Tabbner’s Nursing Care Theory and Practice Gabrielle Koutoukidis

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Tabbner’s
Nursing Care
Theory and Practice
Gabrielle Koutoukidis
Kate Stainton
Jodie Hughson
sample proofs © Elsevier Australia
6TH EDITION
Tabbner’s
Nursing Care
Theory and Practice
6TH EDITION
Gabrielle Koutoukidis
Dip App Sci (Nurs), BNurs (Mid), Adv Dip Nurs (Ed), MPH, Dip Business,
Voc Grad Cert Business (Transformational Management), MRCNA
Head of Strategic & Business Development, Faculty of Health Science & Community
Studies, Holmesglen Institute, Melbourne, Victoria
Kate Stainton
Dip App Sci (Nurs), BN (Mid), Grad Dip Nurs (Education), MA Hlth Sc (Nurs)
Clinical Nurse Specialist, Newcastle Private Hospital, Newcastle, New South Wales
Jodie Hughson
MPH, Grad Cert Health Promotion, RN
Community Services Manager, Metro South,
Anglicare Southern Queensland, Queensland
sample proofs © Elsevier Australia
Sydney, Edinburgh, London, New York, St Louis, Toronto
Churchill Livingstone
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357
(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
This edition © 2013 Elsevier Australia
5th edition 2009. 4th edition 2005. 3rd edition 1997. 2nd edition 1991. 1st edition 1981.
This publication is copyright. Except as expressly provided in the Copyright Act 1968
and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication
may be reproduced, stored in any retrieval system or transmitted by any means (including
electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior
written permission from the publisher.
Every attempt has been made to trace and acknowledge copyright, but in some cases this
may not have been possible. The publisher apologises for any accidental infringement
and would welcome any information to redress the situation.
This publication has been carefully reviewed and checked to ensure that the content is as
accurate and current as possible at time of publication. We would recommend, however, that
the reader verify any procedures, treatments, drug dosages or legal content described in this
book. Neither the author, the contributors, nor the publisher assume any liability for injury
and/or damage to persons or property arising from any error in or omission from this publication.
National Library of Australia Cataloguing-in-Publication Data
______________________________________________________________________________
Koutoukidis, Gabrielle.
Tabbner’s nursing care : theory and practice / Gabrielle Koutoukidis ; Kate Stainton ; Jodie Hughson.
6th ed.
9780729541145 (pbk.)
Includes index.
Nursing – Textbooks.
Stainton, Kate.
Hughson, Jodie.
610.73
______________________________________________________________________________
Publisher: Libby Houston
Developmental Editors: Elizabeth Coady and Jane Coulcher
Project Coordinator: Natalie Hamad
Edited by Sybil Kesteven
Proofread by Tim Learner
Picture research by Karen Forsythe
Illustrators: Trina McDonald and Rod McLean
Cover and internal design by George Creative
Index by Robert Swanson
Typeset by Midland Typesetters, Australia
Printed in China by China Translation and Printing Services
sample proofs © Elsevier Australia
v
Contents
Contributors
Reviewers
xi
xiii
Foreword
Publisher’s dedication
Preface
xv
xvi
xvii
Acknowledgments
Text features
xviii
xx
Unit 1 The evolution of the nursing
profession
Chapter 1 Nursing: Historical, present and
future perspectives Jodie Hughson
What is nursing?
Nursing—the profession
Influences on nursing
3
4
13
19
Chapter 2 Legal and ethical aspects of
nursing care Kalpana Raghunathan
Introduction
Legal aspects of nursing practice
Areas of legal liability in nursing
Legal issues in the nursing specialties
Ethical aspects of nursing
22
23
23
26
32
34
Chapter 3 Nursing research Leah East
Nursing research
Evidence-based practice
Research methods
The research process
Proposal writing for research approval
How is research utilised in practice?
The enrolled nurse and nursing research
41
42
42
44
45
51
55
56
Unit 2 The contemporary healthcare
environment
Goetz Ottman
Chapter 6 Communication Jodie Hughson
Components of the communication process
Levels of communication
Elements of the communication process
Factors that influence the communication process
Forms of communication
Assertiveness to enhance communication
Therapeutic communication
Skills to facilitate therapeutic communication
Communicating with children, adolescents and
older adults
Communicating with clients’ relatives, friends and
significant others
Barriers that interfere with therapeutic
communication
Culturally safe communication
Clients with special requirements
Complications in nurse–client relationships
Communication within the healthcare team
77
78
79
80
84
85
86
88
89
92
97
98
98
99
100
103
106
107
107
111
112
113
114
115
120
122
Chapter 7 Leadership and management
Gabrielle Koutoukidis
Chapter 4 Systems of healthcare delivery
Introduction
Components of a healthcare system
Chapter 5 Health promotion, education
and wellness Marguerite Hoiby and Kate Stainton
Concepts of health and wellness
Models of health and wellness
Variables influencing health beliefs and practices
Impact of acute and chronic illness on client and
family
Health promotion
Prerequisites for health
Goals and targets for Australia’s and New Zealand’s
health in the 21st century
The role of the nurse in health promotion
The nursing process in health promotion and health
education
61
62
62
The nurse as a leader and manager
Models of nursing care delivery
Leadership styles
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127
128
128
129
vi
Contents
Contemporary leadership theories
Management
The nurse as a delegator
Preparing nurse leaders for the future
131
132
134
135
Child health services
Needs of infants and children
Chapter 11 Growth and development:
Late childhood through to adolescence
Preadolescence
Growth and development of the preadolescent
Adolescence
Growth and development of the adolescent
Issues in adolescence
Cultural diversity
Health risks
Health promotion
Nursing implications
199
200
200
201
201
208
210
211
213
213
Chapter 12 Growth and development
from the younger adult through to the
older adult Christine Baker
Emerging adulthood
Growth and development in early adulthood
Health risks/problems
Growth and development in middle-aged adults
Health risks/problems
Cultural diversity
Health promotion
Implementing the nursing process
217
218
218
220
223
225
226
227
227
Chapter 13 Older adulthood Carol Barbeler
Ageism
Growth and development
Health risks/problems
Cultural aspects of ageing
Health assessment and promotion
Care settings
Nursing care of the ageing person
Implementing the nursing process
230
231
232
236
240
241
241
244
244
Margaret Webb
Unit 3 Health beliefs, cultural
diversity and safety
Chapter 8 Cultural diversity in Australia
and New Zealand Robyn Williams
Introduction
What is culture?
Culture and wellbeing
Effective communication
Culture, the individual and their profession
Cultural diversity and clients’ experiences of the
system
Culture in practice
Chapter 9 Indigenous health Robyn Williams
Overview
Indigenous health before colonisation
Indigenous health after colonisation
Social determinants of Indigenous health
Indigenous health and the living environment
Major government responses to Indigenous health
challenges
Indigenous health, capacity and resilience
141
142
142
146
149
150
152
154
159
161
162
163
164
164
165
168
Unit 4 Nursing care throughout the
life span
Chapter 10 Theories of growth and
development: Conception through to late
childhood Andree Gamble
Conception
Development of the placenta, membranes, liquor
and cord
Intrauterine development and growth
Transition to extrauterine life
Theories of development
Growth and development
Growth and development of the infant
Health risks/problems
Growth and development of the child
Health risks/problems
Factors influencing growth and development
Cultural diversity
Health promotion
Paediatric nursing care
173
174
174
176
177
178
180
182
185
185
190
191
193
193
194
194
196
Unit 5 Critical thinking and reflective
practice
Chapter 14 Critical thinking, problembased learning and reflective practice
Introduction
Critical thinking
Problem-based learning
Reflective practice
251
252
252
253
254
Chapter 15 Components of the nursing
process Gillianne Meek
An overview of the nursing process
259
260
Valerie Zielinski
sample proofs © Elsevier Australia
Chapter 16 Documentation and reporting
skills Cindy Stainton
Purpose of documentation
Legal and ethical considerations
Documentation guidelines and principles
Reporting
270
271
272
272
279
Unit 6 Health assessment
Chapter 17 General health assessment
Shyamala Munusamy
287
Guidelines for conducting a general health
assessment
Assessment techniques
Routine shift assessment
Diagnostic investigations
Recording and reporting
Teaching considerations
Clinical handover
Advance health directives
288
295
297
298
298
298
298
299
Chapter 18 Vital signs Amy Dearsley
Guidelines for taking vital signs
Body temperature
Steps in obtaining an accurate measurement of
body temperature
Pulse
Respiration
Pulse oximetry—measuring oxygen saturation
Blood pressure
Chapter 19 Admission, transfer and
discharge processes Louise Alexander
Types of admission
Reactions to admission
The admission process
Admitting the client to the mental health unit
Admitting a child to a healthcare facility
Admitting an adolescent to a healthcare facility
Discharge planning
301
302
302
306
311
315
319
320
332
333
333
337
340
340
343
343
Unit 7 Basic healthcare needs
Chapter 20 Infection prevention and control
Teresa Lewis
Healthcare-associated infection is preventable
Nature of infection
Microorganisms
Infection prevention and control in practice
359
360
360
361
368
Contents
vii
Chapter 21 Hygiene and comfort Carmel Duff
Factors affecting personal hygiene
Skin and skin care
Bathing and showering
Hair care
Eye, ear and nasal care
Mouth care
Nail care
Hygiene summary
Promoting comfort
Bed making
Comfortable positioning
393
394
394
396
403
405
407
409
410
410
413
419
Chapter 22 Medications Adriana Tiziani
Pharmacology
Pharmacokinetics
Pharmacodynamics
Nursing care and administration of medications
Systems of measurement
Administering medications
Monitoring the effects of medications
Safe handling of hazardous substances
Safe storage, administration and disposal of
medications
Medications and the older adult
Continuation of medication after discharge
425
426
429
432
433
441
445
461
461
465
465
465
Unit 8 Health promotion and
psychosocial and physiological
nursing care
Chapter 23 Oxygenation Kylie Porritt
Structure of the respiratory system
Scientific principles of ventilation and respiration
Structure of the cardiovascular system
Circulation of blood
Structure of the lymphatic system
Factors affecting the respiratory system
Pathophysiology related to the respiratory system
Specific disorders of the respiratory system
Factors affecting the cardiovascular system
Pathophysiology related to the circulatory system
Specific disorders of the circulatory system
Diagnostic tests
Cardiovascular diagnostic tests
Nursing a client with a respiratory and/or cardiac
system disorder
The client with an artificial airway
Nursing a client with an artificial airway
sample proofs © Elsevier Australia
473
474
478
481
489
490
492
494
495
497
499
501
504
505
509
518
519
viii
Contents
The client with thoracic drainage tubes
Nursing a client with a chest drain
Nursing practice and oxygen administration
Chapter 24 Meeting fluid and electrolyte
needs Katie Piper
Homeostasis
Fluid balance
Electrolyte imbalances
Nursing assessment of client with fluid and/or
electrolyte needs
Intravenous therapy
Understanding acid–base balance
Chapter 25 Rest and sleep Carol Barbeler
Physiology of sleep
Sleep disorders
Factors leading to sleep disturbances
Assessing sleep patterns
Sleep-promotion measures
521
523
524
533
534
538
541
542
546
551
555
556
559
561
561
563
Chapter 26 Movement and exercise
Susan Lanyon
The physiology of movement
Body mechanics
Disease processes that influence body mechanics
Development of movement and exercise through
the life span
Overweight and obesity in Australia and
New Zealand
The benefits of physical activity
Principles of muscle movement in exercise
Assessment of movement, mobility and the
musculoskeletal system
Diagnosis of a musculoskeletal disorder
Nursing care of the individual with a
musculoskeletal disorder
Treatment of bone injuries and musculoskeletal
disorders
General treatment of musculoskeletal disorders
Ambulation after prolonged immobilisation
Walking aids
Complications associated with reduced mobility
568
569
570
570
572
574
574
576
578
581
581
582
583
585
586
588
The integumentary system
Wound healing
Types of wounds
Wound management
607
609
612
613
623
626
634
Chapter 28 Nutrition Lucinda Brown
Nutrition overview
Nutrition assessment
Nutrients
Diets to meet client needs
Nursing practice and nutritional needs
Common disorders associated with nutrition
643
644
645
650
651
655
659
Chapter 29 Urinary elimination Susan Brown 670
671
The urinary system
Alterations in urinary system functioning
673
Manifestations of urinary system disorders
673
Changes to voiding patterns
674
Specific disorders of the urinary system
680
Incontinence
682
Catheters
685
Specialist urology nursing activities
689
Chapter 30 Bowel elimination Susan Brown
The digestive system
Disorders of the digestive system
696
697
707
Chapter 31 Pain management
718
Fundamentals of pain
719
720
Pain management across the life span
Nursing interventions for a client experiencing pain 727
Yangama Jokwiro
Chapter 32 Sensory abilities
Suzanne McArthur
Classification of sense organs
The eye
The ear
Disorders of the eye
Specific disorders of the eye
Disorders of the ear
736
737
739
741
744
748
755
Chapter 33 Neurological health
Chapter 27 Skin integrity and wound care
Greer Hosking
Pathophysiological effects and major manifestations
of skin disorders
Specific disorders of the skin
Care of the individual with a skin disorder
Pressure injuries
Leg ulcers
Burn injuries
Surgical wounds
594
595
597
598
599
Fiona Skene and Gabrielle Koutoukidis
The function and structure of the neurological
system
Pathophysiological influences and effects of
disorders of the nervous system
Assessing neurological status
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762
763
768
771
Contents
Diagnostic tests
Specific disorders of the nervous system
Care of the client with a nervous system disorder
Care of the unconscious client
774
777
786
790
Chapter 34 Endocrine health John Elias
Structure and function of the endocrine system
Endocrine disorders
Care of the client with an endocrine disorder
802
803
808
821
Chapter 35 Reproductive health
Christine Baker
The male reproductive system
Disorders of the male reproductive system
Nursing interventions in male reproductive health
The female reproductive system
Disorders of the female reproductive system
Assessment and diagnostic tests
Women’s health promotion
Contraception
Disorders of reproduction
Sexual abuse
Survivors of torture and trauma
Child sexual abuse
Sexually transmitted infections
831
832
833
839
839
840
847
849
850
853
854
854
855
855
Chapter 39 Behavioural and social aspects
of disability Trevor Skerry
931
Definitions of disability
932
Conceptual models of disability
933
Classifications of disability
933
Historical background
934
The philosophy of inclusion and normalisation
935
Responses to disability
938
Person-centred planning
939
Family caregiving—impact and support
942
Health promotion: disability prevention
944
Chapter 40 Acute care Michelle Hall
Scope of practice
Where is acute care delivered?
Impact of acute illness
Acute disorders
Clinical pathways
Karen Stilo
Chapter 36 Palliative care Jacqui Allen
Death and dying
Palliative care
Person- and family-centred palliative care
Multidisciplinary palliative care
Symptom management
Loss and grief
Care of the dying
Care of the bereaved
Support for the nurse
863
864
865
866
866
867
871
871
873
874
Chapter 37 Mental health Finbar Hopkins
Concepts of mental health and mental illness
The provision of care
Historical perspectives and mental healthcare
Care of clients with specific emotional or
behavioural challenges
Legal and ethical aspects of mental health nursing
Ethical issues and dilemmas
876
877
886
890
893
910
911
948
949
949
950
951
959
Perioperative care
Surgery
Preoperative care
Intraoperative phase
Postoperative care
963
964
964
967
974
979
Chapter 42 Emergency care
Jennifer Jennings
Introduction
Recognising and responding to an emergency
Changes in vital signs
Basic life support
Applying the principles of emergency care
Defibrillation with the automated external
defibrillator
Post-resuscitation care
In hospital code documentation
Staff debriefing
Managing specific emergency situations
Cardiac emergencies
991
992
993
994
996
996
999
1000
1001
1002
1002
1003
Chapter 43 Maternal and newborn care
Chapter 38 Rehabilitation nursing
Aims and characteristics of rehabilitation
918
919
920
924
926
928
Chapter 41 Perioperative nursing
Unit 9 Healthcare in specialised
practice areas
Kate Stainton
Philosophy of rehabilitation
Adjustment to disability
The rehabilitation team
The process of rehabilitation
Planning and implementation
Culturally relevant care
ix
916
917
Kate Stainton
Pregnancy
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1008
1009
x
Contents
Prenatal care and preparation
Labour
Postnatal care
1012
1013
1017
Chapter 44 Community-based care
Anne Moates
Community healthcare
Community health nurse role
Models of care in community health
Issues for community health nurses in home care
The nursing process and community nursing
1030
1031
1033
1034
1035
1036
Remote and rural Australia
Health and illness patterns in rural and remote
Australia
Remote area and rural nursing
Effective healthcare service delivery in remote
settings
Stress related to working in a remote health context
Access to health services in rural and remote areas
Credits
Index
Chapter 45 Rural and remote care
Robyn Williams and Gabrielle Koutoukidis
Introduction
1040
1041
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1041
1042
1044
1044
1047
1050
1054
1061
xi
Contributors
The publisher and editors would like to thank all past and
present contributors and reviewers.
Louise Alexander BNur, Postgrad Cert (Psych Nurs),
PGC (Education), MEd (PET)
Lecturer, Bachelor of Nursing (Mental Health),
Holmesglen Institute, Victoria, Australia
Jacqui Allen RN, BA (Hons), MPsych
Lecturer in Nursing, Deakin University, Victoria, Australia
Christine Baker MNsg, Grad Dip Ad & Voc Ed,
BHlthSc, Dip VET, Cert IV TAE, Cert Sexual Health,
MRNCA
Senior Educator, Nursing Programs, Swinburne University,
Victoria, Australia
Carol Barbeler RN, BNur (Post-reg), M Appl Gerontol,
Dip Training & Assessment
Educator, Nursing and Aged Care, GippsTAFE, Victoria,
Australia
Lucinda Brown RN, MPH, Grad Dip Health Sci
Lecturer, Deakin University, School of Nursing and
Midwifery, Victoria, Australia
Sue Brown BHlthSc, MHlthSc, GCert (TT) (Vic), DN
(La Trobe), RN
Nurse Consultant: Life in Place
Andree Gamble RN, BN, Postgrad Dip Adv Clin Nurs
(Child Health), Postgrad Cert Prof Educ & Training, Grad
Cert Clin Simulation, M Nurs Sci, Cert IV TAA, Dip Bus
Lecturer, Bachelor of Nursing, Holmesglen, Melbourne,
Victoria, Australia
Michelle Hall BN, Grad Cert (Health Prof Ed), Cert IV
(TAE)
Teacher, Nursing, Health Science and Biotechnology
Department, Holmesglen, Melbourne, Victoria
Marguerite Hoiby RSCN, RN, Cert Spinal Injuries &
Rehab Nursing, Cert Op Room Nursing, Grad Dip Educ
Admin, Grad Dip Bus
Quality & Risk Manager, Linacre Private Hospital,
Victoria, Australia
Lead Auditor Quality Management Systems (ISO) &
Reproductive Technology Accreditation Committee
(RTAC)
British Standards International Aged Care Assessor
Aged Care Accreditation Standards & Accreditation
Australian Sessional Trainer, Skills Training Australia, Knox,
Victoria, Australia
Finbar Hopkins RN, RMN, RM, BA Sciences (Nurs),
Grad Dip (Women’s Health), MA
Lecturer in Nursing, University of Melbourne, Victoria,
Australia
Greer Hosking RN, ONC, BEd, Cert IV Training and
Amy Dearsley RN/RM
Assessment
Educational specialist, Laerdal Australia
Jodie Hughson MPH, Grad Cert Health Promotion, RN
Carmel Duff RN, Grad Dip Adv Nurs (Education)
Lecturer in Nursing, Deakin University, Melbourne,
Victoria, Australia
Community Services Manager, Metro South, Anglicare
Southern Queensland, Australia
Jennifer Jennings RN, BN, Grad Dip (Adv Clin
Leah East BN, RN (Hons), PhD
School of Nursing and Midwifery, University of Western
Sydney, New South Wales, Australia
John P Elias BSc (Hons), PhD
Human Bioscience Lecturer, Holmesglen Bachelor of
Nursing, Melbourne, Victoria, Australia
Practice), GCHPE, Grad Cert Health Prof Educ, GCCS,
Grad Cert Clinical Simulation
Yangama Jokwiro BSc (NS), MSc (Physiology)
Bioscience Lecturer, Holmesglen Institute, Melbourne,
Victoria, Australia
sample proofs © Elsevier Australia
xii
Contributors
Gabrielle Koutoukidis Dip App Sci (Nurs), BNurs (Mid),
Adv Dip Nurs (Ed), MPH, Dip Business, Voc Grad Cert
Bus (Transformational Management), MRCNA
Head of Strategic & Business Development, Faculty of
Health Science & Community Studies, Holmesglen
Institute, Melbourne, Victoria, Australia
Curriculum Development, Careers Australia, Victoria,
Australia
Fiona Skene RN, M Multimedia, MEd, affiliate of
ANNA (Australasian Neuroscience Nurses’ Association)
Trevor Skerry MEd, Grad Dip Adult Ed, Grad Dip
Susan Lanyon RN, CCRN, Grad Dip Midwifery, BT/BA
Teacher of Nursing, Holmesglen Institute, Melbourne,
Victoria, Australia
Teresa Lewis RN, Cert Intensive Care Nurs (Post-reg),
Cert Infect Control Nurs (Post-reg)
Infection Prevention and Control Manager, Newcastle
Private Hospital, New South Wales, Australia
Member Australasian College of Infection Prevention &
Control (ACIPC) [previously Australian Infection Control
Association (AICA)]
Health Counselling, B Special Ed, Dip Teaching
Lecturer, School of Health Sciences, RMIT University,
Victoria, Australia
Board Member, Australian Society of Intellectual
Disabilities (ASID)
Cindy Stainton RN, Crit Care Cert, Postgrad Dip Health
Service Management, MRCNA
Nurse Director, Western Australia Country Health Service,
Great Southern, Western Australia, Australia
Kate Stainton Dip AppSc (Nurs), BN (Mid), Grad Dip
Suzanne McArthur RN, BEd (La Trobe), Postgrad Dip
Crit Care Nurs (Austin), Cert IV TAA
Nursing Course Coordinator; Diploma of Nursing,
Advance TAFE, Bairnsdale, Victoria, Australia
Member, Australian Wound Management Association
Member, Moderation Delivery Committee Certificate
IV/Diploma in Nursing, Victoria, Australia
Gillianne Meek RN, BSc (Hons), MN
Team Leader, Waiariki Institute of Technology, Rotorua,
New Zealand
Anne Moates RN, Midwife, MCHN, M Pub Health,
MEd, B AppSci (Nurs), Grad Dip Adv Nurs (Child,
Family and Community Nursing), Grad Dip Adv Nurs
(Neonatal Intensive Care Nursing), Grad Cert Nurs (Educ)
Senior Educator, Health and Nursing, Chisholm Institute,
Victoria, Australia
Nurs (Education), MA Hlth Sc (Nurs)
Clinical Nurse Specialist, Newcastle Private Hospital,
Newcastle, New South Wales, Australia
Karen Stilo RN, BN, Grad Cert Perioperative Nursing,
Dip TAA
Teacher in Diploma of Nursing, Holmesglen Institute,
Melbourne, Victoria, Australia
Adriana Tiziani BSc, DipEd, MEdSt, RN
Course Director, Postgraduate Studies in Wound Care,
Monash University, Parkville, Victoria
Nursing Teacher, Health Science and Biotechnology
Department, Holmesglen Institute, Melbourne, Victoria,
Australia
Shyamala Munusamy BHSc (Nursing), Adv Dip Nurs
(Neuroscience), Dip Nurs (Singapore), Cert IV TAA
Margaret Webb BNurs, RM, MEd (AWE), Grad Dip
(FTE), AdvDip (Business)
Project Manager, Department of Education and Training,
Queensland
Executive Director, MW Projects Queensland, Australia
Goetz Ottman PhD
Robyn Williams BA, RN, Grad Dip Ed, MPET
Lead Researcher, Uniting Care Community Options/
Deakin University Research Partnership, Victoria, Australia
Course Coordinator, Bachelor Health Science, School of
Health, Charles Darwin University, Northern Territory,
Australia
Katie Piper RN, MN, BN
Lecturer, Holmesglen Institute, Melbourne, Victoria,
Australia
Kylie Porritt RN, MNSc, PhD
Research Fellow, The Joanna Briggs Institute, University of
Adelaide, South Australia, Australia
Valerie Zielinski RN, RM, PhD, BEd, MEd Admin,
FRCNA
Clinical Coordinator and Teacher (Nursing), FACTS
(Future Aged Care Learning Solutions), Geelong, Victoria,
Australia
Kalpana Raghunathan RN, MHuman Resource Mgt,
MDevelopment Studies, BSociology, BN, Dip BusMgt,
Dip Community Development
sample proofs © Elsevier Australia
xiii
Reviewers
Terri-Jayne Bissell RN, IPN, MN (Adv Clin Ed), BHSc,
Cert (Crit Care), Cert (High Dependency), Cert IV (TAA)
School of Nursing, Queensland University of Technology,
Brisbane, Queensland, Australia
Dianne Cheeseman Grad Dip Educ (N), BNur, RN,
RCHN, Dip BTTM, MRCNA
Teacher, Nursing/Aged Care/Health Studies, Metropolitan
South Institute of TAFE, Brisbane, Queensland, Australia
Ali Drummond BNSc
Indigenous Nurse Advisor, Nursing and Midwifery Office,
Queensland Health, Queensland, Australia
Jeff Harding BAppSc Advanced Nursing (Nurs Ed), Cert
IV TAA
RNRPL Coordinator
Teacher, Department of Health Services, Swinburne TAFE,
Melbourne, Victoria, Australia
Janet Kerswell Unnasch RN, Grad Dip MH, Cert IV
TAA
Guest Nursing Lecturer for Institute of Continuing and
TESOL Education, The University of Queensland
(ICTE-UQ)
Ellie Kirov BSc (BiolSc) (Hons), PhD
Lecturer, School of Natural Sciences, Edith Cowan
University, Perth, Western Australia
Lecturer, Health Studies, Perth Institute of Business and
Technology, Perth, Western Australia
Anoni Morse BA, RN, Paed Cert, AMH Cert
Teacher, Health Services North West, Tasmanian
Polytechnic, Tasmania, Australia
Teresa Sargent BN, RN
Registered Nurse, Wesley Private Hospital, Brisbane,
Queensland, Australia
Clarissa Spencer RN
Teacher, Western Institute of TAFE, New South Wales,
Australia
Kay Syminton-Foley DipComN, ADN, BN, Postgrad
Dip HSc, RN
Senior Academic Staff Member, Waikato Institute of
Technology, Hamilton, New Zealand
Mandy Williams RN (UK & NZ), MHSc Health Prof Ed
Blended Learning Coordinator, Waiariki Institute of
Technology, Rotorua, New Zealand
sample proofs © Elsevier Australia
xv
Foreword
Over the years the role and function of the enrolled nurse
has expanded to become the nurse professional you see
today, employed in all healthcare settings across Australia
and New Zealand. Very different indeed from 1979 when
Nurse ‘Ray’ Tabbner was compelled to sit down to write
the first Tabbner—Nursing Care: Theory and Practice—
replacing the original Handbook for Nursing Aides.
The enrolled nurse of the twenty-first century, like
their registered nurse colleague, is a very different creature
from their colleague of those bygone days. The differences
are immense. To start with, today’s enrolled nurse has a
significantly expanded educational preparation. Over the
years even the title has evolved from that of ‘nursing aide’ to
today’s ‘enrolled nurse’. ‘Enrolled nurse’ is a title protected
by legislation, as are ‘registered nurse’, ‘midwife’ and ‘nurse
practitioner’. This legislation is monitored and supported
by the Nursing and Midwifery Board of Australia to protect
those needing healthcare and health education.
With the course now being delivered at diploma level
it is necessary to have comprehensive depth to the content
and I believe the sixth edition of Tabbner’s Nursing Care
is an all-encompassing teaching tool. I see it being used
both in the classroom and the workplace for many years to
come. The content is inclusive of all facets of the life span
in a health and health promotion context in metropolitan,
rural and remote settings. The text has been concisely and
clearly set out to guide the undergraduate nurse and their
educators as they traverse the enrolled nurse course.
From that solid underpinning the knowledge gained will
support those articulating to advanced diploma level, thus
expanding the career pathways within enrolled nursing.
Over the years previous editions of Tabbner’s Nursing
Care have been used in many countries to educate the
enrolled nurse (however titled). I foresee future generations
of nurses gaining from this edition a wealth of the
knowledge, skills and techniques so essential to being a
professional healthcare provider.
As people avail themselves of the content in Tabbner’s
Nursing Care sixth edition it will become apparent how
much critical thinking has gone into the development of
this edition. All who use this book can only be enlightened.
It has been developed in a clear and concise manner to
make it extremely user friendly and easy to assist with
study. The authors and editors must be thanked for their
efforts in doing this. This text will energise and educate the
enrolled nurse of the future.
Someone who must be thanked and recognised is Nurse
Ray Tabbner. All those years ago she had the courage and
foresight to establish the educational journey that enrolled
nursing has since taken, culminating now in this sixth
edition. It is wonderful to see that her work continues to be
recognised in the title of this publication and I thank the
authors, Gabrielle Koutoukidis, Kate Stainton and Jodie
Hughson, for this body of work.
The sixth edition of Tabbner’s Nursing Care is testimony
to the journey of the enrolled nurse, past, present and
future.
Maryanne Craker
President
National Enrolled Nurse Association of Australia
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xvi
Publisher’s dedication
Alice Ray Tabbner
25 December 1919–13 December 1994
Ray (as she preferred to be known) Tabbner was born in
Birmingham, England. After working in the St John
Ambulance in World War II where she said she ‘became
engrossed in nursing’, she completed her training as a nurse
in the 1940s. She moved to Australia in 1948 and worked in
a number of Sydney hospitals before settling in Melbourne.
Ray established a career in nursing education in 1953
taking on the role of Tutor at the recently established
Melbourne School of Nursing. In 1954 she successfully
completed her Sister Tutors Diploma through the College
of Nursing Australia and remained a Tutor at the school
until 1961 when she was awarded the Inaugural Nurse
Scholarship in Geriatrics from Mount Royal Hospital. In
consequence of receiving this award, Ray was appointed
to the position of Deputy Matron of Geriatric Nursing
at Mount Royal. She later established the Nursing Aides
course at the Fairfield Hospital in Melbourne under
the leadership of Vivian Bulwinkel, and in 1973 was
appointed Deputy Director Nursing (Education), one of
three executive positions at the Royal Melbourne Hospital.
An innovative educator and mentor, Ray Tabbner was
one of the first nurses to call for the establishment of ‘Nurse
Banks’ in Australia to ensure flexibility in the nursing
workforce for those nurses wishing to pursue family or
other interests while pursuing their chosen profession. She
was also a great advocate of ongoing training to ensure
nurses could maintain flexibility in their lives and return to
nursing with confidence.
In 1975 she was appointed Principal Teacher at
the Melbourne Nursing Aides School (later renamed
Melbourne School for Enrolled Nurses), a position she
occupied until 1978 when she retired to write. Originally
entitled The Handbook for Nursing Aides, it was later
renamed Nursing Care: Theory & Practice, and since the
publication of the first edition in 1981, it has become
known and loved by generations of nursing students as
simply Tabbner’s.
An article published in 1973 in the Melbourne Sun
described her as being ‘as flighty as your average banker.
Her dark hair has streaks of steel grey and the creases in
her dazzlingly white nurse’s uniform would slice bread’.
However, students from the 1950s to the 1970s remember
her with great fondness and warmth. Ray Tabbner was said
to be very approachable and a welcome relief from many
‘military style’ nurse educators. She taught everything
from Anatomy & Physiology to Bandaging and Nursing
Care and made a great impression on her students. As one
student from 1955 put it, ‘Everything Miss Tabbner said,
I learned’.
The Tabbner name has become synonymous with
Enrolled Nurse/Registered Nurse Division 2 education not
only throughout Australia — the influence of her name
extends via this publication to New Zealand, the United
Kingdom, the Middle East, Africa and the West Indies.
This sixth edition of Tabbner’s Nursing Care is dedicated
to her memory and her contribution to nurse education.
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xvii
Preface
The sixth edition of Tabbner’s Nursing Care is a
significant revision which reflects the scope of practice
in contemporary enrolled nursing practice while still
retaining the strengths of previous editions that have
made it an essential resource for enrolled nursing students
and their facilitators.
The role of the enrolled nurse
The enrolled nurse is an essential member of the healthcare
team, providing client-centred nursing care which includes
recognising what is normal and abnormal in assessing,
intervening and evaluating individual health and functional
status. Enrolled nurses’ responsibilities also include
providing support and comfort, assisting with activities of
daily living to enable clients to achieve their optimal level
of independence, and providing for the emotional needs
of clients. Where state and territory law and organisational
policies allow, enrolled nurses may administer prescribed
medicines or maintain intravenous fluids, in accordance
with their educational preparation.
Enrolled nurses are required to be informationtechnology literate, with specific skills in the application of
healthcare technology. Enrolled nurses demonstrate critical
and reflective thinking skills in contributing to decision
making, which include reporting changes in health
and functional status and individual client responses to
healthcare interventions. Enrolled nurses work as part
of the healthcare team to advocate for and facilitate the
involvement of clients, their families and significant others
in planning and evaluating care and progress towards health
outcomes. The role also requires them to act as preceptors
for students and other healthcare workers.
Career opportunities for enrolled nurses are expanding
and include: acute care; perioperative, emergency, intensive
and coronary care; aged care; rehabilitation; community
and mental health nursing, and general practice settings.
In addition, enrolled nurses work in specialty areas such
as nursing education, diabetes education, continence
management, dementia management, lactation consultancy, workplace safety and wound care. There are also
increasing opportunities for enrolled nurses to move into
management positions.
Sixth edition of Tabbner’s Nursing Care
As a new editorial team, we have ensured a holistic, personcentred approach to client care throughout the textbook,
allowing students to appreciate the skill and scope required
to be a competent enrolled nurse. All chapters have been
completely revised with a focus on critical thinking and
problem solving and national registration requirements
have been addressed where appropriate.
Four new chapters have been included to highlight a
range of contemporary nursing issues:
• Leadership and management
• Older adulthood
• Acute care
• Rural and remote care.
The new full colour internal design enhances photos
and illustrations to provide clear and meaningful visual
aids to learning.
The sixth edition has been carefully developed to align
with the Diploma of Nursing in the HLT07 National
Health Training Package for the enrolled nursing student.
It provides a contemporary approach to nursing practice
and is an invaluable teaching resource. The text provides
the theoretical knowledge on the care that clients may
require in a range of healthcare settings and offers special
features to enhance student learning of the material.
This edition is a culmination of the efforts of many
nursing academics and professionals who are passionate
about the education of enrolled nurses and the important
role they play in healthcare settings. We are grateful for their
enthusiasm and support throughout the writing process.
As the new editing team of Tabbner’s Nursing Care 6E
we would like to acknowledge Rita Funnell and Karen
Lawrence, the editors of the fourth and fifth editions of
Tabbner’s, for their invaluable work and major contribution
to the education of enrolled nurses. In addition we would
like to thank the team at Elsevier for their hard work and
perseverance in ensuring the publication of this edition.
Gabby Koutoukidis
Kate Stainton
Jodie Hughson
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xviii
Acknowledgments
I was delighted to be invited as an editor again for Tabbner’s
6E and to have the opportunity to do this alongside two
very good friends of mine – Kate and Jodie – whom I
thank so much for coming on this journey with me.
This sixth edition is the culmination of work by many
writers and nursing educators and I would like to thank
all contributors—especially to both nursing teams at
Holmesglen for jumping at the chance to write chapters—
sometimes with very short timelines!
I would also like to acknowledge all the nursing students
and teams I have worked with over the years who have
inspired in me a passion for teaching and ensuring best
nursing practice.
Gabby Koutoukidis
This edition has been an epic adventure which has
consumed many hours of my spare time! I thank my
husband Stuart for listening, advising and his patience. I
thank my children for their interest and understanding.
I also thank the Elsevier team for all the hard work in
getting this edition to publication.
Nursing is an art: and if it is to be made an art, it requires
an exclusive devotion as hard a preparation as any painter’s
or sculptor’s work; for what is the having to do with dead
canvas or dead marble, compared with having to do with
the living body, the temple of God’s spirit? It is one of the
Fine Arts: I had almost said, the finest of Fine Arts.
Florence Nightingale
I hope this edition of Tabbner’s prepares future nurses well!
Jodie Hughson
To my husband, Anthony, and children Ben, Alex and
Maddy, thank you so much for your understanding and
support. Now you can have the study back, Anthony,
and the kids can stop wondering if they are going to get fed!
To my co-editors, authors and the team at Elsevier
thank you for all your knowledge and hard work.
Kate Stainton
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xix
Standard steps for all nursing
procedures/interventions
These are the essential steps that must be done consistently
with each client contact in order to deliver responsible and
safe nursing care.
Before the procedure
Step 1
• Mentally review the steps of the procedure beforehand
• Discuss the procedure with your instructor/supervisor/
team leader, if required
• Confirm correct facility protocols/safe operating
procedures
Step 2
• Check the order in the chart, client’s nursing/medical
history
• Review handover report to assess specific instruction
or need of client
• Gather equipment/supplies. If using a procedure
trolley, ensure it is cleaned
• Perform hand hygiene
Step 3
• Introduce yourself to the client and/or family
• Gain client consent to perform the procedure
• Check the client’s identification, using two identifiers.
When verifying identity, get client to verbalise name
and check against identification band as well as
relevant documentation
• Explain the procedure to the client in terms they can
understand
• Assess client to determine whether intervention is still
appropriate
• Identify teaching needed and describe what the client
can expect
Step 4
• Provide privacy
• Keep yourself safe, e.g. raise the bed to appropriate
working height
• Provide adequate lighting for the procedure
• Arrange supplies and equipment
During the procedure
Step 5
• Perform hand hygiene
• Put on gloves following standard precautions as
appropriate
• Place on eyewear, mask and gown as appropriate
• Ensure client safety and comfort throughout
procedure
Step 6
• Promote client independence and involvement if
possible
• Assess client tolerance to the procedure
After the procedure
Step 7
• Dispose of used supplies and sharps appropriately.
Remove eyewear and other protective equipment and
discard or store appropriately
• Remove gloves (if worn) and perform hand hygiene
• Clean used equipment and store appropriately
Step 8
• Make the client comfortable and inform them of how
the procedure went, or of any results/values
• Restore the bed height, tidy the bed and surrounding
area. Place call bell and personal items within reach
• Perform hand hygiene
Step 9
• Record and document assessment findings, details of
the procedure performed and the client’s response
• Report abnormalities as required
• Reassess client to ensure there are no adverse effects/
events from the procedure.
(References: deWit S (2009) Fundamental Concepts and Skills for
Nursing, 3rd edn. Philadelphia: WB Saunders, reproduced with
permission; and Perry AG, Potter PA and Elkin MK (2012) Nursing
Interventions & Clinical Skills, 5th edn. St Louis: Mosby Elsevier.)
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Text features
Learning Outcomes assist students to focus on key
information in each chapter
CHAPTER 26
Movement and exercise
Susan Lanyon
Key Terms are listed at the beginning of each chapter
and defined within the text
Learning Outcomes
Learning Outcomes
Lear
O
Learning
Chapter Focus introduces the key concepts in each
chapter
• Assess clients for impaired mobility and activity
intolerance
• Assist in plann
planning and implementing nursing care
plans for clien
clients with a musculoskeletal disorder
• Accor
A
ding to specified role and function, perform the
According
nursing
ng activi
ities described in this chapte
chapter safely and
activities
ac
accura
accurately in the clinical environment
At the completion of this chapter and with some further
reading, students should be able to:
• Define
fine the key terms
Defi
• Describe and implement the principles of good posture
osture
and body mechanics
• Describe the role of the musculoskeletal system in
n the
he
l i off movement
regulation
• Describe how joints are involved in movement
Key Terms
• State differences between isotonic, isometric and
active and passive exercise
muscle atrophy
isokinetic exercise
arthrography
rthrography
weight and obesity
obesi
overweight
• Describe and define range of movement (ROM)
benign tumours
orthostatic or postural
ved in
• Identify and demonstrate joint movements involved
body mechanics
hypotension
ROM exercises
contractures and ankylosis
osteoclasts and osteoblasts
• Define obesity and describe how variables such ass
crutch-walking gait
osteogenic sarcoma
family values and diet influence adult obesity
dangling
osteomyelitis
• Describe how older adults may benefit from exercise
deep vein thrombosis
osteoporosis
• Identify and describe the complications associated with
(DVT)
plantar flexion (footdrop)
immobility and implement appropriate preventive
haematopoiesis
PRICE: prevention, rest,
measures
health and wellbeing
ice, compression and
• State the influences and effects associated with
hypostatic
pneumonia
elevation
disorders of the musculoskeletal system
Movement
Mov
and exercise | Chapter 26 569
isotonic/isometric/
pursed-lip
breathing
• Identify the major musculoskeletal system disorders
isokinetic exercise
range of movement (ROM)
that impact movement and exercise
metastatic bone tumours
• Describe the major manifestations of musculoskeletal
system disorders CH
CHAPTER
CHA
HAP
APTER
APTE
APT
PTER
TER
R FOCUS
FOC
• Briefly describe the specific disorders of the
Movement
andinexercise
are essential components for restoring, maintaining and enhancing
e
physical and psychomusculoskeletal system
outlined
this chapter
social
As society
e
health.
government and
• Define the diagnostic
tests
that may
be usedbecomes
to assess increasingly sedentary in both work and home environments,
health agencies are researching and evaluating the eff
effects
ffects of inactivity on health,
health disease processes, ageing and
musculoskeletal function
morbidity.
y Research
R
suggests that despite the rising trend in health conditions related
rela
to obesity and immobility,
the commencement of an exercise program can retard and even reverse the pro
progression of conditions such as
osteoporosis, heart disease, diabetes mellitus and the effects
ffects of ageing.
eff
The human body is ideally suited to movement. Regular exercise promotes health, feelings of wellbeing and
prevents illness throughout the life span. Exercise is made possible by the muscular, skeletal and nervous systems.
These interconnected systems work together to make movement possible and for most human movement they must
function effectively for optimal physical performance. Disease processes that disable one or more of these systems
may inhibit or restrict mobility. To ensure mobility and exercise are maximised and maintained, allied health teams
should devise care plans to meet individual needs and abilities based on the specific strengths and disabilities of each
client in their care.
Healthcare workers are in a unique position to educate and support clients to make lifestyle changes for
improvement in health and prevention of disease. Effective and timely health promotion can significantly
contribute to long-term client health and potentially reduce disease progression and hospital re-admission. For
those with recurring mobility issues, nurses and allied health professionals can support the transition to mobility
aids and promote independence and quality of life on discharge to home or an assisted facility. Nurses who promote
and encourage mobility and movement play a significant role in the client’s healthcare experience. This important
contribution can have a lasting impact on the client’s recovery and rehabilitation and benefit society with its positive
outcomes.
Key Terms
CHAPTER FOCUS
LIVED EXPERIENCE
Lived Experiences are taken from actual clinical
situations to help students understand a particular health
experience from the point of view of clients, their families
or nurses and other health professionals.
CLINICAL INTEREST BOX 26.2
Self-care behaviours and exercise
• Make the most of opportunities for exercise—use
stairs, park a kilometre away from work or walk to work
once or twice a week, walk faster and use lunchtimes
for exercise
• Choose an enjoyable physical activity
• Plan 3–4 exercise activities per week
• Before starting exercise sessions, ensure medical
clearance if in a high-risk group
Clinical
Interest
boxes offer
information on
developmental
considerations,
cultural aspects
of care, current
research and
client teaching
• Alternate different types of exercise to keep interest
up; for example, Pilates followed by weight-training
sessions then walking or bike riding
LIVED
L
LIVE
LIV
IIVE
VED
ED
DE
EXPERIENCE
XPE
XPERIENCE
• Invite a friend to walk or join a health club or gym
I found as I was getting older that I wasn’t as flexible
seizing up and I decided to take positive
flexible as I used to be. My joints were se
function. Keeping active with swimming and cycling allows
allow me to keep moving without putting
action to prevent loss off function.
pressure on painful joints. I haven’t felt this good in years.
Felicity, 65 years
• Build up exercise sessions to avoid over-exertion
Nursing care plan 26.2
Clinical Scenario Box 27.1
Mr Darcy, an 88-year-old man, was discharged from
hospital following admission for a urinary tract infection.
As he has no family, Mr Darcy was taken home by hospital
transport and was escorted into his home where he lives
alone, and placed in a lounge chair. Two days later, a nurse
from hospital in the home did a follow-up visit on Mr Darcy.
On arrival the nurse found Mr Darcy still sitting in the
lounge chair; he had not moved from the chair since his
arrival at home, 2 days prior. He had been incontinent of
both urine and faeces. Mr Darcy made minimal eye contact
and was not able to give coherent answers to questions.
A client with a musculoskeletal disorder
Nursing action
Rationale
Preparation of environment
Promote an area conducive to rest including pillows for elevation and bed cradle for air
circulation around injured limb or newly applied cast
Specific equipment acquisition
Ensure availability of equipment that is requested to enhance joint mobility and repair,
e.g. CPM machine, traction equipment, plaster, mobility assistance aids
Prevention of potential
problems related to immobility
Air or padded mattress to protect pressure areas
Bedsides to enhance client protection from falls
Antiembolic stockings to reduce risk of DVT
Plan of breathing exercises to reduce stasis of secretions
Client comfort
Analgesia for client comfort
Placement of articles within easy reach to prevent straining
Call bell within reach to reduce anxiety and feelings of isolation
Hot/cold packs to reduce pain and inflammation
• What other allied health professionals would you
include in your care of Mr Darcy?
Nutrition
Plan diet for optimal healing including proteins, carbohydrates, vitamins, minerals and
ensuring adequate hydration and caloric needs
• What specialised wound dressing regimen will Mr Darcy
require and what are the expected outcomes?
Allied health referral
Specialist advice for mobility aids, ROM exercises and assistance for posturing and
mobilisation to promote independence and rehabilitation
While assisting Mr Darcy, the nurse noted a large lesion
on his sacrum. Mr Darcy was transferred to an acute care
facility where surgical debridement took place, identifying
a stage IV pressure injury on his sacrum.
• What would be the recommendation for care for
Mr Darcy?
• Before Mr Darcy is discharged, what additional
assessments will he require? Will you recommend that
he is discharged back to his own home?
Clinical Scenarios provide context for
practice and include questions for student
reflection
(Crisp & Taylor 2009; Farrell & Dempsey 2011; Gulanick & Myers 2010)
Nursing care plans provide comprehensive examples of a step-by-step guide to
patient care within a specific scenario
sample proofs © Elsevier Australia
xxi
Procedural Guidelines use a
step-by-step format emphasising
the use of the nursing process
and include rationales for each
step
Procedural Guideline 27.2: Shortening a drain tube
Review and carry out the standard steps for all nursing procedures/interventions
Action
Rationale
Follow the steps described in the guideline for dressing a
wound, up to and including cleaning the wound
The stab wound is cleansed to remove exudate, thus
preventing contamination
Using the stitch cutter, remove any suture securing the tube in
the wound
Enables the tube to be rotated, if necessary, and shortened
If the tube is round, gently rotate it
Rotation of the tube frees any adherent granulation tissue
Withdraw the tube the prescribed length, e.g. 1.25 cm
Tube must only be shortened the prescribed length, to allow
the wound to heal from within
Secure tube with sterile safety pin below level of planned cut
Prevents tube from slipping into the wound
Cut off excess tube
Prevents it pressing on the wound
Place and secure a clean dressing or pouch over the tube
Protects the skin from irritation from wound drainage
A gauze dressing is generally placed between the pin and the
skin, and another dressing or pouch placed over the tube
Protects the skin from irritation
Remove and discard gloves and towels
Prevents cross-infection
Assist the client to reassume a comfortable position
Promotes comfort
Remove and attend to the equipment appropriately. Perform
hand hygiene
Prevents cross-infection
Report and document the procedure
Appropriate care can be planned and implemented
References and Recommended
Reading encourage further reading
within each chapter topic
Summary
Summary
S
ummary
The Summary highlights
the key points in the chapter
content
Review Questions assist
students with comprehension
and review of the chapter
content
Palliative care is a speciality area of nursing. Nurses are
valuable members of the multidisciplinary palliative care
team and provide care to individuals with a life-limiting
illness and their families. Palliative care takes place in many
different settings, and many people prefer to die at home.
In palliative care contexts, dying is a natural process and
people who are dying should be empowered to live life
p
as fullyy as possible
within the limits of their illness. The
Review
Questions
Re
Review
Questions
1
2
3
4
5
Critical Thinking Exercises
stimulate the student to think
critically and problem solve
palliative care team aims to meet physical, psychological
and spiritual needs that arise for clients at the end of their
life and to support the client’s family. Quality palliative care
and symptom management has the person and their family
at the centre of care. Nurses are an important part of the
multidisciplinary team supporting a ‘good death’ for clients
in the home and inpatient settings.
References
Refer
Refe
efer
errence
ences
ences
nc s and Recommended
Recom
Reading
di
Berger AM Shuster JL Von Roe
Critical
Thinking
Exercise
C
Critical
Cri
r
Thinking
Exercises
1
1
2
3
4
Maher D & Hemmin
Hemming L (2005) Understanding p
family: holistic a
assessment in palliative care
of Community N
Nursing 10:318–22
McLean Heitkamper
Heitkampe M, Ross Staats C, Harringt
(2008) Palliative care. In: Brown D & Edward
Lewis’s Medical–
Medical–Surgical Nursing, 2nd edn.
Sydney, pp 153–67
153–
Mooney D (2009) U
Understanding loss, death an
In: Crisp J & T
Taylor C (eds) Potter & Perry’s F
Tay
of Nursing, 3rd edn. Elsevier, Sydney, pp 498
New Zealand Ministry of Health (2001) The New
Palliative Care Strategy. Online. Available: ww
nz/moh.nsf/pagesmh/2951
O’Connor M (2008) Palliative care in the commu
D & van Loon A (eds) Community Nursing in
Blackwell Publishing, Oxford
Old JL & Swagerty D (2007) A Practical Guide to
Lippincott, Williams & Wilkins, Hagerstown,
Smith M (2002) Spiritual issues. In: Lugton J & K
Palliative Care: the nursing role. Churchill Liv
Stein-Parbury J (2009) Patient and Person: interp
nursing, 4th edn. Elsevier, Sydney
Tiziani A (2010) Havard’s Nursing Guide to Drug
Elsevier, Sydney
Varcarolis E & Halter M (2010) Foundations of P
Mental Health Nursing: a clinical approach. W
Philadelphia
Victorian Department of Human Services (2011)
Palliative Care Program. Online. Available: w
gov.au/palliativecare/index.htm
Woodruff R (2004) Palliative Medicine, 4th edn.
University Press, Melbourne
World Health Organization (2008) Cancer Pain R
Palliative Care. Report of a WHO Expert Com
Technical Report Series No 804. WHO, Gene
Available: http://whqlibdoc.who.int/trs/WHO_
A
http://whqlibdoc.who.int/trs/WHO
O_
References and Recom
Berger AM, Shuster JL, Von Roenn JH (2006) Principles
and Practice of Palliative Care and Supportive Oncology.
Lippincott Williams & Wilkins, Hagerstown MD
List three (3) major functions of a multidisciplinary palliative care tea
team.
Birks M & Chapman Y (2009) Complementary therapies in
T
C (eds) Potter &
Describe how you could provide a warm, caring environment for a d
dying resident in an aged-care facility.nursing practice. In: Crisp J & Taylor
F
Nursing, 3rd edn. Elsevier, Sydney,
Perry’s Fundamentals
of Nursing,
List five (5) physical symptoms associated with incurable illness.
pp 700–817
Brown Jrcomfortable
E (2007) Supporting the Child and the Family in
What nursing actions could help an emaciated client whose pain is controlled but who cannot get physically
Paediatric Palliative Care. Jessica Kingsley Publishers,
in bed?
London
Describe five (5) ways you can promote a sense of wellbeing in the partner of a client who is dying in Chaplin
the acute-care
hospital
J & Mitchell
D (2005) Spiritual issues. In: Lugton J &
setting.
McIntyre M (eds) Palliative Care: The Nursing Role, 2nd edn.
Elsevier, Edinburgh, pp 169–99
Cheraghi M, Payne S, Salsali M (2005) Spiritual aspects of
end-of-life care for Muslim patients: experiences from Iran,
International Journal of Palliative Nursing 11:468–74
Cicero JK (2007) Waking Up Alone: Grief and Healing. Author
House, Bloomington IN
D’Avanzo C (2007) Mosby’s Pocket Guide to Cultural Health
Assessment, 4th edn. Mosby Elsevier, St Louis
In what ways does the culture in busy acute care hospitals impact on the experience of clients who are
dying?
How does
it
deWit
S (2009)
Fundamental
Concepts and Skills for Nursing,
In what
ways
does the
culture
in busy
care for tthe client who is dying3rdand
edn.
WB
Saunders,
St Louis
their
family
in
impact
on their
family members?
How
might nurses
improveacute
the circumstances
Egan G (2010) Exercises in Helping Skills: A manual to
this setting?
accompany the skilled helper. A problem-management and
not curable. Reflect on
your own values,
The specialist has just told you that you have a brain tumour that is inoperable and n
opportunity-development
approach to helping, 9th edn.
attitudes and beliefs and consider what changes would happen in your life as a result of this prognosis. What
would you
need Learning, Belmont CA
Brooks/Cole
Cengage
to help you cope? If you were living in a rural area 2 hours drive from the nearest city, could you easilyErsek
access
services
M, health
Irving G,
Botti Mto(2008) Pain management. In: Brown
meet your needs?
& Edwards H (eds) Lewis’s Medical–Surgical Nursing,
2ndhospice
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Sydney, pp 121–52
Joe, 72, has lung cancer. He has been admitted to the hospice today. He has been a frequent visitor to the
day centre
Foyle L & Hostad J (2007) Innovations in Cancer and Palliative
over the last few months, and several staff members have noted his positive attitude and how well he seems to have been
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coping physically and emotionally. Joe’s condition has deteriorated now and he is not expected to live
for more than
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days. He is alert but extremely agitated at the moment. Margaret, his wife, can’t understand this anxiety because
he
has
been
to teach doctors, nurses, clergy, and their own families.
so calm throughout his illness. She and his three daughters are finding his agitation very distressing. Consider
factors
Scribner,
Newthat
Yorkmay
be related to Joe’s anxiety. How would you explore his agitation with him? Which other health professionals
may
to be M (2002) Transcultural Nursing
Leininger
Mneed
& McFarland
consulted?
Concepts, Theories, Research and Practice, 3rd edn.
McGraw-Hill, New York
Tracey, 22 years old, has just died from leukaemia. You have been nursing Tracey for the past 2 weeks in the hospice and you
che.
Litwak K (2009) Somatosensory function, pain, and headache.
developed a caring relationship with her over this period. On hearing that Tracey has died, you experience
sense ofPorth
loss.C & Matfin G (eds) Pathophysiology,
In:aMattson
Reflect on your feelings. How might this experience influence your ability to nurse?
8th edn. Lippincott, Williams & Wilkins, Philadelphia,
pp 1225–60
Online
O
Onlin
nl
nlin
ine
e Res
R
Re
Resources
esource
ourcess
ource
Online Resources
National Association for Loss and Grief (Australl
www.nalag.org.au/
National Association for Loss and Grief (NZ): ww
w
Palliative Care Australia: www.palliativecare.org.
www.palliativecare.org.
National Association for Lo
Online Resources provide useful
web links related to the chapter
content
sample proofs © Elsevier Australia
948
CHAPTER 40
Acute care
Michelle Hall
Learning Outcomes
CHAPTER FOCUS
After the completion of this chapter, and with further
reading, students should be able to:
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nurses and the impact this has on clinical practice
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the enrolled nurse; these are explored in this chapter.
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all nurses and as the scope of practice expands
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these crucial tools for practice.
Key Terms
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Acute care | Chapter 40
949
LIVED EXPERIENCE
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Clarissa Kovacevic, RN
SCOPE OF PRACTICE
WHERE IS ACUTE CARE DELIVERED?
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to an ageing population, increase in chronic diseases and
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sample proofs © Elsevier Australia
950
Unit 9 | Healthcare in specialised practice areas
Table 40.1 | ICUs can be classified as:
General ICU
Those that care for both medical and
surgical clients
Combined ICU
Combined ICUs where an ICU is
combined with an HDU and/or
coronary care unit
Paediatric ICU
Specialises in care of paediatrics
Neonatal ICU
Specialises in care of neonates
Speciality ICU
Examples are cardiothoracic,
neurological or oncology
Martin et al 2010
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some time in a hospital on a general ward. Although
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paediatrics. When a client is admitted to acute care, the aim
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Box 40.1 Cultural awareness
When caring for clients from a Chinese background it is
important to have an understanding of Chinese culture
and beliefs. Many Chinese believe in the Yin (female,
negative energy, cold) and Yang (male, positive energy,
hot). If an imbalance occurs between the Yin and the
Yang, illness results. Foods, illness and treatments are
classified as hot or cold. Clients and their families will
try to restore the balance of Yin and Yang so you may
find clients with heat or cool packs, depending on how
the illness has been classified. Likewise, the family
may bring in food that they think will help to restore this
balance.
Home care
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been shown to result in better outcomes, such as reduced
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of Australia, and client fees, donations, sponsorship,
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IMPACT OF ACUTE ILLNESS
The client
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stress that an acute illness causes. When diagnosed with
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sample proofs © Elsevier Australia
Acute care | Chapter 40
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Clinical Scenario Box 40.1
Rebecca’s acute care experience
About 2 years ago Rebecca started experiencing intense
headaches which culminated one day in her passing
out at work. She worked as a nurse and her nurse unit
manager put her in a wheelchair and took her around
to the emergency department of the hospital that she
worked in. This was the beginning of 2 months of being
admitted and discharged from hospital five times. She
had all the tests done, MRI, CT, blood test and even a
lumbar puncture and no doctor could tell Rebecca why
her head felt like it was going to explode. When admitted
to the wards, she felt that once the nurses realised that
they were caring for a fellow nurse, they treated her
differently to other clients. Treatments didn’t get explained
as it was assumed that she understood what was
happening. No one explained to her the reasoning behind
all the tests she was having. For Rebecca, one of the
scariest experiences was when she had a drug reaction;
she thought she was going to die.
On her last admission one of the nurses looking after her
suggested she see an osteopath and get her back and
neck looked at. Rebecca took her advice and achieved
some relief. Two years on and what started as an acute
episode has turned into a chronic pain issue. Rebecca
has had to change jobs and work part-time as the chronic
pain causes her constant exhaustion. This has had a
major impact on her life and she has had to modify her
lifestyle to manage the pain she experiences every day.
The family
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stress it is important to communicate expected healthcare
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Clinical Scenario Box 40.2
Rebecca’s acute care experience:
the family’s perspective
When Rebecca started experiencing headaches I
thought nothing of it; she has suffered from migraines
since a young age. Then suddenly they escalated
and she had to be admitted to hospital multiple times.
I cannot explain the sense of helplessness I felt as her
mother. I felt I should have been able to make it all
better. It was very frustrating that the doctors could not
give us any answers; they didn’t listen to her when she
said it wasn’t a migraine. One of the worst moments
for me was receiving a phone call from my sister who
was visiting Rebecca when she had the drug reaction.
My sister thought Rebecca was going to die. Another
moment that stands out for me was being ordered from
her room as nurses rushed in. No one told me what was
going on. I found out later she had been given too much
morphine and had a dangerously low respiratory rate.
Two years on and I am proud of how Rebecca deals
with the pain; most people have no idea that she has
pain every day. It is lucky that I am a casual worker so
I can take time off when Rebecca needs to be taken
to hospital; I don’t know what would happen if I had to
work full-time.
Lisa, mother of Rebecca
ACUTE DISORDERS
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JOPUIFSDIBQUFST'PSNPSFJOGPSNBUJPOPOTQFDJëDTZTUFNT
SFGFSUPUIF$POUFOUT
Cellulitis
CellulitisJTBDPNNPODBVTFPGMJNCTXFMMJOH'BSSFMM
%FNQTFZ
*UJTBOBDVUFMPDBMJTFECBDUFSJBMJOGFDUJPO
PGUIFEFSNJTBOETVCDVUBOFPVTUJTTVF3VBOFUΉBM
Clinical manifestations
$MJOJDBM NBOJGFTUBUJPOT PG DFMMVMJUJT JODMVEF MPDBMJTFE
TXFMMJOH SFEOFTT BOE QBJO ɨF DMJFOU NBZ BMTP EFWFMPQ
TZTUFNJDTJHOTPGJOGFDUJPOTVDIBTGFWFSDIJMMTBOETXFBUJOH
'BSSFMM%FNQTFZ
sample proofs © Elsevier Australia
952
Unit 9 | Healthcare in specialised practice areas
Pathophysiology
ɨFDFMMVMJUJTJOGFDUJPODBOTQSFBEEVFUPUIFQSPEVDUJPO
PGBTVCTUBODFLOPXOBTIZBMVSPOJEBTFTQSFBEJOHGBDUPS
ɨJT TVCTUBODF JT QSPEVDFE CZ UIF DBVTBUJWF BHFOU BOE
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OPSNBMMZMPDBMJTFJOGFDUJPO-F.POFFUΉBM
$FMMVMJUJT
DBOPDDVSGPMMPXJOHBTLJOCSFBLEPXOPSTVSHJDBMXPVOE
JO TPNF JOTUBODFT UIFSF JT OP PCWJPVT DBVTBUJWF JODJEFOU
&SPO $PNNPO TJUFT PG JOGFDUJPO JODMVEF DSBDLT
CFUXFFO UPFT JOKFDUJPO TJUFT BCSBTJPOT BOE DPOUVTJPOT
VMDFSTJOHSPXOUPFOBJMTBOEIBOHOBJMT'BSSFMM%FNQTFZ
)VNBOBOEJOTFDUCJUFTIBWFBIJHISJTLPGDBVTJOH
DFMMVMJUJT&SPO
4FF$MJOJDBM*OUFSFTU#PY
Medical management
When the infection is mild, the client can be treated with
PSBM BOUJCJPUJDT 'PS TFWFSF DBTFT JOUSBWFOPVT BOUJCJPUJD
UIFSBQZJTSFRVJSFE'BSSFMM%FNQTFZ
Nursing care
When caring for the client with cellulitis the nurse should
JOTUSVDU UIF DMJFOU UP FMFWBUF UIF BêFDUFE BSFB BCPWF UIF
IFBSU 'BSSFMM %FNQTFZ 8BSN NPJTU QBDLT
TIPVMECFBQQMJFEUPUIFBSFBFWFSZUPIPVSTDBSFNVTU
CF UBLFO JO DMJFOUT XJUI EFDSFBTFE TFOTPSZ QFSDFQUJPO UP
FOTVSFCVSOTEPOPUPDDVS'BSSFMM%FNQTFZ
Client education
$MJFOU FEVDBUJPO GPS DFMMVMJUJT IBT BO FNQIBTJT PO
QSFWFOUJPOPGGVUVSFFQJTPEFT'BSSFMM%FNQTFZ
Venous thromboembolism
7FOPVTUISPNCPFNCPMJTN75&
JODMVEFTCPUIEFFQWFJO
UISPNCPTJT%75
BOEQVMNPOBSZFNCPMJTN1&
$PMMJOT
*UJTFTUJNBUFEUIBU75&XJMMPDDVSJOCFUXFFO
BOEPGBMMHFOFSBMNFEJDBMDMJFOUTBOEPG
CLINICAL INTEREST BOX 40.1
Risk factors in the development of
cellulitis
t
t
t
t
t
t
t
t
t
t
t
Venous insufficiency or stasis
Lymphoedema
Surgery
Diabetes mellitus
Malnutrition
Substance abuse
Presence of another infection
Compromised immune system
Trauma
Intravenous drug use
Radical mastectomy with axillary dissection
(Farrell & Dempsey 2011)
DMJFOUT XIP IBWF TVêFSFE B DFSFCSPWBTDVMBS BDDJEFOU BOE
PGDSJUJDBMMZJMMDMJFOUT.PSSJTPO
Deep vein thrombosis
Deep vein thrombosis%75
JTBUISPNCPTJTJOUIFEFFQ
WFJOTPGUIFCPEZVTVBMMZJOWPMWJOHUIFMPXFSFYUSFNJUJFT
$PMMJOT
ɨFUISPNCPTJTDBOQBSUJBMMZPSDPNQMFUFMZ
PCTUSVDU UIF WFJO SFTUSJDUJOH CMPPE ìPX UP UIF BêFDUFE
FYUSFNJUZ$PMMJOT
Clinical manifestations
"EJBHOPTJTPG%75DBOCFEJïDVMUUPNBLFBTUIFDMJOJDBM
manifestations can be similar to other diseases such as
DFMMVMJUJT $MJOJDBM NBOJGFTUBUJPOT PG B %75 NBZ JODMVEF
VOJMBUFSBM PFEFNB QBJO MPDBMJTFE XBSNUI BOE FSZUIFNB
$BSUFS 'PS JOGPSNBUJPO PO QSFWFOUJPO PG %75T
TFF$I
Pathophysiology
" UISPNCPTJT DBO EFWFMPQ XIFO UIFSF BSF DIBOHFT JO UIF
WFTTFM XBMMT DIBOHFT JO CMPPE ìPX PS DIBOHFT JO CMPPE
DPNQPTJUJPOɨFTFUISFFDPOEJUJPOTBSFLOPXOBT7JSDIPXT
USJBE#BDPO
Diagnostic tests
*GB%75JTTVTQFDUFEBCMPPEUFTULOPXOBTUIF%EJNFS
DBO CF QFSGPSNFE ɨJT EFUFDUT ëCSJO CSFBLEPXO UIBU JT
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JT VTFE GPS OFHBUJWF QSFEJDUBCJMJUZ POMZ NFBOJOH UIBU B
OFHBUJWF SFTVMU JOEJDBUFT OP %75 XIJMF B QPTJUJWF XJMM
SFTVMUJOGVSUIFSUFTUTCFJOHDBSSJFEPVU$BSUFS
*G
BQPTJUJWF%EJNFSPDDVSTUIFDMJFOUNBZUIFOCFTFOUGPS
BO VMUSBTPVOE‰UIF NPTU BQQSPQSJBUF BOE BDDVSBUF UFTU
GPSΉEJBHOPTJOHB%75$BSUFS
Medical management
0ODF UIF EJBHOPTJT PG %75 JT NBEF USFBUNFOU OFFET UP
DPNNFODFJNNFEJBUFMZ5SBEJUJPOBMMZDMJFOUTXFSFQVUPOCFE
SFTUBTUIFBTTVNQUJPOXBTUIBUNPWFNFOUXPVMEEJTMPEHF
UIFUISPNCVTBOEMFBEUPBQVMNPOBSZFNCPMJTN"OEFSTPO
FUΉ BM ɨF DVSSFOU USFBUNFOU SFHJNFO JODMVEFT B
DPNCJOBUJPO PG BOUJDPBHVMBUJPO UIFSBQZ BOE UISPNCPMZUJD
UIFSBQZ XJUI UIF BJN PG QSFWFOUJOH UIF UISPNCVT GSPN
HSPXJOHPSGSBHNFOUJOH'BSSFMM%FNQTFZ
Nursing care
8IFO DBSJOH GPS UIF DMJFOU XJUI B %75 UIF OVSTF NVTU
monitor the client for potential complications of treatment
TVDIBTCMFFEJOHBOEUISPNCPDZUPQFOJBɨFOVSTFTIPVME
BMTP NBJOUBJO DMJFOU DPNGPSU CZ FMFWBUJOH UIF BêFDUFE
FYUSFNJUZBQQMZJOHDPNQSFTTJPOTUPDLJOHTBOEBENJOJTUFS
JOH BOBMHFTJB UIFTF BMM IFMQ UP JODSFBTF DJSDVMBUJPO 'BSSFMM
%FNQTFZ ɨF BêFDUFE MFH TIPVME CF BTTFTTFE
FWFSZTIJGUGPSTJHOTPGTLJOCSFBLEPXOEPXOUPFOBCMFFBSMZ
JOUFSWFOUJPOɨFDMJFOUNVTUBMTPCFNPOJUPSFEGPSTJHOTPG
1&TFFCFMPX
-F.POFFUΉBM
Client education
1SJPS UP EJTDIBSHF JOGPSN UIF DMJFOU UIBU UIFZ OFFE UP
SFQPSUBOZVOVTVBMCMFFEJOHUPUIFJSEPDUPS'PSXPNFO
sample proofs © Elsevier Australia
Acute care | Chapter 40
menstrual bleeding may be slightly increased: they should
contact their doctor if it increases significantly. Men
should shave with an electric razor to reduce the risk of
cuts and soft-bristle toothbrushes should be used. Contact
sports should be avoided while taking anticoagulation
drugs (LeMone et al 2011).
Pulmonary embolism
Pulmonary embolism (PE) is a major cause of mortality
and morbidity (Otair et al 2009). For 25% of clients who
suffer a PE the first clinical symptom is death (Farley et al
2009). The risk factors associated with the development
of a PE are very similar to those for a DVT (see Clinical
Interest Box 40.2).
Clinical manifestations
The clinical manifestations of PE may include chest pain,
chest wall tenderness, palpitations, back and shoulder
pain, upper abdominal pain, syncope, haemoptysis,
dyspnoea and painful respirations (Farley et al 2009).
Pathophysiology
PE involves obstruction of a section of the pulmonary
artery tree by a thrombus or embolism (Sheares 2011). This
thrombus or embolism forms in the venous system or right
side of the heart (Farrell & Dempsey 2011) and commonly
originates in the leg or pelvic vein (Sheares 2011).
Diagnostic tests
Diagnosis of PE can be difficult because of the non-specific
symptoms that are manifested (Otair et al 2009). If the
CLINICAL INTEREST BOX 40.2
Risk factors associated with DVT
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
t
Surgery
*ODSFBTFEBHF
'BNJMZIJTUPSZ
5ISPNCPQIJMJB
Cancer
.ZPDBSEJBMJOGBSDU
*TDIBFNJDDFSFCSPWBTDVMBSBDDJEFOU
$ISPOJDPCTUSVDUJWFQVMNPOBSZEJTFBTF
)FBSUPSSFTQJSBUPSZGBJMVSF
Pregnancy
)PSNPOFUIFSBQZJODMVEJOHUIFPSBMDPOUSBDFQUJWFQJMM
BOEIPSNPOFSFQMBDFNFOUUIFSBQZ
"DVUFJOnBNNBUJPOEJTPSEFST
0CFTJUZ
#FESFTU
*NNPCJMJTBUJPOPGFYUSFNJUJFT
7BSJDPTFWFJOT
Trauma
953
clinical manifestations indicate the possibility of PE (chest
pain, chest wall tenderness, palpitations, back and shoulder
pain, upper abdominal pain, syncope, haemoptysis,
dyspnoea and painful respirations) (Farley et al 2009), then
a D-dimer test may be ordered; if this test is positive then
more investigations are required to confirm the diagnosis.
Table 40.2 outlines investigations for diagnosis of PE.
In recent years the computed tomography pulmonary
angiogram (CTPA) has replaced pulmonary angiograms
in the diagnosis of PEs (Sheares 2011). This type of CT
evaluates slices as narrow as 1.0 mm (Farrell & Dempsey
2011) allowing for accurate visualisation of a PE by enabling
visualisation of the pulmonary arteries (Sheares 2011).
The main disadvantages of the CTPA are that the client
Table 40.2 | Investigations for diagnosis of
pulmonary embolism
$IFTUYSBZ
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(ECG)
.BZJOEJDBUFUIBUUIFSJHIUWFOUSJDMFJT
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"SUFSJBMCMPPE
gases
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TDBO72
scan)
"WFOUJMBUJPOQFSGVTJPOTDBOJOWPMWFT
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(CTPA)
$51"IBTSFQMBDFEQVMNPOBSZBOHJPHSBNT
JOUIFEJBHOPTJTPG1&T5IJTUZQFPG$5
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$51"BSFUIBUUIFDMJFOUNVTUCFUSBOTGFSSFE
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$5JTOPUQPSUBCMFBOEUIFDMJFOUNVTUCF
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JODMJFOUTXJUISFOBMJNQBJSNFOUBOEUIPTF
UBLJOHNFUGPSNJO
Farrell & Dempsey 2011; Sheares 2011
sample proofs © Elsevier Australia
954
Unit 9 | Healthcare in specialised practice areas
must be transferred to a diagnostic imaging department
BTUIF$5JTOPUQPSUBCMFBOEUIFDMJFOUNVTUCFJOKFDUFE
with contrast, which can cause allergic reactions and is
contraindicated in clients with renal impairment and those
UBLJOHNFUGPSNJO'BSSFMM%FNQTFZ
Medical management
ɨF CFTU USFBUNFOU GPS DMJFOUT BU SJTL PG EFWFMPQJOH B 1&
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JT
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molecular weight heparin or heparinoids such as enoxaparin.
ɨFBEWBOUBHFPGUIFTFESVHTJTUIFOFFEGPSMFTTGSFRVFOU
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TJHOJëDBOUSJTLGPSIBFNPSSIBHF'BSSFMM%FNQTFZ
4FF5BCMFGPSFNFSHFODZNBOBHFNFOUPG1&
Nursing care
ɨF NBOBHFNFOU PG B 1& EFQFOET PO UIF TFWFSJUZ PG
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%FNQTFZ
8IFODBSJOHGPSUIFDMJFOUXJUIB1&UIF
OVSTFNVTUNPOJUPSGPSTJHOTPGCMFFEJOHBOEPOMZFTTFOUJBM
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NVTU CF NBOBHFE XJUI NFEJDBUJPO JG OFDFTTBSZ 7JUBM
TJHOTTIPVMECFNPOJUPSFEFWFSZIPVSTJODSFBTJOHXIFO
EFUFSJPSBUJPOJTOPUFE'BSSFMM%FNQTFZ
Client education
ɨF DMJFOU XJMM SFRVJSF FEVDBUJPO SFHBSEJOH BEIFSFODF UP
NFEJDBUJPO SFHJNFOT ɨJT XJMM JODMVEF BOUJDPBHVMBOUT
UIFSBQZ FEVDBUJPO TFF DMJFOU FEVDBUJPO GPS %75 BCPWF
BOE JOGPSNBUJPO SFHBSEJOH GPMMPXVQ BQQPJOUNFOUT BOE
CMPPEUFTUT-F.POFFUΉBM
Diverticulitis
*UJTFTUJNBUFEUIBUVQUPPGQFPQMFPWFSUIFBHFPG
IBWF EJWFSUJDVMPTJT B EJTFBTF XIFSF QPVDIFT LOPXO
BT EJWFSUJDVMB EFWFMPQ JO UIF CPXFM XBMM VTVBMMZ JO UIF
TJHNPJEDPMPO)BSWBSE8PNFOT)FBMUI8BUDI
Table 40.3 | Emergency management of
pulmonary embolism
Nasal oxygen
Relieves hypoxaemia and respiratory
distress
Insertion of
intravenous lines
Prepares for medication
administration
ECG
Provides continuous monitoring for
arrhythmias and right ventricular
failure
Medications
May include digoxin glycosides,
diuretics, enoxaparin, heparin and
antiarrhythmic agents. Sedatives may
be administered to relieve anxiety
Blood tests
Include serum electrolytes, full blood
count, haematocrit and arterial blood
gases
Indwelling urinary
catheter
Inserted to monitor fluid output
Mechanical
ventilation
Used if the clinical assessment and
investigations warrant it
Farrell & Dempsey 2011
Clinical manifestations
$MJFOUT XJUI EJWFSUJDVMJUJT XJMM QSFTFOU XJUI MFGU MPXFS
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Pathophysiology
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Diagnostic tests
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$5XJUIDPOUSBTUBTJUXJMMFOBCMFWJTVBMJTBUJPOPGJOGFDUJPO
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Medical management
5SFBUNFOU PG EJWFSUJDVMJUJT JOWPMWFT CSPBETQFDUSVN BOUJ
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sample proofs © Elsevier Australia
Acute care | Chapter 40
BOBCTDFTTUIBUGBJMTUPSFTQPOEUPBOUJCJPUJDUIFSBQZBESBJO
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Nursing care
"T UIF DMJFOU XJUI EJWFSUJDVMJUJT JT BU SJTL GPS CPXFM
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be assessed at the same time, measuring girth, auscultating
CPXFMTPVOETBOEQBMQBUJOHGPSUFOEFSOFTT"OZDIBOHFT
NVTUCFJNNFEJBUFMZSFQPSUFEUPUIFEPDUPSBTUIFZNBZ
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QBJO-F.POFFUΉBM
Client education
0OEJTDIBSHFDMJFOUTOFFEFEVDBUJPOPOEJFU"IJHIëCSF
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Guillain-Barré syndrome
Guillain-Barré syndrome (#4
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JOGFDUJPO -VHH ɨF QBUIPQIZTJPMPHZ PG (#4
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XJMM JOJUJBMMZ DPNQMBJO PG EFDSFBTFE GVODUJPO XFBLOFTT
and decreased sensation in their arms and legs, with or
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NVTDMF XFBLOFTT DPNNFODJOH EJTUBMMZ UIFO USBWFMMJOH
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CFDBVTFPGSFTQJSBUPSZEZTGVODUJPOBOEVQUPXJMMEJF
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Unit 9 | Healthcare in specialised practice areas
Prerenal failure
Hypovolaemia
(reduced intravascular volume)
Hypotension
Cardiac insufficiency
Volume
redistribution
Total loss
GI loss
(vomiting, diarrhoea,
surgical fistulae)
Reduced effective
circulation volume
(ascites, oedema, CCF)
Haemorrhage
(visible and occult)
Altered vascular
capacitance
(sepsis, shunting,
vasodilation)
Renal loss
(diuretics, polyurea)
Skin loss
(excessive sweating,
burns)
Figure 40.1 $BVTFTPGQSFSFOBMGBJMVSF
(Blakeley 2008)
Intrarenal failure
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Figure 40.2 $BVTFTPGJOUSBSFOBMGBJMVSF
(Blakeley 2008)
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Acute care | Chapter 40
Medical management
Postrenal failure
The investigations required depend on the individual and
the results of the health assessment (Murphy & Byrne
2010). Once a diagnosis is made the medical aim is to
restore chemical balance and prevent complications to
allow the kidney to repair itself (Farrell & Dempsey 2011).
If there is a known cause it is treated and eliminated. For
some clients dialysis is required (see Ch 29).
Obstruction
Internal pelvic/ureteral
External ureteral
Surrounding or
infiltrating tumour/other
obstruction
Stones
957
Tumour
Figure 40.3 Causes of postrenal failure
(Blakeley 2008)
Nursing care
When caring for the client with ARF the nurse needs
to closely monitor fluid balance. This can be done by
commencing the client on a strict fluid balance and daily
weighing regimen, ensuring that the client is weighed at the
same time on the same scales and in the same clothes every
time. The nurse should also monitor the client for signs of
oedema and any difficulty in breathing (Farrell & Dempsey
2011). Clients with ARF are at increased risk of infection
and skin breakdown, therefore the nurse should ensure
asepsis when caring for these clients and meticulous skin
care to prevent skin breakdown (Farrell & Dempsey 2011).
Client education
Diagnostic test
When a client is suspected of having ARF there are many
investigations that may be ordered. These include:
t Urinalysis
t Blood test tests (including urea, creatinine and
electrolytes, full blood examination, coagulation
status, virology for hepatitis B and C and HIV)
t Renal ultrasounds
t CT, MRI
t Renal biopsy (Murphy & Byrne 2010).
The client with ARF needs education to identify
complications of fluid volume excess such as increased
weight or oedema. Educate to avoid nephrotoxic agents
for at least 1 year post ARF. The client will need to avoid
stress and infection (LeMone et al 2011). (See Table 40.4.)
Sepsis
Sepsis is an infection of the blood stream that spreads
quickly and can be difficult to diagnose (Dellacroce 2009).
For a diagnosis of sepsis to be made the client must have
a known infection and systemic inflammatory reaction
syndrome (SIRS) (see Clinical Interest Box 40.3).
Table 40.4 | Differences between acute renal failure and chronic renal failure
Acute renal failure
Chronic renal failure
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Unit 9 | Healthcare in specialised practice areas
CLINICAL INTEREST BOX 40.3
SIRS
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Table 40.5 | Signs of organ failure
Body system
Clinical manifestation
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The most common sites of infection that lead to sepsis
are infections in the bloodstream, skin, respiratory tract,
gastrointestinal tract and genitourinary tract (Schub &
Schub 2011). Gram-negative and gram-positive bacteria are
the usual causative agents; however, the infection can also
be due to fungi, viruses and protozoa (Farrell & Dempsey
2011).
Clinical manifestations
Clinical manifestations include fever, peripheral oedema,
hypotension, tachycardia, tachypnoea and hot flushed skin
(LeMone et al 2011).
Risk factors for the development of sepsis include
cauterisation, invasive devices, certain surgery, urinary
tract infections, appendicitis, diverticulitis, Crohn’s
disease, cholecystitis, renal disease, prostatitis, meningitis
and complicated obstetric delivery (Schub & Schub 2011).
Older adults, children and immunosuppressed clients are
at an increased risk of sepsis progressing to severe sepsis
and septic shock (Schub & Schub 2011).
Pathophysiology
Sepsis develops when the body is unable to contain a
localised infection, enabling the infective agent to enter
the blood stream (Dellacroce 2009). The associated
SIRS can impair the clotting cascade, causing systemic
inflammation, vasodilation and capillary leakage which
contributes to hypotension and can lead to organ failure
(Whitehead 2010). Sepsis can develop into severe sepsis.
Severe sepsis involves all the clinical features of sepsis
but has the added complication of organ dysfunction
(Dellacroce 2009) (see Table 40.5). When a client is
diagnosed with severe sepsis there is a 30–35% chance of
death (Whitehead 2010).
One of the major complications of severe sepsis is
hypotension. When a client remains hypotensive in spite
of adequate fluid resuscitation, the client has progressed
into septic shock (Dellacroce 2009). Septic shock is a
life-threatening condition, with 1400 people worldwide
dying each day (Gerber 2010). After diagnosis of septic
shock, 30% of clients will die within the first month
and 50% within 6 months (Gerber 2010). See Clinical
Scenario Box 40.3.
Diagnostic test
As soon as sepsis is suspected blood cultures should be
taken, ideally prior to the commencement of antibiotic
Clinical Scenario Box 40.3
Septic shock
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Acute care | Chapter 40
therapy. The cultures should be taken from all lumens of
central and peripheral lines (Dellacroce 2009).
Medical management
Oxygen therapy should be commenced at high-doses to
stabilise oxygen saturations (Steen 2009). Fluid resuscitation which includes both colloids (albumin and packed
red blood cells) and crystalloids (normal saline and Ringer’s
lactate) is commenced, with the aim of maintaining blood
pressure greater than >100 systolic blood pressure (SBP)
(Dellacroce 2009). Urine output is monitored with a goal
of >0.5 mL/kg/hr and it is recommended that a urinary
catheter be inserted (Steen 2009). Broad-spectrum
intravenous antibiotics are commenced until an infective
agent is identified; these should be commenced within
1 hour of the diagnosis (Steen 2009). The client’s serum
lactate levels may need to be measured as increased levels
indicate progressing disease (Steen 2009).
Nursing care
The best treatment for sepsis is prevention, which all nurses
must aim to achieve by being diligent with handwashing
and the use of aseptic technique and standard and
additional precautions.
CLINICAL PATHWAYS
A clinical pathway is best described as a multidisciplinary,
locally approved plan of care for a client based on guidelines
and, wherever possible, evidenced for a particular client
group (Duffy et al 2011).
The clinical pathway was introduced in the 1980s in
the USA to meet the needs of healthcare professionals and
improve quality of care for clients (Duffy et al 2011). The
main aim is to encourage standardisation of care for all
clients (Neuman et al 2009) with similar requirements
throughout a specific time frame by providing clinical
standards and expected outcomes (D’Entermont 2009;
Neuman et al 2009).
The development of clinical pathways combines an
evidence-based approach, with local policy and procedure
and current practice to develop a process map which in
959
turn is developed into a pathway (Day 2009). The pathway
enables less variation and more transparency in client care
(Vanhaecht et al 2009).
Clinical pathways are most advantageous when client
outcomes are predictable, thus ensuring that the client
receives relevant clinical interventions and assessments
(Allen et al 2009). While clinical pathways cannot be
used for all clients, in 80% of cases a clinical pathway is
indicated (Duffy et al 2011). Pathways provide a daily care
plan for the client, and include guidelines on assessment,
treatment, activities of daily living, nutrition, education,
referrals to be made and discharge planning (D’Entermont
2009).
The novice nurse can find pathways especially helpful
by providing a guide as to what is expected of the client
on any given day (D’Entermont 2009). However, it is not
just the novice nurse who benefits from clinical pathways;
even the most experienced nurse will encounter client
conditions they are unfamiliar with and the pathway will
enable them to provide the most appropriate care for these
clients.
Clinical pathways can form all or part of the client’s
medical records (Duffy et al 2011). At the end of a shift,
providing there has been no variation from the pathway,
the nurse responsible for the client’s care signs off that
all expected outcomes and interventions have been met.
When a variation from the plan has occurred the nurse is
expected to document this in the client’s progress notes.
Studies have shown that clinical pathways improve
client outcomes, promote decision making and may lead
to shorter hospital stays and reductions in readmission
(Allen et al 2009). Shorter hospital stays are achieved
as clinical pathways act as an organisational device
by encouraging proactive interventions and the use
of relevant resources for the client (Allen et al 2009).
However, not all clients are appropriate for clinical
pathways. Clinical pathways are not effective when
care needs to be flexible, such as with the care of the
client post cerebrovascular accident (Allen et al 2009).
Clinical pathways can never replace professional clinical
judgment (D’Entermont 2009).
Summary
This chapter has presented some common and not so
common conditions the enrolled nurse may encounter
when working in the acute, aged or community care
sectors. It has explored the area of acute care provided in
venues other than hospitals and presented an introduction
to clinical pathways. There are many acute conditions the
enrolled nurse will come across, in various settings, and
this introduction, along with further reading, provides a
general introduction to a broad range of conditions that
may be seen in acute settings.
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Unit 9 | Healthcare in specialised practice areas
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Review Questions
1 You suspect your client has cellulitis. What are the common sites the infection originates from?
2 Which two (2) conditions are included under the term venous thromboembolism?
3 Identify the major risk factors associated with the development of a DVT.
4 What does a positive D-dimer test indicate?
5 Outline the treatment of a client who has been diagnosed with a pulmonary embolism.
6 Describe diverticulitis.
7 List the clinical manifestations of diverticulitis.
8 What is a preceding factor for the development of Guillain-Barré syndrome?
9 Explain the pathophysiology of Guillain-Barré syndrome.
10 Provide a cause of each stage of acute renal failure.
11 What two (2) conditions must be present for a diagnosis of sepsis?
12 What are the common sites where a sepsis infection originates?
13 Define the term clinical pathway.
14 What is the main aim of clinical pathways?
15 For what clients are clinical pathways most appropriate?
Critical Thinking Exercises
1
You are looking after a client who has been admitted post a myocardial infarct. He is recovering post CABG surgery. Your client
is the main income earner in his family and has three young children at home.
a
Identify physical issues for this client.
b Identify psychological issues for this client.
c
2
List appropriate ongoing care including allied healthcare that this client will require.
You receive handover from the morning nurse on one of your clients who is expected to be discharged this afternoon. Your client
is a 39-year-old female admitted with a DVT who has responded well to treatment and will be transferred to the care of HITH.
The nurse handing over to you reports that this morning the client complained of slight back and shoulder tip pain which was
resolved with paracetamol. All paper work has been completed and the client is waiting for her discharge medications before
she can leave. When you enter the client’s room, you find her pale and complaining of dyspnoea and chest pain.
a
What is your first action going to be?
b What do you think has happened?
c
What sign did the morning nurse miss?
d What diagnostic tests need to be done?
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Acute care | Chapter 40
References and Recommended Reading
Allen D, Gillen E, Rixson L (2009) Systematic review of the
effectiveness of integrated care pathways: what works,
for whom, in which circumstances? Integrated Journal of
Evidence-based Healthcare 7:61–74
Anderson CM, Overend TJ, Godwin J et al (2009) Ambulation
after deep vein thrombosis: a systemic review,
Physiotherapy Canada 61(3):133–42
Arnetz JE, Winblad U, Höglund AT et al (2010) Is patient
involvement during hospitalisation for acute myocardial
infarction associated with post-discharge treatment
outcomes? An exploratory study, Health Expectations
13(3):298–311
Bacon S (2009) Understanding venous thromboembolism,
Practice Nursing 20:334–41
Blakeley S (ed) (2008) Renal Failure and Replacement
Therapies. Springer, London
Carter K (2010) Identifying and managing deep vein
thrombosis, Primary Health Care 20(1):30–8
Cegarra-Navarro JG, Wensley AKP, Sànchez-Polo MT (2011)
Improving quality of service of home healthcare units
with health information technologies, Health Information
Management Journal 40(2):30–8
Collins S (2009) Deep vein thrombosis—an overview, Practice
Nurse 37(9):23–5
Day R (2009) Developing care pathways for hospice and
neurological care: Evaluating a pilot, British Journal of
Neuroscience Nursing 5(2):79–84
Davidson JE (2009) Family-centred Care. Meeting the needs
of patients’ families and helping families adapt to critical
illness, Critical Care Nursing 29(3):28–35
Dellacroce H (2009) Surviving sepsis: the role of the nurse,
RN 72:16–21
D’Entermont B (2009) Clinical pathways: the Ottawa hospital
experience, Canadian Nurse 105:8–9
Department of Health, Victoria (2012) Hospital in the Home.
Online. Available: http://health.vic.gov.au/hith/
Dougherty CM & Thompson EA (2009) Intimate partner
physical and mental health after sudden cardiac arrest and
receipt of an implantable cardioverter defibrillator, Research
in Nursing & Health 32:432–42
Duffy A, Payne S, Timmins F (2011) The Liverpool Care
Pathway: does it improve quality of dying? British Journal of
Nursing 20(15):942–6
Eagar SC, Cowin LS, Gregory L et al (2010) Scope of practice
conflict in nursing: A new war or just the same battle?
Contemporary Nurse 36(1–2):86–95
Eron LJ (2009) Cellulitis and soft-tissue infections, American
College of Physicians ITC1:1–16
Farley A, McLafferty E, Hendry C (2009) Pulmonary embolism:
identification, clinical features and management, Nursing
Standard 23:49–50
Farrell M & Dempsey J (eds) (2011) Smeltzer & Bare’s Textbook
of Medical-Surgical Nursing, 2nd edn. Lippincott Williams &
Wilkins, Broadway, NSW
Gerber K (2010) Surviving sepsis: a trust wide approach. A
multi-disciplinary team approach to implementing evidencebased guidelines, Nursing in Critical Care 15(3):141–51
Gould A, Ho KM, Dobb G (2010) Risk factors and outcomes
of high-dependency patients requiring intensive care unit
admission: a nested care-control study, Anaesthesia &
Intensive Care 38(5):855–61
Harvard Women’s Health Watch (2011) Diverticular disease
prevention and treatment, Harvard Women’s Health Watch
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Haultain R, Weston K, Rolls S (2011) Realising enrolled nurses’
full potential, Kai Tiaki Nursing New Zealand 17(1):28–9
Hsu C, O’Connor M, Lee S (2009) Understanding of death
and dying for people of Chinese origin, Death Studies
23(2):153–74
Kelly MA & McKinley S (2010) Patient’s recovery after critical
illness at early follow up, Journal of Clinical Nursing 19(5–6):
691–700
LeMone P, Burke KM, Dwyer T et al (eds) (2011) MedicalSurgical Nursing. Critical Thinking in Client Care. Pearson,
Frenchs Forest, NSW
Lipman M (2011) Diverticulitis reconsidered, Consumer Reports
on Health 23:11
Lugg J (2010) Recognising and managing Guillain-Barré
syndrome, Emergency Nurse 18(3):27–30
Martin JM, Hart GK, Hick P (2010) A unique snapshot of
intensive care resources in Australia and New Zealand,
Anaesthesia & Intensive Care 38(1):149–58
Morrison R (2006) Venous thromboembolism: scope of the
problem and the nurse’s role in risk assessment and
prevention, Journal of Vascular Nursing 24(3):82–90
Murphy F & Byrne G (2010) The role of the nurse in the
management of acute kidney injury, British Journal of
Nursing 19(3):146–52
Nankervis K, Kenny A, Bish M (2008) Enhancing scope of
practice for the second level nurse: A change process
to meet growing demand for rural health services,
Contemporary Nurse 29(2):159–73
Neuman MD, Archan S, Karlawish JH et al (2009) The
relationship between short-term mortality and quality of
care for hip fractures: A meta-analysis of clinical pathways
for hip fracture, Journal of the American Geriatrics Society
57(11):2046–54
O’Connor T (2010) Providing intensive care, Kai Tiaki Nursing
New Zealand 16(4):15–17
Own C, Hemmings L, Brown T (2009) Lost in translation.
Maximizing handover effectiveness between paramedics
and receiving staff in the emergency department,
Emergency Medicine Australasia 21:102–7
Otair H, Chaudhry M, Shaikh S et al (2009) Outcome of patients
with pulmonary embolism admitted to the intensive care
unit, Annals of Thoracic Medicine 4(1):13–16
Pritchard J (2010) Guillain-Barré syndrome, Clinical Medicine
10(4):399–401
Rogers J (2010) Risk assessment and treatment of venous
thromboembolism, Emergency Nurse 18(8):24–6
Royal District Nursing Service (RDNS) (2011) Who We Are.
Fact Sheet. Online. Available: www.rdns.com.au/media_
and_resources/media/Documents/2011%20Royal%20
District%20Nursing%20Service%20Fact%20Sheet.pdf
Ruan X, Liu HN, Couch JP et al (2010) Recurrent cellulitis
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Sheares K (2011) How do I manage a patient with suspected
acute pulmonary embolism? Clinical Medicine 11(2):
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CINAHL Information Systems
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223–31
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with sepsis, Nursing Standard 23(48):48–55
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Unit 9 | Healthcare in specialised practice areas
Vandall-Walker V (2010) The work of family members: pushing
our boundaries, Dynamics 21(2):39
Vanhaecht K, De Witte K, Panella M et al (2009) Do pathways
lead to better organized care processes? Journal of
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Online Resource
Royal District Nursing Service: www.rdns.com.au
sample proofs © Elsevier Australia

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