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About the Authors Audrey Berman received her BSN from the University of California– San Francisco and later returned to that campus to obtain her MS in physiologic nursing and her PhD in nursing. Her dissertation was entitled Sailing a Course through Chemotherapy: The Experience of Women with Breast Cancer. She worked in oncology at Samuel Merritt Hospital prior to beginning her teaching career in the diploma program at Samuel Merritt Hospital School of Nursing in 1976. As a faculty member, she participated in the transition of that program into a baccalaureate degree and in the development of the master of science in nursing program. Over the years, she has taught a variety of medical-surgical nursing courses in the prelicensure programs. She currently serves as
the dean of nursing at Samuel Merritt College (an affiliate of Sutter Health). Dr. Berman has traveled extensively, visiting nursing and health care institutions in Germany, Israel, Spain, Korea, Botswana, Australia, Japan, and Brazil. She serves on the board of directors for the Bay Area Tumor Institute. She is a member of the American Nurses Association and Sigma Theta Tau and is a site visitor for the Commission on Collegiate Nursing Education. She has twice participated as an NCLEX-RN item writer for the National Council of State Boards of Nursing. She is certified as an advanced oncology nurse and as an AIDS educator and has presented locally, nationally, and internationally on topics related to nursing education, breast cancer, and technology in health care. Dr. Berman authored the scripts for more than 35 nursing skills videotapes in the 1990s. She was a coauthor of the sixth and seventh editions of Fundamentals of Nursing and, with Shirlee Snyder, coauthor of the fifth edition of Kozier & Erb’s Techniques in Clinical Nursing.
Shirlee J. Snyder graduated from Columbia Hospital School of Nursing in Milwaukee, Wisconsin, and subsequently received a bachelor of science in nursing from University of Wisconsin–Milwaukee. Because of an interest in cardiac nursing and teaching, she earned a master of science in nursing with a minor in cardiovascular clinical specialist and teaching from the University of Alabama in Birmingham. A move to California resulted in becoming a faculty member at Samuel Merritt Hospital School of Nursing in Oakland, California. Shirlee was fortunate to be involved in the phasing out of the diploma and ADN programs and development of a baccalaureate intercollegiate nursing program. She held numerous positions during her 15-year tenure at Samuel Merritt College, including curriculum coordinator, assistant director–instruction, dean of instruction, and associate dean of the Intercollegiate Nursing Program. She is an associate professor alumnus at Samuel Merritt College. Her interest and experiences in nursing education resulted in Shirlee obtaining a doctorate of education focused in curriculum and instruction from the University of San Francisco. Dr. Snyder moved to Portland, Oregon, in 1990 and taught in the ADN program at Portland Community College for 8 years. During this teaching experience she became interested in
computer-assisted instruction (CAI) and initiated Web-based assessment testing for student learning. She presented locally and nationally on topics related to using multimedia in the classroom and promoting ethnic and minority student success. Another career opportunity in 1998 led her to the Community College of Southern Nevada in Las Vegas, Nevada, where Dr. Snyder was the nursing program director with responsibilities for the associate degree and practical nursing programs for 5 years. During this time she became involved in coauthoring the fifth edition of Kozier & Erb’s Techniques in Clinical Nursing with Audrey Berman. In 2003, Dr. Snyder returned to baccalaureate nursing education. She embraced the opportunity to be one of the nursing faculty teaching the first nursing class in the baccalaureate nursing program at the first state college in Nevada, which opened in 2002. She is currently the associate dean of the School of Nursing at Nevada State College in Henderson, Nevada. Dr. Snyder is an advisory board member for the Nevada Geriatric Education Center and a member of the American Nurses Association, Sigma Theta Tau, and a variety of task groups addressing the Southern Nevada nursing shortage. She has been a site visitor for the National League for Nursing Accrediting Commission and the Northwest Association of Schools and Colleges. Dr. Snyder’s experiences in nursing education and teaching keep her current in nursing and nursing education. She appreciates all she learns from the students she has taught and her past and present faculty colleagues.
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about the Authors vii
Barbara Kozier was educated in Vancouver, British Columbia, Canada. After obtaining a bachelor of arts degree from the University of British Columbia, she entered the nursing program at that institution. After 4 years of study she graduated with a bachelor’s degree in nursing. She obtained a position at Bella Bella, an aboriginal settlement on the northern coast of British Columbia. She then nursed with the Victorian Order of Nurses providing home care. Following a position with a large general hospital as an acute care
nurse in a medical surgical unit, she taught medical and surgical nursing, pediatric nursing, psychiatric nursing, and community nursing courses at the Vancouver General Hospital School of Nursing. Ms. Kozier then enrolled at the University of Washington where she studied for 2 years, taught part time, and obtained her master of nursing title. Barbara is a member of three honor societies: Sigma Theta Tau (nursing), Pi Lambda Theta (education), and Delta Sigma Pi (Canadian Honor Society for University Women). Barbara was a member and a chair of many nursing and government committees. She wrote a number of texts and collaborated with Glenora Erb on four books: Techniques of Clinical Nursing, Fundamentals of Nursing, Concepts and Issues in Nursing Practice, and Essentials of Nursing Practice.
Glenora Lea Erb was born in Calgary, Alberta, Canada. All of her schooling took place in Calgary and, with her identical twin sister, she attended the Nursing School of Calgary General Hospital. She was awarded a gold medal when she graduated and was recognized as an outstanding bedside nurse. Following 2 years traveling in Asia, Europe, India, Australia, and
New Zealand, Ms. Erb returned to Vancouver and taught nursing at St. Paul’s Hospital School of Nursing, and later at a 2-year program at the British Columbia Institute of Technology. At this time she also coauthored textbooks on Fundamentals of Nursing, Techniques of Clinical Nursing, Concepts and Issues in Nursing Practice, and Essentials of Nursing Practice. Glen died at home December 24, 2001 of breast cancer. Her death has meant that nursing has lost a highly skilled clinical nurse and her friends and family have lost a sensitive and giving person.
Dr. Maysoon S. Abdalrahim received her BSc degree in nursing and MSc degree in nursing education from the University of Jordan, and her PhD in nursing care from the Faculty of Health and Caring Sciences, Gothenburg University, Sweden. Dr. Maysoon has been a member of the Faculty of Nursing at the University of Jordan since 1985. Her main speciality is nursing care of adult clients, and acute pain
assessment and management. Over the years, she has taught medical surgical nursing, pathophysiology, health assessment, and professional writing courses. She currently serves as the Assistant Dean for Quality Affairs. She has co-authored several textbooks about the fundamentals of sursing, nursing skills and English for nurses. She has also participated in the translation of English nursing and medical books into Arabic. Dr. Maysoon is a member of the core group in the preceptorship program, Jordanian-Swedish exchange project, a member of Sigma Theta Tau (Nursing), and a member of the quality assurance committee at the University of Jordan.
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viii about the Authors
Dr. Fathieh Abu-Moghli earned her Bachelor of Science degree from the Faculty of Nursing at the University of Jordan. She was awarded a scholarship from the university to continue her graduate studies, earning her Masterâ€™s degree and PhD in Nursing Administration from Alexandria University, Egypt. Dr. Abu-Moghli is an expert in management and leadership, curriculum building, quality improvement, and personnel management. She had occupied many academic and administrative positions within the Faculty of Nursing at the University of Jordan, as well as at the Jordan University Hospital. She has
served as director of the Studies Department at the Center of Consultation, as a member of the executive board of the Jordanian Nursing Council for four years, and as a member of the Jordanian Nurses and Midwives Council. She is a member of several committees at the faculty and university level. Jointly appointed as associate professor within the Faculty of Nursing and the Faculty of Rehabilitation Sciences at the University of Jordan, Dr. Abu-Moghli is also the vice-dean and chairperson of graduate studies at the Faculty of Nursing. She teaches at the level of undergraduate and graduate programs, and is also a reviewer for several international and prestigious journals. She works as a consultant for many national and international institutions and has presented locally, nationally, and internationally on topics related to nursing education, nursing ethics, and AIDS.
Dr. Mohammad Saleh, a registered nurse, tissue viability specialist, and Ph.D-holder, was born in Amman, Jordan. He is now an assistant professor and head of adult health nursing within the Clinical Nursing Department at the University of Jordan. He received his Bachelor of Science in nursing from the University of Jordan in 1995, and began his nursing career at the Ministry of Health Hospitals, Jordan. While practicing nursing, he gave continuing education seminars regarding the nursing implication of dealing with surgical and critically-ill patients. A decade ago, he moved to the United Kingdom and settled in Leicester city, where he received his MPhil and Ph.D in Nursing from De Monte Forte University.
Ultimately, Dr. Saleh would like to use his knowledge of caring for critically ill patients, and the principles of tissue viability nursing, to create new knowledge, through research and close study of relevant populations, utilizing critical thinking, therapeutic communication, and appropriate teaching, management, and consultative skills in the exercise of professional responsibilities. He would like to engage in the teaching process for subjects including fundamentals of nursing, applied research, community health, and medical and surgical nursing, and in instructional development to contribute not only to the general knowledge base in the field of nursing but also to the ways in which knowledge is created and shared. Dr. Saleh continues to teach in undergraduate and graduate programs at the University of Jordan in Amman, and had published work in the field of tissue viability nursing, nursing education, nursing management, critical care nursing, and nursing research.
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Brief contents Special Features 000
Chapter 12 Activity and Exercise 000
Chapter 13 Oxygenation 000
Chapter 14 Fluid, Electrolyte, and Acid–Base Balance 000
Acknowledgments 000 Chapter 1 Nursing: Historical and Current Practice 000 Chapter 2 Health, Wellness, and Illness 000 Chapter 3 Legal Aspects of Nursing 000 Chapter 4 Values, Ethics, and Advocacy 000 Chapter 5 Culture and Heritage 000
Chapter 15 Nutrition 000 Chapter 16 Elimination 000 Chapter 17 Sleep 000 Chapter 18 Pain Management 000 Chapter 19 Promoting Psychosocial Health 000 Chapter 20 Medications 000 Chapter 21 Perioperative Nursing 000
Chapter 6 Critical Thinking and the Nursing Process 000
Chapter 22 Circulation 000
Chapter 7 Vital Signs 000
Appendix A 000
Chapter 8 Health Assessment 000
Appendix B 000
Chapter 9 Safety and Infection Control 000
Appendix C 000
Chapter 10 Hygiene 000 Chapter 11 Skin Integrity and Wound Care 000
English-Arabic Glossary 000 Index 000 Credits 000
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Table of Contents About the Authors vi Preface xv Contributors xxx Thank You xxii Special Features xii Chapter 1
Values, Ethics, and Advocacy 000 Values 000 Morality and Ethics 000 Nursing Ethics 000 Specific Ethical Issues 000 Advocacy 000
Culture and Heritage 000 Cultural Nursing Care 000 Concepts Related to Cultural Nursing Care 000
Vital Signs 000 Body Temperature 000 Pulse 000 Respirations 000 Blood Pressure 000 Oxygen Saturation 000
Health Assessment 000 Physical Health Assessment 000 General Survey 000 The Integument 000 The Head 000 The Neck 000 The Thorax and Lungs 000 The Cardiovascular and Peripheral Vascular Systems 000 The Breasts and Axillae 000 The Abdomen 000 The Musculoskeletal System 000 The Neurologic System 000 The Female Genitals and Inguinal Area 000 The Male Genitals and Inguinal Area 000 The Rectum and Anus 000 Diagnostic Testing 000
Legal Aspects of Nursing 000 General Legal Concepts 000 Regulation of Nursing Practice 000 Contractual Arrangements in Nursing 000 Selected Legal Aspects of Nursing Practice 000 Areas of Potential Liability in Nursing 000 Legal Protections in Nursing Practice 000 Reporting Crimes, Torts, and Unsafe Practices 000 Legal Responsibilities of Students 000
Critical Thinking and the Nursing Process 000 Critical Thinking 000 The Nursing Process 000 Assessing 000 Diagnosing 000 Planning 000 Implementing 000 Evaluating 000 Documenting and Reporting 000 Reporting 000
Health, Wellness, and Illness 000 Concepts of Health, Wellness and Well-Being 000 Models of Health and Wellness 000 Variables Influencing Health Status, Beliefs, and Practices 000 Health Care Adherence 000 Illness and Disease 000
Nursing: Historical and Current Practice 000 History of Nursing 000 Current Nursing Practice 000 Roles and Functions of the Nurse 000 Criteria of a Profession 000 Factors Influencing current Nursing Practice 000 Nursing Education 000 Types of Educational Programs 000 Nursing Research and Evidence-Based Practice 000 Health Care Delivery Systems 000 Types of Health Care Agencies and Services 000 Providers of Health Care 000
Selected Parameters for Cultural Nursing Care 000 Providing Culturally Sensitive Nursing Care 000
Safety and Infection Control 000 Factors Affecting Safety 000 Infection Control 000 Isolation Precautions 000 Isolation Practices 000 Sterile Technique 000 Role of the Infection Control Nurse 000
Chapter 10 Hygiene 000 Hygienic Care 000 Skin 000 Feet 000
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table of Contents xi
Nails 000 Mouth 000 Hair 000 Eyes 000 Ears 000 Nose 000 Supporting a Hygienic Environment 000 Making Beds 000
Chapter 11 Skin Integrity and Wound Care 000 Skin Integrity 000 Types of Wounds 000 Pressure Ulcers 000 Wound Healing 000
Chapter 12 Activity and Exercise 000 Normal Movement 000 Exercise 000 Factors Affecting Body Alignment and Activity 000 Effects of Immobility 000
Chapter 13 Oxygenation 000 Structure and Function of the Respiratory System 000 Respiratory Regulation 000 Factors Affecting Respiratory Function 000 Alterations in Respiratory Function 000
Chapter 14 Fluid, Electrolyte, and Acid–Base
Body Fluids and Electrolytes 000 Acid–Base Balance 000 Factors Affecting Body Fluid, Electrolytes, and Acid–Base Balance 000 Disturbances in Fluid Volume, Electrolyte, and Acid–Base Balances 000
Chapter 15 Nutrition 000 Essential Nutrients 000 Energy Balance 000 Body Weight and Body Mass Standards 000 Factors Affecting Nutrition 000 Nutritional Variations Throughout the Life Cycle 000 Standards for a Healthy Diet 000 Altered Nutrition 000
Chapter 16 Elimination 000 Urinary Elimination 000 Factors Affecting Voiding 000 Urinary Elimination Problems 000 Fecal Elimination 000 Factors that Affect Defecation 000 Fecal Elimination Problems 000 Bowel Diversion Ostomies 000
Chapter 17 Sleep 000 Physiology of Sleep 000 Functions of Sleep 000
Normal Sleep Patterns and Requirements 000 Factors Affecting Sleep 000 Common Sleep Disorders 000
Chapter 18 Pain Management 000 The Nature of Pain 000 Physiology of Pain 000
Chapter 19 Promoting Psychosocial Health 000 Self-Concept 000 Factors That Affect Self-Concept 000 Spirituality 000 Sexual Health 000 Stress 000 Loss and Grief 000 Dying and Death 000
Chapter 20 Medications 000 Drug Standards 000 Legal Aspects of Drug Administration 000 Effects of Drugs 000 Drug Misuse 000 Actions of Drugs on the Body 000 Factors Affecting Medication Action 000 Routes of Administration 000 Medication Orders 000 System of Measurement 000 Administering Medications Safely 000 Oral Medications 000 Nasogastric and Gastrostomy Medications 000 Parenteral Medications 000 Respiratory Inhalation 000 Irrigations 000
Chapter 21 Perioperative Nursing 000 Types of Surgery 000 Preoperative Phase 000 Intraoperative Phase 000 Postoperative Phase 000
Chapter 22 Circulation 000 Physiology of the Cardiovascular System 000 Factors Affecting Cardiovascular Function 000 Alterations in Cardiovascular Function 000
Appendix A 000 Appendix B 000 Appendix C 000 English-Arabic Glossary 000 Index 000 Credits 000
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Assessment Interview Activity and Exercise 000 Giving and Removing a Bedpan 000 Heritage Assessment Tool 000 Oxygenation 000 Sleep Disturbances 000
Client Teaching Active ROM Exercises 000 Administering Medications At Home 000 Breathing and Coughing Exercises 000 Client Self-Management of Pain 000 Controlling Postural Hypotension 000 Foot Care 000 Guidelines for Healthy Nutrition 000 Healthy Defecation 000 Home Care Activity and Exercise 000 Home Care and Circulation 000 Home Care and Fluid, Electrolyte, and Acid–Base Balance 000 Home Care Oxygenation 000 Managing Diarrhea 000 Managing Pain in the Home Setting 000 Minimal Requirements for Physical Activity 000 Pelvic Muscle Exercises (Kegel Exercises) 000 Preparing for Diagnostic Testing 000 Promoting a Healthy Heart 000 Promoting Fluid and Electrolyte Balance 000 Promoting Sleep 000 Skin Problems and Care 000 Sleep at Home 000 Suctioning a Tracheostomy or Endotracheal Tube at Home 000 Suctioning in the Home 000 Tracheostomy Care at Home 000 Using a Bed or Chair Exit Safety Monitoring Device in the Home 000 Using a Metered-Dose Inhaler 000
Using an Incentive Spirometer 000 Using Canes 000 Using Cough Medications 000 Using Crutches 000 Using Walkers 000
Clinical Manifestations Circulation 000 Fever 000 Hypothermia 000 Hypoxia 000 Impending Clinical Death 000 Insomnia 000 Malnutrition 000 Stress 000
Nursing Care Plan A Client Experiencing Pain 000 Administering Medications 000 Deficient Fluid Volume 000 For a Client at Risk of Postoperative Surgical Site Infection 000 For a Client with a Complication Due to Infection 000 For a Client with Imbalanced Nutrition 000 For A Client With Skin Problems 000, 344 For Clients at Risk for Impaired Skin Integrity 000 For Ineffective Airway Clearance 000 Individualizing Care for Clients with Pain 000 Risk for Disuse Syndrome 000 Sleep 000
Practice Tips Administering Medications by Nasogastric or Gastrostomy Tube 000 Administering Metered-Dose Inhalers and Nebulizers to 000 Applying Restraints ( 000
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Special Features xiii
Assessing Surgical Wounds ( 000 Assessment for Postural Hypotension 000 Bed-Making 000 Caring for Clients with a Venous Access Device 000 Communication during an Interview 000 Documentation 000 Eye Care for the Comatose or Unconscious Client 000 Legal Protection for Nurses 000 Pressure Ulcer Prevention and Treatment 000 Preventing Catheter-Associated Urinary Infections 000 Providing Passive ROM Exercises 000 Reporting a Crime, Tort, or Unsafe Practice 000 Safe Use of Stretchers 000 Steps to Follow after Exposure to Bloodborne Pathogens (Follow Agency Policy for Variations) 000 Supporting Religious Practices 000 Techniques for Therapeutic Communication 000 Vein Selection and Easier Starting of Intravenous Infusions 000 Wheelchair Safety 000
Research Notes Are Nurses Committed to Medication Error? 000 Can Children Describe Their Own Pain, and How Do Their Descriptions Match Those of Their Parents? 000 Do the Weather Conditions Affect Total Body Water? 000 Does Cultural Background Influence the Perception of Pain? 000 Does Pressure Ulcer Risk Assessment Have an Impact on Hospitalized Patient Outcomes? 000 Does Providing Preoperative Education Reduce Anxiety and Promote Recovery in Open-Heart Surgery? 000 How Do Differences in Social and Religious Culture Affect Delivery of Health Care? 000 How Do Muslim Women Describe their Experiences in Intensive Care Units? 000 How do Saudi Arabian Nurses Perceive Nursing Care? 000 How Do Surgical Nurses Perceive Clients Suffering from Pain? 000 How does Parental Smoking Influence the Risk of Respiratory Symptoms among School Boys in Al-Khobar City, Saudi Arabia? 000 Is the Current Nursing Practice of Caring for Patients Receiving Blood Transfusions Sufficient to Prevent the Anticipated Risks? 000 Is There a Relationship Between Sleep Duration and Quality, Diet, and Hormones of Obesity? 000 Is There a Relationship Between Sleep Duration and Quality, Diet, and Obesity Hormones? 000
What Actions Should be Taken to Combat Obesity and Promote Physical Activity in Arab Countries? ( 000 What are Islamic Religious Leaders’ Knowledge and Attitudes towards AIDS and their Perception of People Living with HIV/AIDS? ( 000 What are Patients’ Preferences for Nurses’ Gender in Jordan? 000 What are the Distribution and Resistance Trends of Uropathogens in Sharjah, UAE? 000 What are the Factors Associated with the High Prevalence of Obesity in the Eastern Mediterranean Region? 000 What are the Features of Cardiovascular Diseases in Arab Countries? 000 What are the Implications of Physical Inactivity on the Health of the Saudi Society? 000 What are the Most Common Indications for Tracheostomy in the UAE? 000 What are the Prevailing Sleep Patterns and Problems Among School Children? 000 What Challenges to Health Care Delivery do the Differences in Cultural and Religious Beliefs of Arab American Patients Pose? 000 What Factors Affect Elderly People’s Acceptance of Home Care and Nursing Homes? 000 What is the Status of Nursing in the Arab World? 000 Would Incontinent Arab Females Seek Health Care? 000
Skills Adding Medications to Intravenous Fluid Containers 000 Administering a Gastrostomy or Jejunostomy Feeding 000 Administering a Subcutaneous Injection 000 Administering a Tube Feeding 000 Administering an Enema 000 Administering an Intradermal Injection for Skin Tests 000 Administering an Intramuscular Injection 000 Administering Intravenous Medications Using IV Push 000 Administering Ophthalmic Instillations 000 Administering Oral Medications 000 Administering Otic Instillations 000 Administering Oxygen by Cannula, Face Mask, or Face Tent 000 Administering Vaginal Instillations 000 Applying an External Catheter 000 Applying Antiemboli Stockings 000 Applying Restraints 000 Assessing a Peripheral Pulse 000 Assessing an apical pulse 000 Assessing an Apical-Radial Pulse 000 Assessing Blood Pressure 000
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xiv Special Features
Assessing Body Temperature 000 Assessing Respirations 000 Assessing the Abdomen 000 Assessing the Breasts and Axillae 000 Assessing the Ears and Hearing 000 Assessing the Eye Structures 000 Assessing the Eye Visual Acuity and Visual Fields 000 Assessing the Heart and Central Vessels 000 Assessing the integument 000 Assessing the Mouth and Oropharynx 000 Assessing the Musculoskeletal System 000 Assessing the Neck 000 Assessing the Neurologic System 000 Assessing the Nose and Sinuses 000 Assessing the Peripheral Vascular System 000 Assessing the Skull and Face 000 Assessing the Thorax and Lungs 000 Assisting the Client to Ambulate 000 Assisting the Client to Sit on the Side of the Bed (Dangling) 000 Bathing an Adult or Pediatric Client 000 Brushing and Flossing the Teeth 000 Cardiopulmonary Resuscitation 000 Changing a Bowel Diversion Ostomy Appliance 000 Changing an Intravenous Container, Tubing, and Dressing 000 Changing an Occupied Bed 000 Changing an Unoccupied Bed 000 Cleaning a Sutured Wound and Applying a Sterile Dressing 000 Discontinuing an Intravenous Infusion 000 Donning a Sterile Gown and Gloves (Closed Method) 000 Donning and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear) 000 Donning and Removing Sterile Gloves (Open Method) 000 Establishing and Maintaining a Sterile Field 000 Hand Washing 000 Implementing Seizure Precautions 000 Initiating and Maintaining a Blood Transfusion Using a Y-Set 000
Inserting a Nasogastric Tube 000 Insertion of an Oropharyngeal Airway 000 Irrigating a Wound 000 Logrolling a Client 000 Managing Gastrointestinal Suction 000 Measuring Oxygen Saturation 000 Mixing Medications Using One Syringe 000 Monitoring an Intravenous Infusion 000 Moving a Client Up in Bed 000 Nursing Interventions for Clients with Endotracheal Tubes 000 Obtaining a Capillary Blood Specimen to Measure Blood Glucose 000 Obtaining a Wound Drainage Specimen for Culture 000 Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning 000 Performing Bladder Irrigation 000 Performing Urethral Urinary Catheterization 000 Preparing Medications from Ampules 000 Preparing Medications from Vials 000 Providing a Back Massage 000 Providing Foot Care 000 Providing Hair Care for Clients 000 Providing Perineal-Genital Care 000 Providing Special Oral Care for the Unconscious Client 000 Providing Tracheostomy Care 000 Removing a Nasogastric Tube 448 Removing, Cleaning, and Inserting a Hearing Aid 274 Shampooing the Hair of a Client Confined to Bed 272 Starting an Intravenous Infusion 409 Suctioning a Tracheostomy or Endotracheal Tube 371 Teaching Moving, Leg Exercises, Deep Breathing, and Coughing 641 Terminating a Blood Transfusion 419 Transferring between Bed and Chair 333 Transferring Between Bed and Stretcher 334 Turning a Client to the Lateral or Prone Position in Bed 329 Using a Bed or Chair Exit Safety Monitoring Device 208
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Preface Nurses today must be able to grow and evolve to meet the demands of a dramatically changing health-care system. The technological advances, the emphasis on quality and health care cost and shifting the focus of health care delivery from an illness perspective to disease prevention and health promotion have all contributed to the complexity of nurses’ role. Nurses have to care for chronic illnesses associated with increased life expectancy and health problems related to lifestyle versus previously prevalent infectious diseases. The unique role of the nurse demands a blend of nurturance, sensitivity, caring, empathy, commitment, and skill founded on a broad base of knowledge. Nurses need skills in technology, communication, and interpersonal relations to be effective members of the collaborative health-care team. They need to think critically and be creative in implementing nursing strategies with clients of diverse cultural backgrounds in increasingly varied settings and implementing change where necessary. They need skills in teaching, leading, managing and ethical decision making. They need to understand holistic healing modalities and complementary therapies. Fundamentals of Nursing: Concepts, Process, and Practice, Arab World Edition, addresses concepts of contemporary professional nursing in the Arab world. These concepts include, but are not limited to, caring, wellness, health promotion, disease prevention, holistic care, multiculturalism, nursing theories, nursing informatics, nursing research, ethics, and advocacy. In this edition, every chapter has been extensively revised, with content being updated and tailored to reflect the practice of nursing across the Middle East, and specifically the Arab world. The Arab world is highly influenced by culture and religion. In addition, environmental and social problems are increasing in complexity and variability. Therefore, nursing education programs need to prepare nurses to utilize a culturally-sensitive approach to nursing care. In this text, students of nursing are introduced to a challenging and rewarding profession from both the perspective of the nurse and a holistic understanding of clients within the Arab context. This book is designed to guide nursing students in the Arab world in the foundation level of the baccalaureate program at nursing schools. It will aid students to acquire the basic knowledge and skills that are necessary to care for individual, family and community clients across the lifespan and along the illnesswellness continuum in a variety of settings.
The Arab World Edition The eighth U.S. edition of this text, Fundamentals of Nursing: Concept, Process and Practice, as well as previous U.S. editions, is considered a valuable text in the Arab world. It has been adopted in many faculties of nursing across the Arab
world, especially in Jordan and the Gulf area, for years. The eighth edition, in particular, provided the core knowledge and skills needed to deliver timely, sensitive, quality, and individualized care to the individuals, families and communities with whom the nurse works. However, we, as faculty members and nursing educators, found that while the book was comprehensive and reflects the standards of care used in many global areas, it needed to be modified to address the Arab world’s standards and resources. We believe that the following updates in this Arab World Edition increase the value of the book for Arab nursing students and future nurses: n
Reflecting the culture and focusing on issues related to Arab and religious culture that affect the nursing care of individuals. Reduction in the length of the book, from 52 to 22 chapters. This will help the students and instructors focus on the knowledge and skills that are really needed at the foundation level of nursing practice. Summarizing, without affecting the merit of the content, makes the book more accessible, affordable, and easier to handle and read. Cutting down details that are thought to be unessential as they relate to systems or strategies (i.e. problem-oriented medical records and computerized records) not in use in some Arab countries. Emphasis on the Arab world’s nursing practices, using studies and evidence-based references supporting current nursing practices in the Arab world and clinical examples from the region. Using simple language appropriate to students for whom English is a second language, and using Arabic names to make the book more engaging and accessible to students in the Arab world.
New Features For years, Fundamentals of Nursing has been a gold standard that helps students embark on their careers in nursing. This Arab World Edition retains many of the features that have made this textbook the number-one choice of nursing students and faculty. We have also added opening case studies and closing critical reflections in each chapter to give students an insight into the type of real-world cases they might be faced with, giving them an opportunity to see how theory is applied to real cases, encouraging them to reflect on what they have learnt and how it may be applied to real situations. The Arab World Edition also features regional Research Notes, reinforcing the theory presented in the text. These also demonstrate how nursing studies in the Arab world have contributed to our understanding of nursing practices, and allow students to examine real research conducted across the region.
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Supplements To supplement the textbook, we have included a variety of instructor aids in our supplements package. INSTRUCTORâ€™S RESOURCE MANUAL. This manual contains a wealth of material to help faculty plan and manage the Fundamentals of Nursing course. It includes chapter overviews, detailed lecture suggestions and outlines, learning outcomes, tips, and more for each chapter. POWERPOINT SLIDES. For use in class, these slides include the key topics and figures from the book to supplement your lectures. TEST GENERATOR. An electronic test generator lets you view and edit testbank questions, transfer questions to tests, and print the test in a variety of customized formats
Thanks We wish to extend a sincere thank you to the talented team involved in producing the Arab World Edition of this book. In particular, we would like to express our deepest appreciation and gratitude to our Senior Development Editor, Sophie Bulbrook, for her meticulous and exceptional efforts to make this work a success and for her exceptional ability to coordinate the Arab World Editions team. Our appreciation also extends
to Rasheed Roussan, Acquisitions Editor, for his dedication to working with us as a team. Our thanks also extend to Michelle Thomson and Kate Sherington, Project Editors, and Christopher Crow, Senior Manufacturing Controller; for producing this book with precision, and to our designer, Sarah Fach, for managing the beautiful design. Many of the photos in this Arab World Edition were photographed by Patrick Watson, setting courtesy of the School of Nursing at Nevada State College. Last, but not least, we would like to acknowledge nursing students of the Arab world, our nurses and leaders of the future. Our dear students: you are called to open your eyes, minds, and hearts. You are called to see, read, understand, comprehend, and appreciate the opportunity you have to become nurses, and the gift you have been awarded to work with those in need of your care and passionate attention. You are called to become the bright future of the profession of nursing. We hope that this Arab World Edition will be appreciated by nursing students and educators in the region, and in the wider world. Fathieh Abdullah Abu-Moghli Maysoon Salim Abdalrahim Mohammad Saleh
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Nursing Excellence for the Next
Nursing Excellence Starts Here! Fundamentals of Nursing continues to set the foundation for nursing excellence. Now in it’s eighth edition. Fundamentals of Nursing is designed for success in today’s classroom and to prepare tomorrow’s nurses.
Excellence from the Start….
ChApter 1 / Nursing: historical and Current practice 19
Start by reviewing learning outcomes and key terms. criticaL reFLectiOn
Learning Outcomes help critical concepts. to stand in class and talkidentify about nursing history, roles of the nurse, future career opportunities, and nursing professional qualities? Let us return to the opening case study at the start of this chapter. Now that you have read the chapter, do you feel confidence
Nursing: Historical and Current Practice
Before doing so, try to write a short essay about nursing status in your country and ask your instructor permission to present it in class, and then request feedback from your colleagues and instructor to improve your essay. this will prepare you to answer any questions raised while performing this community service activity.
Learning OutcOmes After completing this chapter, you will be able to: 1. Discuss historical and current factors influencing the development of nursing. 2. Identify the essential aspects of nursing.
3. Identify four major areas within the scope of nursing practice.
historical perspectives of nursing practice reveal recurring themesChApter 1 n / Some professional organizations have 19 recommended that Nursing: historical and Current practice or influencing factors. Women have traditionally cared for others, minimum entry into practice be at the baccalaureate or master’s beginning with Arab women in early Islam. Visionary leaders have degree level made notable contributions to improve the status of nursing. n the concept of research has been introduced into nursing education programs, and research journals in nursing have been n the scope of nursing practice includes promoting wellness, developed. preventing illness, restoring health, and caring for the dying. n Although traditionally the majority of nurses were employed in n Both quantitative and qualitative research involve identifying hospital settings, today the numbers of nurses working in home a research problem/question, collecting data, and analyzing health care, and community health settings are increasing. the data. Quantitative studies are reported using descriptive analytical statistics, and qualitative studies are reported in n everycase nurse may at function in aofvariety of roles that notyou have read theand Let us return to the opening study the start this chapter. Noware that chapter, do you feel confidence narrative format. exclusive of one another. these roles include caregiver, to stand in class and talk about nursing history, roles of the nurse, future career opportunities, and nursing professional qualities? communicator, teacher, client advocate, counselor, change n health care delivery services can be categorized by the type of Before doing so, try to write a short essay about nursing status in your country and ask your instructor permission to present it agent, leader, manager, case manager, and research consumer. service: (a) primary prevention: health promotion and illness in class, and then request feedback from your colleagues and instructor improve your essay.prevention, this will prepare you toprevention: answer diagnosis and treatment, (b) secondary n With advanced education and experience, nurses cantofulfill any questions raised while performing this community service activity. and (c) tertiary prevention: rehabilitation, health restoration, and advanced practice roles such as clinical nurse specialist, palliative care. nurse practitioner, nurse midwife, nurse anesthetist, educator, administrator, and researcher. n hospitals provide a wide variety of services on an inpatient and outpatient basis. hospitals can be categorized as n Current nursing practice is influenced by cultural and religious cHaPter HigHLigHts public or private, acute care or long-term care. Many other values, economics, consumer demand, family structure, n historical perspectives of nursing practice recurring themes information n Some have recommended that and day-care centers, also settings, such as clinics, offices, gender issues,reveal science and technology, and professional organizations or influencing factors. Women have traditionally cared for others, entry into practiceprovide be at the baccalaureate or master’s care. telecommunications, legislation, demographic and minimum social changes, beginning with Arab womenthe in early Islam. Visionary have degree level nursing shortage, andleaders the work of nursing organizations. n Various providers of health care coordinate their skills to assist made notable contributions to improve the status of nursing. n the concept of research has been introduced into nursing a client. their mutual goal is to restore a client’s health and n Nursing education curricula are continually undergoing revisions 20 the Naturepromoting of Nursing wellness, education programs, and research in nursing have been n the scope of nursing practice includes promotejournals wellness. in response to new scientific knowledge and technological, developed. preventing illness, restoring cultural, health, and caringand forsocioeconomic the dying. political, changes in society. n Although traditionally the majority of nurses were employed in n Both quantitative and qualitative research involve identifying hospital settings, today the numbers of nurses working in home a research problem/question, collecting data, and analyzing health care, and community health settings nurse are increasing. the data. Quantitative studies are reported usingcounseling descriptivefor young adults with a strong family 3. Nutrition 5. A student is caring for Mr Ahmad, a 72-year-old Arab test yOur KnOWLedge and analytical studiesofare reported in n every nurse may function in a variety ofwho roles not after being hospitalized. high cholesterol client isthat veryare upset the moststatistics, and qualitativehistory format. exclusive of one another. these roles include caregiver, 2. A4. study examining the bereavement process in spouses 1. health promotioncommunication is best represented by should which narrative of the which removal of tonsils for a client with recurrent tonsillitisof appropriate strategy include communicator, teacher, clientfollowing advocate, counselor, change n health care delivery services can be categorized by thecancer type of of theactivities? following? 7. clients Which with of theterminal following statements is true regarding types of agent, leader, manager, case manager, and research service: (a) primary prevention:3.health promotion and illness Ahealth study exploring factors influencing weight control 1. Administering 1. Asking hisimmunizations son consumer. to make decisions for him care agencies? prevention, (b) secondary prevention: diagnosis and treatment, n With advanced education and 2. experience, nurses behavior Giving a bath 2. Speaking to can himfulfill very loudly 1. hospitals provide only acute, inpatient services. and (c) tertiary prevention: rehabilitation, health restoration, advanced practice roles such as nurse specialist, 4. A2. study examining a client’sand feelings before and after a to 3. clinical preventing accidents in the home 3. Using gentle touch while providing morning care public health agencies are funded by governments palliative nurse practitioner, nurse midwife, nurse anesthetist, educator, boneinvestigate marrow aspiration 4. performing diagnostic procedures 4. Including him in the decisions related to his carecare. and provide health programs. administrator, and researcher. n hospitals provide a wide variety of services on an inpatient 4. the use of a qualitative research process is most appropriate 3. Surgery can only be performed inside a hospital setting. 2. Which of the following social forces is most likely to 6. Which of the following is an example of a primary prevention and outpatient basis. hospitals can beofcategorized asstudies? n Current nursing practice is influenced by cultural and religious for which thenursing, following 4. Skilled extended care, and long-term care facilities significantly activity?impact the future supply and demand for nurses? public or private, acute care or care. Many other and weight loss or gain in values, economics, consumer demand, family structure, 1. long-term A study measuring provide care fornutrition the elderly whose insurance no longer 1. Aging 1. Antibiotic treatment of a suspected urinary tract settings, such as clinics, offices, clients and day-care centers, also gender issues, science and technology, information and with hospital cancer covers stays. 2. economics infection provide care. telecommunications, legislation, demographic and social changes, 2. A study examining oxygen levels after endotracheal 3. Science/technology 2. Occupational therapy to assist a client in adapting his or see coordinate answers to test Your Knowledge . the nursing shortage, and the work of nursing organizations. n Various providers of health care skills to assistin appendix a suctioningtheir 4. telecommunications her home environment following a stroke a client. their mutual goal is to3.restore a client’s health andreactions to stress after open n Nursing education curricula are continually undergoing revisions A study examining client 3. Quantitative research is most appropriate for which promote wellness. in response to new scientific knowledge and technological, heart surgery of the following cultural, political, and socioeconomic changesstudies? in society. 4. A study measuring differences in blood pressure before, 1. A study measuring the effects of sleep deprivation on during, and after a procedure wound healing n
4. Describe the diverse roles of nurses and the expanded career roles. 5. Discuss the criteria of a profession and the professionalization of nursing. 6. Describe factors that could influence current nursing practice.
7. Explain the functions of national and international nurses’ associations. 8. Describe the different types of educational nursing programs in the Arab world. 9. Explain the importance of quantitative and qualitative research in nursing practice. 10. Differentiate health care services based on primary, secondary, and tertiary disease-prevention categories 11. Identify the various roles of health care professionals.
…To the Finish M01_KOZI7296_00_SE_C01.indd 1
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The end of each chapter summarizes and applies chapter information. Chapter highlights focus your attention and review critical concepts.
Test your knowledge helps you prepare for the NCLEXRN® test yOur KnOWLedge exam. Alternative-style questions are also included.
Abu-Mogli, F., Nabolsi, M., Khalaf, I., & Suliman, W. (2010). Islamic religious leaders’ knowledge and attitudes towards AIDS and their perception of
ember, C. r., ember, M., & peregrine, p. N. (2002). Anthropology (10th ed.). Upper Saddle river, NJ: prentice hall.
J. I., & Miller, S. (2005). Caring for patients while respecting their people living with hIV/AIDS: A qualitative study. Scandinavian Journal of 2. A study examining the erickson, bereavement process in spouses of 1. health promotion is best represented by which of the privacy: renewing our commitment. Online Journal of Issues in Nursing, Caring Sciences, 24(4), 655–662. clients with terminal cancer following activities? 10(2), Manuscript 2. retrieved June 11, 2006, from http://www. Adubato, S. (2004). Making the communication connection. Nursing nursingworld.org/MainMenuCategories/ANAMarketplace/ANAperiodicals/ Management, 35(9), 33–35. 3. A study exploring factors influencing weight control 1. Administering immunizations OJIN/tableofContents/Volume102005/No2May05/tpc27_116017.aspx Agency for healthcare research and Quality. (2005). Guide tobehavior health care 2. Giving a bath M01_KOZI7296_00_SE_C01.indd 19 June 24, 2006, from http://www.ahrq.gov/consumer/ 8/10/11 Fitzgerald, M. h. (2001). Gaining knowledge of culture during professional quality. retrieved 4. A study examining a client’s feelingsInbefore a (eds.), Practice knowledge and 3. preventing accidents in theguidetoq home education. J. higgs,and & A.after titchen bone aspiration expertise in the health professions (pp. 149–156). Oxford: Butterworth Ahmed, A. A. (2008). health and disease: An Islamic framework. In marrow A. 4. performing diagnostic procedures
References give you source for supporting and evidencebased material and additional information.
Sheikh, & A. r. Gatrad (eds.), Caring for Muslim patients (2nd ed.,
4. the use of a qualitative research process is most appropriate 2. Which of the following social forces is most likelyradcliffe to Gallagher, e., & Searle, C. (1985). health services and the political culture of pp. 35–43). Oxford: publishing. for which the following studies? significantly impact the future supply demand for nurses? Saudi Arabia. Social Science & Medicine, 21(3), 251–262. Aiken, L. h., and Clarke, S. p., Cheung, r. B., Sloane, D. M., & Silber, S. h. of (2003). Gordon, S., weight & Nelson, S. (2005). educational levels of hospital nurses and surgical patient 1. mortality. A study measuring nutrition and loss or gain An in end to angels. Moving away from the 1. Aging virtue script toward a knowledge-based identity for nurses. American Journal of the American Medical Association, 290(12),1617–1623. clients with cancer 2. economics Journal of Nursing, 105(5), 62–69. Amugi-Crouch, A., & Meurier, C. (2005). Cultural and spiritual health 2. (p A 311–330) study examining oxygen levels endotracheal 3. Science/technology Graber, D. r.,after & Mitcham, M. D. (2004). Compassionate clinicians: take assessment. Vital Notes for Nurses: Health Assessment. suctioning patient care beyond the ordinary. Holistic Nursing Practice, 18(2), Wiley-Blackwell. 4. telecommunications 87–94. to stress after open Al-Shahri, M. (2002). Culturally sensitive caring for Saudi patients. reactions 3. Quantitative research is most appropriate for which Nursing, 13(2), 133–138. 3. A study examining client hall, L., & Doran, D. (2004). Nurse staffing, care delivery model, and patient Journal of Transcultural surgery care quality. Journal of Nursing Care Quality, 19(1), 27–33. statement of the following studies? American Nurses Association. (2003). Nursing: A social policyheart 4. A study measuring differences inM.,blood pressure before, hasanain, Connell, K., Menon, U., & tranmer, p. (2010). patient-centered (2ndof ed.). Kansas City, MO: on Author. 1. A study measuring the effects sleep deprivation care American Nurses Association. (2006). ANA hall of fame. retrieved April 23, during, and after a procedure for Muslim women: provider and patient perspectives. Journal of wound healing
2006, from http://www.ana.org/hof/richla.htm Anspaugh, D. J., hamrick, M. h., & rosata, F. D. (2003). Wellness: Concepts and applications. New York, NY: McGraw-hill. Azaizeh, h., Saad, B., Khalil, K., & Said, O. (2006). the state of the art of traditional Arab herbal medicine in the eastern region of the Mediterranean: A review. Evidence-Based Complementary and Alternative Medicine 3(2), 229–235. Baumann, S. L. (2004). Similarities and differences in experiences of hope. Nursing Science Quarterly, 17(4), 339–344. Beyea, S. C. (2004). Improving verbal communication in clinical care. AORN Journal, 79(5), 1053–1057. Boggatz, t., Farid, t., Mohammedin, A., & Dassen, t. (2009). Factors related to the acceptance of home care and nursing homes among older egyptians: A cross-sectional study. International Journal of Nursing Studies, 46(12), 1585–1594. Brown, G. (2004). Nursing and its future status. Minority Nurse Newsletter, 11(1), 1. Cashion, A. K., Driscoll, C. J., & Sabek, O. (2004). emerging genetic technologies in clinical and research settings. Biological Research for Nursing, 5(3), 159–167. Coffman, M. J. (2004). Cultural caring in nursing practice: A meta-synthesis of qualitative research. Journal of Cultural Diversity, 11(3), 100–109. DeLenardo, C. (2004). Web-based tools steer patient-focused care. Nursing Management, 35(12), 60–64. Dhami, S., & Sheikh, A. (2000). the Muslim family: predicament and promise. Western Journal of Medicine, 173(5), 352–356. Dowling, M. (2004). exploring the relationship between caring, love and intimacy in nursing. British Journal of Nursing, 13(21), 1289–1292.
Women’s Health, 20(1), 73–83. hjelm K., Bard K., Berntorp, K. & Apelqvist, J. (2009). postpartum in women born in Sweden and the Middle east. Midwifery, 25(5), 564–575. International Council of Nurses. (2005). About the International Council of Nurses. retrieved June 19, 2006, from http://www.icn.ch/ abouticn. htm Jan, r. (1996). rufaida Al-Asalmiy, the first Muslim nurse. Image – the Journal of Nursing Scholarship, 28(3), 267–268. Liu, K. (2003). Breakthroughs in cancer 8/10/11 gene therapy. 5:06 PMSeminars in Oncology Nursing, 19(3), 217–226. Lovering, S. (2008). Arab Muslim nurses’ experiences of the meaning of caring. Unpublished Doctor of health Science thesis, University of Sydney, Australia. Mahasneh, S. M. (2001). Islamic teachings and practices concerning death, dying and bereavement. Amman Malath Foundation for humanistic Care. Malloch, K., & porter-O’Grady, t. (2005). Introduction to evidence-based practice in nursing and health care. Sudbury, MA: Jones & Bartlett. Marrone, S. (2008). Factors that influence critical care nurses’ intentions to provide culturally congruent care to Arab Muslims. Journal of Transcultural Nursing, 19(9), 8–15. Melnyk, B. M., & Fineout-Overholt, e. (2004). Evidence-based practice in nursing and healthcare. philadelphia, pA: Lippincott Williams & Wilkins. Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York: Dover Books (original work published 1860). polit, D. F., & Beck, C. t. (2005). Essentials of nursing research: Methods, appraisal, and utilization (6th ed.). philadelphia, pA: Lippincott Williams & Wilkins.
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Client-focused Nursing Evidence- ChApter 17/ Sleep 509
n n n n n n n
how would you describe your sleeping problem? What changes have occurred in your sleeping pattern? how often does this happen? how many cups of coffee, tea, or caffeinated beverages do you drink per day? Do you drink alcohol? if so, how much? Do you have difficulty falling asleep? Do you wake up often during the night? if so, how often? Do you wake up earlier in the morning than you would like and have difficulty falling back to sleep? how do you feel when you wake up in the morning? Do you sleep more than usual? if so, how often do you sleep? Do you have periods of overwhelming sleepiness? if so, when does this happen?
n n n
have you ever suddenly fallen asleep in the middle of a daytime activity? Does anything unusual happen when you laugh or get angry? has anyone ever told you that you snore, walk in your sleep, or stop breathing for a while when sleeping? What have you been doing to deal with this sleeping problem? Does it help? What do you think might be causing this problem? Do you have any medical condition that might be causing you to sleep more (or less)? Are you receiving medications for an illness that might alter your sleeping pattern? Are you experiencing any stressful or upsetting events or conflicts that may be affecting your sleep? how is your sleeping problem affecting you?
Assessment Interview Boxes help you learn the type and range of what to ask in particular situations.
assessmeNt INteRvIew n
676 UNIt I / the Nature of Nursing
n Any prescribed medications, over-the-counter medications, these methods have been effective. Questions the nurse might and herbal remedies taken during the day ask the client with a sleeping disturbance are shown in the acClient Teaching boxes n Bedtime Home rituals before companying Assessment Interview. clIeNt teachINg caresleep and circulation give tips and tools to help n Any difficulties remaining awake during the day and times Health History self-care, clients facilitate when difficulties occurred dietary aLteratiOns maintaining cardiac OutPut and tissue PerfusiOn A health history is obtained to rule out medical or psychiatric n Any worries that the client believes may affect sleep monitor potential problems, n teach the symptoms of heart failure to the client and family and n Instruct the client and family about prescribed dietary restrictions causes of the client’s difficulty sleeping. It is emphasize importantwhen to to contact n Factors that the client believes have a positive or negative the primary care provider. such as a low-sodium diet. refer to a dietitian as needed for further perform prescribed note that the presence of a medical or psychiatric illness (e.g., on sleep of maintaining regular instruction. n teach the client about effect the importance depression, therapies,Parkinson’s and assist in other disease, Alzheimer’s disease, arthritis, physical activity to promote circulation and vascular health. emphan Discuss dietary measures to reduce the risk of atherosclerosis, If the client is a child, the sleep diary or log may be comor other disorders) not exclude the possibilitysize thatthe a second client teachingdoes experiences. need to increase activity levels gradually with the goal of including reducing total and saturated fats in the diet, reducing pleted by a parent. problem (e.g., obstructive sleep apnea) may beexercising contributing (walking, swimming, weight training, or aerobic exercise weight if obese, and increasing the intake of dietary fiber. as recommended to the difficulty sleeping. Since medications can frequently by the care provider) for at least 20 minutes four medicatiOns diagnostic studies to five times be per week. cause or exacerbate sleep disturbances, information should n Instruct the client and family about prescribed medications, n Instruct the client to avoid exposure to cold, wearing warm clothing Sleep is measured objectively in a sleep disorder laboratory obtained about all of the prescribed and nonprescription mediincluding effects, side effects, and administration instructions. as needed. by polysomnography: an electroencephalogram (EEG), electrocations, including herbal remedies that a client consumes. n teach cardiopulmonary resuscitation or refer instruction. myogram (EMG), andforelectro-oculogram (EOG) are recorded Physical examination simultaneously. Electrodes are placed on the scalp to record brain waves (EEG), on the outer canthus of each eye to record Physical examination cannot detect sleep abnormalities unless 344has UNIt I / the Nature of Nursing eye movement (EOG), and on the chin muscles to record the the client obstructive sleep apnea or some other health probstructural electromyogram TheHeart electrodes transmit lem. Common findings among clients with sleep apnea include clIeNt teachINg Promoting a(EMG). Healthy Nursing care Plans help electric energy from the cerebral cortex and muscles of the face an enlarged and reddened uvula and soft palate, enlarged tonnuRsing CaRe Plan For a client Withtoskin Problems pens that record the brain waves and muscle activity on graph sils and adenoids (in children), obesity (in adults), and in male you approach care from the n exercise regularly, participating in at least 20 minutes (40 minutes n If female, discuss with your health care provider the advantages paper. Respiratory effort and airflow, ECG, leg movements, clients a neck size greater than 42 cm. Occasionally a deviated nursing process is preferred) of vigorousnursing exercise four to five times a week. desired OutcOmes and risks of hormone replacement therapy afterperspective. menopause (or assessment data diagnOsis and oxygen saturation are also monitored. Oxygen saturation septum may be noted, but it is rarely the cause of obstructive after a total hysterectomy). n Do not smoke. is determined by monitoring with a pulse oximeter, a lightsleep apnea. Risk for disuse syndrome immobility consequences Nursing Assessment n Maintain your ideal weight. n Consult your primary care provider about the advisability of lowcellactivity that attaches to the earasorevidenced adose finger. Oxygen related toelectric decreased physiological, by notherapy to further reduce the risk of cardiovascular aspirin n eat a diet low in totalsensitive fat, saturated fats, and cholesterol. tawfeek ahmad, a 69-year-old, unmarried accountant being treated sleep diary resulting from balsaturation andinadequate ECG assessments of particular importance if n are pressure ulcersdisease. n reduce stress and manage anger. for congestive heart failure, states he has dyspnea with mild activity. ance apnea betweenisoxygen supply Through A sleep specialist may aask keep stopping a sleep diary ormanage log sleep suspected. polysomnography, the clin blood Decreased muscle strength. (“I cannot climb flightclients of stairstowithout and resting and diabetes n effectively and hypertension, maintaining and activity demand associated with struggling, noisy respirations) durbreathless walking on levelpicture ground.”of )and prefers for 1 to 2 become weeks in order toeven getwhen a more complete their ent’s (movements, glucose blood pressure levels within normal limits. immobility consequences decreased cardiac output and the orthopneic position. he works home andall sitsor at aselected table for sleep complaints. A sleep diary mayatinclude ing sleep can be assessed. Suchpsychocognitive, activity of which the client is as evidenced obesity. the day. information that pertain to the client’s aspects ofmost the of following unaware may be the cause of arousal by no during sleep. specific problem: n apathy diagnostic data Physical examination n Sleep disturbances CardiaC medications and also for potential complications. Examples diagnosing n Time of (a) going to bed, (b) trying to fall asleep, (c) falling Complete blood count and uriheight: 178 cm n Negative body image. include: Insomnia, the NANDA International (2007) diagnosis given to n Position the client in a high Fowler’s position to decrease asleepWeight: (approximate ofnormal waking up nalysis within limits. 102 kg time), (d) any instances mobility, as evidenced by mildlywith clients with sleep problems, is usually maden more explicit and reduce pulmonary congestion. temperature: 37.8°C and duration of these periods, (e) waking uppreload in the morning, When diuretics are administered, the nurse assesses intake Chest X-ray reveals an enlarged compromised BpM descriptions as “difficulty oroutput “difficulty Fluid such restriction is usuallyfalling not asleep” and (f)pulse any rate: naps94and their duration heart.n Monitor intake and output. and and potassium level (because many diuretics can n Walking respirations: 20/minute staying for example, (delayed onset of sleep) level). required forduraclients with mildasleep,” to moderate cardiac insomnia dysfuncn Activities performed 2 to 3 hours before bedtime (type, lower potassium n Balance. Blood pressure: 174/92 mmhg related to overstimulation proper to bedtime. tion. With severe heart failure, a fluid restriction may be tion, and time) n When positive inotropic medications are administered, the rales present in both lungs Various factors and etiologies may be involved must assess be ordered. n Consumption ofslightly caffeinated nurseand should blood pressure, heart rate, peripheral respirations labored beverages and alcohol and specified for the individual. These include physical amounts of pale those beverages pulses,discomfort and lung sounds as indicators of cardiac output. Color medications n When antihypertensive medications are administered, it is 3+ (5 mm) edema both feet Many classes of medications are administered to clients with and ankles critical for the nurse to monitor blood pressure. Additioncardiovascular disorders. Drugs such as nitrates, calcium ally, many antihypertensive medications can cause postural nursing interventiOns/seLected activities ratiOnaLe channel blockers, and angiotensin-converting enzyme (ACE) hypotension. inhibitors reduce the workload of the heart and prevent vasoPositioning Preventing Venous stasis constriction. Various drugs are used to treat cardiac dysrhythM17_KOZI7296_00_SE_C17.indd 509 to alleviate dyspnea, e.g., high Fowler’s. 7/25/11 12:54 PM a. position a. Clients with increased pulmonary secretions are able to breathe mias. Positive inotropic drugs such as digitalis are used to When clients have limited mobility or are confined to bed, better when upright because abdominal organs are lower and increase the contractile strength ofgreater the heart. Beta venous return to the heart is impaired and the risk of venous there is room for lungadrenergic and diaphragmatic excursion. blocking agents such as propranolol or metoprolol may be stasis increases. Immobility is a problem not only for ill or b. provide support to edematous areas, given e.g., elevate feet onthe footsympathetic b. elevating the dependent assists tissue pressure to block nervous system area action on with the decreasing debilitated clients but also for some travelers who sit with legs stool when sitting. and promoting fluid return to the venous system and the heart. heart and decrease oxygen consumption. Direct vasodilators dependent for long periods in a motor vehicle or an airplane. may be used for clients with peripheral vascular disease and strength c. encourage active range of motion exercises. c. active rOM helps keep muscles in current and stasis promotes Venous can lead to thrombus formation and edema of the circulation. also helps mediburn unneeded calories. sometimes hypertension. Often clientsMild areactivity on numerous extremities. cations, and it is an important role of the nurse to help the client Preventing venous stasis is an important nursing intervention exercise therapy: muscle control understand the purposes, effects, and side effects of the differto reduce the risk of complications following surgery, trauma, d. Collaborate with physical, occupational, recreational therad. this client will need a multidisciplinary approach his care. each problems. Positioning and leg exercises are entand medications. ortomajor medical A01_KOZI7296_00_SE_FM.indd 18 8/23/11
pists in developing and executing an individually tailored exercise
member contributes from his or her area of expertise. research
Care, Critical Thinking and Based Practice! 402 UNit i / the Nature of Nursing
data cLuster Omar, a 67-year-old retired man who has a history of heart disease, has experienced a weight gain of 6 kg during the past month. he states his wedding ring is too tight to remove, his ankles are swollen, he can hear his heart beat at times, and he has shortness of breath with exertion. physical findings reveal delayed capillary refill; bounding pulse (86 BpM); pitting edema in feet, ankles, and lower legs; and moist lung sounds (rales/crackles). nursing diagnOsis
Excess fluid volume
weight: 6 kg in 1 month n pitting edema: +4 in both legs n adventitious sound: crackles in both lungs n Capillary refill: more than 3 seconds
desired OutcOmes n Client
will lose 6 kg of body weight within 2 weeks with the help of diuretic. n Client will exhibit freedom from leg edema and adventitious breath sounds within 2 weeks of diuretic therapy.
Identifying Nursing iagnoses. Outcomes, and D Interventions boxes provide guidelines for establishing diagnose, outcomes and interventions for situations and conditions. ▲
ideNtifyiNg NuRsiNg diagNoses, outcomes, aNd iNteRveNtioNs clients with Fluid Volume excess
seLected interVentiOns Monitor for indications of fluid overload • Crackles • elevated Bp • edema (on scale from 1+ to 4+) • Neck vein distention. n Maintain accurate intake and output record. n Weigh daily. n report to the physician if signs and symptoms persist or worsen. n
ChApter 1 / Nursing: historical and Current practice 19
ideNtifyiNg NuRsiNg diagNoses, outcomes, aNd iNteRveNtioNs
Critical Reflections clients with impaired gas exchange provide a brief case study criticaL reFLectiOn Data Cluster rami, 43 years old, was brought to the emergency room by his brother who stated that rami became breathless and fell followed by questions on the floor while trying to get up to go to the bathroom. he appears very lethargic stuporous; pulseofisthis 120chapter. BpM; respiration 12you breaths us return to the opening caseand study at the start Now that have read the chapter, do you feel confidence thatper encourage students to gases revealLeta ph minute and very shallow. Blood of 7.28, paCO 49 mmhg, hCO3– 25 meq/L, and oxygen saturation (O2 sat) 86%. to stand in class and2 talk about nursing history, roles of the nurse, future career opportunities, and nursing professional qualities? analyze, compare, contemBefore doing so, try to write a short essay about nursing status in your country and ask your instructor permission to present it By desired OutcOmes seLected interVentiOns plate, nursing interpretdiagnOsis and evaluate eVidenced in class, and then request feedback from your colleagues and instructor to improve your essay. this will prepare you to answer n Blood gases reveal ph of n C lient’s aBGs will reveal n Monitor respiratory Impaired gas exchange information. any questions raised while performing this community service activity.pattern.
O2 sat above 95%, ph n M onitor respiratory patterns and between 7.35 and 7.45, auscultate lung sounds. and paCO2 less than 45 mmhg with the help cHaPter HigHLigHts n Monitor aBG levels frequently. n Shortness of breath of oxygen therapy. ChApter 1 / Nursing: historical and 13 n historical perspectives of nursing practice reveal recurring themes n Current Somepractice professional organizations have recommended that and decreased level of n M onitor neurological status or influencing factors. Women have traditionally cared for others, minimum entry into practice be at the baccalaureate or master’s consciousness n C lient will be able to (e.g., level of consciousness). beginning with Arab women in early Islam.with Visionary leaders have degree level Research Notes focus tolerate activity ReseaRch Note What ismade the status of nursing the arab World? n place client on nasal cannula of 2 of research has been introduced into nursing notable contributions to in improve the status n the concept minimal shortness of of nursing. on evidence-based practice. L/min. education programs, and research journals in nursing have been n the scope of nursing practice includes promoting wellness, breath. the purpose of this study was to address some of the factors affecting the ratio hasfor reached 50/50 in palestine. thus, the employdeveloped. preventing illness, restoringexample, health, and caring the dying. These boxes highlight relen p lace client in semi-Fowler’s posithe development of the nursing profession in Arab countries. the stament of foreign nurses is increasing in the Gulf region. n Although traditionally the majority of nurses were employed in n Both quantitative and qualitative research involve identifying tion to facilitate breathing. tus of nursing in the Arab world was presented in three dimensions: vant nursing journal articles nursing image hospital settings, today the numbers of nurses working in home a research problem/question, collecting data, and analyzing education, practice, and image. n p development rovide mechanical ventilation if Image is one factor are thatincreasing. affects the of the nursing profesand implications fordescriptive nursing health care, and community health settings the data. Quantitative studies are reported using nursing educatiOn sion. the image of nurses hasnot improved lately, but still lacks appeal statistics, and qualitative studies are reported in necessary. and analytical n every nurse may function in a variety of roles that are care. and prestige. Some countries, such as Bahrain and Jordan, were satisthe majority of nursing education programs exclusive in the Arabofworld range narrative format. one another. these roles include caregiver, fied advocate, with the image of nursing. from practical nurse preparation programs (18 months of study) to client communicator, teacher, counselor, change n health care delivery services can be categorized by the type of an associate degree (2 years of study) or a 3-year diploma program. imPLicatiOns agent, leader, manager, case manager, and research consumer. service: (a) primary prevention: health promotion and illness Baccalaureate and graduate programs are very limited. Some coun(b) secondary prevention: diagnosis and treatment, n With advanced education and experience, nursesofcan Based on the results thisfulfill study, it is important prevention, to know that Promoting Wellness tries, such as tunisia, Morocco, Algeria, and Libya, do not have the advanced practice roles such clinicalinnurse specialist, the as nursing the Arab world has improved in the and last (c) 10 tertiary years. prevention: rehabilitation, health restoration, and baccalaureate. Someabout countries, egypt, Jordan, palestine, Leba- potential effects when this is not done. Nurses can promote cliMost people rarely think theirlike fluid, electrolyte, or acid– Also, Arab countries are planning to improve the quality of nursing palliative care. nursepreparation. practitioner,Most nurse midwife, nurse anesthetist, educator, non, Saudi and offer master’s-level ents’ health by providing wellness teaching that will help them base balance. They Arabia, know it is Iraq, important to drink adequate fluids education. administrator, and researcher. n hospitals provide a wide variety of services on an inpatient doctorate-level nurses in the Arab world are graduates of American maintain fluid and electrolyte balance. and consume a balanced diet, but they mayn not understand the and outpatient basis. hospitals can be categorized as Current nursing practice is influenced by cultural and religious or european universities. public or private, acute care or long-term care. Many other values, economics, consumer demand, family structure, Note: From “Status of nursing in the Arab world,” by r. Shukri, 2005, Ethnicity & nursing Practice 15, 88–89. settings, such as clinics, offices, and day-care centers, also gender issues, science and Disease, technology, information and there is a shortage of nurses in the Arab world. the male/female ratio provide care. telecommunications, legislation, demographic and social changes, of practicing nurses has increased rapidly in some Arab countries. For the nursing shortage, and the work of nursing organizations. n Various providers of health care coordinate their skills to assist a client. their mutual goal is to restore a client’s health and n Nursing education curricula are continually undergoing revisions promote wellness. in response to new scientific knowledge and technological, cultural, political, and; socioeconomic changes in society. emphasis on the importance of evidence-based practice (eBP)
7.28, paCO2 49 mmhg, and hCO3– 25 meq/L, O2 sat 86%.
Approaches to Nursing research
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that is, the use of some form of proof in making clinical deciThere are two major approaches in nursing research to invessions. This proof, or evidence, can arise from tradition, authortigating diverse phenomena. These approaches originate from ity, experience, trial and error, logic or reason, or research. The test yOur KnOWLedge different philosophical perspectives and use different methods breadth and diversity of nursing research is reflected in the 2. A study examining the bereavement process in spouses of collectionbyand analysis promotion is bestfor represented which of theof data. examples of recent nursing studies shown1.inhealth Box 1-2.
clients with terminal cancer following activities? 3. A study exploring factors influencing weight control 1. Administering immunizations Quantitative research 2. Giving a bath Quantitative research progresses through systematic,behavior logical examples of nursing studies 4. A study examining a client’s feelings before and after a 3. preventing accidentssteps in theaccording home to a specific plan to collect information, often boneusing marrow aspiration 4. performing diagnosticunder procedures conditions of considerable control, that is analyzed
hjelm, Bard, Berntorp, and Apelqvist (2009) explored the beliefs A01_KOZI7296_00_SE_FM.indd 19 8/23/11 10:18 PM theviewed use of aasqualitative research process is most appropriate statistical research is 4. often 2. Which of the following social forcesprocedures. is most likelyQuantitative to about health and illness 3 months postpartum in women born n
Excellence in the
Capillary Blood Glucose A capillary blood specimen is often taken to measure blood glucose when frequent tests are required or when a venipuncture cannot be performed. This technique is less painful than a venipuncture and easily performed. Hence, clients can perform this technique on themselves. The development of home glucose test kits and reagent strips has simplified the testing of blood glucose and greatly facilitated the management of home care by clients with diabetes. A number of manufacturers have developed blood glucose meters or monitors (Figure 8-28 n).
Figure 8-28 n Blood glucose monitor, test strips, and lancet injector.
Capillary blood specimens are commonly obtained from the lateral aspect or side of the finger in adults. This site avoids the
nerve endings and calloused areas at the fingertip. The earlobe Step-by-step skills. A NEW easy-to-follow, two-column format helps students understand may be used if the client is in shock or the fingers are edematous. Skill 8-16 describes how to obtain a capillary blood specitechniques and practice s equence. men and measure blood glucose using a portable meter.
Includes a complete Equipment list for easy preparation.
eQuiPment Blood glucose meter (glucometer) Blood glucose reagent strip compatible with the meter 2 × 2 gauze n Warm cloth or other warming device (optional) n n n
PerFOrmance 1. Introduce self and verify the client’s identity using institution’s protocol. explain the procedure to the client. 2. Wash hands and observe appropriate infection control procedures. put on gloves. 3. provide for client privacy. 4. assess the client’s skin at the puncture site to determine if it is intact and the circulation is sufficient. Check color, warmth, and capillary refill. review the client’s record for medications that may prolong bleeding, such as anticoagulants. 5. Calibrate the meter and run a control sample according to the manufacturer’s instructions. 6. Select and prepare the vascular puncture site. ● Choose a vascular puncture site (e.g., the side of an adult’s finger). avoid sites beside bone. ● Clean the site with the antiseptic swab and allow it to dry completely. 7. Obtain the blood specimen. ● place the injector, against the site, and release the needle, thus permitting it to pierce the skin. Make sure the lancet is at a 90-degree angle to the site. 1 ● Gently squeeze (but do not touch) the puncture site until a large drop of blood forms.
antiseptic swab n Disposable gloves n Sterile lancet n Lancet injector n
1 place the injector against the site.
hold the strip under the puncture site until adequate blood covers the indicator square. the pad will absorb the blood and I / The Nature of Nursing 278 UNIT a chemical reaction will occur. Do not smear the blood. 2 ask the client to apply pressure to the skin puncture site with a gauze.
CHANGING AN UNOCCUPIED BED continued
OBtaining a caPiLLary BLOOd sPecimen tO measure BLOOd gLucOse
assists with a wide variety of x-ray film procedures, from simple chest radiography to more complex fluoroscopy. The nuclear medicine technologist uses radioactive substances to provide Criticalinformation steps are and can administer Easy-to-find diagnostic therapeutic doses of radioactive as part of a therapeutic regimen. visuallymaterials represented rationales give
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2 Roll soiled linen inside the bottom sheet and hold away from the body.
3 Placing the bottom sheet on the bed.
(Al Dodge, Pearson Education/PH College)
you a better understanding of why A pharmacist prepares and dispenses pharmaceuticals illustrations! things are done. in hos-
Pharmacist photos and
pital and community settings. The role of the pharmacist in monitoring and evaluating the actions and effects of medications on clients is becoming increasingly prominent. A clinical pharmacist is a specialist who guides physicians in prescribing Clinical Alertsassistant highlight medications. A pharmacy is aspecial worker who administers medications to clients orsuch works the pharmacy information asinsafety issues under the direction of the pharmacist. 118 the Nature of Nursing
cLinicaL chills aLert (the plateau phase). Depending on the degree of temperature elevation, other signs may occur during the course
Significant overlap may occur among those providers who can perform of the VeryForhigh temperatures, such as(MD), 41 to a42 ºC, damcertain health carefever. activities. example, an anesthesiologist age nurse, the parenchyma of therapist cells throughout the body,forparticularly neonatal care or a respiratory may be responsible assisting ain newborn babywhere with breathing problems. All providers perform the brain destruction of neuronal cells is irreversible. client teaching. n to the liver, kidneys, and other body organs can also be Damage
4 Placing a clean drawsheet on the bed. (Patrick Watson)
Clinical Manifestations New to this edition! These boxes are a quick resource to learn key signs and symptoms of illness.
CLInICaL manIFESTaTIonS HypOtHermia
n n n n n M10_KOZI7296_00_SE_C10.indd n
great enough to disrupt functioning and eventually cause death. When the cause of the high temperature is suddenly removed, Physical therapist the set point of the hypothalamic thermostat is suddenly reduced The licensed physical therapist assists clients to a lower value, perhaps even backwith to themusculoskeloriginal normal level. etal problems. Physical therapists treat movement In this instance, the hypothalamus now dysfunctions attempts to lower the by means temperature, of heat, water,and exercise, massage, andresponses electric current. the usual heat loss causing a reducThe physical therapist’s functions include assessing client mobiltion of the body temperature occur: excessive sweating and a knowledge about ity and strength, providing measures (e.g., exercises hot, flushed skin therapeutic due to sudden vasodilatation. This is referred munity setting recand heat to applications improve mobility and strength), and who has as the flushtophase. Nursing interventions for a client ory services about teaching new skills (e.g., how to walk with an artificial leg). a fever are designed to support the body’s normal physiologic munity nutritionists Some physical therapists provide their in hospitals; During processes, provide comfort, andservices prevent complications. romote health and however, independent establish in commuthe course ofpractitioners fever, the nurse needsoffices to monitor the client’s vital amilies about balnities and serve clients either at the office or in the home. Physisigns closely. nt women. cal therapy aides also measures work withduring physical Nursing thetherapists chill phaseand areclients. designed to help the client decrease heat loss. At this time, the body’s physiA01_KOZI7296_00_SE_FM.indd 20
special knowledge nd to treat disease. d with therapeutic utritional needs of ation of meals to
Roll all soiled linen inside the bottom sheet, hold it away from your uniform, and place it directly in the linen hamper, not on the floor. 2 Rationale These actions are essential to prevent the transmission of microorganisms to the nurse and others. l Grasp the mattress securely, using the handles if present, and move the mattress up to the head of the bed. 7. Apply the bottom sheet and drawsheet. l Place the folded bottom sheet with its center fold on the center of the bed. Make sure the sheet is edge side down for a smooth component. Spread the sheet out over the mattress, and allow a sufficient amount of sheet at the top to tuck under the mattress. 3 Rationale The top of the sheet needs to be well tucked under to remain securely in place, especially when the head of the bed is elevated. Place the sheet along the edge of the mattress at the foot of the bed and do not tuck it in (unless it is a contour or fitted sheet). l Miter the sheet at the top corner on the near side (Figure 107, above) and tuck the sheet under the mattress, working from the head of the bed to the foot. l If a waterproof drawsheet is used, place it over the bottom sheet from the middle of the client’s back to the area of the mid-thigh or knee. Fanfold the uppermost half of the folded drawsheet at the center or far edge of the bed and tuck in the near edge. 4 l Lay the cloth drawsheet over the waterproof sheet in the same manner. l Optional: Before moving to the other side of the bed, place the top linens on the bed edge side up, unfold them, tuck them in, and miter the bottom corners. Rationale Completing one entire side of the bed at a time saves time and energy. 8. Move ton the other side and secure the bottom linens. l Tuck in the bottom sheet under the head of the mattress, n pull the sheet firmly, and miter the corner of the sheet. l Pull the nremainder of the sheet firmly so that there are no wrinkles. Rationale Wrinkles can cause discomfort for the client n and breakdown of skin. Tuck the sheet in at the side. l Complete this same process for the drawsheet(s). l
. Dentists are also maintain healthy y hospitals, espeon their staff.
Newborns are routinely screened for congenital metabolic conditions. Tests for phenylketonuria (PKU) and congenital hypothyroidism are required in some countries. Other conditions that are frequently screened include sickle cell disease and galactosemia. Screening involves collecting peripheral venous blood (via a heel-stick) on a prepared blotting paper and sending the specimen to the state laboratory for analysis. Discovered abnormalities allow the provider and parents to plan early care (e.g., special diets for children with PKU) that can prevent longterm complications.
ents receive finanetting. This role is team who is most e nature of the clise, a social worker, pist, or any other ase manager’s role the United States, ng role in the Arab mpared to nurses.
e alongside health ces in conjunction
196 the Nature of Nursing
5 A vertical toe pleat.
9. Apply or complete the top sheet, blanket, and spread. l Place the top sheet, edge side up, on the bed so that its
Decreased body temperature, pulse, and centerfold is at respirations the center of the bed and the top edge is even with the top edge of the mattress. Severe shivering (initially) Unfold the sheet over the bed. Optional: Make a vertical or a horizontal toe pleat in the Feelings of cold and chills sheet to provide additional space for the client’s feet. pale, cool, waxy skin a. Vertical toe pleat: Make a fold in the sheet 5 to 10 cm (2 to 4 in.) perpendicular to the foot of the bed. 5 Frostbite (nose, fingers, toes) hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma l l
Hypothermia may be induced or accidental. Induced hypothermia is the deliberate lowering of the body temperature to decrease the need for oxygen by the body tissues such as during certain surgeries. Accidental hypothermia can occur as a result of (a) exposure to a cold environment, (b) immersion in cold water, and (c) lack of adequate clothing, shelter, or heat. In elders the problem can be accompanied by a decreased metabolic rate and the use of sedatives. If skin and underlying tissues are damaged by freezing cold, this results in frostbite. Frostbite
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Clinical Setting! Chapter 9 / Safety and Infection Control 239
steps to follow after exposure to Bloodborne Pathogens (follow agency Policy for variations)
report the incident immediately to appropriate personnel within the agency. Seek appropriate evaluation and follow-up. this includes: l Identification and documentation of the source individual when feasible and legal. l testing of the source for hepatitis B, hepatitis C, and hIV when feasible and consent is given. l Making results of the test available to the source individual’s health care provider. l testing of blood of exposed nurse (with consent) for hepatitis B, hepatitis C, and hIV antibodies. l post-exposure prophylaxis if medically indicated. l Medical and psychologic counseling regarding personal risk of infection or risk of infecting others. For a puncture/laceration: l encourage bleeding. l Wash/clean the area with soap and water. l Initiate first aid and seek treatment if indicated. l For a mucous membrane exposure (eyes, nose, mouth), saline or water flush for 5 to 10 minutes.
POst exPOsure PrOtOcOL
n n n n n n
when started more than 24 hours after exposure. Starting treatment after a longer period (e.g., 1 week) should be considered for high-risk exposures previously untreated. For ’high-risk’ exposure (high blood volume and source with a high hIV titer): three-drug treatment is recommended. For ‘increased-risk’ exposure (high blood volume or source with a high hIV titer): three-drug treatment is recommended. For ‘low-risk’ exposure (neither high blood volume nor source with a high hIV titer): two-drug treatment is considered. Drug prophylaxis continues for 4 weeks. Drug regimens vary and new drugs and regimens are continuously being developed. hIV antibody tests should be done shortly after exposure (baseline), and 6 weeks, 3 months, and 6 months afterward.
Practice Tips provide instant-access s ummaries of clinical do’s and don’ts. ▲
Hepatitis B n n
anti-hBs testing 1 to 2 months after last vaccine dose. hBIG and/or hepatitis B vaccine within 1 to 7 days following exposure for nonimmune workers.
anti-hCV and aLt at baseline and 4 to 6 months after exposure.
treatment should be started as soon as possible, preferably within hours after exposure. treatment may be less effective
nursing Care Plan
for a client With a complication due to infection
potential complication of infection: fever
Maintain or restore defenses. avoid the spread of infectious organisms. reduce or alleviate problems associated with the infection.
Mrs riham is a 76-year-old woman who has been admitted to the acute care facility for fever, shortness of breath, productive cough, dehydration, and nutritional deficiency. She was isolated and visitors were asked to wear a mask as a personal protective measure when visiting her. Nursing staff who intervene with Mrs riham have been strictly instructed to wash hands 5 to 10 minutes before and after any procedure applied to Mrs riham.
nursing History (a) assess the degree to which Mrs riham is at risk of developing an infection. (b) review Mrs riham’s chart and structure the nursing interview to collect data regarding the factors influencing the development of infection, especially the existing disease process, history of recurrent infections (e.g., upper respiratory tract infections), current medications and therapeutic measures such immunosuppressive drugs, current emotional stressors, nutritional status, and history of immunizations.
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Acknowledgements We would like to thank the following reviewers for their thoughtful comments and suggestions for this new Arab World Edition:
Reviewers Muyassar Sabri Awadallah, MSN, RN, College of Health Sciences, Bahrain
Manar Nabolsi, PhD, RN, University of Jordan, Jordan
Sawsan AS Majali, RN, PhD, Jordanian Hashemite Fund for Human Development, Jordan
Naglaa EL Mokadem Ph.D, RN, Menofyia University, Egypt
Intesar Ahmed, Fatima College of Health Sciences, UAE
Dr Shewikar Farrag; Ph.D; MSC; BSC; RN, Umm Al-Qura University, Saudi Arabia
Myrna A. A. Doumit. PhD, MPH, RN, Lebanese American University, Lebanon
Shadia Abdullah Hassan Yousuf BSN, MSN, PhD, King Abdulaziz University, Saudi Arabia
Dr. Elham Al Nagshabandi, King Abdulaziz University, Saudi Arabia
Professor Alice Reizian.RN.D.N.Sc.(UCSF), Alexandria University, Egypt
Professor Cheherezade M. K. Ghazi, British University in Egypt, Egypt
This text would also not have been possible without the assistance of peer and student reviewers, chapter and case contributors, and supplement authors for previous editions of Fundamentals of Nursing. Weâ€™d like to thank them all for their valuable insight, suggestions, and contributions, which have informed our work on this adaptation.
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Culture and Heritage Learning Outcomes After completing this chapter, you will be able to: 1. Acknowledge cultural communalities and differences between Arab regions. 2. Discuss the components of culturally focused nursing, heritage consistency, and health traditions. 3. Describe examples of the different health views of culturally diverse people. 4. Differentiate biomedical care from folk healing. 5. Identify factors related to communication with culturally diverse clients and colleagues. 6. Recognize the core practice competencies of culturally competent nursing care. 7. Identify methods of heritage assessment. 8. Plan culturally sensitive, appropriate, and competent nursing interventions.
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KEY TERMS assimilation, 71 bicultural, 71 biomedical health belief, 73 culture, 69 culture shock, 72 discrimination, 72
diversity, 71 folk medicine, 73 holistic health belief, 73 magico-religious health belief, 72 prejudice, 71 race, 71
religion, 72 scientific, 73 socialization, 72 stereotyping, 71 subculture, 71 transcultural nursing, 71
Case Study Mrs Salma Fatima, a 24-year-old female, was admitted to the labor and delivery department of a private general hospital in Beirut, Lebanon. Salma was having labor pains 5 minutes apart. She was accompanied by her husband, Majed (AbuAbdallah), and Mrs Naifeh (Um Sanad), her sister. Um Sanad was able to communicate with the health care providers on behalf of the couple. The family is from Jiddah, a city on the western coast of Saudi Arabia, and are in Lebanon while Mr Majed conducts some business in the area. They have been in the country for 2 months. Their plan had been to return to Saudi Arabia for the birth but it appears the family was unaware that the time of birth was so close. Mrs Fatima had expected her pregnancy to last for another month.She has two children, boys aged 4 and 6, and had one spontaneous abortion 2 years ago. Her two sons are healthy except
To provide quality care, nurses must become informed about and be sensitive to the culturally diverse subjective meanings of health, illness, caring, and healing practices. Culture can be defined as the nonphysical traits, such as values, beliefs, attitudes, and customs, that are shared by a group of people and passed from one generation to the next (Spector, 2004). Culture is also the “thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (Office of Minority Health, 2001, p. 131). Many people of different cultures maintain the cultural values, beliefs, traditions and practices of their heritage (things passed down from the previous generation). Culture and heritage provides the blueprint for a group’s behavior. It defines how health is perceived, how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the health problem are expressed, who should provide treatment and how, and what kind of treatment should be given. Nurses must be aware that, although people from a given group share certain beliefs, values, and experiences, often there is also widespread intragroup diversity. Major differences within groups may be due to such factors as age, gender, level of education, socioeconomic status, and area of origin in the
that the youngest has had frequent ear infections since coming to Lebanon. Mr Majed told hospital staff that his wife’s siblings and parents have no medical problems. Mrs Fatima’s sister, the family midwife, came from Saudi Arabia to be a companion in the home while Mr Majed was at work. The two women do not leave the house without Mr Majed. Mr Majed has stated that his wife would prefer that no men outside her family be allowed in her room. Mrs Fatima wanted her husband to remain in her room during her hospital stay to be a host to visitors. The physician wants to monitor Mrs Fatima’s blood glucose levels because diabetes mellitus is a major health problem in people from Saudi Arabia. After studying this chapter, you will be able to identify the issues you need to address when caring for Mrs Fatima’s and reflect on this situation.
home country (rural or urban). Such factors influence the client’s beliefs about health and illness, practices, help-seeking behaviors, and expectations of nurses. For these reasons, effort must be made and care taken to avoid stereotyping people from a specific group. The Arab world includes 22 countries in the Middle East and North Africa, extending from the Atlantic coast of Northern Africa to the Arabian Gulf (see Figure 5-1 n). Arabs are inhabitants of the Arab world who speak various dialects of the Arabic language and have a shared sense of geographic, historical, and cultural identity. The term Arab is not based on race; it includes peoples with widely varied physical features. Of the 22 Arab countries, 11 are in Asia—Bahrain, Iraq, Kuwait, Jordan, Lebanon, Oman, Qatar, Saudi Arabia, Syria, UAE, and Yemen—and 10 are in Africa—Algeria, Djibouti, Eritrea, Egypt, Libya, Morocco, Mauritania, Somalia, Sudan, and Tunisia. Palestinians live under Israeli rule, under the autonomy of the partial Palestinian Authority in the West Bank and Gaza, or as refugees throughout the world. Arabs have a feeling of unified entity despite of the national boundaries and diverse religious beliefs. The large majority of Arabs are Muslim (92 percent), but the Arab world also includes Christians and Jews. Therefore, the religion of Islam shapes Arab 69
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70 The Nature of Nursing
The Arab World
Figure 5-1 n The Arab world consists of 22 countries, where inhabitants speak various dialects of Arabic and have a shared cultural identity.
identity and Arabic, being the language of the Holy Qur’an, is the official language. Ethnic groups such as Persians, Turks, Armenians, Kurds, Berbers, and other minorities live in some Arab countries. Cultural variations are observed among people living in rural and urban areas. For example, 84 percent of Lebanese live in urban areas compared with only 29 percent of Yemen’s population.
Clinical Alert No practice is universal, and behaviors and attitudes, while they may follow certain trends or have a common influence, may vary greatly. Culture and language are vital factors in how nursing care is delivered and received, and the diverse cultural needs of clients are expected to be met. n
Differences across Arab regions Despite the similarities among Arab countries there are differences due to their geographic dispersion. Arab countries can be divided into regions: North Africa (Egypt, Sudan, Somalia, Djibouti, Libya, Tunisia, Algeria, Morocco, Comoros and Mauritania), Bilad Ash-Sham (Lebanon, Syria, Palestine, Jordan, and Iraq), and the Arabian Peninsula (Bahrain, Kuwait, Qatar, Oman, Yemen, Saudi Arabia, and the UAE). Each of these regions has its own cultural traditions, customs, and practices. Other factors also contribute to variations between Arab countries. These factors include: n
Topography: The topographical variation in the Arab world greatly affects the social organization and contributes to lifestyle differences between people of the three regions. Living in high, low, or desert areas affects peoples’ ways of earning their living, dressing, and which foods they consume. Location on the Mediterranean: People in countries that have port cities connecting Africa to Europe have the
opportunity to work in trade. Their lives are more business-oriented because of the more developed nature of these trade cities on the coast. The Arabian Peninsula is the major connection of the Arab world to the Western world. Oil, along with tourism to the city of Mecca for Muslim pilgrimage, has given the region the ability to provide free health care and education for its citizens. These varied backgrounds must be kept in mind when applying cultural norms, considering that many nurses, especially Egyptians and Jordanians, leave their home countries and work in foreign and other Arab countries, mainly in the Arab Gulf. Moreover, people from one Arab country often seek health care services elsewhere in the Arab world.
Cultural Nursing Care Responsibility for cultural health care is shared among “individuals, professional associations, regulatory bodies, health services delivery and accreditation organizations, educational institutions, and governments” (Canadian Nurses Association, 2004, p. 1). Professional nursing care is culturally sensitive, culturally appropriate, and culturally competent. This type of nursing is critical to meeting the complex nursing care needs of a given person, family, and community. It is the provision of nursing care across cultural boundaries, taking into account the context in which the client lives as well as the situations in which the client’s health problems arise. n
Culturally sensitive implies that nurses possess some basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in the setting in which they are practicing. Culturally appropriate implies that nurses apply the underlying background knowledge that must be possessed to provide a given client with the best possible health care.
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Chapter 5 / Culture and Heritage 71 n
Culturally competent implies that, within the delivered care, nurses understand and attend to the total context of the client’s situation and use a complex combination of knowledge, attitudes, and skills.
The term ‘transcultural nursing’ has been used by nurse Madeleine Leininger since the 1950s. Transcultural nursing focuses on differences and similarities among cultures with respect to human care, health, and illness based upon people’s cultural values, beliefs, and practices. Its aim is to provide cultural specific or culturally congruent nursing care to people (Leininger & McFarland, 2005). Countless conflicts in health care delivery situations are predicated on cultural misunderstandings. Often these misunderstandings are related to universal situations, such as verbal and nonverbal language misunderstandings, the conventions of courtesy, sequencing of interactions, phasing of interactions, objectivity, and so forth. Many cultural misunderstandings are unique to the delivery of nursing care. Cultural nursing care is essential and demands that nurses be able to assess and interpret a given client’s health beliefs and practices and cultural needs.
Concepts Related to Cultural Nursing Care All groups of people face issues in adapting to their environment: providing nutrition and shelter, caring for and educating children, dividing labor, developing social organization, controlling disease, and maintaining health. Humans adapt to varying environments by developing cultural solutions to meet these needs. Culture refers to norms and practices of a particular group that are learned and shared and guide thinking, decisions, and actions. Culture is a universal experience, but no two cultures are exactly alike. Cultural patterns are learned, and it is important for nurses to note that members of a particular group may not share identical cultural experiences. Thus, each member of a cultural group will be somewhat different from his or her own cultural counterparts. For example, third-generation Arabs will differ in their cultural understanding from first-generation Arabs.
Subculture Large cultural groups often have cultural subgroups or subsystems. A subculture is usually composed of people who have a distinct identity and yet are related to a larger cultural group. A subcultural group generally shares ethnic origin or physical characteristics with the larger cultural group. Examples of cultural subgroups include occupational groups (e.g., nurses), societal groups (e.g., feminists), and ethnic groups (e.g., Persians, Turks, Armenians, Kurds, Berbers, and other minorities).
Bicultural Bicultural is used to describe a person who has dual patterns of identification and crosses two cultures, lifestyles, and sets of values (Spector, 2004). For example, a young man whose father is an Arab and whose mother is European may honor his traditional Arabic heritage while also being influenced by his mother’s cultural values.
Diversity Diversity refers to the fact or state of being different. Many factors account for diversity: race, gender, sexual orientation, culture, ethnicity, socioeconomic status, educational attainment, religious affiliation, and so on. Diversity therefore occurs not only between cultural groups but also within a cultural group.
Assimilation Assimilation is the process by which an individual develops a new cultural identity. Assimilation means becoming like the members of the dominant culture. The process of assimilation encompasses various aspects, such as behavioral, marital, identification, and civic. The underlying assumption is that the person from a given cultural group loses his or her original cultural identity to acquire the new one. In fact, because this is a conscious effort it is not always possible, and the process may cause severe stress and anxiety. Assimilation can also be described as a collection of subprocesses: a process of inclusion through which a person gradually ceases to conform to any standard of life that differs from the dominant group standards and, at the same time, a process through which the person learns to conform to all the dominant group standards. The process of assimilation is considered complete when the foreigner is fully merged into the dominant cultural group (McLemore & Romo, 2005).
Race Race is the classification of people according to shared biologic characteristics, genetic markers, or features. People of the same race have common characteristics such as skin color, bone structure, facial features, hair texture, and blood type. Different ethnic groups can belong to the same race, and different cultures can be found within one ethnic group. It is important to understand that not all people of the same race have the same culture. Culture should not be confused with either race or ethnic group.
Prejudice Prejudice is a negative belief or preference that is generalized about a group and that leads to ‘prejudgment.’ Prejudice occurs because either the person making the judgment does not understand the particular person or his or her heritage, or the person making the judgment generalizes an experience of one individual from a culture to all members of that group. It may also be referred to as racism.
Stereotyping Stereotyping is assuming that all members of a culture or ethnic group are alike. For example, a nurse may assume that all Arabs have brown eyes or that all Arabs are Muslims. Stereotyping may be based on generalizations founded in research, or it may be unrelated to reality. For example, research indicates that most Arab families prefer to have many children; however, some do not. Stereotyping that is unrelated to reality is frequently an outcome of racism or discrimination. Nurses need to realize
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72 The Nature of Nursing
that not all people of a specific group have the same health beliefs, practices, and values. It is therefore essential to identify a specific client’s beliefs, needs, and values rather than assuming they are the same as those attributable to the larger group.
Discrimination Discrimination, the differential treatment of individuals or groups based on categories such as race, ethnicity, gender, social class, or exceptionality, occurs when a person acts on prejudice and denies other persons one or more of their fundamental rights.
Culture Shock Culture shock is a disorder that occurs in response to transition
from one cultural setting to another. A person’s former behavior patterns are ineffective in such a setting, and basic cues for social behavior are absent (Spector, 2004). This phenomenon may occur when one moves from one geographic location to another or when a person immigrates to a new country. It may occur when a person is admitted into a hospital and has to adapt to a foreign situation. Expressions of culture shock may range from confusion and anxiety, to silence and immobility, to agitation, rage, or fury.
becomes a second cultural identity. If the difference between the two cultures is very big, socialization into the new culture may be an extremely difficult and painful process. As time passes, many people experience biculturalism and divided loyalties. In addition, many people who have been socialized in cultures wherein traditional health care resources are used may prefer to use this type of care even when residing within a cultural setting with modern health care resources available.
Selected Parameters for Cultural Nursing Care This section outline selected phenomena of significance to nursing.
HEALTH Traditions Model The HEALTH traditions model (Spector, 2004) is predicated on the concept of holistic health and describes what people do from a traditional perspective to maintain, protect, and restore health. Imagine health as a complex, interrelated, threefold phenomenon; that is, the balance of all aspects of the person: the body, mind, and spirit. n
Religion Although the word has many definitions, religion may be considered a system of beliefs, practices, and ethical values about divine or superhuman power or powers worshipped as the creator(s) and ruler(s) of the universe. Ethnicity and religion are clearly related, and one’s religion quite often is determined by one’s ethnic group. Religion gives a person a frame of reference and a perspective with which to organize information. Religious teachings about health help to present a meaningful philosophy and system of practices within a system of social controls having specific values, norms, and ethics. Illness is sometimes seen as the punishment for the violation of religious codes and morals. It is not possible to isolate the aspects of culture, religion, and ethnicity that shape a person’s worldview. Each is part of the other, and all three are united within the person.
Clinical Alert In times of distress or illness, the Muslim finds the greatest comfort in the remembrance of God. The severely ill person, who might be distracted by his or her pain, greatly benefits from the nurse’s assistance in notifying someone who could come and provide by prayer and reading from the Holy Qur’an. n
Socialization Socialization is the process of being raised within a culture and
acquiring the characteristics of that group. Education—graduating from high school and enrolling in the nursing school—is a form of socialization. For many people who have been socialized within the boundaries of one culture the second culture
The body includes all physical aspects, such as genetic inheritance, body chemistry, gender, age, nutrition, and physical condition. The mind includes cognitive processes, such as thoughts, memories, and knowledge of such emotional processes as feelings, defenses, and self-esteem. The spiritual facet includes both positive and negative learned spiritual practices and teachings, dreams, symbols, stories, protecting forces, and metaphysical or native forces.
These aspects are in constant flux and change over time, yet each is completely related to the others and also related to the context of the person. The context includes the person’s family, culture, work, community, history, and environment (Spector, 2004). The HEALTH traditions model consists of nine interrelated facets, represented by the following (see also Table 5-1): 1. Traditional methods of maintaining HEALTH—physical, mental, and spiritual—include following a proper diet and wearing proper clothing, concentrating and using the mind, and practicing one’s religion. 2. Traditional methods of protecting HEALTH—physical, mental, and spiritual—include wearing protective objects, such as amulets, avoiding people who may cause trouble, and placing religious objects in the home or reciting daily protective prayers in the morning and afternoon. 3. Traditional methods of restoring HEALTH—physical, mental, and spiritual—include the use of herbal remedies, exorcism, and healing rituals.
Health Beliefs and Practices Three views of health beliefs include magico-religious, scientific, and holistic. In the magico-religious health belief view,
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Table 5-1 The Nine Interrelated Facets of Health (Physical, Mental, and Spiritual) and Personal Methods of Maintaining, Protecting, and Restoring Health Maintain HEALTH
Physical Proper clothing Proper diet Exercise/rest
Special foods and food combination Symbolic clothing
Homeopathic remedies Liniments Herbal teas Special foods Massage Acupuncture/moxibustion
Mental Concentration Social and family support systems Hobbies Avoid certain people who can cause illness Family activities
Relaxation Exorcism Curanderos and other traditional healers Nerve teas
Spiritual Religious worship Prayer Meditation Religious customs Superstitions Wearing amulets and other symbolic objects to prevent the ’evil eye’ or defray other sources of harm Religious rituals, special prayers Meditation Traditional healings Exorcism
Note: from Cultural Diversity in Health and Illness (6th ed., p. 76), by R. E. Spector, 2004, Upper Saddle River, NJ: Prentice Hall.
health and illness are controlled by supernatural forces. The client may believe that illness is the result of ‘being bad’ or opposing God’s will. Getting well is also viewed as dependent on God’s will. The client may make statements such as “If it is God’s will, I will recover” or “What did I do wrong to be punished with cancer?” Some cultures believe that magic can cause illness. A witch may put a spell on the client. Some people view illness as possession by an evil spirit. The belief that the evil eye could harm a mother’s milk has been described in the literature. In Egypt, the belief that the entrance of a menstruating woman into the room can harm a mother or baby is referred to as mushahra. The perception of the evil eye presents a barrier to women breastfeeding, because a mother might deny her child the benefits of her breast milk if she fears she has been subjected to the evil eye. Although these beliefs are not supported by empirical evidence, clients who believe that such things can cause illness may in fact become ill as a result. Such illnesses may require magical treatments in addition to scientific treatments. For example, a man who experiences gastric distress, headaches, and hypertension after being told that a spell has been placed on him may recover only if the spell is removed by the culture’s healer. The scientific or biomedical health belief is based on the belief that life and life processes are controlled by physical and biochemical processes that can be manipulated by humans. The client with this view will believe that illness is caused by germs, viruses, bacteria, or a breakdown of the human machine, the body. This client will expect a pill, or treatment, or surgery to cure health problems. The holistic health belief holds that the forces of nature must be maintained in balance or harmony. Human life is one aspect of nature that must be in harmony with the rest of nature. When the natural balance or harmony is disturbed, illness results. The concept of yin and yang in the Chinese culture and the hot–cold theory of illness in many Spanish cultures are examples of holistic health beliefs. When a Chinese client has a
yin illness or a ‘cold’ illness such as cancer, the treatment may include a yang or ‘hot’ food (e.g., hot tea). What is considered hot or cold varies considerably across cultures. In many cultures, the mother who has just delivered a baby should be offered warm or hot foods and kept warm with blankets because childbirth is seen as a cold condition. Conventional scientific thought recommends cooling the body to reduce a fever. The primary care provider may order liquids for the client and cool compresses to be applied to the forehead, the axillae, or the groin. Many cultures believe that the best way to treat a fever is to increase elimination of toxins through sweating (Fontaine, 2005). Clients from these cultures may want to cover up with several blankets, take hot baths, and drink hot beverages. The nurse must keep in mind that a treatment strategy that is consistent with the client’s beliefs may have a better chance of being successful. Sociocultural forces, such as politics, economics, geography, religion, and the predominant health care system, influence the client’s health status and health care behavior. For example, people who have limited access to scientific health care may turn to folk medicine or folk healing. Folk medicine is defined as those beliefs and practices relating to illness prevention and healing that derive from cultural traditions rather than from modern medicine’s scientific base. Many persons have special teas or ‘cures’ (such as chicken soup) used by older family members to prevent or treat colds, fevers, indigestion, and other common health problems. A frequent component of treatment is some ritual practice on the part of the healer or the client to cause healing to occur. Because folk healing is more culturally based, it is often more comfortable and less frightening for the client.
Clinical Alert Treatments once considered to be folk treatments, including acupuncture, therapeutic touch, and massage, are now being investigated for their therapeutic effect. n
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It is important for the nurse to obtain information about folk or family healing practices that may have been used before or while the client used medical treatment. Often clients are reluctant to disclose the use of home remedies with health care professionals for fear of being laughed at. However, the use of alternative healing practices represents an opportunity for nurses to inform clients about what the nursing profession offers in this regard.
Family Patterns The family is the basic unit of society. Cultural values can determine communication within the family group, the norm for family size, and the roles of specific family members. In some families, the man is considered the provider and decision maker. The woman may need to consult her husband before making decisions about her medical treatment or the treatment of her children. In some families the mother or grandmother is viewed as the leader of the family and is usually the decision maker. The nurse needs to identify who has the ‘authority’ to make decisions in a client’s family. If the decision maker is someone other than the client, the nurse needs to include that person in health care discussions.
Clinical Alert The elderly in the Arab community are regarded with deep respect. They are given priority in all walks of life. Whether they live together with their children or separately, parents are usually consulted in all decisionmaking processes. n
Cultural family values may also dictate the extent of the family’s involvement in the hospitalized client’s care. In some cultures, only the nuclear and the extended family will want to visit for long periods and participate in care. In other cultures, the entire community may want to visit and participate in the client’s care. This can cause concern on nursing units with strict visiting policies. The nurse should evaluate the positive benefits of family participation in the client’s care and modify visiting policies as appropriate. Cultures that value the needs of the extended family as much as those of the individual may believe that personal and family information must stay within the family. Some cultural groups are very reluctant to disclose family information to outsiders, including health care professionals. This attitude can present difficulties for health care
Practice TIPS n n n
Communication Style Communication and culture are closely interconnected. Through communication, the culture is transmitted from one generation to the next, and knowledge about the culture is transmitted within the group and to those outside the group. Communicating effectively with clients of various ethnic and cultural backgrounds is critical to providing culturally competent nursing care. There are cultural variations in both verbal and nonverbal communication.
Verbal Communication The most obvious cultural difference is in verbal communication: vocabulary, grammatical structure, voice qualities, intonation, rhythm, speed, pronunciation, and silence. One example of something that is very divisive to communication in the Arab world is the prevalence of dialects. Dialects of the Arabic language not only vary by region; they can even vary by country or even from city to city or village to village. In general, the dialects are more similar to other dialects in their region than they are with dialects of people from other parts of the Arab world. The dialects not only change pronunciations but can have different words or phrases for the same meaning depending on the region, or have different meaning for the same word or phrase. For example, the phrase “how are you?” in Arabic translates to “ezayyik” in Egypt but to “keef haalak” or “ishloonik” in places like Bilad Ash-Sham, Iraq, and parts of the Arabian Peninsula. The dialects can have different meaning to the same words or phrases. For example, the word Azra’ indicates the color blue in Bilad Ash-Sham whereas it means purple in Egypt, and the phrase “Yateek alafieh” indicates an appreciation for someone’s effort in Bilad Ash-Sham but is not good to be used in Tunisia. Initiating verbal communication may be influenced by cultural values. The busy nurse may want to complete nursing admission assessments quickly. The client, however, may be offended when the nurse immediately asks personal questions. In some cultures, social courtesies should be established before business or personal topics are discussed. Discussing general topics can convey that the nurse is interested and has time for the client. This enables the nurse to develop a rapport with the client before progressing to discussion that is more personal. Techniques for therapeutic communication are shown in the accompanying Practice Tips.
Techniques for Therapeutic Communication
Avoid slang words, medical terminology, and abbreviations. Augment spoken conversation with gestures or pictures to increase the client’s understanding. Speak slowly, in a respectful manner, and at a normal volume. Speaking loudly does not help the client understand and may be offensive.
professionals who require knowledge of family interaction patterns to help clients with emotional problems.
Frequently validate the client’s understanding of what is being communicated. Do not automatically interpret a client’s smiling and nodding to mean that the client understands; the client may only be trying to please the nurse and not understand what is being said.
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Nonverbal Communication To communicate effectively with culturally diverse clients, the nurse needs to be aware of two aspects of nonverbal communication behaviors: what nonverbal behaviors mean to the client and what specific nonverbal behaviors mean in the client’s culture. Before assigning meaning to nonverbal behavior, the nurse must consider the possibility that the behavior may have a different meaning for the client and the family. To provide safe and effective care, nurses who work with specific cultural groups should learn more about cultural behavior and communication patterns within these cultures. Nonverbal communication can include the use of silence, touch, eye movement, facial expressions, and body posture. Some cultures are quite comfortable with long periods of silence, whereas others consider it appropriate to speak before the other person has finished talking. Many people value silence and view it as essential to understanding a person’s needs or use silence to preserve privacy. Some cultures view silence as a sign of respect, whereas to other people silence may indicate agreement. Touching involves learned behaviors that can have both positive and negative meanings. Cultures dictate what forms of touch are appropriate for individuals of the same and opposite gender. In the American culture, a firm handshake is a recognized form of greeting that conveys character and strength. A handshake may not be accepted between religious male and female Muslims or even in Hindu or some far Asian countries. In some European cultures, greetings may include a kiss on one or both cheeks. In Arab culture a kiss is not appropriate for a public greeting between persons of the opposite sex, even those who are family members; however, a kiss on the cheek is acceptable as a greeting among individuals of the same sex. Moreover, in Arab cultures, male health care providers may be prohibited from touching or examining certain parts of the female body; similarly, females may be prohibited from caring for males. The nurse should watch interaction among clients and families for cues to the appropriate degree of touch in that culture. The nurse can also assess the client’s response to touch when providing nursing care, for example, by noting the client’s reaction to a physical examination or a bath. Facial expression can also vary between cultures. People from some cultures are more likely to smile readily and use
Space Orientation Space is a relative concept that includes the individual, the body, the surrounding environment, and objects within that environment. The relationship between the individual’s own body and objects and persons within space is learned and is influenced by culture. For example, in nomadic societies space is not owned, it is occupied temporarily until the tribe moves on. In Western societies people tend to be more territorial, as reflected in phrases such as “This is my space” or “Get out of my space.” The client may physically withdraw or back away if the nurse is perceived as being too close. The nurse will need to explain to the client why there is a need to be close. To assess the lungs with a stethoscope, for example, the nurse needs to move into the client’s intimate space. The nurse should first explain the procedure and await permission to continue.
What are Patients’ Preferences for Nurses’ Gender in Jordan?
A study was conducted in Jordan to examine patients’ preferences for nurses’ gender. The study sample (919 patients) was recruited from the medical and surgical floors in seven hospitals that represent three health sectors: public, private, and university hospitals. Research assistants were trained to collect the data using a standardized individual interview. The interview questionnaire consisted of two parts. Part one recorded participants’ characteristics and part two consisted of a seven-item scale examining patients’ attitudes towards nurses’ gender. The results indicated that two-thirds of female patients preferred to be cared for by female nurses, compared with only 3.4 percent who preferred to be cared for by male nurses. On the other hand, one-third of male patients’ preferred to be cared for by male nurses, and only 10 percent preferred female nurses.
facial expression to communicate feelings. Facial expressions can also convey a meaning opposite to what is felt or understood. Eye movement during communication has cultural foundations. In Western cultures, direct eye contact is regarded as important and generally shows that the other is attentive and listening. It conveys self-confidence, openness, interest, and honesty. However, other cultures may view eye contact as impolite or an invasion of privacy. In fact, your strong gaze may be interpreted as a sign of disrespect among Asian and Arab cultures, and patients may feel that direct eye contact is impolite or aggressive. These patients may avert their eyes when talking with you and others they perceive as authority figures. The nurse should not misinterpret the character of the client who avoids eye contact. Body posture and hand gestures are also culturally learned. For example, making a V sign with one’s middle and index fingers means victory in some cultures, but it is an offensive gesture in other cultures. Tapping the index finger on one’s temple may mean someone is intelligent in the United States but crazy in Holland. Communication is an essential part of establishing a relationship with a client and his or her family. It is also important for developing effective working relationships with health care colleagues. To enhance their practice, nurses can observe the communication patterns of clients and colleagues and be aware of their own communication behaviors.
Implications The current percentage (65 percent) of male nursing students enrolled in nursing programs can be used to predict the direction of future distribution of nurse gender in Jordan, and shows that male nurses will dominate the profession. Although patients’ preferences for nurses’ gender can be investigated in several ways, the present study was concerned only with presenting the general theme of the patients’ view for nurses’ gender and to explore whether the high percentage of male nursing students in Jordan is justifiable. Therefore, the authors recommend further studies to explore the essence of this phenomenon. Note: From “Patients’ preferences for nurses’ gender in Jordan,” by M. M. Ahmad, & J. A. Alasad, 2007, International Journal of Nursing Practice, 13(4), 237–242.
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Time Orientation Time orientation refers to an individual’s focus on the past, the present, or the future. Most cultures include all three time orientations, but one orientation is more likely to dominate. The culture of nursing and health care values time. Appointments are scheduled, and treatments are prescribed with time parameters (e.g., changing a dressing once a day). Medication orders include how often the medicine is to be taken and when (e.g., digoxin 0.25 mg, once a day, in the morning). Nurses need to be aware of the meaning of time for clients. When caring for clients who are “present oriented,” it is important to avoid fixed schedules. The nurse can offer a time range for activities and treatments. For example, instead of telling the client to take digoxin every day at 10.00 am, the nurse might tell the client to take it every day in the morning or every day after getting out of bed.
Nutritional Patterns The cultural meanings associated with food vary widely. For example, sharing meals may be associated with solidifying social or business ties, celebrating life events, expressing appreciation, recognizing accomplishment, expressing wealth or social status, and validating social, cultural, or religious ceremonial functions. Culture determines which foods are served and when, the number and frequency of meals, who eats with whom, and who gets the choicest portions. Culture also determines how foods are prepared and served, how they’re eaten (with chopsticks, fingers, or forks), and where people shop for their favorite food. Food-related cultural behaviors can include whether to breast-feed or bottle-feed infants, and when to introduce solid foods to them. Food can also be considered part of the remedy for illness. Foods classified as ‘hot’ foods or foods that are hot in temperature may be used to treat illnesses that are
c lassified as ‘cold’ illnesses. For example, corn meal (a ‘hot’ food) may be used to treat arthritis (a ’cold’ illness). Each culture group defines what it considers to be hot and cold entities.
Providing Culturally Sensitive Nursing Care All phases of the nursing process are affected by the client’s and the nurse’s cultural values, beliefs, and behaviors. As the client’s culture and the nurse’s culture come together in the nurse– client relationship, a unique cultural environment is created that can improve or impair the client’s outcome. Self-awareness of personal biases can enable nurses to develop modifying behaviors or (if they are unable to do so) to remove themselves from situations where care may be compromised. Nurses can become more aware of their own culture through values clarification as discussed in Chapter 4 . The nurse must also consider the cultural values dominant in the health care setting because those, too, may influence the client’s outcome. The following assumptions are the core tenets of providing care that is culturally appropriate (College of Nurses of Ontario, 2009). n n
Everyone has a culture. Culture is individual. Individual assessments are necessary to identify relevant cultural factors within the context of each situation for each client. An individual’s culture is influenced by many factors, such as race, gender, religion, ethnicity, socioeconomic status, sexual orientation, and life experience. The extent to which particular factors influence a person will vary. Culture is dynamic. It changes and evolves over time as individuals change over time. Reactions to cultural differences are automatic, often subconscious and influence the dynamics of the nurse–client relationship.
Research Note What are Islamic Religious Leaders’ Knowledge and Attitudes towards AIDS and their Perception of People Living with HIV/AIDS? Research has indicated that Arab countries are highly influenced by Islam, and Islamic values influence every aspect of peoples’ lives. Religious leaders in Islamic society are very influential and trustworthy personnel who are important in shaping social values. They have considerable influence on public opinion and can have a positive role in raising the awareness of society about healthy and nondiscriminating behaviors towards AIDS patients. Therefore, a qualitative study was conducted to explore Muslim religious leaders’ perceptions, knowledge, and attitudes towards AIDS and AIDS prevention, and their attitudes towards people living with HIV/AIDS. Participants for the focus groups were selected through the Ministry of Awqaf (Religious affairs) and the Islamic Culture Center at the University of Jordan. Two focus groups were conducted to collect the data: one for the male religious leaders (10 people) and one for female religious leaders (10 people). The two focus groups were conducted separately because of cultural sensitivity. The study results showed that Muslim religious leaders do not perceive AIDS as a major health problem in Jordan, and that following the Islamic values reduces the
risky behaviours. The religious leaders reflected varied responses to people living with HIV/AIDS but they agreed that they have responsibilities toward the prevention of HIV/AIDS, and that sex education contributes to healthy behaviours and consequently to the prevention of HIV transmission. The findings of this study provided an insight into Muslim religious leaders’ perception of people living with HIV/AIDS and highlighted the importance of their role in the prevention of AIDS.
Implications Exploring the attitudes and beliefs of religious leaders will pave the way to incorporating this group into AIDS prevention programs and to planning culturally appropriate evidence-based strategies to combat AIDS and assist health care providers (nurses and physicians) in providing needed treatment and care for those living with AIDS. Note: From “Islamic religious leaders’ knowledge and attitudes towards AIDS and their perception of people living with HIV/ AIDS: A qualitative study.” by F. AbuMoghli, M. Nabolsi, I. Khalaf, & W. Suliman, 2010, Scandinavian Journal of Caring Sciences, 24(4), 655–662.
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A nurse’s culture is influenced by personal beliefs as well as by nursing’s professional values. The values of the nursing profession are upheld by all nurses. The nurse is responsible for assessing and responding appropriately to the client’s cultural expectations and needs.
Nursing Management Assessing The Assessment Interview on pg 81 depicts the questions to ask when conducting a heritage assessment. The tool is a way of interviewing and facilitating communication with clients and their families. It is designed to enhance the process in order to determine whether clients are identifying with their traditional cultural heritage (heritage consistency) or if they have acculturated into the dominant culture of the modern society in which they reside (heritage inconsistency). The tool may be used in any setting to facilitate conversation and help in the planning of cultural care. Once a conversation begins and the person describes aspects of cultural heritage, it becomes possible to develop an understanding of the person’s unique health and illness beliefs, practices, and cultural needs.
Examples of Heritage Consistency The following factors and examples indicative of heritage consistency can be explored to determine the depth to which a person identifies with his or her traditional heritage; that is, the cultural beliefs and practices of his or her family heritage: 1. The person’s childhood development occurred in the person’s country of origin or ethnic group. For example, an Egyptian who was born and raised in a Gulf country and was exposed only to the culture, foods, and customs of the Gulf area. 2. Extended family members encouraged participation in traditional religious and cultural activities. For example, the parents sent the person to religious (parochial, nonpublic) school, and most social activities were church related. 3. The individual engages in frequent visits to the country of origin. The desire to return to the old country or to the old neighborhood is prevalent in many people; however, many people, for various reasons, do not return. 4. The individual’s family home is within the ethnic community of which he or she is a member. As adults, persons elect to live with their families in the ethnic neighborhood wherein the people are from a similar heritage. 5. The individual participates in ethnic cultural events, such as religious festivals or national holidays, sometimes with singing, dancing, and costumes. For example, the person is active in social and cultural groups and participates in family festivities. 6. The individual was raised in an extended family setting. For example, when the person was growing up, grandparents or aunts and uncles may have been living in the same house or close by. The person’s social frame of reference was the family.
7. The individual maintains regular contact with the extended family. For example, the person maintains close ties with family members of the same generation, the surviving members of the older generation, and members of the younger generation. 8. The individual’s name has not been localized. For example, the person has restored the family name to its original if it had been changed by immigration authorities at the time the family immigrated or if the family changed the name at a later time in an attempt to assimilate to the dominant culture more fully. 9. The individual was educated in a parochial school with a religious or ethnic philosophy similar to the family’s background. The person’s education plays an enormous role in socialization, and the major purpose of education is to socialize a given person into the dominant culture. Children learn English and Arabic and the customs and norms of Arab life in the schools. In the parochial or private schools, they not only learn English and Arabic but also are socialized in the culture and norms of the particular religious or ethnic group that is sponsoring the school. 10. The individual engages in social activities primarily with others of the same religious or ethnic background. For example, the major portion of the person’s personal time is spent attending meetings and events sponsored by those with whom he or she identifies. 11. The individual has knowledge of the culture and language of origin. For example, the person has been socialized in the traditional ways of the family and expresses this as a central theme of life. 12. The individual expresses pride in his or her heritage. For example, the person may identify him- or herself as ethnic Arab and display flags, wear clothing, or participate in ethnic activities to a great extent.
Conveying Cultural Sensitivity The process of heritage and health traditions assessment is important. How and when questions are asked requires sensitivity and clinical judgment. The timing and phrasing of questions need to be adapted to the individual. Timing is important in introducing questions. Sensitivity is needed in phrasing questions. Trust must be established before clients can be expected to volunteer and share sensitive information. The nurse therefore needs to spend time with clients, introduce some social conversation, and convey a genuine desire to understand their values and beliefs. Before a heritage assessment begins, determine what language the client speaks, and the client’s degree of fluency in the English language. It is also important to learn about the client’s communications patterns and space orientation. This is accomplished by observing both verbal and nonverbal communication. For example, does the client do the speaking or defer to another? What nonverbal communication behaviors does the client exhibit (e.g., touching, eye contact)? What significance do these behaviors have for the nurse–client interaction? What is the client’s proximity to other people and objects within the
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Heritage Assessment Tool
This set of questions is to be used to describe a given client’s—or your own—ethnic, cultural, and religious background. In performing a heritage assessment it is helpful to determine how deeply a given person identifies with his or her traditional heritage. This tool is most useful in setting the stage for assessing and understanding a person’s traditional health and illness beliefs and practices and in helping to determine the community resources that will be appropriate to target for support when necessary. The greater the number of positive responses, the greater the degree to which the person may identify with his or her traditional heritage. The one exception to positive answers is the question about whether a person’s name was changed. 1. Where was your mother born? 2. Where was your father born? 3. Where were your grandparents born? a. Your mother’s mother? b. Your mother’s father? c. Your father’s mother? d. Your father’s father? 4. How many brothers ______ and sisters ______ do you have? 5. What setting did you grow up in? Urban _______ Rural _______ 6. What country did your parents grow up in? Father Mother 7. How old were you when you came to this country? 8. How old were your parents when they came to this country? Mother Father 9. When you were growing up, who lived with you? 10. Have you maintained contact with a. Aunts, uncles, cousins? (1) Yes ______ (2) No ______ b. Brothers and sisters? (1) Yes ______ (2) No ______ c. Parents? (1) Yes ______ (2) No ______ d. Your own children? (1) Yes ______ (2) No ______ 11. Did most of your aunts, uncles, cousins live near your home? (1) Yes ______ (2) No ______ 12. Approximately how often did you visit family members who lived outside of your home? (1) Daily ______ (2) Weekly (3) Monthly ______ (4) Once a year or less ______ (5) Never ______ 13. Was your original family name changed? (1) Yes ______ (2) No ______
environment? How does the client react to the nurse’s movement toward the client? What cultural objects within the environment have importance for health promotion or health maintenance? Cultural competence in nursing involves delivering care that integrates the mind, the body, the spirit, and the cultural values of the individual (Fontaine, 2005). A potential outcome is that the client can “promote, maintain, and/or regain mutually desired and obtainable levels of health within the realities of their life circumstances” (Kagawa-Singer, & Kassim-Lakha, 2003, p. 580). There are several steps involved in the process that lead to the development of cultural competency. The knowledge and skills necessary to incorporate cultural care
4. What is your religious preference? 1 (1) Islam ______ (2) Jewish ______ (3) Protestant ______ Denomination ______ (4) Catholic ______ (5) Other ______ (6) None ______ 15. Is your spouse the same religion as you? (1) Yes ______ (2) No ______ 16. Is your spouse the same ethnic background as you? (1) Yes ______ (2) No ______ 17. What kind of school did you go to? (1) Public ______ (2) Private ______ (3) Parochial ______ 18. As an adult, do you live in a neighborhood where the neighbors are the same religion and ethnic background as yourself? (1) Yes ______ (2) No ______ 19. Do you belong to a religious institution? (1) Yes ______ (2) No ______ 20. Would you describe yourself as an active member? (1) Yes ______ (2) No ______ 21. How often do you attend your religious institution? (1) More than once a week ______ (2) Weekly ______ (3) Monthly ______ (4) Special holidays only ______ (5) Never ______ 22. Do you practice your religion in your home? (1) Yes ______ (2) No ______ (if yes, please specify) (3) Praying ______ (4) Qur’an reading ______ (5) Diet ______ (6) Celebrating religious holidays ______ 23. Do you prepare foods special to your ethnic background? (1) Yes ______ (2) No ______ 24. Do you participate in ethnic activities? (1) Yes ______ (2) No ______ (if yes, please specify) (3) Singing ______ (4) Holiday celebrations ______ (5) Dancing ______ (6) Festivals ______ (7) Costumes ______ (8) Other ______ 25. Are your friends from the same religious background as you? (1) Yes ______ (2) No ______ 26. Are your friends from the same ethnic background as you? (1) Yes ______ (2) No ______ 27. What is your native language? ______ 28. Do you speak this language? (1) Prefer ______ (2) Occasionally ______ (3) Rarely ______ 29. Do you read your native language? (1) Yes ______ (2) No ______
Note: From Cultural Diversity in Health & Illness (6th ed., pp. 321–323), by R. E. Spector, 2004, Upper Saddle River, NJ: Prentice Hall.
into standard nursing require the acquisition of a broad base of knowledge about different heritages and social structures. It is an ongoing process and the skills and knowledge base grow over time. As one’s knowledge base grows, the ability to convey cultural sensitivity also grows (see Box 5-1). The following are examples of the necessary steps: 1. Become aware of one’s own cultural heritage. Where were your parents and grandparents born? What are examples of their traditional health and illness beliefs and practices? Do they value privacy in relation to pain, or is it permissible to state that you are in pain? Are the rights of the
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Box 5-1 Arab Cultural Commonalities that May Have an Impact on Health Care Delivery n n
n n n n
Preferring to be treated by a medical provider of the same sex, especially female patients. Nurses are perceived as helpers, not health care professionals, and their suggestions and advice are not taken seriously. Doctors may need to explain the nurse’s role to the patient. Arabs are not accustomed to the profession of social workers, clinical psychologists, or family and marriage therapists. Arabs rely on their families, other relatives, and close friends for support and help. Arabs may prefer medical treatment that involves prescribing pills or giving injections, rather than simple medical counseling. Muslims follow a halal diet (Muslim diet), which prohibits some types of meat, like pork, and medications/foods that contain alcohol. For example, a Muslim patient may refuse to take some medications or foods that contain alcohol, or pork or pig products. In some Muslims societies women are strictly secluded from men; in these societies, women may have little contact outside of the home.
individual valued over and above the rights of the family? Only by knowing one’s own culture (values, practices, and beliefs) can a person be ready to learn about another’s. 2. Become aware of the client’s heritage and health traditions as described by the client. It is important to avoid assuming that all people of one ethnic background have the same cultural beliefs and values. When the nurse has knowledge of the client’s culture, mutual respect between client and nurse is more likely to develop. 3. Become aware of the client’s preferences in health practices, diet, hygiene, and so on. During this part of the interview, a nurse can also identify the client’s preferences in health practices, diet, hygiene, and so on. 4. Form a nursing plan with the client that incorporates his or her cultural beliefs regarding the maintenance, protection, and restoration of health. In this way, cultural values, practices, and beliefs can be incorporated with the necessary nursing care. Culturally sensitive and competent nurses convey this sensitivity to clients, support people, and other health care personnel. Some ways to do so follow: n
Always address clients, support people, and other health care personnel by the way they wish to be addressed. In Western countries people like to be addressed by their last names (e.g., Mrs Aylia, Dr Rush) until they give you permission to use other names. In some cultures, the more formal style of address is a sign of respect, whereas the informal use of first names may be considered disrespectful. Arabs are accustomed to being called by the name of their older sons (e.g., Abu Mohammad, Um Ahmad). When meeting a person for the first time, introduce yourself by your full name, and then explain your role (e.g., “My name is Alia Hasan and I am a student nurse at X University”). This helps establish a relationship and
n n n
Muslims pray as many as five times a day, starting before sunrise and ending at night. Abstaining from alcohol is mandatory for Muslims. Among devout Muslims, fasting is required during the holy month of Ramadan, with no food or drink consumed between sunrise and sunset. The ill are supposed to be exempt from fasting, but among people who are fasting oral medication and intravenous solutions are prohibited (religious scholars are in favor of allowing it, but debate is still ongoing). Muscular injections are permitted. Women are exempt from fasting during menstruation and 40 days postpartum unless they are clear from bleeding and spotting. Despite their illness the Muslim patient may try to fast during Ramadan. Arabic culture in general, regardless of being Christian or Muslim, believes in death as “the will of God” and that nobody can stop it or delay it. Arab culture and the Islamic religion emphasize maintaining good health, especially through personal hygiene practices and a healthy diet. They place a high value in modern medicine and have confidence in the medical profession.
provides an opportunity for clients, others, and nurses to learn the pronunciation of one another’s names and their roles. Be authentic with people, and be honest about the knowledge you lack about their culture. When you do not understand a person’s actions, politely and respectfully seek information. Use language that is culturally sensitive; for example, do not use ‘man’ or ’mankind’ when referring to a woman. Find out what the client thinks about his or her health problems, illness, and treatments. Assess whether this information fits with the dominant health care culture. If the beliefs and practices do not fit, establish whether this will have a negative effect on the client’s health. Do not make any assumptions about the client, and always ask about anything you do not understand. Show respect for the client’s values, beliefs, and practices, even if they differ from your own or from those of the dominant culture. If you do not agree with them, it is important to respect the client’s right to hold these beliefs. Show respect for the client’s support people. In some cultures, men in the family make decisions affecting the client, while in other cultures women make the decisions. Make a concerted effort to obtain the client’s trust, but do not be surprised if it develops slowly or not at all. The heritage assessment takes time and usually needs to extend over several meetings.
Diagnosing The nursing diagnoses developed by NANDA International are focused on nursing care provided in the United States and Canada and are based on Western cultural beliefs. It is essential
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to expand the understanding of the nursing practice to include cultural beliefs of Eastern and Arab culture. Nurses must provide appropriate care to clients of any culture. This is accomplished through developing cultural sensitivity and considering how a client’s culture influences his or her responses to health conditions, much as the nurse considers how a client’s age or gender influences a nursing diagnosis, plan, and delivery of nursing care.
Nursing Intervention The implementation of cultural nursing care includes (a) cultural preservation and maintenance and (b) cultural accommodation and negotiation. Cultural preservation may involve the use of cultural health care practices, such as giving herbal tea, chicken soup, or ‘hot’ foods to the ill client. Accommodation of the client’s viewpoint and negotiating appropriate care requires expert communication skills, such as responding empathetically, validating information, and effectively summarizing content. Negotiation is a collaborative process. It acknowledges that the nurse–client relationship is reciprocal and that different views exist of health, illness, and treatment. The nurse attempts to bridge the gap between the nurses’s scientific and the client’s cultural perspectives. During the negotiation process, the client’s views are explored and acknowledged. Relevant scientific information is then provided. If the client’s views reveal that certain behaviors would not affect the client’s condition adversely, then they are incorporated in planning care. If the client’s views can lead to harmful behavior or outcomes, then an attempt is made to shift the client’s perspectives to the scientific view. Negotiation occurs when cultural treatment practices conflict with those of the health care system. It must be determined precisely how the client is managing the illness, what practices could be harmful, and which practices can be safely combined with Western medicine. For example, reducing dosages of an antihypertensive medication or replacing insulin therapy with herbal measures may be detrimental. Some herbal remedies are synergistic with Western medicines and others are antagonistic; therefore, it is necessary to fully inform the client about the possible outcomes. When a client chooses to follow only cultural practices and declines all prescribed medical or nursing interventions, the
nurse and client must adjust the client goals. Monitoring the client’s condition to identify changes in health and to recognize impending crises before they become irreversible may be all that is realistically achievable. At a time of crisis, the opportunity may arise to renegotiate care. Providing cultural nursing care is challenging. It requires discovery of the meaning of the client’s behavior, flexibility, creativity, and knowledge to adapt nursing interventions. An effort must be made to learn from each experience. This knowledge will improve the delivery of culture-specific care to future clients. Box 5-2 offers suggestions for providing such care to clients and families.
Evaluating Evaluating nursing care of clients that incorporates the concepts of heritage and ethnicity is performed in the same way as with any client. Client outcomes are compared with the goals and expected outcomes established following comprehensive assessment that includes sensitivity to cultural diversity. However, if the outcomes are not achieved, and the client and nurse are from different cultures, the nurse should be especially careful to consider whether the client’s belief system has been adequately included as an influencing factor.
Box 5-2 Providing Culturally Competent Care to Families n n
n n n n
Include cultural assessment of the client and family as part of overall assessment. Learn the rituals, customs, and practices of the major cultural groups with whom you come into contact. Learn to appreciate the richness of diversity and consider it an asset rather than a hindrance in your practice. Don’t make assumptions about beliefs or practices. Ask about the client’s use of cultural or alternative approaches to healing. Identify your personal biases, attitudes, prejudices, and stereotypes. Recognize that it is the client’s (or family’s) right to make their own health care choices. Explain in detail the client’s condition and the treatment plan if the client is willing for you to do this. Convey respect and cooperate with traditional helpers and caregivers.
Critical Reflection We have seen in this chapter that there are many cultural implications that need to be considered when providing health care. People have different health beliefs and the nurse will need to be culturally sensitive to these. After having read the chapter, let us go back to the case study presented at the beginning of this chapter. What issues should you consider in providing health care to Mrs Salma? What concepts related to cultural nursing care should you take into consideration?
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Chapter Highlights The Arab world is made up of 22 countries across the Middle East and North Africa. n Ethnic minority groups live in many Arab countries. These include Persians, Turks, Armenians, Kurds, Berbers, and other minorities. Differences within Arab culture also exist between people living in urban and those in rural areas, and among countries. n People in the Arab world come from a variety of backgrounds, and may retain at least some of their traditional values, including health beliefs and prctices. n People may live within their traditional heritage or they may embrace both their original ethnocultural traditional heritage(s) and the new culture. n
An individual’s heritage and cultural background can influence health beliefs and practices. n Health beliefs and practices, family patterns, communication style, space and time orientation, and nutritional patterns may influence the relationship between the nurse and the client who have different cultural backgrounds. n When assessing a client, the nurse considers the client’s cultural values, beliefs, and practices related to health and health care. n
Test Your Knowledge 1. Which of the following behaviors is most indicative of culturally sensitive nursing practice? 1. Helps client recognize the need to adapt health practices to fit commonly accepted practices. 2. Discusses the meaning of the medical regime to the client. 3. Informs client that lack of adherence to medical regime may be detrimental. 4. Asks a person from the same culture to explain the relevance of the intervention. 2. In initiating care for a client of a different culture than the nurse, which of the following would be an appropriate statement? 1. “Since, in your culture, people don’t drink ice water, I will bring you hot tea.” 2. “Do you have any books I could read about people of your culture?”
3. “Please let me know if I do anything that is not acceptable in your culture.” 4. “You will need to set aside your usual customs and practices while you are in the hospital.” 3. Students ask the nurse to explain the differences between culture and race. Which of the following is the best response? 1. Culture is limited to a shared language or religion. 2. Race describes common characteristics within a specific heritage group. 3. Culture is socially oriented and race addresses shared physical traits. 4. Culture is the degree by which one’s lifestyle matches one’s heritage. See Answers to Test Your Knowledge in Appendix A
References Abu-Moghli, F., Nabolsi, M., Khalaf, I., & Suliman, W. (2010). Islamic religious leaders’ knowledge and attitudes towards AIDS and their perception of people living with HIV/ AIDS: A qualitative study. Scandinavian Journal of Caring Sciences, 24(4), 655–662. Ahmad, M. M., & Alasad, J. A. (2007) Patients’ preferences for nurses’ gender in Jordan. International Journal of Nursing Practice, 13(4), 237–242. Ahmad, N. M. (2004). Arab-American culture and health care. Retrieved June 1, 2011 from www.cwru.edu/med/epidbio/mphp439/ArabAmericans.htm California Healthcare Interpreters Association. (2002). California standards for healthcare interpreters: Ethical principles, protocols, and guidance on roles and interventions. Los Angeles: Author. Canadian Nurses Association. (2004). Position statement: Promoting culturally competent care. Retrieved April 22, 2006, from http:// www.cna-aiic.ca/CNA/documents/pdf/publications/PS114_Cultural_ Competence_2010_e.pdf College of Nurses of Ontario, (2009). Culturally Sensitive Care Pub. No. 41040 ISBN 1-894557-52-2. Retrieved April 2011 from http://www.cno. org/Global/docs/prac/41040_CulturallySens.pdf Fontaine, K. L. (2005). Complementary and alternative therapies for nursing practice (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall.
Kagawa-Singer, M., & Kassim-Lakha, S. (2003). A strategy to reduce crosscultural miscommunication and increase the likelihood of improving health outcomes. Academic Medicine, 78(6), 577–587. Leininger, M. M., & McFarland, M. R. (2005). Culture care diversity & universality: A worldwide nursing theory (2nd ed.). Boston, MA: Jones & Bartlett. McLemore, S. D., & Romo, H. D. (2005). Racial and ethnic relations in America (7th ed.). Boston, MA: Allyn & Bacon. Office of the Deputy Chief of Staff for Intelligence US Army Training and Doctrine Command. (2006). Arab cultural awareness. Handbook 2 FT. Leavenworth, Kansas. Retrieved April 2011, from http://www.fas.org/irp/ agency/army/arabculture.pdf Office of Minority Health. (2001). National standards for culturally and linguistically appropriate services in health care. Washington, DC: US Department of Health and Human Services. Spector, R. E. (2004). Cultural diversity in health and illness (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Wikipedia.org. (2010). Arab culture. Retrieved June 1, 2011, from http:// en.wikipedia.org/wiki/Arab_culture
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Learning Outcomes After completing this chapter, you will be able to: 1. Identify essential nutrients and their dietary sources. 2. Explain essential aspects of energy balance. 3. Discuss body weight and body mass standards. 4. Identify factors influencing nutrition. 5. Identify developmental nutritional considerations. 6. Evaluate a diet using a food guide pyramid. 7. Discuss essential components and purposes 足nutritional assessment and nutritional screening.
8. Identify risk factors for and clinical signs of malnutrition. 9. Describe nursing interventions to promote optimal 足nutrition. 10. Discuss nursing interventions to treat clients with nutritional problems. 11. Perform the skills of inserting enteral tubes, 足administering feedings and medications through enteral tubes, and removing enteral tubes.
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Key terms anabolism, 415 basal metabolic rate (BMR), 417 body mass index (BMI), 417 caloric value, 416 calorie, 416 catabolism, 415 cholesterol, 416 complete proteins, 415 disaccharides, 415 dysphagia, 419 enteral, 433 enzyme, 415 essential amino acids, 415 fat-soluble vitamins, 416 fats, 416 fatty acids, 416 gastrostomy, 437 glycerides, 416 glycogenesis, 415 hemoglobin, 430 ideal body weight (IBW), 417 incomplete proteins, 415 jejunostomy, 437 kcal, 416
large calorie, 416 lipids, 416 lipoproteins, 416 macrominerals, 416 macronutrients, 414 malnutrition, 426 metabolism, 417 microminerals, 416 micronutrients, 414 mid-arm circumference (MAC), 429 mid-arm muscle circumference, 429 minerals, 416 monosaccharides, 415 nasoenteric tube, 437 nasogastric tube, 434 nasointestinal tube, 437 nitrogen balance, 415 nitrogen balance, 415 nonessential amino acids, 415 nutrients, 414 nutrition, 414 nutritional value, 414 obese, 426 oils, 442
overweight, 426 parenteral, 442 partially complete proteins, 415 percutaneous endoscopic gastrostomy (PEG), 437 percutaneous endoscopic jejunostomy (PEJ), 437 polysaccharides, 415 polyunsaturated fatty acids, 416 protein-calorie malnutrition (PCM), 426 pureed diet, 432 resting energy expenditure (REE), 417 saturated fatty acids, 416 skinfold measurement, 428 small calorie, 416 triglycerides, 416 tube, 437 undernutrition, 426 unsaturated fatty acids, 416 urea, 430 vitamin, 416 water-soluble vitamins, 416
Case Study Laila is a 55-year-old woman who has recently been diagnosed with unstable angina. Her physician has recommended that she lose weight and eat a low cholesterol diet. Laila followed the advice of the physician but went too far, which resulted in her being admitted to the medical floor to treat her malnutrition problems. She had lost 17 kg during the past 6 months. While taking the client’s history,
Nutrition is what a person eats and how the body uses it. Nutrients are organic and inorganic substances found in foods that are required for body functioning. Adequate food intake consists of a balance of nutrients: water, carbohydrates, proteins, fats, vitamins, and minerals. Foods differ greatly in their nutritional value (the content of a specified amount of nutrients found in a food), and no one food provides all essential nutrients. Nutrients have three major functions: providing energy for body processes and movement, providing structural material for body tissues, and regulating body processes.
Essential Nutrients The body’s most basic nutrient need is water. Following this, the next most important nutritional need is for nutrients that provide energy. The energy-providing nutrients are carbohydrates, fats,
you asked Laila about the reasons for her condition. She replied, “I was afraid that my heart condition would get worse if I ate, and now I have no appetite to eat at all.” After reading this chapter you will be able to identify factors influencing nutrition and identify risks and symptoms of malnutrition. You will be provide nursing intervention and perform skills to treat clients with nutritional problems.
and proteins. These will be referred to as macronutrients (because they are needed in large amounts to provide energy) and vitamins and minerals will be referred to as micronutrients. Vitamins and minerals are required in small amounts to metabolize the energyproviding nutrients.
Carbohydrates There are of two basic types of carbohydrates: simple carbohydrates (sugars) and complex carbohydrates (starches and fiber). As with all nutrients, carbohydrates must be ingested, digested, and metabolized.
Types of Carbohydrates Sugars. Sugars, the simplest of all carbohydrates, are water
soluble and are produced naturally by both plants and animals.
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Sugars may be monosaccharides (single molecules such as glucose—the most simple sugar—fructose, and galactose) or disaccharides (double molecules). Most sugars are produced naturally by plants, especially fruits, sugar cane, and sugar beets. However, other sugars are from an animal source. For example, lactose, a combination of glucose and galactose, is found in animal milk. Processed or refined sugars (e.g., table sugar, molasses, and corn syrup) have been extracted and concentrated from natural sources. Starches. Starches (polysaccharides) are the insoluble,
n onsweet forms of carbohydrate. They are composed of branched chains of dozens or hundreds of glucose molecules. Like sugars, nearly all starches exist naturally in plants, such as grains and potatoes. Other foods, such as cereals, breads, flour, and puddings, are processed from starches. Fiber. Fiber, a complex carbohydrate derived from plants,
supplies roughage, or bulk, to the diet. However, fiber cannot be digested by humans but satisfies the appetite and helps the digestive tract to function effectively and eliminate waste. Fiber is present in the outer layer of grains, bran, and in the skin, seeds, and pulp of many vegetables and fruits. Natural sources of carbohydrates also supply vital nutrients, such as protein, vitamins, and minerals that are not found in processed foods.
Carbohydrate Metabolism An enzyme is a biologic catalyst that speeds up chemical reactions. Major enzymes include ptyalin (salivary amylase), pancreatic amylase, and the disaccharidases—maltase, sucrase, and lactase— and are used in carbohydrate digestion. The desired end products of carbohydrate digestion are monosaccharides, which are absorbed by the small intestine in a healthy person. After the body breaks carbohydrates down into glucose, some glucose continues to circulate in the blood to maintain blood levels and to provide a readily available source of energy. The remainder is either used as energy or stored, either as glycogen, a large polymer (compound molecule) of glucose, or as fat (glucose that cannot be stored as glycogen is converted to fat), by a process called glycogenesis in the liver and skeletal muscles. Insulin, a hormone secreted by the pancreas, enhances the transport of glucose into cells.
Proteins Every cell in the body contains some protein, and about threequarters of body solids are proteins. Amino acids are basic structural units of proteins and categorized as essential or nonessential. Essential amino acids are those that cannot be manufactured in the body and must be supplied in the diet. Nine essential amino acids—histidine, isoleucine, leucine, lysine, methionine, phenylalanine, tryptophan, threonine, and valine— are necessary for tissue growth and maintenance. A tenth, arginine, appears to have a role in the immune system. Nonessential amino acids are those that the body can manufacture. Nonessential amino acids include alanine, aspartic acid, cystine, glutamic acid, glycine, hydroxyproline, proline, serine, and tyrosine. Proteins may be complete or incomplete. Complete proteins contain all of the essential amino acids plus many nonessential
ones. Most animal proteins, including meats, poultry, fish, dairy products, and eggs are complete proteins. Some animal proteins are partially complete proteins and contain less than the required amount of one or more essential amino acids. Examples are gelatin and the milk protein casein. Incomplete proteins lack one or more essential amino acids (most commonly lysine, methionine, or tryptophan) and are usually derived from vegetables such as corn. A balanced ratio of amino acids can be achieved if a mixture of plant proteins is included in the diet. A combination of proteins such as corn (low in tryptophan and lysine) and beans (low in methionine) is a complete protein. Such combinations of two or more vegetables are called complementary proteins. To take full advantage of vegetable proteins is to eat them with a small amount of animal protein. Eating Mansaf (rice with hot yogurt and meat), Kabsah (rice with meat), or Maklobah (rice, vegetables and chicken) are examples of combining vegetable and animal proteins.
Protein Digestion Digestion of protein foods begins in the mouth, where the enzyme pepsin breaks protein down into smaller units. Most proteins are digested in the small intestine. The pancreas secretes the proteolytic enzymes trypsin, chymotrypsin, and carboxypeptidase; glands in the intestinal wall secrete aminopeptidase and dipeptidase. These enzymes break protein down into smaller molecules and eventually into amino acids. Amino acids are absorbed by active transport through the small intestine into the portal blood circulation. The liver uses some amino acids to synthesize specific proteins (e.g., liver cells and the plasma proteins albumin, globulin, and fibrinogen).
Storage Plasma proteins are a storage medium that can rapidly be converted back into amino acids. Other amino acids are transported to tissues and cells throughout the body where they are used to make protein for cell structures. In a sense, protein is stored as body tissue. The body cannot actually store excess amino acids for future use. However, a limited amount is available in the ‘metabolic pool’ that exists because of the constant breakdown and buildup of the protein in body tissues.
Protein Metabolism Protein metabolism includes three activities: anabolism (building tissue), catabolism (breaking down tissue), and nitrogen balance. Anabolism. All body cells synthesize proteins from amino acids. The types of proteins formed depend on the characteristics of the cell and are controlled by its genes. Catabolism. Because a cell can accumulate only a limited amount of protein, excess amino acids are degraded for energy or converted to fat. Protein degradation occurs primarily in the liver. Nitrogen Balance. Because nitrogen is the element that distinguishes protein from lipids and carbohydrates, nitrogen balance reflects the status of protein nutrition in the body. Nitrogen balance is a measure of the degree of protein anabolism and catabolism; it is the net result of intake and loss of nitrogen. When nitrogen intake equals nitrogen output, a state of nitrogen balance exists.
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Lipids Lipids (fats and oils) are organic substances that have the same elements (carbon, hydrogen, and oxygen) as carbohydrates, but they contain a higher proportion of hydrogen. Fats may be solid or liquid (oil). Fatty acids are the basic structural units of most lipids. Fatty acids are described as saturated or unsaturated. Saturated fatty acids are those in which all carbon atoms are filled to capacity (i.e., saturated) with hydrogen; an example is butyric acid, found in butter. An unsaturated fatty acid is one that could accommodate more hydrogen atoms than it currently does. It has at least two carbon atoms that are not attached to a hydrogen atom; instead, there is a double bond between the two carbon atoms. Fatty acids with one double bond are called monounsaturated fatty acids; those with more than one double bond (or many carbons not bonded to a hydrogen atom) are polyunsaturated fatty acids. An example of a polyunsaturated fatty acid is linoleic acid, found in vegetable oil. Lipids are classified as simple or compound. Glycerides, the simple lipids, are the most common form of lipids. They consist of a glycerol molecule with up to three fatty acids attached. Triglycerides (which have three fatty acids) account for more than 90% of the lipids in food and in the body. Triglycerides may contain saturated or unsaturated fatty acids. Saturated triglycerides are found in animal products, such as butter, and are usually solid at room temperature. Unsaturated triglycerides are usually liquid at room temperature and are found in plant products, such as olive oil and corn oil. Cholesterol is a fat-like substance that is both produced by the body and found in foods of animal origin. Most of the body’s cholesterol is synthesized in the liver; however, some is absorbed from the diet (e.g., from milk, egg yolk, and organ meats). Cholesterol is needed to create bile acids and to synthesize steroid hormones. Along with phospholipids, large quantities of cholesterol are present in cell membranes as well as other cell structures.
Lipid Digestion Although chemical digestion of lipids begins in the stomach, they are digested mainly in the small intestine, primarily by bile, pancreatic lipase, and enteric lipase, an intestinal enzyme. The end products of lipid digestion are glycerol, fatty acids, and cholesterol. These are immediately reassembled inside the intestinal cells into triglycerides and cholesterol esters (cholesterol with a fatty acid attached to it), which are not water soluble. For these reassembled products to be transported and used, the small intestine and the liver must convert them into soluble compounds called lipoproteins. Lipoproteins are made up of various lipids and a protein.
Lipid Metabolism Converting fat into usable energy occurs through the use of the enzyme hormone-sensitive lipase that breaks down triglycerides in adipose cells, releasing glycerol and fatty acids into the blood. 0.45 kg of fat provides 3,500 kilocalories. Fasting persons will obtain most of their calories from fat metabolism, but some amount of carbohydrate or protein must also be used because the brain, nerves, and red blood cells require glucose. Only the glycerol molecules in fat can be converted to glucose. A typical
triglyceride has 50 carbon atoms, of which the one glycerol molecule represents only three carbons (Rolfes, Pinna, Whitney, 2006).
Micronutrients A vitamin is an organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze metabolic processes. Thus, when vitamins are lacking in the diet, metabolic deficits result. Vitamins are generally classified as fat soluble or water soluble. Water-soluble vitamins include vitamin C and the B-complex vitamins: B1 (thiamine), B2 (riboflavin), B3 (niacin or nicotinic acid), B6 (pyridoxine), B9 (folic acid), B12 (cobalamin), pantothenic acid, and biotin. The body cannot store water-soluble vitamins; thus, people must get a daily supply in the diet. Water-soluble vitamins can be affected by food processing, storage, and preparation. Fat-soluble vitamins include vitamins A, D, E, and K. The body can store these vitamins, although there is a limit to the amounts of vitamins E and K the body can store. Therefore, a daily supply of fat-soluble vitamins is not absolutely necessary. Vitamin content is highest in fresh foods that are consumed as soon as possible after harvest. Minerals are found in organic compounds, as inorganic compounds, and as free ions. Calcium and phosphorus make up 80% of all mineral elements in the body. The two categories of minerals are macrominerals and microminerals. Macrominerals are those that people require daily in amounts over 100 mg. They include calcium, phosphorus, sodium, potassium, magnesium, chloride, and sulfur. Microminerals are those that people require daily in amounts less than 100 mg. They include iron, zinc, manganese, iodine, fluoride, copper, cobalt, chromium, and selenium. Common problems associated with the mineral nutrients are iron deficiency resulting in anemia, and osteoporosis resulting from loss of bone calcium.
Energy Balance Energy balance is the relationship between the energy derived from food and the energy used by the body. The body obtains energy in the form of calories from carbohydrates, protein, and fat. The body uses energy for voluntary activities such as walking and talking and for involuntary activities such as breathing and secreting enzymes. A person’s energy balance is determined by comparing his or her energy intake with energy output.
Energy Intake The amount of energy that nutrients or foods supply to the body is their caloric value. A calorie (c, cal, kcal) is a unit of heat energy. A small calorie is the amount of heat required to raise the temperature of 1 gram of water 1°C. This unit of measure is used in chemistry and physics. A large calorie (Calorie, kilocalorie, or Kcal) is the amount of heat energy required to raise the temperature of 1 gram of water 15 to 16°C. The energy liberated from the metabolism of food has been determined to be: n n n
4 Calories/gram of carbohydrates. 4 Calories/gram of protein. 9 Calories/gram of fat.
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Energy Output Metabolism refers to all biochemical and physiologic processes
by which the body grows and maintains itself. Metabolic rate is normally expressed in terms of the rate of heat liberated during these chemical reactions. The basal metabolic rate (BMR) is the rate at which the body metabolizes food to maintain the energy requirements of a person who is awake and at rest. The energy in food maintains the basal metabolic rate of the body and provides energy for activities such as running and walking. Resting energy expenditure (REE) is the amount of energy required to maintain basic body functions; in other words, the calories required to maintain life. The REE of healthy persons is generally about 1 cal/kg of body weight/hour for men and 0.9 cal/kg/hour for women although there is great variation among individuals. BMR is calculated by measuring the REE in the early morning, 12 hours after eating.
Body Weight and Body Mass Standards Maintaining a healthy or ideal body weight requires a balance between the expenditure of energy and the intake of nutrients. Generally, when energy requirements of an individual equate with the daily caloric intake, the body weight remains stable. Ideal body weight (IBW) is the optimal weight recommended for optimal health; however, many health professionals consider the body mass index to be a more reliable indicator of a person’s healthy weight. For people older than 18 years, the body mass index (BMI) is an indicator of changes in body fat stores and whether a person’s weight is appropriate for height, and may provide a useful estimate of malnutrition. However, the results must be used with caution in people who have fluid retention (e.g., ascites or edema), athletes, or elders. To calculate the BMI: 1. Measure the person’s height in meters, e.g., 1.7 m. 2. Measure the weight in kilograms, e.g., 72 kg. 3. Calculate the BMI using the following formula: BMI =
Weight in kilograms (Height in meters)2
or 72 kilograms 1.7 * 1.7(meter)2
Box 15-1 provides an interpretation of the results. Another measure of body mass is the percentage of body fat. Because BMI uses only height and weight, it can give misleading results for certain groups of clients such as athletes, the frail elderly, and children. Percentage of body fat can be measured by underwater weighing and dual-energy x-ray absorptiometry (DEXA), but these methods are time-consuming and expensive. Other indirect, but more practical measures include waist circumference (see Box 15-1), skinfold testing, and near-infrared interactance. Bioelectrical impedance analysis (BIA) is used by some modern weight scales and is considered one of the most accurate methods of body fat determination (Kyle et al., 2004). The speed
BOX 15-1 Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks Disease Risk* Relative to Normal Weight and Waist Circumference
Men 102 cm or less Obesity Women 88 cm Class or less
Men >102 cm Women >88 cm
30.0– 34.9 I
Extremely high Extremely high
Extreme obesity 40.0+
*Disease risk for type 2 diabetes, hypertension, and cardiovascular disease. †Increased waist circumference can also be a marker for increased risk even in persons of normal weight. Note: from Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report, by the National Heart, Lung, and Blood Institute, 1998, p. xvii, Washington, DC: U.S. Department of Health & Human Services. Retrieved June 25, 2006 from http://www.nhlbi.nih.gov/ guidelines/obesity/ob_gdlns.htm
with which an electrical signal passes through the body is influenced by the amount of water in the body. The more muscle, the more water the body can hold, and the easier it is for current to pass through it. The more fat, the more resistance to the current. Height, age, gender, and weight or other physical characteristics such as body type, physical activity level, and ethnicity are used with the impedance data to determine percentage body fat. BIA is safe and it does not hurt.
Factors Affecting Nutrition Although the nutritional content of food is an important consideration when planning a diet, an individual’s food preferences and habits are often major factors affecting actual food intake. Habits about eating are influenced by developmental considerations, gender, ethnicity and culture, beliefs about food, personal preferences, religious practices, lifestyle, economics, medications and therapy, health, alcohol consumption, advertising, and psychologic factors.
Development People in rapid periods of growth (i.e., infancy and adolescence) have increased needs for nutrients. Elders, on the other hand, need fewer calories and dietary changes in view of the risk of coronary heart disease, osteoporosis, and hypertension.
Gender Nutrient requirements are different for men and women because of body composition and reproductive functions. The larger muscle mass of men translates into a greater need for calories and proteins. Because of menstruation, women require more
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iron prior to menopause than men do. Pregnant and lactating women have increased caloric and fluid needs.
Ethnicity and Culture Ethnicity often determines food preferences. Traditional foods (e.g., dates, meat, and rice for Arabs, rice for Asians, pasta for Italians, and curry for Indians) are eaten long after other customs are abandoned (see Box 15-2 for a list of selected variations in nutritional practices and preferences among different cultures).
BOX 15-2 Selected Variations in Nutritional Practices and Preferences Among Different Cultures African American Heritage Gifts of food are common and should never be rejected. Diets are often high in fat, cholesterol, and sodium. n Being overweight is viewed as positive. n Most persons are lactose intolerant. n n
Arab Heritage n n
n n n n n n
Many spices and herbs are used, such as cinnamon, allspice, cloves, mint, ginger, and garlic. Meats are often skewer-roasted or slowly boiled; most common are lamb and chicken. Meat should drained of blood before cooking. Bread is served at every meal. Muslims do not eat pork as it is forbidden, and all meats must be cooked well done. Eating dates and drinking Arabic coffee is common. Food is eaten (and clients fed) with the right hand. Beverages are drunk after the meal, not during. Muslims fast during daylight hours during the month of Ramadan (which may fall at a slightly different time each year on non-Muslim calendars). Hand washing is essential before eating
Chinese Heritage Foods are served at meals in a specific order. Each region in China has its own traditional diet. n Traditional Chinese may not want ice in their drinks. n Foods are chosen to balance yin and yang in order to avoid indigestion.
Nurses should not use a ‘good food, bad food’ approach, but rather should realize that variations of intake are acceptable under different circumstances. The only ‘universally’ accepted guidelines are (a) to eat a wide variety of foods to ensure adequate nutrients and (b) to eat moderately to maintain correct body weight. Food preference probably differs as much among individuals of the same cultural background as it does generally between cultures. Not all Italians like pizza, for example, and many undoubtedly enjoy Mexican food.
Beliefs about Food Beliefs about effects of foods on health and well-being can affect food choices. Many people acquire their beliefs about food from television, magazines, and other media. For example, some people are reducing their intake of animal fats in response to evidence that excessive consumption of animal fats is a major risk factor in vascular disease, including heart attack and stroke (Sauvaget, Nagano, Hayashi, & Yamada, 2004). Food trends that involve nontraditional food practices are relatively common. It may be based either on the belief that certain foods have special powers or on the notion that certain foods are harmful. Examples of some food beliefs in the Arab world are given in Box 15-3. Determining the needs for such a diet for the client enables the nurse to support the client’s needs and suggest more nutritious elements.
Personal Preferences Individual likes and dislikes can be related to typical food and familiarity. Some adults are very adventuresome and eager to try new foods. Others prefer to eat the same foods repeatedly. Preferences in the tastes, smells, flavors (blends of taste and smell), temperatures, colors, shapes, and sizes of food influence a person’s food choices. For example, some people may prefer sweet and sour tastes to bitter or salty tastes. Textures play a great role in food preferences. Some people prefer firm to soft, tender to tough, smooth to lumpy, or dry to moist.
Jewish Heritage Dietary laws govern killing, preparation, and eating of foods. Meat and milk are not eaten at the same time; dairy substitutes (e.g., margarine) are permitted. n Pork is one meat that is forbidden to eat. n All blood must be drained from meats. n Always wash hands before eating.
Religious Practices Religious practice also affects diet. Islam prohibits eating carnivorus animals, pork, alcohol intake, and meat from animals not prepared in the Halal way (that is, properly slaughtered). Box 15-4 shows some nutritional principles in Islam.
Mexican Heritage n n n n n n
Rice, beans, and tortillas are core, essential foods. Many persons are lactose intolerant. Leafy green vegetables and stews with bones provide calcium. Being overweight is viewed as positive. Sweet fruit drinks, including adding sugar to juice, are popular. The main meal of the day is at noontime. Foods are chosen according to hot and cold theory.
BOX 15-3 Examples of Food Beliefs in the Arab World Having yogurt and fish (such as tuna) may induce poisoning. Honey is healthier than sugar, more readily digested, and a cure for many diseases. n Eating garlic may prevent hypertension. n Raw eggs, honey, ginger, oysters, black beans, and lizard meat increase fertility. n Organic foods are always healthier than those exposed to pesticides. n n
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BOX 15-4 Nutritional Principles in Islam n
n n n
An important principle in Islam is that the food consumed will have a direct effect not only on the physical body but also the soul. To keep optimum health a proper diet and nutrition must be ensured. The Prophet Muhammad (PBUH) said: “Stomach is the home of disease. Diet is the main medicine” (Sahih Muslim). Allah asked everyone to eat what is lawful. Allah says in Surah AlBaqarah (The Heifer): “Ye people eat of what is on earth lawful and wholesome” (Qur’an 2:168). Muslims are to eat the food, but do not waste excess. Allah says in the Qur’an in Surah Al-A’raf (The Heights): “Eat and drink, but waste not excess, for Allah loves not the prodigals” (Qur’an 7:31). Muslims are to select the best-quality food. Allah says in the Qur’an in Surah Al Kahf (The Cave): “Now send ye then one of you with the money of yours to the town: let him find out which is the best food [to be had)…”( Qur’an 18:29). The idea of moderation through diet is mentioned in Surah Taha: “Eat of the good things we have provided for your sustenance, but commit no excess therein.” In another approach, Islam demands from its followers total abstinence from food and drinks for one whole month (Ramadan) from dawn to sunset. Fasting increases productivity and curbs inflation. Allah says in the Qur’an in Surah Al-Baqarah (The Heifer): “O ye who believe! Fasting is prescribed for you as it was prescribed for those before you, that ye may learn self-restraint.” About fasting, the Prophet Muhammed said: “Fast [the month of Ramadan] so as to heal your bodies from diseases.”
Note: from Health, Nutrition in Islam, Powerpoint presentation by M. A. Arafa, Associate Professor of Epidemiology at High Institute of Public Health, Alexandria University, Egypt. Retrieved 2010, from http://www.pitt.edu/super7/5011-6001/5601.ppt.
Lifestyle Certain lifestyles are linked to food-related behaviors. People who are always in a hurry probably buy convenience grocery items or eat restaurant meals (or junk food). People who spend many hours at home may take time to prepare more meals. Individual differences also influence lifestyle patterns (e.g., cooking skills, concern about health). Some people work at different times, such as evening or night shifts. They might need to adapt their eating habits to this and also make changes in their medication schedules if they are related to food intake. Muscular activity affects metabolic rate more than any other factor; the harder the activity, the greater the stimulation of the metabolism. Mental activity, which requires only about 4 Kcal per hour, provides very little metabolic stimulation.
Economics Not all persons have the financial resources for extensive food preparation and storage facilities. The quality and quantity of a person’s food can be affected by their socioeconomic status. The nurse should not assume that all clients have their own resources to buy fruits, meat, or higher-fat and -protein foods.
Medications and Therapy The effects of drugs on nutrition vary considerably. They may alter appetite, disturb taste perception, or interfere with nutrient absorption or excretion. Nurses need to be aware of the nutritional effects of specific drugs when evaluating a client for nutritional problems. Conversely, nutrients can affect drug utilization. Some nutrients can decrease drug absorption; others enhance absorption. Selected drug and nutrient interactions are shown in Table 15-1. Therapies (e.g., chemotherapy and radiation) prescribed for certain diseases may also adversely affect eating patterns and nutrition. Oral ulcers, intestinal bleeding, or diarrhea resulting from the toxicity of antineoplastic agents used in chemotherapy can seriously diminish a person’s nutritional status. The effects of radiotherapy depend on the area that is treated. For example, radiotherapy of the head and neck may cause decreased salivation, taste distortions, and swallowing difficulties; radiotherapy of the abdomen and pelvis may cause malabsorption, nausea, vomiting, and diarrhea. Many clients feel profound fatigue and anorexia (loss of appetite).
Health An individual’s health status greatly affects eating habits and nutritional status. The lack of teeth, ill-fitting dentures, or a sore mouth makes chewing food difficult. Difficulty swallowing (dysphagia) due to a painfully inflamed throat or a narrowing of the esophagus can prevent a person from obtaining adequate nourishment. Disease processes and surgery of the gastrointestinal tract can affect digestion, absorption, metabolism, and excretion of essential nutrients. Gastrointestinal and other diseases also create nausea, vomiting, and diarrhea, all of which can adversely affect a person’s appetite and nutritional status.
Advertising Advertising is thought to influence people’s food choices and eating patterns to a certain extent. Of note is that such products as coffee, frozen foods, and soft drinks are more heavily advertised than such products as bread, vegetables, and fruits. Convenience foods (frozen or packaged and easy to prepare) and take-out (fast) foods, snack foods, candy, soda, and sugared cereals are heavily advertised over fresh, healthy foods. In many countries of the Arab world, food advertisements must have Ministry of Health approval to be targeted to a certain audience. In the Arab world there has been an increase in advertising that targets elders in particular and encourages use of herbs and supplements, which require the need to be regulated according to food and health system. Some of these products are nutritionally safe whereas others are not and can cause interactions with medications they might be taking or cause unexpected side effects.
Psychologic Factors Although some people overeat when stressed, depressed, or lonely, others eat very little under the same conditions. Anorexia and weight loss can indicate severe stress or depression.
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Table 15-1 Selected Drug–Nutrient Interactions Drug
Effect on Nutrition
Decreases serum folate and folacin nutrition Increases excretion of vitamin C, thiamine, potassium, amino acids, and glucose May cause nausea and gastritis Decrease absorption of phosphate and vitamin A Inactivate thiamine May cause deficiency of calcium and vitamin D Increase excretion of sodium, potassium, chloride, calcium, magnesium, zinc, and riboflavin May cause anorexia, nausea, vomiting, diarrhea, or constipation Decrease absorption of vitamin B12 May cause diarrhea, nausea, or vomiting Increases excretion of potassium, magnesium, and calcium May cause anorexia, nausea, or vomiting Is incompatible with protein hydrolysates May cause calcium and potassium depletion Decrease absorption of vitamins A, D, E, and K Hydralazine (Apresoline) may cause anorexia, vomiting, nausea, and constipation Methyldopa (Aldomet) increases need for vitamin B12 and folate May cause dry mouth, nausea, vomiting, diarrhea, and constipation Colchicine decreases absorption of vitamin B12, carotene, fat, lactose, sodium, potassium, protein, and cholesterol Prednisone decreases absorption of calcium and phosphorus Increases food intake (large amounts may suppress intake)
Effect on Drugs
Can cause toxicity when taken with a variety of medications including cisapride, carbamazepine, diazepam, cyclosporine, verapamil, nifedipine, amiodarone (Dahan, & Altman, 2004) Can decrease the effectiveness of warfarin (Coumadin) Interferes with absorption of tetracycline antibiotics
Antacids containing aluminum or magnesium hydroxide Thiazide diuretics
Vitamin K Milk
Anorexia nervosa and bulimia are severe psychophysiologic conditions seen most frequently in female adolescents.
Nutritional Variations Throughout the Life Cycle Nutritional requirements vary throughout the life cycle. Guidelines follow for the major developmental stages.
Neonate to 1 Year The neonate’s fluid and nutritional needs are met by breast milk or formula milk. Fluid needs of infants are proportionately greater than those of adults because of a higher metabolic rate, immature kidneys, and greater water losses through the skin and the lungs. The last is largely due to rapid respirations. The total daily nutritional requirement of the newborn is about 80 to 100 mL of breast milk or formula per kilogram of body weight. The newborn infant’s stomach capacity is about 90 mL, and feedings are required every 2.5 to 4 hours.
Children Children learn eating habits from their parents. It is the parents’ responsibility to be good nutritional role models, both in terms of what they eat and how they incorporate food into their lifestyle. During the preschool and early school-age years children learn lifelong eating habits. It is the parents’ responsibility to
provide the child with adequate amounts of nutritious foods in an environment that is relaxed and comfortable for eating. It is the child’s responsibility to decide what and how much of the nutritious foods to eat. Parents should be counseled that eating can become a source of conflict if the parent tries to tell the child what and how much to eat, or if the child tries to tell the parent what foods should be eaten. Children’s access to ‘junk food’ should be limited, but completely forbidding a food may also create conflict. Although adolescents who are vegetarians are at risk for some nutritional deficits, the diet of adolescents who eat eggs, milk products, and, on occasion, non-red meat is more healthy than that of their red-meat-eating peers (Haddad, & Tanzman, 2003). Common problems related to nutrition and self-esteem among adolescents include obesity, anorexia nervosa, and bulimia. Obesity is a common problem of the preadolescent period and continues to be a problem in the adolescent period. Many obese adolescents feel ugly and socially unacceptable. Depression is not unusual among obese adolescents.
Adult The nutritional habits established during young adulthood often lay the foundation for the patterns maintained throughout a person’s life. Many adults are aware of the food groups but may not be knowledgeable about how many servings of each group
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Table 15-2 Problems Associated with Nutrition in Older Adults Problems Difficulty chewing Lowered glucose tolerance Decreased social interaction, loneliness
Loss of appetite and senses of smell and taste Limited income
Difficulty sleeping at night
Nursing Interventions Encourage regular visits to the dentist to have dentures repaired, refitted, or replaced. Chop fruits and vegetables finely; shred green, leafy vegetables; select ground meat, poultry, or fish. Eat more complex carbohydrates (e.g., breads, cereals, rice, pasta, and potatoes) rather than sugar-rich foods. Promote appropriate social interaction at meals, when possible. Encourage the client and spouse to take an interest in food preparation and serving, perhaps as an activity they can do together. Encourage family or caregivers to present the food at a dining table with place mats, table cloths, and napkins to trigger eating associations for the elder. If food preparation is not possible, suggest community resources, such as home delivery meals. Suggest picnics outdoors or inviting friends over for meals. Eat essential, nutrient-dense foods first; follow with desserts and low-nutrient-density foods. Review dietary restrictions, and find ways to make meals appealing within these guidelines. Eat small meals frequently instead of three large meals a day. Suggest using generic brands and coupons. Substitute milk, dairy products, and beans for meat. Avoid convenience foods if able to cook. Buy foods that are on sale and freeze for future use. Suggest community resources and nutrition programs. Have the major meal at noon instead of in the evening. Avoid tea, coffee, or other stimulants in the evening.
they need or how much a serving constitutes. The nurse should provide the adult client with resources such as a chart or list that contains the foods and the amounts needed in each category.
Elders Most elders take several medications as a result of having an increase in the number of chronic illnesses (see Table 15-1). Considerations for potential problems related to elderly nutrition should be taken into account (see Table 15-2 for problems associated with nutrition in older adults and prompt nursing interventions). Conditions such as neuromuscular disorders and dementia can make it difficult for elders to eat or to be fed. Safety should always be a priority concern with attention paid to prevent aspiration. All health care personnel and family caregivers should be taught proper techniques to reduce this risk. Effective techniques include the following: n
Use the chin-tuck method when feeding clients with dysphagia. Having them flex the head toward the chest when swallowing decreases the risk of aspiration into the lungs. Use foods of prescribed consistency. Many elders can swallow foods with thicker consistency more easily than thin liquids. Try to focus on food preferences: the family can help provide this information. Try to maintain mealtime as a positive social occasion with conversations and extra attention to creating a pleasant environment.
Standards for a Healthy Diet Various daily food guides have been developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning. Food group plans emphasize the
general types or groups of foods rather than the specific foods, because related foods are similar in composition and often have similar nutrient values. For example, all grains, whether wheat or oats, are significant sources of carbohydrate, iron, and the B vitamin thiamine. The scope of the expert consultation of the World Health Organization (WHO) and Food and Agriculture Organization (FAO), and the subsequent recommended nutrient requirements, included over 20 essential nutrients. These nutrients comprise the basis of all human nutrition: protein, energy, vitamin A and carotene, vitamin D, vitamin E, vitamin K, thiamine, riboflavin, niacin, vitamin B6, pantothenic acid, biotin, vitamin B12, folate, vitamin C, antioxidants, calcium, iron, zinc, selenium, magnesium, and iodine. For each nutrient, consideration was given to function, metabolism, dietary intake patterns, requirement levels, and toxicity. Basal requirements, safe intake levels, recommended dietary allowances, and tolerable upper intake levels are to be established for each. A detailed technical report of the Joint WHO/FAO Expert Consultation, in addition to a briefer handbook on human nutrient requirements, were published in 1999 (http://www.who.int/nutrition/topics/ nutrecomm/en/index.html.)
The Food Guide Pyramid The Food Guide Pyramid is a graphic aid that was developed by the U.S. Department of Agriculture (USDA) as a guide in making daily food choices. There are many food pyramids originated from the general food guide pyramid such as the pyramid for young children (Figure 15-1 n) and the pyramid for elders (Figure 15-2 n). Using and following this guide does not guarantee that a person will consume the necessary levels of all essential nutrients. For example, someone who chooses cooked and low-fiber fruits and vegetables might have an inadequate intake of dietary fiber even though the recommended number of servings is eaten.
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422 The Nature of Nursing Fats and sweets—eat less
Milk group—2 servings
Meat group—2 servings
Vegetable group—3 servings
Fruit group—2 servings
Grain group—6 servings
U.S. Department of Agriculture Center for Nutrition Policy and Promotion, March 1999, Program Aid 1649
WHAT COUNTS AS ONE SERVING GRAIN GROUP 1 slice of bread 1/2 cup of cooked rice or pasta 1/2 cup of cooked cereal 1 ounce of ready-to-eat cereal
FRUIT GROUP 1 piece of fruit or melon wedge 3/4 cup of juice 1/2 cup of canned fruit 1/4 cup of dried fruit
VEGETABLE GROUP 1/2 cup of chopped raw or cooked vegetables 1 cup of raw leafy vegetables
MILK GROUP 1 cup of milk or yogurt 2 ounces of cheese
MEAT GROUP 2 to 3 ounces of cooked lean meat, poultry, or fish 1/2 cup of cooked dry beans, or 1 egg counts as 1 ounce of lean meat. 2 tablespoons of peanut butter count as 1 ounce of meat.
FATS AND SWEETS Limit calories from these.
Four- to 6-year-olds can eat these serving sizes. Offer 2- to 3-year-olds less, except for milk. Two- to 6-year-old children need a total of 2 servings from the milk group each day.
Figure 15-1 n Food guide pyramid for young children. (Note: From U.S. Department of Agriculture and U.S. Department of Health and Human Services, 1999.)
However, the food guide is easy to follow, and people who eat a variety of foods from each group, in the suggested amounts, are likely to come close to recommended nutrient levels. The Food Guide Pyramid does not address fluid intake or provide guidelines about combination foods or about c onvenience foods.
Recommended Dietary Intake The Committee on the Scientific Evaluation of Dietary Reference Intakes of the Institute of Medicine in United States publishes
the Dietary Reference Intakes (DRIs) tables, which contain four sets of reference values: estimated average requirements (EARs), recommended dietary allowances (RDAs), adequate intakes (AIs), and tolerable upper intake levels (ULs). Definitions of these terms are found in Box 15-5. The values for RDAs and AIs in the tables are modified for different age groups and according to gender. The effect of illness or injury (increasing the need for nutrients) and the variability among individuals within any given subgroup are not taken into account in the DRIs.
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Figure 15-2 n A modified food guide pyramid for people older than 70 years of age. (Copyright ÂŠ 2002 from Tufts University School of Nutrition Science and Policy. Reproduced with permission. http://nutrition.tufts.edu)
Consumers most commonly learn recommended dietary intake information from the U.S. Food and Drug Administration (FDA) nutrition labels called Nutrition Facts. Food labeling is required for most prepared foods, such as breads, cereals, canned and frozen foods, snacks, desserts, and drinks. Nutrition labeling for raw produce (fruits and vegetables) and fish is
voluntary. It is important that everyone learn how to read and interpret these labels. The section at the top of the label 1 in Figure 15-3 n indicates serving size and number of servings in the container. The remaining information on the label indicates the values for each serving. Thus, if the person consumes a container that has more
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424 The Nature of Nursing
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Figure 15-3 n The Nutrition Facts Label (Note: from â€œHow to Understand and Use the Nutrition Facts Labelâ€?, by the U.S. FDA/Center for Food Safety & Applied Nutrition, 2004. Retrieved September 4, 2006 from www. cfsan.fda.gov/~dms/foodlab.html#twoparts)
than one serving, the person must multiply the values in order to know the real nutrient content. The next section 2 indicates the number of total calories and calories from fat per serving. Based on a 2,000-calorie diet, a serving with 40 calories is considered low, 100 calories moderate, and 400 calories high. Section 3 has those nutrients that should be minimized: fats, cholesterol, and sodium. A % Daily Value (DV) of 5% or less is low, and 20% or more is high. When adding the % DV from all foods eaten in one day, the goal is to keep the total below 100%. Effective January 1, 2006, packaged foods must list trans-fat
content. Trans-fats are created when unsaturated oils are hydrogenated to create a solid form and are used in frying foods, margarine, and many snack products. They are also present in meat and dairy fats. Trans-fats have been shown to increase cholesterol and contribute to heart disease. The next section 4 includes fiber, vitamins, and minerals commonly insufficient in American diets. When adding the percentage values from all foods eaten in one day, the goal is to keep the total DV of each of these at least at 100%. Again, a % DV of 5 or less is low and 20% or more is high. The footnote 5 indicates the approximate
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Research Note What are the Factors Associated with the High Prevalence of Obesity in the Eastern Mediterranean Region? Musaiger (2004) has discussed the prevalence and factors associated with overweight and obesity in the Eastern Mediterranean Region. The prevalence of overweight and obesity among schoolchildren was alarming. A prevalence of 3–9% overweight and obese children has been recorded at preschool age, whereas among schoolchildren it is 12–25%. A remarkable increase in obesity also has been noted among adolescents, ranging from 15 to 45%. Regarding gender differences, in adulthood, women showed a higher prevalence of obesity (35–75%) than men (30–60%).
Implications The study addressed several factors such as change in dietary habits, socioeconomic factors, inactivity, and patterns of physical activity associated to obesity in this region. The author recommended national programs to prevent and control obesity in the countries of the region. These programs may include education on nutrition as well as assessment of psychosocial problems that may lead to overeating. Note: from “Overweight and obesity in the Eastern Mediterranean Region: Can we control it?” by A. Musaiger, 2004, Eastern Mediterranean Health Journal, 10(6), 789.
BOX 15-5 Definitions for Dietary Reference Value Tables Dietary reference intakes (DRIs): The standards for nutrient recommendations that include the following values. Estimated average requirement (EAR): The average daily nutrient intake value estimated to meet the requirement of half the healthy individuals in a particular life stage and gender group. Recommended dietary allowance (RDA): The average daily nutrient intake level sufficient to meet the nutrient requirement of nearly all (97 to 98%) healthy individuals in a particular life stage and gender group. Adequate intake (AI): Used when RDA cannot be determined. A recommended average daily nutrient intake level based on observed or experimentally determined approximations or estimates of nutrient
DVs for fat cholesterol, sodium, total carbohydrate, and fiber in 2,000- and 2,500-calorie diets. The 2,000-calorie values are used for the % DV numbers in the upper sections. If the label on a food is missing, consumers can retrieve the information from several websites.
Vegetarian Diets People may become vegetarians for economic, health, religious, ethical, or ecologic reasons. There are two basic vegetarian diets: those that use only plant foods (vegan) and those that include milk, eggs, or dairy products. Some people eat fish and poultry but not beef or lamb; others eat only fresh fruit, juices, and nuts; and still others eat plant foods and dairy products but not eggs. Vegetarian diets can be nutritionally sound if they include a wide variety of foods and if proper protein and vitamin and mineral supplementation are provided (Anonymous, 2003). Because the proteins found in plant foods are incomplete proteins, vegetarians must eat complementary protein foods to obtain all the essential amino acids. A plant protein can be complemented by combining it with a different plant protein. The combination produces a complete protein (see Box 15-6). Obtaining complete proteins is especially important for growing children and pregnant and lactating women, whose
intake for a group (or groups) of healthy people that are assumed to be adequate. Tolerable upper intake level (UL): The highest average daily nutrient intake level likely to pose no risk of adverse heath effects to almost all individuals in a particular life stage and gender group. As intake increases above the UL, the potential risk of adverse health effects increases. Note: reprinted with permission from Dietary Reference Intakes: Applications in Dietary Planning © 2003 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.
BOX 15-6 Combinations of Plant Proteins that Provide Complete Proteins Grains plus legumes = complete protein. Legumes plus nuts or seeds = complete protein. Grains, legumes, nuts, or seeds plus milk or milk products (e.g., cheese) = complete protein. Grains
Nuts and Seeds
Black-eyed peas Split peas
Sesame seeds Sunflower seeds
Black-eyed peas and rice Lentil soup and whole wheat bread Beans and tortillas Lima beans and sesame seeds or Cereal with milk Macaroni with cheese
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protein needs are high. Generally, legumes (starchy beans, peas, lentils) have complementary relationships with grains, nuts, and seeds. Complementary foods must be eaten in the same meal. Diets such as the fruitarian diet do not provide sufficient amounts of essential nutrients and are not recommended for long-term use. Foods of animal origin are the best source of vitamin B12. Therefore, vegans need to obtain this vitamin from other sources: brewer’s yeast, foods fortified with vitamin B12, or a vitamin supplement. Because iron from plant sources is not absorbed as efficiently as iron from meat, vegans should eat iron-rich foods (e.g., green leafy vegetables, whole grains, raisins, and molasses) and iron-enriched foods. They should eat a food rich in vitamin C at each meal to enhance iron absorption. Calcium deficiency is a concern only for strict vegetarians. It can be prevented by including in the diet soybean milk and tofu (soybean curd) fortified with calcium and leafy green vegetables.
deficiencies in caloric intake (e.g., those with cancer and chronic disease). Characteristics of PCM are depressed visceral proteins (e.g., albumin), weight loss, and visible muscle and fat wasting. Protein stores in the body are generally divided into two compartments: somatic and visceral. Somatic protein consists largely of skeletal muscle mass; it is assessed most commonly by conducting anthropometric measurements such as the midarm circumference (MAC) and the mid-arm muscle circumference (MAMC). Visceral protein includes plasma protein, hemoglobin, several clotting factors, hormones, and antibodies. It is usually assessed by measuring serum protein levels such as albumin and transferrin, discussed in the Laboratory Data section of Assessing, which follows.
Malnutrition is commonly defined as the lack of necessary or
appropriate food substances, but in practice includes both undernutrition and overnutrition. Overnutrition refers to a caloric intake in excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue. As the amount of stored fat increases, the individual becomes overweight or obese (see Box 15-1, on BMI). Excess body weight increases the stress on body organs and predisposes people to chronic health problems such as hypertension and diabetes mellitus. Obesity that interferes with mobility or breathing is referred to as morbid obesity. Obese people may also manifest undernourishment in important nutrients (e.g., essential vitamins or minerals) even though excess calories are ingested. Undernutrition refers to an intake of nutrients insufficient to meet daily energy requirements because of inadequate food intake or improper digestion and absorption of food. An inadequate food intake may be caused by the inability to acquire and prepare food, inadequate knowledge about essential nutrients and a balanced diet, discomfort during or after eating, dysphagia, anorexia, nausea, vomiting, and so on. Improper digestion and absorption of nutrients may be caused by an inadequate production of hormones or enzymes or by medical conditions resulting in inflammation or obstruction of the gastrointestinal tract. Inadequate nutrition is associated with marked weight loss, generalized weakness, altered functional abilities, delayed wound healing, increased susceptibility to infection, decreased immunocompetence, impaired pulmonary function, and prolonged length of hospitalization. In response to undernutrition, carbohydrate reserves, stored as liver and muscle glycogen, are mobilized. However, these reserves can only meet energy requirements for a short time (e.g., 24 hours) and then body protein is mobilized. Protein-calorie malnutrition (PCM) is associated with the manifestation of undernutrition seen in starving children and recognized as a significant problem of clients with long-term
Nursing Management The purpose of the nutritional assessment is to identify clients at risk for malnutrition and those with poor nutritional status. In most health care facilities, the responsibility for nutritional assessment and support is shared by the primary care provider, the dietitian, and the nurse. Generally nurses perform a nutritional screen. Components of a nutritional assessment are shown in Table 15-3 and may be remembered as ABCD data: anthropometric, biochemical, clinical, and dietary.
Nutritional Screening According to nutritional screening, clients who are found to be at moderate or high risk are followed with a comprehensive assessment by a dietitian (see Box 15-7). Nurses carry out nutritional screens through routine nursing histories and physical examinations. Custom-designed screens for a particular population (e.g., elders and pregnant women) and specific disorders (e.g., cardiac disease) are available.Screening tools such as the Patient-Generated Subjective Global Assessment (PG-SGA) and the Nutrition Screening Initiative (NSI) can be incorporated into the nursing history. The PG-SGA is a method of classifying clients as well nourished, moderately malnourished, or severely malnourished based on a dietary history and physical examination. It was established primarily for use with cancer patients but has been widely tested and is appropriate for both inpatient and outpatient clients with various diagnoses (Green, & Watson, 2005).
Nursing History As mentioned above, nurses obtain considerable nutritionrelated data in the routine admission nursing history. Data include but are not limited to the following: n n n n n
Age, gender, and activity level Difficulty eating (e.g., impaired chewing or swallowing) Condition of the mouth, teeth, and presence of dentures Changes in appetite Changes in weight
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Table 15-3 Components of a Nutritional Assessment Anthropometric Data
Screening Data n Height n Weight n Ideal body weight n Usual body weight n Body mass index n Hemoglobin n Serum albumin n Total lymphocyte count n Skin n Hair and nails n Mucous membranes n Activity level n 24-hour food recall n Food frequency record
Additional In-Depth Data n Triceps skinfold (TSF) n Mid-arm circumference (MAC) n Mid-arm muscle circumference (MAMC)
n n n n n
n n n
Serum transferrin level Urinary urea nitrogen Urinary creatinine excretion Hair analysis Neurological testing
Selective food frequency record Food diary Diet history
BOX 15-7 Summary of Risk Factors for Nutritional Problems Diet History n n n n n n n n n n
Chewing or swallowing difficulties (including ill-fitting dentures, dental caries, and missing teeth) Inadequate food budget Inadequate food intake Inadequate food-preparation facilities Inadequate food-storage facilities Intravenous fluids (other than total parenteral nutrition for 10 or more days) Living and eating alone No intake for 10 or more days Physical disabilities Restricted or fashionable diets
Medical History Adolescent pregnancy or closely spaced pregnancies n Alcohol or substance abuse n Catabolic or hypermetabolic condition: burns, trauma n Chronic illness: end-stage renal disease, liver disease, HIV, pulmonary disease (COPD), cancer n
n n n n n
Physical disabilities that affect purchasing, preparing, and eating food Cultural and religious beliefs that affect food choices Living arrangements (e.g., living alone) and economic status General health status and medical condition Medication history.
Physical Examination Physical examination reveals some nutritional deficiencies and excesses in addition to obvious weight changes. Assessment focuses on rapidly proliferating tissues such as skin, hair, nails, eyes, and mucosa but also includes a systematic review comparable to any routine physical examination. See Clinical
n n n n n n
Dental problems: difficulty chewing, ill-fitting dentures Fluid and electrolyte imbalance Gastrointestinal problems: anorexia, dysphagia, nausea, vomiting, diarrhea, constipation Neurologic or cognitive impairment Oral and gastrointestinal surgery Unintentional weight loss or gain of 10% within 6 months
Medication History* n n n n n n n n n n
Antacid Antidepressants Antihypertensives Anti-inflammatory agents Antineoplastic agents Aspirin Digitalis Diuretics (thiazides) Laxatives Potassium chloride
*The potential effects of some medications on nutrition are shown in Table 15-1.
Manifestations and Figure 15-4 malnutrition.
for signs associated with
Calculating Percentage of Weight Loss Accurate assessment of the client’s height, current body weight (CBW), and usual body weight (UBW) is essential. Calculation and interpretation of the percentage of deviation from UBW and the percentage of weight loss are shown in Box 15-8. The nurse should describe any weight loss or gain, the duration of the change, and whether the weight change was intentional or unintentional.
Dietary History A dietary history includes data about the client’s usual eating patterns and habits; food preferences, allergies, and intolerances; frequency, types, and quantities of foods consumed;
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Figure 15-4 n Example of nutritional deficiencies. A, Dull, sparse hair from protein deficiency. B, Inflammation of the corners of the mouth from riboflavin deficiency. C, Inflammation of the tongue from niacin, B6, or riboflavin deficiency. D, Spongy bleeding gums from vitamin C deficiency. (A and B from Centers for Disease Control and Prevention (CDC), C from Custom Medical Stock Photo, Inc., D from Pearson Education/PH College)
BOX 15-8 Calculating and Interpreting the Percentage of Deviation from Usual Body Weight and the Percentage of Weight Loss Calculating Percentage of Usual Body Weight Current weight % usual body weight = * 100 Usual body weight Mild malnutrition Moderate malnutrition Severe malnutrition
85–90% 75–84% Less than 74%
Calculating Percentage of Weight Loss Usual weight - current weight % weight loss = * 100 Usual weight Significant Weight Loss 5% over 1 months 7.5% over 3 months 10% over 6 months
Severe Weight Loss >5% over 1 months >7.5% over 3 months >10% over 6 months
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and social, economic, ethnic, or religious factors influencing nutrition. Factors may include, but are not limited to, living and eating companions, ability to purchase and prepare food, availability of refrigeration and cooking facilities, income, and effect of religion and ethnicity on food choices. Four possible methods for collecting dietary data are a 24-hour food recall, a food frequency record, a food diary, and a diet history. Medical and psychosocial factors are also assessed to evaluate their impact on nutritional requirements, food habits, and choices. Data obtained are analyzed and translated into caloric and nutrient intake. Results are compared with the DRIs that are appropriate for the client’s age, gender, and condition.
Anthropometric Measurements Anthropometric measurements are noninvasive techniques that aim to quantify body composition. A skinfold measurement is performed to determine fat stores. The most common site for
measurement is the triceps skinfold (TSF). The fold of skin measured includes subcutaneous tissue but not the underlying muscle. It is measured in millimeters using special calipers. To measure the TSF, locate the midpoint of the upper arm (halfway between the acromion process and the olecranon process), then grasp the skin on the back of the upper arm along the long axis of the humerus (Figure 15-5 n). Placing the calipers 1 cm below the nurse’s fingers, measure the thickness of the fold to the nearest millimeter. The mid-arm circumference (MAC) is a measure of fat, muscle, and skeleton. To measure the MAC, ask the client to sit or stand with the arm hanging freely and the forearm flexed to horizontal. Measure the circumference at the midpoint of the arm, recording the measurement in centimeters, to the nearest millimeter (e.g., 24.6 cm) (Figure 15-6 n). The mid-arm muscle circumference (MAMC) is then calculated by using reference tables or by using a formula that incorporates the TSF and the MAC. The MAMC is an estimate of lean body
Clinical Manifestations Malnutrition Area of Examination (possible cause)
Signs Associated With Malnutrition
General appearance and vitality
Apathetic, listless, looks tired, easily fatigued
Overweight or underweight
Dry, flaky, or scaly; pale or pigmented; presence of petechiae or bruises; lack of subcutaneous fat; edema
Brittle, pale, ridged, or spoon shaped (iron)
Dry, dull, sparse, loss of color, brittle (see Figure 15-4 A)
Pale or red conjunctiva, dryness, soft cornea, dull cornea, night blindness (vitamin A deficiency)
Swollen, red cracks at side of mouth, vertical fissures (B vitamins) (see Figure 15-4 B)
Swollen, beefy red- or magentacolored (B vitamins); smooth appearance (B vitamin deficiency); decrease or increase in size (see Figure 15-4 C)
Spongy, swollen, inflamed; bleed easily (vitamin C deficiency) (see Figure 15-4 D)
Underdeveloped, flaccid, wasted, soft
Anorexia, indigestion, diarrhea, constipation, enlarged liver, protruding abdomen
Decreased reflexes, sensory loss, burning and tingling of hands and feet (B vitamins), mental confusion or irritability
Figure 15-5 n Measuring the triceps skinfold
Figure 15-6 n Measuring the mid-arm circumference. (Patrick Watson)
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Table 15-4 Standard Values for Anthropometric Measurements for Adults Measurement Triceps skinfold (mm) Mid-arm circumference (cm) Mid-arm muscle circumference (cm2)
Male 12 32 54
Female 20 28 30
Note: from The Merck Manual of Diagnosis and Therapy, 18th ed., by M. H. Beers and R. Berkow (Eds.), 2006. Copyright John Wiley & Sons. Reprinted with permission.
mass, or skeletal muscle reserves. If tables are not available, the nurse uses the following formula to calculate the MAMC from the TSF and MAC direct measurements: MAC(cm) - 3.143 TSF(mm) 10 Standard values for anthropometric measurements for adults are shown in Table 15-4. Changes in anthropometric measurements often occur slowly and reflect chronic rather than acute changes in nutritional status. They are, therefore, used to monitor the client’s progress for months to years rather than days to weeks. Ideally, initial and subsequent measurements need to be taken by the same clinician. In addition, measurements obtained need to be interpreted with caution as it may be affected by hydration and normal changes in body composition related to aging. MAMC cm =
Laboratory Data Laboratory tests provide objective data to the nutritional assessment, but because many factors can influence these tests, no single test specifically predicts nutritional risk or measures the presence or degree of a nutritional problem. The tests most commonly used are serum proteins, urinary urea nitrogen and creatinine, and total lymphocyte count. Serum Proteins. Tests commonly include hemoglobin,
albumin, transferrin, and total iron-binding capacity. A low hemoglobin level may be evidence of iron deficiency anemia.
Albumin, is one of the most common visceral proteins evaluated as part of the nutritional assessment. A low serum albumin level is a useful indicator of altered liver function, hydration status, and losses from open wounds and burns. Transferrin is a protein that responds more quickly to protein depletion than albumin. Transferrin levels below normal indicate protein loss, iron deficiency anemia, pregnancy, hepatitis, or liver dysfunction. An increase in total iron binding capacity (TIBC) can indicate iron deficiency; a decrease, anemia. Prealbumin, also referred to as thyroxine-binding albumin and transthyretin, is the most responsive serum protein to rapid changes in nutritional status. It is now considered the ‘gold standard’ for assessing for possible protein malnutrition (Kuszajewski, & Clontz, 2005). It should be measured twice a week: prealbumin levels of 15 to 35 mg/dL are normal, whereas below 15 mg/dL indicates clients at risk, and below 11 mg/dL indicates that aggressive nutritional intervention is needed. Urinary Tests Urinary urea nitrogen and urinary creatinine are measures of protein catabolism and the state of nitrogen
balance. Urea directly reflects the intake and breakdown of dietary protein, the rate of urea production in the liver, and the rate of urea removal by the kidneys. The state of nitrogen balance is determined by comparing the nitrogen intake (grams of protein) to the nitrogen output over a 24-hour period. A positive balance indicates intake exceeds nitrogen output; a negative nitrogen balance occurs when output exceeds nitrogen intake. Urinary creatinine reflects a person’s total muscle mass. The greater the muscle mass, the greater the excretion of creatinine. As skeletal muscle atrophies during malnutrition, creatinine excretion decreases. Standards for creatinine excretion are developed based on gender and height. Urinary creatinine is also influenced by protein intake, exercise, age, renal function, and thyroid function. Total Lymphocyte Count. Certain nutrient deficiencies and malnutrition can depress the immune system. The total number of lymphocytes decreases as protein depletion occurs.
Diagnosing NANDA International (2007) includes the following diagnostic labels for nutritional problems: n n n n
Imbalanced nutrition: more than body requirements Imbalanced nutrition: less than body requirements Readiness for enhanced nutrition Risk for imbalanced nutrition: more than body requirements.
Many other NANDA International nursing diagnoses may apply to certain individuals, because nutritional problems often affect other areas of human functioning. In this case, the nutritional diagnostic label may be used as the etiology of other diagnoses. Examples include: n n n n
Activity intolerance related to inadequate intake of iron-rich foods resulting in iron deficiency anemia Constipation related to inadequate fluid and fiber intake Low self-esteem related to obesity Risk for infection related to immunosuppression secondary to insufficient protein intake.
Nursing Intervention Nursing interventions for optimal nutrition for hospitalized clients are often provided in collaboration with the physician and the dietitian. The nurse reinforces dietary instructions and creates an atmosphere that encourages eating, provides assistance with eating, monitors the client’s appetite and food intake, administers enteral and parenteral feedings, and consults with the primary care provider and dietitian about nutritional problems that arise. In the community setting, the nurse’s role is largely educational. For example, nurses promote optimal nutrition at health fairs, in schools, at prenatal classes, and with well or ill clients and support people in their homes. In the home setting, nurses also initiate nutritional screens, refer clients at risk to appropriate resources, instruct clients about enteral and
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parenteral feedings, and offer nutrition counseling as needed. Nutrition counseling involves more than simply providing information. The nurse must help clients integrate diet changes into their lifestyle and provide strategies to motivate them to change their eating habits (see Client Teaching for guidelines of healthy nutrition).
Assisting with Special Diets Alterations in the client’s diet are often needed to treat a disease process such as diabetes mellitus, to prepare for a special examination or surgery, to increase or decrease weight, to restore nutritional deficits, or to allow an organ to rest and promote healing. Diets are modified in one or more of the following aspects: texture, kilocalories, specific nutrients, seasonings, or consistency. Hospitalized clients who do not have special needs eat the regular (standard or house) diet, a balanced diet that supplies the metabolic requirements of a sedentary person (about 2,000
Client Teaching n n n n n n
Guidelines for Healthy Nutrition
Instruct clients about the content of a healthy diet based on the available nutrition guidelines in their country. Encourage clients, particularly older clients, to reduce dietary fat. Instruct strict vegetarians about proper protein complementation and additional vitamin and mineral supplementation. Discuss foods high in specific nutrients required such as protein, iron, calcium, vitamin C, and fiber. Discuss importance of properly fitted dentures and dental care. Discuss safe food preparation and preservation techniques as appropriate.
Dietary Alterations n n n n n n
Explain the purpose of the diet. Discuss allowed and excluded foods. Explain the importance of reading food labels when selecting packaged foods. Include family or significant others. Reinforce information provided by the dietitian or nutritionist as appropriate. Discuss herbs and spices as alternatives to salt and substitutes for sugar.
For Overweight Clients n n n n n
Discuss physiologic, psychologic, and lifestyle factors that predispose to weight gain. Provide information about desired weight range and recommended calorie intake. Discuss principles of a well-balanced diet and high- and low-calorie foods. Encourage intake of low-calorie, caffeine-free beverages and plenty of water. Discuss ways to adapt eating practices by using smaller plates, taking smaller servings, chewing each bite a specified number of times, and putting one’s fork down between bites. Discuss ways to control the desire to eat by taking a walk, drinking a glass of water, or doing slow deep-breathing exercises.
Kcal) (see Client Teaching on Guidelines for Healthy Nutrition, below). Most agencies offer clients a daily menu from which to select their meals for the next day; others provide standard meals to each client on the general diet. Certain foods (e.g., cabbage, which tends to produce flatus, and highly seasoned and fried foods, which are difficult for some people to digest) are usually omitted from the regular diet. A variation of the regular diet is the light diet, designed for postoperative and other clients who are not ready for the regular diet. Foods in the light diet are plainly cooked and fat is usually minimized, as are bran and foods containing a great deal of fiber. Diets that are modified in consistency are often given to clients before and after surgery or to promote healing in clients with gastrointestinal distress. These diets include clear liquid, full liquid, soft, and diet as tolerated. In some health institutions, gastrointestinal surgery clients are not permitted red-colored liquids or candy since, if vomited, the color may be confused with blood.
Discuss the importance of exercise and help the client plan an exercise program. n Discuss stress reduction techniques. n Provide information about available community resources (e.g., weight-loss groups, dietary counseling, exercise programs, selfhelp groups). n
For Underweight Clients n n n n n n n
Discuss factors contributing to inadequate nutrition and weight loss. Discuss recommended calorie intake and desired weight range. Provide information about the content of a balanced diet. Provide information about ways to increase calorie intake (e.g., high-protein or high-calorie foods and supplements). Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. If appropriate, discuss ways to purchase low-cost nutritious foods. Provide information about community agencies that can assist in providing food
Preventing Foodborne Illness Reinforce hygienic handling of food and dishes. l Wash hands before preparing foods. l Wash hands and all dishes and utensils with hot water and soap after contact with raw meats. l Defrost frozen foods in the refrigerator. l Cook beef, poultry, and eggs thoroughly. Use a cooking thermometer. l Refrigerate leftovers promptly (at 5°C or less) and keep no more than 3 to 5 days. l Wash or peel raw fruits and vegetables. l Do not use foods from containers that have been damaged or have opened seals. l Follow the rules ‘keep hot foods hot and cold foods cold’ and ‘when in doubt, throw it out.’ n Instruct clients to seek medical attention for prolonged vomiting, fever, abdominal pain, or severe diarrhea following a meal. n
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Clear Liquid Diet. This diet is limited to water, tea, coffee, or other carbonated beverages, strained and clear juices, and plain gelatin. Note that ‘clear’ does not necessarily mean ‘colorless.’ This diet provides the client with fluid and carbohydrate (in the form of sugar) but does not supply adequate protein, fat, vitamins, minerals, or calories. It is a short-term diet (24–36 hours) provided for clients after certain surgeries or in the acute stages of infection, particularly of the gastrointestinal tract. The major objectives of this diet are to relieve thirst, prevent dehydration, and minimize stimulation of the gastrointestinal tract. Examples of foods allowed in clear liquid diets are shown in Box 15-9. Full Liquid Diet. This diet contains only liquids or foods that turn to liquid at body temperature, such as ice cream (see Box 15-9). Full liquid diets are often eaten by clients who have gastrointestinal disturbances or are otherwise unable to tolerate solid or semisolid foods. This diet is not recommended for long-term use because it is low in iron, protein, and calories. In addition, its cholesterol content is high because of the amount of milk offered. Clients who must receive only liquids for long periods are usually given a nutritionally balanced oral supplement, such as Ensure. The full liquid diet is monotonous and difficult for clients to accept. Planning six or more feedings per day may encourage a more adequate intake. Soft Diet. The soft diet is easily chewed and digested. It is
often ordered for clients who have difficulty chewing and swallowing. It is a low-residue (low-fiber) diet containing very few uncooked foods; however, restrictions vary among agencies and according to individual tolerance (see Box 15-9). The pureed diet is a modification of the soft diet. Liquid may be added to the food, which is then blended to a semisolid consistency. Diet as Tolerated. Diet as tolerated is ordered when the client’s appetite, ability to eat, and tolerance for certain foods may change. For example, on the first postoperative day a client may be given a clear liquid diet. If no nausea occurs, normal intestinal motility has returned as evidenced by active
bowel sounds and client reports passing gas, and the client feels like eating, the diet may be advanced to a full liquid, light, or regular diet. Modification for Disease. Many special diets may be
prescribed to meet requirements for disease process or altered metabolism. For example, a client with diabetes mellitus may need a diet recommended by dietician in that health institution labeled as Diabetic diet. An obese client may need a calorie- restricted diet, a cardiac client may need sodium and cholesterol restrictions, and a client with allergies will need a hypoallergenic diet. Some clients must follow certain diets (e.g., low-salt diet) for a lifetime. If the diet is long term, the client must understand the diet and also develop a healthy, positive attitude toward it. Assisting clients and support persons with special diets is a function shared by the dietitian or nutritionist and the nurse. The dietitian informs the client and support persons about the specific foods allowed and not allowed and assists the client with meal planning. The nurse reinforces this instruction, assists the client to make changes, and evaluates the client’s responses. Dysphagia. Some clients may have an inability to swallow but otherwise have no difficulty with choosing a healthy diet. These clients may have inadequate solid or fluid intake, be unable to swallow their medications, or aspirate food or fluids into the lungs—causing pneumonia. Clients at risk for dysphagia include elders, those who have experienced a stroke, cancer patients who have had radiation therapy to the head and neck, and others with cranial nerve dysfunction. Nurses may be the first persons to detect dysphagia and are in an excellent position to recommend further evaluation; implement specialized feeding techniques and diets; and work with clients, family members, and other health care professionals to develop a plan to assist the client with difficulties. If the client condition suggests dysphagia, the nurse should review the history in detail; interview the client or family; assess the mouth, throat, and chest; and observe the client swallowing. Presence of the gag reflex,
BOX 15-9 Examples of Foods for Clear Liquid, Full Liquid, and Soft Diets Clear Liquid
Coffee, regular and decaffeinated
All foods on clear liquid diet plus:
All foods on full and clear liquid diets, plus:
Milk and milk drinks Puddings, custards
Meat: All lean, tender meat, fish, or poultry (chopped, shredded); spaghetti sauce with ground meat over pasta
Carbonated beverages Bouillon, fat-free broth Clear fruit juices (apple, cranberry, grape) Other fruit juices, strained Ice creams Gelatin Sugar, honey Hard candy
Ice cream, sherbet Vegetable juices Refined or strained cereals (e.g., cream of rice) Cream, butter, margarine Eggs (in custard and pudding) Smooth peanut butter Yogurt
Meat alternatives: Scrambled eggs, omelet, poached eggs; cottage cheese and other mild cheese Vegetables: Mashed potatoes, sweet potatoes, or squash; vegetables in cream or cheese sauce; other cooked vegetables as tolerated (e.g., spinach, cauliflower, asparagus tips), chopped and mashed as needed; avocado Fruits: Cooked or canned fruits; bananas, grapefruit and orange sections without membranes, apple sauce Breads and cereals: Enriched rice, barley, pasta; all breads; cooked cereals (e.g., oatmeal) Desserts: Soft cake, bread pudding
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BOX 15-10 Improving Appetite n
n n n
Provide familiar food that the person likes. Often the relatives of clients are pleased to bring food from home but may need some guidance about special diet requirements. Select small portions so as not to discourage the anorexic client. Avoid unpleasant or uncomfortable treatments immediately before or after a meal. Provide a tidy, clean environment that is free of unpleasant sights and odors. A soiled dressing, a used bedpan, an uncovered irrigation set, or even used dishes can negatively affect the appetite. Encourage or provide oral hygiene before mealtime. This improves the client’s ability to taste. Relieve illness symptoms that depress appetite before mealtime; for example, give an analgesic for pain or an antipyretic for a fever or allow rest for fatigue. Reduce psychologic stress. A lack of understanding of therapy, the anticipation of an operation, and fear of the unknown can cause anorexia. Often, the nurse can help by discussing feelings with the client, giving information and assistance, and allaying fears.
often thought to indicate that the client can swallow safely, has not been shown to be a reliable indicator (Zagaria, 2005). Confirmation of the tendency for food to divert to the trachea is best done through x-ray.
Stimulating the Appetite Physical illness, unfamiliar or unpalatable food, environmental and psychologic factors, and physical discomfort or pain may depress the appetite of many clients. However, it leads to weight loss, decreased strength and other nutritional problems.
A decreased food intake is often accompanied by a decrease in fluid intake, which may cause fluid and electrolyte problems. Stimulating a person’s appetite requires the nurse to determine the reason for the lack of appetite and then deal with the problem. Some general interventions for improving the client’s appetite are summarized in Box 15-10.
Assisting Clients with Meals Because clients in health care institutions are frequently confined to their beds, meals are brought to the client. The client receives a tray that has been assembled in a central kitchen. Nursing personnel may be responsible for giving out and collecting the trays; however, in most settings this is done by dietary personnel. Long-term care facilities and some hospitals serve meals to mobile clients in a special dining area. Guidelines for providing meals to clients are summarized in Box 15-11. Plates with rims and plastic or metal plate guards enable the client to pick up the food by first pushing it against this raised edge. A suction cup or damp sponge or cloth may be placed under the dish to keep it from moving while the client is eating. No-spill mugs and two-handled drinking cups are especially useful for persons with impaired hand coordination. Stretch terry cloth and knitted or crocheted glass covers enable the client to keep a secure grasp on a glass. Lidded tip-proof glasses are also available. Figures 15-8 n and 15-9 n show some of these aids.
Enteral Nutrition An alternative feeding method to ensure adequate nutrition includes enteral (through the gastrointestinal system) methods.
BOX 15-11 Providing Client Meals n n n
n n n
Offer the client assistance with hand washing and oral hygiene before a meal. If it is permitted, assist the client to a comfortable position in bed or in a chair, whichever is appropriate. Clear the overbed table so that there is space for the tray. If the client must remain in a lying position in bed, arrange the overbed table close to the bedside so that the client can see and reach the food. Check each tray for the client’s name, the type of diet, and completeness. Do not leave an incorrect diet for a client to eat. Assist the client as required (e.g., remove the food covers, butter the bread, pour the tea, and cut the meat). For a blind person, identify the placement of the food as you would describe the time on a clock (Figure 15-7 n). For instance, the nurse might say, “The potatoes are at 8 o’clock, the chicken at 12 o’clock, and the green beans at 4 o’clock.” After the client has completed the meal, observe how much and what the client has eaten and the amount of fluid taken. Use a standard tool to estimate the amount eaten in relation to a typical meal. For example, if served two pieces of bread and a cup of tea for breakfast, although the client may have eaten all of these, they certainly do not represent 100% of a nutritious breakfast. If the client is on a special diet or is having problems eating, record the amount of food eaten and any pain, fatigue, or nausea experienced.
If the client is not eating, document this so that changes can be made, such as rescheduling the meals, providing smaller, more frequent meals, or obtaining special self-feeding aids. 12 o’clock
Figure 15-7 n For a client who is blind, the nurse can use the clock system to describe food on a plate.
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Enteral nutrition (EN), also referred to as total enteral nutrition (TEN), is provided when the client is unable to ingest foods or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted. Enteral feedings are administered through nasogastric and small-bore feeding tubes, or through gastrostomy or jejunostomy tubes. Enteral Access Devices. Enteral access is achieved by
Figure 15-8 n Left to right: glass holder, cup with hole for nose, two-handed cup holder.
Figure 15-9 n Dinner place with guard attached and lipped plate facilitate scooping; wide-handled spoon and knife facilitate grip.
means of nasogastric or nasointestinal (nasoenteric) tubes, or gastrostomy or jejunostomy tubes. A nasogastric tube is inserted through one of the nostrils (nasal openings), down the nasopharynx, and into the alimentary tract (gastrointestinal tract). Traditional firm, large-bore nasogastric tubes (i.e., those larger than 12 Fr in diameter; tubes are sized by the diameter of the lumen using the French (Fr) scale: the larger the number, the larger the lumen) are placed in the stomach. Examples are the Levin tube, a flexible rubber or plastic, single-lumen tube with holes near the tip, and the Salem sump tube, with a double lumen. The larger lumen of the Salem sump tube allows delivery of liquids to the stomach or removal of gastric contents. When the Salem tube is used for suction of gastric contents, the smaller vent lumen (the proximal port is often referred to as the blue pigtail) allows for an inflow of atmospheric air, which prevents a vacuum if the gastric tube adheres to the wall of the stomach. Irritation of the gastric mucosa is thereby avoided. Softer, more flexible and less irritating small-bore tubes (smaller than 12 Fr in diameter) are frequently used. Nasogastric tubes are used for feeding clients who have adequate gastric emptying, and who require short-term feedings. They are not advised for feeding clients without intact gag and cough reflexes since the risk of accidental placement of the tube into the lungs is much higher in those clients. These reflexes are present if a tongue depressor advanced to the back of the throat elicits retching or coughing responses. Skill 15-1 provides guidelines for inserting a nasogastric tube. Skill 15-2 outlines the steps for removing a nasogastric tube.
Inserting a Nasogastric Tube Equipment n n n n n n n n n
Large- or small-bore tube (nonlatex preferred) Nonallergenic adhesive tape, 2.5 cm wide Clean gloves Water-soluble lubricant Facial tissues Glass of water and drinking straw 20- to 50-mL syringe with an adapter Basin pH test strip or meter
Performance 1. Assist the client to a high Fowler’s position if his or her health condition permits, and support the head on a pillow.
n n n n n n n n n
Bilirubin dipstick Stethoscope Disposable pad or towel Clamp or plug (optional) Anti-reflux valve for air vent if Salem sump tube is used Suction apparatus Safety pin and elastic band CO2 detector (optional) Flash light to examine nares
ationale It is often easier to swallow in this position and R gravity helps the passage of the tube. Place a towel or disposable pad across the chest.
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INSERTING A NASOGASTRIC TUBE continued
Insert the tube, with its natural curve toward the client, into the selected nostril. Ask the client to hyperextend the neck, and gently advance the tube toward the nasopharynx. Rationale Hyperextension of the neck reduces the curvature of the nasopharyngeal junction. Direct the tube along the floor of the nostril and toward the ear on that side. Rationale Directing the tube along the floor avoids the projections (turbinates) along the lateral wall. Slight pressure and a twisting motion are sometimes required to pass the tube into the nasopharynx, and some client’s eyes may water at this point (tears). Rationale Tears are a natural body response. Provide the client with tissues as needed. If the tube meets resistance, withdraw it, relubricate it, and insert it in the other nostril. Rationale The tube should never be forced against resistance because of the danger of injury. Once the tube reaches the oropharynx (throat), the client will feel the tube in the throat and may gag and retch. Ask the client to tilt the head forward, and encourage the client to drink and swallow. Rationale Tilting the head forward facilitates passage of the tube into the posterior pharynx and esophagus rather than into the larynx; swallowing moves the epiglottis over the opening to the larynx. 2 If the client gags, stop passing the tube momentarily. Have the client rest, take a few breaths, and take sips of water to calm the gag reflex. In cooperation with the client, pass the tube 5 to 10 cm with each swallow, until the indicated length is inserted. If the client continues to gag and the tube does not advance with each swallow, withdraw it slightly, and inspect the throat by looking through the mouth. Rationale The tube may be coiled in the throat. If so, withdraw it until it is straight, and try again to insert it.
2. Prior to performing the insertion, introduce self and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. The passage of a gastric tube is unpleasant because the gag reflex is activated during insertion. Establish a method for the client to indicate distress and a desire for you to pause the insertion. Raising a finger or hand is often used for this. 3. Perform hand hygiene and observe other appropriate infection control procedures (e.g., wearing clean gloves). 4. Provide for client privacy. 5. Assess the client’s nares (nostrils). l Ask the client to hyperextend the head, and, using a flashlight, observe the intactness of the tissues of the nostrils, including any irritations or abrasions. l Examine the nares for any obstructions or deformities by asking the client to breathe through one nostril while occluding the other. l Select the nostril that has the greater airflow. 6. Prepare the tube. l If a small-bore tube is being used, ensure stylet or guidewire is secured in position. Rationale An improperly positioned stylet or guidewire can traumatize the nasopharynx, esophagus, and stomach. 7. Determine how far to insert the tube. l Use the tube to mark off the distance from the tip of the client’s nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the xiphoid. 1 Rationale This length approximates the distance from the nares to the stomach. This distance varies among individuals. l Mark this length with adhesive tape if the tube does not have markings. 8. Insert the tube. l Put on gloves. l Lubricate the tip of the tube well with water-soluble lubricant or water to ease insertion. Rationale A water-soluble lubricant dissolves if the tube accidentally enters the lungs. An oilbased lubricant, such as petroleum jelly, will not dissolve and could cause respiratory complications if it enters the lungs.
Pharynx Epiglottis (open) Larynx Esophagus Trachea
Epiglottis (closed) Esophagus Trachea
1 Measuring the appropriate length to insert a nasogastric tube.
2 Swallowing closes the epiglottis continued on page 436
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INSERTING A NASOGASTRIC TUBE continued If a CO2 detector is used, after the tube has been advanced approximately 30 cm, draw air through the detector. Any change in color of the detector indicates placement of the tube in the respiratory tract. Immediately withdraw the tube and reinsert. 9. Ascertain correct placement of the tube. l Aspirate stomach contents, and check the pH, which should be acidic. Rationale Testing pH is a reliable way to determine location of a feeding tube. Gastric contents are commonly pH 1 to 5. 6 or greater would indicate the contents are from lower in the intestinal tract or in the respiratory tract. Some researchers suggest that a pH of greater than 5 should be followed by further confirmation of tube location (Huffman et al., 2004). l Aspirate can also be tested for bilirubin. Bilirubin levels in the lungs should be almost zero, while levels in the stomach will be approximately 1.5 mg/dL and in the intestine over 10 mg/dL. l Almost all nasogastric tubes are radiopaque, and position can be confirmed by x-ray. Check agency policy. If a smallbore tube is used, leave the stylet or guidewire in place until correct position is verified by x-ray. If the stylet has been removed, never reinsert it while the tube is in place. Rationale The stylet is sharp and could pierce the tube and injure the client or cut off the tube end. l Place a stethoscope over the client’s epigastrium and inject 10 to 30 mL of air into the tube while listening for a whooshing sound. Although still one of the methods used, do not use this method as the primary method for determining placement of the feeding tube because it does not guarantee tube position. l If the signs indicate placement in the lungs, remove the tube and begin again. l If the signs do not indicate placement in the lungs or stomach, advance the tube 5 cm, and repeat the tests. 10. Secure the tube by taping it to the bridge of the client’s nose. l If the client has oily skin, wipe the nose first with alcohol to defat the skin. l Cut 7.5 cm of tape, and split it lengthwise at one end, leaving a 2.5-cm tab at the end. l Place the tape over the bridge of the client’s nose, and bring the split ends either under and around the tubing, or under the tubing and back up over the nose. 3 Rationale Taping in this manner prevents the tube from pressing against and irritating the edge of the nostril. 11. Once correct position has been determined, attach the tube to a suction source or feeding apparatus as ordered, or clamp the end of the tubing. 12. Secure the tube to the client’s gown. l Loop an elastic band around the end of the tubing, and attach the elastic band to the gown with a safety pin. or
Attach a piece of adhesive tape to the tube, and pin the tape to the gown. Rationale The tube is attached to prevent it from dangling and pulling. l If a Salem sump tube is used, attach the anti-reflux valve to the vent port (if used) and position the port above the client’s waist so gastric contents do not flow into the vent lumen. 13. Document relevant information: the insertion of the tube, the means by which correct placement was determined, and client responses (e.g., discomfort or abdominal distention). 14. Establish a plan for providing daily nasogastric tube care. l Inspect the nostril for discharge and irritation. l Clean the nostril and tube with moistened, cotton-tipped applicators. l Apply water-soluble lubricant to the nostril if it appears dry or encrusted. l Change the adhesive tape as required. l Give frequent mouth care. Due to the presence of the tube, the client may breathe through the mouth. 15. If suction is applied, ensure that the patency of both the nasogastric and suction tubes is maintained. l Irrigations of the tube may be required at regular intervals. In some agencies, irrigations must be ordered by the primary care provider. l If a Salem sump tube is used, follow agency policies for irrigating the vent lumen with air to maintain patency of the suctioning lumen. Often, a sucking sound can be heard from the vent port if it is patent. l Keep accurate records of the client’s fluid intake and output, and record the amount and characteristics of the drainage. 16. Document the type of tube inserted, date and time of tube insertion, type of suction used, color and amount of gastric contents, and the client’s tolerance of the procedure. Conduct appropriate follow-up, such as degree of client comfort, client tolerance of the nasogastric tube, correct placement of nasogastric tube in stomach, client understanding of restrictions, color and amount of gastric contents if attached to suction, or stomach contents aspirated.
3 Taping a nasogastric tube to the bridge of the nose.
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Removing a Nasogastric Tube n n
Disposable pad or towel Tissues
Performance 1. Prepare l Confirm the physician’s order to remove the tube. l Assist the client to a sitting position if health permits. l Place the disposable pad or towel across the client’s chest to collect any spillage of secretions from the tube. l Provide tissues to the client to wipe the nose and mouth after tube removal. 2. Prior to performing the removal, introduce self and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 3. Perform hand hygiene and observe other appropriate infection control procedures (e.g., clean gloves). 4. Provide for client privacy. 5. Detach the tube. l Disconnect the nasogastric tube from the suction apparatus, if present. l Unpin the tube from the client’s gown. l Remove the adhesive tape securing the tube to the nose. 6. Remove the nasogastric tube. l Put on clean gloves. l (Optional) Instill 50 mL of air into the tube. Rationale This clears the tube of any contents such as feeding or gastric drainage. l Ask the client to take a deep breath and to hold it. Rationale This closes the glottis, thereby preventing accidental aspiration of any gastric contents.
Although the focus of this chapter is nutrition, nasogastric tubes may be inserted for reasons other than to provide a route for feeding the client, including these: n
To prevent nausea, vomiting, and gastric distention following surgery. In this case, the tube is attached to a suction source. To remove stomach contents for laboratory analysis. To lavage (wash) the stomach in cases of poisoning or overdose of medications.
A nasoenteric (or nasointestinal) tube, a longer tube than the nasogastric tube (at least 1 m for an adult) is inserted through one nostril down into the upper small intestine. Some health institutions may require specially trained nurses or primary care providers for this procedure. Nasoenteric tubes are used for clients who are at risk for aspiration. Clients at risk for aspiration are those who manifest the following: n n n n n n
Decreased level of consciousness Poor cough or gag reflexes Endotracheal intubation Recent extubation Inability to cooperate with the procedure Restlessness or agitation.
Clean gloves 50-mL syringe (optional) n Plastic trash bag n n
Pinch the tube with the gloved hand. Rationale Pinching the tube prevents any contents inside the tube from draining into the client’s throat. l Smoothly, withdraw the tube. l Place the tube in the plastic bag. Rationale Placing the tube immediately into the bag prevents the transference of microorganisms from the tube to other articles or people. l Observe the intactness of the tube. 7. Ensure client comfort. l Provide mouth care if desired. l Assist the client as required to blow the nose. Rationale Excessive secretions may have accumulated in the nasal passages. 8. Dispose of the equipment appropriately. l Place the pad, bag with tube, and gloves in the receptacle designated by the agency. Rationale Correct disposal prevents the transmission of microorganisms. 9. Document all relevant information. l Record the removal of the tube, the amount and appearance of any drainage if connected to suction, and any relevant assessments of the client. 10. Perform a follow-up examination, such as presence of bowel sounds, absence of nausea or vomiting when tube is removed, and intactness of tissues of the nares. l Relate findings to previous assessment data if available. l Report significant deviations from normal to the primary care provider
Gastrostomy and jejunostomy devices are used for long-term nutritional support, generally more than 6 to 8 weeks. Tubes are placed surgically or by laparoscopy through the abdominal wall into the stomach (gastrostomy) or into the jejunum (jejunostomy). A percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) is created by using an endoscope to visualize the inside of the stomach, making a puncture through the skin and subcutaneous tissues of the abdomen into the stomach, and inserting the PEG or PEJ catheter through the puncture. The surgical opening is sutured tightly around the tube or catheter to prevent leakage. Care of this opening before it heals requires surgical asepsis. The catheter has an external bumper and an internal inflatable retention balloon to maintain placement. When the tract is established (about 1 month), the tube or catheter can be removed and reinserted for each feeding. Alternatively, a skin-level tube can be used that remains in place. A feeding set is attached when needed.
Enteral Feedings. The type and frequency of feedings and
amounts to be administered are ordered by physician and followed appropriately by nurse. Liquid feeding mixtures are available commercially or may be prepared by the dietary
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department in accordance with the primary care provider’s orders. A standard formula provides 1 Kcal per milliliter of solution with protein, fat, carbohydrate, minerals, and vitamins in specified proportions. Enteral feedings can be given intermittently or continuously. Intermittent feedings are the administration of 300 to 500 mL of enteral formula several times per day. The stomach is the preferred site for these feedings, which are usually administered over at least 30 minutes. Bolus intermittent feedings are those that use a syringe to deliver the formula into the stomach. Because the formula is delivered rapidly by this method, it is not usually recommended but may be used in long-term situations if the client tolerates it. These feedings must be given only into the stomach; the client must be monitored closely for distention and aspiration. Continuous feedings are generally administered over a 24-hour period using an infusion pump (often referred to as a kangaroo pump) that guarantees a constant flow rate (Figure 15-10 n). Continuous feedings are essential when feedings are administered in the small bowel. They are also used when smaller bore gastric tubes are in place or when gravity flow is insufficient to instill the feeding. Cyclic feedings are continuous feedings that are administered in less than 24 hours (e.g., 12 to 16 hours). These feedings, often administered at night, allow the client to attempt to eat regular meals through the day. Because nocturnal feedings may use higher nutrient densities and higher infusion rates than the standard continuous feeding, particular attention needs to be given to monitoring fluid status and circulating volume. Enteral feedings are administered to clients through open or closed systems. Open systems use an open-top container or a syringe for administration. Enteral feedings for use with open systems are provided in flip-top cans or powdered formulas that are reconstituted with sterile water. Sterile water, rather than tap water, reduces the risk of microbial contamination. Open systems should have no more than 8 to 12 hours of formula poured at one time. At the completion of this time, remaining formula should be discarded and the container rinsed before new formula is poured. The bag and tubing should be replaced every 24 hours (Rolfes, Pinna & Whitney, 2006). Closed systems consist of a prefilled container that is
Figure 15-10 n An enteric feeding pump.
spiked with enteral tubing and attached to the enteral access device. Prefilled containers can hang safely for 48 hours if sterile technique is used. Skill 15-3 provides the essential steps involved in administering a tube feeding, and Skill 15-4 indicates the steps involved in administering a gastrostomy or jejunostomy tube feeding.
Administering a Tube Feeding skill 15-3
Equipment Correct type and amount of feeding solution 60-mL catheter-tip syringe n Emesis basin n Clean gloves n pH test strip or meter n n
Large syringe or calibrated plastic feeding bag with label and tubing that can be attached to the feeding tube or prefilled bottle with a drip chamber, tubing, and a flow-regulator clamp n Measuring container from which to pour the feeding (if using open system) n Water (60 mL unless otherwise specified) at room temperature n Feeding pump as required n
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ADMINISTERING A TUBE FEEDING continued
Do not add colored food dye to tube feedings. Previously, blue dye was often added to assist in recognition of aspiration. However, the U.S. FDA reports cases of many adverse reactions to the dye, including toxicity and death. n Performance 1. Help the client to assume high Fowler’s position as rationalized in Skill 15-1. Rationale These positions enhance the gravitational flow of the solution and prevent aspiration of fluid into the lungs. 2. Prior to performing the feeding, introduce self and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Inform the client that the feeding should not cause any discomfort but may cause a feeling of fullness. 3. Perform hand hygiene and observe appropriate infection control procedures (e.g., clean gloves). 4. Provide privacy for this procedure if the client desires it. Tube feedings are embarrassing to some people. 5. Assess tube placement as indicated in Skill 15-1. 6. Assess residual feeding contents. Rationale This is done to evaluate absorption of the last feeding; that is, whether undigested formula from a previous feeding remains. If the tube is in the small intestine, residual contents cannot be aspirated. l If the tube is placed in the stomach, aspirate all contents and measure the amount before administering the feeding. l If 100 mL (or more than half the last feeding) is withdrawn, check with the nurse in charge or refer to institutional policy before proceeding as the amount may be reinstilled. Rationale At some agencies, a feeding is delayed when the specified amount or more of formula remains in the stomach. or l Reinstill the gastric contents into the stomach if this is the agency policy or primary care provider’s order. Rationale Removal of the contents could disturb the client’s electrolyte balance. l If the client is on a continuous feeding, check the gastric residual every 4 to 6 hours or according to institutional protocol. 7. Administer the feeding. l Before administering feeding: l Check the expiration date of the feeding. l Warm the feeding to room temperature. Rationale An excessively cold feeding may cause abdominal cramps. l When an open system is used, clean the top of the feeding container with clean water before opening it. Rationale This minimizes the risk of contaminants entering the feeding syringe or feeding bag. Feeding Bag (Open System) l Hang the labeled bag from an infusion pole about 30 cm above the tube’s point of insertion into the client.
Clamp the tubing and add the formula to the bag. Open the clamp, run the formula through the tubing, and reclamp the tube. Rationale The formula will displace the air in the tubing, thus preventing the instillation of excess air into the client’s stomach or intestine. Attach the bag to the feeding tube 1 and regulate the drip by adjusting the clamp to the drop factor on the bag (e.g., 20 drops/mL) if not placed on a pump.
Syringe (Open System) l Remove the plunger from the syringe and connect the syringe to a pinched or clamped nasogastric tube. Rationale Pinching or clamping the tube prevents excess air from e ntering the stomach and causing distention. l Add the feeding to the syringe barrel. 2 l Permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe to adjust the flow as needed. Pinch or clamp the tubing to stop the flow for a minute
hdhgkajgk;ela dakljhkda;ala agdkal;
1 Using a calibrated plastic bag to administer a tube feeding.
2 Using the barrel of a syringe to administer a tube feeding. continued on page 440
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ADMINISTERING A TUBE FEEDING continued if the client experiences discomfort. Rationale Quickly administered feedings can cause flatus, cramps, and/or vomiting. Prefilled Bottle With Drip Chamber (Closed System) l Remove the screw-on cap from the container and attach the administration set with the drip chamber and tubing. 3 l Close the clamp on the tubing. l Hang the container on an intravenous pole about 30 cm above the tube’s insertion point into the client. Rationale At this height, the formula should run at a safe rate into the stomach or intestine. l Squeeze the drip chamber to fill it to one-third to one-half of its capacity. l Open the tubing clamp, run the formula through the tubing, and reclamp the tube. Rationale The formula will displace the air in the tubing, thus preventing the instillation of excess air. l Attach the feeding set tubing to the feeding tube and regulate the drip rate to deliver the feeding over the desired length of time or attach to a feeding pump. 8. If another bottle is not to be immediately hung, flush the feeding tube before all of the formula has run through the tubing. l Instill 50 to 100 mL of water through the feeding tube or medication port. Rationale Water flushes the lumen of the tube, preventing future blockage by sticky formula. l Be sure to add the water before the feeding solution has drained from the neck of a syringe or from the tubing of an administration set. Rationale Adding the water before the syringe or tubing is empty prevents the instillation of air into the stomach or intestine and thus prevents unnecessary distention. 9. Clamp the feeding tube. Rationale Clamping prevents leakage and air from entering the tube if done before water is instilled. l Clamp the feeding tube before all of the water is instilled. 10. Ensure client comfort and safety. l Secure the tubing to the client’s gown. Rationale This minimizes pulling of the tube, thus preventing discomfort and dislodgment. l Ask the client to remain sitting upright in Fowler’s position or in a slightly elevated right lateral position for at least 30 minutes. Rationale These positions facilitate digestion and movement of the feeding from the stomach along the alimentary tract, and prevent the potential aspiration of the feeding into the lungs. l Check the institutional policy on the frequency of changing the nasogastric tube and the use of smaller lumen tubes if a large-bore tube is in place. Rationale These measures prevent irritation and erosion of the pharyngeal and esophageal mucous membranes. 11. Dispose of equipment appropriately. l If the equipment is to be reused, wash it thoroughly with water so that it is ready for reuse. l Change the equipment every 24 hours or according to policy.
3 Feeding set tubing with drip chamber. (Ross Products Division, Abbot Laboratories. Used with permission)
12. Document all relevant information. l Document the feeding, including amount and kind of solution taken, duration of the feeding, and assessments of the client. l Record the volume of the feeding and water administered on the client’s intake and output record. 13. Monitor the client for possible problems. l Carefully assess clients receiving tube feedings for problems. l To prevent dehydration, give the client supplemental water in addition to the prescribed tube feeding as ordered. Variation: Continuous-Drip Feeding l Clamp the tubing at least every 4 to 6 hours, or as indicated by protocol or the manufacturer, and aspirate and measure the gastric contents. Then flush the tubing with 30 to 50 mL of water. Rationale This determines adequate absorption and verifies correct placement of the tube. If placement of a small-bore tube is questionable, a repeat x-ray should be done. l Determine protocol regarding withholding a feeding. Many agencies withhold the feeding if more than 75 to 100 mL of feeding is aspirated. l To prevent spoilage or bacterial contamination, do not allow the feeding solution to hang longer than 4 to 8 hours. Check policy or manufacturer’s recommendations regarding time limits. l Follow policy regarding how frequently to change the feeding bag and tubing. l Changing the feeding bag and tubing every 24 hours reduces the risk of contamination. 14. Perform a follow-up examination. l Relate findings to previous assessment data if available. Tolerance of feeding (e.g., nausea, cramping). l Report significant deviations from normal to the primary care provider.
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Administering a Gastrostomy or Jejunostomy Feeding n
Correct amount of feeding solution Graduated container and tubing with clamp to hold the feeding n 60-mL catheter-tip syringe
For Tube Insertion
For a Tube that Remains in Place
Precut 10 cm : 10 cm gauze squares Uncut 10 cm : 10 cm gauze squares
Clean gloves Moisture-proof bag n Water-soluble lubricant n Feeding tube (if needed)
Performance 1. Prior to performing the feeding, introduce self and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Discuss how the results will be used in planning further care or treatments. 2. Perform hand hygiene and observe other appropriate infection control procedures (e.g., clean gloves). 3. Provide for client privacy. 4. Assess and prepare the client as shown in Skill 15-3. 5. Insert a feeding tube, if one is not already in place. l Wearing gloves, remove the dressing. Then discard the dressing and gloves in the moisture-proof bag. l Apply new clean gloves. l Lubricate the end of the tube, and insert it into the ostomy opening 10 to 15 cm. 6. Check the location and patency of a tube that is already in place. l Determine correct placement of the tube by aspirating secretions and checking the pH. l Follow agency policy for amount of residual formula. This may include withholding the feeding, rechecking in 3 to 4 hours, or notifying the physician if a large residual remains. l For continuous feedings, check the residual every 4 to 6 hours and hold feedings according to agency policy. l Remove the syringe plunger. Pour 15 to 30 mL of water into the syringe, remove the tube clamp, and allow the water to flow into the tube. Rationale This determines the patency of the tube. If water flows freely, the tube is patent. l If the water does not flow freely, notify the nurse in charge and/or primary care provider. 7. Administer the feeding. l Hold the barrel of the syringe 7 to 15 cm above the ostomy opening.
Slowly pour the solution into the syringe and allow it to flow through the tube by gravity. l Just before all the formula has run through and the syringe is empty, add 30 mL of water. Rationale Water flushes the tube and preserves its patency. l If the tube is to remain in place, hold it upright, remove the syringe, and then clamp or plug the tube to prevent leakage. l If a catheter was inserted for the feeding, remove it. 8. Ensure client comfort and safety. l After the feeding, ask the client to remain in the sitting position or a slightly elevated right lateral position for at least 30 minutes. Rationale This minimizes the risk of aspiration. l Assess status of peristomal skin. Rationale Gastric or jejunal drainage contains digestive enzymes that can irritate the skin. Document any redness and broken skin areas. l Check the peristomal skin, applying a skin protectant, and applying appropriate dressings if needed. Generally, the peristomal skin is washed with mild soap and water at least once daily. The tube may be rotated between thumb and forefinger to release any sticking and promote tract formation. Petrolatum or other skin barrier creams may be applied around the stoma, and precut 10 cm × 10 cm gauze squares may be placed around the tube. The precut squares are then covered with regular 10 cm × 10 cm gauze squares, and the tube is coiled over them. l Observe for common complications of enteral feedings: aspiration, hyperglycemia, abdominal distention, diarrhea, and fecal impaction. Report findings to primary care provider. Often, a change in formula or rate of administration can correct problems. l When appropriate, teach the client how to administer feedings and when to notify the health care provider concerning problems. 9. Document all assessments and interventions.
Mild soap and water Clean gloves n Petrolatum or other skin barrier creams n
Table 15-5 lists essential assessments to conduct before administering tube feedings. The nurse must also check the expiration date on a commercially prepared formula or the preparation date and time of agency-prepared solution, discarding any formula that has passed the expiration date or that was prepared more than 24 hours previously. Feedings are usually administered at room temperature unless the order specifies otherwise. The nurse warms the specified amount of solution in a basin of warm water or leaves it to stand for a while until it reaches room temperature. Because a formula that is warmed can grow microorganisms, it should not hang longer than the manufacturer recommends. Continuous-feeding
formulas should be kept cold; excessive heat coagulates feedings of milk and egg, and hot liquids can irritate the mucous membranes. However, excessively cold feedings can reduce the flow of digestive juices by causing vasoconstriction and may cause cramps.
Managing Clogged Feeding Tubes Even if feeding tubes are flushed with water before and after feedings and medications, they can still become clogged. This can occur when the feeding container runs dry, solid medication is not adequately crushed, or medications are mixed with formula. Even the important practice of aspirating to check
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Table 15-5 Assessing Clients Receiving Tube Feedings Assessments Allergies to any food in the feeding Bowel sounds before each feeding or, for continuous feedings, every 4 to 8 hours Correct placement of tube before feedings Presence of regurgitation and feelings of fullness after feedings Dumping syndrome: nausea, vomiting, diarrhea, cramps, pallor, sweating, heart palpitations, increased pulse rate, and fainting after a feeding Abdominal distention, at least daily (Measure abdominal girth at the umbilicus.) Diarrhea, constipation, or flatulence
Urine for sugar and acetone Hematocrit and urine specific gravity Serum blood urea nitrogen and sodium levels
residual volume increases the incidence of clogging (Reising, & Neal, 2005). To avoid the necessity of removing the tube and reinserting a new tube, both prevention and intervention strategies must be used. To prevent clogged feeding tubes, flush liberally (at least 30 mL water) before, between, and after each separate medication is instilled, using a 60-mL piston syringe. The larger the barrel of the syringe, the less the pressure exerted. Too great a pressure can rupture the tube, especially small-bore feeding tubes. Do not add medications to formula or to each other. Many strategies have been used to try to unclog feeding tubes. Strategies that have shown inconsistent effectiveness include instilling meat tenderizer, carbonated beverages, or cranberry juice, or flushing with small barrel syringes with or without digestive enzymes such as papain or chymotrypsin. Soda has actually been found to make the clog worse (Novartis Nutrition Corporation, 2003).
Parenteral Nutrition Parenteral nutrition (PN), also referred to as total parenteral nutrition (TPN) or intravenous hyperalimentation (IVH), is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired. Parenteral nutrition is administered intravenously such as through a central venous catheter into the superior vena cava. Parenteral feedings are solutions of dextrose, water, fat, proteins, electrolytes, vitamins, and trace elements; they provide all needed calories. Because TPN solutions are hypertonic (highly concentrated in comparison to the solute concentration of blood), they are injected only into high-flow central veins, where they are diluted by the client’s blood. TPN is a means of achieving an anabolic state in clients who are unable to maintain a normal nitrogen balance. Such clients may include those with severe malnutrition, severe burns, bowel
Rationale Common allergenic foods include milk, sugar, water, eggs, and vegetable oil. To determine intestinal activity To prevent aspiration of feedings May indicate delayed gastric emptying, need to decrease quantity or rate of the feeding, or high fat content of the formula Jejunostomy clients may experience these symptoms, which result when hypertonic foods and liquids suddenly distend the jejunum. To make the intestinal contents isotonic, body fluids shift rapidly from the client’s vascular system. Abdominal distention may indicate intolerance to a previous feeding. The lack of bulk in liquid feedings may cause constipation. The presence of hypertonic or concentrated ingredients may cause diarrhea and flatulence. Hyperglycemia may occur if the sugar content is too high. Both increase as a result of dehydration. Feeding formula may have a high protein content. If a high protein intake is combined with an inadequate fluid intake, the kidneys may not be able to excrete nitrogenous wastes adequately.
disease disorders (e.g., ulcerative colitis or enteric fistula), acute renal failure, hepatic failure, metastatic cancer, or major surgeries where nothing may be taken by mouth for more than 5 days. TPN is not risk-free. Infection control is of utmost importance during TPN therapy. The nurse must always observe surgical aseptic technique when changing solutions, tubing, dressings, and filters. Clients are at increased risk of fluid, electrolyte, and glucose imbalances and require frequent evaluation and modification of the TPN mixture. TPN solutions are 10 to 50% dextrose in water, plus a mixture of amino acids and special additives such as vitamins (e.g., B complex, C, D, K), minerals (e.g., potassium, sodium, chloride, calcium, phosphate, magnesium), and trace elements (e.g., cobalt, zinc, manganese). Additives are modified to each client’s nutritional needs. Fat emulsions may be given to provide essential fatty acids to correct and/or prevent essential fatty acid deficiency or to supplement the calories for clients who, for example, have high calorie needs or cannot tolerate glucose as the only calorie source. Note that 1,000 mL of 5% glucose or dextrose contains 50 grams of sugar. Thus, a liter of this solution provides less than 200 calories! Because TPN solutions are high in glucose, infusions are started gradually to prevent hyperglycemia. The client needs to adapt to TPN therapy by increasing insulin output from the pancreas. For example, an adult client may be given 1 liter (40 mL/hr) of TPN solution the first day; if the infusion is tolerated, the amount may be increased to 2 liters (80 mL/hr) for 24 to 48 hours, and then to 3 liters (120 mL/hr) within 3 to 5 days. Glucose levels are monitored during the infusion. When TPN therapy is to be discontinued, the TPN infusion rates are decreased slowly to prevent hyperinsulinemia and hypoglycemia. Weaning a client from TPN may take up to 48 hours but can occur in 6 hours as long as the client receives adequate carbohydrates either orally or intravenously.
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Enteral or parenteral feedings may be continued beyond hospital care in the client’s home or may be initiated in the home.
If the outcomes are not achieved, the nurse should explore the reasons. The nurse might consider the following questions: n n
Is the client experiencing symptoms that cause loss of appetite (e.g., pain, nausea, fatigue)? Were the outcomes unrealistic for this person? Were the client’s food preferences considered? Is anything interfering with digestion or absorption of nutrients (e.g., diarrhea)?
Was the cause of the problem correctly identified? Was the family included in the teaching plan? Are family members supportive?
Nursing Care Plan
For a Client with Imbalanced Nutrition
Imbalanced nutrition: less than body requirements/intake of nutrients insufficient to meet metabolic needs
Adequacy of usual pattern of nutrient intake in terms of calories and vitamins
Mrs Rajha is a 70-year-old woman who is 167 cm tall and weighs 88 kg. She was recently admitted to the medical unit. She reports having lost 20 kg in weight during the past 2 months and recently had a stroke resulting in left-sided weakness. She also has had nothing by mouth for the past 24 hours and has needs to begin tube feeding. Nursing History History taking indicates that she eats mostly bread, cereal, whole milk, and canned fish and meats. She eats almost no fruits and vegetables. n She wears dentures and has impaired chewing and swallowing. n History revealed left-side weakness with disability to cook and eat food and that she is on several medications (aspirin, digitalis, thiazides). n
Height: 167 cm Weight: 88 kg Physical examination revealed anorexia; indigestion; dysphagia; 20 kg weight loss in last 2 months; dry flaky skin; apathetic; easily fatigued; reddened conjunctiva; wasted muscles; and with loss of concentration and confusion
UBW: 85% TSF is 9.2 cm MAC is 18.2 cm MAMC is 20.4 cm Hemoglobin: 11.8 mg/dL Serum albumin: 15 mg/dL
Nursing Interventions/Selected Activities
a. Assist Mrs Rajha in a special diet
a. To restore nutritional deficits
b. Provide Mrs Rajha with a soft diet as tolerated after checking gag and cough reflexes.
b. Soft diet is easily chewed and digested. It is often ordered for clients who have difficulty chewing and swallowing
c. Provide familiar food that Mrs Rajha likes; avoid unpleasant or uncomfortable treatments immediately before or after a meal; provide a tidy, clean environment that is free of unpleasant sights and odors; encourage or provide oral hygiene before mealtime and reduce psychologic stress
c. To encourage the client’s appetite and food intake
d. Assist Mrs Rajha as required (e.g., remove the food covers, butter the bread, pour the tea, and cut the meat).
d. To encourage food intake
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Nursing Care Plan For a Client with Imbalanced Nutrition continued
Nursing Interventions/Selected Activities
e. If Mrs Rajha’s general condition has deteriorated and she is unable to take oral food, assist in insertion of a nasogastic tube and administering enteral feeding as indicated.
e. To maintain optimal nutrition and prevent complications of under nutrition
f. Assist Mrs Rajha to assume Fowler’s position (at least 30 degrees elevation) in bed or a sitting position in a chair, the normal position for eating. If a sitting position is contraindicated, a slightly elevated right side-lying position is acceptable.
f. These positions enhance the gravitational flow of the solution and prevent aspiration of fluid into the lungs.
g. Assess enteral tube placement prior to administering tube feeding.
g. To prevent tube-misplacement complications such as aspiration of fluids and food in the lungs
h. Assess residual feeding contents.
h. To evaluate absorption of the last feeding; that is, whether undigested formula from a previous feeding remains. If the tube is in the small intestine, residual contents cannot be aspirated.
i. Administer the feeding at room temperature.
i. Excessively cold formulas may induce abdominal cramps and diarrhea.
j. Instill 50 to 100 ml of water through the feeding tube after administering food.
j. To flush tube and preventing future blockage by sticky formula.
k. Ensure client comfort and safety and secure the tubing to her gown.
k. To minimize pulling the tube, thus preventing discomfort and dislodgement.
l. Ask the client to remain sitting upright in Fowler’s position or in a slightly elevated right lateral position for at least 30 minutes.
l. These positions facilitate digestion and movement of the feeding from the stomach along the alimentary tract, and prevent the potential aspiration of the feeding into the lungs.
Evaluation Outcome measures has been partially achieved. Mrs Rajha’s general condition improved as her vital signs are stable (temperature 37.6°C, pulse 68 BPM, respiratory rate: 18/minute, blood pressure 110/90 mmHg). Mrs Rajha tolerated feeding and did not develop nausea or vomiting. Mild anorexia, indigestion, and dysphagia have been monitored. The client gained 2 kg in 1 week and her skin condition is moist. Mrs Rajha is still feeling fatigued and has loss of concentration, but her orientation level has improved for person, place, and time. Bowel sounds can be clearly auscultated, and no diarrhea or constipation have been experienced, with concentrated urine.
Critical Reflection Let us return to Laila’s case at the start of this chapter. Now that you have read this chapter, what are the possible nursing diagnoses that can be listed in the client’s medical record? What instruction would you give Laila as part of health teaching to manage her health problems? What procedures can be performed to provide Laila with optimal nutrition if she continues to refuse eating by the oral route?
Chapter Highlights Essential nutrients are grouped into categories: carbohydrates, proteins, lipids, vitamins, and minerals. n Nutrients serve three basic purposes: forming body structures (such as bones and blood), providing energy, and helping to regulate the body’s biochemical reactions. n The amount of energy that nutrients or foods supply to the body is their caloric value. The amount of energy required n
to maintain basic body functions is referred to as the resting energy expenditure (REE). The basal metabolic rate (BMR) is the rate at which the body metabolizes food to maintain the energy and requirements of a person who is awake and at rest. n A person’s state of energy balance can be determined by comparing caloric intake with caloric expenditure.
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Chapter 15 / Nutrition 445
Ideal body weight (IBW) is the optimal weight recommended for optimal health. Body mass index (BMI) and percentage body fat are indicators of changes in body fat stores. They indicate whether a person’s weight is appropriate for height and may provide a useful estimate of nutrition. Factors influencing a person’s nutrition include development, gender, ethnicity and culture, beliefs about foods, personal preferences, religious practices, lifestyle, economics, medications and therapy, health, advertising, and psychologic factors. Nutritional needs vary considerably according to age, growth, and energy requirements. Adolescents have high energy requirements due to their rapid growth; a diet plentiful in milk, meats, green and yellow vegetables, and fresh fruits is required. Middle-aged adults and elders often need to reduce their caloric intake because of decreases in metabolic rate and activity levels. Various daily food guides have been developed to help healthy people meet the daily requirements of essential nutrients and to facilitate meal planning. These include the Food Guide Pyramid. Both inadequate and excessive intakes of nutrients result in malnutrition. The effects of malnutrition can be general or specific, depending on which nutrients and what level of deficiency or excess are involved. Assessment of nutritional status may involve all or some of the following: nursing history data, nutritional screening, physical examination, calculation of the percentage of weight loss, a dietary history, anthropometric measurements, and laboratory data.
Major goals for clients with or at risk for nutritional problems include the following: maintain or restore optimal nutritional status, decrease or regain specified weight, promote healthy nutritional practices, and prevent complications associated with malnutrition. Assisting clients and support persons with therapeutic diets is a function shared by the nurse and the dietitian. The nurse reinforces the dietitian’s instructions, assists the client to make beneficial changes, and evaluates the client’s response to planned changes. Because many hospitalized clients have poor appetites, a major responsibility of the nurse is to provide nursing interventions that stimulate their appetites. Whenever possible, the nurse should help incapacitated clients to feed themselves; a number of self-feeding aids help clients who have difficulty handling regular utensils. Enteral feedings, administered through nasogastric, nasointestinal, gastrostomy, or jejunostomy tubes, are provided when the client is unable to ingest foods or the upper gastrointestinal tract is impaired. A nasogastric or nasointestinal tube is used to provide enteral nutrition for short-term use. A gastrostomy or jejunostomy tube can be used to supply nutrients via the enteral route for long-term use. The two most accurate methods of confirming gastrointestinal tube placement are radiographs and pH testing of aspirate. Parenteral nutrition (PN), provided when the gastrointestinal tract is nonfunctional (e.g., absorptive capacity impaired), is given intravenously into a large central vein (e.g., the superior vena cava).
Test Your Knowledge 1. Which of the following nursing diagnoses is most appropriate for a client with a body mass index (BMI) of 35? 1. Imbalanced nutrition: less than body requirements 2. Imbalanced nutrition: more than body requirements 3. Risk for imbalanced nutrition 4. Deficient knowledge
4. Which of the following is the best indication of proper placement of a nasogastric tube in the stomach? 1. Client is unable to speak. 2. Client gags during insertion. 3. pH of the aspirate is less than 5. 4. Fluid is easily instilled into the tube.
2. An adult reports eating, on average, the following each day: 3 cups dairy, 2 cups fruit, 2 cups vegetables, 142 g grains, and 142 g meat. The nurse would counsel the client to: 1. Maintain the diet; the servings are adequate. 2. Increase the number of servings of dairy. 3. Decrease the number of servings of vegetables. 4. Increase the number of servings of grains.
5. What is the proper technique with gravity tube feeding? 1. Feeding bag is hung 30 cm higher than the tube’s insertion point into the client. 2. Nurse administers the next feeding only if there is less than 25 mL of residual volume from the previous feeding. 3. Place client in the left lateral position. 4. Feeding is administered directly from the refrigerator.
3. Which of the following are allowed on a full liquid diet? Select all that apply. 1. Scrambled eggs 2. Chocolate pudding 3. Tomato juice 4. Hard candy 5. Mashed potatoes 6. Cream of wheat cereal 7. Oatmeal cereal 8. Fruit ‘smoothies’
6. A 55-year-old female is about 9 kg over her desired weight. She has been on a ‘low-calorie’ diet with no improvement. Which of the following statements reflects a healthy approach to the desired weight loss? 1. “I need to increase my exercise to at least 30 minutes every day.” 2. “I need to switch to a low-carbohydrate diet.” 3. “I need to keep a list of my forbidden foods on hand at all times.” 4. “I need to buy more organic and less processed foods.”
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446 The Nature of Nursing
7. An elderly Asian client has mild dysphagia from a recent stroke. The nurse plans the client’s meals based on the need to: 1. Have at least one serving of thick dairy (e.g., pudding, ice cream) per meal. 2. Eliminate the beer usually ingested every evening. 3. Include as many of the client’s favorite foods as possible. 4. Increase the calories from lipids to 40%. 8. Which of the following meals would the nurse recommend to the client as highest in calcium, iron, and fiber?
1. 37 g cottage cheese with 1/3 cup raisins and 1 banana 2. 1/2 cup broccoli with 3 ounces chicken and 1/2 cup peanuts 3. 1/2 cup spaghetti with 2 ounces ground beef and 1/2 cup lima beans plus 1/2 cup ice cream 4. 3 ounces tuna plus 1 ounce cheese sandwich on whole wheat bread plus a pear See Answers to Test Your Knowledge in Appendix A.
References American Dietetic Association. (2003). National dysphagia diet: Standardization for optimal care. Chicago, IL: Author. Anonymous. (2003). Position of the American Dietetic Associations and Dieticians of Canada: vegetarian diets. Journal of the American Dietetic Association, 103(6), 748–765. Dahan, A., & Altman, H. (2004). Food-drug interaction: Grapefruit juice augments drug bioavailability—mechanism, extent, and relevance. European Journal of Clinical Nutrition, 58, 1–9. Daniels, J. (2004). Fad diets: Slim on good nutrition. Nursing, 34(12), 22–23. Dochterman, J., & Bulechek, G. B. (Eds.). (2004). Nursing interventions classification (NIC) (4th ed.). St. Louis, MO: Mosby. Ellett, M. L. C. (2004). What is known about methods of correctly placing gastric tubes in adults and children. Gastroenterology Nursing, 27(6), 253–261. Ellett, M. L. C., Beckstrand, J., Flueckiger, J., Perkins, S. M., & Johnson, C. S. (2005). Predicting the insertion distance for placing gastric tubes. Clinical Nursing Research, 14(9), 11–27. Green, S. M., & Watson, R. (2005). Nutritional screening and assessment tools for use by nurses: Literature review. Journal of Advanced Nursing, 50(9), 69–83. Haddad, E. H., & Tanzman, J. S. (2003). What do vegetarians in the United States eat? American Journal of Clinical Nutrition, 78(3), 626S—632S. Hogan, S. L. (2004). How to help wounds heal. RN, 67(8), 26–31. Huffman, S., Jarczyk, K. S., O’Brien, E., Pieper, P., & Bayne, A. (2004). Methods to confirm feeding tube placement: Application of research to practice. Pediatric Nursing, 30(9), 10–13. Institute of Medicine. (2003). Dietary reference intakes: Applications in dietary planning. Washington, DC: National Academies Press. Khair, J. (2005). Guidelines for testing the placement of nasogastric tubes. Nursing Times, 101(20), 26–27. Kuszajewski, M. L., & Clontz, A. S. (2005). Prealbumin is best for nutritional monitoring. Nursing, 35(5), 70—71. Kyle, U. G., Bosaevs, I. De Lorenzo, A. D., Devrenberg, P., Elia, M., Go-mez, J. M., et al. (2004). Bioelectrical impedance analysis part I: review of principles and methods. Clinical Nutrition, 23(5), 1226—1243.
Metheny, N. A., & Meert, K. L. (2004). Monitoring feeding tube placement. Nutrition in Clinical Practice, 19(5), 487–495. Musaiger, A. (2004). Overweight and obesity in the Eastern Mediterranean Region: Can we control it? Eastern Mediterranean Health Journal, 10(6), 789. Novartis Nutrition Corporation. (2003). Nasogastric tube care and maintenance procedures. New York: Author. Retrieved June 25, 2006, from http://www. novartisnutrition.com/us/productDetail?id=42 Nutrition Screening Initiative. (2003). Determine your nutritional health. Washington, DC: National Council on Aging. Padua, C. A., Kenny, A., Planchon, C., & Lamoureux, C. (2004). Enteral feedings: What the evidence says. American Journal of Nursing, 104(7), 62–70. Reising, D. L., & Neal, R. S. (2005). Enteral tube flushing: What you think are the best practices may not be. American Journal of Nursing, 105(3), 58–64. Rolfes, S. R., Pinna, K., & Whitney, E. (2006). Understanding normal and clinical nutrition (7th ed.). Belmont, CA: Thomson Wadsworth. Sauvaget, C., Nagano, J., Hayashi, M., & Yamada, M. (2004). Animal Protein, animal fat, and cholesterol intakes and risk of cerebral infarction mortality in the adult health study. Stroke, 35(7), 1531—1537. Williams, T. A., & Leslie, G. D. (2004). A review of the nursing care of enteral feeding tubes in critically ill adults: Part 1. Intensive and Critical Care Nursing, 20(6), 330–343. Williams, T. A., & Leslie, G. D. (2005). A review of the nursing care of enteral feeding tubes in critically ill adults: Part 2. Intensive and Critical Care Nursing, 21(9), 5–15. Wright, L., Cotter, D., Hickson, M., & Frost, G. (2005). Comparison of energy and protein intakes of older people consuming a texture modified diet with a normal hospital diet. Journal of Human Nutrition and Dietetics, 18(3), 213–219. http://www.who.int/nutriition/topics/nutrecomm/en/ index.html Zagaria, M. A. E. (2005). Implications of dysphagia in the elderly. U.S. Pharmacist, 30(1), 30–39.
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Glossary Absorption | امتصاص
the process by which a drug passes into the bloodstream Accountability | مسؤولية
the ability and willingness to assume responsibility for one’s actions and to accept the consequences of one’s behavior Acid | حمض
a substance that releases hydrogen ions (H+) in solution Acidosis | حماض
a condition that occurs with increases in blood carbonic acid or with decreases in blood bicarbonate; blood pH below 7.35 Acquired immunity | احلصانة او املناعة املكتسبة
see Passive immunity
Active euthanasia | ً قتل من يشكو مرضا ً عضاال بطريقة خالية من األلم مبشاركة ومعرفة من املريض نفسه
actions that directly bring about the client’s death with or without consent Active immunity | الفعال المناعة
Acute pain | ألم حاد
pain that lasts only through the expected recovery period (less than 6 months), whether it has a sudden or slow onset and regardless of the intensity Adherence | االلتزام
the extent to which an individual’s behavior (for example, taking medications, following diets, or making lifestyle changes) coincides with medical or health advice; commitment or attachment to a regimen Advance health care directives | الصحية توجيهات مسبقة للرعاية ّ
a variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences Adventitious breath sounds | أصوات التنفس الشاذة
abnormal or acquired breath sounds Adverse effects | اعراض جانبية
more severe side effects that may justify the discontinuation of a drug
a resistance of the body to infection in which the host produces its own antibodies in response to natural or artificial antigens
Advocate | مؤيد لقضية،يدافع عن
Active ROM exercises | مجموعة من التدريبات النشطة
Aerobic | هوائي
individual who pleads the cause of another or argues or pleads for a cause or proposal
isotonic exercises in which the client moves each joint in the body
living only in the presence of oxygen
Active transport | النقل النشط
any activity during which the body takes in more or an equal amount of oxygen than it expends
movement of substances across cell membrane against the concentration gradient Activity tolerance | درجة حتمل الفرد،للنشاط نطاق النشاط
the type and amount of exercise or daily activities an individual is able to perform Activity-exercise pattern | منط النشاط
refers to a person’s pattern of exercise, activity, leisure, and recreation Actual loss | (الفعلي (اخلسارة الفعلية الفقدان ّ
Aerobic exercise | التمارين الهوائية
Afebrile | بح َّمى ُ ص ُحوْ ٍب ْ غير ُ َم ْ
absence of a fever
Afterload | ُح ُمو َل ٌة تِل ِْويَّة
the resistance against which the heart must pump to eject blood into the circulation Agglutinogens | لزينات
a substance that acts as an antigen and stimulates the production of agglutinins
can be identified by others and can arise either in response to or in anticipation of a situation
Agonist | ناهض
Actual nursing diagnosis | التشخيص التمريضي الواقعي
Agonist analgesic | مسكن ألم ناهض
a client problem that is present at the time of the nursing assessment. Acute illness | مرض حاد
typically characterized by severe symptoms of relatively short duration Acute infection | التهاب حاد
those that generally appear suddenly or last a short time
a drug that interacts with a receptor to produce a response full agonists which are pure opioid drugs that bind tightly to mu receptor sites, producing maximum pain inhibition, an agonist effect Agonist-antagonist analgesic | مناهض-مسكن ألم ناهض
mixed agonist-antagonist drugs that can act like opioids and relieve pain (agonist effect) when given to a client who has not taken any pure opioids 681
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Airborne precautions | احتياطات النقل الهوائي
Antiseptics | املطهرات
Algor mortis | برودة املوت
Anuria | ان ِْقطا ُع ال َبول؛زُرَام
methods used to reduce exposure to infectious agents the gradual decrease of the body’s temperature after death Alopecia | (تساقط الشعر (الصلع
the loss of scalp hair (baldness) or body hair Ambulation | حتريك،َسير
the act of walking
Ampule | وعاء زجاجي اوبالستيكي يحتوي مادة دوائية-االمبولة
a small glass container for individual doses of liquid medications Anabolism | عملية البناء
a process in which simple substances are converted by the body’s cells into more complex substances (e.g., building tissue, positive nitrogen balance) Anaerobic | الالهوائي
living only in the absence of oxygen Anaerobic exercise | التمرينات اللهوائية
involves activity in which the muscles cannot draw out enough oxygen from the bloodstream; used in endurance training Anger | الغضب
an emotional state consisting of a subjective feeling of animosity or strong displeasure Angiogenesis | عملية بناء اوعية دموية جديدة
the process by which new blood loops (capillaries) build up in a healed wound Angle of Louis | زاوية لويس
the junction between the body of the sternum and the manubrium; the starting point for locating the ribs anteriorly Anions | (األنيونات (األيونات السالبة
ions that carry a negative charge; includes chlorine (Cl–), bicarbonate (HCO3–), phosphate (HPO42–), and sulfate (SO4) Ankylosed | يصاب بالتصلب، يصاب بالقسط،َمقْ سوط
permanently immobile joints Anorexia | فقدان الشهية للطعام
agents that inhibit the growth of some microorganisms the failure of the kidneys to produce urine, resulting in a total lack of urination or output of less than 100 mL per day in an adult Anxiety | القلق
a state of mental uneasiness, apprehension, or dread producing an increased level of arousal caused by an impending or anticipated threat to self or significant relationships Apical pulse | نبض قمة القلب
a central pulse located at the apex of the heart Apical-radial pulse | ض كُ ْع ُب ِر ّي ٌ ْنَب
measurement of the apical beat and the radial pulse at the same time Apnea | انقطاع التنفس
a complete absence of respirations Approximated | مقاربة االنسجة
closed tissue surfaces
Arrhythmia | عدم اتساق النبض،راب النَّظْ م ْ ُ ِاضط
a pulse with an abnormal rhythm
Arterial blood gases (ABGs) | الشرياني غازات ال ّدم ّ
specimen of arterial blood that assesses oxygenation, ventilation, and acid–base status Arterial blood pressure | ضغط الدم الشرياني
the measure of the pressure exerted by the blood as it pulsates through the arteries َّ ُّب Arteriosclerosis | ي َ َ الشرايني؛ت َ َت ٌ صل ُ صل ّ ِ ُّب ِشرْيَان
a condition in which the elastic and muscular tissues of the arteries are replaced with fibrous tissue Asepsis | العقامة
freedom from infection or infectious material Assault | محاولة اعتداء أو تهجم
an attempt or threat to touch another person unjustifiably Assessing | تقييم
lack of appetite
the process of collecting, organizing, validating, and recording data (information) about a client’s health status
Antagonist | مضاد
Assimilation | استيعاب
drug that inhibits cell function by occupying the drug’s receptor sites Antibodies | االجسام املضادة
immunoglobulins, part of the body’s plasma proteins, defend primarily against the extracellular phases of bacterial and viral infections Anticipatory grief | حزن استباقي
grief experienced in advance of the event Anticipatory loss | فقدان استباقي
the experience of loss before the loss actually occurs Antigen | (مستضد (مولد الضد
a substance capable of inducing the formation of antibodies
the process by which an individual develops a new cultural identity and becomes like the members of the dominant culture Assisted suicide | املساعدة في االنتحار أو محاولة االنتحار
a form of active euthanasia in which clients are given the means to kill themselves Associate degree programs | برامج التمريض املشارك
nursing programs that are offered in community colleges (academies) 2 years in length. Atelectasis | انخماص الرئة
a condition that occurs when ventilation is decreased and pooled secretions accumulate in a dependent area of a bronchiole and block it
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Atherosclerosis | تصلب الشرايني
buildup of fatty plaque within the arteries Atria | [ أُذَين:أُذَي ْ َنان ؛ [املفرد
two upper hollow chambers of the heart Atrioventricular (AV) node | العقدة ُاألذَي ِن ّي ُة ال ُب َطي ِن ّية
conduction pathways that slightly delay transmission of the impulse from the atria to the ventricles of the heart Atrioventricular (AV) valves | صمامات القلب بني األذينني والبطني
between the atria and ventricles of the heart, the tricuspid valve on the right and the bicuspid or mitral valve on the left Atrophy | ضمور
wasting away; decrease in size of organ or tissue (e.g., muscle) Attitudes | اجتاه،موقف
mental stance that is composed of many different beliefs; usually involving a positive or negative judgment toward a person, object, or idea Auscultation | التسمع
the process of listening to sounds produced within the body Auscultatory gap | )ثَغْرَةٌ ت َ َس ُّم ِعيَّة (في قياس الضغط
the temporary disappearance of sounds normally heard over the brachial artery when the sphygmomanometer cuff pressure is high and the sounds reappear at a lower level Autoantigen | مستضد ذاتي
an antigen that originates in a person’s own body Autonomy | استقالل
the state of being independent and self-directed, without outside control, to make one’s own decisions Autopsy | تشريح اجلثة لتحديد سبب الوفاة
an examination of the body after death to determine the cause of death and to learn more about a disease process Bacteremia | جترثم
bacteria in the blood Bacteria | نوع من اجلراثيم-بكتيريا
the most common infection-causing microorganisms Basal metabolic rate (BMR) | معدل االسقالب االساسي
the rate of energy utilization in the body required to maintain essential activities such as breathing
Bedpan | قصرية السرير
a receptacle for urine and feces for clients who are restricted to bed Beliefs | معتقدات
interpretations or conclusions that one accepts as true Beneficence | فائدة،منفعة
the moral obligation to do good or to implement actions that benefit clients persons and their support persons Bereavement | عزاء
a subjective response of a person who has experienced the loss of a significant other through death Bevel | شطبة
the slanted part at the tip of a needle Bicultural | ثنائي الثقافة
used to describe a person who crosses two cultures, lifestyles, and sets of values Bioethics | ات ال َبيولو ِجيَّة ُ ََّاأل ْخال ِقي
ethical rules or principles that govern right conduct concerning life Biomedical | health belief املعتقدات الصحية املتعلقة باألمور الطِبِّ ّي ٌة ال َب ُيولُو ِجي ّة
see Scientific health belief
Bioterrorism | االرهاب البيولوجي
intentional attack using biological weapons such as viruses, bacteria, or other germs transmitted by airborne droplet nuclei smaller than 5 microns Biotransformation | التحول البيولوجي
process by which a drug is converted to a less active form; also called detoxification Bladder training | ريب املَثانَة ُ ْتَد
client postpones voiding, resists or inhibits the sensation of urgency, and voids according to a timetable rather than according to the urge to void Blood chemistry | كيمياء الدم
a number of tests performed on blood serum (the liquid portion of the blood) Blood pressure (BP) | ضغط الدم
Base of support | قاعدة االرتكاز
the area on which an object rests
the force exerted on arterial walls by blood flowing within the vessel
Bases | قواعد
Bloodborne pathogens | اجلراثيم املنقولة بالدم
(alkalis) have low hydrogen ion concentration and can accept hydrogen ions in solution Battery | إعتداء بالضرب
(legal) the willful or negligent touching of a person (or the person’s clothes or even something the person is carrying), which may or may not cause harm Bed rest | راحة تامة في السرير
strict confinement to bed (complete bed rest), or the client may be allowed to use a bedside commode or have bathroom privileges
those microorganisms carried in blood and body fluids that are capable of infecting other persons with serious and difficult-totreat viral infections, namely, hepatitis B virus, hepatitis C virus, and HIV Body image | صورة اجلسم
how a person perceives the size, appearance, and functioning of his or her body and its parts Body mass index (BMI) | مؤشر كتلة اجلسم
indicates whether weight is appropriate for height
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Body substance isolation (BSI) | احتياطات عزل العدوى
generic infection control precautions for all clients except those with diseases transmitted through the air Body temperature | حرارة اجلسم
the balance between the heat produced by the body and the heat lost from the body Bowel incontinence | التغوط الالإرادي
loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter ْ ُب Bradycardia | (ضرْب َ ٍة في ال َدقيقَ ة َ 60 ْط ُء القَ لْب (أَقَلُ ِمن
abnormally slow pulse rate, less than 60 beats per minute Bradypnea | س ٌ ُّبطء ال َت َنف
abnormally slow respiratory rate, usually less than 10 respirations per minute Brand name | اسم الدواء بالعالمة التجارية
the name given to a drug by the drug’s manufacturer Breach of duty | خرق الواجب
Carrier | حامل املرض
a person or animal that harbors a specific infectious agent and serves as a potential source of infection, yet does not manifest any clinical signs of disease Case manager | مدير حالة
a nurse who works with the multidisciplinary health care team to measure the effectiveness of the case management plan and monitor outcomes Catabolism | عملية الهدم
a process in which complex substances are broken down into simpler substances (e.g., breakdown of tissue) Cathartics | عالج مسهل
drugs that induce defecation Cations | (الكاتيونات (األيونات املوجبة
ions that carry a positive charge; includes sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+) Causation | السببية-العالقة بني السبب واملسبب
a standard of care that is expected in the specific situation but that the nurse did not observe; this is the failure to act as a reasonable, prudent nurse under the circumstances
a fact that must be proven that the harm occurred as a direct result of the nurse’s failure to follow the standard of care and the nurse could have (or should have) known that failure to follow the standard of care could result in such harm
Buccal | داخل اخلد
Cell-mediated defenses | املناعة اخللوية
pertaining to the cheek Buffers | دوارئ
prevent excessive changes in pH by removing or releasing hydrogen ions َّ Bundle of His | (ي ( ُحز ْ َم ُة هيس ُ الش ّ ي ال ُب َطي ِن ُّ ريط ُاألذَي ِن
the right and left bundle branches of the ventricular conduction pathways Calculi | حصاة الكلى أو املثانة
Callus | نسيج لني
a thickened portion of the skin
see Cellular immunity
Cellular immunity | املناعة اخللوية
also known as cell-mediated defenses, occur through the T-cell system Center of gravity | مركز اجلاذبية
the point at which the mass (weight) of the body is centered Central venous catheter | قثطار وريدي مركزي
catheter that is usually inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium Cerebral death | الدماغي املوت ّ
the amount of energy that nutrients or foods supply to the body
the higher brain center or cerebral cortex is irreversibly destroyed
Calorie (c, cal, kcal) | السعرة احلرارية
Cerumen | مادة شمعية- االذن-صمالخ او صمغ
Caloric value | القيمة احلرارية
a unit of heat energy equivalent to the amount of heat required to raise the temperature of 1 kg of water 1°C Cannula | القنية
a tube with a lumen (channel) that is inserted into a cavity or duct and is often fitted with a trocar during insertion Cardiac output (CO) | ي ُ ِّالن ّ تاج القَ ل ِْب
the wax-like substance secreted by glands in the external ear canal Change agent | عامل تغيير
person (or group) who initiates change or who assists others in making modifications in themselves or in the system Change-of-shift report | عاتقرير بني الورديات
a report given to nurses on the next shift
the amount of blood ejected by the heart with each ventricular contraction
Chart | (ملف (سجل
Caregiver | مقدم الرعاية
Charting | توثيق
a role that has traditionally included those activities that assist the client physically and psychologically Carminative | ِقر ْ ِمز
an agent that promotes the passage of flatus from the colon
a formal, legal document that provides evidence of a client’s care the process of making an entry on a client record Chemical name | االسم الكيميائي للدواء
the name by which a chemist knows a drug; describes the constituents of the drug precisely
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Chemical restraints | آليات ضبط حركة املريض باستخدام االدوية
Closed questions | األسئلة املغلقة
َ تَوْلِ ْي ُد Chemical thermogenesis | احلرَارَة الكيميائي
Closed-wound drainage system | نظام تصريف اجلروح املغلق
medications used to control socially disruptive behavior the stimulation of heat production in the body through increased cellular metabolism caused by increases in thyroxine output Cholesterol | الكوليستيرول
a lipid that does not contain fatty acid but possesses many of the chemical and physical properties of other lipids Chronic illness | مرض مزمن
illness that lasts for an extended period of time, usually greater than 6 months Chronic infection | التهاب مزمن
infection that occurs slowly, over a very long period, and may last months or years Chronic malignant pain | ألم مزمن خبيث
pain associated with advanced, progressive diseases ,such as cancer HIV/AIDS or burn pain, which tend to be treated more aggressively than “nonmalignant pain.” Chronic pain | ألم مزمن
prolonged pain, usually recurring or persisting over 6 months or longer, and interferes with functioning Chyme | الكَيموس
digested products that leave the stomach through the small intestine and then pass through the ileocecal valve Circulating immunity | املناعة املتداولة
see Humoral immunity
Circulating nurse | املمرضة املساعدة في العمليات
assists scrub nurses and surgeons during surgery Civil action | اإلجراءات املدنية
deals with the relationship between individuals in society Civil law | القانون املدني
the body of law that deals with relationships among private individuals; also known as private law Clean voided specimen | عينة البول الروتينية
urine specimen for routine urinalysis Clean | نظيف
free of potentially infectious agents Cleaning bath | حمام املريض بهدف النظافة الشخصية
A type of bath given chiefly for hygiene purposes Client | العميل
restrictive question requiring only a short answer consists of a drain connected to either an electric suction or a portable drainage suction, such as a Hemovac or Jackson-Pratt Clubbing | تعجر األصابع ّ
elevation of the proximal aspect of the nail and softening of the nail bed Coanalgesic | أدوية مصاحبة املسكنات
medication that is not classified as a pain medication; however, it has properties that may reduce pain alone, or in combination with other analgesics; relieve other discomforts; potentiate the effect of pain medication; or reduce the pain medication’s side effects Code Blue | رمز لدعوة فريق االنعاش
emergency announcing cardiac/respiratory arrest and initiating interventions Code of ethics | دليل اخالقبات املهن
a formal statement of a group’s ideals and values; a set of ethical principles shared by members of a group, reflecting their moral judgments and serving as a standard for professional actions Cognitive skills | املهارات املعرفية
intellectual skills that include problem solving, decision making, critical thinking, and creativity Collaborative care plans | خطط الرعاية التعاونية
see Critical pathways
Collaborative interventions | التدخالت التعاونية
actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and physicians Collagen | مادة الكوالجني
a protein found in connective tissue; a whitish protein substance that adds tensile strength to a wound Colonization | املستعمرات اجلرثومية
the presence of organisms in body secretions or excretions in which strains of bacteria become resident flora but do not cause illness Colostomy | َفغْر ُ القَ ولون
an opening into the colon (large bowel) Commode | مرحاض
a portable, chairlike structure used as a toilet
a person who engages the advise or services of another person who is qualified to provide this service
Common law | القانون العام
Client advocate | وكيل العميل
Communicable disease | االمراض السارية
nurses acts to protect the clients, represent thier needs and assist them in exercising their rights. Client record | ملف املريض
the body of principles that evolves from court decisions a disease that can spread from one person to another Communicator | التواصل
nurses identify client problems and then communicate these verbally or in writing to other members of the health team
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Compensation | تعويض
covering up weaknesses by emphasizing a more desirable quality or by overachievement in a more comfortable area Complete blood count (CBC) | ع ّد دموي شامل
specimens of venous blood; includes hemoglobin and hematocrit measurements, erythrocyte (RBC) count, leukocyte (WBC) count, red blood cell indices, and a differential white cell count Complete proteins | بروتني كامل
a protein that contains all of the essential amino acids as well as many nonessential ones Compliance | التزام،إذعان
the extent to which an individual’s behavior coincides with medical or health advice Complicated grief | الحزن المعقد
pathologic grief; exists when coping strategies are maladaptive Compromised host | مضيف معرض لإلصابة بالعدوى
any person at increased risk for an infection
Conduction | نقل االندفاع بواسطة عصب من األعصاب،توصيل
the transfer of heat from one molecule to another in direct contact Consequence-based (teleological) theories | النظرية املعتمدة على النتائج،النظرية الغائِيَّة
the ethics of judging whether an action is moral Constant fever | حمى مستمرة
a state in which the body temperature fluctuates minimally but always remains above normal Constipation | امسا ك
passage of small, dry, hard stool or passage of no stool for an abnormally long time Contact precautions | وسائل منع العدوى باالتصال املباشر مع املصاب
methods used to reduce exposure to infectious agents easily transmitted by direct client contact or by contact with items in the client’s environment Contamination | تلوث
the presence of strains of microorganisms on certain areas of the human body, or on surfaces or areas in the environment Contract | عقد
a written or verbal agreement between two or more people to do or not do some lawful act Contract law | قاتون التعاقد
Convection | (احلمل (احلرارى
the dispersion of heat by air currents Coping | التكيف ّ
dealing with change Coping mechanism | التكيف آليات ّ
an innate or acquired way of responding to a changing environment or specific problem or situation Coping strategy | استراتيجيات التكيّف
see Coping mechanism Core temperature | درجة احلرارة األساسية
the temperature of the deep tissues of the body (e.g., thorax, abdominal cavity); relatively constant at 37°C (98.6°F) Corn | مسمار القدم
a conical, circular, painful, raised area on the toe or foot Coronary arteries | التالشريانات التاجية
a network of vessels known as the coronary circulation Costal (thoracic) breathing | الصدري/التنفس الضلعي
use of the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles Counseling | املشورة
the process of helping a client to recognize and cope with stressful psychologic or social problems, to develop improved interpersonal relationships, and to promote personal growth Creatine kinase (CK) | كرْياتني ِ كيناز ُ ال
enzyme that is released into the blood during a myocardial infarction (MI) Credentialing | اعتماد
the process of determining and maintaining competence in practice; includes licensure, registration, certification, and accreditation Crepitation | خشخشة،طقطقة
(1) a dry, crackling sound like that of crumpled cellophane, produced by air in the subcutaneous tissue or by air moving through fluid in the alveoli of the lungs; (2) a crackling, grating sound produced by bone rubbing against bone Crime | جرمية أو جناية
an act committed in violation of public (criminal) law and punishable by a fine and/or imprisonment Criminal actions | جنائية/أعمال إجرامية
deal with disputes between an individual and the society as a whole
the enforcement of agreements among private individuals or the payment of compensation for failure to fulfill the agreement
Criminal law | القانون اجلنائي
Contractility | انقباضية،لوصيَّة ِ َق
the inherent ability of cardiac muscle fibers to shorten or contract
a set of questions one can apply to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas
Contracture | تقلص العضلة أو الوتر تقلصا دائما
Critical pathways | مقررات متهيدية
permanent shortening of a muscle and subsequent shortening of tendons and ligaments
deals with actions against the safety and welfare of the public Critical analysis | تحليل نقدي
multidisciplinary guidelines for client care based on specific medical diagnoses designed to achieve predetermined outcomes
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Critical thinking | املنطقي التفكير ّ
a cognitive process that includes creativity, problem solving, and decision making Culturally appropriate | املناسب ثقافيا
application of underlying background knowledge that must be possessed to provide a given client with the best possible health care Culturally competent | قادر على فهم وحتليل الواقع الثقافي،كفؤ ثقافيا
Defecation | تغوط،تبرز
expulsion of feces from the rectum and anus Defendant | املدعى عليه
(legal) person against whom a plaintiff files a complaint Dehiscence | انفصال حواف اجلرح عن بعضها
the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate
within the delivered care the nurse understands and attends to the total context of the client’s situation and uses a complex combination of knowledge, attitudes, and skills
Dehydration | تجفاف
Culturally sensitive | ذو شفافية ثقافية
the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome
care that demonstrates basic knowledge of and constructive attitudes toward the health traditions observed among the diverse cultural groups found in the setting Culture | حضارة،ثقافة
a world view and set of traditions used and transmitted from generation to generation by a particular group, includes related attitudes and institutions
insufficient fluid in the body Delegation | تفويض
Demography | علم دراسة السكان
the study of population, including statistics about distribution by age and place of residence, mortality, and morbidity Dental caries | تسوس االسنان
Culture shock | صدمة ثقافية
Dependent functions | الوظائف التابعة
Cumulative effect | التأثير التراكمي لعقار معني
Dependent interventions | التدخالت التابعة
a disorder that occurs in response to transition from one cultural setting to another
with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out
the increasing response to repeated doses of a drug that occurs when the rate of administration exceeds the rate of metabolism or excretion
those activities carried out on the order of a physician, under a physician’s supervision, or according to specified routines
Cyanosis | ازرقاق اجللد
see Therapeutic effect
Desired effect | الفعالية العالجية املرغوبة لعقار ما
bluish discoloration of the skin and mucous membranes caused by reduced oxygen in the blood
Detoxification | ازالة السموم
Damages | عطل وضرر
Detrusor muscle | صة َ ِالعضلة النَّاف
if malpractice caused the injury, the nurse is held liable for damages that may be compensated Dandruff | قشرة الرأس
A dry or greasy, scaly material shed from the scalp Data | البيانات
Database | قاعدة البيانات
all information about a client, includes nursing health history and physical assessment, physician’s history, physical examination, and laboratory and diagnostic test results Decision making | صناعة القرار
the process of establishing criteria by which alternative courses of action are developed and selected Deductive reasoning | املنطق االستنتاجي
making specific observations from a generalization Defamation | تشويه للسمعة،قذف
(legal) a communication that is false, or made with careless disregard for the truth, and results in injury to the reputation of another
the smooth muscle layers of the bladder Diagnosis | التشخيص
a statement or conclusion concerning the nature of some phenomenon Diagnostic labels | التسميات التشخيصية
title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association (NANDA) standardized taxonomy of terms Diaphragmatic (abdominal) breathing | البطني/التنفس اجلابي
contraction and relaxation of the diaphragm, observed by the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and downward movement Diarrhea | اسهال
defecation of liquid feces and increased frequency of defecation Diastole | انبساط عضلة القلب
the period during which the ventricles relax Diastolic pressure | ي ُ الضغ َّ ّ ِْط االن ِْبساط
the pressure of the blood against the arterial walls when the ventricles of the heart are at rest
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Diffusion | االنتشار
the mixing of molecules or ions of two or more substances as a result of random motion Directive interview | مقابلة توجيهية
a highly structured interview that uses closed questions to elicit specific information Dirty | متسخ
denotes the likely presence of microorganisms, some of which may be capable of causing infection Disaccharides | سكريات ثنائية
sugars that are composed of double molecules Discrimination | متييز
the differential treatment of individuals or groups Discussion | مناقشة
an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem Disease | مرض
an alteration in body function resulting in a reduction of capacities or shortening of the normal life span Disinfectants | مطهر
agents that destroy pathogens other than spores Distribution | توزيع
the transportation of a drug from its site of absorption to its site of action Diuresis | غزارة البول
the production of large amounts of urine by the kidneys without an increased fluid intake Diuretics | دواء مدر للبول
agents that increase urine secretion Diurnal | نَهارِ ّي
Diversity | تنوع
the fact or state of being different Do not resuscitate (DNR) | أمر بعدم اإلنعاش
a physician’s order that specifies no effort be made to resuscitate the client with terminal or irreversible illness in the event of a respiratory or cardiac arrest
Drug abuse | االدمان على دواء معني
excessive intake of a substance either continually or periodically Drug allergy | فرط احلساسية
an immunologic reaction to a drug Drug dependence | االعتماد الفسيولوجي على دواء معني
inability to keep the intake of a drug or substance under control Drug habituation | التعود النفسي على دواء معني
a mild form of psychologic dependence on a drug Drug half-life | الزمن التقديري لتصريف دواء معني
the time required for the elimination process to reduce the concentration of a drug to one-half what it was at initial administration Drug interaction | تداخل االدوية
the beneficial or harmful interaction of one drug with another drug Drug tolerance | القدرة على حتمل دواء معني
a condition in which successive increases in the dosage of a drug are required to maintain a given therapeutic effect Drug toxicity | التسمم من دواء معني
the quality of a drug that exerts a deleterious effect on an organism or tissue Dullness | أصم ّية ّ
a thudlike sound produced during percussion by dense tissue of body organs such as the liver, spleen, or heart Duration | م ّدة الصوت
the length of time that a sound is heard Duty | واجب،مهمة
the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care Dysphagia | عسر البلع
difficulty or inability to swallow Dyspnea | ضيق التنفس
difficult or labored breathing Dysrhythmia | َخلَلُ النَّظْ م
a pulse with an irregular rhythm Dysuria | سر ُ التَّ َب ُّول ْ ُع
painful or difficult voiding
Documenting | التوثيق
Edema | وذمة
Dorsal position | (االستِلْقاء ْ ض ِعيَّ ُة ْ َض ِعيَّ ُة الظَّ ْهرَيَّة (و ْ الو َ
Ego defense mechanisms | آليات الدفاغ عن األنا
see Charting or Recording a back-lying position without a pillow
the presence of excess interstitial fluid in the body
Dorsal recumbent position | االستِلْقاء الظَّ ْه ِر ّي ْ ض ِعيَّ ُة ْ َو
a back-lying position with the head and shoulders slightly elevated
(Freud) mental mechanisms that develop as the personality attempts to defend itself, establish compromises among conflicting impulses, and allay inner tensions
Droplet nuclei | نواة وسيلة التعرض للعدوى
Elasticity of the arterial wall | مرانة اجلدران الشريانية
residue of evaporated droplets that remains in the air for long periods of time
expansibility or stretching of the vessels
Droplet precautions | وسائل منع العدوى بالتعرض
performed when surgical intervention is the preferred treatment for a condition that is not imminently life threatening or to improve the client’s life
methods used to reduce exposure to infectious agents transmitted by particle droplets larger than 5 microns
Elective surgery | جراحة اختيارية
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Electrolytes | كهارل
chemical substances that develop an electric charge and are able to conduct an electric current when placed in water; ions Elimination half-life | الزمن التقديري لتصريف دواء
Essential amino acids | حمض اميني اساسي
amino acids that cannot be manufactured in the body and must be supplied as part of the protein ingested in the diet Ethics | آداب مهنية
see Drug half-life
the rules or principles that govern right conduct
Embolus | جلطة دموية اوهوائية او دهنية
Ethnopharmacology | علم تاثير االعراق على االدوية
a blood clot (or a substance such as air) that has moved from its place of origin and is causing obstruction to circulation elsewhere (plural: emboli) Emergency surgery | جراحة عاجلة
surgery that is performed immediately to preserve function or the life of the client َّ Endocardium | الشغاف الداخلي
a layer of the heart wall lining the inside of the heart’s chambers and great vessels Endogenous | ذاتي
developing from within Enema | حقنة شرجية
a solution introduced into the rectum and sigmoid colon to remove feces and/or flatus Enteral | من خالل اجلهاز الهضمي-معوي
the study of the effect of ethnicity on responses to prescribed medicines Etiology | علم أسباب األمراض
the causal relationship between a problem and its related or risk factors Eupnea | تنفس طبيعي
normal, quiet breathing Euthanasia | االقتل الرحيم
defined as intentionally speeding up a client’s death Evaluating | تقويم
a planned ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes Evaluation statement | بيان التقومي
through the gastrointestinal system
a statement that consists of two parts: a conclusion and supporting data
Enuresis | سلس البول
Evidence-based practice (EBP) | املمارسة املبنية على األدلة العلمية
bed-wetting; involuntary passing of urine in children after bladder control is achieved Enzymes | انزمي
biologic catalysts that speed up chemical reactions Epicardium | النِّخاب
the visceral pericardium adhering to the surface of the heart, forming the heart’s outermost layer Epidural | احلقن في منطقة فوق اجلافية
commonly used route for parenteral administration into the epidural space (the area inside the spinal column but outside the dura mater) Epithelialization | االندمال بتشكل النسيج الظهاري
epithelial cells’ migration across the new tissue to form a barrier between the wound and the environment in woundhealing process Equianalgesia | مساو التسكني
equal analgesia; used when referring to the doses of various opioid analgesics that provide approximately the same pain relief
the use of some form of substantiation in making clinical decisions Evisceration | هجرة االعضاء من خالل جرح معني
extrusion of the internal organs Exacerbation | تفاقم حدة املرض
the period during a chronic illness when symptoms reappear after remission Excretion | تصريف
elimination of a waste product produced by the body cells from the body Exercise | مترين
a type of physical activity; a planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness Exhalation | زفير
(expiration) the movement of gases from the lungs to the atmosphere Exogenous | تطور خارجي
developing from outside sources
Erythema | (احمرار اجللد (حمامي
Expectorate | تيطرد البلغم
Erythrocytes | كريات الدم احلمراء
Expert witness | شاهد خبير
a redness associated with a variety of skin rashes red blood cells, or RBCs Eschar | ندبة
thick necrotic tissue produced by burning, by a corrosive application, or by death of tissue associated with loss of vascular supply, bacterial invasion, and putrefaction
to cough and spit up mucus or other materials one who has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within that area of expertise Expiration | موت
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Express consent | يفيد القبول،يفيد املوافقة
Fifth vital sign | العالمة احليوية اخلامسة
Extracellular fluid (ECF) | السائل خارج اخللوي
Filtration | الرشح
an oral or written agreement
fluid found outside the body cells Exudate | خراج
process whereby fluid and solutes move together across a membrane from one compartment to another
material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
Fissures | شق
Faith | إيمان
Flaccid | رخو،مترهل
an active “mode of being-in-relation” to another or others in which we invest commitment, belief, love, and hope False imprisonment | احلجز بقصد الوقاية
the unlawful restraint or detention of another person against his or her wishes Fats | دهون
deep grooves that occur as a result of dryness and cracking of the skin weak or lax
Flatness | أصمية حتت ّ
an extremely dull sound produced, during percussion, by very dense tissue, such as muscle or bone Flatulence | امتالء البطن بالغازات
lipids that are solid at room temperature
the presence of excessive amounts of gas in the stomach or intestines
Fat-soluble vitamins | الفيتامينات الذائبة بالدهون
Flatus | ريح،غاز البطن
A, D, E, and K vitamins that the body can store Fatty acids | االحماض الدهنية
the basic structural units of most lipids made up of carbon chains and hydrogen Fear | اخلوف
an emotional response to an actual, present danger
gas or air normally present in the stomach or intestines Flow sheet | مخطط بياني
a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications; often charted in graph form Fluid volume deficit (fvd) | نقص حجم الدم
Febrile | متعلق باحلمى،ُح َّم ِو ّي
(hypovolemia) loss of both water and electrolytes in similar proportions from the extracellular fluid
Fecal impaction | البراز ِ ُ ان ِْحشار
Fluid volume excess (FVE) | فرط حجم الدم
a mass or collection of hardened, putty-like feces in the folds of the rectum
(hypervolemia) retention of both water and sodium in similar proportions to normal extracellular fluid (ECF)
Fecal incontinence | السلس الغائطى
Focus charting | االتوثيق املركّز
pertaining to a fever; feverish
see Bowel incontinence Feces | براز،غائط
(stool) body wastes and undigested food eliminated from the bowel Felony | جنحة
a crime of a serious nature, such as murder, punishable by a term in prison Fever | حمى
elevated body temperature Fever spike | حمي ِ بروز
a temperature that rises to fever level rapidly following a normal temperature and then returns to normal within a few hours Fibrin | الليفني
an insoluble protein formed from fibrinogen during the clotting of blood Fibroblasts | االنسجة الليفية
a type of cell that synthesizes the extracellular matrix and collagen; it plays a critical role in wound healing Fidelity | اخالص
a moral principle that obligates the individual to be faithful to agreements and responsibilities one has undertaken
a method of charting that uses key words or foci to describe what is happening to the client Folk medicine | الطب الشعبي
beliefs and practices relating to illness prevention and healing that derive from cultural traditions rather than from modern medicine’s scientific base Foot drop | ت َ َدلِّي القَ َدم
plantar flexion contracture Foreseeability | النظرة املستقبلية،االستشراف
a link that must exist between the nurse’s act and the injury suffered Formal nursing care plan | خطة الرعاية التمريضية الرسمية
a written or computerized guide that organizes information about the client’s care Fowler’s position | شبه جلوس:وضعية فولر
a bed-sitting position with the head of the bed raised to 45 degrees Friction | احتكاك
rubbing; the force that opposes motion Functional strength | مقدرة وظيفية
ability of the body to perform work
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Fungi | فطريات
infection-causing microorganisms that include yeasts and molds Gait | مشية
the way a person walks Gastrostomy | َفغْر ُ امل َِع َدة
an opening through the abdominal wall into the stomach Gastrostomy tube | انبوب من خالل فتحة املعدة
a tube that is surgically placed directly into the client’s stomach and provides a route for administering nutrition and medications
Health | الصحة
“a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity” (WHO, 2006, p1), or “a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent possible” (ANA, 1980, p. 5). Health care proxy | وثيقة متكن شخصا ً من أخذ القرار مبا: وثيقة التفويض يتعلق بالرعاية الصحية عن شخص آخر
diameter of a shaft
a legal statement that appoints a proxy to make medical decisions for the client in the event the client is unable to do so
General anesthesia | تخدير عام
Health care system | الصحية نظام الرعاية ّ
Generic name | االسم العام للدواء ويصف تركيبه الكيميائي
Health promotion | تعزيز الصحة
Glomerulus | كُ َبيبات:]كُ َبي َبة [ج
Heart failure | هبوط القلب
Gauge | مقياس االبرة-عيار
the induced loss of all sensation and consciousness a drug name not protected by trademark and usually describing the chemical structure of the drug a tuft of capillaries in the kidney surrounded by Bowman’s capsule Glycerides | مركب دهني-اجلليسيرايد
the most common form of lipids consisting of a glycerol molecule with up to three fatty acids
the totality of services offered by all health disciplines any activity undertaken for the purpose of achieving a higher level of health and well-being a condition that develops if the heart cannot keep up with the body’s need for oxygen and nutrients to the tissues; usually occurs because of myocardial infarction, but it may also result from chronic overwork of the heart Heart-lung death | موت القلب والرئة
the process of glycogen formation
the traditional clinical signs of death: cessation of the apical pulse, respirations, and blood pressure
Goals/desired outcomes | النتائج املرجوة/ األهداف
Heat balance | اتزان حراري
Glycogenesis | ()عملية تكوين اجلليكوجني
a part of a care plan that describes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions Governance | )احلوكمة (املرجعية
the establishment and maintenance of social, political, and economic arrangements by which practitioners control their practice, self-discipline, working conditions, and professional affairs
the state a person is in when the amount of heat produced by the body exactly equals the amount of heat lost Heat exhaustion | انهاك حراري
condition that is the result of excessive heat and dehydration َ ضرْب َ ُة Heat stroke | احلرارَة َ
life-threatening condition with body temperature greater than 106°F
Granulation tissue | النسيج احلبيبي
Hematocrit | مك َداس الدَّم
Grief | احلزن
Hemoglobin (Hg) | خضاب الدم
Habit training | تعويد
Hemolytic transfusion reaction | تفاعل نقل الدم االنحاللي
Harm | أذى أو ضرر
Hemoptysis | نفث الدم
young connective tissue with new capillaries formed in the wound healing process emotional suffering often caused by bereavement attempts to keep clients dry by having them void at regular intervals; also referred to as timed voiding or scheduled toileting (Injury) the client or plaintiff must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client; the plaintiff will be asked to document physical injury, medical costs, loss of wages, “pain and suffering,” and any other damages Haustra | يبات القَ وْلُون ُ ق ُ َب
pouches that form in the large intestine when the longitudinal muscles are shorter than the colon
the proportion of red blood cells (erythrocytes) to the total blood volume the red pigment in red blood cells that carries oxygen destruction of red blood cells as a result of transfusion of incompatible blood the presence of blood in the sputum Hemorrhage | نزيف
excessive loss of blood from the vascular system Hemorrhoids | بَواسير
distended veins in the rectum Hemostasis | وقف النزيف-االرقاء
cessation of bleeding
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Hemothorax | صدر م ّدمي
Hypercalcemia | فرط الكالسيوم في الدم
Heritage | تراث
Hypercapnia | فرط ثنائي أكسيد الكربون في الدم
a collection of blood in the pleural cavity cultural values, beliefs, traditions and practices passed down from previous generations Hernia | فتق
a protrusion (such as of the intestine through the inguinal wall or canal) High Fowler’s position | شبه جلوس مع رفع الرأس واجلذع زاوية:وضعية فولر درجة90-60 مقدارها
a bed-sitting position in which the head of the bed is elevated 90 degrees Higher brain death | املوت املراكز العليا من املخ
see Cerebral death
Hirsutism | ظهور الشعر في االماكن غير املرغوبة بكثرة كالوجه-الشعرانية
abnormal hairiness, particularly in women Holism | الشمولية
an excess of calcium in the blood plasma a condition in which carbon dioxide accumulates in the blood Hypercarbia | فرط ثنائي أكسيد الكربون في الدم
Hyperchloremia | فرط الكلورفي الدم
an excess of chloride in the blood plasma Hyperinflation | فرط االنتفاخ
giving the client breaths that are 1 to 1.5 times the tidal volume through the ventilator circuit or via a manual resuscitation bag Hyperkalemia | فرط البوتاسيوم في الدم
an excess of potassium in the blood plasma Hypermagnesemia | فرط املغنيسيوم في الدم
an excess of magnesium in the blood plasma
all living organisms are seen as interacting, unified wholes that are more than the sums of their parts
Hypernatremia | فرط الصوديوم في الدم
Holistic health belief | املعتقد الطبي الشمولي
Hyperoxygenation | فرط األكسجة
holds that the forces of nature must be maintained in balance or harmony Holy day | األيام املقدسة
a day set aside for special religious observance Homeostasis | االتزان البدني، فسيولوجيا االستتباب
an excess of sodium in the blood plasma done with a manual resuscitation bag or through a ventilator; increases oxygen flow (usually to 100%) before suctioning and between suction attempts Hyperphosphatemia | فرط الفوسفات في الدم
an excess of phosphate in the blood plasma
the tendency of the body to maintain a state of balance or equilibrium while continually changing; a mechanism in which deviations from normal are sensed and counteracted
Hyperpyrexia | الس ُخونَة ُّ فَر ْ ُط
Hope | األمل
an abnormal booming sound produced during percussion of the lungs
a multidimensional concept that includes perceiving realistic expectations and goals, having motivation to achieve goals, anticipating outcomes, establishing trust and interpersonal relationships, relying on internal and external resources, having determination to endure, and being oriented to the future Hospice | الرعاية في مرحلة االحتضار
the delivery of care for terminally ill clients either in health care facilities or in the client’s home Hospice nursing | التمريض في مرحلة االحتضار
Hyperresonance | مفرط الرنني
Hypersomnia | فَر ْ ُط النَّوم
Hypertension | ْط ِ الضغ َّ فَر ْ ُط
an abnormally high blood pressure; over 140 mm Hg systolic and/or 90 mm Hg diastolic َ فَر ْ ُط Hyperthermia | احلرارَة
an extremely high body temperature (e.g., 41°C [105.8°F])
care frequently given to terminally ill clients in their home; often considered a subspecialty of public health nursing
Hypertonic | مفرط التوتر
Hub | محور احملقنة
Hypertrophy | تضخم فى منو عضو
Humoral immunity | احلصانة او املناعة اخللطية
Hypertrophic scar | ندبة متضخمة
Hygiene | االنظافة
Hyperventilation | فَر ْ ُط التَّ ْه ِويَة
Humidifiers | جهاز مرطّ ب
Hypervolemia | فرط حجم الدم
the part of a needle that fits onto a syringe antibody-mediated defense; resides ultimately in the B lymphocytes and is mediated by the antibodies produced by B cells the science of health and its maintenance devices that add water vapor to inspired air
solutions that have a higher osmolality than body fluids enlargement of a muscle or organ occurs when the body overproduces collagen, which causes the scar to be raised above the surrounding skin; yh scars take the form of a red raised lump on the skin very deep, rapid respirations increased blood volume
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Hypocalcemia | نقص الكالسيوم في الدم
Illicit drugs | ادوية غير مشروعة
Hypochloremia | نقص الكلورفي الدم
Illness | توعك-داء-مرض
deficiency of calcium in the blood plasma deficiency of chloride in the blood plasma Hypodermic | حتت اجللد
under the skin
Hypodermic syringe | محقنة معدة للالستخدام حتت اجللد
a type of syringe that comes in 2-, 2.5-, and 3-mL sizes; the syringe usually has two scales marked on it: the minim and the milliliter Hypokalemia | نقص البوتاسيوم في الدم
deficiency of potassium in the blood plasma Hypomagnesemia | نقص املغنيسيوم في الدم
deficiency of magnesium in the blood plasma Hyponatremia | نقص الصوديوم في الدم
deficiency of sodium in the blood plasma Hypophosphatemia | نقص الفوسفات في الدم
deficiency of phosphate in the blood plasma Hypotension | ْط ِ الضغ َّ هبوط/ص ُ ْنَق
an abnormally low blood pressure; less than 100 mm Hg systolic in an adult Hypothermia | هبوط احلرارة/ص ُ ْنَق
a core body temperature below the lower limit of normal Hypotonic | ناقص التوتر
solutions that have a lower osmolality than body fluids Hypoventilation | نقص التهوية
very shallow respirations
Hypovolemia | نقص حجم الدم
an abnormal reduction in blood volume Hypoxemia | نقص التأكسج في الدم
drugs that are sold illegally; street drugs a highly personal state in which the person feels unhealthy or ill, may or may not be related to disease Illness behavior | السلوك اثناء املرض
the course of action a person takes to define the state of his or her health and pursue a remedy Immune defenses | الدفاعات املناعية
see Specific defenses Immunity | املناعة
a specific resistance of the body to infection; it may be natural, or resistance may develop after exposure to a disease agent Immunoglobulins | مناعي اومتعلق باملناعة
Impaired nurse | اإلدمان:)املمرض غريب األطوار(من لديه مشكلة مثال
a nurse whose practice has deteriorated because of chemical abuse Implied consent | موافقة ضمنية
consent that is assumed in an emergency when consent cannot be obtained from the client or a relative Incentive spirometers | مقياس الهواء احلافز
devices that measure the flow of air inhaled through the mouthpiece Incomplete proteins | بروتني غير مكتمل
protein that lacks one or more essential amino acids; usually derived from vegetables Independent functions | الوظائف املستقلة
areas of health care unique to nursing, separate and distinct from medical management Independent interventions | التدخالت املستقلة
reduced oxygen in the blood
activities that the nurse is licensed to initiate as a result of the nurse’s own knowledge and skills
Hypoxia | نقص التأكسج في األنسجة
Individualized care plan | خطة الرعاية الفردية
insufficient oxygen anywhere in the body Iatrogenic disease | مرض عالجي املنشأ
disease caused unintentionally by medical therapy Iatrogenic infections | التهاب عالجي املنشا
a plan tailored to meet the unique needs of a specific client— needs that are not addressed by the standardized plan Inductive reasoning | استنتاج استقرائي
making generalizations from specific data
infections that are the direct result of diagnostic or therapeutic procedures
Infection | عدوى
Ideal body weight (IBW) | وزن اجلسم املثالي
Inferences | االستدالالت
the optimal weight recommended for optimal health Idiosyncratic effect | تأثير متييزي غير متوقع لدواء معني-تأثير متصل بالتعامل
the disease process produced by microorganisms interpretations or conclusions made based on cues or observed data
a different, unexpected, or individual effect from the normal one usually expected from a medication; the occurrence of unpredictable and unexplainable symptoms
Infiltration | رتشاح
Ileal conduit | ي ْ َم ّ جرَى لَفائِ ِف
Inflammation | استجابة ذات طابع التهابي
Ileostomy | ي ّ َفغْر ُ اللَّفائِ ِف
Informal nursing care plan | خطة العناية التمريضية غير الرسمية
channel created when a segment of the ileum is removed and the intestinal ends reattached an opening into the ileum (small bowel)
a swelling beneath the skin caused by an intravenous needle dislodged from the vein local and nonspecific defensive tissue response to injury or destruction of cells a strategy for action that exists in the nurse’s mind
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Informed consent | يفيد املوافقة املبنية على املعرفة
a client’s agreement to accept a course of treatment or a procedure after receiving complete information, including the risks of treatment and facts relating to it, from the physician Ingestion | تناول الطعام
the act of taking in food or medication Ingrown toenail | الظفر املنغرز
the growing inward of the nail into the soft tissues around it, most often results from improper nail trimming Inhalation | شهيق
(inspiration) the act of breathing in; the intake of air or other substances into the lungs Inhibiting effect | تأثير مثبط لدواء معني
the decreased effect of one or both drugs Injury | أذى أو اصابة
Insensible heat loss | حسوس ْ نقص حرارة غَ ْير ُ ُم
Intradermal | طبقة االدمة من اجللد
under the epidermis (into the dermis) Intradermal (ID) injection | احلقن في طبقة االدمة من اجللد
the administration of a drug into the dermal layer of the skin just beneath the epidermis Intramuscular | في العضل
into the muscle
Intramuscular (IM) injection | احلقن العضلي
injections into muscle tissue that are absorbed more quickly than subcutaneous injections because of the greater blood supply to the body muscles Intraoperative phase | اثناء العملية اجلراحية-مرحلة التداخل اجلراحي
begins when the client is transferred to the operating table and ends when the client is admitted to the postanesthesia care unit intraspinal | احلقن في منطقة احلبل الشوكي
into the spinal cord
heat loss that occurs from evaporation (vaporization) of moisture from the respiratory tract, mucosa of the mouth, and the skin
intrathecal | احلقن في منطقة القراب
Insensible water loss | نقص املاء غير احملسوس
Intravascular fluid | السائل داخل الوريد
continuous and unnoticed water loss In-service education | التعليم الداخلي
education that is designed to upgrade the knowledge or skills of employees Insomnia | أَرَق
inability to obtain a sufficient quality or quantity of sleep Inspection | (التأمل (التفتيش
the visual examination, that is, assessment by using the sense of sight
see Intraspinal plasma
Intravenous | احلقن الوريدي
within a vein
Invasion of privacy | انتهاك اخلصوصية
a direct wrong of a personal nature, it injures the feelings of the person and does not take into account the effect of revealed information on the standing of the person in the community Ions | األيونات
atoms or group of atoms that carry a positive or negative electric charge; electrolytes
Insulin syringe | محقنة خاصة باعطاء االنسولني
Irrigation (lavage) | ري اجلروح بهدف تنظيفها
Inspiration | َشهيق
similar to a hypodermic syringe, but the scale is specially designed for insulin: a 100-unit calibrated scale intended for use with U-100 insulin
a flushing or washing-out of a body cavity, organ, or wound with a specified solution that may or may not be medicated Ischemia | اسكيميا-نقص التروية الدموية
the loudness or softness of a sound, amplitude
deficiency of blood supply caused by obstruction of circulation to the body part
Intermittent fever | ُح َّمى ُم َتقَ ِّط َعة
Islamic law (Sharia) | القانون االسالمي
Intensity | ش ّدة الصوت
a body temperature that alternates at regular intervals between periods of fever and periods of normal or subnormal temperatures Interpersonal skills | مهارات التواصل
all verbal and nonverbal activities people use when communicating directly with one another interstitial fluid | (السائل النسيجي (السائل اخلاللي
fluid that surrounds the cells, includes lymph
law that is based on the Holy Qur’an and Sunna Isokinetic (resistive) exercise | مترينات املقاومة
muscle contraction or tension against resistance Isolation | عزل
practices that prevent communicable disease
Isometric (static or setting) exercise | التمرينات الثابتة
a planned communication; a conversation with a purpose
tensing of a muscle against an immovable outer resistance that does not change muscle length or produce joint motion
Intracellular fluid (ICF) | السائل داخل اخللوي
Isotonic | متساوي التوتر
Interview | مقابلة
fluid found within the body cells, also called cellular fluid
solutions that have the same osmolality as body fluids
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Isotonic (dynamic) exercise | مترينات متساوية التوتر
exercise in which muscle tension is constant and the muscle shortens to produce muscle contraction and active movement Jaundice | اليرقان
Line of gravity | خط اجلاذبية
an imaginary vertical line running through the center of gravity Lipids | دهون
a yellowish color of the sclera, mucous membranes, and/or skin
organic substances that are greasy and insoluble in water but soluble in alcohol or ether
Jejunostomy | الصائِم َّ ُ َفغْر
Lipoproteins | دهنيات قابلة للذوبان
Justice | عدالة
Litigation | يقاضى،يرفع دعوى أمام القضاء
an opening through the abdominal wall into the jejunum fairness
Keloid | من انواع الندب-جدرة
a hypertrophic scar containing an abnormal amount of collagen Korotkoff’s sounds | (ا ْختِبار ُ كوروتكوف (ألم الدم الشريانية
a series of five sounds produced by blood within the artery with each ventricular contraction Kussmaul’s breathing | كوسماوُل س ْ ٌ ُّت َ َنف
hyperventilation that accompanies metabolic acidosis in which the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing Large calorie (Calorie, kilocalorie [kcal]) | قياس-كيلو كالوري السعرات احلرارية
Lateral position | الوضعية اجلانبية
a side-lying position Law | قانون
a rule made by humans that regulates social conduct in a formally prescribed and binding manner Laxatives | ملني لألمعاء،مسهل لطيف لألمعاء
medications that stimulate bowel activity and assist fecal elimination Leader | القائد
a person who influences others to work together to accomplish a specific goal Leukocytosis | زيادة عدد كريات الدم البيضاء
an increase in the number of white blood cells Liability | مسؤولية قانونية
the quality or state of being legally responsible for one’s obligations and action and to make financial restitution for wrongful acts Libel | قذف،تشهير
defamation by means of print, writing, or pictures License | ترخيص رسمي للعمل،إذن
a legal permit granted to individuals to engage in the practice of a profession and to use a particular title Licensed practical nurse (LPN) | مساعد متريض مرخص
a nurse who practices under the supervision of a registered nurse, providing basic direct technical care to clients Lifestyle | منط احلياة
the values and behaviors adopted by a person in daily life
soluble compounds made up of various lipids the action of a lawsuit Living will | وصية
a document that states medical treatments(s) the client chooses to omit or refuse in the event that the client is unable to make these decisions Livor mortis | الزرقة الر ّ ّم ّية
discoloration of the skin caused by breakdown of the red blood cells; occurs after blood circulation has ceased; appears in the dependent areas of the body Local anesthesia | تخدير موضعي
an anesthetic agent used for minor surgical procedures that is injected into a specific area Local infection | التهاب او عدوى موضعية
an infection that is limited to the specific part of the body where the microorganisms remain Logrolling | دحرجة األخشاب
a technique used to turn a client whose body must at all times be kept in straight alignment (like a log) Lordosis | قَعس،انحناء العمود الفقرى إلى أمام
an exaggerated concavity in the lumbar region of the vertebral column Loss | (فقدان (خسارة
an actual or potential situation in which a valued ability, object, or person is inaccessible or changed so that it is perceived as no longer available Low Fowler’s position شبه جلوس مع رفع الرأس واجلذع زاوية:وضعية فولر درجة45-15 مقدارها
a bed-sitting position in which the head of the bed is elevated between 15 and 45 degrees, with or without knee flexion Lung compliance | امتثال الرئة
expansibility of the lung Lung recoil | ارتداد الرئة
the tendency of lungs to collapse away from the chest wall Macrominerals | امالح معدنية بكمية كبيرة
any of the minerals that people require daily in amounts over 100 mg Macronutrients | مواد غذائية بكميات كبيرة
refers to carbohydrates, fats, and protein because they are needed in large amounts (e.g., hundreds of grams) to provide energy
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Magico-religious health belief | ،املعتقد الصحي ذو الطبيعة الدينية االعتقاد باملعجزات
a belief system in which people attribute the fate of the world and those in it to the actions of God, the gods, or other supernatural forces for good or evil Major surgery | عملية جراحية كبرى
surgery that involves a high degree of risk for a variety of reasons; it may be complicated or prolonged; large losses of blood may occur; vital organs may be involved; postoperative complications may occur Malnutrition | سوء التغذية
a disorder of nutrition; insufficient nourishment of the body cells Malpractice | اإلهمال املهني
the negligent acts of persons engaged in professions or occupations in which highly technical or professional skills are employed Manager | املدير
ْاالستِق Metabolism | الب؛األيض َ ْ
the sum of all physical and chemical processes by which a living substance is formed and maintained and by which energy is made available for use by the organism Metabolites | نواجت عمليات االيض
end products or enzymes
Metered-dose inhaler (MDI) | جهاز استنشاق االدوية بجرعات مقننة
a handheld nebulizer, which is a pressurized container of medication that can be used by the client to release the medication through a mouthpiece Microminerals | امالح معدنية او فيتامينات بكميات قليلة
a vitamin or mineral
Micronutrients | مواد غذائية بكميات قليلة
vitamins and minerals that are needed in small amounts (e.g., milligrams or micrograms) to metabolize energy-providing nutrients
one who is appointed to a position in an organization that gives the power to guide and direct the work of others
Micturition | ت َ َب ُّول
Mandated reporters | املكلفني باالبالغ
Mid-arm circumference (MAC) | مقياس محيط منتصف الذراع
a role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities
a measure of fat, muscle, and skeleton
Manubrium | قبضة القص
calculated by using reference tables or by using a formula that incorporates the triceps skinfold and the MAC
the handle-like superior part of the sternum that joins with the clavicles
Mid-arm muscle circumference (MAMC) | مقياس محيط عضلة الذراع
Midstream urine specimen | عينة منتصف جريان البول
Meatus | ُالصماخ ِّ
urine specimens for urine culture
Meconium | ي ّ ِْعق
pain intensity rating of 1–3 range in a numeric rating scale.
an opening, passage, or channel the first fecal material passed by the newborn, normally up to 24 hours after birth Medical asepsis | اجراءات احلد من انتشار اجلراثيم ونقلها
Mild pain | ألم خفيف
Minerals | امالح معدنية عضوية وغير عضوية املصدر
a substance found in organic compounds, as inorganic compounds and as free ions
all practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and spread of microorganisms
Minor surgery | عملية جراحية صغرى
Medication | دواء-عالج
Misdemeanor | جرم تطبق عليه عقوبة جزائية،اجلنحة
a substance administered for the diagnosis, cure, treatment, or relief of a symptom or for prevention of disease Medication reconciliation | مقارنة ادوية املريض عند دخوله
comparison of medications client is taking to physician’s admission, transfer, and/or discharge orders Meditation | التأمل
mental exercise that directs the mind to think inwardly by closing the sense organs to external stimulation Metabolic acidosis | حماض استقالبي
a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH falls to less than 7.35 Metabolic alkalosis | قالء استقالبي
a condition characterized by an excess of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH rises to greater than 7.45
surgery that involves little risk, produces few complications, and is often performed in a “day surgery” facility a legal offense usually punishable by a fine or a short-term jail sentence, or both Mobility | حركة
ability to move about freely, easily, and purposefully in the environment Moderate pain | ألم متوسط الشدة
pain intensity of 4–6 in a numeric rating scale Monosaccharides | سكريات احادية
sugars that are composed of single molecules Monounsaturated fatty acids | احماض دهنية احادية غير ذائبة
a fatty acid with one double bond
Moral development | التطور األخالقي
process of learning to tell the difference between right and wrong and of learning what ought and ought not to be done
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Moral rules | القواعد األخالقية
specific prescriptions for actions Morality | اجلانب األخالقي,الفضيلة
Nitrogen balance | توازن نيتروجيني يعبر عن عملية ايض البروتينات
a measure of the degree of protein anabolism and catabolism; net result of intake and loss of nitrogen
a doctrine or system denoting what is right and wrong in conduct, character, or attitude
Nociception | حتفيز استجابة األلم
Mourning | احلداد
Nociceptor | مستقبالت األلم
the process through which grief is eventually resolved or altered Multidisciplinary care plan | خطة الرعاية املتعددة االختصاصات
a standardized plan that outlines the care required for clients with common, predictable—usually medical—conditions Myocardial infarction (MI) | اجللطة القلبية
the physiologic processes related to pain perception a pain receptor
Nocturia | ي ّ بُوالٌ لَي ِل
voiding two or more times at night Nocturnal emissions | ي ُ َسل ّ ول اللَّي ِل ِ َس ال َب
orgasm and emission of semen during sleep
heart attack; cardiac tissue necrosis owing to obstruction of blood flow to the heart
nocturnal enuresis | سلس البول الليلي
Myocardium | العضلة القلبية
nocturnal frequency | كثرة عدد مرات التبول الليلي
a layer of the heart wall; cardiac muscle cells that form the bulk of the heart and contract with each beat
the need for older adults to arise during the night to urinate
Narcolepsy | حالة مرضية تتميز بنوبات نوم عميق قصيرة،تَغْفيق
an uncontrollable desire for sleep or attacks of sleep during the day
an interview using open-ended questions and empathetic responses to build rapport and learn client concerns
Nasoenteric tube | انبوب انفي معوي
nonessential amino acids | حامض اميني غير اساسي
involuntary urination at night
nondirective interview | مقابلة غير توجيهية
a tube inserted through one of the nostrils, down the nasopharynx, and into the alimentary tract
an amino acid that the body can manufacture
Nasogastric tube | انبوب انفي معدي
the duty to do no harm
nonmaleficence | مبدأ أخالقي يتعلق بعدم التسبب باألذى
a tube inserted by way of the nasopharynx and placed into the client’s stomach for the purpose of feeding the client or to remove gastric secretions
nonspecific defenses | غير محدودة-طرق الوقاية الذاتية من العدوى
Nasointestinal tube | انبوب انفي معوي
nonsteroidal anti-inflammatory drugs (NSAIDs) | األدوية املسكنة مضادة لإللتهاب الالستيرويدية
see Nasoenteric tube
Nasopharyngeal suctioning | الشفط األنفي البلعومي
aspiration of secretions from the upper respiratory tract using nasopharyngeal catheter Nasotracheal suctioning | الشفط األنفي الرغامي
aspiration of secretions from the trachea using nasotracheal catheter Negligence | اإلهمال
failure to behave in a reasonable and prudent manner; an unintentional tort Nephrostomy | فَغر (استئصال)ُ الكُل َْية
diversion of urine from a kidney to a stoma Nerve block | إحصار العصب
chemical interruption of a nerve pathway effected by injecting a local anesthetic Neurogenic bladder | املثانة العصبية
interference with the normal mechanisms of urine elimination in which the client does not perceive bladder fullness and is unable to control the urinary sphincters; the result of impaired neurologic function Neuropathic pain | ألم االعتالل العصبي
the result of a disturbance of the peripheral or central nervous system that results in pain that may or may not be associated with an ongoing tissue-damaging process
bodily defenses that protect a person microorganisms, regardless of prior exposure
drugs that relieve pain by acting on the peripheral nerve endings to inhibit the formation of the prostaglandins that tend to sensitize nerves to painful stimuli; have analgesic, antipyretic, and anti-inflammatory effects; include aspirin and ibuprofen nonverbal communication | التواصل الاللفظي
communication other than words, including gestures, posture, and facial expressions nosocomial infections | عدوى املستشفيات
infections associated with the delivery of health care services in a health care facility NPO | ال شىء بالفم
from the Latin nil per os meaning “nothing by mouth nursing diagnosis | التمريضي التشخيص ّ
the nurse’s clinical judgment about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable nursing ethics | أخالقيات مهنة التمريض
ethical issues that occur in nursing practice nursing intervention | التداخالت التمريضية
any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes
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nursing process | العملية التمريضية
a systematic rational method of planning and providing nursing care Nutrients | مادة غذائية عضوية اوغير عضوية املصدر
organic or inorganic substances found in food Nutrition | عملية التغذية
osmolality | أسمواللية
the concentration of solutes in body fluids Osmosis | )تناضح (ارتشاح غشائي
passage of a solvent through a semipermeable membrane from an area of lesser solute concentration to one of greater solute concentration
the sum of all interactions between an organism and the food it consumes
osteoporosis | العظْ م َ ُت َ َخل ُْخل
nutritive value | الغذائية
Ostomy | إحداث فتحة،َفغْر
the nutrient content of a specified amount of food obese (obesity) | السمنة
when body mass index (BMI) is greater than 30 kg/m2 objective data | البيانات املوضوعية
information (data) that is detectable by an observer or can be tested against an accepted standard; can be seen, heard, felt, or smelled official name | االسم الرسمي لدواء معني
the name under which a drug is listed in one of the official publications (e.g., the International Pharmacopeia) Oils | زيوت
lipids that are liquid at room temperature Oliguria | ِقلَّ ُة ال َبول
production of abnormally small amounts of urine by the kidney onset of action | الزمن املستغرق للالستجابة لدواء معني
demineralization of the bone a suffix denoting the formation of an opening or outlet such as an opening on the abdominal wall for the elimination of feces or urine Otic | وصف يتعلق باالذن
referring to the ear
Otoscope | منظار األذن
an instrument used to examine the ears overhydration | فرط سوائل اجلسم
occurs when water is gained in excess of electrolytes, resulting in low serum osmolality and low serum sodium levels, also known as hypo-osmolar imbalance or water intoxication overnutrition | تغذية مفرطة
a caloric intake in excess of daily energy requirements, resulting in storage of energy in the form of adipose tissue
the time after drug administration when the body initially responds to the drug
overweight | فرط الوز-)البدانة
open-ended questions | األسئلة املفتوحة
Packing | حشو اجلرح بغيار معني
questions that specify only the broad topic to be discussed and invite clients to discover and explore their thoughts and feelings about the topic
a BMI of 26–30 kg/m2
filling an open wound or cavity with a material such as gauze Pain | ألم
ophthalmic | وصف يتعلق بالعني
referring to the eye
“whatever the experiencing person says it is, existing whenever he or she says it does” McCaffery & Pasero (1999: 17)
opportunistic pathogen | جراثيم انتهازية
pain threshold | عتبة األلم
a microorganism causing disease only in a susceptible individual
the amount of pain stimulation a person requires before feeling pain
Oral | وصف يتعلق بالفم
pain tolerance | حتمل األلم
referring to the mouth Oropharyngeal suctioning | الشفط الفموي البلعومي
aspiration of secretions from the upper respiratory tract using oropharygeal catheter orthopnea | ضيق التنفس االضجعاعي
ability to breathe only when in an upright position (sitting or standing) orthopneic position | ي ض ِعيَّ ُة ِ ِاالضط ْ ضيق النَّفَ ِس ْ َو ّ جاع ِ
the maximum amount and duration of pain that an individual is willing to endure palliative care | )الرعاية التلطيفية (ا ُمللَطَّ فة
symptom care of clients for whom disease no longer responds to cure-focused treatment Pallor | شحوب
the absence of underlying red tones in the skin; may be most readily seen in the buccal mucosa
sitting position that relieves respiratory difficulty; the client leans over and is supported by an overbed table across the lap
Palpation | جس ّ
orthostatic hypotension | ي ِ ضغ َ ص ُ ْنَق ّ ِ ْط الد َّ ِم ِاالنْتِصاب
Parasites | طفيليات
decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions
the examination of the body using the sense of touch microorganisms that live in or on another from which it obtains nourishment
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parasomnia | ومي ّ َ َخ َطلٌ ن
a cluster or pattern of waking behavior that appears during sleep, such as somnambulism (sleepwalking), sleeptalking, and enuresis (bed-wetting) parenteral | اعطاء االدوية باحلقن
drug administration occurring outside the alimentary tract; injected into the body through some route other than the alimentary canal (e.g., intramuscularly) partial pressure | الضغط اجلزئي
the pressure exerted by each individual gas in a mixture according to its percentage concentration in the mixture partially complete proteins | بروتني شبه كامل
proteins that contain less than the required amount of one or more essential amino acids; cannot alone support continued growth passive immunity | املناعة املكتسبة
a resistance of the body to infection in which the host receives natural or artificial antibodies produced by another source passive euthanasia | قتل من يشكو مرضا ً عضاال ً بطريقة خالية من األلم دون مشاركة أومعرفة من املريض نفسه
percutaneous endoscopic gastrostomy (PEG) | تركيب انبوب تغذية باملعدة عن طريق التنظير
feeding catheter inserted into the stomach through the skin and subcutaneous tissues of the abdomen percutaneous endoscopic jejunostomy (PEJ) | تركيب التنظير انبوب تغذية بالصائم عن طريق
feeding catheter inserted into the jejunum through the skin and subcutaneous tissues of the abdomen Perfusion | تروية
passage of blood constituents through the vessels of the circulatory system pericardium | الشغاف،غالف القلب
double layer of fibroserous membrane of the heart; the parietal, or outermost, pericardium serves to protect the heart and anchor it to surrounding structures periodontal disease | امراض اللثة
disorder of the supporting structures of the teeth perioperative period | مراحل العملية اجلراحية
refers to the three phases of surgery: preoperative, intraoperative, and postoperative
allowing a person to die by withholding or withdrawing measures to maintain life
peripheral pulse | َّالنبض املحُ يطِي
passive ROM exercises | مترينات نطاق احلركة السلبية
peripherally inserted central venous catheter (PICC) | الزرق الطرفي لقثطار وريدي مركزي
another person moves each of a client’s joints through its complete range of movement, maximally stretching all muscle groups within each plane over each joint pathogenicity | االمراضية
the ability to produce disease; a pathogen is a microorganism that causes disease Patient | املريض
a person who is waiting for or undergoing medical treatment and care patient-controlled analgesia (PCA) | محكمة األلم
a pain management technique that allows the client to take an active role in managing pain peak plasma level | تركيز دواء معني في بالزما الدم
the concentration of a drug in the blood plasma that occurs when the elimination rate equals the rate of absorption pediculosis | التقمل
infestation with head lice
a pulse located in the periphery of the body (e.g., foot, wrist)
catheter inserted in the basilic or cephalic vein just above or below the antecubital space Peristalsis | موجات متعاقبة من التقلص
wavelike movements produced by circular and longitudinal muscle fibers of the intestinal walls; the movement propels the intestinal contents onward personal values | القيم الفردية
values internalized from the society or culture in which one lives pH | درجة احلموضة
a measure of the relative alkalinity or acidity of a solution; a measure of the concentration of hydrogen ions phagocytes | خاليا البلعمة
cells that ingest microorganisms, other cells, and foreign particles Phagocytosis | عملية البلعمة
a flexible rubber drain
the process of ingesting microorganisms, other cells, and foreign particles
perceived loss | )الفقدان املدرك (اخلسارة املدركة
pharmacist | صيدالني
percussion | قرع
pharmacodynamics | ديناميكية الدواء في التأثير على فسيولوجية اخللية
penrose drain | انبوب تصريف مطاطي
the loss experienced by a person that cannot be verified by others a method in which the body surface is struck to elicit sounds that can be heard or vibrations that can be felt percutaneous | عن طريق اجللد
through the skin
a person licensed to prepare and dispense drugs and prescriptions the process by which a drug alters cell physiology pharmacogenetics | علم الوراثة الدوائي
the process by which the effect of a drug is influenced by genetic variations such as gender, size, and body composition
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pharmacokinetics | علم احلرائك الدواية
Plateau | احملافظة على استقرار تركيز الدواء في الدم
pharmacology | علم االدوية
pneumothorax | استرواح الصدر
the study of the absorption, distribution, biotransformation, and excretion of drugs the scientific study of the actions of drugs on living animals and humans pharmacy | صيدلية
the art of preparing, compounding, and dispensing drugs; also refers to the place where drugs are prepared and dispensed physical activity | النشاط اجلسدي
bodily movement produced by skeletal muscles that requires energy expenditure and produces progressive health benefits Physical restraints | آليات ضبط حركة املريض بهدف حمايته
any manual method or physical or mechanical device, material, or equipment attached to the client’s body that restrict the client’s movement physiologic dependence | االعتماد الفسيولوجي على دواء معني
a maintained concentration of a drug in the plasma during a series of scheduled doses collection of air in the pleural space point of maximal impulse (PMI) | ص َوى ْ ُنُقْ َط ُة الدَّف َْع ِة الق
the point where the apex of the heart touches the anterior chest wall polydipsia | عُ طاش
polypnea | ت َ َسر ُّ ُع التَّ َنفُ س
abnormally fast respirations polysaccharides | سكريات متعددة
a branched chain of dozens, sometimes hundreds, of glucose molecules; starches polyunsaturated fatty acids | احماض دهنية متعددة غير ذائبة
fatty acid with more than one double bond (or many carbons not bonded to a hydrogen atom)
biochemical changes occurring in the body as a result of excessive use of a drug
Polyuria | بُوال
PIE | التقومي، املدخالت،)اختصار (املشكلة
postmortem examination | تشريح اجلثة،فحص اجلثة بعد الوفاة
an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions piggyback | وصف لوصل السوائل او االدوية الوريدية
postoperative phase | مرحلة ما بعد العملية اجلراحية
begins with the admission of the client to the postanesthesia area and ends when healing is complete
secondary IV setup where the second IV set connects the second container to the tubing of the primary container at the upper port
postural drainage | وضعي نزح ّ
Pitch | طبقة الصوت
potentiating effect | التاثير التنشيطي للدواء
the frequency or number of vibrations heard during auscultation pitting edema | وذمة منطبعة
edema in which firm finger pressure on the skin produces an indentation (pit) that remains for several seconds Placebo | غفل
any form of treatment (e.g., medication) that produces an effect in the client because of its intent rather than its chemical or physical properties
the drainage, by gravity, of secretions from various lung segments the increased effect of one or both drugs prayer | الصالة
human communication with divine and spiritual entities preemptive analgesia | مسكنات تداخلية
the administration of analgesics prior to an invasive or operative procedure in order to treat pain before it occurs Prefilled unit-dose systems | ادوية محضرة مسبقا وجاهزة لالعطاء
infringement of a person claiming infringement of legal rights by one or more persons
injectable medications that are disposable and are available as (a) prefilled syringes ready for use, or (b) prefilled sterile cartridges and needles the require the attachment of a reusable holder (injection system) before use
plantar wart | ثؤلول اخمصي
prejudice | حتيز،حكم مسبق
plaintiff | جانب االدعاء،املدعي
a wart on the sole of the foot Plaque | طبقة عازلة على االسنان
a negative belief or preference that is generalized about a group and that leads to “prejudgment”
an invisible soft film consisting of bacteria, molecules of saliva, and remnants of epithelial cells and leukocytes that adhere to the enamel surface of teeth
Preload | ح ِم ْيل ْ ََّط ِل ْي َع ُة الت
Plasma | بالزما الدم
preoperative phase | مرحلة ما قبل العملية اجلراحية
the fluid portion of the blood in which the blood cells are suspended
the degree to which muscle fibers in the ventricle are stretched at the end of diastole begins when the decision to have surgery is made and ends when the client is transferred to the operating table
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prescription | وصفة طبية
the written direction for the preparation and administration of a drug pressure ulcers | تقرحات الفراش
any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly called decubitus ulcers, bed sores, pressure sores primary intention healing | شفاء اجلروح االولي
protein-calorie malnutrition | سوء التغذية الناجت عن نقص البروتينات والسعرات احلرارية
problem of clients with long-term deficiencies in caloric intake; characteristics include depressed visceral proteins (e.g., albumin), weight loss, and visible muscle and fat wasting psychologic dependence | االعتماد النفسي على دواء معني
a state of emotional reliance on a drug to maintain one’s wellbeing; a feeling of need or craving for a drug
tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring
public law | القانون العام
principles-based (deontological) theories | نظرية الواجب
Pulse | النبض
emphasize individual rights, duties, and obligations priority setting | وضع األولويات
the process of establishing a preferential order for nursing strategies prn order | االمر الطبي باعطاء الدواء عند احلاجة
“as needed order”; permits the nurse to give a medication when, in the nurse’s judgment, the client requires it problem solving | حل املشكالت
obtaining information that clarifies the nature of the problem and suggests possible solutions problem-oriented medical record (POMR) | السجالت الطبية املوجهة حلل املشكلة
refers to the body of law that deals with relationships between individuals and the government and governmental agencies the wave of blood within an artery that is created by contraction of the left ventricle of the heart pulse deficit | ض والقَ لْب ِ ْقيص ُة النَّبْض (الفَ رْقُ ب َ َني ُسرْعَ َتي النَّب َ َ )ن
the difference between the apical pulse and the radial pulse pulse oximeter | ياس التَّأَك ُْسج ((مقياس مستوى األكسجني ِ ُ ْ)مق
a noninvasive device that measures the arterial blood oxygen saturation by means of a sensor attached to the finger pulse pressure | ي ُ الضغ ِ ْْط النَّب َّ ّ ض
the difference between the systolic and the diastolic blood pressure pulse rhythm | التواتر النبضي
the pattern of the beats and intervals between the beats
data about the client are recorded and arranged according to the client’s problems, rather than according to the source of the information
pulse volume | احلجم النبضي
profession | املهنة
pureed diet | وجبة مهروسة
an occupation that requires extensive education or a calling that requires special knowledge, skill, and preparation
a modification of the soft diet; liquid may be added to the food, which is then blended to a semisolid consistency
professional values | القيم املهنية
ُ purkinje fibers | الياف بُور ْ ِكي ِنيي
professionalism | االحتراف
Pus | صديد
a set of attributes, a way of life that implies responsibility and commitment
a thick liquid associated with inflammation and composed of cells, liquid, microorganisms, and tissue debris
professionalization | التمهني
Pyrexia | ُح َّمى ؛ ُسخونَة
values acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers
the strength or amplitude of the pulse, the force of blood exerted with each heart beat
fibers of the ventricular conduction pathways that terminate in ventricular muscle, stimulating contraction
the process of becoming professional; acquiring characteristics considered to be professional
a body temperature above the normal range, fever
progress notes | مالحظات تقدم احلالة
a type of research approach that is often associated with naturalistic inquiry, which emphasizes understanding the human.
chart entries made by a variety of methods and by all health professionals involved in a client’s care for the purpose of describing a client’s problems, treatments, and progress toward desired outcomes prompted voiding | التبول احملفز
supplements habit training by encouraging the client to try to use the toilet (prompting) and reminding the client when to void prone position | كباب (منقلب الوجه إلى أدنى ْ َ)و ِ ْ ض ِعيَّ ُة االن
face-lying position, with or without a small pillow
qualitative research | البحث النوعي
Quality | جودة الصوت
a subjective description of a sound (e.g., whistling, gurgling) quantitative research | البحث الكمي
a type of research approach progresses through systematic, logical steps according to a specific plan to collect information, and analyzed using statistical procedures. Race | ساللة
classification of people according to shared biologic characteristics and physical features
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radiation | اشعاع
report | تقرير
َ َُمجال range of motion (ROM) | احلر َ ِكيَّة
reservoir | حاضنة اجلراثيم في سلسلة نقل العدوى
reactive hyperemia | احمرار اجللد عند زوال الضغط عنه
resident flora | اجلراثيم املتعايشة
the transfer of heat from the surface of one object to the surface of another without contact between the two objects the degree of movement possible for each joint a bright red flush on the skin occurring after pressure is relieved Receptor | مستقبل
a location on the surface of a cell membrane or within a cell (usually a protein) to which a drug chemically binds reconstitution | عملية حل الدواء
the technique of adding a solvent to a powdered drug to prepare it for injection Record | سجل
a written communication providing formal, legal documen tation of a client’s progress recording | (تسجيل (توثيق
the process of making written entries about a client on the medical record referred pain | ألم رجيع
pain perceived to be in one area but whose source is another area Reflux | َجزْر (جريان رجوعي) ارتداد
regional anesthesia | تخدير موضعي ملنطقة ما في اجلسم
the temporary interruption of the transmission of nerve impulses to and from a specific area or region of the body; the client loses sensation in an area of the body but remains conscious relapsing fever | ُحل َّمى الرَّا ِج َعة
the occurrence of short febrile periods of a few days interspersed with periods of 1 or 2 days of normal temperature relationships-based (caring) theories | النظريات األخالقية املبنية على دراسة العالقات،النظريات الرعوية
stress courage, generosity, commitment, and the need to nurture and maintain relationships Religion | معتقد ديني،ديانة
an organized system of worship remission | مرحلة السكون في االمراض املزمنة
a period during a chronic illness when there is a lessening of severity or cessation of symptoms ُ remittent fever | احل َّمى ا ُمل َترَدِّدَة
whether oral or written, it should be concise, including pertinent information but no extraneous detail a source of microorganisms
microorganisms that normally reside on the skin and mucous membranes, and inside the respiratory and gastrointestinal tracts residual urine | ي ّ ِال َبولُ الثُّمال
the amount of urine remaining in the bladder after a person voids resonance | رنني
a low-pitched, hollow sound produced over normal lung tissue when the chest is percussed respiration | التنفس
the act of breathing; transport of oxygen from the atmosphere to the body cells and transport of carbon dioxide from the cells to the atmosphere respiratory acidosis | حموض تنفسي
(hypercapnia) a state of excess carbon dioxide in the body respiratory alkalosis | قالء تنفسي
a state of excessive loss of carbon dioxide from the body respiratory character | طبيعة التنفس
see Respiratory quality
respiratory membrane | غشاء تنفسي
where gas exchange occurs between the air on the alveolar side and the blood on the capillary side; the alveolar and capillary walls form the respiratory membrane respiratory quality | نوعية التنفس
refers to those aspects of breathing that are different from normal, effortless breathing, includes the amount of effort exerted to breathe and the sounds produced by breathing respiratory rhythm | التواتر التنفسي
refers to the regularity of the expirations and the inspirations responsibility | مسؤولية
the specific accountability or liability associated with the performance of duties of a particular role resting energy expenditure (REE) | كمية الطاقة الالزمة للمحافظة على الوظائف احليوية
the amount of energy required to maintain basic body functions restraints | قيود حلماية املريض
protective devices used to limit physical activity of the client or a part of the client’s body
the occurrence of a wide range of temperature fluctuations, more than 2°C (3.6°F) over the 24-hour period, all of which are above normal
review of systems | استعراض أجهزة اجلسم
renin-angiotensin-aldosterone system | جهاز الرينني أجنيوتانسني
right | حق
system initiated by specialized receptors in the juxtaglomerular cells of the kidney nephrons that respond to changes in renal perfusion
a brief review of essential functioning of various body parts or systems (legal) a privilege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily
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rigor mortis | موتي صمل ّ
the stiffening of the body that occurs after death risk factors | عوامل تتعلق بقابلية وزيادة حدوث مرض ما-عوامل اخلطورة
factors that cause a client to be vulnerable to developing a health problem risk nursing diagnosis | التشخيص التمريضي احملتمل
seizure precautions | اجراءات حماية املريض اثناء النوبات
safety measures taken by the nurse to protect clients from injury should they have a seizure selectively permeable | انتقائي النفاذية
cell membranes that allow substances to move across them with varying degrees of ease
clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene
self-awareness | الوعي بالذات
Role | دور
self-concept | مفهوم الذات
the set of expectations about how a person occupying a specific position behaves
the collection of ideas, feelings, and beliefs one has about oneself
role ambiguity | غموض الدور
self-esteem | احترام الذات
unclear role expectations; people do not know what to do or how to do it and are unable to predict the reactions of others to their behavior Role development | تطوير الدور
involves socialization into a particular role Role mastery | اتقان الدور
performance of role behaviors that meet social expectations role performance | األداء
what a person does in a particular role in relation to the behaviors expected of that role Safety monitoring device | جهاز خاص مبراقبة حركة املريض لتفادي وقوعه
a position-sensitive switch that triggers an audio alarm when a client attempts to get out of the bed or chair Saliva | لعاب
the clear liquid secreted by the salivary glands in the mouth, sometimes referred to as spit saturated fatty acids | احماض دهنية ذائبة
those in which all carbon atoms are filled to capacity (i.e., saturated) with hydrogen Scabies | اجلرب
a contagious skin infestation caused by an arachnid, the itch mite scientific health belief | املعتقد الصحي العلمي
based on the belief that life and life processes are controlled by physical and biochemical processes that can be manipulated by humans
the relationship between one’s perception of oneself and others’ perceptions of oneself
the value one has for oneself; self-confidence semi-Fowler’s position | شبه جلوس مع رفع الرأس واجلذع زاوية:وضعية فولر درجة45-15 مقدارها
see Low Fowler’s position
semilunar valves | الصمامات الهاللية
crescent moon-shaped valves between the cardiac ventricles and the pulmonary artery (pulmonic valve) and the aorta (aortic valve) Sepsis | خمج او تعفن
the presence of pathogenic organisms or their toxins in the blood or body tissues septicemia | خمج الدم هو تعفن الدم
occurs when bacteremia results in systemic infection Septum | احلاجز، جدار فاصل،غشاء فاصل
a dividing structure such as that between the cardiac chambers or between the two sides of the nose severe pain | ألم شديد
pain intensity of 7–10 in a numeric rating scale sexual health | الصحة اجلنسية
the integration of the somatic, emotional, intellectual, and social aspects of sexuality, in ways that are positively enriching and that enhance personality, communication, and love Shaft | محور االبرة
the part of a needle that is attached to the hub
screening examination | فحص التحر ّي
shearing force | قوة االنزالق املؤدية الى نقص التروية الدموية
(review of systems) a brief review of essential functioning of various body parts or systems
a combination of friction and pressure that, when applied to the skin, results in damage to the blood vessels and tissues
scrub person | ممرضة العمليات التي تساعد الطبيب
side effect | االثار اجلانبية للدواء
person who assists the surgeon
secondary intention healing | عملية شفاء اجلروح الثانوية
the secondary effect of a drug that is unintended; usually predictable and may be either harmless or potentially harmful
wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring
Signs | العالمات
Seizure | نوبات –حتدث عادة مع الصرع
sims’ position | (ض ِعيَّ ُة سيمز (وضعية اضطجاعية للفحص املهبلي ْ َو
a sudden onset of a convulsion or other paroxysmal motor or sensory activity
Data that are detectable by an observer or can be measured or tested against an accepted standard. side-lying position with lowermost arm behind the body and uppermost leg flexed
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single order | االمر الطبي الخذ دواء مرة واحدة فقط وفي وقت محدد
spiritual distress | االعتالل الروحي
sinoatrial (SA or sinus) node | يب ّي ٌة أُذَي ِني ّة ِ عقدة َج
spiritual health | الصحة الروحية
common medication order that is a “one-time order”; medication is to be given once at a specified time the primary pacemaker of the heart located where the superior vena cava enters the right atrium skinfold measurement | في حالة اجلفاف-قياس االنثناءات اجللدية
an indicator of the amount of body fat, the main form of stored energy slander | تشوية للسمعة،افتراء
defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a reputation is damaged Sleep | نوم
an altered state of consciousness in which the individual’s perception of and reaction to the environment are decreased sleep apnea | انقطاع النفس أثناء النوم
periodic cessation of breathing during sleep
a disturbance in or a challenge to a person’s belief or value system that provides strength, hope, and meaning to life see Spiritual well-being spirituality | الروحانية
belief in or relationship with some higher power, creative force, driving being, or infinite source of energy Sputum | بلغم أو قشع
the mucous secretion from the lungs, bronchi, and trachea standardized care plan | خطة الرعاية املوحدة
formal plan that specifies the nursing care for groups of clients with common needs (e.g., all clients with myocardial infarction) standards of care | معايير الرعاية
the skills and learning commonly possessed by members of a profession standing order | االمر الطبي املستدام العطاء دواء معني على فترة زمنية معينة
Sleep hygiene | النوم الصحي
refers to interventions used to promote sleep
a written document about policies, rules, regulations, or orders regarding client care; gives nurses the authority to carry out specific actions under certain circumstances
small calorie (c, cal) | للقياس-سعرة حرارية صغيرة
stat order | االمر الطبي باعطاء دواء معني حاال
the amount of heat required to raise the temperature of 1 g of water 1°C SOAPIE | ، التدخالت، التقييم، البيانات املوضوعية،الشخصية اختصار (البيانات ّ التقومي،(التخطيط
an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning socialization | التكيف االجتماعي
common medication order which indicates that the medication is to be given immediately and only once statutory law | القوانني التشريعية
a law enacted by any legislative body stereotyping | يكون اآلراء املقولبة عن شخص
assuming that all members of a culture or ethnic group are alike
a process by which a person learns the ways of a group or society in order to become a functioning participant
sterile field | منطقة معقم
somatic pain | ألم جسدي املنشأ
sterile technique | آلية احملافظة على التعقيم ملنطقة معينة
source-oriented clinical record | السجل السريري املعتمد على مصدر التوثيق
sterilization | عملية التعقيم
pain that originates in the skin, muscles, bone, or connective tissue
a record in which each person or department makes notations in a separate section or sections of the client’s chart specific defenses | الوظيفة املناعية للجسم ضد اجلراثيم
immune functions directed against identifiable bacteria, viruses, fungi, or other infectious agents specific gravity | الثقل النوعي
the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water, taken as a standard Spinal cord stimulation (SCS) | حتفيز احلبل الشوكي
involves the insertion of a cable that allows the placement of an electrode directly on the spinal cord and is used with nonmalignant pain that has not been controlled with less invasive therapies
A specified area that is considered free from microorganisms practices that keep an area or object free of all microorganisms a process that destroys all microorganisms, including spores and viruses Sternum | القص ّ
Stoma | فغرات:] ُفغْرَة [ج
an artificial opening in the abdominal wall; it may be permanent or temporary stool | غائط،براز
Stress | اجهاد
an event or set of circumstances causing a disrupted response; the disruption caused by a noxious stimulus or stressor Stressor | الضغوط النفسية
any factor that produces stress or alters the body’s equilibrium
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stridor | صرير
a harsh, crowing sound made on inhalation caused by constriction of the upper airway stroke volume (SV) | ْضة ْ َح َ ج ُم النَّف
tachycardia | ت َ َسر ُّ ُع القَ لْب
an abnormally rapid pulse rate; greater than 100 beats per minute tachypnea | فرط التنفس
the amount of blood ejected with each cardiac contraction
abnormally fast respirations; usually more than 24 respirations per minute
subculture | الثقافة جلزء من اجملتمع
Tandem | احلقن الوريدي املرادف
subcutaneous | حتت اجللد
Tartar | رواسب ذات طبيعة قطرانية على االسنان
usually composed of people who have a distinct identity and yet are related to a larger cultural group beneath the layers of the skin; hypodermic subjective data | شخصية بيانات ّ
data that are apparent only to the person affected; can be described or verified only by that person sublingual | حتت اللسان
under the tongue
suctioning | شفط
secondary IV setup in which the second container is attached to the line of the first container at the lower, secondary port a visible, hard deposit of plaque and dead bacteria that forms at the gum lines taxonomy | التصنيف
a classification system or set of categories, such as nursing diagnoses, arranged on the basis of a single principle or consistent set of principles Teacher | املعلم
the aspiration of secretions by a catheter connected to a suction machine or wall outlet
a nurse who helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health
supine position | االستِلْقاء ْ ض ِعيَّ ُة ْ َو
Technical skills | املهارات التقنية
see Dorsal position
suppositories | حتاميل
solid, cone-shaped, medicated substances inserted into the rectum, vagina, or urethra suprapubic catheter | قَث َْطرَةٌ فَوقَ العانَة
catheter inserted through the abdominal wall above the symphysis pubis into the urinary bladder surface temperature | احلرارة السطحية
the temperature of tissue, the subcutaneous tissue, and fat surgical asepsis | اجراءات جراحية للمحافظة على خلومنطقة معينة من اجلراثيم
see Sterile technique Susceptibility | قابلية
the ability of the host to acquire an infection Suture | خيط جراحي
a thread used to sew body tissues together symptoms | األعراض
“hands on” skills such as those required to manipulate equipment, administer injections and move or reposition patients telecommunications | االتصاالت السكلية واالسكلية
the transmission of information from one site to another, using equipment to transmit information in the forms of signs, signals, words, or pictures by cable, radio, or other systems tertiary intention | آلية شفاء اجلروح الثالثية
healing that occurs in wounds left open for 3 to 5 days and then closed with sutures, staples, or adhesive skin closures therapeutic baths | احلمام العالجي للمريض
given for physical effects, such as to soothe irritated skin or to treat an area (e.g., the perineum) therapeutic effect | التأثير العالجي لدواء معني
the primary effect intended of a drug; reason the drug is prescribed third space syndrome | متالزمة احليز الثالث
information (data) apparent only to the person affected that can be described or verified only by that person
fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid
synergistic | تآزر األدوية بإعطاء مفعول معني
ُ الوري ِد thrombophlebitis | اخلثارِ ّي ُ ِالْت َ هاب
when two different drugs increase the action of one or another drug systemic infection | انتشار العدوى لتشمل اجهزة اجلسم
occurs when pathogens spread and damage different parts of the body Systole | إنقباض القلب
the period during which the ventricles contract systolic pressure | ي ُ الضغ ِ ْط االن ِْق َّ ّ باض
the pressure of the blood against the arterial walls when the ventricles of the heart contract
inflammation of a vein followed by formation of a blood clot thrombus | خثرة،جلطة دموية
a solid mass of blood constituents in the circulatory system; a clot (plural: thrombi) Ticks | حشرات صغيرة تنقل االمراض-القراد
small gray-brown parasites that bite into tissue and suck blood and transmit several diseases to people, in particular Rocky Mountain spotted fever, Lyme disease, and tularemia. َ tidal volume | ج ُم ا َملدِّ ّي ْ احل
the volume of air that is normally inhaled and exhaled
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tinea pedis | التهاب فطري في القدم وعادة ما يحدث لدى الرياضيني-سعفة القدم
athlete’s foot (ringworm of the foot), which is caused by a fungus tissue perfusion | تروية االنسجة
passage of fluid (e.g., blood) through a specific organ or body part Topical | اخلارجي-لالستعمال املوضعي
applied externally (e.g., to the skin or mucous membranes) tort | لضرر
a civil wrong committed against a person or a person’s property
on one scale and in sixteenths of a minim (up to 1 minim) on the other scale tympany | تط ّبل
a musical or drumlike sound produced during percussion over an air-filled stomach and abdomen undernutrition | سوء التغذية او نقص التغذية
an intake of nutrients insufficient to meet daily energy requirements because of inadequate food intake or improper digestion and absorption of food universal precautions (UP) | املعايير العاملية للوقاية من العدوى
law that defines and enforces duties and rights among private individuals that are not based on contractual agreements
techniques to be used with all clients to decrease the risk of transmitting unidentified pathogens; currently, Standard Precautions incorporate UP and BSI
trade name | االسم التجاري لدواء معني
unprofessional conduct | سلوك مناف ألخالق املهنةسلوك غير محترف
tort law | قانون الضرر
name given a drug by the manufacturer transcultural nursing | التمريض بني الثقافات
providing care within the differences and similarities of the beliefs, values, and patterns of cultures Transcellular fluid | السائل العابر للخاليا
compartment of extracellular fluids; includes cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids transcutaneous electrical nerve stimulation (TENS) | تنبية العصب بتأثير التيار الكهربائي عبر اجللد
one of the grounds for action against the nurse’s license; includes incompetence or gross negligence, conviction of practicing without a license, falsification of client records, and illegally obtaining, using, or possessing controlled substances unsaturated fatty acid | احماض دهنية غير ذائبة
a fatty acid that could accommodate more hydrogen atoms than it currently does Urea | ناجت هضم وتصريف البروتينات-مادة اليوريا
a substance found in urine, blood, and lymph; the main nitrogenous substance in blood
a noninvasive, nonanalgesic pain control technique that allows the client to assist in the management of acute and chronic pain
ureterostomy | َفغْر ُ احلالِب
transdermal patch | اللصقات اجللدية
the feeling that one must urinate
type of urinary diversion that involves surgery of the ureters Urgency | ِإلحْ اح
a particular type of topical or dermatologic medication delivery system
urinary frequency | كثرة عدد مرات التبول
Trial | محاكمة
urinary incontinence | َس ال َبول ُ َسل
the period during which all relevant facts are presented to a jury or judge triglycerides | الدهنيات الثالثية
substances that have three fatty acids; they account for more than 90% of the lipids in food and in the body Trigone | ُمثَلَّث
a triangular area at the base of the bladder marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior corner tripod (triangle) position, | الوضعية املثلثية
the need to urinate often
a temporary or permanent inability of the external sphincter muscles to control the flow of urine from the bladder urinary reflux | ارتداد البول،االرجتاع البولي
backward flow of urine
urinary retention | احتباس البول
the accumulation of urine in the bladder and inability of the bladder to empty itself urinary stasis | ي ّ ِرُكودٌ بَول
stagnation of urinary flow
the proper standing position with crutches; crutches are placed about 15 cm (6 in.) in front of the feet and out laterally about 15 cm (6 in.), creating a wide base of support
urination | تبول
troponin | )تروبونني (بروتني عضلي
a specific, consequence-based, ethical theory that judges as right the action that does the most good and least amount of harm for the greatest number of persons; often used in making decisions about the funding and delivery of health care
enzyme that is released into the blood during a myocardial infarction (MI) tuberculin syringe | حقنة خاصة لفحص مرض السل
originally designed to administer tuberculin; a narrow syringe, calibrated in tenths and hundredths of a milliliter (up to 1 mL)
(micturition, voiding) the process of emptying the bladder utilitarianism | النظرية النفعية
utility | مبدأ النفعية،املنفعة
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validation | التصديق
the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data ُ مناورة فالسالفا (مناورة َّ اخل valsalva maneuver | (شاء
forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with venous blood return to the heart value set | مجموعة القيم
all of the values (e.g., personal, professional, religious) that a person holds value system | النظام القيمي،منظومة القيم
vial | عبوة دواء –قنينة
a medication container with a sealed rubber cap, for single or multiple doses vibration | اهتزاز
a series of vigorous quiverings produced by hands that are placed flat against the chest wall to loosen thick secretions virulence | االمراضية-قدرة اجلرثومة على احداث مرض
ability to produce disease viruses | فيروسات
nucleic acid-based infectious agents viscous | َل ِزج
the organization of a person’s values along a continuum of relative importance
visual acuity | حدة اإلبصار
values | القيم
visual fields | حقل اإلبصار
something of worth; a belief held dearly by a person
the area an individual can see when looking straight ahead
values clarification | توضيح القيم
visceral pain | ألم حشوي
a process by which individuals define their own value vaporization | تبخر
continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin vasodilation | توسع االوعية الدموية
an increase in the caliber (lumen) of blood vessels vector-borne transmission | نقل العدوى من خالل ناقل –حشرة
a vector is an animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent vehicle-borne transmission | املناشف-نقل العدوى من خالل وسائط
a vehicle is any substance that serves as an intermediate means to transport and introduce an infectious agent into a susceptible host through a suitable portal of entry venipuncture | بزل الوريد
puncture of a vein for collection of a blood specimen or for infusion of therapeutic solutions ventilation | ت َ ْه ِويَة
the movement of air in and out of the lungs; the process of inhalation and exhalation ventilation | ترويح-تهوية
the movement of air in and out of the lungs; the process of inhalation and exhalation ventricles | البطينني
two lower chambers of the heart Veracity | الصدق
a moral principle that holds that one should tell the truth and not lie Verbal communication | التواصل اللفظي
the use of verbal language to send and receive messages vesicostomy | َفغْر ُ املَثانَة
surgical production of an opening into the bladder
the degree of detail the eye can discern in an image
results from stimulation of pain receptors in the abdominal cavity, cranium, and thorax َ الس َع ُة vital capacity | احل َي ِويَّة َّ
the maximum amount of air that can be exhaled after a maximum inhalation vital signs | مات َح َيوية ٌ عَ َال
measurements of physiologic functioning, specifically body temperature, pulse, respirations, and blood pressure; may include pain and pulse oximetry vitamin | فيتامينات
an organic compound that cannot be manufactured by the body and is needed in small quantities to catalyze metabolic processes Voiding | تبول
volume-control infusion set | احلقن الوريدي املضبوط
small fluid containers (100 to 150 mL in size) attached below the primary infusion container so that the medication is administered through the client’s IV line volume expanders | فاسح حجم البالزما
used to increase the blood volume following severe loss of blood (e.g., from hemorrhage) or loss of plasma (e.g., from severe burns, which draw large amounts of plasma from the bloodstream to the burn site) water-soluble vitamins | الفيتامينات الذائبة باملاء
vitamins that the body cannot store, so people must get a daily supply in the diet; include C and B-complex vitamins well-being | احليوية والنشاط
a subjective perception of balance, harmony, and vitality wellness | حالة الشعور باحليوية والنشاط
a state of well-being; engaging in attitudes and behaviors that enhance quality of life and maximize personal potential
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Pearsonâ€™s innovative Arab World Editions have been developed specifically for students studying in the Arab world. Regional cases and examples make the book more relevant to students, while international examples provide a comparative perspective. Engaging pedagogical features, local photographs and accompanying resources also support students and lecturers across the region www.mymanagementlab.com
Fundamentals of Nursing
Arab World Editions
Concepts, Process, and Practice
Fundamentals of Nursing provides a comprehensive introduction to the principles of nursing, addressing key learning outcomes through theoretical explanations and practical illustrations. An emphasis on Arab world nursing practices and a consideration of the religious and cultural values that impact on patient treatment in the region make this book an invaluable resource for anyone planning to study or work as a nurse in this part of the world.
Arab World Edition
An essential companion for nursing students in the Arab region
Fundamentals of Nursing
Kozier Erb Berman Snyder Abdelrahim Abu Moghli Saleh
Concepts, Process, and Practice Barbara Kozier Glenora Erb Audrey Berman Shirlee J. Snyder Maysoon Abdalrahim Fathieh Abu-Moghli Mohammad Saleh
Published on Jul 30, 2012