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textbook of medical surgical nursing .pdf



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TWELFTH

EDITION

Suzanne C. Smeltzer, EdD, RN, FAAN

Janice L. Hinkle, PhD, RN, CNRN

Professor and Director, Center for Nursing Research
Villanova University College of Nursing
Villanova, Pennsylvania

Formerly, Senior Research Fellow, Acute Stroke Programme
Oxford Brookes University and John Radcliffe Hospital
Oxford, United Kingdom

Brenda G. Bare, RN, MSN

Kerry H. Cheever, PhD, RN

Formerly, Associate Administrator/Chief Nurse Executive
Inova Mount Vernon Hospital
Alexandria, Virginia

Professor and Chairperson
St. Luke’s School of Nursing at Moravian College
Assistant Vice President
St. Luke’s Hospital & Health Network
Bethlehem, Pennsylvania

ERRNVPHGLFRV RUJ
i

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Twelfth Edition
Copyright © 2010 by Wolters Kluwer Health / Lippincott Williams & Wilkins.
Copyright © 2008 by Lippincott Williams & Wilkins, a Wolters Kluwer business. Copyright © 2004, 2000 by Lippincott
Williams & Wilkins. Copyright © 1996 by Lippincott-Raven Publishers. Copyright © 1992, 1988, 1984, 1980, 1975, 1970,
1964 by J. B. Lippincott Company.
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form
or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and
retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government
employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams &
Wilkins at 530 Walnut Street, Philadelphia, PA 19106, via email at permissions@lww.com, or via our website at lww.com
(products and services).
Printed in China.
9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Brunner & Suddarth’s textbook of medical-surgical nursing. — 12th ed. /
Suzanne C. Smeltzer ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-7817-8589-1 (1 volume American ed. : alk. paper) —
ISBN 978-0-7817-8590-7 (2 volume American ed. : alk. paper) —
ISBN 978-1-60831-080-7 (1 volume international ed.) —
ISBN 978-1-60831-088-3 (2 volume international ed.)
1. Nursing. 2. Surgical nursing. I. Brunner, Lillian Sholtis. II.
Smeltzer, Suzanne C. O’Connell. III. Title: Brunner and Suddarth’s
textbook of medical-surgical nursing. IV. Title: Textbook of
medical-surgical nursing.
[DNLM: 1. Nursing Care. 2. Perioperative Nursing. WY 150 B8972
2010]
RT41.T46 2010
617'.0231—dc22
2009029135
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application
of the information in this book and make no warranty, express or implied, with respect to the content of the publication.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text
are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions,
the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings
and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in his or her clinical practice.
LWW.com

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CONTRIBUTORS

Linda L. Altizer, RN, MSN, ONC, FNE

Kim Cantwell-Gab, MN, ARNP-BC, CVN, RVT, RDMS

Health Professions Coordinator
Hagerstown Community College
Hagerstown, Maryland
Chapter 66: Assessment of Musculoskeletal Function

Acute Care and Adult ARNP
SW Washington Medical Center –Thoracic and
Vascular Surgery
Vancouver, Washington

Chapter 69: Management of Patients With Musculoskeletal
Trauma

Chapter 31: Assessment and Management of Patients With Vascular
Disorders and Problems of Peripheral Circulation

Roberta H. Baron, MSN, RN, AOCN

Patricia E. Casey, RN, MSN

Clinical Nurse Specialist
Memorial Sloan-Kettering Cancer Center
New York, New York

Director, NCDR Training and Orientation
American College of Cardiology
Washington, District of Columbia

Chapter 48: Assessment and Management of Patients With
Breast Disorders

Chapter 27: Management of Patients With Dysrhythmias and
Conduction Problems

Janice M. Beitz, RN, PhD, CS, CNOR,

Jill Cash, RN, MSN, APRN, CNP

CWOCN, CRNP

Professor
La Salle University
Philadelphia, Pennsylvania
Chapter 38: Management of Patients With Intestinal and
Rectal Disorders

Family Nurse Practitioner
Logan Primary Care
West Frankfort, Illinois
Chapter 59: Assessment and Management of Patients With Hearing
and Balance Disorders

Kerry H. Cheever, PhD, RN

Cancer Network Administrator
Abramson Cancer Center of the University
of Pennsylvania
Philadelphia, Pennsylvania

Professor and Chairperson
St. Luke’s School of Nursing at Moravian College
Assistant Vice President
St. Luke’s Hospital & Health Network
Bethlehem, Pennsylvania

Chapter 16: Oncology: Nursing Management in Cancer Care

Chapter 68: Management of Patients with Musculoskeletal Disorders

Elizabeth Blunt, PhD, RN, APRN-BC

Linda Carman Copel, PhD, RN, PHMCNS, BC,

Catherine M. Belt, MSN, RN, AOCN

Coordinator Nurse Practitioner Programs
Villanova University College of Nursing
Villanova, Pennsylvania
Chapter 53: Assessment and Management of Patients With
Allergic Disorders

CNE, FAPA

Professor
Villanova University
Villanova, Pennsylvania
Chapter 4: Health Education and Health Promotion
Chapter 6: Homeostasis, Stress, and Adaptation

Lisa Bowman, MSN, RN, CRNP, CNRN
Nurse Practitioner, Division of Cerebrovascular Disease
and Neurological Critical Care
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania

Chapter 7: Individual and Family Considerations Related to Illness

Susanna Garner Cunningham, PhD, BSN, MA,
FAAN, FAHA

Chapter 62: Management of Patients With
Cerebrovascular Disorders

Professor
University of Washington
Seattle, Washington

Jo Ann Brooks, DNS, RN, FCCP, FAAN

Chapter 32: Assessment and Management of Patients
With Hypertension

Vice President, Quality
Clarian Health
Indianapolis, Indiana

Elizabeth Petit de Mange, PhD, MSN, NP-C, RN

Chapter 23: Management of Patients With Chest and Lower
Respirator y Tract Disorders

Assistant Professor
Villanova University College of Nursing
Villanova, Pennsylvania

Chapter 24: Management of Patients With Chronic Pulmonar y
Disease

Chapter 42: Assessment and Management of Patients With
Endocrine Disorders

iii

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iv

Contributors

Susan K. Dempsey-Walls, MN, RN, AOCNS, ACHPN

Theresa Lynn Green, PhD, MSCHRM, BSCN, RN

Oncology Clinical Nurse Specialist
Orlando Health/M. D. Anderson Cancer Center Orlando
Orlando, Florida

Assistant Professor
University of Calgary
Calgary, Alberta

Chapter 49: Assessment and Management of Problems Related to Male
Reproductive Processes

Chapter 11: Principles and Practices of Rehabilitation

Nancy Donegan, RN, BSN, MPH

Assistant Dean, Curricular Initiatives
University of Pennsylvania School of Nursing
Philadelphia, Pennsylvania

Director, Infection Control
Washington Hospital Center
Washington, District of Columbia

Margaret J. Griffiths, MSN, RN, CNE

Chapter 50: Assessment of Immune Function

Chapter 70: Management of Patients With Infectious Diseases

Chapter 51: Management of Patients With Immunodeficiency

Diane K. Dressler, MSN, RN, CCRN

Janice L. Hinkle, PhD, RN, CNRN

Clinical Assistant Professor
Marquette University College of Nursing
Milwaukee, Wisconsin

Formerly, Senior Research Fellow, Acute Stroke Programme
Oxford Brookes University and John Radcliffe Hospital
Oxford, United Kingdom

Chapter 28: Management of Patients With Coronary Vascular Disorders

Chapter 5: Adult Health and Nutritional Assessment

Chapter 30: Management of Patients With Complications from
Heart Disease

Chapter 54: Assessment and Management of Patients With Rheumatic
Disorders

Phyllis Dubendorf, RN, MSN, CRNP, CNRN

Chapter 64: Management of Patients With Neurologic Infections,
Autoimmune Disorders, and Neuropathies

Clinical Nurse Specialist
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Chapter 65: Management of Patients With Oncologic or Degenerative
Neurologic Disorders

Chapter 61: Management of Patients With Neurologic Dysfunction

Joyce Young Johnson, RN, MN, PhD

Susan M. Fallone, MS, RN, CNN
Clinical Nurse Specialist, Adult and Pediatric Dialysis
Albany Medical Center
Albany, New York

Dean, College of Sciences and Health Professions
Department of Nursing
Albany State University
Albany, Georgia
Chapter 1: Health Care Delivery and Nursing Practice

Chapter 43: Assessment of Renal and Urinar y Tract Function

Chapter 2: Community-Based Nursing Practice

Jacqueline D. K. Fenicle, RN, MSN

Chapter 3: Critical Thinking, Ethical Decision Making, and
the Nursing Process

Director of Patient Care Services
Regional Burn Center and Burn Recovery
Lehigh Valley Health Network
Allentown, Pennsylvania

Chapter 8: Perspectives in Transcultural Nursing

Tamara M. Kear, MSN, RN, CNN

Chapter 57: Management of Patients With Burn Injur y

Assistant Professor
Gwynedd-Mercy College
Gwynedd Valley, Pennsylvania

Eleanor R. Fitzpatrick, RN, BSN, MSN, CCRN

Chapter 45: Management of Patients With Urinar y Disorders

Clinical Nurse Specialist
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania

Elizabeth K. Keech, PhD, MA, BSN

Chapter 39: Assessment and Management of Patients
With Hepatic Disorders
Chapter 40: Assessment and Management of Patients
With Biliar y Disorders

Assistant Professor
Villanova University College of Nursing
Villanova University
Villanova, Pennsylvania
Chapter 12: Health Care of the Older Adult

H. Lynne Kennedy, MSN, RN, RNFA, CNOR, CLNC,
Kathleen Kelleher Furniss, RNC, MSN, WHNP-BC, DMH
Coordinator, Women’s Imaging and Women’s Health NP
Mountainside Hospital and Drew University
Montclair, New Jersey
Chapter 46: Assessment and Management of Female
Physiologic Processes
Chapter 47: Management of Patients With Female
Reproductive Disorders

Alumnus CCRN

RNFA, OR Fellowship Instructor, CEU/CME Seminar
Planner/Instructor
Inova Fair Oaks Hospital
Fairfax, Virginia
Chapter 18: Preoperative Nursing Management
Chapter 19: Intraoperative Nursing Management
Chapter 20: Postoperative Nursing Management

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Contributors

Mary Beth Flynn Makic, PhD, RN, CNS,
CCNS, CCRN

Research Nurse Scientist
Critical Care and Assistant Professor
University of Colorado Hospital
University of Colorado Denver-College of Nursing
Aurora, Colorado
Chapter 15: Shock and Multiple Organ Disfunction Syndrome

Barbara J. Maschak-Carey, MSN, RN, CDE
Diabetes Clinical Nurse Specialist
Program Coordinator, Look AHEAD Study
University of Pennsylvania
Philadelphia, Pennsylvania
Chapter 41: Assessment and Management of Patients
With Diabetes Mellitus

v

Janet A. Parkosewich, DNSC, RN, CCRN, FAHA
Interim Nurse Researcher
Yale New Haven Hospital
New Haven, Connecticut
Chapter 26: Assessment of Cardiovascular Function

M. Miki Patterson, PhD, PNP, ONP
Visiting Professor
University of Massachusetts Lowell
Lowell, Massachusetts
Chapter 67: Musculoskeletal Care Modalities

Jana L. Perun, MS, ARNP, AOCNP
Advanced Registered Nurse Practitioner
Cancer Institute of Florida
Altamonte Springs, Florida
Chapter 22: Management of Patients With Upper Respiratory Tract Disorders

Agnes Masny, MSN, RN, MPH, CRNP
Nurse Practitioner
Fox Chase Cancer Center
Philadelphia, Pennsylvania

Kimberly L. Quinn, MSN, RN, ACNP, ANP,
CCRN, ANCP-C

Chapter 9: Genetics and Genomics Perspectives in Nursing

Nurse Practitioner for Thoracic Surgery
Union Memorial Hospital
Baltimore, Maryland

Phyllis J. Mason, MS, ANP-BC

Chapter 35: Management of Patients With Oral and Esophageal Disorders

Instructor
The Johns Hopkins University School of Nursing
Baltimore, Maryland

JoAnne Reifsnyder, PhD, ACHPN

Chapter 34: Assessment of Digestive and Gastrointestinal Function
Chapter 37: Management of Patients With Gastric and
Duodenal Disorders

Martha Mulvey, MSN, RN, ANP-BC, ACNS-BC
ANP Neurosciences Epilepsy Program Adult and Pediatrics
The University Hospital
Newark, New Jersey
Chapter 14: Fluid and Electrolytes: Balance and Disturbance

Victoria B. Navarro, MAS, MSN, RN
Director of Nursing
The Wilmer Eye Institute at Johns Hopkins
Baltimore, Maryland
Chapter 58: Assessment and Management of Patients With Eye and
Vision Disorders

Donna Nayduch, MSN, RN, ACNP
Trauma Consultant
K-Force Consulting
Tampa, Florida
Chapter 71: Emergency Nursing
Chapter 72: Terrorism, Mass Casualty, and Disaster Nursing

Assistant Professor and Program Director
Chronic Care Management
Jefferson School of Population Health
Thomas Jefferson University
Philadelphia, Pennsylvania
Chapter 17: End-of-Life Care

Judith Reishtein, PhD, RN
Assistant Professor
College of Nursing & Health Professions
Drexel University
Philadelphia, Pennsylvania
Chapter 21: Assessment of Respiratory Function
Chapter 25: Respiratory Care Modalities

Catherine Stewart Sackett, BS, CRNP
Nurse Practitioner
Wilmer Eye Institute at Johns Hopkins
Medstar Research Institute
Baltimore, Maryland
Chapter 58: Assessment and Management of Patients With Eye
and Vision Disorders

Linda Schakenbach, MSN, RN, CNS, CCRN,
CWCN, ACNS-BC

Professor and Director of the Graduate Nursing Program
Hunter College, CUNY Hunter College School of Nursing
New York, New York

Clinical Nurse Specialist
Medical Cardiac Nursing
Inova Fairfax Hospital
Inova Heart and Vascular Institute
Falls Church, Virginia

Chapter 52: Management of Patients With
HIV Infection and AIDS

Chapter 29: Management of Patients With Structural, Infectious, and
Inflammator y Cardiac Disorders

Kathleen M. Nokes, PhD, RN, FAAN

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vi

Contributors

Suzanne C. Smeltzer, EdD, RN, FAAN

Jean Smith Temple, DNS, MSN, BSN

Professor and Director, Center for Nursing Research
Villanova University College of Nursing
Villanova, Pennsylvania

Associate Dean & Associate Professor
Valdosta State University College of Nursing
Valdosta, Georgia

Chapter 10: Chronic Illness and Disability

Chapter 1: Health Care Delivery and Nursing Practice

Karen A. Steffen-Albert, MSN, RN, CCRN, CNRN
Clinical Nurse Specialist, Nursing Research & Quality
Thomas Jefferson University Hospital
Philadelphia, Pennsylvania

Chapter 2: Community-Based Nursing Practice
Chapter 3: Critical Thinking, Ethical Decision Making, and
the Nursing Process
Chapter 8: Perspectives in Transcultural Nursing

Chapter 63: Management of Patients With Neurologic Trauma

Mary L. Thomas, MS, RN, AOCN

Cindy Stern, MSN, RN, CCRP

Hematology Clinical Nurse Specialist
VA Palo Alto Health Care System
Palo Alto, California

Cancer Network Administrator
Abramson Cancer Center of the University of
Pennsylvania Health System
Philadelphia, Pennsylvania
Chapter 16: Oncology: Nursing Management in Cancer Care

Caroline Steward, RN, MSN, APN-C, CCRN, CNN
Nurse Educator Fresenius Medical Care North America
Northern Region Eastern Division
Ewing, New Jersey

Chapter 33: Assessment and Management of Patients With
Hematologic Disorders

Renay D. Tyler, MSN, RN, ACNP, CNSN
Acute Care Nurse Practitioner
The Parenteral–Enteral Support Service
The Johns Hopkins Hospital
Baltimore, Maryland

Chapter 44: Management of Patients With Renal Disorders

Chapter 36: Gastrointestinal Intubation and Special
Nutritional Modalities

Christina Stewart-Amidei, RN, MSN, CNRN, CCRN

Joyce S. Willens, PhD, RN, BC

Instructor
University of Central Florida
Orlando, Florida

Assistant Professor
Villanova University College of Nursing
Villanova, Pennsylvania

Chapter 60: Assessment of Neurologic Function

Chapter 13: Pain Management

Christine Tea, MSN, RN, NEA-BC, CBN

Iris Woodard, BSN, RN-CS, ANP

Service Line Director
Inova Fair Oaks Hospital
Fairfax, Virginia

Nurse Practitioner
Kaiser Permanente
Rockville, Maryland

Chapter 18: Preoperative Nursing Management

Chapter 55: Assessment of Integumentar y Function

Chapter 19: Intraoperative Nursing Management

Chapter 56: Management of Patients With Dermatologic Problems

Chapter 20: Postoperative Nursing Management

Acknowledgments
The authors gratefully acknowledge the contributions and expertise of Dale Halsey Lea, MS, RN, MPH, FAAN.

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P R E FA C E

The first edition of Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing was published in 1964 under the
leadership of Lillian Sholtis Brunner and Doris Smith Suddarth. Lillian and Doris pioneered a medical-surgical nursing textbook that has become a classic. Medical-surgical
nursing has come a long way since 1964 but continues to be
strongly influenced by the expansion of science, medicine,
surgery, and technology, as well as a myriad of social, cultural, economic, and environmental changes throughout
the world. Nurses must be particularly skilled in critical
thinking and clinical decision-making as well as in consulting and collaborating with other members of the multidisciplinary health care team.
Along with the challenges that today’s nurses confront,
there are many opportunities to provide skilled, compassionate nursing care in a variety of health care settings, for
patients in the various stages of illness, and for patients
across the age continuum. At the same time, there are significant opportunities for fostering health promotion activities for individuals and groups; this is an integral part of
providing nursing care.
Continuing the tradition of Lillian’s and Doris’s first edition, this 12th edition of Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing is designed to assist nurses in
preparing for their roles and responsibilities within the
complex health care delivery system. A goal of the textbook
is to provide balanced attention to the art and science of
adult medical-surgical nursing. The textbook focuses on
physiologic, pathophysiologic, and psychosocial concepts as
they relate to nursing care, and emphasis is placed on integrating a variety of concepts from other disciplines such as
nutrition, pharmacology, and gerontology. Content relative
to health care needs of people with disabilities, nursing research findings, ethical considerations, and evidence-based
practice has been expanded to provide opportunities for the
nurse to refine clinical decision-making skills.

Organization
Brunner & Suddarth’s Textbook of Medical-Surgical Nursing,
12th edition, is organized into 16 units. Units 1 through 4
cover core concepts related to medical-surgical nursing
practice. Units 5 through 16 discuss adult health conditions
that are treated medically or surgically. Each unit covering
adult health conditions is structured in the following way,
to facilitate understanding:
• The first chapter in the unit covers assessment and includes a review of normal anatomy and physiology of
the body system being discussed.
• The subsequent chapters in the unit cover management of specific disorders. Pathophysiology, clinical
manifestations, assessment and diagnostic findings,
medical management, and nursing management are
presented. Special “Nursing Process” sections, provided for selected conditions, clarify and expand on
the nurse’s role in caring for patients with these conditions.

Features
Practice-Oriented Features

Nurses assume many different roles when caring for patients. Many of the features in this textbook have been developed to help nurses fulfill these varied roles.
The Nurse as Practitioner
One of the central roles of the nurse is to provide holistic care
to patients and their families, both independently and through
collaboration with other health care professionals. Many features in Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing are designed to assist students with clinical practice.
Nursing Process sections. The nursing process is the basis
for all nursing practice. Special sections throughout the
text, organized according to the nursing process framework,
clarify the nurse’s responsibilities in caring for patients with
selected disorders.
Plans of Nursing Care. These plans, provided for selected disorders, illustrate how the nursing process is
applied to meet the person’s health care and nursing needs.
Applying Concepts from NANDA, NIC, and NOC.
Each unit begins with a case study and a chart presenting
examples of NANDA, NIC, and NOC terminologies related
to the case study. Concept maps, which provide a visual representation of the NANDA, NIC, and NOC chart for each case
study, are found on the accompanying Web site
to
this book at thepoint.lww.com/Smeltzer12e. This feature introduces the student to the NIC and NOC language and classifications and brings them to life in graphic form.
Assessment charts. These charts help to focus the
student’s attention on data that should be collected as
part of the assessment step of the nursing process.
Risk Factor charts. These charts draw the student’s
attention to factors that can impair health.
Guidelines charts. These charts review key nursing
interventions, and the rationales for those interventions, for specific patient care situations.
Pharmacology charts and tables. Pharmacology
charts and tables remind the student of important considerations relative to administering medications and monitoring drug therapy.
Nursing Alerts. These special sections offer brief tips
for clinical practice and red-flag warnings to help students avoid common mistakes.
Critical Care. These special sections highlight nursing
process considerations for the critically ill patient.
Gerontologic Considerations. In the United States,
older adults comprise the fastest-growing segment of
the population. This icon is applied to headings, charts, and
tables as appropriate to highlight information that pertains
specifically to the care of the older adult patient.
vii

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viii

Preface

Genetics in Nursing Practice charts. These charts
summarize and highlight the role that genetics play in
many disorders.
Physiology/Pathophysiology figures. These illustrations
and algorithms help students to understand normal physiologic and pathophysiologic processes.
The Nurse as Educator
Health education is a primary responsibility of the nursing
profession. Nursing care is directed toward promoting, maintaining, and restoring health; preventing illness; and helping
patients and families adapt to the residual effects of illness.
Teaching, in the form of patient education and health promotion, is central to all of these nursing activities.
Patient Education charts. These charts help the
nurse to prepare the patient and family for procedures,
assist them with understanding the patient’s condition, and
explain to them how to provide for self-care after discharge
from the health care facility.
Home Care checklists. These checklists review points
that should be covered as part of patient education
prior to discharge from the health care facility.
Health Promotion charts. These charts review important points that the nurse should discuss with the patient to prevent common health problems from developing.
The Nurse as Patient Advocate
Nurses advocate for patients by protecting their rights (including the right to health care) and assisting patients and
their families to make informed decisions about health care.
Ethics and Related Issues charts. These charts present a scenario, a description of potential ethical dilemmas that could arise as a result of the scenario, and a list
of questions about the scenario to stimulate thought and
discussion.
The Nurse as Researcher
Nurses identify potential research problems and questions
to increase nursing knowledge and improve patient care.
Use and evaluation of research findings in nursing practice
are essential to further the science of nursing.
Nursing Research Profiles. These charts identify the implications and applications of nursing research findings for
nursing practice.
Evidence-Based Practice (EBP) questions. This icon
appears next to critical thinking exercises that encourage the student to think about the evidence base for
specific nursing interventions. A journals supplement offers
students free online access to over 70 journal articles that
relate to the evidence-based practice questions in the text.
Pedagogical Features

Learning Objectives. Each chapter begins with a list of
learning objectives. These give the student an overview of
the chapter and help to focus his or her reading.
Glossaries. Glossaries provided at the beginning of each
chapter let the student review vocabulary words before

reading the chapter, and also serve as a useful reference tool
while reading.
Critical Thinking Exercises. These questions, which appear at the end of each chapter, foster critical thinking by
challenging the student to apply textbook knowledge to
clinical scenarios.
References and Selected Readings. A list of current references cited is given at the end of each chapter.
Resources. A resource list at the end of each chapter directs the reader to sources of additional information, Web
sites, agencies, and patient education materials.

A Comprehensive Package for
Teaching and Learning
To further facilitate teaching and learning, a carefully designed ancillary package is available. In addition to the usual
print resources, we are pleased to present multimedia tools
that have been developed in conjunction with the text.
Resources for Students

Interactive DVD-ROM. Packaged with the textbook
at no additional charge, this DVD helps students test
their knowledge and enhance their understanding of
medical-surgical nursing. This DVD includes:
• More than 700 study questions organized by unit
• 3,500 NCLEX-style cross-disciplinary questions
• Concepts in Action™Animations
• Nursing in Action™ Videos
• Clinical Simulations
• Spanish-English Audioglossary
• Drug Monographs
• Other Learning Tools
Study Guide to Accompany Smeltzer, Bare, Hinkle &
Cheever: Brunner & Suddarth’s Textbook of MedicalSurgical Nursing, 12th edition. Available at student bookstores or at www.LWW.com, this study guide presents a variety of exercises to reinforce the textbook content and
enhance learning.
Handbook to Accompany Smeltzer, Bare, Hinkle &
Cheever: Brunner & Suddarth’s Textbook of MedicalSurgical Nursing, 12th edition. Available at student bookstores or at www.LWW.com, this clinical reference presents
need-to-know information on nearly 200 commonly encountered disorders in an easy-to-use alphabetized outline
format.
Resources for Instructors

Instructor’s Resource DVD-ROM. The instructor’s resource DVD contains the following items:
• A thoroughly revised and augmented test generator,
containing more than 2,000 NCLEX-style questions
• Sample syllabi for one-, two-, and three-semester
courses
• Strategies for effective teaching
• PowerPoint™ lectures, guided lecture notes, and prelecture quizzes
• An image bank
• Discussion topics and assignments

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Preface

Resources for Students and Instructors

ThePoint* (thepoint.lww.com) Students and instructors
can visit thePoint to access supplemental multimedia resources to enhance their learning.
It is with pleasure that we introduce these resources—
the textbook and the ancillary package—to you. One of our
primary goals in creating these resources has been to help
nurses and nursing students provide quality care to patients
*thePoint is a trademark of Wolters Kluwer Health.

ix

and families across health care settings and in the home.
We hope that we have succeeded in that goal, and we welcome feedback from our readers.

Suzanne C. O’Connell Smeltzer, EdD, RN, FAAN
Brenda G. Bare, RN, MSN
Janice L. Hinkle, PhD, RN, CNRN
Kerry H. Cheever, PhD, RN

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REVIEWERS

Earnest Ruth Agnew, RN, MSN

Janet E. Burton, MSN, RN, CMSRN

Nursing Instructor/Simulation Lab Coordinator
Itawamba Community College
Fulton, Mississippi

Clinical Nurse Specialist/Clinical Instructor
Columbus Regional Hospital
Columbus, Indiana

Rita Amerio, PhD(c), RN

Patricia W. Campbell, RN, MSN

Undergraduate Director, College of Nursing and
Health Professions
Lewis University
Romeoville, Illinois

Faculty
Carolinas College of Health Sciences
Charlotte, North Carolina

Linda Barkoozis, RN, MSN
Professor of Nursing
College of DuPage
Glen Ellyn, Illinois

Joanna G. Barnes, MSN, RN
ADN Program Coordinator
Grayson County College
Denison, Texas

Carol A. Berube, RN, MSN
Instructor
Brockton Hospital of Nursing
Brockton, Massachusetts

Dana M. Botz, MSN, RN
Faculty
North Hennepin Community College
Brooklyn Park, Minnesota

Sharon McFadden Bradley, MSN, RN, CNL
Clinical Assistant Professor
Coordinator for Curriculum and Evaluation
University of Florida
Gainesville, Florida

Jo Ellen Branstetter, RN, MS, MS (N), PhD
Professor
Cox College
Springfield, Missouri

Janet Witucki Brown, PhD, RN, CNE
Associate Professor
The University of Tennessee, Knoxville
Knoxville, Tennessee

Julia C. Burgett, MSN, RN, CNE, CNRN
Associate Professor
St. Mary’s/Marshall University
Huntington, West Virginia

Patricia Burkard, RNC, MSN
Professor
Moorpark College
Moorpark, California
x

Marilyn V. Clithero, RN, MSN
Assistant Professor
Cox College
Springfield, Missouri

Johnnie Sue Cooper, MSN, RN, FNP-BC
Nursing Instructor
Mississippi University for Women
Columbus, Mississippi

Marianne Craven, PhD(c), RN
Professor
Utah Valley University
Orem, Utah

Deborah L. Dalrymple, RN, MSN, CRNI
Professor
Montgomery County Community College
Blue Bell, Pennsylvania

Martha L. Davis, MSN, RN
Associate Degree Nursing Instructor
Itawamba Community College
Fulton, Mississippi

Jane F. deLeon, PhD, RN
Assistant Professor
San Francisco State University
San Francisco, California

David J. Derrico, RN, MSN
Assistant Clinical Professor
University of Florida
Gainesville, Florida

Carol M. Diehl, MSN, MSED, RN
Simulation Coordinator
The Reading Hospital School of Health Sciences
Reading, Pennsylvania

Larinda Dixon, RN, MSN, EdD
Professor
College of DuPage
Glen Ellyn, Illinois

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Reviewers

xi

Denise R. Doliveira, RN, MSN

Nancy J. Harrer, RN, MS

Associate Professor
Community College of Allegheny County, Boyce Campus
Pittsburgh, Pennsylvania

Assistant Professor
Community College of Baltimore County
Catonsville, Maryland

Cynthia L. Donell, MSN, RN, CNE

Kathleen Hayes, RN, MSEd, MSN

Campus Director of Nursing
Harrisburg Area Community College, York Campus
York, Pennsylvania

Professor
Norwalk Community College
Norwalk, Connecticut

Sandra K. Eggenberger, PhD, RN

Bonnie Heintzelman, MSN, RN, CMSRN

Professor
Minnesota State University
Mankato, Minnesota

Instructor
Thomas Jefferson University
Philadelphia, Pennsylvania

Cynthia L. Fenske, MS, RN

Pam Henderson, MSN, RN

Lecturer IV
University of Michigan
Ann Arbor, Michigan

Executive Director ADN/PN Programs
University of Arkansas, Fort Smith
Fort Smith, Arkansas

Dilyss Gallyot, RN, MS, CCRN

Kevin D. Hite, RN, MSN

Associate Professor
College of DuPage
Glen Ellyn, Illinois

Assistant Professor
Fairmont State University
Fairmont, West Virginia

Theresa A. Glanville, RN, MS, CNE

Wanda K. Hoerning, RN, MA, NP-C

Professor
Springfield Technical Community College
Springfield, Massachusetts

Adjunct Instructor
College of Staten Island and Manatee Community College
Staten Island, New York and Bradenton, Florida

Cornelia Gordon, RN, BSN, BA, MA

Janice J. Hoffman, PhD, RN, CCRN

Nursing Instructor
McLennan Community College
Waco, Texas

Assistant Professor and Vice Chair
University of Maryland
Baltimore, Maryland

Kathy Gray-Siracusa, PhD, RN, MBA, CCRN, NEA-BC

Jane Hook, RN, MN

Assistant Professor
Villanova University College of Nursing
Villanova, Pennsylvania

Lecturer
California State University, Los Angeles
Los Angeles, California

Kim Green, RN, MSN

Connie Houser, MS, RNC-OB, CNE

Assistant Professor
Western Kentucky University
Bowling Green, Kentucky

Nursing Instructor
Central Carolina Technical College
Manning, South Carolina

Jacqueline Guhde, MSN, RN, CNS

Norlyn B. Hyde, RN, C, MSN, CNS

Assistant Professor
The University of Akron
Akron, Ohio

Professor
Louisiana Tech University
Ruston, Louisiana

Karen Toby Haghenbeck, PhD, FNP-BC,

Kathy J. Keister, PhD, RN, CNE

RN-BC, CCRN

Assistant Professor
Pace University
Pleasantville, New York

Mary E. Hanson-Zalot, MSN, RN
Assistant Dean, ASN-BSN
Thomas Jefferson University
Philadelphia, Pennsylvania

Assistant Professor
Wright State University
Dayton, Ohio

Patricia A. Kent, MS, ACNP-BC
Clinical Assistant Professor
University of Massachusetts Amherst School of Nursing
Amherst, Massachusetts

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xii

Reviewers

Penny Y. Kessler, DNS(c), RN

Ildiko E. Monahan, MS, RN, ANP

Clinical Assistant Professor
University of Minnesota City
Minneapolis, Minnesota

Nurse Educator
St. Elizabeth College of Nursing
Utica, New York

Deborah R. Klinger, RN, MSN, MBA

Suzie Morrow, MSN, RN, CNE

Associate Professor
Manatee Community College
Bradenton, Florida

Catherine Lein, MS, FNP-BC
Assistant Professor
MSU College of Nursing
East Lansing, Michigan

Linda C. Lott, RN, MSN
AD Nursing Instructor
Itawamba Community College
Fulton, Mississippi

Tamar Jones Lucas, BSN, MSN, RN, BC
ADN Instructor
Itawamba Community College
Fulton, Mississippi

Billie A. Lynes, FNP, MSN
Professor/Gynocologic Oncology Nurse Practitioner
Mt. San Antonio College
Walnut, California

Shirley B. MacNeill, MSN, RN
ADN Nursing Instructor
Lamar State College, Port Arthur
Porth Arthur, Texas

Phyllis Magaletto, MS, RN, BC
Instructor
Cochran School of Nursing
Yonkers, New York

Gina Maiocco, PhD, RN, CCRN, CCNS
Assistant Professor
Coordinator BS/BA to BSN Program
West Virginia University
Morgantown, West Virginia

Andrea R. Mann, MSN, RN

Associate Professor
Southwest Baptist University
Springfield, Missouri

Mary Ellen Moyer-Hutcherson, RN, MSN
Professor
Florida Community College
Jacksonville, Florida

Janice A. Neil, RN, PhD
Associate Professor
East Carolina University
Greenville, North Carolina

Pamela S. Newton, RN, BSN
Traveling Nurse
Home Care RN Case Manager IV Team
Pathways Home Health and Hospice
Sunnyvale, California

Rebecca Otten, RN, MSN, EdD
Assistant Professor
California State University Fullerton
Fullerton, California

Verna C. Pangman, RN, MEd, MN
Senior Instructor
University of Manitoba
Winnipeg, Manitoba

Susan R. Parslow, RN, PhD
Associate Professor
Boise State University
Boise, Idaho

Linda Peake, MS, RN, C, CNE
Professor, Curriculum Coordinator
St. Mary’s/Marshall University Cooperative and Program
Huntington, West Virginia

Instructor, Third Level Chair at Frankford
Instructor Pharmacology at Penn State
Frankford Hospital School of Nursing
Penn State University
Philadelphia, Pennsylvania

Lisa Peden, RN, MSN

Sharon McDonald, MSN, RN

Assistant Professor
The College of St. Scholastica
Duluth, Minnesota

Nursing Instructor
University of Southern Mississippi
Hattiesburg, Mississippi

Nancy Miller, MS, RN
Faculty
Minneapolis Community and Technical College
Minneapolis, Minnesota

Associate Professor
Dalton State College
Dalton, Georgia

Beverly Raway, PhD, RN

Marisue Rayno, RN, MSN, EdD(c)
Faculty
Luzerne County Community College
Nanticoke, Pennsylvania

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Reviewers

Kathleen T. Rine, MSN, RN, OCN

Deborah Steele, PhD, RN, LMFT

Instructor
School of Nursing
Thomas Jefferson University
Philadelphia, Pennsylvania

Assistant Professor
California State University, Fresno
Fresno, California

Kathy Rodger, RN, BSN, MN
Faculty
Nursing Education Program of Saskatchewan (NEPS)
SIAST Wascana Campus
Regina, Saskatchewan

Donna Russo, RN, MSN, CCRN, CNE
Nursing Instructor
Frankford Hospital School of Nursing
Philadelphia, Pennsylvania

Lisa A. Streeter, MSRN, CNE
Nursing Instructor
St. Elizabeth College of Nursing
Utica, New York

Wendy J. Waldspurger Robb, PhD, RN, CNE
Assistant Professor
Director of the Graduate Nursing Program
Cedar Crest College
Allentown, Pennsylvania

Kristen J. Rogers, MSN, CNE, RN
Director, Service Excellence
The Washington Hospital
Washington, Pennsylvania

Tanya Lynn Rogers, APRN, BC, MSN
Associate Professor
Fairmont State University
Fairmont, West Virginia

Judith L. Samsel, RN, MSN
Professor/Chairperson, Nursing Department
Broome Community College
Binghamton, New York

Mary Ellen Santucci, PhD, RN
Assistant Professor
Widener University
Chester, Pennsylvania

Jo-Ann V. Sawatzky, RN, PhD
Associate Professor
University of Manitoba
Winnipeg, Manitoba

Ruth L. Schaffler, PhD, ARNP
Assistant Professor
Pacific Lutheran University
Tacoma, Washington

Donald G. Smith, Jr, MA, PhD, RN, ACRN
Assistant Professor
Hunter College, CUNY
New York, New York

Nancy Steffen, RN, MSN
Instructor
Century College
White Bear Lake, Minnesota

Marie H. Thomas, PhD, RN
Instructor
Forsyth Technical Community College
Winston-Salem, North Carolina

Linda Turchin, RN, MSN, CNE
Assistant Professor
Fairmont State University
Fairmont, West Virginia

Carol A. Velas, MSN, RN
Assistant Coordinator, Health Sciences
Associate Professor of Nursing
Moorpark College
Moorpark, California

Mary Walden, RN, MSN, DNP(c), CWOCN
Faculty
Itawamba Community College
Fulton, Mississippi

Terri L. Walker, MSN, RN
Professor
Oklahoma City Community College
Oklahoma City, Oklahoma

Mary Welhaven, PhD, RN
Professor
Winona State University, Rochester
Rochester, Minnesota

Stuart L. Whitney, EdD, RN, CNS
Clinical Associate Professor
University of Vermont
Burlington, Vermont

Donna Williams, RN, MSN, DNP(c)
Faculty
Itawamba Community College
Fulton, Mississippi

Emily Ray Wilson, RN, MSN, MA, AOCN
Instructor and Course Coordinator
Michigan State University
East Lansing, Michigan

Debra Wilson, MSN, FNP
Assistant Professor
California State University, Bakersfield
Bakersfield, California

xiii

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Reviewers

Thomas Worms, MSN, RN

Jean Yockey, MSN, FNP-BC, CNE

Professor
Truman College
Chicago, Illinois

Associate Professor
University of South Dakota
Vermillion, South Dakota

Rebecca Yarnell, RN, MSN
Associate Professor
Roane State Community College
Harriman, Tennessee

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CONTENTS

unit

Basic Concepts in Nursing

1

2

3

Ethics Versus Morality 25
Ethics Theories 25
Approaches to Ethics 25
Moral Situations 25
Types of Ethical Problems in Nursing 26
Preventive Ethics 28
Ethical Decision Making 29
The Nursing Process 29
Definition 29
Using the Nursing Process 30

1
2

Health Care Delivery and Nursing Practice 4
The Health Care Industry and the
Nursing Profession 5
Nursing Defined 5
The Patient/Client: Consumer of Nursing and
Health Care 5
Health Care in Transition 5
Health, Wellness, and Health Promotion 6
Health 6
Wellness 6
Health Promotion 6
Influences on Health Care Delivery 6
Population Demographics 7
Changing Patterns of Disease 7
Advances in Technology and Genetics 8
Demand for Quality Health Care 8
Alternative Health Care Delivery Systems 9
Roles of the Nurse 9
Practitioner Role 9
Leadership Role 10
Research Role 10
Models of Nursing Care Delivery 10
Community-Based Nursing and CommunityOriented/Public Health Nursing 10
Expanded Nursing Roles 11
Interdisciplinary Collaborative Practice 12
Community-Based Nursing Practice 14
Community-Based Care 15
Home Health Care 15
Nursing in the Home Setting 16
Discharge Planning for Home Care 17
Community Resources and Referrals 17
Home Health Visits 17
Other Community-Based Health Care Settings 19
Ambulatory Settings 19
Occupational Health Programs 19
School Health Programs 20
Community Nurse–Managed Centers 20
Care for the Homeless 20
Critical Thinking, Ethical Decision Making,
and the Nursing Process 22
Critical Thinking 23
Rationality and Insight 23
Components of Critical Thinking 23
Critical Thinking in Nursing Practice 23
Ethical Nursing Care 25

4

Health Education and Health Promotion 41
Health Education Today 42
Purpose of Health Education 42
Adherence to the Therapeutic Regimen 42
Gerontologic Considerations 43
The Nature of Teaching and Learning 43
Learning Readiness 43
The Learning Environment 45
Teaching Techniques 45
Teaching Special Populations 45
The Nursing Process in Patient Teaching 47
Assessment 47
Nursing Diagnosis 47
Planning 48
Implementation 48
Evaluation 48
Health Promotion 49
Definition 49
Health and Wellness 49
Health Promotion Models 49
Components of Health Promotion 50
Health Promotion Throughout the Lifespan 51
Adolescents 51
Young and Middle-Aged Adults 51
Gerontologic Considerations 52
Nursing Implications 53

5

Adult Health and Nutritional Assessment 55
Considerations for Conducting a Health History
and Physical Assessment 56
The Role of the Nurse 56
Communicating Effectively 56
Ethical Use of History or Physical
Examination Data 56
Increasing Use of Technology 56
Health History 57
The Informant 57
Components of the Health History 57
Other Health History Formats 64
Physical Assessment 64
Examination Considerations 65
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Contents

Components of the Physical Examination 65
Nutritional Assessment 67
Lifespan Considerations 68
Components of Nutritional Assessment 68
Factors Influencing Nutritional Status
in Various Situations 71
Analysis of Nutritional Status 73
Assessment in the Home and Community 73

unit

8

Perspectives in Transcultural Nursing 108
Cultural Concepts 109
Subcultures 109
Minorities 110
Transcultural Nursing 110
Culturally Competent Nursing Care 110
Cross-Cultural Communication 111
Culturally Mediated Characteristics 112
Space and Distance 113
Eye Contact 113
Time 113
Touch 113
Observance of Holidays 113
Diet 114
Biologic Variations 114
Complementary and Alternative Therapies 114
Causes of Illness 115
Biomedical or Scientific 115
Naturalistic or Holistic 115
Magico-Religious 116
Folk Healers 116
Cultural Assessment 116
Additional Cultural Considerations:
Know Thyself 116
Health Disparities 117
The Future of Transcultural Nursing Care 117

9

Genetics and Genomics Perspectives
in Nursing 119
Genomic Framework for Nursing Practice 120
Integrating Genetic and Genomic Knowledge 121
Genes and Their Role in Human Variation 121
Inheritance Patterns 124
Chromosomal Differences and
Genetic Conditions 126
Genetic and Genomic Technologies in Practice 127
Genetic Testing 128
Genetic Screening 128
Testing and Screening for Adult-Onset Conditions 128
Personalized Genomic Treatments 132
Applications of Genetics and Genomics in
Nursing Practice 134
Genetics and Genomics in Health Assessment 134
Genetic Counseling and Evaluation Services 137
Ethical Issues 141

2

Biophysical and Psychosocial Concepts in
Nursing Practice 76

6

7

Homeostasis, Stress, and Adaptation 78
Fundamental Concepts 79
Steady State 79
Stress and Adaptation 79
Overview of Stress 80
Types of Stressors 80
Stress as a Stimulus for Disease 80
Psychological Responses to Stress 80
Physiologic Response to Stress 81
Maladaptive Responses to Stress 84
Indicators of Stress 84
Nursing Implications 85
Stress at the Cellular Level 85
Control of the Steady State 86
Cellular Adaptation 86
Cellular Injury 87
Cellular Response to Injury: Inflammation 89
Cellular Healing 90
Nursing Implications 91
Stress Management: Nursing Interventions 91
Promoting a Healthy Lifestyle 91
Enhancing Coping Strategies 92
Teaching Relaxation Techniques 92
Educating About Stress Management 93
Enhancing Social Support 93
Recommending Support and Therapy Groups 93
Individual and Family Considerations
Related to Illness 96
Holistic Approach to Health and Health Care 97
The Brain and Physical and Emotional Health 97
Mental Health and Emotional Distress 97
Anxiety 98
Posttraumatic Stress Disorder 99
Depression 100
Substance Abuse 101
Family Health and Distress 103
Nursing Implications 103
Loss and Grief 104
Nursing Implications 104
Death and Dying 105
Spirituality and Spiritual Distress 105
Nursing Implications 105

10

Chronic Illness and Disability 144
Overview of Chronicity 145
Definition of Chronic Conditions 145
Prevalence and Causes of Chronic Conditions 145
Characteristics of Chronic Conditions 147
Implications of Managing Chronic Conditions 148
Phases of Chronic Conditions 148
Nursing Care of Patients With
Chronic Conditions 149
Applying the Nursing Process Using the Phases of the
Chronic Illness System 150

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Home and Community-Based Care 151
Nursing Care for Special Populations With
Chronic Illness 152
Overview of Disability 152
Definitions of Disability 152
Prevalence of Disability 153
Characteristics of Disability 153
Federal Legislation 155
Right of Access to Health Care 155
Barriers to Health Care 157
Federal Assistance Programs 160
Nursing Care of Patients With Disabilities 160
Nursing Considerations
During Hospitalization 160
Health Promotion and Prevention 161
Significance of “People-First” Language 161
Gerontologic Considerations 161
Disability in Medical-Surgical Nursing Practice 162
Home and Community-Based Care 162

11

Principles and Practices of Rehabilitation 166
Americans With Disabilities Act 168
Patients’ Reactions to Disability 168
The Rehabilitation Team 169
Areas of Specialty Rehabilitation 169
Assessment of Functional Ability 170
Disability and Sexuality Issues 194
Fatigue 194
Complementary and Alternative Therapies 194
Promoting Home and Community-Based Care 195
Teaching Patients Self-Care 195
Continuing Care 195

12

Health Care of the Older Adult 200
Overview of Aging 201
Demographics of Aging 201
Health Status of the Older Adult 201
Nursing Care of the Older Adult 202
Theories of Aging 202
Age-Related Changes 202
Physical Aspects of Aging 203
Psychosocial Aspects of Aging 209
Cognitive Aspects of Aging 211
Pharmacologic Aspects of Aging 212
Mental Health Problems in the Older Adult 213
Depression 213
Delirium 214
Dementia 217
Geriatric Syndromes 220
Impaired Mobility 220
Dizziness 220
Falls and Falling 220
Urinary Incontinence 221
Increased Susceptibility to Infection 221
Altered Pain and Febrile Responses 222
Altered Emotional Impact 222
Altered Systemic Response 222

xvii

Other Aspects of Health Care of the Older Adult 222
Elder Neglect and Abuse 222
Social Services 223
Health Care Costs of Aging 223
Home Health Care 223
Hospice Services 224
Aging with a Disability 224
Ethical and Legal Issues Affecting the Older Adult 224

unit 3
Concepts and Challenges in
Patient Management 228

13

Pain Management 230
Importance of Pain Assessment and Management 231
Types of Pain 231
Classic Categories of Pain 231
Pain Classified by Location 232
Pain Classified by Etiology 232
Harmful Effects of Pain 232
Effects of Acute Pain 232
Effects of Chronic Pain 232
Pathophysiology of Pain 232
Nociceptors 232
Peripheral Nervous System 234
Central Nervous System 234
Gate Control Theory 235
Factors Influencing Pain Response 235
Past Experience 236
Anxiety and Depression 236
Culture 236
Gerontologic Considerations 236
Gender 237
The Nurse’s Role in Assessment and Care of
Patients with Pain 237
Assessment 237
Nursing Care 240
Pain Management Strategies 242
Premedication Assessment 242
Agents Used to Treat Pain 244
Approaches for Using Analgesic Agents 248
Routes of Administration 251
Placebo Effect 254
Gerontologic Considerations 254
Promoting Home and Community-Based Care 255
Activities to Promote Comfort 256
Neurologic and Neurosurgical Approaches to
Pain Management 258
Evaluating Pain Management Strategies 259

14

Fluid and Electrolytes: Balance and Disturbance
Fundamental Concepts 264
Hypervolemia 273
Sodium Imbalances 275
Potassium Imbalances 280
Calcium Imbalances 284

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Immediate Preoperative Nursing Interventions 438
Expected Patient Outcomes 439

Magnesium Imbalances 288
Phosphorus Imbalances 290
Chloride Imbalances 292
Acute and Chronic Metabolic Acidosis
(Base Bicarbonate Deficit) 294
Acute and Chronic Metabolic Alkalosis
(Base Bicarbonate Excess) 295
Acute and Chronic Respiratory Acidosis
(Carbonic Acid Excess) 296
Acute and Chronic Respiratory Alkalosis
(Carbonic Acid Deficit) 296
Mixed Acid–Base Disorders 297
Parenteral Fluid Therapy 298

15

Shock and Multiple Organ
Dysfunction Syndrome 312
Overview of Shock 313
Stages of Shock 314
General Management Strategies in Shock 320
Hypovolemic Shock 322
Cardiogenic Shock 325
Circulatory Shock 327
Multiple Organ Dysfunction Syndrome 332
Promoting Home and Community-Based Care 333

16

Oncology: Nursing Management in Cancer Care
Epidemiology of Cancer 337
Pathophysiology of the Malignant Process 338
Detection and Prevention of Cancer 342
Diagnosis of Cancer 345
Tumor Staging and Grading 345
Management of Cancer 346
Nursing Care of Patients With Cancer 366
Cancer Survivorship 391

17

End-of-Life Care 395
Nursing and End-of-Life Care 396
Settings for End-of-Life Care 398
Nursing Care of Terminally Ill Patients 402
Nursing Care of Patients Who Are Close to Death 414
Coping With Death and Dying: Professional
Caregiver Issues 418

unit 4
Perioperative Concepts and Nursing
Management 422

18

Preoperative Nursing Management 424
Perioperative Nursing 425
Advances in Technology and Anesthesia 425
Surgical Classifications 425
Preadmission Testing 425
Special Considerations During the
Perioperative Period 425
Informed Consent 428
Preoperative Assessment 428
General Preoperative Nursing Interventions 434

19

Intraoperative Nursing Management 442
The Surgical Team 443
The Surgical Environment 446
The Surgical Experience 448
Potential Intraoperative Complications 455

20

Postoperative Nursing Management 461
Care of the Patient in the Postanesthesia
Care Unit 462
Care of the Hospitalized Postoperative Patient 468

unit

5

Gas Exchange and Respiratory
Function 484

21

Assessment of Respiratory Function 486
Anatomic and Physiologic Overview 487
Assessment 495
Diagnostic Evaluation 507

22

Management of Patients With Upper Respiratory
Tract Disorders 517
Rhinitis 518
Viral Rhinitis (Common Cold) 520
Rhinosinusitis 521
Pharyngitis 526
Tonsillitis and Adenoiditis 528
Peritonsillar Abscess 529
Laryngitis 530
Epistaxis (Nosebleed) 534
Nasal Obstruction 535
Fractures of the Nose 536
Laryngeal Obstruction 537
Cancer of the Larynx 537

23

Management of Patients With Chest and Lower
Respiratory Tract Disorders 551
Pneumonia 554
Aspiration 565
Severe Acute Respiratory Syndrome 567
Pulmonary Tuberculosis 567
Lung Abscess 572
Pleurisy 573
Pleural Effusion 574
Empyema 575
Pulmonary Edema 576
Acute Respiratory Failure 576
Acute Respiratory Distress Syndrome 577
Pulmonary Arterial Hypertension 579
Pulmonary Heart Disease (Cor Pulmonale) 581
Pulmonary Embolism 582
Sarcoidosis 587
Lung Cancer (Bronchogenic Carcinoma) 588
Tumors of the Mediastinum 592

336

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The Electrocardiogram 721
Analyzing the Electrocardiogram Rhythm Strip 725
Adjunctive Modalities and Management 741
Cardioversion and Defibrillation 741
Pacemaker Therapy 743
Implantable Cardioverter Defibrillator 747
Electrophysiologic Studies 751
Cardiac Conduction Surgery 752

Blunt Trauma 593
Penetrating Trauma: Gunshot and Stab Wounds 596
Pneumothorax 596
Cardiac Tamponade 599
Subcutaneous Emphysema 599

24

25

Management of Patients With Chronic
Pulmonary Disease 601
Chronic Obstructive Pulmonary Disease 602
Bronchiectasis 614
Asthma 620
Status Asthmaticus 630
Cystic Fibrosis 631
Respiratory Care Modalities 635
Incentive Spirometry (Sustained
Maximal Inspiration) 640
Mini-Nebulizer Therapy 641
Intermittent Positive-Pressure Breathing 642
Chest Physiotherapy 642
Emergency Management of Upper Airway
Obstruction 645
Endotracheal Intubation 646
Tracheostomy 648
Mechanical Ventilation 651
Preoperative Management 664
Postoperative Management 666

28

Management of Patients With Coronary
Vascular Disorders 755
Coronary Atherosclerosis 756
Angina Pectoris 762
Acute Coronary Syndrome and Myocardial
Infarction 768
Surgical Procedures: Coronary Artery
Revascularization 779

29

Management of Patients With Structural, Infectious,
and Inflammatory Cardiac Disorders 797
Mitral Valve Prolapse 798
Mitral Regurgitation 799
Mitral Stenosis 800
Aortic Regurgitation 801
Aortic Stenosis 801
Nursing Management: Valvular
Heart Disorders 802
Valve Replacement 804
Nursing Management: Valvuloplasty
and Replacement 806
Septal Defects 807
Cardiomyopathy 807
Rheumatic Endocarditis 814
Infective Endocarditis 815
Myocarditis 817
Pericarditis 818

30

Management of Patients With Complications
From Heart Disease 823
Cardiac Hemodynamics 824
Chronic Heart Failure 825
Pulmonary Edema 839
Thromboembolism 841
Pericardial Effusion and Cardiac Tamponade 842
Cardiac Arrest 843

31

Assessment and Management of Patients With
Vascular Disorders and Problems of
Peripheral Circulation 847
Anatomic and Physiologic Overview 848
Assessment 852
Diagnostic Evaluation 852
Peripheral Arterial Occlusive Disease 863
Upper Extremity Arterial
Occlusive Disease 866
Thromboangiitis Obliterans
(Buerger’s Disease) 866
Aortoiliac Disease 867

unit 6
Cardiovascular, Circulatory, and
Hematologic Function 682

26

27

Assessment of Cardiovascular Function 684
Anatomic and Physiologic Overview 685
Anatomy of the Heart 685
Function of the Heart 687
Gerontologic Considerations 690
Gender Considerations 690
Assessment of the Cardiovascular System 691
Health History 691
Physical Assessment 697
Diagnostic Evaluation 705
Laboratory Tests 705
Chest X-Ray and Fluoroscopy 707
Electrocardiography 707
Cardiac Stress Testing 709
Echocardiography 710
Radionuclide Imaging 711
Cardiac Catheterization 713
Electrophysiologic Testing 715
Hemodynamic Monitoring 715
Management of Patients With Dysrhythmias and
Conduction Problems 720
Dysrhythmias 721
Normal Electrical Conduction 721

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Aneurysms 868
Other Aneurysms 871
Dissecting Aorta 871
Arterial Embolism and Arterial
Thrombosis 872
Raynaud’s Phenomenon 873
Chronic Venous Insufficiency/
Postthrombotic Syndrome 880
Leg Ulcers 881
Varicose Veins 884
Lymphangitis and Lymphadenitis 886
Lymphedema and Elephantiasis 886

unit

7

Digestive and Gastrointestinal Function

32

Assessment and Management of Patients
With Hypertension 889
Hypertension 890
Pathophysiology 890
Clinical Manifestations 891
Assessment and Diagnostic Findings 892
Medical Management 892
Hypertensive Crises 900

33

Assessment and Management of Patients With
Hematologic Disorders 903
Assessment and Diagnostic Evaluation 909
Hypoproliferative Anemias 914
Hemolytic Anemias 920
Polycythemia Vera 927
Secondary Polycythemia 928
Neutropenia 929
Lymphopenia 930
Acute Myeloid Leukemia 933
Chronic Myeloid Leukemia 934
Acute Lymphocytic Leukemia 935
Chronic Lymphocytic Leukemia 936
Hodgkin Lymphoma 941
Non-Hodgkin Lymphomas 943
Primary Thrombocythemia 947
Secondary Thrombocytosis 948
Thrombocytopenia 949
Idiopathic Thrombocytopenic
Purpura 950
Platelet Defects 951
Hemophilia 951
Von Willebrand’s Disease 954
Vitamin K Deficiency 954
Complications of Anticoagulant
Therapy 955
Disseminated Intravascular Coagulation 955
Thrombotic Disorders 959
Hyperhomocysteinemia 959
Antithrombin Deficiency 959
Protein C Deficiency 960
Protein S Deficiency 960
Activated Protein C Resistance and Factor V
Leiden Mutation 960
Acquired Thrombophilia 960

976

34

Assessment of Digestive and
Gastrointestinal Function 978
Anatomic and Physiologic Overview 979
Anatomy of the Gastrointestinal System 979
Function of the Digestive System 980
Gerontologic Considerations 982
Assessment of the Gastrointestinal System 982
Health History 982
Physical Assessment 984
Diagnostic Evaluation 986
Serum Laboratory Studies 986
Stool Tests 987
Breath Tests 987
Abdominal Ultrasonography 987
DNA Testing 988
Imaging Studies 988
Endoscopic Procedures 990
Manometry and Electrophysiologic Studies 994
Gastric Analysis, Gastric Acid Stimulation Test, and
pH Monitoring 995
Laparoscopy (Peritoneoscopy) 995

35

Management of Patients With Oral and
Esophageal Disorders 997
Dental Plaque and Caries 998
Dentoalveolar Abscess or Periapical Abscess 1000
Malocclusion 1001
Temporomandibular Disorders 1002
Jaw Disorders Requiring Surgical Management 1002
Parotitis 1002
Sialadenitis 1003
Salivary Calculus (Sialolithiasis) 1003
Neoplasms 1003
Nursing Management of the Patient With Conditions
of the Oral Cavity 1004
Achalasia 1011
Diffuse Esophageal Spasm 1011
Hiatal Hernia 1012
Diverticulum 1013
Perforation 1013
Foreign Bodies 1014
Chemical Burns 1014
Gastroesophageal Reflux Disease 1014
Barrett’s Esophagus 1015
Benign Tumors of the Esophagus 1015
Cancer of the Esophagus 1017

36

Gastrointestinal Intubation and Special
Nutritional Modalities 1021
Gastrointestinal Intubation 1022
Tube Types 1022
Nursing Management 1023
Gastrostomy and Jejunostomy 1031

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Hepatitis G Virus and GB Virus-C 1145
Toxic Hepatitis 1145
Drug-Induced Hepatitis 1145
Primary Liver Tumors 1158
Liver Metastases 1158
Liver Transplantation 1161
Liver Abscesses 1165

Parenteral Nutrition 1034
Establishing Positive Nitrogen Balance 1034
Clinical Indications 1035
Formulas 1035
Initiating Therapy 1035
Administration Methods 1035
Discontinuing Parenteral Nutrition 1037

37

Management of Patients With Gastric and
Duodenal Disorders 1043
Gastritis 1044
Peptic Ulcer Disease 1047
Morbid Obesity 1055
Gastric Cancer 1056
Gastric Surgery 1060
Duodenal Tumors 1062

38

Management of Patients With Intestinal and
Rectal Disorders 1067
Constipation 1068
Diarrhea 1070
Fecal Incontinence 1072
Irritable Bowel Syndrome 1073
Conditions of Malabsorption 1074
Appendicitis 1075
Diverticular Disease 1077
Peritonitis 1080
Types of Inflammatory Bowel Disease 1082
Management of Chronic Inflammatory
Bowel Disease 1084
Small Bowel Obstruction 1097
Large Bowel Obstruction 1098
Colorectal Cancer 1098
Polyps of the Colon and Rectum 1107
Diseases 1108
Nursing Management of Patients With Anorectal
Conditions 1110

40

Assessment and Management of Patients
With Biliary Disorders 1169
Cholecystitis 1171
Cholelithiasis 1172
Acute Pancreatitis 1181
Chronic Pancreatitis 1185
Pancreatic Cysts 1190
Cancer of the Pancreas 1190
Tumors of the Head of the Pancreas 1192
Pancreatic Islet Tumors 1193
Hyperinsulinism 1194
Ulcerogenic Tumors 1194

41

Assessment and Management of Patients With
Diabetes Mellitus 1196
Hypoglycemia (Insulin Reactions) 1222
Diabetic Ketoacidosis 1225
Hyperglycemic Hyperosmolar
Nonketotic Syndrome 1227
Macrovascular Complications 1230
Microvascular Complications 1231
Diabetic Neuropathies 1235
Foot and Leg Problems 1236
Management of Hospitalized Patients
With Diabetes 1238

42

Assessment and Management of Patients
With Endocrine Disorders 1245
Assessment 1248
Diagnostic Evaluation 1249
Pathophysiology 1250
Specific Disorders of the Pituitary Gland 1251
Anatomic and Physiologic Overview 1253
Pathophysiology 1254
Assessment and Diagnostic Findings 1254
Specific Disorders of the Thyroid Gland 1256
Specific Disorders of the Parathyroid
Glands 1272
Specific Disorders of the Adrenal Glands 1276
Corticosteroid Therapy 1285

unit 8
Metabolic and Endocrine Function

39

1114

Assessment and Management of Patients
With Hepatic Disorders 1116
Assessment 1119
Diagnostic Evaluation 1120
Jaundice 1123
Portal Hypertension 1123
Ascites 1124
Esophageal Varices 1128
Hepatic Encephalopathy and Coma 1133
Other Manifestations of Hepatic Dysfunction 1137
Hepatitis A Virus 1139
Hepatitis B Virus 1141
Hepatitis C Virus 1144
Hepatitis D Virus 1144
Hepatitis E Virus 1145

unit

9

Urinary Tract Function

43

1290

Assessment of Renal and Urinary
Tract Function 1292
Anatomic and Physiologic Overview 1293
Anatomy of the Renal and Urinary
Tract Systems 1293

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Function of the Renal and Urinary
Tract Systems 1295
Gerontologic Considerations 1298
Assessment of the Renal and Urinary
Tract Systems 1299
Health History 1299
Physical Assessment 1301
Diagnostic Evaluation 1303
Urinalysis and Urine Culture 1303
Specific Gravity 1304
Osmolality 1304
Renal Function Tests 1304
Diagnostic Imaging 1306
Urologic Endoscopic Procedures 1308
Biopsy 1309

44

45

Management of Patients With Renal Disorders
Nephrosclerosis 1314
Primary Glomerular Diseases 1314
Polycystic Kidney Disease 1318
Acute Renal Failure 1320
Chronic Renal Failure (End-Stage
Renal Disease) 1325
Dialysis 1328
Management of Patients Undergoing
Kidney Surgery 1346
Kidney Transplantation 1351
Management of Patients With Urinary
Disorders 1358
Lower Urinary Tract Infections 1359
Upper Urinary Tract Infections 1365
Urinary Incontinence 1366
Urinary Retention 1370
Neurogenic Bladder 1371
Catheterization 1372
Cancer of the Bladder 1381
Cutaneous Urinary Diversions 1383
Continent Urinary Diversions 1387
Other Urinary Diversion Procedures 1388

unit

47

Management of Patients With Female
Reproductive Disorders 1437
Candidiasis 1438
Bacterial Vaginosis 1439
Trichomoniasis 1440
Gerontologic Considerations 1440
Human Papillomavirus 1442
Herpesvirus Type 2 Infection (Herpes Genitalis,
Herpes Simplex Virus) 1442
Endocervicitis and Cervicitis 1445
Pelvic Infection (Pelvic
Inflammatory Disease) 1446
Human Immunodeficiency Virus Infection
and Acquired Immunodeficiency
Syndrome 1447
Pelvic Organ Prolapse: Cystocele,
Rectocele, Enterocele 1449
Uterine Prolapse 1450
Vulvar Cysts 1452
Vulvar Dystrophy 1453
Ovarian Cysts 1453
Benign Tumors of the Uterus: Fibroids
(Leiomyomas, Myomas) 1453
Endometriosis 1454
Chronic Pelvic Pain 1456
Adenomyosis 1456
Endometrial Hyperplasia 1456
Cancer of the Cervix 1457
Cancer of the Uterus (Endometrium) 1459
Cancer of the Vulva 1459
Cancer of the Vagina 1462
Cancer of the Fallopian Tubes 1462
Cancer of the Ovary 1462
Hysterectomy 1464
Radiation Therapy 1467

48

Assessment and Management of Patients With
Breast Disorders 1471
Assessment 1472
Diagnostic Evaluation 1473
Fissure 1480
Lactational Abscess 1480
Cysts 1480
Fibroadenomas 1480
Benign Proliferative Breast Disease 1480
Other Benign Conditions 1481
Male Breast Cancer 1501

49

Assessment and Management of Problems Related
to Male Reproductive Processes 1504
Assessment 1506
Diagnostic Evaluation 1507
Disorders of Ejaculation 1511

1311

10

Reproductive Function

46

Preconception/Periconception
Health Care 1431
Ectopic Pregnancy 1432

1394

Assessment and Management of Female
Physiologic Processes 1396
Assessment 1400
Diagnostic Evaluation 1409
Menstruation 1413
Perimenopause 1414
Menopause 1414
Menstrual Disorders 1417
Dyspareunia 1421
Contraception 1421
Abortion 1427
Infertility 1429

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Benign Prostatic Hyperplasia (Enlarged
Prostate) 1514
Cancer of the Prostate 1516
The Patient Undergoing Prostate Surgery 1523
Epididymitis 1531
Testicular Torsion 1532
Testicular Cancer 1532
Hydrocele 1535
Varicocele 1535
Vasectomy 1535
Cancer of the Penis 1537
Priapism 1538
Peyronie’s Disease 1538
Urethral Stricture 1538
Circumcision 1538

unit

11

Immunologic Function

1542

50

Assessment of Immune Function 1544
Anatomic and Physiologic Overview 1545
Anatomy of the Immune System 1545
Function of the Immune System 1546
Advances in Immunology 1553
Genetic Engineering 1553
Stem Cells 1553
Assessment of the Immune System 1553
Health History 1553
Physical Assessment 1557
Diagnostic Evaluation 1557
Nursing Management 1558

51

Management of Patients With
Immunodeficiency 1561
Phagocytic Dysfunction 1562
B-Cell Deficiencies 1564
T-Cell Deficiencies 1565
Combined B-Cell and T-Cell
Deficiencies 1567
Deficiencies of the Complement
System 1569

52

Complementary and Alternative Modalities 1592
Supportive Care 1593

53

Assessment and Management of Patients
With Allergic Disorders 1606
Assessment 1609
Diagnostic Evaluation 1609
Anaphylaxis 1614
Allergic Rhinitis 1616
Contact Dermatitis 1623
Atopic Dermatitis 1623
Dermatitis Medicamentosa
(Drug Reactions) 1624
Urticaria and Angioneurotic
Edema 1625
Hereditary Angioedema 1625
Food Allergy 1625
Latex Allergy 1626

54

Assessment and Management of Patients
With Rheumatic Disorders 1631
Rheumatic Diseases 1632
Diffuse Connective Tissue Diseases 1643
Degenerative Joint Disease (Osteoarthritis) 1650
Spondyloarthropathies 1652
Metabolic and Endocrine Diseases Associated With
Rheumatic Disorders 1653
Fibromyalgia 1654
Arthritis Associated With Infectious
Organisms 1655
Neoplasms and Neurovascular, Bone, and
Extra-Articular Disorders 1655
Miscellaneous Disorders 1655

unit

12

Integumentary Function

55

Management of Patients With HIV
Infection and AIDS 1573
Epidemiology 1574
HIV Transmission 1574
Gerontologic Considerations 1575
Prevention of HIV Infection 1575
Transmission to Health Care Providers 1577
Pathophysiology 1577
Stages of HIV Disease 1579
Assessment and Diagnostic Findings in
HIV Infection 1580
Treatment of HIV Infection 1582
Clinical Manifestations 1586
Medical Management 1590

xxiii

1658

Assessment of Integumentary Function 1660
Anatomic and Physiologic Overview 1661
Anatomy of the Skin, Hair, Nails, and Glands of
the Skin 1661
Functions of the Skin 1663
Gerontologic Considerations 1664
Assessment 1664
Health History 1665
Physical Assessment 1665
Skin Consequences of Selected Systemic
Diseases 1673
Diagnostic Evaluation 1674
Skin Biopsy 1674
Immunofluorescence 1674
Patch Testing 1674
Skin Scrapings 1674
Tzanck Smear 1674
Wood’s Light Examination 1674
Clinical Photographs 1674

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Contents

Orbital Trauma 1782
Ocular Trauma 1784
Dry Eye Syndrome 1786
Conjunctivitis 1787
Uveitis 1790
Orbital Cellulitis 1790
Benign Tumors of the Eyelids 1791
Benign Tumors of the Conjunctiva 1791
Malignant Tumors of the Orbit 1791
Malignant Tumors of the Eyelid 1791
Malignant Tumors of the Conjunctiva 1791
Malignant Tumors of the Globe 1791
Enucleation 1792
Cytomegalovirus Retinitis 1794
Hypertension-Related Eye Changes 1794

Management of Patients With
Dermatologic Problems 1676
Perineal and Perianal Pruritus 1683
Hidradenitis Suppurativa 1684
Seborrheic Dermatoses 1684
Acne Vulgaris 1685
Viral Skin Infections 1689
Fungal (Mycotic) Skin Infections 1691
Parasitic Skin Infestations 1692
Exfoliative Dermatitis 1698
Pemphigus 1699
Bullous Pemphigoid 1700
Dermatitis Herpetiformis 1700
Toxic Epidermal Necrolysis and
Stevens-Johnson Syndrome 1702
Malignant Skin Tumors 1706
Metastatic Skin Tumors 1713
Kaposi’s Sarcoma 1713
Wound Coverage: Grafts and Flaps 1713
Cosmetic Procedures 1715

59

Management of Patients With Burn Injury
Overview of Burn Injury 1719
Incidence 1719
Gerontologic Considerations 1719
Outlook for Survival and Recovery 1720
Severity 1720
Pathophysiology 1721
Management of Burn Injury 1725
On-the-Scene Care 1725
Medical Management 1725
Nursing Management 1728
Gerontologic Considerations 1729
Medical Management 1729
Nursing Management 1742
Psychological Support 1745
Abnormal Wound Healing 1747
Outpatient Burn Care 1751

58

unit

14

Neurologic Function

unit 13
Sensorineural Function

1718

Assessment and Management of Patients With
Hearing and Balance Disorders 1801
Assessment 1804
Diagnostic Evaluation 1806
Foreign Bodies 1811
External Otitis (Otitis Externa) 1812
Malignant External Otitis 1812
Masses of the External Ear 1813
Gapping Earring Puncture 1813
Acute Otitis Media 1813
Serous Otitis Media 1814
Chronic Otitis Media 1814
Otosclerosis 1817
Middle Ear Masses 1817
Motion Sickness 1818
Ménière’s Disease 1819
Benign Paroxysmal Positional Vertigo 1820
Tinnitus 1820
Labyrinthitis 1820
Ototoxicity 1823
Acoustic Neuroma 1823

60

1754

Assessment and Management of Patients
With Eye and Vision Disorders 1756
Assessment 1760
Diagnostic Evaluation 1762
Low Vision and Blindness 1764
Glaucoma 1767
Cataracts 1772
Keratoconus 1776
Corneal Surgeries 1776
Refractive Surgeries 1777
Retinal Detachment 1779
Retinal Vascular Disorders 1780
Age-Related Macular Degeneration 1781

1828

Assessment of Neurologic Function 1830
Anatomic and Physiologic Overview 1831
Cells of the Nervous System 1831
Neurotransmitters 1831
The Central Nervous System 1831
The Peripheral Nervous System 1835
Motor and Sensory Pathways of the Nervous
System 1838
Assessment of the Nervous System 1841
Health History 1841
Physical Assessment 1842
Gerontologic Considerations 1849
Diagnostic Evaluation 1850
Computed Tomography Scanning 1850
Magnetic Resonance Imaging 1850

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Positron Emission Tomography 1851
Single Photon Emission Computed Tomography 1852
Cerebral Angiography 1852
Myelography 1852
Noninvasive Carotid Flow Studies 1853
Transcranial Doppler 1853
Electroencephalography 1853
Electromyography 1853
Nerve Conduction Studies 1854
Evoked Potential Studies 1854
Lumbar Puncture and Examination of
Cerebrospinal Fluid 1854
Promoting Home and Community-Based
Care 1855

61

62

63

Management of Patients With
Neurologic Dysfunction 1857
Supratentorial and Infratentorial Approaches 1874
Transsphenoidal Approach 1880
The Epilepsies 1882
Status Epilepticus 1888
Management of Patients With
Cerebrovascular Disorders 1895
Ischemic Stroke 1896
Pathophysiology 1896
Clinical Manifestations 1897
Assessment and Diagnostic Findings 1899
Prevention 1899
Medical Management 1900
Hemorrhagic Stroke 1910
Pathophysiology 1911
Clinical Manifestations 1911
Assessment and Diagnostic Findings 1912
Prevention 1912
Complications 1912
Medical Management 1913
Management of Patients With
Neurologic Trauma 1918
Head Injuries 1919
Pathophysiology 1919
Clinical Manifestations 1920
Assessment and Diagnostic Findings 1920
Gerontologic Considerations 1920
Medical Management 1921
Brain Injury 1921
Types of Brain Injury 1921
Management of Brain Injuries 1923
Spinal Cord Injury 1933
Pathophysiology 1933
Clinical Manifestations 1934
Assessment and Diagnostic Findings 1934
Emergency Management 1934
Medical Management (Acute Phase) 1934
Management of Acute Complications of Spinal
Cord Injury 1938

xxv

Medical Management of Long-Term Complications of
Spinal Cord Injury 1943

64

Management of Patients With Neurologic Infections,
Autoimmune Disorders, and Neuropathies 1949
Meningitis 1950
Brain Abscess 1952
Herpes Simplex Virus Encephalitis 1953
Arthropod-Borne Virus Encephalitis 1954
Fungal Encephalitis 1954
Creutzfeldt-Jakob and Variant
Creutzfeldt-Jakob Disease 1955
Multiple Sclerosis 1956
Myasthenia Gravis 1963
Guillain-Barré Syndrome 1966
Trigeminal Neuralgia (Tic Douloureux) 1970
Bell’s Palsy 1972
Mononeuropathy 1973

65

Management of Patients With Oncologic or
Degenerative Neurologic Disorders 1975
Primary Brain Tumors 1976
Cerebral Metastases 1981
Spinal Cord Tumors 1984
Parkinson’s Disease 1986
Huntington Disease 1992
Alzheimer’s Disease 1993
Amyotrophic Lateral Sclerosis 1993
Muscular Dystrophies 1995
Degenerative Disk Disease 1997
Herniation of a Cervical Intervertebral Disk 1998
Herniation of a Lumbar Disk 2001
Postpolio Syndrome 2002

unit

15

Musculoskeletal Function

66

2006

Assessment of Musculoskeletal Function 2008
Anatomic and Physiologic Overview 2009
Structure and Function of the Skeletal System 2009
Structure and Function of the Articular System 2011
Structure and Function of the Skeletal Muscle
System 2012
Gerontologic Considerations 2014
Assessment 2014
Health History 2014
Physical Assessment 2015
Diagnostic Evaluation 2019
Imaging Procedures 2019
Bone Densitometry 2020
Bone Scan 2020
Arthroscopy 2021
Arthrocentesis 2021
Electromyography 2021
Biopsy 2021
Laboratory Studies 2021

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68

Contents

Musculoskeletal Care Modalities 2023
The Patient in a Cast, Splint, or Brace 2024
Casts 2024
Splints and Braces 2025
General Nursing Management of a Patient in a Cast,
Splint, or Brace 2025
Nursing Management of the Patient With an
Immobilized Upper Extremity 2029
Nursing Management of the Patient With an
Immobilized Lower Extremity 2029
Nursing Management of the Patient With a Body or
Spica Cast 2029
The Patient With an External Fixator 2030
Nursing Management 2030
The Patient in Traction 2032
Skin Traction 2032
Skeletal Traction 2034
Nursing Management 2035
The Patient Undergoing Orthopedic Surgery 2036
Nursing Interventions 2037
Total Hip Replacement 2038
Management of Patients With
Musculoskeletal Disorders 2052
Low Back Pain 2053
Pathophysiology 2053
Clinical Manifestations 2053
Assessment and Diagnostic Findings
Medical Management 2053
Nursing Assessment 2054
Nursing Management 2054
Common Upper Extremity Problems
Common Foot Problems 2059
Metabolic Bone Disorders 2062
Prevention 2062
Gerontologic Considerations 2063
Pathophysiology 2063
Risk Factors 2063
Assessment and Diagnostic Findings
Medical Management 2065
Pathophysiology 2068
Gerontologic Considerations 2068
Assessment and Diagnostic Findings
Medical Management 2068
Pathophysiology 2068
Clinical Manifestations 2069
Assessment and Diagnostic Findings
Medical Management 2069
Gerontologic Considerations 2069
Musculoskeletal Infections 2069
Pathophysiology 2070
Clinical Manifestations 2070
Assessment and Diagnostic Findings
Prevention 2070
Medical Management 2070
Clinical Manifestations 2073

Assessment and Diagnostic Findings 2073
Medical Management 2073
Nursing Management 2073
Bone Tumors 2073
Types 2073
Pathophysiology 2074
Clinical Manifestations 2074
Assessment and Diagnostic Findings 2074
Medical Management 2075
Nursing Management 2075

69

Management of Patients With
Musculoskeletal Trauma 2080
Contusions, Strains, and Sprains 2081
Joint Dislocations 2081
Injuries to the Tendons, Ligaments, and Menisci 2082
Fractures 2084
Fractures of Specific Sites 2092
Sports-Related Injuries 2108
Occupation-Related Injuries 2108
Amputation 2108
Prevention of Injuries in Nursing Personnel 2116

unit

16

Other Acute Problems
2053

70

2057

71
2065

2068

2069

2070

2118

Management of Patients With
Infectious Diseases 2120
The Infectious Process 2121
Infection Control and Prevention 2124
Home-Based Care of the Patient With an
Infectious Disease 2132
Diarrheal Diseases 2134
Sexually Transmitted Diseases 2143
Emerging Infectious Diseases 2147
Travel and Immigration 2150
Emergency Nursing 2153
Collection of Forensic Evidence 2164
Injury Prevention 2165
Multiple Trauma 2165
Intra-Abdominal Injuries 2165
Crush Injuries 2167
Fractures 2167
Frostbite 2169
Hypothermia 2169
Near Drowning 2170
Decompression Sickness 2171
Anaphylactic Reaction 2171
Insect Stings 2172
Animal and Human Bites 2173
Snake Bites 2173
Spider Bites 2174
Tick Bites 2174
Ingested (Swallowed) Poisons 2175
Carbon Monoxide Poisoning 2177

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Skin Contamination Poisoning
(Chemical Burns) 2177
Food Poisoning 2178
Acute Alcohol Intoxication 2183
Alcohol Withdrawal Syndrome/Delirium
Tremens 2183
Sexual Assault 2185
Overactive Patients 2187
Violent Behavior 2187
Posttraumatic Stress Disorder 2188
Underactive or Depressed Patients 2188
Suicidal Patients 2188

72

Terrorism, Mass Casualty, and Disaster Nursing
Federal, State, and Local Responses
to Emergencies 2192
Hospital Emergency Preparedness Plans 2193
Preparedness and Response 2197
Natural Disasters 2198
Weapons of Terror 2199

Appendix A: Diagnostic Studies
and Interpretation 2211
Appendix B: Understanding
Clinical Pathways 2230
Index I-1

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1

Basic Concepts in Nursing

Concepts from NANDA, NIC,
Case Study • Applying
and NOC
The Community with an Identified Health Problem
A nurse working in an urgent care clinic that serves an economically
depressed urban area notes a high incidence of elderly patients with
dehydration and heatstroke in the summer months. The nurse verifies
the observations by accessing data about hospital admissions for
dehydration and heatstroke. The nurse determines that many of the
admitted patients live in the area served by the clinic and that
many of the patients live alone and have other chronic illnesses.
The nurse sees the need for a plan that includes a community
response to this problem. The plan includes arranging an
education program about the prevention of dehydration; a community support buddy system in which neighbors or volunteers call or
visit homebound elders during critical periods in the summer; and
economic support to air condition the senior citizens’ center.

Visit thePoint to view a concept map that
illustrates the relationships that exist between
the nursing diagnoses, interventions, and
outcomes for the patient’s clinical problems.

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Nursing Classifications and Languages
NANDA
NURSING DIAGNOSES

NIC
NURSING INTERVENTIONS

NOC
NURSING OUTCOMES
Return to functional baseline
status, stabilization of, or
improvement in:
COMMUNITY COMPETENCE—
Capacity of a community to
collectively problem solve to
achieve community goals

INEFFECTIVE COMMUNITY THERAPEU-

COMMUNITY HEALTH

TIC REGIMEN MANAGEMENT—

DEVELOPMENT—Assisting

Pattern of regulating and
integrating into community
processes programs for
treatment of illness and the
sequelae of illness that are unsatisfactory for meeting healthrelated goals

members of a community to
identify a community’s health
concerns, mobilize resources,
and implement solutions
PROGRAM DEVELOPMENT—
Planning, implementing, and
evaluating a coordinated set of
activities designed to enhance
wellness, or to prevent, reduce
or eliminate one or more health
problems for a group or
community

INEFFECTIVE COMMUNITY COPING—

SURVEILLANCE: COMMUNITY—

COMMUNITY HEALTH STATUS—The

Pattern of community activities
(for adaptation and problem solving) that is unsatisfactory for
meeting the demands or needs
of the community

Purposeful and ongoing acquisition, interpretation, and synthesis
of data for decision making in the
community

general state of well-being of a
community or population

READINESS FOR ENHANCED COMMU-

ENVIRONMENTAL RISK

NITY COPING—Pattern

PROTECTION—Preventing

of community activities for adaptation and
problem solving that is satisfactory for meeting the demands or
needs of the community but can
be improved for management of
current and future problems/
stressors

and detecting disease and injury in populations at risk from environmental hazards

Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis: Mosby.
Johnson, M., Bulechek, G., Butcher, H. K., et al. (2006). NANDA, NOC, and NIC linkages (2nd ed.). St. Louis: Mosby.
Moorhead, S., Johnson, M., Mass, M. L., et al. (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis: Mosby.
NANDA International. (2007). Nursing diagnoses: Definitions & classification 2007–2008. Philadelphia: North American Nursing
Diagnosis Association.

3

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chapter

1

Health Care Delivery and
Nursing Practice

LEARNING OBJECTIVES

GLOSSARY

On completion of this chapter, the learner will be
able to:

Advanced Practice Nurse (APN): a title which
encompasses the nurse practitioners (NPs), clinical
nurse specialists (CNSs), certified nurse midwives
(CNMs) and certified registered nurse anesthetists
(CRNAs).
Collaborative practice model: involves nurses,
physicians, and ancillary health personnel functioning
within a decentralized organizational structure and
collaboratively making clinical decisions.
Community-oriented nursing practice: nursing intervention that promotes wellness, reduces the spread of
illness, and improves the health status of groups of citizens or the community at large with emphasis on
primary, secondary, and tertiary prevention.
Continuous quality improvement (CQI): the ongoing examination of processes used to provide care, with the
aim of improving quality by assessing and improving
those processes that might improve patient care
outcomes and patient satisfaction.
Health–illness continuum: description of a person’s health
status as a range with anchors that include poor health
or imminent death on one end of the continuum to highlevel wellness on the other end.

1 Define health and wellness.
2 Describe factors causing significant changes in the
health care delivery system and their impact on health
care and the nursing profession.
3 Describe the practitioner, leadership, and research roles
of nurses.
4 Describe nursing care delivery models.
5 Discuss expanded nursing roles.

4

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Health care in the United States has undergone changes
over the years as society has continued to change. Nursing,
as a health care profession and a major component of the
health care system, has been significantly affected by these
changes. Nursing has played an important role in the health
care system and will continue to do so.

The Health Care Industry and the
Nursing Profession
Nursing Defined
Since the time of Florence Nightingale, who wrote in 1858
that the goal of nursing was “to put the patient in the best
condition for nature to act upon him,” nursing leaders have
described nursing as both an art and a science. However,
the definition of nursing has evolved over time. In its Social
Policy Statement (2003), the American Nurses Association
(ANA) defined nursing as the diagnosis and treatment of
human responses to health and illness. The ANA identifies
the following phenomena as the focus for nursing care and
research:
• Self-care processes
• Physiologic and pathophysiologic processes such as
rest, sleep, respiration, circulation, reproduction, activity, nutrition, elimination, skin, sexuality, and
communication
• Comfort, pain, and discomfort
• Emotions related to health and illness
• Meanings ascribed to health and illnesses
• Decision making and ability to make choices
• Perceptual orientations such as self-image and control
over one’s body and environments
• Transitions across the lifespan, such as birth, growth,
development, and death
• Affiliative relationships, including freedom from oppression and abuse
• Environmental systems
Nurses have a responsibility to carry out their role as described
in the Social Policy Statement to comply with the nurse practice act of the state in which they practice, and to comply
with the Code of Ethics for Nurses as spelled out by the ANA
(2001) and the International Council of Nurses (ICN, 2006).
To have a foundation for examining the delivery of nursing
care, it is necessary to understand the needs of health care
consumers and the health care delivery system, including the
forces that affect nursing and health care delivery.

Health Care Delivery and Nursing Practice

The patient who seeks care for a health problem or problems (increasing numbers of people have multiple health
problems) is also an individual person, a member of a family, and a citizen of the community. Patients’ needs vary depending on their problems, associated circumstances, and
past experiences. Many patients, who as consumers of
health care have become more knowledgeable about health
care options, are assuming a collaborative approach with
the nurse in the quest for optimal health (Hakesley-Brown
& Malone, 2007). Among the nurse’s important functions
in health care delivery are identifying the patient’s immediate needs and working in concert with the patient to address them.
The Patient’s Basic Needs

Certain needs are basic to all people. Some of these needs
are more important than others. Once an essential need is
met, people often experience a need on a higher level of priority. Addressing needs by priority reflects Maslow’s hierarchy of needs (Fig. 1-1).
Maslow’s Hierarchy

Maslow ranked human needs as follows: physiologic needs;
safety and security; sense of belonging and affection; esteem
and self-respect; and self-actualization, which includes selffulfillment, desire to know and understand, and aesthetic
needs. Lower-level needs always remain, but a person’s ability to pursue higher-level needs indicates movement toward
psychological health and well-being. Such a hierarchy of
needs is a useful framework that can be applied to the various nursing models for assessment of a patient’s strengths,
limitations, and need for nursing interventions.

Health Care in Transition
Changes occurring in health care delivery and nursing are
the result of societal, economic, technologic, scientific, and
political forces that have evolved throughout the 20th and

Selfactualization

Esteem and
self-respect

The Patient/Client: Consumer of Nursing
and Health Care
The central figure in health care services is, of course, the
patient. The term patient, which is derived from a Latin
verb meaning “to suffer,” has traditionally been used to describe a person who is a recipient of care. The connotation
commonly attached to the word is one of dependence. For
this reason, many nurses prefer to use the term client, which
is derived from a Latin verb meaning “to lean,” connoting
alliance and interdependence. The term patient is used
throughout this book, with the understanding that either
term is acceptable.

5

Belongingness and
affection
Safety and security

Physiologic needs

Figure 1-1

This scheme of Maslow’s hierarchy of human
needs shows how a person moves from fulfillment of basic
needs to higher levels of needs, with the ultimate goal being integrated human functioning and health.

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21st centuries. Among the most significant changes are
shifts in population demographics, particularly the increase
in the aging population and the cultural diversity of the
population; changing patterns of diseases; increased technology; increased consumer expectations; higher costs of
health care and changes in health care financing; and other
health care reform efforts. These changes have led to institutional restructuring, staff reduction and cross-training, increased outpatient care services, decreased lengths of hospital stay, and increased health care in community and home
settings. Such changes have dramatically influenced where
nurses practice. These changes have influenced society’s
view of health and illness and affected the focus of nursing
and health care.
As the proportion of the population reaching age 65
years has increased, and with the shift from acute illnesses
to chronic illnesses, the traditional disease management
and care focus of the health care professions has expanded.
There is increasing concern about emerging infectious diseases, trauma, obesity, and bioterrorism. Thus, health care
must focus more on disease prevention, health promotion,
and management of chronic conditions and disability than
in previous times. This shift in focus coincides with a nationwide emphasis on cost control and resource management directed toward providing safe, cost-efficient and costeffective health care services to the population as a whole.

Health, Wellness, and Health
Promotion
The health care system in the United States, which traditionally has been disease oriented, is placing increasing emphasis on health and its promotion. Similarly, a significant
number of nurses in past decades focused on the care of patients with acute conditions, but now many are directing
their efforts toward health promotion and illness prevention.

Health
How health is perceived depends on how health is defined. The World Health Organization (WHO) defines
health in the preamble to its constitution as a “state of
complete physical, mental, and social well-being and not
merely the absence of disease and infirmity” (WHO, 2006
pg. 1). Although this definition of health does not allow
for any variation in degrees of wellness or illness, the concept of a health–illness continuum allows for a greater
range in describing a person’s health status. By viewing
health and illness on a continuum, it is possible to consider a person as being neither completely healthy nor
completely ill. Instead, a person’s state of health is everchanging and has the potential to range from high-level
wellness to extremely poor health and imminent death.
Use of the health–illness continuum makes it possible to
regard a person as simultaneously possessing degrees of
both health and illness. On the health–illness continuum, even people with a chronic illness or disability may
attain a high level of wellness if they are successful in
meeting their health potential within the limits of their
chronic illness or disability.

Wellness
Wellness has been defined as being equivalent to health.
Wellness involves being proactive and being involved in
self-care activities aimed toward a state of physical, psychological, and spiritual well-being (Clark, Stuifbergen, Gottlieb, et al., 2006). Hood and Leddy (2007) consider that
wellness has four components: (1) the capacity to perform
to the best of one’s ability, (2) the ability to adjust and adapt
to varying situations, (3) a reported feeling of well-being,
and (4) a feeling that “everything is together” and harmonious. With this in mind, it becomes evident that the goal
of health care providers is to promote positive changes that
are directed toward health and well-being. The sense of
wellness has a subjective aspect that addresses the importance of recognizing and responding to patient individuality
and diversity in health care and nursing.

Health Promotion
Today, increasing emphasis is placed on health, health
promotion, wellness, and self-care. Health is seen as resulting from a lifestyle oriented toward wellness. The result has been the evolution of a wide range of health promotion strategies, including multiphasic screening,
genetic testing, lifetime health monitoring, environmental and mental health programs, risk reduction, and nutrition and health education. A growing interest in self-care
skills is reflected by the large number of health-related
publications, conferences, and workshops designed for the
lay public.
People are increasingly knowledgeable about their
health and take more interest in and responsibility for
their health and well-being. Organized self-care education programs emphasize health promotion, disease prevention, management of illness, self-care, and judicious
use of the professional health care system. In addition,
numerous Web sites and chat groups promote sharing of
experiences and information about self-care with others
who have similar conditions, chronic diseases, or disabling conditions.
Special efforts are being made by health care professionals to reach and motivate members of various cultural and
socioeconomic groups about lifestyle and health practices.
Stress, unhealthy diet, lack of exercise, smoking, use of illicit drugs, high-risk behaviors (including risky sexual practices), and poor hygiene are all lifestyle behaviors known to
affect health negatively. Health care professionals are concerned with encouraging behavior that promotes health.
The goal is to motivate people to make improvements in
the way they live, to modify risky behaviors, and to adopt
healthy behaviors.

Influences on Health Care Delivery
The health care delivery system is constantly adapting as
the population shifts its health care needs and expectations
change. The shifting demographics of the population, the
increase in chronic illnesses and disability, the greater emphasis on health care costs, and technologic advances have
resulted in changing emphases in health care delivery and
in nursing.

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Population Demographics
Changes in the population in general are affecting the need
for and the delivery of health care. The U.S. Bureau of the
Census (2007) estimated that there were more than 303
million people in the country. Population growth is attributed in part to improved public health services and improved nutrition.
Not only is the population increasing, but also its composition is changing. The decline in birth rate and the increase in lifespan due to improved health care have resulted
in fewer school-age children and more senior citizens, many
of whom are women. Much of the population resides in
highly congested urban areas, with a steady migration of
members of ethnic minorities to the inner cities and a migration of members of the middle class to suburban areas.
The number of homeless people, including entire families,
has increased significantly. The population has become
more culturally diverse as increasing numbers of people
from different national backgrounds enter the country.
Because of population changes, the health care needs of
people of specific ages, of women, and of diverse groups of
people in specific geographic locations is altering the effectiveness of traditional means of providing health care. As a
result, far-reaching changes in the overall health care delivery system are necessary.
Aging Population

The elderly population in the United States has increased
significantly and will continue to grow in future years. In
2003, the 35.9 million adults who were older than 65 years
of age constituted 12.4% of the U.S. population (U.S. Bureau of the Census, 2004). By the year 2030, 20% of the
U.S. population is expected to be older than 65 years of age.
According to the U.S. Bureau of the Census (2000), the
number of people 65 to 74 years of age was 8 times larger in
1999 than in 1900, and the number of people 75 to 84 years
of age was 16 times larger. In addition, people 85 years of
age and older constituted one of the fastest-growing segments of the population; the number was 34 times larger in
1999 than in 1900.
The health care needs of older adults are complex and
demand significant investments, both professional and financial, by the health care industry. Many elderly people
suffer from multiple chronic conditions that are exacerbated by acute episodes. In particular, elderly women,
whose conditions are frequently underdiagnosed and undertreated, are of concern. There are approximately three
women for every two men in the older population, and elderly women are expected to continue to outnumber elderly
men.
Cultural Diversity

An appreciation for the diverse characteristics and needs of
people from varied ethnic and cultural backgrounds is important in health care and nursing. Some projections indicate that by 2030, racial and ethnic minority populations in
the United States will triple. With increased immigration,
both legal and illegal, this figure could approach 50% by the
year 2030 (U.S. Bureaus of Census, 2004). As the cultural
composition of the population changes, it is increasingly

Health Care Delivery and Nursing Practice

7

important to address cultural considerations in the delivery
of health care. Patients from diverse sociocultural groups
not only bring various health care beliefs, values, and practices to the health care setting, but also have a variety of
risk factors for some disease conditions and unique reactions
to treatment. These factors significantly affect a person’s responses to health care problems or illnesses, to caregivers,
and to the care itself. Unless these factors are assessed for,
understood, and respected by health care providers, the care
delivered may be ineffective, and health care outcomes may
be negatively affected.
Culture is defined as learned patterns of behavior, beliefs,
and values that are shared by a particular group of people.
Included among the many characteristics that distinguish
cultural groups are the manner of dress, language spoken,
values, rules or norms of behavior, gender-specific practices,
economics, politics, law and social control, artifacts, technology, dietary practices, and health beliefs and practices.
Health promotion, illness prevention, causes of sickness,
treatment, coping, caring, dying, and death are part of every
culture. Every person has a unique belief and value system
that has been shaped at least in part by his or her cultural
environment. This belief and value system guides the person’s thinking, decisions, and actions. It provides direction
for interpreting and responding to illness and disability and
to health care.
To promote an effective nurse–patient relationship and
positive outcomes of care, nursing care must be culturally
competent, appropriate, and sensitive to cultural differences. All attempts should be made to help patients retain
their unique cultural characteristics. Providing special foods
that have significance and arranging for religious observances may enable patients to maintain a feeling of wholeness at a time when they may feel isolated from family and
community.
Knowing the cultural and social significance that particular situations have for each patient helps the nurse avoid
imposing a personal value system when the patient has a
different point of view. In most cases, cooperation with the
plan of care occurs when communication among the nurse,
the patient, and the patient’s family is directed toward understanding the situation or the problem and respecting
each other’s goals.

Changing Patterns of Disease
During the past 50 years, the health problems of the American people have changed significantly. Although many infectious diseases have been controlled or eradicated, others,
such as tuberculosis, acquired immunodeficiency syndrome
(AIDS), and sexually transmitted diseases/infections, are on
the rise. An increasing number of infectious agents are
becoming resistant to antibiotic therapy as a result of widespread and inappropriate use of antibiotics. Obesity has
become a major health concern, and the multiple comorbidities that accompany it, such as hypertension, heart disease, diabetes, and cancer, add significantly to its associated
mortality.
Conditions that were once easily treated have become
more complex and life-threatening. The prevalence of
chronic illnesses and disability is increasing because of the
lengthening lifespan in the United States and the advances

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in care and treatment options for conditions such as cancer,
human immunodeficiency virus (HIV) infection, and cystic
fibrosis. In addition, improvements in care for trauma and
other serious acute health problems have meant that many
people with these conditions live decades longer than in
the past. People with chronic illness are the largest group of
health care consumers in the United States. Because the
majority of health problems seen today are chronic in nature, many people are learning to maximize their health
within the constraints of chronic illness and disability.
As chronic conditions increase, health care broadens
from a focus on cure and eradication of disease to include
the prevention or rapid treatment of exacerbations of
chronic conditions. Nursing, which has always encouraged
patients to take control of their health and wellness, has a
prominent role in the current focus on management of
chronic illness and disability.

Advances in Technology and Genetics
Advances in technology and genetics have occurred more
rapidly during the past several decades compared with other
time periods. Sophisticated techniques and devices have
revolutionized surgery and diagnostic testing, making it possible to perform many procedures and tests on an outpatient
basis. Increased knowledge and understanding of genetics
have resulted in expanded screening, diagnostic testing, and
treatments for a variety of conditions. The sophisticated
communication systems that connect most parts of the
world, with the capability of rapid storage, retrieval, and
dissemination of information, have stimulated brisk change
as well as swift obsolescence in health care delivery strategies. Advances in genetics and technology have also resulted in many ethical issues for the health care system,
health care providers, patients, families, and society.

Demand for Quality Health Care
Nurses in acute care settings must work with other health
care team members to maintain quality care while facing
pressures to discharge patients and decrease staffing costs.
Nurses in hospitals now care for patients who are hospitalized for relatively few days. Nurses in the community care
for patients who need high-technology acute care services
as well as long-term care in the home. The importance of
effective discharge planning and quality improvement cannot be overstated. Acute care nurses must also work with
community-based nurses and others in community settings
to ensure continuity of care.
The general public has become increasingly interested in
and knowledgeable about health care and health promotion
through television, newspapers, magazines, the Internet,
and other communications media. Health care is a topic of
political debate. The public has also become very health
conscious and subscribes to the belief that health and quality health care constitute a basic right, rather than a privilege for a chosen few.
Quality Improvement and Evidence-Based Practice

In the 1980s, hospitals and other health care agencies implemented ongoing quality assurance (QA) programs.
These programs were required for reimbursement for services and for accreditation by the Joint Commission (previ-

ously known as the Joint Commission for Accreditation of
Healthcare Organizations [JCAHO]). These QA programs
sought to establish accountability to society on the part of
the health professions for the quality, appropriateness, and
cost of health services provided.
In the early 1990s, it was recognized that quality of care
as defined by regulatory agencies is difficult to measure. QA
criteria were identified as measures to ensure minimal expectations only; they did not provide mechanisms for identifying causes of problems or for determining systems or
processes that needed improvement. Continuous quality
improvement (CQI) was identified as a more effective
mechanism for maintaining quality health care and its implementation was mandated in health care organizations in
1992. The Joint Commission specifies that patients have
the right to health care (1) that is considerate and preserves
dignity; (2) that respects cultural, psychosocial, and spiritual values; and (3) that is age specific (Joint Commission,
2007).
Unlike QA, which focuses on individual incidents or errors and minimal expectations, CQI focuses on the
processes used to provide care, with the aim of improving
quality by assessing and improving those processes that
most affect patient care outcomes and patient satisfaction.
CQI involves analyzing, understanding, and improving
clinical, financial, and operational processes. Nurses directly involved in the delivery of care are engaged in analyzing data and refining the processes used in CQI. Their
knowledge of the processes and conditions that affect patient care is critical in designing changes to improve the
quality of the care provided.
Closely related to the implementation of CQI is the
move to transform health care through evidence-based
practice (EBP). The facilitation of EBP involves identifying
and evaluating current literature and research, as well as
incorporating the findings into patient care as a means of
ensuring quality care (Bourgault, Ipe, Weaver, et al., 2007;
Fineout-Overholt, Melnyk & Schultz, 2005). EBP includes
the use of outcome assessment and standardized plans of
care such as clinical guidelines, clinical pathways, and algorithms. Many of these measures are being implemented by
nurses, particularly by nurse managers and advanced practice nurses, often in collaboration with other health care
professionals.
Clinical Pathways and Care Mapping

Many health care facilities and home health services use
clinical pathways or care mapping to coordinate care for patients (Kinsman, James & Ham, 2004). Clinical pathways
are tools for tracking a patient’s progress toward achieving
positive outcomes within specified time frames. Clinical
pathways based on current literature and clinical expertise
have been developed for patients with certain diagnosisrelated groups (DRGs) (eg, heart failure, ischemic stroke,
fractured hip), for high-risk patients (eg, those receiving
chemotherapy), and for patients with certain common
health problems (eg, diabetes, chronic pain). The pathways
indicate key events, such as diagnostic tests, treatments, activities, medications, consultation, and education, that
must occur within specified times for patients to achieve the
desired and timely outcomes.

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A case manager often facilitates and coordinates interventions to ensure that the patient progresses through the
key events and achieves the desired outcomes. Nurses who
provide direct care have an important role in the development and use of clinical pathways through their participation in researching the literature and then developing, piloting, implementing, and revising clinical pathways. In
addition, nurses monitor outcome achievement and document and analyze variances. Examples of clinical pathways
can be found in Appendix B.
Other EBP tools used for planning patient care are care
mapping, multidisciplinary action plans (MAPs), clinical
guidelines, and algorithms. These tools are used to move patients toward predetermined outcome markers. Algorithms
are used more often in acute situations to determine a particular treatment based on patient information or response.
Care maps, clinical guidelines, and MAPs (the most detailed of these tools) help facilitate coordination of care and
education throughout hospitalization and after discharge.
Because care mapping and guidelines are used for conditions in which a patient’s progress often defies prediction,
specific time frames for achieving outcomes are excluded. A
patient with a highly complex condition or multiple underlying illnesses may benefit more from care mapping or
guidelines than from clinical pathways, because the use of
outcome milestones (rather than specific time frames) is
more realistic.
Through case management and the use of clinical pathways or care mapping, patients and the care they receive are
continually assessed from preadmission to discharge—and
in many cases after discharge to the home care and community settings. Continuity of care, effective utilization of
services, and cost containment are the major benefits for society and for the health care system.

Alternative Health Care Delivery
Systems
The rising cost of health care over the past few decades has
led to the use of managed health care and alternative health
care delivery systems, including health maintenance organizations (HMOs) and preferred provider organizations
(PPOs).
Managed Care

The continued escalation of health care costs over the
course of the past several decades has prompted business, labor, and government to assume greater control over the financing and delivery of health care. The common features
that characterize managed care include prenegotiated payment rates, mandatory precertification, utilization review,
limited choice of providers, and fixed-price reimbursement.
The scope of managed care has expanded from inhospital
services to HMOs or variations such as PPOs; ambulatory,
long-term, and home care services; and related diagnostic
and therapeutic services.
Managed care has contributed to a dramatic reduction in
inpatient hospital days, continuing expansion of ambulatory
care, fierce competition, and marketing strategies that appeal to consumers as well as to insurers and regulators. Hospitals are faced with declining revenues, a declining number
of patients, more severely ill patients with shorter lengths of

Health Care Delivery and Nursing Practice

9

stay, and a need for cost-effective outpatient or ambulatory
care services. As patients return to the community, they
have more health care needs, many of which are complex.
The demand for home care and community-based services is
escalating. Despite their successes, managed care organizations are faced with the challenge of providing quality services under resource constraints. Case management is a strategy used by many organizations to meet this challenge.
Case Management

Case management is a system of coordinating health care
services to ensure cost-effectiveness, accountability, and
quality care. The premise of case management is that the responsibility for meeting patient needs rests with one person
or team whose goals are to provide the patient and family
with access to required services, to ensure coordination of
these services, and to evaluate how effectively these services
are delivered.
Case management has gained such prominence because
of decreased costs of care associated with decreased lengths
of hospital stays coupled with rapid and frequent interunit
transfers from specialty to standard care units. The case
manager role focuses on managing the care of a caseload of
patients and collaborating with nurses and other health care
personnel who provide care. In some settings, particularly
the community setting, the focus of the nurse case manager
is on managing the treatment plan of the patient with complex conditions. The case manager follows the patient
throughout hospitalization and at home after discharge in an
effort to coordinate health care services that will avert or delay rehospitalization. The caseload is usually limited in scope
to patients with similar diagnoses, needs, and therapies.
Case management was designed to plan and coordinate
the inpatient and outpatient services needed by patients.
The goals of case management are quality, appropriateness,
and timeliness of services as well as cost reduction. Evidence-based pathways or similar plans are often used in case
management of similar patient populations (Craig & Huber, 2007; Huber & Craig, 2007).

Roles of the Nurse
As stated previously, nursing is the diagnosis and treatment
of human responses to health and illness and therefore focuses on a broad array of phenomena. Professional nurses
who work in institutional, community-oriented, or community-based settings have three major roles: the practitioner
role, which includes providing care, teaching, and collaborating; the leadership role; and the research role. Although
each role carries specific responsibilities, these roles are
characteristic of all nursing positions, relate to one another,
and are designed to meet the immediate and future needs of
consumers who are the recipients of nursing care. Often,
nurses act in a combination of roles to provide comprehensive patient care.

Practitioner Role
The practitioner role involves those actions taken by nurses
to meet the health care and nursing needs of individual patients, their families, and significant others. This role is a

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dominant one for nurses in primary, secondary, and tertiary
health care settings and in home care and community nursing. It is achieved through use of critical thinking, clinical
judgment, and the nursing process, all of which are key
tools for nursing practice. Nurses help patients meet their
needs by using direct intervention, by teaching patients and
family members to perform care, and by coordinating and
collaborating with other disciplines to provide needed services.

Leadership Role
The leadership role is often viewed as a role assumed by
nurses who have titles that suggest leadership and who are
the leaders of large groups of nurses or related health care
professionals. However, because of the constant fluctuation
of health care delivery demands and consumers, a broader
definition of nursing leadership, one that identifies the leadership role as inherent within all nursing positions, is required. The leadership role involves those actions that
nurses execute when they assume responsibility for the actions of others directed toward determining and achieving
patient care goals. Many staff nurses now work in settings
where they are held accountable for the nursing care delivered by unlicensed assistive personnel (UAPs) who work
under their direct supervision.
Nursing leadership involves four components: decision
making, relating, influencing, and facilitating. Each of these
components promotes change and the ultimate outcome of
goal achievement. Basic to the entire process is effective
communication, which determines the success of the
process and achievement of goals. The components of the
leadership process are appropriate during all phases of the
nursing process and in all settings. A new role, the clinical
nurse leader (CNL) is a nurse generalist with a master’s degree in nursing and a special background in clinical leadership to help patients navigate through complex health care
systems (American Association of Colleges of Nursing
[AACN], 2007).

Research Role
The primary task of nursing research is to contribute to the
scientific base of nursing practice. Studies are needed to determine the effectiveness of nursing interventions and nursing care. The science of nursing grows through research,
leading to the generation of scientifically based rationale for
nursing practice and patient care. This process is the basis
of EBP, with a resultant increase in the quality of patient
care.
The research role is considered to be a responsibility of
all nurses in clinical practice. Nurses are constantly alert for
nursing problems and important issues related to patient
care that can serve as a basis for the identification of researchable questions. Nurses with a background in research
methods can use their research knowledge and skills to initiate and implement timely, relevant studies.
Nurses directly involved in patient care are often in the
best position to identify potential research problems and
questions, and their clinical insights are invaluable. Nurses
also have a responsibility to become actively involved in
ongoing research studies. This may involve facilitating the
data collection process, or it may include actual collection

of data. Explaining the study to patients and their families
and to other health care professionals is often of invaluable
assistance to the researcher who is conducting the study.
Above all, nurses must use research findings in their
nursing practice; the use, validation, replication, dissemination, and evaluation of research findings further the science
of nursing. As stated previously, EBP requires the critique of
the best evidence available in research-based studies and
validating their saliency to nursing practice. Nurses must
continually be aware of studies that are directly related to
their own area of clinical practice and critically analyze
those studies to determine the applicability of their implications for specific patient populations. Relevant conclusions and implications can be used to improve patient care.

Models of Nursing Care Delivery
Several organizational methods or models that vary greatly
from one facility to another and from one set of patient circumstances to another may be used to carry out nursing
care. These methods and models have changed over the
years and have included functional nursing, team nursing,
primary nursing, and patient-focused or patient-centered
care. The models most commonly utilized today include primary nursing, which is characterized by assigning one primary nurse to accept overall responsibility for a given patient’s individualized nursing care, and patient-focused care,
which is characterized by assigning a nurse to manage the
care of a caseload of patients during a given shift, who may
then delegate care activities to other nursing personnel, including UAPs.

Community-Based Nursing and
Community-Oriented/Public
Health Nursing
Community health nursing, public health nursing, community-based nursing, and home health nursing may be discussed together. However, although aspects of patient care
in each type do overlap, these terms are distinct from one
another. The similar practice settings may blur these distinctions (Stanhope & Lancaster, 2008), and confusion exists regarding the differences. The central idea of communityoriented nursing practice is that nursing intervention can
promote wellness, reduce the spread of illness, and improve
the health status of groups of citizens or the community at
large. Its emphasis is on primary, secondary, and tertiary prevention. Nurses in these settings have traditionally focused
on health promotion, maternal and child health, and
chronic care.
Community-based nursing occurs in a variety of settings
within the community, including home settings, and is directed toward people and families (Stanhope & Lancaster,
2008). Most community-based and home health care is directed toward specific patient groups with identified needs,
which usually relate to illness, injury, or disability, resulting
most often from advanced age or chronic illness. However,
nurses in the community are meeting the needs of groups of
patients with a variety of problems and needs. Home health

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care is a major aspect of community-based care discussed
throughout this text. Community-based programs and
agencies for specific populations (eg, the elderly, ventilatordependent patients), as well as home health care agencies,
hospices, independent professional nursing practices, and
freestanding health care agencies, provide home health care
services.
With shorter hospital stays and increased use of outpatient health care services, more nursing care is provided in
the home and community setting. As a result, nurses have a
choice of practicing in a variety of health care delivery settings. These settings include acute care medical centers,
ambulatory care settings, clinics, urgent care centers, outpatient departments, neighborhood health centers, home
health care agencies, independent or group nursing centers,
and managed care agencies.
Community nursing centers are nurse managed and provide primary care services such as ambulatory and outpatient care, immunizations, health assessment and screening
services, and patient and family education and counseling.
These centers serve varied and often underserved populations that typically include a high proportion of patients
who are rural, very young, very old, poor, or members of
racial minorities.
Various agencies provide care in the home and community to meet the needs of patients who are discharged from
acute care institutions to their homes and communities
early in the recovery process and with complex needs. Many
patients are elderly, and many have multiple medical and
nursing diagnoses and multisystem health problems that require acute and intensive nursing care, including ventilatory support and intravenous (IV) or parenteral nutrition
therapy.
As a result, there are many opportunities for employment for nurses in the community and home care settings.
Home care nursing is a specialty area that requires advanced
knowledge and skills in general nursing practice, with emphasis on community health and acute medical-surgical
nursing. Also required are high-level assessment skills, critical thinking, and decision-making skills in a setting where
other health care professionals are not available to validate
observations, conclusions, and decisions.
Home care nurses often provide “high-tech, high-touch”
services to patients with acute health care needs. In addition, they are responsible for patient and family teaching
and for contacting community resources and coordinating
the continuing care of patients. For these reasons, the scope
of medical-surgical nursing encompasses not only the acute
care setting within the hospital, but also the acute care setting as it expands into the community and the home.
Throughout this textbook, the home health care needs of
patients are addressed, with particular attention given to
the teaching, self-care management, and health maintenance needs of patients and their families.

Expanded Nursing Roles
Professional nursing is adapting to meet changing health
needs and expectations. The role of the nurse has expanded to improve the distribution of health care services

Health Care Delivery and Nursing Practice

11

and to decrease the cost of health care. Nurses may receive advanced education in such specialties as family
care, critical care, coronary care, respiratory care, oncologic care, maternal and child health care, neonatal intensive care, rehabilitation, trauma, rural health, and
gerontologic nursing. In medical-surgical nursing, the
most significant titles associated with an advanced specialized education include nurse practitioner (NP) and clinical nurse specialist (CNS), and the more recent title of advanced practice nurse (APN), which encompasses both
NPs and CNSs. Certified nurse-midwives (CNMs) and
certified registered nurse anesthetists (CRNAs) are also
identified as APNs. Nurses who function in these roles
provide direct care to patients through independent practice, practice within a health care agency, or collaboration with a physician. Specialization in nursing has
evolved as a result of the recent explosion of technology
and knowledge.
Most states require both NPs and CNSs to have graduate-level education. NPs are prepared as specialists (eg, family, acute care, pediatric, geriatric). They define their role in
terms of direct provision of a broad range of health care
services to patients and families. The focus is on providing
direct health care to patients and collaborating with other
health professionals. In most states, nurse practitioners have
prescriptive authority and may receive direct Medicare reimbursement.
CNSs, on the other hand, are prepared as specialists
who practice within a circumscribed area of care (eg, cardiovascular, oncology). They define their role as having
five major components: clinical practice, education, management, consultation, and research. Studies have shown
that CNSs often focus on their education and consultation roles, which involve education and counseling of patients and families, as well as education, counseling, and
consultation with nursing staff. Some states have granted
CNSs prescriptive authority if they have the required educational preparation. CNSs practice in a variety of settings, including the community and the home, although
most practice in acute care settings. CNSs are ideal case
managers because they have the educational background
and the clinical expertise to organize and coordinate services and resources to meet the patient’s health care needs
in a cost-effective and efficient manner. The expanding
role of the nurse case manager has contributed to the designation of the APN case manager as an advanced practice role (Hamric, Spross & Hanson, 2005).
With advanced practice roles has come a continuing
effort by professional nursing organizations to define more
clearly the practice of nursing. States’ nurse practice acts
give nurses the authority to perform functions that were
previously restricted to the practice of medicine. These
functions include diagnosis (nursing), treatment, performance of selected invasive procedures, and prescription of medications and treatments. The board of nursing
in each state stipulates regulations regarding these functions, defines the education and experience required, and
determines the clinical situations in which a nurse may
perform these functions. Additionally, the introduction
of the Doctor of Nursing Practice (DNP) as the terminal
practice degree has generated considerable discussion

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regarding the level of preparation needed for APNs
(AACN, 2006).
Initial care, ambulatory health care, palliative care,
and anticipatory guidance are all important in nursing
practice. Advanced practice roles enable nurses to function interdependently with other health care professionals and to establish more collegial relationships with
physicians. The role of advanced practice nurses is expected to continue to increase in terms of scope, responsibility, and recognition.

Interdisciplinary Collaborative Practice
This chapter has explored the changing role of nursing.
Many references have been made to the significance of
nurses as members of the health care team. As the unique
competencies of nurses become more clearly articulated,
there is increasing evidence that nurses provide health care
services distinct to the profession. However, nursing continues to recognize the importance of collaboration with
other health care disciplines in meeting the needs of patients.
Some institutions use the collaborative practice model
(Fig. 1-2). Nurses, physicians, and ancillary health personnel function within a decentralized organizational structure,
collaboratively making clinical decisions. A joint practice
committee, with representation from all care providers, may
function at the unit level to monitor, support, and foster
collaboration. Collaborative practice is further enhanced
with integration of the health or medical record and with
joint patient care record reviews. The collaborative model,
or a variation of it, promotes shared participation, responsibility, and accountability in a health care environment that
is striving to meet the complex health care needs of the
public.

CRITICAL THINKING EXERCISES
1 Your clinical assignment is in a long-term care facility. Identify a patient care issue (eg, nutritional status)
that could be improved. Describe the mechanism that is
available within a clinical facility to address such quality
improvement issues.
2 You are planning the discharge of an elderly patient
who has several chronic medical conditions. A case manager has been assigned to this patient. How would you explain the role of the case manager to the patient and her
husband?
3 You are assigned to care for a hospitalized patient who is obese, with a history of diabetes, and a new
diagnosis of stable angina. There is a clinical nurse leader
(CNL) assigned to provide consistent, quality care for this
patient from hospital admission to discharge. Identify the
evidence that supports the effectiveness of CNLs in supervising care of patients and promoting positive patient
outcomes. What is the strength of the evidence? How
might this specific patient’s care be affected?

The Smeltzer suite offers these additional
resources to enhance learning and facilitate
understanding of this chapter:
• thePoint online resource, thepoint.lww.com/Smeltzer12E
• Student CD-ROM included with the book
• Study Guide to Accompany Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing
REFERENCES AND SELECTED READINGS
Books

Nurse

Patient
Ancillary
health
personnel

Physician

American Association of Colleges of Nursing. (2006). The essentials of doctoral
education for advanced nursing practice. Washington, DC: Author.
American Association of Colleges of Nursing. (2007). White paper on the education and role of the clinical nurse leader. Washington, DC: American Nurses
Publishing.
American Nurses Association. (2001). Code of ethics for nurses with interpretive
statements. Washington, DC: Author.
American Nurses Association. (2003). Nursing’s social policy statement (2nd ed.).
Washington, DC: Author.
Hamric, A. B., Spross, J. A. & Hanson, C. M. (2005). Advanced practice nursing: An integrative approach (5th ed.). St. Louis: Elsevier.
Hood, L. & Leddy, S. K. (2007). Leddy & Pepper’s conceptual bases of professional
nursing (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
Melnyk, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing
& healthcare. Philadelphia: Lippincott Williams & Wilkins.
Pender, N., Murdaugh, C. & Parsons, M. (2006). Health promotion in nursing
practice (5th ed.). Upper Saddle River, NJ: Pearson Education, Inc.
Stanhope, M. & Lancaster, J. (2008). Public health nursing: Population-centered
health care in the community (7th ed.). St. Louis: Mosby-Elsevier.
Stanley, J. M. (2005). Advanced practice nursing (2nd ed.). Philadelphia: F. A.
Davis.
World Health Organization. (2006). Constitution of the World Health Organization (45th ed.). New York: World Health Organization.

Journals and Electronic Documents

Figure 1-2

Collaborative practice model.

Bourgault, A., Ipe, L., Weaver, J., et al. (2007). Development of evidence-based
guidelines and critical care nurses’ knowledge of enteral feeding. Critical Care
Nurse, 27(4), 17–29.
Clark, A., Stuifbergen, A., Gottlieb, N., et al. (2006). Health promotion in
heart failure: A paradigm shift. Holistic Nursing Practice, 20(2), 73.

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Craig, K. & Huber, D. (2007). Acuity and case management: A healthy dose of
outcomes, Part II. Professional Case Management, 12(4), 199–210.
Fineout-Overholt, E., Melnyk, B. & Schultz, A. (2005). Transforming
health care from the inside out. Journal of Professional Nursing, 21(6),
335–344.
Hakesley-Brown, R. & Malone, B. (2007). Patients and nurses: A powerful
force. The Online Journal of Issues in Nursing, 12(1), Manuscript 4. Available
at: http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANA
Periodicals/OJIN.aspx
Huber, D. & Craig, K. (2007). Acuity and case management: A healthy dose of
outcomes, Part I. Professional Case Management, 12(3), 132–144.
International Council of Nurses (ICN). (2006). ICN code of ethics for nurses.
Available at: www.icn.ch/icncode.pdf
Joint Commission. (2007). Improving America’s hospitals: A report on quality and
safety. www.jointcommissionreport.org/
Kinsman, L., James, E. & Ham, J. (2004). An interdisciplinary, evidencebased process of clinical pathway implementation increases pathway
usage. Lippincott’s Case Management: Managing the Process of Patient Care,
9(4), 184–196.
MacDonald, J., Herbert, R. & Thibeault, C. (2006). Advanced practice nursing: Unification through a common identity. Journal of Professional Nursing,
22(9), 172–179.

Health Care Delivery and Nursing Practice

13

Reid Ponte, P. (2004). The American health care system at a crossroads: An
overview of the American Organization of Nurse Executives Monograph.
Online Journal of Issues in Nursing, 9(2), Manuscript 2. nursingworld.org/
MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN.aspx
U.S. Bureau of the Census. (Internet release date: January 13, 2000). Profile of
older Americans: 2000. Population projections of the United States by age, sex,
race, and Hispanic origin: 1995-2005. Current Population Reports, P25-1130.
Washington, DC: Author. Available at: www.census.gov/population/projections/nation/summary/np-t3-b.txt
U.S. Bureau of the Census. (Internet release date: March 10, 2004). Census Bureau estimates number of adults, older people and school-age children in States.
Washington, DC: Author. Available at: www.census.gov/Press-Release/
www/releases/archives/population/001703.html
U.S. Bureau of the Census. (Internet release date: March 18, 2004). Census
Bureau projects tripling of Hispanic and Asian populations in 50 years; NonHispanic whites may drop to half of total population. Washington, DC:
Author. Available at: www.census.gov/Press-Release/www/releases/archives/
population/001720.html
U.S. Bureau of the Census. (Internet release date: Dec. 27, 2007). Census
Bureau projects population of 303.1 million. Washington, DC: Author.
Available at: www.census.gov/Press-Release/www/releases/archives/population/
011108.html

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2

Community-Based
Nursing Practice

LEARNING OBJECTIVES

GLOSSARY

On completion of this chapter, the learner will be
able to:

community-based nursing: nursing care of individuals and
families that is designed to (1) promote and maintain
health and (2) prevent disease. It is provided as patients
transition through the health care system to healthrelated services outside of the hospital setting
primary prevention: health care delivery focused on
health promotion and prevention of illness or disease
secondary prevention: health care delivery centered on
health maintenance and aimed at early detection of disease, with prompt intervention to prevent or minimize
loss of function and independence
tertiary prevention: health care delivery focused on minimizing deterioration associated with disease and improving quality of life through rehabilitation measures

1 Discuss the changes in the health care system that have
increased the need for nurses to practice in communitybased settings.
2 Compare the differences and similarities between community- and hospital-based nursing.
3 Describe the discharge planning process in relation to
home care preparation.
4 Explain methods for identifying community resources
and making referrals.
5 Discuss how to prepare for a home health care visit and
how to conduct the visit.
6 Identify personal safety precautions a home care nurse
should take when making home visits.
7 Describe the various types of nursing functions provided
in ambulatory care facilities, in occupational health and
school nursing programs, in community nurse–managed
centers, in hospice care settings, and in facilities that
provide services to the homeless.

14

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As described in Chapter 1, the shift in health care delivery
from inpatient to outpatient settings is a result of multiple
factors, including new population trends. Changes in federal legislation, tighter insurance regulations, decreasing
hospital revenues, and alternative health care delivery systems have also affected the ways in which health care is delivered. The growing number of older adults in the United
States increases the demand for medical, nursing, and social
services within the public health system. Hospitals and
other health care providers are reimbursed at a fixed rate for
patients who have the same diagnosis as defined by diagnosis-related groups (DRGs). Under this system, hospitals and
other health care providers can reduce costs and earn income by carefully monitoring the types of services they provide and discharging patients as soon as possible. Consequently, patients are being discharged from acute care
facilities to their homes or to residential or long-term care
facilities in early stages of recovery.
As health care delivery shifts into the community, more
nurses are working in a variety of community-based settings.
These settings include public health departments, ambulatory health clinics, long-term care facilities, hospice settings, industrial settings (as occupational nurses), homeless
shelters and clinics, nursing centers, home health agencies,
urgent care centers, same-day surgical centers, short-stay facilities, and patients’ homes. In these settings, nurses often
deliver care without direct on-site supervision or support of
other health care personnel. They must be self-directed,
flexible, adaptable, and accepting of various lifestyles and
living conditions. To function effectively, nurses in these
settings must have expertise in independent decision making, critical thinking, assessment, health education, and
competence in basic nursing care (Stanhope & Lancaster,
2008).
In addition, nurses in community settings must be culturally competent, as culture plays a role in the delivery of
care. Culture can be structured within the context of care
through the utilization of a theoretical framework involving
cultural competence (Jirwe, Gerrish & Emami, 2006).

Community-Based Care
Community-based nursing is a philosophy of care in which
the care is provided as patients and their families move
among various service providers outside of hospitals. This
nursing practice focuses on promoting and maintaining the
health of individuals and families, preventing and minimizing the progression of disease, and improving quality of life
(Stanhope & Lancaster, 2008). Community health nurses
provide direct care to patients and families and use political
advocacy to secure resources for aggregate populations (eg,
the aged population). Community health nurses have many
roles, including epidemiologist, case manager for a group of
patients, coordinator of services provided to a group of patients, occupational health nurse, school nurse (Fig. 2-1),
visiting nurse, or parish nurse. (In parish nursing, the members of a religious community—the parish—are the recipients of care.) These roles have one element in common: a
focus on community needs as well as on the needs of indi-

Community-Based Nursing Practice

15

Figure 2-1 Community-based nursing takes many forms and
focuses. Here the school nurse performs screening for scoliosis.

vidual patients. Community-based care is generally focused
on individuals or their families, although efforts may be undertaken to improve the health of the entire community.
The primary concepts of community-based nursing care
are self-care and preventive care within the context of culture and community. Two other important concepts are
continuity of care and collaboration. Some communitybased areas of nursing have become specialties in their
own right, such as school health nursing and home health
nursing.
Nurses in community-based practice provide preventive
care at three levels—primary, secondary, and tertiary. Primary prevention focuses on health promotion and prevention of illness or disease, including interventions such as
teaching about healthy lifestyles. Secondary prevention
centers on health maintenance and is aimed at early detection and prompt intervention to prevent or minimize loss of
function and independence, including interventions such
as health screening and health risk appraisal. Tertiary prevention focuses on minimizing deterioration and improving
quality of life, including rehabilitation to assist patients in
achieving their maximum potential by working through
their physical or psychological challenges. Home care
nurses often focus on tertiary preventive nursing care, although primary and secondary prevention are also addressed.

Home Health Care
Home care nursing is a unique component of communitybased nursing. Home care visits are made by nurses who
work for home care agencies, public health agencies, and
visiting nurse associations; by nurses who are employed by
hospitals; and by parish nurses or faith community nurses

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who work with the members of faith-based communities to
promote health. Such visits may also be part of the responsibilities of school nurses, clinic nurses, or occupational
health nurses. Home health care agencies are continuing to
employ more nurses. Because of the high acuity level of patients, nurses with acute care and critical care experience
are in demand in this field.
The type of nursing services provided to patients in their
homes varies from agency to agency. Nurses from home care
or hospice agencies make home visits to provide skilled
nursing care, follow-up care, and teaching to promote
health and prevent complications. Hospice nursing has become a specialty area of nursing practice in which nurses
provide palliative care in patients’ homes and within hospice centers, thus promoting comfort, peace, and dignity to
patients who are dying. Clinic nurses may conduct home
visits as part of patient follow-up. Public health, parish, and
school nurses may make visits to provide anticipatory guidance to high-risk families and follow-up care to patients
with communicable diseases. Many home care patients are
acutely ill, and many have chronic health problems or disabilities, requiring that nurses provide more education and
monitoring to patients and families. Holistic care is provided in the home through the collaboration of an interdisciplinary team that includes professional nurses; home
health aides; social workers; physical, speech, and occupational therapists; and physicians. An interdisciplinary approach is used to provide health and social services with
oversight of the total health care plan by a case manager,
clinical nurse specialist, or nurse practitioner. Interdisciplinary collaboration is required if a home health agency is to
receive Medicare certification (Stanhope & Lancaster,
2008).
Home health care services are provided by official, publicly funded agencies; nonprofit agencies; private businesses;
proprietary chains; and hospital-based agencies. Some agencies specialize in high-technology services. Most agencies
are reimbursed from a variety of sources, including Medicare
and Medicaid programs, private insurance, and direct patient payment. Many home health care expenditures are financed by Medicare, which allows nurses to manage and
evaluate patient care for seriously ill patients who have
complex, labile conditions and are at high risk for rehospitalization. Each funding source has its own requirements for
services rendered, number of visits allowed, and amount of
reimbursement the agency receives. The elderly are the
most frequent users of home care services. To be eligible for
service, the patient must be acutely ill, homebound, and in
need of skilled nursing services.
Health care visits may be intermittent or periodic, and
case management via telephone or via Internet may be used
to promote communication with home care consumers.
The nurse instructs the patient and family about skills and
self-care strategies and about health maintenance and promotion activities (eg, nutritional counseling, exercise programs, stress management). Nursing care includes skilled assessment of the patient’s physical, psychological, social, and
environmental status (Fig. 2-2). Nursing interventions may
include intravenous (IV) therapy and injections, parenteral
nutrition, venipuncture, catheter insertion, pressure ulcer
treatment, wound care, ostomy care, and patient and family

Figure 2-2 Assessment is an important part of any home

health visit.

teaching. Complex technical equipment, such as dialysis
machines and ventilators, is often part of home health care
(Stanhope & Lancaster, 2008). Nurses have a role in evaluating the safety and effectiveness of technology in the
home setting. In addition, “tele-health” is an emerging
trend in home health care; this facilitates exchange of information via telephone lines between patients and nurses
regarding health information such as blood glucose readings,
vital signs, and cardiac parameters (Stanhope & Lancaster,
2008). Use of a broad spectrum of computer and Internet resources, such as Web cams, also facilitates exchange of information.

Nursing in the Home Setting
The home care nurse is a guest in the patient’s home and
must have permission to visit and give care. The nurse has
minimal control over the lifestyle, living situation, and
health practices of the patients he or she visits. This lack of
full decision-making authority can create a conflict for the
nurse and lead to problems in the nurse–patient relationship. To work successfully with patients in any setting, the
nurse must be nonjudgmental and convey respect for patients’ beliefs, even if they differ sharply from the nurse’s.
This can be difficult when a patient’s lifestyle involves activities that a nurse considers harmful or unacceptable, such
as smoking, use of alcohol, drug abuse, or overeating.
The cleanliness of a patient’s home may not meet the
standards of a hospital. Although the nurse can provide
teaching points about maintaining clean surroundings, the
patient and family decide if they will implement the nurse’s
suggestions. The nurse must accept their decisions and deliver the care required regardless of the conditions of the
setting.
The kind of equipment and the supplies or resources that
usually are available in acute care settings are often unavailable in the patient’s home. The nurse has to learn to
improvise when providing care, such as when changing a
dressing or catheterizing a patient in a regular bed that is

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not adjustable and lacks a bedside table (Smith-Temple &
Johnson, 2005).
Infection control is as important in the home as it is in
the hospital, but it can be more challenging in the home
and requires creative approaches. As in any situation, it is
important to clean one’s hands before and after giving direct patient care, even in a home that does not have running water. If aseptic technique is required, the nurse must
have a plan for implementing this technique before going to
the home. This applies to universal precautions, transmission-based precautions, and disposal of bodily secretions
and excretions. If injections are given, the nurse must use a
closed container to dispose of syringes. Injectable and other
medications must be kept out of the reach of children during visits and must be stored in a safe place if they are to remain in the house.
Friends, neighbors, or family members may ask the nurse
about the patient’s condition. The patient has a right to
confidentiality, and information should be shared only with
the patient’s permission. If the nurse carries a patient’s medical record into a house, he or she must put it in a secure
place to prevent it from being picked up by others or from
being misplaced.

Discharge Planning for Home Care
Discharge planning is an important part of making the transition from the acute to the home care setting, and it is
mandated for Medicare reimbursement. Discharge planning
begins with the patient’s admission to the hospital and must
consider the possible need for follow-up home care. Several
different personnel (eg, social workers, home care nurses,
and case managers) or agencies may be involved in the
planning process.
The development of a comprehensive discharge plan requires collaboration with professionals at both the referring
agency and the home care agency, as well as other community agencies that provide specific resources upon discharge.
The process involves identifying the patient’s needs and developing a thorough plan to meet them. It is essential to
have open lines of communication with family members to
ensure their understanding and cooperation.

Community Resources and Referrals
As case managers, community-based nurses may make referrals to other team members, such as home health aides
and social workers. These nurses work collaboratively with
the health team and the referring agency or person. Continuous coordinated care among all health care providers
involved in a patient’s care is essential to avoid duplication
of effort by the various personnel caring for the patient.
A community-based nurse must be knowledgeable about
community resources available to patients as well as services
provided by local agencies, eligibility requirements, and any
possible charges for the services. Most communities have directories of health and social service agencies that the nurse
can consult. These directories must be updated as resources
change. If a community does not have a resource booklet,
an agency may develop one for its staff. It should include
the commonly used community resources that patients
need, as well as the costs of the services and eligibility requirements. The telephone book and the Internet are often

Community-Based Nursing Practice

17

useful in helping patients identify the location and accessibility of grocery and drug stores, banks, health care facilities, ambulances, physicians, dentists, pharmacists, social
service agencies, and senior citizens’ programs. In addition,
a patient’s place of worship or parish may be an important
resource for services.
The community-based nurse is responsible for informing
the patient and family about the community resources
available to meet their needs. During initial and subsequent
home visits, the nurse helps the patient and family identify
these community services and encourages them to contact
the appropriate agencies. When appropriate, nurses may
make the initial contact.

Home Health Visits
Preparing for a Home Visit

Most agencies have a policy manual that identifies the
agency’s philosophy and procedures and defines the services
provided. Becoming familiar with these policies is essential
before initiating a home visit. It is also important to know
the agency’s policies and the state law regarding what actions to take if the nurse finds a patient dead, suspects abuse,
determines that a patient cannot safely remain at home, or
observes a situation that possibly indicates malicious harm
to the community at large.
Before making a home visit, the nurse should review the
patient’s referral form and other pertinent data concerning
the patient. It may be necessary to contact the referring
agency if the purpose for the referral is unclear or if important information is missing. The first step is to call the patient to obtain permission to visit, schedule a time for the
visit, and verify the address. This initial phone conversation provides an opportunity to introduce oneself, identify
the agency, and explain the reason for the visit. If the patient does not have a telephone, the nurse should see if the
people who made the referral have a number where a
phone message can be left for the patient. If an unannounced visit to a patient’s home must be made, the nurse
should ask permission to come in before entering the
house. Explaining the purpose of the referral at the outset
and setting up the times for future visits before leaving are
also recommended.
Most agencies provide nurses with bags that contain
standard supplies and equipment needed during home visits. It is important to keep the bag properly supplied and to
bring any additional items that might be needed for the
visit. Patients rarely have the medical supplies needed for
treatment.
Conducting a Home Visit

Personal Safety Precautions
Community nurses must pay particular attention to personal safety, because their practice settings are often in
unknown environments. Based on the principle of due diligence, agencies must inform employees of at-risk working
environments. Agencies have policies and procedures concerning the promotion of safety for clinical staff, and training is provided to facilitate personal safety. Environments
must be proactively assessed for safety by the individual
nurse and agency.

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Chart 2-1• Safety Precautions in Home Health Care
• Learn or preprogram a cell phone with the telephone numbers of the agency and police and emergency services.
Most agencies provide cell phones for their nurses so that
the agency can contact the nurse, and so that the nurse
can contact the agency in case of an emergency or unexpected situation.
• Carry agency identification and a charged cell phone to make
telephone calls in case you become lost or have problems.
• Let the agency know your daily schedule and the
telephone numbers of your patients so that you can be located if you do not return when expected.
• Know where the patient lives before leaving to make the
visit and carry a map for quick referral.
• Keep your car in good working order and have sufficient
gas in the tank.
• Park the car near the patient’s home and lock the car during the visit.
• Do not drive an expensive car or wear expensive jewelry
when making visits.

Whenever a nurse makes a home visit, the agency should
know the nurse’s schedule and the locations of the visits.
The nurse should learn about the neighborhood and obtain
directions to the destination. A plan of action should always be established in case of emergencies. If a dangerous
situation is encountered during the visit, the nurse should
return to the agency and contact his or her supervisor or law
enforcement officials, or both. Suggested precautions to
take when making a home visit are presented in Chart 2-1.
Initial Home Visit
The first visit sets the tone for subsequent visits and is crucial
in establishing the nurse–patient relationship. The situations
encountered depend on numerous factors. Patients may be in
pain and unable to care for themselves. Family members may
be overwhelmed and doubt their ability to care for their loved
ones. They may not understand why the patient was sent
home from the hospital before being totally rehabilitated.
They may not comprehend what home care is or why they
cannot have 24-hour nursing services. It is critical that the
nurse conveys an understanding of what patients and families
are experiencing and how the illness is affecting their lives.
During the initial home visit, which usually lasts less
than an hour, the individual patient is evaluated and a plan
of care is established to be followed or modified on subsequent visits. The nurse informs the patient of the agency’s
practices, policies, and hours of operation. If the agency is
to be reimbursed for the visit, the nurse asks for insurance
information, such as a Medicare or Medicaid card.
The initial assessment includes evaluating the patient,
the home environment, the patient’s self-care abilities or
the family’s ability to provide care, and the patient’s need
for additional resources. Identification of possible hazards,
such as cluttered walk areas, potential fire risks, air or water
pollution, or inadequate sanitation facilities, is also part of
the initial assessment.
Documentation considerations for home visits follow
fairly specific regulations. The patient’s needs and the nurs-

• Know the regular bus schedule and know the routes when
using public transportation or walking to the patient’s
house.
• When making visits in high-crime areas, visit with another
person rather than alone.
• Schedule visits only during daylight hours.
• Never walk into a patient’s home uninvited.
• If you do not feel safe entering a patient’s home, leave the
area.
• Become familiar with the layout of the house, including exits from the house.
• If a patient or family member is intoxicated, hostile, or obnoxious, reschedule the visit and leave.
• If a family is having a serious argument or abusing the patient or anyone else in the household, reschedule the visit,
contact your supervisor, and report the abuse to the appropriate authorities.

ing care provided must be documented to ensure that the
agency qualifies for payment for the visit. Medicare, Medicaid, and third-party payers require documentation of the patient’s homebound status and the need for skilled professional nursing care. The medical diagnosis and specific
detailed information on the functional limitations of the patient are usually part of the documentation. The goals and
the actions appropriate for attaining them must be identified. Expected outcomes of the nursing interventions must
be stated in terms of patient behaviors and must be realistic
and measurable. They must reflect the nursing diagnosis or
the patient’s problems and must specify those actions that
address the patient’s problems. Inadequate documentation
may result in nonpayment for the visit and care services.
Determining the Need for Future Visits
While conducting an assessment of a patient’s situation, the
home care nurse evaluates the need for future visits and the
frequency with which those visits may need to be made. To
make these judgments, the nurse should consider the questions listed in Chart 2-2. With each subsequent visit, these
same factors are evaluated to determine the continuing
health needs of the patient. As progress is made and the patient, with or without the help of significant others, becomes more capable of self-care and more independent, the
need for home visits may decline.
Ending the Visit
As the visit comes to a close, it is important to summarize
the main points of the visit for the patient and family and
to identify expectations for future visits or patient achievements. The following points should be considered at the
end of each visit:
• What are the main points the patient or family should
remember from the visit?
• What positive attributes have been noted about the
patient and the family that will give them a sense of
accomplishment?

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Chart 2-2 • Assessing the Need for
Home Visits
Current Health Status
• How well is the patient progressing?
• How serious are the present signs and symptoms?
• Has the patient shown signs of progressing as expected,
or does it seem that recovery will be delayed?

Community-Based Nursing Practice

19

phone service available, or can an emergency cell
phone service be provided?
• What signs of complications should be reported immediately?
• How frequently will visits be made? How long will
they last (approximately)?
• What is the day and time of the next visit? Will a different nurse make the visit?

Home Environment
• Are worrisome safety factors apparent?
• Are family or friends available to provide care, or is the
patient alone?

Other Community-Based Health Care
Settings

Level of Self-Care Ability

Ambulatory Settings

•
•
•
•

Ambulatory health care is provided for patients in community- or hospital-based settings. The types of agencies that
provide such care are medical clinics, ambulatory care units,
urgent care centers, cardiac rehabilitation programs, mental
health centers, student health centers, community outreach
programs, and nursing centers. Some ambulatory centers provide care to a specific population, such as migrant workers or
Native Americans. Neighborhood health centers provide
services to patients who live in a geographically defined area.
The centers may operate in freestanding buildings, storefronts, or mobile units. Agencies may provide ambulatory
health care in addition to other services, such as an adult day
care or health program. The kinds of services offered and the
patients served depend on the agency’s mission.
Nursing responsibilities in ambulatory health care settings include providing direct patient care, conducting patient intake screenings, treating patients with acute or
chronic illnesses or emergency conditions, referring patients to other agencies for additional services, teaching patients self-care activities, and offering health education programs that promote health maintenance. A useful tool for
community-based nurses might be the classification scheme
developed by the Visiting Nurses Association of Omaha,
which contains patient-focused problems in one of four domains: environmental, psychosocial, physiologic, and
health-related behaviors (Barton, Clark & Baramee, 2004).
Nurses also work as clinic managers, direct the operation
of clinics, and supervise other health team members. Nurse
practitioners, educated in primary care, often practice in
ambulatory care settings that focus on gerontology, pediatrics, family or adult health, or women’s health. Constraints
imposed by federal legislation and ambulatory payment classifications require efficient and effective management of patients in ambulatory settings. Nurses can play an important
part in facilitating the function of ambulatory care facilities.

Is the patient capable of self-care?
What is the patient’s level of independence?
Is the patient ambulatory or bedridden?
Does the patient have sufficient energy, or is he or she
frail and easily fatigued?
• Does the patient need and use assistive devices?
Level of Nursing Care Needed
• What level of nursing care does the patient require?
• Does the care require basic skills or more complex interventions?
Prognosis
• What is the expectation for recovery in this particular instance?
• What are the chances that complications may develop if
nursing care is not provided?
Educational Needs
• How well has the patient or family grasped the teaching
points made?
• Is there a need for further follow-up and retraining?
• What level of proficiency does the patient or family show
in carrying out the necessary care?
Mental Status
• How alert is the patient?
• Are there signs of confusion or thinking difficulties?
• Does the patient tend to be forgetful or have a limited attention span?
Level of Adherence
• Is the patient following the instructions provided?
• Does the patient seem capable of following the instructions?
• Are the family members helpful, or are they unwilling or
unable to assist in caring for the patient as expected?

• What were the main points of the teaching plan or
the treatments needed to ensure that the patient and
family understand what they must do? A written set of
instructions should be left with the patient or family,
provided they can read and see (alternative formats
include video or audio recordings). Printed material
must be in the patient’s primary language and in large
print when indicated.
• Whom should the patient or family call if they need
to contact someone immediately? Are current emergency telephone numbers readily available? Is tele-

Occupational Health Programs
Federal legislation, especially the Occupational Safety and
Health Act (OSHA), has been enacted to ensure safe and
healthy work conditions. A safe working environment results in decreased employee absenteeism, hospitalization,
and disability, as well as reduced costs.
Occupational nurses may work in solo units in industrial
settings, or they may serve as consultants on a limited or
part-time basis. They may be members of an interdisciplinary team composed of a variety of personnel such as nurses,

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20

Unit 1

Basic Concepts in Nursing

physicians, exercise physiologists, health educators, counselors, nutritionists, safety engineers, and industrial hygienists. Occupational health nurses may:
• Provide direct care to employees who become ill or
injured
• Conduct health education programs for company staff
members
• Set up programs aimed at establishing specific health
outcomes, such as healthy eating and regular exercise
• Monitor employees’ hearing, vision, blood pressure, or
blood glucose
• Track exposure to radiation, infectious diseases, and
toxic substances, reporting results to government
agencies as necessary
Occupational health nurses must be knowledgeable
about federal regulations pertaining to occupational health
and familiar with other pertinent legislation, such as the
Americans With Disabilities Act.

School Health Programs
School health programs provide services to students and
may also serve the school’s community. School-age children
and adolescents with health problems are at major risk for
underachieving or failing in school. The leading health
problems of elementary school children are injuries, infections (including influenza and pneumonia), malnutrition,
dental disease, and cancer. The leading problems of high
school students are alcohol and drug abuse, injuries, homicide, pregnancy, eating disorders, sexually transmitted
diseases/infections (STDs/STIs), sports injuries, dental disease, and mental and emotional problems. Contemporary
school health issues that are being examined include school
violence, which may affect students’ and teachers’ physical
and emotional health, and the increasing numbers of overweight and obese children and adolescents.
Ideally, school health programs have an interdisciplinary health team consisting of physicians, nurses, dentists, social workers, counselors, school administrators,
parents, and students. The school may serve as the site for
a family health clinic that offers primary health and mental health services to children and adolescents as well as
to all family members in the community. Advanced practice nurses perform physical examinations and diagnose
and treat students and families for acute and chronic illnesses within the scope of their practice. These clinics are
cost-effective and benefit students from low-income families who lack access to traditional health care or have no
health insurance.
School nurses play a number of roles, including care
provider, health educator, consultant, and counselor. They
collaborate with students, parents, administrators, and
other health and social service professionals regarding student health problems. School nurses perform health screenings, provide basic care for minor injuries and complaints,
administer medications, monitor the immunization status of
students and families, identify children with health problems, provide teaching related to health maintenance and
safety, and monitor the weight of children in order to facilitate prevention and treatment of obesity. They need to be
knowledgeable about state and local regulations affecting
school-age children, such as ordinances for excluding stu-

dents from school because of communicable diseases or parasites such as lice or scabies.
School nurses are also health education consultants for
teachers. In addition to providing information on health
practices, teaching health classes, and participating in the
development of the health education curriculum, school
nurses educate teachers and classes when a student has a
special problem, a disability, or a disease such as hemophilia, asthma, or human immunodeficiency virus (HIV)
infection.

Community Nurse–Managed Centers
Community nurse–managed centers are a relatively new
concept in community-based nursing, having appeared only
in recent decades. Frequently sponsored by academic institutions, these centers typically are designed for the delivery
of primary health care and typically serve people who are
vulnerable, uninsured, and without access to health services.
Community nurse–managed centers, which are usually run
by advanced practice nurses, serve a large number of patients
who are poor, members of minority groups, women, elderly,
or homeless. The nurses provide health teaching, wellness
and illness care, case management services, and psychosocial
counseling (Pohl, Barkauskas, Benkert, et al., 2007). In
some areas, various community partnership models facilitate
care for the growing number of migrant workers.

Care for the Homeless
Homelessness is a growing problem. The homeless population is heterogeneous and includes members of both dysfunctional and intact families, the unemployed, and those
who cannot find affordable housing. In addition, increasing
numbers of women with children (often victims of domestic abuse), elderly people, and veterans since the military
action following the terrorist attacks of September 11,
2001, are homeless. Some people are temporarily homeless
as a result of catastrophic natural disasters.
Homeless people are often underinsured or uninsured
and have limited or no access to health care. Because of
numerous barriers, they seek health care late in the course
of a disease and deteriorate more quickly than patients who
are not homeless. Many of their health problems are related in large part to their living situation. Street life exposes people to the extremes of hot and cold environments
and it compounds their health risks. Homeless people have
high rates of trauma, tuberculosis, upper respiratory tract
infections, poor nutrition and anemia, lice, scabies, peripheral vascular disorders, STDs/STIs, dental problems, arthritis, hypothermia, skin disorders, and foot problems. Common chronic health problems also include diabetes,
hypertension, heart disease, acquired immunodeficiency
syndrome (AIDS), mental illness, and abuse of alcohol or
other drugs (National Coalition for the Homeless, 2007a).
These problems are made more difficult by living on the
streets or discharge to a transitory, homeless situation in
which follow-up care is unlikely. Shelters frequently are
overcrowded and unventilated, promoting the spread of
communicable diseases such as tuberculosis. Homeless people also tend to have a higher incidence of death prior to
the age of 62 (National Coalition for the Homeless, 2006a,
2006b).

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Community-based nurses who work with homeless people must be nonjudgmental, patient, and understanding.
They must be skilled in dealing with people who have a
wide variety of health problems and needs and must recognize that individualized treatment strategies are required in
highly unpredictable environments. Nursing interventions
are aimed at evaluating the health care needs of people who
live in shelters and attempting to obtain health care services for all homeless people.

CRITICAL THINKING EXERCISES
1 You are a nurse employed at the health clinic of a
community college. The dean asks you to organize a series
of health fairs for the school year that focus on key problems of teenagers and young adults. How might you determine the key issues and trends that need to be
addressed? Name the top five areas of concern that you
will address.
2 A 27-year-old woman with newly diagnosed
diabetes is being referred for home care after discharge
from the hospital, and she needs glucose monitoring and
teaching. She has several family members at home, but
they all work. You are concerned about her ability to understand the basic information and applications for
around-the-clock management. What resources could
you use to assess her health literacy? How would you go
about obtaining this information? What is the evidence
base that supports conducting a literacy assessment to determine what is needed for appropriate home care followup in facilitating self-care measures in diabetes home care
management? What is the strength of the evidence?

The Smeltzer suite offers these additional
resources to enhance learning and facilitate
understanding of this chapter:
• thePoint online resource, thepoint.lww.com/Smeltzer12E
• Student CD-ROM included with the book
• Study Guide to Accompany Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing

REFERENCES AND SELECTED READINGS
*Asterisk indicates nursing reseach.

Books
Clark, M. J. (2007). Community health nursing: Advocacy for population health (5th
ed). Upper Saddle River, NJ: Prentice-Hall/Pearson Education, Inc.
Maurer, F. & Smith, C. (2005). Community/public health nursing practice: Health
for families and populations (3rd ed.). St. Louis: Elsevier-Saunders.
NANDA International. (2007). Nursing diagnoses: Definitions & classification
2007–2008. Philadelphia: Author.
Pender, N., Murdaugh, C. & Parsons, M. (2006). Health promotion in nursing practice
(5th ed.). Upper Saddle River, NJ: Prentice-Hall/Pearson Education, Inc.

Community-Based Nursing Practice

21

Smith-Temple, A. J. & Johnson, J. Y. (2005). Nurses’ guide to clinical procedures.
Philadelphia: Lippincott Williams & Wilkins.
Solari-Twadell, P. A. & McDermott, M. A. (2006). Parish nursing: Development,
education, and administration. St. Louis: Elsevier.
Stanhope, M. & Lancaster, J. (2008). Community and public health nursing (7th
ed). St. Louis: Mosby.

Journals and Electronic Documents
Barton, A. J., Clark, L. & Baramee, J. (2004). Tracking outcomes in
community-based care. Home Health Care Management & Practice, 16(3),
171–176.
Centers for Disease Control and Prevention. CDC/ATSDR strategic plan for public health workforce development. Available at: www.cdc.gov
Connor, A., Rainer, L. P., Simcox, J., et al. (2007). Increasing the delivery of
health care services to migrant farm workers families through a community
partnership model. Public Health Nursing, 24(4), 355–360.
*Gee, T., Smith, T., Solomon, M., et al. (2007). The clinical, psychosocial, and
socioeconomic concerns of urban youth living with diabetes. Public Health
Nursing, 24(4), 318–328.
Jirwe, M., Gerrish, K. & Emami, A. (2006). The theoretical framework of cultural competence. Journal of Multicultural Nursing & Health, 12(3),
6–11.
National Association for Home Care and Hospice. (2007). Hospice facts and statistics. Available at: www.nahc.org/facts/hospicefx07.pdf
National Coalition for the Homeless. (June, 2006a). Healthcare and homelessness.
(Fact sheet #4). www.nationalhomeless.org/publications/facts/health.html
National Coalition for the Homeless. (June, 2006b). Mental illness and homelessness. (Fact sheet #5). Available at: www.nationalhomeless.org/publications/facts/mental_illness.pdf
National Coalition for the Homeless. (August, 2007a). Why are people homeless?
(Fact sheet #1). Available at: www.nationalhomeless.org/publications
/facts/Why.pdf
National Coalition for the Homeless. (August, 2007b). How many people experience homelessness? (Fact sheet #2). Available at: www.nationalhomeless.
org/publications/facts/how_many.pdf
National Coalition for the Homeless. (August, 2007c). Who is homeless? (Fact
sheet #3). Available at: www.nationalhomeless.org/publications/facts/
whois.pdf
National Coalition for the Homeless. (August, 2007d). Homeless veterans. (Fact
sheet #14). Available at: www.nationalhomeless.org/publications/facts/
veterans.html
National Coalition for the Homeless. (August, 2007e). Homelessness among elderly persons. (Fact sheet #15). Available at: www.nationalhomeless.org/
publications/facts/elderly.html
*Pohl, J. M., Barkauskas, V. H., Benkert, R., et al. (2007). Impact of academic
nurse-managed centers on communities served. Journal of the American Academy of Nurse Practitioners, 19(5), 268–275.
Sensenig, J. A. (2007). Learning through teaching: Empowering students and
culturally diverse patients at a community-based nursing care center. Journal
of Nursing Education, 46(8), 373–379.

RESOURCES
Case Management Society of America (CMSA), www.cmsa.org
Centers for Disease Control and Prevention (CDC), www.cdc.gov
Centers for Medicare and Medicaid Services (CMS), www.cms.hhs.gov
Department of Health and Human Services (2006). Midcourse review: Healthy
people 2010. Executive summary. www.healthypeople.gov/data/midcourse/
html/introduction.htm
National Association for Home Care, www.nahc.org
National Association of School Nurses, Inc., Eastern Office, P.O. Box 1300,
Scarborough, ME 04070-1300; 1-877-627-6476; www.nasn.org
National Guideline Clearing House (NGC), www.guideline.gov
National Institute for Literacy, www.nifl.gov
NurseLinx.com (MDLinx Inc.), 1025 Vermont Avenue, NW, Suite 810, Washington, DC 20005; 1-202-543-6544; www.nurselinx.com
Parish Nursing Health Information Resource, www.parishnursing.umaryland.edu
Urban Institute, www.urban.org

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