Page 1 - Basic Care and Comfort Study Guide for the NCLEX-RN Exam
These questions represent one of four subdivisions of the topic Physiological Integrity covered on the NCLEX-RN® exam. They examine the best practices for patient care during daily living activities, such as hygiene, physical movement, and obtaining nutrition. Here are some of the concepts you are likely to encounter in these questions.
An important part of the basic care and comfort of your patients will involve your ability to assess the need for assistive devices, provide instructions for their use, and evaluate the patient’s ability to effectively use them.
Types of Assistive Devices
Assistive devices can include those for physical ambulation and safety, such as a walker, cane, and/or crutches. It is also important to keep in mind that devices such as hearing aids, sound amplifiers, and other alerting devices may be necessary for a patient with a hearing deficit. Likewise, a service animal, walking cane, and Braille devices may be utilized by patients with vision deficits or blindness. A patient with a speech impairment (such as after a stroke, etc.) may require the use of wordboards, pictureboards, or handheld speech-generating electronic devices to properly communicate.
Assessing the Patient for Device Need
Each patient will need a full assessment to determine the proper assistive devices that would be the most helpful. Just as two patients with the same medical condition may require different therapies for optimal health and functioning, no two patients with the same speech, auditory, physical, or communication deficits will need the same assistive devices. You must individualize your recommendations based upon the specific needs of each patient.
Assisting with Proper Use of Devices
Nurses play an important educational role for their patients who need to use assistive devices. When the patient has been fully assessed and the correct assistive device chosen, the nurse must ensure that the patient is able to use the device safely and in a manner that allows the patient to efficiently and safely perform activities of daily living while allowing for the maximum amount of independence possible.
Evaluating the Success of Device Use
Successful use of assistive devices can be determined by direct patient observation as well as his or her ability to remain injury-free due to correct usage of the device. The patient should also feel a sense of enhanced self-esteem and self-worth with proper use. If adjustments to physical devices need to be made (cane length, height of crutches, etc.), you will be responsible for helping the patient make this correction. Likewise, if a particular assistive device does not seem to be allowing a patient to perform to his or her full potential, discuss alternative choices and make arrangements for the patient to try something new.
Helping patients meet their elimination needs is central to their basic care and comfort. Both bowel and bladder functions can become altered, which will require you to provide appropriate nursing interventions for your patient’s health and well-being.
Assessment for Elimination Issues
A patient may develop an alteration of either bowel or bladder function (or both) for many reasons. These reasons include, but are not limited to: age, decreased muscular tone, physical disorders including anatomical structural disorders, neurological disorders, and psychological problems. Medication use can also affect your patient’s ability to properly void urine and/or feces. A full nursing assessment is necessary to identify the proper interventions for each patient.
Common Terms Relating to Urination Problems
Urinary elimination is more commonly referred to as micturition. One of the most common problems related to micturition is a urinary tract infection (UTI).
Polyuria: excessive production of urine (>2.5 L in 24 hours). Normal output is about 2 L a day. Nocturnal polyuria, or nocturia, occurs only during the night time hours.
Oliguria: less than normal urinary output (<400 mL in 24 hours).
Anuria: lack of production of urine or severely scant amount of urine (<50 mL in 24 hours).
Dysuria: painful or difficult urination.
Urinary incontinence: the involuntary leakage of urine or loss of bladder control. The five main types are: functional, reflex, stress, urge, and total.
Urinary retention: the accumulation of urine in the bladder due to the inability to completely empty it.
Urgency: the strong, sudden, and uncontrollable urge to urinate.
Common Terms Relating to Bowel Problems
The passage of stool is referred to as defecation. You will need to identify potential bowel problems based on the age and health of your patient.
Constipation: less than three bowel movements a week.
Diarrhea: watery or loose stool. The medical definition of diarrhea is three or more loose stools over a 24-hour period.
Fecal impaction: an accumulation of rock-hard stool inside the rectum that cannot be passed.
Flatulence: the expulsion of gastrointestinal gas.
At times, you will be responsible for performing irrigations of bodily orifices in order to provide therapeutic intervention and maintain proper organ function. This may include: bladder, eye, ear, and ostomy (urostomy for urinary diversion and colostomy for fecal diversion). A gown should always be used to protect from sprays and splashes in addition to goggles and protective masks when these occurrences are expected, and gloves should always be worn. Sterile technique is always used with the exception of fecal diversion irrigation in which you should use clean technique.
Skin Care for Incontinent Patients
Providing constant and vigilant skincare is essential for an incontinent patient. Skin that is exposed to urine and feces should be washed and dried. In addition, the use of certain barrier products can help prevent skin breakdown and complications. These may include solid skin barriers, moisture barrier ointments, moisture barrier pastes, and skin sealants.
Patients who cannot urinate on their own or who are unable to ambulate will need a urinary catheter to promote urination. The most common of these is the Foley catheter. The size of the catheter is referred to as the French or Fr. Men, women, and children all require different sized catheters. Due to the high risk of infection, catheter insertion is always performed under sterile technique and never delegated to unlicensed medical personnel.
Evaluation of Restorative Methods
Successful management of bowel and bladder elimination issues should include (at the very least):
regular, painless, and nearly complete emptying of both urine and stool without urgency
the ability to recognize and respond to the need to urinate and defecate
good maintenance of skin integrity.
Patients with urinary or fecal incontinence may undergo bladder or bowel training to develop better control over elimination. Also, be mindful of basic interventions that can have a significant impact on a patient’s ability to properly urinate and defecate such as diet, fluids, exercise, privacy, timing, and positioning if bedridden.
Mobility and Immobility
A nurse will need to assess a patient’s mobility, including strength, gait, motor skills, coordination, and balance. Appropriate interventions are necessary to prevent immobility, which carries the risk of complications such as skin breakdown and contractures.
Patients’ ability to be mobile is vital to their physical and psychological health. It is defined as “the ability to move freely, easily, and purposefully in one’s environment.” It is essential for life and plays a key function in one’s recovery and overall health. Your assessment of mobility should uncover deficiencies that can be corrected with appropriate nursing interventions to be implemented into the patient’s care plan.
Direct visualization of the patients is the best way to assess their mobility. Standardized tests may be used, but simply observing the way they move in bed, sit unassisted, rise from sitting to standing, transfer from the bed to chair, or stand and walk can provide good information. Observe the gait during walking. Gait can give valuable information about balance, motor strength, joint mobility, and muscle coordination. Your assessment should also test each of these factors individually as well.
In some cases, your patient will require the use of assistive devices including traction devices, splints, braces, and casts. These will be applied, maintained, and removed by you. You will need to be familiar with each, why they are used and be able to instruct your patient on their use. The main function of these devices is to provide proper alignment for healing, reduce pain, and prevent complications that may lead to future immobility.
For immobile patients, you will likely need to apply and maintain assistive devices that prevent venous thromboembolism. These may include compression stockings, anti-embolism stockings or hose, and/or automatic sequential compression devices. All of these promote improved venous return in an immobile patient and must be ordered by a licensed practitioner.
Immobility (especially complete bed rest) can lead to life-threatening complications that are both physical and psychological. The nurse and the entire healthcare team must take appropriate measures to both restore mobility and prevent complications. Be familiar with the adverse consequences of immobility and measures to take to intervene.
The main causes of immobility include: pain, motor/nervous system impairment, functional problems, weakness, psychological problems, and medication-induced side effects.
Completely immobile patients are at high risk of skin breakdown. Frequent repositioning can help improve the skin’s turgor and perfusion as well as reduce the pressure, shearing, and friction on localized areas. Keep in mind that a patient’s fluid and nutritional needs are integral to skin health. You may also need to utilize supportive and assistive devices such as a wedge, pillow, and pressure-relieving mattress to prevent the formation of pressure ulcerations, and skin breakdown.
The venous circulatory system is adversely affected by immobility as muscular contractions help increase the flow of venous blood from the lower extremities to the lungs and heart. Venous stasis, venous dilation, embolus formation, and thrombophlebitis are among the most common complications. Edema, orthostatic hypotension, and generalized hypotension may also develop.
To promote proper circulation, anti-embolic devices may be used, such as those described above. In addition, the nurse must implement active, active assisted, and passive range of motion exercises, as well as positioning and repositioning to promote proper circulation, and routine exercise and mobilization. This may include rehabilitative exercise with both physical and/or occupational therapy.
Immobility can lead to thickened respiratory secretions, pooling of secretions in the lungs, and the inability to effectively clear them from the lungs and airways. Because of this, patients are at risk for atelectasis, pneumonia, and other respiratory infections. Immobility also leads to shallow, ineffective respirations, decreased airflow, and decreased vital capacity of the lungs.
Immobile patients will need the incorporation of coughing, deep breathing, incentive spirometry, and other inspiratory exercises in order to prevent these complications. Some patients may also require postural drainage, percussion, and vibration performed by the nurse or respiratory therapist following these exercises to mobilize secretions.
Immobile joints are at risk for developing stiffness, pain, decreased range of motion, and contractures. Decreased weight-bearing movement leads to muscle atrophy and weakness. This also leads to loss of calcium from the skeletal system leading to osteoporosis, hypercalcemia, and fractures. These complications can be avoided with the implementation of range of motion exercises and a variety of muscular exercises that can be done in bed. A tilt table can be used to stimulate weight-bearing exercise in certain patients.
Other Potential Complications
Other physiologic changes due to immobility can include: urinary complications, bowel alterations, weight gain, electrolyte imbalances (calcium, nitrogen, etc.), and psychological problems including depression.
Immobile patients will need special positioning to maintain proper body alignment and optimal physiological functioning. Be familiar with the most commonly used positions and assistive devices used to maintain positioning (bolsters, wedges, etc.), and always be sure to educate the patient on the importance of positioning and how he or she can assist in the process.
Some patients may require the use of traction devices to achieve and maintain optimal positioning for healing. The most commonly used types include external fixation devices, halo traction, and skeletal traction. The most common condition requiring the use of these devices is a fracture, but other serious medical conditions may require traction. The nurse may set up a patient’s traction and will be responsible for maintaining it, ensure patient comfort and positioning during use, and perform adjustments when necessary. Nursing assessments during the use of traction will include frequent neurological and skin integrity exams of the affected limb/area. Frequent repositioning will also be necessary.
Evaluation of Patient Response
Nurses will decide if their patients are meeting their expected goals with regard to mobility and avoidance of complications. Several interventions such as those discussed in the previous sections may be used simultaneously to ensure patients’ safety, health, and expected recovery. Each patient should also be evaluated for psychological effects of immobility that can affect his or her quality of life such as social isolation and sensory deprivation. Adjustments to the care plan should include the proper interventions to avoid these negative outcomes.
Non-Pharmacological Comfort Interventions
Patient comfort measures will often include the use of non-pharmacological interventions. These techniques can range from the simple application of heat and cold to hypnosis, biofeedback, and other complex mind-body exercises. Different patients will have varying degrees of success with each. You will need to use your knowledge of your patient’s pathophysiology and perceptions of pain to determine which will be the most helpful.
Each patient should have a nursing assessment for the use of alternative and/or complementary therapy. Depending on the specific needs and preferences of each patient, these services may fit well with more traditional therapies. Examples can include: meditation/relaxation therapy, aroma therapy, acupuncture, massage, mind-body exercises, music therapy, herbs, and dietary supplements.
Determining the Need for Pain Management
Pain is a highly complex, subjective, and individualized sensation. Be familiar with the numerous theories on the phenomenon of pain (Specificity Theory, Intensive, Peripheral Pattern, etc.) as well as the four phases of pain and the varying types (acute, chronic, neuropathic, visceral, localized, diffuse, etc.).
Proper pain management begins with your nursing assessment of a patient’s pain. The most reliable indicator is the subjective description of the pain. Objective indicators such as vital signs and behavior changes (crying, guarding, etc.) have been found to be less reliable, but may be the only indicators in patients unable to communicate their complaints of pain.
For adults, numeric or facial pain scales are useful, as is the “PQRST” method for assessment. In children younger than age 3, observational behavioral pain assessment scales may be used as well as a number of standardized pain assessment scales.
Other Alternative Therapies
Do not underestimate the importance of other non-pharmacological comfort measures such as the use of music, warm blankets, and environmental controls such as low lighting and relaxation sounds (white noise, water, etc.) on a patient’s overall mood. Simple measures can often increase a patient’s sense of security and well-being.
Be aware of any contraindications to alternative therapies. Depending on a patient’s diagnosis, condition (pregnancy, hypertension, age, etc.) or medication regimen, therapies such as herbal supplementation, acupressure/acupuncture, and aromatherapy may not always be appropriate or safe.
Nurses will play an important role in the interdisciplinary team that oversees a patient’s palliative care. Often, nurses serve as the coordinator of this care, but provide assessments and close, physical care for patients at the end of life. The most important aspects of palliative nursing care are symptom management, pain control, and family support.
Your role will also require frequent discussions of the patient’s goals at the end of life and execution of the corresponding intervention whether you agree with it or not. You must focus your care to support the patient’s physical, emotional, psychosocial, and spiritual needs at this critical time.
Patients will undergo a number of physical, psychological, and emotional changes near death. As expected, nurses must care for both the patients and their families during this uncertain and difficult time.
Nursing interventions at the end of life will focus on comfort and will be guided by individual patient needs. These may include: an increased need for sleep, a decreased need for food and fluids, agitation and restlessness, incontinence of bowel and bladder, respiratory secretions and congestion, change in breathing patterns, decreased body temperature and skin pallor, disorientation and vision-like experiences, social withdrawal, and expressing the need to have closure and say goodbyes. The goal of care is for the patient to remain free of pain during this period.
Counseling Patients and Families
The nurse will play a critical role in helping the family members of a terminal loved one understand and accept the changes they will see in the patient near the end of life. Both patient and family members should be educated and counseled on these changes in advance of their occurrence. Again, it is important to stress to family members that their loved one will be made as comfortable as possible and free from pain and suffering near the end of life.
When evaluating the outcome of alternative therapies and comfort measures, it is important to ask for, and incorporate, your patient’s feedback into your evaluation. In addition to verbal feedback, pay attention to nonverbal body posturing and behaviors as well. This evaluation is very similar to that for pharmacologic therapy.
When evaluating the outcome of palliative care interventions, it is important to consider the patient’s stated goals. The goal of this type of care focuses on meeting the physical, emotional, and spiritual needs of each individual patient. Pain and symptom control are of utmost importance. With regard to the dying patient and family, you will need to evaluate if there is understanding and acceptance of the present situation. Ideally, family members should help take part (when appropriate) in end-of-life care. Appropriate referrals may be necessary if grief counseling and other supportive therapies are appropriate.