Nursing Path

CARING is the essence of NURSING. -Jean Watson

Nursing Path

Knowing is not enough, we must APPLY. Willing is not enough, we must DO. -Bruce Lee

Nursing Path

Treat the patient as a whole, not just the hole in the patient.

Nursing Path

Success is not final. Failure is not fatal. It is the courage to continue that counts. -Winston Churchill

Nursing Path

A problem is a chance for you to do your best. -Duke Ellington

Crisis Intervention

Crisis is a situation or period in an individual’s life that produces an overwhelming emotional response. This event occurs when an individual is confronted by a certain life circumstance or stressor that he or she cannot effectively manage by using his or her usual coping skills. Crisis is an unexpected event that can create uncertainty to an individual and has been viewed as a threat to a person’s important goals.

Stages of Crisis
The first stage of crisis occurs when the person is confronted by a stressor. Exposure to this stressor would result to anxiety. The individual then tries to handle things by using his or her customary coping skills. Second stage of crisis occurs when the person realizes that his usual coping ability is ineffective in dealing with anxiety. As the person becomes aware of his unsuccessful effort in dealing with the perceived stressor, he moves on to the next stage of crisis where the individual tries to deal with the crisis using new methods of coping.  The fourth stage of crisis takes place when the person’s coping attempts of resolving the crisis fail. The individual then experiences disequilibrium and significant distress.

Types of crisis
  1. Maturational crisis – also called developmental crisis. These are predictable events in a person’s life which includes getting married, having a baby and leaving home for the first time.
  2. Situational crises – unexpected or sudden events that imperils ones integrity. Included in this type of crisis are: loss of a job, death of a loved one or relative and physical and emotional illness of a family member or an individual.
  3. Adventitious crisis – also called social crisis. Included in this category are: natural disasters like floods, earthquakes or hurricanes, war, terrorist attacks, riots and violent crimes such as rape and murder.

Crisis Intervention
Crisis intervention refers to the methods used to offer immediate, short-term help to individuals who experience an event that produces emotional, mental, physical, and behavioral distress or problems.
Guide for an effective crisis intervention:
  1. Assist the person to view the event or issue in a different perspective.
  2. Assist the individual to use the existing support systems. It is vital to help the person find new sources of support that can help in decreasing the feelings of being alone or overwhelmed.
  3. Assist the individual in learning new methods of coping that will help resolve the current crisis and give him or her new coping skills to be used in the future when dealing with another overwhelming situation.

Cognitive Disorders

  • Cognitive disorders are characterized by the disruption of thinking, memory, processing, and problem solving.
  • Types of cognitive disorders include: delirium, dementia, and memory loss disorders (amnesia or dissociative fugue).

Risk Factors
  1. Physiological changes such as neurological, metabolic, and cardiovascular disease.
  2. Cognitive changes
  3. Family genetics
  4. Infections
  5. Tumors
  6. Sleep disorders
  7. Substance abuse
  8. Drug intoxications and withdrawals

Signs and Symptoms
  1. Irritability; mood most frequently seen in organic brain disorder.
  2. Change in level of consciousness.
  3. Difficulty thinking with sudden onset.
  4. State of awareness ranging from hyper vigilance to stupor or coma.
  5. Impairment in cognition and thought process, particularly short-term memory.
  6. Anxiety
  7. Confabulation

Therapeutic Nursing Management
  1. The nurse plays a primary role in providing a safe environment for the client and others.
  2. Exogenous stimuli in the environment can intensify the client’s level of orientation.
  3. Cognitive changes may often include a period of confusion or forgetfulness.
  4. The nurse may encourage family members to bring photographs or familiar items as strategy to orient the client.
  5. Psychological treatment may focus more on the family to offer them support during this stressful time.
  6. Cognitive changes affect the family and care providers. Cognitive decline often means a change in the family roles and activities of daily living.
  7. Pharmacologic therapy is implemented to reduce or alleviate the associated symptoms such as antianxiety medications, antidepressants, and antipsychotics.

Nursing Interventions
  1. Determine the cause and treatment of the underlying causes.
  2. Remain with the client, monitoring behavior, providing reorientation and assurance.
  3. Provide a room with a low level of visual and auditory stimuli.
  4. Provide palliative care with the focus on nutritional support.
  5. Reinforce orientation to time, place, and person.
  6. Establish a routine.
  7. Client protection may be required.
  8. Have client wear an identification bracelet, in case she or he gets lost.
  9. The client should not be left alone at home
  10. Break test into small steps, giving one instruction at a time.

Bladder Cancer


  1. Bladder cancer is papillomatous growth in the bladder urothelium that undergo malignant changes and that may infiltrate the bladder wall.
  2. Predisposing factors include cigarette smoking, exposure to industrial chemicals and exposure to radiation.
  3. Common signs of metastasis include the liver, bones and lungs
  4. As the tumor progresses can extend to the rectum, vagina and retro- peritoneal structures.

  • Painless hematuria
  • Dysuria
  • Gross hematuria
  • Obstruction of urine flow
  • Development of fistula ( urine from the vagina, fecal material in the urine)

Diagnostic Evaluation

Biopsies of the tumor and adjacent mucosa are definitive, but the following procedures are also used:
  • Cystoscopy, biopsy of tumor and adjacent mucosa
  • Excretory urography
  • Computed CT Scan
  • Ultrasonography
  • Bimanual examination by anesthesia
  • Cytologic evaluation of fresh urine and saline bladder washings
Molecular assays, bladder tumor antigens, adhesion molecules and others are being studied.

Primary Nursing Diagnosis
  • Risk for altered urinary elimination related to the obstruction of urinary flow

Medical Management

  1. Most bladder cancer are poorly radio sensitive and require high doses of radiation
  2. Radiation therapy is more acceptable for advance disease that cannot be eradicated by surgery.
  3. Palliative radiation maybe used to relieve pain and bowel obstruction and control potential hemorrhage and leg edema cause by venous or lymphatic obstruction.
  4. Intracavitary radiation maybe prescribed which protect adjacent tissues.
  5. External radiation combined with chemotherapy or surgery maybe prescribed because the external radiation alone maybe ineffective.
  6. Complications of radiations:
            a. A bacterial cystitis
            b. Proctitis
            c. Fistula formation
            d. Ileitis or colitis
            e. Bladder ulceration and hemorrhage


    1. Intravesical instillation
  • An alkylating chemotherapeutic agent is instilled into the bladder
  • This method provides an concentrated topical treatment with little systemic absorption
  • Chemotherapeutic agents used may include thiotepa, mitomycin (Mutamycin), doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and bacille Calmette-Guerin.
  • The medication is injected into a urethral catheter and retain for two hours.
  • Following instillation, the clients position is rotated every 15 to 30 minutes, starting in the supine position to avoid lying on full bladder.
  • After 2 hours, the client voids in a sitting position and is instructed to increase fluids to flash the bladder.
  • Treat the urine as biohazard and send to radioisotope laboratory for monitoring.
  • For 6 hours following intravesical therapy, disinfect the toilet with household bleach after the client has voided.
    2. Systemic chemotherapy
  • Systemic chemotherapy is used to treat inoperable or late tumors.
  • Agents used may include, cysplatin (Platinol), doxorubicin (Adremycin), cyclophospamide (Cytosan), methotrexate (Folex) and Pyridoxine
    3. Complications of chemotherapy
  • Bladder irritation
  • Hemorrhagic cystitis
Surgical Interventions

    1. Transurethral resection of the bladder
  • Local resection and fulguration ( destruction of tissue by electrical current through electrodes place in direct contact with the tissue)
  • Perform for early tumor for cure or for inoperable tumors for palliation.
    2. Partial Cystectomy
  • Partial cystectomy is the removal of up to half of the bladder
  • The procedure is done for early tumors and for clients who cannot tolerate radical cystectomy.
  • During the initial postoperative period bladder capacity is reduced greatly to about 60 mL; however, as the bladder tissue expand, the capacity increases to 200 -400 mL.
  • Maintenance of a continuous output of urine following surgery is critical to prevent bladder distention and stress on the suture line.
  • A urethral catheter and a suprapubic catheter maybe in place, in the suprapubic catheter maybe left in place for 2 weeks until healing occurs.
    3. Cystectomy and urinary diversion
  • The procedure involves removal of the bladder and urethra in the women, and the bladder, the urethra, and usually the prostrate and seminal vesicles in men.
  • When the bladder and urethra are remove, permanent urinary diversion is required.
  • The surgery meybe performed into stages if the tumor is expensive, with the creation of the urinary diversion first and the cystectomy several weeks later.
  • If a radical cystectomy is performed lower extremity lymphedema may occur as a result of lymp node dissection, and impotence may occur in the may client.
    4. Ileal conduit
  • The ileal conduit also is called ureteroileostomy or Bricker’s procedure.
  • Ureters are implanted into a segment of the ileum, with the formation of an abdominal stoma.
  • The urine flows into the conduit and is propelled continually out through the stoma by peristalsis.
  • The client is required to wear an appliance over the stoma to collect the urine.
  • Complications include obstruction, pyelonephritis, leakage at the anastomosis site, stenosis, hydronephrosis, calculuses, skin irritation and ulceration, and stomal defects.
    5. Kock pouch
  • The Koch pouch is a continent internal ileal reservoir created from a segment of the ileum and ascendingcolon.
  • The ureters are implanted into the side of the reservoir, and a special nipple valve is constructed to attach the reservoir to the skin.
  • Postoperatively, the client will have a 24 to 26 Foley catheter in place to drain urine continuously until the pouch has healed.
  • The catheter is irrigated gently with NS to prevent obstruction from mucus or clots.
  • Following removal of the catheter, the client is instructed in how to self-catheterize and to drain the reservoir at 4 to 6 hour intervals.
    6. Indiana pouch
  • A continent reservoir is created from the ascending colon and terminal ileum, making a pouch larger than the Koch pouch.
  • Postoperatively, the client will have a 24 to 26 Foley catheter inplace to drain urine continuously until the pouch has healed.
  • The Foley catheter is irrigated gently with NS to prevent obstruction from mucus or clots.
  • Following removal of the Foley catheter, the client is instructed in how to self-catheterize and to drain the reservoir at 4 to 6 hour intervals.
    7. Creation of a neobladder
  • Creation of a neobladder is similar to the creation of an internal reservoir, with the difference being that instead of emptying through an abdominal stoma, the bladder empties through a pelvic outlet into the urethra.
  • The client empties the neobladder by relaxing the external sphincter and creating abdominal pressure or by intermittent self- catheterization.
    8. Percutaneous nephrostomy or pyelostomy
  • These procedures are used when the cancer is inoperable to prevent obstruction.
  • The procedures involve a percutaneous or surgical insertion of a nephrostomy tube into the kidney for drainage.
  • Nursing interventions involves stabilizing the tube to prevent dislodgement and monitoring output.
    9. Ureterostomy
  • Ureterostomy may be performed as a palliative procedure if the ureters are obstructed by the tumor.
  • The ureters are attached to the surface of the abdomen, where the urine flows directly into a drainage appliance without a conduit.
  • Potential problems include infection, skin irritation,and obstruction to urinary flow as a result of strictures at the opening.
    10. Vesicostomy
  • The bladder is sutured to the abdomen, and a stoma is created in the bladder wall.
  • The bladder empties through the stoma.

Pharmacologic Intervention
  • Chemotheraphy with a combination of methotrexate, 5-fluorouracil (5-FU), vinblastine, doxorubicin (Adriamycin), and cisplatin (M-VAC) and new agents gemcitabine and taxane, possibly by topical chemotheraphy applied directly to the bladder wall
  • Intravesical BCG (effective with superficial transitional cell carcinoma)
  • Cytotoxic agent infusions through the arterial supply of the involved organ
  • Formalin, phenol, or silver nitrate instillations to achieve relief of hematuria and strangury (slow and painful discharge of urine) in some patients

Nursing Intervention

For patients who require radical cystectomy with urinary diversion, offer support and reinforcement of the information. Be sure what to expect. Involve another family member in the preoperative education. If it is needed, arrange a preoperative visit by someone who has adjusted well to a similar diversion.

If any type of stoma is to be created, arrange for a preoperative visit from the enterostomal therapist. The enterostomal therapist can assist in the selection and marking of the stoma site (although the stoma site is somewhat contingent upon the type of urinary diversion to be performed) and can introduce the patient to the external urine collection pouch and related care.

Preoperative interventions
  1. Administer bowel preparation as prescribed, which may include a clear liquid diet, laxatives and enemas, and antibiotics to lower the bacterial count in the bowel.
  2. Assist the surgeon and the enterostomal nurse in selecting an appropriate skin site for creation of the abdominal stoma.
  3. Encourage the client to talk about his or her feelings related to the stoma creation.
Postoperative interventions
  1. Monitor Vital signs.
  2. Assess incision site.
  3. Assess stoma (should be red and moist) every hour for the first 24 hours.
  4. Monitor for edema in the stoma, which may be present in the immediate postoperative period.
  5. If the stoma appears dark and dusky, notify the physician immediately because this indicates necrosis
  6. Monitor for prolapse or retraction of the stoma.
  7. Assess for return of bowel function; monitor for peristalsis, which will return in 3 to 4 days.
  8. Maintain NPO status as prescribed until bowel sounds return.
  9. Monitor urine flow, which is continuous (30 to 60 mL per hour) following surgery.
  10. Notify the physician if the urine output is less than 30 mL an hour or if no urine output occurs for more than 15 minutes.
  11. Ureteral stents or catheters may be in place for 2 to 3 weeks or until healing occurs; maintain stability with catheters to prevent dislodgment.
  12. Monitor urinary output closely and irrigate catheter (if present ) gently to prevent obstruction, as prescribed, with 60 mL of NS.
  13. Monitor for hematuria.
  14. Monitor for signs of peritonitis.
  15. Monitor for bladder distention following a partial cystectomy.
  16. Monitor for shock, hemorrhage, thrombophlebitis, and lower extremity lymphedema following a radical cystectomy.
  17. Monitor the urinary drainage pouch for leaks, and check skin integrity.
  18. Monitor the pH of the urine (do not place the dipstick in the stoma) because strong alkali urine can cause skin irritation and facilitate crystal formation.
  19. Instruct the client regarding the potential for urinary tract infection or the development of the calculuses.
  20. Instruct the client to assess the skin for irritation and to monitor the urinary drainage pouch for any leakage.
  21. Encourage the client to express feelings about changes in body image, embarrassment, and sexual dysfunction.

Documentation Guidelines
  • Description of all dressings, wounds, and drainage-collection devices
  • Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel and bladder patterns of voiding
  • Response to and side effects experienced related to intravesical instillations of chemotherapy or BCG; systemic chemotherapy
  • Teaching performed, the patient’s understanding of the content, the patient’s ability to perform procedures demonstrated

Discharge and Home Healthcare Guidelines

  • Following creation of an ileal conduit, teach the patient and significant others the care of the stoma and urinary drainage system. If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist.
  • Teach the patient the specific procedure to catheterize the continent cutaneous pouch or reservoir. A simple stoma covering made from a feminine hygiene pad can be worn between catheterizations.
  • Stress the need for the patient to wear a medical ID bracelet.
  • Following orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding.
  • Instruct the patient on methods for performing Kegel exercises during and between voidings to minimize incontinence. Suggest wearing incontinence pads until full control is achieved.
  • Also instruct the patient on self-catheterization techniques in case the patient is unable to void. Instruct patients where to obtain ostomy pouches, catheters, and other supplies. Teach the patient how to clean and store catheters between use following the clean technique.
  • Encourage the patient to verbalize concerns about radiation therapy, and reassure the patient that she or he is not “radioactive.” Instruct the patient to wash skin gently with mild soap, rinse with warm water, and pat the skin dry each day but not to wash off the ink marking that outlines the radiation field.
  • Encourage the patient to avoid applying any lotions, perfumes, deodorants, or powder to the treatment area.
  • Encourage the patient to wear nonrestrictive soft cotton clothing directly over the treatment area and to protect the skin from sunlight and extreme cold.
  • Stress the need to maintain the schedule for follow-up visits and disease surveillance as recommended by the physician.

Billroth Surgery


Billroth Surgery is a partial resection of the stomach with anastomosis to the duodenum (Billroth I) or to the jejunum (Billroth II). It is a standard treatment for ulcer disease, stomach cancer, injury and other diseases of the stomach. This was first described by Theodor Billroth, the pioneer in modern surgery.
Billroth I & Billroth II
Billroth I is also called gastroduodenostomy. It involves the partial gastrectomy or removal of the antrum and pylorus of stomach) with anastomosis of the gastric stump to the duodenum.

Billroth II is also called gastrojejunostomy. It involves the partial gastrectomy or removal of the antrum and pylorus of stomach) with anastomosis of the gastric stump to the jejunum.

  1. After removing a piece of the stomach, the surgeon reattaches the remainder to the rest of the bowel
  2. Billroth I gastroduodenostomy specifically joins the upper stomach back to the duodenum while Billroth II joins it to the jejunum

  1. Thorough Medical History Taking and assessment
  2. Intravenous or intramuscular administration of antibiotics
  3. Insertion of intravenous lines for administration of electrolytes and supply of compatible blood

Nursing Consideration (Postoperative)
  1. Monitor Vital Signs Accurately
  2. Monitor Operative Site and assess for any signs of infection
  3. Administer pain Medication as indicated or as ordered

Possible Side Effects
  1. Duodenogastric reflux, resulting in persistent vomiting
  2. Dumping syndrome, occurring after a meal and characterized by sweating, abdominal pain, vomiting, lightheadedness, and diarrhea
  3. Low blood sugar levels (hypoglycemia) after a meal
  4. Malabsorption of necessary nutrients, especially iron, in patients who have had all or part of the stomach removed

Benign Prostatic Hypertrophy or Hyperplasia


  1. A slow enlargement of the prostate gland occurs, with hypertrophy and hyperplasia of normal tissue.
  2. The enlargement causes narrowing of the urethra and results in partial or complete obstruction.
  3. The cause is unknown, and the disorder usually occurs in men older than 50 years.


Because the condition occurs in older men, changes in hormone balances have been associated with the cause. Androgens (testosterone) and estrogen appear to contribute to the hyperplastic changes that occur. Other theories, such as those involving diet, heredity, race, and history of chronic inflammation, have been associated with BPH, but no definitive links have been made with these potential contributing factors.

  1. Urgency, frequency, and hesitancy
  2. Changes in sizes and force of urinary stream
  3. Retention
  4. Dribbling
  5. Nocturia
  6. Hematuria
  7. Urinary stasis
  8. UTIs
Physical Examination

Inspect and palpate the bladder for distension. A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

The International Prostate Symptom Score
  1. Incomplete emptying: Over the past month, how often have you had the sensation of not emptying your bladder completely after you have finished urinating? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)
  2. Frequency: Over the past month, how often have you had to urinate again less than 2 hours after you finished urinating? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)
  3. Intermittency: Over the past month, how often have you stopped and started again several times when urinating? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)
  4. Urgency: Over the past month, how often have you found it difficult to postpone urination? (Not at all _ 0, less than 1 time in 5 _ 1, less than half the time _ 2, about half the time _ 3, more than half the time _ 4, almost always _ 5)

Diagnostic Evaluation
  1. Physical examination, including digital rectal examination (DRE).
  2. Urinalysis and urodynamic studies to determine obstructed flow
  3. Renal function tests, including serum creatinine levels
  4. Complete blood studies, including clotting studies

Primary Nursing Diagnosis
  • Urinary retention (acute or chronic) related to bladder obstruction

Medical Management

The treatment plan depends in the cause, severity of obstruction, and condition of the patient. Treatment measures include:
  • Immediate catheterization if patient cannot void (a urologist may be consulted if an ordinary catheter cannot be inserted). A suprapubic cystostomy is sometimes necessary.
  • “Watchful waiting” to monitor disease progression.
  • Balloon dilation or alpha-1 adrenergic receptor blockers (terazosin) to relax smooth muscle of the bladder neck and prostate
  • Hormonal manipulation with antiandrogen (finasteride [Proscar]) decreases the size of the prostate and improves urinary flow.
  • Saw palmetto is a botanical remedy for mild to moderate BPH.
Surgical Management
  • Transurethral laser resection with ultrasound guidance
  • Transurethral needle ablation (spares urethra, nerves, muscles, and membranes)
  • Microwave thermotheraphy (using transurethral probe) applied to hypertrophied tissue, which then becomes necrotic and sloughs off
Surgical procedures such as prostatectomy can be used to remove the hypertrophied portion of the prostrate gland. Other kinds of surgery include:
  • Transurethral resection of the prostrate (TUR or TURP); urethral endoscopic procedure is most common approach.
  • Suprapubic prostatectomy (perineal incision); incontinence, impotence, or rectal injury may be complications
  • Retropubic prostatectomy (low abdominal incision)

Transurethral resection of the prostrate (TUR or TURP)

Pharmacologic Intervention
  1. Phenoxybenzamine (alpha-adrenergic) 10 mg PO bid, to blocks effects of postganglionic blocker synapses at the smooth muscle and exocrine glands; improvement of urinary flow in 75% of patients
  2. Finasteride (5-alpha reductase) 5 mg PO qd, to shrinks prostate gland and improves inhibitor urine flow
  3. Other Medications: Prazosin, alfuzosin, doxazosin

Nursing Intervention
  1. Encourage fluid intake of up to 2000 to 3000 mL per day unless contraindicated.
  2. Prepare for bladder drainage via urinary catheterization for distention.
  3. Avoid administering medications that case urinary retention, such as anticholinergics, antihistamines, and decongentants.
  4. Administer finasteride (proscar) as prescribes to shrink the prostate gland and improve urine flow.
  5. Prepare the client for surgery as prescribed.
Surgical interventions for Benign Prostatic Hyperplasia
    a. Perineal prostatectomy
    b. Retropubic prostatectomy
    c. Suprapubic prostatectomy
    d. Transurethral resection of the prostate

Postoperative Care Following Transurethral Resection of the Prostate

    Continuous Bladder Irrigation (CBI)
  • A three- way (lumen) irrigation is used to decrease bleeding and to keep the bladder free from clots:
  • One lumen for inflating the balloon (30mL)
  • One lumen for installation (inflow)
  • One lumen for outflow
  • Maintain traction on the catheter if applied to prevent bleeding by pulling the catheter taut and tapping it to the abdomen or thigh.
  • Instruct the client to keep the leg straight if traction is applied to the catheter and it is taped to the thigh.
  • Catheter traction is not release without a physician’s order and usually is released after any bright red drainage has diminished.
  • Use normal saline or prescribed solution only to prevent water intoxication.
  • Run the solution at a rate, as prescribed, to keep the urine pink.
  • Run the solution rapidly if bright red drainage or clots are present.
  • Run the solution at about 40 gtt/min when the bright red drainage clears.
  • If the urinary catheter becomes obstructed, turn off the CBI and irrigate the catheter wit 30 to 50 mL of normal saline if prescribed; notify physician if obstruction does not resolve.
  • Monitor for transurethral resection syndrome or severe hyponatremia (water intoxication) caused by the excessive absorption of bladder irrigation during surgery (altered mental status, bradycardia , increase blood pressure, and confusion).
  • Discontinue CBI and Foley catheter as prescribed, usually 24 to 48 hours after surgery.
  • Monitor for continence and urinary retention when the catheter is removed.
  • Inform the client that some burning, frequency, and dribbling may occur following catheter removal.
  • Inform the client that he should be voiding 150 to 200 mL of clear yellow urine every 3 to 4 hours by 3 days after surgery.
  • Inform the client that he may pass small clots and tissue debris for several days.
  • Teach the client to avoid heavy lifting, stressful exercise, driving, Valsalva’s maneuver, and sexual intercourse for 2 to 6 weeks to prevent strain, and to call the physician if bleeding occurs or there is a decreased in urinary stream.
  • Instruct the client to drink 2400 to 3000 mL of fluid each day, preferably before 8PM
  • Instruct the client to avoid alcohol, caffeinated beverages, and spicy foods and avoid overstimulation of the bladder
  • Instruct the client that if the urine becomes bloody, to rest and increase fluid intake, and that if the bleeding does not subside, to notify the physician.

Documentation Guidelines
  • Presence of urinary discomfort, bleeding, frequency, retention, or difficulty initiating flow
  • Presence of bladder distension, discomfort, and incontinence
  • Intake and output; color of urine, presence of clots, quality of urine (clear versus cloudy)
  • Presence of complications: Urinary retention, bleeding, infection
  • Reaction to information regarding sexual function

Discharge and Home Healthcare Guidelines
  • PATIENT TEACHING. Instruct patients about the need to maintain a high fluid intake (at least 2 L/day) to ensure adequate urine output. Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention.
  • MEDICATIONS. Provide instructions about all medications used to relax the smooth muscles of the bladder or to shrink the prostate gland. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician.
  • PREVENTION. Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension recur.
  • POSTOPERATIVE. Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors. Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.

Bell’s Palsy


  • Bell’s palsy (facial paralysis) is due to peripheral involvement of the seventh cranial nerve on one side, which results in weakness or paralysis of the facial muscles.
  • The cause is unknown, but possible causes may include vascular ischemia, viral disease (herpes simplex, herpes zoster), autoimmune disease, or a combination.
  • Bell’s palsy may represent a type of pressure paralysis in which ischemic necrosis of the facial nerve causes a distortion of the face, increased lacrimation (tearing), and painful sensations in the face, behind the ear, and in the eye.
  • The patient may experience speech difficulties and may be unable to eat on the affected side owing to weakness.
  • Most patients recover completely, and Bell’s palsy rarely recurs.

Medical Management

  • The objectives of management are to maintain facial muscle tone and to prevent or minimize denervation.
  • Corticosteroid therapy (prednisone) may be initiated to reduce inflammation and edema, which reduces vascular compression and permits restoration of blood circulation to the nerve.
  • Early administration of corticosteroids appears to diminish severity, relieve pain, and minimize denervation.
  • Facial pain is controlled with analgesic agents or heat applied to the involved side of the face.
  • Additional modalities may include electrical stimulation applied to the face to prevent muscle atrophy, or surgical exploration of the facial nerve.
  • Surgery may be performed if a tumor is suspected, for surgical decompression of the facial nerve, and for surgical rehabilitation of a paralyzed face.

Nursing Management

Patients need reassurance that a stroke has not occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients. Teaching patients with Bell’s palsy to care for themselves at home is an important nursing priority.
Teaching Eye Care
Because the eye usually does not close completely, the blink reflex is diminished, so the eye is vulnerable to injury from dust and foreign particles. Corneal irritation and ulceration may occur. Distortion of the lower lid alters the proper drainage of tears. Key teaching points include the following:
  • Cover the eye with a protective shield at night.
  • Apply eye ointment to keep eyelids closed during sleep.
  • Close the paralyzed eyelid manually before going to sleep.
  • Wear wraparound sunglasses or goggles to decrease normal evaporation from the eye.
Teaching About Maintaining Muscle Tone
  • Show patient how to perform facial massage with gentle
  • upward motion several times daily when the patient can tolerate the massage.
  • Demonstrate facial exercises, such as wrinkling the forehead,
  • blowing out the cheeks, and whistling, in an effort to prevent muscle atrophy.
  • Instruct patient to avoid exposing the face to cold and drafts

Barium Swallow (Esophagography)


Barium swallow
, also known as esophagography, is the radiographic or fluoroscopic examination of the pharynx and the fluoroscopic examination of the esophagus after ingestion of thick and thin mixtures of barium sulfate.
This test, is commonly performed as part of the upper GI series, is indicated for patients with history of dysphagia and regurgitation. Further testing is usually required for a definitive diagnosis.
After the barium is swallowed, it pours over the base of the tongue into the pharynx. A peristaltic wave propels it through the entire length of the esophagus in about 2 seconds. When the peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens, allowing the barium to enter the stomach. After passage of the barium, the cardiac sphincter closes. Normally, it evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.

  • To diagnose hiatal hernia, diverticula, and varices.
  • To detect strictures, ulcers, tumors, polyps, and motility disorders.

Patient Preparation
  1. Explain to the patient that this test evaluates the function of the pharynx and esophagus.
  2. Instruct the patient to fast after midnight before the test.
  3. If the patient is infant, delay the feeding to ensure complete digestion of the barium.
  4. Explain that the test takes approximately 30 minutes.
  5. Describe the milkshake consistency and chalky taste of the barium preparation the patient will ingest; although it’s flavored, it may be unpleasant to swallow.
  6. Tell him he’ll first receive a thick mixture and then a thin one and that he must drink 12 to 14 oz (355 to 414 ml) during the examination.
  7. Inform him that he’ll be placed in various positions on a tilting radiograph table and that radiographs will be taken.
  8. If gastric reflux is suspected, withhold antacids, histamine-2 (H2) blockers, and proton pump inhibitors, as ordered.
  9. Just before the procedure, instruct the patient to put a hospital gown without snap closures and to remove jewelry, dentures, hairpins, and other radiopaque objects from the radiograph field.
  10. Check the patient history for contraindications to the barium swallow, such as intestinal obstruction and pregnancy. Radiation may have teratogenic effects.
  1. The patient is placed in an upright position behind the fluoroscopic screen, and his heart, lungs, and abdomen are examined.
  2. The patient is instructed to take one swallow of the thick barium mixture; pharyngeal action is recorded using cineradiography.
  3. The patient is instructed to take several swallows of the thin barium mixture. Passage of the barium is examined fluoroscopically; spot films of the esophageal region are taken from lateral angles and from the right and left posteroanterior angles.
  4. To accentuate small strictures or demonstrate dysphagia, the patient may be asked to swallow a “barium marshmallow” (soft white bread soaked in barium) or a barium pill.
  5. The patient is then secured to the X-ray table and rotated to trendelenburg position to evaluate esophageal peristalsis or demonstrate hiatal hernia and gastric reflux.
  6. The patient is instructed to take several swallows of barium while the esophagus is examined fluoroscopically; spot films are taken.
  7. After the table is rotated to a horizontal position, the patient takes several swallows of the barium so that the esophageal junction and peristalsis may be evaluated.
  8. Passage of the barium is fluoroscopically observed and the spot films are taken with the patient in the supine and prone position.
  9. During fluoroscopic examination of the esophagus, the stomach and the duodenum are also carefully studied because neoplasms in these areas may invade the esophagus and cause obstruction.
Nursing Interventions for Barium Swallow
  1. Check the additional films and fluoroscopic evaluations haven’t been ordered before allowing the patient to resume his usual diet.
  2. Instruct the patient to drink plenty of fluids, unless contraindicated, to help eliminate the barium.
  3. Give cathartic as prescribed.
  4. Tell the patient to notify the physician if he fails to expel the barium in 2 to 3 days.
  5. Inform the patient that stools will be chalky and light colored for 24 to 72 hours.

Normal Results
  • The swallowed barium bolus pours over the base of the tongue into the pharynx.
  • A peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens, allowing the bolus to enter the stomach. After the passage of the bolus, the cardiac sphincter closes.
  • The bolus evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.
Abnormal Results
  • Barium swallow may reveal hiatal hernia, diverticula, and varices.
  • Strictures, tumors, polyps, ulcers, and motility disorders, such as pharyngeal muscular disorders, esophageal spasms, and achalasia (cardiospasm) may be detected.

  • Barium retained in the intestine may harden, causing obstruction or fecal impaction.
  • Abdominal distention and absent bowel sounds, which may indicate constipation and may suggest barium impaction.

Bulimia Nervosa

  • The Diet-Binge-Purge Disorder”.
  • Is a disorder characterized by alternating dieting, binging and purging through vomiting, enema, and laxatives.
  • The person engages in episodes of starvation and other methods of controlling weight (diet pills, excessive exercise, enemas, diuretics, laxatives), then engages in uncontrolled and rapid eating for about two hours (over 8000 calories in 2 hours and 50,000 in 1 day) then terminates binging by inducing self to vomit, going to sleep or going to social activities.
  • Weight fluctuations are due to alternating fasting and binging.
    1. Bulimia means insatiable appetite. 
    2. Binging means eating an unusually large amount of food over a short period of time. 
    3. Purging is an attempt to compensate for calories consumed via self-induced vomiting or abuse of laxatives, diuretics, or enemas.
  • A chronic disorder that usually manifest first during late adolescence and early adulthood, around the ages 15-24 years. It almost always occurs after a period ofdieting.
  • The bulimic often belong to a family and society that place great value on external appearance. The person strives to be thin to be accepted because they believe self-worth requires being thin.
  • Usually of normal weight or obese, extrovert, reports self loathing, low self-esteem, has symptoms of depression, of fear of losing control, with self-destructive tendencies such as suicide.
  • These individuals are known to be perfectionist, achievers scholastically and professionally and highly dependent on the approval of others to maintain self-esteem. They hide their disorder because of fear of rejection.
  • Like anorexia, bulimia can kill. Even though bulimics put up a brave front, they are often depressed, lonely, ashamed, and empty inside. Friends may describe them as competent and fun to be with, but underneath, when they hide their guilty secrets, they are hurting. Feeling unworthy, they suffered from great difficulty talking about their feelings, which almost always include anxiety, depression, self-doubt, and deeply buried anger. Impulse control may be a problem like shoplifting, sexual adventurousness, alcohol and drug abuse, and other kinds of risk taking behavior in which the person acts with little consideration of consequences.
  • The person is aware that the behavior is abnormal, but is unable to stop because she is immobilized by her fear that she cannot stop her behavior voluntarily. The binge episode usually ends when the person becomes exhausted eating, develops GIT discomfort, runs out of food or is noticed by others.
  • After the episode she becomes guilty and depressed that she was unable to control herself, and engages in self-critism. Then she purges her self as a form of cleansing and punishment.

Common Complications Related to the Manner of Purging
  • Chronic inflammation of the lining of the esophagus due to induced vomiting, acidic gastric secretions irritates esophageal mucosa.
  • Rupture of esophagus and stomach.
  • Electrolyte imbalance causing cardiac arrythmias, hypokalemia due to diarrhea,hypochloremia due to vomiting, hyponatremia due to vomiting and diarrhea.
  • Dehydration.
  • Enlargement of the parotid gland.
  • Irritable bowel syndrome.
  • Rectal prolapse or abscess.
  • Dental erosion.
  • Chronic edema.
  • Fungal infection of vagina and rectum.

Nursing Diagnosis
  • Alterations in health maintenance.
  • Altered nutrition: Less than body requirements.
  • Altered nutrition: More than body requirements
  • Anxiety
  • Body image disturbance
  • Ineffective family coping; compromised
  • Ineffective individual coping
  • Self-esteem disturbance

Nursing Interventions
  1. Patient with bulimia are aware of their problems and they want to be helped because they feel helpless and unable to control themselves during episodes of binging. But because of their intense desire to please and need to conform they may resort to manipulative behavior and tell half-truths during interview to gain trust and acceptance of nurses. Create an atmosphere of trust. Accept person as worthwhile individual. If they know that no rejection or punishment is forthcoming they disclose their problem, they will be more open and honest.
  2. Develop strength to cope with problems. Encourage patient to discuss positive qualities about themselves to increase self-esteem.
  3. Help patient identify feelings and situations associated with or that triggers binge eating.
    • Assist to explore alternative and positive ways of coping.
    • Encourage making a journal of incident and feelings before-during and after a binge episode.
    • Make a contract with the patient to approach the nurse when they feel the urge to binge so that feelings and alternative ways of coping can be explored.
  4. Encourage adhering to meal and snack schedule of hospital. This decreases the incidence of binging, which is often precipitated by starvation and fasting.
  5. Encourage participating in group activities with other persons having the same eating disorder to gain additional support.
  6. For young adolescent living at home, encourage family therapy to correct dysfunctional family patterns.
  7. Cognitive behavioral therapy is the ideal therapy to help the bulimic understand the problem and explore appropriate behaviors.

Bipolar Disorder


A mood disorder, formerly known as manic depression is characterized by recurrent episodes of depression and mania. Either phase may be predominant at any given time or elements of both phases may be present simultaneously.

Risk Factors
  1. Biochemical imbalances
  2. Family genetics – one parent, child has 25% risk; two parents, 50-75% risk.
  3. Environmental factors such as stress, losses, poverty, social isolation.
  4. Psychological influences – inadequate coping, denial of disordered behavior.

Specific Biological Factors
  1. Possible excess of norepinephrine, serotonin, and dopamine.
  2. Increased intracellular sodium and calcium
  3. Neurotransmitters supersensitive to transmission of impulses
  4. Defective feedback mechanism in limbic system.

Signs and Symptoms
  1. Risk for self or others
  2. Impaired social interactions
  3. Mania
    • Persistent elevated or irritable mood
    • Poor judgment
    • Increase in talking and activities, grandiose view of self and abilities.
    • Impulsivity such as spending money, giving away money or possessions.
    • Impairment in social and occupational functioning
    • Decreased sleep
    • Distractibility
    • Delusions, paranoia, and hallucinations
    • Dislike of interference or intolerance of criticism
    • Denial of illness
    • Agitation
    • Attention seeking behavior
    • Depression

Nursing Diagnoses
  1. High risk for violence, directed at self or others
  2. Impaired verbal communication
  3. Anxiety
  4. Individual coping, ineffective
  5. Disturbance of self-esteem
  6. Alteration in though processes
  7. Alteration in sensory perceptions
  8. Self-care deficits
  9. Sleep pattern disturbances
  10. Alteration in nutrition

Therapeutic Nursing Management
  1. Environment
  2. Psychological treatment
    • Individual Psychotherapy – may be used to identify stressors and pattern of behavior.
    • Group therapy – establishes a supportive environment and redirect inappropriate behavior.
    • Family therapy – verbalizes family frustration and establishes a treatment plan for outpatient use.
  3. Somatic and Psychopharmacologic treatments
    • electroconvulsive therapy
    • Psychopharmacology

Nursing Interventions
  1. Assess client’s suicidal feelings and intentions and escalating behavior regularly.
  2. Set consistent limits on inappropriate behavior to help the client de-escalate.
  3. Establish a calm environment for the client.
  4. Reinforce and focus on reality.
  5. Provide outlets for physical activity but prevent client for escalating.
  6. Client may be very likable during “high periods”. Staff members need to avoid participating in this behavior, at other times, client may be very irritable and staff members should approach client quietly and with limits, if necessary.
  7. If the client cannot control self and other methods are not successful, staff may need to provide client protection if a threat of a self-harm or injury to other exist.
  8. Monitor client’s nutrition, fluid intake and sleep.
  9. Discuss with the client and family the possible environment or situational causes, contributing factors and triggers for a mood disorder with recurrent episodes of depression and mania.

Assist Patient from the Bed to Chair or Wheelchair

I. Purpose
  1. To strengthen the patient gradually.
  2. To provide a change in position. (In wheelchair to take her around for a change)

II. Equipment
  • Chair or wheelchair
  • Patient’s robe and slippers
  • Pillows
  • Blanket, sheet or draw sheet

III. Procedure
  1. See that the chair or wheelchair is in good condition.
  2. Place the chair conveniently at night angles to the bed—back of chair parallel to the foot of the bed and facing the head of bed.
  3. Place pillow on the seat of the chair. If using wheelchair, line it with a blanket or sheet and arrange pillows on the seat and against the back. Put the foot rest up and lock the wheels.
  4. Take the patient’s pulse
  5. Assist the patient to a sitting position on bed, i.e., put one arm under the head and shoulders and the other arm under her knees and pivot her to a sitting position with the legs hanging over the side of the bed.
  6. Watch the patient for a minute to defect any change in his color, pulse and respiratory rate.
  7. Put on patient’s robe and slippers. Place the foot stool under the patient’s feet.
  8. Stand directly in front of the patient and with a hand under each axilla, assist him to stand, step down and turn around, with his back to the chair. Let patient flex his knees and lower body to seat him to the chair. Anchor chair with foot or have someone hold it on. (Or let patient place his arm over your shoulders while you put your arm around his waist. Turn patient around with his back to the chair and seat him gently). Help him get comfortable in the chair.
  9. Adjust the pillows and wrap blanket over patient’s lap. If in a wheelchair adjust the foot rests.
  10. Observe frequently for changes in color and pulse rate, dizziness or sign of fatigue.
  11. To put him back to bed, assist to stand, help to turn and stand on stool and back to bed. Support patient while he sits on the side of bed. Remove robe and slippers. Pivot to a sitting position in bed, supporting her head and shoulders with one arm and her knees with the other arm, and lower slowly to bed in lying position.
  12. Draw up bedding. Take pulse after.

Assessment- Objective & Subjective Data

Review of clinical record
  1. Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations
  2. Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.

  1. The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support.
  2. The goals of an interview are to develop a rapport with the client and to collect data
  3. An interview has 3 major stages:
      1. Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time.
      2. Body: during this phase, the client responds to open and closed-ended questions asked by the nurse.
      3. Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.
  4. Types of questions
    1. Closed questions used in directive interview
      • Re____ short factual answers; e.g. “Do you have pain?”
      • Answers usually reveal limited amounts of information
      • Useful with clients who are highly stressed and/or have difficulty communicating
    2. Open-ended questions used in nondirective interview
      • Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’
      • Specify the broad area to be discussed and invite longer answers
      • Useful at the start of an interview or to change the subject
    3. Leading questions
      • Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?”
      • Suggests what answer is expected
      • Can result in client giving inaccurate data to please the nurse
      • Can limit client choice of topic for discussion

Nursing History
  1. Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response)
  2. Subjective data
    • May be called “covert data”
    • Not measurable or observable
    • Obtained from client (primary source), significant others, or health professionals (secondary sources).
    • For example, the client states, “I have a headache”
    • Objective data
    • May be called “overt data”
    • Can be detected by someone other than the client
    • Includes measurable and observable client behavior
    • For example, a blood pressure reading of 190/110 mmHg.

Physical assessment
  1. Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion
  2. A body system format for physical assessment is found below:
    • General assessement
    • Integumentary system
    • Head, ears, eyes, nose, throat
    • Breast and axillae
    • Thorax and lungs
    • Cardiovascular system
    • Nervous system
    • Abdomen and gastrointestinal system
    • Anus and rectum
    • Genitourinary system
    • Reproductive system
    • Musculoskeletal system

Psychosocial assessment
  1. Helpful framework for organizing data
  2. A suggested format for psychosocial assessment is found below:
    • Vocation/education/financial
    • Home and Family
    • Social, leisure, spiritual and cultural
    • Sexual
    • Activities of daily living
    • Health Habits
    • Psychological
  3. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection

  1. The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records)
  2. Consultation with individuals who can contribute to the client’s database is helpful in achieving the most complete and accurate information about a client
  3. Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the client’s status prior to admission

Review of literature
  1. A professional nurse engages in continued education to maintain knowledge of current information related to health care
  2. Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database

Assessment - First Step in the Nursing Process

  • It is systematic and continuous collection, validation and communication of client data as compared to what is standard/norm. 
  • It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles. 


To establish a data base (all the information about the client):
  • nursing health history 
  • physical assessment 
  • the physician’s history & physical examination 
  • results of laboratory & diagnostic tests material from other health personnel

FOUR Types of Assessment
  1. Initial assessment – assessment performed within a specified time on admission 
    • Ex: nursing admission assessment 
  2. Problem-focused assessment – use to determine status of a specific problem identified in an earlier assessment 
    • Ex: problem on urination-assess on fluid intake & urine output hourly 
  3. Emergency assessment – rapid assessment done during any physiologic/physiologic crisis of the client to identify life threatening problems. 
    • Ex: assessment of a client’s airway, breathing status & circulation after a cardiac arrest. 
  4. Time-lapsed assessment – reassessment of client’s functional health pattern done several months after initial assessment to compare the client’s current status to baseline data previously obtained.

  1. Collection of data 
  2. Validation of data 
  3. Organization of data 
  4. Analyzing of data 
  5. Recording/documentation of data

  • Observation of the patient + Interview of patient, family & SO + examination of the patient + Review of medical record

Collection of data 
  • gathering of information about the client 
  • includes physical, psychological, emotion, socio-cultural, spiritual factors that may affect client’s health status 
  • includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods) 
  • includes current/present problems of client (pain, nausea, sleep pattern, religious practices, meds or treatment the client is taking now) 
Types of Data 
  1. Subjective data 
    • also referred to as Symptom/Covert data 
    • Information from the client’s point of view or are described by the person experiencing it. 
    • Information supplied by family members, significant others; other health professionals are considered subjective data. 
    • Example: pain, dizziness, ringing of ears/Tinnitus 
  2. Objective data 
    • also referred to as Sign/Overt data 
    • Those that can be detected observed or measured/tested using accepted standard or norm. 
    • Example: pallor, diaphoresis, BP=150/100, yellow discoloration of skin 
Methods of Data Collection 
  1. Interview 
    • A planned, purposeful conversation/communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling. 
    • it is used while taking the nursing history of a client 
  2. Observation 
    • Use to gather data by using the 5 senses and instruments. 
  3. Examination 
    • Systematic data collection to detect health problems using unit of measurements, physical examination techniques (IPPA), interpretation of laboratory results. 
    • should be conducted systematically: 
      1. Cephalocaudal approach – head-to-toe assessment 
      2. Body System approach – examine all the body system 
      3. Review of System approach – examine only particular area affected 
Source of data 
  1. Primary source – data directly gathered from the client using interview and physical examination. 
  2. Secondary source – data gathered from client’s family members, significant others, client’s medical records/chart, other members of health team, and related care literature/journals. 
    • In the Assessment Phase, obtain a Nursing Health History - a structured interview designed to collect specific data and to obtain a detailed health record of a client. 
Components of a Nursing Health History: 
    • Biographic data – name, address, age, sex, martial status, occupation, religion. 
    • Reason for visit/Chief complaint – primary reason why client seek consultation or hospitalization. 
    • History of present Illness – includes: usual health status, chronological story, family history, disability assessment. 
    • Past Health History – includes all previous immunizations, experiences with illness. 
    • Family History – reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness). 
    • Review of systems – review of all health problems by body systems 
    • Lifestyle – include personal habits, diets, sleep or rest patterns, activities of daily living, recreation or hobbies. 
    • Social data – include family relationships, ethnic and educational background, economic status, home and neighborhood conditions. 
    • Psychological data – information about the client’s emotional state. 
    • Pattern of health care – includes all health care resources: hospitals, clinics, health centers, family doctors. 

Validation of Data 
  • The act of “double-checking” or verifying data to confirm that it is accurate and complete. 
Purposes of data validation 
  1. ensure that data collection is complete 
  2. ensure that objective and subjective data agree 
  3. obtain additional data that may have been overlooked 
  4. avoid jumping to conclusion 
  5. differentiate cues and inferences 
  • Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure. 
  • The nurse interpretation or conclusion based on the cues. 
  • Example: 
    • Red swollen wound = infected wound
    • Dry skin = dehydrated 

Organization of Data 

Uses a written or computerized format that organizes assessment data systematically.
  1. Maslow’s basic needs 
  2. Body System Model 
  3. Gordon’s Functional Health Patterns: 
Gordon’s Functional Health Patterns 
  1. Health perception-health management pattern. 
  2. Nutritional-metabolic pattern 
  3. Elimination pattern 
  4. Activity-exercise pattern 
  5. Sleep-rest pattern 
  6. Cognitive-perceptual pattern 
  7. Self-perception-concept pattern 
  8. Role-relationship pattern 
  9. Sexuality-reproductive pattern 
  10. Coping-stress tolerance pattern 
  11. Value-belief pattern 

Analyze data 
  • Compare data against standard and identify significant cues. Standard/norm are generally accepted measurements, model, pattern: 
    • Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern 

Communicate/Record/Document Data 
  • nurse records all data collected about the client’s health status 
  • data are recorded in a factual manner not as interpreted by the nurse 
  • Record subjective data in client’s word; restating in other words what client says might change its original meaning.

Asepsis and Infection Control


Medical asepsis
  1. Includes all practices intended to confine a specific microorganism to a specific area
    1. Asepsis
    2. Infection
    3. Inflammation 
    4. Immune Response 
    5. Types of Immunity 
    6. Nosocomial Infection 
    7. Factors Increasing Susceptibility to Infection 
    8. Universal Precautions (UP) 
    9. Body Substance Isolation (BSI) 
    10. Standard Precautions 
    11. Transmission-based Precautions 
    12. Managing Equipment Used for Isolation Clients 
    13. Bloodborne Pathogen Exposure 
    14. Puncture/Laceration 
  2. Limits the number, growth, and transmission of microorganisms
  3. Objects referred to as clean or dirty (soiled, contaminated)
Surgical asepsis
  1. Sterile technique
  2. Practices that keep an area or object free of all microorganisms
  3. Practices that destroy all microorganisms and spores
  4. Used for all procedures involving sterile areas of the body

Principles of Aseptic Technique

  1. Only sterile items are used within sterile field.
  2. Sterile objects become unsterile when touched by unsterile objects.
  3. Sterile items that are out of vision or below the waist level of the nurse are considered unsterile.
  4. Sterile objects can become unsterile by prolong exposure to airborne microorganisms.
  5. Fluids flow in the direction of gravity.
  6. Moisture that passes through a sterile object draws microorganism from unsterile surfaces above or below to the surface by capillary reaction.
  7. The edges of a sterile field are considered unsterile.
  8. The skin cannot be sterilized and is unsterile.
  9. Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis


Signs of Localized Infection
  • Localized swelling
  • Localized redness
  • Pain or tenderness with palpation or movement
  • Palpable heat in the infected area
  • Loss of function of the body part affected, depending on the site and extent of involvement
Signs of Systemic Infection
  • Fever
  • Increased pulse and respiratory rate if the fever high
  • Malaise and loss of energy
  • Anorexia and, in some situations, nausea and vomiting
  • Enlargement and tenderness of lymph nodes that drain the area of infection
Factors Influencing Microorganism’s Capability to Produce Infection
  • Number of microorganisms present
  • Virulence and potency of the microorganisms (pathogenicity)
  • Ability to enter the body
  • Susceptibility of the host
  • Ability to live in the host’s body
Anatomic and Physiologic Barriers Defend Against Infection
  • Intact skin and mucous membranes
  • Moist mucous membranes and cilia of the nasal passages
  • Alveolar macrophages
  • Tears
  • High acidity of the stomach
  • Resident flora of the large intestine
  • Peristalsis
  • Low pH of the vagina
  • Urine flow through the urethra
NANDA Diagnosis
  • Risk for Infection
    • State in which an individual is at increased risk for being invaded by pathogenic microorganisms
  • Risks factors
    • Inadequate primary defenses
    • Inadequate secondary defenses

Related Diagnoses
  • Potential Complication of Infection: Fever
  • Imbalanced Nutrition: Less than Body Requirement
  • Acute Pain
  • Impaired Social Interaction or Social Isolation
  • Anxiety
Interventions to Reduce Risk for Infection
  • Proper hand hygiene techniques
  • Environmental controls
  • Sterile technique when warranted
  • Identification and management of clients at risk

Chain of Infection 

  1. The chain of infection refers to those elements that must be present to cause an infection from a microorganism
  2. Basic to the principle of infection is to interrupt this chain so that an infection from a microorganism does not occur in client 
  3. Infectious agent; microorganisms capable of causing infections are referred to as an infectious agent or pathogen 
  4. Modes of transmission: the microorganism must have a means of transmission to get from one location to another, called direct and indirect 
  5. Susceptible host describes a host (human or animal) not possessing enough resistance against a particular pathogen to prevent disease or infection from occurring when exposed to the pathogen; in humans this may occur if the person’s resistance is low because of poor nutrition, lack of exercise of a coexisting illness that weakens the host. 
  6. Portal of entry: the means of a pathogen entering a host: the means of entry can be the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract). 
  7. Reservoir: the environment in which the microorganism lives to ensure survival; it can be a person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support organism that are pathogenic to humans are inanimate objects food and water, and other humans. 
  8. Portal of exit: the means in which the pathogen escapes from the reservoir and can cause disease; there is usually a common escape route for each type of microorganism; on humans, common escape routes are the gastrointestinal, respiratory and the genitourinary tract.

Breaking the Chain of Infection 

Etiologic agent
  • Correctly cleaning, disinfecting or sterilizing articles before use 
  • Educating clients and support persons about appropriate methods to clean, disinfect, and sterilize article 
Reservoir (source)
  • Changing dressings and bandages when soiled or wet 
  • Appropriate skin and oral hygiene 
  • Disposing of damp, soiled linens appropriately 
  • Disposing of feces and urine in appropriate receptacles 
  • Ensuring that all fluid containers are covered or capped 
  • Emptying suction and drainage bottles at end of each shift or before full or according to agency policy 
Portal of exit
  • Avoiding talking, coughing, or sneezing over open wounds or sterile fields 
  • Covering the mouth and nose when coughing or sneezing 
Method of transmission
  • Proper hand hygiene 
  • Instructing clients and support persons to perform hand hygiene before handling food, eating, after eliminating and after touching infectious material 
  • Wearing gloves when handling secretions and excretions 
  • Wearing gowns if there is danger of soiling clothing with body substances 
  • Placing discarded soiled materials in moisture-proof refuse bags 
  • Holding used bedpans steadily to prevent spillage 
  • Disposing of urine and feces in appropriate receptacles 
  • Initiating and implementing aseptic precautions for all clients 
  • Wearing masks and eye protection when in close contact with clients who have infections transmitted by droplets from the respiratory tract 
  • Wearing masks and eye protection when sprays of body fluid are possible 
Portal of entry
  • Using sterile technique for invasive procedures, when exposing open wounds or handling dressings 
  • Placing used disposable needles and syringes in puncture-resistant containers for disposal 
  • Providing all clients with own personal care items 
Susceptible host
  • Maintaining the integrity of the client’s skin and mucous membranes 
  • Ensuring that the client receives a balanced diet 
  • Educating the public about the importance of immunizations

Modes of Transmission 
  1. Direct contact: describes the way in which microorganisms are transferred from person to person through biting, touching, kissing, or sexual intercourse; droplet spread is also a form of direct contact but can occur only if the source and the host are within 3 feet from each other; transmission by droplet can occur when a person coughs, sneezes, spits, or talks. 
  2. Indirect contact: can occur through fomites (inanimate objects or materials) or through vectors (animal or insect, flying or crawling); the fomites or vectors act as vehicle for transmission 
  3. Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the air for long periods and dust particles containing infectious agents can become airborne infecting a susceptible host generally through the respiratory tract 

Course of Infection 
  1. Incubation: the time between initial contact with an infectious agent until the first signs of symptoms the incubation period varies from different pathogens; microorganisms are growing and multiplying during this stage 
  2. Prodromal Stage: the time period from the onset of nonspecific symptoms to the appearance of specific symptoms related to the causative pathogen symptoms range from being fatigued to having a low-grade fever with malaise; during this phase it is still possible to transmit the pathogen to another host 
  3. Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to as the acute stage; during this stage, it may be possible to transmit the infectious agent to another, depending on the virulence of the infectious agent 
  4. Convalescence: time period that the host takes to return to the pre-illness stage; also called the recovery period; the host defense mechanisms have responded to the infectious agent and the signs and symptoms of the disease disappear; the host, however, is more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label related to this process would be Risk for Infection 


  • The protective response of the tissues of the body to injury or infection; the physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic 
Body’s response 
  1. The “inflammatory response” begins with vasoconstriction that is followed by a brief increase in vascular permeability; the blood vessels dilate allowing plasma to escape into the injured tissue 
  2. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack and ingest the invaders (phagocytosis); this process is responsible for the signs of inflammation 
  3. Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result of the heat from the increased blood in the area, swelling occurs from fluid accumulation; the pain occurs from pressure or injury to the local nerves. 

Immune Response 

  1. The immune response involves specific reactions in the body to antigens or foreign material 
  2. This specific response is the body’s attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes 
  3. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity 
    • When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen
    • Once the antigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen 
    • After the antigen is gone, the lymphokines disappear 
    • Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again. 
  4. Humoral response: the ability of the body to develop a specific antibody to a specific antigen (antigen-antibody response) 
    • B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections 
    • Active immunity is produced when the immune system is activated either naturally or artificially. 
      • Natural immunity involves acquisition of immunity through developing the disease 
      • Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity) 
      • Passive immunity does not require a host to develop antibodies, rather it is transferred to the individual, passive immunity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen.

Types of Immunity 

Active Immunity
  • Host produces antibodies in response to natural antigens or artificial antigens 
  • Natural active immunity 
    • Antibodies are formed in presence of active infection in the body 
    • Duration lifelong 
  • Artificial active immunity 
    • Antigens administered to stimulate antibody formation 
    • Lasts for many years 
    • Reinforced by booster 
Passive Immunity 
  • Host receives natural or artificial antibodies produced from another source 
  • Natural passive immunity 
    • Antibodies transferred naturally from an immune mother to baby through the placenta or in colostrums 
    • Lasts 6 months to 1 year 
  • Artificial passive immunity 
    • Occurs when immune serum (antibody) from an animal or another human is injected 
    • Lasts 2 to 3 weeks

Nosocomial Infection 

  1. Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system
  2. Iatrogenic infection: these nosocomial infections are directly related to the client’s treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning 
  3. Exogenous Infection: are a result of the healthcare facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection 
  4. Endogenous Infection: can occur from clients themselves or as a reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish. 
Risks for Nosocomial Infections 
  • Diagnostic or therapeutic procedures 
    • Iatrogenic infections 
  • Compromised host 
  • Insufficient hand hygiene

Factors Increasing Susceptibility to Infection 

  1. Age: young infants & older adults are at greater risk of infection because of reduced defense mechanisms 
    • Young infants have reduced defenses related to immature immune systems 
    • In elderly people, physiological changes occur in the body that make them more susceptible to infectious disease; some of these changes are: 
      • Altered immune function (specifically, decreased phagocytosis by the neutrophils and by the macrophages) 
      • Decreased bladder muscle tone resulting in urinary retention 
      • Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate normal secretions 
      • Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric emptying. 
  2. Heredity: some people have a genetic predisposition or susceptibility to some infectious diseases 
  3. Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene practices, can influence a person’s susceptibility to infectious diseases 
  4. Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases; nutritional practices that do not supply the body with the basic components necessary to synthesized proteins affect the way the body’s immune system can respond to pathogens 
  5. Stress: stressors, both physical and emotional, affect the body’s ability to protect against invading pathogens; stressors affect the body by elevating blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes energy stores, thus increasing the risk of infection 
  6. Rest, exercise and personal health habits: altered rest and exercise patterns decrease the body’s protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the body’s response to pathogens 
  7. Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal defense mechanisms in the body, making the client more susceptible to infection; the immune system functions throughout the body and depends on the following: 
    • Intact skin and mucous membranes 
    • Adequate blood cell production and differentiation 
    • A functional lymphatic system and spleen 
    • An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune disease, the body has a problem with recognizing its own tissue and cells; people with autoimmune disease are at increased risk of infection related to their immune system deficiencies. 
  8. Environmental: an environment that exposes individuals to an increased number of toxins or pathogens also increases the risk of infection; pathogens grow well in warm moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an environment that increases exposure to toxic substances also increases risk 
  9. Immunization history: inadequately immunized people have an increased risk of infection specifically for those diseases for which vaccines have been developed. 
  10. Medications and medical therapies: examples of therapies and medications that increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery

Diagnostic Tests Used to Screen for Infection 
  1. Signs and symptoms related to infections are associated with the area infected; for instance, symptoms of a local infection on the skin or mucous membranes are localized swelling, redness, pain and warmth 
  2. Symptoms related to systemic infections include fever, increased pulse & respirations, lethargy, anorexia, and enlarged lymph nodes 
  3. Certain diagnostic tests are ordered to confirm the presence of an infection. 

Category-specific Isolation Precautions 
  • Strict isolation 
  • Contact isolation 
  • Respiratory isolation 
  • Tuberculosis isolation 
  • Enteric precautions 
  • Drainage/secretions precautions 
  • Blood/body fluid precautions

Disease-specific Isolation Precautions
  • Delineate practices for control of specific diseases 
    • Use of private rooms with special ventilation 
    • Cohorting clients infected with the same organism 
    • Gowning to prevent gross soilage of clothes 

Universal Precautions (UP) 

  • Used with all clients 
  • Decrease the risk of transmitting unidentified pathogens 
  • Obstruct the spread of bloodborne pathogens (hepatitis B and C viruses and HIV) 
  • Used in conjunction with disease-specific or category-specific precautions 

Body Substance Isolation (BSI

  • Employs generic infection control precautions for all clients 
  • Body substances include: 
    • Blood 
    • Urine 
    • Feces 
    • Wound drainage 
    • Oral secretions 
    • Any other body product or tissue

Standard Precautions 

  • Used in the care of all hospitalized persons regardless of their diagnosis or possible infection status 
  • Apply to: 
    • Blood 
    • All body fluids, secretions, and excretions except sweat (whether or not blood is present or visible) 
    • Nonintact skin and mucous membranes 
  • Combine the major features of UP and BSI 

Transmission-based Precautions 

  • Used in addition to standard precautions 
  • For known or suspected infections that are spread in one of three ways: 
    • Airborne 
    • Droplet 
    • Contact 
  • May be used alone or in combination but always in addition to standard precautions 

Managing Equipment Used for Isolation Clients 

  • Many supplied for single use only 
  • Disposed of after use 
  • Agencies have specific policies and procedures for handling soiled reusable equipment 
  • Nurses need to become familiar with these practices 

Bloodborne Pathogen Exposure 

  • Report the incident immediately 
  • Complete injury report 
  • Seek appropriate evaluation and follow-up 
  • Identification and documentation of the source individual when feasible and legal 
  • Testing of the source for hepatitis B, C and HIV when feasible and consent is given 
  • Making results of the test available to the source individual’s health care provider 
  • Testing of blood exposed nurse (with consent) for hepatitis B, C, and HIV – please check these to match style used in book – fairly certain it should be caped antibodies 
  • Postexposure prophylaxis if medically indicated 
  • Medical and psychologic counseling 


  • Encourage bleeding 
  • Wash/clean the area with soap and water 
  • Initiate first aid and seek treatment if indicated 
  • Mucous membrane exposure (eyes, nose, mouth) 
  • Flush with saline or water flush for 5 to 10 minutes 

Postexposure Protocol (PEP) for HIV 
  • Start treatment as soon as possible preferably within hours after exposure 
  • 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 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 continuously being developed 
  • HIV antibody tests should be done shortly after exposure (baseline), and 6 weeks, 3 months, and 6 months afterward 

Postexposure Protocol (PEP) for Hepatitis B 

  • 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 

Postexposure Protocol (PEP) for Hepatitis C 

  • Anti-HCV and ALT at baseline and 4 to 6 months after exposure