Basic Care and Comfort

Basic Care and Comfort General Information These questions represent one of four subdivisions of the topic Physiological Integrity covered on the NCLEX exam. They examine the best practices for patientcare during daily living activities, such as hygiene, physical movement, and obtaining nutrition. Here are some of the concepts you are likely to encounter in these questions. Assistive Devices An important part of the basic care and comfort of your patients will involve your ability to assess the need for assistive devices, provide instructions for their use, and evaluate the patient’s ability to effectively use them. Types of Assistive Devices Assistive devices can include those for physical ambulation and safety, such as a walker, cane, and/or crutches. It is also important to keep in mind that devices such as hearing aids, sound amplifiers, and other alerting devices may be necessary for a patient with a hearing deficit. Likewise, a service animal, walking cane, and Braille devices may be utilized by patients with vision deficits or blindness. A patient with a speech impairment (such as after a stroke, etc.) may require the use of wordboards, pictureboards, or handheld speech-generating electronic devices to properly communicate. Assessing the Patient for Device Need Each patient will need a full assessment to determine the proper assistive devices that would be the most helpful. Just as two patients with the same medical condition may require different therapies for optimal health and functioning, no two patients with the same speech, auditory, physical, or communication deficits will need the same assistive devices. You must individualize your recommendations based upon the specific needs of each patient. Assisting with Proper Use of Devices Nurses play an important educational role for their patients who need to use assistive devices. When the patient has been fully assessed and the correct assistive device chosen, the nurse must ensure that the patient is able to use the device safely and in a manner that allows the patient to efficiently and safely perform activities of daily living while allowing for the maximum amount of independence possible. Evaluating the Success of Device Use Successful use of assistive devices can be determined by direct patient observation as well as his or her ability to remain injury-free due to correct usage of the device. The patient should also feel a sense of enhanced self-esteem and self-worth with proper use. If adjustments to physical devices need to be made (cane length, height of crutches, etc.), you will be responsible for helping the patient make this correction. Likewise, if a particular assistive device does not seem to be allowing a patient to perform to his or her full potential, discuss alternative choices and make arrangements for the patient to try something new. Elimination Helping patients meet their elimination needs is central to their basic care and comfort. Both bowel and bladder functions can become altered, which will require you to provide appropriate nursing interventions for your patient’s health and well-being. Assessment for Elimination Issues A patient may develop an alteration of either bowel or bladder function (or both) for many reasons. These reasons include, but are not limited to: age, decreased muscular tone, physical disorders including anatomical structural disorders, neurological disorders, and psychological problems. Medication use can also affect your patient’s ability to properly void urine and/or feces. A full nursing assessment is necessary to identify the proper interventions for each patient. Common Terms Relating to Urination Problems Urinary elimination is more commonly referred to as micturition. One of the most common problems related to micturition is a urinary tract infection (UTI). Polyuria: excessive production of urine (>2.5 L in 24 hours). Normal output is about 2 L a day. Nocturnal polyuria, or nocturia, occurs only during the night time hours. Oliguria: less than normal urinary output (<400 mL in 24 hours). Anuria: lack of production of urine or severely scant amount of urine (<50 mL in 24 hours). Dysuria: painful or difficult urination. Urinary incontinence: the involuntary leakage of urine or loss of bladder control. The five main types are: functional, reflex, stress, urge, and total. Urinary retention: the accumulation of urine in the bladder due to the inability to completely empty it. Urgency: the strong, sudden, and uncontrollable urge to urinate. Common Terms Relating to Bowel Problems The passage of stool is referred to as defecation. You will need to identify potential bowel problems based on the age and health of your patient. Constipation: less than three bowel movements a week. Diarrhea: watery or loose stool. The medical definition of diarrhea is three or more loose stools over a 24-hour period. Fecal impaction: an accumulation of rock-hard stool inside the rectum that cannot be passed. Flatulence: the expulsion of gastrointestinal gas. Irrigations At times, you will be responsible for performing irrigations of bodily orifices in order to provide therapeutic intervention and maintain proper organ function. This may include: bladder, eye, ear, and ostomy (urostomy for urinary diversion and colostomy for fecal diversion). A gown should always be used to protect from sprays and splashes in addition to goggles and protective masks when these occurrences are expected, and gloves should always be worn. Sterile technique is always used with the exception of fecal diversion irrigation in which you should use clean technique. Skin Care for Incontinent Patients Providing constant and vigilant skin care is essential for an incontinent patient. Skin that is exposed to urine and feces should be washed and dried. In addition, the use of certain barrier products can help prevent skin breakdown and complications. These may include solid skin barriers, moisture barrier ointments, moisture barrier pastes, and skin sealants. Alternative Therapies Patients who cannot urinate on their own or who are unable to ambulate will need a urinary catheter to promote urination. The most common of these is the Foley catheter. The size of the catheter is referred to as the French or Fr. Men, women, and children all require different sized catheters. Due to the high risk of infection, catheter insertion is always performed under sterile technique and never delegated to unlicensed medical personnel. Evaluation of Restorative Methods Successful management of bowel and bladder elimination issues should include (at the very least): regular, painless, and nearly complete emptying of both urine and stool without urgency the ability to recognize and respond to the need to urinate and defecate remaining infection-free good maintenance of skin integrity. Patients with urinary or fecal incontinence may undergo bladder or bowel training to develop better control over elimination. Also, be mindful of basic interventions that can have a significant impact on a patient’s ability to properly urinate and defecate such as diet, fluids, exercise, privacy, timing, and positioning if bedridden. Mobility and Immobility A nurse will need to assess a patient’s mobility, including strength, gait, motor skills, coordination, and balance. Appropriate interventions are necessary to prevent immobility, which carries the risk of complications such as skin breakdown and contractures. Mobility Patients’ ability to be mobile is vital to their physical and psychological health. It is defined as “the ability to move freely, easily, and purposefully in one’s environment.” It is essential for life and plays a key function in one’s recovery and overall health. Your assessment of mobility should uncover deficiencies that can be corrected with appropriate nursing interventions to be implemented into the patient’s care plan. Mobility Assessment Direct visualization of the patients is the best way to assess their mobility. Standardized tests may be used, but simply observing the way they move in bed, sit unassisted, rise from sitting to standing, transfer from the bed to chair, or stand and walk can provide good information. Observe the gait during walking. Gait can give valuable information about balance, motor strength, joint mobility, and muscle coordination. Your assessment should also test each of these factors individually as well. Assistive Devices In some cases, your patient will require the use of assistive devices including traction devices, splints, braces, and casts. These will be applied, maintained, and removed by you. You will need to be familiar with each, why they are used and be able to instruct your patient on their use. The main function of these devices is to provide proper alignment for healing, reduce pain, and prevent complications that may lead to future immobility. For immobile patients, you will likely need to apply and maintain assistive devices that prevent venous thromboembolism. These may include compression stockings, antiembolism stockings or hose, and/or automatic sequential compression devices. All of these promote improved venous return in an immobile patient and must be ordered by a licensed practitioner. Immobility Immobility (especially complete bed rest) can lead to life-threatening complications that are both physical and psychological. The nurse and the entire healthcare team must take appropriate measures to both restore mobility and prevent complications. Be familiar with the adverse consequences of immobility and measures to take to intervene. The main causes of immobility include: pain, motor/nervous system impairment, functional problems, weakness, psychological problems, and medication-induced side effects. Skin Integrity Completely immobile patients are at high risk of skin breakdown. Frequent repositioning can help improve the skin’s turgor and perfusion as well as reduce the pressure, shearing, and friction on localized areas. Keep in mind that a patient’s fluid and nutritional needs are integral to skin health. You may also need to utilize supportive and assistive devices such as a wedge, pillow, and pressure-relieving mattress to prevent the formation of pressure ulcerations, and skin breakdown. Circulation The venous circulatory system is adversely affected by immobility as muscular contractions help increase the flow of venous blood from the lower extremities to the lungs and heart. Venous stasis, venous dilation, embolus formation, and thrombophlebitis are among the most common complications. Edema, orthostatic hypotension, and generalized hypotension may also develop. To promote proper circulation, anti-embolic devices may be used, such as those described above. In addition, the nurse must implement active, active assisted, and passive range of motion exercises, as well as positioning and repositioning to promote proper circulation, and routine exercise and mobilization. This may include rehabilitative exercise with both physical and/or occupational therapy. Respiratory System Immobility can lead to thickened respiratory secretions, pooling of secretions in the lungs, and the inability to effectively clear them from the lungs and airways. Because of this, patients are at risk for atelectasis, pneumonia, and other respiratory infections. Immobility also leads to shallow, ineffective respirations, decreased airflow, and decreased vital capacity of the lungs. Immobile patients will need the incorporation of coughing, deep breathing, incentive spirometry, and other inspiratory exercises in order to prevent these complications. Some patients may also require postural drainage, percussion, and vibration performed by the nurse or respiratory therapist following these exercises to mobilize secretions. Musculoskeletal System Immobile joints **are at risk for developing stiffness, pain, decreased range of motion, and contractures. Decreased weight-bearing movement leads to **muscle atrophy and weakness. This also leads to loss of calcium **from the skeletal system leading to osteoporosis, hypercalcemia, and fractures. These complications can be avoided with the implementation of **range of motion exercises and a variety of muscular exercises that can be done in bed. A tilt table can be used to stimulate weight-bearing exercise in certain patients. Other Potential Complications Other physiologic changes due to immobility can include: urinary complications, bowel alterations, weight gain, electrolyte imbalances (calcium, nitrogen, etc.), and psychological problems including depression. Body Alignment Immobile patients will need special positioning to maintain proper body alignment and optimal physiological functioning. Be familiar with the most commonly used positions and assistive devices used to maintain positioning (bolsters, wedges, etc.), and always be sure to educate the patient on the importance of positioning and how he or she can assist in the process. Traction Some patients may require the use of traction devices to achieve and maintain optimal positioning for healing. The most commonly used types include external fixation devices, halo traction, and skeletal traction. The most common condition requiring the use of these devices is a fracture, but other serious medical conditions may require traction. The nurse may set up a patient’s traction and will be responsible for maintaining it, ensure patient comfort and positioning during use, and perform adjustments when necessary. Nursing assessments during the use of traction will include frequent neurological and skin integrity exams of the affected limb/area. Frequent repositioning will also be necessary. Evaluation of Patient Response Nurses will decide if their patients are meeting their expected goals with regard to mobility and avoidance of complications. Several interventions such as those discussed in the previous sections may be used simultaneously to ensure patients’ safety, health, and expected recovery. Each patient should also be evaluated for psychological effects of immobility that can affect his or her quality of life such as social isolation and sensory deprivation. Adjustments to the care plan should include the proper interventions to avoid these negative outcomes. Non-Pharmacological Comfort Interventions Patient comfort measures will often include the use of non-pharmacological interventions. These techniques can range from the simple application of heat and cold to hypnosis, biofeedback, and other complex mind-body exercises. Different patients will have varying degrees of success with each. You will need to use your knowledge of your patient’s pathophysiology and perceptions of pain to determine which will be the most helpful. Patient Assessment Each patient should have a nursing assessment for the use of alternative and/or complementary therapy. Depending on the specific needs and preferences of each patient, these services may fit well with more traditional therapies. Examples can include: meditation/relaxation therapy, aroma therapy, acupuncture, massage, mindbody exercises, music therapy, herbs, and dietary supplements. Determining the Need for Pain Management Pain is a highly complex, subjective, and individualized sensation. Be familiar with the numerous theories on the phenomenon of pain (Specificity Theory, Intensive, Peripheral Pattern, etc.) as well as the four phases of pain and the varying types (acute, chronic, neuropathic, visceral, localized, diffuse, etc.). Proper pain management begins with your nursing assessment of a patient’s pain. The most reliable indicator is the subjective description of the pain. Objective indicators such as vital signs and behavior changes (crying, guarding, etc.) have been found to be less reliable, but may be the only indicators in patients unable to communicate their complaints of pain. For adults, numeric or facial pain scales are useful, as is the “PQRST” method for assessment. In children younger than age 3, observational behavioral pain assessment scales may be used as well as a number of standardized pain assessment scales. Other Alternative Therapies Do not underestimate the importance of other non-pharmacological comfort measures such as the use of music, warm blankets, and environmental controls such as low lighting and relaxation sounds (white noise, water, etc.) on a patient’s overall mood. Simple measures can often increase a patient’s sense of security and well-being. Contraindications Be aware of any contraindications to alternative therapies. Depending on a patient’s diagnosis, condition (pregnancy, hypertension, age, etc.) or medication regimen, therapies such as herbal supplementation, acupressure/acupuncture, and aromatherapy may not always be appropriate or safe. Palliative Care Nurses will play an important role in the interdisciplinary team that oversees a patient’s palliative care. Often, nurses serve as the coordinator of this care, but provide assessments and close, physical care for patients at the end of life. The most important aspects of palliative nursing care are symptom management, pain control, and family support. Your role will also require frequent discussions of the patient’s goals at the end of life and execution of the corresponding intervention whether you agree with it or not. You must focus your care to support the patient’s physical, emotional, psychosocial, and spiritual needs at this critical time. End-of-Life Support Patients will undergo a number of physical, psychological, and emotional changes near death. As expected, nurses must care for both the patients and their families during this uncertain and difficult time. Assisting Patients Nursing interventions at the end of life will focus on comfort and will be guided by individual patient needs. These may include: an increased need for sleep, a decreased need for food and fluids, agitation and restlessness, incontinence of bowel and bladder, respiratory secretions and congestion, change in breathing patterns, decreased body temperature and skin pallor, disorientation and vision-like experiences, social withdrawal, and expressing the need to have closure and say goodbyes. The goal of care is for the patient to remain free of pain during this period. Counseling Patients and Families The nurse will play a critical role in helping the family members of a terminal loved one understand and accept the changes they will see in the patient near the end of life. Both patient and family members should be educated and counseled on these changes in advance of their occurrence. Again, it is important to stress to family members that their loved one will be made as comfortable as possible and free from pain and suffering near the end of life. Evaluating Outcomes When evaluating the outcome of alternative therapies and comfort measures, it is important to ask for, and incorporate, your patient’s feedback into your evaluation. In addition to verbal feedback, pay attention to nonverbal body posturing and behaviors as well. This evaluation is very similar to that for pharmacologic therapy. When evaluating the outcome of palliative care interventions, it is important to consider the patient’s stated goals. The goal of this type of care focuses on meeting the physical, emotional, and spiritual needs of each individual patient. Pain and symptom control are of utmost importance. With regard to the dying patient and family, you will need to evaluate if there is understanding and acceptance of the present situation. Ideally, family members should help take part (when appropriate) in end-of-life care. Appropriate referrals may be necessary if grief counseling and other supportive therapies are appropriate. Nutrition and Oral Hydration The intake of the proper amount of water—in addition to the various nutrients, vitamins, and minerals required to maintain and promote health and wellness—will be a nursing priority for every patient. This will require you to have working knowledge of the four food groups (dairy, meat, fruits/vegetables, and grains) and the needs of your patients based on their age, weight, condition, medications, and ability to eat and drink independently. You should also be aware of cultural or religious considerations that play a role in nutritional recommendations and choices. Assessing the Patient Each patient should have a nutritional assessment that includes a stated intake history (subjective), one or more standardized tools (objective), anthropometric data like height, weight, BMI, etc. (objective), clinical data like activity, skin condition, quality of mucous membranes, etc. (objective), and biochemical data such as albumin, creatinine, hemoglobin, and transferrin (objective) to screen for proper intake and potential deficiencies. Physical Ability Paramount to a patient’s ability to have proper oral nutrition and hydration is an assessment of his or her ability to eat independently, chew adequately, and swallow properly. Poor dentition can also affect a patient’s ability to eat properly so this should be included in your assessment as well. It is important to remember that neurological conditions and side effects from therapies such as chemotherapy and/or radiation may affect your patient’s physical ability to obtain proper hydration and nutrition. Nutritional Requirements While most patients will simply require a well-rounded diet, some may have special restrictions due to specific health conditions or personal beliefs. Health conditions such as diabetes, hypertension, and high cholesterol mandate low-carbohydrate, low-sodium, and low-cholesterol diets, respectively. Specific religious and cultural entities, such as Jewish or Hindu populations, practice elimination of specific types of meat, particularly pork and beef, respectively. Food Restrictions Be mindful that patients may also have certain food restrictions both due to allergies to foods and potential medication interactions. Drugs can affect the digestive process overall, but foods may also hinder or enhance the action of the drug. Examples would include foods rich in vitamin K antagonizing the effects of warfarin and grapefruit juice inhibition of the cytochrome P450 enzyme, one of the most important in the metabolism of many different drugs. Patient Preferences Your patient’s preference for certain foods and quantities of food and water may depend on several factors. Each should be discussed and taken into consideration when developing the nutritional care plan. A few factors that may affect these preferences may include: age, gender, ethnicity, culture, personal preferences, and personal beliefs about food and food intake, as well as spiritual and religious practices and rituals. Mathematical Calculations The nurse will need to employ several mathematical calculations with regard to a patient’s nutrition and hydration. Examples include calorie counts, body mass index (BMI), and maintaining the daily intake and output record. Managing Food Intake It will be your responsibility to help your patient maintain, gain, or lose weight by developing a dietary plan that meets his or her specific needs based on your assessment. While most patients will likely need to lose weight, remember that those suffering with chronic diseases or conditions that involve nausea, vomiting, or diarrhea may need to gain weight. Regardless, all patients should have a balanced and healthy diet that includes a variety of choices and appropriate preferred foods. Calorie Counts Diets intended to stimulate weight loss or gain will involve the use of calorie counts. This will involve calculations of the number of calories in each gram of fat, protein, and carbohydrate that is eaten. The quantity or weight of the food consumed is needed for the calorie content of the food. Food labels provide this valuable information, and your patient should be educated on their use as well as how to calculate the number of calories consumed in both fresh and prepared foods. Supplements Despite a well-rounded diet, nutritional supplementation may be necessary. Examples include drinks such as Ensure® and Boost®, which provide extra protein and some essential vitamins and minerals. Measuring BMI To assist in understanding of how a patient’s nutritional status impacts his or her health, simple calculations like body mass index (BMI) may be calculated. The formula for measuring BMI is BMI= kg/m2 (body mass index = kilometers/meters squared). This formula helps to determine the measure of body fat based on a patient’s height. A result less than or equal to 18.5 indicates the patient is underweight, 18.5–24.9 normal weight, 25–29.9 overweight, and 30+ obese. Some patient’s results may be impacted by increase in muscle mass, as muscle is heavier than fat. Eating Independence Just as in all other activities of daily living, nurses and all other members of the healthcare team should encourage as much independence in eating as the patient can manage. If assistive devices are needed for this process, they must be incorporated into the patient’s care plan. Alternative Feeding Methods For patients unable to eat on their own or unable to get adequate amounts of food via oral intake, enteral nutrition may be given. This may be given on a continuous basis, intermittently, or in bolus form. Enteral feeding is done with a variety of different tubes; nasogastric, gastrostomy, and percutaneous endoscopic gastrostomy (PEG) are a few examples. Commercially prepared formulas are used for these feedings and are selected based on the patient’s specific nutritional needs. Pureed foods may also be used with some types of tube feedings. Nurses must maintain the tubes and ostomy sites, maintain their correct positioning and cleanliness, and ensure proper functioning and patency. Common complications to watch for are aspiration, leakage, diarrhea, dehydration, nausea, vomiting, tube displacement, nasal irritation (naso tubes only), and infection (ostomy sites). Monitoring Intake and Output Measuring a patient’s daily intake and output (I&O) is essential for proper management and care. Intake includes calculation of all food and fluids consumed orally, given intravenously, and through tube/enteral feedings per day. Output is calculated by the volume of urine, vomitus, and wound/ostomy drainage that is produced per day and the number of bowel movements or volume of diarrhea excreted in a day. These calculations can be used (in part) to explain changes in a patient’s weight, hydration status, laboratory values, and vital signs. Hydration Fluid imbalances can be in one of two categories: fluid excess ( edema) or fluid deficits (dehydration). Each will have distinguishing clinical features and corresponding changes in a patient’s vital signs with which you should be familiar. Medications can trigger imbalances as can the age, gender, and underlying medical condition of the patient (diabetes, fever, etc.). Personal Hygiene Personal hygiene is considered an activity of daily living. Each patient will need assessment of these functions and may need intervention if unable to properly or safely perform hygiene activities independently. Hygiene Assessment Your assessment should include the patient’s ability to: bathe, wash, and shower; perform foot, hair, nail, and perineal care; shave; and perform proper oral and mouth care, including denture care when indicated. Remember that many different influences (cultural, religious, energy level, underlying condition, etc.) will impact a patient’s hygiene habits and routines. Just like any other aspect of patient care, hygiene care should be tailored to your patient’s needs, practices, routines, and preferences. Daily Care Modification Different patients will require different levels of nursing care and intervention for their hygiene needs. As you assess each patient, be mindful of the established standards for each task and provide proper education when necessary. Also incorporate assistive devices such as shower chairs, handrails, back sponges, and special tools for nail care. Remind patients to use devices consistently and demonstrate proper use to ensure their safety while maintaining the maximum amount of independence. Post-Mortem Care Nurses will provide post-mortem care and prepare the deceased’s body for viewing by the family and loved ones. This will include washing and drying the body, removing all medical equipment (IV lines, catheters, etc.), placing the arms, hands, and legs in good alignment, closing the eyes and jaw, and placing a shroud over the body. An identification tag should be placed on the toe, outside of the shroud, prior to transportation to the morgue. Rest and Sleep Rest and sleep are critical to overall health and recovery from an illness or acute stage of a medical condition or disease. Sleep disorders and lack of rest can negatively impact a patient’s physical and psychological health and well-being. Assess for Patient Needs Patients will vary in their individual needs for sleep and rest depending on their age, developmental stage, level of wellness, and activity level. It is important to note that, regardless of a patient’s baseline sleep needs, his or her needs will be increased during the time of an illness or other health-related problem. Other factors that can affect sleep include: medications, lifestyle choices, work schedules, sleep environment, and emotional/psychological stress. Proper nursing interventions can be tailored when a specific sleep disorder has been identified. To determine this, a full physical examination, subjective sleep history, sleep log, and polysomnography are useful tools. Use Pathophysiology Knowledge Based on the specifics of a patient’s sleep disorder, you can use your knowledge of the associated pathophysiology to help your patient sleep and rest better. These interventions may include pharmacologic measures (pain control and nocturnal enuresis), non-pharmacological measures (stress/anxiety relief via relaxation techniques), and assistive devices (continuous positive airway pressure/CPAP for sleep apnea). Adjust Patient Care Schedules Appropriately Establishing a routine of good sleep hygiene will help your patients rest better while under your care and provide a template for them to follow once they are back at home. Regular bedtimes and wake times, regular physical activity, limiting daytime naps, avoidance of heavy meals and alcohol later in the evening, and establishing a quiet, calm, and relaxing sleep environment are just a few examples of this.