Learning Materials

Scope of practice refers to the range of services that a trained healthcare professional is considered competent to perform and is legally permitted to carry out under the terms of their professional nursing license. It provides a legal framework and structured guidance for the activities that nurses can safely undertake. As a nursing student—and later as a qualified nurse—it is essential to continually reflect on whether a task falls within your scope of practice. Acting outside of this scope may place patient safety at risk and can also have serious consequences for your professional registration. Nurses are also required to follow professional standards when delivering care. These standards are established by regulatory bodies, professional organisations, and healthcare agencies to ensure that care is provided safely, ethically, and competently. This chapter introduces the key principles of scope of practice and standards of care, forming a foundation for safe and accountable nursing practice.

Before discussing scope and standards of nursing care, it is helpful to understand the historical development of the nursing profession. Nursing traditions began during the 5th and 6th centuries as a form of charitable care, where individuals provided support to the sick, the poor, widows, and orphans. These early foundations were strongly influenced by religious principles, with much of the care provided by nuns. During the Middle Ages, advances in medical and surgical practice led to more formalised training for healthcare practitioners. As a result, care gradually shifted from a purely religious focus to a more structured medical approach. A major turning point in nursing occurred in the mid-19th century with the work of Florence Nightingale. Despite societal expectations at the time, she pursued nursing as a professional calling and recognised the need for trained and educated nurses. In 1860, she established the first formal school of nursing, helping to transform nursing into a respected profession. Nightingale’s contributions became especially evident during the Crimean War, where she observed poor sanitation and high mortality rates among wounded soldiers. Through careful observation and statistical analysis, she demonstrated that many deaths were due to preventable infections. By introducing simple interventions such as improved hygiene, clean water, and better nutrition, mortality rates were dramatically reduced. Her work laid the foundation for evidence-based practice and emphasised the importance of the environment in promoting healing. She also highlighted the importance of building trusting relationships with patients and maintaining confidentiality—principles that remain central to nursing practice today. Modern nursing has continued to evolve alongside advances in healthcare. Today, nurses represent the largest group within the healthcare workforce and play a vital role in health promotion, disease prevention, care coordination, and end-of-life care. Nursing practice remains holistic, addressing not only physical needs but also emotional, social, and spiritual wellbeing.

Standards for nursing care are established by several organisations, including state Nurse Practice Acts, professional nursing bodies, employer policies, and federal regulators. These standards provide guidance to ensure that care is delivered safely and competently. Nurses must legally follow the regulations set out in the Nurse Practice Act (NPA) in the state where they practice. The NPA defines the scope of practice and establishes rules for professional conduct. Failure to follow these regulations can result in disciplinary action, including the loss of a nursing license. Nursing students are also accountable for the care they provide. They are expected to recognise the limits of their knowledge and experience and to seek guidance when necessary. Practising beyond one’s competence can lead to serious professional consequences. Professional organisations such as the American Nurses Association (ANA) provide further guidance through documents such as the Code of Ethics for Nurses and standards of professional practice. These frameworks outline expectations for ethical behaviour, communication, collaboration, and accountability. In addition to national standards, nurses must also follow employer policies, procedures, and protocols. These are specific to each healthcare setting and must always be followed, even if they differ from what was taught in training. Nursing practice is also influenced by federal regulations. Organisations such as The Joint Commission and the Centers for Medicare and Medicaid Services establish safety standards and quality requirements that healthcare institutions must follow.

Health care is delivered across different levels, each focusing on specific aspects of care. Primary care focuses on health promotion and disease prevention. It includes services such as health education, immunisations, and early screening, and is typically provided in settings such as community clinics, schools, and general practice. Secondary care refers to acute care provided when a person becomes ill or injured. This type of care is delivered in settings such as hospitals, urgent care centres, and specialist clinics. Tertiary care addresses long-term conditions and rehabilitation. It aims to restore or maintain a patient’s level of functioning and is provided in settings such as rehabilitation units, long-term care facilities, and hospice services. Effective healthcare relies on collaboration between members of the healthcare team. This team includes providers, nurses, support staff, and other professionals working together to deliver holistic care. Nurses play a central role in coordinating care and ensuring that communication between team members is effective. They must also follow the chain of command when raising concerns, ensuring that issues are escalated appropriately to maintain patient safety.

Nurses can be held legally accountable for their actions when providing care. Failure to follow professional standards may result in negligence or malpractice claims. Negligence refers to a failure to act with reasonable care, while malpractice involves professional misconduct that results in harm to a patient. To establish malpractice, several elements must be proven, including duty of care, breach of duty, causation, and harm. Common examples of unsafe practice include:

• Failure to assess patients appropriately
• Insufficient monitoring
• Failure to communicate important changes
• Lack of documentation

Informed consent is another key legal principle. Patients must understand and voluntarily agree to treatment, including its risks and alternatives. Nurses act as advocates and witnesses, ensuring that patients have the opportunity to ask questions and make informed decisions. Confidentiality is protected under laws such as HIPAA. Nurses must ensure that patient information is only shared with authorised individuals and must avoid discussing patient details in public or inappropriate settings. Ethical practice is guided by principles such as:

• Beneficence (doing good)
• Nonmaleficence (avoiding harm)
• Autonomy (respecting patient choices)
• Justice (fairness)

The Code of Ethics for Nurses provides a framework for professional conduct and decision-making, ensuring that nurses uphold their responsibilities to patients, colleagues, and society.

Strong communication skills are essential for providing safe, high-quality, client-centred care. Nurses build therapeutic relationships with clients and families every day to ensure that health concerns, needs, and preferences are identified and addressed. When communication breaks down, important information may not be exchanged, and client needs may go unrecognised. Nurses support effective communication by establishing trust, listening actively, and creating caring human connections with clients and families. Nurses also play a key role in communication within the multidisciplinary team. Communication with other healthcare team members must be professional, organised, accurate, complete, and concise. This chapter introduces key methods for establishing effective communication in nursing practice.

Effective communication is one of the Standards of Professional Performance established by the American Nurses Association. It requires nurses to communicate clearly and respectfully in all areas of practice. Communication involves a sender, a message, and a receiver. The message must be clear, concise, and understood by the receiver. Feedback is also important because it helps confirm whether the message has been interpreted correctly. Verbal communication involves the use of spoken or written words. In nursing, effective verbal communication means using language that the client can understand, avoiding unnecessary jargon, and adapting information to the client’s age, developmental level, health literacy, and preferred method of communication. Nonverbal communication includes facial expressions, tone of voice, body language, eye contact, posture, and pace of speech. Nonverbal messages can strongly influence how communication is received. Nurses should be aware of their own nonverbal cues and use them intentionally to show attention, respect, and care. A useful approach to nonverbal communication is SOLER:

• S — Sit facing the client
• O — Maintain an open posture
• L — Lean slightly forward
• E — Maintain appropriate eye contact
• R — Remain relaxed

Nurses should also recognise different communication styles. Passive communication may avoid conflict but can prevent concerns from being expressed. Aggressive communication may disrespect others. Assertive communication is preferred because it allows nurses to express concerns clearly while respecting the rights and feelings of others. Personal space is another important communication concept. Nurses usually communicate within a professional social distance, but assessment and procedures often require entering a client’s personal space. Nurses must remain sensitive to the client’s comfort, culture, and preferences. Barriers to communication can include medical jargon, lack of attention, noise, poor lighting, hearing or speech difficulties, language differences, cultural differences, stress, pain, and medication effects. Nurses should actively reduce these barriers and check understanding throughout the interaction.

The nurse-client relationship, also known as a helping relationship, is central to holistic and compassionate nursing care. Through this relationship, nurses build rapport, establish trust, and support clients in discussing their feelings, concerns, care needs, and decisions. The nurse-client relationship is professional and purposeful. It allows the nurse to practise the art of nursing by connecting the client’s expressed needs, behaviours, and concerns with therapeutic support and clinical judgement. The nurse-client relationship develops through several phases. The preinteraction phase occurs before meeting the client, when the nurse reviews available information and reflects on possible biases. The orientation phase begins when the nurse introduces themselves, explains their role, establishes privacy, and begins to build trust. The working phase is where most therapeutic communication occurs, with the nurse focusing on the client’s concerns, feelings, and goals. The termination phase occurs when the interaction ends, and the nurse summarises progress, reviews support, and closes the encounter respectfully. Therapeutic communication is professional communication used to support client understanding, participation, and wellbeing. It includes active listening, empathy, silence, clarification, summarising, reflection, and open-ended questions. These techniques encourage clients to explore their feelings, identify concerns, and participate in decisions about their care. Active listening is especially important. It involves showing interest verbally and nonverbally, checking understanding, and allowing the client time to express themselves. Therapeutic use of touch may also communicate care and empathy, but it must always be respectful, culturally appropriate, and acceptable to the client. Common therapeutic communication techniques include:

• Active listening
• Using silence
• Seeking clarification
• Summarising
• Reflecting
• Offering empathy
• Asking open-ended questions
• Providing realistic hope

Nurses must also avoid nontherapeutic responses that can block communication. These include giving personal opinions, changing the subject, offering false reassurance, asking judgmental “why” questions, showing approval or disapproval, arguing, or responding defensively. Therapeutic communication should be adapted to the client’s individual needs. Children may need calm, simple explanations and demonstrations. Adolescents may benefit from choices within clear boundaries. Older adults may need support with hearing or vision impairments. Clients with language differences require trained medical interpreters rather than family members for important health information. Clients with communication disorders, such as aphasia, may need additional support. Nurses should reduce noise, speak slowly, use simple questions, provide alternative communication tools, and collaborate with family members and speech therapists when appropriate. Confidentiality must always be maintained when communicating with clients, families, and healthcare team members. Patient information should only be shared with those directly involved in care and should never be discussed in public areas or shared inappropriately.

Professional communication with other members of the healthcare team is an important part of nursing practice. Nurses communicate with colleagues through reports, handoff communication, transfer reports, and urgent updates about changes in client condition. Standardised communication tools help ensure that information is shared clearly, concisely, and accurately. One commonly used format is ISBARR, which stands for Introduction, Situation, Background, Assessment, Request or Recommendation, and Repeat back. A shorter version, SBAR, is also widely used in healthcare settings. ISBARR helps nurses organise important information:

• Introduction: identify yourself, your role, and where you are calling from
• Situation: explain the immediate concern and client status
• Background: provide relevant diagnoses, history, results, allergies, or code status
• Assessment: share your clinical findings and interpretation
• Request/Recommendation: state what you need or recommend
• Repeat back: confirm new orders or important instructions for accuracy

Handoff reports occur when responsibility for client care is transferred from one caregiver or team to another. Effective handoff communication supports continuity of care and helps prevent errors, delays, and omissions. Bedside handoff reports allow nurses to exchange real-time information at the client’s bedside. This can improve client safety, nurse satisfaction, and client involvement in care. However, confidentiality must always be considered, especially if visitors are present or the room is shared. Transfer reports are used when a client is moved to another unit or another healthcare agency. These reports are often more detailed because the receiving team needs accurate information to continue safe care. Conflict may occur in healthcare settings due to misunderstandings, disagreements, workload pressures, or unclear communication. Nurses should use professional and assertive communication to reduce conflict and support a safe working environment.

Most client information in modern healthcare settings is stored electronically. Electronic health records provide secure, real-time access to client information for authorised healthcare professionals while supporting confidentiality and continuity of care. Nurses frequently access information such as the history and physical, provider orders, medication administration records, treatment records, laboratory results, diagnostic test results, and progress notes. Reviewing this information helps nurses understand the client’s condition, treatment plan, and progress. Documentation is a legal and professional responsibility. In healthcare, it is often said that if something was not documented, it was not done. Documentation must therefore be accurate, timely, objective, factual, and professional. Important documentation principles include:

• Document only what you assessed, observed, or performed
• Use correct medical terminology, grammar, and spelling
• Include date, time, and signature according to policy
• Avoid unsafe or unapproved abbreviations
• Do not document care before it has been completed
• Never chart assessments, treatments, or medications that were not performed

Documentation supports continuity of care, quality assurance, reimbursement, research, and legal review. Nurses document assessments, progress notes, care plans, interventions, medication administration, treatments, and client responses. Common documentation formats include charting by exception, focused DAR notes, narrative notes, SOAPIE notes, discharge summaries, Minimum Data Set charting in long-term care, and incident reports. DAR notes organise documentation into Data, Action, and Response. SOAPIE notes organise information into Subjective, Objective, Assessment, Plan, Interventions, and Evaluation. These structured formats help nurses document care clearly and link assessment findings to nursing actions and outcomes. Incident reports are completed when unexpected events occur, such as falls, medication errors, injuries, or near misses. They are used to identify safety concerns and improve systems of care. Incident reports are not part of the medical record and should not be mentioned in the client’s chart, although the event and nursing actions should be documented appropriately.

Every person is shaped by cultural values and beliefs. Culture can strongly influence health beliefs, including how illness is understood, how illness is prevented, and how medical treatments are accepted. Culturally responsive care integrates a client’s cultural beliefs, values, and preferences into their healthcare. It is intentional, respectful, and client-centred. By recognising culture as part of care, nurses can build trust and rapport with clients and families. Holistic nursing care considers the physical, mental, spiritual, cultural, and social needs of the client. As a nursing student, developing cultural competence is part of learning to provide safe and respectful care. Cultural competence is a lifelong process of applying evidence-based nursing in ways that respect the client’s cultural values, beliefs, worldview, and practices. Cultural humility is also essential. It involves recognising personal biases, accepting that one cannot know everything about every culture, and approaching cultural learning as an ongoing process. This chapter introduces concepts related to adapting nursing care to meet the needs of diverse clients.

Culture refers to the beliefs, attitudes, customs, and practices shared by a group of people. It influences language, communication patterns, family roles, religion, food practices, dress, rituals, and views about health and illness. Culture is not fixed. It changes over time as people interact with other groups, communities, and experiences. Nurses must also remember that they have their own cultural beliefs, which can influence how they view care, time, communication, and professional behaviour. A subculture is a smaller group within a larger culture. Subcultures may be based on age, occupation, hobbies, religion, gender identity, geography, or other shared characteristics. A person may belong to several cultures and subcultures at the same time. Culture can be expressed through many factors, including:

• Language and communication style
• Religion and spiritual beliefs
• Gender identity and sexual orientation
• Age and generation
• Socioeconomic status
• Education and employment
• Geography and immigration status
• Ability or disability

These overlapping aspects of identity are often described as intersectionality. This means that people’s identities are not separate, but connected and shaped by multiple experiences. Culture may influence family involvement, decision-making, pain expression, food choices, use of home remedies, views of treatment, and when or how a person seeks healthcare. Nurses should avoid assumptions and instead ask respectful questions to understand the client’s individual preferences. Concepts such as stereotyping, ethnocentrism, discrimination, prejudice, and bias can interfere with culturally responsive care. Nurses have a responsibility to recognise these risks and practise in a way that is fair, inclusive, and respectful. Social justice is also central to culturally responsive care. Nurses should understand that social determinants of health, such as housing, education, income, employment, safety, and access to healthcare, can strongly affect health outcomes.

The Patient’s Bill of Rights supports culturally competent and respectful care. Although different versions exist, its central purpose is to protect the client’s right to accurate information, fair treatment, privacy, dignity, and self-determination. Clients have the right to be treated with respect and sensitivity. They also have the right to receive understandable information about their diagnosis, treatment, prognosis, risks, benefits, and alternatives. The Patient’s Bill of Rights supports the client’s involvement in decisions about care. This includes the right to accept or refuse treatment, participate in planning care, and make decisions through advance directives when appropriate. Privacy and confidentiality are also important rights. Clients should expect that their personal health information and healthcare records will be protected and only shared according to legal and professional standards. Although the Patient’s Bill of Rights extends beyond cultural care, it reinforces the importance of respecting each client’s dignity, values, preferences, and decision-making rights.

The freedom to express cultural beliefs is a fundamental right. Nurses recognise that people speak, behave, and make decisions in different ways because culture influences how they understand the world. Cultural competence is a lifelong process. It involves applying evidence-based nursing care in ways that are consistent with the client’s values, beliefs, worldview, and practices. Developing cultural competence requires awareness, curiosity, sensitivity, and ongoing reflection. Culturally competent nurses are more likely to develop trusting and supportive relationships with clients. These relationships can improve communication, support health promotion, and contribute to better health outcomes. Transcultural nursing theory, developed by Dr. Madeleine Leininger, provides an important foundation for culturally competent care. Transcultural nursing focuses on understanding and integrating cultural beliefs and practices into care so that clients can maintain health, regain health, or face illness and death in a meaningful way. Nurses have an ethical responsibility to provide culturally competent care. Professional standards emphasise cultural humility, inclusiveness, human rights, and the reduction of health disparities. Developing cultural competence includes:

• Cultural awareness — reflecting on personal values, biases, and assumptions
• Cultural knowledge — learning about cultural health beliefs and practices
• Cultural sensitivity — showing respect and avoiding judgement
• Cultural skill — using cultural information when planning care
• Cultural encounters — engaging with clients from diverse backgrounds to deepen understanding

Cultural competence does not mean memorising facts about every culture. Instead, it means approaching each client with respect, humility, curiosity, and a willingness to learn.

Despite efforts to promote culturally competent care, health disparities continue to affect vulnerable populations. Some groups experience higher rates of illness, greater disease burden, and reduced access to quality healthcare. Health disparities are differences in health outcomes linked to economic, social, political, or environmental factors. These factors are often called social determinants of health and include the conditions in which people are born, live, learn, work, play, worship, and age. Examples of social determinants of health include:

• Safe and affordable housing
• Access to education
• Availability of healthy food
• Access to healthcare services
• Public safety
• Environmental conditions

Health disparities may affect people based on race, ethnicity, gender, age, disability, mental health, sexual orientation, gender identity, socioeconomic status, geography, or other characteristics linked to discrimination or exclusion. A related concept is healthcare disparity, which refers specifically to differences in access to healthcare and insurance coverage. These disparities can contribute to lower quality of life, increased costs, and reduced life expectancy. Culturally responsive care is one strategy for reducing health disparities. Nurses can support this by creating culturally sensitive environments, performing cultural assessments, using respectful communication, and adapting care to meet individual needs. When culturally responsive care is absent, clients may experience miscommunication, distress, mistrust, or reduced adherence to treatment. Nurses are therefore in a strong position to help reduce disparities and improve client outcomes.

Culturally sensitive care begins with respect. Nurses should introduce themselves by name and role, ask clients how they wish to be addressed, and acknowledge family members or visitors respectfully. Nurses should observe the client’s preferences related to eye contact, personal space, touch, language, and other forms of verbal and nonverbal communication. Inclusive language should be used, and nurses should avoid wording that labels or defines clients by a condition or disability. It is acceptable to ask respectful questions when clarification is needed. Nurses do not need to know everything about a client’s culture, but they should be open, honest, and nonjudgmental. Cultural beliefs should be incorporated into care whenever possible, as long as they do not create safety concerns. Medical interpreters are essential when a client has limited ability to speak, read, write, or understand the language used in the healthcare setting. Family members should not be used as interpreters for important healthcare information because this can lead to errors, omissions, or discomfort for the client. When using a medical interpreter, nurses should:

• Allow extra time for the conversation
• Face and speak directly to the client
• Use short, clear sentences
• Avoid slang, idioms, jargon, and abbreviations
• Ask the client to repeat key information to confirm understanding
• Document interpreter use according to policy

Nurses may also need to discuss sexuality and related health concerns. These conversations should take place in a private, respectful, and nonjudgmental environment. Nurses should give the client full attention, ask permission before discussing sensitive topics, and seek additional support or referrals when needed.

After establishing a culturally sensitive environment, nurses should include cultural assessment as part of client care. Cultural assessment helps nurses understand the client’s beliefs, values, concerns, and preferences so care can be adapted appropriately. One useful approach is the Four Cs of Culture model. This model encourages nurses to ask about what the client considers to be the problem, what they believe caused the problem, how they are coping, and how concerned they are. The Four Cs can be framed as:

• Consider: What does the client think the problem is? What do they call it?
• Cause: What does the client believe caused the problem?
• Coping: What has the client done to manage or treat the problem?
• Concern: How serious does the client believe the problem is?

These questions help the nurse identify cultural beliefs that may influence treatment, decision-making, coping, and communication. Cultural assessment should be completed respectfully and without assumptions. The goal is not to stereotype clients, but to understand the individual person and provide care that is safe, meaningful, and responsive to their needs.

After creating a culturally sensitive environment and completing a cultural assessment, nurses can continue to provide culturally responsive care. This involves creating a culturally safe environment, using cultural negotiation, and considering the impact of culture on decision-making, space, eye contact, touch, and food choices. A culturally safe environment allows clients to express their cultural beliefs, values, and identity without fear of judgement or discrimination. This responsibility belongs both to individual nurses and to healthcare organisations. Cultural negotiation occurs when the nurse and client work together to find a mutually acceptable approach to care. When a cultural preference does not place the client or others at risk, nurses should try to accommodate it. For example, medication schedules, clothing, family involvement, or dietary preferences may sometimes be adapted while still maintaining safe care. Decision-making may also be influenced by culture. Some clients value individual decision-making and self-determination, while others may involve family or community members in important healthcare decisions. Nurses should assess and respect the client’s preferred approach whenever possible. Personal space and touch are culturally influenced. Nurses often need to enter a client’s personal space during assessment or procedures, but they should explain what they are doing and ask permission before close contact. Concerns about modesty, gender of the caregiver, or touch should be respected. Eye contact also varies across cultures. In some cultures, direct eye contact is viewed as respectful and honest; in others, it may be seen as rude or inappropriate. Nurses should observe the client’s cues and adapt their approach. Food choices are deeply connected to culture, identity, family, healing, and religious practice. Nurses should consider dietary preferences and restrictions and work with the client and healthcare team to accommodate them when safe and feasible.

Nurses use the nursing process as a critical thinking model to guide safe and client-centred care. It helps nurses analyse information, prioritise needs, make decisions, and plan interventions for clients they may have only just met. The nursing process acts as a road map for nursing actions. It helps nurses organise care in a systematic way and supports decisions that promote the client’s health, safety, and wellbeing. This chapter explains how the nursing process is used as a standard of professional nursing practice to provide safe, effective, and individualised care.

Before using the nursing process, it is important to understand how critical thinking and clinical reasoning support nursing practice. Nurses make decisions by analysing information, validating cues, and planning care based on client needs, current evidence, and professional standards. Critical thinking means more than simply following instructions. It involves questioning, validating information, considering alternatives, and acting in ways that protect client safety. Critical thinkers demonstrate qualities such as independence of thought, fairness, humility, integrity, curiosity, perseverance, and confidence. Clinical reasoning is the process of gathering and analysing client information, evaluating its significance, and deciding which actions are most appropriate. This ability develops over time through knowledge, practice, and clinical experience. Nurses use both inductive and deductive reasoning. Inductive reasoning involves noticing specific cues, recognising patterns, and forming a hypothesis about what may be happening. For example, redness, warmth, and tenderness around a surgical incision may lead the nurse to suspect infection. Deductive reasoning begins with a general rule, standard, or policy and applies it to a specific situation. Nurses use standards from professional organisations, regulations, and employer policies to guide safe care. Clinical judgement is the outcome of critical thinking and clinical reasoning. It involves recognising cues, identifying the most important client concern, generating evidence-based solutions, and taking action to provide safe care. The nursing process is commonly remembered using the mnemonic ADOPIE:

• Assessment
• Diagnosis
• Outcome Identification
• Planning
• Implementation
• Evaluation

The nursing process is continuous and cyclical. As the client’s condition changes, nurses reassess, revise plans, and adapt interventions. Nursing is both a science and an art. The science of nursing involves clinical judgement, evidence-based practice, and systematic decision-making. The art of nursing involves compassion, caring relationships, respect for dignity, and holistic support for the client’s physical, emotional, cultural, spiritual, and psychosocial needs.

Assessment is the first step of the nursing process. It involves collecting relevant data and information about the client’s health, situation, needs, and responses. Nurses use assessment to gather information, recognise cues, and begin analysing what the client may need. Assessment data may be subjective or objective. Subjective data is information reported by the client or family members. It reflects the client’s experience, feelings, symptoms, and concerns. When documenting subjective data, nurses often use quotation marks to record the client’s own words. Objective data is information that can be observed or measured. Examples include vital signs, physical examination findings, laboratory results, and diagnostic test results. Assessment data may be collected through:

• Interviewing the client or family
• Physical examination
• Reviewing laboratory and diagnostic results
• Reviewing the medical record

Interviewing requires active listening, observation, clarification, and therapeutic communication. Nurses should be alert to both verbal and nonverbal cues and should validate assumptions before making conclusions. A physical examination uses techniques such as inspection, auscultation, palpation, and percussion. Assessment may be comprehensive, such as a head-to-toe assessment, or focused on a specific concern. Nurses use different types of assessment depending on the situation, including primary survey, admission assessment, ongoing assessment, focused assessment, and time-lapsed reassessment. Registered nurses analyse assessment findings as part of the nursing process. LPNs/LVNs and UAPs may collect certain data within their scope of practice, but the RN remains responsible for analysis, supervision, and clinical judgement.

Diagnosis is the second step of the nursing process. During this step, the registered nurse analyses assessment data to identify actual or potential nursing diagnoses, problems, and client needs. After collecting assessment data, the nurse determines which findings are expected or unexpected, normal or abnormal, and clinically relevant. The nurse then clusters related information, recognises patterns, and forms hypotheses about the client’s nursing needs. A nursing diagnosis is a clinical judgement about a human response to a health condition or life process. Nursing diagnoses are different from medical diagnoses. A medical diagnosis identifies a disease or condition, while a nursing diagnosis focuses on how the client responds to that condition. For example, two clients may both have heart failure, but one may need education about medications while another may experience anxiety about the impact of the illness on family life. Their nursing diagnoses may therefore be different. Nursing diagnoses guide the nursing care plan and help nurses select appropriate interventions. NANDA-I nursing diagnoses are grouped into domains that support nurses in identifying patterns of client responses. Common types of nursing diagnoses include:

• Problem-focused diagnoses
• Health-promotion diagnoses
• Risk diagnoses
• Syndrome diagnoses

Nursing diagnosis statements often include the problem, related factors, and defining characteristics. This is sometimes remembered using PES format:

• P: Problem
• E: Etiology or related factors
• S: Signs and symptoms or defining characteristics

Prioritisation is also part of diagnosis. Nurses decide which concerns require attention first based on client safety, urgency, Maslow’s hierarchy of needs, airway, breathing and circulation, and whether the problem is acute or chronic.

Outcome identification is the third step of the nursing process. During this step, the registered nurse identifies expected outcomes for an individualised plan of care. Outcomes are developed in collaboration with the client, family members, significant others, and the interprofessional team when appropriate. They should reflect the client’s needs, values, culture, preferences, and ethical considerations. Goals are broad statements describing the overall direction of care. They may be short-term or long-term depending on the care setting and the client’s condition. For example, in a critical care setting, a short-term goal may be expected within one shift, while in an outpatient setting, a short-term goal may be expected within several weeks. Expected outcomes are more specific than goals. They describe measurable client behaviours or responses that should occur within a specific time frame after nursing interventions are implemented. Outcome statements should be client-centred and usually begin with “The client will…” They should be directed toward resolving the defining characteristics of the nursing diagnosis and should be meaningful to the client. A useful way to write outcomes is the SMART framework:

• Specific: clearly states what is expected
• Measurable: includes observable or measurable criteria
• Attainable: realistic for the client’s condition and resources
• Relevant: connected to the client’s needs and goals
• Time-limited: includes a time frame for evaluation

Outcome identification is performed by registered nurses and is outside the scope of practice for LPNs/LVNs, although they should be aware of expected outcomes in the care plan.

Planning is the fourth step of the nursing process. During this step, the registered nurse develops a collaborative, evidence-based plan to achieve the expected outcomes. The plan should be individualised, holistic, and developed in partnership with the client, family, significant others, and interprofessional team. It should also be prioritised for safety and optimal client outcomes. Nursing interventions are evidence-based actions that nurses perform to help clients reach expected outcomes. These interventions should address the related factors or causes of the nursing diagnosis when possible. Nursing interventions may be:

• Direct care: interventions performed with the client, such as wound care, repositioning, or ambulation
• Indirect care: interventions performed away from the client, such as documentation, care coordination, or communication with providers

Nursing interventions may also be classified as:

• Independent: actions the nurse can perform without a provider order
• Dependent: actions requiring a provider order or prescription
• Collaborative: actions carried out with other healthcare professionals

Individualisation is essential. A planned intervention should match the client’s preferences, needs, values, condition, and resources. Interventions are documented in the nursing care plan to support continuity of care across shifts and team members. Nursing care plans are created by registered nurses. LPNs/LVNs may assist with planned interventions within their scope of practice, but the RN remains responsible for planning and clinical judgement.

Implementation is the fifth step of the nursing process. During this step, the nurse carries out the identified plan of care using critical thinking, clinical judgement, and ongoing reassessment. Implementation is not simply completing tasks. Nurses must consider the client’s current condition, safety, priorities, and response to care. If the client’s condition changes, a planned intervention may no longer be safe and the care plan may need to be revised. Nurses prioritise interventions using principles such as Maslow’s hierarchy of needs, airway, breathing and circulation, urgency, and client safety. Least invasive actions are often preferred when they are appropriate and effective. Client safety is central during implementation. Nurses are in a position to prevent errors before they reach the client. This includes questioning unsafe orders, recognising changes in condition, communicating concerns, and participating in quality improvement. Delegation may occur during implementation. Registered nurses may delegate appropriate tasks to LPNs/LVNs or unlicensed assistive personnel, but they remain accountable for the outcome. Responsibilities requiring clinical judgement cannot be delegated. Interventions must be documented accurately and in a timely manner. If an intervention is not documented, it may be considered not done. Timely documentation also helps prevent errors and supports continuity of care. Implementation also includes coordination of care, health teaching, and health promotion. Client education should occur during care whenever appropriate, such as teaching about medications, side effects, treatment plans, or self-management at home.

Evaluation is the sixth step of the nursing process. During this step, the registered nurse evaluates the client’s progress toward expected goals and outcomes. Evaluation focuses on whether nursing interventions were effective. Nurses reassess the client, compare findings with expected outcomes, and determine whether outcomes were met, partially met, or not met within the identified time frame. If outcomes are not met, the care plan should be revised. This may include changing the nursing diagnosis, updating expected outcomes, modifying interventions, or identifying barriers that affected progress. Reassessment occurs whenever the nurse interacts with the client, communicates with the interprofessional team, or reviews updated laboratory or diagnostic results. Nursing care plans should be updated as client priorities change. Helpful questions during evaluation include:

• Did anything unexpected occur?
• Has the client’s condition changed?
• Were the outcomes and time frames realistic?
• Are the nursing diagnoses still accurate?
• Were the interventions appropriate?
• What barriers affected the client’s progress?
• Are different interventions needed?

Evaluation is performed by registered nurses and is outside the scope of practice for LPNs/LVNs, although they may assist by collecting reassessment data.

A national focus on reducing medical errors has been in place since the Institute of Medicine released To Err is Human: Building a Safer Health System. This report highlighted the serious impact of healthcare errors and encouraged safety to be built into the systems and processes used to provide client care. Since then, several safety initiatives have been developed, including annual National Patient Safety Goals from The Joint Commission and quality and safety education initiatives for nurses. These initiatives emphasise the importance of safe systems, effective communication, error prevention, and continuous improvement. This chapter introduces key safety concepts and strategies that help promote a safe healthcare environment for clients, families, nurses, and other healthcare team members.

Safety is a basic human need and receives high priority in nursing care. Nurses often use Maslow’s Hierarchy of Needs to prioritise urgent client needs, with physiological needs and safety needs receiving the highest priority. Client safety is central to nursing practice in every healthcare setting. Nurses help protect clients from harm during care and also teach clients and caregivers how to prevent injuries at home and in the community. Safe care also includes protecting nurses and healthcare workers, because nurses must remain safe and well in order to care for others effectively. Medical errors can have serious consequences for clients and families. Some events are considered “never events,” meaning they are serious, clearly identifiable, measurable, and usually preventable. Examples include wrong-site surgery, serious medication errors, client suicide in a healthcare setting, or death or injury related to restraints. Sentinel events are serious safety events that reach the client and result in death, permanent harm, or severe temporary harm. These events signal the need for immediate investigation and response. Healthcare organisations often investigate serious events and near misses through root cause analysis. Root cause analysis examines the underlying system issues that contributed to an event rather than focusing only on individual blame. This helps organisations identify safer processes and prevent future harm. Near misses are errors that could have caused harm but did not, either by chance or because they were intercepted. Reporting near misses is important because they reveal risks in the system before harm occurs.

Safety strategies are developed from research and best practice to reduce the likelihood of errors and create safer standards of care. These strategies include medication safety initiatives, checklists, and structured communication tools. Medication errors are a major safety concern. National safety initiatives include lists of abbreviations that should not be used, error-prone abbreviations, frequently confused medications, high-alert medications, and medications that should not be crushed. Nurses also use the rights of medication administration and perform safety checks when administering medications. Checklists are another important safety strategy. Complex healthcare procedures often rely on memory, but memory can be affected by stress, interruptions, and multitasking. Checklists reduce reliance on memory and support consistent safe practice. Surgical checklists, for example, help improve teamwork and communication and reduce errors during procedures. Structured team communication is also essential. Client harm can occur when information is missing, incomplete, inaccurate, or delayed. Tools such as ISBARR and handoff reports help healthcare professionals exchange information in a clear, concise, and organised way. ISBARR stands for:

• Introduction
• Situation
• Background
• Assessment
• Request or Recommendation
• Repeat back

Handoff reports are used when responsibility for client care transfers from one caregiver or team to another. Effective handoff communication helps maintain continuity and safety of care.

A culture of safety reflects the behaviours, beliefs, and values within an organisation that support safety and clinical excellence. It requires leadership, teamwork, openness, accountability, and a focus on learning rather than blame. Inadequate leadership can increase the risk of adverse events. Safety may be weakened when organisations fail to support event reporting, ignore staff concerns, allow intimidation, fail to implement recommendations, or do not address staff burnout. A strong culture of safety includes three important components:

• Just Culture: people are encouraged to report safety concerns, while clear distinctions are made between human error, at-risk behaviour, and reckless behaviour.
• Reporting Culture: staff report errors and near misses without fear of unfair punishment.
• Learning Culture: organisations use safety information to improve systems and prevent future harm.

Just Culture recognises that many errors result from system problems rather than individual carelessness. However, it also recognises that reckless behaviour, such as consciously ignoring serious risks or falsifying records, must still be addressed. Errors may be understood as simple human error, at-risk behaviour, or reckless behaviour. Simple human error may require system changes and support. At-risk behaviour may require coaching and increased awareness. Reckless behaviour may require formal disciplinary action. A strong safety culture encourages nurses and students to report errors, near misses, and unsafe conditions. This allows organisations to learn, improve processes, and protect clients from future harm.

National Patient Safety Goals are published by The Joint Commission to improve client safety. These goals are tailored to different healthcare settings and are updated based on safety data, expert input, and current risks. Nurses and nursing students should be aware of the goals that apply to the setting in which they provide care. These goals guide evidence-based safety practices and help reduce preventable harm. Common safety goals in nursing care settings include:

• Identifying clients correctly using at least two identifiers
• Using medications safely
• Preventing infection through effective hand hygiene
• Preventing falls
• Preventing pressure injuries

These goals are integrated into daily nursing practice. For example, nurses confirm client identity before medications or treatments, communicate medication information during transitions of care, assess fall risk, implement fall precautions, and assess skin integrity to prevent pressure injuries.

Falls are common safety events in healthcare settings and can cause serious injury, disability, or death. Older adults are at particularly high risk. Even when a fall does not cause injury, it can lead to fear of falling, reduced activity, weakness, and increased future fall risk. Fall risk is often caused by multiple factors. Common risk factors include lower body weakness, impaired balance, medications that cause sedation or dizziness, vision problems, poor footwear, urinary urgency, confusion, equipment such as IV poles or catheters, and environmental hazards. Nurses assess fall risk regularly and use fall prevention strategies based on the client’s individual needs. Fall risk assessment tools may be used to identify clients at higher risk and guide interventions. Universal fall precautions apply to all clients. These include:

• Keeping the call light within reach
• Keeping personal items within safe reach
• Keeping the bed in a low position when resting
• Locking bed and wheelchair wheels
• Using non-slip footwear
• Keeping floors clean, dry, and uncluttered
• Providing appropriate lighting
• Following safe client handling practices

Additional interventions are based on individual risk factors. Scheduled hourly rounding can reduce falls by meeting client needs proactively, such as toileting, repositioning, pain control, and access to personal items. Medication-related fall risk should also be reviewed. Clients taking medications that increase sedation, confusion, impaired balance, or orthostatic hypotension may need closer monitoring and medication review.

Restraints are devices, methods, or processes used to restrict a client’s freedom of movement. They may include mechanical restraints, chemical restraints, seclusion, side rails, hand mitts, soft limb restraints, or vest restraints, depending on how they are used. Although restraints may be intended to keep a client safe, they can cause physical and psychological harm. Clients may experience fear, humiliation, anger, pressure injuries, muscle loss, contractures, falls, or entanglement. For this reason, restraint-free care is considered the standard whenever possible. Restraints should only be used when less restrictive alternatives have failed and when there is a clear safety need. When restraints are necessary, nurses must preserve the client’s dignity, monitor frequently, meet basic needs, and follow legal, regulatory, and agency requirements. Medical restraints are used for nonviolent behaviours, such as preventing removal of life-sustaining tubes or devices. Behavioural restraints are used in emergency situations when a client is violent or self-destructive and poses an immediate risk of harm. Important restraint principles include:

• Use the least restrictive option possible
• Attempt alternatives first whenever safe
• Use restraints only for safety, not convenience
• Obtain and renew orders according to policy
• Monitor the client frequently
• Provide hydration, nutrition, toileting, repositioning, and range of motion
• Discontinue restraints as soon as safely possible

Alternatives to restraints include routine schedules, intentional rounding, toileting, pain management, diversionary activities, supervised areas, bed or chair alarms, and sitters when appropriate.

Safety risks vary across age groups and developmental stages. Nurses should understand common risks for each group and provide education that supports prevention. Infants and preschoolers are at risk for motor vehicle injuries, falls, choking, drowning, and accidental poisoning. Because young children are curious and lack judgement about danger, adult supervision and childproofing are essential. School-aged children are at risk for motor vehicle injuries, drowning, poisoning, bicycle accidents, and head injuries. Nurses provide education about car safety, bicycle helmets, safe independence, stranger safety, and recognising signs of maltreatment or abuse. Adolescents are at high risk for motor vehicle accidents, especially related to speeding, seat belt non-use, and distracted driving. They are also at risk for sports-related traumatic brain injuries and substance misuse. Nurses can support prevention through education, screening, and early identification of risk behaviours. Adults may face safety concerns such as intimate partner violence and substance misuse. Nurses are often the first healthcare professionals to recognise signs of abuse or unsafe situations. Compassion, privacy, and effective communication are essential when supporting vulnerable clients. Older adults are at increased risk for falls, motor vehicle injuries, medication errors, fires, elder abuse, neglect, and financial exploitation. Nurses should be alert to signs such as unexplained injuries, poor hygiene, weight loss, anxiety, withdrawal, confusion, or unexplained financial changes. Across the life span, nurses play an important role in identifying safety risks, educating clients and families, reporting concerns when required, and promoting safe environments.

Nurses must also consider safety risks in the work environment. Common risks include sharps injuries, exposure to blood-borne pathogens, lifting injuries, lack of personal protective equipment, fire hazards, and chemical exposure. A safe work environment protects both nurses and clients. Nurses have the right to a workplace that supports physical, mental, and social wellbeing and enables safe care. Sharps injuries and blood-borne pathogen exposure are serious risks because they can transmit illnesses such as hepatitis B, hepatitis C, and HIV. Nurses should use safety-engineered devices, dispose of sharps correctly, follow standard precautions, and report exposures immediately. If a sharps injury or exposure occurs, nurses should follow agency policy and take immediate action, such as washing the area, flushing mucous membranes, reporting the incident, and seeking medical evaluation. Safe client handling is also essential. Manual lifting can cause serious musculoskeletal injuries. Nurses should use safe patient handling equipment and follow workplace procedures to reduce injury risk. Personal protective equipment, such as gloves, gowns, goggles, face shields, and respirators, protects healthcare workers and clients from infection. Nurses must follow agency procedures and transmission precautions when using PPE. Fire safety is another important responsibility. Healthcare workers must know how to respond to a fire, where alarms and extinguishers are located, and how evacuation procedures work. RACE is used for fire response:

• Rescue: remove anyone in immediate danger
• Activate: activate the fire alarm
• Confine: close doors and windows to contain the fire
• Extinguish/Evacuate: extinguish small fires if safe or evacuate if needed

PASS is used for fire extinguisher use:

• Pull: pull the pin
• Aim: aim at the base of the fire
• Squeeze: squeeze the handle
• Sweep: sweep side to side

Safety Data Sheets provide information about workplace chemicals, including hazards, first aid measures, handling, storage, exposure controls, and emergency procedures. Nurses should know how to access and use this information when needed.

Cognition refers to the ability to think, process information, and make decisions. Throughout life, people continually receive information from the world around them and decide how to respond. Some responses are made with awareness, while others are more automatic or reflexive. Cognitive development begins early in life and continues through childhood, adolescence, and adulthood as people learn, adapt, solve problems, and respond to changing situations. Many factors can affect cognitive function. Illness, infection, alcohol, drugs, medications, poor oxygenation, stress, grief, sensory deprivation, and sensory overload can all temporarily or permanently affect a person’s ability to think and make decisions. Nurses monitor for changes in mental status and report concerns to healthcare providers. Recognising changes in cognition is important because cognitive impairment may indicate an underlying condition that requires assessment and treatment. This chapter introduces cognitive development and common acute and chronic cognitive impairments in adults.

Cognitive development is part of human growth and development. Growth refers to physical changes, while development includes biological, social, emotional, and cognitive changes that occur throughout life. Cognition begins at birth and continues across the life span. Although there are expected developmental milestones, each person’s cognitive development is shaped by their experiences, environment, relationships, and health. Developmental theories help nurses understand how people think, relate to others, and respond to care at different life stages. Erikson’s psychosocial theory describes stages across the life span, including trust versus mistrust in infancy, autonomy versus shame in toddlerhood, identity versus role confusion in adolescence, and integrity versus despair in later adulthood. Piaget’s cognitive development theory focuses on how children learn and make sense of the world. His stages include sensorimotor, pre-operational, concrete operational, and formal operational development. These stages describe how children move from learning through sensory and motor experiences to using symbols, logic, and abstract reasoning. Cognitive impairment refers to difficulty with mental processes that affect how a person understands, responds to, and functions in the world. Cognitive functioning may involve:

• Attention
• Decision-making
• Judgement
• Language
• Memory
• Perception
• Planning
• Reasoning

Cognitive impairment in children may range from mild difficulty in specific areas to more significant intellectual disability. Intellectual disability involves deficits in intellectual and adaptive functioning that begin during the developmental period. In adults and older adults, cognitive changes should not automatically be viewed as a normal part of ageing. Losing language skills, becoming disoriented, or being unable to make decisions appropriately are not normal ageing changes. Assuming that all older adults experience cognitive impairment can contribute to ageism. When cognitive changes occur, nurses should consider possible causes such as delirium, dementia, and depression. Dementia is usually chronic and progressive, while delirium is acute and often caused by an underlying physiological problem. Depression can also affect cognition and decision-making, especially in older adults. Delirium requires urgent attention because it may indicate infection, hypoxia, electrolyte imbalance, medication effects, pain, sleep deprivation, or another acute condition. Nurses should monitor mental status closely and promptly report sudden changes.

Alzheimer’s disease is an irreversible and progressive brain disorder that slowly affects memory, thinking, behaviour, and eventually the ability to complete basic daily activities. It is the most common cause of dementia. Changes in the brain may begin years before symptoms appear. Alzheimer’s disease is associated with abnormal protein deposits, including amyloid plaques and tau tangles. These changes damage neurons and interfere with communication between brain cells. As the disease progresses, more areas of the brain are affected. Early symptoms of Alzheimer’s disease may include memory loss that disrupts daily life, difficulty planning or solving problems, difficulty completing familiar tasks, confusion with time or place, changes in judgement, withdrawal from work or social activities, and changes in mood, personality, or behaviour. Alzheimer’s disease progresses through stages. In the preclinical stage, brain changes may be present before symptoms are noticeable. Mild cognitive impairment may involve subtle symptoms that do not greatly affect daily life. As dementia progresses from mild to moderate and severe stages, the person may need increasing support with daily activities, communication, mobility, safety, and personal care. Diagnosis involves a combination of medical history, mental status testing, physical and neurological assessment, and diagnostic testing. Common cognitive screening tools include the Mini Mental State Examination and the Mini-Cog. There is currently no cure for Alzheimer’s disease. Some medications may be prescribed to slow progression or manage symptoms, but nursing care remains essential for promoting safety, dignity, comfort, and quality of life. Behavioural symptoms can be especially challenging for clients and caregivers. These may include:

• Anxiety or agitation
• Aggression or anger
• Hallucinations or delusions
• Restlessness or pacing
• Sleep disturbance or sundowning
• Emotional distress

Nurses should remember that behaviours may be a way of communicating unmet needs such as pain, hunger, thirst, fear, fatigue, toileting needs, overstimulation, or discomfort. The nurse should assess possible causes before responding. Helpful approaches include creating a calm environment, reducing noise and clutter, using simple communication, offering reassurance, maintaining routines, checking for pain or physical discomfort, and avoiding unnecessary confrontation or argument. Sundowning refers to increased confusion, restlessness, anxiety, or agitation that begins or worsens later in the day. Strategies such as maintaining a routine, reducing evening stimulation, improving lighting, limiting caffeine, encouraging daytime activity, and promoting rest may help. Alzheimer’s disease also affects caregivers. Family members and unpaid caregivers may experience emotional, physical, and financial strain. Nurses should monitor for caregiver stress and provide education about support services, respite care, adult day care, residential care options, hospice care when appropriate, and community resources.

The five basic senses—sight, hearing, touch, smell, and taste—help people understand and respond to the world around them. Nurses also rely heavily on their senses when providing care, such as listening to client responses, assessing heart and lung sounds, observing skin changes, identifying odours from wounds, and feeling pulses during circulation assessment. When a person experiences sensory impairment, their ability to function safely can be affected. Sensory impairment may involve loss of one or more senses, too much sensory input, or too little sensory input. Nurses identify sensory impairments and implement interventions that improve safety, functioning, dignity, and quality of life. The goal is to support clients and families by helping them engage with their surroundings and communicate as effectively as possible. This chapter introduces common sensory impairments and related nursing care.

Sensory function depends on an intact nervous system. Sensory receptors receive stimuli from the environment and convert them into signals that travel to the brain. The brain then interprets these signals and triggers an appropriate response. Sensation occurs through three related processes: reception, perception, and reaction. Reception occurs when a sensory receptor is stimulated. Perception occurs when the brain interprets the sensation. Reaction is the person’s response to the perceived stimulus. Sensory impairment refers to difficulty with one or more senses, such as vision, hearing, touch, smell, or taste. It may affect how a person interacts with the environment and can increase safety risks. Vision impairments are common in older adults and may include macular degeneration, cataracts, glaucoma, diabetic retinopathy, and presbyopia. These conditions may affect central vision, peripheral vision, near vision, and the ability to read, drive, recognise hazards, or complete daily activities safely. Hearing loss is also common with ageing. Age-related hearing loss may make it difficult to hear normal conversation, especially when background noise is present. Hearing loss may also be caused by ear wax, exposure to loud noise, medications, or ear conditions affecting balance. Kinesthetic impairments affect the ability to feel sensations such as touch, pressure, vibration, pain, or position. Peripheral neuropathy is one example and may cause burning, tingling, numbness, pain, or difficulty with balance and fine motor tasks. Sensory impairments can increase the risk of social isolation, especially when clients avoid conversations or social settings because of hearing or vision difficulties. Early recognition and support are important across the life span. Sensory overload occurs when a person receives more stimuli than they can process. In healthcare settings, alarms, lights, conversations, procedures, and frequent interruptions may contribute to overload. Symptoms may include irritability, restlessness, confusion, agitation, and increased sensitivity. Sensory deprivation occurs when a person receives too little meaningful stimulation. This may occur because of sensory impairment, limited visitors, isolation precautions, or lack of interaction. Symptoms may include tiredness, disorientation, depression, apathy, or hallucinations.

When caring for clients with altered sensory function, nurses use the nursing process to assess needs, identify risks, plan interventions, and evaluate outcomes. Assessment begins by establishing a therapeutic relationship. Clients may be hesitant to discuss sensory problems, so rapport and respectful communication are important. The nurse should assess the client’s current sensory function, risk factors, use of assistive devices, and the impact of sensory impairment on daily life. The nurse should also assess the environment. Clients with sensory impairments are at increased risk for falls and injury, so lighting, handrails, clear walkways, water temperature, and environmental hazards should be considered. Common nursing diagnoses related to sensory impairment include:

• Risk for Injury
• Risk for Adult Falls
• Impaired Verbal Communication
• Social Isolation

Outcomes should focus on safety, communication, function, and quality of life. For example, a broad goal may be that the client remains free from injury. A more specific expected outcome may be that the client verbalises the layout of the room within a set time frame. Nursing interventions should be individualised. For clients with impaired vision, nurses should ensure access to glasses, provide adequate lighting, reduce glare, describe the environment, keep the room uncluttered, avoid rearranging furniture, and provide large-print materials when needed. For clients with hearing impairment, nurses should gain the client’s attention before speaking, reduce background noise, face the client directly, speak clearly, use short sentences, avoid shouting, and ensure hearing aids or assistive devices are working. For impaired tactile sensation, nurses should help prevent injury by checking water temperature, reducing burn risks, and encouraging safe environmental practices. For impaired oral communication, nurses should allow extra time, use simple explanations, ask short questions when appropriate, provide communication boards or alternative methods, and collaborate with speech therapists. For sensory overload, nurses should reduce noise, combine care activities when possible, limit unnecessary interruptions, and create a calm environment. For sensory deprivation, nurses should provide meaningful stimulation such as clocks, calendars, reading materials, family photos, music, conversation, and family involvement when appropriate. Evaluation involves determining whether interventions improved safety, communication, functioning, and quality of life. The care plan should be revised if outcomes are not met or if the client’s needs change.

Sufficient oxygenation is vital to maintain life. When prioritising nursing interventions, nurses often use the “ABCs”: airway, breathing, and circulation. This reflects the importance of ensuring that oxygen can enter the body, move through the lungs and bloodstream, and reach the tissues. Several body systems work together during oxygenation. The airway must be open and clear, the lungs must move air in and out effectively, the alveoli must support gas exchange, the heart must pump oxygenated blood, and there must be enough haemoglobin to carry oxygen to the tissues. Any alteration in this process can have serious consequences. Conditions such as asthma, chronic obstructive pulmonary disease, pneumonia, heart disease, and anaemia can impair oxygenation and require prompt nursing assessment and intervention.

Oxygenation involves the respiratory, cardiovascular, and haematological systems. These systems work together to bring oxygen into the body, move it into the blood, deliver it to tissues, and remove carbon dioxide. The respiratory system supports gas exchange. During external respiration, oxygen moves from the alveoli into the blood, while carbon dioxide moves from the blood into the alveoli to be exhaled. During internal respiration, oxygen moves from systemic capillaries into body tissues, while carbon dioxide moves from the tissues into the blood. Ventilation is the mechanical movement of air into and out of the lungs. Effective ventilation is needed so air can reach the alveoli for gas exchange. Lung sounds can provide important information about respiratory status. Adventitious sounds may include:

• Rhonchi: low-pitched sounds associated with mucus in larger airways
• Rales/crackles: popping sounds often associated with fluid in the lungs
• Wheezes: whistling sounds caused by narrowed airways
• Stridor: high-pitched inspiratory sound linked to upper airway obstruction
• Pleural rub: rubbing sound caused by inflamed pleural surfaces

The cardiovascular system transports oxygenated blood to the body. The pulmonary circuit moves blood between the heart and lungs, while the systemic circuit moves oxygenated blood to tissues and returns deoxygenated blood to the heart. Cardiac output refers to the amount of blood pumped by the heart in one minute. Perfusion refers to blood flow through arteries to organs and tissues. If cardiac output or perfusion is impaired, oxygen delivery to tissues may be reduced. The haematological system supports oxygen transport through haemoglobin in red blood cells. Most oxygen in the blood is carried by haemoglobin. When haemoglobin reaches tissues, oxygen is released and carbon dioxide is carried back to the lungs for exhalation. Pulse oximetry measures peripheral oxygen saturation (SpO2). For most adults, the target SpO2 range is usually 94–98%, although clients with chronic respiratory conditions such as COPD may have a lower prescribed target range. Pulse oximetry is useful but may be inaccurate with poor perfusion, cold extremities, severe anaemia, or carbon monoxide exposure. Arterial blood gases provide more detailed information about oxygen, carbon dioxide, pH, bicarbonate, and arterial oxygen saturation. ABGs are often used when a client has deteriorating or unstable respiratory status. Hypoxia is reduced tissue oxygenation. Early signs may include anxiety, restlessness, confusion, increased heart rate, and increased respiratory rate. Late signs include cyanosis and decreased level of consciousness. Hypercapnia is an elevated level of carbon dioxide in the blood. It may occur with hypoventilation or impaired gas exchange. Symptoms may include tachycardia, dyspnoea, flushed skin, confusion, headache, dizziness, sedation, or shallow respirations. Hypoxia and hypercapnia can become medical emergencies. Nurses must recognise early signs of respiratory distress and respond promptly according to agency policy. Interventions that may support oxygenation include positioning, raising the head of the bed, encouraging breathing and coughing techniques, managing oxygen equipment, administering prescribed respiratory medications, suctioning when needed, providing pain relief, planning rest periods, and reporting worsening symptoms. Enhanced breathing and coughing techniques may include pursed-lip breathing, incentive spirometry, coughing and deep breathing, huffing technique, and vibratory positive expiratory pressure therapy.

Nurses use the nursing process to assess and care for clients with alterations in oxygenation. Assessment includes both subjective and objective data. Subjective assessment focuses on the client’s experience of dyspnoea, cough, sputum, chest pain, and related symptoms. Dyspnoea is the subjective feeling of shortness of breath or difficulty breathing and may be rated on a 0–10 scale. If the client reports chest pain, the nurse should assess whether emergency symptoms are present, such as pressure-like chest pain, pain radiating to the jaw or arm, shortness of breath, dizziness, nausea, or other signs of acute deterioration. Objective assessment includes airway status, respiratory rate, respiratory effort, oxygen saturation, lung sounds, heart rate, skin colour, cyanosis, clubbing, use of accessory muscles, and ability to speak in full sentences. Signs such as tachypnoea, tachycardia, restlessness, confusion, noisy breathing, and tripod positioning may indicate respiratory distress. Diagnostic testing may include chest X-ray, sputum culture, arterial blood gas testing, and other investigations based on the client’s condition. Common nursing diagnoses for decreased oxygenation may include:

• Impaired Gas Exchange
• Ineffective Breathing Pattern
• Ineffective Airway Clearance
• Decreased Cardiac Output
• Decreased Activity Tolerance

Broad goals for clients with oxygenation problems include maintaining adequate movement of air into and out of the lungs, improving oxygen saturation, reducing dyspnoea, and supporting safe activity tolerance. Nursing interventions may include anxiety reduction, respiratory monitoring, positioning, oxygen therapy management, breathing and coughing techniques, medication administration, suctioning, rest periods, and health teaching. Health promotion teaching may include:

• Receiving recommended influenza and pneumococcal vaccines
• Stopping smoking
• Drinking adequate fluids when appropriate
• Participating in physical activity as tolerated
• Using prescribed respiratory devices correctly

When implementing interventions, nurses should reassess the client’s current level of dyspnoea and modify care based on the client’s condition. If dyspnoea worsens, interventions such as ambulation may need to be delayed, and additional support may be required. Evaluation includes documenting the client’s response and reassessing respiratory rate, heart rate, oxygen saturation, lung sounds, work of breathing, and the client’s reported level of dyspnoea.

Nurses are frequently exposed to clients with communicable diseases, but infection can often be prevented through strong immune defences, safe practice, and infection control measures. Several factors affect the body’s ability to defend against infection, and some individuals are at greater risk than others. When infection occurs, early recognition is essential to prevent it from spreading within the individual and to others. Preventing infection and reducing the spread of infection are major nursing responsibilities. This chapter introduces the physiology of inflammation and infection, as well as nursing interventions used to prevent transmission.

Microorganisms are naturally present in the environment and on or inside the human body. Some microorganisms live harmlessly on the skin, in the nasopharynx, or in the gastrointestinal tract and are called normal flora. Each person has an individual collection of microorganisms called a microbiome. The microbiome is acquired at birth, changes over time, and can influence immune function. Microorganisms that cause disease are called pathogens. Common types of pathogens include:

• Viruses: genetic material protected by a protein coat that invades host cells to replicate
• Bacteria: single-celled organisms, some of which can cause infection
• Fungi: organisms that may cause infections such as oral thrush or yeast infections
• Parasites: organisms that live in or on a host and benefit at the host’s expense

Antibiotics are used to treat bacterial infections but do not work against viruses. Antiviral, antifungal, antiparasitic, and anthelmintic medications may be used depending on the type of pathogen involved. Some bacteria have become resistant to antibiotics, making infections more difficult to treat. Examples include MRSA and other multidrug-resistant organisms.

The body has several natural defences against infection. Nonspecific innate immunity is present from birth and targets invading pathogens in a general way. Physical defences include the skin, mucous membranes, endothelia, and the microbiome. The skin acts as a protective barrier, while mucous membranes trap pathogens and debris. In the respiratory tract, cilia help move mucus and trapped particles away from the lungs. Mechanical defences help remove pathogens from the body. Examples include tears, blinking, urine flow, coughing, sneezing, and peristalsis in the gastrointestinal tract. The microbiome also helps protect against infection by competing with pathogens for nutrients and binding sites. When the microbiome is disrupted, such as after antibiotic use, opportunistic infections may occur. Chemical defences include sebum, enzymes, acidic environments, and chemical mediators. These substances help inhibit microbial growth and support immune responses. Inflammation occurs when pathogens breach the body’s defences or when injury occurs. It helps recruit immune cells, remove damaged tissue, and begin repair. Common signs of inflammation include:

• Redness
• Swelling
• Heat
• Pain
• Altered function

Fever is also part of the inflammatory response. A low-grade fever may help the body fight infection, but very high or prolonged fever can cause harm and requires monitoring. Specific adaptive immunity is activated when innate defences are not enough. B cells produce antibodies, T cells help coordinate and attack infected cells, and memory cells provide longer-term protection. Vaccines work by supporting adaptive immunity and preparing the body to respond quickly to specific pathogens.

Infection occurs when a microorganism invades and grows within the body. Infection can cause disease when it disrupts normal structure or function. A pathogen’s ability to cause disease is called pathogenicity. Virulence refers to how likely a pathogen is to cause serious disease. Highly virulent pathogens can cause severe illness, while less virulent pathogens may cause mild symptoms or no symptoms at all. Pathogens may be primary or opportunistic. A primary pathogen can cause disease even in a healthy host. An opportunistic pathogen causes disease when the host’s defences are weakened, such as after surgery, during chemotherapy, with immunodeficiency, or when skin is not intact. Infection develops through stages of pathogenesis:

• Exposure: the person encounters a pathogen
• Adhesion: the pathogen attaches to host tissue
• Invasion: the pathogen spreads into local tissue or the body
• Infection: the pathogen multiplies and causes disease

Infections may be local, secondary, or systemic. A local infection is limited to one area, such as a wound or bladder infection. A secondary infection occurs during or after treatment for another infection. A systemic infection spreads throughout the body and may cause fever, malaise, increased heart rate, and enlarged lymph nodes. Bacteremia refers to bacteria in the bloodstream. Sepsis occurs when infection triggers a widespread inflammatory response that can damage tissues and organs. Septic shock is a life-threatening drop in blood pressure that can lead to organ failure and death. Nurses must recognise early signs of systemic infection and sepsis. Concerning signs include fever or low temperature, increased heart rate, increased respiratory rate, low blood pressure, confusion, shortness of breath, clammy skin, and worsening pain or discomfort. Infection-related disease often progresses through stages: incubation, prodromal period, acute illness, decline, and convalescence. A person may be contagious during different stages depending on the pathogen.

Antibiotics are used to treat bacterial infections by killing bacteria or stopping them from reproducing. They do not treat viral infections such as colds or influenza. Antiviral medications may be used for some viral infections. Antifungal medications treat fungal and yeast infections. Antiparasitic and anthelmintic medications are used to treat parasitic and worm infections. Antibiotic resistance is a major public health concern. It occurs when microorganisms develop the ability to survive medications that were once effective against them. Resistant infections can lead to longer hospital stays, higher treatment costs, and increased risk of death. Antimicrobial stewardship promotes the appropriate use of antibiotics and other antimicrobial medications. It aims to improve client outcomes, reduce resistance, and decrease the spread of multidrug-resistant organisms. Nurses support antimicrobial stewardship through client education. Clients should understand that antibiotics only work for bacterial infections and should complete the full prescribed course unless advised otherwise by their provider. Stopping antibiotics early or using them unnecessarily can contribute to resistance.

Nurses play an important role in preventing the spread of infection. The chain of infection describes how infection is transmitted. Breaking any link in the chain can help stop the spread of disease. The links in the chain of infection are:

• Infectious agent: the organism causing infection
• Reservoir: where the organism lives and grows
• Portal of exit: how the organism leaves the reservoir
• Mode of transmission: how the organism is transferred
• Portal of entry: how the organism enters a new host
• Susceptible host: the person at risk of infection

Infection can be prevented by hand hygiene, disinfection, sterilisation, vaccination, cough etiquette, safe injection practices, standard precautions, transmission-based precautions, and appropriate use of personal protective equipment. Standard precautions are used for all clients, regardless of known infection status. They include hand hygiene, use of PPE when exposure is possible, respiratory hygiene, safe handling of equipment and linen, safe injection practices, and correct environmental cleaning. Hand hygiene is one of the most effective ways to prevent infection. It should be performed before touching a client, before aseptic tasks, after contact with blood or body fluids, after touching a client or their environment, and immediately after removing gloves. Transmission-based precautions are used in addition to standard precautions for infections that spread through specific routes. These include contact, droplet, and airborne precautions. Clients may require a private room, dedicated equipment, signage, limited transport, and appropriate PPE. Enteric precautions are used for gastrointestinal pathogens such as C. difficile or norovirus. Soap and water should be used for hand hygiene because alcohol-based hand rubs are not effective against C. difficile spores. Reverse isolation, also called neutropenic precautions, is used to protect immunocompromised clients from pathogens in the environment. This may include meticulous hand hygiene, limiting exposure to certain foods or plants, private rooms, and masking during transport. Isolation can affect mental wellbeing. Nurses should explain the reason for precautions, reduce stigma, provide reassurance, and encourage safe interaction and meaningful activities. Aseptic technique prevents transfer of microorganisms during procedures. Sterile technique aims to eliminate microorganisms from a sterile field and is used during procedures such as urinary catheter insertion, wound dressing changes, and central line care. Other infection prevention measures include oral care, daily bathing, clean linens, appropriate glove use, disinfecting mobile devices, removing contaminated gripper socks before returning to bed, and maintaining intact skin.

Nurses use the nursing process to assess, prevent, and manage infection. Assessment begins by identifying symptoms of infection. During the early prodromal period, clients may report general symptoms such as malaise, headache, fever, and loss of appetite. As infection progresses, more specific signs and symptoms may develop. Fever is a common sign of infection and inflammation. Infection can also increase heart rate and respiratory rate because of increased metabolic demand. Nurses should also assess for local signs of infection such as redness, warmth, swelling, tenderness, and purulent drainage. Older adults may show subtle signs of infection. They may not develop a fever or elevated white blood cell count. New confusion, lethargy, or change in mental status may be an early sign of infection, especially urinary tract infection. Diagnostic testing may include:

• Complete blood count with differential
• Erythrocyte sedimentation rate
• C-reactive protein
• Serum lactate level when sepsis is suspected
• Blood cultures
• Urine, sputum, wound, nasal, or nasopharyngeal cultures
• Chest X-ray when lower respiratory infection is suspected

When both blood cultures and antibiotics are ordered, cultures should be collected before antibiotics are administered whenever possible, because antibiotics may affect culture results. Nursing diagnoses depend on the client’s condition and type of infection. Common examples include Risk for Infection, Risk for Shock, Hyperthermia, Ineffective Airway Clearance, and other diagnoses related to the affected body system. Nursing interventions may include monitoring vital signs, assessing for signs of infection and sepsis, maintaining aseptic or sterile technique, using appropriate precautions, promoting nutrition and fluids, encouraging rest, supporting hygiene, changing saturated dressings, encouraging vaccination, and teaching clients when to report symptoms. For fever or hyperthermia, interventions may include monitoring level of consciousness, adjusting room temperature, encouraging fluids, administering prescribed antipyretics, applying cooling methods when needed, and monitoring for dehydration. When caring for clients with active infection, nurses administer antimicrobials as prescribed, monitor culture and sensitivity results, and report new results to the provider so treatment can be adjusted if needed. Nurses must monitor for signs of SIRS, sepsis, and septic shock. Concerning signs include heart rate greater than 90, temperature greater than 38°C or less than 36°C, respiratory rate greater than 20, low blood pressure, abnormal white blood cell count, new confusion, and signs of poor perfusion. Evaluation focuses on whether infection prevention or treatment interventions are effective. If outcomes are not met, the plan of care should be revised.

The integumentary system includes the skin, hair, and nails. The skin is the largest organ of the body and has many important functions. Skin helps regulate body temperature, supports sensation, protects the body from harmful substances such as dirt, bacteria, and viruses, and helps retain moisture. Maintaining intact skin is essential for preventing infection and supporting overall health. This chapter introduces the anatomy and physiology of the integumentary system, factors that affect healthy skin and wound healing, and nursing interventions used to protect and repair the skin.

The skin has three main layers: the epidermis, dermis, and hypodermis. The epidermis is the thin outer layer. The dermis contains hair follicles, sebaceous glands, blood vessels, sweat glands, and nerve endings. The hypodermis, also called the subcutaneous layer, contains mostly adipose tissue, along with blood vessels and nerve endings. Hair grows from follicles in the dermis and is made mainly of keratin-filled cells. Hair helps provide insulation, protects the skin from ultraviolet light, contributes to sensation, and supports nonverbal communication through structures such as the eyebrows. Nails are accessory organs of the skin made of dead keratinocytes. They protect the fingers and toes, enhance sensation, and help with fine motor tasks. Skin integrity refers to skin health. Impaired skin integrity means the epidermis or dermis is damaged. When deeper structures such as muscle, tendon, bone, or ligaments are damaged, this is referred to as impaired tissue integrity. Several risk factors can affect skin health and wound healing, including:

• Impaired circulation and oxygenation
• Impaired immune function
• Diabetes
• Inadequate nutrition
• Obesity
• Excess moisture or dry skin
• Smoking
• Older age

Good circulation is necessary to deliver oxygen, nutrients, immune cells, and clotting factors to tissues. Arterial insufficiency reduces oxygenated blood flow to tissues and can cause cool skin, pale colour, pain with activity, arterial ulcers, and tissue necrosis. Venous insufficiency affects the return of blood and fluid from the extremities and may cause edema, brown leathery skin changes, and venous ulcers. Diabetes can delay wound healing because elevated blood glucose affects circulation, oxygen delivery, immune function, and infection risk. Diabetic neuropathy may also reduce pain sensation, causing injuries to go unnoticed. Nutrition is essential for skin health and healing. Protein, vitamins A, C, D, and E, and minerals such as zinc, selenium, and copper are especially important. Clients with poor wound healing may need dietetic support. Moisture balance is also important. Too much moisture can cause maceration and skin breakdown, while very dry skin can crack and increase infection risk. Nurses support skin health by keeping skin clean, dry, moisturised, and protected. Smoking can impair wound healing by reducing oxygen delivery and affecting the inflammatory phase of healing. Older adults are also at increased risk of skin injury because their skin is thinner and less elastic.

Wound healing occurs in four main phases: hemostasis, inflammation, proliferation, and maturation. Hemostasis begins immediately after injury. Blood vessels constrict and clotting factors activate to stop bleeding. Platelets release growth factors that begin the repair process. The inflammatory phase follows. Blood vessels dilate so white blood cells can move to the wound area and begin cleaning the wound bed. This phase may be seen as redness, swelling, pain, warmth, and drainage. The proliferative phase begins within a few days. New tissue forms through epithelialisation, angiogenesis, collagen formation, and wound contraction. Granulation tissue develops and is usually pink, moist, and fragile. The maturation phase strengthens the wound through continued collagen formation. Scar tissue may form as the wound heals. Wounds may heal by:

• Primary intention: wound edges are closed with sutures, staples, glue, or another closure method
• Secondary intention: the wound remains open and fills in from the bottom with granulation tissue
• Tertiary intention: the wound is left open initially and closed later, often after infection or swelling has improved

Common wound types include skin tears, venous ulcers, arterial ulcers, diabetic ulcers, and pressure injuries. Wound care includes assessing wounds, cleansing wounds, performing dressing changes, protecting healthy tissue, preventing infection, and supporting healing.

Pressure injuries are localised damage to the skin or underlying soft tissue, usually over a bony prominence, caused by prolonged pressure, often combined with shear. Pressure injuries commonly occur over areas such as the sacrum, heels, ischia, and coccyx. They form when tissue is compressed between a hard external surface, such as a bed or chair, and an internal bony surface. Shear occurs when tissue layers move over one another, stretching and damaging blood vessels. Friction occurs when the skin rubs against a surface, such as bed linen or a wheelchair arm. Both shear and friction increase the risk of skin breakdown. Hospital-acquired or worsening pressure injuries are considered preventable safety events. Nurses help prevent pressure injuries through careful assessment, repositioning, skin care, nutrition support, moisture management, and pressure reduction. Pressure injuries are staged according to tissue damage:

• Stage 1: intact skin with nonblanchable redness
• Stage 2: partial-thickness skin loss with exposed dermis
• Stage 3: full-thickness tissue loss with visible fat but no exposed bone, tendon, ligament, cartilage, or muscle
• Stage 4: full-thickness tissue loss with exposed bone, tendon, ligament, cartilage, or muscle
• Unstageable: full-thickness tissue loss where the wound base is covered by slough or eschar
• Deep tissue pressure injury: persistent deep red, maroon, or purple discoloration, sometimes with a blood-filled blister

Slough is usually yellow, soft, and moist inflammatory tissue. Eschar is dark brown or black dead tissue that may be dry, thick, and leathery. These may need removal by trained healthcare providers for accurate staging and healing. Stage 3 and Stage 4 pressure injuries may involve undermining or tunnelling. Undermining occurs when tissue under the wound edge is eroded. Tunnelling refers to channels extending from the wound under the skin.

The Braden Scale is an evidence-based assessment tool used to identify a client’s risk for developing pressure injuries. It assesses six risk factors and produces a total score. The lower the score, the higher the risk. Braden Scale risk levels include:

• Mild risk: 15–18
• Moderate risk: 13–14
• High risk: 10–12
• Severe risk: less than 9

The six Braden Scale categories are sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Sensory perception assesses the client’s ability to respond meaningfully to pressure-related discomfort. Clients who cannot feel or communicate discomfort are at increased risk and may need more frequent skin inspection, heel protection, specialty mattresses, and repositioning. Moisture assesses how often the skin is exposed to moisture from perspiration, urine, stool, or wound drainage. Excess moisture increases the risk of skin breakdown. Interventions include moisture barriers, frequent pad checks, linen changes, toileting plans, and skin protection. Activity assesses the client’s physical activity level. Clients who walk frequently have lower risk, while chair-fast or bedfast clients require structured mobility plans, pressure relief, specialty cushions, heel elevation, and turning schedules. Mobility assesses the client’s ability to change or control body position. Clients with limited mobility require regular repositioning, skin inspection, heel elevation, specialty beds when needed, and support with small weight shifts. Nutrition assesses intake of food, fluids, protein, and supplements. Poor intake increases pressure injury risk and delays healing. Interventions may include dietary monitoring, nutrition supplements, fluid encouragement, family-supported preferred foods, and dietetic referral. Friction and shear assess whether the client slides against surfaces or requires assistance with movement. Interventions include keeping linens clean and wrinkle-free, avoiding massage over pressure points, using protectors, using draw sheets and adequate assistance for repositioning, and limiting head-of-bed elevation when appropriate. Preventing pressure injuries requires teamwork. Registered nurses, licensed practical nurses, nursing assistants, dietitians, physical therapists, providers, and other team members all contribute to assessment, prevention, repositioning, nutrition, mobility, and wound care.

Pain is a universal sensation that everyone experiences. Acute pain is also a common reason why clients seek medical care. Nurses work with the interdisciplinary team to assess and manage pain using a multidimensional approach. Effective pain management promotes comfort, reduces suffering, supports healing, and improves quality of life. This chapter introduces best practices and standards of care for pain assessment and pain management.

Pain is a personal sensory and emotional experience. A client’s report of pain should always be respected, even when pain is not visible or easily measurable. Pain may occur because of actual or potential tissue damage, but it can also persist after healing or occur without a clearly detectable cause. Verbal description is only one way pain is expressed; clients who cannot communicate verbally may still experience pain. Pain begins when nociceptors detect harmful stimuli and send signals through nerve pathways to the spinal cord and brain. A-delta fibres carry fast, sharp pain, while C fibres carry slower, dull, aching, or burning pain. Types of pain include:

• Visceral pain: diffuse, deep pain from internal organs
• Deep somatic pain: dull aching pain from muscles, bones, tendons, or ligaments
• Superficial pain: sharp, well-localised pain from the skin or superficial tissues
• Neuropathic pain: burning or pins-and-needles pain caused by nerve damage or disease

Pain may be acute or chronic. Acute pain has a specific cause and limited duration and may cause changes in vital signs. Chronic pain lasts longer than six months and can affect physical function, mood, sleep, social life, and daily activities. The pain experience is influenced by biological, psychological, social, cultural, developmental, and spiritual factors. Some clients are at increased risk of undertreated pain, including older adults, nonverbal clients, cognitively impaired clients, non-English-speaking clients, clients with substance use history, and clients whose cultural or religious beliefs affect pain expression. Nurses must assess pain carefully and avoid assuming that lack of verbal complaint means absence of pain.

Asking a client to rate pain from 0 to 10 is useful for screening, but a complete pain assessment requires more detail. Nurses should also identify the client’s comfort-function goal, which describes the pain level that allows the client to complete important activities. Pain assessment mnemonics help nurses collect consistent information. PQRSTU includes:

• Provocative/Palliative: what makes the pain better or worse?
• Quality/Quantity: what does the pain feel like?
• Region/Radiation: where is the pain, and does it move?
• Severity: how severe is the pain?
• Timing/Treatment: when does it occur, and what has helped?
• Understanding: what does the client think is causing it?

OLDCARTES and COLDSPA are also used to guide pain assessment. These frameworks help nurses ask about onset, location, duration, characteristics, aggravating factors, radiation, treatment, effects, pattern, severity, and associated factors. Standardised pain scales may be used depending on the client:

• 0–10 numeric scale: commonly used for clients who can rate pain verbally
• FACES scale: useful for children and clients who respond better to visual tools
• FLACC scale: used for young children or clients unable to verbalise pain
• COMFORT Behavioural Scale: used for children receiving mechanical ventilation
• PAINAD scale: used for clients with advanced dementia who cannot communicate pain clearly

Comfort-function goals connect pain management to recovery and function. For example, one client may need pain reduced to 3 out of 10 to walk safely, while another may need a lower level to participate in therapy. If the client’s pain exceeds their comfort-function goal, the nurse should intervene and reassess within an appropriate time frame, often within one hour.

Pain management requires collaboration between nurses, healthcare providers, pharmacists, and sometimes pain specialists. Analgesics may be classified as nonopioids, opioids, or adjuvant medications. A general principle is to use the lowest effective dose, the least invasive route, and the medication with the fewest side effects that still manages the client’s pain effectively. Nonopioid analgesics include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). Acetaminophen can treat mild pain and fever, but excessive doses can cause severe liver damage. Nurses must calculate the total daily dose, especially when combination medications contain acetaminophen. NSAIDs, such as ibuprofen, naproxen, and ketorolac, reduce pain, fever, and inflammation. They may increase the risk of gastrointestinal bleeding, kidney injury, heart attack, heart failure, and stroke, especially in older adults or clients taking certain medications. Opioids are used for moderate to severe pain. They block pain processing but can cause serious adverse effects. The most serious risk is respiratory depression, usually preceded by sedation. Nurses must monitor respiratory rate, oxygen saturation, sedation level, and mental status. Other opioid adverse effects include:

• Constipation
• Nausea and vomiting
• Urinary retention
• Pruritus
• Sedation
• Respiratory depression

Patient-controlled analgesia allows the client to self-administer prescribed opioid doses through a programmed pump. Only the client should press the PCA button. Nurses monitor closely for oversedation and respiratory depression. Adjuvant medications are not primarily classified as analgesics but can help manage pain, especially neuropathic pain. Examples include amitriptyline and gabapentin. Nonpharmacological pain management can be used alongside medication or independently. Examples include relaxation techniques, massage, heat or cold therapy, meditation, music, positioning, acupuncture, yoga, Tai Chi, and other complementary approaches. Pain management should balance comfort, function, safety, and the risk of opioid-related harm.

Sleep is one of the basic physiological needs identified in Maslow’s Hierarchy of Needs. Getting enough quality sleep at the right times supports physical health, mental health, safety, and quality of life. Chronic sleep deficiency can increase the risk of heart disease, kidney disease, high blood pressure, diabetes, stroke, and weakened immune function. This chapter introduces the physiology of sleep, common sleep disorders, and interventions that support healthy sleep.

Sleep is regulated by two internal biological mechanisms: circadian rhythms and sleep-wake homeostasis. Circadian rhythms follow an approximately 24-hour cycle and help regulate wakefulness, body temperature, metabolism, hormone release, and the timing of sleep. Environmental cues such as light and temperature help align the body clock with day and night. Sleep-wake homeostasis tracks the body’s need for sleep. The longer a person stays awake, the stronger the pressure to sleep becomes. Adenosine is linked to this sleep drive and builds up during wakefulness. Melatonin increases in the evening and signals the body to prepare for sleep, while cortisol rises in the early morning and helps the body wake. Several factors can affect sleep, including:

• Medical conditions
• Medications
• Stress
• Sleep environment
• Food and fluid intake
• Exposure to artificial light
• Shift work or jet lag

Sleep occurs in cycles of non-REM and REM sleep. A full sleep cycle usually lasts around 80 to 100 minutes, and most people complete several cycles each night. Non-REM sleep includes:

• Stage 1: transition between wakefulness and sleep
• Stage 2: early sleep phase
• Stage 3: deep or slow-wave sleep, important for restoration

During REM sleep, brain activity increases, the eyes move rapidly, and dreaming occurs. REM sleep becomes more common later in the night. Sleep supports healthy brain function, emotional regulation, memory, learning, decision-making, physical healing, immune function, growth, and daytime performance. Sleep deficiency can reduce concentration, slow reaction time, increase errors, affect mood, and increase the risk of accidents. Microsleep may occur when a person briefly falls asleep without realising it, which can be dangerous during activities such as driving. Common sleep disorders include insomnia, obstructive sleep apnea, and narcolepsy. Insomnia causes difficulty falling asleep, staying asleep, or achieving good-quality sleep. It may be short term or chronic. Healthy sleep habits, cognitive behavioural therapy, and selected medications may be used for treatment. Obstructive sleep apnea occurs when the upper airway becomes repeatedly blocked during sleep, reducing or stopping airflow. Symptoms may include loud snoring, gasping, daytime sleepiness, morning headaches, dry mouth, and poor concentration. Treatment may include CPAP or oral appliances. Narcolepsy causes extreme daytime sleepiness and sudden episodes of sleep. It may also involve sleep attacks, sleep paralysis, hallucinations when falling asleep or waking, and disrupted nighttime sleep. Treatment may include medications and scheduled daytime naps.

Since the time of Florence Nightingale, sleep has been recognised as important for healing and recovery. Sleep disturbances are common during illness and hospitalisation, especially among surgical clients. Hospitalised clients may experience disrupted sleep because of:

• Pain or anxiety
• Uncomfortable beds
• Being too warm or too cold
• Noise from alarms, equipment, staff, or other clients
• Frequent interruptions from care activities
• Intravenous lines, urinary catheters, or drainage tubes

Poor sleep can increase daytime sleepiness, reduce mobility, delay recovery, and affect participation in rehabilitation. Strategies that can support sleep include:

• Reducing noise and light at night
• Bundling care activities to reduce awakenings
• Supporting the client’s usual bedtime routine when possible
• Creating a cool, quiet, comfortable sleep environment
• Limiting electronic devices before bedtime
• Encouraging daytime activity when appropriate
• Avoiding caffeine, nicotine, alcohol, and heavy meals close to bedtime
• Offering comfort measures such as extra pillows, music, eye masks, or ear plugs

Hospitals can promote healing by creating more restful environments. Examples include dimming lights, using quieter equipment, reducing hallway noise, offering sleep kits, and educating clients and families about the importance of sleep for recovery.

Mobility includes moving the extremities, changing position, sitting, standing, transferring, and walking. These basic activities can become difficult during recovery from surgery, injury, chronic illness, or musculoskeletal conditions. Mobility is important because it helps prevent complications associated with immobility and supports independence, comfort, dignity, and well-being. Nurses assist clients to be as mobile as possible according to their individual condition, safety needs, and level of independence.

Mobility is the ability to change and control body position. It requires muscle strength, energy, skeletal stability, joint function, balance, and neuromuscular coordination. Functional mobility includes:

• Bed mobility: moving around in bed, including lying to sitting and sitting to lying
• Transferring: moving from one surface to another, such as bed to chair
• Ambulation: walking independently, with assistance, or with an assistive device

Immobility may be caused by acute illness, chronic disease, traumatic injury, pain, fatigue, neurological disorders, musculoskeletal disorders, or psychological factors. Prolonged immobility can affect several body systems. Possible complications include:

• Depression, anxiety, and reduced quality of life
• Orthostatic hypotension and thrombus formation
• Atelectasis, pneumonia, hypoxia, and pulmonary embolism
• Skin breakdown and pressure injuries
• Muscle atrophy, contractures, foot drop, osteoporosis, falls, and fractures
• Constipation, fecal impaction, nausea, and malnutrition
• Urinary retention and urinary tract infection

Strategies to promote mobility may be performed while the client is in bed or when the client is able to get out of bed. In-bed strategies include repositioning, range-of-motion exercises, and dangling at the bedside. Out-of-bed strategies include transferring, standing, and ambulation. Nurses must assess the client’s mobility status and level of assistance before moving or transferring them. Levels of assistance include dependent, maximum assistance, moderate assistance, minimal assistance, contact guard assist, stand-by assist, and independent. Weight-bearing status may also guide mobility. Common prescriptions include:

• Nonweight-bearing: the affected leg must not support weight
• Toe-touch weight-bearing: toes may touch the floor for balance only
• Partial weight-bearing: limited weight may be placed on the affected leg
• Weight-bearing as tolerated: the client may bear weight according to comfort and ability
• Full weight-bearing: the leg can support full body weight

Safe client handling is essential because moving and lifting clients can cause injury to nurses and health care workers. Proper body mechanics are helpful, but they do not fully prevent injury. Safe patient handling and mobility programs use assessment, assistive devices, staff training, and appropriate technology to protect both clients and staff. Assistive devices may include gait belts, slider boards, sit-to-stand lifts, mechanical lifts, walkers, canes, and wheelchairs. These devices support safe movement while promoting independence whenever possible. Range-of-motion exercises help maintain joint movement and prevent contractures. They may be passive, active, or active-assist, depending on the client’s ability and prescribed plan. Repositioning helps maintain body alignment, prevent pressure injuries, reduce discomfort, and prevent complications such as foot drop and contractures. Common positions include supine, prone, lateral, Sim’s, Fowler’s, semi-Fowler’s, Trendelenburg, and tripod position. When assisting clients to sit, stand, transfer, or ambulate, nurses should monitor for dizziness, vertigo, orthostatic hypotension, weakness, and fall risk. If a client begins to fall, the nurse should not try to catch them, but should help lower them safely to the floor while protecting the head.

Assessment of mobility begins with muscle strength, coordination, and the client’s ability to move safely. Nurses assess bed mobility, sitting balance, ability to dangle, ability to bear weight, transfers, standing, walking with assistance, and independent ambulation. Because immobility affects multiple body systems, nurses also perform a broader assessment. This includes cardiovascular, respiratory, gastrointestinal, genitourinary, skin, and musculoskeletal assessment. Nurses should assess for:

• Blood pressure changes and orthostatic hypotension
• Peripheral pulses, capillary refill, and edema
• Signs of deep vein thrombosis
• Respiratory rate, oxygen saturation, lung sounds, and work of breathing
• Signs of atelectasis or pneumonia
• Bowel sounds, abdominal distension, constipation, or stool changes
• Urinary retention, urgency, frequency, dysuria, or incontinence
• Skin breakdown or pressure injury risk

Mobility needs vary across the life span. Infants, children, adolescents, adults, and older adults all require age-appropriate mobility assessment and education. Older adults are especially at risk for functional decline during hospitalisation, so unnecessary bedrest should be avoided when possible. Common nursing diagnoses related to mobility include impaired physical mobility and other diagnoses related to fall risk, activity intolerance, skin integrity, or self-care deficits. A sample nursing diagnosis is:

Impaired Physical Mobility related to decreased muscle strength as evidenced by slow movement and altered gait.

A broad goal for a client with impaired mobility may be:

The client will participate in activities of daily living to the fullest extent possible for their condition.

A sample SMART outcome may be:

The client will demonstrate appropriate use of adaptive equipment, such as a walker, for safe ambulation by the end of the shift.

Nursing interventions focus on promoting mobility and preventing complications of immobility. Interventions may include:

• Mobilising the client as early and safely as possible
• Encouraging independence with activities of daily living
• Supporting participation in physical therapy
• Performing or encouraging range-of-motion exercises
• Managing pain before activity or therapy
• Using assistive devices correctly
• Implementing fall precautions
• Encouraging deep breathing and coughing exercises
• Repositioning bed-bound clients regularly
• Protecting skin and pressure areas
• Using devices to prevent contractures or foot drop when needed

During implementation, nurses review current orders for weight-bearing and assistance level, reassess the client’s current condition, and use safe handling methods. Tools such as the Banner Mobility Assessment Tool may help guide safe mobility decisions. Nurses should monitor vital signs, dizziness, weakness, dyspnea, skin colour, pain, and tolerance before, during, and after activity. If orthostatic hypotension is suspected, vital signs should be checked while the client is lying, sitting, and standing. Evaluation focuses on the client’s progress toward their SMART outcomes. Mobility goals should be realistic, safe, individualised, and revised when the client’s condition changes.

Nurses promote healthy nutrition to prevent disease, support recovery from illness and surgery, and help clients manage chronic conditions through appropriate dietary choices. Healthy nutrition reduces the risk of obesity and chronic diseases such as diabetes mellitus and cardiovascular disease. Encouraging healthy eating habits early helps clients maintain long-term health. During illness or recovery, nurses support nutrition even when appetite is poor or symptoms such as nausea are present. For chronic conditions, nurses provide education on therapeutic diets, such as low-carbohydrate diets for diabetes or low-fat, low-sodium diets for cardiovascular disease. Nurses also advocate for clients at risk of nutritional deficits. For example, identifying swallowing difficulties may lead to referral for a swallow study to prevent aspiration. Psychosocial risks such as poor home nutrition are also assessed and addressed. In some cases, nurses administer alternative nutrition such as enteral (tube feeding) or parenteral (intravenous) nutrition. This chapter reviews digestive system function, essential nutrients, nutritional guidelines, and application of the nursing process to nutrition.

The digestive system breaks down food, absorbs nutrients, and supports immune function. Digestion begins in the mouth (mastication), continues through the esophagus via peristalsis, and into the stomach where food becomes chyme. In the small intestine, nutrients are absorbed through villi into the bloodstream. The large intestine absorbs water and forms waste for elimination. Nutrients are essential for energy, growth, and bodily functions. Macronutrients provide energy:

• Carbohydrates: main energy source (4 kcal/g); simple vs complex; glycemic index affects blood glucose
• Proteins: tissue repair, immunity, fluid balance (4 kcal/g); complete vs incomplete proteins
• Fats: energy, insulation, hormone production (9 kcal/g); saturated, unsaturated, and trans fats

Micronutrients include:

• Vitamins: essential for metabolism, healing, and immunity (water-soluble and fat-soluble)
• Minerals: support bone, muscle, nerve, and cardiac function (macrominerals and trace minerals)

Nutritional guidelines such as Dietary Reference Intakes (DRIs) and MyPlate help guide balanced eating. A healthy diet includes:

• Vegetables (variety of types)
• Whole grains over refined grains
• Fruits
• Dairy or alternatives
• Lean protein sources
• Healthy fats in moderation

Factors affecting nutrition include:

• Physiological factors (appetite, swallowing, GI function)
• Cultural and religious beliefs
• Economic status
• Medications
• Surgery and metabolic demands
• Alcohol and drug use
• Psychological state (stress, depression)

Assessment includes subjective and objective data. Subjective data:

• Diet history (24-hour recall, food diary)
• Preferences, cultural practices
• Medical history, medications, lifestyle

Objective data:

• Physical appearance (skin, hair, nails)
• Height, weight, BMI
• Signs of malnutrition or obesity

BMI categories:

• <18.5: Underweight
• 18.5–24.9: Normal
• 25–29.9: Overweight
• ≥30: Obese

Laboratory data:

• Hemoglobin (anemia)
• Albumin/prealbumin (protein status)
• WBC (immune status)
• Transferrin (iron transport)

Diagnosis examples:

• Imbalanced Nutrition: Less than Body Requirements
• Overweight or Obesity
• Impaired Swallowing

Outcomes focus on restoring nutritional balance. Example:

The client will select dietary modifications to improve nutritional status by discharge.

Interventions include:

• Monitoring intake and nutritional status
• Supporting food preferences and cultural needs
• Providing supplements when needed
• Assisting with feeding
• Educating about diet and nutrition
• Encouraging a pleasant eating environment

Special diets include:

• NPO
• Clear liquids
• Full liquids
• Mechanical soft
• Pureed
• Therapeutic diets (diabetic, cardiac, renal)

Enteral nutrition delivers nutrients via feeding tubes when oral intake is not possible. Safety includes verifying placement and preventing aspiration. Parenteral nutrition delivers nutrients intravenously when the GI tract cannot be used. Requires close monitoring. Implementation includes:

• Managing symptoms (pain, nausea)
• Positioning clients safely for meals
• Encouraging independence
• Monitoring for swallowing difficulties

Evaluation focuses on improvement in weight, lab values, intake, and overall nutritional status.

The human body maintains a delicate balance of fluids and electrolytes to help ensure proper functioning and homeostasis. When fluids or electrolytes become imbalanced, individuals are at risk for organ system dysfunction. If an imbalance goes undetected and is left untreated, organ systems cannot function properly and ultimately death will occur. Nurses must be able to recognize subtle changes in fluid or electrolyte balances in their clients so they can intervene promptly. Timely assessment and intervention prevent complications and save lives.

The body is in a constant state of change as fluids and electrolytes are shifted in and out of cells in an attempt to maintain balance. Even slight changes can significantly affect body systems. Body Fluids

Body fluids consist of water, electrolytes, plasma, proteins, and solutes. Intracellular fluid (ICF) is inside cells and rich in potassium. It accounts for approximately 60% of total body fluid and 40% of body weight. Extracellular fluid (ECF) is outside cells and rich in sodium. It includes: - Intravascular fluid (blood) - Interstitial fluid (between cells) - Transcellular fluid (e.g., cerebrospinal, synovial) Loss of intravascular fluid leads to hypovolemia and can progress to shock. Fluid Movement

Fluid movement occurs through: - Osmosis (water moves toward higher solute concentration) - Hydrostatic pressure (pushes fluid out) - Oncotic pressure (pulls fluid in via albumin) Low albumin causes fluid to leak into tissues, leading to edema. Solute Movement

- Diffusion: movement from high to low concentration - Active transport: movement against gradient (requires energy) Example: sodium–potassium pump Fluid Regulation

Fluid balance is regulated by: - ADH (retains water) - Thirst mechanism - RAAS system (raises blood pressure via sodium and water retention) Key concept: “Water follows sodium” Fluid Output

Fluid leaves the body through: - Urine (~1500 mL/day) - Skin, lungs, GI tract (insensible losses) Urine output <30 mL/hr is an early sign of dehydration or kidney dysfunction. Fluid Imbalance

Two types: - Excess fluid volume (hypervolemia) - Deficient fluid volume (hypovolemia) Hypervolemia occurs when fluid is retained. Symptoms include edema, ascites, dyspnea, and crackles. Hypovolemia occurs when fluid loss exceeds intake. Symptoms include thirst, dry mucous membranes, decreased urine output, dizziness, tachycardia, and mental status changes.

Intravenous fluids restore or maintain fluid balance. Isotonic Solutions
Same concentration as blood. Remain in intravascular space. Example: 0.9% NaCl, Lactated Ringer’s. Used for hypovolemia. Risk: hypervolemia. Hypotonic Solutions
Lower concentration than blood. Fluid moves into cells. Example: 0.45% NaCl, D5W. Used for cellular dehydration. Risk: cerebral edema. Hypertonic Solutions
Higher concentration than blood. Fluid moves out of cells. Example: 3% NaCl. Used for severe hyponatremia. Risk: hypervolemia and respiratory distress.

Electrolytes play an important role in bodily functions and fluid regulation. There is a very narrow target range for normal electrolyte values, and slight abnormalities can have devastating consequences. For this reason, it is crucial to understand normal electrolyte ranges, causes of electrolyte imbalances, signs and symptoms of imbalances, and appropriate treatments.

Sodium

Sodium levels in the blood typically range from 136-145 mEq/L. Refer to each agency’s normal reference range on the lab report. Sodium is the most abundant electrolyte in the extracellular fluid (ECF) and is maintained by the sodium-potassium pump. Sodium plays an important role in maintaining adequate fluid balance in the intravascular and interstitial spaces.

Hypernatremia refers to an elevated sodium level in the blood. Typically, hypernatremia is caused by excess water loss due to lack of fluid intake, vomiting, or diarrhea. Elevated sodium levels cause osmotic movement of water out of the cells to dilute the blood, causing cellular dehydration. This can affect neurological function, causing confusion, irritability, lethargy, and seizures. Other signs include severe thirst and sticky mucous membranes. Treatment includes decreasing sodium intake, increasing oral water intake, and rehydrating with a hypotonic IV solution.

Hyponatremia refers to a decreased sodium level in the blood. It can be caused by excess water intake or excessive administration of hypotonic IV solutions. Altered sodium levels often cause neurological symptoms because water moves into brain cells, causing them to swell. Symptoms include headache, confusion, seizures, and coma. Treatment depends on the cause and may include limiting water intake, discontinuing hypotonic IV fluids, or gradually raising sodium with a hypertonic IV saline solution if severe.

Potassium

Potassium levels normally range from 3.5 to 5.1 mEq/L. Potassium is the most abundant electrolyte in intracellular fluid and is maintained inside the cell by the sodium-potassium pump. It is regulated by aldosterone in the kidneys and is obtained from foods such as bananas, oranges, and tomatoes. Aldosterone causes sodium reabsorption and potassium excretion in the distal tubule of the kidneys. Insulin also moves potassium into cells from the ECF.

Potassium is necessary for normal cardiac function, neural function, and muscle contractility. Abnormal potassium levels can cause serious heart rhythm and contractility problems. Potassium is poorly conserved by the body and much is lost in urine output, so supplements may be required with loop and thiazide diuretics. Potassium may be given orally or by IV infusion mixed with fluids, but potassium must NEVER be administered IV push because it can immediately stop the heart.

Hyperkalemia refers to increased potassium levels in the blood. It can be caused by kidney failure, metabolic acidosis, potassium-sparing diuretics, or potassium supplements. Signs and symptoms include irritability, cramping, diarrhea, ECG abnormalities, dysrhythmias, and cardiac arrest.

Treatment for hyperkalemia depends on severity. Mild cases may require decreased potassium intake and medication adjustment. Severe cases may require sodium polystyrene sulfonate, insulin with careful blood glucose monitoring and IV dextrose, IV calcium gluconate to protect cardiac muscle, or temporary hemodialysis.

Hypokalemia refers to decreased potassium levels in the blood. It can be caused by vomiting, diarrhea, potassium-wasting diuretics, insulin use, or lack of potassium in the diet. Signs and symptoms include weakness, arrhythmias, lethargy, and a thready pulse. Treatment includes increasing dietary potassium and oral or IV potassium supplementation. IV potassium must be administered carefully because rapid administration can cause cardiac arrest.

Calcium

Calcium levels normally range from 8.6-10.2 mg/dL. Calcium circulates in the bloodstream, but most is stored in bones. It is important for bone and teeth structure, nerve transmission, and muscle contraction. Calcium excretion and reabsorption are regulated by parathyroid hormone (PTH). When calcium levels are low, PTH causes calcium to be reabsorbed in the kidneys and intestine and released from bones. Calcium is also affected by diet and physical activity. Activity moves calcium into bones, while immobility causes calcium release from bones. Dietary sources include dairy products, green leafy vegetables, sardines, and whole grains.

Hypercalcemia refers to an increased calcium level. It can be caused by prolonged immobilization, cancers, hyperparathyroidism, and parathyroid tumors. Signs and symptoms often affect the gastrointestinal and musculoskeletal systems and include nausea, vomiting, constipation, increased thirst and/or urination, and skeletal muscle weakness. Treatment includes decreasing calcium intake, phosphate supplementation, hemodialysis, surgical removal of the parathyroid gland if indicated, and weight-bearing exercise as tolerated.

Hypocalcemia refers to a decreased calcium level. It can be caused by hypoparathyroidism, vitamin D deficiency, renal disease, or high phosphorus levels. Signs and symptoms include numbness and tingling of the lips, tongue, hands, and feet; muscle cramps; and tetany. Chvostek’s sign is involuntary facial twitching when the facial nerve is tapped. Trousseau’s sign is hand spasm after inflating a blood pressure cuff above systolic pressure for three minutes. Treatment includes dietary calcium and vitamin D, oral or IV calcium supplementation, and decreasing phosphorus if elevated.

Phosphorus

Phosphorus levels typically range from 2.5-4.0 mg/dL. Phosphorus is stored in bones and is mainly found in intracellular fluid. It is important for energy metabolism, RNA and DNA formation, nerve function, muscle contraction, and bone, teeth, and membrane building and repair. It is excreted by the kidneys and absorbed by the intestines. Dietary sources include dairy products, fruits, vegetables, meat, and cereal.

Hyperphosphatemia is an increased phosphorus level and can be caused by kidney disease, crush injuries, or overuse of phosphate-containing enemas. It is often asymptomatic, but signs of hypocalcemia may occur due to the inverse relationship between phosphorus and calcium. Treatment includes decreasing phosphorus intake, phosphate-binder medications, and hemodialysis.

Hypophosphatemia is a decreased phosphorus level. Acute causes include alcohol abuse, burns, diuretic use, respiratory alkalosis, resolving diabetic ketoacidosis, and starvation. Chronic causes include hyperparathyroidism, vitamin D deficiency, prolonged use of phosphate binders, hypomagnesemia, or hypokalemia. Severe cases can cause muscle weakness, anorexia, encephalopathy, seizures, and death. Treatment includes treating the cause, oral or IV phosphorus replacement, and increasing phosphate-containing foods.

Magnesium

Magnesium levels typically range from 1.5-2.4 mEq/L. Magnesium is essential for normal cardiac, nerve, muscle, and immune system functioning. About half of the body’s magnesium is stored in bones, about 1% is in extracellular fluid, and the rest is intracellular. Dietary sources include green leafy vegetables, citrus, peanut butter, almonds, legumes, and chocolate.

Hypermagnesemia refers to an elevated magnesium level. It is usually caused by renal failure, excess magnesium replacement, or use of magnesium-containing laxatives or antacids. Signs and symptoms include bradycardia, weak and thready pulse, lethargy, tremors, hyporeflexia, muscle weakness, and cardiac arrest. Treatment includes increasing fluid intake, stopping magnesium-containing medications, hemodialysis or peritoneal dialysis in severe cases, and calcium gluconate to reduce cardiac effects until magnesium levels are lowered.

Hypomagnesemia refers to decreased magnesium levels. It typically results from inadequate intake, loop diuretics, alcohol use disorder, or chronic proton pump inhibitor use. Signs and symptoms include nausea, vomiting, lethargy, weakness, leg cramps, tremor, dysrhythmias, and tetany associated with concurrent hypocalcemia. Treatment includes increasing dietary magnesium and oral or IV magnesium supplementation.

As with electrolytes, correct balance of acids and bases in the body is essential to proper body functioning. Even slight variance outside normal can be life-threatening. The kidneys and lungs work together to correct imbalances. The kidneys compensate for shortcomings of the lungs, and the lungs compensate for shortcomings of the kidneys.

Arterial Blood Gases

Arterial blood gases (ABGs) are measured by collecting blood from an artery, most commonly the radial artery. ABGs measure pH, PaO2, PaCO2, HCO3, and SaO2.

pH

pH is a scale from 0-14 used to determine acidity or alkalinity. A neutral pH is 7. Normal blood pH is 7.35-7.45. A blood pH less than 7.35 is acidic, and a blood pH greater than 7.45 is alkaline.

The lungs and kidneys help maintain pH. During acidosis, the respiratory rate increases to eliminate acid as CO2, while the kidneys excrete hydrogen ions and retain bicarbonate. During alkalosis, the respiratory rate decreases to retain CO2, while the kidneys excrete bicarbonate and retain hydrogen ions.

PaCO2

PaCO2 is the partial pressure of arterial carbon dioxide. The normal range is 35-45 mmHg. CO2 forms an acid in the blood and is regulated by the lungs. Increased or deeper respirations remove CO2, raising pH. Decreased or shallow respirations retain CO2, lowering pH.

HCO3

HCO3 is bicarbonate. The normal range is 22-26. It is a base managed by the kidneys and helps make blood more alkaline. The kidneys retain or excrete HCO3 depending on the body’s pH needs.

PaO2

PaO2 is the partial pressure of arterial oxygen. It more accurately measures oxygenation status than SaO2 and is used to manage clients in respiratory distress. Critical ABG values can lead to serious complications and death if not corrected quickly.

ABG Components and Normal Values

• pH: 7.35-7.45; critical less than 7.25 or greater than 7.60
• PaO2: 80-100 mmHg; critical less than 60 mmHg
• PaCO2: 35-45 mmHg; critical less than 25 or greater than 60 mmHg
• HCO3: 22-26 mEq/L; critical less than 10 or greater than 40 mEq/L
• SaO2: 95-100%; critical less than 88%

Interpreting ABGs

ABGs can be interpreted as respiratory acidosis, respiratory alkalosis, metabolic acidosis, or metabolic alkalosis. They may also be classified as compensated, partially compensated, or uncompensated.

The ROME method means Respiratory Opposite, Metabolic Equal. If PaCO2 moves opposite to pH, the imbalance is respiratory. If HCO3 moves in the same direction as pH, the imbalance is metabolic.

Respiratory Acidosis

Respiratory acidosis occurs when CO2 builds up in the body, causing the blood to become acidic. It is identified by pH below 7.35 and PaCO2 above 45. Causes include acute asthma exacerbation, COPD, heart failure with pulmonary edema, anesthesia, alcohol, opioids, and sedatives.

Symptoms of hypercapnia may include anxiety, mild dyspnea, sluggishness, headaches, hypersomnolence, delirium, paranoia, depression, confusion, decreased level of consciousness, seizures, and coma. The nurse should assess airway, breathing, and circulation and seek urgent assistance if respiratory distress is present. Treatment focuses on improving ventilation, reversing oversedation, administering nebulizers, using BiPAP or CPAP, or intubation and mechanical ventilation if needed.

Respiratory Alkalosis

Respiratory alkalosis occurs when the body removes too much CO2 through respiration, causing increased pH. It is identified by pH above 7.45 and PaCO2 below 35. Causes include hyperventilation from anxiety, panic attacks, pain, fear, head injuries, mechanical ventilation, salicylate overdose, asthma exacerbation, pulmonary embolism, and other respiratory disorders.

Symptoms include shortness of breath, dizziness, light-headedness, chest pain or tightness, paresthesias, and palpitations. Treatment involves addressing the underlying cause, reassurance, removing stressors, and breathing retraining.

Breathing Retraining

The client places one hand on the abdomen and one on the chest and observes which hand moves more. The client is guided to breathe so the abdominal hand moves more than the chest hand. The client breathes in slowly over four seconds, pauses, and breathes out over eight seconds. After 5 to 10 cycles, anxiety and hyperventilation may improve.

If breathing retraining is not successful and severe symptoms persist, a short-acting benzodiazepine may be prescribed. Current research indicates that breathing into a paper bag can cause significant hypoxemia and is no longer recommended. If used, oxygen saturation should be continuously monitored.

Metabolic Acidosis

Metabolic acidosis occurs when acids accumulate or there is not enough bicarbonate. It is identified by pH below 7.35 and HCO3 below 22. Causes include diabetic ketoacidosis, lactic acidosis, severe diarrhea, renal disease, and salicylate excess.

Nurses may suspect metabolic acidosis when rapid breathing occurs as the lungs try to remove excess CO2. Other symptoms include confusion, decreased level of consciousness, hypotension, electrolyte disturbances, circulatory collapse, and death if untreated. Treatment includes IV fluids, glucose management, circulatory support, and IV sodium bicarbonate when pH drops below 7.1.

Metabolic Alkalosis

Metabolic alkalosis occurs when there is too much bicarbonate or excessive loss of hydrogen ions. It is identified by pH above 7.45 and HCO3 above 26. Causes include prolonged vomiting, nasogastric suctioning, excessive urinary loss from diuretics or mineralocorticoids, sodium bicarbonate administration, and hydrogen ion shifting into cells due to hypokalemia.

Nurses may suspect metabolic alkalosis when respiratory rate decreases as the lungs retain CO2. The client may also be confused. Uncorrected metabolic alkalosis can cause hypotension and cardiac dysfunction. Treatment depends on the cause and may include treating vomiting, stopping GI suctioning, stopping diuretics, treating hypokalemia, stopping bicarbonate, or dialysis for clients with kidney disease.

Analyzing ABG Results

1. Step 1: pH. pH below 7.35 is acidosis. pH above 7.45 is alkalosis.
2. Step 2: PaCO2. PaCO2 below 35 is alkalotic. PaCO2 above 45 is acidotic. If PaCO2 moves opposite the pH, the problem is respiratory.
3. Step 3: HCO3. HCO3 below 22 is acidotic. HCO3 above 26 is alkalotic. If HCO3 moves in the same direction as pH, the problem is metabolic.
4. Step 4: Compensation. Fully compensated means pH is normal but PaCO2 and HCO3 are both abnormal. Partially compensated means pH is abnormal and both PaCO2 and HCO3 are abnormal. Uncompensated means pH is abnormal and either PaCO2 or HCO3 is abnormal, but not both.

The nursing process is used continuously when caring for individuals who have fluid, electrolyte, or acid-base imbalances, or are at risk for developing them, because their condition can change rapidly. This systematic approach ensures subtle cues are not overlooked and that outcomes and interventions match the client’s current condition.

Assessment

A thorough assessment provides information about current fluid, electrolyte, and acid-base balance, as well as risk factors for developing imbalances. A chart review or focused health history is a good place to start, and gaps or discrepancies should be verified during the physical assessment. Life span and cultural considerations should also be considered.

Subjective Assessment

Subjective data is obtained from the client or from family members or friends. It includes age; history of chronic disease, surgeries, or trauma; dietary intake; activity level; prescribed medications and adherence; pain; and bowel and bladder functioning.

A history of kidney disease or heart failure places the client at risk for fluid volume excess. Diuretic use places the client at risk for fluid volume deficit and electrolyte and acid-base imbalances. Diabetes mellitus also increases risk for fluid, electrolyte, and acid-base imbalances.

Objective Assessment

Objective data is directly observed through inspection, auscultation, and palpation. A complete head-to-toe assessment helps avoid missing important clues.

• Accurate daily weights should be taken on the same scale, at the same time, with similar clothing. A 1 kg change in 24 hours equals about 1 L of fluid and should be reported.
• Accurate 24-hour intake and output helps validate weight findings. Urine output below 30 mL/hour or 0.5 mL/kg/hour should be reported.
• Elevated blood pressure and bounding pulses may indicate fluid volume excess.
• Decreased blood pressure, elevated heart rate, and weak or thready pulse may indicate fluid volume deficit.
• Systolic blood pressure below 100 mm Hg in adults should be reported unless other parameters are provided.
• Lung crackles may indicate fluid volume excess and are often first heard in the lower posterior lung fields.
• Tight, edematous, shiny skin may indicate fluid volume excess.
• Skin tenting, dry mucous membranes, or dry skin may indicate fluid volume deficit.
• New confusion or decreased level of consciousness may indicate fluid, electrolyte, or acid-base imbalance.
• Cardiac arrhythmias may occur with acid-base imbalance and electrolyte imbalance, especially hypo- or hyperkalemia and alkalosis.

Diagnostic and Lab Work

Diagnostic tests and lab work provide important information about fluid status, electrolyte balance, and acid-base balance. They should be clustered with subjective and objective assessment data to form a complete picture before reporting concerns to the provider.

Common lab tests include serum osmolarity, urine specific gravity, hematocrit, and blood urea nitrogen (BUN).

• Serum osmolarity: normal range 275-295 mmol/kg. Elevated levels indicate concentrated blood and often fluid volume deficit. Decreased levels may indicate fluid volume excess.
• Urine specific gravity: normal range 1.010-1.020. Above 1.020 indicates concentrated urine and possible fluid deficit. Below 1.010 indicates dilute urine.
• Hematocrit: normal range is 42-52% for men and 37-47% for women. Deficient fluid volume can elevate hematocrit; excessive fluid volume can dilute hematocrit.
• BUN: normal range 7-20 mg/dL. Increased BUN may indicate worsening kidney function or fluid volume deficit.

Electrolytes such as sodium, potassium, calcium, phosphorus, and magnesium should be monitored closely in clients at risk. Chest X-ray may identify fluid in the lungs. ECG may identify arrhythmias caused by electrolyte imbalances. ABGs are used for critically ill clients, such as those with diabetic ketoacidosis or severe respiratory distress.

Life Span Considerations

Newborns and infants have a larger proportion of water weight than adults, about 75%. Their RAAS system and kidney concentration ability are less developed, increasing the risk of hyponatremia and fluid volume deficit. They are also less able to excrete potassium, placing them at risk for hyperkalemia. Vomiting and diarrhea can quickly cause fluid and electrolyte disturbances.

Children and adolescents are at risk for dehydration when physically active in hot environments or during illness with diarrhea, vomiting, or fever. Parents should be educated about fluid intake during sweating or illness.

Older adults are at risk due to surgery, chronic heart or kidney disease, diuretic use, decreased mobility, decreased thirst reflex, and reduced kidney function. These factors increase risk for fluid volume deficit and electrolyte abnormalities.

Diagnoses

Nursing diagnoses related to fluid, electrolyte, and acid-base imbalances include Excess Fluid Volume, Deficient Fluid Volume, Risk for Imbalanced Fluid Volume, and Risk for Electrolyte Imbalance.

Example: Fluid Volume Excess related to a compromised regulatory mechanism as evidenced by edema, crackles in lower posterior lungs, and weight gain of 2 kg in 24 hours.

Example: Deficient Fluid Volume related to insufficient fluid intake as evidenced by blood pressure 90/60, dry mucous membranes, decreased urine output, and increased hematocrit.

Risk diagnoses do not contain related factors because they identify vulnerability for a potential problem. Instead, “as evidenced by” refers to evidence of risk.

Outcome Identification

Goals depend on the nursing diagnosis and client situation. For Excess Fluid Volume, an overall goal is that the client will achieve fluid balance. A SMART outcome may be: “The client will maintain clear lung sounds with no evidence of dyspnea over the next 24 hours.”

For electrolyte imbalance, goals include maintaining serum sodium, potassium, calcium, phosphorus, magnesium, and/or pH within normal range, and maintaining normal sinus rhythm with regular rate.

Planning Interventions

Evidence-based interventions should be planned according to the client’s history and specific imbalance.

Implement Interventions Safely

Clients can quickly move from one imbalance to another based on treatment. The nurse must reassess the client before implementing interventions to make sure the current status still warrants the prescribed intervention.

• Monitor daily weights. A change greater than 1 kg in 24 hours should be reported.
• Monitor edema using a 1+ to 4+ scale.
• Monitor intake and output over 24 hours.
• Monitor serum osmolarity, serum sodium, BUN, and hematocrit.
• For IV fluids, monitor for excessive fluid volume, crackles, and dyspnea.
• For diuretics, monitor for fluid volume deficit, hypokalemia, and hyponatremia.
• Implement fall precautions for orthostatic hypotension, restlessness, anxiety, or confusion.

Evaluation

The effectiveness of interventions must be continuously evaluated. If outcomes are met, the plan may be discontinued. If outcomes are not met, outcomes and interventions may need revision.

• Fluid Volume Excess improvement: decreased crackles, decreased edema, decreased shortness of breath, and improved jugular venous distention.
• Fluid Volume Deficit improvement: increased blood pressure, decreased heart rate, normal skin turgor, and moist mucous membranes.
• Electrolyte imbalance improvement: electrolyte levels return to normal and signs/symptoms resolve.
• Acid-base imbalance improvement: ABGs return to normal or baseline, vomiting or diarrhea resolves, and no respiratory distress is present.

After ingesting food and fluids, the body eliminates waste products through the urinary system and the gastrointestinal system.

Nurses provide care for clients with common elimination alterations, including urinary tract infections, urinary incontinence, urinary retention, constipation, diarrhea, and bowel incontinence.

This chapter provides an overview of these alterations and the associated nursing care.

Urinary System

The urinary system, also referred to as the renal system or urinary tract, consists of the kidneys, ureters, bladder, and urethra.

Its purpose is to eliminate waste from the body, regulate blood volume and blood pressure, control levels of electrolytes and metabolites, and regulate blood pH.

The kidneys filter blood in the nephrons and remove waste in the form of urine. Urine exits the kidneys through the ureters and enters the bladder, where it is stored until expelled by urination, also called voiding.

A healthy adult with normal kidney function produces 800–2,000 mL of urine per day, depending on fluid intake and fluid loss through sweating and breathing. The bladder typically holds about 360–480 mL of urine.

Normal urine should be clear, pale to light yellow, and not foul-smelling. Some foods or medications may change urine colour or smell. For example, phenazopyridine may cause orange urine.

Urinary Terms

• Anuria: absence of urine output; less than 50 mL in 24 hours.
• Dysuria: painful or difficult urination.
• Frequency: need to urinate several times during the day or night.
• Hematuria: blood in the urine.
• Oliguria: decreased urine output; less than 500 mL in 24 hours, or less than 0.5 mL/kg/hr in adults and children.
• Nocturia: need to get up at night to urinate.
• Polyuria: more than 2.5 L of urine in 24 hours.
• Pyuria: white blood cells or pus in urine, often indicating infection.
• Urgency: urgent need to void.

Gastrointestinal System

The gastrointestinal system includes the mouth, esophagus, stomach, small intestine, large intestine, and anus.

Food and fluid are pushed through the GI tract by peristalsis. The stomach mixes food with digestive enzymes, and the small intestine absorbs water and nutrients into the bloodstream.

The large intestine absorbs water and changes waste from liquid into stool. The rectum stores stool until it is passed through the anus during a bowel movement.

Bowel Elimination Terms

• Black stools: may occur from iron supplements or bismuth subsalicylate.
• Rectal bleeding: bright red blood in stool, also called hematochezia; should be reported.
• Tarry stools: black, sticky stools called melena, often caused by upper GI bleeding; should be reported.

Life Span Considerations

Newborns and infants: Meconium is the first bowel movement and is sticky and black to dark green. Breastfed babies often have yellow, curdled stools and may have bowel movements after every feeding. Formula-fed babies usually have fewer bowel movements and pastier stools.

Toddlers: Toilet training usually begins between ages two and three. Enuresis means bed-wetting and is generally normal unless it continues past age seven or eight.

Children: School-aged children may develop constipation from delaying bowel movements at school.

Adults: Adult females may develop urinary incontinence related to pregnancy, delivery, menopause, or vaginal hysterectomy. Adult males may develop urgency, urinary retention, or overflow incontinence due to prostate enlargement.

Older adults: Peristalsis slows with aging. Older adults should be encouraged to increase fluids, fiber, and activity as appropriate to prevent constipation. If a bowel movement with soft, formed stool does not occur every three days, a bowel management program should be initiated.

A urinary tract infection (UTI) occurs when bacteria, usually from the rectum, enter the urethra and infect the urinary tract.

The most common type is a bladder infection, also called cystitis. Kidney infection, or pyelonephritis, is more serious because it can have long-lasting effects on the kidneys.

Risk Factors

• Previous UTI
• Sexual activity, especially with a new partner
• Pregnancy
• Older age or young childhood
• Structural problems in the urinary tract, such as prostate enlargement

Symptoms

• Pain or burning during urination
• Frequent urination
• Urgency with small amounts of urine
• Bloody urine
• Pressure or cramping in the groin or lower abdomen
• Confusion or altered mental status in older adults

Symptoms of Kidney Infection

• Fever above 101°F / 38.3°C
• Shaking chills
• Lower back or flank pain
• Nausea or vomiting

UTIs can spread to the blood and cause septicemia and sepsis. Diagnostic tests may include urine dip, urinalysis, or urine culture.

Interventions

Antibiotics are prescribed for urinary tract infections. Nurses teach clients to complete the full course of antibiotics, even if symptoms improve, to reduce antibiotic resistance.

Health teaching includes:

• Drink extra fluids to help flush bacteria from the urinary tract.
• Urinate after sexual activity.
• Stay well-hydrated and urinate regularly.
• Take showers instead of baths.
• Avoid douching, sprays, or powders in the genital area.
• Teach females to wipe front to back.

Urinary incontinence is the involuntary loss of urine. It can affect physical, psychological, and social well-being.

Many clients are embarrassed to discuss incontinence or believe it is a normal part of aging. Nurses can improve quality of life by assessing sensitively and teaching methods to prevent and manage incontinence.

Types of Urinary Incontinence

• Stress urinary incontinence: urine loss with coughing, laughing, jumping, or physical exertion. Often caused by weak pelvic floor muscles.
• Urge urinary incontinence: leakage caused by urgency; also called overactive bladder.
• Mixed urinary incontinence: combination of frequency, urgency, and stress incontinence.
• Overflow incontinence: small amounts leak from a bladder that remains full, often in males with enlarged prostate.
• Functional incontinence: normal bladder control but difficulty reaching the toilet due to mobility, clothing, or cognitive problems.

Assessment

Assessment begins with sensitive screening questions, such as:

• Do you have problems with leakage or dribbling of urine?
• Do you ever have problems making it to the bathroom in time?

A voiding diary may include:

• When and how much the client urinates
• Urinary leakage and activity during leakage
• Sudden urges to urinate
• How often the client wakes at night to use the bathroom
• Type and volume of food and fluids
• Medication use, such as diuretics
• Pain, dribbling, weak urine flow, or feeling the bladder is not empty

Interventions

Nurses use therapeutic communication to reduce embarrassment and support quality of life.

Bladder control training includes:

• Pelvic floor exercises: Kegel exercises strengthen muscles used to stop urination.
• Timed voiding: urinating on a schedule, gradually increasing time between voids.
• Lifestyle changes: weight loss, reducing caffeine, preventing constipation, avoiding heavy lifting, limiting bedtime fluids, and scheduling diuretics earlier in the day.
• Protective products: incontinence underwear, pads, skin protection, and female urethral support products.

Teaching Pelvic Floor Exercises

• Identify the correct muscles by stopping urine flow or imagining stopping gas.
• Lie down, tighten pelvic muscles for a count of 3, then relax for a count of 3.
• Work up to 10–15 repetitions.
• Complete exercises at least three times daily.
• Practise lying, sitting, and standing.
• Improvement may take several weeks; maximum effect may take 3–6 weeks.

Other Treatment Options

• Biofeedback: sensors help clients become aware of body signals.
• Mechanical devices: pessaries support the urethra and may reduce leakage.
• Anticholinergic medications: such as oxybutynin may treat urge or mixed incontinence but can cause dry mouth, constipation, dizziness, and drowsiness.
• Surgery: such as sling procedure or bladder neck suspension if other treatments are ineffective.

Urinary retention occurs when the client cannot empty all urine from the bladder.

It may be acute, such as sudden inability to urinate after anesthesia, or chronic, such as gradual incomplete emptying from prostate enlargement.

Urinary retention may be caused by blockage or by the bladder being unable to create enough force to expel urine. Retained urine increases the risk of UTI because bacteria can multiply in the bladder.

Assessment

Symptoms may range from none to severe abdominal pain. Providers use history, physical assessment, and diagnostic tests. Nurses may measure post-void residual using a bladder scanner or straight catheterization.

Performing a Bladder Scan

• Use a portable, noninvasive scanner to estimate urine volume.
• After voiding, position the client supine.
• Select male or female; if a female has had a hysterectomy, select male.
• Apply warmed gel and place probe about one inch above the symphysis pubis, directed toward the bladder.
• Scan and centre the crosshairs over the urine image.
• If post-void residual is greater than 300 mL, notify the provider.

Indwelling urinary catheterization should be avoided when possible to reduce CAUTI risk.

Interventions

• Urinary catheterization to drain the bladder
• Bladder training therapy
• Medications
• Surgery if needed

Alpha blockers such as tamsulosin may be used for urinary retention caused by prostate enlargement. Transurethral resection of the prostate may be performed if prostate-related retention does not respond to medication.

Constipation

Constipation is defined as infrequent or difficult evacuation of feces. It is often diagnosed when a client has fewer than three bowel movements per week.

Causes include slowed peristalsis from decreased activity, dehydration, low fiber intake, medications such as opioids, depression, or abdominal surgery.

Symptoms may include rectal pressure, abdominal cramps, bloating, distension, and straining.

Fecal Impaction

Fecal impaction occurs when stool accumulates in the rectum. A hallmark sign is seepage of liquid stool from the anus, which should not be confused with diarrhea.

Large hard stool may be treated with mineral oil enemas or digital removal using a lubricated, gloved finger.

Constipation Interventions

• Establish the client’s normal bowel pattern.
• Aim for a bowel movement at least every 72 hours.
• Use prescribed bowel regimen such as stool softeners and mild stimulant laxatives.
• Use stronger laxatives, suppositories, or enemas if oral medications are ineffective.
• Teach increased fluids, dietary fiber, and activity.
• Helpful foods include prune juice, prunes, and apricots.
• Fiber products such as methylcellulose or psyllium should be mixed with a full 8-ounce glass of water.

Intestinal Obstruction or Paralytic Ileus

Intestinal obstruction is partial or complete blockage of the intestines. It may be caused by paralytic ileus, where peristalsis does not move contents forward, or by a mechanical cause such as fecal impaction.

Risk factors include abdominal surgery, general anesthesia, chronic opioid use, electrolyte imbalance, bacterial or viral intestinal infection, decreased blood flow to the intestines, and kidney or liver disease.

Symptoms include abdominal distention or fullness, abdominal pain or cramping, inability to pass gas, vomiting, constipation, or diarrhea.

Bowel sounds must be assessed. High-pitched tinkling sounds may occur with early obstruction. Hypoactive bowel sounds may indicate constipation or occur after surgery, anesthesia, or opioid use. Absent bowel sounds may indicate ileus or mechanical obstruction.

Obstruction/Ileus Interventions

• Maintain strict NPO status.
• Insert or maintain NG tube with suction as prescribed.
• Monitor for return of bowel sounds.
• Report worsening pain, distention, rigidity, or symptoms.
• Surgery may be required if symptoms are not relieved or tissue death is suspected.

Diarrhea is defined as more than three unformed stools in 24 hours. It can cause dehydration, skin breakdown, and electrolyte imbalance.

Diarrhea is caused by increased peristalsis, which moves stool too quickly through the large intestine so water is not effectively reabsorbed.

Causes

• Infectious processes such as bacteria, viruses, and protozoa
• Food poisoning
• Medications such as antibiotics and laxatives
• Food intolerances or allergies
• Anxiety
• Irritable bowel disease and Crohn’s disease
• Dumping syndrome in tube feeding or after gastric bypass
• C. difficile infection after antibiotic therapy

Clients with C. difficile often have watery, foul-smelling stools. Transmission-based precautions are used to prevent spread.

Interventions

• Promote hydration with water or electrolyte-containing fluids.
• Administer IV fluids if dehydration occurs.
• Monitor electrolyte disturbances.
• Monitor for skin breakdown and apply skin protectants.
• Administer prescribed medications such as loperamide, psyllium, or anticholinergic agents when appropriate.
• Use rectal tubes only when prescribed and closely monitor for rectal mucosa damage.

Bowel incontinence is the accidental loss of bowel control causing unexpected passage of stool. It may range from leaking a small amount of stool or gas to inability to control bowel movements.

The rectum, anus, pelvic muscles, and nervous system must work together to control bowel movements. The client must also recognize and respond to the urge to defecate.

Causes

• Chronic constipation causing stretching and weakening of the anus muscles and intestines
• Fecal impaction
• Long-term laxative use
• Colectomy or bowel surgery
• Lack of sensation of the need to have a bowel movement
• Gynecological, prostate, or rectal surgery
• Injury to anal muscles due to childbirth

Interventions

• Use therapeutic communication to reduce embarrassment.
• Encourage a food diary to identify trigger foods.
• Increase fiber to bulk and thicken stool, aiming for about 30 grams of fiber daily.
• Use products such as psyllium to add bulk to stool.
• Assist the client to the toilet after meals and when they feel the urge.
• Ensure privacy and comfort during toileting.
• Teach bowel retraining to schedule bowel movements at a consistent time.
• Encourage warm fluids or breakfast in the morning to stimulate the natural urge.
• For some neurological causes, a laxative may be scheduled every three days.
• Teach pelvic floor exercises to improve anal sphincter control.
• Encourage protective pads or undergarments to support confidence outside the home.
• Surgery may be needed if conservative treatments are not effective.

Urinary Elimination Assessment

Assessment includes asking about voiding habits, frequency, difficulty urinating, and painful urination. The bladder may be palpated above the symphysis pubis for distention.

If incontinence is present, inspect the perineal area for skin breakdown. If urinary retention is suspected, measure post-void residual using a bladder scanner or straight catheterization.

Bowel Elimination Assessment

Subjective assessment includes asking about the client’s normal bowel pattern, date of last bowel movement, stool characteristics, and recent changes.

A normal pattern is usually one bowel movement every one to three days with soft or formed stool.

Additional assessment includes bowel routines, fiber and fluid intake, activity, opioid use, recent barium procedures, and recent abdominal surgery under general anesthesia.

Inspect the abdomen for distension, bulging, bruising, or pulsatile masses. Auscultate bowel sounds in all four quadrants and note whether they are present, hyperactive, or hypoactive.

If bowel sounds are absent or obstruction/ileus is suspected, notify the provider immediately. Light palpation may identify tenderness, abnormal masses, or firmness in the left lower quadrant. Do not deeply palpate if pulsatile masses, rigidity, or suspected abdominal problems are present.

During inpatient care, clients may be asked to call the nurse after a bowel movement so stool amount, consistency, and colour can be assessed.

Ostomies

Ostomies are surgical openings in the abdomen for stool to pass into a bag-like appliance.

• Ileostomy: opening at the junction of the small and large intestines; stool is liquid.
• Colostomy: opening farther along the large intestine; stool is more formed.

Urinary Diagnostic Tests

Urine Dip

A urine dip uses a chemical strip placed into urine. Colour changes indicate substances such as white blood cells, protein, or glucose. A clean catch midstream sample is preferred.

Urinalysis

A urinalysis includes physical, chemical, and microscopic examination of urine. It looks for evidence of infection, including bacteria, white blood cells, leukocyte esterase, or nitrite.

Urine Culture

A urine culture identifies the microbe causing infection. Cultures are commonly performed for recurring UTIs or hospitalized clients at risk for hospital-associated infection.

A properly collected clean catch sample with more than 100,000 colony forming units per milliliter of one type of bacteria usually indicates infection.

If the culture is positive, susceptibility testing guides antibiotic treatment. Nurses should review results to ensure the antibiotic is effective. “No growth” usually means no infection. Growth of several bacteria may indicate contamination and require repeat collection.

Cystoscopy

Cystoscopy is performed using a small tube with a camera inserted through the urethra into the bladder. Fluid expands the bladder so the walls can be visualized. Biopsy samples may be taken.

After the procedure, encourage four to six glasses of water per day as appropriate. A small amount of blood may be present, but ongoing bleeding after urinating three times or signs of infection should be reported.

Urodynamic Flow Test

Urodynamic testing evaluates how well the bladder, sphincters, and urethra store and release urine. It may show whether involuntary bladder contractions are causing leakage.

Bowel Diagnostic Tests

Stool-Based Tests

Stool samples can be tested for bacteria, viruses, parasites, cancer, or occult blood.

The Guaiac-Based Fecal Occult Blood Test detects hidden blood and may be used annually for colon cancer screening. Before the test, clients avoid certain foods and medications as instructed. If positive, colonoscopy is scheduled.

The Stool DNA Test, also called Cologuard, looks for abnormal DNA from cancer or polyp cells and checks for occult blood.

Colonoscopy

Colonoscopy uses a colonoscope inserted through the anus to examine the colon and rectum. It is used for colon cancer screening and to evaluate inflamed tissue, abnormal growths, or lesions.

Before the procedure, the client completes bowel prep, often with clear liquids and laxatives. Some medications such as aspirin or anticoagulants may be withheld. The client is usually NPO after a specified time.

During the procedure, sedative medication is given. Polyps may be removed and sent for biopsy. Because air is inserted into the colon, bloating or cramping may occur, and the client should be encouraged to pass gas.

The client cannot drive afterward and requires transportation. Rare complications include bleeding and perforation.

Barium Enema

A barium enema is a special X-ray of the large intestine and rectum before and after barium is instilled by enema. It is also called a lower GI series.

The client completes bowel preparation beforehand. After the procedure, encourage fluids as appropriate, and a laxative may be prescribed to prevent hard stools and constipation.

Abdominal CT Scan

An abdominal CT scan uses a series of X-rays to create cross-sectional images of the abdomen. Contrast may be given orally, rectally, or intravenously.

If contrast is used, the client may be NPO for four to six hours. Check for allergies to iodine or contrast dye. Kidney function should be verified using BUN, creatinine, and EGFR because IV contrast can worsen kidney function.

If kidney function labs are abnormal, notify the provider before IV contrast. Metformin restrictions may apply. Jewellery should be removed.

After contrast, encourage fluids to help eliminate it as appropriate. If barium was used, stools may be light coloured, and laxatives are often prescribed to prevent impaction or obstruction.

Diagnosis

Examples of nursing diagnoses include:

• Constipation related to insufficient fluid and fiber intake as evidenced by decreased stool frequency, hypoactive bowel sounds, and straining.
• Diarrhea related to gastrointestinal irritation as evidenced by cramping, hyperactive bowel sounds, and more than three liquid stools in 24 hours.
• Bowel Incontinence related to generalized decline in muscle tone as evidenced by involuntary passage of stool.
• Stress Incontinence related to weak pelvic floor muscles as evidenced by leakage when laughing and jumping.
• Urinary Urge Incontinence related to ineffective toileting habits as evidenced by inability to reach the toilet in time and frequently wet underclothes.
• Urinary Retention related to blockage in the urinary tract as evidenced by dribbling, frequent voiding, and sensation of bladder fullness.

Planning Interventions

Alteration	Interventions
Urinary Tract Infection	Administer antibiotics, encourage fluids, and teach UTI prevention.
Urinary Incontinence	Use therapeutic communication, teach Kegel exercises, timed voiding, lifestyle changes, and protective products.
Urinary Retention	Monitor post-void residual, perform bladder scanning, catheterize if ordered, administer medications, monitor for UTI, and teach bladder control as appropriate.
Constipation	Implement bowel regimen, encourage fluids, fiber, and activity.
Fecal Impaction	Administer mineral oil enemas or digitally remove impacted stool as ordered.
Intestinal Obstruction or Paralytic Ileus	Maintain NPO status, monitor bowel sounds and abdomen, report worsening symptoms, and maintain NG tube if ordered.
Diarrhea	Encourage fluids, maintain IV hydration if ordered, monitor electrolytes and skin, administer medications, and use rectal tube if ordered.
Bowel Incontinence	Use therapeutic communication, food diary, fiber, toileting after meals, privacy, incontinence products, bowel retraining, and pelvic floor exercises.

Implementing Interventions

Assess a hospitalized client’s bowel pattern and date of last bowel movement daily. Implement a bowel management plan as needed to achieve a bowel movement every one to three days.

Before giving laxatives or stool softeners, assess recent stool characteristics and withhold medication if loose stools or diarrhea are occurring.

When giving medication for diarrhea, assess recent stool consistency and bowel pattern and withhold medication if diarrhea has resolved or constipation is developing.

Many elimination alterations require health teaching for home management. Health teaching is an independent nursing intervention and does not require a provider order.

Evaluation

Nurses evaluate the effectiveness of interventions based on SMART outcomes for each client. They determine whether outcomes were met or whether reassessment and revised interventions are required.

Loss and grief are universal human experiences, with death being the ultimate loss. Nurses are often the first line of support for clients and families coping with serious illness, loss, and end-of-life care.

This chapter is based on the End-of-Life Nursing Care Consortium (ELNEC) curriculum, which prepares nurses and other health care professionals to provide specialized end-of-life care. It discusses grief, loss, palliative care, hospice, symptom management, actively dying clients, and support for families.

Loss, Grief, and Mourning

Loss is the absence of something valued, such as health, independence, relationships, roles, or life itself.

Grief is the emotional response to loss. It may include anger, frustration, loneliness, sadness, guilt, regret, peace, or emotional fluctuation. Grief affects people physically, psychologically, socially, and spiritually.

Mourning is the outward social expression of loss. It is shaped by culture, customs, rituals, personality, and previous life experiences.

Types of Grief

Anticipatory grief occurs before a loss, such as after diagnosis of a terminal illness or before loss of independence, health, body image, or important life experiences.

Acute grief begins immediately after death and may include shock, disbelief, confusion, withdrawal, and uncertainty about identity or role.

Normal grief includes physical, emotional, cognitive, and behavioural responses such as chest tightness, sadness, fear, guilt, confusion, crying, withdrawal, and changes in relationships.

Disenfranchised grief occurs when a loss is not openly recognized or socially validated, such as grief related to stigmatized illness, pregnancy loss, divorce, or severed relationships.

Complicated grief occurs when grief is prolonged, intense, or interferes with functioning. It may include guilt, distress, impaired functioning, or suicidal thinking. Risk factors include sudden death, suicide, homicide, death of a child, multiple losses, lack of support, unresolved previous grief, and witnessing suffering.

Types of Complicated Grief

• Chronic grief: grief reactions continue for a very long time.
• Delayed grief: grief reactions are postponed or suppressed.
• Exaggerated grief: intense grief that may include nightmares, phobias, delinquent behaviour, or suicidal thoughts.
• Masked grief: grief-related behaviours interfere with functioning, but the person does not recognize them as grief.

Stages of Grief

Kübler-Ross identified five stages of grief, often remembered as DABDA: denial, anger, bargaining, depression, and acceptance. Clients and families may move between stages, repeat stages, skip stages, or experience them in no fixed order.

Denial occurs when the person refuses to acknowledge the loss or acts as though it is not happening.

Anger may mask pain and sadness and may be directed at oneself, others, the deceased, or health care professionals.

Bargaining occurs when the person tries to regain control or negotiate a different outcome.

Depression may involve intense sadness, withdrawal, fatigue, loss of interest, sleep disturbance, poor focus, and ineffective coping.

Acceptance means acknowledging the new reality and beginning to cope, reengage, and find comfort in new routines.

Grief Tasks

• Notification and shock: acknowledging the reality of the loss.
• Experiencing the loss: emotionally and cognitively working through the pain.
• Reintegration: adjusting to life without the deceased while retaining memories.

Palliative Care and Hospice

Palliative care focuses on quality of life, prevention and relief of suffering, and physical, psychosocial, and spiritual care. It can occur alongside curative treatments such as dialysis, chemotherapy, or surgery.

Hospice care is a type of palliative care for clients expected to live six months or less. Curative treatments are stopped, but comfort-focused medical care continues. Hospice supports the client and family through dying, death, and bereavement.

Comfort care is used when goals shift from cure to symptom control, pain relief, and quality of life. Interventions such as vital signs, blood draws, or invasive procedures may be stopped if they do not promote comfort.

Ethical and Legal Considerations

Nurses must respect and advocate for the client’s wishes, even when there are conflicts among providers, family members, or the client. Ethics committees can support complex decision-making.

DNR orders instruct health care professionals not to perform CPR if breathing or heartbeat stops. A DNR does not mean stopping all medical treatment.

Advance directives include a health care power of attorney and a living will. These documents guide care when the client can no longer speak for themselves.

Caring for the Family

Families may experience a process of “fading away” as they realize their loved one is dying. This includes redefining life, feeling burdened, searching for meaning, living day to day, preparing for death, and contending with change.

Caregivers often need practical help, honest communication, inclusion in decision-making, reassurance, emotional support, and access to community resources.

A Good Death

A good death includes meeting client preferences, pain relief, emotional well-being, family preparation, dignity, respect, spiritual comfort, quality of life, and trust in the care team.

Bereavement

Bereavement includes grief and mourning after a loved one dies. Nurses support survivors by encouraging expression of grief, delaying major decisions, supporting spirituality, facilitating coping, and communicating with the interdisciplinary team.

Self-Care for Nurses

End-of-life care can affect nurses emotionally and spiritually. Repeated losses can contribute to compassion fatigue and burnout. Nurses should use healthy coping strategies such as prayer, meditation, exercise, art, music, counselling, employee assistance programs, and debriefing sessions.

Assessment

Grief assessment includes the client, family members, and significant others. It begins at diagnosis of acute, chronic, or terminal illness and continues through illness, dying, and bereavement.

Grief may appear as physical symptoms, emotional symptoms, or cognitive symptoms. These include headaches, tremors, muscle aches, exhaustion, insomnia, appetite changes, weight changes, anxiety, guilt, anger, fear, sadness, helplessness, confusion, hallucinations, and difficulty concentrating.

Behaviours that may endanger the client or family, such as depression, suicidal ideation, or symptoms lasting longer than six months, should be reported to the health care provider.

Outcome Identification

Goals and outcomes are customized to the client and family. Grief resolution may be shown by resolving feelings about the loss, verbalizing acceptance, maintaining the living environment, and seeking social support.

A sample goal is: “The client will experience grief resolution.”

A sample SMART outcome is: “The client will discuss the meaning of the loss to their life in the next two weeks.”

Planning and Implementing Interventions

The most important nursing interventions are active listening and supportive presence.

Coping Enhancement

• Assist the client to identify short- and long-term goals.
• Assist the client to examine available resources.
• Break complex steps into smaller steps.
• Encourage relationships with others who share common interests.
• Use a calm and reassuring approach.
• Provide an atmosphere of acceptance.
• Provide factual information about diagnosis, treatment, and prognosis.
• Encourage realistic hope.
• Discourage decision-making during severe stress.
• Support cultural and spiritual resources.
• Encourage verbalization of feelings, fears, and perceptions.
• Encourage family involvement where appropriate.
• Teach relaxation techniques.

Anticipatory Grieving Interventions

• Develop a trusting relationship with the client and family.
• Keep the client and family informed about the client’s condition.
• Explain care options such as palliative care, hospice, and home care.
• Actively listen and normalize expressions of grief.
• Discuss and document preferred place of death.
• Assess family resources and caregiver role strain.
• Respect different wishes and feelings among the client and family members.
• Refer to counsellors or chaplains as appropriate.

Grief Work Facilitation

• Identify the loss.
• Assist the client to identify the initial reaction to the loss.
• Listen to expressions of grief.
• Encourage discussion of previous losses and memories.
• Make empathetic statements.
• Encourage identification of fears.
• Educate about grief stages and tasks where appropriate.
• Support personal grieving stages.
• Encourage cultural, religious, and social customs.
• Answer children’s questions honestly and encourage discussion of feelings.
• Identify community support.
• Reinforce progress.

Evaluation

Nurses evaluate whether interventions help the client and family cope and progress through the grief process based on customized outcome criteria.

Palliative care is client- and family-centred care that improves quality of life by anticipating, preventing, and treating suffering. It addresses physical, psychological, social, and spiritual needs while supporting client autonomy and choice.

Dimensions of Palliative Care

• Physical: functional ability, fatigue, sleep, nausea, appetite, constipation, and pain.
• Psychological: anxiety, depression, distress, fear, cognition, and happiness.
• Social: finances, caregiver burden, roles, relationships, affection, and appearance.
• Spiritual: hope, suffering, meaning, religion, and transcendence.

Nursing Interventions

• Elicit the client’s goals for care.
• Listen to the client and family.
• Communicate with the interdisciplinary team.
• Advocate for the client’s wishes.
• Manage end-of-life symptoms.
• Encourage reminiscing.
• Support religious rituals and spiritual practices.
• Refer to chaplains, clergy, and spiritual support.

Common Symptoms

Pain: Pain is what the client says it is. If the client cannot verbalize pain, assess behavioural cues. The goal is to balance pain relief with side effects and alertness.

Dyspnea: Dyspnea is subjective breathing discomfort. Assess severity, ability to speak, anxiety, respiratory effort, oxygenation, lung sounds, pain, triggers, and effect on quality of life. Opioids, positioning, pursed-lip breathing, fans, open windows, tripod position, calm environment, and relaxation may help.

Cough: Cough can cause pain, fatigue, vomiting, and insomnia. Medications may include opioids, dextromethorphan, benzonatate, guaifenesin, or anticholinergics.

Anorexia and cachexia: These are common in advanced disease. Interventions should focus on pleasure, favourite foods, small frequent meals, high-calorie easy-to-chew foods, and reducing odours. Families should be taught that forcing food may increase discomfort near end of life.

Constipation: Common causes include low intake, opioids, chemotherapy, and immobility. The goal is a bowel movement at least every 72 hours. Treatment may include stool softeners, stimulants, suppositories, or enemas.

Diarrhea: More than three unformed stools in 24 hours. It can cause dehydration, skin breakdown, electrolyte imbalance, and caregiver burden. Treatment includes hydration, IV fluids if appropriate, loperamide, psyllium, or anticholinergics.

Nausea and vomiting: Assess history, previous treatment, medication history, frequency, intensity, and triggers. Interventions include room-temperature foods and fluids, avoiding odours, avoiding bulky meals, relaxation, music therapy, aromatherapy, and antiemetics.

Depression: Sadness and grief are expected, but persistent helplessness, hopelessness, or suicidal ideation require treatment. Interventions may include antidepressants, counselling, autonomy, family participation, reminiscing, grief counselling, symptom management, spiritual support, relaxation, and suicide assessment.

Anxiety: Anxiety may occur because of prognosis, mortality, finances, uncontrolled symptoms, and loss of control. Interventions include symptom management, relaxation, guided imagery, counselling, spiritual support, open-ended questions, active listening, concrete information, and stress diaries. Benzodiazepines may be used but require monitoring for oversedation, falls, and delirium.

Cognitive changes: Delirium is common in palliative care and may occur in up to 90% of clients in the final days and hours. Symptoms include agitation, confusion, hallucinations, and inappropriate behaviour. Causes may include medications, metabolic changes, organ failure, or opioid toxicity.

Fatigue: Fatigue may be caused by chronic disease, anemia, infection, poor sleep, chronic pain, or medication side effects. Energy conservation techniques may help.

Pressure injuries: End-of-life clients are at risk due to poor nutrition and decreased mobility. Prevention includes mobility, repositioning, moisture control, and nutrition as appropriate. Kennedy Terminal Ulcer may occur shortly before death due to multiorgan failure.

Seizures: Seizures may be caused by infection, trauma, brain injury, tumours, medications, metabolic imbalance, toxicity, or withdrawal. Treatment focuses on prevention, limiting trauma, and medications such as phenytoin, phenobarbital, benzodiazepines, or levetiracetam.

Sleep disturbances: Sleep problems affect quality of life. Nurses can promote sleep by creating a quiet environment, supporting routines, and advocating for uninterrupted rest.

Recognizing approaching death allows the client, family, and interdisciplinary team to prepare. The nurse’s two primary responsibilities are symptom management and preparing the family for what to expect.

Nurses also assist with organ donation, postmortem care, and arrangements. They should provide developmentally appropriate education, facilitate hospice support where possible, respect client wishes, and support a dignified death.

Families may need simple explanations repeated because they may be tired, emotional, and unable to retain information. Written resources may be helpful.

Common Symptoms During Dying

The dying process may involve sedation and lethargy leading to coma and death, or confusion, restlessness, muscle jerks, seizures, and death. Clients may fluctuate between decreased consciousness, lucidity, agitation, hallucinations, and restlessness.

Pain and Dyspnea

Assessment may rely on behavioural cues such as grimacing and posturing. Dyspnea or “air hunger” may occur. Pain pumps, oral medications, or sublingual medications may be used. Roxanol, a concentrated morphine sulfate solution, may be administered sublingually for pain or air hunger.

Morphine relieves pain and can relax respiratory muscles to improve air exchange. Nurses should balance analgesia with the client’s goal for alertness.

Principle of Double Effect

The Rule of Double Effect means that if the intent is relief of pain and suffering, administering medication is morally justifiable even if there is an unintended risk of hastening death. Nurses should provide pain relief in the final days and hours without fear of sedation or respiratory depression limiting appropriate opioid use.

Terminal Secretions

Terminal secretions, or the “death rattle,” usually occur 3–23 hours before death. They result from air moving over secretions in the mouth and upper airways. Anticholinergic medications such as atropine or scopolamine may be used. Repositioning on the side may help. Suctioning is generally not recommended because it is often ineffective and may cause distress.

Phases of Dying

Actively dying: The client may experience pain, dyspnea, fatigue, cough, incontinence, nausea, vomiting, depression, anxiety, and seizures. Care focuses on symptom management and emotional support.

Transitioning: The client withdraws physically, interacts less, may hallucinate, and may show signs of hypoxia and acidosis. The environment should be calm, quiet, and comfortable.

Imminent death: Death may occur at any point due to multisystem organ failure, usually within 24 hours. Signs may include cool clammy skin, mottling, rapid or irregular pulse, inability to move, confusion, restlessness, lethargy, hallucinations, Cheyne-Stokes respirations, noisy breathing, and decreased or dark urine.

Supporting the Family

The family may need extra support as death becomes more real. Vital signs, lab draws, and invasive procedures are usually stopped if they do not benefit the client. Nurses may support families through reminiscence, calming music, touch, massage, presence, and prayer according to preferences.

Family members may be coached to say: ask forgiveness, forgive, say thank you, say I love you, and say goodbye.

Death Vigil

Families often want to be present in the hours before death. Common fears include the client dying alone, not knowing what to do, watching suffering, not knowing if death has occurred, and fear of giving the last medication dose at home. Nurses should address these fears proactively.

Death and Postmortem Care

Clinical death refers to cessation of heartbeat or brain death. Biological death follows when brain cells and other organ cells die due to lack of oxygen. The nurse should listen to the apical heartbeat for one full minute to confirm and document death according to policy.

Documentation after death includes date and time, client name, physician contact, people present, lack of response to stimuli, absence of apical pulse, and arrangements for transport.

Postmortem care should preserve dignity. Tubes and equipment may be removed unless coroner approval is required. The body should be bathed, dressed, positioned, aligned, and prepared respectfully. Dentures should be placed in the mouth, leaking wounds dressed, and incontinence products applied if needed.

The nurse should support family members as they say goodbye and should not rush them. After the family leaves, identification tags are applied and the body is moved according to policy.

Organ Donation

If the client is an organ or tissue donor, procedures should follow state, setting, and agency policies. Federal law and Medicare regulations require hospitals to give surviving family members the opportunity to authorize organ and tissue donation. There is no cost for organ or tissue donation.

Assessment

Assessments are generally limited at the end of life because the goal is comfort. Nurses may need to remind the care team that routine vital signs, intake and output, lab draws, and full assessments may not be required when they do not promote comfort.

Subjective Assessment

Many clients at end of life may be nonverbal, but some may have periods of reminiscence. Families should be informed that communication may vary and that hearing may remain intact. Family and friends should be encouraged to share thoughts, feelings, and comforting stories.

Objective Assessment

Objective assessment should focus on comfort. Nurses should observe for pain cues such as grimacing, moaning, furrowed brow, and guarding. They should also monitor for laboured breathing, terminal secretions, cool clammy skin, mottled extremities, diminished pulses, skin breakdown, and urinary retention.

Unexpected findings such as severe pain not relieved by protocol, acute laboured breathing, terminal secretions, or urinary retention with bladder distention should be reported to the provider.

Diagnosis

Diagnosis statements focus on comfort. Priority concerns may include acute pain, ineffective breathing, family coping, caregiver role strain, and death anxiety.

Outcomes

An overall goal is: “The client will experience dignified life closure.”

Indicators may include expression of readiness for death, resolution of important issues, and sharing feelings about dying.

A sample SMART outcome is: “The client will express their fears associated with dying by the end of the shift.”

A common nursing goal is: “The client will experience adequate pain management based on their expressed goals for pain relief and alertness.”

Planning and Implementing Interventions

Many clients need medications such as morphine and lorazepam to ease pain, dyspnea, and anxiety. Routes of administration should be appropriate for the client’s rapidly changing condition. Concentrated oral solutions may be absorbed through the buccal membranes. If pain needs are high, the provider may need to be contacted about a subcutaneous pump.

For terminal secretions, anticholinergic medications such as atropine or scopolamine may be administered. Oral care is essential because secretions are reduced. Oral swabs and lip moisturizer promote comfort.

Interventions in the Last Days and Hours

• Honor the client’s preferences for end-of-life care.
• Provide respectful physical assessment and care.
• Reduce harsh light, loud voices, alarms, and unnecessary noise.
• Reinforce the steps of the dying process for the family.
• Be present and use active empathetic listening.
• Encourage a quiet and comfortable environment.
• Assess pain and provide pain relief according to preferences.
• Assess fears related to death.
• Assist with life review and reminiscence.
• Provide music of the client’s choosing.
• Provide social support for families.
• Recognize spiritual needs and support rituals and prayer.
• Encourage family members to be physically close and touch their loved one if desired.
• When death occurs, allow time for closure and explain next steps.

Evaluation

Nurses evaluate interventions based on outcome criteria. They should monitor for escalating discomfort that is not controlled by the current plan and educate the family about whom to contact if concerns arise.

Spirituality includes a sense of connection to something bigger than oneself and typically involves a search for meaning and purpose in life. People may describe a spiritual experience as sacred or transcendent, or simply feel a deep sense of aliveness and interconnectedness.

Some people’s spiritual life is linked to a religious association with a church, temple, mosque, or synagogue, whereas others pray and find comfort in a personal relationship with God or a higher power. Others find meaning through their connections to nature or art. A person’s definition of spirituality and sense of purpose often changes throughout life as it evolves based on personal experiences and relationships.

Research has demonstrated the importance of spirituality in health care. Spiritual distress is common in clients and family members experiencing serious illness, injury, or death. Addressing spirituality and providing spiritual care can improve health and quality of life, including how clients experience pain, cope with stress and suffering, and approach end of life.

Consensus-driven recommendations define a spiritual care model where all clinicians address spiritual issues and work with trained chaplains who are spiritual care specialists. By therapeutically using presence, unconditional acceptance, and compassion, nurses often provide spiritual care and help clients find hope and meaning in their life experiences.

The Interprofessional Spiritual Care Education Curriculum (ISPEC), developed by George Washington University for health care professionals, is an education initiative to improve spiritual care for seriously ill clients in the United States and internationally. This chapter introduces concepts from the ISPEC curriculum, reviews religious beliefs and practices of various world religions, and discusses therapeutic interventions nurses can use to promote clients’ and their own spiritual well-being.

When clients are initially diagnosed with an illness or experience a serious injury, they often grapple with the existential question, “Why is this happening to me?” This question is often a sign of spiritual distress.

Spiritual distress is defined by NANDA-I as “a state of suffering related to the impaired ability to integrate meaning and a purpose in life through connections with self, others, the world, and/or a power greater than oneself.” Nurses can help relieve this suffering by therapeutically responding to signs of spiritual distress and advocating for spiritual needs throughout the health care experience.

Spirituality

Provision 1 of the ANA Code of Ethics states that the nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Optimal nursing care enables the client to live with as much physical, emotional, social, and religious or spiritual well-being as possible and reflects the client’s own values.

ISPEC defines spirituality as “a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence and experience relationship to self, family, others, community, society, nature, and the significant or sacred.” Spiritual needs and spirituality are often mistakenly equated with religion, but spirituality is broader. Elements of spirituality include faith, meaning, love, belonging, forgiveness, and connectedness.

An integrative review of nursing literature described spirituality as integration of body, mind, and spirit into a harmonious whole, often referred to as holistic care. Spirituality was associated with inner strength, looking into one’s soul, believing there is more to life than worldly affairs, and trying to understand who we are and why we are on this earth.

Transcendence was described as understanding oneself as part of a greater picture or something greater than oneself. Spirituality was found to positively affect health and promote recovery by helping clients view life from different perspectives and look beyond anxiety to develop understanding of illness and change.

Relationships and connectedness were also powerful spiritual interventions. Presence was described as especially influential, bringing comfort, peace, happiness, joy, acceptance, and hope. Nurses facilitate clients’ search for meaning by enabling them to express beliefs and supporting participation in religious and cultural practices.

Spiritual Assessment

The Joint Commission requires health care organizations to provide a spiritual assessment when clients are admitted. Spiritual assessment can include questions such as:

• Who or what provides you with strength or hope?
• How do you express your spirituality?
• What spiritual needs can we advocate for you during this health care experience?

In addition to routine spiritual assessment, nurses may notice cues related to spiritual distress or a desire to enhance spiritual well-being. When these cues are identified, spiritual care should be provided to relieve suffering and promote spiritual health.

Many hospitals, nursing homes, assisted living facilities, and hospices employ professionally trained chaplains to assist with spiritual, religious, and emotional needs. Chaplains support people of all religious faiths and cultures and customize their approach to each individual’s background, age, and medical condition. A nurse can make a chaplain referral without a provider order.

A chaplain assists clients and families to develop a spiritual view of serious illness, injury, or death, promoting coping and healing. This may include suffering, hope, mystery, peacemaking, forgiveness, and prayer.

It can be helpful for nurses to have basic knowledge about common religions and religious practices as they support clients’ spiritual beliefs. However, a full spiritual assessment is necessary to determine an individual’s beliefs, which may or may not follow specific practices outlined for a religion.

Religious Classifications

For centuries, humankind has sought to understand and explain the meaning of life. Religion, in one form or another, has been found in all human societies since human societies first appeared.

Religion is a unified system of beliefs, values, and practices that a person holds sacred or considers spiritually significant. Some people associate religion with a place of worship, such as a synagogue or church, a practice such as attending religious services, baptism, or communion, or a concept that guides daily life, such as sin or kharma.

Religions have been classified based on what or whom people worship. Every culture has atheists, who do not believe in a divine being or entity, and agnostics, who hold that ultimate reality such as God is unknowable. Being a nonbeliever in a divine being does not mean the individual has no morality.

Monotheism includes Judaism, Christianity, and Islam. People who practice Judaism are called Jews, people who practice Christianity are called Christians, and people who practice Islam are called Muslims. Jews, Christians, and Muslims believe in many of the same historical sacred stories, referred to by Christians as the Old Testament.

Judaism

After their exodus from slavery in Egypt in the thirteenth century B.C., Jews became a nomadic society worshipping only one God. The Jewish covenant, a promise of a special relationship with Yahweh, is an important element of Judaism. The sacred text of Judaism is the Torah, which contains the same sacred stories in the first five books of the Christian Bible. The Talmud is a collection of additional sacred Jewish oral interpretations of the Torah. Jews emphasize moral behavior and action in life. Jewish religious services are held in a synagogue.

Christianity

Christianity began over 2,000 years ago in Palestine with the birth of a Jew named Jesus Christ. Jesus was a charismatic leader and is believed by Christians to be the son of God. Christians believe Jesus was crucified as an atonement for humanity’s sins. The sacred text for Christians is the Bible, including the Old Testament and New Testament. Christians attend religious services in a church or cathedral.

Christianity is broadly split into three branches: Catholic, Protestant, and Orthodox. The Catholic branch is governed by the Pope and bishops. Protestant denominations include Lutherans, Baptists, Presbyterians, Methodists, Seventh-Day Adventists, Pentecostals, and Mormons. Although all Christians believe the Bible is sacred, different denominations may have variations in their sacred texts.

Although monotheistic, Christians often describe God through three manifestations called the Holy Trinity: the Father, the Son, and the Holy Spirit. Another foundation of Christian faith is the Ten Commandments, a set of rules that includes acts considered sinful, such as theft, murder, and adultery.

Islam

Islam is a monotheistic religion that follows the teaching of the prophet Muhammad, born in Mecca, Saudi Arabia, in 570 C.E. Muhammad is viewed as a prophet and messenger of Allah. Followers of Islam are called Muslims and attend religious services in mosques. Islam means “peace” and “submission.”

Muslims are guided by five beliefs and practices, often called pillars of faith: believing that Allah is the only god and Muhammad is his prophet, participating in daily prayer, helping those in poverty, fasting as a spiritual practice, and participating in pilgrimage to Mecca.

Hinduism

Hinduism originated in the Indus River Valley about 4,500 years ago in what is now northwest India and Pakistan. Hindus believe in a divine power that can manifest as different entities. Three main incarnations are Brahma, Vishnu, and Shiva.

Multiple sacred texts, collectively called the Vedas, contain hymns and rituals from ancient India and are mostly written in Sanskrit. Hindus believe in dharma, referring to duty in the world and “right” actions, and karma, the idea that spiritual ramifications of actions are balanced in this life or a future life through reincarnation. Most Hindus observe religious rituals at home, and rituals vary greatly among regions, villages, and individuals.

Buddhism

Buddhism is a philosophy founded by Siddhartha Gautama around 500 B.C.E. Siddhartha gave up a comfortable life to follow one of poverty and spiritual devotion. At age thirty-five, he meditated under a sacred fig tree and vowed not to rise before achieving enlightenment, called bodhi. After this experience, he became known as Buddha, or “enlightened one.”

Buddha’s teachings encourage Buddhists to lead a moral life by accepting the Four Noble Truths: life is suffering, suffering arises from attachment to desires, suffering ceases when attachment to desires ceases, and freedom from suffering is possible by following the middle way. The middle way encourages people to live in the present, practice acceptance of others, and accept personal responsibility.

Common Religious Beliefs and Practices

Religious beliefs and practices may impact nursing care. Nursing interventions should always be customized according to each client’s specific values, practices, and beliefs.

Buddhist Clients

• Buddhism places strong emphasis on mindfulness, so clients may request peace and quiet for meditation, especially during crises.
• Some Buddhists may express concerns about modesty, especially treatment by someone of the opposite sex.
• Some Buddhists are strictly vegetarian and may refuse meat, animal by-products, or medications produced using animals.
• Mindful awareness may affect decisions about pain medications due to concern that analgesics may cloud awareness.
• Clients or families may pray or chant out loud repetitiously, often quietly.
• Families may wish to place a picture of the Buddha in the client’s room.
• In end-of-life care, Buddhists may be concerned about safeguarding awareness and consciousness.
• As death approaches, staff should minimize actions that disturb concentration or meditation.
• After death, staff should keep the body as still as possible and avoid jostling during transport.
• Families may request that the body remain available for religious rites for several hours after death.

Catholic Clients

• Sacraments and blessings by a Catholic priest may be highly important, especially before surgery or when death is possible.
• If a client is near death, there may be an urgent request for the Sacrament of the Sick, also called Last Rites.
• Requests for baptism should be relayed to a Catholic priest. If an infant is likely to die before a priest can arrive, the infant may be baptized by any person with proper intent.
• Clients may request Holy Communion before surgery. If the client is NPO, this request should be approved by the care team as medically safe.
• Clients may keep religious objects such as a rosary, scapula, or religious medal.
• If religious objects must remain during a procedure, discuss keeping them in a sealed bag near the client. For radiology or MRI, ask if a nonmetal substitute can be brought.
• Interruption of Mass attendance or holy day observance may be stressful. Clergy or a chaplain may be contacted.
• Clients may have moral questions about withholding or withdrawing life-sustaining treatment. A priest can offer guidance.
• Clients may request non-meat diets, especially during Lent.

Hindu Clients

• Hindu clients may have concerns about modesty, especially treatment by someone of the opposite sex.
• Genital and urinary issues are often not discussed with a spouse present.
• Many Hindus are strictly vegetarian and may not consume meat, animal by-products, or medications produced using animals.
• Some Hindus may avoid certain vegetables such as onions or garlic.
• Fasting is common, and clients may wish to discuss implications for medical and dietary care.
• Washing may require running water from a tap or poured from a pitcher.
• Many Hindus use the right hand for clean tasks such as eating and the left hand for unclean tasks such as toileting.
• Clients may wear jewelry or adornments with strong cultural or religious meaning; these should not be removed without discussion.
• Death is viewed as a crucial transition with karmic implications. There may be a strong desire to die at home rather than in hospital.
• Family may wish to perform pre-death rituals, such as tying a thread around the person’s neck or wrist.
• After death, family members may request to wash the client’s body, usually by family members of the same sex.
• Family may request constant attendance of the deceased’s body or to accompany the body to the morgue.

Jehovah’s Witnesses Clients

• The strict prohibition against receiving blood products is a defining health care concern.
• Blood products include red blood cells, white blood cells, platelets, plasma, transfusion of stored blood, medication using blood products, or food containing blood products.
• Even when death may occur without transfusion, blood products are refused.
• Administering blood may result in excommunication and legal consequences for the facility.
• Some blood fractions, such as albumin, immunoglobulin, and hemophiliac preparations, may be allowed, but clients are guided by conscience.
• Organ donation and transplantation are allowed, but clients are guided by conscience.
• Jehovah’s Witnesses are often prepared to seek treatment options that do not conflict with religious concerns.
• Adults may carry a card stating religiously based directives for treatment without blood.
• Faith-healing is not part of Jehovah’s Witness tradition. Prayers are often said for comfort and endurance.
• It is inappropriate to tell the family of a deceased Jehovah’s Witness client, “He’s in a better place now.”
• Jehovah’s Witnesses do not celebrate birthdays or Christian holidays.

Jewish Clients

• Some Jewish clients may strictly observe the Sabbath from sundown Friday to sundown Saturday and avoid “work.”
• Prohibited tasks may include writing, flipping a light switch, pushing buttons, adjusting a motorized bed, or operating a PCA pump.
• Tearing paper can be considered work, so roll toilet paper may need to be replaced with individual sheets.
• Medical procedures should not be scheduled during the Sabbath or religious holidays unless lifesaving.
• Jewish holidays such as Passover, Rosh Hashanah, and Yom Kippur may affect procedure scheduling and dietary needs.
• Jewish holidays run from sundown to sundown.
• Jewish clients may request a Kosher diet, including rules about food preparation, prohibited foods such as pork and gelatin, and combinations such as beef with dairy.
• During Passover, there is a distinction between Kosher food and Kosher for Passover food.
• Handwashing before eating may have religious significance.
• Some Jewish clients may have concerns about modesty, especially treatment by someone of the opposite sex.
• End-of-life decisions such as withholding or withdrawing life-sustaining therapy are deeply debated, and families may consult a rabbi.
• After death, Jewish tradition directs quick burial and usually no autopsy unless required by the Medical Examiner.
• Embalming and cremation are not permitted according to Jewish tradition.
• Family may request that someone accompany the body in hospital or to the morgue to say prayers and read psalms.
• There may be a request that amputated limbs be made available for burial.
• Emergency actions understood as saving a life, such as emergency surgery or organ donation during the Sabbath, may be exceptions.
• Male Jewish clients may wear a yarmulke or kippah during prayer or at all times.
• Clients or family members may wear prayer shawls or use phylacteries.
• There may be a request for at least ten people, called a minyan, to be allowed in the room for prayer.
• A Jewish person need not be religious to identify culturally as Jewish.
• The word “Jew” is commonly used within Jewish culture, but non-Jews should be mindful of its historical connotations.

Muslim Clients

• Muslim clients may have strong concerns about modesty, especially treatment by someone of the opposite sex.
• A Muslim woman may need to cover her body completely and should be given time before anyone enters the room.
• Women may request that a family member be present during exams and may wish to remain clothed if possible.
• Muslim men may find examination by a woman challenging.
• Nudity is discouraged, and casual physical contact by non-family members of the opposite sex should be avoided.
• Some Muslims may avoid eye contact as part of modesty.
• Muslims may request Halal food, although some choose vegetarian diets to avoid pork, gelatin, or other Haram foods.
• Medication ingredients such as pork, gelatin, or alcohol may be a concern.
• Concerns about alcohol-based hand rubs should be addressed sensitively, possibly with input from an imam.
• Washing may require running water, so sponge baths may not feel sufficient.
• Many Muslims wash before and after meals and before prayers.
• Muslim prayers are conducted five times a day.
• Clients may wish to pray by kneeling and bending to the floor, but Islamic tradition recognizes when this is not medically advisable.
• Clients may react to suffering with emotional reserve and may hesitate to request pain management.
• Some may refuse pain medication if they view pain as spiritually enriching.
• There may be a request that amputated limbs be made available for burial.
• Muslim tradition generally discourages withholding or withdrawing life-sustaining therapy, though families may consult an imam.
• A family member may request to be present with a dying person to whisper a proclamation of faith in the client’s ear before death.
• After death, family may request to wash the client and position the bed to face Mecca.
• Burial is usually completed as soon as possible.
• Autopsy is rarely allowed unless required by a Medical Examiner.
• Organ donation opinions vary within Islamic circles.
• During Ramadan, Muslims refrain from food and drink from dawn until sundown. Clinicians should explore whether fasting is medically appropriate and consider predawn meals, dates and spring water to break the fast, and delayed dinner after sunset.

Pentecostal Clients

• Pentecostal clients may pray exuberantly. Noise concerns can often be managed by closing the room door.
• Pentecostals may pray by speaking in tongues, which has deep religious significance for worshippers.
• Clients or families may request that large numbers of people be allowed in the room for prayer.
• Clients or families may express strong belief in miraculous healing.

Now that concepts related to spirituality and beliefs and practices of common world religions have been reviewed, the nursing process can be applied to promoting spiritual health.

Assessment

Subjective Assessment

Agencies often provide a standardized spiritual assessment tool to complete when a client is admitted. If a standardized tool is not available, the FICA model can be used. The FICA model contains open-ended questions about personal spiritual beliefs in a way that is open and nonjudgmental:

• F — Faith or beliefs: What are your spiritual beliefs? Do you consider yourself spiritual? What things do you believe in that give meaning to life?
• I — Importance and influence: Is faith/spirituality important to you? How has your illness and/or hospitalization affected your personal practices or beliefs?
• C — Community: Are you connected with a faith center in the community? Does it provide support or comfort during times of stress? Is there a person, group, or leader who supports you in your spirituality?
• A — Address: What support can we provide to support your spiritual beliefs or practices?

The HOPE tool is also helpful for incorporating spiritual assessment questions into a medical interview:

• H: Sources of hope, meaning, comfort, strength, peace, love, and connection
• O: Organized religion
• P: Personal spirituality and practices
• E: Effects of spirituality on medical care and end-of-life issues

The H section asks about sources of hope and basic spiritual resources without focusing on religion. The O and P sections ask about religious rituals and spiritual practices. A normalizing statement may be helpful, such as: “For some people, their religious or spiritual beliefs act as a source of comfort and strength in dealing with life’s ups and downs. Is this true for you?”

The E section refers to effects of spirituality and beliefs on decisions related to medical care and end-of-life issues. This may include barriers to preferred spiritual resources, fears related to end-of-life issues, and conflicts between values, beliefs, and prescribed treatment.

Objective Assessment

In addition to asking open-ended questions, the nurse should observe clients for cues indicating difficulty finding meaning, purpose, or hope in life. It is also important to monitor for supportive relationships.

Clients experiencing chronic or serious illness may make statements indicating spiritual distress. Examples include:

• Lack of meaning: “I am not the person I used to be.”
• Hope: “I have nothing left to hope for.”
• Mystery: “Why me?”
• Isolation: “All my family and friends are gone.”
• Helplessness: “I have no control over my life anymore.”

Diagnoses

Readiness for Enhanced Spiritual Well-Being: A sample PES statement is, “Readiness for Enhanced Spiritual Well-Being as evidenced by expressed desire to increase time outdoors and be closer to nature.” The nurse could encourage clients to visit local parks and walk outdoors.

Impaired Religiosity: Hospitalized clients may be unable to attend religious services they are accustomed to attending. This contributes to impaired religiosity, which occurs when life circumstances such as hospitalization, illness, stress, substance use disorder, or other factors negatively affect faith, spirituality, or the ability to maintain faith or spirituality practices. A sample PES statement is, “Impaired Religiosity related to environmental barriers to practicing religion as evidenced by difficulty adhering to prescribed religious beliefs.” The nurse could contact the client’s pastor to arrange a visit or determine if services can be viewed online.

Spiritual Distress: Events that place clients at risk for spiritual distress include birth of a child, death of a significant other, exposure to death or traumatic events, life transition, or terminal care. Associated conditions include chronic disease, depression, loss of a body part, loss of function of a body part, or treatment regimen. A sample PES statement is, “Spiritual Distress related to anxiety associated with illness as evidenced by crying, insomnia, and questioning the meaning of suffering.” A nurse would implement interventions to enhance coping.

Outcome Identification

Goals and SMART outcomes should be customized to each client and situation.

For Readiness for Enhanced Spiritual Well-Being, a sample goal is, “The client will demonstrate hope as evidenced by the following indicators: expressed expectation of a positive future, faith, optimism, belief in self, sense of meaning in life, belief in others, and inner peace.” A related SMART outcome is, “The client will express a sense of meaning and purpose in life by discharge.”

For Spiritual Distress, a sample goal is, “The client will demonstrate improved spiritual health as evidenced by one of the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others to share thoughts, feelings, and beliefs.” A sample SMART outcome is, “The client will express a purpose in life by discharge.”

Planning Interventions: Providing Spiritual Care

When providing spiritual care, the RN must not impose their religious or spiritual beliefs on the client. Guidelines include:

• Take cues from the client: Let the client lead the conversation and do not press further than they want to share. Be aware of nonverbal cues and gently seek clarification if words and body language do not match.
• Ask how to support the client spiritually: Ask what the client needs to feel supported in their faith and accommodate requests when possible, such as clergy visits, quiet prayer time, meditation, or visiting the chapel.
• Support clients within their own faith tradition: Respect and support the client’s values and beliefs rather than promoting the nurse’s values and beliefs.
• Listen without adding your own stories: Focus on the client’s fears and concerns. Name and validate emotions when possible.
• Pray with a client if requested, or provide someone who will: Nurses may pray with clients when the focus remains on the client’s preferences and beliefs. If uncomfortable, request a chaplain.
• Share an encouraging thought or word: A scripture verse based on client preference or an inspirational poem may help during difficult moments.
• Use presence and touch: Sometimes quiet presence is spiritually comforting. Touch can also be therapeutic after asking permission.

Therapeutic Nursing Interventions to Provide Spiritual Support

• Use therapeutic communication to establish trust and empathetic caring.
• Be available to actively listen to feelings and express empathy.
• Treat the client with dignity and respect.
• Determine the importance of faith or beliefs for the client or family.
• Encourage life review through reminiscence.
• Be open to expressions of concern, loneliness, or powerlessness.
• Provide privacy and quiet time for spiritual activities.
• Be aware of religious rules, celebrations, and customs that may affect nursing care, such as dietary restrictions, fasting, blood transfusions, or free-flowing water for cleansing.
• Facilitate meditation, prayer, religious traditions, and rituals.
• Pray with the individual, as appropriate.
• Provide spiritual music, literature, radio, television, or online programs as appropriate.
• Instruct about relaxation, meditation, and guided imagery.
• Arrange visits with the chaplain, clergy, or spiritual advisor.
• Promote hope however the individual defines it without giving false reassurance.
• Encourage forgiveness.
• Encourage participation in interactions with family, friends, and others.
• Encourage participation in support groups.

Implementing Interventions

Nurses should support clients’ spiritual and religious preferences when implementing interventions. The nurse should respect and listen to the client’s expression of beliefs and not impose their own beliefs. Spiritual or religious practices should be accommodated if safe and feasible.

If a client has a spiritual belief, value, or practice that conflicts with the treatment plan, the nurse should explain the rationale for the intervention. If the client is unwilling to complete the treatment because of spiritual or religious beliefs, the nurse should attempt to negotiate the treatment plan with the client and/or health care provider. For example, a nurse can advocate for rescheduling a procedure after the Sabbath or modifying dietary plans and medication administration times during Ramadan.

Evaluation

When evaluating interventions that promote spiritual health, refer to the overall goal: “The client will demonstrate spiritual health as evidenced by the following indicators: feelings of faith, hope, meaning, and purpose in life with connectedness with self and others.” Review the client’s progress toward personalized SMART outcomes customized to their situation.

Provision 5 of the American Nurses Association Code of Ethics states, “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.”

Spiritual care is associated with better health and well-being for everyone, including nurses and nursing students. A desire to help others in need is an important part of spirituality, described as a life-giving force based on faith, discovering meaning and purpose in life, and offering the gift of self to others.

Spiritual resources can help nurses and nursing students overcome the emotional toll associated with caring for seriously ill and dying clients and can help prevent compassion fatigue and burnout.

Many spiritual traditions use contemplative practices to increase compassion, empathy, and quiet the mind. Examples include:

• Meditation: Meditation can induce calm, clear-headedness, and improved concentration and attention. It may reduce sensitivity to pain, enhance the immune system, help regulate difficult emotions, and relieve stress. Mindfulness meditation has been helpful for depression, anxiety, cancer, fibromyalgia, chronic pain, rheumatoid arthritis, type 2 diabetes, chronic fatigue syndrome, and cardiovascular disease.
• Yoga: Yoga is a centuries-old spiritual practice that creates a sense of union through physical postures, ethical behaviors, and breath expansion. Systematic yoga practice has been found to reduce inflammation and stress, decrease depression and anxiety, lower blood pressure, and increase well-being.
• Journaling: Journaling helps people become aware of their inner life and feel connected to experiences. Writing during difficult times may help a person find meaning and become more resilient. Helpful questions include: What experiences give me energy? What experiences drain my energy? Were there experiences today where I felt alive and experienced flow?
• Prayer: Prayer can elicit relaxation, hope, gratitude, and compassion. Belief in a higher power can provide comfort and support in difficult times.
• Spiritual community and friends: Joining a church, synagogue, temple, mosque, meditation center, yoga class, or other local spiritual group can provide belonging and support.
• Nurturing relationships: Relationships require time and care. Creating rituals, such as a weekly phone call or shared walk, can strengthen relationships and positive energy.
• Mindfulness: Mindfulness is awareness that arises through paying attention, on purpose, in the present moment, and nonjudgmentally. It helps people pause, see habitual negative thought patterns, and respond more skillfully. With regular practice, mindfulness can help develop a broader perspective and choose more effective responses.
• Spending time in nature: Many individuals cite time in nature as a spiritual practice that contributes to mental health.

The needs of the older adult population will continue to influence health care through this century. The aging baby boomer population, along with an increased average life span, has led to an increased number of older adults and is expected to continue growing.

The U.S. Census Bureau projects that 1 in 5 Americans will be over the age of 65 by 2030, and by 2034, the number of older individuals will outnumber children for the first time in U.S. history.

Each individual ages in their own way, and the physical, psychosocial, and cognitive health of older individuals varies widely. Because of this broad scope of health and illness in the aging population, providing nursing care that meets the needs of each older adult can be challenging.

Although there are common physiological changes that occur with aging, many individuals ignore symptoms by incorrectly attributing them to the aging process. For example, many older adults mistakenly believe that arthritis pain is a normal part of growing older and do not seek treatment. This can result in decreased physical activity and increased risk for chronic disease.

Providing individualized nursing care and health teaching to older adults can promote preventative health care, effective self-management, and quality of life.

Ageism

Gerontology is the study of the social, cultural, psychological, cognitive, and biological aspects of aging.

There are many stereotypes and negative attitudes about aging adults that persist in the United States and around the world. This bias can be linked to a lack of knowledge about the aging process and misunderstandings about older adults. Many individuals have anxiety about aging that can lead to negative stereotypes of older individuals.

Ageism is stereotyping and discrimination against individuals or groups based on age.

Ageism among nurses and other health care professionals puts older people at risk. Research has demonstrated that ageism in health care negatively impacts older adults’ overall health, well-being, and quality of care received. Ageism results in increased risks of mortality, poor functional health, and slower recovery from illness. Negative perceptions about aging can also lead to poor mental health and depression.

Integrity Versus Despair

Aging individuals must continually adjust to changes in health and physical strength, lifestyle changes related to retirement, the loss of significant others, and changing roles and relationships with family members and friends. Older individuals may find it difficult to accept changes associated with aging.

Erikson’s theory of development describes the stage of older adulthood as “Integrity versus Despair.” This stage begins at approximately age 65 and ends at death. During this stage, older adults reflect on their accomplishments and the person they have become.

If older adults feel they have led a successful life, they often feel satisfied and develop a sense of integrity. Conversely, individuals who feel unsuccessful or feel they did not achieve their life goals may feel unsatisfied and experience hopelessness and despair, which can lead to depression.

Nurses can assist older adults in developing a sense of integrity by encouraging reminiscence about previous positive life events and relationships and cultivating a positive mindset of guiding the next generation.

Many older adults, especially those with declining health due to chronic disease, recognize that changes in health status and mobility threaten the autonomy and independence they previously experienced. As a result, many older adults strive to remain autonomous and avoid being overly reliant on others for daily care.

Older adults often engage in self-management activities in response to changes in health and physical strength. These may range from simple daily tasks, such as medication management, to more complex tasks, such as relocating to residences better suited to physical and mental health changes.

Research has found that older adults often draw on earlier life experiences and skills when faced with physical or cognitive decline. They reflect on resilience used to overcome earlier challenges and apply skills and knowledge gained through previous activities to manage new health changes. However, not all older adults have sufficient personal and external resources for successful self-management. Nurses can assist by personalizing health self-management strategies that emphasize existing skills and knowledge.

Retirement

Older adults vary in their level of activity. Many continue working into their seventies and beyond. Individuals may continue working because of a sense of purpose or because of income needs.

Some older individuals experience a loss of identity when they retire because their work role was an important part of their life. Retirement can bring freedom and adventure, but it may also create a need to find new identity and purpose.

Social Isolation

Retirement, loss of daily interaction with coworkers, and death of family members and friends can lead to social isolation in older adults.

Social support affects health and quality of life and should be included as part of assessment. Nurses should be familiar with community resources that provide socialization opportunities and provide referrals for clients needing additional services.

Modified Living Environment

Although many older adults live in assisted living facilities or skilled nursing centers, many prefer to live at home. Modifications may be needed to promote safety and independence.

Examples include grab bars, elevated toilet seats, good lighting, minimization of clutter, and removal of rugs throughout the home. Assessment of the home environment for safety and mobility is an important aspect of home care nursing.

If an older adult requires more care than family members can provide at home, nurses provide information about care options and make referrals to social workers and case managers.

Community-based resources may enhance care for older adults. Local aging and disability resource centers can help facilitate referrals based on specific needs. Other resources include adult day centers, home health agencies that provide in-home personal care and nursing services, community-based residential facilities, and residential care apartment complexes.

If an older adult requires 24-hour nursing care, placement in a nursing home, also called a skilled nursing facility, may be required.

When performing a comprehensive assessment on an older adult, findings are used to establish baseline physical, cognitive, psychosocial, and spiritual well-being.

It is appropriate to consider the potential impact of declining strength and physical functioning on psychological status using Erikson’s developmental stage of Integrity versus Despair. It is also important to consider the impact of chronic disease on the ability to function and complete Activities of Daily Living, or ADLs. Many older adults who can perform ADLs without assistance consider themselves healthy.

Older adults should be given adequate time to answer questions thoughtfully and move through physical assessment requests comfortably.

Fulmer SPICES Tool

The Fulmer SPICES tool is an evidence-based tool used to assess frequent needs of older adults. It focuses on common problems in aging individuals and can lead to early intervention and treatment.

• S: Sleep disorders
• P: Problems with eating or feeding
• I: Incontinence
• C: Confusion
• E: Evidence of falls
• S: Skin breakdown

Cognitive impairment and memory deficits are not considered normal aspects of aging. However, there are expected physiological changes that occur with aging. Nurses should be familiar with expected findings so that unexpected changes can be reported and addressed.

Expected and Unexpected Assessment Findings

Cardiovascular System

Expected findings: Blood vessel walls thicken; vessels narrow and lose elasticity; valves become less efficient; calcification may be noted; peripheral circulation decreases; systolic blood pressure increases; cardiac output decreases; and baroreceptor sensitivity decreases.

Unexpected findings to report: New hypertension, orthostatic hypotension, or vital signs outside normal ranges.

Critical conditions: Chest pain, symptomatic hypotension or hypertension, or new onset/change in oxygenation require immediate notification or emergency services.

Respiratory System

Expected findings: Decreased cough reflex, increased chest wall rigidity, decreased lung compliance, and fewer alveoli.

Unexpected findings to report: Vital signs outside normal ranges.

Critical conditions: Hemoptysis, decreased oxygen saturation not responding to treatment, or labored breathing require immediate notification or emergency services.

Musculoskeletal System

Expected findings: Loss of muscle mass and strength, increased subcutaneous tissue deposits, joint degeneration, loss of bone density, and decreased proprioception.

Unexpected findings to report: New changes in strength or mobility, or falls.

Critical conditions: Sudden unilateral weakness, facial drooping, slurred speech, or falls with suspected injury require immediate notification or emergency services.

Genitourinary System

Expected findings: Decreased renal perfusion; fewer nephrons; decreased bladder capacity; reduced sphincter tone in females; and prostate enlargement in males.

Unexpected findings to report: New difficulties with urination, including frequency, urgency, incontinence, hesitation, retention, or pain.

Critical condition: Urine output less than 30 mL/hour requires immediate notification or emergency services.

Gastrointestinal System

Expected findings: Decreased salivary and gastric secretions, decreased gut motility, reduced production of intrinsic factor, hemorrhoids, impaired rectal sensation, and constipation.

Unexpected findings to report: Black stool, blood in stool, liquid seepage of stool, nausea, vomiting, diarrhea, loss of appetite, or unintended weight loss.

Critical conditions: Absent bowel sounds or a rigid, distended abdomen require immediate notification or emergency services.

Integumentary System

Expected findings: Decreased skin elasticity, pigmentation changes, thinning and greying hair, slower nail growth, sweat and oil gland atrophy, and lesions associated with aging such as skin tags and seborrheic keratosis.

Unexpected findings to report: Suspicious moles, lesions, lumps, skin breakdown, rashes, or signs of infection in a skin wound.

Endocrine System

Expected findings: Altered hormone production, reduced ability to adapt to stress, decreased thyroid function, decreased insulin sensitivity, and changes in sleep patterns.

Unexpected findings to report: Unintended weight changes or blood glucose levels outside range.

Critical conditions: Symptomatic blood glucose less than 50 or greater than 400 requires immediate notification or emergency services.

Immune System

Expected findings: Decreased core temperature elevation, decreased thymus size, and decreased T-cell function.

Unexpected findings to report: Redness, warmth, tenderness, fever, or other signs of infection; change in mental status or confusion suggestive of infection.

Critical conditions: Suspected or actual infection with two or more signs suggesting possible sepsis: temperature greater than 38°C or less than 36°C, heart rate greater than 90 bpm, respiratory rate greater than 20 or PaCO2 less than 32, WBC greater than 12,000 or less than 4,000, or over 10% immature forms or bands.

Reproductive System

Expected findings: In females, decreased estrogen levels, atrophy of uterus, vagina, and breasts, vaginal irritation, and dryness. In males, erectile dysfunction may occur.

Unexpected findings to report: Vaginal bleeding or breast lump.

One goal of Healthy People 2030 is to improve the health and well-being of older adults. It is estimated that by 2060 almost one quarter of the U.S. population will be age 65 or older.

Older adults are at higher risk for chronic health problems such as diabetes, osteoporosis, and Alzheimer’s disease. In addition, 1 in 3 older adults fall each year, and falls are a leading cause of injury for this age group. Older adults are also more likely to be hospitalized for infectious diseases such as pneumonia, which is a leading cause of death for this age group.

Nurses can help older adults receive preventive care, including vaccines to protect against flu and pneumonia. Other Healthy People 2030 goals for older adults include early detection of dementia with appropriate intervention; decreased hospitalization for urinary infections, falls, and pneumonia; decreased medication-related safety issues; improved physical activity; improved oral health; decreased complications of osteoporosis; and reduced vision loss from macular degeneration.

Nurses can advocate for improved health care for older adults while actively involving them in decisions about care and promoting quality of life. Common areas of health promotion include nutrition, physical activity, safe medication use, and psychosocial well-being.

Nutrition

Heart disease, cancer, chronic lung disease, and stroke are the leading causes of death in older adults. Nurses can provide health teaching focused on good nutrition, physical activity, smoking cessation, and moderate alcohol use to promote improved health outcomes.

Nutrition can pose special challenges for older adults. Chewing may be difficult if there are problems with dentition. Lack of oral care, missing teeth, or poorly fitting dentures can cause older adults to avoid healthy foods. Regular dental care should be encouraged.

Finances may impact nutritional intake when older adults have difficulty meeting basic needs such as housing, food, and health care. The inability to plan, shop, and prepare meals due to activity intolerance, cognitive impairment, or physical limitations can also affect nutrition.

Nurses can initiate referrals to social workers or case managers for financial or health care concerns and promote community resources such as Meals on Wheels or senior meal site centers. Helping individuals meet nutritional needs is an important part of health promotion.

Physical Activity

Physical activity is important throughout the life span. Older individuals may be limited by physical limitations, pain, and fear of falling. Musculoskeletal problems such as impaired balance and arthritis can affect the ability to walk or participate in regular exercise.

Helping older adults find appropriate ways to maintain activity is an important nursing intervention. Nurses can advocate by encouraging regular health care checks and discussion of concerns that limit activity. Older adults should be reassured that pain is not considered a normal part of aging and can be effectively treated so they can maintain activity comfortably.

Safe Medication Use

Because chronic disease is more common in older adults, many take multiple medications to manage symptoms and conditions. Polypharmacy, or the use of many medications, increases the risk of adverse medication effects.

Older adults may receive prescriptions from multiple providers and become confused when managing daily medication use. Aging also changes absorption, distribution, metabolism, and excretion of medications, affecting safe medication use.

The American Geriatrics Society maintains a list of medications to potentially avoid or use cautiously in older adults because of risk for harm. In addition, nurses can promote medication safety by encouraging all medications from multiple providers to be filled at the same pharmacy so interactions and duplications can be checked.

A daily pill dispenser may help older adults take medications as prescribed. Nurses should perform medication reconciliation during all clinic visits and on admission to health care agencies to review current medication use.

Psychosocial Well-Being

As individuals age, they often experience loss of significant others, family members, and friends. These losses increase the risk for social isolation and depression. Poor mobility and transportation issues can also contribute to isolation.

As older adult males experience multiple losses, their suicide risk increases. Nurses can provide information about community resources and outreach programs to promote social interaction for individuals experiencing isolation.

Aging individuals continue to have sexual needs, and this aspect of health should not be ignored. Assessment of these needs allows the nurse to integrate them into the plan of care and make appropriate referrals when necessary.

Adapting Health Teaching

There are many considerations when working with older adults and promoting optimal health and quality of life. Teaching methods should be modified depending on the individual’s knowledge, skills, and abilities.

Some older adults readily use electronic technology, while others have low digital literacy or difficulty accessing electronic health resources. Nurses should adapt health teaching to the needs of the individual and provide verbal, written, or electronic resources as needed while considering sensory, cognitive, and functional impairments.

The goal of health promotion and health teaching is to improve understanding, motivation, engagement in self-management, and quality of life.