Table of Contents

Titles of related interest

Title page

Copyright page

About the series

Preface

Acknowledgements

About the editors

Contributors

How to get the best out of your textbook

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About the companion website

Part 1: Common Principles Underlying Medical and Surgical Nursing Practice

1: Principles of nursing assessment

Introduction

The purpose of nursing assessment

Assessment frameworks

Methods of assessment

Rapid assessment of the acutely ill patient

Documenting patient assessment and record-keeping

Conclusion

2: Principles of drug administration

Introduction

Drug formulation

How the body handles drugs: Pharmacokinetics

Therapeutics

Conclusion

Glossary

3: Principles of intravenous therapy

Introduction

Anatomy and physiology of the veins

Overview of vascular access devices

Administration of intravenous therapy

Principles of infection prevention

Maintaining a closed intravenous system

Maintaining patency

Managing complications

Blood transfusion therapy

Conclusion

4: Principles of nutritional care

Introduction

Nutritional screening and assessment

Calculating nutritional requirements

Dietary guidelines

Effect of illness on nutrition

Refeeding syndrome

Effect of surgery on nutrition

Nutritional support

Conclusion

5: Principles of infection prevention and control

Introduction

Physiology associated with infection

Overview of common microbiology and pathogenic organisms

Frequently encountered pathogenic microorganisms

Infection control principles

Asepsis

Decontamination

Healthcare waste management

Isolation of patients

Care bundles

Conclusion

6: Principles of acute care for older people

Introduction

Caring for people in later life

Older people in the acute care setting

Nursing assessment and the older adult

Care of the older person with confusion in the acute care setting

Medications and the older person

Falls and fall prevention

Conclusion

7: Principles of end of life care

Introduction

The nature of dying

Comfort at the end of life

Communication at the end of life

Ethics and end of life care

Conclusion

8: Principles of perioperative nursing

Introduction

General issues and anaesthesia

Patient safety

Anaesthesia

Roles of circulating and scrub practitioners

Aseptic technique/infection control

Accountability

Patient positioning

Surgical sutures

Surgical needles

Surgical dressings

Surgical drains

Surgical instruments

Surgical specialities

Recovery

Postoperative nausea and vomiting

Pain management

Conclusion

9: Principles of high-dependency nursing

Introduction

The high-dependency environment

Current policy in high-dependency care

Technological developments in high-dependency care

The role of the nurse as a member of the high-dependency team

Nursing assessment and monitoring of the highly dependent patient

Respiratory assessment, monitoring and intervention

Cardiovascular assessment, monitoring and intervention

Neurological assessment, monitoring and intervention

Conclusion

10: Principles of emergency nursing

Introduction

Historical context of emergency nursing

Triage

Common surgical emergencies

Common medical emergencies

Patient assessment in the ED

Advanced life support

Assessment and stabilisation of emergency trauma conditions

Minor trauma

Burns

Head injuries

Assessment and stabilisation of adverse behavioural presentations

Care of the critically ill and dying patient in the ED

Conclusion

Part 2: Adult Medical and Surgical Nursing

11: Nursing care of conditions related to the skin

Introduction

The structure and function of the skin

Maintaining normal tissue integrity

Skin assessment

Treatments

Common skin diseases

Wound healing

Wound assessment

Wound management

Surgical wounds

Pressure ulcers

Conclusion

12: Nursing care of conditions related to the respiratory system

Introduction

Anatomy and physiology

Nursing care and assessment of symptoms

Respiratory function testing

Respiratory interventions

Management of specific conditions

Conclusion

13: Nursing care of conditions related to the circulatory system

Introduction

Anatomy and physiology

Assessment

Diagnostic investigations

Coronary artery disease

Arrhythmias

Cardiac surgery

Valvular heart disease

Heart failure

Vascular disorders

Conclusion

14: Nursing care of conditions related to the digestive system

Introduction

Nursing assessment

Nursing care

Diagnostic investigations

Conditions of the digestive system

The biliary system

Irritable bowel disease

Appendicitis

Bariatric surgery

Conclusion

15: Nursing care of conditions related to the urinary system

Introduction

Anatomy and physiology

Conditions of the prostate

Kidney cancer

Bladder cancer

Urinary tract infections

Acute kidney injury

Chronic kidney disease

Renal replacement therapy

Conclusion

16: Nursing care of conditions related to the endocrine system

Introduction

The endocrine system

The hypothalamus and pituitary gland

The thyroid gland

The adrenal glands

The pancreas

Conclusion

17: Nursing care of conditions related to the neurological system

Introduction

Anatomy and physiology

Investigations

Nursing assessment of the neurological system

Traumatic brain injury and raised ICP

Intracranial tumours

Cerebrovascular disorders

Epilepsy

Infections of the neurological system

Multiple sclerosis

Motor neuron disease

Parkinson's disease

Alzheimer's disease

Conclusion

18: Nursing care of conditions related to the immune system

Introduction

The immune system

Organ transplant

Hypersensitivity disorders

Anaphylaxis

Autoimmunity

Human immunodeficiency virus and acquired immune deficiency syndrome

Conclusion

19: Nursing care of conditions related to haematological disorders

Introduction

Overview of blood

Blood transfusion

Investigations

Anaemia

Polycythaemia

Haemophilia

Thrombocytopenia

Disseminated intravascular coagulation

Multiple myeloma

Leukaemia

Lymphoma

Haematopoietic stem cell transplant

Conclusion

20: Nursing care of conditions related to the musculoskeletal system

Introduction

Anatomy and physiology

Osteoarthritis

Osteomyelitis

Rheumatoid arthritis

Fracture injuries

Osteoporosis

Neurovascular assessment and plaster care

Bone metastases

Conclusion

21: Nursing care of conditions related to the ear, nose, throat and eye

Introduction

Diagnostic investigations

The ear

The nose

The throat (pharynx)

The eye

Conclusion

22: Nursing care of conditions related to reproductive health

Introduction

The female reproductive system

The male reproductive system

Disorders of the female reproductive system

Disorders of the male reproductive system

Conclusion

Index

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Library of Congress Cataloging-in-Publication Data

ISBN 9780470658239

Fundamentals of medical-surgical nursing : a systems approach / edited by Anne-Marie Brady, Catherine McCabe, Margaret McCann.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-470-65823-9 (pbk. : alk. paper) – ISBN 978-1-118-49091-4 (mobi) – ISBN 978-1-118-49092-1 (ePDF) – ISBN 978-1-118-49093-8 (ePub) – ISBN 978-1-118-51479-5 – ISBN 978-1-118-51478-8

I. Brady, Anne-Marie, 1965–, editor of compilation. II. McCabe, Catherine, editor of compilation. III. McCann, Margaret, editor of compilation.

[DNLM: 1. Perioperative Nursing. WY 161]

RD99.24

617'.0231–dc23

2013017938

A catalogue record for this book is available from the British Library.

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Wiley's Fundamentals series are a wide-ranging selection of textbooks written to support pre-registration nursing and other healthcare students throughout their course. Packed full of useful features such as learning objectives, activities to test knowledge and understanding, and clinical scenarios, the titles are also highly illustrated and fully supported by interactive MCQs, and each one includes access to a Wiley E-Text: powered by VitalSource – an interactive digital version of the book including downloadable text and images and highlighting and note-taking facilities. Accessible on your laptop, mobile phone or tablet device, the Fundamentals series is the most flexible, supportive textbook series available for nursing and healthcare students today.

The impetus for this book came from the experience of teaching undergraduate and postgraduate nursing students and the realisation that a comprehensive textbook on medical and surgical nursing was needed to inform and guide learning related to the nursing care of adults. This book is designed to provide a broad overview and a practical understanding of the principles related to adult nursing. It examines the principles underpinning medical and surgical nursing and includes contemporary developments in clinical care, drawing extensively on national and international evidence. Using a systems approach, the book is designed to provide a comprehensive application of the relevant anatomy and physiology, which will inform medical and surgical nursing practice.

The book comprises 22 chapters and is presented in two sections that are designed to guide readers so they can reach an understanding of the context and the key aspects of medical and surgical nursing practice.

• Part 1: Common Principles Underlying Medical and Surgical Nursing Practice
• Part 2: Adult Medical and Surgical Nursing

Part 1 addresses common principles that underpin medical and surgical nursing practice. Chapter 1 presents an overview of the principles underlying the comprehensive nursing assessment of patient care needs. The management of medications is a major component of the everyday work of the nurse in a medical-surgical environment, and Chapters 2 and 3 provide a comprehensive overview of the principles underlying care and the nurses' responsibilities in relation to drug administration, both oral and parental. Nutritional assessment and support is a key responsibility of medical-surgical nursing care and is given detailed consideration in Chapter 4. The prevention and control of infection is discussed in Chapter 5 as this a fundamental element of all healthcare practice. Influenced by changing demographics, caring for the older person represents a significant proportion of everyday medical-surgical nursing practice, and Chapter 6 seeks to develop an understanding of the unique care needs of this population. Chapter 7 aims to develop the nurse's ability to provide appropriate and individualised care to families at the final stage of life. Chapter 8 provides students with an overview of the principles of perioperative nursing. High-dependency care is an increasing feature of medical and surgical care environments and is addressed in Chapter 9. The final chapter in this section gives the reader an overview of emergency department nursing and an understanding of the diverse nature of presenting medical/surgical emergencies, trauma and shock.

In Part 2, a systems approach is taken to afford an overview of adult nursing in medical and surgical acute care environments. The nursing care related to all the systems is discussed in Chapters 11–22 and covers topics related to the skin and the respiratory, cardiovascular, digestive, urinary, endocrine, neurology, immune, haematological, musculoskeletal, eye/ear,/nose/throat and reproductive systems. Each chapter presents a brief overview of the related anatomy and physiology to enhance students' understanding. All of the main conditions are considered, with a focus on relating the main concerns and priorities of medical and surgical nursing. Each chapter is associated with additional sources of information such as further reading, professional organisations and online resources.

To be used in addition to the traditional text, learning outcomes, conclusion and references, the website provides a series of reflective questions to prompt further discussion in both the classroom and the work setting. Case studies are employed where possible to enable the reader to engage with the content from a service provider/user perspective. Multiple choice questions are also provided to enable self-evaluation.

The primary market for this textbook is undergraduate students in general nursing at the 3rd level in Ireland and the UK. The book should, however, be of interest to all students undertaking nursing degrees and courses in which general nursing skills are an expectation for professional performance. It will also be relevant to students of other nursing disciplines undertaking health service professional degrees who wish to understand the comorbidities of clients in their care. In additional, it will be a resource for staff already working in medical and surgical nursing.

Anne-Marie Brady

Catherine McCabe

Margaret McCann

Acknowledgements

The editors wish to acknowledge and thank all of the contributors for their commitment, time and effort in sharing their professional clinical and academic expertise. We also wish to thank the reviewers who have provided us with valuable critique as we have developed this work.

Anne-Marie Brady PhD BSN MSc PG Dip CHSE PG Dip Stats RGN RNT

Anne-Marie Brady is an assistant professor at Trinity College Dublin and has been involved in undergraduate and postgraduate education since 2000. She has completed a PhD, PG Diploma in Clinical Health Sciences Education and in Statistics at Trinity College Dublin, and a MSc and BSN at Northeastern University Boston, Massachusetts, USA. Her particular areas of research and teaching interest are general nursing and healthcare management She has considerable international nursing experience, having worked in the UK, USA and Irish Republic.

Catherine McCabe PhD MSc BSc RGN RNT

Catherine McCabe has been an assistant professor at Trinity College Dublin since 2002. Her particular area of interest in teaching is general nursing and advanced nursing practice. The focus of her research is primarily exploring the effect of technology and multimedia systems on enhancing communications systems and quality of life for patients with chronic and life-threatening illnesses both in acute care settings and in the home. She has written a great deal on communication in nursing and published a number of papers on her research on communication and technology in healthcare.

Margaret McCann MSc BSc RGN RNT FFNMRCSI

Margaret McCann has been an assistant professor in the School of Nursing and Midwifery, Trinity College Dublin since 2005 and was previously employed as a lecturer in the Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland. She obtained an MSc in Nursing from the University of Manchester and Royal College of Nursing in 2001. She has been involved in nurse education since 1996. Margaret's primary teaching and research interests lie in the area of urology and renal care. The focus of her research is on the prevention and control of vascular access infection in haemodialysis, and she has published a number of papers on issues relating to renal care and vascular access.

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Introduction

Assessment is the first step in determining the condition of the patient's health and their immediate and long-term needs. The nursing assessment of patients on admission to hospital or on attendance at clinics is key to clinical decision-making and to planning patient care that takes account of the individual patients' needs and circumstances. Nurses have responsibility for carrying out the initial and ongoing patient assessments, for initiating interventions that take patients' needs into consideration and for evaluating the effectiveness of these interventions.

The nursing assessment is one component within a larger, multidisciplinary team assessment during which the patient is assessed by different healthcare professionals as part of the care pathway and patient referral process. A multifactorial assessment of the older person for falls, for example, can involve the nurse, doctor, physiotherapist, occupational therapist, optician and other healthcare professionals working in specialist areas of practice such as cardiac assessment. As a member of the multidisciplinary team, the nurse often plays a key role in coordinating the patient assessment and ensuring that appropriate referrals are made and followed up.

The principles of nursing assessment presented in this chapter are in line with the national guidelines from the professional nursing board in Ireland, An Bord Altranais, and in the UK the Nursing and Midwifery Council (NMC). The principles need to be read in conjunction with local policies and procedures for the nursing assessment, which are usually set by the hospital or healthcare employer. At ward or unit level, more specific assessment procedures may apply; for example, cerebrovascular or stroke units may include an assessment of swallowing and mood as part of the assessment of a patient newly diagnosed with a cerebrovascular accident – a stroke.

The purpose of nursing assessment

Assessment is the first stage in the nursing process and is key to developing a care plan that is tailored to a patient's individual needs (Figure 1.1).

The purpose of assessment is to achieve the following:

• Obtain baseline data and track changes. On admission to hospital or on a first visit to the clinic, it is important to carry out a comprehensive assessment of the patient to establish a set of baseline data against which subsequent assessments can be compared and any changes indicating a deterioration or improvement in the patient's condition tracked.
• Early recognition of the critically ill or deteriorating patient. Identifying patients who are ‘at risk’ is key to initiating a rapid response from the medical emergency or rapid response team. ‘Track and Trigger’ (e.g. Alert® and other early warning systems) incorporate objective physiological and subjective criteria that can be used to support the nurse's decision about when to call the medical team for help and avert more serious patient emergencies (National Institute for Health and Clinical Excellence [NICE], 2007). If a Track and Trigger system has not been set up in the hospital, a nurse who is concerned about a patient should take urgent action and notify the medical team.
• Risk assessment. Assessment is the first step in preventing complications, the aim being to identify patients who are ‘at risk’ of developing complications associated with their healthcare problem, hospitalisation and reduced mobility. Key areas for risk assessment include pressure ulcers, infection, falls and constipation. Local hospital policy may include risk assessment tools as part of the admission procedure, for example the Braden, Waterlow and Norton scores to identify patients at risk of pressure ulcers and to activate an action plan and interventions to prevent pressure ulcers developing.
• Screening for health problems. Nursing assessment provides an ideal opportunity for health promotion and for screening patients for risk factors associated with obesity, cancer, cardiovascular disease, diabetes mellitus and other major Irish and UK health problems. It also provides the opportunity to screen for specific problems such as emotional distress or organisms important in infection control (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and vancomycin-resistant Enterococcus [VRE]).
• Identify actual and potential problems and prioritise care. The patient's current problems (actual problems) and problems that could develop in the future (potential problems) need to be identified so that the care plan can be tailored to individual patient needs. Importantly, once the range of patient problems has been identified, care can be prioritised so that major problems are dealt with first.
• Care planning, tailored to individual patient needs. The purpose of assessment is not only to determine and document the patient's current condition, but also to provide evidence for the planning and provision of nursing care. Although standardised care plans are available in some units or hospitals, the nursing actions that are required to meet a patient's needs and problems should be tailored to take account of individual patient needs.
• Discharge planning. Patient assessment also includes the early identification of patients' needs for forward planning and organising the supports and community services necessary to facilitate a timely discharge from hospital. Recent trends indicate that patients' stay in hospital is shortening, the use of day surgery is increasing, and policies on early discharge and discharge planning are setting the standards for healthcare practice (Capelastegui et al. 2008; Saczynski et al. 2010; Shepperd et al. 2010). Although the reasons for a delay in discharging the patient home from hospital are multifactorial, patient assessment that includes information about the patient's home and social circumstances, family and community supports will help prevent problems arising from a poor knowledge of a patient's home situation or the support available, and will avert delays related to non-medical reasons.

Assessment frameworks

An important principle underpinning the nursing approach to patient assessment is that it is systematic, comprehensive and person-centred. Many of the assessment frameworks used in clinical practice are linked to nursing theories such as the activities of living (Roper et al. 2000) or the self-care deficit theory of nursing (Orem 2001), or to other theory including Maslow's (1999) hierarchy of needs.

Nursing models and theories serve as a guide for clinical practice and provide for a structured approach insofar as they map out what areas to include in a patient assessment. The number of new or modified assessment frameworks for nursing practice is ever increasing, but a common feature across different nursing assessments is the inclusion of the core aspects of physical, psychosocial and spiritual assessment within the context of family, community and environment (Figure 1.2). The decision of which assessment framework to use is made by healthcare organisations and nursing management, who then oversee its implementation in their admission procedures and nursing documentation. This is important because it provides a way of assuring a standardised approach to nursing assessment and quality patient care.

In terms of how this translates into practice and what information is gathered during the nursing assessment, the broad areas to consider include biographical and health data, a systematic review of patient systems and functions, and a social assessment:

• Biographical and health data. Obtaining information about the patient's health history is vital for putting the current problem or illness into context (Kaufman 2008).

• Patient assessment. This involves a ‘head-to-toe’ systematic review of the patient. A review of systems and functions enables the nurse to elicit information about problems and provide vital clues to support a clinical diagnosis or uncover a problem of which the patient is unaware. The depth of the patient assessment will depend on the patient's condition and the urgency of the clinical situation (Tagney 2008).

• Social assessment. Taking a social history enables an early identification of patients' needs and problems that might delay discharge from hospital. Social history-taking is not always considered a priority in acute healthcare services, but it helps nurses to identify the patient's needs so that appropriate referrals can be made to the health and social services and service delivery is coordinated (Atwal 2002).