inadequate quality and quantity of sleep, either of the rapid eye movement or the non-rapid eye movement type.

Sleep hygiene The practices or habits a person performs to promote a restful sleep.

Somatic pain Non-localised pain originating in support structures such as tendons, ligaments and nerves; may be a deep pain.

Somnambulism Sleepwalking.

Tolerance Can occur after repeated administration of an opioid analgesic, when a specific dose loses its effectiveness, and the person requires larger and larger doses to produce the same level of analgesia.

Transcutaneous electrical nerve stimulation (TENS) Method of applying minute amounts of electrical stimulation to large-diameter nerve fibres via electrodes placed on the skin to block the passage of pain to the dorsal spinal root.

Transduction The changing of noxious stimuli in sensory nerve endings to energy impulses.

Transmission Movement of impulses from the site of origin to the brain.

Trigger point A hypersensitive point that when stimulated causes a local twitch or ‘jump’ response.

Visceral pain Discomfort in the internal organs that is less localised and more slowly transmitted than cutaneous pain.

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Instructional strategies • Differentiate between acute pain, chronic pain, and chronic acute pain, and give an example of each type of pain. o Acute pain: Acute pain is characterised by sudden onset and relatively short duration. Intensity will vary from mild to severe, regardless of severity; it demonstrates a steady decrease in intensity over a time-limited period. A gallbladder attack or a broken bone are examples of acute pain. o Chronic pain: Pain that lasts six months or longer is generally considered chronic pain. This pain may last even after the pathology has been resolved. It is more common in the older population. Back pain is considered to be the most common chronic illness complaint. Other disease processes such as rheumatoid arthritis can cause chronic pain, persisting until death. o Chronic acute pain: This type of pain incorporates characteristics of both acute pain and chronic pain.

The pain is time limited; however, that time may extend into months and years. A good example of a condition that can produce chronic acute pain is a severe burn; another would be cancer. It has been said that chronic pain actually changes a person’s personality.

• Describe pain that is qualified by origin: cutaneous, somatic, or visceral. Cutaneous pain is found in the nerve endings of the skin and results in a well-localised ‘burning’ or ‘prickling’ sensation. Somatic pain arises from supportive structures of the body (tendons, ligaments, and nerves) and is not as well localised. Visceral pain is found deep in the internal organs and the location is not always specified.

• Discuss factors affecting the pain experience and use of therapeutic modalities for pain. Age is a factor affecting a person’s perception and tolerance of pain. A child may have pain but not comprehend the phenomenon. Decreasing anxiety and fright related to pain is one therapeutic modality for the child experiencing pain. Peer pressure may have implications for adolescents experiencing pain. The adolescent experiencing pain may attempt to downplay their pain for fear of ridicule or attack on selfconcept. The older adult may have problems with verbalising pain due to perceptions aging inevitably leads aches and pains. In addition to available pain medication, techniques such as therapeutic touch, guided imagery, and massage may be helpful therapeutic modalities for pain. It is important for nurses to provide age-appropriate assessment tools when assessing pain in all age groups. Previous experience with pain may be an indicator of how the person copes with pain. Those who use positive coping mechanisms may be more apt to use these again; those who use more dysfunctional coping mechanisms may also use similar mechanisms again. A person’s culture may influence how a person perceives pain and how it is verbalised. This is especially important for the nurse to understand because those who may require pain medication may not ask for it.

• What routes of pain medication are commonly used? Give examples of when they may not be appropriate. Pain medications can be given orally. Oral administration of pain medication may be contraindicated in individuals with dysphagia or an impaired level of consciousness. A person with nausea may not be able to keep a pill down, so another route might be more appropriate. Subcutaneous injection is the preferred route for parenteral administration. Intramuscular injection is rarely used due to unreliable opioid absorption s. Intravenous (IV) drug administration is also commonly used for pain management. Patient-controlled analgesia (PCA) is great for those requiring continuous pain medication.

However, the person must be taught appropriate usage of a PCA to ensure its efficacy.

• Discuss the difference between rest and sleep. Rest is a state of relaxation and mental and physical calmness. Activities such as lying down, reading, and taking a quiet walk can be done during rest. Sleep refers to a state of altered consciousness during which an individual experiences minimal physical activity © Cengage Learning Australia 2024

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and a general slowing of the body’s physiological processes. Sleep occurs in a periodic cycle and usually lasts for several hours at a time. A disruption in the usual sleep routine can further impair sleep. Sleep is necessary for physiological and psychological healing to occur.

• Discuss the categories of sleep. There are two categories of sleep. The first category, non-rapid eye movement (NREM) sleep, has four stages. Stage 1 lasts only 10 minutes and is considered light sleep.

Stage 2 is still light sleep; however, it is characterised by slowing of the electroencephalogram patterns.

After approximately 20 minutes of stage 2 sleep, the person enters stages 3 to 4 sleep. Stage 3 and stage 4 sleep are difficult to separate. In stage 3, sleep is of medium depth, and in stage 4, sleep is deep. If aroused during stage 3 or 4 sleep, the person can take up to 15 seconds to become fully awake. The second category of sleep is rapid eye movement (REM) sleep. The electroencephalogram pattern during this sleep is that which is seen while awake. Dreams occur 80% of the time during this category of sleep.

REM sleep periods become longer as the night progresses, and an average adult can have four to six periods of REM sleep per night.

• Explain the impact of illness or hospitalisation on a person’s sleep pattern. Being ill or hospitalised is stressful. This stress usually will disrupt a person’s sleep. Reasons why hospitalisation negatively impacts a person’s sleep include physical or emotional pain, loss of familiar surroundings, loss of routine, fear of the unknown, timing of procedures and treatments, noise level, and loss of privacy. Nursing interventions should be planned and implemented to address these reasons early in the person’s hospitalisation to address alteration in sleep patterns.

Resource aids Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. (2012). Acute pain management: Scientific evidence (5th ed.). Retrieved from https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf Department of Health. (2021). National Strategic Action Plan for Pain Management Retrieved from https://www.health.gov.au/sites/default/files/documents/2021/05/the-national-strategic-actionplan-for-pain-management-the-national-strategic-action-plan-for-pain-management.pdf

Online resources •

Australasian Sleep Association provides consumers and health professionals information regarding sleep and the management of sleep disorders, http://www.sleep.org.au

•

Australian Commission on Safety and Quality in Healthcare provides national recommendations for safe medication practices including labelling of intravenous and epidural infusions, http://www.safetyandquality.gov.au

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Chronic Pain Australia provides chronic pain management resources/strategies for consumers and health professionals, http://www.chronicpainaustralia.org.au

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International Association for the Study of Pain (IASP) is the leading expertise society in pain management, http:www.iasp-pain.org

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Pain Australia is a non-profit organisation whose goal is improve pain management in Australia, http://www.painaustralia.org.au

Evaluation strategies • Invite members of the professional community (e.g., registered nurse, anaesthetist, pain management team) to discuss the topic of ‘Pain as the fifth vital sign’ Have students be prepared to ask questions of the professional panel in terms of the importance of pain assessment and control of pain management for individuals who have acute and chronic pain syndromes.

• Have the students use Table 38-4 ‘Pain assessment questions’ to formulate a questionnaire for individuals experiencing pain throughout the lifespan (ranging from infants to the older adult). What measures could the students use to effectively assess pain levels?

• Have students write a reflective journal on how important sleep patterns are in maintaining biologic rhythms. What problems do they think will occur when individuals experience a sleep disorder?

• Have students analyse their own sleep patterns. As a student, it is easy for normal sleep patterns to be altered. Have the students keep a sleep journal for one week. Document the time going to sleep, the ease with which sleep occurred, number of times woken up during sleep, and if sleep resulted in feeling rested and rejuvenated. Identify reasons for interrupted sleep. Discuss the information gained from personal sleep journals in the classroom.

•

In the clinical area, have students identify which groups of people are more likely to be prescribed medications for sleep. Identify the type of medication prescribed and actions.

•

Have students analyse how pain is controlled in individuals in the clinical setting. Have students provide documentation of whether a pain scale is used to measure pain and whether or not responses to pain interventions are documented in the nurse’s notes.

•

Have students discuss appropriate assessment and intervention for a person suspected of practicing drug-seeking behaviour. Give examples of effective assessments for distinguishing between actual physical need and psychological demand for pain medication.

•

Encourage class discussion on how pain affects other body systems. Include respiratory status, elimination, and mobility.

•

Pain is more prominent in certain medical diagnoses, for example, cancer. How can use of the diagnosis assist nursing students develop a pain assessment and management plan?

•

Have students practice assessing pain among various age groups with appropriate pain-rating scales.

•

In the laboratory setting, provide complementary pain management modalities for students to practice, such as relaxation tapes, guided imagery, progressive muscle relaxation techniques, biofeedback, cutaneous stimulation, and transcutaneous stimulation devices. Using the information in Figure 38-13, have the students practice acupressure points for headache relief.

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Review questions 1.

Which of the following groups are least at risk for underassessment of pain? a. Children b. Adults c. Older adults d. Aboriginal and Torres Strait Islander peoples e. Refugees.

Answer: b Rationale: Adults are least at risk for the underassessment of pain. All of the other groups are at risk groups for various reasons. Children are at risk due to their developmental stage and limited vocabulary. Older adults are more likely to have difficulties verbalising pain due to other medical conditions such as cognitive impairment, communication disorders (e.g., dysphasia) or dementia.

Further, the pain experienced in older adulthood is likely to be more complex due to multiple comorbidities. Aboriginal and Torres Strait Islander peoples are more likely to underreport pain compared to Australians who have a Caucasian background. This reluctance to report pain is multifaceted including a mistrust of health care professionals due to their past treatment associated with the enduring effects of colonisation as well as a possible language barrier. Similarly, refugees are at risk of underassessment due to a number of factors such as language barriers, cultural factors (e.g., stoicism), mistrust and fear.

2.

Which of the following characteristics is assessed when admitting someone in pain? a. The frequency of analgesia administered b. The pain’s onset and duration c. The person’s support system d. The person’s level of understanding e. The person’s pupil size.

Answer: c Rationale: The best practice for determining a person’s pain and the effectiveness of pain management is to ask the person; self-report, not physiologic changes, is the gold standard for assessing pain. Vital signs may increase for brief periods with acute pain, but this does not occur with chronic pain or anxiety. An increase in vital signs may be caused by other problems, such as anxiety. The frequency of pain medication tells you only how often the medication has been administered; it does not tell you if the person is experiencing pain.

3.

Mrs Smith is an 88-year-old woman who has sustained a fractured neck of femur post-fall. She is currently on the ‘fast-track’ list for surgery. Mrs Smith was diagnosed with dementia 5 years ago and normally lives in a residential care facility. Which of the following pain assessment tools should you use with Mrs Smith? a. FLACC tool b. VAS tool c. Abbey pain scale d. NRS tool e. BPI tool

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Answer: c Rationale: The correct answer is the Abbey pain scale. This tool has been specifically designed for use with people who have dementia. Using either the NRS or VAS tools to assess Mrs Smith’s pain is not advised due to her dementia. The FLACC tool is only used with children. The brief pain inventory is used for assessing chronic or complex pain. It may also be difficult to use this tool due to Mrs Smith’s dementia.

4.

Which of the following statement regarding pain and sleep is most correct? a. A person may sleep despite being in pain. b. A sleeping person is resting comfortably. c. The brain shuts down during sleep, and the person does not feel pain. d. The person in pain is not able to fall asleep. e. The person in pain is predisposed to enuresis.

Answer: a Rationale: Individuals can sleep despite pain, especially those who have been living with pain for a long time and are exhausted. Some physiologic processes actually become more active during sleep; for example, secretion of some hormones increases, as does activity of the brain’s pathways for learning and memory.

5.

Which of the following statements best describes someone with chronic pain? a. They become chronic complainers. b. They often experience depression. c. They rarely become suicide risks. d. They have a very high incidence of addiction. e. They are malingerers.

Answer: b Rationale: Depression is common in individuals who have chronic pain; as a group, they have an increased risk of suicide. Approximately 4 to 5 per cent of individuals who have chronic pain and use opioids for one year become addicted. Less than 1 per cent of people who receive opioids for shortterm treatment of acute pain (one to three days) will become addicted.

6.

Which of the following are absolute contraindications for epidural analgesia? (Select all that apply.) a. A person refuses to have the epidural. b. A person has a known coagulopathy. c. A person has an infection at the proposed insertion site. d. A person who has renal impairment. e. A child under the age of 10.

Answer: a, b and c Rationale: A person has a right to self-determination; hence, they may choose to refuse epidural analgesia. Epidurals should not be used in people who have a known coagulopathy as there is an increased risk of an epidural haematoma forming which can lead to spinal cord compression and paralysis. A local infection at the site is another contraindication due to the epidural being a potential portal of entry for microorganisms. This can lead to an epidural abscess and/or spinal infection.

Epidurals are an appropriate form of analgesia in children. The person who has a renal impairment can

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also receive epidural analgesia, however, monitoring of their renal function should occur during treatment.

7.

Which actions are recommended to ensure safe use of PCAs? (Select all that apply.) a. Oxygen therapy must occur concurrently. b. Two nurses must sign when therapy is initiated and with all dosing orders. c. PCA solutions and concentrations are standardised. d. A second nurse must witness the wasting of any opioid left in the pump. e. Nurses can activate the PCA. Answer: a, b, c, d Rationale: Most facilities have policies in place regarding the safe use of PCAs including standard protocols, the use of oxygen therapy whilst the PCA is used and a second nurse’s signature for all medication changes and wasting of any opioid. Nurse-activated PCA or PCA by proxy are risky practices because they override an important safeguard build into the system: A person who is comfortable or sedated will not give himself or herself another dose, but a well-intentioned nurse or family member could cause significant over-sedation by delivering an unneeded dose.

8.

When is it appropriate to administer a placebo for pain? a. When the person is requesting frequent pain relief, yet are ambulating around the ward. b. When the prescribing practitioner orders a placebo. c. When the person is a substance addict and you need to assess their ‘real’ pain. d. When the person is participating in research and has given informed consent. e. Never.

Answer: d Rationale: The only time a placebo can be ethically used is in a research setting when the person has given informed consent regarding the use of placebos as part of the research protocol.

9.

Which factors can impair sleep and rest? (Select all that apply.) a. Pain control b. Anxiety c. Noise level d. A change in one’s normal bedtime e. Decaffeinated foods and beverages f. Alcohol and nicotine.

Answer: a, b, c, d, e, and f Rationale: All of the factors can influence the quality and quantity of sleep and rest.

10. Which of the following are good sleep hygiene practices? (Select all that apply.) a. Drinking a warm glass of milk before bed. b. Taking a sleeping pill one hour before bed. c. Watching TV in bed. d. Reading a book in bed via an e-reader. e. Having a long nap in the late afternoon.

Answer: a

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Rationale: Milk contains the substance tryptophan which promotes sleep by stimulating the brain’s production of serotonin. Non-pharmacological interventions should be the first line of treatment in helping a person to sleep. Long naps in the late afternoon and light-emitting devices including televisions and e-readers may disrupt the person’s normal circadian rhythm, leading to poor sleep quality and/or quantity.

Spotlight on critical thinking Mrs Jones is a 62-year-old woman whom you are caring for post-laminectomy. She currently has a PCA in situ and is day 1 postoperatively. While you are performing PCA assessment, Mrs Jones states her pain is 6 out of 10. When you question Mrs Jones about why she isn’t using the PCA, she confesses she is worried that she may become addicted to morphine.

1.

Is Mrs Jones’ statement valid? Why? Suggested answer: No, the PCA is being used for acute pain during a short timeframe. The appropriate administration of analgesia via this method, makes addiction highly unlikely.

2.

What strategies could you use to educate Mrs Jones’ on the use of her PCA? Suggested answer: Appropriate answers may include: • Explain to Mrs Jones when to use PCA, for example, pre-emptive prior to mobilisation.

• Ensure she understands that the PCA has safety mechanisms such as the lock-out period to prevent overdosage.

• How Mrs Jones know that the PCA is available for use, for example, green button.

3.

What are some non-pharmacological strategies that can be used to decrease the risk of opioid-induced constipation? How do they work?

Suggested answer: Appropriate responses to this question include increasing water intake, increasing exercise, increasing fibre via fruit such as prunes, encouraging the person to drink juices such as prune or pear juice.

Individuals who take NSAIDs are at risk of gastrointestinal ulceration and bleeding.

4.

What nursing interventions can be implemented to limit this risk?

Suggested answer: When responding to this question students should note that NSAIDs shouldn’t be taken on an empty stomach, and instead they should be given with food or a glass of milk. They may also consider consulting with the NP or medical officer regarding the need for H2-Histamine antagonists or proton pump inhibitors to be prescribed.

Mr Smith is confused about managing his shoulder pain from osteoarthritis. He has heard that complementary therapies are effective for this type of pain and wants to try something that doesn’t involve ‘taking a fistful of pills every day’.

5.

What will you tell him about the complementary therapy and pharmacology? Why?

Suggested answer: Suggest to Mr Smith that he talk with his general practitioner about available complementary therapies, and if there are any interaction with his current treatments. This will assist him to

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understand the benefits, side effects, and evidence quality. Remind him not to stop his current medications without first discussing it with his general practitioner.

You are caring for Mr Sebastiani who underwent a radical prostatectomy earlier in the shift. Mr Sebastiani has a continuous epidural infusion in situ. When checking the level of Mr Sebastiani’s sensory block (dermatome level) using ice, he has nil sensation below his umbilicus on the left side, however, can feel the ice on his right side.

6.

What is your next nursing action? Why? Suggested answer: Mr Sebastiani has a hemi-(uneven) block. The first nursing action is repositioning Mr Sebastiani to his right side to see if this improves the analgesia experienced on his right side. The rolling of Mr Sebastiani to his unaffected side promotes the gravity filtration of the local anaesthetic. His block needs to be reassessed 15 to 30 minutes after rolling him to see if the block has evened out.

Several hours later, you find Mr Sebastiani’s sensory block is even. You assess Mr Sebastiani’s Bromage score to be 1. He is requesting to sit out of bed.

7.

How would you respond to Mr Sebastiani? Justify your answer.

Suggested answer: A Bromage score of 1 indicates Mr Sebastiani has partial movement of his legs. This means his ability to weight-bear is compromised and at risk of a fall. When justifying their answers, students may also refer to the standing orders for epidural analgesia and postoperative orders.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 3 Resource aids....................................................................................................................................................... 5 Online resources.................................................................................................................................................. 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking ................................................................................................................................ 9

Chapter 39 Mobility Key terms Abduction To move a body part away from the midline.

Adduction To move a body part toward from the midline.

Ambulation Assisted or unassisted walking.

Arthrography A contrast media examination of a joint and surrounding soft tissue to explore unexplained joint pain, trauma, ligament tears or lacerations, dislocation or abnormalities of synovial membranes.

Arthroscopy An endoscopic examination of a joint (usually the knee).

Atrophy Thinning of skin surface and loss of markings; thin, flabby muscles due to a reduction in muscle size and shape.

Balance The body’s ability to maintain postural equilibrium Base of support Foundation on which a person or object rests.

Body alignment Position of body parts in relation to each other.

Body composition The proportion of fat to lean body tissue.

Body mechanics Purposeful and coordinated use of body parts and positions during activity.

Bone Ossified connective tissue.

Cane/walking stick Used by the person who can bear weight on both legs but has some weakness in one leg or hip.

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Centre of gravity The centre point of an object’s mass.

Contracture A condition of fixed resistance to the passive stretch of a muscle.

Crepitus Grating or crackling sensation caused by two rough surfaces rubbing together.

Crutch A wooden or metal staff used to increase a person’s mobility.

Disturbed body image Confused mental image of one’s own body.

Endurance The ability to withstand movement in terms of duration and absence of fatigue.

Exercise Any physical activity that elevates the heart rate above its resting level.

Extension To straighten a joint.

Flexibility The ability to use a muscle through its complete range of motion.

Flexion To bend a joint.

Friction Force of two surfaces moving against one another; massage technique whereby the heels of the hands or the thumb pads are used to apply deep, penetrating pressure on knotted muscles.

Functional assessment Assessment of the person’s ability to perform ADL. Gait belt The way that one walks.

Hypertrophy Increase in muscle size and shape due to an increase in muscle fibre.

Hypotonicity A decrease in muscle tone.

Incontinence Loss of the ability to initiate, control or inhibit elimination.

Independent mobility The ability to walk, run, sit and turn without mechanical or personal aid.

Joints The articulations between two bones.

Knee scooter A four-wheeled device that the person with non-weight-bearing ability of the foot or ankle of one leg is able to use.

Kyphosis Abnormally increased convexity in the curvature of the spine (cervical, usually).

Line of gravity Vertical line passing through the centre of gravity.

Logrolling Technique for moving a person whose cervical spine must stay in alignment with the entire vertebral column.

Lordosis Abnormal forward curvature of the lumbar spine.

Muscle strength The amount of force exerted by the muscles against resistance.

Muscle tone Normal state of balanced tension present in the body that allows muscles to respond quickly to stimuli.

Muscles Bands or bundles of fibrous tissue that convert energy into mechanical work.

Musculoskeletal disorders (MSDs) Injuries and disorders of the muscles, nerves, tendons, ligaments, joints, cartilage and spinal discs.

Musculoskeletal system Body system comprising bones, cartilage, joints, tendons, ligaments, bursa and muscles.

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Myelogram An injection of a contrast medium into the spinal canal (via a lumbar puncture) under fluoroscopy.

Myoneural junction Point at which nerve endings encounter muscle cells.

Opposition A body part rotating across another part at nearly a 180° angle; e.g., the thumb touching the little finger.

Orthostatic hypotension (OH) Refers to a sudden drop of 25 mmHg in systolic pressure and 10 mmHg in diastolic pressure when the person moves from a lying to a sitting position, or from a sitting to a standing position.

Passive range of motion exercises ROM exercises performed by the nurse for the dependent individual.

Physical activity Movement involving muscles.

Pressure site Any skin surface area on which the person is lying or sitting.

Proprioception Awareness of posture, movement and changes in equilibrium, and knowledge of position, weight and resistance of objects, in relation to the body.

Range of motion (ROM) Extent to which a joint can move.

Restraints Protective devices used to limit the physical activity of a person or to immobilise a person or extremity.

Side rails Rails placed on the sides of beds and stretchers to prevent falls.

Skin shear The result of dragging skin across a hard surface, causing tears to the deep.

Spasticity An increase in muscle tension often noted with extreme flexion or extension.

Total mobility Unrestricted movement and the ability to engage in activities that include walking, running, sitting, standing, lifting, pushing, pulling and performing ADL.

Instructional strategies • Discuss ways in which a decrease in mobility can hinder activities of daily living. First, the inability to walk independently or with the use of an assistive device will hinder ambulation. All other activities of daily living will be impeded. Even a person using a walker or wheelchair will have difficulty getting around and carrying things. Many homes are not well equipped for anyone with mobility deficits. Stairs, steps, and height of counters and other structures can become problem areas for the mobility-impaired person.

Activity intolerance related to general weakness affects ability to perform self-care activities, such as bathing and dressing. Ability to prepare foods or go to the store will be affected when mobility is decreased. Any person with a decrease in mobility needs to be assessed for ability to perform activities of daily living or available assistance to perform these activities (both in hospital and when they return home). There are numerous other examples – use some from your own practice/experience.

• Discuss mobility and functional ability throughout the lifespan. o Children – In childhood, activities such as sitting, crawling, walking, running, and hopping are common.

From infancy, movement begins with sitting and crawling. As a toddler, walking, running, jumping, kicking, and climbing stairs are common activities. The pre-schooler increases strength and refines skills by running, walking, and jumping. By middle childhood, there is improved posture; increase in muscle tissue; decrease in fat; and improved strength, coordination, and physical capacities. © Cengage Learning Australia 2024

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o Adolescents – During adolescence, activity and mobility landmarks are development of muscles plus cardiac, respiratory, and metabolic functions through physical conditioning. o Adulthood – The young adult’s musculoskeletal and nervous systems function at peak efficiency. In middle adulthood, there is a gradual decrease in muscle mass, strength, and agility. Activity and mobility for the young and middle-aged adult are focused on maintaining or developing tone, strength and coordination. o In the older adult, loss of bone density, muscle atrophy, reduced muscle mass, loss of strength, and decreased cartilage strength begin to occur, which all lead to functional alterations in mobility. The older adult needs to continue to participate in activity to keep muscle mass, tone, and strength and reduce the effects of cartilage deterioration.

• Discuss the physiological effects of immobility. Within the neurological system, immobility is a stressor that can lead to frustration, lower self-esteem, anxiety, helplessness, depression, dissatisfaction, restlessness, unhappiness, and decreased competency. Within the cardiovascular system, immobility increases the heart’s workload, which can lead to thrombi formation and orthostatic hypotension.

Immobility effects on the respiratory system include limited chest expansion, respiratory muscle atrophy, and ineffective cough. Decreased physical mobility leads to musculoskeletal impairment, alteration in muscle strength and mass, fatigue, decreased joint mobility, and bone demineralisation. Gastrointestinal effects of inactivity include loss of appetite and altered elimination patterns (constipation, functional incontinence). Regarding the integumentary system, the skin is prone to pressure ulcer formation as a result of immobility.

• The physical examination is a vital part of the nursing assessment. Discuss the purposes of the musculoskeletal, neurological, and functional assessments. o Musculoskeletal – In this assessment, the nurse examines the individual for specific mobility factors.

Body alignment and mechanics, posture and joint range of motion, muscle strength and tone, and skin inspection are all parts of the musculoskeletal examination. o Neurological – Cranial nerves, motor system, sensory system, and reflexes are studied in the neurological examination. Balance and gait, coordination, and proprioception are examined. Nerves, pain, and tactile stimulation are also assessed. Reflexes are examined during the neurological examination. o Functional – This examination focuses on the person's ability to perform activities of daily living. The degree of independence while performing these activities is studied. Specific instruments are often used to perform this assessment, such as the PULSES Profile (see, for example: http://www.physiopedia.com/The_Pulses_Profile) and the Barthel Index.

• Define the emergency principle of RICE treatment for musculoskeletal injuries. Explain why joint

stabilisation and proper alignment are so important in preventing further injury. RICE stands for rest, ice, compression, and elevation. It is the method used for the treatment of musculoskeletal injuries in an emergency setting. Rest of the affected area, along with the application of ice, compression, and elevation, can help to prevent further damage. Ice is often used in the first 24 hours on an intermittent basis. Compression and elevation help to prevent swelling and maintain blood flow to the area. Joint stabilisation and proper alignment are necessary in order to prevent overextension or hypermobility of the joint or affected area. It is critical to remember that musculoskeletal injuries should not be manipulated past the point of normal joint motion and, in some cases, movement should be restricted

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until the joint itself is stabilised. A clinical example of this is the placement of a neck collar in emergency situations, which maintains proper alignment of the neck with regard to the spinal cord.

• What measures can a nurse use to maintain proper body mechanics in the clinical setting when taking

care of people? Nurses (in any clinical setting) must be aware of proper body mechanics when providing individual care so that injuries can be avoided. Lifting objects using a base of support is recommended. If lifting objects from the floor, the nurse should bend at the hip and knees and avoid bending from the waist. The person’s bed should be adjusted to a reasonable height to avoid bending over and straining of the lower back of the nurse. Wound care (for instance) can require long periods of standing in an awkward position, straining muscles. Setting up for wound care should take the nurse's physical comfort into consideration. Setups that require excessive stretching are not recommended because this may cause strain to the lower back and arms. When preparing to assist individuals or physicians with clinical activities, objects should be within arm’s reach. It is important that when transferring or ambulating a person, the nurse has adequate help if needed to steady the individual, maintain their safety and prevent injuries.

Resource aids Altman, G., & Morrison, A. (2005). Delmar’s comprehensive nursing skills DVD version. Cengage Delmar Learning.

Introduction to passive range of motion exercises; Patient lifting techniques: Turning and transferring the patient [videos]. Health Sciences Consortium.

The mobility series [interactive videodisks]. Athens, OH: Fuld Institute for Technology in Nursing Education.

Range of Joint Motion Evaluation Chart (n.d.) Washington State Department of Social and Health services. https://www.dshs.wa.gov/sites/default/files/forms/pdf/13-585a.pdf

Online resources •

The following is an excellent example of a musculoskeletal assessment https://www.youtube.com/watch?v=aUMTPa_9qlY

•

This video on you tube takes the viewer through assessment of the elderly person for their falls risk https://www.youtube.com/watch?v=wR4F3wl7qx0

Evaluation strategies •

Invite a physical therapist or related assistive personnel to run the class through strengthening exercises and discussion of techniques successful in preventing injury related to lifting or assisting clients (body mechanics).

•

Have students review CPS8, Clinical Skill 24, Passive Range-of-Motion (ROM) Exercises. Using this procedure as a guide, practice range of motion with other students. Using your text, determine what each type of motion is called.

•

Have students separate into two teams and provide pictures or actual examples of assistive devices (e.g., bed board, footboard, or trochanter roll, mobility assists – wheelchair, knee walker, canes,

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walkers, hand splints). Ask each team to answer four questions for each item you provide. (1) What is the name of the assistive device? (2) What is its function? (3) What is a clinical example of when this assistive device can be used? (4) Is there any potential downside to using this device?

•

Invite an exercise physiologist to come in and talk with the students about the benefits of exercise.

Have the students do research on the Internet on the number of exercise methods available to the average health care consumer. Have the students share their information with the guest speaker to see how or if these methods are based on sound scientific principles.

•

Have students watch each other in the laboratory setting and performing a gait analysis. Discuss with the students the importance of gait analysis for individuals across the life span.

•

Have students design an interactive mobility laboratory that includes the following stations: functional (research tools on the internet, e.g., Timed Up & Go [TUG]) and physical assessment, benefits of exercise, and normal ageing changes that affect mobility. Have students determine which people could benefit from this type of interactive laboratory.

•

Have the students practice each of the skills identified in the chapter, including lifting, transferring, turning, and positioning; moving in bed; assisting from bed to wheelchair, commode, or chair; assisting from bed to stretcher; assisting with ambulation and safe walking; and assisting with crutches, cane, or walker. Have the necessary assistive devices available for the students to use. Have the students take turns serving as the immobile person or as the nurse. Plan the practice session in advance so the students will know to wear comfortable clothes during this laboratory session.

•

Have students develop a care plan for the following people: (1) an individual on therapeutic bed rest, (2) someone who is bedridden, and (3) a person who is recovering from knee surgery.

Review questions 1.

To prevent injury when assisting people to move in bed, which of the following is assessed? a. The task b. The individual’s limitations and abilities c. The load or amount of weight you will have to deal with d. Any equipment that is available for you to use e. All of the above.

Answer: e Rationale: Each of the answers is assessed to minimise injury to the person, and to you.

2.

Which of the following best explains why you should use a drawsheet/slippery slide sheet when moving a person up in bed with wet linens? a. Decrease possible skin shearing a. Increase the person’s mobility b. Keep the bed linens clean c. Keep the person's skin dry d. Keep your hands clean.

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Answer: a Rationale: Dragging skin across a surface causes skin shear, which results in skin breakdown. Therefore, the person should be lifted slightly off the bed by use of a drawsheet.

3.

When assisting a postoperative person to get out of bed the first time, which of the following must you do? a. Have the person bend the knees and push up in the bed b. Instruct the person to sit on the side of the bed before standing c. Place the foot of the bed in a high position so it’s easier for the person to get out of bed d. Raise all four side rails to assist the person in getting into a seated position e. Raise the level of the bed so you do not hurt your back.

Answer: b Rationale: Sitting on the side of the bed (dangling) helps prevent orthostatic hypotension with resultant dizziness. Postoperatively, anyone should dangle their feet over the side of the bed for a few minutes prior to standing.

4.

In order to flex a person’s knee during ROM exercises, which of the following should you instruct the person to do? a. Adduct the knee b. Abduct the knee c. Invert the knee d. Flex the knee e. Extend the knee.

Answer: d Rationale: The knee is a hinge joint and really only flexes. A full knee extension means you can completely straighten out your leg. Abduction and adduction of the knee are not normal functions.

5.

Which action demonstrates inappropriate body mechanics? a. Raising the bed to waist height when making it b. Flexing the knees when lifting an object from the floor c. Holding heavy equipment close to the body when walking d. Placing the feet close together when transferring a person e. Tightening the abdominal muscles.

Answer: a Rationale: Bending at the waist causes muscle strain and potential back injury. The knees should be bent in order to lift with leg muscles. When lifting an object from the floor, the knees should be bent.

Heavy objects should be held close to one’s centre of gravity. When preparing to move a person, you should spread your feet apart to establish a wide base of support.

6.

Mrs Elgar will be ambulating for the first time since surgery. Which of the following should you consider when assisting her? a. Those who are fearful of walking should be told to look at their feet when walking to ensure correct positioning.

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b. Anyone who can lift their legs only 2.5–5 cm off the bed do not have sufficient muscle power to permit walking. c. If Mrs Elgar begins to fall, you should protect her head. d. You should have a physical therapist present when ambulating a person for the first time. e. All of the above.

Answer: c Rationale: To maintain safety of the falling person, you may carefully ease the person to the floor by using the wall or your own body ( this is controversial, and you will have to determine what the guidelines are at any facility where you work as well as take into consideration your own size and strength and the falling person's size/weight); however, it is always necessary to protect the person’s head during the fall. Looking downward changes the centre of gravity and increases the risk of falls.

Lifting the legs 2.5–5 cm off the bed demonstrates thigh muscle strength sufficient for walking. A physical therapist is not always available, nor necessary for post-surgical walking.

7.

A person has been bedridden for five days. Which of the following might you expect the person to exhibit? a. Eupnoea b. High energy level c. Hunger d. Pressure injuries e. Excess urinary output.

Answer: d Rationale: Anyone on bedrest is at increased risk of developing pressure injuries due to pressure on bony prominences. Bedrest interferes with respiration, leads to fatigue and decreases appetite and can reduce urinary output, especially if the person has been reluctant to drink (and hence to use the bedpan/urinal).

8.

Pressure injuries are a very serious consequence of immobility. What causes a pressure injury? a. Prolonged, unrelieved pressure on (usually) a bony prominence b. Shearing forces applied during repositioning c. Friction from ‘dragging’ skin over the bedclothes d. Moisture (urine, faeces, drainage) that leads to skin softening e. All of the above.

Answer: e Rationale: All of these answers are contributing factors to the development of pressure injuries.

9.

To prevent the formation of pressure injuries, the bottom sheet on the person’s bed should be: a. changed every day b. covered by a drawsheet c. covered with a waterproof pad d. kept free of wrinkles e. made with mitred corners.

Answer: d

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Rationale: Wrinkled bed linens can contribute to skin breakdown by causing skin irritation. Therefore, bed linens should be kept wrinkle free and dry. The remainder of the answers would be dependent on the person, their condition and what is available at the facility.

10. You are caring for Mr Mahler, who has weakness of the right arm and leg following a cerebrovascular accident (stroke). You are about to start doing ROM exercises with him. Which of the following do you need to consider? a. Instruct him in active ROM exercises for all his limbs b. Do passive ROM exercises on his right side only c. The physiotherapist will do these d. You will need to keep doing the exercises even if it hurts him e. Eventually he will need to learn to do assisted ROM exercises on his weak side.

Answer: b Rationale: Passive ROM exercises are done on the affected side because Mr Mahler has limited voluntary movement on his right side, and the ROM exercises are meant to maintain the joint and muscle movement. Active ROM are feasible only if the person can actually move the limb/joint by himself. Physiotherapists may do ROM, but usually it is the nursing staff who undertake this nursing activity. No exercise should be taken to the point of pain. He will need to learn to do assisted ROM, but that will not occur immediately.

Spotlight on critical thinking Professionalism: preventing MSDs versus individual needs A newly hired nursing assistant is assigned to help move a person in order to change the linens. The charge nurse overhears the nursing assistant say that she is not going to move the person because he is too heavy and ‘I don't want to hurt myself!’

1.

Discuss the education needed to meet the person’s needs and protect the staff from injury. What assistive devices could you use to facilitate the move?

Suggested solution: Consider the following: • reviewing the state and the facility's policy on manual handling • ensuring the new staff member is aware of the manual handling equipment available, how to use it (e.g., lifts) and where it is stored • working with the new staff member and assessing her use of good body mechanics and the manual handling equipment, and reminding her of their use if necessary.

Preventing injury 2.

You see an elderly person in a wheelchair with their feet dangling outside the footrests. Their carer does not seem to notice. How do you approach this carer to ensure that the wheelchair-bound person is not injured?

Suggested solution:

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• Educate the carer and the chair-bound person about the risks for injury to the ankles and feet.

• Ensure the chair-bound person has the strength to keep their feet on the rests. Check that the footrests are useful for the person (i.e., have outer ridges to stabilise the foot on the rest.

• Demonstrate the use of the footrests.

3.

The risk for falling is a very real possibility when someone’s mobility is impaired. During a home visit to elderly Mr Linde who is on crutches following a fracture of his right ankle, the health care nurse notices some contributing factors and decides to make some recommendations. Discuss the common contributing factors to falls and outline some of the recommendations that could be made to increase his safety.

Suggested solution: Answers might include: • polypharmacy – review of medications • clutter on the floor – make Mr Linde aware of the problem, may need home help • loose rugs or old carpets with turned up edges – may need to be removed, tacked down or use nonslip tape underneath • phone or computer cables may need to be tucked in behind furniture • pets can easily trip the person – they have to be aware of their furry friend's whereabouts and habits • Lighting in the house needs to be adequate at night – nightlights, leaving on the toilet light.

4.

Side rails are meant to prevent injury. Discuss how side rails can contribute to injury of the bed-bound person and outline some measures you can take to minimise the risk of injury.

Suggested solution: Especially if the person is confused or sedated, they may try to climb over (and fall) or through (and get caught) the side rail to escape. The person should be in a room near to the nursing station, checked frequently, reminded to use the call bell to obtain help, have their 'things' (glasses, water, TV remote, etc) close by on an overbed table); they may need a minder (volunteer, relative).

Empathy: for discussion 5.

Have you ever broken a bone, been in a cast or in traction that limited your movement and mobility?

Describe the physical, emotional and social experience it caused. Using your own experience (or a classmate’s) as a guide, what can you as a nurse do to assist someone who finds themselves immobile?

Suggested solution: Answers might include the following: • Pain and pressure on a part of the body, inability to, for instance, scratch an itch, or relieve the pressure on a part of the body. Directing someone else about how to position a limb, body part can be embarrassing (e.g., turning onto your side, breast tissue/testicles squashed and uncomfortable) and frustrating because you know what needs to be done to be comfortable, but the carer cannot get it right – or doesn't have time to do so.

• Often you cannot reach/obtain something (water, a dropped book, a cover or blanket) and need assistance for the smallest things.

• Would you feel anger, fear that damage was being done, embarrassment that you could not attend to your own toileting or hygiene needs?

• Socially, you may feel isolated as contact with another is virtually up to them. Social media and mobile phones have helped with the isolation, however, you may not be able to participate in the activities that your friends are doing, and that forms a type of alienation. These limitations and

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feelings may further alienate friends when they visit – little to share and hostility from the anger and isolation.

Experience it During laboratory time, assume each of the positions described in Table 39-12 for a short period of time.

6.

Which areas of your body are compressed between your bones and the mattress? Take stock of all areas – including ears, nose, elbows and patellas.

Suggested solution: Now consider maintaining that position for up to 2 hours. How would that niggling little aggravation feel if you were immobile for that length of time? What can you do?

• Be patient and demonstrate that you are willing to help the person get comfortable.

• Check back as often as you can to see if they need something or need some repositioning (elevating a casted limb for example).

• Make sure they can contact you – put the call bell within reach – attached to the bed clothes so it cannot fall away.

Make sure they can reach their necessities (e.g., water, TV control, Book, Newspaper, etc.) by putting them on the over-bed table within reach.

7.

Which positions are most comfortable? How could each be made more comfortable?

Suggested solution: Answers will vary by student. Discussion should also include how different people may find different positions more comfortable than others.

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Content Key terms .......................................................................................................................................................1 Instructional strategies ..................................................................................................................................4 Resource aids .................................................................................................................................................7 Online resources ............................................................................................................................................7 Animation ......................................................................................................................................................7 Evaluation strategies......................................................................................................................................8 Review questions ...........................................................................................................................................8 Spotlight on critical thinking ........................................................................................................................11

Chapter 40 Skin integrity and wound healing Key terms Acute wounds A wound that proceeds through an organised, appropriate repair process resulting in the sustained restoration of anatomical and functional integrity.

Angiogenesis The formation of new blood vessels.

Approximated Bring the edges of a wound together so they can be held in place (with tape, sutures, staples, wound glue) until healing and epithelisation occur.

Avascular scar A scar that is white because it lacks a blood supply.

Bandages Long rolls of material, such as gauze, webbing, crepe or muslin, designed to be wrapped around body parts.

Binders Bandages made for specific body parts, usually the abdomen, head or torso.

Bio film A dense sheet of bacteria that adhere to each other within an extracellular polymeric matrix that acts as a physical barrier to both biological (e.g., polymorphonuclear leucocytes) and pharmaceutical (e.g., antibiotics) antimicrobial action.

Black wounds A wound that contains necrotic tissue (eschar).

Blanching Reduction of blood flow causing the skin to turn white when pressure is applied.

Blanket continuous sutures Sutures in which the single thread is grounded again in the last suture exit. © Cengage Learning Australia 2024

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Chronic wounds A wound that proceeds through a disorganised and inappropriate repair process, and is often not able to restore either anatomical or functional integrity.

Clean wounds Intentional wound created under conditions in which no inflammation or infection was encountered, and the respiratory, alimentary, genito-urinary and oropharyngeal tracts were not entered.

Clean-contaminated wounds Intentional wound created by entry into the alimentary, respiratory, genitourinary or oropharyngeal tract under controlled conditions.

Closed suction drainage systems Fluid-draining method that commonly has a reservoir capable of creating negative pressure or a vacuum.

Collagen The most abundant protein in the body, and the material of tissue repair.

Contaminated wounds Open, traumatic wound or intentional wound in which there was a major break in aseptic technique, spillage from the gastrointestinal tract, or incision into infected urinary or biliary tracts.

Continuous sutures Sutures made with one thread, tied at the beginning and end of the suture line.

Culture Dynamic and integrated structures of knowledge, beliefs, behaviours, ideas, attitudes, values, habits, customs, languages, symbols, rituals, ceremonies and practices that are unique to a particular group of people; growing microorganisms to identify a pathogen.

Culture and sensitivity (C&S) tests Tests performed to identify both the nature of the invading organisms and their susceptibility to commonly used antibiotics.

Debridement A patient-centred approach to health care that prioritises the cultural context and needs of people in the provision of care. It involves understanding and respecting the unique beliefs, values, practices and experiences of people and incorporating these into the delivery of care.

Deep wounds Wounds involving the epidermis and deep dermis.

Dehiscence Partial or complete separation of a wound’s edges and the layers below the skin.

Dirty and infected wounds Traumatic wound with retained dead tissue or intentional wound created in situations where purulent drainage was present.

Epibole Rolled wound edges.

Epithelialisation Growth of epithelial tissue.

Evisceration Occurs when the person’s viscera protrude through the disrupted wound.

Exudate Material and cells discharged from blood vessels.

Exudation Emitting or exuding of fluid and cells from blood vessels into tissues.

Fourth-degree wounds Wounds that are deeper than full-thickness loss, extending into the muscle and bone.

Full-thickness wounds Skin loss that extends through the epidermis and dermis and into subcutaneous fat and deeper structures.

Granulation tissue During the proliferative phase of open-wound healing, new tissue with a rich blood supply forms at the base of the wound. It has an irregular surface and supports collagen formation and © Cengage Learning Australia 2024

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vascular generation to fill in the space of the wound, and ultimately provides a platform for epithelial migration.

Haematoma Localised collection of blood underneath the tissues that may appear as a reddish-blue swelling or mass.

Haemorrhage Persistent bleeding.

Haemorrhagic exudate Exudate with a large component of red blood cells due to capillary damage, which allows red blood cells to escape.

Haemosiderin An iron (brown) pigment that is a product of RBC haemolysis.

Homeostasis Cessation of bleeding that occurs by vasoconstriction of large blood vessels in the affected area.

Hypertrophic scars Red, raised scars that remain within the borders of the injury.

Infection Invasion and a multiplication of microorganisms in body tissue that result in cellular injury.

Inflammation Non-specific cellular response to tissue injury or infection.

Intentional wound Wound that occurs during treatment or therapy, usually under aseptic conditions, such as surgical incisions and venepunctures.

Intermittent sutures Sutures that are each tied individually.

Ischaemia Oxygen deprivation, usually caused by poor perfusion, that is usually temporary and localised.

Keloid A type of scar composed mainly of collagen.

Maturation Process of becoming fully grown and developed; involves physiological and behavioural aspects.

Micropore particle technology (MPPT) Fine, loosely aggregated particles that absorb wound exudate into a micropore structure where capillary action pulls the exudate away from the wound surface towards the upper surface of the MPPT layer.

Partial-thickness wounds Involves the epidermis and upper dermis, the layer of skin beneath the epidermis.

Penrose drains Functions by gravity and has an open end that drains onto dressings.

Phagocytosis Process by which certain cells engulf and dispose of foreign bodies.

Pressure injury (PI) Localised area of tissue necrosis that develops when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time; also known as a pressure ulcer, bedsore or decubitus ulcer.

Pressure injury prevention bundles A structured group of interventions, based on nurse–patient partnerships, that are used to improve individual outcomes.

Pressure ulcer Impaired skin integrity related to mechanical factors such as unrelieved, prolonged pressure; shearing forces; and restraint.

Primary intention healing Occurs in wounds that have minimal tissue loss and edges that are well approximated (closed).

Purulent exudate Pus, generally occurring with severe inflammation accompanied by infection. © Cengage Learning Australia 2024

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Pyrogenic bacteria Bacteria that produce pus.

Red wounds Wound that is the colour of normal granulation tissue and in the proliferative phase of wound repair.

Secondary intention healing Outcomes of the ‘sick role’ other than alleviation of anxiety (primary gain); examples include gaining attention and sympathy, avoiding responsibilities, and receiving financial compensation or reward.

Sepsis A life-threatening organ dysfunction caused by a dysregulated host response to infection, including immune suppression, excessive inflammation and a hypermetabolic response to an infection.

Seroma A collection of serum in the wound.

Serous exudate Exudate that is composed primarily of serum (the clear portion of blood), is watery in appearance, and has a low protein count.

Shearing The force exerted against the skin when a person is moved or repositioned in bed by being pulled or allowed to slide down in bed.

Sinus tracts Channels formed from a suppurating mass (such as an abscess) to the surface of the body.

Sling A cloth support for an injured arm that wraps around the back of the neck to maintain the arm in a set position.

Sloughing Shedding of dead tissue as a result of skin ulceration.

Superficial wounds Confined to the epidermis layer, which comprises the four outermost layers of skin.

Suppuration The process of pus formation.

Suture Surgical means of closing a wound by sewing, wiring or stapling the edges of the wound together.

Tertiary intention healing Also known as delayed or secondary closure; it is indicated when primary closure of a wound is undesirable.

Tunnelling Where the wound extends under the margin of the skin.

Unintentional wounds Unanticipated wound, often the result of trauma or an accident.

Wound Disruption in the integrity of body tissue.

Yellow wounds Has either fibrinous slough or purulent exudate from bacteria.

Instructional strategies •

Wounds heal at various speeds and with varying levels of healing. What factors encourage wound healing and what factors discourage healing? o An intact immune system helps stimulate wound healing. Any problem with the immune system will affect the degree and success of healing. o With more advanced age comes decreased ability to heal properly and quickly. o People with good blood circulation heal better than those with diseases such as diabetes.

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o Factors such as smoking, poor nutrition, obesity, and drug therapy will negatively affect healing.

Table 40-1, ‘Factors affecting wound healing’, lists these conditions in greater detail.

•

Discuss the ways in which tissue heals. o Tissue can heal in three ways. The first way is through primary intention healing. This is when a wound has minimal tissue loss and the edges of the wound are closed. o Secondary intention healing occurs when a wound involves extensive tissue loss or when the edges of a wound cannot be closed. The wound is left open, and granulation tissue fills in the tissue deficit.

This type of healing takes longer, and scar formation will occur. o Tertiary intention healing is indicated when primary closure of a wound is undesirable. Conditions in which healing by tertiary intention may occur include poor circulation or infection. Suturing of the wound is delayed until the problems resolve and more favourable conditions exist for wound healing.

•

The nurse is responsible for adequately assessing wound characteristics. Discuss what is included in the assessment of a wound. o Assessment of the wound begins with the anatomical location. This can be accomplished by marking on a diagram the location of the wound. o The size of the wound is assessed next. The size includes length, width, and depth measured in centimetres. A sterile tape measure is used to determine length and width and a sterile cotton swab inserted into the wound is used to assess depth. o The wound edges are assessed for undermining or rolling as well as approximation and reepithelialisation. If the wound is tunnelled or undermined, the direction of the tunnelling is to be documented. o The wound bed is to be assessed for colour, swelling, and drainage. Note granulation, epithelialisation, necrotic tissue, slough and eschar. The amount, colour, location, odour, and consistency of drainage should be noted. o The surrounding tissue is assessed for inflammation, induration, maceration, excoriation and erosion. o Presence of pain or tenderness is assessed next. The person is assessed for pyrexia, other symptoms (e.g., headache, nausea) and general malaise. o Laboratory data findings complete the assessment of the wound. Wound cultures, white blood cells counts, and other serum laboratory values should be documented.

•

Discuss what measures are implemented by nurses to provide for wound care. o The nurse who is first responder or in the position to render immediate measures must assess the wound. o Potential for haemorrhage should be determined and vital signs measured. o The nurse must immediately protect the wound and apply dressings as indicated.

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o For both immediate and maintenance care, the wound should be cleaned and dressed. The wound may need to be irrigated to remove any debris. The wound should be cleaned from clean to dirty.

Some wounds require sterile technique; others are appropriately dressed using clean technique. o The nurse must monitor the wound for drainage. Amount, colour, consistency, and odour are all parts of the drainage monitoring process. o If a wound has staples or sutures, the nurse is responsible for any dressings ordered and monitoring of drainage. The nurse may also be required to remove sutures or staples and leave the wound exposed or apply steri-strips, and a dressing for protection and comfort or if the wound continues to ooze. o Drains if any are attended (shortened, re-vaccuumed) as ordered.

•

Discuss ways in which the nurse can prevent an individual from disturbing wounds or dressings. o If the individual is competent, discussing with them the importance of refraining from probing the wound and/or removing the dressing to 'have a look' is often sufficient. Emphasis the need to keep it clean, not disturb the re-epithelialisation process and for comfort. o If the person under care has cognitive deficits, the nurse may appropriately ask a family member to stay with them. If a family member is unavailable to supervise, nursing assistive personnel may be required to stay at the bedside. A thorough assessment will help the nurse determine possible assistance for a confused or head-injured person. o Restraints may also be necessary to protect a wound area. For a child, a family member may also be requested to monitor the child’s actions. Restrictive articles, such as mitts, may discourage attempts to remove dressings. Splints may immobilise an infant or small child effectively. Remember these are restraints and need to be ordered and closely monitored.

•

Anyone with a decrease in mobility is at greater risk of developing pressure sores. Discuss which individuals are at risk and ways to assess and help prevent the development of pressure injuries: o Immobile people are at high risk for developing pressure injuries. o Anyone who is incontinent is also at risk. o Those with pronounced bony prominences, such as emaciated individuals, are vulnerable to pressure injury. o Anyone with limited mobility due to illness, injury, and cognitive or behavioural deficits is also a candidate for developing pressure injury. o On admission, anyone at risk should be assessed thoroughly for any signs of beginning development of pressure injury. Any existing sores or reddened areas should be monitored and dressed as ordered to prevent further breakdown of the area. Those identified as ‘at-risk’ need to be repositioned appropriately and at intervals timely enough to prevent breakdown. o Anyone in restraints should be monitored frequently, as per agency protocol, to prevent problems from immobility.

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o Use of special beds, such as the Totalcare, Gelbodies, Roto Rest, eggcrate mattress, and air-filled mattresses, are appropriate interventions to prevent skin breakdown. o Keeping sheets clean and wrinkle free and the person clean and dry also help to maintain skin integrity. o Nutrition is also of valuable assistance when monitoring pressure injuries.

Resource aids Nursing management of dermal ulcers [video]. American Journal of Nursing.

Skin care online course [E-course]. (2007). Cengage Delmar Learning.

Skin integrity and wound healing [E-course]. (2008). Cengage Delmar Learning.

Online resources •

The following website discusses several types of wounds and their treatment. https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/wounds-how-to-care-for-them

•

Good discussion of some of the traditional dressings (impregnated gauze, absorption pads) available: https://www.youtube.com/watch?v=sVQQIB8_Ze0

•

This is a commercial site and much of the information is from older research/sources, but does have an excellent explanation of all of the wound essentials: https://www.clinimed.co.uk/wound-care/woundessentials

•

The following resources present current research on pressure injuries: https://www.ahrq.gov/patientsafety/settings/hospital/resource/pressureulcer/tool/pu3.html

•

Pan Pacific Guideline for the Prevention and Management of Pressure Injury (2012). Published by the Australian Wound Management Association in collaboration with the New Zealand, Wound Care Society, Hong Kong Enterostomal Therapists Association and the Wound Healing Society (Singapore). https://www.awma.com.au/files/publications/2012_awma_pan_pacific_guidelines.pdf

Animation Play the animation SKIN Anatomy for the students e.g., https://www.youtube.com/watch?v=63YdIH2S2ls.

Discuss the layers of the skin. The skin is the largest organ in the body. It serves as a protective barrier against invasion of microorganisms and provides a tough covering for vital organs. The skin has two layers. The epidermis has a layer of dead cells and contains melanocytes. The dermis includes sweat glands, sebaceous glands, nerve receptors, blood vessels, and hair follicles. The nerve receptors serve to communicate pain, touch, heat, and cold. Body temperature is regulated by the dilation or constriction of blood vessels. The nails rest on a bed of blood vessels. Ask the students which layers of the skin are affected with pressure ulcers. What changes in normal skin functioning will be altered with a pressure ulcer?

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Evaluation strategies • Heat and cold applications for wound healing are effective forms of treatment. Encourage discussion with students regarding the time frame of most effective treatment for heat and cold and discuss contraindications for the use of heat and cold therapy.

• In the laboratory setting, provide supplies for the students to practise bandaging methods. Bandaging methods to practise include circular turns, spiral turns, spiral reverse turns, figure-eight turns, and recurrent turns. Refer to Figure 40-9 for examples of each of the bandaging methods.

• In the clinical area, have the students utilise the Braden scale for predicting pressure sore risk (Table 40-5)

and the Norton scale for pressure injury risk (Table 40-6) on the same client. After the clinical experience, have the students analyse the data collected from the two pressure ulcer scales and identify whether the findings were similar or different. What interventions could be planned to help the client prevent pressure ulcer development?

• Use a case study of an elderly person with several areas of potential or actual pressure ulcers, and discuss

with the class how to assess these areas, prevent further breakdown, and prevent formation of new areas of ulcerations.

• Discuss what measures could be used in helping an individual diagnosed with diabetes prevent problems

with skin integrity. Have the students develop a plan of care to support this type of person in maintaining healthy skin.

• Have a wound care or enterostomal nurse come into the classroom setting and discuss the aspects of wound care and enterostomal therapy.

• Have the students rotate through wound care centres and observe the enterostomal nurse in action to see first-hand how the individual is cared for in the clinical setting.

• Have the students discuss the discharge-planning needs of someone who is sent home with a wound care problem.

• Have the students use the internet and search for the latest available information relative to the care of

people with wounds and pressure ulcers. Discuss whether any of these new treatment methods are being used in the hospital facilities they attend or in the community setting.

Review questions 1. You have to apply a bandage to the forearm over a wound on the arm. Which bandaging method should be used? a. Circular turns b. Spiral turns c. Spiral reverse turns d. Figure eight turns e. Anchored recurrent turns © Cengage Learning Australia 2024

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Answer: b or c Rationale: See Figure 40-9 for context. B – spiral bandage would be the first choice, but if the person is large (muscular, obese), then the spiral reverse turn would be more appropriate.

2.

Proper technique for obtaining a wound culture is to: a. cleanse the wound with NS prior to obtaining the specimen b. swab the wound drainage c. remove crust from the necrotic tissue, then swab d. obtain the specimen from drainage on the dressing e. swab the base of the wound before cleansing.

Answer: a Rationale: A wound culture should be obtained from a cleaned wound since microbes responsible for the infection are more likely to be found in viable tissue. Swabbing before cleansing may not 'capture' the actual microbes that are infecting the wound. Wound drainage contains old and mixed organisms.

The nurse does not usually debride the wound to obtain a specimen.

3.

Which immediate interventions are the most appropriate for a person with an ankle sprain and haematoma? (Choose as many as you think apply – can you justify your choice?) a. Ace bandage b. Keep limb dependent c. Elevate limb d. Ice bag e. Warm packs Answer: a, c, d Rationale: Ace bandages compress the damaged area and minimise swelling of the body part. Rest minimises movement of the sprain to limit damage to the soft tissue and fosters clotting to reduce haemorrhage/haematoma formation. Ice promotes vasoconstriction and helps prevent oedema formation, controls bleeding, and anesthetises the body part. Elevation of the body part assists with venous return to decrease swelling. Warm packs are not used immediately as they assist to vasodilate the arterioles and increase both swelling and haemorrhage.

4.

The appropriate nursing action for a person with a Braden scale score of 14 is to: a. position them in a 30° side lying position b. implement a turning schedule c. apply a transparent wound dressing on the coccyx d. request an order for physical therapy e. implement a PI prevention bundle Answer: e Rationale: A Braden scale score of 14 places the person at moderate risk for a pressure ulcer. A pressure injury (PI) prevention bundle is an educational approach (both staff and the individual) to prevent the occurrence of a pressure injury. If appropriate, a turning schedule may be part of this. A transparent barrier may also be appropriate for anyone with scores of 13 or 14, if they 'lost points' in the moisture,

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friction and shear, activity and mobility categories. Physical therapy would be requested if normal nursing measures, such as assisting to ambulate, could not be done.

5.

Which wound care instruction should be given to a person being discharged from the hospital with a skin tear? a. Cover the skin tear with a transparent dressing b. Use a non-adherent dressing over the wound c. Leave the tear open to the air to dry d. Eat a high-fat diet to promote wound healing e. Drink 3 L of water every day to keep the skin hydrated.

Answer: b Rationale: A non-adherent dressing is used to treat skin tears. A transparent dressing causes maceration of the skin and may cause further skin trauma with removal. A diet high in fat does not promote healing; the diet should be high in protein and vitamin C. The primary treatment of skin tears is protecting them from further trauma so they can heal. They heal more quickly if they remain moist, and the thin layer of skin does not become a stiff, dry adherent to the wound. Drinking 3 L of water is not appropriate, 1.5 to 2 L per day is adequate to maintain hydration.

6.

A deep ulcer with exposed or directly palpable fascia, muscle and tendon in the ulcer would be staged as what degree of ulceration? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable PI Answer: d Rationale: Stage 4 pressure injury is described as full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supportive tissue. Undermining and sinus tracts may also be associated with Stage IV injuries.

7.

Biofilm is a detrimental development in a wound bed. Which of the following statements about biofilm is true? (Select all that apply.) a. Biofilm acts as a physical barrier to both biological and pharmaceutical antimicrobial action. b. Biofilm is found exclusively on wound bases. c. Biofilm inhibits formation of granulation tissue and epithelialisation of the wound. d. Biofilm prevents inflammation that interferes with healing. e. Biofilm develops over several days following contamination of a wound.

Answer: a, c Rationale: Biofilm is a dense sheet of bacteria that adheres to each other within an extracellular polymeric matrix that acts as a physical barrier to both biological (e.g., polymorphonuclear leucocytes) and pharmaceutical (e.g., antibiotics) antimicrobial action Biofilm can be found on wound bases, on drains or urinary catheters among other medical devices. The biofilm that forms on the surface of the

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wound bed impairs formation of granulation tissue and epithelialisation of the wound. It promotes a low-grade inflammation that interferes with healing and is an important factor in antibiotic resistance.

Biofilm can develop as quickly as 6 hours following contamination of a wound.

Spotlight on critical thinking Choosing a dressing For each of the following wounds, determine which dressing would be most appropriate. Explain your reasoning.

1.

An elderly lady has a skin tear (3 cm × 1 cm) and substantial bruising around it.

Suggested solution: A skin tear with bruising requires a non-adherent dressing (minimal absorption as most skin tears do not bleed/leak too much) that is held in place by ace bandages or a net. You do not want to use any dressing that will stick to the wound and destroy granulating tissue or reepithelialisation when it is removed. Avoid adhesives over bruised areas, especially on those with fragile skin.

2.

An active 20-month-old girl fell and sustained an abrasion on her shin. There is a clear exudate seeping down her leg.

Suggested solution: This toddler is active and will require an island type of dressing with a non-adherent centre and moderate absorption surrounded by an adhesive that will keep it in place.

3.

A 40-year-old man has a deep wound that is clean and the base is granulating.

Suggested solution: This wound is healing. It will require protection from an alginate or foam type dressing. The amount of exudate will determine whether you need little or moderate absorption. The dressing may be reinforced by a combine if the exudate is excessive. It would be held in place by adhesive tape.

4.

A 63-year-old man has a chronic wound on his leg with little exudate, some visible slough and dark brown eschar on the base.

Suggested solution: This wound will need debridement. Depending on the wound/person/physician, it could be treated with a hydrocolloid dressing.

Classification of wounds Classify the following descriptions of wounds. Identify the cause of the wound, cleanliness and loss of tissue thickness.

5.

A paralysed woman has a long-standing wound on her right hip that is draining purulent material, is 4 cm across, and in which you can see black eschar and fat.

Suggested solution: This wound is probably a Stage 4 pressure injury

6.

An athletic young man comes to A&E with a gash he sustained to his calf during a cross-country run. The wound is 3 cm deep, 6 cm long, bleeding profusely and has jagged edges.

Suggested solution: This wound is unintentional (accidental) and contaminated.

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7.

A 42-year-old woman fell off a ladder while cleaning the windows. She sustained a scalp wound that is bleeding heavily. When you mop up the blood, you can see tissue and skull.

Suggested solution: This wound is unintentional (accidental), contaminated and full thickness.

8.

A 76-year-old man who has just come back from theatre with a small incision in the upper right quadrant through which his gall bladder was removed.

Suggested solution: This is an intentional wound (incision), clean and contaminated (entry into the GIT)

9.

An 11-year-old girl has returned from theatre having had an open reduction of the radius and ulna following a horse-riding accident in which she sustained a communicating fracture and rupture of the radial artery.

Suggested solution: This is a complex wound – unintentional which makes it contaminated, full thickness as it extends to the bone and involves broken bones and severed arteries. Since it was also an open reduction of the radius and ulna and repair of the radial artery, it is incisional as well. It would be treated as a contaminated wound with antibiotic cover and close observation.

Reflection on the legal and ethical aspects of wound care: impaired skin integrity resulting from abuse A woman presents to your clinic with multiple bruises on her breasts, thighs, and abdomen; fresh abrasions on her hands and knees, with gravel mixed in; and two puncture wounds on her left shoulder blade, surrounded by streaks of blue ink. Her injuries are highly suggestive of abuse, especially the puncture wounds, because these could not have been self-inflicted.

10. How do you feel about caring for this woman? What are the skin care priorities?

Suggested solution: When responding to this question, ask the students to consider the stereotype of abuse in our societies, any experiences they have had with physical abuse, ask them to try to define the feeling in words, and how this might affect their care and approach to the woman.

Depending on state laws, photograph, document the wounds, then clean and dress them. They would be treated as contaminated wounds and antibiotic therapy instituted.

11. What other issues should be addressed with this woman once her wounds have been evaluated and any immediate physical needs attended to?

Suggested solution: Ask the students to consider her physical safety at home (does she have someplace safe to go?), if she has children at risk, her story and if she wishes to acknowledge the abuse and report it, or press charges; if she has psychological support available, provide education about the availability of shelter, social and financial support and how to access it.

12. What are the procedures for reporting suspected abuse in your state/territory?

Suggested solution: Ask the students to research this and report back to the class. It is mandatory in Australia to report abuse. This Australian College of Nursing (2023) website provides a detailed description of the reporting procedure/information: https://www.acn.edu.au/wpcontent/uploads/position-statement-nurses-and-violence.pdf). In New Zealand, ask students to research the various states for comparison. © Cengage Learning Australia 2024

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Reflection: caring for people with pressure injuries Advanced-stage PIs can have extensive necrotic tissue, significant drainage and a very strong odour.

13. Have you ever seen skin in an advanced stage of tissue deterioration?

Suggested solution: There are videos available if students have not seen this level of injury SEE, for example: http://www.youtube.com/watch?v=sdXIDpPmuw0.

14. How would you feel about caring for a person with a stage IV pressure injury?

Suggested solution: Ask the students to consider the person as a whole (empathise with them), would they feel fear about acting competently in caring for this person, would there be disgust over the sights and smells associated with the injury?

15. Would your opinion be different if the person were an 8-year-old comatose child or an 80-year-old bedridden person?

Suggested solution: Try to get the students to reflect on why there might be a difference in how they feel (look at the stereotypes of age, of activity levels, their feelings toward the person and their family) 16. Each of the people described below has at least one risk factor for developing a PI. List the risk factors for each person and write a mini care plan to reduce their chance of developing a PI. a. 52-year-old obese female, 2 days postoperative for a knee replacement, who has an indwelling urinary catheter. b. A 74-year-old thin man who is awaiting surgery for a fractured hip. c. A 91-year-old emaciated woman with a blood sugar of 6 mmol/L who is sitting in a wheelchair. d. A 67-year-old obese man who has cellulitis of his right lower leg.

Suggested solution: All of the following people need the usual pressure injury care: appropriate nutrition, hydration, hygiene, skin care, pain management, positioning, support surfaces – in addition to the answers given for each: a. Suggested solution: This woman's obesity and relative immobility increase her risk of developing a pressure injury. Her care plan would include frequent turning and mobilising her as quickly as possible. b. Suggested solution: This man is thin and also immobile from the fractured hip. He cannot mobilise at the moment, so a pressure alleviating mattress, skin care and relieving the pressure (turning within the limits of his condition) are important aspects of his care. c. Suggested solution: This lady is emaciated, old-old and is wheelchair bound. She needs a rigorous positioning schedule, appropriate high protein supplements as well as good nutrition and hydration.

Her hygiene needs should be attended frequently. She should be sitting on a weight distributing cushion. d. Suggested solution: This man is obese, and the cellulitis puts him at risk for developing a pressure injury. His leg will need to be elevated, but make sure there is no pressure put on the heel of that foot. He will be taking antibiotics and needs appropriate nutrition and hydration. His obesity means he will be frequently repositioned. Skin care and hygiene are extremely important due to the bacterial infection causing the cellulitis. © Cengage Learning Australia 2024

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 2 Resource aids....................................................................................................................................................... 4 Online resources.................................................................................................................................................. 4 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking ................................................................................................................................ 8

Chapter 41 Sensation, perception and cognition Key terms Affect Mood or feeling.

Afferent nerve pathways Ascending pathways that transmit sensory impulses to the brain.

Aneurysm Weakness in the wall of a blood vessel.

Aphasia Impaired, unfocused or absence of language function.

Arousal A component linked closely to the appearance of wakefulness and alertness.

Awareness The capacity to perceive sensory impressions and react appropriately through thoughts and actions.

Cognition The intellectual ability to think.

Consciousness State of awareness of self, others and the surrounding environment.

Disorientation A mentally confused state in which the person’s awareness of time, place, self and situation is impaired.

Drug and alcohol problems Problems affecting individuals (e.g., cirrhosis of the liver, severe paranoia), families (e.g., job loss, domestic violence) and communities (e.g., increased medical costs, increased crime) that are generated when substances are misused in excessive amounts, frequently, or over a long period of time.

Efferent nerve pathways Descending pathways that send sensory impulses from the brain.

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Electroencephalogram (EEG) Graphic recording of the heart’s electrical activity.

Fluency Ability to talk in a steady manner.

Hallucination A sensory perception that occurs in the absence of external stimuli and is not based on reality.

Illusion An inaccurate perception or misinterpretation of sensory stimuli.

Immediate memory The retention of information for a specified and usually short period of time.

Judgement The ability to compare or evaluate alternatives to life situations and arrive at an appropriate course of action.

Kinaesthetic An awareness of body position.

Level of consciousness (LOC) Degree of cognitive functioning involving level of arousal of the reticular activating system.

Lumbar puncture Aspiration of cerebrospinal fluid from the subarachnoid space.

Memory The ability to register, store and retrieve information.

Mental status examination A systematic assessment of the person’s emotional and cognitive functions.

Orientation Perception of self in relation to the surrounding environment.

Perception Person’s sense and understanding of the world; conscious awareness of pain Presbycusis The term used to describe hearing loss that gradually occurs as a person ages, due to the natural ageing of the auditory system. Hearing is often more difficult with high-pitched sounds and the person with presbycusis often experiences difficulty in hearing conversations, particularly those involving women’s voices.

Prosody Melody of speech that conveys meaning through changes in tempo, rhythm and intonation.

Recent memory The result of events that have occurred over the past 24 hours.

Remote memory The retention of experiences that occurred during earlier periods of life.

Sensation The ability to receive and process stimuli received through the sensory organs.

Sensory deficit A change in the perception of sensory stimuli.

Sensory deprivation A state of reduced sensory input from the internal or external environment, manifested by alterations in sensory perceptions.

Sensory overload Increased perception of the intensity of auditory and visual stimuli.

Sensory perception The ability to receive sensory impressions and, through cortical association, relate the stimuli to past experiences to form an impression of the nature of the stimulus.

Tinnitus A ringing in the ears.

Visceral Feelings originating from large organs within the body.

Instructional strategies • Discuss the structures within the central nervous system. The nervous system is composed of two subsystems: the central nervous system and the peripheral nervous system. The central nervous system

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includes the brain and spinal cord. The peripheral nervous system is composed of the somatic nervous system and the autonomic nervous system. The autonomic nervous system is further subdivided into the sympathetic and parasympathetic nervous systems.

• When performing a neurologic assessment, focus is placed on assessing a person’s cerebral function by evaluating memory, judgement, and emotion. How would you assess a person in these areas, and what documentation would be required in the medical record? When assessing a person’s memory, attention must be focused on the three different types of memory: immediate, recent, and remote. It is important to determine if a person has any memory deficits in any of these three areas. Questions can be asked of a person with regard to specific time constraints so each area is assessed. Documentation for each type of memory should reflect that person’s memory is intact or a person has memory deficits. When assessing a person’s judgement, it is important to (1) ask the person questions a requiring logical reasoning and (2) ask basic questions to which the average person is to respond (such as safety issues). Documentation of findings for use of proper judgement would be a person’s ability to display logical reasoning. When assessing the person’s affect, it is important to be aware of a person’s emotional state during the interview/assessment process. Emotions have a great deal to do with the person’s and may influence the person’s attitude and performance. Documentation of findings related to affect should be as objective as possible.

• Discuss with the person factors lead to sensory deprivation and sensory overload and contributions the person feels nurses can make to decrease those potentially debilitating conditions. Sensory deprivation is the result of reduced sensory input from both the internal and external environments. Visual or auditory impairments, use of sedative-type medications, trauma to the brain, and decreased access to stimuli caused by isolation all contribute to sensory deprivation. Manifestations of sensory deprivation include hallucinations, confusion, depression, and boredom, among others. Nurses have the responsibility to encourage activities that create stimuli for a person. A person with visual impairments may benefit from the use of a radio. A person who suffers from sensory deprivation due to isolation will require interaction with nurses on a more frequent basis.

Sensory overload is the result of too much stimuli from both the external and internal environments.

Pain, activity-filled busy environments, presence of strangers, and medications contribute to a person’s sensory overload. Manifestations of sensory overload include anxiety, disorientation, insomnia, fatigue and decreased ability to problem solve and make decisions. Nurses have the responsibility to decrease external stimuli when possible. Keeping the room quiet, lights dimmed, and interactions to a minimum will help a person. Controlling pain will assist in reducing a person sensory overload.

• Discuss strategies to stabilise or improve cognitive functioning in the older adult. The older adult has no decline in intellectual functioning. The area of concern for many older adults is memory loss. Ways to enhance cognitive development in older adults include reading, studying a new topic or language, learning how to use a computer, solving math problems, and working word puzzles. Strategies to help with memory loss include making lists and posting reminder notices.

• Discuss the need to assess level of consciousness on a person. What is the advantage of using the Glasgow Coma Scale (GCS) as an assessment tool? Level of consciousness (LOC) is of utmost importance to be assessed. If a person is awake and alert, then interactions are appropriate to a person’s needs. A person who is drowsy or lethargic may not understand questions or commands or may respond inappropriately.

This could lead to improper care; for example, a surgical consent may be signed without a person fully understanding the consent’s content. A person who is confused or lethargic may be experiencing the

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effects of drug overdose or interaction or may have a problem that needs to be addressed. A semicomatose or comatose person will have needs in addition to routine nursing care. Again, a thorough assessment needs to be completed to assess the reason for decreased LOC. If a baseline had previously been established, then any change to LOC warrants full investigation. GCS use permits assessment and documentation of LOC from nurse to nurse and from shift to shift. This tool reminds nurses to check LOC every 4 to 8 hours for decrease or improvement in LOC. • Many new nurses start out their careers working in an acute care facility or other long-term care facility.

In what ways can the nurse in one of these facilities promote a person’s sensory stimulation? Maintain verbal communication with the person. Call them by name and reinforce your name to them. Encourage verbalisation on the part of a person, involving them in activities. Reinforce location, date, and time.

Discuss the need to perform procedures, discuss all medications, and incorporate use of accessory equipment (e.g., glasses or hearing aid).

Resource aids NSQHS Standards user guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium. https://www.safetyandquality.gov.au/publications-andresources/resource-library/nsqhs-standards-user-guide-health-service-organisations-providing-carepatients-cognitive-impairment-or-risk-delirium Estes, M. E. Z., Calleja P., Theobald, K., & Harvey T. (2016). Health assessment and physical examination (Australian and New Zealand 2nd ed.). Cengage Learning.

University of Western Australia, National Ageing Research Institute (2017). Kimberley Indigenous Cognitive Assessment (KICA). Perth: University of Western Australia.

The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. For more information, visit: https://mocacognition.com/.

Online resources • Australian Government Hearing Services Program (the program) is managed by the Office of Hearing Services (the Office) for eligible people to access a range of hearing services https://www.health.gov.au/our-work/hearing-servicesprogram?utm_source=hearingservices.gov.au&utm_medium=callouthome&utm_campaign=digital_transformation • Australian Hearing provides hearing services to people eligible under the Australian Government Hearing Services Program. https://www.hearing.com.au • Blind Foundation is New Zealand's main provider of sight-loss related services to the blind and those with low vision https://blindlowvision.org.nz/contact-us • Deaf Aotearoa Information for people with a hearing impairment http://deaf.org.nz • Effective communication with deaf people: A guide to working with New Zealand Sign Language interpreters https://www.odi.govt.nz/nzsl/tools-and-resources/working-effectively-with-nzsl-interpreters • Guide Dogs Australia is the nation's leading providers of orientation and mobility services, including Guide Dogs, we assist people who are blind or have a vision impairment gain the freedom and independence to © Cengage Learning Australia 2024

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move safely and confidently around their communities, and to fulfil their potential https://guidedogs.com.au • Hearing Association New Zealand Information for people with a hearing impairment. https://www.hearing.org.nz • Hearing Matters is accredited to provide hearing services to pensioners and veterans under the Australian Government Hearing Services Program. http://www.hearingmatters.com.au • Indigenous eye health workers' web resource provides the Indigenous eye health workforce and related workers with access to quality information about the eye health of Aboriginal and Torres Strait Islander peoples. https://healthinfonet.ecu.edu.au/learn/health-topics/eye-health • Vision Australia is a leading national provider of blindness and low vision services in Australia. We work in partnership with Australians who are blind or have low vision to help them achieve the possibilities they choose in life. https://www.visionaustralia.org

Evaluation strategies • During clinical placement arrange two or three people receiving with whom students perform the GCS over a period of 2 to 3 days. Discuss any changes the person may have and variation among practitioners in assigning scores.

• If possible, arrange for students interview people who have experienced sensory overload, sensory deprivation, or a semiconscious state. What information was gleaned from these interviews? Can these be generalised to include other people?

• Have students reflect on clinical environments and how they can impact the sensory stimulation of the person receiving care, family members, and staff. Discuss what interventions can be used to minimise sensory overload in the clinical setting.

• Provide students with cognitive function documentation used in the clinical setting. Discuss the information that can be conveyed using these tools. Discuss comprehensive documentation and communication of findings.

• There is a great deal of information regarding the use of complementary therapies to promote cognitive function. Ask students perform an Internet search to examine available product types. Discuss how nurses can learn more about such items regarding safety and efficacy.

• In the clinical area, arrange for students conduct a neurological screening assessment. Refer to Table 41-4 for the contents of this assessment. In the post clinical conference, discuss students assessment findings and if the students had any particular challenges completing the assessments.

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Review questions 1.

Which of the following is the lobe devoted to interpreting visual input? a. Frontal b. Occipital c. Parietal d. Temporal e. Wernecke’s Answer: b Rationale: Occipital lobe – where visual perception occurs.

2.

Which of the following is an assessment tool used by RN to provide insight as to what additional assessment is needed? a. CSE b. DSM c. MSA d. OCD e. GCS Answer: c, e Rationale: A mental status examination (MSA) is a structured assessment of a person’s behavioural and cognitive functioning. It incorporates descriptions of the person’s appearance, general behaviour, level of consciousness, alertness, motor and speech activity, mood and affect, thoughts and perception, attitudes and insight.

The Glasgow Coma Score (GCS) is scored between 3 and 15, 3 being the worst, and 15 the best.

GCS assesses three parameters: Best Eye Response (4), Best Verbal Response (5), Best Motor Response (6).

'GCS of 10' is essentially meaningless, and it is important to break the number into its components, such as E3V3M4 = GCS 10.

A GCS Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.

3.

Which nursing activity is the most therapeutic for a person with a visual impairment? a. Face a person’s interpreter to avoid confusion. b. Inform a person when you are entering the room. c. Speak in a high-pitched tone of voice. d. Talk rapidly to help a person quickly process information. e. Provide the person with printed information to augment learning.

Answer: b Rationale: It is important to verbally inform a visually impaired person one’s presence. The nurse should directly face a person when speaking and use a normal tone, volume and rate of speaking.

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4.

A person is admitted to the intensive care unit following surgery. Which potential problems should be a priority for you in planning to care for this person? a. Decreased anxiety b. Impaired mobility c. Sensory deprivation d. Sensory overload e. Improved cognition.

Answer: d Rationale: Sensory overload is commonly experienced by people being treated in intensive care units due to lighting, noise, and activity levels. Anxiety levels are usually higher in people who are critically ill.

Impaired mobility is a problem but is not as important as addressing sensory overload.

5.

A person is admitted to the emergency department following a car accident in which he was driving under the influence of alcohol. The person says, ‘There are ants crawling on my arms!’ This person is likely experiencing which type of hallucination? a. Auditory b. Gustatory c. Olfactory d. Tactile e. Visual Answer: d Rationale: Tactile hallucinations involve the perception of being touched by things not actually present in the environment. Alcohol intoxication can result in acute states of confusion.

6.

You must assess a person experiencing a sensory deficit for development of which of the following? a. Back pain b. Pneumonia c. Polyuria d. Pressure ulcers e. Polydipsia Answer: d Rationale: Sensory deficits may lead to the development of a pressure ulcer because a person is unable to feel prolonged pressure on body parts. Therefore, the nurse must be especially watchful for the development of skin breakdown in a person experiencing a sensory deficit.

7.

A person is exhibiting signs of confusion. Which nursing actions will promote a safe environment for this person? (Select all that apply.) a. Apply restraints to prevent falls. b. Keep the ambient noise level high. c. Keep the bed in a low position and close to the floor. d. Keep the room clean and organised. e. Perform all ADL for a person in order to conserve their energy. f. Place a person in a quiet area with no visitors.

Answer: c, d

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Rationale: The bed should be placed in a low position to minimise injury from falls. A clean, uncluttered environment promotes safety. Restraints should be used only as a last resort and with much caution in those who are confused. High noise levels can add to confusion by providing too much stimulation. A person should be encouraged to perform as many self-care activities as possible. Social isolation may increase confusion.

8.

Which action is therapeutic for a person who is unconscious? a. Explain procedures to the person in a normal tone of voice. b. Perform nursing tasks quickly and quietly in order not to disturb the person. c. Place the person in a quiet room far away from the nurses’ station. d. Request that family members leave the person alone until consciousness is regained. e. Offer small and frequent sips of water to maintain hydration.

Answer: a

9.

Which of the following is one function of the RAS? a. Maintenance of posture b. Thirst and fluid regulation c. Maintenance of arousal and consciousness d. Emotional and cognitive function regulation e. Blood pressure regulation.

Answer: c

Spotlight on critical thinking Legal/ethical You live in a neighbourhood where there are several small children who run into and out of the street while playing. Your 72-year-old neighbour, Mr Roald, confides in you one afternoon that he is ‘finding it harder to see’. Then he tells you, ‘Next week when I go in for my driver’s licence renewal, I am not going to tell them about my little problem’.

1.

How do you respond to Mr Roald?

Suggested solution: Explain to Mr Roald that he might not lose his licence; he may just need a vision test and might be able to have prescription glasses to improve his sight.

2.

Outline two reasons why Mr Roald may not want to disclose to his doctor that his sight is declining.

Suggested solution: Reasons may include restriction on his ability to drive; impact on independence, that he does not know what can be done to improve his vision; and that he thinks it is a natural part of the ageing process that he just needs to tolerate.

3.

Describe two ramifications for Mr Roald or the children in your street if he does continue to drive.

Suggested solution: Mr Roald’s vision is critical to his ability to drive safely. Accidents could occur if he is driving with impaired vision.

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4.

Describe three factors which could impact on Mr Roald if he is no longer able to drive.

Suggested solution: Social isolation, not able to do shopping, feeling of being dependent on others.

Professionalism Imagine you are the practice nurse working at the general practice which Mr Roald attends.

5.

Outline three indicators Mr Roald might display which would alert you to the fact that his sight is declining.

Suggested solution: Indicators include losing ability to read text close up, difficulty distinguishing colours e.g., black from dark blue, and increasing difficulty driving at night

6.

How would you respond to Mr Roald if you identified his sight as impaired?

Suggested solution: Discuss your observations with Mr Roald, and ask how he feels about this. Address his concerns honestly and allow him time to digest the information. This information can include type of vision impairment identified, ways this can be addressed, and what he can do to overcome safety risks associated. You can also give him a referral to an optometrist.

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 3 Online resources.................................................................................................................................................. 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking ................................................................................................................................ 7

Chapter 42 Elimination Key terms Acute urinary incontinence A transient and reversible problem of loss of urine.

Ammonia contact dermatitis Papular rash with saturated, macerated skin.

Bacteriuria Bacteria in the urine.

Bristol stool chart Categorises stools into seven clearly described stool forms.

Coaptation Sealing (for example) of the urethral lumen to prevent the escape of urine.

Colonoscopy A visual endoscopic examination of the large intestine.

Colostomy A permanent or temporary faecal diversion.

Constipation Infrequent and difficult passage of hard stool.

Defecation Evacuation of faeces from the rectum.

Detrusor muscle Smooth muscle of the bladder wall.

Detrusor sphincter dyssynergia An uncontrolled contraction of striated muscle of the sphincter mechanism during micturition.

Diarrhoea Passage of liquefied stool (increased frequency and altered consistency of stool sufficient to represent a change in bowel habits).

Digestive chyme Mixture of partially digested food and secretions.

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Dyssynergia A loss of coordination between the bladder and sphincter mechanism.

Dysuria Painful urination.

Ectopia A congenital defect in which leaks occur from a source outside the urethra.

Electromyography Recording of the electrical activity of a muscle.

Enema administration A procedure used to introduce fluid into the lower bowel to cleanse it, to assist in the evacuation of stool or flatus, or to instill medication.

External male catheter (EMC) A device that resembles a condom with a large-calibre connector at its distal end, connected to a drainage bag via a leg bag or bedside container for urinary containment.

Extraurethral incontinence Uncontrolled loss of urine caused when the sphincter mechanism has been bypassed.

Faecal incontinence Involuntary loss of stool of sufficient duration and volume to create a social or hygienic problem.

Faecal microbiota transplant (FMT) A healthy person’s stool is delivered directly into the bowel of an unhealthy person to restore healthy bowel microflora.

Flatulence Discharge of gas from the rectum.

Fluid balance chart A specially designed device to monitor urinary elimination patterns.

Functional incontinence Loss of urine caused by altered mobility or dexterity, access to the toilet, or changes in mentation.

Glucose Primary ingested molecule used by the body to produce energy.

Haematuria Blood in the urine; microscopic haematuria is the presence of blood noted on microscopic examination of the urine; gross haematuria is the presence of blood visible to the naked eye.

Haemorrhoids Perianal varicosity of the haemorrhoidal veins.

Ileostomy A diversion of the bowel at the level of the ileum.

Ileus An obstruction of the bowel.

Impaired urinary elimination The state in which the individual experiences a disturbance in urine elimination.

Intrinsic sphincter deficiency (ISD) Inability or deficiency of the urethral sphincter to maintain closure.

Kidneys A pair of reddish brown, bean-shaped organs located in the retroperitoneal space, adjacent to vertebral bones T12 to L2.

Micturition The evacuation of urine from the bladder.

Monilial rash Maculopapular, red rash with satellite lesions.

Nocturia Awakening from sleep to urinate.

Obstipation Intractable constipation.

Occult Blood in the stool that can be detected only through a microscope or by chemical means.

Orthotopic urinary diversion The formation of a new urinary storage reservoir.

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Overactive bladder (OAB) syndrome A mix of urinary urgency, daytime frequency and nocturia (waking up to urinate).

Persistalsis Coordinated, rhythmic, serial contraction of the smooth muscles of the gastrointestinal tract, ureters.

Polyp A small, abnormal growth of tissue.

Pyuria Pus (dead leukocytes) in the urine.

Renal pelvis A temporary storage area for urine before transport to the lower urinary tract.

Rugae Regular folds of tissue observed in the normal vagina.

Specific gravity (SG) Weight of urine compared with weight of distilled water; a specific gravity greater than 1.0 indicates solutes in the urine.

Stoma Surgically created opening.

Stool Faecal material.

Stress urinary incontinence (SUI) Uncontrolled loss of urine caused by physical exertion in the absence of a bladder contraction.

Ureter A long tube, shaped like an inverted S, that begins at the renal pelvis, passes under the psoas muscle of the back, and enters the pelvis near the sacroiliac junction to end at the bladder.

Urethra A tube that is a conduit for urinary elimination.

Urethral hypermobility The abnormal movement of the bladder base and urethra during physical exertion.

Urge urinary incontinence Uncontrolled discharge of urine caused by hyperactive (unstable) contractions of the detrusor muscle.

Urinalysis (UA) Laboratory analysis of the urine.

Urinary incontinence Uncontrolled loss of urine of sufficient duration and volume to create a social or hygienic problem.

Urinary overflow Volume of urine that overflows actual bladder capacity.

Urinary retention Inability to completely evacuate the bladder.

Urobilinogen Derived from the normal bacterial action of intestinal floras on bilirubin.

Urodynamics A set of tests that measure bladder and surrounding abdominal pressures.

Voiding Process of urine evacuation.

Volvulus Twisting of the intestine.

Instructional strategies • Discuss factors that affect elimination. What nursing interventions can be used to maintain adequate elimination patterns? Age or developmental level affects elimination control. Young infants are unable to control elimination patterns until the age of approximately 18 months. At the other end of the spectrum, an elderly person may have control issues related to decreasing muscle tone that affect bladder control.

Diet affects elimination patterns, as the amount of fluid and fibre can contribute to urinary and bowel

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health. It is important to maintain adequate fluid and fibre intake, as a balanced diet can help with elimination balance. Exercise can help promote muscle tone that aids in the control of elimination. The use of medications can also be a factor in elimination patterns. This includes over-the-counter (OTC) medications, nutritional and herbal supplements, and prescribed medications. Nursing interventions that can be used to maintain adequate elimination patterns include dietary instruction relating to adequate fibre and fluids, promotion of exercise schedule to maintain consistency and muscle tone, assessment of client for potential problems related to elimination, and client education in monitoring for potential elimination problems.

• Discuss interventions appropriate to maintain elimination. For both urinary and bowel elimination health, a person should be instructed on the need for adequate fluid intake according to individual health status needs. The diet should be assessed and instruction should be provided according to the elimination problem. For urinary elimination, the person should be instructed to avoid foods known to be bladder irritants. For bowel elimination, they should be instructed on foods high in dietary fibre. Additional instruction should address lifestyle and prevention, including adequate sleep, rest, and exercise. If appropriate, people should be instructed on the adverse effects of alcohol and tobacco on elimination.

Management of stress promotes healthy bowel and urinary elimination and should be included in teaching, as appropriate. Instruction should also be included on elimination habits and responding to the urge to void or defecate. Lastly, positions that promote normal elimination should be identified and instructed, as appropriate.

• Discuss the types of urinary incontinence. Acute urinary incontinence is transient and reversible. It is related to illness or injury. It can resolve when the underlying medical problem is corrected. Some medications may also contribute to acute urinary incontinence. Chronic urinary incontinence is long lasting and may be permanent. There are four types of chronic incontinence: stress urinary incontinence, instability incontinence, functional incontinence, and extraurethral incontinence. Stress urinary incontinence is caused by poor or absent sphincter control. Instability incontinence is caused by premature or hyperactive contraction of the detrusor muscle. Functional incontinence is related to problems with alteration in mobility, difficulty accessing bathroom or toilet, or changes in mentation.

Extraurethral incontinence occurs when the sphincter mechanism is bypassed altogether.

• What assessment responsibilities does the nurse have in relation to elimination? The nurse should perform a health history. This will elicit subjective data related to urinary and bowel elimination. The physical examination gives the nurse both subjective and objective data necessary to determine need for intervention or teaching. Laboratory and diagnostic data will also provide useful information. Assessment of the above will help determine appropriate nursing interventions.

• What should the student nurse be cognisant of when performing either a female catheterisation or a male catheterisation? For both procedures, establishing privacy is of utmost importance. Assist the person into the proper position for the procedure; drape as indicated. For women, cleansing of the perineum is vital.

Using lubricant, insert the catheter into the meatus until urine flows. Insert it an additional 1−3 inches.

Inflate the retention balloon, checking to determine if the catheter is securely positioned. Secure the catheter to the leg, position the drainage bag, below the level of the bladder to facilitate gravity flow. For men, cleanse the glans penis before catheter insertion. Using lubricant, gently insert the catheter into the meatus until urine flows. Insert the catheter until the hub of the catheter is met. Inflate the retention balloon and check placement. Tape the catheter to the person’s leg and attach the drainage bag below the level of the bladder to facilitate gravity flow.

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• Discuss nursing considerations for enema administration. Nurses must consider the purpose of an enema: to cleanse the lower bowel; to assist in the removal of stool or flatus; or to administer medications.

Enemas can be of large or small volume. When administering large-volume enemas, the nurse needs to be cautious as fluid and electrolyte imbalances can occur. Even if an enema is prescribed to be administered until ‘clear’, the maximum amount of fluid to be administered in any one series should never be greater than 3 litres.

Online resources • Continence Foundation of Australia: brochures and educational resources. https://www.continence.org.au/resources.php • Continence NZ: brochures and educational resources https://www.continence.org.nz • Nurse TV: Incontinence nursing https://www.youtube.com/watch?v=TVQINkIA-U0 • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz • The Australian Council of Stoma Associations (ACSA). http://australianstoma.com.au

Evaluation strategies • Have students read the Spotlight on critical thinking ‘Assessment of elimination patterns’ and have them answer the questions. Discuss their responses to the questions in small groups.

• Have students read the Spotlight on critical thinking: ‘Caring and compassion: sensitivity during the genital exam’ and ‘Professionalism during the rectal assessment’ have them answer the questions.

Discuss in small groups how to practise nursing regarding these sensitive and potentially embarrassing areas.

• Encourage students to explore current nursing research regarding the process of elimination and bring their results to discuss in class. How does this research affect the practice of nursing?

• Discuss various types of devices used for urinary or faecal incontinence. Provide samples of these devices in the laboratory setting for the students to manipulate in a practice environment. When are some more appropriate than others, and what are necessary nursing assessments related to specific devices?

• In the laboratory setting, provide equipment used to conduct urinary catheterisation and enemas. Since these procedures can be intimidating, provide the students with an opportunity to practise applying sterile gloves and manipulating the sterile catheter. This might help reduce student stress. Help the students recognise the difference between inserting a catheter for urinary elimination and inserting the catheter for administering an enema.

• Have students discuss how altered elimination patterns affect individual people. Have students reflect on what it would mean to have acute and chronic elimination problems. Discuss options available that would assist a person in making lifestyle adaptations.

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Review questions 1.

The lower urinary tract consists of: a. the bladder, urethra and pelvic floor muscles b. the bladder, ureters and the pelvic floor muscles c. the kidneys, urethra and the pelvic floor muscles d. the kidneys, renal pelvis and urethra e. the bladder, ureters and urethra.

Answer: a

2.

What is the action of the parasympathetic nervous system on a person’s ability to pass stool? a. Relaxation of the external sphincter b. Contraction of the external sphincter c. Relaxation of the internal sphincter d. Contraction of the internal sphincter e. Assist both sphincters to strain at stool.

Answer: c

3.

A person with a spinal cord injury will have bowel and bladder dysfunction. What is this type of dysfunction known as? a. Functional incontinence b. Injury-related stress incontinence c. IBS d. Neurological incontinence e. Injury-related urge incontinence.

Answer: d

4.

You perform a simple UA and obtain the following results, Leucocytes – present, Nitrites – present, Hb – present. What would you suspect? a. The person is sick and dehydrated b. The UA displays a normal result c. The UA indicates a UTI d. The UA indicates diabetes e. The person has urinary incontinence.

Answer: c

5.

Anticholinergic and antispasmodic medications, such as oxybutynin and propantheline, are commonly used to treat which type of chronic urinary incontinence? a. SUI b. Reflex urinary incontinence c. Urinary retention d. Total urinary incontinence e. Urge urinary incontinence.

Answer: e

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6.

A healthy stoma should appear: a. dusky and moist b. pale and pink c. blue with areas of black d. moist and pink e. dry and red.

Answer: d

7.

Which of the following should you include in the procedure for female urinary catheterisation? a. Expose the urinary meatus with your dominant hand b. Lubricate the first 5 cm of the catheter c. Insert the catheter 18 cm with the sterile, gloved hand d. Allow the labia to relax after the meatus is cleansed e. Irrigate the catheter with normal saline.

Answer: b

8.

After an assessment, what type of exercises can improve symptoms of urinary incontinence? Also known as pelvic floor exercises. a. Tefal b. Kegel c. Kelly d. Tager.

Answer: b

Spotlight on critical thinking Caring and compassion: Sensitivity during the genital exam Assessment of the genital area can produce feelings of anxiety and embarrassment for both individuals and nurses alike. Before beginning the genital examination, consider the person’s cultural background and the beliefs or attitudes they may have about the examination. Consider the person’s body image. Remember that you are assessing a person, not just a body part.

1.

Does the person’s culture prohibit a female nurse from examining a man?

2.

Does the person’s culture prohibit a male nurse from examining a woman?

3.

How might you reduce a person’s embarrassment during the examination?

Answers will vary. Discussion should include asking the person what might make them feel more comfortable.

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Assessment of elimination patterns Consider your feelings about urinary and faecal incontinence. Many people, including health care professionals, consider incontinence to be a hygiene rather than a health concern. Parents may view incontinence in children to be a form of misbehaviour. Some adults consider incontinence to be a form of childlike or infantile behaviour, or they may believe that urinary or faecal leakage is an inevitable consequence of ageing. Consider what your feelings would be if you lost control of your bowels or your bladder: 4.

Would you want your health care providers to consider this a significant problem worthy of aggressive treatment?

5.

Would you feel embarrassed about bringing up this problem with a nurse or doctor?

6.

Would you be relieved when a nurse or doctor asked you about this problem?

7.

Would you desire privacy when discussing this health care issue?

Suggested solution: Answers to questions 4–7 will vary, however, students may consider: Accessing the Australian Continence Foundation or the New Zealand Continence Association’s websites to view and discuss the available resources including the National toilet map and card.

Professionalism: professionalism during the rectal assessment A rectal examination may cause the person to feel uncomfortable or embarrassed. How would you handle the following situations if they were to occur during the rectal assessment?

8.

The person has a bowel movement.

9.

The person passes flatus during the examination.

Suggested solution: Students may consider some of the ways they can overcome their own and the person’s embarrassment. Ask them to consider an embarrassing situation that they experienced. How did they respond, and how would they have appreciated others responses to their dilemma?

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Content Key terms ............................................................................................................................................................. 1 Instructional strategies ........................................................................................................................................ 3 Resource aids....................................................................................................................................................... 5 Online resources.................................................................................................................................................. 5 Evaluation strategies ........................................................................................................................................... 5 Review questions................................................................................................................................................. 6 Spotlight on critical thinking ................................................................................................................................ 8

Chapter 43 Perioperative nursing care Key terms Anaesthesia Absence of pain. Medically induced loss of sensation for surgical or pain control purposes.

Antiembolism stockings Elastic stockings that compress leg veins to facilitate the return of venous blood.

Anxiety Subjective response that occurs when a person experiences a threat to wellbeing, a diverse feeling of dread or apprehension.

Arthroplasty Total hip replacement.

Continuous passive motion (CPM) device Device that increases ROM and stimulates healing of the articular cartilage by decreasing swelling and the formation of adhesions.

Cullen’s sign Bluish discoloration around the umbilicus in post-op patients; can indicate intra-abdominal or peritoneal bleeding.

Dry shave The removal of hair by clipping or the use of a depilatory.

Electrocardiogram (ECG) Graphic recording of the heart’s electrical activity.

Extubation Removal of an endotracheal tube.

Fear A feeling of dread related to an identifiable source that the person validates.

General anaesthesia Anaesthesia that causes the loss of all sensation and consciousness; used for major surgical procedures.

Holding area Where the surgical team prepares the person for surgery.

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Hypovolaemic shock The marked reduction in circulating blood volume.

Incentive spirometers Breathing devices that measure the patient’s ventilatory volumes.

Infiltrate anaesthesia Refer to intradermal, subcutaneous or submucosal injection to provide a circumscribed area of anaesthesia.

Intraoperative (during surgery) Phase that begins when the person is transferred to the operating room and ends when he/she is transferred to a postanaesthesia care unit.

Intubation Insertion of an endotracheal tube into the bronchus through the nose or mouth to ensure an airway.

Local anaesthesia Anaesthesia that causes the loss of sensation to a localised body part (e.g., spraying the back of the throat with lidocaine decreases the gag reflex).

Lock-out interval Minimum time allowed between doses for the person to self-medicate; feature found in infusion pumps used for patient-controlled analgesia.

Malignant hyperthermia (MH) A potentially lethal syndrome caused by a hypermetabolic state that is precipitated by the administration of certain anaesthetic agents.

Patient-controlled analgesia (PCA) Device that allows the individual to control the delivery of intravenous or subcutaneous pain medication in a safe, effective manner through a programmable pump.

Perioperative Refers to the management and treatment of the individual during the three phases of surgery: preoperative, intraoperative and post-op.

Pneumatic compression device Device that provides intermittent compression cycles to the veins of the extremities to promote circulation.

Postoperative (post-op; after surgery) Begins when the person leaves the operating room and is taken to a postanaesthesia care unit; this phase continues until the individual is discharged from the care of the surgeon.

Preoperative (pre-op; before surgery) Refers to the time interval that begins when the decision is made for surgery until the person is transferred to the operating room.

Pulse oximeter Sensor device used to measure the oxygen saturation level of the haemoglobin in peripheral blood.

Regional anaesthesia Anaesthesia that causes the loss of sensation in a particular area of the body (e.g., laparoscopy for a tubal sterilisation).

Surgical asepsis Sterile technique: consists of those practices that eliminate all microorganisms and spores from an object or area.

Surgical consent form A person’s written permission to allow the surgeon to provide surgery.

Time out The surgical team’s short pause, just before incision, to confirm that they are about to perform the correct procedure on the correct body part of the correct patient.

Topical anaesthesia The direct application of local anaesthetics to tissues in the form of ointments, lotions, solutions or sprays.

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Transcutaneous electrical nerve stimulation (TENS) Method of applying minute amounts of electrical stimulation to large-diameter nerve fibres via electrodes placed on the skin to block the passage of pain to the dorsal spinal root.

Trocars Surgical instruments used to place light and air into a cavity to aid in laparoscopic surgery.

Urgency Timely intervention of surgery.

Instructional strategies • Discuss the concept of perioperative nursing. Define the nursing roles in each phase and identify the responsible nursing body who designates outcome-based criteria. Perioperative nursing refers to the scope of care for any person undergoing a surgical procedure. It begins during the preoperative phase (before surgery), when the person is prepared for the surgical procedure. During this time frame, pertinent assessment (labs and diagnostics), accurate history, and informed consent are obtained. The nurse makes sure that the preoperative checklist is complete and that all diagnostics have been completed prior to the surgery. Preoperative medication may be ordered on call to the operating room (OR), and the ward nurse may administer the medication. A collaborative effort is in place with the surgeon, anaesthetist and nurse; they validate that the person is ready for surgery.

The next phase is the intraoperative phase, during which the person is transferred to the OR and undergoes the actual procedure. During this time frame, the person is monitored by the anaesthetist and attended to by the surgeon and operative team. The nurses working in the OR have various duties, such as circulating and scrub functions. These nurses are responsible for assisting the surgeon, setting up the instruments, draping the person, and confirming instrument counts. The circulating nurse fills out the intraoperative record and records the time the procedure started and ended, the solutions used, and the specimens obtained. The medical diagnosis is also seen on this record, and the nurse accurately records both the preoperative and postoperative diagnosis.

When the person is transferred to the recovery room or PACU, the postoperative phase begins.

During this time frame, the recovery room nurse, following the orders of the surgeon and monitors the person. The nurse is responsible for continuous monitoring of the person, paying attention to arterial blood gases (ABGs), surgical site, vital signs, fluids, and pain and sedation levels. The nurse may have to medicate the person and must be aware of all prior intraoperative procedures. It is very important that the nurses (and health care team members) communicate during each phase of the perioperative period in order to maximise patient outcomes. The recovery room nurse is responsible for verbal report back to the ward nurse. The Australian College of Operating Room Nurses (ACORN) is the agency that defines evidence-based practice in this area.

• Discuss the Joint Commission’s 2009 National Patient Safety Goals for all procedures and surgeries. The Joint Commission established National Patient Safety Goals to help accredited organizations address specific areas of concern regarding patient safety. The goals are studied and changed annually. The goals for procedures and surgeries for 2009 are as follows: implement best practices for preventing surgical infections; clearly identify the intended site for the procedure or surgery; and perform a time-out immediately prior to the procedure to assess for correct patient, correct site, correct position, and correct procedure.

• Identify the different types of anaesthetic agents that are available for use in the clinical setting. Compare disadvantages and advantages of each type. List an example of when each type of anaesthetic could be used. General anaesthesia involves the use of agents that will render the person in an unconscious state.

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General anaesthesia can be administered via intravenous or inhalation routes. Intubation is required to maintain the person’s gas exchange. Advantages are that it can be quickly administered in an emergency setting and the person can be totally anaesthetised, allowing for complex surgical interventions to be performed. Disadvantages are that intubation can cause irritation to throat or mouth and possible aspiration of stomach contents if the person has not been NPO (nil per orally) before the surgical intervention. Cardiac bypass surgery and bowel resections can be performed under general anaesthesia.

Regional anaesthesia relates to the administration of anaesthetic agents through either spinal or epidural space to achieve an area of decreased feeling, sensation, and movement. This type of anaesthesia allows the person to be somewhat awake during the surgical procedure, but the person does not feel pain due to blocking of nerve endings. Disadvantages are that there can be leakage of the anaesthetic into the spinal or epidural space, causing headaches, rising levels of anaesthesia, and/or incomplete anaesthesia effect. Most surgical procedures can be performed under regional anaesthesia, the most common being orthopaedic surgery and childbirth (caesarean and vaginal deliveries). Local anaesthesia relates to the administration of anaesthetic agents using topical or infiltration methods. Topical anaesthetics are available in sprays, ointments, lotions, solutions, or patches. Infiltration methods involve subcutaneous, intradermal, or submucosal injection into the desired area. Disadvantages are that usually local anaesthesia does not last very long, an allergic reaction can ensue following administration of anaesthetic, and incomplete anaesthesia can occur, leading to residual pain and possible persistent numbness. Incision and drainage and oral surgeries are examples of procedures that use this type of anaesthesia.

• Discuss how problem identification for a perioperative patient change from the preoperative phase to the postoperative phase of care. In the preoperative phase, problem identification address learning deficits, anxiety, and fear. During the intraoperative phase, problem identification focus on risks or potential for problems, such as risk for positioning injury, risk for injury, risk for infection, or hypothermia. Once in the postoperative phase of care, problem identification addresses actual or potential problems that occur either as a result of the anaesthesia or the operative procedures. Examples of problem identification at this time include ineffective airway clearance, ineffective breathing pattern, ineffective tissue perfusion, deficient fluid volume, imbalanced nutrition, urinary retention, acute pain, risk for infection, and situational low self-esteem due to altered body image or the need to be dependent on others during the recuperation period.

• Describe components of preoperative teaching. What types of information are given to the preoperative patient? What may hinder effective preoperative teaching? The nurse’s role in preoperative teaching is to help decrease anxiety in the preoperative patient. This teaching may include the person and family members. Any teaching aids, videos, or pamphlets should be given to the person. The person should be informed of attendance at all times by a nurse during this process. Instructions on deep breathing, progressive exercise and diet, and availability of pain medication should be discussed. Give rationale for use of an incentive spirometer, heat or ice therapy, and any dressings that might be present postoperatively. Include any other devices that would pertain to a specific surgery. Anxiety on the part of the person will hinder effective teaching preoperatively. Any language barrier between nurse and patient will decrease the amount of teaching done or patient understanding.

• Name the different categories of surgical interventions and give examples. Surgeries are emergency, urgent, or elective. An emergency surgery might be after a trauma, such as an exploratory abdominal surgery or removal of a bullet lodged near a vital organ. An urgent surgery might include a caesarean delivery with a baby showing signs of distress. An elective surgery might be surgery to remove a benign © Cengage Learning Australia 2024

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polyp or plastic surgery. Surgeries can also be diagnostic/exploratory, reconstructive, curative, palliative, or transplant.

Resource aids Australian College of Operating Room Nurses. (2020). Standards for perioperative nursing. ACORN. Httpe://www.acorn.org.au/standards Perioperative Nurses College of the New Zealand Nurses Organisation (PNC NZNO) (2019). Homepage.

Retrieved from http://www.nzno.org.nz/groups/colleges/perioperative_nurses_college

Online resources • Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au • Nursing Council of New Zealand: http://www.nursingcouncil.org.nz

Evaluation strategies • Give the students an interactive clinical scenario by providing them with a medical problem requiring

surgical intervention. Then have the students perform a preoperative check assessment on each other, paying attention to review of systems (ROS), social history, dietary history, and medications (over-thecounter and prescription). Have students assist by role playing regarding anaesthesia choice. Review with students the importance of preoperative assessment and communication and documentation of findings.

• Have students read the Spotlight on critical thinking box section entitled ‘Responding to a person’s altered self-image’ and answer the questions at the end of the display. Discuss the students’ answers in a small- or large-group setting.

• Obtain forms from the clinical setting regarding perioperative management. Divide the students into three groups according to the phases of the preoperative process, and have the students review required documentation regarding outcome criteria.

• Have the students write down what they think a postoperative report should convey for a surgical patient returning to the surgical ward. Validate with students the importance of a thorough and detailed report.

• Assign students in the clinical setting to follow a person during the perioperative period. This should include assisting the person during the preoperative period, completing the surgical checklist, and accompanying the person to the surgical holding area. If appropriate according to agency policy, have the student accompany the person into the operating room and observe the procedure. Once the procedure is completed, the student should accompany the person, if approved by agency policy, to the post anaesthetic care unit. Ideally, the student should accompany the person back to the medical-surgical care area and observe the report provided from the post anaesthetic care unit nurse to the ward nurse. At the completion of this experience, have the student reflect on preoperative assessment by anaesthesia, preoperative teaching, and postoperative teaching in the clinical setting. Were the National Patient Safety Goals achieved for the person? Discuss how they were achieved.

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Review questions 1.

Pre-op teaching regarding an upcoming outpatient surgery should include: a. Post-op exercises and nursing interventions b. risk for post-op complications c. risks and benefits of the proposed surgical procedure d. risks and benefits of anaesthesia choices e. a description of the surgical procedure.

Answer: a Rationale: Preoperative teaching should include anticipated postoperative nursing interventions such as turning, coughing, deep breathing and leg exercises. Risks and benefits of the proposed surgical procedure and anaesthesia choices are discussed with the person primarily by the surgeon and anaesthesiologist.

2.

Which of the following indicates the greatest risk factor for someone scheduled for general anaesthesia? a. Expresses concern about the scheduled procedure b. Ate a pack of biscuits within the last 2 hours c. Has a history of smoking and had the last cigarette 24 hours ago d. Has a history of hypertension that is controlled by diet and exercise e. Voided 300 mL during pre-op check.

Answer: b Rationale: Clients are instructed not to eat or drink anything prior to general anaesthesia in order to reduce the risk of aspiration. Although cigarette smoking and controlled hypertension may increase risks of complications postoperatively, aspiration poses a more significant risk in this situation. Concerns do not pose a risk factor for general anaesthesia, although clients may experience anxiety and express concerns prior to general anaesthesia.

3.

Which is a priority nursing intervention used to prevent infection in the perioperative person? a. Preparation of the skin overlying the surgical site b. Maintenance of hemodynamic status c. Maintenance of person’s temperature d. Determination of estimated blood loss e. Evaluation of the neurological status.

Answer: a Rationale: Preparation of the skin is a priority nursing intervention use to prevent infection.

Maintenance of hemodynamic status, temperature, and estimated blood loss do not impact the person’s risk of infection.

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4.

Which of the following is not a volatile liquid used as an inhalation general anaesthetic? a. Desflurane b. Sevoflurane c. Caroflurane d. Isoflurane e. Ketamine.

Answer: e Rationale: Ketamine is a medication mainly used for starting and maintaining anaesthesia. It induces a trance-like state while providing pain relief, sedation and memory loss. It is not an inhalation anaesthetic.

5.

During assessment of a person scheduled for a procedure to rule out cancer, you observe tears in their eyes. Which response by you is the most therapeutic intervention? a. Contact the surgeon to speak with the person. b. Ask the person to describe his or her feelings. c. Medicate the person with a preoperative analgesic. d. Reassure the person that there is nothing to worry about. e. Move through the remaining assessment as quickly as possible.

Answer: b Rationale: Having the person express their feelings will assist the nurse in selecting the most appropriate nursing intervention. The surgeon may be contacted if the person has specific concerns but would not be contacted prior to an initial assessment. Medicating the person with a preoperative analgesic would be inappropriate without first addressing the person’s concerns or questions.

6.

Which is the priority nursing intervention for a person during the postoperative phase? a. Establish a patent airway. b. Maintain adequate BP. c. Establish level of consciousness. d. Assess level of pain. e. Assess fluid balance.

Answer: a Rationale: The first priority in caring for a person in the postoperative period is the establishment of a patent airway. Maintenance of hemodynamic stability, determination of level of consciousness, and assessment of pain are all important aspects of postoperative care but are not the first priority.

7.

Postoperatively, a person is experiencing impaired capillary refill to the lower extremities. The most appropriate problem identification is: a. ineffective breathing pattern b. ineffective airway clearance c. ineffective tissue perfusion d. infection e. inappropriate Q/V ratio.

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Answer: c Rationale: Decreased oxygen results in the failure to nourish the tissue at the capillary level. Ineffective breathing pattern refers to inspiration and/or expiration that does not provide adequate ventilation; Ineffective airway clearance is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

8.

The post-op phase begins when the person is transferred from the operating room and ends when: a. Their VSs are stable b. They are fully alert and responsive c. the person is discharged from the agency d. the person is discharged from the surgeon’s care e. the person is able to self-care.

Answer: d Rationale: The surgeon discharges the person from their care when the physiological functions and healing of the procedure have occurred, and provided there are no complications.

9.

Common pre-op diagnostic tests include: a. FBE and U&Es b. V/Q and CT scan c. Mental Status Assessment (MSA) and neurological exam d. lumbar puncture and BP reading e. liver function studies.

Answer: a Rationale: A full blood examination and urea and electrolytes are common preoperative diagnostic tests that provide important information for safely managing the person undergoing surgery.

Spotlight on critical thinking Caring and compassion 1.

What skills are essential for nurses working in the perioperative environment?

Suggested solution: • assessment skills (and a high level of suspicion about abnormal findings) • communication and interpersonal skills (with compassion and confidence) • organisational skills (efficient, effective and safe) • teaching skills (for people with different age levels, understanding, and interest).

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Fundamentals of Nursing 3e: Instructors Manual

Responding to a person’s altered self-image A 30-year-old woman is admitted for removal of a breast due to cancer of the breast. Her mother died at age 30 from breast cancer. The woman has been married for 5 years and has a 3-week-old infant. You have to admit and interview the woman for the nursing history.

2.

As a nursing student, how can you assist this woman in verbalising fears about alterations in body image?

Suggested solution: Listening to the person, staying with them while they verbalise or cry, referring them to a more experienced nurse, perhaps arranging a volunteer (with the person's permission) who has had the surgery, made necessary adaptations and wished to talk to others about it. There are agencies that assist people with common surgeries (mastectomy, prostatectomy) that you could contact for assistance. Refer the person back to their surgeon if necessary.

3.

How would you approach the medical diagnosis?

Suggested solution: Answers will be individual, but the following should be considered. Ask the woman what she is having surgery for. She will be able then to articulate her understanding, and perhaps begin to talk about the changes it will make in her life and the fears she is having.

4.

Would you feel comfortable helping this woman verbalise her fears?

Suggested solution: As long as you don't pretend to have knowledge and understanding that you don't have, listening to her fears will help her.

Legal and ethical: Nursing intervention You are caring for a 16-year-old boy who was in a car accident and is scheduled for bladder surgery. The parents are present for perioperative teaching. You explain what will happen during the surgical procedure and that the boy will have a catheter after surgery. The boy gets upset, saying he does not want a tube.

5.

How would you respond to him?

Suggested solution: Find out why. Educate the person about the treatment and their understanding about it. Report the information to your supervisor or the physician.

6.

What type of age-related teaching materials might you use in this situation?

Suggested solution: Video, brochure, comic type material. Find out if the catheter will be penile or suprapubic. Stress that the catheter is necessary, painless and will be removed as soon as his bladder is able to function on its own.

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